How Psychological How Psychological Assessments Can Help Assessments Can Help

You With Those You With Those Puzzling PatientsPuzzling Patients

Add Your Name HereAdd Your Name Here

What Percent of Primary Care What Percent of Primary Care Visits Are Driven By Visits Are Driven By

Psychological Factors?Psychological Factors?

60%

40%

Medical Reason

Psychological Reason

Cummings & VandenBos, Cummings & VandenBos, 19811981

Of The 10 Most Common Physical Of The 10 Most Common Physical Complaints In Primary Care, Complaints In Primary Care,

What Percent Were Explained What Percent Were Explained Organically ?Organically ?

85%

15%

Organic Basis Found

No Organic Basis Found

Kroenke & Mangelsdorff, Kroenke & Mangelsdorff, 19891989

Primary care MDs Primary care MDs treat more patients treat more patients with psychological with psychological conditions than do conditions than do

mental health mental health professionals professionals

In The Fast Pace of Primary In The Fast Pace of Primary Care, Many Mental Health Care, Many Mental Health Patients Fall Through the Patients Fall Through the

CracksCracks Patients with psychological problems Patients with psychological problems

are difficult to treat in the primary are difficult to treat in the primary care systemcare system

As a result, psychiatric disorders are As a result, psychiatric disorders are overlooked by primary care overlooked by primary care physicians between 33% and 79% of physicians between 33% and 79% of the time (Higgins, 1994).the time (Higgins, 1994).

You Order Tests You Order Tests All Of The TimeAll Of The Time

X-rays, MRIs, Blood Tests,EKGs, X-rays, MRIs, Blood Tests,EKGs, etc.etc.

Ironically, what you see so oftenIronically, what you see so often

— Stress and Psych Problems —— Stress and Psych Problems —

is the one thing you cannot is the one thing you cannot order a test for.order a test for.

Until now.Until now.

True or False?True or False?

Since pain and depression are Since pain and depression are subjective states, they cannot be subjective states, they cannot be measured scientifically.measured scientifically.

FalseFalse

Psychometrics is the Psychometrics is the scientific method used scientific method used

to assess subjective to assess subjective states, such as pain, states, such as pain,

depression or anxiety.depression or anxiety.

How Good Are How Good Are Psychometric Tests?Psychometric Tests?

A review based on 125 meta-A review based on 125 meta-analyses and 800 studies concluded analyses and 800 studies concluded good psychometric tests are good psychometric tests are comparable to good medical tests in comparable to good medical tests in their ability to diagnose and predict their ability to diagnose and predict outcome (Meyer, et al, 2001)outcome (Meyer, et al, 2001)

Psychological factors are more Psychological factors are more reliable predictors of back pain than reliable predictors of back pain than imaging and diagnostic disc injection imaging and diagnostic disc injection (Carragee et al, 2004)(Carragee et al, 2004)

What is the Value of What is the Value of using Psychological using Psychological

TestsTests How much more difficult would you How much more difficult would you

life be if you didn’t have tests like x-life be if you didn’t have tests like x-rays or blood tests?rays or blood tests?

In the same way, psychometric tests In the same way, psychometric tests can help you assess subjective can help you assess subjective experiences, and identify experiences, and identify psychosocial complicationspsychosocial complications

New psychological tests, New psychological tests, like the BHIlike the BHI™™ 2 and BBHI 2 and BBHI™™

2, have been developed 2, have been developed specifically use with specifically use with medical patients…medical patients…

and can help to answer and can help to answer many of your questions.many of your questions.

Is This Patient’s Level Of Pain High?Is This Patient’s Level Of Pain High?

Is this pain higher than Is this pain higher than the average patient?the average patient?

Is it higher than the Is it higher than the average healthy person?average healthy person?

What is the patient’s pain What is the patient’s pain percentile rank?percentile rank?

A BHI 2 could answer A BHI 2 could answer these questionsthese questions

10 = Bad Pain

0 = No Pain

8

9

7

5

6

3

1

2

4

Rate Your PainRate Your Pain

What Psych Conditions What Psych Conditions Bring Patients into Bring Patients into

Primary Care?Primary Care?

Chronic Pain/ Somatization

25%

Family Problems

10%

Job Stress 10%

Anxiety20%

Depression 20%

Misc 15%

Tulkin and Gordon, Tulkin and Gordon, 19981998

Miscellaneous includes substance abuse & personality disorders

Only The BHI 2 Assesses All Of These Variables

The BHI 2 was designed The BHI 2 was designed to help psychologists and to help psychologists and

physicians collaboratephysicians collaborate It can help to answer a physician’s It can help to answer a physician’s

questionsquestions

It points out to the psychologist what It points out to the psychologist what info is needed from the physicianinfo is needed from the physician

The Health PsychologyThe Health PsychologyArrow of Causality:Arrow of Causality:Which Comes First?Which Comes First?

Severe Physical

Symptoms

Extreme Anxiety

Only the BHI 2 and BBHI 2 Only the BHI 2 and BBHI 2 interpret both possibilitiesinterpret both possibilities

The BHI 2 and BBHI 2 The BHI 2 and BBHI 2 allow you to track allow you to track

changes in painchanges in pain

The BHI 2 Was Designed to The BHI 2 Was Designed to Assess Common Psychological Assess Common Psychological

ConcernsConcerns

DepressionDepression AnxietyAnxiety Family DysfunctionFamily Dysfunction Survivor of ViolenceSurvivor of Violence Borderline personalityBorderline personality Etc.Etc.

They Were Also Designed to They Were Also Designed to Assess Common Medical Assess Common Medical

Concerns.Concerns. PainPain

Including percentile rank, variability and Including percentile rank, variability and distributiondistribution

FunctioningFunctioning SomatizationSomatization Satisfaction with medical careSatisfaction with medical care Prescription abusePrescription abuse Muscular Bracing Muscular Bracing

Tension headaches, myofascial pain, TMJTension headaches, myofascial pain, TMJ Etc.Etc.

For Those Patients Who For Those Patients Who Are Especially PuzzlingAre Especially Puzzling

60%

40%

Medical Reason

Psychological Reason

40%

60%

Medical Reason

Psychological Reason

A certain percentage of psychologically-involved patients may be difficult for you to figure out. A referral for a BHI 2 test might shed some light on the matter.

Case HxCase Hx

39 Year old female. Somatization?39 Year old female. Somatization? diffuse physical symptomsdiffuse physical symptoms no objective medical findingsno objective medical findings resists examinationresists examination noncompliant with PTnoncompliant with PT no response to any treatmentno response to any treatment

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On the BHI 2 On the BHI 2 bidirectionalbidirectional scales, the scales, the length of the bar shows length of the bar shows

how far the score how far the score deviates from the mean.deviates from the mean.

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Case History 1: ValidityCase History 1: Validity

These validity scoresgive no indication of

biased responding

Validity Scales

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Case History 1: Physical Sx ScaleCase History 1: Physical Sx Scale

Unusually high level of diffuse somatic symptoms, coupled with

great difficulties functioning

Physical Symptom Scales

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Case History 1: Affective scalesCase History 1: Affective scales

Reports of depression Reports of depression are are higherhigher than 87% of than 87% of

patientspatients

Affective Scales

Very Very lowlow level of anger. Total absence of anger, level of anger. Total absence of anger, or difficulty expressing angry feelings?or difficulty expressing angry feelings?

(Somatization often involves denied feelings)(Somatization often involves denied feelings)

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Case History 1: Psychosocial ScalesCase History 1: Psychosocial Scales

Psychosocial Scales The patient reports a history of

trauma and abuse. Is that why she hates being examined?

The patient views the workplace and medical setting as being supportive.

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Case History 1: Character ScalesCase History 1: Character Scales

Character Scales Symptom Dependency High =

using symptoms to meet dependency needs

Perseverance High = still showing some

determination and optimism

TreatmentTreatment

During examination and procedures, During examination and procedures, be sensitive to her Hx of traumabe sensitive to her Hx of trauma

Initiate treatment for depressionInitiate treatment for depression Psychotherapy and Rx Psychotherapy and Rx

Assertiveness training for Assertiveness training for appropriate expression of anger appropriate expression of anger

TreatmentTreatment

Work to improve support systemWork to improve support system Decrease family conflicts if possibleDecrease family conflicts if possible

Set up behavioral plan to help her to Set up behavioral plan to help her to increase her level of functioning increase her level of functioning

Encourage Encourage occasionaloccasional medical visits medical visits its an important part of her support systemits an important part of her support system overall work to decrease medical overall work to decrease medical

utilization by addressing underlying psych utilization by addressing underlying psych problemsproblems

The Results?The Results?

A satisfied patient who gets the care A satisfied patient who gets the care she needs…she needs…

And for you, the satisfaction of And for you, the satisfaction of effectively treating a challenging effectively treating a challenging case.case.