Pain complaint
Intensity of pain at this moment on a scale of 10 (0 = no pain, 10 = excruciating pain)
Location of pain, with radiation
Description of pain, kind of pain
Course of pain during the day
Chronicity of pain (continuous, intermittent, exact duration)
History of pain
Since when have you had pain complaints?
Previous diagnostic tests by a doctor?
If so, what were the results?
Previous treatment?
If so, what were the results?
Ideas about pain
What is in your opinion the cause of your pelvic pain?
Pain–coping strategies
What do you do when the pain increases?
What do you do to prevent the pain increasing (medication, taking rest)?
What do you do when the pain has decreased, when you are improving?
Consequences
Cognitive
What are your thoughts when pain exacerbates? Do you worry about (the (consequences of) your pain? To what extent do you feel able to influence pain? Do you feel helpless regarding your pain?
Emotional
Do you feel anxious, depressed, irritated, annoyed, distressed, or unhappy?
Behavioral
Do you go on with your activities despite pain or do you stop because of pain? How many prescribed and nonprescribed drugs do you use and what is the effect on pain? Current or past alcohol abuse and use of other psychoactive drugs? Do you visit complementary healthcare providers?
Physical
Do you experience accompanying symptoms such as sweating, nausea, and a high heart rate? Do you feel tired or exhausted? Do you experience muscle tension? Is your participation in physical exercise and/or sexual functioning affected by pain experience? Can you fulfill your household duties?
Social
Do you experience problems in your relationship with your partner, relatives, or friends and/or in your job? Does pain affect your participation in pleasurable activities, going on vacation?
11.6.3.1 What Are the Questions to Address the Cognitive, Emotional, Behavioral, Physical, and Social Consequences of Living in Pain?
Case History: Continued
When asked for, Renata Emerald mentions some of the consequences of her pain, which in turn lead to more pain. She is feeling really desperate at some times. When she experiences more severe pain she feels burdened by her pain. She cannot accept that the pain influences her everyday life to such an extent, and as a result, she gets angry. In its turn, this anger causes tension everywhere in her body. She recognizes that this increased bodily tension might have a negative effect on the level of experienced pain.
With great effort, she succeeds in fulfilling her regular household duties, but still she is convinced that she fails as a partner and mother. When the pain obliges her to rest, she blames herself for her inactivity. As soon as the symptoms improve, she resumes her activities and tries to catch up on lost time. Subsequently, the pain might increase as a result of overexertion. A vicious circle can be drawn and illustrates a pattern that emerges when someone has “nonaccepting thoughts about pain” (Fig. 11.1).
Fig. 11.1
“Nonaccepting thoughts about pain.” An example of a vicious circle between cognitive, emotional, behavioral, physical, and social consequences and chronic pelvic pain
Moreover, since she had to go on sick leave, contacts with her former colleagues are becoming less and less over time. This increases her feelings of despair.
Another example of a vicious circle is shown in Fig. 11.2. Catastrophizing appraisals and cognitions may maintain and even increase pain.
Fig. 11.2
Catastrophizing: “Anxious thoughts and avoidance behavior.” An example of a vicious circle between cognitive, emotional, behavioral, physical, and social consequences and chronic pelvic pain (Used with permission of Informa Healthcare from [17])
The most difficult but also the most essential step during this interview is the next step (step 4) because the patient is encouraged to change her biomedical view on pain into a biopsychosocial perspective.
11.6.4 Step 4: Reorientation
After a summary of the findings of the consultation so far, specific points are communicated to the patient:
- 1.
An explanation of current views on chronic (pelvic) pain is given. “Being in pain” is an unpleasant sensory and emotional, thus subjective experience. An objective quantification of the severity of pain as experienced by the patient is impossible, but the consequences of CPP for everyday life illustrate the impact and burden of these complaints. Moreover, the patient is informed that only a minority of patients suffering from CPP will recover over time, taking a narrow definition of recovery as complete relief of pain.
- 2.
Further examinations are considered to be of minor value because each imaging investigation or invasive technique evaluates only the shape or size of the internal organs. If an abnormality is diagnosed, it is judged coincidental rather than causal. That the cause of CPP cannot be explained properly is “bad news” and might lead to deterioration of the patient’s condition because her expectations of a specific diagnosis and subsequent medical solution for her pain are not met.
- 3.
By recapitulating the medical aspects and psychosocial consequences of the patient’s complaint, the gynecologist expresses and demonstrates his or her genuine interest in and acknowledgment of the patient and her pain. Using one of the vicious circles as an example, the gynecologist can explain how the consequences of pain in everyday life can prolong and even worsen her pain.
- 4.
At this stage, the patient is given the opportunity to reorientate her thinking about chronic pain. She is encouraged to change her view from the former dualistic biomedical way of thinking toward a multidimensional biopsychosocial perspective.
For some women, it is easy to make this reorientation, because they have experienced again and again that most investigations and medical treatment did not help to relieve her complaints. They recognize and understand that the impact of their pain is reflected in the consequences of pain in day-to-day life, which in its turn are linked to the experienced pain. Other women find it really difficult to hear that from a medical point of view “nothing more can be done.” They need time to be able to make a reorientation. Only a minority, for instance, those women who are involved in labor law procedures, will not be able to follow another point of view on chronic pain.
11.6.4.1 What Are Essential Ingredients to Be Able to Support the Patient with Chronic Pelvic Pain to Change Her View on Pain from a Biomedical Toward a Biopsychosocial View on Pain?
Case History: Continued
Renata Emerald recognizes herself in the summary of her pelvic pain history, current pain experience, and the impact of her pain on everyday life. She is really disappointed to hear that further investigations and a surgical treatment will not be provided. It is really difficult for her to give up her quest for this supposed cure, immediately. It becomes clear that Renata needs time to reconsider her former beliefs and to accept a new perspective. After having read some parts of the self-help book The Pain Survival Guide [13], she recognizes how she is troubled by her pain, like others with chronic pain. She also realizes that she has to start to live with her pain. She makes a new appointment with her gynecologist although she is rather reserved about the new direction.
11.6.5 Step 5: Pain Management
If the patient is willing to identify with and accept the CB model as previously presented, the gynecologist is in a position to explain what can be achieved with pain management based on this model. Referral to a cognitive behavioral psychologist with special chronic pain expertise is recommended for further evaluation. This should also include the assessment of psychological comorbidity such as anxiety and depressive disorders.
In this way, it is possible to tailor pain management to the needs of a particular patient. This approach aims to alleviate the impact of pain on daily life. A combination of medical (pain medication), physical (functional restoration, i.e., graded activity and graded exposure to stimuli that may generate pain), and psychological modalities can be offered that can help to live with pain (such as goal setting, problem solving, relaxation training, development of effective coping strategies, changing maladaptive beliefs about pain). These ingredients aim to help the patient reclaim her own life despite chronic pain. At the start of this trajectory, it is difficult to predict to what extent the patient will recover from her pain. Medical consultation has to continue on a regular basis during treatment to provide support for the pain management program and to preempt any perception of feeling dismissed. If complaints should increase at a given point in time, a thorough medical examination remains mandatory, as some underlying conditions such as endometriosis can manifest new symptoms.
11.7 Specific Therapeutic Aspects
Treatment modalities for CPP that are studied so far vary and depend on a different point of view on chronic pelvic pain and supposed action of the intervention.
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