Chronic Pain and Biopsychosocial Disorders

VOLUME 5, ISSUE 7 NOVEMBER/DECEMBER 2005

The journal with the practitioner in mind.

ChronicChronic PPainain andand BiopsychosocialBiopsychosocial DisordersDisorders

By Daniel Bruns, PsyD and John Mark Disorbio, EdD

ccounting for over 35 million of- pain. In other cases however, the psycho- While chronic pain is generally recog- fice visits a year, pain represents logical difficulties may be the conse- nized as being a biopsychosocial phe- A the most prevalent reason why an quence of the pain condition, itself.12 nomenon, what is often overlooked is that individual chooses to seek out medical Thus, when pain appears in conjunction illness, injury, psychological and social treatment.1 So prevalent, in fact, research with stress, anxiety, depression or other factors interact over the course of time to has shown that the cost associated with the psychiatric syndromes, the arrow of produce distinctly different types of treatment of pain exceeds the costs at- causality can sometimes point from pain biopsychosocial disorders. Effective treat- tributable to the treatment of other dis- to psychiatric condition, and in other ment requires that the clinician not only orders, such as heart disease, respiratory cases from psychiatric condition to pain. identify the biological, psychological and disease, or cancer.2 Pain also represents a Overall, the research literature suggests social aspects of a condition, but also un- condition that has both medical and psy- that psychological difficulties are com- derstand how each component interacts. chological components. mon among patients with pain. Left un- Chronic pain is widely regarded as a detected and untreated, these difficulties Types of Biopsychosocial Disorders biopsychosocial disorder.3-8 Chronic pain may impede a patient’s progress in treat- A classification system for biopsychosocial and associated disability are often life-al- ment and lead to long-lasting symptoma- disorders was created during the devel- tering conditions, have a profound psy- tology. Among those who report pain and opment of the Battery For Health Im- chosocial impact, and psychiatric condi- injury, psychosocial factors may play a provement 2 (BHI™2). Unlike most psy- tions are common in such patients. One major role in delayed recovery. One study chological tests, which were designed to study of an injured patient population of psychosocial factors demonstrated an assess psychiatric disorders, the BHI 2 was found a 55% incidence of depression,9 ability to accurately predict delayed re- designed to assess biopsychosocial disor- where even minimal levels of depression covery for patients suffering acute pain ders in general, with particular attention were associated with increased rates of so- 91% of the time without using medical in- being paid to chronic pain disorders. The cial morbidity and service utilization.10 formation.13 Another study found that development of the BHI 2 began with a Another study reported that of 1595 in- psychosocial factors play a dominant role model of biopsychosocial disorders, jured patients, 64% had one or more di- in surgical outcome.14 Lastly, in a World which held that biological, psychological agnosable psychiatric disorders, com- Health Organization study of 25,916 and social aspects of these disorders be- pared to a prevalence of 15% in the gen- medical patients from around world, psy- come intertwined, in various ways, over eral population.11 In some cases, preex- chological factors were found to be a the course of their history. isting psychological conditions may pre- stronger contributor to disability than was The BHI 2 model classified biopsy- dispose the patient to develop chronic disease severity.15 chosocial disorders into four distinct

types. Called psychomedical classifica- subsequent reactive depression was a con- headaches, are extremely common. Other tion, this approach classified these disor- sequence of the pain condition, there is types of psychophysiological disorders in- ders into a 2x2 schema (see Table 1). This no direct biological mechanism whereby clude temporomandibular joint pain sec- divided biopsychosocial disorders into the disease directly causes the depression. ondary to bruxing, stress-related heart ones that had either physical (physio- In reactive biopsychosocial disorders, the palpitations and functional dyspepsia.19 genic) or psychosocial (psychogenic) ori- psychological symptoms are produced by Somatizing biopsychosocial disorders gins. It also divided these disorders into the patient’s perception of, and reaction denote a group of disorders that, like psy- ones where the mind-body connection to, the disease process and its conse- chophysiological disorders, have their was physical, as opposed to psychologi- quences.12 Consistent with this, one study origin in psychological processes. How- cal.16 As part of this model, an overall par- found that in a large cohort of patients ever, they differ in that there are no de- adigm was developed to try to depict the with pain-related disability, the preva- tectable organic changes to the body. This interrelationship of biopsychosocial vari- lence of major depression was 25 times group of disorders includes somatoform ables over the natural history of these dis- higher than general population esti- disorders, anxiety or depression that is orders (see Figure 1). mates.11 manifested physically, and some types of factitious disorders. Biopsychosocial Disorders with a Biopsychosocial Disorders with a In somatizing disorders, psychological Physical Origin Psychological Origin processes give rise to the perception or re- Some psychomedical disorders clearly In contrast to disorders having a physical port of physical symptoms, which the pa- originate with a physical injury or disease origin, a psychogenic disorder is one in tient interprets as organic in nature, even process, and can be broken down into two which an individual’s psychological though no detectable organic disorders subtypes: organic biopsychosocial disor- processes trigger the onset of a biopsy- are present.20-22 Most somatizing disorders ders and reactive biopsychosocial disor- chosocial disorder. Although the term involve the misguided pursuit of a med- ders. Both types can be described as phys- “psychogenic” has negative connotations ical solution to a problem that is essen- ical conditions that lead to the subsequent for some, this is unwarranted. There is tially psychological in nature. Persons development of a psychological condition nothing inherently “bad” about psycho- with somatizing disorders have an under- and social consequences. logical conditions. At the same time, when lying psychological condition, which for Organic biopsychosocial disorders are patients with psychogenic conditions per- conscious or unconscious reasons they do those that begin with an organic condi- sist in seeking a medical explanation for not acknowledge. They wrongly attribute tion that affects the central nervous sys- their symptoms, both patient and physi- the symptomatology of this psychological tem and, in so doing, manifests itself cog- cian are likely to become frustrated. Like condition to a medical disorder, while the nitively or emotionally. Some organic psy- physiogenic conditions, psychogenic con- underlying psychological dynamics go chological disorders are the result of in- ditions are common, neither good nor unrecognized. This tendency to medical- jury, such as the memory loss or height- bad, and can benefit from care by appro- ize symptoms may be reinforced by the ened emotionality secondary to brain in- priate professionals. patient’s social environment.23 jury. In other cases, organic biopsychoso- There are two types of psychogenic dis- An example of a somatizing disorder cial disorders result from disease, such as orders: psychophysiological and somatiz- would be a patient with severe anxiety depression secondary to a bipolar disor- ing disorders. Both types can be described who repeatedly goes to an emergency der. In these conditions, underlying or- as psychological conditions that subse- room to be evaluated for a heart attack. ganic processes produce the psychologi- quently lead to the development of phys- This patient refuses to believe that this cal symptoms. For example, an organic ical symptomatology. could be a psychiatric condition, and in- biopsychosocial disorder could begin with Psychophysiological biopsychosocial stead insists on repeated cardiac assess- hypothyroidism. This hypothyroidism disorders have their origin in the psy- ments. However, if the patient can be con- could effect on the central nervous sys- chosocial realm, but they come to have an vinced that a particular organic condition tem, producing depression. This depres- objective effect on the body through an has been ruled out, somatoform disorders sion could then impact the patient so- organic connection. This effect is gener- can “metastasize” into other body areas cially, both at home and in the workplace. ally produced through the effects of the or organ systems, producing an evolving Reactive biopsychosocial disorders also “fight or flight response” involving both pattern of diffuse symptoms. Thus, just begin with an objective disease or injury. the autonomic nervous system and hor- when one disease is ruled out, a new and In this case, there is no direct mechanism mones associated with stress. Stress or puzzling symptom is reported. This may by which the disease process produces the strong emotional reactions can cause hun- require a consultation with another spe- psychological complications. Instead, dreds of physiological changes in the cialist, and a new round of medical tests with reactive disorders it is the psycho- body, including accelerated heart rate, in- begin. In this case, focusing on the phys- logical impact of the condition that pro- creased blood pressure and muscle ten- ical symptomatology enables the patient duces the psychological reaction. For ex- sion, cooling of the hands and feet due to to avoid acknowledging the underlying ample, suppose an injured patient with vascular constriction, and rapid respira- anxiety. Thus, the patient seeks a medical chronic pain has difficulty functioning, tion, to name just a few.17,18 When the body explanation that prevents the patient and as a result suffers the loss of a job. experiences psychophysiological reac- from having to admit that he or she has The patient may then react to the job loss tions such as these, a variety of physical any emotional weaknesses. Denying any with feelings of depression. In this case, symptoms can result. Some psychophysi- psychological conditions out of a deep even though the loss of the job and the ological disorders, such as tension sense of shame, somatizing patients in-

stead save face by reframing these symp- tient status is achieved, significant sec- injury was associated with increased lev- toms as being signs of a medical condi- ondary gain may also be available.24 els of depression, anxiety disorders, sub- tion. They therefore seek the wrong kind stance abuse and other psychiatric condi- of treatment, which ultimately is not what The Natural History of tions.27 In the workplace, job dissatisfac- is needed and, at best, offers only a calm- Biopsychosocial Disorders tion has been found to play a significant ing placebo value. The natural history of biopsychosocial role in the report of back pain.28 Patients with somatizing disorders disorders often follows an identifiable Chronic stress can give rise to the onset sometimes do acknowledge emotional path. While there are four different types of painful conditions through a variety of distress. When they do, though, they often of biopsychosocial disorders, their natu- psychophysiological mechanisms, such as regard any psychological difficulties as ral histories share common threads. Dur- when emotional distress or stress-related being the consequence of the reported ing the development of the BHI 2, a par- muscular bracing leads to pain.29,30 Addi- physical conditions, rather than the adigm was developed to explain how bi- tionally, various psychological conditions cause. For example, sometimes a patient ological, psychological, and social can increase the risk that physical symp- like the one above might admit to being processes could interact over the course toms will be reported, even when no or- anxious. In this case however, the twist is of time to produce the various types of ganic pathology is present. One example that the patient says that the anxiety is biopsychosocial disorders. of this would be a somatizing disorder due to the fact that death could occur at called alexithymia, where emotional pain any moment from a heart attack, and Factors Affecting Onset of is not recognized, and is instead report- physicians are refusing to listen! In so Biopsychosocial Disorders ed as physical pain.31,32 By whatever means doing, they deny that their condition has In the physically healthy person, psy- pain appears, once it does, the experience a psychological origin. Thus, when pa- chosocial and behavioral factors may in- of pain can be shaped by a variety of psy- tients with somatizing disorders do ac- crease the risk of onset of a variety of phys- chological and social forces. knowledge emotional distress, they por- ical illnesses or injuries. For example, if tray any psychological difficulties as being the patient engages in an unhealthy Psychological reactions to illness the consequence of the reported physical lifestyle with regard to diet, exercise, or and injury conditions (that is, a reactive disorder), stress, this increases the risk of a variety Following the onset of a serious illness or which is the reverse of the actual state of of medical conditions. Other psychologi- injury, it is quite common for patients to affairs. cal factors may also increase the risk of in- have a psychological reaction to it. Illness, Another form of somatizing disorder is jury. injury, pain and distress can lead to a re- the factitious disorder. In these disorders, One study found that up to half of all duction in the ability to function, in- psychological processes give rise to the re- traumatic brain injury hospitalizations creasing the disruption of work patterns, port of physical symptoms. Such patients are associated with alcohol intoxication, and leading to greater financial distress.33 are believed to be motivated by primary while up to two thirds may have a history Limitations in functioning can also lead gain. That is, they find the idea of being of substance abuse.25 Patients reporting to an alteration of family roles, and this a patient to be intrinsically appealing, and drug or alcohol abuse were also found to may cause friction within the family if the report or self-induce symptoms in order be more likely to sustain violent injuries.26 patient cannot perform the tasks that he to gain patient status. However, once pa- Other studies have also found that brain or she is expected to do.34,35 Finally, limi-

ORIGIN OF DISORDER TYPE OF MIND-BODY CONNECTION Physical Origin Psychological Origin

Organic Psychological Disorders Psychophysiological Disorders

Physical Sample Depression due to severe brain injury or Chronic anxiety leads to muscular bracing Connection Types: hypothyroidism and tension headaches Illness or injury has direct effect on CNS, Chronic autonomic arousal or unhealthy Mechanism: and on emotions, cognition, or personality behaviors lead to actual organic problems

Reactive Psychological Disorders Somatizing Disorders

Sample Injury produces pain, disability and reactive Psychogenic pain, somatization Psychological Types: depression Connection Misperception or exaggerated report of phys- Understandable emotional reaction to an Mechanism: ical symptoms without organic basis, which objective physical condition are driven by psychodynamics

TABLE 1. Chronic Pain and Types of Psychomedical Disorders. (Adapted from Bruns and Disorbio, 2003)

tations in functioning can interfere with studies found 70%11 and 77%,42 which are guide this patient in the direction that is recreational activities, reducing the pa- far higher levels than those found in the needed. However, if this is not the case, tient’s available psychological outlets. As general population.11 As they are associ- this may plant the seeds for a growing dis- a result, the onset of a medical condition ated with chronic maladaptive behavior, satisfaction with medical care, and in- may lead to anxiety over an uncertain fu- personality disorders are also thought to crease the risk of noncompliance. ture, anger about the perceived unfair- interfere with recovering from illness or Another factor in the social environ- ness of the circumstances, and depression injury. ment that cannot be overlooked is the over the difficulties in life. In addition to A variety of other psychological traits presence of secondary gain.52 Secondary whatever physical symptoms are present, can also magnify how a patient may re- gain is often equated with monetary gain, this emotional distress can increase the spond to the onset of a medical condition. as is commonly seen when litigation is patient’s overall level of suffering, and in- Some patients are more prone to somati- present, or when the patient may be eli- terfere with functioning.36 zation or somatic preoccupation, and this gible for disability benefits. However, an- may magnify their perception of symp- other form of secondary gain occurs when Complications Secondary to toms. Additionally, some patients may be patients use the report of their medical Psychological Vulnerabilities pain-intolerant, or feel entitled to be symptoms to gain the attention and sup- The course of a biopsychosocial disorder pain-free.43 The combination of being port of others. In this manner, the effect may intersect with preexisting psycholog- preoccupied with intolerable symptoms of social secondary gain is to allow the pa- ical vulnerabilities. For example, if a pa- tends to lead to a very distressed patient tient to fulfill dependency needs. tient with chronic pain has had a history with unrealistic expectations. For the dysfunctional patient in the of chemical dependency, and is subse- Overall, the effect of psychological vul- worker’s compensation system, a cornu- quently prescribed opioid analgesics, the nerabilities is to increase the intensity of copia of reinforcers are available. By re- possibility of opioid abuse will need to be problematic psychological reactions to porting work-related pain, a worker may addressed.37 the onset of a medical condition. These receive time off with pay, light duty when Another psychological vulnerability is a same vulnerabilities can also interfere at work, gain control over hours worked, history of chronic depression or anxiety. with treatment in a number of ways. Over- and be provided free opioids and fre- This affective vulnerability may increase all, the effect of these vulnerabilities is to quent massages. Additionally, if the pa- the intensity of the affective response to increase the degree of psychosocial diffi- tient does not do well in treatment, this pain or disability. Additionally, if a patient culties secondary to a medical condition, will tend to increase the amount of any has had chronic difficulties with express- and in so doing, to delay recovery. disability settlement. For the typical re- ing emotions, this may precipitate a cri- sponsible individual, these are not temp- sis,38 as he or she is now experiencing in- Influence of the Social Environment tations. However, the high level of per- tense affective distress, without the abili- A patient’s social environment can also sonality disorders in chronic pain patients ty to articulate it. Emotional distress tends significantly influence the respond to suggests that when antisocial or other dys- to erode a patient’s adaptive energies, and treatment. Having a serious illness or in- functional traits are present, these incen- reduce the ability to tolerate pain and jury can stress the family system,44,45 often tives can prove to be substantial barriers frustration. The resultant overall level of requiring other family members to to recovery.11, 53 perceived suffering, while in part being change and adapt. If a family is appro- attributable to physical symptoms, is also priately supportive, this is not a problem. The Biopsychosocial Vortex in part attributable to the emotional dis- However, if family dysfunction is present, For the patient who is psychologically tress the patient is experiencing.36 the patient’s elevated level of need at healthy, there are a numerous motivations Some psychological vulnerability risk home may lead to conflict, and to failure to recover. Patients are generally frustrat- factors have to do with certain cognitive of the family to offer support. Reports of ed with their physical symptoms and dif- traits. For example, patients who have a a history of being physically or sexually ficulties with functioning. The desire to low perceived sense of self-efficacy may abused are also associated with chronic be healthy motivates them to strive to have more difficulty adjusting to an ill- pain.46,47 Alternatively, an overly solicitous overcome whatever hurdles are in their ness or injury, and perceive themselves as family may reinforce patient passivity, en- path. Most patients are able to persevere being unable to make the needed behav- couraging the patient to adopt a disabled through the course of treatment and re- ioral changes.39 Similarly, pessimism has role.48,49 cover. However, in some cases, whether been found to be related to poor func- The course of a pain condition is in- due to the severity of the medical condi- tioning.40 If a person believes that he or fluenced greatly by the doctor-patient re- tion, incorrect diagnosis, inadequate she cannot do something, this may have lationship.50,51 If the physician is perceived treatment, preexisting psychological vul- a disabling effect. In contrast, persever- as being competent and supportive, pa- nerabilities, complicating psychological ance has been found to be associated with tient distress decreases. However, if a pa- reactions, or factors in the social environ- positive outcomes from pain conditions.41 tient feels that he or she is not being taken ment, some patients fail to recover, and Numerous studies have found person- seriously, the patient may be motivated to instead enter a downward spiral (see Fig- ality disorders to be closely associated magnify the reports of pain or other ure 1). with chronic pain and delayed recovery. symptoms in order to persuade the physi- A number of factors can contribute to For example, one study of injured pa- cian to take action. If the doctor-patient this downward spiral. First, some patients tient populations found a 51% incidence relationship is able to overcome this ob- have unrealistic expectations of a total of personality disorders,12 while other stacle, then the physician may be able to cure, or seek a cure that does not involve

effort on their own part. Such patients may have no desire to alter their lifestyle, perform unpleasant exercises, or take med- ications that have unpleasant side effects. When such patients fail to persevere with more realistic treatment, and demand instead a magical solution, physicians may become frustrated and lose interest in treating the patient. The patient may make some last efforts to cope with the symptoms. There may be a further exaggeration of symptoms, seeking to motivate clinicians and family to be more responsive. However, if this does not lead to the ideal solution that is hoped for, the patient may experience a growing sense of depression and agitation mixed with severe insomnia, and feel that recovery is hopeless. The disgruntled patient may also develop a growing sense of anger directed toward the medical profession, and by a desire for retribution on those who are blamed for caus- ing this condition. At this point, whatever the patient’s objective medical condition is, the psychosocial complications are so severe as to se- verely undermine any chances for a positive outcome. The ex- treme emotional distress may act to aggravate any underlying medical condition, magnify the perception of symptoms, and interfere with compliance. Being physically and emotionally ex- hausted, the patient may feel too tired to exercise. Additional- ly, the patient at this point can become progressively more intolerant of pain, medication side effects, and the frustrations of medical treatment in general. Because of these severe psychosocial complications, medical conditions that might otherwise improve may thus become intractable biopsychosocial disorders. In some cases, even when the original organic condition has resolved, there can be en- during residual symptoms — maintained by the severe emotional distress and psychophysical complications—which remain refractory to all care.

The Somatoform Solution In some cases, a patient may consciously or unconsciously ar- rive at a “somatoform solution” to life’s problems. In this sce- nario, psychosocial processes are reorganized around the report of pain or other physical symptoms, and this becomes the modus operandi for addressing a variety of life challenges. Like the child who learns to complain of a tummy ache to avoid something unpleasant at school, the somatoform patient comes to use the complaint of physical symptoms as a face-savings means of interacting with the world. Some somatoform symptoms are quite benign and extremely common, such as using the report of a physical symptom to excuse oneself from an undesirable social event. In contrast, somatoform disorders can become much more serious in nature. Through the complaint of pain or other physical symptoms, the somatoform solution may enable a patient to justify with- drawal from disliked home responsibilities, or escape from workplace stressors. Somatoform symptoms may provide a means of coercing others to provide the support that is desired, justify the receipt of financial compensation, and enable the patient to assume a dependent role. For a patient who was unable to adequately express emotional needs before, somatoform symptoms can be a way of seeking the support of others without having to directly express any underlying emotional needs. In some cases, somatoform symptoms become associated with feelings of enti- tlement, and the symptoms can consciously or unconsciously

of psychological and social variables discussed in this paper. This BHITM 2 SCALES test assesses 18 scales (see table 2), and numerous other vari- Scale Group Scale Name ables as well. In order to make sense of the information generated by the Validity and symptom Defensiveness * BHI 2, part of the development of this test involved the cre- magnification Self Disclosure ation of a computerized software system to aid in interpretation. Using a technology, which is sometimes referred to as “narrow Physical Symptoms Somatic Complaints * artificial intelligence,” the BHI 2 software examines over a hun- (somatization) dred variables and then writes two plain language explanations, Pain Complaints * one for the clinician, and another for the patient. Unlike some Function * psychological tests, which conclude that somatoform disorders Muscular Bracing are present without taking medical findings into account, the BHI 2 was designed to be used in conjunction with medical tests. Affect Depression * Since it was intended to assess biopsychosocial disorders, the Anxiety * BHI 2 computerized report addresses problems unique to these Hostility conditions, such as considering the type of biopsychosocial disorder, and addressing the “arrow of causality” problem noted Character Disorders Borderline Personality above. Symptom Dependency While the BHI 2 offers a thorough evaluation of biopsy- Chronic Maladjustment chosocial disorders, it is too lengthy for some situations. Con- Substance Abuse sequently, a shorter version, the Brief Battery For Health Im- Perseverance provement 2 (BBHI™ 2) was also developed, which is better suit- ed for use in the fast pace of medical settings.54 The BBHI 2 can Social Environment Family Dysfunction be administered in 8-10 minutes, and provides a multidimen- Survivor of Violence sional assessment of pain, as well as assessing function, depres- Doctor Dissatisfaction sion, anxiety, somatization, symptom magnifying/minimizing, Job Dissatisfaction and 17 additional critical items. It can be used for both assessing biopsychosocial complications and for tracking treatment * Included on the BBHI 2 outcomes as well. TABLE 2. BHI™2 Scales Conclusion empower the patient to extort compensation from others, or to The psychomedical vortex provides a paradigm of how biopsy- gain revenge on others for perceived injustices. chosocial disorders become intractable. Using this paradigm, a The somatoform solution may also offer various types of pri- variety of interventions can be identified which may act to pre- mary (internal) gain. One type of primary gain involves inter- vent a downward spiral into this vortex. Alternately, when a nal absolution, where the presence of pain or other physical seemingly intractable condition has already appeared, this symptoms can enable a patient to avoid guilt for what might model can offer some suggestions as to how to identify the road- otherwise be considered to be irresponsible behavior. Similarly, blocks to recovery, and where to intervene. exaggerated disability can be employed internally to justify work When chronic pain appears within the context of a biopsy- avoidance or maintain a self-righteous expectation that others chosocial disorder, comprehensive assessment requires assess- should provide care. The somatoform solution may thus give ing all of the biological, psychological and social aspects of the the patient permission to retreat from personal autonomy, be- condition, and understanding the relationship between them. come dependent, receive support and monetary compensation, By correctly assessing the type of biopsychosocial disorder that and justify the abuse of prescription or illicit drugs. Beyond this, is being treated, and understanding the history of how it de- such patients may feel entitled to the admiration of others for veloped, a more effective treatment plan can be developed. Re- having to endure the reported serious medical condition. Such search suggests that when the biological, psychological and so- patients are less apt to assume responsibility for their failures, cial aspects of disabling pain are all identified and adequately instead blaming such failures on the unconscionable acts of oth- addressed, even complex biopsychosocial disorders can be treat- ers, who caused the injury, provided poor treatment, or who un- ed successfully.55 I reasonably withheld their support. This may be a conscious or unconscious process, since such patients may not be cognizant Dr. Bruns is a psychologist who works with Health Psychology Associ- of the degree to which their perceived physical symptomatol- ates in Greeley, Colorado. He has worked with chronic pain patients for ogy is produced by psychological processes. over 20 years and has also worked in work hardening and functional restoration rehabilitation programs. He has served on four Colorado Assessment and Intervention state task forces with the mission to create evidence-based medical guide- Biopsychosocial disorders are complex, and require a multidi- lines for patients with chronic pain and other conditions. Dr. Bruns has mensional assessment. The psychomedical classification system taught graduate school classes in psychopathology and psychological as- and the biopsychosocial vortex described above were used to de- sessment, currently works as a consultant to major medical corporations, velop the BHI 2. The goal in BHI 2 development was to create, and conducts workshops to train physicians in the assessment and treat- in one psychological test, the ability to assess the full spectrum ment of biopsychosocial pain disorders. Dr. Bruns is the webmaster of

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Unrecognized Psychological Factors May Significantly Interfere with Patient Treatment BioPsychoSocial Assessments for Medical Patients

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