VOLUME 5, ISSUE 7 NOVEMBER/DECEMBER 2005 The journal with the practitioner in mind. ChronicChronic PPainain andand BiopsychosocialBiopsychosocial DisordersDisorders ©2005 PPM Communications, Inc. Reprinted with permission. www.ppmjournal.com . The BHI™2 Approach to Classification and Assessment By Daniel Bruns, PsyD and John Mark Disorbio, EdD ccounting for over 35 million of- pain. In other cases however, the psycho- While chronic pain is generally recog- fice visits a year, pain represents logical difficulties may be the conse- nized as being a biopsychosocial phe- A the most prevalent reason why an quence of the pain condition, itself.12 nomenon, what is often overlooked is that individual chooses to seek out medical Thus, when pain appears in conjunction illness, injury, psychological and social treatment.1 So prevalent, in fact, research with stress, anxiety, depression or other factors interact over the course of time to has shown that the cost associated with the psychiatric syndromes, the arrow of produce distinctly different types of treatment of pain exceeds the costs at- causality can sometimes point from pain biopsychosocial disorders. Effective treat- tributable to the treatment of other dis- to psychiatric condition, and in other ment requires that the clinician not only orders, such as heart disease, respiratory cases from psychiatric condition to pain. identify the biological, psychological and disease, or cancer.2 Pain also represents a Overall, the research literature suggests social aspects of a condition, but also un- condition that has both medical and psy- that psychological difficulties are com- derstand how each component interacts. chological components. mon among patients with pain. Left un- Chronic pain is widely regarded as a detected and untreated, these difficulties Types of Biopsychosocial Disorders biopsychosocial disorder.3-8 Chronic pain may impede a patient’s progress in treat- A classification system for biopsychosocial and associated disability are often life-al- ment and lead to long-lasting symptoma- disorders was created during the devel- tering conditions, have a profound psy- tology. Among those who report pain and opment of the Battery For Health Im- chosocial impact, and psychiatric condi- injury, psychosocial factors may play a provement 2 (BHI™2). Unlike most psy- tions are common in such patients. One major role in delayed recovery. One study chological tests, which were designed to study of an injured patient population of psychosocial factors demonstrated an assess psychiatric disorders, the BHI 2 was found a 55% incidence of depression,9 ability to accurately predict delayed re- designed to assess biopsychosocial disor- where even minimal levels of depression covery for patients suffering acute pain ders in general, with particular attention were associated with increased rates of so- 91% of the time without using medical in- being paid to chronic pain disorders. The cial morbidity and service utilization.10 formation.13 Another study found that development of the BHI 2 began with a Another study reported that of 1595 in- psychosocial factors play a dominant role model of biopsychosocial disorders, jured patients, 64% had one or more di- in surgical outcome.14 Lastly, in a World which held that biological, psychological agnosable psychiatric disorders, com- Health Organization study of 25,916 and social aspects of these disorders be- pared to a prevalence of 15% in the gen- medical patients from around world, psy- come intertwined, in various ways, over eral population.11 In some cases, preex- chological factors were found to be a the course of their history. isting psychological conditions may pre- stronger contributor to disability than was The BHI 2 model classified biopsy- dispose the patient to develop chronic disease severity.15 chosocial disorders into four distinct Practical PAIN MANAGEMENT, Nov/Dec 2005 2 ©2005 PPM Communications, Inc. Reprinted with permission. C h r o n i c P a i n a n d B i o p s y c h o s o c i a l D i s o r d e r s types. Called psychomedical classifica- subsequent reactive depression was a con- headaches, are extremely common. Other tion, this approach classified these disor- sequence of the pain condition, there is types of psychophysiological disorders in- ders into a 2x2 schema (see Table 1). This no direct biological mechanism whereby clude temporomandibular joint pain sec- divided biopsychosocial disorders into the disease directly causes the depression. ondary to bruxing, stress-related heart ones that had either physical (physio- In reactive biopsychosocial disorders, the palpitations and functional dyspepsia.19 genic) or psychosocial (psychogenic) ori- psychological symptoms are produced by Somatizing biopsychosocial disorders gins. It also divided these disorders into the patient’s perception of, and reaction denote a group of disorders that, like psy- ones where the mind-body connection to, the disease process and its conse- chophysiological disorders, have their was physical, as opposed to psychologi- quences.12 Consistent with this, one study origin in psychological processes. How- cal.16 As part of this model, an overall par- found that in a large cohort of patients ever, they differ in that there are no de- adigm was developed to try to depict the with pain-related disability, the preva- tectable organic changes to the body. This interrelationship of biopsychosocial vari- lence of major depression was 25 times group of disorders includes somatoform ables over the natural history of these dis- higher than general population esti- disorders, anxiety or depression that is orders (see Figure 1). mates.11 manifested physically, and some types of factitious disorders. Biopsychosocial Disorders with a Biopsychosocial Disorders with a In somatizing disorders, psychological Physical Origin Psychological Origin processes give rise to the perception or re- Some psychomedical disorders clearly In contrast to disorders having a physical port of physical symptoms, which the pa- originate with a physical injury or disease origin, a psychogenic disorder is one in tient interprets as organic in nature, even process, and can be broken down into two which an individual’s psychological though no detectable organic disorders subtypes: organic biopsychosocial disor- processes trigger the onset of a biopsy- are present.20-22 Most somatizing disorders ders and reactive biopsychosocial disor- chosocial disorder. Although the term involve the misguided pursuit of a med- ders. Both types can be described as phys- “psychogenic” has negative connotations ical solution to a problem that is essen- ical conditions that lead to the subsequent for some, this is unwarranted. There is tially psychological in nature. Persons development of a psychological condition nothing inherently “bad” about psycho- with somatizing disorders have an under- and social consequences. logical conditions. At the same time, when lying psychological condition, which for Organic biopsychosocial disorders are patients with psychogenic conditions per- conscious or unconscious reasons they do those that begin with an organic condi- sist in seeking a medical explanation for not acknowledge. They wrongly attribute tion that affects the central nervous sys- their symptoms, both patient and physi- the symptomatology of this psychological tem and, in so doing, manifests itself cog- cian are likely to become frustrated. Like condition to a medical disorder, while the nitively or emotionally. Some organic psy- physiogenic conditions, psychogenic con- underlying psychological dynamics go chological disorders are the result of in- ditions are common, neither good nor unrecognized. This tendency to medical- jury, such as the memory loss or height- bad, and can benefit from care by appro- ize symptoms may be reinforced by the ened emotionality secondary to brain in- priate professionals. patient’s social environment.23 jury. In other cases, organic biopsychoso- There are two types of psychogenic dis- An example of a somatizing disorder cial disorders result from disease, such as orders: psychophysiological and somatiz- would be a patient with severe anxiety depression secondary to a bipolar disor- ing disorders. Both types can be described who repeatedly goes to an emergency der. In these conditions, underlying or- as psychological conditions that subse- room to be evaluated for a heart attack. ganic processes produce the psychologi- quently lead to the development of phys- This patient refuses to believe that this cal symptoms. For example, an organic ical symptomatology. could be a psychiatric condition, and in- biopsychosocial disorder could begin with Psychophysiological biopsychosocial stead insists on repeated cardiac assess- hypothyroidism. This hypothyroidism disorders have their origin in the psy- ments. However, if the patient can be con- could effect on the central nervous sys- chosocial realm, but they come to have an vinced that a particular organic condition tem, producing depression. This depres- objective effect on the body through an has been ruled out, somatoform disorders sion could then impact the patient so- organic connection. This effect is gener- can “metastasize” into other body areas cially, both at home and in the workplace. ally produced through the effects of the or organ systems, producing an evolving Reactive biopsychosocial disorders also “fight or flight response” involving both pattern of diffuse symptoms. Thus, just begin with an objective disease or injury.