Patients have lived a lifetime of ups and downs; successes and set backs prior to entering a PM&R clinic for treatment. The impact of an individual’s prior life experiences on their current physical and mental wellbeing cannot be underestimated. Likewise the individuals past experiences often serve as the foundation for the development of their expectations of themselves and those around them. Clinicians should be sensitive to the fact that each patient has a unique background that will contribute to their clinical outcome.


A patient past history should explore past medical history, prior evaluations/treatments, physical demands at work/recreation, psychiatric history, social stressors, substance abuse, family medical/psychiatric history, history of physical/sexual abuse and other barriers to clinical success (insurance, education, pharmacy access, support network).

Psychiatric Comorbidities

In the face of a chronic condition that limits one’s ability to function, it would be surprising if this did not affect a person’s mood. Pain and functional limitations may trigger a predisposition to a mood disorder. In turn the inability to cope with the mood disorder may worsen the perception of pain and further limits the patient’s function. This vicious cycle challenges clinicians and patients to identify the relationship between psychological factors and the patient’s pain complaint. Mood disorders can be the primary cause or the result of a physical debilitating condition.

It is important for clinicians to get involved early with patients that have new onset of pain that has started to affect their mood disorder as they are at high risk for progression to chronic pain conditions. Other psychological factors that are may also be a barrier to recovery from an new pain episode include: maladaptive pain beliefs, lack of social support, heightened emotional reactivity, job dissatisfaction, substance abuse, compensation status, psychiatric diagnosis and severe pain behaviors.

Depression:
  • Patients with chronic pain report 3-4 times greater rates of depression compared to the general public.
  • 30% of patients with chronic pain have major depression.
  • 60-70% of patients with depression report pain symptoms – Common with fibromyalgia
Anxiety: Generalized anxiety disorder can be rooted in chronic worry and ruminations about present and future pain experience. 
  • 26% to 59% of the general population report anxiety.
  • Anxiety is more common in patients with chronic pain that also have depression.
  • Anxiety impacts pain by increasing muscle tension, influencing patient expectations for future pain suffering, increasing vigilance to pain stimuli, and promoting avoidance behavioral patterns that may interfere with functional.
  • 30% of patients involved in a motor vehicle accident that require medical attention suffer Post-traumatic stress disorder (PTSD). These patients report more severe pain, greater disability, and less response to medical treatment. Return-to-work may also be limited by PTSD from a work related injury.


Personality disorders. Patients with both a personality disorder and chronic pain can pose unique challenges. The hallmark of personality disorders is enduring and entrenched personality traits that may be incompatible with coping mechanisms essential to managing chronic pain conditions.
  •  Patient’s with diagnosed personality disorders should work closely with their healthcare providers to establish a effective medication plan. 
  •  Counseling strategy should focus on realistic expectations for pain relief, appropriate utilization of services, adherence to treatment plan and self-management of pain.