Pain Assessment Battery (PAB)

The Pain Assessment Battery (PAB) by Bruce N. Eimer, Ph.D. and Lyle M. Allen III, M.A., is a comprehensive assessment tool for evaluating and documenting the behavioral and psychological dimensions of chronic pain syndrome, PTSD, post-concussive symptoms, and hypochondriachal and conversion syndromes. This battery assists in treatment selection and referral, helps to assess the validity of pain complaints, and aids in identifying drug-seeking propensities. The seven instruments in the PAB include four tests designed for unattended computer administration, two interviews, and a behavioral and mental status checklist. The scoring software supports outcome analysis by graphically comparing protocols.

• Pain Coping Inventory

• Stress Symptoms Checklist

• Pain Experience Scale

• Coping Style Profile

• Pain History and Status Interview

• Interview Behavior Checklist

Bruce N. Eimer, Ph.D., ABPP has written a 1998 textbook published by John Wiley and Sons entitled Pain Management Psychotherapy: A Practical Guide. Much of the PAB has been described in this comprehensive work which has received extremely positive reviews from such recognized experts as Dennis Turk, Albert Ellis, Richard Weiner, Arnold Lazarus, and David Tollison. In addition to coauthoring the PAB, Lyle M. Allen III, M.A. has coauthored the Computerized Assessment of Response Bias (CARB) and the Word Memory Test (WMT)—each of which is designed to assess subject effort in the context of compensation-related assessments in patients claiming cognitive or somatic interference and disability.

Pain Coping Inventory (PCI)

The Pain Coping Inventory (PCI) forms the centerpiece of the PAB. This 92 item inventory assesses the behavioral, cognitive and psychological dimensions of chronic pain. The test calculates 18 separate scales arranged under 5 dimensions: Physical and Temporal Qualities, Pain Interference, Health-related Behaviors, and Psychological Adjustment and Maladjustment. The PCI software also calculates indices of Pain Coping, Nociception, Treatment Resistance and Alienation, and Global Impairment, as well as scores for Extreme Beliefs and Symptom Magnification. The scoring software also flags extreme item ratings and critical levels of item endorsement for its pathognomic scales. The PCI includes scales measuring pain severity, continuity and duration, muscle bracing, sleep disturbance, activity interference, stress and anxiety, self-efficacy, positive self-talk, motivation and chemical dependency. The PCI assesses psychological risk factors for chronic disability: hysteria, depression, inactivity, negative beliefs, hostility and dissatisfaction. The 41 PCI scales and indices have very high internal consistency (median alpha reliability = 0.77) and have been validated against the CARB and the Multidimensional Pain Inventory by Turk and Rudy using 444 chronic pain patients.

The questions comprising the PCI paper-and-pencil questionnaire and the computerized test administration program are organized into five sections. The first section of the test is entitled Degree of Distress and contains eight items which assess the pain’s intensity or strength, its temporal pattern (continuity and duration), and two symptoms associated with posttraumatic stress syndromes (nightmares and intrusive ideation). The second section of the test is entitled Health-Related Behaviors and contains seven items that assess alcohol consumption, working ability, fun activities, dietary habits, junk food consumption, and exercise frequency. The third section of the PCI is entitled Frequency of Distress and contains 18 items which assess activity interference, behavioral dysfunction, and psychological distress associated with pain. The fourth section of the PCI is entitled Coping Success and contains 25 items which assess pain coping strategies, pain relief, quality of life, and selfefficacy perceptions. The fifth and final section of the PCI is entitled Your Beliefs and contains 34 items which directly assess a patient’s beliefs about pain, pain control, self-efficacy, pain permanence, psychological factors affecting pain, other people’s responses, justice/injustice and fairness, entitlement, and pain’s effects.

Content validity

One of the advantages of the PCI as a pain assessment instrument is that the individual items directly address pain and pain-related problems. Thus, the items have a high degree of face validity and relevance to pain patients. The test items were constructed based on a review of the pain literature, and the authors’ clinical experience with the issues commonly presented by chronic pain patients. The final pool of 92 items was selected based on collecting and evaluating over 500 pain patients’ responses to a much larger sample of items. This occurred over several revisions of the test (Eimer & Allen, 1995). Based on readability analyses, the items retained were determined to have no higher than an eighth-grade reading level. The authors report that pain patients demonstrate no significant problems understanding the test items, and had favorable responses to the current version of the test. Because of the test items’ content validity, and the clarity of their response options, the PCI can provide clinically relevant information just from an examination of a patient’s raw response which is similar to an informative, structured clinical interview.

PCI Normative Sample

The PCI’s normative sample consisted of 444 chronic pain patients who were referred to outpatient behavioral chronic pain treatment programs for evaluation or treatment (mean age = 40.8 years; SD = 12.12 years). More detailed information can be found on the last two pages of this document. Forty-three percent of the sample were male, and 57 percent were female. Ninety-two percent of the sample presented with primary pain complaints of greater than 3 months duration. The majority of patients in the sample had pain of two to three years in duration. Seventy-one percent had pain of at least two years in duration. The most common presenting pain complaints were low back and neck pain, followed by headaches. The most common pain-related diagnoses in the sample were related to lumbar and cervical discogenic disease, myofascitis (myositis), diffuse musculo-skeletal pain, fibromyalgia, and chronic headaches (migraine, tension, and mixed).

Explanation of PCI Indices

Each of the PCI indices is explained below. The majority of these indices have very good internal consistency reliability as measured by coefficient alphas ranging between 0.70 and 0.93. PCI INVALIDITY INDICES The first two indices represent the test’s “invalidity indices.” They are the Extreme Beliefs Frequency (EBF) and the Symptom Magnification Frequency (SMF). High EBF and SMF summary scores reflect a large number of extreme ratings on the test items. They may be associated with a tendency to magnify or exaggerate pain complaints and other symptoms.

GLOBAL IMPAIRMENT INDEX

A Global Impairment Index, or GII, is computed as the sum of all 92 item ratings on the test keyed in the direction of greater dysfunction. The GII is considered a global measure of pain-related impairment and dysfunction, and is thought to measure the degree of generalization of the chronic pain condition (Eimer & Allen, 1995). Its internal consistency, as measured by coefficient alpha, is 0.85.

PATIENT ALIENATION INDEX

The Patient Alienation Index, or PAI, is a summary measure of negative cognitions and beliefs associated with anger, paranoia, mistrust, alienation, depression and treatment resistance. Its internal consistency is excellent (coefficient alpha = 0.92).

DEGREE AND FREQUENCY OF DISTRESS INDICES

Two summary measures of pain and distress are the Degree of Distress Index (DODI) and the Frequency of Distress Index (FODI). Both scale indices have good internal consistency reliabilities (DODI alpha = 0.72; FODI alpha = 0.89)

PHYSICAL SEVERITY AND
 BEHAVIORAL INTERFERENCE INDICES

The Physical Severity Index, or PSI, is a summary measure of the physical and temporal intensity of the pain (alpha = 0.71). The Behavioral Interference Severity Index, or BISI, is a summary measure of the intensity and frequency with which pain is reported to interfere with basic activities of daily living (alpha = 0.58).

PSYCHOLOGICAL MALADJUSTMENT SEVERITY
 AND NOCICEPTIVE INDICES

The Psychological Maladjustment Severity Index, or PMSI, and the Nociceptive Index, or NI, are two summary measures of emotional distress associated with pain. The PMSI combines measures of “catastrophizing” about pain, stress and anxiety, depression, hostility, paranoia, and alienation. Its alpha coefficient is excellent (0.93). The NI also has an excellent alpha coefficient of 0.91.

ADDITIONAL “EMOTIONAL DISTRESS” SUB-SCALES

The PCI computer scoring program calculates 11 sub-scales which are meant to measure unique and important components of pain-related emotional distress.

POSITIVE COPING INDICES

Several “positive coping indices” are also computed and recorded. The Psychological Coping Index, or PsyCI (alpha = 0.76), is a summary index that encompasses measures associated with adaptive coping, including “perceived self-efficacy,” “mental, or psychological, conditioning,” use of “positive self-talk,” “psychological motivation,” and positive “quality of life.” Other indices include the Healthful Behavior Index, or HBI, a measure of positive, or healthful behaviors related to good nutrition, regular exercise, and appropriate use of pain medicines; the Coping Success Index, or CSI; the Health-Related Behaviors Index, or HRBI; and the Pain Coping Index, or PCI.

The Stress Symptoms Checklist (SSCL)

The 38-item SSCL (Eimer & Allen, 1995) is a 38 item self-report instrument which was developed specifically to assess anxiety-related and stress symptoms including symptoms of posttraumatic stress disorder associated with chronic pain. Patients rate the frequency with which they have experienced each symptom during the past two weeks on a seven-point verbal-numerical Likert scale ranging from one (never) to seven (always). Several scores are then derived. Among these, the SSCL Total Sum of Ratings (Sum) and Total Symptom Percentage (SxPct) have been used as indices for tracking treatment outcome.  Also, Total Sums of Ratings and Total Symptom Percentages at the 90th percentile and above (see well as direct measures of the tendency to make extreme ratings on the checklist (e.g., high Percentages of Ratings >=6), have been used as measures of symptom magnification or invalidity.

Factor Analysis

The 38 SSCL items were submitted to a principal components factor analysis with varimax orthogonal rotation designed to achieve simple structure. A two-factor simple structure solution was derived that accounted for 42.74% of the total variance. Significant (>0.45) loadings are in boldface from a sample of 249 chronic pain patients, a subsample of our larger sample of 444 patients who completed the SSCL as part of their evaluation. Factor I, labeled Posttraumatic Anxiety Symptoms (PTAS, 19 items), is loaded heavily with items measuring anxiety-related symptoms associated with posttraumatic stress conditions (e.g., intrusive thoughts, fear of losing control, nervous around people). Factor II, labeled Pain and Impairment (PI, 16 items), is loaded heavily with items measuring symptoms of pain, inefficiency, cognitive interference, and pain-related impairment. Based on the items with loadings of 0.50 and above on these factors, two Factor Scales were constructed. Both Factor Scales evidenced excellent internal consistency reliability based on coefficient alphas (PTAS = 0.93; PI = 0.91). To assess whether the mean SSCL Total Sum of Ratings would be, as expected, substantially greater for the pain patient sample than for the comparison non-patient group, a 2-tailed Student’s t-test was conducted. The mean difference between the pain patient and non-patient groups for the SSCL Total Sum of Ratings came to 44.64 (Pain Patient Mean = 95.43; Non-patient Mean = 50.79). This difference was highly significant at the .0001 level (t-value = 10.24, p<.0001).

Test Retest Reliability

To assess the SSCL's stability or test-retest reliability, we administered the test to a sub-sample of the non-patient teacher group (N = 20) a second time after stress reduction therapy. The test-retest reliability was acceptable (Pearson product-moment correlation coefficient of .67 for the SSCL Total Sum of Ratings).  There was also a statistically significant change in the group mean for this sub-sample between Time 1 and Time 2 based on a 2-tailed Student t-test comparison (SSCL mean Total Sum of Ratings for Time 1 = 53.1; Time 2 = 41.8; t-value = 2.34; p<.03). This result supports the utility of the instrument as a treatment outcome measure. Time 1 was at the outset of the two weekend, 6-day stress management course; Time 2 was on the last day of the course. Course participant's total SSCL scores decreased, as expected.

Construct Validity

The construct validity of the SSCL for this sample of 48 non-patients was assessed using Pearson product-moment correlations between the SSCL and several other measures. These were: the Anxiety Symptom Questionnaire (ASQ; Lehrer & Woolfolk, 1982), a measure of cognitive, behavioral, and somatic symptoms of anxiety; the Cognitive Error Questionnaire (CEQ; Lefebvre, 1981), a measure of the tendency to employ cognitive distortions; and the Irrational Belief Scale (IBS; Malouff & Schutte, 1986). The results of the correlational analysis indicate statistically significant relationships (p<.001) between the SSCL Total Sum of Ratings and the other total test scores (ASQ r = .75; CEQ r = .71; IBS r = .47).

Other Components of the PAB

The Pain Experience Scale (PES) identifies primary pain source areas, quantifies pain frequency and severity, and elicits qualitative pain descriptors. This brief questionnaire supplements the PCI using the 0 - 10 rating form that is characteristic of many pain assessments. The PES also provides McGill-like adjectives which the patient selects to describe his or her pain. The PES can be self-administered using paper and pencil or computer, and can be added to a CogShell Battery definition using components from the PAB or other instruments from CogniSyst.

The Coping Style Profile (CSP) is a simple 9 item questionnaire that assesses a person’s preferred modalities for coping with problems such as chronic pain. The CSP is an extension of Arnold Lazarus’s “BASIC ID” concept, and may be useful in both assessment and planning pain treatment. The CSP can be self-administered using paper and pencil or computer, and can be added to a CogShell Battery definition using other instruments from CogniSyst. The CSP is normed on 151 pain patients with chronic pain.

The Pain History and Status Interview (PHxS) identifies primary pain source and secondary pain reception areas, elicits a pain history, and documents physical, medical, social and vocational variables associated with the pain’s onset, course and current status. The PHxS is administered with paper and pencil, and the results are entered into the PHxS software in order to generate an editable textual summary of the patient condition. The PHxS is not self-administered but can provide background text that can form the introduction and background of the clinical assessment.

The Interview Behavior Checklist (IBCL) provides adjectives that conveniently document the clinician’s observations of the patient’s mental status and session behavior. The six areas covered by the IBCL include orientation, speech, affect/mood, attitude/manner, task orientation and physical appearance.

PAB Time Requirements

An experienced examiner can administer all 6 instruments with the patient in approximately 1 hour and 45 minutes. Briefer examinations can be completed in 45 minutes using only the PES, PCI, SSCL and PHxS. The PCI, SSCL, CSP and PES can be administered unattended under CogShell and the interviews (PHxS & PII) and the IBCL can be conducted by the examiner using the computer to record the patient information in real-time. The PAB is currently shipped with copyable paper and pencil forms, and all instruments can be input from these forms by secretary or other paraprofessional in the office.

PAB Reporting Features

The PCI and SSCL produce T-score graphs that can be printed or viewed on screen. The PCI, SSCL, PES and CSP also produce pre-post graphs to track outcome in response to treatment when data are available. In each graph the earliest and most recent protocols are automatically plotted if more than one patient record is available. The centerpiece PCI also features interactive selection of items by endorsement level, allowing the clinician to conveniently select and examine those items chiefly responsible for scale elevations. A sample PAB report is attached or available upon request.

The PAB & the CogShell™ Assessment Environment

The CogShell™ Assessment Environment is software that provides a patient database and single interface for all tests and instruments published by CogniSyst, Inc. CogShell™ offers direct administration, input, editing, and report generation. CogShell™ is a user-friendly, menu driven environment that supports administration of single or multiple instrument batteries from CogniSyst. All of the PAB instruments run inside of CogShell™, and as outlined above, most support direct computerized administration. The computer requirements are minimal: we support all versions of Microsoft Windows. Many of our instruments also provide data export to support clinical and experimental research. CogShell™ is provided free with the purchase of any instrument published by CogniSyst, Inc.