The BHI is a 202 item psychological inventory designed for the assessment of medical patients. It is administered via paper and pencil, and takes about 25-35 minutes to complete. The BHI was developed over a 12 year period, and the present published version is the fifth version of the test. The BHI is published by Pearson Assessments, which is the sole distributor of the MMPI. The purpose of the BHI is to assess the interaction between medical and psychological factors. The BHI has now been superceded by the BHI 2, the second version of this test.
As part of the BHI scientific validation, data was gathered at over 90 sites in 36 US states. This produced two normative samples matched to US census data, one being a rehabilitation patient sample, and the other being a sample of persons in the community. This project was probably the largest single research study ever conducted of psychological factors effecting rehabilitation patients. It involved administering the BHI, MMPI-2, MCMI-III, Tennessee Self Concept Scale, Minnesota Satisfaction Questionnaire, Toronto Alexithymia Scale, McGill Pain questionnaire, a Projective Pain Drawing, as well as medical and other information from the patient sample. This data was used as the basis for the BHI test.
Research in the fields of psychology and medicine has indicated that psychological factors influence medical outcome in a variety of ways. Many studies have found that psychosocial factors have been more predictive of medical outcome than have medical diagnosis or other medical factors. As a result, there is a growing recognition in the medical protocols of a variety of organizations that psychological assessment and interventions play an important role in effectively treating chronic medical conditions.
The BHI was designed to facilitate the interdisciplinary treatment of medical patients. It can help a mental health professional know what questions to a physician, and can assist a medical professional in knowing when to make a psychological referral.
The MMPI-2 is the grand daddy of psychological tests. It is the most used psychological test, and over the last 50 years it has been the subject of an enormous amount of research. It is not likely that any psychological test will surpass the MMPI's research base in the foreseeable future. Why use anything else?
The MMPI and later the MMPI-2 were developed for the purpose of assessing a variety of psychological conditions such as hypochondria, depression, and schizophrenia. Like any test, the MMPI has advantages and disadvantages. No one test can do everything best. The MMPI's strength is certainly its scientific research basis. However, the MMPI was primarily designed to assess persons with psychological disorders. When the MMPI is administered to persons with medical disorders, interpretation becomes more difficult ( Naliboff, B. D., Cohen, M. J., Yellenan; 1982). A commonly sited difficulty is that the MMPI Hypochondriasis scale has a number of items that are potentially actual medical symptoms. As a result, a medical patient who is reporting actual medical symptoms is at higher risk for producing a false positive score. Thus, the presence of both psychological and medical diagnoses can make the interpretation of an MMPI profile more complicated. The MMPI is not alone in this difficulty, the same can be said of most psychological tests.
In contrast, the BHI was designed from it's inception to be a psychological test for medical patients. By focusing on this specific goal, it was possible to reduce the effects of certain confounding variables. The BHI was normed on two national samples, one being an injured patient sample, and the other being a community sample ("normals"). Both norm groups were randomly selected from a pool of subjects gathered from 36 states. The resulting samples closely approximated US Census statistics. This enables two kinds of comparisons. For example, the BHI can state that a patient is endorsing more depressive responses than does the average person in the community. This is what the MMPI and most other tests are able to do. Beyond this, however, the BHI is able to indicate whether a person is more or less depressed than the average patient in rehabilitation.
The advantage of the BHI is that by focusing on one kind of disorder, it is able to perform a more in-depth analysis. For example, the BHI Advanced Interpretation Guide suggests an algorithm that identifies 33,124 different somatoform profiles. Each of these profiles leads to clinical hypotheses which may clarify the underlying dynamics, and suggest interventions.
It should be noted here that medical patients are more likely to be depressed and anxious than their counterparts in the community (Bruns, Disorbio and Disorbio, 1996c; Maruta, 1989). This is not surprising, as a serious medical condition can be both frightening and discouraging. The question arises though as to how much depression is "normal" in the patient population? At present, the BHI can assess how depressed a given patient is compared to the average patient. Additional data which is presently unpublished will enable the comparison of many patient's profile not just with the average patient, but the average patient with the same diagnosis. This will make it possible to truly be comparing "apples to apples", and not apples to oranges.
In addition, the BHI physical symptom scales are designed to allow for "medical cross-validation". This enables a physician to examine the endorsed symptoms on any scale, and to compare this symptomatic report with what would be expected for that given patients medical condition. This makes it possible for a physical to make a determination as to whether the patient's responses to items involving pain in 10 body areas and symptoms in 9 categories match what would be expected for that person's medical condition. This can further reduce the risk of false positive scores.
One of the strengths of the BHI is its norms. The BHI patient normative sample included patients with the following characteristics:
During the test construction process, subjects assessed included persons suffering from
Data on the BHI was obtained over five successive rounds of test construction. The final phase of data collection was obtained from over 90 sites in 36 states. The community and the patient normative samples were randomly selected from this pool of subjects. The resulting samples closely matched US census data for sex, age, race and level of education. The information produced during this stage of test construction produced a spreadsheet with 2.4 million cells of data.
The 0-10 pain rating scale is widely used, but prior to the BHI, it had never been nationally normed and validated. As the BHI patient normative sample is a broad one which matches census data, it can be used as an estimate of what the average patient in rehabilitation is likely to report. This can assist the clinician in determining whether a patient's pain complaints are within the average range or not.
There is also a great deal of additional BHI data that remains to be published. This includes information about pain complaints by diagnosis. For example, this data contains the average pain profile for back pain patients, whiplash patients, and so on. There are many other interesting findings, such as differences between young and old persons with the same diagnosis, and differences between persons with the same diagnosis in different insurance systems (e.g. Work Comp vs private insurance). All of these findings are based on the BHI national patient sample.
Over the 10 year history of the BHI development, persons with a variety of diagnoses were assessed. The intent of the BHI was always to produce a psychological inventory for the assessment of medical patients. During the course of the Final BHI norming, however, the national patient sample was focused on patients in rehabilitation for pain or injuries. From the information we have available, there would appear to be a good deal of similarities across medical diagnoses. For example, regardless of diagnosis, there is a general tendency for patients with a serious medical condition to react with depression and anxiety.
A number of hypotheses remain to be tested scientifically. For example, we hypothesize that in general the degree of affective reaction to a medical condition is more closely associated with subjectively perceived severity of the condition, rather than the actual diagnosis. Thus, the degree of a patient's reactive depression may be more influenced by degree of threat the patient perceives with a particular diagnosis, than whether the patient is suffering from diabetes or a herniated disk. In the clinical setting, we have found that the BHI often gives very useful information about persons with a variety of non orthopedic diagnoses.
It is also worth pointing out here that the BHI items were written so as to be general in nature, so as to not preclude its use with any diagnosis. Outside of the BHI pain scale, the word "pain" appears in only 5 of the BHI's 202 items.
A few of the BHI questions are especially personal in nature. Perhaps the most personal of these are those items about having been abused at some point in your life. While these items are very sensitive, research and clinical experience indicates that this is important information to know. In a nutshell though, a history of rape or abuse may change how a patient feels about being examined or receiving certain kinds of manual therapies.
Although this is important information, is Sometimes Not Appropriate Situation To Be Asking These Questions. Under such circumstances, these items can simply be crossed out. The BHI can be scored without asking these items, and it will not invalidate the test.
More information about the BHI
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