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PREDICTING SELF-REPORTED DISABILITY in CHRONIC PAIN PATIENTS with the MMPI-2-RF a Thesis Submitted to Kent State University in P

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PREDICTING SELF-REPORTED DISABILITY in CHRONIC PAIN PATIENTS with the MMPI-2-RF a Thesis Submitted to Kent State University in P PREDICTING SELF-REPORTED DISABILITY IN CHRONIC PAIN PATIENTS WITH THE MMPI-2-RF A thesis submitted To Kent State University in partial Fulfillment of the requirements for the Degree of Master of Arts by Jesica Leigh Rapier December, 2014 © Copyright All rights reserved Except for previously published materials Thesis written by Jesica Leigh Rapier B.A., Eastern Kentucky University, 2011 M.A., Kent State University, 2014 Approved by Yossef S. Ben-Porath, Professor, Ph.D., Psychological Sciences, Masters Advisor Maria Zaragoza, Department Chair, Ph.D., Psychological Sciences James L. Blank, Interim Dean, Ph.D., College of Arts and Sciences TABLE OF CONTENTS TABLE OF CONTENTS…………………………………………………………………..iii LIST OF TABLES..……………………………………………………………………….. v ACKNOWLEDGMENTS..………………………………………………………………..vi CHAPTERS I. Introduction..………………………………………………………………… 1 Anxiety, Depression, and Chronic Pain Treatment Outcome…………… 4 The MMPI and Chronic Pain Treatment Outcomes…………………… 6 Chronic Pain and the MMPI-2………………………………………… 8 The MMPI-2-RF and Chronic Pain…………………………………… 10 Current Study………………………………………………………...… 12 II. Method…………………………………………………………………..… 15 Measures..……………………………………………………………... 16 Procedures..…………………………………………………………… 16 Analysis Plan………………………………………………………….. 17 III. Results..…………………………………………………………………. 19 One-Way Repeated Measures ANOVA..……...…………………….... 19 Correlational Analyses..…………….……………………………….... 19 Hierarchical Linear Modeling (HLM)..……………………………….. 20 IV. Discussion………………………………………………………………… 23 Clinical Implications …………………………………………………. 25 Limitations……………………………………………………………. 27 Conclusion……………………………………………………………. 28 REFERENCES …………………...……..…………………………………………... 29 iii APPENDICES A. Pain Disability Index.……………………………………………………… 41 iv LIST OF TABLES Table 1. ANOVA: PDI And Total Score at Each Time Point……………………………… 36 Table 2. MMPI-2-RF and Intake Pain Disability Index: Correlations……………………… 37 Table 3. Final Estimation of Fixed Effects: H-O, RC, and Somatic/ Cognitive Specific Problems Scales………………………………………………………… 38 Table 4. Final Estimation of Fixed Effects: Internalizing and Interpersonal Specific Problems Scales…………………………………………………………………… 39 Table 5. Final Estimation of Fixed Effects: PSY-5 Scales. ………………………………… 40 v ACKNOWLEDGEMENTS There are many people to whom I owe my gratitude for their support and wisdom in the completion of this project. First and foremost, I would like to thank my advisor, Dr. Yossef S. Ben-Porath, for his continued support and guidance throughout this process. Through encouraging independence and your confidence in me, I have come to realize some of my capabilities and increased my own confidence as a researcher. Furthermore, I would like to extend my appreciation to my lab members, Ryan Marek and Anthony Tarescavage, for their insights and encouragement. Their brotherly companionship and academic wisdom has been and continues to be a great source of support. I would also like to thank Emily Gathright and Kate Zelic for the many hours we shared at the library “co- ruminating”- I believe they owe us our own booth. Lastly, I would like to send a special acknowledgement to Dr. David Kalmbach, my personal academic support system and better half. May you continue to be successful in your pursuits and provide me continued guidance through your knowledge and love. vi INTRODUCTION Chronic pain is problematic not only because of its aversive physical sensation, but also because of its association with occupational and social functioning, ability to live independently, and overall quality of life. Though advances in chronic pain rehabilitation have offered increasingly effective treatment options for individuals with chronic pain, a large number of individuals do not respond to current treatment protocols (Han, Geffen, Browning, Kenardy, & Geffen, 2011). It is important to investigate characteristics associated with treatment response in order to improve outcomes. Identifying psychological factors associated with both good and poor treatment response could facilitate better-informed and appropriate patient referrals, as well as future improvements in chronic pain treatment. By identifying characteristics associated with good response, providers can improve treatment planning for chronic pain patients. Similarly, by identifying vulnerabilities to treatment-refractory pain, clinicians may consider potentially beneficial adjunctive treatment. Taken together, this research will allow for chronic treatment that is more individually tailored, thus improving outcomes. However, to evaluate psychological factors associated with pain treatment outcomes, it would likely prove beneficial to measure a wide range of psychological and personality characteristics. The Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF; Ben-Porath & Tellegen, 2008/2011) is a commonly used and well- established assessment tool that assesses a broad range of personality and psychopathology constructs. Recent research has supported its predictive abilities of treatment outcomes in both 1 mental health and medical treatment settings, including bariatric and spine surgery candidates (Marek, Ben-Porath, Merrell, Ashton, & Heinberg, 2014; Block, Ben-Porath, & Marek, 2013). Along the lines of this emerging literature, the present study aims to evaluate the predictive abilities of the MMPI-2-RF in a chronic pain rehabilitation program. The multiple aspects of chronic pain include the physical sensation component, as well as biological, psychological, and environmental factors (Turk & Wilson, 2010; Scascighini, 2008). Because of the complex nature of chronic pain, a multidisciplinary approach to treatment is most effective. Patients engaged in Multidisciplinary Pain Management Programs (MPMP) receive therapeutic services for the psychological influences of pain, physical therapy for rehabilitation, and medication management for pain control, which requires the concerted efforts of providers in multiple disciplines (Wright & Gatchel, 2002; Flor, Fydrich, & Turk, 1992). Flor, Fydrich, and Turk’s (1992) review supported the efficacy of MPMP, and their results indicated that patients who undergo MPMP are twice as likely to return to work as compared to patients treated with single modality treatments. Despite support for MPMP, Han, Geffen, Browning, Kenardy, and Geffen (2011) found that many patients who received this treatment reported no change in pain (~60%), and a small subset of patients reported an increase in pain (~5%). The large number of individuals who respond poorly to these treatments highlights the importance of identifying treatment refractory patients. Furthermore, comparisons between patients engaged in chronic pain rehabilitation versus treatment in general medical settings, the largest distinguishing factors were psychosocial problems and difficulties in functioning (Crook, Weir, & Tunks, 1989). Thus, understanding the psychological characteristics of individuals who do not respond well to treatment will allow for the improvement of current chronic pain treatment practices, as well as improvement in the individual tailoring of treatment to patients’ psychological profiles. 2 However, as addressed in Morely, Williams, and Eccleston’s (2013) review on evaluating psychological treatments for chronic pain, there are a number of considerations for examining the chronic pain literature. One of the primary considerations is the diversity in diagnoses in chronic pain treatment clinics. The authors argue that this heterogeneity in treatment settings has resulted in controlled trials focusing on single diagnostic groups, such as depression (see Ang, Bair, Damush, Wu, Tu, & Kroenke, 2010 for example), which ultimately neglects a number of patients with various other psychiatric illnesses and patients who do not reach the threshold for a clinical diagnosis. They suggest that describing the psychological characteristics of chronic pain patients may be more useful in treatment planning rather than targeting symptoms of specific diagnoses. A second notable limitation of prior research concerns inconsistency of how treatment progress is measured in these studies. As patients, clinicians, and insurance companies have differing views of the definition of successful pain treatment (Turk & Melzack, 2011), treatment outcomes vary widely between studies. As previously discussed, pain is comprised of multiple subjective and objective components. Subjective measures of improvement focus on pain severity or discomfort and perceived functional impairments in various aspects of life. However, given the naturally subjective appraisal of pain by patients, some clinicians prefer objective indications of pain improvement, such as the ability to complete physical tasks (e.g., climbing stairs, lifting light weights) and the number of visits to primary care physicians (i.e., fewer visits indicating good treatment response). This inconsistency in treatment outcome measurement makes comparisons between studies difficult (Thorn, Cross, & Walker, 2007). As such, it is important for investigations studying pain to maximize uniformity between studies to allow for comparison. 3 Anxiety, Depression, and Chronic Pain Treatment Outcome The impact of comorbid psychiatric illness on chronic pain has been a primary focus of treatment research. Of chronic pain patients, 52% present with comorbid depression (Bair, Robinson, Katon, & Kroenke, 2003). Prior research has demonstrated a bidirectional association between depression and chronic pain. Chronic pain
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