The Perception of Being a Burden in Acute and Chronic Pain Patients Is Associated with Affirmation of Different Types of Suicidality.

OBJECTIVES: The perception of being a burden or self-perceived burden (SPB) is associated with suicide ideation in chronic pain patients (CPPs). The objective of this study was to determine if SPB is associated with five types of suicidality (wish to die, active suicide ideation, presence of suicide plan, history of suicide attempts, and preference for death over being disabled) in CPPs and acute pain patients (APPs). METHODS: Affirmation of SPB was statistically compared between community nonpatients without pain (CNPWP), APPs, and CPPs. APPs and CPPs who had affirmed any of the five types of suicidality were compared statistically for affirmation of SPB. Hierarchical regression analysis was utilized to determine the significance of SPB in predicting each of the five types of suicidality in APPs and CPPs controlling for age, gender, race, education status, and two types of measures of depression (current depression and vegetative depression). RESULTS: APPs and CPPs were statistically more likely to affirm SPB than CNPWPs and CPPs were more likely than APPs to do so. There were no differences between APPs and CPPs in affirming SPB in APPs and CPPs who had affirmed any of the five types of suicidality. In CPPs, SPB predicted each type of suicidality in a significant fashion utilizing both types of depression measures. For APPs, SPB predicted each type of suicidality in a significant fashion except for history of suicide attempt controlling for vegetative depression. CONCLUSIONS: SPB is associated with the vast majority of different types of suicidality in APPs and CPPs.

Do Acute and Chronic Pain Patients Differ on Affirmation of One Aspect of Pain Acceptance? Acknowledgement that a Cure Is Unlikely.

BACKGROUND: Many chronic pain patients (CPPs) cannot be cured of their pain, but can learn to manage it. This has led to research on pain "acceptance" which is defined as a behavior pattern with awareness of pain but not directed at changing pain. OBJECTIVE: CPPs who have accepted their pain generally acknowledge that a cure is unlikely. Time with pain may be necessary to reach such an acknowledgment. It was therefore hypothesized that fewer acute pain patients (APPs) than CPPs should affirm that a cure is unlikely and that other described aspects of acceptance such as denial of disability status should be associated with cure is unlikely in both APPs and CPPs. STUDY DESIGN: APPs and CPPs were compared for frequency of endorsement of 2 items/questions with face validity for cure is unlikely: little hope of getting better from pain (LH) and physical problem (pain) can't be cured (CBC). Demographic variables and variables reported associated with acceptance were utilized in logistic prediction models for the above items in APPs and CPPs. SETTING: Rehabilitation programs/offices. RESULTS: CPPs were statistically more likely than APPs to affirm both LH and CBC. In both APPs and CPPs, items reported associated with acceptance, e.g., denial of disability status, predicted LH and CBC. LIMITATIONS: Information gathered from CPP self-reports. CONCLUSIONS: APPs versus CPPs differ on their affirmation on acknowledgement that a cure is unlikely.

Prevalence comparisons of somatic and psychiatric symptoms between community nonpatients without pain, acute pain patients, and chronic pain patients.

OBJECTIVES: Somatic/psychiatric symptoms are frequently found in chronic pain patients (CPPs). The objectives of this study were to determine 1) which somatic/psychiatric symptoms are more commonly found in acute pain patients (APPs) and CPPs vs community nonpatients without pain (CNPWPs) and 2) if somatic/psychiatric symptom prevalence differs between APPs and CPPs. DESIGN: The above groups were compared statistically for endorsement of 15 symptoms: fatigue, numbness/tingling, dizziness, difficulty opening/closing mouth, muscle weakness, difficulty staying asleep, depression, muscle tightness, nervousness, irritability, memory, falling, nausea, concentration, and headaches. RESULTS: After controlling for age, gender, and level of pain, APPs and CPPs had a statistically significantly greater prevalence (at a P < 0.01 level) for 11 and 13 symptoms, respectively, vs CNPWPs. After controlling for age, gender, and level of pain, CPPs had a statistically significantly greater prevalence (at a P < 0.01 level) for eight symptoms vs APPs. Symptoms were highly correlated in both APPs and CPPs. CONCLUSIONS: CPPs are characterized to a significantly greater extent than comparison groups by somatic/psychiatric symptoms that are highly intercorrelated. This has implications for clinical practice and future research.

Exploring the Relationship of Three Medical Entitlement Beliefs and Psychiatric/Psychological Variables for Acute and Chronic Pain Patients.

OBJECTIVES: The belief in medical care entitlement has recently resulted in major changes in the medical system in the United States. The objectives of this study were the following: to compare endorsement of three medical entitlement beliefs (I deserve the best medical care no matter what the cost [BMC], I am entitled to all of the medical care I want at no charge [NC], I shouldn't have to wait to see my doctors [W]) in community nonpatients without pain (CNPWP), acute pain patients (APPs), and chronic pain patients (CPPs) and to develop predictor models for these beliefs in APPs and CPPs. DESIGN: CNPWP, APPs, and CPPs were compared statistically for frequency of endorsement of each belief. All available variables were utilized in logistic regression models to predict each belief in APPs and CPPs. Those affirming/nonaffirming each belief were compared by t-test for affirmation of narcissism, dependency, and antisocial practices on three scales from established inventories. RESULTS: CPPs were significantly more likely than APPs to endorse BMC. No other comparisons were significant. The logistic regression models identified variables that related to narcissism, anger, doctor dissatisfaction, depression, and anxiety, which entered the models for both APPs and CPPs for some beliefs. Those APPs and CPPs who affirmed the beliefs of NC and W were more likely than their counterparts to affirm antisocial practices, but not narcissism or dependency. CONCLUSIONS: Patient medical entitlement beliefs may be related to some psychiatric/psychological issues.

The Psychological Evaluation of Patients with Chronic Pain: a Review of BHI 2 Clinical and Forensic Interpretive Considerations.

Pain is the most common reason why patients see a physician. Within the USA, it has been estimated that at least 116 million US adults suffer from chronic pain, with an estimated annual national economic cost of $560-635 billion. While pain is in part a sensory process, like sight, touch, or smell, pain is also in part an emotional experience, like depression, anxiety, or anger. Thus, chronic pain is arguably the quintessential biopsychosocial condition. Due to the overwhelming evidence of the biopsychosocial nature of pain and the value of psychological assessments, the majority of chronic pain guidelines recommend a psychological evaluation as an integral part of the diagnostic workup. One biopsychosocial inventory designed for the assessment of patients with chronic pain is the Battery for Health Improvement 2 (BHI 2). The BHI 2 is a standardized psychometric measure, with three validity measures, 16 clinical scales, and a multidimensional assessment of pain. This article will review how the BHI 2 was developed, BHI 2 concepts, validation research, and an overview of the description and interpretation of its scales. Like all measures, the BHI 2 has strengths and weaknesses of which the forensic psychologist should be aware, and particular purposes for which it is best suited. Guided by that knowledge, the BHI 2 can play a useful role in the forensic psychologist's toolbox.

The prevalence of smokers within chronic pain patients and highest pain levels versus comparison groups.

OBJECTIVES.: The objectives of this study were to (1) compare the prevalence of smoking within chronic pain patients (CPPs) to community non-patients without pain (CNPWP), community patients with pain (CPWP), and acute pain patients (APPs); and (2) compare smokers to nonsmokers within CPPs, APPs, and CPWP for highest pain level. DESIGN.: CNPWP, CPWP, APPs, and CPPs were compared to each other for smoking status (nonsmoker, less than one pack per day, one pack/day or more, any amount per day). Within CPWP, APPs, and CPPs, smokers were also compared to nonsmokers by t-test for highest reported pain level. For both analyses, sub-analyses were performed controlling for age or gender, or race or education. RESULTS.: Utilizing all available patients, the prevalence of smokers within CPPs was significantly greater vs each of the comparison groups (CNPWP, CPWP, APPs). In the sub-analyses, only CPPs who were 38 or younger or male or White, or had some college or above were at greater risk than CPWP for smoking one pack or greater per day. CPP smokers were not significantly more likely than nonsmokers to have higher pain, and this was confirmed in the sub-analyses. CONCLUSIONS.: The prevalence of smokers could be significantly greater within CPPs vs CPWP. CPPs who smoke do not have higher levels of pain than nonsmoking CPPs.

Exploration of the relationship between disability perception, preference for death over disability, and suicidality in patients with acute and chronic pain.

HYPOTHESIS: Passive, active, and historical suicidality are associated with preference for death over disability. DESIGN: Community nonpatients without pain, community patients with pain, and patients with acute and chronic pain were compared for endorsement of disability perception and preference for death over disability. Phi correlations and chi-square analyses were calculated between preference for death over disability and six suicidality items representing passive, active, and historical suicidality. Logistic regression was used to predict preference for death over disability in patients with acute and chronic pain. RESULTS: For patients with acute and chronic pain, endorsement of preference for death over disability correlated significantly with all six suicidality items. The logistic regression models identified the following variables as predictors for preference for death over disability in patients with acute pain: the Behavior Health Inventory (BHI 2) family dysfunction scale, history of wanting to die, and disability perception. For patients with chronic pain, predictors were the BHI 2 Borderline scale, history of wanting to die, treated fairly by family item, frequent suicide ideation, people I trust turn on me item, and disability perception. Preference for death over disability was a statistically significant predictor in patients with chronic pain for disability perception, recent suicide ideation, having a suicidal plan, and a history of wanting to die but was not a significant predictor for any suicide items in patients with acute pain. CONCLUSION: Preference for death over disability is associated with passive and active suicide ideation and historical suicidality in patients with chronic pain.

Exploration of anger constructs in acute and chronic pain patients vs. community patients.

OBJECTIVES: (1) Determine and compare prevalence of forms of anger (FOA; anger, hostility, aggression, anger-in, anger-out, chronic anger) in community nonpatients (n=478), community patients (n=158), acute pain patients (APPs; n=326), chronic pain patients (CPPs; n=341); and (2) develop FOA predictor models in APPs and CPPs. DESIGN: A large set of items containing the FOA items was administered to the above groups, who were compared statistically for FOA endorsement. APPs and CPPs affirming the anger and chronic anger items were compared with those not affirming on all available variables including the Battery for Health Improvement (BHI-2) with significant variables (P≤0.001) utilized in predictor models for anger and chronic anger in APPs and CPPs. Setting community plus rehabilitation facilities. RESULTS: FOA affirmation ranged from 8.28% for chronic anger in nonpatients to 37.54% for anger in CPPs. Only CPPs were more likely to affirm anger (P≤0.04) and chronic anger (P≤0.01) at a significantly higher rate than community patients. In both APPs and CPPs, all FOA items except anger management-in were significantly correlated with other FOA items. For anger and chronic anger for CPPs and APPs, hostility was the strongest predictor. All models predicted anger and chronic anger significantly better than the base rate prediction. CONCLUSION: According to the results of this study anger and chronic anger are more frequently found in CPPs vs. community patients supporting the clinical perception that many CPPs are angry. As such,clinicians should actively screen CPPs for the presence of anger in order to engage these CPPs in anger management treatment.

Predictors of homicide-suicide affirmation in acute and chronic pain patients.

OBJECTIVES: 1) Determine and compare prevalence for homicide-suicide (H-S) affirmation in community non-patients (N=478), community patients (N=158), acute pain patients (APPs; N=326), and chronic pain patients (CPPs; N=341); and 2) Develop H-S predictor models in APPs and CPPs. DESIGN: A large set of items containing the H-S item was administered to the above groups, who were compared statistically for H-S endorsement. APPs and CPPs affirming the H-S item were compared with those not affirming on all available variables including the Battery for Health Improvement (BHI 2) with significant variables (P≤ 0.001) utilized in predictor models for H-S in APPs and CPPs. SETTING: Community plus rehabilitation facilities. RESULTS: The above population groups affirmed the H-S item according to the following percentages: healthy community 1.88%, community patients 3.16%, rehabilitation patients without pain 3.64%, rehabilitation AAPs 3.99%, and rehabilitation CPPs 4.40%. For both APPs and CPPs, the H-S item was significantly correlated with some suicidality items and some homicide items. The model for APPs identified "having a suicide plan" as being predictive of H-S affirmation. For CPPs, the items of having thoughts of revenge killing, being motivated to seek revenge without any verbal warning, and the Doctor Dissatisfaction Scale of the BHI 2 predicted H-S affirmation. The APPs model classified 96% of the APPs correctly, while the CPPs model classified 97% of the CPPs correctly. These predictor rates, however, were no better than the base rate. CONCLUSION: The prevalence of H-S affirmation within APPs and CPPs is not insignificant. The APPs predictor model points to a close association between H-S affirmation and suicidality. The CPPs model indicates that there is a close association between H-S affirmation, and anger/hostility and anger directed at physicians. These results, however, should not lead to the belief that CPPs are at greater risk for actual H-S completion for the following reasons: 1) H-S is an extremely rare event; and 2) predictive validity of the H-S item for actual H-S completion has not been determined.

Variables associated with self-prediction of psychopharmacological treatment adherence in acute and chronic pain patients.

OBJECTIVES: The objectives of this article were the following: (1) determine risk for self-predicted future psychopharmacological nonadherence in rehabilitation acute pain patients (APPs) and rehabilitation chronic pain patients (CPPs) vs. pain-free community controls and community patients, and (2) determine which variables predict nonadherence. DESIGN: The Battery for Health Improvement 2 was developed utilizing a healthy (pain-free) community sample (N = 1,478), a community patient sample (N = 158), and a rehabilitation patient sample (N = 777) of which 326 were APPs, 341 were CPPs, and 110 were patients without pain. These groups predicted their future psychopharmacological treatment adherence. Risk for nonadherence was calculated for each group utilizing the healthy community sample as the reference group. Nonadherent and adherent APPs and CPPs were compared statistically on variables of interest. Significant variables (P ≤ 0.01) were utilized in APPs' and CPPs' logistic regression models to predict nonadherence. SETTING: The participants in this article were from a variety of settings. RESULTS: Of APPs and CPPs, 10.74% and 10.85%, respectively, predicted that they would be nonadherent. Risk for nonadherence was greater in both groups vs. healthy nonpain community subjects and nonhealthy community patients. The predictors for APPs' nonadherence were general resistance to using medications and a tendency to forget physicians' suggestions. For CPPs, the predictors were general resistance to using medications, fear of dependence on prescription medications, and fighting with loved ones. The models classified 90% and 89% of APPs and CPPs (respectively) correctly. However, these were no better than the base rate. CONCLUSIONS: APPs and CPPs are at greater risk for self-predicted psychopharmacological nonadherence than healthy community subjects and community patients. We cannot as yet predict self-predicted psychopharmacological nonadherence at greater than the base rate. However, the identified variables could be clinically useful.

Borderline personality disorder features and pain: the mediating role of negative affect in a pain patient sample.

OBJECTIVES: There is considerable evidence that personality disorders, including borderline personality disorder (BPD), tend to co-occur with chronic pain. There is also evidence that mood disorders co-occur with chronic pain conditions. Given the central role of affective instability and negative mood states in BPD, we proposed that affective features of depression, anxiety, and hostility may account for the association between BPD features and the severity of pain reported in a patient sample. METHODS: Seven hundred seventy-seven patient participants completed the Battery for Health Improvement. This included measures of DSM-IV BPD features, affect scales (depression, anxiety, hostility), and pain items assessing the severity of pain and somatic symptoms. RESULTS: As predicted, individuals with higher levels of BPD features reported greater severity of pain and somatic complaints, including higher levels of maximum and minimum pain levels in the past month. In addition as predicted, this association was no longer significant after controlling for affect scales. In particular, depression was strongest in accounting for this association. DISCUSSION: These results indicate that the association between BPD features and pain is accounted for by negative affect, primarily in the form of depression. This is consistent with current theoretical perspectives on BPD. This also suggests that clinicians observing or detecting BPD features among pain patients should consider negative affect, especially depression, in addressing these issues.

What variables are associated with an expressed wish to kill a doctor in community and injured patient samples?

Working in a health care setting has been identified as a primary risk factor for violent assault, which is often perpetrated by patients. Patient dangerousness is a multidimensional phenomenon, which may include violent ideation, homicidal planning, a history of violent acts, or overt threatening behavior. Although the verbal report of thoughts of killing a doctor is only one of many risk factors for patient dangerousness, reports of homicidal ideation are widely regarded as being sufficient to warrant concern, and to indicate a need for further assessment of the patient. In this study, 2264 subjects (1329 healthy community subjects, 158 non-healthy community subjects, and 777 rehabilitation patients) were asked if they had a desire to kill a doctor that they had seen. Subjects responding positively to this item were compared to subjects responding negatively to the item using all available demographic variables and BHI 2 scales using chi-square or t-test. Significant variables (p<.01) were then utilized in a logistic regression to generate a model for this wish. Three variables significantly predicted this wish: the Doctor Dissatisfaction (p<.001) and Borderline (p<.001) scales of the BHI 2, and injury-related litigation status (p=.002). The presence of one of these variables, especially Doctor Dissatisfaction, should prompt a more thorough assessment of potential danger to healthcare workers.

Risk for five forms of suicidality in acute pain patients and chronic pain patients vs pain-free community controls.

OBJECTIVES: . The objective of this study was to determine the risk for five forms of suicidality in rehabilitation acute pain patients (APPs) and rehabilitation chronic pain patients (CPPs) vs pain-free community controls. DESIGN: The Battery for Health Improvement 2 was developed utilizing a healthy (pain-free) community sample (N = 1,478), a community patient sample (N = 158), and a rehabilitation patient sample (N = 777). These groups were asked five suicidality questions relating to history of wanting to die, wanting to die because of pain, recent frequent suicide ideation, having a suicide plan, and history of suicide attempt. Of the rehabilitation patients, 326 were identified as being APPs, 341 as being CPPs, and 110 as having no pain. The risk for affirming each of the five suicidality questions was calculated for rehabilitation APPs, rehabilitation CPPs, and rehabilitation patients without pain utilizing the healthy pain-free community sample as the reference group. In addition, risk was calculated for various subgroups of rehabilitation patients: those with worker's compensation status, with litigation status, and with personal injury status. SETTING: There are a variety of settings. RESULTS: In rehabilitation CPPs the risk for suicidality was greater than community pain-free controls for three suicidality questions: history of wanting to die, recent frequent suicide ideation, and having a suicide plan. Worker's compensation status, litigation status, and personal injury status appeared to increase risk for affirmation of some types of suicidality in CPPs. Rehabilitation APPs were at greater risk for all five suicidality items than the community pain-free controls. CONCLUSION: Rehabilitation CPPs are at greater risk for some forms of suicidality than community pain-free controls. This risk is increased by variables such as worker's compensation status, litigation status, and personal injury status. However, it is yet unclear if these variables actually predict suicidality as this requires further analysis.

Correlates of self-reported violent ideation against physicians in acute--and chronic-pain patients.

OBJECTIVES: Physicians are at risk for patient-perpetrated violence. This study attempts to identify predictors for violent ideation against medical doctors (VI-MD), in acute-pain patients (APPs) and chronic-pain patients (CPPs). This is the first such study in the literature. DESIGN: Patients were asked if they had thoughts of killing one of their physicians (VI-MD) during the development of the Battery for Health Improvement (BHI 2). This instrument was developed utilizing a healthy community sample (n = 1,478), a community patient sample (n = 158) and a rehabilitation patient sample (patients undergoing rehabilitation for pain or physical injury in a variety of settings) (n = 777). Of the rehabilitation patient sample, 326 were identified as APPs, 341 as CPPs, and 110 as having no pain. The APPs and CPPs were compared for the risk of affirming VI-MD, and those two groups were then compared by t-test and chi(2)-square on categorical demographic variables, categorical nondemographic variables, and BHI 2 scale scores. Significant variables (P < 0.001) were then utilized as independent variables in logistic regression models for APPs and CPPs to predict VI-MD affirmation. SETTING: Patients treated in a variety of settings. RESULTS: Risk for affirmation of VI-MD was increased in the following groups relative (number of times) to the healthy community sample as follows: rehabilitation patients, 3.5; rehabilitation patients without pain, 2.8; rehabilitation patients with acute pain, 3.1; rehabilitation patients with chronic pain, 4.1; rehabilitation patients with Worker's Compensation or personal injury 4.6; rehabilitation patients with litigation 7.3; and rehabilitation patients with Worker's Compensation and litigation and chronic pain, 10.4. In the APPs logistic regression models, demographic variables did not predict VI-MD affirmation, but some BHI 2 scales and items did (P < 0.001). These pertained to depression, hostility and doctor dissatisfaction (angry at the physician). A high perseverance score on the BHI 2 predicted against VI-MD affirmation among APPs. For CPPs, three major variables predicted VI-MD affirmation: being in litigation; borderline traits and doctor dissatisfaction (trusting/not trusting the physician, forced to see physician, patient does not trust). The logistic regressions classified 95.7% of APPs and CPPs correctly. However, because of the total low numbers of rehabilitation patients affirming VI-MD (5.5%), the logistic regression prediction was only slightly better than the base rate prediction of 94.5%. CONCLUSIONS: Being a rehabilitation patient increases the relative risk of affirming VI-MD. This risk is further increased by such variables as chronic pain, Worker's Compensation status, personal injury status, and, most important, litigation. We cannot as yet predict VI-MD affirmation significantly better than base rate prediction. Some variables implicated in this study for VI-MD affirmation relate to the physician-patient interaction and are clinically useful.

Assessment of biopsychosocial risk factors for medical treatment: a collaborative approach.

There is a growing body of evidence that psychosocial variables have a significant ability to predict the outcome of medical treatment procedures, especially when the procedure is performed to reduce pain. The study described in this paper serves as an illustration of the valuable role psychologists can play in dealing with the challenges of biopsychosocial assessment of patients who are candidates for medical treatments, especially elective, invasive procedures. Based on a convergent model of risk factors that can potentially influence outcomes from spinal surgery and spinal cord stimulation, exclusionary and cautionary risk factors were identified, and the BHI 2 and BBHI 2 tests were used to assess them. An estimate of the prevalence of these risk factors was calculated using data obtained from 1,254 patient and community subjects gathered from 106 sites in 36 US states. Standardized Cautionary Risk and Exclusionary Risk scores demonstrated a test-retest reliability of .85 to .91. Evidence of validity of these scores was also provided based on subjective and objective criteria, using multiple groups of patients and community subjects. Recommendations are made regarding how biopsychosocial assessments could be used in collaborative settings for presurgical candidates to identify risks that could compromise a patient's ability to benefit from other medical treatments as well. Once identified, appropriate interventions could ameliorate these risks, or lead to the consideration of other treatments that are more likely to be effective. Methods of refining this approach for specific clinical applications are also discussed.

What are the variables that are associated with the patient's wish to sue his physician in patients with acute and chronic pain?

OBJECTIVES: Although there is limited research on patient attributes that may be related to reasons for launching a malpractice suit, no such research has been performed in acute pain patients (APPs) or chronic pain patients (CPPs). The objective of this study was then to develop some statistical models that would describe such patients' attributes. METHODS: A statement about having thoughts of suing a physician (sue medical doctor [MD]) is the focus of this study, and was contained within the Battery for Health Improvement (BHI) research version (BHI-R). The BHI-R was administered to 1,487 community subjects (1,329 healthy and 158 nonhealthy) and 777 patients in rehabilitation of whom 326 were APPs, 341 were CPPs, and 110 had no pain. In addition, descriptive data, such as whether the patient had an attorney for a worker's compensation claim, was collected. The sue MD Likert scale responses were dichotomized, and the relative risks for the sue MD wish were calculated for the aforementioned groups utilizing the healthy community group as the reference group. With APPs and CPPs, those patients responding alternatively affirmatively to the sue MD statement were compared with those patients responding negatively on all available categorical variables and BHI 2 scales via appropriate statistics. If a BHI 2 scale was statistically significant at P < 0.001, then all the questions from this scale were analyzed for significance by chi-square. Significant categorical variables (P < 0.001) and significant BHI 2 questions were then utilized as independent variables in a logistic regression model to assess the predictability of the independent variables for sue MD. SETTING: Variety of settings. RESULT: The relative risks for affirming the sue MD statement relative to the healthy community sample for various groups were as follows in order of ascending risk: APPs in rehabilitation; nonhealthy community members; rehabilitation patients in general; rehabilitation patients without pain; CPPs in rehabilitation; and with the highest risk being rehabilitation patients with worker's compensation litigation. For APPs, the logistic regression model utilized three variables: trusting physicians (protected against sue MD); physicians appearing to be motivated by financial incentives; and being upset over one's health (depression variable). This model classified 96% of the patients correctly. For CPPs, the logistic regression model also utilized three variables: being in worker's compensation litigation; being coerced to see a distrusted physician; and being angry with the physician. This model classified 93% of the patients correctly. CONCLUSIONS: CPPs are at a greater risk than patients without pain and APPs for harboring the sue MD wish. Some patient attributes and the referral/treatment situation appear to be important predictors for harboring the sue MD wish, but differ between APPs and CPPs.

Chronic nonmalignant pain and violent behavior.

Research suggests that violence has entered the medical setting to a remarkable degree, causing medical professionals to be at the highest risk for becoming the victims of assaults and violent acts. This article reviews general theories of aggression and research on these theories, and uses them to assess risk factors in patients with chronic pain. There are data to suggest that pain may increase the risk of aggressiveness in some patients. However, it may decrease the risk in others paradoxically. The research available underscores the need for evaluating patients with pain for the risk of violent or aggressive behavior; specific recommendations are made in this regard.