Pain measurement

1. A Geriatric Psychosocial Assessment
of Pain-induced Depression
James E. Wilson
School of General Psychology
Oral Defense
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2. Personal Interest
• I chose this topic based on a personal interest in
older adults and the socialization process in the
United States that creates aging bias across many
aspects of their lives.
• My interest include aging research focusing on:
education that pain in just not a part of aging
• I provide continuing education for professionals
on the perception of mental health and aging
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3. Background
• Beers and Jones (2009) reported the
percentage of older adults in the United States
suffering from chronic pain is 50%. In
fact, chronic pain is so prevalent among older
adults that leaders at the American Geriatric
Society are recommending pain assessment
become the fifth vital sign (Hunt, 2006).
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4. Literature Review
• This literature review examines the body of research on pain-
induced depression among the geriatric population to include:
• The unique experience of chronic pain in older adults, Depressive
symptoms in older
• The connection between chronic pain and depression in older
adults
• The Biopsychosocial theory,
• Pain management for older adults
• Age-specific considerations
• The social consequences of chronic pain and depression in older
adults
• Instrumentation /review of current measures
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5. Terms Specific to the Literature Review
• Older adults. This refers to the population or
cohort of individuals based on age; the age
requirement is 60 years of older (American
Psychological Association of Aging, 2010).
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6. Terms Specific to the Literature Review
• Pain-induced depression. depression that has
been onset by difficulties in dealing with pain.
It shares many symptoms of major
depression, including sleep
disturbance, fatigue, and cognitive difficulties.
It can be distinguished by exploring pain
beliefs on two levels – catastrophizing and
perceived helplessness behaviors related to
pain (Lopez et al., 2008).
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7. Terms Specific to the Literature Review
• Chronic pain. This is pain that persist beyond six
months and results in impaired physical functioning
and emotional strain. There are three types of chronic
pain: somatic (resulting from localized tissue damage in
muscles, tendons, ligaments, bone, and joints, and
includes such disorders as arthritis); visceral (viscera
receptors are heightened in sensitivity to include
stretching, infection, and inflammation, and includes
such disorders as cancer); and neuropathic (caused by
damage to peripheral nerves resulting in a
burning, tingling, or electric-like shock. and includes
such disorders as diabetic neuropathy) (Laird, 1999).
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8. Findings of the Literature Review
• According to Laforest, Gigna, and Gquvin
(2004), chronic pain is a unique experience in
older adults based on the following challenges:
social beliefs on aging, multiple sources of
pain, lack of support system, and the high cost of
pain management.
• Schuler, Njoo, Hestermann, Oster, and Hauer
(2004) identified physical comorbidities, such as
vision, hearing loss, and cognitive decline, as
additional factors that make pain perception a
unique experience in older adulthood.
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9. Findings of the Literature Review
• The social consequences of this unique
experience for older adults are
hopelessness, perceived disability, social
isolation, decreased life satisfaction, and
suicide attempts (Fiske, O’Riley, &
Widoe, 2008).
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10. Findings of the Literature Review
• A proper diagnosis of pain-induced
depression, however, cannot be established
unless pain and depression are examined
together not through separate assessment tools
(Montorio, Izal, & Velasco, 2008).
• Campbell, Clauw, and Keefe (2003) suggested
that assessment development for pain-induced
depression be centered around the
Biopsychosocial theory (BPS) because both pain
and depression in older adults are multifaceted
concepts.
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11. Findings of the Literature Review
• Peng, Fuchs, Peters, and Turk (2007) reviewed
the use of BPS in the cognitive appraisal of
pain in older adults and they suggested the
following identified areas be applied to
assessment development: appraisal, belief
history and formation, catastrophizing, fear
and avoidance beliefs, perceived control, and
self-efficiency versus vulnerability
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12. Findings of the Literature Review
• Montorio and Izal (2006) and Ferrel, Stein, and
Beck (2000), which reviewed the
development, validity, and reliability of the
GDS and GPM, identifies that while neither
are appropriate for measuring pain-induced
depression, the formatting to include the
simple yes/no responses should be carried
forward when developing a BPS-based
assessment.
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13. Findings of the Literature Review
• The literature review in this study reveals a
GAP in research in development of a
multidimensional scale to detect pain-induced
depression among geriatrics.
• A true assessment of pain-induced depression
would measure how pain impacts daily living
by focusing on the individual’s ideology of
pain perception.
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14. Theoretical Base
• The Chosen theoretical base for this study is the
Biopsychosocial (BPS) a theory that considers the
chronic pain experience as one that is
multifaceted.
• It was chosen because it acknowledges the
medical/biological links to pain, emotional
factors, cognitive processes, and the social
consequences that result from the interactive
process. In other words it’s holistic value in
diagnostic development.
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15. Competing Theoretical Base
• Gate control theory of chronic pain
• Focus on the medical model of pain only
briefly acknowledges that the T cells in the
central nervous system that act as a gate
heighten emotional sensitivity
• Little research on how this can be used in
diagnosis of depression related to pain.
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16. Problem Statement
• The problem that this study is addressing is
the absence of a psychological assessment
that measures pain-induced depression
among the geriatric population.
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17. Purpose of the Study
• The purpose of this research is to develop an
evidenced-based assessment of pain-induced
depression specific to the geriatric population.
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18. Nature of the Study
• This study will be used as a clinical trail to gain
insight into a psychological new measure and
it’s ability to detect pain-induced depression
in older adults.
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19. Research Question and Hypotheses
• Research question. What differences would be found in
the assessment of pain-induced depression using the
GEAP in comparison to the GDS and GPM?
• Null hypothesis (H0). There will be no differences in
item consistency/ internal reliability tested by item
analysis between the GDS, GPM, and the GEAP in the
assessment of pain-induced depression in geriatrics.
• Alternative hypothesis (H1). There are differences in
item consistency/ internal reliability tested by item
analysis between the GEAP, GDS, and GPM in the
assessment of pain-induced depression in geriatrics.
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20. Research Question and Hypotheses
• Null hypothesis (H1). There will be no differences
in the convergent and discriminate validity
between the set of measures of the
GEAP, GDS, and GPM in the assessment of pain-
induced depression in geriatrics.
• Alternative hypothesis (H2). There will be
differences in the convergent and discriminate
validity between the set of measures of the
GEAP, GDS, and GPM in the assessment of pain-
induced depression in geriatrics.
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21. Limitations and Delimitations
• One limitation to this study was that a
convenience sample of participants related to
location
• Limitations also exist in test development of
self-rating scales.
• Another limitation in brief self-report
measures
• This study was limited in scope to older adults
60 years or older
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22. Significance of the Study
• According to Karp, Rudy, and Weiner
(2008), one of the most commonly overlooked
symptoms of chronic pain is depression. They
found that when depression is expressed in a
generalized pain assessment by older
adults, scales such as the GDS are accessed to
obtain the level of depression. This becomes a
social problem for this population because
such scales were not developed for those
suffering from chronic pain.
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23. Social Change Implications
• The positive social change implications
include: the ability to aid in early detection
and reducing the potential risk for suicide
attempts and reduction in failed pain
management and cost for older adults
suffering from chronic pain and depression.
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24. Research Design and Approach
• This study uses a quantitative survey design
approach
• A quantitative survey design approach is
appropriate for this study because there are
two or more quantitative variables, which
include the GDS depression score, the GPM
pain score, and the pain-induced depression
score on the GEAP
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25. Research Design and Approach
• Campbell, Clauw, and Keefe (2003) research supported
a quantitative survey research design in assessment
development that focuses on social factors rather than
etiological methods of diagnosis, which is currently
used in scale development for depression and pain
scales (Campbell, Clauw, & Keefe, 2003).
• Bennett, Walker, Moore, Lamberty, and O’Dwyer
(2007) supported a quantitative survey design
approach that focuses on the emotional consequences
created through the socialization of pain in older
adults. This study will develop questions around these
suggestions using the quantitative survey design
approach.
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26. Setting and sample/participants
• Participants that are being selected must meet
the following criteria: (a) age, the client must
be 60 years or older; (b) client would need to
have experienced persistent pain (pain for six
months or more); (c) be under the care of a
pain management doctor; and (d) report
depressed mood related to chronic pain.
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27. Procedures.
• Participants would be recruited through a
general intake process from a network of 44
geriatric mental health outpatient clinics.
• participation would be voluntary
• A pilot study will take place first (After IRB
approval) to assess the proposed data analysis
techniques and gain additional participant
feedbacks on the appropriateness of the
questions develop for the scale.
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28. Pilot study
• Participants for the PILOT STUDY will be from
one of the 44 sites and will not be assess again
in the final study to prevent contamination.
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29. Procedures
• Standards for pilot studies in psychological
research state that the sample size should range
between 20% to 30% of your original calculated
sample size for the full study (Daniel, 2002).
• The calculated sample size for the full study = 125
participants
• Pilot= 32 participants
• The administration method for all three scales
will include the reading of the questions by the
administrator
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30. Methods
• Item response theory (IRT) analysis for
content analysis and exploratory factor
analysis.
• An IRT provides internal consistency reliability
assessing the consistency of results across
items within a test.
• Exploratory factor analysis would be used to
check for variations across the three scales or
construct validity.
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31. Competing Research Design
• qualitative phenomenological approach using structured interview.
• problem lies in the analysis process.
• Thematic content analysis which is most often used when reviewing
data from the phenomenological approach generates a spectrum:
one that is too broad to develop into a standardized assessment
• another criticism of thematic content analysis stating that the
coding system developed fragments segments of statements to
create a whole which distorts the context of the original meaning.
• Austrian and Kern (2008) believe that qualitative research is helpful
in finding the contextual meaning associated with chronic pain in
older adults but not in assessment development.
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32. Instrumentation
• The GDS in this study will be used to gather a
generalized depression rating among
participants.
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33. Instrumentation
• The GPM will be used in this study to measure
the physical consequences of pain. The questions
when scored fall under five unique subscales:
disengagement of pain (the only items on the
measure formed around depression)(items
9, 10, 11, 12, 15, 18, 24), pain intensity (items
13, 17, 19, 20, 21, 22, 23), pain with ambulation
(items 4, 5, 6, 7), pain with strenuous activities
(items 1, 2, 3) and pain with other activities
(items 8, 13, 14, 15, 16). (Ferrell, Stein, &
Beck, 2000).
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34. Instrumentation GEAP
• GEAP.
• This scale was developed to measure pain-
induced depression, which is defined by
Lopez, Montorio, Izal, and Velasco (2008) as
depression that is onset by chronic pain.
• Questions were formed on two primary levels
catastrophizing and perceived helplessness.
Each primary level was then broken into three
secondary: appraisal and beliefs, perceived
helplessness and cognitive interference based on
Gatchel, Peng, Fuchs, Peters, & Turk (2007).
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35. Instrumentation GEAP
• Original version had 35 questions , this version
of the scale was given to 10 psychiatrists with
specialization in geriatrics for review of
appropriateness of questions.
• The original 35 questions were then narrowed
down to 25 questions based on their
feedback.
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36. Instrumentation GEAP
• Those questions which received a 1 or 2 were
eliminated from the scale the total number
dropped equals 10 and included the following
questions 9, 10, 11, 21, 22, 28, 29, 30, 31, and 35.
• The finalized version consist of 25 yes or no
questions
• The rating scale would be as follows: 0-5 – no to
little pain-induced depression, 5-9 – moderate
pain-induced depression, and 10 and above –
severe pain-induced depression.
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37. References
• Campbell, L., Clauw, D., & Keefe, F. (2003). Persistent pain
and depression: A Biopsychosocial perspective. Society of
Biological Psychiatry, 18(2), 399-409.
• Ferell, B., Stein, W., & Beck, J. (2000). The geriatric pain
measure: Validity, reliability and factor analysis. The Journal
of the American Geriatric Society, 48(12), 1669-1673.
• Hunt, T. (2006). Treating pain in the older person. Journal of
Pain and Palliative Care, 20(4), 55-57.
• Lopez, A., Montorio, I., Izal, M., & Velasco, L. (2008). The
role of psychological variables in explaining depression in
older people with chronic pain. Aging and Mental
Health, 12(6), 735-745.
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38. References
• Lopez, A., Montorio, I., Izal, M., & Velasco, L. (2008). The
role of psychological variables in explaining depression in
older people with chronic pain. Aging and Mental
Health, 12(6), 735-745.
• Marwijk, H., Wallace, P., DeBrock, G., & Hermans, J. (2005).
Evaluation of the feasibility, reliability and diagnostic value
of shortened versions of the geriatric depression scale.
British Journal of General Practice, 45(2), 195-199.
• Mavandadi, S., & Katz, I. (2007). Effects of depression
treatment on depressive symptoms in older adulthood: The
moderating role of pain. The Journal of American
Geriatrics, 55(2), 202-211.
• Meeks, T. W., Dunn, L.B., Daniel, K.
S., Shahrokh, G., Sewell, J. H., & Lebowitz, B. D. (2008).
Chronic pain and depression among geriatric psychiatry
inpatients. International Journal of Geriatric
Psychiatry, 23(4), 637-642.
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39. References
• Peng, R., Fuchs, P., Peters, M., & Turk, D. (2007).
The Biopsychosocial approach to chronic pain:
Scientific advances and future directions.
Psychological Bulletin, 133(4), 581-624.
• Schuler, M., Njoo, N., Hestermann, M., Oster, P., &
Hauer, K. (2004). Acute and chronic pain in
geriatrics: Clinical characteristics of pain and the
influence of cognition. Pain Medicine, 5(3), 253-
262.
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