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

Daniel Bruns & John Mark Disorbio

Received: 9 July 2014 /Accepted: 14 October 2014 /Published online: 6 November 2014# The Author(s) 2014. This article is published with open access at Springerlink.com

Abstract Pain is the most common reason why patients see aphysician. Within the USA, it has been estimated that at least116 million US adults suffer from chronic pain, with an esti-mated annual national economic cost of $560–635 billion.While pain is in part a sensory process, like sight, touch, orsmell, pain is also in part an emotional experience, like depres-sion, anxiety, or anger. Thus, chronic pain is arguably thequintessential biopsychosocial condition. Due to the over-whelming evidence of the biopsychosocial nature of pain andthe value of psychological assessments, the majority of chronicpain guidelines recommend a psychological evaluation as anintegral part of the diagnostic workup. One biopsychosocialinventory designed for the assessment of patients with chronicpain is the Battery for Health Improvement 2 (BHI 2). The BHI2 is a standardized psychometric measure, with three validitymeasures, 16 clinical scales, and a multidimensional assess-ment of pain. This article will review how the BHI 2 wasdeveloped, BHI 2 concepts, validation research, and an over-view of the description and interpretation of its scales. Like allmeasures, the BHI 2 has strengths and weaknesses of which theforensic psychologist should be aware, and particular purposesfor which it is best suited. Guided by that knowledge, the BHI 2can play a useful role in the forensic psychologist’s toolbox.

Keywords Chronic pain . Psychological assessment .

Psychological evaluation . Psychological screen . Forensic .

Litigation . Battery for Health Improvement 2 . Brief Battery

for Health Improvement 2 . BHI 2 . BBHI 2 . Presurgical .

Treatment outcome . Standardized test . Opioid risk . Healthpsychology . Rehabilitation . Risk . Suicide . Violence .

Litigiousness

Pain is the most common reason why patients see a physician:Something hurts (Centers for Disease Control and Prevention2010; National Center for Health Statistics 1992). Thus, thepresence of pain is a primary driving force that underlies thedemand for health care. Within the USA, it has been estimatedthat at least 116 million US adults suffer from chronic pain,with an estimated annual national economic cost of $560–635billion (Institute of Medicine 2011). Chronic pain is alsoclosely associated with disability (Ehde et al. 2003; Zaleet al. 2013). In 2012, 10.8 million persons were receivingSocial Security Disability Income (SSDI), at the cost of$128 billion annually, not including the associated costs ofMedicare (Congressional Budget Office 2012). Of SSDI re-cipients in 2011, 44 % were prescribed opioid pain relievers(Morden et al. 2014).

A recent report from the Institute of Medicine studied theproblem of pain in the USA. It concluded that pain hasbiological, psychological, and social components, and effec-tive treatments for pain must address all three of these com-ponents. This report stated that “effective pain management isa moral imperative, a professional responsibility, and the dutyof people in the healing professions” (Institute of Medicine2011; p. S-3). The International Association for the Study ofPain has affirmed the biopsychosocial nature of pain andconcluded that pain has a dual nature. While pain is in part asensory process, like sight, touch, or smell, pain is also in partan emotional experience, like depression, anxiety, or anger(Merskey and Bogduk 1994). At the neurophysiological level,the experience of pain is inextricably linked with physiolog-ical arousal, mood, memory, and cognition (Apkarian et al.

D. Bruns (*) : J. M. DisorbioHealth Psychology Associates, 1610 29th Avenue Place Suite 200,Greeley, CO 80634, USAe-mail: dbruns@healthpsych.com

J. M. Disorbioe-mail: jmdisorbio@earthlink.net

J. M. Disorbio113 Blue Grouse Road, Evergreen, CO 80634, USA

Psychol. Inj. and Law (2014) 7:335–361DOI 10.1007/s12207-014-9206-y

2009; Melzack 2001). Thus, chronic pain represents the quin-tessential biopsychosocial condition.

One of the challenges of treating patients with chronic painis that pain leads to increased demand for opioid medication tosuppress the pain, and surgical interventions to “fix” the pain.Unfortunately, due to pain’s complex nature, iatrogenic com-plications are common. One study examined the number ofunintentional deaths in the USA from prescription opioid painmedications and found that it exceeds the number of deathsdue to cocaine and heroin combined (Centers for DiseaseControl and Prevention 2012). Another study examining theeffects of surgical treatments for patients with spinal painfound that while an objectively successful fusion occurred in84 % of lumbar fusion patients, nearly half were dissatisfiedwith their outcome, and many were totally disabled at follow-up (LaCaille et al. 2005). Because pain treatments such asthese can lead to iatrogenic complications, these treatmentscan be both costly and counter-productive.

The study by LaCaille and colleagues above illustrates animportant conclusion of another study. In many cases, ortho-pedic surgeries for chronic pain are performed when theprimary outcome goals are to change behavior: to induce thepatient to say, “My pain is much better,” to say, “I don’t needopioids anymore,” to report satisfaction with health care, or toreturn to work (Bruns and Disorbio 2009). While medicalimaging techniques are helpful for making objective diagno-ses, these imaging techniques were not designed to assessfeelings or predict behavior. Consequently, pain self-reportscannot be replaced by neuroimaging or other technologies(Robinson et al. 2013). Given the prominent psychologicalcomponent of chronic pain, the advice of Hippocrates isespecially apt: “It is more important to know what sort ofperson has a disease, than to know what sort of disease aperson has” (Hippocrates, 400 BCE). Thus, since chronic painis known to be a complex, biopsychosocial condition, a pre-requisite of effective pain treatment is accurate assessment ofnot only the medical aspects of pain but also the psychosocialaspects as well.

Psychological interventions for chronic pain have beenshown to be safe and effective treatments for pain (Hoffmanet al. 2007) but are generally underutilized (Robbins et al.2003). Studies have shown that psychological treatmentscombined with exercise can produce improvements in func-tioning that equal those of surgery for back pain (Brox et al.2010; Chou et al. 2009). The economic benefits of a treatmentmodel that integrated psychological services was tested in a15-year longitudinal study of 29 million patients, which pro-vided evidence that a biopsychosocial model for treating painand injury provided better care at less cost (Bruns et al.2012b). This model relied heavily on psychological assess-ments for treatment planning.

An extensive review of the evidence determined that psy-chological tests are the scientific equal of medical tests (G. J.

Meyer et al. 2001) and can sometimes exceed the ability ofmedical tests to predict the outcome of medical treatments forpain (Carragee et al. 2005; Carragee et al. 2004). Due to theoverwhelming evidence for the biopsychosocial nature of painand the value of psychological assessments, the majority ofchronic pain guidelines recommend a psychological evalua-tion as an integral part of the diagnostic workup (Bruns inpress). These guidelines create a mandate for both clinical andforensic psychological evaluations of chronic pain.

Psychological assessments for medical patients serve anumber of purposes. These include providing an accuratemeans of describing a medical patient’s mental status, medicalsymptoms, traits, attitudes, abilities, and the patient’s percep-tion of the social environment. This in turn can facilitatemaking determinations about how to diagnose or classify thepatient, plan interventions, predict outcome, and measurechange (Bruns in press; Bruns and Disorbio 2013; Turneret al. 2001). One biopsychosocial inventory designed for theassessment of patients with chronic pain is the Battery forHealth Improvement 2 (BHI 2) (Bruns and Disorbio 2003).The BHI 2 is a standardized psychometric measure, a primarypurpose of which is to perform clinical and forensic evalua-tions of patients with pain and injury. This article will providean overview of how the BHI 2 was developed, BHI 2 inter-pretive concepts, and the nature and validation of its scales.

Overview of the BHI 2

The goal of the BHI 2 development was to create a compre-hensive biopsychosocial inventory to assess medical patientswith pain and/or injury specifically, and somatic symptomdisorders more generally. Consequently, the BHI 2 is bestconceptualized not as a psychological inventory, but ratheras a biopsychosocial inventory.

A brief review of the BHI 2’s development and validationprocess (Bruns and Disorbio 2003) is as follows:

1. The BHI 2 originated with a paradigm called the vortexmodel, which is a graphical representation of thebiopsychosocial model as it pertains to the onset of injury,illness, chronic pain, and intractable biopsychosocial dis-orders (Fig. 1). This model attempted to organize whatwas known about how patients respond to health chal-lenges, and why some patients get into a “downwardspiral” of worsening symptoms. The vortex model servedas a guide for BHI 2 development, and as a conceptualparadigm for performing a biopsychosocial evaluation inthe clinical setting.

2. Development of the BHI 2 began when, based on thisbiopsychosocial paradigm, over 1,100 items were gen-erated, of which 600 were selected for empiricalassessment.

336 Psychol. Inj. and Law (2014) 7:335–361

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The

VortexParadigm

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developed

Psychol. Inj. and Law (2014) 7:335–361 337

3. The 600 selected items were administered to 2,507 sub-jects gathered from 106 sites in 36 US states, along witha number of other measures. Information from treatingproviders was also gathered.

4. From the overall sample, patient and community devel-opment groups were identified, and these were used toexplore the psychometrics of the prototypical BHI 2scales.

5. Later, patient and community normative groups werealso developed and were stratified to match US Censusdata for age, gender, race, and education. These twonorm groups serve as estimates of the responses of theaverage American patient with pain or injury, and theaverage American community member.

6. Eight other reference groups were also identified. Fromthe patient norm group, subgroups for chronic pain, headinjury/headache pain, neck pain, upper extremity pain,low back pain, and lower extremity pain were identified.Additionally, fake good and fake bad groups were alsoobtained.

7. The scales to develop were identified through a reviewof the literature and were represented in the vortexparadigm. The BHI 2’s scales are organized in accor-dance with the biopsychosocial model, and the contentof the scales and items were developed to represent thevarious aspects of the paradigm.

8. Items were assigned to the 18 BHI 2 scales based on theappropriateness of the item content, and the ability of theitem to differentiate one group of subjects from another,item to scale correlations, item to criteria correlations,and resultant scale to criteria correlations.

9. The BHI 2 development process produced three validitymeasures (Validity Items (random responding), Self-Disclosure, and Defensiveness), “biological” scalesassessing medical symptoms (Somatic Complaints,Pain Complaints, Functional Complaints, and MuscularBracing), psychological measures of affect and charac-terological dysfunction (Depression, Anxiety, Hostility,Border l ine , Symptom Dependency, ChronicMaladjustment, Substance Abuse, and Perseverance),and measures of the patient’s social environment(Family Dysfunction, Doctor Dissatisfaction, Survivorof Violence, and Job Dissatisfaction). At cross-valida-tion, the mean test-retest reliability and Cronbach’s alphaof the BHI 2 scales were .93 and .84, respectively.

10. The development process also yielded 40 content-basedsubscales. Items were assigned to these subscales basedon the appropriateness of the item content as determinedby the opinion of a panel of 12 expert judges. Thedescription of these scales goes beyond the scope of thispaper. However, the content validity established by thismethod supported the content validity of the parent scaleof which the subscale is a part. The mean test-retest

reliability, Cronbach’s alpha, and interjudge agreementregarding item content of the BHI 2 content-based sub-scales were .88, .69, and .92, respectively.

11. Following the completion of the test development pro-cess, the BHI 2 has been the subject of numerous peer-reviewed studies about variousmatters of clinical interest.

12. Because the BHI 2 scales were validated in differentways, validity is a more complex topic and will bediscussed on a scale-by-scale basis below.

Along with tests such as the Minnesota MultiphasicPersonality Inventory-2-RF (Ben-Porath and Tellegen 2011),the Millon Clinical Multiaxial Inventory III (Millon et al.1997), and the Millon Behavioral Medicine Diagnostic(Millon et al. 2001), the BHI 2 has been listed as a commonlyused test for patients with chronic pain in multiple medicaltreatment guidelines (American College of Occupational andEnvironmental Medicine 2008; California Division ofWorkers' Compensation 2009; Colorado Division ofWorkers' Compensation 2012; Oklahoma PhysicianAdvisory Committee 2007; Work Loss Data Institute 2009),has been integrated into clinical protocols (Bruns and Disorbio2013), and was favorably peer reviewed by the Buros Centerfor Testing (Vitelli 2007). This review concluded that the BHI2 could benefit from further studies about validity assessmentand malingering, and longitudinal studies about medical treat-ment outcome. Despite these weaknesses, the review conclud-ed that “the reliability and validity research of the BHI 2demonstrates that it is one of the best instruments availablefor assessing the broad range of treatment needs in clinicalpopulations” (Vitelli 2007; p. 75).

At the time of this writing, the BHI 2 or Brief BHI 2 (BBHI2) has been accepted as evidence in several US federal courtcases (Chambers v. Astrue 2013; Cowgar v. Commissioner OfSocial Security Administration 2008; Cowger v. Astrue 2008;Davis v. Astrue 2009; Lewis v. Astrue 2012; Webb v. Astrue2009). The short version of the BHI 2, the Brief Battery forHealth Improvement 2 (BBHI 2), has been accepted as evi-dence in one US federal case (McGuire v. Astrue 2008).Although the BHI 2 and BBHI 2 have been accepted asevidence in federal courts, there have been no specific judicialrulings pertaining to the tests themselves. However, in onecase, one psychologist’s testimony was determined to be morepersuasive than that of a second psychologist due to the factthat the first psychologist had performed validity testing,which included the BHI 2 scales (Webb v. Astrue). In twoother cases, testimony was given that the BHI 2 “is a moresophisticated test” than the Beck Depression Inventory(Cowgar v. Commis s i one r O f Soc ia l Secur i t yAdministration; Cowger v. Astrue).1

1 Note that the opinion Cowgar v. Commissioner Of Social SecurityAdministration was filed with a typo, misspelling “Cowger.”

338 Psychol. Inj. and Law (2014) 7:335–361

Bidirectional Scales and the Interpretation of Low Scores

Many human traits and symptoms are more or less normallydistributed, and scores that deviate from the mean in either thehigh or low direction are equally “abnormal” in the statisticalsense. Similar to measures of cognitive ability, where bothhigh and low scores are meaningful, some measures of moodor personality also return a near normal distribution of scores,where high and low scores are of equal significance (McCraeet al. 2010; Russell et al. 2002). Scales which produce mean-ingful high and low scores are sometimes called “bipolarscales” (Widiger 2011), but to avoid confusion with the diag-nosis of the same name, the term “bidirectional scales”will bepreferred here. Recent research has suggested that conceptu-alizing psychological measures as being unidirectional may bemistaken, as maladaptive traits can be observed in patientswith scores at both ends of a scale’s distribution (Petterssonet al. 2014). For example, one study concluded that on aneuroticism scale (measuring high negative affectivity), alow score was suggestive of the glib and fearless traits seenin psychopaths. Thus, both very high and very low scores onthis scale were indicative of psychological dysfunction(Widiger 2011).

Bidirectional scales would appear to be of particular inter-est in the assessment of patients with chronic pain, orsomatoform or somatic symptom disorders. This is becauseunusually low scores on somemeasures may suggest denial orsuppressed report, and numerous studies have associated cog-nitive and emotional suppression with heightened psycho-physiological reactivity and symptom report.

Studies have found that thought suppression increases theoccurrence of obsessive ruminations about the very subjectthat the patient is trying to ignore (Wegner 1994; Wegner andLane 2002). The avoidance of talking about strong feelings orimportant experiences has also been associated with autonom-ic arousal. For example, studies have found that suppressedanger increased blood pressure more than manifest anger(Vogele et al. 1997) and is also associated with increased pain(Quartana et al. 2010). The suppression of negative emotionsis also associated with compromised functioning of the im-mune system (Petrie et al. 2002; Petrie et al. 1998), whileemotional inhibition and reports of unusually low stress areassociated with elevated levels of muscular bracing andmyofascial pain (Traue 2002). Other studies have demonstrat-ed that emotional repression predicts poor outcome followingmultidisciplinary treatment for chronic pain (Burns 2000),higher levels of cardiac reactivity (Burns et al. 1999), hyper-tension (Gleiberman 2007), and with behavioral signs ofanxiety (Giese-Davis et al. 2014). A factor analytic study ofpatients with chronic pain identified one factor consisting ofpatients with high pain and disability but an absence of emo-tional distress (Burns et al. 2001). Patients who suppressemotions are also less likely to recall undesirable information

about their health (Millar 2006). Overall, while the interpre-tation of low scores is the cornerstone of neuropsychologicalassessment, the interpretation of low scores/low reports isoften overlooked when assessing patients with chronic pain.

Diagnostically, unusually low affective reports have beenassociated with a personality construct called “alexithymia,”meaning “without words for feelings” (Sifneos 1996).Research has established that alexithymia includes difficultyidentifying or describing feelings, externally oriented think-ing, and a limited capacity for imagination (Lumley et al.2007). Two studies have concluded that there is a consistentlink between alexithymia and somatization (Allen et al. 2011;Bailey and Henry 2007), while other studies concluded thatalexithymia contributes to the emergence of somatic symp-toms in major depression (Gulec et al. 2013), to somatizationafter brain injury (Wood et al. 2009), to unrecognized affectivedistress associated with pain (Lumley et al. 2002), to increasedillness behavior (Lumley et al. 1997), and to stronger electro-dermal response in biofeedback (Friedlander et al. 1997). Thisrelationship between alexithymia and somatization was alsosupported by the findings of a large population study (Mattilaet al. 2008). Although neither the DSM-5 (AmericanPsychiatric Association 2013), DSM-IV (AmericanPsychiatric Association 2000), nor the ICD-10 (WorldHealth Organization 2010) mentions alexithymia, all note thatsome somatizing patients may exhibit unexpectedly low levelsof affective distress, which is consistent with the above.

As an example of the effects of unrecognized affec-tive distress, a patient who is having an anxiety attackcould state emphatically that the symptoms are not dueto severe stress or anxiety and instead assert that she/heis having a heart attack. In such a scenario, the patientmay report extremely high physical distress but deny orbe unaware of the emotional origins of the symptom.The research reviewed above suggests that the denial ofthe affective component may actually increase the so-matic component of the symptoms, and this suggests aneed for the assessment of low affective scores.

Although some of the BHI 2 scales exhibit a truncateddistribution of scores below the mean, and a positive skew(e.g., Pain Complaints, Substance Abuse, and Survivor ofViolence), some are close to being normally distributed, withother scales exhibiting a negative skew (e.g., Defensiveness,Anxiety, and Perseverance) (Table 1). One BHI 2 scale,Perseverance, is negatively skewed to the degree that negativeT scores are possible (which occurs when a T score is morethan 5 standard deviations below the mean). Statistically,scores which are 5 standard deviations below the mean arejust as “abnormal” as scores which are 5 standard deviationsabove, and the studies reviewed above suggest that suchunusually low scores might be as clinically meaningful ashigh ones. The interpretation of such low scores is sometimesless clear, though.

Psychol. Inj. and Law (2014) 7:335–361 339

Table1

BHI2scalereliability,skew

andcorrelations

with

selectmeasures

Cronbach’s

alpha

Test-retest

stability

Bidirectional

skew

Correlatio

nwith

select

MMPI-2

measures

Correlatio

nwith

selectMCMI-IIImeasures

Correlatio

nwith

othermeasures

Self-disclosure

.97

.94

.061

F–Kindex

.69

Disclosure

.62

Defensiveness

.83

.93

−.081

Profile

elevation

−.62

Debasem

ent

−.56

SomaticCom

plaints

.93

.97

.848

Hy-ODANX

.76.66.74

McG

illPain

Questionnaire

.74

Pain

Com

plaints

.85

.95

.756

Scored

Pain

DrawingM

cGill

Pain

Questionnaire

.70.61

Functio

nal

Com

plaints

.82

.92

.335

SF-36Fu

nctio

nMBMDPain

SensitivityMBMDPsych

Referral

−.64

.52.52

MuscularBracing

.84

.94

−.106

ANX

.65

Depression

.91

.93

.512

D.70

Dysthym

icMajor

Depression

.71.67

Anxiety

.83

.90

−.108

ANX

.54

Hostility

.89

.88

.622

ANG

.67

Borderline

.86

.88

.476

Neg

TxIndicator

.66

Borderline

.62

Symptom

Dependency

.82

.88

−.034

Hy-OAPS

.54.44

Chronic

Maladjustment

.77

.94

.238

Pd.46

AntisocialA

lcohol

Dependence

.62.57

SubstanceAbuse

.75

.94

1.137

AAS

.55

Alcohol

Dependence

.40

Perseverance

.81

.93

−.167

Ego

Strength

Neg

TxIndicator

.51−.62

Family

Dysfunctio

n.81

.92

.478

FAM

Pd.70.58

Survivor

ofViolence

.79

.96

.560

FAM

.55

DoctorDissatisfaction

.84

.88

.244

JobDissatisfaction

.88

.97

.190

MinnesotaSatisfaction

Questionnaire

−.64

Adapted

from

Bruns

andDisorbio(2003)

andMillon

etal.(2010)

340 Psychol. Inj. and Law (2014) 7:335–361

While moderately low scores on the BHI 2 or other psy-chological measures may reflect that the patient is copingunusually well, as scores become very low or extremely low,a different type of adjustment problem may be indicated. Forexample, an utter absence of any perceived affective distresscould be explained as being attributable to extraordinary re-silience, or alternately to psychopathy, alexithymia, denial, ordissociation. In the clinical setting, as each of these alterna-tives is associated with different behaviors, behavioral obser-vations and the patient’s history might be needed to helpdetermine which interpretation is correct.

On all of the BHI 2 scales, the lowest possible raw score is0, and this can be a useful benchmark in interpretation. Forexample, in order for a patient to receive a raw score of 0 onHostility, the patient must have strongly disagreed with 16items having to do with anger. If, in an interview, a patientdenied ever having any angry thoughts, feelings, or behaviors16 times, it would seem remarkable. Consequently, scores thislow on the BHI 2 are empirically unusual, and often intuitivelyand clinically meaningful. Even so, the interpretation of lowpsychological scales scores is often problematic.

A final caveat here is that as a rule, there is far less researchon psychological measures about the interpretation of lowscores as opposed to high scores.

BHI 2 Interpretation Using Multiple Norm Groups

Any standard score compares the raw score of the individualto some reference group, and that comparison must be refer-enced when interpreting the score. When interpreting a pa-tient’s score, there are two questions to answer:

The first question to answer is “how does this patientcompare to other similar patients?” To the extent that a par-ticular patient is atypical, normal treatment protocols may notapply. Further, knowledge of how a patient differs from atypical patient can inform treatment decisions and assist inthe process of selecting patients for medical treatments. As ageneral psychometric principle, the closer the norm group to apatient’s status and circumstances, the more relevant theresult ing score (American Educational ResearchAssociation, American Psychological Association, NationalCouncil on Measurement in Education, and Joint Committeeon Standards for Educational and Psychological Testing(U.S.) 1999).

A second question that is sometimes overlooked is “howdoes this patient compare to the average healthy person?” Toassess the severity of a patient’s psychological condition, orthe degree to which a patient has been harmed by an injury, acomparison to a healthy state is required. This is because theeffect of a medical condition cannot be seen in a comparisonto other medical patients, as all have been affected by a similarloss of health. For example, if a patient who has had a recent

traumatic amputation reports an average level of PTSD com-pared to other patients with traumatic amputations, this aver-age level of PTSD does not mean that no PTSD is present.Instead, it means that compared to other amputees, the level ofPTSD is similar. If this same patient’s PTSD score was com-pared to the average person in the community, however, itmay be that the patient’s level of distress now appears quiteelevated. Overall, it can be seen that if the norm group isextreme, a patient with an extreme problem will appear nor-mal relative to that group, but that is not the same as a state ofhealth. This leads to the somewhat counterintuitive interpre-tive dilemma if a PTSD scale utilized a norm group consistingof extremely traumatized subjects, an average score would bepositive for PTSD.

A few tests used for the assessment of medical patientsattempt to address the questions above by having multiplenorm groups, notably the Minnesota Multiphasic PersonalityInventory-2 Restructured Form (MMPI-2-RF), the MillonBehavioral Medicine Diagnostic (MBMD), and the BHI 2.However, these tests all address this matter in different ways,with different advantages and disadvantages. For forensicassessment, the MMPI-2-RF includes disability litigant normsand spinal surgery norms (Ben-Porath and Tellegen 2011),while the MBMD utilizes both general medical and chronicpain norms (Millon et al. 2010). The BHI 2's use of normgroups is somewhat different than these measures, however(Bruns and Disorbio 2003), and is described below.

As opposed to utilizing a highly specific norm group, theBHI 2 patient norm group utilizes a more diverse cross sectionof patients in treatment for pain or injury, consisting of anapproximately equal number of patients with acute injuriesand chronic pain. This group included spinal surgery patients,nonspinal surgery patients, interventional pain medicine pa-tients, chronic pain patients, work hardening patients, acutepain patients, and brain injury patients, with 26 % being inlitigation. These patients were obtained from 90 sites in 30 USstates, recruiting patients from both facilities that treatedchronic pain and that treated acute injuries. Patients werestratified to match US Census demographics (Bruns andDisorbio 2003). This approach has broad applicability, be-cause patients referred for spinal presurgical evaluations mighthave acute conditions, while patients referred prior to spinalcord stimulation are invariably suffering from chronic pain,and litigation is common in the workers’ compensation andpersonal injury systems. Overall, this approach produced apsychometrically representative but less extreme normativesample that represented an attempt to depict the averagepatient in treatment for pain or injury. The second BHI 2 normgroup is the community norm group, which was also stratifiedto match US Census demographics (Bruns and Disorbio2003).

In addition to the two main normative groups, the BHI 2also includes eight smaller, narrowly focused reference

Psychol. Inj. and Law (2014) 7:335–361 341

groups. These are chronic pain, head injury/headache, neckinjury, upper extremity injury, low back injury, lower extrem-ity injury, fake good, and fake bad. These additional morenarrowly focused normative groups are integrated into theinterpretive analysis and used to address specific questions ifneeded.

The BHI 2 differs from other multi-norm tests in thatas opposed to having the user choose between alternativenorm groups, the BHI 2 patient and community normgroups are integrated into a single continuum. This isaccomplished in the following manner, using pain as anexample: Not surprisingly, the average patient in treatmentfor pain or injury reports more pain than does the averagenonpatient in the community. Even so, there are somePain Complaints scores on the BHI 2 that fall within thenormal range for both the patient and community normgroups. These levels of pain are designated as “averagescores.” As scores on the Pain Complaints scale increase,at some point, the level of pain reported will be unusualfor a healthy person but still commonly seen in patients intreatment for pain. As the level of Pain Complaints in-creases further, at some point, it will also become anunusual level of pain reports for a patient as well.

Conversely, with regard to interpreting low reports of pain,a patient may report less pain than does the average patient intreatment for pain or injury. As the Pain Complaints scores fallstill lower, however, the level of pain will not only be belowthe typical patient in treatment, but also below that seen in thetypical healthy person, which would be particularly unusual.Using this algorithm, the Pain Complaints scale integratesboth community and patient norms into a single continuum(Fig. 2). The BHI 2 integrated norm profile is interpreted asfollows, utilizing the profile shown in Fig. 3:

1. The BHI 2 profile uses a deviation bar chart, where thelength of the bar represents how far the patient’s scoredeviates from the mean score. Thus, statistically, the bar isa visual representation of a z score. The longer the bar, themore the score deviates from the mean in either a positiveor negative direction.

2. T scores within the shaded T=40 to T=60 range aretypical for the normative patient and communitysamples, and approximately 68 % of the samplesscored within this range.

3. Patient T scores are represented by black diamonds. Ablack diamond outside the average range indicates a levelof symptoms that is unusual for patients with pain andinjury. For unusual patients, the typical medical protocolmay not apply.

4. Community T scores are represented by white diamonds.Awhite diamond outside the average range indicates thatthe patient is different than the average nonpatient in thecommunity.

5. The Somatic Complaints scale score has the white dia-mond outside the average range (indicating a high scorefor community members), and the black dot inside theaverage range (indicating an average score for patients).Thus, while patients commonly report this level ofSomatic Complaints, healthy people do not.

6. In this profile, both diamonds are outside the averagerange for the Pain Complaints scale. This indicates thatthe patient is not only reporting more pain than the aver-age person in the community, but also reportingmore painthan the average patient in treatment for pain or injury.

7. The Hostility scale score was the lowest score observed inthis administration, being at the first percentile, indicatinga remarkable absence of any reported anger or irritability.It should be noted that the raw score on this scale was 0,the lowest possible score. Thus, the patient must havestrongly disagreed with all 16 items, which is statisticallyvery unusual.

In general, community norms are more sensitive withregard to detecting low levels of problematic symptomsthan are the patient norms, but at the risk of increased falsepositive findings.

Extremely high symptom level for a patient (99th %)and extraordinarily high vs. a healthy state

Very high symptom level for a patient (95th %)and extremely high vs. a healthy state

High symptom level for a NONpatient (84th %)But average for a patient

Very low symptom level for a patient (5th %)and even low for a healthier NONpatient

Average range of symptomatic complaintsreported by both patients and NONpatients

High symptom level for a patient (84th %)and very high vs. a healthy state

Low symptom level for a patient (16th %)But average for healthier NONpatients

Extremely low symptom level for a patient (1st %)and even far below that seen in NONpatients

Fig. 2 The interpretive continuum of BHI 2 scale scores using integratedpatient and nonpatient norm groups

342 Psychol. Inj. and Law (2014) 7:335–361

BHI 2 Scale Interpretation

The following section provides an overview of the BHI 2 scales.This will include a brief synopsis of the scales’ rationale anddevelopment process, validity research, and interpretive consi-derations. Except as otherwise noted, the information presentedbelow was derived from the BHI 2 validation study (Bruns andDisorbio 2003). An overview of each scale’s reliability, and itscorrelates and bidirectional skew is summarized in Table 1.

Validity Scales and Methods

Validity Items

Development The BHI 2 utilizes two separate validity condi-tions to determine whether or not a protocol can be meaning-fully interpreted. The first condition has to do with bizarreresponding, while the second has to do with failure to respond(i.e., leaving items blank). With regard to the first condition,the BHI 2 contains four Validity Items, which have extreme orbizarre content and are rarely endorsed. While a patient witha thought disorder might endorse one or more of these items,an alternate interpretation is that the patient was responding inthe aberrant direction on these items due to illiteracy, randomresponding, visual/cognitive problems, or poor motivation.

Scale Interpretation When a patient endorses one or more ofthe Validity Items, the item is printed out for the clinician toreview along with a validity caution. If three or more of theseitems are endorsed, the entire BHI 2 is regarded as invalid dueto bizarre responding. If this method determines that the BHI 2administration is valid overall, the scales are next testedindividually.

Blank Responses

Method The second validity condition occurs when a patientfails to respond to a number of items. Based on this method,the BHI 2 scales are invalidated one at a time. If any scale has25 % or more of its items left blank, that scale is judged to beinvalid and is not scored. This allows the BHI 2 to invalidateone scale at a time based on the blank item condition, ratherthan invalidate the entire test if one scale was left blank. TheBHI 2 computer algorithms will generate an interpretive re-port of the information available if one or more scales arevalid. This reduces the risk that a test administration willproduce no usable results. If all 18 scales are invalid due toblank items, then the entire BHI 2 protocol is invalid. Notethat if the patient is not in the workforce now or at the time ofonset of the condition, the test instructs the patient to leave theJob Dissatisfaction scale blank. This scale is then designated

Muscular Bracing %

%%%

%%

%%%

%

%

%

%

%

%%

%

%81187

3644

8994

78

97

8719

1

6394

51

70

94

Average5043

67

674237

67718176

684529

55

69

525665

9113

18

1334

28512220

2510

0

15

15

116

39

4749

65

623735

636668

57

624228

53

65

505466

Self-DisclosureAverageDefensiveness

50

AnxietyHostility

DepressionAverageExt. Low

High

LowLowHigh

HighMod. High

High

High

Average

Average

Average

Very HighVery High

Job DissatisfactionDoctor DissatisfactionSurvivor of Violence

Pain ComplaintsSomatic Complaints

10

Perseverance

Symptom Dependency

Substance Abuse

Chronic Maladjustment

Borderline

Affective Scales

Physical Symptom Scales

ScalesComm.

T Scores Percentile

Patient Profile

Patient

Battery for Health Improvement 2

ScoreRaw

Validity Scales

Character Scales

T-Score Profile Rating

Psychosocial Scales

906040

Functional Complaints

Family Dysfunction High 92

Fig. 3 BHI 2 profile of patient with chronic pain

Psychol. Inj. and Law (2014) 7:335–361 343

as invalid, while the remainder of the BHI 2 scales areinterpreted.

Defensiveness

Development The Defensiveness scale was developed empir-ically to assess both positive and negative response distortionsusing the following method. Patients in treatment for pain andinjury were recruited and asked to subtly fake the BHI 2 goodor bad, being cautioned that if their faking was too obvious,they might be caught and they should try to avoid that. Thismethod was used as research has shown that if patients thinkthat they will be undergoing assessment for faking, they areable to feign deficits in a way that is both less exaggerated andmore believable (Youngjohn et al. 1999). Both groups ofpatients were then asked 475 questions, and items that wereable to significantly differentiate both fake good and fake badscenarios from patients were selected for the BHI 2Defensiveness scale (Bruns and Disorbio 2003).

Scale Interpretation High scores suggest a positive bias (fak-ing good), and low scores a negative bias (faking bad). Thisscale is highly bidirectional and negatively skewed. Patientswho are low in Defensiveness are describing their life andcircumstances as terrible, while patients who are high inDefensiveness describe their life and circumstances as great.In either case, however, the Defensiveness scale does notcontain items pertaining to personally sensitive information,so neither high nor low scores involve much self-disclosure.In the validity section of the BHI 2 report, unusualDefensiveness scores are compared to the two faking refer-ence groups, producing a subtle fake good percentile rank or asubtle fake bad percentile rank. This makes it possible for theexaminer to better interpret any response bias in the patient’sBHI 2 profile.

Validity Research At cross-validation, the Defensivenessscale was able to significantly differentiate subtle fake goodversus patient groups and subtle fake bad versus patientgroups significantly at p

Overland et al. 2012), inactivity (McBeth et al. 2010), com-plaints of nonmusculoskeletal medical problems (Kadam et al.2005), greater medical utilization (Kadam et al. 2005), auto-nomic dysfunction (McBeth et al. 2007), occupational disabil-ity (Mayer et al. 2008), Waddell signs (Chan et al. 1993),treatment outcome (Takata and Hirotani 1995; Voorhies et al.2007), performance on isokinetic measures of strength andfunction (Ohnmeiss et al. 2000), and continuing chronic pain12 years in the future (Andersson 2004). As pain has beenidentified by two systemic reviews as an important predictorof poor outcome from spinal surgery (Celestin et al. 2009; denBoer et al. 2006), a principle goal of the BHI 2 was to developa multidimensional assessment of pain. The BHI 2 utilizes ahybrid approach to assess both pain intensity like a VAS/NRS,and pain distribution like a pain drawing. To accomplish this,the BHI 2 Pain Complaints scale asks about pain intensity inten different body areas, which provides a composite score.

Interpretation High scores on the Pain Complaints scale in-dicate widespread pain in multiple body areas. This pattern ofdiffuse pain complaints can be observed in patients withdiffuse rheumatoid arthritis, fibromyalgia, and chronic paingenerally. This diffuse pattern of pain is difficult to explain inpatients with a localized injury and suggests the possibilitythat central sensitization2 may be contributing to pain percep-tion. Low scores on the Pain Complaints scale indicate that thepatient is unusually pain free, possibly suggesting stoicism orreluctance to share information about pain.

Validity Research The Pain Complaints scale correlated to .70with a scored pain drawing, and to .61 with the McGill PainQuestionnaire. The number of body areas with pain on thisscale was also determined by one study to be a significantpredictor of a failure to make functional improvements fol-lowing interdisciplinary treatment (Freedenfeld et al. 2002).Patients who are faking good tend to get lower scores on PainComplaints (Disorbio et al. 2014). Patients with both cancer-related and noncancer-related breakthrough pain also scoredhigher on Pain Complaints (Portenoy et al. 2010).

Other BHI 2 Pain Measures

Highest Pain, Lowest Pain, and Pain Now Similar to theBrief Pain Inventory (Cleeland 2009), the BHI 2 asks thepatient to rate his/her highest, lowest, and current pain levels.BHI 2 Highest Pain levels have been positively associated

with breakthrough pain (Portenoy et al. 2010), with wantingpain medication (Bruns et al. 2013), with medication noncom-pliance (Bruns et al. 2013), with smoking (Fishbain et al.2013), with pain catastrophizing (Bruns et al. 2013), and withboth delayed sleep onset and frequent awakenings (Bruns andBruns 2011).

Pain Range Pain Range assesses the variability of the pa-tient’s pain complaints by comparing the difference betweenthe patient’s highest and lowest pain reports in the last month.If a patient’s Pain Range score is empirically low (6), it raisesthe question as to what circumstances produce the unusualpain variation. One study found that pain variability is asso-ciated with depression and more severe pain (Zakoscielna andParmelee 2013). However, the BHI 2 Pain Range measure hasnot been empirically investigated itself.

Pain Tolerance Index The Pain Tolerance Index (PTI) is aBHI 2 measure of pain intolerance. The BHI 2 PTI scorecorrelated significantly with depression, anxiety, somatiza-tion, quality of life, disability, pain interference, and withphysical difficulties with functioning (Bruns et al. 2005).PTI norms and reliability have been developed (Disorbioet al. 2013).

Pain Diagnostic Category In the clinical setting, paindrawings are judged by visual inspection with regard tothe degree that they are displaying an “anatomical distri-bution” or not. In contrast, the BHI 2 assessment of the“anatomical distribution” of pain reports utilizes a comput-erized empirical approach. This analysis utilizes five BHI2 pain normative groups, which are head injury/headache,neck injury, upper extremity injury, low back injury, andlower extremity injury. This approach mathematically com-pares the distribution of a patient’s 10 pain reports on theBHI 2 to patients in various diagnostic categories, using aseries of discriminant functions. At cross-validation, thismethod accurately classified patients’ pain diagnostic cate-gory 81 % of the time (p

Somatic Complaints

Scale Development The items of the Somatic Complaintsscale were selected so that they represented a cross sectionof the physical symptomatology associated with psychologi-cally distressing conditions (e.g., somatization, physicalsymptoms of panic, generalized anxiety, and major depres-sion). Research on the report of somatization symptomsshows that these symptoms are associated with chronic pain(Fishbain et al. 2009a) and disability (Harris et al. 2009).Another study found that somatization predicts suicidalityeven when depression is controlled for (Chioqueta and Stiles2004). Somatization has also been identified by two systemicreviews as an important predictor of poor outcome from spinalsurgery (Celestin et al. 2009; den Boer et al. 2006)

Scale Interpretation A variety of medical and psychologicalconditions are associated with somatic distress. Depression,anxiety, and pain all have overlapping physical comorbiditiesin the form of physiological arousal, fatigue, difficulty con-centrating, loss of libido, and similar symptoms. A high scoreon the Somatic Complaints scale suggests that the patient isvery somatically distressed. This scale is only moderatelybidirectional, but low scores nevertheless suggest that thepatient is unusually symptom free and could be concernedabout reporting physical weaknesses or vulnerabilities.

Validity Research High BHI 2 Somatic Complaints scalescores are associated with having an uncertain diagnosis(Fishbain et al. 2010a), with fearing that the physician hasmissed something important (Fishbain et al. 2010a), withfeeling entitled to medical care at no cost (Fishbain et al.2014c), with frequent suicidal thoughts (Fishbain et al.2012b), with having a suicide plan (Fishbain et al. 2012b),with a history of suicide attempt (Fishbain et al. 2012b), withlitigious ideation in patients with acute pain (Fishbain et al.

2008), and with pain severity (Fishbain et al. 2014d). Recentresearch has hypothesized that somatic complaints such asthese are perhaps better conceptualized as comorbidities ofchronic pain, which are closely associated with the pain syn-drome (Fishbain et al. 2014a).

Functional Complaints

Scale Development In contrast to measures such as theOswestry (Fairbank and Pynsent 2000), or the SF-36Function Scale (Ware et al. 1993), which measure physicalimpairment (such as howmuch you can lift or how far can youcan walk), the BHI 2 Functional Complaints scale is focusedon assessing the perception of disability. This involves thebelief that one is unable to be gainfully employed and unableto adequately perform activities of daily living, whatever thatmight entail. Functioning was identified by two systemicreviews as an important predictor of poor outcome from spinalsurgery (Celestin et al. 2009; den Boer et al. 2006) and is theoutcome goal for most treatments in physical medicine.

Interpretation Patients with high scores on FunctionalComplaints perceive themselves as being disabled and unableto function at work, home, or both. Functional Complaints is abidirectional scale, and patients with low scores are denyingthat they have functional limits. When possible, the interpre-tation of the Functional Complaints scale should be performedin conjunction with whatever medical information is availableabout the patient’s objective ability to function. If there arelarge discrepancies between the patient’s perceived and actualphysical abilities, the greater these discrepancies, the morelikely it is that the perceptions of disability are attributable toan unrealistic cognitive appraisal of physical limitations.

Validity Research High scores on the BHI 2 FunctionalComplaints scale are associated with a perceived need of painmedication (Bruns et al. 2013), feeling entitled to medical careat no cost (Fishbain et al. 2014c), and breakthrough pain(Portenoy et al. 2010). The BHI 2 Functional Complaintsscale has strong negative correlation (−.62) with the SF 36Function scale, which measures functional ability rather thandisability (Bruns and Disorbio 2003).

Muscular Bracing

Scale Development Muscle tension has been called the mostdiscriminative symptom of generalized anxiety disorder.However, muscle tension has a complex relationship withanxiety, and perceptions of muscle tension may be eitherobjectively true or subjectively perceived (Pluess et al.2009). Perceived muscle tension is associated with diffusesubjective feelings of “tension,” which may be physical oraffective in nature. The Muscular Bracing scale was designed

Diagnostic probabilities

Head Injury/Headache 67%

Neck Injury 88%

Upper Extremity Injury 54%

Back Injury 22%

Lower Extremity Injury 16%

Pain Diagnostic Category

Predicted by BHI 2 Neck InjurySelected by Clinician Head Injury/Headache

Fig. 4 BHI 2 pain diagnostic analysis

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to assess this experience of feeling tense. The items on thescale were generated based on item content, refined using aninternal consistency method, and subsequently investigated inthe empirical studies listed below.

Interpretation Patients with high scores on muscular bracingare reporting perceptions of chronic problems with muscletension and being perceived by others as tense persons. Thismay be objectively true, or may correspond with a subjectivesense of tension, which is perceived as being muscular innature but may actually be more closely associated withanxious arousal. The Muscular Bracing scale is almost per-fectly normally distributed, with low scores indicating reportsof a complete lack of muscle tension and being perceived byothers as being unusually relaxed.

Validity Research The Muscular Bracing scale correlated to.65 with the Anxiety (ANX) scale of the MMPI-2. In addition,the Muscular Bracing scale correlated to .68, .59, .60, and .52with the BHI 2 Somatic Complaints, Anxiety, Depression, andHostility scales, respectively. High BHI 2 Muscular Bracingscale scores are associated with having an uncertain diagnosis(Fishbain et al. 2010a), with pain catastrophizing (Bruns et al.2013), with a history of childhood molestation in females withchronic pain (Fishbain et al. 2014b), and with wanting to diebecause of pain (Fishbain et al. 2012a). In one study, MuscularBracing was the strongest predictor of both delayed sleeponset and of unrefreshing sleep (Bruns and Bruns 2011).

Affective Scales

It has been estimated that about 30 % of the variance inpsychological tests results was attributable to difficulties withphysical functioning (Naliboff et al. 1982), and as a result,many psychological tests are influenced heavily by a diseaseor injury, its sequelae, and medication side effects as opposedto the patient’s psychological condition (Turk and Melzack1992). When constructing the BHI, controlling for such falsepositive findings was a priority.

The assessment of depression and anxiety is particularlyconfounded by medical symptomatology. In order to controlfor this, the BHI 2 includes two separate measures for bothdepression and anxiety. The BHI 2 Depression and Anxietyscales focus on thoughts and feelings, and measure what couldbe thought of as phenomenological depression/anxiety. Twoseparate measures, Vegetative Depression and AutonomicAnxiety, are subscales of Somatic Complaints and includethe physical symptoms of depression and anxiety, respectively(e.g., fatigue, weight change, loss of libido, and racing heart).The advantage of this strategy is to reduce the risk of falsepositive findings on the Depression and Anxiety scales due tophysical symptoms of medical illness. The disadvantage ofthis approach is that by dividing both depression and anxiety

assessment into two separate scales, neither scale contains theentire diagnostic criteria. However, when both Depression/Vegetative Depression measures are elevated, or Anxiety/Autonomic Anxiety measures are elevated, this suggests thatcognitive, affective, and physiological symptoms of theseconditions are all present.

Depression

Scale Development Depression is an important variable tomeasure in patients with chronic pain, as there is a highprevalence of depressive symptoms in those with pain. TheBHI 2 Depression scale differs from most others in that it alsoincludes items pertaining to sad thoughts and feelings associ-ated with physical health problems. Depression was identifiedby two systemic reviews as an important predictor of pooroutcome from spinal surgery (Celestin et al. 2009; den Boeret al. 2006).

Scale Interpretation A high score on the BHI 2 Depressionscale indicates that the patient is aware of feeling subjectively sadand depressed and is reporting feelings of helplessness, difficul-ties with adjusting to health changes, bitter disappointment withhealth, anhedonia, and thoughts of suicide. In contrast, this scaleis moderately bidirectional, and a low score on Depressionindicates that the patient is denying having sad feelings ornegative thoughts and is reporting believing that the future seemsbright, feels energetic and optimistic, and feels that life is easyand satisfying. If a patient was reporting a serious medicalproblem, low scores would seem counterintuitive and couldpossibly reflect denial or alexithymic tendencies.

Validity Research The BHI 2 Depression scale correlated to.70 with the MMPI-2 Depression (D) scale, to .71 with theMCMI-III Dysthymic Disorder (D) scale, and to .67 with theMCMI-III Major Depression (CC) scale. High BHI 2Depression scores have been associated with wanting to die(Fishbain et al. 2012b), with wanting to die because of pain(Fishbain et al. 2012b), with wanting to die because life is hard(Fishbain et al. 2012b), with frequent suicidal thoughts(Fishbain et al. 2012b), with having a suicide plan (Fishbainet al. 2012b), with thoughts of suing a physician in acutepatients (Fishbain et al. 2008), with thoughts of killing aphysician (Bruns et al. 2010), with feeling entitled to not haveto wait to see a physician (Fishbain et al. 2014c), with failureto make functional improvements during interdisciplinarytreatment (Freedenfeld et al. 2002), and with breakthroughpain (Portenoy et al. 2010).

Anxiety

Scale Development The construct that the BHI 2 Anxietyscale might be most closely associated with is DSM-5

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Illness Anxiety, and to a lesser extent with fear avoidance.This scale includes items pertaining to worried and fearfulthoughts and feelings associated with physical health prob-lems, illness, and injury, including fears of dying. Anxiety wasidentified by two systemic reviews as an important predictorof poor outcome from spinal surgery (Celestin et al. 2009; denBoer et al. 2006)

Interpretation High scores on the Anxiety scale suggest aperson who is feeling fearful, restless, engages in self-protective behaviors, can have hypochondriacal fears of ill-ness, is prone to worrying, has multiple health fears, andworries that the medical condition may somehow lead todeath. Patients with high scores also have social fears as well.In contrast, patients with low scores on the anxiety scale arereporting being untroubled by worries or health concerns, notworrying about behaviorally guarding themselves so as toavoid injury, and not worrying about contracting illnesses.The BHI 2 Anxiety scale has a moderately bidirectionaldistribution.

Validity Research The BHI 2 Anxiety scale correlated to .54with the MMPI-2 Anxiety (ANX) scale. High BHI 2 Anxietyscale scores are associated with having an uncertain diagnosis(Fishbain et al. 2010a), with fearing that the physician hasmissed something important (Fishbain et al. 2010a), and withfeeling entitled to not have to wait to see a physician (Fishbainet al. 2014c).

Hostility

Scale Development The assessment of hostility was believedto be an important scale to include on the BHI 2, as anger andanxiety are the two components of the fight or flight response.A review of the concept of hostility revealed that it is brokendown into three components: angry feelings, cynical thoughts,and aggressive behaviors (Barefoot 1992). The BHI 2Hostility scale was constructed with items representing allthree of these components.

Interpretation High scores on the Hostility scale suggest apatient who has cynical thoughts about others, is prone toanger and irritability, is quick to take offense, and can respondto frustration with an irritable or even belligerent manner. Lowscores on the Hostility scale indicates that the person isreporting having faith in the kindness of others and beingpatient, long-suffering, and easy-going or passive. As withlow scores generally, unusually low reports of hostility can bethe product of an accurate self-report, denial, dissociation, oralexithymic tendencies.

Validity Research High BHI 2 Hostility scores have beenassociated with feelings of anger (Fishbain et al. 2011c), with

chronic anger (Fishbain et al. 2011c), with thoughts of killinga physician in patients (Bruns et al. 2010), with violent idea-tion generally (Bruns and Disorbio 2000; Bruns et al. 2007),with thoughts of homicide/suicide (Fishbain et al. 2011b),with frequent suicidal thoughts (Fishbain et al. 2012b), withthoughts of suing a physician (Fishbain et al. 2007), withfeeling entitled to not have to wait to see a physician(Fishbain et al. 2014c), with wanting to be totally pain free(Bruns et al. 2013), and with being oppositional (Bruns et al.2013).

Characterological Dysfunction Scales

The prevalence rate of personality disorder in the gen-eral population has been estimated as being between 5.9and 13.5 % (Dersh et al. 2002). In contrast, in fivestudies of patients with chronic pain, the prevalence rateof personality disorder ranged from 40 to 77 % (Dershet al. 2006; Fishbain et al. 1986; Large 1986; Okashaet al. 1999; Polatin et al. 1993). The DSM-5 uses theconcept of the “general personality disorder” to broadlydescribe the maladaptive traits that underlie all person-ality disorders (American Psychiatric Association 2013).The criteria for the general personality disorder involvetwo clusters of traits, with the first cluster of traitsbeing those involving emotional dysfunction and inter-personal conflict (represented by the BHI 2 Borderlinescale), and the second cluster of traits involving ahistory of poor impulse control and impairment in socialfunctioning, occupational achievement, and other areasof function (represented by the BHI 2 ChronicMaladjustment scale).

With regard to the assessment of personality disorders inpatients with chronic pain, a caveat here is that a recent studysuggested that following the onset of chronic pain patientsmay exhibit increased characterological dysfunction, whichmay in turn decrease if the pain is treated effectively (Fishbainet al. 2006).

Borderline

Scale Development By averaging the prevalence rates report-ed by eight separate studies, one study estimated that 30 % ofpatients with chronic pain also suffer from borderline person-ality disorder (Sansone and Sansone 2012). This study wenton to conclude that patients with borderline personality reporthigher levels of pain, theorizing that these patients may havedifficulty with self-regulating pain and may use the painsyndrome to solicit care from others. The items on the BHI2 Borderline scale were generated based on item content. TheBorderline scale items focus on aspects of this characterolog-ical disturbance that were thought to be especially relevant tothe physical rehabilitation setting. This included the loss of

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identity, self-destructive behaviors, and a tendency to develophighly conflicted relationships with others (splitting). Thisscale was refined using an internal consistency method andsubsequently investigated in the empirical studies listedbelow.

Interpretation High scores on the Borderline scale indicatepatients who report low self-esteem, difficulty regulating theirmoods, an intolerance for frustration, a history of conflictedrelationships with others, and a tendency to punish themselvesfor their own perceived weaknesses or defects. This is amoderately bidirectional scale, and low scores reflect claimsof an unusual absence of conflict or mood variations, whichcould be explained by excellent mental health and a strongsupport system, or alternately by an avoidance or denial ofconflict.

Validity Research The BHI 2 Borderline scale correlatedto .62 with the MCMI-III Borderline scale, to .60 withthe MMPI 2 Anxiety (ANX) scales, and to .61 with theMCMI-III Anger (ANG) and Family Problems (FAM)scales. High BHI 2 Borderline scores have been associ-ated with wanting to die (Fishbain et al. 2012b), withwanting to die because life is hard (Fishbain et al.2012b), with frequent suicidal thoughts (Fishbain et al.2012b), with having a suicide plan Fishbain et al.(2012b), with a history of suicide attempt (Fishbainet al. 2012b), with a preference for death over disability(Fishbain et al. 2012a), with chronic anger (Fishbainet al. 2011c), with thoughts of killing a physician(Bruns et al. 2010), with violent thoughts generally(Bruns and Disorbio 2000), with thoughts of homicide/suicide (Fishbain et al. 2011b), with thoughts of suing aphysician (Fishbain et al. 2007), and with medicationnonadherence (Fishbain et al. 2010b).

Chronic Maladjustment

Scale Development The BHI 2 Chronic Maladjustment scaleutilizes items inquiring about a history of difficulties in school,unstable relationships, vocational instability, unstable livingarrangements, financial irresponsibility, impulsivity, failed lifeplans, reckless disregard for safety, and incarceration. Thisscale has considerable diagnostic overlap with antisocial per-sonality. The items of the Chronic Maladjustment scale do nottap the violent aspects of antisocial personality but do focus onthe inability to attain common milestones of successful adultfunctioning seen in general, antisocial, and other personalitydisorders as well.

Interpretation Patients with high scores on the ChronicMaladjustment scale have reported a history of irresponsibleand impulsive behavior, and of failing to succeed in legal,

financial, educational, employment, relationship, and otheraspects of responsible adult life. These patients may be atgreater risk for failing to succeed in a demanding rehabilita-tion program as well. This scale is moderately bidirectional,and low scores indicate that the patient is claiming success inachieving most common milestones of a stable adult life, andto be a responsible social achiever who lives a conventionallife.

Validity Research The Chronic Maladjustment scale was cor-related to .62 with the MCMI-III Antisocial (6A) scale, to .46with the MMPI-2 Psychopathic Deviate (Pd) scale, and to .57and .55 with the MCMI-III Alcohol Dependence andBorderline scales, respectively. The Chronic Maladjustmentscale was also associated with a preference for death overdisability (Fishbain et al. 2012a), and noncompliance withmedication (Bruns et al. 2013).

Symptom Dependency

Scale Development The DSM-IV, DSM-5, and ICD 10 alldiscuss somatizing disorders with regard to the adoption of adependent role, which revolves around the patient’s somaticcomplaints. With regard to somatic symptom disorders, theDSM-5 states that “health concerns may assume a central rolein the individual’s life, becoming a feature of his or heridentity and dominating interpersonal relationships”(American Psychiatric Association 2013; p. 311). In a discus-sion of somatoform disorders, the DSM-IV states this some-what more succinctly, stating that some somatoform disorderscan lead to “dependency and the adoption of a sick role”(American Psychiatric Association 2000; p. 495). The BHI 2Symptom Dependency scale was not intended to assess de-pendent personality per se, but rather to assess how somepatients utilize their symptoms to form dependent attach-ments. The items on the BHI 2 Symptom Dependency scalewere generated based on item content and were refined usingan internal consistency method and subsequently investigat-ed in the empirical studies listed below. Passive copingwas identified by two systemic reviews as an importantpredictor of poor outcome from spinal surgery (Celestinet al. 2009; den Boer et al. 2006).

Interpretation Patients with high scores on the SymptomDependency scale are reporting symptoms that are refractoryto medical care, associated with life stressors, and for whichthey feel entitled to the support of others. This scale is mod-erately bidirectional, and low scores indicate reports that whensuffering from medical problems, the patient wants to be leftalone.

Validity Research The BHI 2 Symptom Dependency scale iscorrelated to .54, .48, .44, and .44 with the MMPI-2 Hysteria–

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Obvious (HyO) scale, Anxiety (A) scale, Addiction PotentialScale (APS), and Negative Treatment Indicators (TRT) scales,respectively. High scores on the BHI 2 Symptom Dependencyscale are associated with decreased likelihood of employmentin the 6 months following interdisciplinary treatment(Freedenfeld et al. 2002), with medical entitlement (Fishbainet al. 2014c), with violent ideation (Bruns et al. 2007), withbeing demanding (Bruns et al. 2013), and with sleep distur-bance and frequent awakenings (Bruns and Bruns 2011). Veryhigh Symptom Dependency scores have been identified as apossible indication of malingering (Rogers 2008).

Substance Abuse

Scale Development The majority of studies of risk factors forpoor medical recovery list substance abuse as a concern(Bruns and Disorbio 2009), with up to half of patients hospi-talized for traumatic injury being intoxicated at the time of theinjury, and two thirds having a history of substance abuse(Corrigan 1995). The Substance Abuse scale is composed oftwo blocks of items. The first block inquires into a history ofabusing alcohol and other substances, while a second set ofitems assesses current dependence on prescriptionmedication.This latter block of items differentiates this scale from mostother substance abuse scales. A remote history of substanceabuse increases the risk that an injury will result in disability(Upmark et al. 1999).

Interpretation A high score on the Substance Abuse scaleindicates that the patient is admitting a history of difficultiesassociated with chemical dependency, and current problemswith prescription medication. This admission does not meanthat the patient is currently suffering from addiction, but itmay increase the risk that the patient would revert to chemicaldependency as a means of coping with a medical problem.This scale is marginally bidirectional, and a low score indi-cates that the patient denies that his or her use of substanceshas ever been inappropriate or caused problems.

Validity Research The BHI 2 Substance Abuse scale correlat-ed to .55 with the MMPI-2 Addiction Admission Scale(AAS), and to .40 with the MCMI-III Alcohol Dependence(B) scale. The content of the BHI 2 Substance Abuse scalediffers from that of the aforementioned alcohol and drugaddiction scales in that it does not have items about addictivepersonality traits and includes some items about addiction toprescription medication. High scores on this scale are associ-ated with medication nonadherence (Fishbain et al. 2010b),and violent ideation (Bruns et al. 2007). A high score on thisscale also predicted a decreased likelihood of employment inthe 6 months following interdisciplinary treatment(Freedenfeld et al. 2002).

Perseverance

Scale Development The concept behind the BHI 2Perseverance scale combines the literature of several positivepsychological variables, which are optimism (Novy et al.1998), psychological hardiness (Callahan 2000; Kobasaet al. 1982), and self-efficacy (Bandura 1992). This scalecontains items representing optimism, hardiness, and self-efficacy, was refined using an internal consistency method,and subsequently investigated in the empirical studies listedbelow

Interpretation High scores on the Perseverance scale indicatethat the patient is reporting self-discipline, emotional resil-ience, and proactive conduct. Very high scores are empiricallyunusual and may involve exaggerated virtue or stubbornness.Perseverance is highly bidirectional, with negative T scoresbeing possible (which occurs when a T score is more than 5standard deviations below the mean). Low Perseverancescores indicate that the patient is reporting poor self-discipline,poor emotional coping, dysfunctional conduct, andhelplessness

Validity Research The BHI 2 Perseverance scale correlatesstrongly (.51) with the MMPI-2 Ego Strength (Es) scale.These scales are similar in that the Ego Strength scale assessestraits that include being reliable, determined, and self-confi-dent, while the Perseverance scale measures feelings of opti-mism, hardiness, and self-efficacy. The Perseverance scale isalso negatively correlated (−.62) with the MMPI-2 NegativeTreatment Indicators (TRT) scale. Extremely highPerseverance scores (thus claiming excessive virtue) havebeen identified as a possible indication of malingering(Rogers 2008). Low BHI 2 Perseverance scale scores areassociated with feelings of anger (Fishbain et al. 2011c), withwanting to die because life is hard (Fishbain et al. 2012b), withfrequent suicidal thoughts (Fishbain et al. 2012b), with apreference for death over disability (Fishbain et al. 2012a),with having an uncertain diagnosis (Fishbain et al. 2010a),with medication nonadherence (Fishbain et al. 2010b), andwith fearing that the physician has missed something impor-tant (Fishbain et al. 2010a).

Social Dysfunction Scales

The third part of the BHI 2 biopsychosocial assessment in-volves the assessment of social factors. The importance ofsocial support for the medical patient was established by ameta-analysis, which found that a supportive family substan-tially improved patient adherence with treatment (DiMatteo2004). Similarly, on the other hand, another study found thatsocial support was associatedwith decreased patient stress andimproved quality of life following surgery (Laxton and Perrin

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2003). Conversely, other studies have found that somatizationis more likely to occur when social conflicts are present (Liuet al. 2011). In the BHI 2 social dysfunction scales, weexplored the primary social domains relevant to the injuredpatient, which are the relationships with the family, the phy-sician, and the employer. Additionally, this part of the testassesses signs of a traumatic social history.

Family Dysfunction

Scale Development The Family Dysfunction scale assessesthe patient’s relationship to family, and the degree of supportthat may be available. When a patient is recovering from aninjury or illness, typically it is the family to which the patientturns for support during this difficult time. However, if thefamily is cold, uncaring, or abusive, or if family relationshipsare highly conflicted, this increases the stress on the patient.Research suggests that a supportive family can facilitate re-covery during a time when patients may be considerably lessfunctional, and more reliant on others (Abbasi et al. 2012;Elkayam et al. 1996). In contrast, a dysfunctional ornonsupportive family (which is being reported when there isa high score on the Family Dysfunction scale) can make thepatient’s circumstances during rehabilitation especially diffi-cult, and might increase the risk of poor recovery.

Interpretation High scores on the Family Dysfunction scaleare indicative of patients who report feeling unloved, unsup-ported, mistreated, or angered by their families. Perceptionssuch as these may give rise to feelings of insecurity, isolation,and vulnerability in the injured or physically ill patient. Giventhe intensity of conflicts present, these patients may relyheavily on their medical caregivers for meeting their securityand support needs.

Validity Research The Family Dysfunction scale correlatedhighly (.70) with the MMPI-2 Family Problems (FAM) scale.High BHI 2 Family Dysfunction scale scores are asso-ciated with medication nonadherence (Fishbain et al.2010b), and with a preference for death over disability(Fishbain et al. 2012a).

Survivor of Violence

Scale Development A series of US Centers for DiseaseControl studies have demonstrated a relationship betweenadverse childhood experiences (ACE), and morbidity andmortality decades later (Felitti et al. 1998). Other studies haveidentified a relationship between ACE and the appearance inadulthood of back pain (Schofferman et al. 1993), poor surgi-cal outcome (Schofferman et al. 1992), and conversion disor-der or somatization (Andreski et al. 1998; Kaplan et al. 2013;Ozcetin et al. 2009). PTSD in adulthood has also been shown

to be associated with chronic pain (Morasco et al. 2013). TheSurvivor of Violence scale is composed of it