Assessing Impairment and Disability in the Pain Patient: A Biopsychosocial Approach

Introduction:

Assessing impairment and disability in the pain patient can be a challenging task due to both administrative and clinical complexities. This blog post aims to provide an overview of the issues involved in this assessment, focusing on the biopsychosocial approach to understanding chronic pain and its impact on functional ability.

Chronic Pain is Common:

Pain is the most common cause of disability, with chronic low back pain alone accounting for more disability than any other condition. Despite advances in physiologic understanding and interventions, challenges associated with chronic pain and disability increase. It is essential to recognize the high prevalence of chronic pain in the population when evaluating workers’ compensation and personal injury claims.

Illness Behavior:

Psychogenic pain, which can be present with or without physical pathology, must be identified. Psychogenic pain is often associated with illness behavior. Illness behaviors are observable actions and conduct that express and communicate a person’s own perception of health. Inappropriate illness behavior may be conscious and intentional, driven by factors such as mistaken beliefs, refusal to consider alternative explanations for symptoms, misattribution of symptoms, falsification of information, fabrication of complaints, manufactured disease, and exaggeration for profit or revenge.

Somatization:

Somatization often contributes to inappropriate illness behavior. Somatization refers to a person’s unconscious use of their body or bodily symptoms for psychological purposes or personal gain. In the AMA Guides, Sixth Edition, it is defined as “a tendency to experience and report somatic complaints (physical symptoms) in response to psychosocial stressors and seek health care services for them.” Somatization can be acute or chronic and may be associated with medical comorbidity, an underlying psychiatric syndrome, a coexistent personality disorder, or a significant psychosocial stressor.

Somatic Symptom Related Disorders:

In DSM-5, somatoform disorders are referred to as “somatic symptom and related disorders.” The DSM-5 classification reduces the number of these disorders and subcategories to avoid problematic overlap. Diagnoses of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed. DSM-5 recognizes that individuals with chronic pain may appropriately be diagnosed as having somatic symptom disorder, with predominant pain.

Biopsychosocial Approach:

The biopsychosocial approach is currently viewed as the most appropriate perspective to understanding, assessing, and treating chronic pain disorders and disability. Chronic pain reflects a complex and dynamic interaction among biological, psychological, and social factors.

Pain, Impairment, and Disability:

Pain, impairment, and disability may coexist or be independent. Pain is a subjective experience defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Impairment is defined in the AMA Guides Sixth Edition as “a significant deviation, loss, or loss of use of any body system or function in an individual with a health condition, disorder, or disease.” Disability is defined as “an umbrella term for activity limitations and/or participation restrictions in an individual with a health condition, disorder or disease.”

Assessing Disability:

Assessing disability associated with chronic pain is complex, and the evaluator must approach the clinical evaluation with recognition of the many factors associated with the experience of pain and disability. The physician should perform a bio-psychosocial assessment, recognizing the array of factors that relate to the experience of pain and disability. Nonorganic findings, that are not explained by physical pathology, may also support a conclusion of symptom magnification.

Symptom Magnification and Malingering:

Symptom magnification, inappropriate illness behavior, and embellishment are not uncommon, particularly in medicolegal circumstances and entitlement programs. Therefore, evaluators need to consider whether the presenting complaints are congruent with recognized conditions and known pathophysiology and have been consistent over time. The evaluator should also determine if there is inappropriate illness behavior or malingering.

Impairment vs Disability:

The terms impairment and disability have distinct meanings. Impairment defines a measurable change (any loss or abnormality of a psychological, physiological, or anatomical structure or function) and is consistent and measurable across different systems and programs. On the other hand, disability is a social construct in that each program or system defines it differently and assigns different weights and benefits to those definitions.

Conclusion:

Assessing impairment and disability in the pain patient requires a thoughtful and comprehensive approach that considers the biopsychosocial factors contributing to the individual’s experience of pain and functional ability. A thorough evaluation is essential for accurate determination of impairment and disability, which can have significant implications for the individual’s quality of life and access to benefits.