Med/Psych Update

Head pain and psychiatric illness: Applying the biopsychosocial model to care

Current Psychiatry. 2015 September;14(9):12-13, 18-21, 24-26

References

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Neuropsychological assessment can be useful, not only to assess neurocognitive functioning (eg, Repeated Battery for the Assessment of Neuropsychological Status) but to identify objective test profiles associated with altered motivation (eg, Rey 15-Item Test, Minnesota Multiphasic Personality Inventory-2-Restructured Form F Scale, Personality Assessment Inventory [PAI] Negative Impression Management) and somatization processes (eg, PAI Somatization Scale). These instruments help to identify the severity of psychiatric and neurocognitive symptoms by comparing scores to normative (eg, healthy control group), clinical (eg, somatization, traumatic brain injury, mild cognitive impairment), and altered motivation (eg, persons instructed to exaggerate symptoms) databases.

If the clinician pursues neurocognitive assessment, direct referral to a neuropsychologist, referral to neurologist, or administration of a cognitive screening tool such as the Montreal Cognitive Assessment, Saint Louis University Mental Status, or Cognitive Log is recommended. If the cognitive screening is positive, next steps include: referring for full neuropsychological assessment, which includes complete cognitive and motor testing, personality testing, and integration of neuroimaging data (eg, MRI, CT scans, and/or EEG).

Assessing the patients’ self-talk or thought patterns as they describe their head pain will help clinicians understand belief systems that may be distorting the reality of the medical condition. For example, a patient might report that “my pain feels like someone is hitting me with an axe”; this is a catastrophic thought that can distort the clarity and perceptibility of pain. Encouraging patients to monitor and analyze their anxiety and associated negative thoughts is an important strategy for improving mood and decreasing somatization. Recording daily thoughts and CBT can help the patient identify and appropriately address his (her) cognitive distortions and futile thinking.

When implementing a treatment plan for somatization disorder, we propose the mnemonic device CARE MD:
• CBT
• Assess (by ruling out a medical cause for somatic complaints)
• Regular visits
• Empathy
• Med-psych interface (help the patient connect physical complaints and emotional stressors)
• Do no harm.

Clinical recommendations
Chronic head pain can be debilitating; psychodiagnostic assessment should therefore be considered an important part of the diagnosis and treatment plan. After ruling out common and emergent primary or secondary causes of head pain, consider psychiatric comorbidities. Depression and anxiety have a strong bidirectional relationship with chronic headache; therefore, we suggest evaluating patients with the intention of alleviating both psychiatric symptoms and head pain.

It is important to diligently assess for common psychiatric comorbidities; using the AMPS and CARE MD mnemonics, along with screening for somatization disorders, is an easy and effective way to evaluate for relevant psychiatric conditions associated with chronic head pain. Because many patients have unusual and complicated responses to head pain that can be explained by non-pathophysiological and non-biomechanical models, using the biopsychosocial model is essential for effective diagnosis, assessment, and treatment. Abortive and prophylactic medical interventions, as well as behavioral, sociocultural, and cognitive assessment, are vital to a comprehensive treatment approach.

Bottom Line
The psychodiagnostic assessment can help the astute clinician identify comorbid psychiatric conditions, psychological factors, and somatic symptoms to develop a comprehensive biopsychosocial treatment plan for patients with chronic head pain. Rule out primary and secondary causes of pain and screen for somatization disorders. Consider medication and psychotherapeutic treatment options.

Related Resources
• Pompili M, Di Cosimo D, Innamorati M, et al. Psychiatric comorbidity in patients with chronic daily headache and migraine: a selective overview including personality traits and suicide risk. J Headache Pain. 2009;10(4):283-290.
• Sinclair AJ, Sturrock A, Davies B, et al. Headache management: pharmacological approaches [published online July 3, 2015]. Pract Neurol. doi: 10.1136/practneurol-2015-001167.

Drug Brand Names
Amitriptyline • Elavil Meperidine • Demerol
Botulinum toxin A • Botox Metoclopramide • Reglan
Divalproex sodium • Depakote Propranolol • Inderide
Ketorolac • Toradol Topiramate • Topamax

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Head pain and psychiatric illness: Applying the biopsychosocial model to care

References

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