CHAPTER 136
Psychosocial Aspects of Arm Illness

ANA-MARIA VRANCEANU, PhD AND DAVID RING, MD, PhD

The psychosocial aspects of illness usually manifest in the difference between disease, nociception, and impairment on one hand, and illness, pain, and disability on the other. Disease is defined as an “objective biological event” that involves disruption of specific body structures or organ systems caused by pathologic, anatomic, or physiologic changes.1 Impairment represents an “objective loss of function” consistent with the magnitude of the biological event. Nociception entails stimulation of nerves that convey information about tissue damage to the brain.

In contrast, illness is defined as a “subjective experience or self-attribution” that a disease is present,² this leads to physical discomfort, emotional distress, behavioral limitations, and psychosocial disruption. Illness is thus how the sick person, the social network, and perhaps the society perceive, live with, and respond to physical symptoms. Disability is the effect of this subjective experience. Pain is the subjective perception that results from the modulation of the sensory input filtered through a person’s genetic makeup, prior learning history, and current physiologic status, appraisals, expectations, mood, and sociocultural factors.

The psychosocial aspects of illness are often considered as all or none (dichotomous); for instance, a patient might say, “You think it’s all in my head.” The fact is that illness, pain, and disability are not dichotomous and neither are the psychosocial and behavioral aspects of illness. They occur on a continuum from adaptation and resiliency to maintained function despite either substantial impairment on one hand or disproportionate complaints and disability with little or no objective impairment on the other. Beyond the underlying pathophysiology or disease, the illness encompasses the complex human reaction to injury and illness. Illness, disability, and pain are always interactive, mind–body events.

Hand specialists are familiar with some of the psychosocial factors associated with arm pain, in particular issues associated with secondary gain, such as active litigation, disability claims, worker’s compensation disputes, and narcotic addictions. Hand specialists may be less familiar and perhaps less appreciative of the importance of other psychosocial factors, such as depression, pain catastrophizing, health anxiety, and heightened illness concern.

Depression, Pain Catastrophizing, and Health Anxiety

Consistent with findings in chronic pain throughout the body, the most common psychosocial factors that influence reported pain intensity and disability are depression, pain catastrophizing or negative pain thoughts, and heightened illness concerns.3 Previously well-compensated psychosocial factors may become problematic when one is confronted with pain. For instance, a person who tends to worry about minor matters may develop pain catastrophizing (a tendency to magnify the pain experience, to feel helpless when thinking about pain, and to ruminate on the pain experience). Someone who has a tendency to worry about his or her health may start viewing a benign pain condition as a sign of serious pathology and may have a difficult time accepting reassurance that the condition is benign (heightened illness concern, health anxiety, or hypochondriasis). A depressed patient may make internal (“It’s my fault”), global (“Everything is going wrong”), and stable (“I will never get over this”) attributions about the pain condition. Pain may exacerbate a predisposition toward depression, may intensify an already existent depression, or may become a somatic focus for depressive symptoms.⁴ A tendency toward negative thinking and appraisal of life situations may translate into a similar appraisal of the pain condition. All of this may convert into reports of increased pain and disability.

Several measures have been developed for assessing these aspects of illness, and some are specific for pain. They use Likert-type scales, asking specific questions from the psychological domain specific to the construct being assessed. Depression is most often assessed with the Center for the Epidemiologic Study of Depression (CESD⁵) scale, the Beck Depression Inventory (BDI⁶), or the Depression Subscale of the Patient Health Questionnaire (PHQ⁷). These measures inquire about typical symptoms of depression, and they vary in terms of their relative emphasis on the somatic or cognitive components of depression. Although major depression is a discrete diagnosis these scales measure depressive traits or symptoms along the continuous spectrum and indicate how they affect illness behavior.

Pain catastrophizing is assessed with the Pain Catastrophizing Scale (PCS⁸), a 13-item measure with three subscales: magnification (e.g., “I become afraid that pain may get worse”), helplessness (e.g., “It is awful and I feel that it overwhelms me”), and rumination (e.g., “I can’t seem to keep it out of my mind”). Pain catastrophizing is one of the strongest predictors of pain intensity and disability across a variety of pain conditions.

Health anxiety can be assessed with the Health Anxiety Inventory,⁹ Whitley Index,¹⁰ and Somatic Symptoms Inventory (SSI¹¹). The SSI inquires about the extent to which patients experience certain bodily functions (e.g., nausea and vomiting, hot or cold spells, heart pounding, heavy arms). The Health Anxiety Inventory and Whitley Index include questions assessing the extent to which patients endorse cognitive aspects of health anxiety (e.g., “Do you worry about your health?,” “Do you often worry about the possibility that you have a serious illness?”). Health anxiety and hypochondriasis are increasingly recognized correlates of pain intensity and disability in chronic pain conditions.

The use of these validated measures may facilitate the health provider’s ability to address these sensitive topics. Empathy and practiced communication skills are requisite. According to the model developed in other fields, these issues may be best addressed by multidisciplinary teams, with the various health providers (surgeons, nonoperative providers such as physiatrists, certified hand therapists, and behavioral medicine specialists or psychologists) working as a team. Such multidisciplinary treatment teams have been successful in treatment of several pain conditions.¹²

Secondary Gain Issues

Fordyce,13 the founder of the social learning theory model of pain, believed that pain is behavior designed to protect oneself or solicit aid and that pain increases (i.e., this behavior is strengthened) when followed by desirable consequences. Fordyce argued that if pain persisted beyond the normal healing time in an environment with secondary gains, the pain would become chronic. He gave as examples of secondary gains, or “desirable consequences” of pain, the following factors: attention and sympathy from family, friends, and physicians; release from task responsibilities at home and at work; narcotic medications; and monetary compensation. Unfortunately patients and hand specialists are not sufficiently mindful of the undesirable consequences of these behaviors, such as anger and rejection when family and friends get tired of having to take on the patient’s daily tasks or exasperation about the patient’s failure to get well; frustration with complicated bureaucracy; increased physical suffering due to chronic narcotic use and dependency; unpleasant side effects with medication; and constant bitter battles for disability benefits during which the patient must take on and exaggerate the sick role. An open discussion of the issues raised by secondary gain and discussion of the long-term consequences can greatly contribute to healing and can prevent chronicity of symptoms and disability.

Psychological Factors Familiar to Hand Specialists

Psychosocial factors are particularly important when a patient’s problem is puzzling (noncharacteristic, nonanatomic, or disproportionately symptomatic and disabling) and the examination and diagnostic procedures are inconclusive or contradictory.14,15 The desire to act immediately and help the patient using typical means available to a hand specialist (e.g., surgery, injections, etc.), although understandable, can be counterproductive in this context. Perhaps hand specialists can learn to take a step back, embrace the limitations of modern medicine, and approach treatment within a biopsychosocial behavioral framework. Approaching illness from a biopsychosocial rather than a purely biomedical approach may create several important possibilities for improving health and peace of mind.

In this section we discuss psychiatric diagnoses and puzzling hand and arm conditions—conditions that are instructive of the interrelation between medical and psychological factors—from factitious disorders, in which medical symptoms are consciously produced, to somatization disorder in which normal bodily symptoms are amplified via cognitive processes. The interrelation between medical and psychological factors is acknowledged and incorporated within the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV). Using different axes to depict psychological (axis I), personality (axis II), medical (axis III), psychosocial stressor (axis IV), and global functioning (axis V), aspects of illness help to form a comprehensive image of a patient.

Factitious Disorders

Factitious disorders are conditions in which a person acts as if he or she has an illness by deliberately producing, feigning, or exaggerating symptoms. There is a motivation to assume the sick role and an absence of external incentives.16 Patients may lie about or fake symptoms, hurt themselves to bring on symptoms, or even alter diagnostic tests (e.g., contaminating a urine sample). People might be motivated to perpetrate factitious disorders either as a patient or by proxy as a caregiver to gain any variety of benefits, including attention, nurturance, sympathy, and leniency, which are perceived as otherwise unobtainable.¹⁷ Patients with factitious disorders deny responsibility, yet they deliberately injure themselves to fulfill psychological needs, sometimes without regard to economic or social gain.¹⁸

Patients with upper extremity problems rarely meet DSM-IV criteria for a factitious disorder. Conversely, patients can present with elements of a factitious disorder, which can sometimes occur in the context of a clear medical condition. Factitious disorders are “a spectrum of consciously simulated disease, ranging from occasional falsification of disease—perhaps in the midst of stress—to the repetitive presentation of exaggerated or false symptoms and conscious production of signs.”¹⁹

Factitious disorders are particularly challenging for hand specialists who are generally pragmatists trained to convert observed details into a specific medical diagnosis that leads to straightforward treatment with fairly predictable results.

Clenched Fist Posturing

The clenched fist is a condition in which the arm is healthy, but all or one, two, or three fingers are tightly flexed. Often, the index finger and thumb are not involved, thereby allowing the patient useful hand function. The conceptualization of the clenched fist syndrome is controversial, with some including it as a factitious disorder, and others as a conversion disorder, acknowledging that the motivation and source of this condition may be unconscious.20 In the short term, the diagnosis can be confirmed by anesthetizing the extremity or the patient and demonstrating the absence of fixed contracture, but in longstanding cases, fixed contracture can develop. A variation on this theme is the stiff index finger that “won’t bend” except under anesthesia.

Factitious Lymphedema and Unexplained Swelling

Unexplained swelling of the hand or arm may be a result of the patient’s surreptitious application of a tourniquet to the extremity. Examples of objects that may be used this way include elastic bandages, sphygmomanometer cuffs, rubber bands, or pieces of string. Placing the extremity in a plaster cast allows the swelling to subside and prevents further application of the constricting band. Many conditions may cause edema of the limb. However, with factitious lymphedema caused by intermittent application of a tourniquet, a so-called broken windowpane pattern of collateral lymphatic circulation distal to the site of tourniquet obstruction is seen. Ruptured lymph channels due to recurrent lymph stasis and direct constriction may also be seen. The size and distribution of the lymphatics are normal, however. There is no abnormality of the lymph nodes.21

Self-Inflicted Wounds and Wound Manipulation

Voluntary self-inflicted wounds often have an obvious origin. Cigarette burns, stab wounds, subcutaneous injection of feces and other noxious substances, and even bite wounds are seen in these patients. The clinician must discriminate between the deliberate self-inflicted wound and the accidental one in patients with other types of mental problems such as the hand that is damaged by accidental intra-arterial injection by a drug addict.

Self-Cutting

Self-cutting is rare but can be quite spectacular, with dozens, sometimes hundreds, of lacerations or scars on the forearms and hands. The lacerations usually involve only the epidermis but occasionally are deeper. The wounds are usually longitudinal or oblique and are most common on the dorsum of the hand and forearm. Self-cutting is common in patients with a borderline personality disorder and is usually conceptualized as means of coping with intense psychological pain as well as need for attention.16

Secrétan’s Syndrome

Secrétan’s syndrome (also known as peritendinous fibrosis, post-traumatic hard edema, and factitious lymphedema) is a condition caused by the patient repeatedly striking the dorsum of the hand with a blunt object or against a blunt object, causing diffuse swelling as a result of a peritendinous fibrosis of the extensor tendons. The literature suggests that Secrétan’s syndrome is an injury that is self-inflicted either for secondary gain or as a conversion reaction and that is best treated with conservative care and psychiatric counseling.22

Munchausen’s Syndrome

SHAFT syndrome

The Somatoform Disorders

The somatoform disorders are conditions in which the presence of physical symptoms suggests a medical condition, but the symptoms are not fully explained by disease (pathophysiology) or by another mental disorder.16 These disorders include pain disorder, somatization disorder, conversion disorder, and hypochondriasis.

Pain Disorder

Pain disorder is diagnosed when pain is the predominant focus of the clinical presentation, when the pain causes substantial disability and distress, and when psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.16 Pain disorders can be diagnosed in both acute and chronic pain. Pain disorders can be subclassified as pain disorder with psychological factors (in which psychological factors are considered a primary component in the etiology and maintenance of pain) and pain disorder with both psychological and medical factors (in which psychological and medical factors are given equal importance). Pain disorders are the most common psychiatric diagnosis in patients with pain, with prevalence rates as high as 97% in some samples of postinjury patients with chronic low back pain in an inpatient rehabilitation setting.²³

Somatization Disorder

Somatization disorder is diagnosed in patients with multiple somatic symptoms—including digestive, sexual, and neurologic symptoms in addition to pain—that cannot be explained by a physical disorder. In order to meet the full criteria for somatization disorder, patients have to have four pain, two gastrointestinal, one sexual, and one pseudoneurologic symptom. In addition, these symptoms are not a function of an underlying medical condition, or, when a medical condition is present, symptoms are in excess of what is normally expected from the history, physical examination, or laboratory findings.16 Although somatization is common among patients with chronic pain, few patients meet the full diagnostic criteria for somatization disorder. The process of somatization is currently conceptualized as involving the focusing of attention on internal stimuli and development of “sensory amplification,”¹¹ along with denial of psychological or interpersonal difficulties,²⁴ resulting in an increase in somatic symptoms that remain partly or completely unexplained by objective disease processes.

Hypochondriasis

Hypochondriasis represents a preoccupation with fears of having, or the idea that one has, a serious disease based on a misinterpretation of bodily symptoms. This preoccupation persists despite appropriate medical evaluation and reassurance. The belief is not delusional and is not restricted to appearance only (e.g., body dysmorphic disorder). In addition, this preoccupation causes significant distress or impairment in social, occupational, or other important areas of functioning. In order to meet the full criteria, the disturbance must last longer than 6 months and may not be better accounted for by other psychological disorders such as obsessive compulsive disorder, pain disorder, or generalized anxiety disorder.¹⁶

Only a small number of hand and arm patients meet the full criteria for hypochondriasis. However, a larger number present with heightened illness concern or health anxiety, which are less severe, yet distressing conditions in which the patient’s concern with a medical or perceived medical condition is exaggerated and consuming. It is important to note that most people are affected and concerned by the presence of pain. However, the majority readily accept reassurance with regard to their pain symptoms and are able to put worries at rest if told that their condition is not dangerous or severe. In patients with heightened illness concern (and its extreme, hypochondriasis), no amount of reassurance is sufficient, and they continue to believe that the doctors “missed” something. Recent research supports the theory that heightened illness concern is an important mechanism for the development of chronic pain conditions.²⁵

Conversion Disorder

Conversion disorder is diagnosed when one or more deficits affecting voluntary or sensory function suggest a neurologic or other general medical condition. Psychological factors are judged to be associated with the symptoms or deficits because the initiation or exacerbation of the symptoms or deficits is preceded by conflicts or other stressors. Symptoms are not intentionally produced or feigned (as in factitious disorders or malingering) and cannot, after appropriate investigations, be fully explained by a general medical condition, by substance abuse effects, or culturally sanctioned behaviors. In addition, the symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.16 The symptoms are not limited to pain or sexual dysfunction, do not occur only as part of somatization disorder, and are not better accounted for by a medical condition. Based on type of symptom deficits, conversion disorders are classified as (1) with motor symptoms or deficits, (2) with sensory symptoms or deficits, (3) with seizures or convulsions, or (4) with mixed presentation.¹⁶ Conversion disorders are rare in pain patients. However, patients may present with symptoms of a conversion disorder, such as sudden onset of arm weakness and perhaps inability to lift the hand, which is found to have no medical explanation.

Other Chronic Unexplained or Puzzling Pain Problems—A Personal Perspective

Repetitive Strain Injury

Several unverifiable pain conditions are accepted illness constructs within hand surgery and medicine including radial tunnel syndrome, pronator syndrome, as well as electrophysiologically normal thoracic outlet, carpal tunnel, and cubital tunnel syndromes, not to mention dynamic scapholunate instability, occult dorsal ganglion, among others. These debatable and unverifiable conditions are similar to other nonspecific conditions,26 such as fibromylagia and chronic fatigue syndrome, which are often comorbid.

The nomenclature of these illness constructs is somewhat troubling, as it implies an understanding of the pathophysiology and a known physical basis where one is by definition lacking. It is recognized, but underappreciated, that chronic nonspecific arm pain is comorbid with depression, health anxiety, pain catastrophizing, and somatization, which are perhaps the only clear targets of intervention in the absence of verifiable and treatable objective pathology.

From a biopsychosocial perspective patients with repetitive strain injury can also be conceptualized as presenting with features of conversion disorder, heightened illness concern, and somatoform disorder. Distress may also manifest in the form of anxiety and depression. Perhaps a biopsychosocial approach similar to that described in the DSM-IV, which considers both medical and psychological factors, should replace the purely medical focus that currently hinders comprehensive management of these illnesses. In this way, unnecessary medical procedures can be avoided, and psychological distress can be addressed, thus increasing the patient’s quality of life and functioning. Some state that these medical labels serve the patient’s need to emphasize the physical rather than the psychosocial or somatoform aspect of his or her illness,^11,27 and thus avoid stigmatization, but the benefit of these diagnoses is short-lived. In the long run, a focus on a purely medical condition and the administration of numerous tests and medical procedures act to reinforce a “sick role” and do not address core issues, such as acceptance, adaptation, and resiliency. No matter the advances to come in medicine, illness will always be a part of human existence, and effective coping skills will improve ability, wellness, and peace of mind.

Complex Regional Pain Syndromes

Complex regional pain syndromes (CRPSs) represent another puzzling chronically painful condition28 with little epidemiologic information, a lack of understanding with regard to natural course or basic pathophysiology, and lack of agreement even on definition and diagnostic criteria.²⁹ The most up-to-date definition of CRPS^29,30 currently adopted by the International Association for the Study of Pain (IASP) reflects the evolution of the controversies of the concepts of reflex sympathetic dystrophy, sympathetically maintained pain, and sympathetically independent pain and attempts to provide a definition focused on a description without any presumption about underlying mechanisms. The current nomenclature reflects the complexity of this condition, the regional distribution of symptoms (which mostly affects hands), and the cardinal symptom of pain. Two types of disorders are included in this category: (1) CRPS I, in which the onset of pain occurs after an injury and involves continued pain, hypersensitivity or allodynia, and evidence of edema or abnormal sudomotor activity, and (2) CRPS II, which has similar criteria, but it implies a known nerve injury, that is, however, not limited to the distribution of the particular nerve.³¹

These diagnostic criteria have been strongly criticized as being too vague, thereby allowing for overdiagnosis.³² Furthermore, the pathogenesis of this disorder is unclear, failing to explain why only a small percentage of patients develop CRPS after an injury or well-defined nerve trauma but the majority do not; whether there is a genetic predisposition, and why such a significant variability exists among the different symptom classes of abnormalities seen in patients with CRPS.

There is general agreement that many patients with CRPS manifest important and profound behavioral and emotional issues,³³ as well as reports of intense pain and severe disability. There is also some evidence that depression, anxiety, and life stressors (frequently reported as present in CRPS patients) might influence the development of this condition through α-adrenaline activity. Van Houdenhove and colleagues³⁴ articulated a conceptualization suggesting the role of hyperarousal due to life stress or other factors preceding or around the time of injury or during the subsequent initial period of healing and difficulties coping.³⁴

CRPS is seen as overlapping with several conditions, including neuromas and phantom limb pain. The key element in all these conditions is that pain is considered “sympathetically maintained.”

Neuromas

Phantom Limb Pain

Phantom limb pain is a clinical condition in which patients experience pain in a limb after amputation. A phantom limb is the sensation that an amputated or missing limb (even an organ, like the appendix) is still attached to the body and is moving appropriately with other body parts.35-37 Approximately 50% to 80% of individuals with an amputation experience phantom sensations in their amputated limb, and the majority of the sensations are painful.³⁸ Phantom limb sensations usually disappear or decrease over time. When phantom limb pain continues for more than 6 months, the prognosis for spontaneous improvement is poor, and pain can become disabling and can lead to a lifelong struggle with chronic pain. Research has identified that, among other factors, pain and psychiatric distress in the form of depression, anxiety, and somatization are predictors of chronicity of phantom limb pain.^39,40

Psychology of the Health-Care Provider

Psychosocial Aspects of Illness

Cognitive processes, behaviors, affective state, and coping style, along with sociocultural factors, are as important or more important than biological factors in management of chronic pain conditions.

The role of cognitive processes is predicated on the evidence that people are not passive responders to physical sensations. Rather, they are actively seeking to make sense of their experiences. They appraise their conditions by matching sensations to some preexisting implicit cognitive schema and determine whether a particular sensation is a symptom of a particular disorder that requires attention or can be ignored. In this way, each person functions with a uniquely constructed reality. When information is ambiguous, people rely on general attitudes and beliefs based on experiences, prior learning history, or input from family and friends. These beliefs determine the meaning and significance of the problem, as well as the perceptions of the appropriate treatment. As such, an understanding of each person’s unique beliefs about pain, appraisals, and coping repertoire becomes critical for treatment success. A great body of research shows that patients’ attitudes, beliefs, expectations, and coping resources are key in reports of pain intensity and disability.^41,42

Beliefs about pain may lead to maladaptive coping, increased suffering, exacerbation of pain, and greater disability. For example, pain that is interpreted as tissue damage rather than viewed as a problem that will improve may lead to more suffering and dysfunction. Also, patients who believe that their pain will last forever may take a fatalistic, passive approach to coping. Beliefs about the implication of the diseases are also important. People high in health anxiety may interpret pain as a sign of a serious disease (e.g., a benign cyst is interpreted as cancer, despite medical reassurance) and have more disability and more intense pain. People who attribute a pain flare-up to a worsening of tissue damage may experience more pain and disability. Cognitive factors thus affect functioning in two interrelated ways: (1) they influence mood and coping efforts, and (2) they affect physiological activity associated with pain, such as muscle tension⁴³ and production of endogenous chemicals.⁴⁴

Self-efficacy, or the belief in one’s ability to successfully achieve a desired outcome, is another cognitive factor that strongly predicts success in coping with pain and reducing disability. Greater self-efficacy leads to reduced anxiety and its physiological component, an increased ability to use distraction as a coping strategy, increased determination to go on with planned activity in spite of pain, and avoidance of rumination on the pain.

In addition to specific self-efficacy beliefs, a number of investigators have suggested that a common set of “cognitive errors” affect perception of pain, affective distress, and disability.^45,46 A cognitive error is a negatively distorted belief about oneself or one’s situation. The most common cognitive errors in pain patients are catastrophizing (rumination, magnification, and helplessness when faced with pain), overgeneralization (assumption that the effect of an event [negative] will apply to outcomes of future or similar events), personalization (interpreting negative events as reflecting personal meaning or responsibility), and selective abstractions (selectively attending to negative aspects of an experience).

Self-regulation of pain and its consequences depends on a person’s specific ways of dealing with pain, adjusting to pain, and reducing or minimizing the distress caused by the pain, all of which represent a set of coping strategies. Studies have found that active coping strategies, such as efforts to function in spite of pain or to distract oneself from pain, or ignoring pain, are associated with adaptive functioning, while passive coping strategies, such as depending on others for help in pain control and letting pain dictate and restrict activity level, are related to greater pain and depression.^39,47

The affective component of pain includes many different emotions, but they are primarily negative in quality. Depression is the most common diagnosis associated with pain,⁴⁸ and it is significantly associated with coping. That is, those who believe that they can continue to function in spite of pain do not become depressed, whereas those who engage in negative thinking, are low in self-efficacy, and are high in health anxiety are more likely to become depressed. Anxiety in the form of pain-related fear and concerns about harm avoidance exacerbate pain symptoms. Anxiety’s cognitive (uncertainty, misperceptions of danger) and physiological (bodily changes triggered by the fight or flight system) symptoms are common when people experience pain, and are strongly associated with disability and pain intensity.⁴⁹ Post-traumatic stress disorder (PTSD) is a subtype of anxiety that can sometimes develop in people with pain triggered by traumatic injuries; it has a strong relationship with disability and pain chronicity. Anger has also been observed in patients with pain. Anger can take the form of frustrations related to the persistence of symptoms, lack of cause, treatment failures, worker’s compensation, finances, and family relations. Anger may affect pain via biological (increased arousal) mechanisms and may interfere with pain acceptance and adherence to treatment. As previously discussed, health anxiety and somatization are also commonplace in pain patients.

Common-sense beliefs about illness and health-care providers are also highly influenced by prior experience and sociocultural transmission of beliefs and expectations across generations. Ethnic group and gender differences influence beliefs about pain and responses to pain. Social factors influence how families and communities respond to and interact with patients. For example, children acquire attitudes about health and health care, perceptions and interpretation of symptoms, and appropriate responses to injury from their parents, cultural stereotypes, and social environment. These influences determine whether they ignore or overreact to symptoms.

People’s behaviors when experiencing pain (e.g., pain behaviors) are additional factors that affect experience with pain, pain intensity, disability, and chronicity. Operant conditioning posits that behaviors that are reinforced are maintained, and those that are not reinforced are stopped. The operant view¹³ proposes that via external contingencies of reinforcement, behaviors such as grimaces to communicate pain, or holding an arm in order to avoid additional pain, are maintained if reinforced by a doting spouse or health-care provider. They may also be maintained by the escape from noxious stimulation through the use of drugs, rest, or avoidance of undesirable activities like work. Avoiding activities can thus serve as a reinforcer maintaining the pain.

In acute pain, reducing an activity may accelerate the healing process. However, repetitively engaging in avoidance of activity leads to anticipatory anxiety about pain (e.g., muscle tension and other symptoms associated with fight or flight or sympathetic activation), which may act as a conditioned stimulus for pain, which may be maintained after healing ends. Over time, more and more activities are perceived as aversive and are avoided. This may lead to deconditioning and more injuries or pain problems.

Persistent avoidance of activities also prevents disconfirmation of the predicted pain. This is a common mechanism in the cause, maintenance, and generalization of most anxiety disorders, and it has good applications for pain. Pain avoidance thus succeeds in preserving the belief that pain continues when engaging in an activity, thereby preventing a corrective experience that pain eventually subsides with activity.

More subtle, yet potent factors affect the pain experience. The Internet and media shape patient’s beliefs about pain and medical treatments. TV advertisements about cures for pain conditions via miracle drugs or intervention, without data to back up their efficacy, and ads about avoiding aging reinforce a desire to stay forever young and fight rather than accept normal age-related degeneration. Magazine articles that mislead patients to change their doctor if their pain is not taken away promote a “patient’s right” to always be pain-free—a notion that is misguided and more likely to detract from rather than enhance health and wellness.

Multidisciplinary Treatment

Multidisciplinary treatment teams that consider the psychosocial as well as the biomedical aspects of illness have proved useful in the management of the most common idiopathic pain conditions, including backache and headache,50-52 as well as more discrete pain conditions such as arthritis.⁵³ These teams typically include surgeons, physiatrists, and other nonoperative care providers, occupational therapists, medical assistants, and behavioral medicine specialists (i.e., psychologists). The role of each provider depends on the individual patient’s presentation.

Although many hand and arm pains are poorly understood or incompletely treatable, and psychosocial factors such as depression and anxiety often exacerbate discrete pain conditions, hand surgeons and hand therapists have been slow to implement multidisciplinary treatment teams. Instead, they continue to operate largely under a biomedical model of illness, potentially neglecting prominent and treatable psychosocial factors. In spite of scientific support for the unique contribution of psychologists to the understanding of the multifactorial nature of pain,⁵⁴ as well as recommendations from governing bodies such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Commission on the Accreditation of Rehabilitation Facilities (CARF), and several professional organizations (American Pain Society, American Academy of Neurology), the psychologist’s role is underappreciated; seen as potentially offensive; and is currently undervalued by patients, health providers, and insurers. A multidisciplinary approach to treatment of hand and arm pain conditions is consistent with evidence-based practice and fits well within the patient-centered model of medical decision making. Having more than one listener rather than one allows the patient to feel cared for. This may increase the patient’s confidence that nothing is being overlooked and all possibilities for increasing wellness are considered.

The gap between the utility and the utilization of a multidisciplinary treatment team is at least in part due to the difficulty communicating the value of a biopsychosocial approach to illness to patients and their health providers. This gap itself represents an example of the need for good communication in the integration and practice of evidence-based medicine and patient-centered care. The quest for best evidence necessitates input that is more multilayered and considerate of myriad possibilities, reflecting less tissue-focused specificity and greater richness and breadth than the historically valued reductionistic approach associated with the biomedical model. Treating illness, not just disease, requires that various aspects of the patient’s situation be addressed, even though these factors may be ambiguous or contradictory. It requires more involvement of our patients, increasing their empowerment. This is best implemented by a multidisciplinary team that values and embraces effective communication skills.

Model of Care

A large body of research shows that the first visit to an orthopedics department, where patients are initially referred or present for treatment, is a strong predictor of the course of illness in pain patients.55

At the first visit, patients need a thorough medical evaluation, including examination, review of available tests, and reassurance that nothing is neglected and no opportunities for improvement in the physical condition are or will be overlooked. The multidisciplinary approach to treatment needs to be emphasized to patients, as means of addressing the interrelation between mind and body and improving quality of life. Patients need room to answer questions, provide feedback, and participate in the decision-making process. Often first visits are uneventful, diagnoses are easily made, and patients are able to follow up with recommendations. However, in some situations psychosocial factors are prominent.

In many circumstances patients with a discrete pain condition that is amenable to medical interventions present with depressed mood, misconceptions about pain and medical treatment, and psychosocial stressors. Hand specialists should be aware of warning signs such as flat affect, squeamishness about pain, complaints of poor sleep and frustration, fear of activity or of returning to work. These signs should not be ignored because it is in these situations that behavioral medicine intervention would be particularly helpful, as patients work to improve important psychosocial issues along with their medical care. When surgeons introduce mind–body concepts to a patient, normalize the situation, and offer services immediately in their office instead of referring the patient elsewhere (which patients rarely follow through on), the patient feels cared for and is more accepting of psychological help.

When the patient presentation is puzzling and does not fit within specific medical diagnosis categories, hand specialists benefit from an open mind about alternatives to a purely medical cause of the condition. Given the challenge of living with chronic unexplained symptoms, the behavioral medicine specialist has a key role. It is important to mention that although surgeons need to be honest about their own findings, they need to be careful not to dichotomize mind–body issues and suggest in any way that symptoms are conscious or unconsciously produced (e.g., factitious disorder or conversion disorder). In such cases, as in the cases of heightened illness concern and somatization, a better approach is to schedule additional appointments aimed at providing additional reassurance to patients, while reinforcing the need to work with the behavioral medicine specialist on improving quality of life.

Regardless of the degree of medical pathology, reassurance from the hand specialist is particularly important, given that patients came to the surgical practice to receive medical care. In the absence of empathy and effective communication and reassurance, patients may feel that their pain is not taken seriously and may become frustrated and upset. Comments such as “Although there is pain, structurally you are intact—there may be some misconceptions here that we can help improve upon in order to increase your sense of wellness”; “Some cars have squeaky breaks, but they are safe to drive; your wrist has pain, but it is a healthy wrist”; “You do need surgery, but let’s get you sleeping better and in a better disposition first” can reassure patients that their pain is taken seriously. With idiopathic pain conditions it is particularly helpful to schedule additional regular appointments to ensure that nothing will be overlooked and increase the patient’s awareness, understanding, and acceptance of chronic nonspecific conditions.

In addition, patients need advice and clear recommendations. Rather than communicating “all is fine, no restrictions in activity” try a message such as: “It is very important to move your arm to avoid stiffness and loss of range of motion. You will feel pain, but that is not a sign of damage. There are more risks associated with not moving your arm than with moving it. Do you think you can do this?”

It is important to avoid misguiding and mistreating patients via unnecessary tests or procedures, or overinterpetations of test results. Examples include incidental or age-related findings that do not correspond with or fully explain the complaint and cortisone shots or other treatments without an explanation that they are at best palliative and without an open discussion of their scientific basis or lack thereof. When patients ask questions about a specific timeframe for their recovery, it is critical to manage expectations. Rather than setting a date on the calendar after which the patient and health provider may be disappointed or even concerned, discuss the normal progression of disease while discussing how everyone is different, and reinforcing how the patient himself can speed up recovery with what he does, including following recommendations and keeping a positive attitude.

Because of the interrelation between physical and psychosocial factors in the manifestation of disease, many patients benefit from meeting with a behavioral medicine specialist for a brief consult focused on evaluating current psychosocial functioning and effective coping skills. Misconceptions about pain and medical treatments are extremely prevalent, and a short conversation about these issues is often enough to place the patient on an optimal recovery path. Based on the initial evaluation, some patients may continue to meet with the behavioral medicine specialist, but others may be well equipped for effective coping on their own. It is important that a treatment plan and a set of goals are put in place at the end of the first visit, along with a list of written recommendations that the patient can take with him.

Patient-Centered Approach and Shared Decision Making

Research suggests that patient participation in decision making results in greater patient satisfaction, improved outcomes, and acceptance and adherence to treatments.56-58 According to Charles and coworkers⁵⁹ the shared decision-making model is based on several concepts. First, decision making involves at least two participants—the health provider and the patient—but the process may also involve family members, relatives, and friends, as well as multiple health providers. This increases the complexity of the process. Communication is particularly important in this context as variations in opinion may be confusing and stressful for the patient and treatment team. For example, a specialist physician’s advice to a patient that the discomfort from lateral epicondylosis does not reflect injury and that remaining active in painful activities does not prevent resolution of the illness may run counter to the primary care provider’s recommendation to rest the elbow and avoid pain. These variations in opinion (the so-called art of medicine) are unavoidable and may increase the patient’s confusion and uncertainty.

The second concept is that all parties (the health providers and the patient and her supporters) take steps to participate in the process of decision making. Research has identified variations in patients’ comfort with sharing their opinions and participating in the decision-making process. Furthermore, some research indicates that often patients’ expressed preferences for sharing opinions and participating in the decision-making process do not always correspond with what actually happens—that is, patients often shy away from participating and instead let the health-care provider take the lead. This occurs due to several patient characteristics, including personality style, contextual factors, social desirability, and cohort effects.⁶⁰ These findings emphasize the importance of exploring a patient’s background and developing a strong patient/health provider relationship that allows the patient to become comfortable in the sharing process. For a patient, shared decision making means that she must be willing to engage in the decision making, disclose preferences, ask questions, weigh and evaluate treatment alternatives, and formulate a treatment choice. This is a problem-solving task that is complex and goes beyond simple information transfer. In the shared decision model, both parties adopt complementary roles, participate, and are satisfied with their level of involvement.

The third concept is that information sharing is requisite to the shared decision model. Patients may bring in information from other sources, including acquaintances, media, and other health providers. The provider brings an honest interest in helping the patient, an individualized comfort, and preference for a particular treatment. Instead of the patient bringing the values and the health provider bringing the information, the patient and the health provider both bring information and values. The sharing process is individualized and dynamic.

Lastly, a shared treatment decision is made, to which health providers and patient and supporters agree. The shared decision is both a process (involving complementary roles and exchange of information) and an outcome—the decision. The decision may be agreement on a treatment plan, but may also be to suspend a decision or even to disagree, in which case the patient is likely to seek additional health provider opinions. Agreement may not indicate that both parties are convinced that they have elected the best treatment—agreement means only that all parties endorse it as the treatment to implement. The health provider, for example, may feel that a patient should hold off on surgery until she is feeling less vulnerable and desperate, but the provider may agree to endorse the patient’s decision to proceed with surgery as part of a negotiated agreement in which the patient is informed that there are risks, including persistent symptoms, but the patient’s preferences are also valued and accounted for. This characteristic helps distinguish the shared decision-making model from the paternalistic and informed models, in which decision making and ultimate responsibility for the decision are clearly vested with the health provider and patient, respectively, whether or not the other party accepts the decision.

Communication Skills: The Key to Effective Evidence-Based Practice/Shared Decision Making

The health provider/patient relationship is one of the most important predictors of patient satisfaction, adherence to medical treatment, and overall treatment success. Health providers whose communication styles are less dominant receive higher satisfaction ratings than those who communicate in a paternalistic or authoritative manner.58

Health providers should be mindful of biases: both their own and those of the patient. Patients and health providers may have their own theories about what is best, based on scientific research (best evidence) or reports from family, friends, or media. Both providers and patients may become victims of the self-serving bias, whereby information that disproves one’s beliefs is dismissed with minimal consideration, and information that is consistent with a belief is given priority. Sue may be focused on her view of pain as meaning damage and may not be able to shift her focus toward accepting that that is not the case with her lateral elbow pain. She may thus keep bringing up that her elbow hurts and she can’t use it, while dismissing the fact that the pain does not mean damage. The health provider may be particularly focused on the message he is delivering, and thus fail to account for Sue’s agenda. This may cause conflict and interfere with the decision-making process.

It is also beneficial to be aware of the emotive power of words, and their strong influence on a patient’s response to treatment and coping styles.⁶¹ Words with relatively negative connotations, such as tear, injury, or overuse, are remembered more than words with a positive connotation. When health providers use the word tear, we may mean to imply the normal defects or developments of aging, or a benign condition that does not require treatment; however, to the patient the same word implies injury, damage, and the need for treatment or repair. It is important for health providers to choose their words carefully and use alternative words with a more accepted neutral or positive message to replace words with a more negative message (e.g., benign defect instead of tear). When such words are not available, a thorough explanation of word choice is merited. In a similar vein, it is important to avoid medicalization of pain conditions that are a part of normal human development whether permanent and incurable (e.g., arthritis) or temporary and self-limiting (lateral epicondylitis). Furthermore, clarification that many conditions are genetic or developmental and not the result of “overuse” or “injury” can relieve the guilt and regret that patients often feel when they have pain associated with activity.

The key elements of good communication are trust, empathy, and confidence in the health-care provider. Patients must perceive that their health-care provider listens, understands, and appreciates their suffering.⁶² They should see their health provider as an ally, not as a technician or an adversary. In order to facilitate this, the health provider should try to listen without interruption at the beginning of the session, to summarize the patient’s statements using the patient’s words, to legitimize the patient’s concerns by repeating them or restating them, and to express empathy⁶³ (“This must be difficult for you.”) and normalize the situation (“Most people in your situation would react the same way.”). Instead of making assumptions about what the patient would like you to address or do, introduce options and follow the patient’s preferences. Prior to addressing difficult issues (e.g., divergences between best evidence and patient preconceptions, heightened illness concern, or misconceptions or catastrophizing), it is important to be sure that you have made a “deposit in the patient’s emotional bank account.” You need to gain the patient’s trust and confidence, and foster in the patient a benevolent and forgiving attitude toward you, prior to raising potentially contentious or offensive issues.

Patients need to feel that their health-care provider has expertise. The health-care provider must show confidence in his or her skills, discuss treating similar patients, provide a thorough explanation of symptoms, and explain the shortcomings of diagnostic and treatment strategies. The health provider should instill and preserve hope: Instead of “I don’t know what’s going on” or “I have nothing to offer you,” try “I wish it were as easy as a surgery or medication, but a creative approach that considers all possibilities is effective” or “We have helped many patients in situations similar to yours with a comprehensive team approach.” It also important to be aware of the stigmatization of the psychological and sociological aspects of illness. It can be difficult to discuss uneasiness, health anxiety, and depression without offending. Good communications skills require a constant focus on the positive.

Good communication skills influence treatment acceptance, adherence, and outcome. Patients are more motivated if their provider is enthusiastic and energized, polite and respectful, celebrates gains (even small ones), exhibits friendly or open facial expression, and provides eye contact. Demonstrating integrity, following up as promised, and returning calls are also important. Using the first visit to develop rapport in some instances may be more fruitful than providing a complete clinical evaluation but not having time to develop that rapport.

Interactions with patients who have prominent psychosocial issues can be frustrating. Patients with certain personality disorders, hostility and anger, or alcohol and drug concerns; patients who have had negative interactions with providers in the past; and patients with limited financial resources (particularly in high-stress situations) can be particularly difficult. In such situations the physician–patient relationship and patient participation are even more important than in a typical situation. Taking the time to listen and understand the patient’s context and the reasons for his behavior or demands may help diminish stress and frustration, while helping to share empathy and an honest desire to help. Lowering one’s voice in response to a patient with an aggressive voice, listening attentively with no interruptions, asking permission to examine and share in the conversation are small but powerful accommodations that help greatly in developing the relationship, diffusing anger, and planning accordingly for a shared treatment approach. In particular, requesting permission is a very strong demonstration of respect: for example, “Can we discuss some of the things that are making you feel uneasy?”; “Would you like to hear some of the advantages and disadvantages associated with the test or procedure?”; “This part of the examination can be painful, but it’s very important. May I proceed?”

Cooper and others^64,65 provide suggestions for how to navigate communication with patients who resist participation in the shared decision model. In this situation the health provider must refrain from acting as an expert telling the patient what to do—communication requires a two-way conversation. A statement such as “You should do these exercises” may lead to defensiveness in patients, whereas an open question like: “What can you do today that you think will make it better?” may help the patient think about her condition in a different way, and one in which she is responsible for recovery. Positive, optimistic language is important—for instance, “Even a few minutes of exercise will help” rather than, “It’s going to be hard to make time for all these exercises.” There may be less resistance to recommendations made for a future visit when saying “You may be ready to try new exercises next week,” rather than saying “We have to add these new exercises right now.” Statements such as “You know your hand better than I do; show me what feels okay for you,” rather than “I will teach you how to treat your hand,” may reinforce the patient’s confidence, and self-efficacy.

Offering choices and having the patient pick among several options may also work well with difficult or resistant patients. For example, instead of “You have to exercise 5 repetitions 5 times a day,” try “Would you prefer to do 5 reps 5 times a day or 3 reps 10 times a day?” Paradoxical suggestions, such as “Going home and exercising every hour would probably be too much trouble,” rather than “When you go home you will have to exercise every hour” may be perceived as a challenge that the patient chooses to take on, rather than as a task that he may not want to undertake. Minimizing the directiveness of the health provider is also helpful, as it emphasizes that the patient benefits from doing the work for herself. A statement such as “It can be extremely helpful to elevate your arm” is better than “I need you to elevate your arm.”

Remarks that help the patient envision resumption of important and valued activities may increase confidence and motivation to try. For example, a statement such as “You still can’t hold a golf club and I don’t know when you will” is negative and uncertain, whereas “In the future, when you are holding your golf club…” shows confidence and empowers the patient to try. Allowing the patient control can build trust and confidence. Instead of telling patients what to do, “I’m going to have you start with this exercise, and do 10 repetitions,” ask the patient’s opinion with questions like “What do you want to start with? How many repetitions of this exercise do you think you can do?”

Psychosocial Assessment and Treatment

CBT is a well-researched, scientific approach that specifies how thoughts (beliefs, attitudes), behaviors, feelings, and sensations are interrelated. As identified through research, in many cases pain triggers negative thoughts such as catastrophizing (rumination, magnification, helplessness), heightened illness concern (intense worry about pain and health that is resistant to reassurance), fear avoidance (avoidance of activities that cause pain for fear of reinjury or causing more damage), and affective reactions that include frustration, irritability, anger, depression, and anxiety. These interactions can become self-maintaining such that distress and disability, as well as physiologic arousal, may continue in spite of absence of original sensory input; patients thus can transition into chronic pain syndromes.66 A key element in CBT treatments is identifying patient’s thoughts when experiencing the pain sensation. As depicted earlier, these thoughts are nonadaptive and associated with behavioral avoidance and emotional distress. Identifying specific negative automatic thoughts about pain and medical treatments appears thus as a crux of successful CBT for pain. The most salient treatment issue is to help the patient understand the interaction between the mind and body, normalize the situation to avoid stigmatization, and specifically show how the treatment will benefit the patient. Delivering CBT in an orthopedic practice has many advantages. First, addressing psychosocial factors and providing educational information early on in the experience of pain may prevent transition toward chronic pain syndromes, while improving quality of life as the pain condition takes its course. Many orthopedic pain conditions have a normal recovery course that ebbs and flows over the course of a year or more, and it is important that patients are aware of this course and learn how to cope with the pain so that they maintain quality of life and conditioning, and do not develop complications such as stiffness or depression and anxiety. Second, CBT is delivered along with medical treatments, and appointments are scheduled at the same time, when possible, which saves patient resources and time and also allows communication and planning on the part of the providers. Patients also feel “cared for” and do not feel that their physical complaints are being ignored. Third, in many cases patients with clinical depression or anxiety, who are in need of psychological interventions, often neglect to follow up with referrals to psychiatric departments, or face long wait times. Lastly, CBT delivered in an orthopedics department can improve the efficacy of medical and surgical interventions. It is also important to note that not all patients presenting to an orthopedics department benefit from CBT. In many situations patients are resilient and cope well. In other cases patients have severe pathology such as untreated severe anxiety disorders or depression, which have been present prior to pain and are exacerbated by pain. In such situations it is important to provide appropriate referrals to patients, while simultaneously working with patients on pain-coping skills.

Summary

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