Table 24–3. A brief sample of general classes and
common instruments for assessing psychological variables relevant
to adjustment and coping with chronic pain
General and specific measures of behavioral,
cognitive/attitudinal, and emotional coping
Vanderbilt Pain Management Inventory (Brown and Nicassio 1987Brown and Nicassio 1987) measures chronic pain coping strategies
(e.g., active, passive) and provides useful information for treatment
planning and recommendations.
Cognitive Coping Strategies Inventory (Butler et al. 1989Butler et al. 1989) assesses the degree to which patients engage
in adaptive and maladaptive cognitive coping strategies.
Coping Strategies Questionnaire (Rosensteil and Keefe 1983Rosensteil and Keefe 1983) rates the frequency of engagement in 48 different
behavioral and cognitive coping strategies in response to pain or
physical symptom experience.
Measures of general health functioning
Millon Behavioral Health Inventory (Millon 1999Millon 1999), one of the most frequently used health inventories
in the United States, provides information across four broad categories:
basic coping styles, psychogenic attitudes, specific disease syndromes,
and prognostic indices. It has good psychometric properties, a large
normative database of representative medical patients, with specific
disease scales developed for specific patient groups. It has recently
been upgraded to the Millon Behavioral Medicine Diagnostic test
(Millon et al. 2000Millon et al. 2000). It assists with identification
of significant psychiatric problems, making specific recommendations,
pinpointing personal and social assets to facilitate adjustment,
identifying medical regimen compliance problems, and structuring
posttreatment plans and self-care responsibilities in the patient's
Sickness Impact Profile (Bergner et al. 1981Bergner et al. 1981) is a behaviorally based measure of health status
designed to assess both psychosocial and physical dysfunction. It
has sound psychometric properties, is used widely with chronic pain
patients, and can provide relevant information regarding degree
of functional limitation in daily activity.
Illness Behavior Questionnaire (Pilowsky and Spence 1975Pilowsky and Spence 1975, 19761976), although not a pure
behavioral measure, does provide useful information about attitudes,
perceived reactions of others, and psychosocial variables. It delineates
seven factors that include general hypochondriasis, disease conviction, psychological
vs. somatic focusing, affective disturbance, affective inhibition,
denial, and irritability. In addition, it has value in identifying
patients who rely on illness behavior as a coping style for need
Specific pain domain inventories
Multidimensional Pain Inventory (Rudy and Turk 1989Rudy and Turk 1989) uses a biopsychosocial conceptualization to
assess relevant psychosocial, cognitive, and behavioral aspects
of responses to pain and includes specific norms for different statistically
derived chronic pain subtypes: interpersonally distressed with inadequate
social support, globally dysfunctional coping, and adaptive coping.
It includes specific norms, its classification system has been replicated
with another measure (Jamison et al. 1994Jamison et al. 1994), and an
inexpensive software scoring program is available (Rosensteil and Keefe 1983Rosensteil and Keefe 1983). This multiaxial classification system appears
to be a psychometrically sound and objective method of integrating
useful psychological information with data from multiple sources
and offers benefit for matching patients to types of pain management
interventions. The recent addition of a measure of defensiveness
seems to increase the inventory's validity (Hopwood et al. 2008Hopwood et al. 2008).
Profile of Chronic Pain: Extended Assessment
Battery (Ruehlman et al. 2005Ruehlman et al. 2005) is
an 86-item instrument with 1) 33 items assessing pain location and severity,
pain characteristics (e.g., worst daily pain), medication use, health
care status, the identity of the most important person in the patient's
life, and functional limitations in 10 areas of daily living; and
2) 13 multi-item subscales addressing aspects of coping (e.g., guarding,
ignoring, task persistence, and positive self-talk), catastrophizing,
pain attitudes and beliefs (including disability beliefs, belief
in a medical cure for pain, belief in pain control, and pain-induced
fear), and positive (tangible and emotional) and negative (insensitivity
and impatience) social responses. National stratified samples across three
age groups, two survey studies providing strong evidence for the
hypothesized factor structure, internal consistency, independence
from response bias, validity, and the presence of normative data
suggest good diagnostic and prescriptive utility.
Hendler Chronic Pain Screening Test (Green and Shellenberger 1991Green and Shellenberger 1991) assesses contribution of physical
vs. psychological variables to pain behavior expressions. It represents
a composite predictor approach for which ratings are derived. Higher
scores reflect less objective and strong psychologically influenced
or motivated pain behavior and suggest recommendations for conservative
treatments with multimodality treatment programs. Very high scores
typically require psychiatric referral and intervention.
Tampa Kinesiophobia Scale (Houben et al. 2005Houben et al. 2005; Todd 1998Todd 1998) is a quick screening
measure of unreasonable or irrational fear of pain and painful reinjury upon
physical movement. It assesses pain phobias or avoidance-conditioned
pain-related disability (i.e., unhealthy pain-maintaining habits
that are a major contributor to pain-related disability) and correlates
highly with similar measures. High scores, once malingering factors
are ruled out, signal the need for combination therapies with emphasis
on providing reeducation, countering maladaptive phobic responses,
and promoting adaptive attitudes and treatment participation/cooperation
(e.g., graduated exposure, cognitive reinterpretation, and systematic
Headache Disability Rating procedure
of Packard and Ham (Montgomery 1995Montgomery 1995) is a scale that
estimates impairment from headache rated on frequency, severity,
and duration of attacks and how activities affect functional skills
and activities of daily living. It includes a modifier variable
for rating motivation (i.e., treatment motivation, exaggeration/overconcern,
and legal interest) that is used to adjust the total impairment
Pain Disability Index (Tait et al. 1987Tait et al. 1987) is a brief instrument that assesses pain-related
disability. It shows good internal consistency in assessing both discretionary
activities and activities more basic to daily living and survival.
Fear-Avoidance Beliefs Questionnaire (Waddell et al. 1993Waddell et al. 1993) is a reliable measure of fear-avoidance beliefs
about physical activity and work activity that predicts disability
in activities of daily living and at work, especially given high
level of distress. This is another measure that helps identify persons likely
to benefit from psychosocial interventions.
Pain Catastrophizing Scale (Sullivan et al. 1995Sullivan et al. 1995) is a brief, well-researched measure of the negative
mental set in the presence or anticipation of pain marked by magnification,
rumination, and helplessness. Higher catastrophizing is predictive
of higher pain intensity ratings, lower tolerance, higher analgesic
use, poorer physical functioning and greater disability, more reports
of pain interference, reduced ability to work and less general activity,
and higher psychological distress and psychosocial dysfunction.
Pain catastrophizing is a robust predictor of analgesic use, distress,
psychosocial dysfunction, and disability and is superior in comparisons
to disease severity, pain levels, age, sex, depression, or anxiety.
It also demonstrates benefit as a therapeutic measure of cognitive
restructuring (Tan et al. 2002Tan et al. 2002).
Chronic Pain Acceptance Questionnaire (Wicksell et al. 2009Wicksell et al. 2009) is a brief and psychometrically sound measure
of the components of pain severity, interference, and emotional
burden. Its two scales, activities engagement and pain willingness,
as well as the total scale, were found to be strongly associated
with pain intensity, disability, depression, and life satisfaction
measures and explained more variance in one study than a measure
of kinesiophobia (Vowles et al. 2008Vowles et al. 2008).
General psychological measures: mood,
anger, and anxiety
Zung Self-Rating Depression Scale (Zeigler and Paolo 1995Zeigler and Paolo 1995) appears well suited for medical settings
and has advantages over other measures: it is shorter and simpler
to administer and score, is at a lower reading level, fits well
with medical and injury situations, and can be easily administered
in an interview format. Items are self-ratings ranging from 1 to
4 ("Not at all" to "Most/all
of time") and scored in the direction of increased depressive
symptomatology (>40 raw score suggests mild depression).
Beck Depression Inventory-2 (Beck et al. 1961Beck et al. 1961) is a common self-report measure that assesses
depressive symptomatology. It has been reported to differentiate
chronic pain patients with and without major depression (Fordyce 1979Fordyce 1979) (optimal cutoff score of 21) and has well-documented
State-Trait Anger Expression Inventory-2 (Skevington 1990Skevington 1990), as well as its recent update, is a reliable, well-normed
instrument for assessing the experience, expression, and control
of both current state and trait anger, an underappreciated concomitant
of chronic pain. Anger Expression and Anger Control scales assess
four relatively independent anger-related traits: 1) expressing
anger outwardly, 2) holding anger in, 3) controlling outward expression,
and 4) controlling internal angry feelings. It provides information
regarding how experience, expression, and control of anger may contribute
to psychophysiological arousal and symptoms and increase risk for
developing somatic symptoms and medical problems. Indirectly, it
offers suggestions for the direction of appropriate interventions.
Beck Anxiety Inventory (Spielberger 1999Spielberger 1999) is a screening measure of severity of patient anxiety.
Specifically designed to reduce overlap with symptoms of depression,
it assesses both physiological and cognitive components of anxiety
in 21 items describing subjective, somatic, or panic-related symptoms. It
reliably differentiates anxious and nonanxious groups in a variety
of clinical settings.
Perceived Stress Scale (Cocchiarella and Andersson 2001Cocchiarella and Andersson 2001) is a widely used instrument for measuring
the degree to which situations in one's life are appraised
as stressful. Items measure how unpredictable, uncontrollable, and
overloaded respondents find their lives and directly query current
levels of experienced stress. Higher scores have been associated
with greater vulnerability to physical and psychological symptoms
after stressful life events.
Comprehensive personality assessment
Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
(Butcher et al. 1989Butcher et al. 1989; Dahlstrom et al. 1975Dahlstrom et al. 1975)
is the most widely used psychological assessment instrument in the
United States. The MMPI is a 567-item (true/false) objective
measure of personality function and emotional status with 10 clinical
and 7 validity scales that were derived through empirical discrimination.
Its predictive abilities are based on more than 50 years of actuarial
data collection and analysis. It is a sensitive measure of psychological
states, traits, and styles (e.g., excessive anxiety, tension, depression,
hostility and problematic anger, somatization tendencies, sociopathy,
substance abuse, deviant thinking and experience, social withdrawal).
Through configural interpretation of the relative scale elevations,
tentative hypotheses regarding personality and coping style and
relative degree of particular types of psychological disturbance
can be gleaned. Importantly, although the MMPI can and is frequently
misused and misinterpreted (e.g., application of psychiatric norms
to medical patients tends to beg psychiatric interpretations), it
represents one of the most useful adjuncts to personality assessment
and treatment planning. Although efforts to distinguish organic
vs. psychological causes for chronic pain and use of cookbook interpretations
on the basis of psychiatric patient normative data (Schreiber and Galai-Gat 1993Schreiber and Galai-Gat 1993; Vendrig 2000Vendrig 2000) represent
failed applications, other significant information regarding emotional
distress and coping styles can be derived.
Pain assessment measures with built-in
response bias indicators
Millon Behavioral Health Inventory (Millon 1999Millon 1999; Millon et al. 2000Millon et al. 2000) includes three built-in
Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
(Butcher et al. 1989Butcher et al. 1989) includes seven validity scales,
along with research and content scales that are potentially useful
in evaluation of response bias. Arbisi and Butcher (2004)Arbisi and Butcher (2004)
provided a rationale for the use of the MMPI in the comprehensive assessment
of chronic pain, including detection of response bias or malingering. Meyers et al. (2002)Meyers et al. (2002) provided evidence for an MMPI-derived validity index
specific to chronic pain patients.
Hendler Chronic Pain Screening Test (Green and Shellenberger 1991Green and Shellenberger 1991): is a measure on which scores of
21–31 suggest exaggeration of pain symptoms, while higher
scores suggest primary psychological influence of pain behavior.