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10 Articles in Volume 6, Issue #3
A Muscular Approach to Headache
Adjuvant Analgesia for Management of Chronic Pain
Breakthrough Pain In Non-Cancer Patients
Case Presentation of Munchausen Syndrome
Electroanalgesic Medical Device
On Knowing
Opioid Malabsorption: Can You Stomach This?
Sedation Safety and Comfort
The American Board of Independent Medical Examiners (ABIME)
The Role of MMPI-2 in Assessment of Chronic Pain

The Role of MMPI-2 in Assessment of Chronic Pain

The Minnesota Multiphasic Personality Inventory (MMPI-2) data is best viewed as one of multiple sources of patient information, including history, social support networks, coping ability, job, and life satisfaction/success, etc.

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is one the most widely used personality assessment instruments in the world1 and arguably the most widely used psychological instruments to study chronic pain.2 The MMPI was developed by Starke Hathaway and J. C. McKinley in 1943 to aid in the diagnosis of psychiatric disorders; it was subsequently revised in 1989 to address several issues related to the normative data and outdated language.1 Hathaway and McKinley initially used an empirical keying approach, in which test constructors selected items based on whether the items could differentiate members of a “normal” group—presumably free of psychopathology—from members of a “criterion” group, where individuals had a certain psychiatric diagnosis. The “normal” group consisted of, but was not limited to, visitors to, and relatives of, patients at the University of Minnesota Hospital. The clinical groups consisted of patients in eight psychiatric diagnostic categories:

  • hypochondriasis
  • depression
  • hysteria
  • psychopathic deviate
  • paranoia
  • psychasthenia
  • schizophrenia
  • hypomania

A Masculinity-Femininity Scale and a Social Introversion Scale were added later and were based on non-clinical patients.1

Essentially, the MMPI-2 consists of a set of 3 main validity scales, 10 standard scales, sometimes referred to as clinical scales, and numerous supplemental and subscales. A patient’s score on each of these scales is compared to a normative sample, which roughly coincides with the demographic characteristics of the United States. Raw scores are then transformed into T-scores. Scales that exceed a T-score of 65 (1.5 standard deviations above the mean of 50) are considered clinically significant. Literally hundreds of validity studies have established the interpretive meanings of various clinical scale configurations.1 It should also be noted that there is a computerized scoring and interpretation system currently available (Pearson Assessments). Table 1 summarizes the 3 main validity and 10 main clinical scales of the MMPI-2.

Common MMPI-2 Scales Associated with Chronic Pain

Individual Scales. The first three clinical scales (hypochondriasis , depression, and hysteria) are the most relevant for medical patients and have been the most widely investigated with pain patients.3 McKinley and Hathaway defined Scale 1 (hypochondriasis ) as an abnormal concern over health. When the MMPI was constructed, subjects in the “clinical” group consisted of individuals who were excessively concerned with possible ailments that were believed to have limited or no organic basis. Elevated scores on Scale 1 suggest the possibility of numerous somatic complaints, selfishness, immaturity, and narcissism.4

The clinical group for Scale 2 (depression) consisted mostly of bipolar (manic-depressive) patients during a depressive episode. Although many individuals with elevations on Scale 2 are depressed, an individual can display an elevated Scale 2, but not meet criteria for a Major Depressive Disorder. Rather, this scale may be thought of as a measure of distress and, when it becomes increasing elevated, suggests the possible presence of depression. Individuals with an elevated Scale 2 tend to be unhappy, pessimistic, self-deprecating, and sluggish.4

Scale 3 (hysteria) was intended for the detection and diagnosis of Conversion hysteria. Hathaway and McKinley used 50 patients with a clinical diagnosis of psychoneurosis, most of whom were believed to have a conversion disorder.2 Butcher and Williams describe patients with a conversion disorder as exhibiting personalities characterized by denial and flamboyant social interactions. These individuals may react to stress with the development of a physical complaint.3 The original understanding of a conversion reaction was believed to be related to a metaphorical resolution of an intrapsychic conflict (primary gain) that may be reinforced by attention or the removal of undesired responsibilities because of the physical problem (secondary gain). Although individuals with an elevated Scale 3 tend to react to stress with physical symptoms, they often have limited insight into their feelings and motivations.2,3 Further, these individuals may frequently need approval and attention from others.2 Elevations on this scale may reflect a difficulty acknowledging or accepting aggressive or hostile feelings. Therefore, hostility may be expressed through indirect or passive means. Although these individuals may demonstrate good interpersonal skills, their ability to form rewarding, reciprocal, and mature relationships is likely to be impaired.3

Although the first three clinical scales have received most of the attention with regard to medical patients, the other clinical scales also provide valuable information. Individuals with an elevated score on Scale 4 (psychopathic deviate) tend to have difficulty delaying gratification, have trouble with authority, and may engage in antisocial behavior. Scale 5 (Masculinity-Femininity) is interpreted differently for men and women. Men with an elevated Scale 5 score often exhibit creativity, sensitivity, and passivity; whereas women exhibit assertiveness and self confidence.4 Individuals who score high on Scale 6 (paranoia) can exhibit frank psychotic functioning, have a suspicious predisposition, or feel abused and mistreated. An elevation on Scale 7 (psychasthenia) may suggest that a person is tense, anxious, and ruminative. A high score on Scale 8 (schizophrenia) can be attributed to several possible reasons, including feelings of alienation and bizarre sensory experiences (e.g., numbness and tingling). Often these individuals carry with them a sense of being damaged and may have difficulty exercising reasonable judgment. Individuals with elevated scores on Scale 9 (hypomania) tend to throw themselves into excessive, and often unproductive, activity as a way to distract themselves from distressing emotions. Further, they may not have a realistic sense of their limitations. Scale 0 (social introversion) appears to detect individuals who prefer to be alone.3

The above reviewed clinical scales can be thought of in several different ways. One way involves perceiving the scales as reflecting either traits (i.e., temperament) or states (i.e., current emotional characteristics). Scales 1 (hypochondriasis ), 2 (depression), 7 (psychasthenia), and 8 (schizophrenia) are typically thought of as state or symptom scales, while Scales 3 (hysteria), 4 (psychopathic deviate), 5 (masculinity-femininity), 6 (paranoia), 9 (hypomania), and 0 (social introversion) are thought of as trait or character scales.6 This distinction may help differentiate Scale 1 (hypochondriasis ) from Scale 3 (hysteria). Trimboli, et al5 described Scale 1 (hypochondriasis ) as a symptom scale in which patients, when distressed, channel emotional distress into somatic complaints. Scale 3 (hysteria) is a character scale and when elevated, it suggests that a person has difficulty facing uncomfortable emotions, and has a tendency to react to stress with the development of physical symptoms.3,6 It is not surprising that Scales 1 and 3 often go hand in hand.

Configuration of Scales. Hathaway and McKinley soon realized that interpreting the configuration of scales, rather than just the single scale elevations, provided the most useful amount of data.3 Therefore, a description of two of the most common configurations with chronic pain patients, involving Scales 1 (hypochondriasis ), 2 (depression), and 3 (hysteria), is warranted.1 First, chronic pain patients often display elevations in Scales 1, 2 and 3, which is termed the “Neurotic Triad.” The “Neurotic Triad” has been used to refer to the first three clinical scales, but is also a profile configuration in which these three scales are all elevated (see Figure 1). Individuals with these elevations tend to have somatic complaints. Further, depressive feelings and difficulty with sleep are common, along with other neurovegetative symptoms of depression. These individuals often interact with others in whining, complaining, and demanding ways.4

A second common configuration involves Scales 1 (hypochondriasis) and 3 (hysteria) being significantly higher than Scale 2 (depression). This profile is often referred to as a “Conversion Valley”3 or “Conversion V”1 (see Figure 2). An individual produces this profile by endorsing somatic symptoms, denying social anxiety, and denying depressive symptoms.5 Although these individuals may or may not meet criteria for a conversion disorder, they often react to stress with the development of physical symptoms, and have limited insight into their emotional lives. Individuals with this profile tend to be sociable, conforming, and passive-dependent.3 Further, the incidence of the “Conversion V” profile for chronic pain patients is 35-60%, but 5 to 15% for general medical patients.4 It should also be noted that, although the person with a “Neurotic Triad” configuration may share some of the same symptoms as the “Conversion V” patient (e.g., somatic complaints), the “Conversion V” patient is likely reporting less psychological distress than the “Neurotic Triad” patient. That is, the “Conversion V” individual may be able to more effectively distract himself or herself from painful and distressing feelings by channeling concerns into physical symptoms.

Table 1. The 3 main validity and 10 main clinical scales of the MMPI-2.
Validity Scales Clinical Scales
L Scale Scale 1 (hypochondriasis )
F Scale Scale 2 (depression)
K Scale Scale 3 (hysteria)
  Scale 4 (psychopathic deviate)
  Scale 5 (masculinity-femininity)
  Scale 6 (paranoia)
  Scale 7 (psychasthenia)
  Scale 8 (schizophrenia)
  Scale 9 (hypomania)
  Scale 0 (introversion)

“Functional" vs “Organic” Pain

Soon after it was developed, the MMPI was used in medical settings to help practitioners distinguish “functional” from “organic” pain, a distinction that is today seen as inadequate and has been replaced with the biopsychosocial approach. This distinction is derived from biomedical and psychoanalytic models of pain that postulate that the amount of pain should coincide with the amount of tissue damage.7,8 With the introduction of the gate control theory of pain by Melzack and Wall9 and the application of the biopsychosocial model to pain, the distinction between “functional” and “organic” is far less meaningful. Keller and Butcher2 succinctly described the difference between “functional” and “organic” pain. “The former implies that the pain problem is caused or maintained by psychosocial factors, whereas the latter assumes a physiologic basis.”2 The “functional” versus “organic” distinction has been applied to pain patients by focusing on how patients appear to be suffering more than expected given no, or vague, physical findings.10 Unfortunately, clinicians’ and researchers’ definitions of “functional” pain and “organic” pain vary widely in studies, and technological advances, not present in earlier studies, have allowed for a more precise identification of underlying pathology. Although the distinction between “functional” and “organic” is now outdated, early empirical investigations of these concepts furthered our understanding of the chronic pain patient.7

Hanvik pioneered attempts to distinguish between “functional” and “organic” patients.11 He examined patients with a primary diagnosis of back pain and divided them into an “organic” and “functional” groups based on x-ray and physical examination findings. Hanvik found that the “functional” patients produced a “Conversion V.” The first three clinical scales were all clinically elevated, but Scales 1 (hypochondriasis) and 3 (hysteria) were significantly higher than Scale 2 (depression). Hanvik indicated that the patients were essentially saying, “I have numerous bodily complaints, but I am relatively unworried, not depressed.”11 Further, the “functional” group was also significantly higher on Scales 1 (hypochondriasis), 2 (depression), 3 (hysteria), 4 (psychopathic deviate), 7 (psychasthenia), and 8 (schizophrenia) than the “organic” group.11

Additional research on the “Conversion V” has been equivocal and provides evidence to support a biopsychosocial approach to understanding pain rather than the “functional” versus “organic” distinction. For instance, Lair and Trapp12 reported that both “organic” and “functional” groups showed “Conversion V” profiles. Schwartz and Krupp13 concluded from their study that the presence of a “Conversion V” does not increase the probability that a patient will receive a functional diagnosis. Leavitt14 also reported that the “Conversion V” pattern did not diffentiate “organic” from “functional” patients.

Figure 1. The Neurotic Triad Figure 2. Conversion V

Although research utilizing MMPI suggests that this instrument can not distinguish between “functional” and “organic” patients, the MMPI may be useful in examining the psychological functioning of chronic pain patients. Of note, the “Conversion V” and “Neurotic Triad” appear to be the two most common profiles reported in chronic pain patients.2 As discussed previously, studies consistently have found that patients with chronic pain produce one of these two configurations.13-16

Sternbach and colleagues research underscored the importance of the MMPI in identifying salient psychological issues in pain patients and moved the use of the MMPI away from the “functional” versus “organic” distinction.17 They defined a type of low-back patient as a person “whose complaint of back pain has persisted for six months or more, who is unable to work and is supported by social security, welfare, or disability payments, and who, despite previous surgery, continues to seek medical or surgical relief.”17 They found that patients with physical findings, compared to those without physical findings, were significantly different on Scale 9 (hypomania), but the mean profile of this entire group showed elevations on Scales 1 (hypochondriasis), 2 (depression), and 3 (hysteria). The researchers noted the absence of a “Conversion V.” They interpreted the combined profile as indicating a “psychophysiological reaction with depression.”17

Certain patients might interpret and utilize physical discomfort in a similar manner regardless of the physical findings. For instance, a chronic low back pain (CLBP) patient with no or limited physical findings and a cancer patient with numerous tumors may both direct most of their attention and energy towards their physical symptoms. Many cancer pain patients will endorse concerns with their physical well being, a sense of dissatisfaction, and unusual bodily experiences.7,18 However, one can imagine a “Conversion V” sub-group of cancer pain patients who are able to understand and describe numerous uncomfortable physical symptoms, but who have difficulty acknowledging their fear or sadness at their situation. In addition to the underlying physical pathology, the attentional focus, processing, and meaning of pain is inextricably entwined with psychological factors.

Snyder6 succinctly summarized the vast literature on this topic in his chapter on the MMPI and pain:

“Overall, findings from these studies suggest that high scores on the MMPI, and particularly on those scales comprising the neurotic triad, confirm a significant psychological component to the patient’s pain complaints and functional limitations, but do not rule out underlying physical pathology. The higher the profile, the more likely that psychological factors play a significant and disproportionately greater role in the patient’s pain syndrome.”6

When pain complaints are viewed through a biopsychosocial model, the “functional-organic” model is far less meaningful, but the MMPI helps to clarify the impact of psychological factors in an individual’s pain experience. The difficulty distinguishing between “functional” and “organic” pain is less of a shortcoming with the MMPI, but more of a shortcoming with the “functional-organic” model.

The MMPI-2 and Prediction of Treatment Outcome

Sternbach19 originally proposed that the above two profiles were potentially useful for predicting treatment outcome. Subsequently, a number of studies started to appear in the scientific literature validating its possible utility. For example, Wifling and colleagues20 evaluated the relationship between success or failure of lumbar fusion for back pain patients. These patients were divided into three groups based on post-surgery work status, pain ratings, motor signs and self-report. It was found that patients who had “good” outcomes displayed generally normal MMPI profiles. Patients with “fair” outcomes yielded a “Conversion V” profile, while those with “poor” outcomes were associated with a variant of the “Conversion V” profile (with sub-threshhold Scale 3 elevations). Other studies21-23 similarly found MMPI profiles to be useful in surgical outcomes prediction.

More recently, Block, Gatchel, et al3 reviewed several other studies demonstrating the relationship between MMPI profiles and spine surgery outcomes. However, as they note, the literature regarding this relationship is not uniformly supportive of the MMPI’s predictive value. In fact, in a seminal article by Southwick and White,24 these authors indicated that, although psychological factors play a significant role in chronic back pain and should be routinely assessed in patients, the utility of the MMPI alone in predicting surgical outcomes was questionable. We will return to this point later in the article.

There have been a number of excellent reviews of MMPI – chronic pain literature.3,25-27 Several studies have also found support for the utility of the MMPI for predicting non-surgical outcomes in patients with musculoskeletal pain disorders. For example, Barnes and colleagues28 evaluated chronic low back pain patients who participated in a comprehensive functional restoration program. These patients were divided into three groups based on their program-completion status and one-year post-program employment status. It was found that patients in the “success” group showed lower pre-treatment MMPI “Neurotic Triad” and hypochondriacal reactor profile scores than “unsuccessful” patients. Other studies have also found similar relationships.29,30 However, the literature has not been unanimously supportive of the predictive utility of MMPI profiles.31,32

Thus, despite more than three decades of research and clinical use of the MMPI for screening surgical and non-operative pain treatment outcomes, there is still much debate concerning the clinical utility of the MMPI, and which profiles are relevant. One possible reason for this state of affairs was the fact that there had not been a large-scale study simultaneously evaluating all the major profile types in one investigation of a defined population. This was remedied in a recent study by Gatchel, Mayer and Eddington (in press).33 Moreover, this same study evaluated one additional MMPI profile not assessed in earlier pain-related studies – what these authors terms the “Disability” Profile. This profile type is comparable to what is called the “Floating Profile” in the psychiatric literature, but is essentially unknown in the musculoskeletal spine, and pain literature.34,35 The MMPI floating profile has been defined as elevation of 4 or more of the clinical scales (T scores above 65). Overall, MMPI floating profiles have been associated with personality disorders (in particular, borderline personality disorder). Individuals with a floating profile do not have one particular defense mechanism to call upon in order to effectively cope with stressors in their lives and, therefore, often experience severe emotional distress. Such patients are also often recalcitrant to psychiatric treatment. This “Disability” profile is similar to this little known or evaluated Floating Profile, but had not previously been associated with chronic pain, disability, workers’ compensation, or musculoskeletal disorders.

The results of this study of 1,489 patients with chronic occupational spinal pain disorders revealed that the traditional MMPI profiles (Normal, Neurotic Triad and Conversion V) failed to classify 74% of the patients. In contrast, the Disability Profile had a prevalence of 53.2% in this large population. This profile was also found to be more effective in identifying psychopathology in these patients, relative to the other profile patterns. The Disability Profile was 14 times more likely to have an Axis I clinical disorder (such as major depressive or anxiety disorders) and 5 times more likely to have an Axis II personality disorder, than the Normal Profile group. Of course, the MMPI is most widely used for personality assessment purposes. Personality characteristics, in turn, are important to consider when treating patients with pain, particularly when making surgical recommendations for pain associated with compensation injuries, for which poorer outcomes have frequently been documented.36 These results suggest that if the MMPI is used for evaluation in a chronic spinal pain disorder population, its clinical utility will be compromised if the Disability Profile is not recognized or is ignored. The relevance of these findings is that this MMPI-2 profile may be the first sign of a Major Depressive Disorder, Anxiety (or Panic) Disorder, or Substance Use/Abuse Disorder. Of equal importance is the detection of a Personality Disorder, as some of these (particularly Borderline, Anti-social, Paranoid or Cluster B) have been shown to be associated with perioperative and postoperative management challenges.

Of course, this newly described Disability Profile will need to be further evaluated for its prediction of outcomes of other treatment modalities, such as surgery—both within and outside the occupational (workers’ compensation) setting. Disability rates and duration of injury are also greater in this population. The musculoskeletal clinical community will need to assess prevalence of this profile in less chronically disabled, and in non-workers’ compensation disorders. Nevertheless, the finding of a relatively convenient way to identify general psychopathology in a musculoskeletal pain disorder population makes the MMPI a more attractive instrument. The question of cost-benefit for use of the MMPI, considering that it is costly, time consuming and potentially frustrating to patients, remains to be answered.

The MMPI-2 and Presurgical Screening

Finally, a brief discussion concerning the use of the MMPI-2 as a pre-surgical screening measure is warranted. In a recent “point – counterpoint” commentary by Block, Deardorff and Gatchel,37 a case study was discussed concerning the feasibility of a spine fusion operation for an individual who had sustained a low back injury and who had objective indices of lumbar pathophysiology. The issue raised was whether the MMPI-2 should be used as a component of pre-surgical psychological screening to determine the potential success of surgery for this patient. A major conclusion of the authors was that the MMPI data should only be viewed as just one source of information considered, along with other types of information (such as the patient’s past medical history, social support networks, coping ability, job and life satisfaction/success, etc.)

As these authors conclude: “It is extremely rare to be able to make a completely accurate prediction of some behavior or treatment based on a single psychological or personality instrument. Multiple sources of data should be used to provide a comprehensive evaluation of a chronic pain patient! . . .

“Unfortunately, because of the long history of the use of the MMPI in many clinical settings, it is often viewed as the Holy Grail of personality/psychological assessment. It definitely is not. Beware of any psychiatric/psychological consultant, who, tries to sell it as a stand alone assessment! That individual is either totally unaware of the current scientific assessment literature, or is trying to sell you a service merely for reimbursement purposes without considering the welfare of the patient or your practice.”37

Last updated on: January 4, 2012
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