BHI™ 2 Miscellaneous Information

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Last update 2/2/2004


BHI 2 and MMPI

BHI 2 Norms: Additional Information

BHI 2 and Pain Assessment

BHI 2 and Assessing Non orthopedic Medical Conditions

BHI 2 and Personal Items

The BHI 2™ and the MMPI™

 The MMPI-2 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 2 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 2 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 2 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 2 is able to indicate whether a person is more or less depressed than the average patient in rehabilitation. The advantage of the BHI 2 is that by focusing on the psychological difficulties encountered in medical patients, it is able to perform an analysis that is more relevant to the medical setting.

It should be noted here that medical patients are more likely to be depressed and anxious than their counterparts in the community ( 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 2 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 2 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.

The BHI 2 Norms

 One of the strengths of the BHI 2 is its norms. The BHI 2 patient normative sample included patients with the following characteristics:


During the test construction process, subjects assessed included persons suffering from

Data on the BHI 2 was obtained over five successive rounds of test construction. The final phase of data collection was obtained from 106 sites in 36 U.S. states. The community and the patient normative samples were selected from this pool of subjects. The resulting samples closely matched US census data for sex, age, race and level of education.


The BHI 2 and Pain Assessment


The 0-10 pain rating scale is widely used, but prior to the BHI 2, it had never been nationally normed and validated. As the BHI 2 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 2 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 2 national patient sample.


The BHI 2 and the Assessment of Non-orthopedic Medical Conditions

Over the 10 year history of the BHI 2 development, persons with a variety of diagnoses were assessed. The intent of the BHI 2 was always to produce a psychological inventory for the assessment of medical patients. During the course of the final BHI 2 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 2 often gives very useful information about persons with a variety of non orthopedic diagnoses.

It is also worth pointing out here that the BHI 2 items were written so as to be general in nature, so as to not preclude its use with any diagnosis. Outside of the BHI 2 pain scale, the word "pain" appears in only 5 of the BHI 2's 217 items.


Options for handling "personal" items on the BHI 2

A few of the BHI 2 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, it is sometimes not appropriate situation to be asking these questions. Under such circumstances, these items can simply be crossed out. The BHI 2 can be scored without asking these items, and it will not invalidate the test.


More information about the BHI 2 available at the Pearson Assessments website.

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