CME questions: psychosomatic pain: new insights and management strategies.

1. Which of the following statements about patients with chronic pain is false?

a. A history of being emotionally, physically, or sexually abused can be identified in almost 50% of women and 25% of men with chronic pain

b. Posttraumatic stress disorder may explain underlying psychopathology 

c. Somatization and dysfunctional behaviors may emerge as patients repress painful memories while paradoxically seeking validation of pain and suffering

d. Normal examinations and test results indicate that pain is psychosomatic 

2. Which of the following statements about chronic pain symptoms is true?

a. Symptoms correlated with objective findings may be easily diagnosed and treated

b. Symptoms not correlated with objective findings may be easily diagnosed and treated when correlated with known anatomic pathways and physiologic disorders

c. Symptoms are very likely to be psychogenic when there are no objective findings and when features do not correspond to known anatomic pathways or physiologic disorders

d. Women who were physically or sexually abused during childhood have psychological problems and symptoms similar to women who are currently experiencing abuse

e. All of the above

3. A past history of abuse has not been identified in:

a. 15 to 30% of women in the general population

b. Certain socioeconomic classes much more so than others

c. Chronic pain patients with an incidence that is two to four times the incidence in the general population

d. About 65% of patients with fibromyalgia and 50% of patients with other chronic pain disorders including facial pain 

4. A prior history of abuse is believed to be linked to an increased incidence of diseases including:

a. Anxiety and depression

b. Epileptic seizures and pseudoseizures (psychogenic seizures)

c. Substance abuse

d. A variety of medical illnesses

e. All of the above

5. Physical and sexual abuses during childhood are associated with development of:

a. Fibromyalgia

b. Chronic fatigue

c. Chronic pelvic pain 

d. Chemical intolerance

e. All of the above

6. The concept that abuse and trauma may produce physiologic changes in the brain is not supported by:

a. Brain MRI scans that show increased numbers of cerebral white matter lesions with a history of abuse and that the number of lesions in patients correlates with the severity of symptoms

b. Evidence of altered pituitary-adrenal functioning in patients with a history of abuse

c. SPECT studies in men and women with conversion disorder

d. SPECT studies in patients with fibromyalgia

7. Greater psychopathology and a poorer prognosis are generally suggested when a patient:

a. Expresses insight regarding potential stressors

b. Seems to have chosen a supportive and loving spouse/partner

c. Has some symptoms which correlate with objective abnormalities or known anatomic patterns

d. Has been under the care of a reasonable number of clinicians for the current symptoms and has been compliant with medical treatments

e. Uses the term "My Fibro" to categorize symptoms

8. Greater psychopathology and a poorer prognosis are likely when a patient:

a. Omits important medical information

b. Has a history of recent hospitalizations for chest pain with normal results

c. Reports a large array of symptoms

d. Is focused on a vast collection of information including test results and Internet literature

e. All of the above

9. Which one of the following principles is not suggested in the management of chronic pain?

a. Referral for psychotherapy is essential when symptoms are unusual or excessive

b. Referral for psychotherapy is essential when unresolved grief and/or repressed trauma is strongly suspected

c. Referral for psychotherapy is essential when the physical examination is characterized by grossly nonanatomic features

d. Referral for psychotherapy is necessary to confirm that symptoms are psychogenic

e. Referral for psychotherapy may be unnecessary in patients with organic diseases

10. The author does not recommend the following in the management of chronic pain:

a. Always ask patients about any history of past or present emotional, physical or sexual abuse

b. Pain should generally be treated as real

c. Dysfunctional behaviors and key features of the physical examination should be recognized and documented because these may provide strong evidence of underlying psychopathology

d. Empathy and validation of symptoms can best be demonstrated by prescribing medications and performing an extensive evaluation

e. Multidisciplinary treatments including psychotherapy should always be considered

Answers to CME Questions

1. D, 2. E, 3. B, 4. E, 5. E, 6. A, 7. E, 8. E, 9. D, 10. D

Hope for a miracle. But don't depend on one.
--the Talmud