8.2 Psychological assessment of pain
The report of anxiety, depression and sexual problems is sufficiently common for these to be important in
assessment and in planning treatment. Distress, described in the patient’s terms or within a psychodiagnostic
framework, is best understood in the context of pain and the meaning of pain to the individual.
Anxiety probably refers to fears of missed pathology as the cause of pain (cancer being foremost
among these) and to uncertainties about the possibilities of treatment and the likely prognosis if treated or
untreated. A question such as that suggested by Howard (14), “What do you believe or fear is the cause of your
pain?” is more suitable than a general anxiety questionnaire.
Depression is also commonly found in men and women with persistent pelvic pain (15). In a study
comparing men and women with low back pain, and women with pelvic pain and men with urogenital pain (16),
it was found that, when differences in age and pain duration and severity were taken into account, there were
no differences in depression according to pain site, and pain site predicted disability.
However, there is a risk when using diagnostic or standard assessment instruments of attributing
pain-related problems to neurovegetative signs of depression (17,18). As Stones et al. (19) has cautioned:
“Psychological distress may be a consequence and not a cause of persistent pain: while identification of
depression is important as part of treatment, caution is required before attribution of causality” (p416).
Pain ratings themselves may be predicted by cognitive and emotional variables (20). Furthermore,
target outcomes of pain severity, distress and disability co-vary only partly, and improvement in one does not
necessarily imply improvement in the others. Therefore, it is particularly important when the primary outcome is
pain to anchor its meaning in a study such as that by Gerlinger et al. (21), who determined clinically important
differences in pain in relation to overall satisfaction with treatment.
There are many measures of restricted function, or disability, most suited to musculosketal pain and
mobility problems rather than the difficulties of the individual with pelvic or urogenital pain. Some include one
or more items related to sexual activity, but there has perhaps been an over-emphasis on the effects of pain on
sexual performance, although the overall relationship may be more important (22).
In the Cochrane review of pelvic pain in women (23), the outcomes of pharmacotherapy, surgery and
physical therapy trials consist of pain scores (patient-rated and physican-estimated); functional measures such
as urinary peak flow rate (for persistent pelvic pain in men); examination findings such as pelvic tenderness
(women); and uptake of further treatment following the trial treatment. A few trials have included QoL, but
none has measured mood change. This indicates a general but mistaken assumption that improvement in pain
leads to resolution of other problems. Furthermore, if all treatments sampled the same domains of pain in their
evaluation, comparison across treatments, by medical personnel and patients, would be more easily achieved
(24). Suggested instruments for assessment in each of these domains can be found in the consensus paper by
Turk et al (25).
8.3 Psychological issues in the treatment of pain
Provision of information that is personalised and responsive to the presenting problem and the concerns
of the patient, conveying belief and concern, is a powerful way to allay anxiety (26). It can be helpful to
provide additional written information or direct the patient to reliable sources. Many practitioners rely on
locally produced material or pharmaceutical products of variable quality, although they endorse the need for
independent materials for patients (27).
Ideally, treatment arises from general principles and practice in the field of chronic pain, with specific
study of the population of concern and design of appropriate treatment trials (28). The field of pelvic pain
shows a curious phenomenon whereby few of the mainstream psychologically based treatments are subjected
to trials and published, but instead there are often rather idiosyncratic versions of treatment components, or
combinations of interventions, published in single, often underpowered trials. It is hard to conclude anything
from these, as is seen in the psychological treatment section of several other chapters.
Psychological interventions may be directed at the pain itself, with the intended outcome of reducing
pain and its consequent impact on life, or adjustment to pain, with improved mood and function and reduced
health care use, with or without pain reduction. The major psychologically based treatment that improves
adjustment, which is aimed more at reducing distress and disability than pain, is cognitive behavioural therapy,
for which there has been > 10 systematic reviews (29), although its effects may be small and maintenance
in the longer term is uncertain. For less disabled and distressed patients, this can be delivered in part over
the internet (30). A systematic review of short-term psychodynamic psychotherapy (31) has reported similar
improvements in “somatic disorders”, which often includes pelvic pain, although it was not among the trials
reviewed. Pain-focused interventions, again with no trials in pelvic pain, have been subjected to systematic
review, including hypnotherapy (32) and autogenic training (33).
However, all these systematic reviews suffer from heterogeneity among the trials, shortcomings in
trial methodology, and little longer-term follow-up to establish maintenance of treatment gains. The crucial
question, of what works best for whom, is unanswered and possibly unanswerable given the complexity of