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A biopsychosocial approach was taken in the assessment of this patient. This approach, which is the most heuristic perspective of pain, assumes that pain is a complex and dynamic interaction among physiological, psychological, and social factors that often results in, or at least maintains, pain and disability. It cannot be broken down into distinct, independent psychosocial or physical components. Therefore, a comprehensive history-taking of biopsychosocial factors that may be involved in the pain perception process must be obtained to understand how it is experienced uniquely by the patient.
This initial information then serves as the "stepping stone" to determine what additional assessment or diagnostic tests need to be conducted. Of course, at the outset, the pain severity of the patient needs to be documented using a pain scale (which was completed before this interview). Indeed, the Joint Commission on Accreditation of Health Care Organizations now requires that health care professionals consider pain as a "fifth vital sign" (added to pulse, blood pressure, core temperature, and respiration) when evaluating patients.
The following assessments also must be made: the patient's own words describing the pain; pain location, duration, aggravating and alleviating factors; present pain management regimen and its effectiveness; effects of pain on activities of daily living; the patient's pain-related goals; and the physical examination.
During this interview, Dr. Gatchel attempted to initially evaluate the overall mental and psychosocial status of the patient, as well as any possible antecedent and secondary variables contributing to the pain. Such information is helpful in understanding what more specific assessment protocols may need to be administered before determining a possible treatment strategy. In addition, an effort was made to help alleviate some of the fear and uncertainty associated with the patient's current pain condition.
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