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Multidimensional Pain Inventory

The Multidimensional Pain Inventory (MPI) (formerly referred to as the West Haven-Yale Multidimensional Pain Inventory; Kerns et al. 1985) is a 52-item inventory developed for the assessment of a patient's idiosyncratic appraisals of chronic pain. The instrument relies on components of the cognitive-behavioral approach to help understand and conceptualize pain. The instrument is used to examine a person's perceptions, appraisals, and emotions and behaviors associated with pain. Coping strategies used by the individual patient are also assessed, as are the patient's reactions to the responses of others to pain complaints. Not only does the MPI enable the examiner to understand the patient's view of his or her own pain, but it can also serve as a basis for the development of treatment interventions (e.g., to be used in psychotherapy).

Response patterns can reveal patient profiles that might become a focus of clinical attention. A dysfunctional profile reveals high levels of perceived pain, life interference from the pain, low levels of perceived life control, and subjective distress. An interpersonally distressed profile is likewise characterized by high levels of perceived pain and life interference, and patients with this profile perceive themselves as having low levels of social support. Last, an adaptive profile is one in which the patient perceives high levels of self-control, along with low levels of perceived pain and perceived life interference from the pain. The profiles summarized here can have predictive value in terms of treatment approaches and treatment outcomes (Bradley and McKendree-Smith 2001).

Fear-Avoidance Beliefs Questionnaire

The Fear-Avoidance Beliefs Questionnaire (FABQ; Waddell et al. 1993) is a 16-item instrument that assesses the beliefs and fears a patient associates with back pain. Each item is ranked along a 7-point Likert scale that ranges from "strongly agree" to "strongly disagree." The patient's beliefs and fears can have an impact on his or her range and extent of activity. The FABQ assesses fears the patient has about eliciting pain through behaviors required at work and in general activity. The higher the level of fear, the higher the level of the patient's perceived disability.

Coping Strategies Questionnaire

The Coping Strategies Questionnaire (Rosenstiel and Keefe 1983) is useful in assessing active (e.g., diverting one's attention, increasing the level of activity) and passive (e.g., praying, hoping, ignoring pain) coping strategies used by patients dealing with chronic pain. The instrument measures the extent to which maladaptive strategies (e.g., catastrophizing) or more adaptive strategies (e.g., reinterpreting the meaning of the pain and using coping self-statements) are employed. Thus, the scale can illustrate those strategies that are effective and that, therefore, should be maximized when dealing with pain. In addition, those strategies that are ineffective and maladaptive can be the focus of therapeutic interventions to foster modification of those strategies.

Minnesota Multiphasic Personality Inventory

The Minnesota Multiphasic Personality Inventory (MMPI; Hathaway et al. 1989) has been used extensively as an assessment tool for a variety of psychological disturbances. It is also among the most widely used assessment instruments in pain syndromes. The MMPI consists of 566 statements requiring true or false responses. The MMPI comprises 10 standard clinical scales assessing psychopathologic states, 3 validity scales, and 4 additional scales evaluating ego strength and other factors. Consultation with a psychologist trained in the administration and interpretation of the MMPI can be very helpful in the use of this instrument.

The MMPI's strength is its usefulness in identifying psychological factors that warrant clinical attention (e.g., drawing attention to those characteristics that might present barriers to treatment and that ultimately could require psy-chotherapeutic intervention) (see Table 3-8). The three scales that have the most relevance to patients with pain are Hypochondriasis (Scale 1), Depression (Scale 2), and Hysteria (Scale 3). High scores on Scale 1 suggest that patients, when emotionally distressed, symptomatically channel the distress into somatic complaints. Scale 2 may be an indicator of general distress, but elevated ratings on this scale can suggest a possible depressive disorder. Elevations on Scale 2 may suggest one is unhappy, pessimistic, and self-deprecating. Patients who score high on Scale 3 are characterologically prone to react by developing physical

Table 3-8. Uses of the Minnesota Multiphasic Personality Inventory for patients with chronic pain

Can be useful for

Identifying personality traits/temperament

Clarifying emotional characteristics

Clarifying psychological functioning of the patient

Determining whether psychological factors play a significant role in the pain Should not be used

For determining "real" versus functional (i.e., "psychogenic") pain As a stand-alone prescreening assessment of surgical or other treatment interventions

For predicting response outcomes for surgical or other treatment interventions symptoms when confronted with stress or uncomfortable emotions. Scales 1 and 3 are often related (Trimboli and Kilgore 1983).

The two most common patterns noted among patients with chronic pain are the conversion V and the neurotic triad (see Figure 3-4). In the conversion V pattern, elevated ratings on Scales 1 and 3, relative to that on Scale 2, form a valley or V shape when represented on an MMPI graphic profile. Despite use of the term conversion, it was never maintained that the pain complaints characterized features of a conversion disorder. Rather, persons with this profile endorse somatic concerns, develop physical complaints in the face of stress, often deny depressive symptoms, and often lack insight into their emotional states (Trim-boli and Kilgore 1983). By contrast, those with the neurotic triad pattern (i.e., with elevations on each of the three scales) have somatic preoccupations and neurovegetative symptoms of depression and are often demanding and complaining.

MMPI profiles may change as a patient makes the transition from acute to chronic pain, suggesting commensurate changes in the patient's psychological state over time. The MMPI patterns are modifiable with successful treatment (Naliboff et al. 1988).

Finally, although some empirical work has suggested that the MMPI can be useful in predicting response outcome to treatment interventions (e.g., surgery), its use has not uniformly demonstrated predictive value in this regard (Block et al. 2003). One argument against the interpretation of chronic pain profiles rests with the contention that the items of the MMPI have intrinsic bias—that the Hypochondriasis, Hysteria, and Depression scale items would be endorsed

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Conversion V pattern

Neurotic triad pattern

Figure 3—4. Common Minnesota Multiphasic Personality Inventory-2 profiles in chronic pain.

Note. In the first graph, the conversion V pattern is depicted by elevations in scales 1 (Hypochondriasis), 2 (Depression), and 3 (Hysteria), but with depression scores less than those of the other two scales creating a valley. In the second graph, the neurotic triad pattern is depicted by elevations in all three scales.

L, Lie Scale; F, Infrequency Scale; K, Suppressor Scale; 1, Hypochondriasis; 2, Depression; 3, Hysteria; 4, Psychopathic Deviance; 5, Masculinity—Femininity; 6, Paranoia; 7, Psychasthenia; 8, Schizophrenia; 9, Hypomania; 10, Social Introversion.

simply by virtue of the fact that the person is in pain (Smythe 1984). The endorsed items might simply replicate the patient's pain complaints and might not fundamentally characterize a personality prototype of the patient with chronic pain, nor would they necessarily predict treatment response.

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