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Chronic Pain andBiopsychosocial

Disorders

©2005 PPM Communications, Inc. Reprinted with permission. www.ppmjournal.com.

The journal wi th the pract i t ioner in mind.

Chronic Pain andBiopsychosocial

Disorders

VOLUME 5, ISSUE 7NOVEMBER/DECEMBER 2005

2Practical PAIN MANAGEMENT, Nov/Dec 2005

©2005 PPM Communications, Inc. Reprinted with permission.

Accounting for over 35 million of-fice visits a year, pain representsthe most prevalent reason why an

individual chooses to seek out medicaltreatment.1 So prevalent, in fact, researchhas shown that the cost associated with thetreatment of pain exceeds the costs at-tributable to the treatment of other dis-orders, such as heart disease, respiratorydisease, or cancer.2 Pain also represents acondition that has both medical and psy-chological components.

Chronic pain is widely regarded as abiopsychosocial disorder.3-8 Chronic painand associated disability are often life-al-tering conditions, have a profound psy-chosocial impact, and psychiatric condi-tions are common in such patients. Onestudy of an injured patient populationfound a 55% incidence of depression,9

where even minimal levels of depressionwere associated with increased rates of so-cial morbidity and service utilization.10

Another study reported that of 1595 in-jured patients, 64% had one or more di-agnosable psychiatric disorders, com-pared to a prevalence of 15% in the gen-eral population.11 In some cases, preex-isting psychological conditions may pre-dispose the patient to develop chronic

pain. In other cases however, the psycho-logical difficulties may be the conse-quence of the pain condition, itself.12

Thus, when pain appears in conjunctionwith stress, anxiety, depression or otherpsychiatric syndromes, the arrow ofcausality can sometimes point from painto psychiatric condition, and in othercases from psychiatric condition to pain.

Overall, the research literature suggeststhat psychological difficulties are com-mon among patients with pain. Left un-detected and untreated, these difficultiesmay impede a patient’s progress in treat-ment and lead to long-lasting symptoma-tology. Among those who report pain andinjury, psychosocial factors may play amajor role in delayed recovery. One studyof psychosocial factors demonstrated anability to accurately predict delayed re-covery for patients suffering acute pain91% of the time without using medical in-formation.13 Another study found thatpsychosocial factors play a dominant rolein surgical outcome.14 Lastly, in a WorldHealth Organization study of 25,916medical patients from around world, psy-chological factors were found to be astronger contributor to disability than wasdisease severity.15

While chronic pain is generally recog-nized as being a biopsychosocial phe-nomenon, what is often overlooked is thatillness, injury, psychological and socialfactors interact over the course of time toproduce distinctly different types ofbiopsychosocial disorders. Effective treat-ment requires that the clinician not onlyidentify the biological, psychological andsocial aspects of a condition, but also un-derstand how each component interacts.

Types of Biopsychosocial DisordersA classification system for biopsychosocialdisorders was created during the devel-opment of the Battery For Health Im-provement 2 (BHI™2). Unlike most psy-chological tests, which were designed toassess psychiatric disorders, the BHI 2 wasdesigned to assess biopsychosocial disor-ders in general, with particular attentionbeing paid to chronic pain disorders. Thedevelopment of the BHI 2 began with amodel of biopsychosocial disorders,which held that biological, psychologicaland social aspects of these disorders be-come intertwined, in various ways, overthe course of their history.

The BHI 2 model classified biopsy-chosocial disorders into four distinct

The BHI™2 Approach to Classification and Assessment

By Daniel Bruns, PsyD and John Mark Disorbio, EdD

types. Called psychomedical classifica-tion, this approach classified these disor-ders into a 2x2 schema (see Table 1). Thisdivided biopsychosocial disorders intoones that had either physical (physio-genic) or psychosocial (psychogenic) ori-gins. It also divided these disorders intoones where the mind-body connectionwas physical, as opposed to psychologi-cal.16 As part of this model, an overall par-adigm was developed to try to depict theinterrelationship of biopsychosocial vari-ables over the natural history of these dis-orders (see Figure 1).

Biopsychosocial Disorders with aPhysical OriginSome psychomedical disorders clearlyoriginate with a physical injury or diseaseprocess, and can be broken down into twosubtypes: organic biopsychosocial disor-ders and reactive biopsychosocial disor-ders. Both types can be described as phys-ical conditions that lead to the subsequentdevelopment of a psychological conditionand social consequences.

Organic biopsychosocial disorders arethose that begin with an organic condi-tion that affects the central nervous sys-tem and, in so doing, manifests itself cog-nitively or emotionally. Some organic psy-chological disorders are the result of in-jury, such as the memory loss or height-ened emotionality secondary to brain in-jury. In other cases, organic biopsychoso-cial disorders result from disease, such asdepression secondary to a bipolar disor-der. In these conditions, underlying or-ganic processes produce the psychologi-cal symptoms. For example, an organicbiopsychosocial disorder could begin withhypothyroidism. This hypothyroidismcould effect on the central nervous sys-tem, producing depression. This depres-sion could then impact the patient so-cially, both at home and in the workplace.

Reactive biopsychosocial disorders alsobegin with an objective disease or injury.In this case, there is no direct mechanismby which the disease process produces thepsychological complications. Instead,with reactive disorders it is the psycho-logical impact of the condition that pro-duces the psychological reaction. For ex-ample, suppose an injured patient withchronic pain has difficulty functioning,and as a result suffers the loss of a job.The patient may then react to the job losswith feelings of depression. In this case,even though the loss of the job and the

subsequent reactive depression was a con-sequence of the pain condition, there isno direct biological mechanism wherebythe disease directly causes the depression.In reactive biopsychosocial disorders, thepsychological symptoms are produced bythe patient’s perception of, and reactionto, the disease process and its conse-quences.12 Consistent with this, one studyfound that in a large cohort of patientswith pain-related disability, the preva-lence of major depression was 25 timeshigher than general population esti-mates.11

Biopsychosocial Disorders with aPsychological OriginIn contrast to disorders having a physicalorigin, a psychogenic disorder is one inwhich an individual’s psychologicalprocesses trigger the onset of a biopsy-chosocial disorder. Although the term“psychogenic” has negative connotationsfor some, this is unwarranted. There isnothing inherently “bad” about psycho-logical conditions. At the same time, whenpatients with psychogenic conditions per-sist in seeking a medical explanation fortheir symptoms, both patient and physi-cian are likely to become frustrated. Likephysiogenic conditions, psychogenic con-ditions are common, neither good norbad, and can benefit from care by appro-priate professionals.

There are two types of psychogenic dis-orders: psychophysiological and somatiz-ing disorders. Both types can be describedas psychological conditions that subse-quently lead to the development of phys-ical symptomatology.

Psychophysiological biopsychosocialdisorders have their origin in the psy-chosocial realm, but they come to have anobjective effect on the body through anorganic connection. This effect is gener-ally produced through the effects of the“fight or flight response” involving boththe autonomic nervous system and hor-mones associated with stress. Stress orstrong emotional reactions can cause hun-dreds of physiological changes in thebody, including accelerated heart rate, in-creased blood pressure and muscle ten-sion, cooling of the hands and feet due tovascular constriction, and rapid respira-tion, to name just a few.17,18 When the bodyexperiences psychophysiological reac-tions such as these, a variety of physicalsymptoms can result. Some psychophysi-ological disorders, such as tension

headaches, are extremely common. Othertypes of psychophysiological disorders in-clude temporomandibular joint pain sec-ondary to bruxing, stress-related heartpalpitations and functional dyspepsia.19

Somatizing biopsychosocial disordersdenote a group of disorders that, like psy-chophysiological disorders, have theirorigin in psychological processes. How-ever, they differ in that there are no de-tectable organic changes to the body. Thisgroup of disorders includes somatoformdisorders, anxiety or depression that ismanifested physically, and some types offactitious disorders.

In somatizing disorders, psychologicalprocesses give rise to the perception or re-port of physical symptoms, which the pa-tient interprets as organic in nature, eventhough no detectable organic disordersare present.20-22 Most somatizing disordersinvolve the misguided pursuit of a med-ical solution to a problem that is essen-tially psychological in nature. Personswith somatizing disorders have an under-lying psychological condition, which forconscious or unconscious reasons they donot acknowledge. They wrongly attributethe symptomatology of this psychologicalcondition to a medical disorder, while theunderlying psychological dynamics gounrecognized. This tendency to medical-ize symptoms may be reinforced by thepatient’s social environment.23

An example of a somatizing disorderwould be a patient with severe anxietywho repeatedly goes to an emergencyroom to be evaluated for a heart attack.This patient refuses to believe that thiscould be a psychiatric condition, and in-stead insists on repeated cardiac assess-ments. However, if the patient can be con-vinced that a particular organic conditionhas been ruled out, somatoform disorderscan “metastasize” into other body areasor organ systems, producing an evolvingpattern of diffuse symptoms. Thus, justwhen one disease is ruled out, a new andpuzzling symptom is reported. This mayrequire a consultation with another spe-cialist, and a new round of medical testsbegin. In this case, focusing on the phys-ical symptomatology enables the patientto avoid acknowledging the underlyinganxiety. Thus, the patient seeks a medicalexplanation that prevents the patientfrom having to admit that he or she hasany emotional weaknesses. Denying anypsychological conditions out of a deepsense of shame, somatizing patients in-

C h r o n i c P a i n a n d B i o p s y c h o s o c i a l D i s o r d e r s



stead save face by reframing these symp-toms as being signs of a medical condi-tion. They therefore seek the wrong kindof treatment, which ultimately is not whatis needed and, at best, offers only a calm-ing placebo value.

Patients with somatizing disorderssometimes do acknowledge emotionaldistress. When they do, though, they oftenregard any psychological difficulties asbeing the consequence of the reportedphysical conditions, rather than thecause. For example, sometimes a patientlike the one above might admit to beinganxious. In this case however, the twist isthat the patient says that the anxiety isdue to the fact that death could occur atany moment from a heart attack, andphysicians are refusing to listen! In sodoing, they deny that their condition hasa psychological origin. Thus, when pa-tients with somatizing disorders do ac-knowledge emotional distress, they por-tray any psychological difficulties as beingthe consequence of the reported physicalconditions (that is, a reactive disorder),which is the reverse of the actual state ofaffairs.

Another form of somatizing disorder isthe factitious disorder. In these disorders,psychological processes give rise to the re-port of physical symptoms. Such patientsare believed to be motivated by primarygain. That is, they find the idea of beinga patient to be intrinsically appealing, andreport or self-induce symptoms in orderto gain patient status. However, once pa-

tient status is achieved, significant sec-ondary gain may also be available.24

The Natural History of Biopsychosocial DisordersThe natural history of biopsychosocialdisorders often follows an identifiablepath. While there are four different typesof biopsychosocial disorders, their natu-ral histories share common threads. Dur-ing the development of the BHI 2, a par-adigm was developed to explain how bi-ological, psychological, and socialprocesses could interact over the courseof time to produce the various types ofbiopsychosocial disorders.

Factors Affecting Onset of Biopsychosocial DisordersIn the physically healthy person, psy-chosocial and behavioral factors may in-crease the risk of onset of a variety of phys-ical illnesses or injuries. For example, ifthe patient engages in an unhealthylifestyle with regard to diet, exercise, orstress, this increases the risk of a varietyof medical conditions. Other psychologi-cal factors may also increase the risk of in-jury.

One study found that up to half of alltraumatic brain injury hospitalizationsare associated with alcohol intoxication,while up to two thirds may have a historyof substance abuse.25 Patients reportingdrug or alcohol abuse were also found tobe more likely to sustain violent injuries.26

Other studies have also found that brain

injury was associated with increased lev-els of depression, anxiety disorders, sub-stance abuse and other psychiatric condi-tions.27 In the workplace, job dissatisfac-tion has been found to play a significantrole in the report of back pain.28

Chronic stress can give rise to the onsetof painful conditions through a variety ofpsychophysiological mechanisms, such aswhen emotional distress or stress-relatedmuscular bracing leads to pain.29,30 Addi-tionally, various psychological conditionscan increase the risk that physical symp-toms will be reported, even when no or-ganic pathology is present. One exampleof this would be a somatizing disordercalled alexithymia, where emotional painis not recognized, and is instead report-ed as physical pain.31,32 By whatever meanspain appears, once it does, the experienceof pain can be shaped by a variety of psy-chological and social forces.

Psychological reactions to illnessand injuryFollowing the onset of a serious illness orinjury, it is quite common for patients tohave a psychological reaction to it. Illness,injury, pain and distress can lead to a re-duction in the ability to function, in-creasing the disruption of work patterns,and leading to greater financial distress.33

Limitations in functioning can also leadto an alteration of family roles, and thismay cause friction within the family if thepatient cannot perform the tasks that heor she is expected to do.34,35 Finally, limi-




TYPE OFMIND-BODY CONNECTION

ORIGIN OF DISORDER

Physical Origin Psychological Origin

PhysicalConnection

Organic Psychological Disorders Psychophysiological Disorders

SampleTypes:

Depression due to severe brain injury orhypothyroidism

Chronic anxiety leads to muscular bracingand tension headaches

Mechanism: Illness or injury has direct effect on CNS,and on emotions, cognition, or personality

Chronic autonomic arousal or unhealthybehaviors lead to actual organic problems

PsychologicalConnection

Reactive Psychological Disorders Somatizing Disorders

SampleTypes:

Injury produces pain, disability and reactivedepression Psychogenic pain, somatization

Mechanism: Understandable emotional reaction to anobjective physical condition

Misperception or exaggerated report of phys-ical symptoms without organic basis, whichare driven by psychodynamics

TABLE 1. Chronic Pain and Types of Psychomedical Disorders. (Adapted from Bruns and Disorbio, 2003)

tations in functioning can interfere withrecreational activities, reducing the pa-tient’s available psychological outlets. Asa result, the onset of a medical conditionmay lead to anxiety over an uncertain fu-ture, anger about the perceived unfair-ness of the circumstances, and depressionover the difficulties in life. In addition towhatever physical symptoms are present,this emotional distress can increase thepatient’s overall level of suffering, and in-terfere with functioning.36

Complications Secondary to Psychological VulnerabilitiesThe course of a biopsychosocial disordermay intersect with preexisting psycholog-ical vulnerabilities. For example, if a pa-tient with chronic pain has had a historyof chemical dependency, and is subse-quently prescribed opioid analgesics, thepossibility of opioid abuse will need to beaddressed.37

Another psychological vulnerability is ahistory of chronic depression or anxiety.This affective vulnerability may increasethe intensity of the affective response topain or disability. Additionally, if a patienthas had chronic difficulties with express-ing emotions, this may precipitate a cri-sis,38 as he or she is now experiencing in-tense affective distress, without the abili-ty to articulate it. Emotional distress tendsto erode a patient’s adaptive energies, andreduce the ability to tolerate pain andfrustration. The resultant overall level ofperceived suffering, while in part beingattributable to physical symptoms, is alsoin part attributable to the emotional dis-tress the patient is experiencing.36

Some psychological vulnerability riskfactors have to do with certain cognitivetraits. For example, patients who have alow perceived sense of self-efficacy mayhave more difficulty adjusting to an ill-ness or injury, and perceive themselves asbeing unable to make the needed behav-ioral changes.39 Similarly, pessimism hasbeen found to be related to poor func-tioning.40 If a person believes that he orshe cannot do something, this may havea disabling effect. In contrast, persever-ance has been found to be associated withpositive outcomes from pain conditions.41

Numerous studies have found person-ality disorders to be closely associatedwith chronic pain and delayed recovery.For example, one study of injured pa-tient populations found a 51% incidenceof personality disorders,12 while other

studies found 70%11 and 77%,42 which arefar higher levels than those found in thegeneral population.11 As they are associ-ated with chronic maladaptive behavior,personality disorders are also thought tointerfere with recovering from illness orinjury.

A variety of other psychological traitscan also magnify how a patient may re-spond to the onset of a medical condition.Some patients are more prone to somati-zation or somatic preoccupation, and thismay magnify their perception of symp-toms. Additionally, some patients may bepain-intolerant, or feel entitled to bepain-free.43 The combination of beingpreoccupied with intolerable symptomstends to lead to a very distressed patientwith unrealistic expectations.

Overall, the effect of psychological vul-nerabilities is to increase the intensity ofproblematic psychological reactions tothe onset of a medical condition. Thesesame vulnerabilities can also interferewith treatment in a number of ways. Over-all, the effect of these vulnerabilities is toincrease the degree of psychosocial diffi-culties secondary to a medical condition,and in so doing, to delay recovery.

Influence of the Social EnvironmentA patient’s social environment can alsosignificantly influence the respond totreatment. Having a serious illness or in-jury can stress the family system,44,45 oftenrequiring other family members tochange and adapt. If a family is appro-priately supportive, this is not a problem.However, if family dysfunction is present,the patient’s elevated level of need athome may lead to conflict, and to failureof the family to offer support. Reports ofa history of being physically or sexuallyabused are also associated with chronicpain.46,47 Alternatively, an overly solicitousfamily may reinforce patient passivity, en-couraging the patient to adopt a disabledrole.48,49

The course of a pain condition is in-fluenced greatly by the doctor-patient re-lationship.50,51 If the physician is perceivedas being competent and supportive, pa-tient distress decreases. However, if a pa-tient feels that he or she is not being takenseriously, the patient may be motivated tomagnify the reports of pain or othersymptoms in order to persuade the physi-cian to take action. If the doctor-patientrelationship is able to overcome this ob-stacle, then the physician may be able to

guide this patient in the direction that isneeded. However, if this is not the case,this may plant the seeds for a growing dis-satisfaction with medical care, and in-crease the risk of noncompliance.

Another factor in the social environ-ment that cannot be overlooked is thepresence of secondary gain.52 Secondarygain is often equated with monetary gain,as is commonly seen when litigation ispresent, or when the patient may be eli-gible for disability benefits. However, an-other form of secondary gain occurs whenpatients use the report of their medicalsymptoms to gain the attention and sup-port of others. In this manner, the effectof social secondary gain is to allow the pa-tient to fulfill dependency needs.

For the dysfunctional patient in theworker’s compensation system, a cornu-copia of reinforcers are available. By re-porting work-related pain, a worker mayreceive time off with pay, light duty whenat work, gain control over hours worked,and be provided free opioids and fre-quent massages. Additionally, if the pa-tient does not do well in treatment, thiswill tend to increase the amount of anydisability settlement. For the typical re-sponsible individual, these are not temp-tations. However, the high level of per-sonality disorders in chronic pain patientssuggests that when antisocial or other dys-functional traits are present, these incen-tives can prove to be substantial barriersto recovery.11, 53

The Biopsychosocial VortexFor the patient who is psychologicallyhealthy, there are a numerous motivationsto recover. Patients are generally frustrat-ed with their physical symptoms and dif-ficulties with functioning. The desire tobe healthy motivates them to strive toovercome whatever hurdles are in theirpath. Most patients are able to perseverethrough the course of treatment and re-cover. However, in some cases, whetherdue to the severity of the medical condi-tion, incorrect diagnosis, inadequatetreatment, preexisting psychological vul-nerabilities, complicating psychologicalreactions, or factors in the social environ-ment, some patients fail to recover, andinstead enter a downward spiral (see Fig-ure 1).

A number of factors can contribute tothis downward spiral. First, some patientshave unrealistic expectations of a totalcure, or seek a cure that does not involve




effort on their own part. Such patients may have no desire toalter their lifestyle, perform unpleasant exercises, or take med-ications that have unpleasant side effects. When such patientsfail to persevere with more realistic treatment, and demand in-stead a magical solution, physicians may become frustrated andlose interest in treating the patient.

The patient may make some last efforts to cope with the symp-toms. There may be a further exaggeration of symptoms, seek-ing to motivate clinicians and family to be more responsive.However, if this does not lead to the ideal solution that is hopedfor, the patient may experience a growing sense of depressionand agitation mixed with severe insomnia, and feel that recov-ery is hopeless. The disgruntled patient may also develop agrowing sense of anger directed toward the medical profession,and by a desire for retribution on those who are blamed for caus-ing this condition.

At this point, whatever the patient’s objective medical condi-tion is, the psychosocial complications are so severe as to se-verely undermine any chances for a positive outcome. The ex-treme emotional distress may act to aggravate any underlyingmedical condition, magnify the perception of symptoms, andinterfere with compliance. Being physically and emotionally ex-hausted, the patient may feel too tired to exercise. Additional-ly, the patient at this point can become progressively more in-tolerant of pain, medication side effects, and the frustrations ofmedical treatment in general.

Because of these severe psychosocial complications, medicalconditions that might otherwise improve may thus become in-tractable biopsychosocial disorders. In some cases, even whenthe original organic condition has resolved, there can be en-during residual symptoms — maintained by the severe emo-tional distress and psychophysical complications—which remainrefractory to all care.

The Somatoform SolutionIn some cases, a patient may consciously or unconsciously ar-rive at a “somatoform solution” to life’s problems. In this sce-nario, psychosocial processes are reorganized around the reportof pain or other physical symptoms, and this becomes the modusoperandi for addressing a variety of life challenges. Like thechild who learns to complain of a tummy ache to avoid some-thing unpleasant at school, the somatoform patient comes touse the complaint of physical symptoms as a face-savings meansof interacting with the world. Some somatoform symptoms arequite benign and extremely common, such as using the reportof a physical symptom to excuse oneself from an undesirable so-cial event. In contrast, somatoform disorders can become muchmore serious in nature.

Through the complaint of pain or other physical symptoms,the somatoform solution may enable a patient to justify with-drawal from disliked home responsibilities, or escape from work-place stressors. Somatoform symptoms may provide a means ofcoercing others to provide the support that is desired, justify thereceipt of financial compensation, and enable the patient to as-sume a dependent role. For a patient who was unable to ade-quately express emotional needs before, somatoform symptomscan be a way of seeking the support of others without having todirectly express any underlying emotional needs. In some cases,somatoform symptoms become associated with feelings of enti-tlement, and the symptoms can consciously or unconsciously




empower the patient to extort compensation from others, or togain revenge on others for perceived injustices.

The somatoform solution may also offer various types of pri-mary (internal) gain. One type of primary gain involves inter-nal absolution, where the presence of pain or other physicalsymptoms can enable a patient to avoid guilt for what mightotherwise be considered to be irresponsible behavior. Similarly,exaggerated disability can be employed internally to justify workavoidance or maintain a self-righteous expectation that othersshould provide care. The somatoform solution may thus givethe patient permission to retreat from personal autonomy, be-come dependent, receive support and monetary compensation,and justify the abuse of prescription or illicit drugs. Beyond this,such patients may feel entitled to the admiration of others forhaving to endure the reported serious medical condition. Suchpatients are less apt to assume responsibility for their failures,instead blaming such failures on the unconscionable acts of oth-ers, who caused the injury, provided poor treatment, or who un-reasonably withheld their support. This may be a conscious orunconscious process, since such patients may not be cognizantof the degree to which their perceived physical symptomatol-ogy is produced by psychological processes.

Assessment and InterventionBiopsychosocial disorders are complex, and require a multidi-mensional assessment. The psychomedical classification systemand the biopsychosocial vortex described above were used to de-velop the BHI 2. The goal in BHI 2 development was to create,in one psychological test, the ability to assess the full spectrum

of psychological and social variables discussed in this paper. Thistest assesses 18 scales (see table 2), and numerous other vari-ables as well.

In order to make sense of the information generated by theBHI 2, part of the development of this test involved the cre-ation of a computerized software system to aid in interpretation.Using a technology, which is sometimes referred to as “narrowartificial intelligence,” the BHI 2 software examines over a hun-dred variables and then writes two plain language explanations,one for the clinician, and another for the patient. Unlike somepsychological tests, which conclude that somatoform disordersare present without taking medical findings into account, theBHI 2 was designed to be used in conjunction with medical tests.Since it was intended to assess biopsychosocial disorders, theBHI 2 computerized report addresses problems unique to theseconditions, such as considering the type of biopsychosocial dis-order, and addressing the “arrow of causality” problem notedabove.

While the BHI 2 offers a thorough evaluation of biopsy-chosocial disorders, it is too lengthy for some situations. Con-sequently, a shorter version, the Brief Battery For Health Im-provement 2 (BBHI™ 2) was also developed, which is better suit-ed for use in the fast pace of medical settings.54 The BBHI 2 canbe administered in 8-10 minutes, and provides a multidimen-sional assessment of pain, as well as assessing function, depres-sion, anxiety, somatization, symptom magnifying/minimizing,and 17 additional critical items. It can be used for both assess-ing biopsychosocial complications and for tracking treatmentoutcomes as well.

ConclusionThe psychomedical vortex provides a paradigm of how biopsy-chosocial disorders become intractable. Using this paradigm, avariety of interventions can be identified which may act to pre-vent a downward spiral into this vortex. Alternately, when aseemingly intractable condition has already appeared, thismodel can offer some suggestions as to how to identify the road-blocks to recovery, and where to intervene.

When chronic pain appears within the context of a biopsy-chosocial disorder, comprehensive assessment requires assess-ing all of the biological, psychological and social aspects of thecondition, and understanding the relationship between them.By correctly assessing the type of biopsychosocial disorder thatis being treated, and understanding the history of how it de-veloped, a more effective treatment plan can be developed. Re-search suggests that when the biological, psychological and so-cial aspects of disabling pain are all identified and adequatelyaddressed, even complex biopsychosocial disorders can be treat-ed successfully.55 !

Dr. Bruns is a psychologist who works with Health Psychology Associ-ates in Greeley, Colorado. He has worked with chronic pain patients forover 20 years and has also worked in work hardening and functionalrestoration rehabilitation programs. He has served on four Coloradostate task forces with the mission to create evidence-based medical guide-lines for patients with chronic pain and other conditions. Dr. Bruns hastaught graduate school classes in psychopathology and psychological as-sessment, currently works as a consultant to major medical corporations,and conducts workshops to train physicians in the assessment and treat-ment of biopsychosocial pain disorders. Dr. Bruns is the webmaster of




BHITM 2 SCALES

Scale Group Scale Name

Validity and symptom magnification

Defensiveness *Self Disclosure

Physical Symptoms Somatic Complaints * (somatization)

Pain Complaints *Function *Muscular Bracing

Affect Depression *Anxiety *Hostility

Character Disorders Borderline PersonalitySymptom DependencyChronic MaladjustmentSubstance AbusePerseverance

Social Environment Family DysfunctionSurvivor of ViolenceDoctor DissatisfactionJob Dissatisfaction

* Included on the BBHI 2

TABLE 2. BHI™2 Scales

healthpsych.com, and is the coauthor of theBHI 2, the BBHI 2, and the Momentary PainScale tests.

Dr. Disorbio is a psychologist who special-izes in the treatment of chronic pain patientsexhibiting delayed recovery. He has worked forover 20 years at an interdisciplinary outpa-tient clinic, Integrated Therapies in Denver,Colorado. During that time, he has been anactive member of the American Academy of Psy-chophysiology and Biofeedback and has re-ceived extensive training in self-regulationtechniques. Dr. Disorbio also works as a con-sultant to major medical corporations, con-ducts workshops to train physicians in the as-sessment and treatment of biopsychosocial paindisorders, and serves on the board of the Na-tional Pain Foundation. Dr. Disorbio is thecoauthor of the BHI 2, the BBHI 2, and theMomentary Pain Scale tests.

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BioPsychoSocial

Unrecognized Psychological Factors May Significantly Interfere with Patient TreatmentBioPsychoSocial Assessments for Medical Patients

DEPRESSION

ANXIETY

SOMATIZATION

PAIN

FUNCTION

QUALITY OF LIFE

BHI™ 2 BBHI™ 2 MBMD™ BSI® 18 P-3® QOLI®

Assessments can help you:

ASSESS patients:• Pre/post interventional

therapies

• In comparison to patients with similar conditions

EVALUATE :• Need for psychological

referral

• Outcomes

MONITOR :• Clinical effectiveness

of a treatment/procedure

• Pain scores in relation to functional status

• Efficacy of pain medication

chronic pain and biopsychosocial disorders - health...

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