Vital and

Health Statistics

Reporting Chronic

Pain Episodes on

Health Surveys

Series 6:

Cognition and Survey Measurement

No, 6

The recall of chronic physical pain on health surveys maybe influenced by

several sources of error, This report describes a program of research exploring

three factors that potentially influence pain reporting: (1) the complexity of the

lexicon used to describe pain, (2) the focus of surveys on either recall of pain

severity or on changes in daily activities and observable behaviors brought on

by pain, and (3) ongoing mental states such as experienced pain and transient

moods,

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Publlc Health Service

Centers far Disease Control

National Center for Health Statistics

Hyaftsville, Maryland

September 1992

DHHS Publication No. [PHS) 92-1081
‘1

‘m

Copyright Information

Allmaterial appear} ngln this reportls in the public domain and maybe

reproduced or copied w!thout permlas [on; citat]on as to source, however, IS

appreciated.

Suggested Citation

Salovey P, Seiber WJ, Smth AF, et al. Reporhng chronic pa]n cplsociesorl

health surveys. National Center for Health Statistics Vital Health Stat 6[6) 1992
National Center for Health Statistics

Manning Feinleib, M.D., Dr.P.H., Director

Jack R, Anderson, Acting Deputy Director

Jacob J. Feldman, Ph. D., Associate Directorj’or AnaZysis

and Epidemiology

Gail F. Fisher, Ph. D., Associate Director for I%znning and

Extramural Programs

Peter L. Hurley, Associate Director for Ktal and Health

Statistics Systems

Robert A, Israel, Associate Director for International

Statistics

Stephen E. Nieberding, Associate Director for

Management

Charles J. Rothwell, Associate Director for Data

Processing and Services

Monroe G, Sirken, Ph.D., Associate Director for Research

and Methodology

David L. Larson, Assistant Directofi Atlanta

Office of Research and Methodology

Monroe G. Sirken, Ph. D., Associate Director

Kenneth W. Harris, Special Assistant for Program

Coordination and Statistical Standards

Lester R. Curtin, Ph.D., Chiej Statistical Methods Staff

James T. Massey, Ph.D., Chiej Surwy Design Staff

Andrew A. White, Ph.D., Chiej Stattitical Technology

Staff

This research was part of a larger project entitled, “National Laboratory

for Collaborative Research in Cognition and Survey Measurement,”

conducted by the National Curter for Health Statistics (NCHS) under

grant SESN86K?320 from the National Science Foundation (NSF).

Monroe G. Sirken, Ph.D., was the principal investigator for this grant,

and Murray Abom, Ph.D., was the NSF program director.

The program of research rep6rted on here was performed under Department of Health and Human Services contract 200-SS-7001 from NCHS

to Yale University. Peter .%dovey,Ph. D., was the principal investigator.

Jarcd B. Jobe, Ph.D., was the NCHS project officer, and is the technical

editor and reviewer for Series 6. Gordon B. Willis, Ph. D., was the

alternate project ot%cer.
Contents

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Oc. ,., ,e ,,. moe... .0 1

Language and pain assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Memory and pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Overview of present experiments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,, . . . . . . . . ..OO. 4

Issue I: Language and pain.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., +0. . . . .. O.O..O... 5

Experiment l: Use oflanguageto describe the consequences ofpainful Iife experiences . . . . . . . . . . . . . . . . . . . . . . . 5

Experiment 2: Multivariate study of group differences inuse ofpain language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Issue II: Recall ofpainversus pain behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I(I

Ex~eriment 3: Recall ofpain andpain behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 10

Experiment 4: Stabili~ of self-report pain severity, interference with life tasks, and interviewer ratings of

pain behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. e. . ..< . . ..e.e13

Issue III: Mental states, pain reporting, and pain recall . .,, , . . . . . . . . . . . . ., .,..,,....,,....,,.,.,,.,,,, ., ..,,,16

Experiment 5: Recalling past pain when present pain fluctuates.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...16

Experiment 6: Mood congruent recall of and judgments about pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...18

Experiment 6A. College student subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..lg

Ex~eriment 6B: Subjects recruited from community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Conclusions, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...26

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...27

Appendixes

1, Ftmther analyses ofexperiment3 data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . . . . ...31

11, Materials used in experiments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . ...33

Text tables

A, Experiment l-Most frequently generated painful incidents in response topain terms. . . . . . . . . . . . . . . . . . . . . . . . 6

B. Es~eriment 2–Four-dimensional solution: Healthy subjects, nonmetric multidimensional scaling . . . . . . . . . . . . . . 8

C, Experiment 2–Four-dimensional solution: Pain patients, nonmetric multidimensional scaling . . . . . . . . . . . . . . . . . 8

D, Experiment 2–Interpreting canonical variates: Loadings of the dimensions of the scaling solution ontheir

Canonica] variates ...,.,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

E, Experiment 2–Canonical correlation analysis between healthy subjects and pain patients: Four-dimensional

solution, ,,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

F, Ex~eriment 2-Four-dimensional solution: Healthy subjects andpain patients combined using INDSC& . . . . . . 9

G, Experiment 2–INDSCAL dimension weights for four-dimensional solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

H. Ex~eriment 3–Recalled-versus-actual pain intensity and pain behaviors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

J, Experiment 3–Recall by diary condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I2

K, Experiment 3–Actual and recalled behaviors by condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I3

L. Experiment 4-Pain behavior rating form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...14

M, Ex~eriment 4–Descriptive statistics on measured variables at two points in time . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

iii
N. Experiment 4–Pearson correlations from time 1 to time 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

0. Experiment 5 –Descriptive statistics for measured variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,,, ,,, ,., ,? 17

P. Experiment 5 – Pearson correlations between diary scales and recall measures . . . . . . . . . . . . ...0.. ,., .,,.!. ,., , 17

Q. Experiment 5 –Predicting recalled usual levels of pain from actual mean during diary phase, variability

during diary phase, and current level of pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

R. Experiment 6A–Means on mood and symptom scales prior to mood induction by mood and gender . . . . . . . . . . . 20

S. Experiment 6A–Ratings of recent painful experiences after mood induction by mood and gender . . . . . . . . . . . . . 21

T. Experiment 6A–Pain ratings of hypothetical stories by mood and gender. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

U. Experiment 6A–Recall of frequency of painful episodes from previous year by mood and gender . . . . . . . . . . . . . 22

V. Experiments 6A and 6B – Correlations of baseline (noninduced) mood and pain ratings across all

experimental conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

W. Experiment 6B –Means on mood and symptom scales prior to mood induction by mood and gender . . . . . . . . ...23

X. Experiment 6B –Recall of frequency of painful episodes from previous year by mood and gender. . . . . . . . . . . . . . 23

Y. Experiment 6B – Ratings of recent painful experience after mood induction by mood and gender. . . . . . . . . . . . . . 24 .

Z. Experiment 6B –Pain ratings of hypothetical stories by mood and gender. . . . . . ,, .,,,,.,, . . . . . . . . . . ,,, ,$, ,.. 25

Symbols

--- Data not available

. . . Category not applicable

Quantity zero

0,0 Quantity more than zero but less than

0.05

z Quantity more than zero but less than

500 where numbers are rounded to

thousands

* Figure does not meet standard of

reliability or precision (estimate is based

on fewer than 20 births in numerator or

denominator)
Reporting Chronic Pain

Episodes on Health Surveys

by Peter Salovey, Ph,D,, and William J.

Sieber, M, Phil., Yale University, Albert F.

Smith, Ph.D., State University of New York at

Binghamton, Dennis C, Turk, Ph. D.,

University of Pittsburgh, and Jared B. Jobe,

Ph,D,, and Gordon B, Willis, Ph.D., Office of

Research and Methodology, National Center

for Health Statistics

Background

Chronic pain is the most universal form of human

stress (1), Millions of Americans suffer from pain-related

problems, often resulting in partial or complete disability.

The social and economic impact of chronic pain is staggering (reviewed in more detail by (l), pp. 73-74). For

example, in the United States every year, 600,000 people

develop pain from arthritis for the first time (2). Twentyfive million Americans experience the painful consequences of migraine headache on a regular basis (3). Low

back pain, another common complaint, disables approximately 7 million citizens and accounts for over 8 million

physician office visits annually (4).

The costs of these and other pain complaints are

enormous, Fully 80 percent of all physician consults are

pain related (5). Each year, Americans purchase about

20,000 tons of aspirin, 225 tablets for every resident (6),

Patients suffering from various chronic pain problems

submit to multiple medical treatments and surgical procedures. Often, these medical interventions are not helpful,

md by 1980, the American Pain Society (7) reported that

over 800 pain clinics in the United States treat what might

be described as failures of the traditional health care

system,

The medical and scientific communities as well as

government agencies such as the Public Health Service all

recognize the need for data of better quality on the

prevalence and severity of chronic pain in the population.

These data are used by government agencies to assess

health-care needs and by epidemiologists to explore relationships between health status and assorted psychological, social, and economic variables (8). The quality of

survey data on experiences with pain is threatened if there

are systematic sources of error in the recall of the intensity

and quality of painful episodes or biases in judgments

about the nature of present and past pain.

We would like to thank Chloe Drake, Stephanie Fishkin, Jean

Giebel, Sasha van der Sleesen, and Beverly Stout for their dedicated

assistance in collecting and managing the data for this project, and

Michael Baron and Theresa Claire for their help in preparing this

document,

Despite the pervasiveness of pain, accurate statistical

accounts of the personal and societal impact of it may be

plagued by problems of language and recall accuracy (9),

Recall of pain experiences, episodes, and intensity may

not be accurate, with chronic pain sufferers often reporting more severe pain in retrospect than at the time of the

actual painful experience (although in certain situations,

as we will discuss, they report less pain in retrospective

accounts). Self-report instruments and surveys suffer from

difficulties in matching descriptive language to the perceptual qualities of pain experiences. These kinds of problems

with language use and recall accuracy pose formidable

challenges to the National Center for Health Statistics and

other designers of health surveys.

Language and pain assessment

One source of error in the recall of pain episodes on

health surveys may be rooted in the complexities of using

language to describe the subjective quality of painful

experiences. In particular, it is possible that individuals

who experience pain chronically use pain-relevant language differently than pain researchers, survey designers,

and others who have had considerably less experience

ruminating about ongoing pain and describing pain to

other people.

The classic study of the language of pain was Melzack

and Torgerson’s (10) well-cited work in which they categorized words used to describe pain and then attempted to

scaIe them on a common intensity dimension. Although

others have examined the language of pain using more

sophisticated scaling methodologies (11), the idea that

individuals suffering from pain use pain language differently from nonpain respondents has not been examined

extensively. Even Melzack and Torgerson (10), who originally collected ratings of pain words from patients, students, and physicians, did not look specifically at group

differences in these ratings or in the way words were

organized.

Enhancing our understanding of the descriptive language of pain can facilitate the construction of surveys and

the understanding of survey data. Traditionally, only the

intensity of pain (e.g., mild, moderate, severe) was elicited

from respondents. Later, Melzack and Torgerson (10)

1
suggested that (a) the English language offers a rich

vocabulary for describing pain experiences, (b) there is

high agreement on the dimensions underlying particular

classes and subclasses of these words, and (c) despite

individual differences in background and pain problems,

most of these pain words are used similarly across

individuals.

In a series of studies using the scaling techniques

available at the time, Melzack and Torgerson identified

three general aspects of pain experience: sensory (temporal, spatial, punctate pressure, incisive pressure, constrictive pressure, traction pressure, thermal, brightness,

dullness), affective (tension, autonomic, fear, punishment), and evaluative (intensity).

This effort led to the design of a multidimensional

pain inventory, and the ability to assess pain on more than

a simpIe intensity dimension. The widely used McGill Pain

Questionnaire (MPQ) (12) was thus developed, based on

these aspects of pain experience. Although the MPQ

measures a variety of aspects of the pain experience, its

Pain Rating Index (PRI) most directly attempts to separate and quantify three distinct components of pain:

sensory-discriminative, motivational-affective, and cognitiveevaluative. These three components are measured using

ratings from 20 adjective subclasses of from 2 to 6 pain

descriptors ranked according to pain intensity.

Although the Pain Rating Index of the MPQ has

demonstrated adequate reliability, validity studies of its

three-dimensional structure have yielded more equivocal

results (13, 14, 15). Turk, Rudy, and Salovey (16) employed confirmato~ factor analysis to examine the stability

of the tricomponent structure of the PRI in two different

hospital samples, Although the three-component structure

was supported, the components were also highly intercorreIated and so did not display adequate discriminant validity.

Turk et al. recommended that only a full-scale PRI score

(representing global pain intensity) be used.

One issue relevant to the design of national health

surveys is whether there are group differences in the use

of pain language. In particular, do individuals who experience a considerable amount of pain (e.g., chronic pain

patients) use pain language differently than individuals

with more acute experiences with pain? A second but

related issue is whether there is any agreement on pain

terms. That is, could a commonly used pain vocabulary be

developed? If so, the designers of surveys might wish to

draw from this lexicon in composing questions.

Difficulties in the use of pain language (as well as

more traditional weaknesses with self-report instruments

of all kinds) have led pain researchers to suggest two other

approaches to eliciting pain-relevant information from

pain sufferers. The first approach is to evaluate pain based

on its impact on the life of the pain patient and those

around him or her (17). The second is to abandon selfreport of pain altogether and instead assess only observable pain behaviors (18–21), Finally, researchers have

combined these two approaches into what is called a

“comprehensive assessment” (22).

Memory and pain

No matter how pain is measured, there is considerable

concern that survey respondents may provide biased accounts of the intensity and quality of their pain experiences, especially when these accounts are made

retrospectively (9, 23). However, the degree (and even the

direction) of bias has been the source of considerable

controversy, Whereas some investigators claim that individuals generally inflate the amount of pain experienced at

a given time when asked to report about it later (24),

others claim that people can accurately report their pain

experiences, at least for several days after the original

episode (25).

A closer examination of some of these studies, however, reveals a more consistent pattern of difficulties in

accurately reporting past pain experiences. A study by

Hunter et al. (25) is often cited as an example of the

accuracy of memory for pain (see 24, p. 282). Yet, Hunter

et al.’s data do not support this conclusion. They divided

16 headache patients into two groups. One reported pain

after 5 days and the other after 1 day and then again after

5 days.

Using various subscales of the McGill Pain Questionnaire, these researchers found that the intensity

and quality of pain reported after 5 days was similar to

that reported by the patients at the time of their initial

interview while experiencing the headache. Five days,

however, is not a long time interval during wjich much

decay in vivid pain relevant memories should be expected. Yet, even after just 5 days, patients described

their pain on the McGill Pain Questionnaire using only

about 70 percent overlap in pain terms as compared

with the initial assessment. Further, 5 of the 16 patients, labeled “shifters,” recalled only 30-50 percent

of their initial pain ratings.

Hunter et al. note that this level of accuracy is

“similar to that for the recall of incidental material”

(p. 43) such as the interviewer’s name. Yet, a pain experience, such as an intense headache, is much more salient,

vivid, personally relevant, and affectively charged than

incidental information such as the interviewer’s name.

Hence, it should be recalled with exceptional accuracy

(26).

Similar studies using the MPQ as the instrument on

which pain is reported, and comparing initial reports to

later memories, have generally yielded low correlations.

After only 7 days, reports of pain by rheumatoid arthritis

patients on the MPQ were only modestly correlated with

initial reports, although reports of a single experience of

ischaemia pain were more accurately recalled (27).

Other studies also provide evidence that retrospective

recall of pain is often inaccurate and usually exaggerated.

Linton and Melin (24) studied 12 back and joint pain

patients undergoing a 3-11 week treatment and found that

ratings of pain at the initiation of treatment were higher

when estimated at termination compared with ratings

2
actually made prior to the beginning of the program. Of

course, patients may have been motivated to inflate their

estimates of pretreatment pain in order to feel that the

effort expended in the treatment program was justified.

In a similar study, Linton and Gotestam (28) had

patients rate their pain on both a verbal scale (O-5 with

each point labeled) or on a visual analog scale (100-mm

line). After 4-9 weeks, 12 of the 15 patients recalled their

pain at baseline as more intense than they had actually

reported it to be, and the biggest discrepancies were noted

on the visual analog scale. This latter effect is probably

due to the retrieval cue provided by the verbal content of

the 5-point scale,

Kent (29) asked dental patients to rate pain expected

prior to a dental procedure, actual pain experienced as a

result of the procedure, and then to recall the amount of

pain they had experienced 3 months after the dental

appointment. Only modest correlations between recalled

and actual pain were obtained, indicating that factors

other than the initial pain experience accounted for most

of the variance in pain recall after 3 months. Interestingly,

among individuals who were not anxious about dental

work, the recalled/e.xperienced correlation was much higher,

but there was virtually no correlation between the two

among highly amiious individuals. In general, recall drifted

in the direction of anxie~ that is, highly anxious individuals remembered the pain experience as much more

severe than it actually was. These results are only suggestive, however, as the reliability of the reported correlations

was compromised by the small sample (15 low-anxious and

8 high-amsious subjects).

In contrast to these examples, there are occasions

when retrospective accounts of pain may be underestimates of actual pain. This outcome seems most likely

when the consequences of pain produce considerable

positive affect, For example, an athlete straining to win a

gold medal at the Olympics might complete a marathon

despite intense pain and later report that she had not

experienced much pain at all, Perhaps the prototype of

this sort of pain is childbirth. Labor is quite painful, yet

most mothers are unlikely to dwell on the intensity of such

pain after the child is born. Guerra (30) noted that “the

parturient will tolerate much more pain and discomfort

than will other surgical patients” (p, 77), In fact, Norvell,

Gaston-Johansson, and Fridh (31) found that pain ratings

on visual analog scales made during three phases of labor

revealed considerably more intense pain than retrospective ratings made 2 days postpartum. It maybe that when

pain intensity is 10W,for example, several days after the

birth of a child, memory for the original experience of pain

is underestimated; but that when existing pain intensity is

high or can be high, as in a chronic pain patient, memory

for the original pain experience is augmented (32). Alternatively, the affective state of the mother during labor

(fearful, anxious) and her affective state after the birth of

the child (joy, relief) are so incongruent that there maybe

considerable interference with recall of material in the

latter state that was encoding during the former (i.e.,

there will be no state-dependent memory facilitation)

(33).

Summary

The literature reviewed suggests that pain may not be

recalled with great accuracy and that in the chronic pain

populations in which pain recall is often studied, retrospective accounts of pain generally yield elevated intensity

ratings. On the other hand, in certain special populations

who experience acute pain of shorter duration, especially

when followed by positive affect or relief from this pain,

retrospective recall of pain can actually produce attenuated pain estimates. The literature suggests several sources

of systematic bias in pain recall:

●

●

●

respondents with different levels of experience in dealing with and reporting pain may organize pain-relevant

language differently; it is also not clear whether there

is a common pain language used to report painful

experiences.

whether pain intensity and quality is assessed verbally

through self-report measures or by rating pain-related

behaviors and pain-related life changes.

mental states such as whether respondents continue to

experience pain at the time of the retrospective rating

and respondents’ affective state at the time the pain

rating is made.

3
Overview of present

experiments

This report describes findings from six experiments

that investigate factors influencing accurate judgments

about and recall of pain and painful experiences. Three

specific factors associated with the judgment and recall of

pain are explored: (a) complexities in the language used

by respondents to describe pain and painful experiences,

(b) the relative susceptibility to cognitive biases of recall

of pain intensity versus pain behaviors, and (c) the influence of ongoing mental states, such as present pain and

mood, at the time of recall.

As with other kinds of subjective experience, the clear

use of language to communicate painful present or past

experiences is fraught with difficulty, The first two experiments deal with language specifically used by respondents

to describe their pain. The first experiment investigates

how episodes of pain are characterized and how different

patterns of pain are described by subjects with varying

pain experiences. Results from this study can suggest the

terms that might be included or avoided in the preparation of health surveys. In addition, if group differences in

language use are found, instruments especially tailored to

specific populations may be recommended. In experiment

2, we ask whether there are any commonalities in the use

of pain language to describe similar painful experiences.

This experiment explores whether individuals who vary in

their experiences with pain also vary in their use of pain

language and in the way pain language is represented in

memory.

If recall of the intensity and quality of pain episodes is

subject to the kinds of biases described earlier, might

there be other ways in which prior experiences with pain

can be assessed that are less prone to error? Experiments

3 and 4 address this issue. Pain researchers have begun to

focus on two alternatives. to simply questioning respondents about pain severity directly. The first is to examine

changes in activities of daily living that are (or were)

concomitants of the pain experience. For example, questions can be formulated about changes in the amount of

time spent working around the home, taking care of lawn

and garden, attending recreational activities such as sporting events or dances, or the curtailing of certain job

responsibilities and sexual activities.

A second approach to improving the accuracy of

survey information regarding pain is to question respondents about specific behaviors associated with pain (e.g.,

change in use of analgesics, number of days on which

crutches were used) and to consider observable behaviors

that accompany the actual experience of pain (e.g., facial

expressions, verbal utterances, abnormal gait, shifting weight

while sitting), The questions asked in experiments 3 and 4

are concerned with whether the recall of past behavioral

changes is more accurate than the recall of prior pain

severity and whether interviewer ratings of pain behaviors

and life changes are more stable over time than recall of

prior pain per se.

The fifth experiment examines whether differences in

survey respondents’ present levels of pain are associated

with the recall of previous painful experiences. The natural fluctuation of pain intensity among chronic pain patients at a pain clinic is exploited in order to study whether

the ebb and flow of their present pain influences their

recall and ratings of past painful episodes. Clinical research suggests that, in fact, when present pain intensity is

high, prior pain is reported to have been more severe than

when present pain intensity is low (32).

The sixth experiment concerns biases in recall and

judgments of pain attributable to respondents’ moods.

Although often overlooked, there is increasingly strong

evidence that mood affects the manner in which information is encoded, organized in memory, and ultimately

retrieved (33, 34). The role of moods and emotions in the

accuracy of judgments about and recall of painful experiences has only recently been studied directly (35), despite

the fact that it has been suggested for quite some time as

the key variable mediating the accuracy of pain recall (25,

27,29, 31, 32, 36).
Issue 1:

Language and pain

Experiment 1: Use of language to describe

the consequences of painful life

experiences

Background

We cannot know another person’s experience of pain

directly, What we can do is describe, in language that is as

objective as possible, episodes that might generally be

expected to result in pain (e.g., receiving an injection,

surgery, having a tooth pulled). Do people share descriptive terms for painful episodes of this sort? Such a shared

language would seem necessary as it is through language

that we obtain reports of pain on surveys.

The purpose of experiment 1 was to determine whether

common pain descriptors are linked consensually to particular kinds of painful episodes. Additionally, we explored the actual language used to define and describe

various pain episodes and whether these descriptions vary

depending on whether one has had personal experience

with the particular pain problem. In this experiment, we

attempted to generate pain vocabulary using a set of

open-ended tasks, responses to which were then categorized. Our goal was to ask subjects to generate pain

language in a spontaneous (as opposed to reactive) manner, as our purpose was rather exploratory. Because this

experiment was the first in a rather lengthy sequence of

experiments, all of which relied on pain language to some

extent, we wanted to obtain a better understanding of the

pain lexicon, Put simply, How do people describe pain

when unconstrained by the structure of surveys?

Design and procedure

Twenty-one native speakers of Engiish randomly seiected from the New Haven, Connecticut, area and 22

pain patients from the Pain Evaluation and Treatment

Institute of the University of Pittsburgh Medical Center

served as subjects in this study and were paid $10 for their

participation. As much as possible, we tried to match the

two sampies in terms of gender ratio, socioeconomic

status, education, and age.

In a single session, subjects completed two tasks:

(a) Subjects were asked a series of questions designed

to elicit spontaneous pain descriptions, Sample questions

included: “Describe the most painful experience you have

ever had“; “What did it feel like?”; “Specifically,what was

the pain like?”; “Can you generate a set of fivewords that

really captures for you the painful experience?”; “Describe your most recent painful experience.” Another

question asked in order to define an upper limit on painful

episodes was, “Describe the most painful situation

imaginable.”

In addition, for the pain patient subjects, a “think

aloud” component was added to the interview. In the

course of these interviews, subjects were asked to rate

their pain for that day. They were then asked to describe

what was going through their minds as they made these

ratings. After thought listing, they were asked a series of

more structured questions to obtain additional information concerning how pain ratings are made, such as How

did you go about making your pain rating? Did your pain

vary much during the course of the day? If so, how did you

arrive at a final number? Imagine a day in which your pain

was excruciating in the morning but then gradualiy improved during the day until it was barely noticeable; How

would you go about rating your pain for that day? What if

your pain was bad, you took some medication, and it got

better; How wouid you go about rating your pain for that

day? And so forth.

(b) The corpus of pain terms most commonly used in

surveys is the one provided in the McGill Pain Questionnaire, These 72 terms have been used as descriptors for

clinical pain syndromes, but subjects have not been asked

to generate memories of painful episodes in response to

them, In this second task, we presented subjects with a

subset of 15 of these terms suggested as an MPQ shortform by Melzack and asked them to describe painful

experiences that could best be characterized by the provided term. So, for exampie, subjects were asked, “describe

a painful experience in which the pain was cramping,” or

“describe a painful experience in which the pain was

heavy.”

Results

When asked to describe a recent painfui incident, the

healthy subjects came up with 18 discrete types of episodes (e.g., cut, headache, burn), and the pain patients,

10. We then asked subjects to generate five words to

describe the pain. If every subject generated five unique

words and no subject generated words on another sub5
ject’s list, 105 different words would have been generated

by the healthy group and 110 words by the pain group. In

fact, 74 different words were generated by the healthy

group and 60 by the pain group, an enormous and heterogeneous assortment of terms. Words most frequently

generated by the healthy subjects were “sharp,”

“throbbing,” and “annoying”; those most frequently mentioned by the pain patients were “sharp,” “aching,” and

“severe,”

This pain term generation task was repeated for “the

most painful experience you have ever had” and for “the

most painful experience imaginable” with similar results.

“The most painful experience you have ever had” was

likely to be either a broken bone or surgery for healthy

subjects and for pain patients. Healthy subjects described

this pain using 73 different terms; most frequent were

“sharp, “ “excruciating,” and “annoying.” Pain patients

generated 53 different terms, most commonly “sharp,”

“excruciating,” and “numb.”

“The most painful experience imaginable” for healthy

subjects was being burnt. Eighty-three different terms

were used to describe the most painful experience imaginable; most frequent were “helpless,” “intense,” and

“sharp. “ “The most painful experience imaginable” for

pain patients was amputation (burning and child birth tied

for second), and they used 50 different terms to describe

it. Most commonly mentioned were “agonizing,” “numb,”

and “excruciating.”

In the next section of the interview, the pain clinic

sample (only) described how they use numbered scales to

make different kinds of pain ratings. Some of the observations culled from these data were: (a) patients are more

likely to use the odd numbers on a O–9 pain scale,

especially 7, (b) patients have great difficulty introspecting

about how they chose from among scale alternatives (e.g.,

the most frequent reason is “I just considered how much

pain I was in”), (c) when pain shifts from excruciating to

barely noticeable in the course of a day, for whatever

reason, patients overwhelmingly choose the number 3 to

represent their average amount of pain for that day, but

they (d) have little understanding about how or why they

did so.

In the final section of the interview, subjects were

asked to generate pain episodes that might involve pain

described by a particular term from the MPQ. Table A

summarizes the most common pain episodes generated in

response to these cues. In table A, “number of

nominations” indicates the number of subjects who mentioned the most frequently generated incident. “Number

of different incidents” refers to the number of different

types of painful incidents nominated for each term by the

healthy and pain samples, respectively, What is most

interesting about these results is that there is considerable

diversity in applying these pain terms to painful episodes.

With the exception of a few items in which semantic

associations are obvious (e.g., splitting – headache), there

is not considerably high agreement in term application,

These findings indicate that individuals have some diffi6

Table A. Experiment 1 -Most frequently generated painful

incidents in response to pain terms

Term Healthy sample Pakr sample

Throbbing ., . . . . . . , . . . . Headache

Nominations ...,....,.9

Different incidents. . . . . . . 9

Shooting . . . . . . . . . . . . .. Muscle

Nominations. . . . . . . ...4

Different incidents. ., . . . . 13

Stabbing. . . . . . . . . . . . . . Stabbing, injection, cramp

Nominations ., , , . . . . . . 3 each

Different Incidents. . . . . , , 13

Sharp . . . . . . . . . . . . . . . . Stomach, head

Nominations . . . . . . . . . . 3 each

Different incidents. . . . . . . I I

Cramping ., . . . . . , . . . . . Menstrual

Nominations ., .,......7

Different incidents. . . . . . . 6

Gnawing . . . . . . . . . . . . .. Dental

Nominations . . . . . . . ...8

Different incidents. , . . . . . 7

Hot . . . . . . . . . . . . . . . .. Burn

Nominations . . . . . . . . . . 13

Different Incidents. . . . . . , 7

Aching . . . . . . . . . . . . . .. Exeriion

Nominations . . . . . . . ...7

Different Incidents. . . . . . . 8

Heavy, . . . . . . . . . . . . . . . Muscle, head, crush

Nominations . . . . . . . . . . 3 each

Different incidents. . . . . . . 12

Tender . . . . . . . . . . . . . . . Bruise, blister, joint

Nominations . . . . . . . . . . 4 each

Differentincidents. . . . . . . I,Z

Splitting . . . . . . . . . . . . .. Headache

Nominations . . . . . . . . ..l4

Different incidents. . . . . . . 7

Tiring . . . . . . . . . . . . . . .. Fatigue

Nominations . . . . . . . ...5

Different incidents. . . . . . . 11

Sickening .,. ... ,,. Nauseausea

Nominations . . . . . . . . . . 10

Different incidents. . . . . . . 9

Fearful . . . . . . . . . . . . . . . Stomach, eurgery, heart,

bone

Nominations . . . . . . . . . . 2 each

Different incidents. . . . . . . 16

Punishing . . . . . . . . . . . . . Beat, torture

Nominations . ., . . . . ...5

Ditferent incidents. . . . . . . 12

Headache

9

9

5

11

Back

5

10

Back

5

11

Leg

7

9

Dental

6

10

Burn

7

11

Head

5

10

5

10

Muscle

4

14

Headache

21

2

Fatigue

7

8

Nausea

16

6

Nerves, illness

3 each

15

Beat, accident

4 each

11

Notc% n = 21 healthy subjects, n = 22 chronic pain subjects.

culty mapping terms onto specific pain instances.

Discussion

The purpose of this first experiment was to explore

the complexities of the pain lexicon in an open-ended and

unstructured way rather than to test specific hypotheses

about pain language, We can draw a number of conclusions about the vocabulary of pain. First, the lexicon is

enormous. When asked to generate pain descriptors, subjects use a plethora of words. Second, subjects are unlikely

to use the same words to describe experiences with pain,

Although a few descriptors, like “sharp”, are rather frequently used, there is little consensus in adjectives that

describe pain. Each subject generally thought up a set of

unique descriptors.
Similarly, when subjects were asked to generate pain

episodes that might result in pain that could be described

by a particular adjective (e.g., tender), overwhelming consensus in episode generation was not discovered. Rather,

subjects generated an array of possible scenarios. (There

were some exceptions to this lack of consensus. About half

the sample produced headache in response to throbbing,

burn in response to hot, headache in response to splitting,

and nausea in response to sickening,)

We detected few differences in the use of pain language in pain patients compared with healthy subjects.

But this question is better explored in a more structured

study. In experiment 2, we examined use of pain language

in these two groups of individuals more systematically. We

asked whether, despite the enormity of the pain lexicon,

there might be a subset of terms that is used rather

consensually across a wide range of people.

Experiment 2: Multivariate study of group

differences in use of pain language

Background

As revealed in experiment 1, pain assessment can

involve the. use of an enormously large set of terms.

Becouse the purpose of communication is to arouse,

within the mind of a recipient, a representation that is the

same as the representation in the mind of the sender, it is

important to select, for use in surveys, a set of pain

descriptors understood similarly by survey designers, utilizers of survey information, and respondents.

The purpose of this experiment was twofold: First, we

wanted to investigate the corpus of commonly used pain

terms to determine whether pain can be reduced sensibly

to a set of terms with clear unambiguous meaning. Second, we wanted to determine if individuals with varying

life experiences involving pain differ in their use of pain

language,

Two different groups of subjects, one suffering from

chronic pain and the other healthy, made direct similarity

rtitings among pain terms. With the aid of several analytic

procedures to identify structure in multivariate data, we

attempted to identify terms that have common meanings.

The nature of the pain lexicon for the two groups of

subjects was also compared.

Method

The following sequence of steps constituted the procedure for experiment 2:

1, A group of 1Spain terms comprising the short form

of the McGill Pain Questionnaire (and used in experiment

1) was selected for analysis.

2. Two groups of subjects – (a) patients with chronic,

intractable nonmalignant pain (e.g., back pain) or patients

with acute recurrent pain (e.g., headache), and (b) healthy

individuals with no documented pain complaints —were

asked to rate the similarity of all possible pairs of pain

terms according to their meanings. They were provided

a list of the 105 pairs of descriptors in a random order

and asked to indicate on a 5-point scale how similar in

meaning the two terms were. These subjects were

native speakers of English. Twenty healthy subjects

sampled randomly from the New Haven community

participated, and 40 pain patients from the Pain Evaluation and Treatment Institute at the University of

Pittsburgh Medical Center volunteered for this study.

Each was paid $10 for participating.

3. Before analyzing these data using multidimensional scaling (MDS), we assessed the correspondence in

similarity ratings made by pain patients and healthy subjects directly. For this analysis, we used equal numbers of

pain patients (randomly selected) and healthy subjects (20

from each group). The average similarity rating for each

pair of descriptors was calculated separately for two halves

of each of the two samples of subjects, and the correlation

across these 105 similarity ratings was computed between

the two halves of the pain patient sample and between the

two halves of the healthy sample. We also computed the

correlation between these mean ratings for the half samples of pain and healthy subjects. This procedure was

repeated 500 times; each time, the two samples were split

into two equal subsamples randomly, using a computer

program written for this purpose, The average within

sample and between sample “split-haIf” correlation was

then computed as an index of overlap in similarity ratings

within healthy and pain subjects and, more importantly,

between the two groups.

4. For the MDS analysis, matrices of similarity ratings

were converted to dissimilarities by subtraction from a

constant and were submitted to two separate nonmetric

multidimensional scaling analyses for the two samples

using the ALSCAL algorithm (37),

5. The similari~ of the two scaling solutions was then

evaluated using canonical correlation analysis. The coordinates of the items on the dimensions in one sample were

related to the corresponding coordinates in the other

sample (this procedure was developed by A.F. Smith

(38)).

6. Then, a multidimensional scaling analysis using the

INDSCAL model was carried out (39). Common group

spaces in two through four dimensions were examined.

Based on obtained stress and proportion of variance

accounted for, a solution was selected for further study.

7. The INDSCAL analysis also yields dimension

weights for each group. These weights represent the

tendency of subjects in each group to utilize that dimension in making their similarity ratings (40). Dimension

weights are analogous to partial correlation coefficients,

and the square of a weight on a particular dimension

indicates the proportion of variance in a specific group’s

proximity data that can be accounted for by that

dimension. Thus, these weights indicate how important

each dimension is to subjects in making their similarity

ratings (41).

7
Table B. Experiment 2- Four-dimensional solution: Healthy

subjects, nonmetric multidimensional scaling

Dimension Dimension Dimension Dimension

Term 1 2 3 4

Throbbing . . . . . . -.15

Shooting . . . . . . . –2.02

Stabbing. . . . . . . -1.80

Sharp . . . . . . . . . -1.52

Cramping . . . . . . .04

Gnawing . . . . . . . .74

Hot . . . . . . . . . . -.55

Aching . . . . . . . . .96

Heavy ..,,...., 1.51

Tender . . . . . . . . -.28

Splitting, . . . . . . -1.30

Tirin g . . . . . . . . 2.20

Sickening . . . . . . 1.28

Fearful . . . . . . . . .12

Punishing , . . . . . .79

1.07

-.60

-.34

-.14

.24

1.45

.22

.82

-.87

2.35

-.53

.01

-1.04

-1.65

-1.00

.48

,25

.27

-.27

.66

.42

–1 .62

.78

.71

-1.28

1,42

.61

–.83

–1 .59

-.21

–.85

-.36

.01

.20

1.28

1.08

-1.52

-.20

–.32

.44

.10

-.41

.47

1.27

–1 ,20

Note: Stress = .12 R2 =.83.

Results

The correlational analysis (Step 3, above) revealed

that the mean correlation between 500 randomly selected

halves of the pain patient sample across the 105 similarity

ratings of descriptor pairs was .65. For the healthy subjects, the mean correlation was .40. And the mean correlation in similarity ratings between any half of the pain

patient sample and any half of the healthy sample was .58.

These correlations suggest that there is a strong overlap in

the similarity ratings generated by pain patients and healthy

subjects. They also suggest that the correspondence in

ratings between the two samples is more or less comparable to the reliability of these ratings within each sample.

Table B reports the dimension coordinates for the

MDS analysis with healthy subjects. After examining stress

values (using Kruskal’s Formula 1) for 1 through 4 dimensional solutions (.49, .26, .17, .12) and corresponding R 2

(.29, ,62, .75, .83), the four-dimensional solution was

chosen as most appropriate for these data (Stress = .12,

R 2 = .83), Additional dimensions resulted in only small

increases in R 2 with almost no further reduction in stress.

There was no attempt to formally interpret the dimensions, as this was not the focus of the experiment, However, visual inspection of the four-dimensional maps

suggested they might represent dimensions of intensity,

emotion/physical, suddenness of onset, and location,

respectively.

Table C reports the dimension coordinates for the

MDS analysis with pain patients. A similar four dimensional solution also seemed appropriate. The stress for 1

through 4 dimensions, respectively, was .52, .27, .19, and

.12, and the variance accounted for by the solution (R 2,

was ,26, .57, ,73, and .85. Visual inspection of the fourdimensional solution suggested that these dimensions were

quite similar to those derived from the healthy sample, It

should be noted that dimension 2 in this solution most

resembles dimension 3 in the healthy subjects’ solution

and vice versa.

Table C. Experiment 2-Four-dimensional solution: Pain patients,

nonmetric multidimensional scaling

Dimension Dimension Dimension Dimension

Term 1 2 3 4

Throbbing . . . . . .

Shooting. . . . . . .

Stabbing. . . . . . .

Sharp . . . . . . . . .

Cramping . . . . . .

Gnawing . . . . . . .

Hot . . . . . . . . . .

Aching . . . . . . . .

Heavy ..,..,...

Tender . . . . . . . .

Splitting . . . . . . .

Tirin g . . . . . . . .

Sickening . . . . . .

Fearful . . . . . . . .

Punishing . . . . . .

.52

1.85

1.66

.95

–.44

-.96

.61

-.83

-.59

–1 .46

1.40

–2.26

–.43

-.03

.03

,22

.00

.25

.39

1.40

.42

-1.53

.29

1.15

-.76

-.79

.73

-.93

–2.58

.16

.39

.36

.06

.05

.34

-.36

-1.76

.46

-1.16

1.72

-.61

-.19

-1.02

-1.86

.06

-.64

.21

-.16

.08

-.54

-1.56

.81

-.40

1.50

-.52

-.61

,76

-.89

.04

1,95

Note: Stress = .12 R 2 = .85.

Table D. Experiment 2- Interpreting canonical variates: Loadings

of the dimensions of the scaling solution on their canonical

variates

Sample Variate I Variate // Variate /// Variate W

Patient

Dimension 1. . . . . –.83 .51 .02 -.23

Dimension 2 . . . . . .x .81 .18 .47

Dimension 3.. , . . –.25 -.= .86 .32

Dimension 4.. , . . -.36 -.23 -X? .76

Healthy

Dimension 1. . . . . .73 –.40 -.38 .41

Dimension 2 . . . . . .% -.19 .92 .06

Dimension 3 . . . . . .26 .91 .G -.32

Dimension 4 . . . . . .46 ,5 -.13 -.85—

Not& Underlined weights indicate highest loading dlmenelon on each variate,

Table E. Experiment 2-Canonical correlation analysis between

healthy subjects and pain patients: Four-dlmenslonal solution

Canonical variate Canonical R Approximate F P

1. . . . . . . . . . . . . . . . . .99 21.17 .0001

2 . . . . . . . . . . . . . . . . . .95 14.39 .0001

3 . . . . . . . . . . . . . . . . . .92 11.55 .0001

4 . . . . . . . . . . . . . . . . . .70 9.50 .01

Not= Total mutually explalned variance in two aats of rating% ,80.

Canonical correlation analysis was used to investigate

overlap in the MDS solutions for the healthy subjects and

pain patients. Table D reports the correlations of dimensional coordinates with canonical variates. The four canonical variates for the healthy subjects correspond, roughly,

to the four MDS dimensions, in order, For the pain patients,

the four canonical variates correspond to the four dimensions

as well, although variate 2 represents primarily dimension 3

and variate 3 represents dimension 2.

Table E shows the correlations between the canonical

variates for the two solutions. As can be seen, there is

substantial and significant overlap in the two solutions,
Table F. Experiment 2- Four-dimensionsl solution: Healthy

subjects and pain patients combined using INDSCAL

Table G. Experiment 2- INDSCAL dimension weights for

four-dimensional solution

Dimension Dimension Dimension Dimension

Term 1 2 3 4

Throbbing . . . . , , , . .19 1.06 .31 .19

Shooting, ,,, ,,, ,. 1.75 .11 .14 –.37

Stabbing, ,., .,,,. 1.42 .13 .28 –.72

Sharp . . . . . . . . . . . 1.06 .20 .14 –.50

Cramping . . . . . . . . -.49 .40 1.24 –.68

Gnawing . . . . . . . . . -1.24 .76 ,42 -1.21

Hot . .,, ...,,.., .86 .60 –1.84 1.36

Aching . . . . . . . . . . -.93 .58 .36 .23

Heavy. . . . . . . . . . . -.63 –1.32 1.13 1.11

Tender . . . . . . . . . . –.73 2.23 -1.03 .35

Splitting, . . . . . . . . 1.10 –.21 1.18 –.98

Tiring .,, ...,,.., -1.61 -.60 .65 1.48

Sickening . . . . . . . . –.76 -1.35 -.79 –.30

Fearful .,,,,..,,. -!20 -1.46 -2.16 -1.65

Punishing . . . . . . . . .21 -1.13 -,01 1.70

Nole:Averageetress= .14;R2 = .79.

For example, the first variates correlate ,99, the second,

.95, the third, ,92, and the fourth, .70, Given the interpretation of variates provided by the previous tables, these

canonical correlations indicate that the first dimension of

each solution is largely the same, the second dimension of

the healthy subjects’ solution is largely the same as the

third dimension of the pain patients’ solution, the third

dimension of the healthy subject’s solution is largely the

same as the second dimension of the pain patient’s solution, and the fourth dimension of each solution, although

not completely the same, shares significant common

variance,

The INDSCAL model was used to generate a third

MDS solution combining the two subject samples into the

same analysis. A single scaling map was thus generated,

but the differential importance of the recovered dimensions to the two groups could be evaluated by examining

the weights associated with each dimension. Table F

reports the coordinates of the INDSCAL solution. Once

again, examination of stress and R 2 suggested that a fourdimensional solution was most appropriate (stress for 2 to

4 dimensions was .2IS,.18, and .14, respectively, and R 2 for

Dimension Dimension Dimension Dimension

Sample 1 2 3 4

Healthy, ..,,.,.,. .62 .46 .31 .28

Pain. . . . . . . . . . . . .52 .37 .47 .39

2 to 4 dimensions was .53, .72, and .79), although a

three-dimensional solution also provided a fairly good

solution for the combined sample data.

The dimension weights for the healthy and pain patient samples are reported in table G. The raw weights in

table G suggest that healthy subjects primarily used the

first two dimensions in making their similarity ratings but

that pain subjects used all four dimensions about equally,

Perhaps the additional expertise regarding pain afforded

the patient sample results in a larger set of relevant

dimensions employed while making judgments about the

meaning of pain words.

Discussion

Although the four dimensions that seem to organize

the pain lexicon (or, at least the words studied here) may

be differentially important to healthy subjects and pain

patients, what is most striking about these data is the

substantial overlap in the similarity ratings and scaling

solutions generated by the two different samples. It seems

that healthy people who may not think often about pain,

and pain patients, who consider pain on a daily basis,

mentally represent the pain lexicon in substantially similar

ways.

The 15 terms chosen for the short form of the MPQ

and used here seem to capture a substantial amount of the

possible variance in the use of pain terms, and their

meanings (relative to each other) seem to be agreed upon

consensually. At this point we might be bold enough to

suggest that when pain is questioned on health surveys,

these 15 descriptors might be reasonable ones to use as

there seems to be considerable consensus regarding their

relative meanings.

9
Issue 11:

Recall of pain versus

pain behaviors

Earlier, we described some of the issues involved in

the recall of painful experiences. We suggested that pain

might be measured more accurately by either examining

concomitant changes in pain sufferers’ lives or when

possible by studying observable pain behaviors rather than

by eliciting self-report ratings. In this section, we suggest

that the recall of pain episodes might be more accurate if

the impact of pain on daily activities is assessed or painrelated behaviors are observed, rather than asking respondents to report on past levels of pain intensity and quality.

Moreover, from the perspective of health surveys, the data

provided by an assessment of pain-related activities and

behaviors may be more meaningful than subjective assessments of intensity and quality.

The questions that concern us here are (a) whether

recall of the daily life consequences of pain and painrelated behaviors is better than of the intensity and quality

of pain itself and, consequently, (b) whether pain is more

accurately assessed if questions are focused on the behavioral and life consequences of past pain experiences.

Fordyce et al, (42) noted that there is little relationship between self-reports of pain and the physical activities one is capable of performing, They suggested greater

attention be paid to observable pain behaviors with less

reliance on self-reports of pain intensity. At present,

however, the issue of whether pain behaviors more accurately capture the experience of pain than do intensity

ratings is largely unaddressed. Researchers, in fact, still

debate whether observed pain behaviors and self-reported

pain ratings are highly correlated (19, 43) or nearly independent (44).

Experiment 3: Recall of pain and pain

behaviors

Background

It is possible that more accurate assessments of previous experiences with pain could be collected if survey

questions focused not on the intensity and quality of

painful experiences but instead on the consequences of

pain: pain behaviors and changes in activities of daily

living. For example, a 27-year-old man may remember

much more accurately that a painful leg injury last winter

prevented him from skiing or caused him to use a crutch

for 14 days than that the painful experience was an 8 on a

10-point scale or could be characterized as “cramping” or

“burning,”

This experiment addressed directly the memory of

respondents for consequences of pain. Chronic pain patients were asked to keep one of three types of daily

diaries: (a) pain intensity ratings, (b) behaviors engaged in

that day, and (c) both pain intensity and behaviors. (A

control group of subjects kept no diary.) Some of the

behaviors were directly relevant to pain (e.g., took aspirin,

took prescription pain medication, used a heating pad),

and some were control behaviors (e.g., paid a bill, talked

on the telephone). After keeping the diary for 1 month,

subjects were then asked to recall their average level of

pain during the diary period and the frequency with which

they engaged in each behavior, These data can thus

inform us about the accuracy with which people remember

pain-relevant versus less relevant behaviors and how recall

accuracy for these behaviors compares with memory of

pain intensity.

Design and procedure

Adults suffering from chronic pain problems were

recruited through newspaper advertisements in the New

Haven community and through the Pain Evaluation and

Treatment Institute in Pittsburgh. All 107 subjects had to

have experienced pain on a daily basis for more than 6

months but could not be receiving treatment for their pain

while participating in the study. Subjects were each paid

$35 for their participation.

Subjects were randomly assigned to one of four conditions: (a) pain and behavior diary (n = 23), (b) pain

only diary (n = 23), (c) behavior only diary (n = 26), or

(d) no diary (n = 35). Subjects in the first three conditions

were asked to complete a daily record for a month, Those

in the first condition indicated which of a variety of

behaviors they engaged in each day; these behaviors

included both those associated with pain and other daily

experiences from a list provided them, Subjects in this

condition also rated their usual level of pain for the day on

a 10-point scale. Subjects in the pain-only diary condition

just completed this latter task, and subjects in the behavioronly condition just completed the behavior diary.

The pain behaviors included on the daily checklist

diaries were: took two or more aspirins, took another

10
Table H. Experiment 3-Recalied-versus.actual pain intensity and pain behaviors

Pain Nonpain

Actual Recalled Actual r7eca//ed Actual Reca//ed

intensity intensity behaviors behaviors behaviors behaviors

Moan . . . . . . . . . . . . . . . . . . . 6.11 6.23 89.23 96.62 66.99 66.25

Standard deflation. . . . . . . . . . . 1.71 1.70 42.59 45.22 24.06 24.58

Nuto:n= 107.

cwer-the-counter remedy, took a prescription pain remedy,

used a heating pad, used a hot water bottle, took a nap,

used a crutch or other device to assist in walking, asked a

member of the family to do something I usually do myself,

complained about my pain to another person, and

avoided routine physical activities. The nonpain (control) behaviors elicited by the diaries included: paid a

bill, read the newspaper, ate chicken for lunch or

dinner, talked on the telephone, used a postage stamp,

and wrote a letter,

Subjects returned their diary records daily on postage

paid and addressed postcards. At the end of the l-month

recordkeeping period, the subjects were telephoned and

asked to recall the number of days during which they

engaged in each of the behaviors. In addition, they were

asked about the number of days during which they experienced, on average, various levels of pain (greater than 2,

greater than 5, greater than 8) and to estimate on 10-point

scales their usual amount of pain during the diary period.

The order of recall was counterbalanced with half of the

subjects recalling pain behavior frequency first and the

other half recalling intensity first.

Results

Table H presents grand means for the recall of pain

intensity, combined pain behaviors, and combined nonpain behaviors collapsed across all 107 subjects. In addition, actual mean pain intensity during the diary period,

and mean aggregated pain and control behaviors are

provided collapsed across all subjects assigned to diary

conditions in which such information was collected. At

this very gross level, recall of all three types of information

seems very good, According to one-way analyses of variimce (ANOVAs) comparing all “actual” versus “recalled”

ratings (including all subjects who provided data in each

cell, even though some subjects cannot contribute data to

all cells), there is remarkable agreement. For instance, the

actual mean level of pain intensity during the 30-day

period was 6.11, and the mean recalled “usual” level of

pain was 6.23. For pain behaviors, the actual mean of

the sum of all behaviors across 30 days was 89.23 and

the recalled summed frequency was 96.62. Nonpain

control behaviors occurred in 66.99 instances and were

rcctdled as 66,25. None of the comparisons between

recalled-versus-actual ratings was close to being statistically significant.

In table J, means are presented by diary condition for

the measures collected at recall including the aggregate

behavior scores. These means were subjected to two

different ANOVAs. In the first, we explored whether

subjects in the four diary conditions differed in terms of

their recalled usual pain intensity; frequency of days

during which pain was greater than 2, 5, and 8; as well as

frequency of pain and control behaviors. There were no

significant differences due to diary condition on any of

these measures, Inspecting the means in table H reveals

very similar scores on all recalled dependent variables

across the four diary conditions. Moreover, when we

compared actual ratings from the diaries with recalled

ratings, in the conditions where such comparisons were

possible, there were no significant differences between a

recalled and actual mean, Once again, inspecting the

means in table H reveals remarkably accurate recall, at

least aggregated over items, on all measures.

There are two reasons why accuracy could be so high

on these kinds of aggregate ratings. One is that, indeed,

subjects simply recall their pain intensities and behaviors

accurately, and so the sums of such reports are also

accurate, Another is that on an item-by-item basis, recall

is actually quite poor. But the error on each item is

random, so that the mean across all items yields the

expected value for that item. The next set of analyses,

reported in table K, explored which of these two explanations for the relative accuracy elicited by this experiment is

more likely the case. In table K, actual and recalled

frequencies by diary conditions are reported for each of

the 16 pain and control behaviors.

Two analyses were conducted on these means. First,

using one-way ANOVAs, we examined whether the subjects assigned to the four cells differed in their recall of

the frequency of each variable. Even though such a univariate analysis tends to maximize Type I error, none of the

analyses produced a significant result, (It should be noted

that within-cell standard deviations were quite high.) In

other words, no matter to what diary condition subjects

were assigned, they all recalled the frequency of each pain

and control behavior approximately equally. For example,

the number of days recalled for taking an aspirin ranged

from 6.20 in the no diary condition to 8.92 in the behavior

diary condition, but these differences were not statistically

significant (F (3, 103) = 0.41, n.s.).

Our second analysis of these data involved comparing,

in the diary conditions where this was possible (i.e.,

behavior diary, both diaries), recalled-versus-actual frequencies for the 16 behaviors. Using two-way ANOVAs,

with the two diary conditions as a between subjects IV and

11
Table J. Experiment 3-Recall by diary condition

Behavior diary Pain diary Both diaries No diary

Measure (n= 26) (n = 23) (n= 23) (n = 35)

Pain intensity

Average pain intensity

Recall:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . .

Actual:

6.00

1.60

6.09

1.50

5.91

2.00

6.71

1.64

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . .

Days of pain greater than 2:

Recall:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard daviatkm. . . . . . . . . . . . . . . . . . . . . .

Actual:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . .

Days of pain greater than 5:

Recall:

6.18

1.44

8.07

1,95

. . .

. . .

. . .

. . .

24,50

6.81

25.96

6.43

26.74

6.40

24.26

8.07

27.17

3.49

26.78

6.04

. . .

. . .

. . .

. . .

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . .

Actual:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . .

Days of pain greater than 8:

Recall:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . .

Actual:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddeviation. . . . . . . . . . . . . . . . . . . . . .

17.81

9.10

18.09

7.37

17,30

10.25

18.20

9.07

18.43

8.04

17.78

10.31

. . .

. . .

.,.

. . .

7.96

9.03

4.91

8.75

5,95

7.75

9.29

9.06

3.22

6.25

4.52

8.94

. . .

. . .

. . .

. . .

Pain behaviors

Recall:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.%andard deviation . . . . . . . . . . . . . . . . . . . . . . .

Actual:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . . .

90.92

45.90

92.91

41.64

99.17

49.08

101.48

45.68

83.82

39.01

95.38

46.42

. . .

. . .

. . .

. . .

Other behaviors

Recall:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddeviation . . . . . . . . . . . . . . . . . . . . . . .

Actual:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . . .

68.38

29.14

67.13

22.70

66.17

23.03

63.60

23.81

71.83

26.65

61.52

19.61

.,.

.,.

. . .

. . .

actual versus recall as awithin subjects IV, there wereno

significant differences either due to condition orin actual

versus recalled frequencies. There was but one significant

conditionxactual/recall interaction. Subjects inthebehavior diary-only condition recalled complaining more than

was actually reported in their diaries. But this was the

only difference between a recalled and actual mean

that was statistically significant in all of table K. In

other words, among the subjects for whom we could

compare actual versus recalled frequenciesof pain and

control behaviors, recall appeared tobe quite accurate

on virtually every (i.e., all but one) item. These issues

are further addressed in the analyses of these data

presented in appendix I.

12

Discussion

Three general conclusions can be drawn from experiment 3: (a) both pain intensity and pain-related behaviors

are recalled rather accurately, (b) what error there is in

recall ofpain intensity and behavior is generally unsystematic (neither consistent inflation nor deflation), and

(c) the actual keeping of a pain intensity and/or pain

behavior diary does not seem to affect subsequent

recollectionsof pain intensityor pain behaviors, Additional data supporting conclusions (b) and (c) are

described in appendix I.

To detect small but systematic biases in recall, a

power analysis conducted prior to the start of the experi-
ment suggested that a sample size of approximately 80

subjects would have been sufficient. With the larger sample recruited for this experiment, we can be confident that

our conclusions supporting the accuracy of pain reporting

are at least not due to low power.

There are a couple of other interesting aspects of

experiment 3, When diarykeeping did have an effect on

subsequent recall (and even this effect was small, see

appendix I), it tended to be on the nonpain relevant

behaviors like eating chicken (cf. Smith, Jobe, and Mingay

(45), who did not find diarykeeping effects on the subsequent recall of dietary information across a much larger

set of foodstuffs), talking on the telephone, or writing a

letter, If any recall inaccuracies were revealed (and there

were not many), they were located primarily on pain

behaviors like “complaining” that were rather vague

and unspecific (Exactly what constitutes a complaint?)

compared with the other behaviors (e.g., taking a

prescription drug, using a heating pad, using a crutch,

etc.), But again, the dominant findings were (a) little

effect on subsequent responses of diarykeeping and (b)

few systematic inaccuracies in the recall of pain intensity or behaviors,

In essence, asking about rather concrete pain-related

behaviors (and pain intensity) seems more or less free, at

least in the present context, from the systematic biases

that have plagued other studies (reviewed at the beginning

of this report), Of course, our pain subjects were not being

treated for their pain problems (and, hence, their pain

experiences and behaviors may have been rather stable

over time, yielding better recall later),

Table K, Experiment 3-Actual and recalled behaviors by condition

Experiment 4: Stability of self-report pain

severity, interference with life tasks, and

interviewer ratings of pain behavior

Background

Recall of how pain interferes with life activities

and the ratings of pain behaviors by observers may be

more stable over time than an individual’s recall of

pain intensity. The present experiment examined

whether an interviewer can elicit fairly stable information about the impact of pain on an individual’s life

and observe and rate pain behaviors. In this study,

individuals who experience chronic, daily pain rated

their typical level of pain intensity and amount of

interference caused by pain at two points in time. At

these same two points in time, an interviewer observed

and coded their pain behaviors. These sources of data

were compared to determine the relative stability of

self-reports of pain, interference, and observed pain

behaviors. We examined whether there is greater

test–retest reliability in observed pain behaviors and

recall of activity interference than in recall of pain

intensity.

The West Haven – Yale Multidimensional Pain Inventory (WHYMPI) is one attempt to assess pain by examining its impact on the life of the patient rather than by

relying exclusively on pain descriptors (17). The WHYMPI

consists of three sections. The first contains measures of

(a) pain severity and suffering (b) pain-related life interference (interference with family and marriage, work, and

Behavior diary Pain diary Both diaries No diary

(n= 26) (n = 23) (n = 23) (n= 35)

Behavior Actual Recalled Actual Recalled Actual Racalled Actual Racalled

Pain behaviors

Take aspkln, , ..,,,,.,......,,. ,., .

Take other over-the-counter medication. . . . , ,

Take prescription medication . . . . . . . . . . . .

Usea heating pad. .,, . .,, ,, . . . . . . . . .

Useahot water bottle. . . . . . . . . . . . . . . . .

Take nap, .,, ., . .,, . . . . . . . . . . . . . .

Usecrutch, ,,, , . . . . . . . . . . . . . . . . . . .

Ask for help . . . . . . . . . . . . . . . . . . . . . . .

Complain .,, ,,, . . . . . . . . . . . . . . . . . .

Avoid physical actlvltles. ., ., ., , . . . . . . . .

7.16

6.45

14.79

9.96

1.12

11.14

2.65

a.22

11.05

11.27

8.92

5.85

13.73

10.00

1.00

10.54

1.85

9.88

14.69

13.08

. . .

. . .

.,.

. . .

. . .

. . .

5.78

7.70

14.39

7.00

1.17

12.43

6.13

I o.7a

18.00

9.52

8.52

6.83

19.29

6.64

0.84

12.21

9.22

9.72

10.89

11.19

7.09

9.43

19.43

7.30

0.74

10.39

9.30

11.74

11.87

11,87

. . . 6.20

. . . 4.54

. . . 16.37

. . . 8.71

. . . 2.11

. . . 11.43

. . . 5.20

. . . 14.89

. . . 17.94

. . . 14.00

Other behaviors

Pay bill, , ., . . . . . . . . . . . . . . . . . . . . . . 6.47 5.35 . . . 4.91 5.40 5.30 4.33

Reed newe . . . . . . . . . . . . . . . . . . . . . . .

. . .

20.71 21.31 20.70 19.74 19.ei

Eatchlcken, ,,, ,, .,....,.,.. . . . . . .

. . . . . . 20.69

6.79 7.00 ,.. 5.43 5.40 7.70 5.00

Talk onthe phone ,,, ,, .,, . . . . . . . . . .

. . .

24.64 24.77 . . . 27.78 21.89 22.87 . . . 25.77

Useapostage stamp . . . . . . . . . . . . . . . . . 9.23 7.00 7.35 6.64 7.83 7.03

Wrlteletier, ,,, ,,, ,,, ,,, .,, ,,, ,o, . ,

. . .

3,99 2.96 . . . 0.96 2.45 2.87 ::: 1.23
recreational activities); (c) dissatisfaction with present

levels of functioning; (d) appraisal of support from spouse,

family, and others; (e) perceived life control, problemsolving ability, and feelings of mastery and competence;

and (f) affective distress. The second part of the WHYMPI

was designed to evaluate patients’ perceptions of the

range and frequency of responses by significant others to

displays of pain and suffering and contains three scales:

punishing responses, solicitous responses, and distracting

responses. The third part is a set of 30 common domestic

activities, household chores, social activities, and recreational activities about which individuals can indicate their

level of participation, Kerns et al. (17) reported adequate

internal consistency and stability for all of the subscales.

In its final form, the WHYMPI contains 60 items. At

present, no empirical work has examined accuracy of

recall for information reported on the WHYMPI, especially the scales in parts 1 and 3 (which concern us here),

compared with recall of the intensity and quality of experienced pain.

A second approach to attenuating the biases inherent

in the self-report of pain intensity and quality is to rely on

ratings of observable pain behaviors instead. The interest

in pain behaviors is usually traced to Fordyce’s (18)

influential work on operant learning factors in the pain

experience. Fordyce proposed that patients display a range

of pain behaviors that serve to communicate to others that

they are experiencing pain and suffering. According to

Fordyce, these might include verbal complaints, paraverbal sounds (e.g., moans), body posturing and gesturing,

display of functional limitations or impairments, and medication use and other pain-attenuating behaviors. Other

studies of pain behavior have been reported in the literature as well. For example, Turk, Wack, and Kerns (21),

using multidimensional scaling and cluster analysis, identified two primary dimensions around which pain behaviors could be organized: audible-visible and affectivebehavioral. Four clusters of pain behaviors were

superimposed on these dimensions and labeled (a) distorted ambulation and posture, (b) negative affect, (c) facial/

audible expressions of distress, and (d) avoidance of

activity.

The accurate observation and measurement of pain

behaviors by health care professionals and other interviewers is somewhat complicated. According to Turk and Flor

(46), the most systematic approach to the quantification of

pain behaviors is that of Keefe and his colleagues. For

example, Keefe and Block (19) developed an observer

coding system for five pain behaviors typically displayed by

back pain patients. Patients were videotaped while performing a structured task, and the frequency of their pain

behaviors counted. These behaviors seem to be observed

reliably, are correlated with patients’ and observers’ subjective pain ratings, and are specific to pain patients

(compared, for example, to depressives and normals

(47-50)). Other pain behavior rating systems have been

developed that do not require videotaping and can be

more easily performed by lay observers (e.g., 20, 51).

14

Table L. Experiment 4-Pain behavior rating form

[0 = present; 1 = not present]

Behavior Rating

1.

2.

3.

4.

5.

6.

7.

8.

9.

10,

11.

12.

13.

14.

15.

Verbal behaviors

Mentions having pain . . . . . . . . . . . . . . . . . 0 1

Complains about pain . . . . . . . . . . . . . . . . 0 1

Gives lively descriptions of pain . . . . . . . . . . 0 1

Groans, moans, or sighs. . . . . . . . . . . . . . . 0 1

Cries . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1

Asks forhelp from others . . . . . . . . . . . . . . 0 1

Grimaces and rubbing

Grimaces . . . . . . . . . . . . . . . . . . . . . . . . 0 1

Rubs painful parts of body . . . . . . . . . . . . . 0 1

Sitting and standing

Braces while sitting down into chair. . . . . . . . 0 1

Changes positions while sitting . . . . . . . . . . 0 1

Braces while rising after sitting. . . . . . . . . . . 0 1

Stands in an unusual posture . . . . . . . . . . . 0 1

Walking

Moves rigidly and stiffly . . . . . . . . . . . . . . . 0 1

Walks with an abnormal gait . . . . . . . . . . . . 0 1

Walks guardedly and carefully . . . . . . . . . . . 0 1

Design and method

Forty adult volunteers from the New Haven community with chronic pain problems of at least 6 months

duration were asked to complete the West Haven –Yale

Multidimensional Pain Inventory (WHYMPI). This measure assesses pain intensity and consequent suffering, but

also examines the impact of pain on patients’ lives and the

extent to which patients participate in common daily

activities,

Subjects were also interviewed by two research assistants. The interview provided an opportuni~ for pain

behaviors to be elicited. On the way to the interview room,

subjects walked up two flights of stairs and opened a sticky

door. Once in the room, they sat in a chair, bent down to

pick up a dropped pen, and at the termination of the

interview rose from their chairs and walked out of the

room, The interviewers coded 15 pain behaviors on 2-point

scales (present/not present).

The pain behavior coding scheme used here was a

substantially modified version of the University of Alabama at Birmingham (UAB) Pain Behavior Scale (20,

p. 393) and can be found in table L. Interrater reliability

for the UAB scale has been reported to be between .94

and .96, and test–retest reliabili~ within individual pain

patients on consecutive days is .89. The validity of this

pain behavior rating scale with outpatients has been demonstrated by Feuerstein et al. (52). After several rounds of

practice, our two raters were able to achieve adequate

reliability in the present experiment (kappa ranged from

.81 to .90 in several different subsamples).

One month later, subjects returned to the laboratory

and were asked to complete the WHYMP1 pain intensity
Table M. Experiment 4- Descriptive statistics on measured

varlablee at two points in time

Variable Time 1 Time 2

Table N. Experiment 4- Pearson correlations from time 1 to time 2

Variable R

WHYMPIratingsof pain intens”Ky

Painseverii . . . . . . . . . . . . . . . . . . . . . . . . . . .

WHYMPI ratings of pain Intensity ●**.,4

Pain severity

Mean, . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . .

Flange, . . . . . . . . . . . . . . . . .

3.le

1.26

0.67-5.67

3.14

1.40

0.67-6.00

WHYMPIratingsof Metasks

Generalpain interference . . . . . . . . . . . . . . . . . . .

***,=

Household chores. . . . . . . . . . . . . . . . . . . . . . . .

***,82

Outdoor work, . . . . . . . . . . . . . . . . . . . . . . . . .

***.82

Actiiitiesawa yfromhom e..,.,.., . . . . . . . . . . .

***.76

Socialactiiities . . . . . . . . . . . . . . . . . . . . . . . . . . **.46

WHYMPI ratings of life tasks

Pain Interference:

Mean, , .,, ,,, , . . . . . . . . . .

Standarddevlatlon . . ., . . . . . .

Range . . . . . . . . . . . . . . . . . .

Household chores:

Mean. ., .,, , . . . . . . . . . . . .

Standard deviation ., . . . . . . . .

Range . . . . . . . . . . . . . . . . . .

Outdoor work:

Mean. , .,, , .,, ...,.,.., .

Standarddevlatlon . . , ., , , . . .

Range . . . . . . . . . . . . . . . . . .

Activities away from home:

Mean, . . . . . . . . . . . . . . . . . .

Standarddeviatlon . . . . . . . . . .

Range . . . . . . . . . . . . . . . . . .

Social activities:

Mean. , ..,,..,,,,....,.,

Standarddevlation . , , , . . . . . .

Range . . . . . . . . . . . . . . . . . .

3.45

1.37

0.64-6.00

3.18

1.26

0.73-6.00

Observedbehaviors

Painbehaviorratings . . . . . . . . . . . . . . . . . . . . . .

***.7,

3.51

1.27

o.ao-s.oo

3.43

1.46

0.80-6.00

Not~n= 40.

‘p<.05

**p<.01

***p<.001

1.54

1.19

0-4.20

1.48

1.06

0-4.00

largest correlations, representing the most stable measures, are those that concern interference with life tasks,

both the general measure and four of the five specific

activities (e.g., r(40) = .S6 for the general interference

scale). Moreover, the observed behaviors were quite stable

over lmonthaswe11(r(40) = ,71), Pain severity ratingsat

the two points in time were also significantly correlated

(r(40) = ,74),These three correlations did not differ

significantly from one another.

3.01

1.19

0.25-6.00

2.77

1.16

0-6.00

2.69

1.02

0.75-4.67

2.41

1.16

0-6.00

Observed behaviors

Summed pain behavior ratings: Discussion

Mean. . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . , . .

Range, .,, ,, ., . .,,..,..,

4.68

4.19

0-19

4.33

4.36

0-13

The fairest conclusion from experiment 4 is that all

three measures of pain–self-reported intensity, selfreported interference, and observed pain behaviors—

represent equally stable sources of information about

pain, Perhaps it is remarkable that interference and behavioral ratings are about as stableas self-reported pain

severity given the complexities involved in measuring such

constructs reliably. Moreover, these measures ofpain may

represent potentially more useful information to survey

researchers than intensity data.

It seems reasonable to conclude that ifmore information than mere recollections about pain intensity is desired, information that is as stable overtime as intensity

can be elicited through questions concerning pain’s interference with life activities or by asking survey takers to

score observed pain behaviors, This last suggestion may

not be as impractical as it might seem at first blush. Our

twopain raters were students not pain professionals, and

they were able to rate pain behaviors with considerable

reliability without substantial training. Perhaps this would

be true as well for the interviewers administering national

health surveys.

Nole:n - 40.

and interference measures. In addition, the interviewers

recorded their pain behaviors. During the intervening

month, none of the patients had initiated any treatment

for the pain problem, Subjects were paid $5 for each of

the two visits to our laboratory.

Results

Descriptive statistics for the WHYMPI subscales and

interviewer ratings of pain behaviors as the two points in

time are provided in table M. In general, the mean ratings

cmall measures-pain severity, interference with life tasks,

ond observed pain behaviors —were rather stable across

the l-month time frame. There were no significant differences due to time on any of the measures.

Correlations between ratings made at time 1 and

those made. 1 month later are provided in table N. The

15
Issue Ill:

Mental states,

pain reporting, and

pain recall

Experiment 5: Recalling past pain when

present pain fluctuates

Background

Pain researchers have long been concerned that retrospective ratings of pain made after pain has been relieved

(or changed in intensity in other ways) are most likely

inaccurate (12, 25). The biasing effects of present pain

levels on past pain recall were explored in experiment 5.

In the same way that happy-versus-sad moods facilitate the recall of positive-versus-negative material from

memory (e.g., 33), ongoing pain experiences may have

similar assimilative effects on memory. Eich, Reeves, Jaeger, and Graff-Radford (32) have noted that because

affect is an integral component of pain behavior and

experience, pain may produce assimilative effects on memory that parallel those engendered by emotions. This line

of theorizing suggests that prior pain is remembered as

more severe than it actually was when the intensity of

present pain is high, but as less severe when the present

pain is low (32, p. 376),

Eich and his colleagues asked 57 headache patients to

maintain pain diaries during a treatment program by

asking them to record hourly ratings of pain on a 10-point

scale. In addition, during weekly scheduled appointments,

they were asked to rate their present pain intensity on the

usual visual analog scale. They were then asked to recall

the “maximum,” “usual,” and “minimum” levels of pain

experienced since their last visit. Patients’ ratings of present

level of pain strongly associated with their recall of maximum, usual, and minimum pain levels since the last visit.

When present pain was high, patients’ recalled pain levels

were higher than their pain diaries indicated. When present

pain was low, their recalled-pain ratings were less severe

than indicated by the diaries. Eich et al.’s results suggest

that studies of pain recall in which currently pain-free

subjects are asked to recall past pain episodes should

result in underestimations of past pain (e.g., 25), but that

when subjects who are still experiencing pain are asked to

recall past pain, they should overestimate it (e.g., 24).

Thus, respondents may use easily available information about their present pain as a basis for judging past

pain episodes, and present pain may make memories for

previous painful situations more available (cf. 53-55). If

present pain does influence survey responses, then the

designers of health surveys may wish to include questions

that assess present pain intensity.

Design and method

Eighty patients undergoing pain assessment at the

Pain Evaluation and Treatment Institute served as subjects in this experiment. All subjects had experienced pain

for at least 6-months duration but were not yet undergoing

active treatment at the time of the study, Subjects were

paid $10 for their participation.

Each subject was asked to provide a rating of their

pain on an hourly basis for 2 weeks, Subjects were asked

to circle a number between O (no pain at all) and 9 (pain

as bad as it could be) hourly on a postcard for each day

during the 14-day diarykeeping period. At the end of each

day, subjects were asked to mail in the postcard.

At the conclusion of the diary period, patients were

contacted by phone and asked to (a) rate their present

pain intensity on a 10-point scale and (b) complete the

Pain Rating Index of the McGill Pain Questionnaire,

(c) rate on 10-point scales their estimates of the usual

amount of pain they experienced during the 2-week diary

period, (d) rate the maximum and minimum amount of

pain experienced during the diary period, and (e) estimate

the number of days during the diary period that their pain

exceeded various predetermined criteria,

Results

Table O provides means and standard deviations for

the major variables collected through diaries and at the

time of recall. A daily mean of the hourly pain ratings was

computed and then for each subject a mean of these daily

means across the 14-day diary period was calculated. As a

measure of variability in a subject’s hourly pain ratings, we

computed the standard deviation in hourly ratings each

day and then calculated the mean of these standard

deviations across the 14-day period. The mean daily pain

rating was 5.53 on the O-9 scale with a mean daily

standard deviation of 0.92.

Means collected at recall could be compared with

those calculated from the diary reports. Subjects remembered their “usual” level of pain as 5.61, which is quite

close to the actual diary average of 5.53, However, on

frequency-oriented questions, subjects showed some tendency to recall pain as more severe than indicated by the

16
Table 0. Experiment5- Descriptive statistics for measured

variables

Standard

Variable Mean deviation Range

Diary scales

Mean pain reported/day . . . . . . . . . . . 5.53 1.97 0.1-9.0

Mean standard devlatlon/day . . . . . . . . 0.92 1.38 o–7.9

Number of days graater than 2 . . . . . . . 12.84 2.47 0-14

Number of days greater than 5 . . . . . . . 7.86 5.51 0-14

Number of days greater than 8. . . . . . 1.95 4.19 0-14

Recall measures

Current level of pain (at recall) . . . . . . . 5.61 2.47 o–9

Usual level ofpaln . . . . . . . . . . . . . . . 5.95 1.93 1-9

Worst level ofpaln . . . . . . . . . . . . . . . 7.96 1.33 3-9

Leaetlevel ofpaln . . . . . . . . . . . . . . 3.30 2.23 o–9

Number of days greater than 2 . . . . . . . 12.14 3.58 0-14

Number of days greater than 5 . . . . . . . 9.00 4.65 0-14

Number of days greater than 8 . . . . . . . 3.62 4.38 o–1 4

Note: n = 80.

diaries, Subjects remembered 3.62 days with an average

pain rating above 8, but in reality there were only 1.95.

Similarly, they recalled 9 days on which their pain averaged more than a 5, but in fact there were only 7.86 such

days. Discrepancy scores created by subtracting recalled

ratings from diary ratings for these two measures were

significantly different from zero (t (79) = 5.31, p < .01

md t(79)= 2,49,p c ,05,respectively),

Another way of understanding these data is to note

that only S of SO subjects underestimated the number of

days of pain intensity greater than S, 30 subjects estimated

them correctly, and 42 subjects overestimated such days.

Estimates of days averaging greater than a pain rating of 2

were more accurate (12.14 recalled, 12.84 in diary), but for

most subjects virtually every day averaged greater than 2

and so the recall task regarding this item is probably much

too easy to show systematic inaccuracies.

In table P, Pearson correlations are provided between

ratings from the diary scales and the recall measures.

Associations between pain level at the time of recall and

the other recall measures are listed as well. Obviously,

people experiencing more intense pain at the time of

recall are more likely to be those individuals who experienced more intense pain during diarykeeping, So, it is not

surprising that there are many positive correlations between pain intensity on the diaries and pain intensity at

recall, Once again, recalled average pain seems fairly

accurate; there is a .83 correlation between average pain

ratings on the diaries and estimates of “usual” pain at

recall. Similarly, recall of days greater than 8 was correlated with the actual number of such days at .75, and for

days greater than 5, the correlation was .71. The range for

days greater than 2 was too restricted for large correlations to emerge on this measure (e.g., more than half of

the subjects indicated that their pain was greater than 2 on

all 14 days).

FinaIly, multiple regression analysis was used to test

the magnitude and direction of influence that pain at time

of recall has on remembered pain intensity. The criterion

for this analysis, which is presented in table Q, was

recalled “usual” amount of pain. We entered into the

analysis as predictors (a) actual mean daily pain from the

diaries, (b) the mean standard deviation of daily pain from

the diaries (to control for amount of pain fluctuation —we

were concerned that if pain rarely fluctuated, its intensity

is easier to recall), and (c) pain at the time of recall. Not

surprisingly, the best predictor of recalled pain was actual

mean pain during the diary period. But, after entering this

variable and controlling for fluctuation (mean standard

deviation), pain at the time of recall contributed significant variance to recalled “usual” level of pain in a positive

direction, Subjects who were in greatest pain at the time

of recall, were most likely to inflate their recall of pain

intensity.

Discussion

Present levels of pain do influence recollections of

past pain. Subjects who experienced more pain at the time

of recall, remembered pain during a prior diarykeeping

period as more severe than subjects who experienced less

pain at recall, controlling for actual levels of pain during

the diary phase and fluctuations in this level of pain.

Table P. Experiment 5- Pearson correlations between diary scales and recall measures

Diary scales

Mean Days Days Days Current

Mean standard greater greater greater level of

Reca// measures pain deviation than 2 than 5 than 8 pain

Current pain . . . . . . . . . . . . . . . . . . .74 –.18 .36 .66 .46

Usual pain . . . . . . . . . . . . . . . . . . .

. . .

.83 .01 .42 ,71 .59 .73

Worst pain, . . .. . . . . . . . . . . . . . . . .66 .19 .45 .58 .33 .58

Least pain . . . . . . . . . . . . . . . . . . . .87 –.28 .30 .78 .66 .61

Days greater than 2 . . . . . . . . . . . . . .36 -.12 .36 .35 .06 .29

Days greater than 5 . . . . . . . . . . . . . .70 –.13 .35 .71 .30 .55

Days greatarthan 8 . . . . . . . . . . . . . .62 –.07 .25 .47 .75 .44

Note: n = eo.

I rl ,22;p <0.05.

lrt,2*p c 0,01.

I rl ,36;p <0.001.

17
Table Q. Experiment 5-Predicting recalled usual levels of pain

from actual mean during diary phase, variability during diary

phase, and current level of pain

Predictor Beta T P

Mean pain/day (diary). . . . . . . . . . . . . . . . 0.54 5.27 .0001

Mean standard deviation/day (diary). . . . . . . 0.12 1.80 .08

Current pain (atrecall ) . . . . . . . . . . . . . . 0.38 3.62 .0006

Not&Rz = .7X F(3,76) = 55.4X/J< .0001.

In this study, there was a bit more evidence for bias in

the recollection of pain intensities as compared with

experiment 3. Although average intensity ratings tended

to be remembered reasonably accurately, ratings regarding the number of days on which pain of different levels

was experienced tended to be overestimated. This was not

the case in experiment 3, but the standard deviations for

both the diary ratings and the recalled estimates for these

variables tended to be higher in that study (perhaps due to

the longer recordkeeping interval) and may have masked

the significance of mean differences,

In a recent article, Eich, Rachman, and Lopatka (35)

claimed that the impact of present levels of pain on

memory for autobiographical information may be mediated by mood. In a well-designed study, they found that

female undergraduates experiencing menstrual pain retrieved more negative life events from memory than when

they were pain free only if menstrual pain was accompanied by an increase in sad mood, With this finding in mind,

we turn to our final experiment, which tested whether

induced mood biases recall and judgments about pain.

Experiment 6: Mood congruent recall of

and judgments about pain

Background

The most frequently cited causes of inaccuracy in the

recall of pain episodes are affect related. Respondents

who experienced fear of going to the dentist remembered

dentaI pain as more severe than it actually was. Mothers

experiencing the joy of giving birth to a new baby tended

to underreport the intense pains of labor after the baby

was born. On the other hand, individuals experiencing

depressed moods, perhaps because their pain problems

had not been alleviated, tended to overestimate the intensity of previous painful experiences. Each of these situations exemplifies the important role played by affect in the

recall of pain. Despite its common endorsement as an

important factor resulting in inaccurate pain reporting,

survey researchers have tended to give scant attention to

affect in the design of surveys and in the interpretation of

their results. Yet, in the past decade, cognitive and personality/social psychologists have become intrigued by the

role played by moods and emotions in the processing of

information (reviewed in 34, 56-58).

There are different ways in which ongoing affective

states might bias the recall of pain experiences. One could

be called “mood congruent pain reporting,” in which

individual’s current mood state, perhaps by influencing the

accessibility of positive-versus-negative memories, directly

biases ratings in a direction consistent with this mood

state. The second bias may occur when mood at the time

of the pain rating does not match the individual’s initial

mood during the pain experience, This mismatch in affective context does not allow the individual to experience

the memorial benefits of state-dependent learning and

recall. These two roles for affect in biasing pain recall

correspond to what has been termed “thought congruity”

(or “mood congruent recall”) and “state-dependent recall”

in the memory literature (59). Thought congruity or mood

congruent recall can be described as the phenomenon

whereby respondents’ thoughts, free associations, fantasies, interpretations, and judgments are thematically congruent with their mood states. State-dependent recall

describes the superior accuracy observed when mood state

during test matches mood state during learning than when

these mood states do not match,

Let us examine the direct impact of mood on pain

ratings first. An observation made by mental and physical

health care professionals alike is that patients reporting

psychological distresses also complain of a variety of

physical symptoms (60). In particular, complaints of diffuse aches and pains are especially likely among patients

experiencing dysphoric moods, Perceived health status

varies directly with degree of dysphoria (61), Of course,

the causal direction of the relationship between psychological distress and physical symptoms is not always

clear.

Croyle and Uretsky (62) reported a study in which

they induced happy and sad moods in the laboratory and

noted that sad subjects perceived themselves to be less

healthy following negative mood induction. Salovey and

Birnbaum (63) asked 66 individuals suffering from influenza to experience either happy, sad, or neutral laboratoryinduced moods. They later assessed the aches, pains, and

other symptomatic discomforts experienced by these individuals. Two relevant findings emerged, The first was that

mood had its most powerful impact on measures of aches

and pains as compared with other symptoms of the flu

(e.g., nasal congestion, gastrointestinal distress, sleepiness). The second finding was that reports of aches and

pains varied depending on subjects’ assignment to mood

condition. Subjects induced into mildly sad affective states

in the laboratory reported considerably greater pain than

neutral mood (control) subjects. Conversely, happy subjects reported fewer aches and pains,

Results consistent with these have been reported in

the pain recall literature. For example, Hunter et al. (25)

identified a group of “shifters,” subjects whose recall of

headache pain was most biased after 5 days. Shifters

tended to have higher levels of pain intensity and to use

significantly more negative affective words to describe

their pain than the other patients. Similarly, Kent (29)

noticed the most memorial distortion for dental pain

among his subjects who reported the greatest dysphoric

16
otiect associated with dental procedures. His subjects

tended to distort their recall for dental pain in a direction

consistent with their anxiety.

The second way in which mood may affect paintwlated memory is that accurate recall is promoted when

mood at the time of initial encoding matches mood at time

of recall, the state-dependent memory effect (33). In any

kind of state-dependent memory phenomenon (e.g., 64,

65), contextual factors (in this case, mood) serve as discriminative cues, such that when learning and recall contexts match, memory is facilitated, and when the two

contexts differ, memory is inhibited. Several studies have

indicated, although the effect is not always obtained, that

mood can act as such a contextual cue in learning and

recall (66, 67),

Studies of mood state-dependent memory lead to the

hypothesis that when mood at the time of the initial

experience of pain matches mood at the time of pain

recall, recall should be more accurate than when there is a

mismatch. So, for example, in the Hunter et al. (25) study,

higher levels of dysphoric affect at assessment were more

strongly associated with “shifting” than any other variable.

Similarly, the positive affect associated with the birth of a

new baby does not match the negative affect associated

with the actual pain of labor, and recall of labor pain

postpartum can be expected to be quite poor (31). Morem’er, the poor recall of preoperative pain following surgery for rheumatoid arthritis among Roche and Gijsbers’s

patients (27) has been explained (by them) as perhaps due

to their much improved affective state following successful

surgery, Many other studies showing poor recall of pain

often relied on initial ratings of pain at a time of heightened dysphoric affect and then later recall when individuals were feeling much better (e.g., 23, 24).

In addition to these two memory-based consequences

of sad mood, negative mood has a second effect that also

predicts it should cause pain estimations to be exaggertited, Sad moods result in a tendency to focus attention on

the self rind away from external stimuli (68–77). Individuals experiencing negative affect should thus be more

attentive to physical symptoms and other bodily changes.

Because of this bodily preoccupation brought on by sad

mood in combination with the ease with which negative

events and experiences are brought to mind when sadness

is induced, judgments of present levels of pain should be

more severe among sad subjects, even if the sadness is

transient.

The literature reviewed suggests that judgments about

present pain and recall of prior pain episodes are influenced by mood. In particular, survey responses regarding

pain may be rendered less accurate when respondents are

experiencing reasonably intense moods and emotions, or

when their current moods are quite different from their

dominant affect at the time of the painful experience. The

purpose of experiment 6, then, was to evaluate whether

ocute mood states influence reports of pain. In the first

version of the present experiment (called experiment 6A),

94 college student subjects were assigned to each of three

mood induction conditions, happy, sad, and neutral (control). The experiment was then replicated (experiment

6B) with 89 adult subjects recruited from the local

community,

Experiment 6A: College student subjects

Method

Ninety-four undergraduates (51 males and 43 females) enrolled in an introductory psychology course served

as subjects and received course credit for their participation. Subjects were between the ages of 18 and 23.

A tape-recorded mood induction procedure based on

one developed by Wright and Mischel (78) and previously

used in this laboratory (63, 79) was employed. Subjects

were told that the focus of the study was on their ability to

imagine vividly a past event and therefore they would be

asked to try to visualize a scene as earnestly as possible.

Once seated in private cubicles, subjects listened through

headphones to a tape-recorded message. Subjects were

instructed by a taped female voice to imagine a previously

experienced event during which they felt either happy,

sad, or neither happy nor sad. The specific instructions

were as follows:

I would like for you to begin imagining a situation that

would make you feel (happy, sad, or neutral). Imagine

the situation as vividly as you can. Picture the events

happening to you. See all the details of the situation.

Picture in your “mind’s eye” the surroundings as clearly

as possible. See the people or objects; hear the sounds;

experience the event happening to you. Think the

thoughts you would actually think in this situation. Feel

the same (happy, sad, neutral) feelings you would feel.

Let yourself react as if you were actually there.

Subjects were then given approximately 3 minutes to

visualize the event and experience the feelings, This procedure, called SeIf-Generated Imagery, has been shown

effective in inducing various mood states (63, 78, 79).

The following measures were completed before the

mood induction procedure was administered:

(a) Happiness subscale of the Differential Emotions

Scale (DES; 80). Subjects rated on 7-point Likert-type

scales 16 different adjectives that loaded on the happiness

factor of the DES.

(b) Present symptoms and pain questionnaire. Subjects were asked to check on a list of 33 symptoms (e.g.,

sore throat, headache) whether they had experienced the

sensation (a) in the previous 7 days, (b) in the previous 24

hours, and (c) if experienced, how much discomfort they

endured due to the symptom (O-4 scale). This symptom

list was based on the Wahler (81) Physical Symptoms

Inventory.

The following questionnaire was completed after the

mood induction procedure and served as a check on

effectiveness of mood induction:

Mood manipulation check. On 7-point scales, subjects

were asked to rate their feelings using a list of six adjec19
Table R. Experiment 6A-Means on mood and symptom scales prior to mood induction by mood and gender

Assigned mood condition

Happy Neutral Sad

Male Female Male Female Male Female

Scale (n= 15) (n= 15) (n= 17) (n= 14) (n = 19) (n= 14)

Differential emotions scale:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.48 4.36 4.24 4.64 4.22 4.30

Standard deviation . . . . . . . . . . . . . . . . . . . . . . .95 1.10 1.05 1.06 ,63 1.27

Present symptoms and pain – past 24 hours:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.57 7.47 7.24 6.29 6.63

Standarddeviation . . . . . . . . . . . . . . . . . . . . . .

8.79

7.63 4.66 5.89 3.34 4.30

Present symptoms and pain - past week:

3.62

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.60 10.73 12.00 9.29 9.89 12.14

Standard deviation . . . . . . . . . . . . . . . . . . . . . . 7.33 4.65 5.83 4.89 4.01 3.70

Present symptoms and pain - discomfort

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94 .70 .65 .62 .56

Standarddeviation . . . . . . . . . . . . . . . . . . . . . .

.72

.93 .37 .51 .45 .40 .33

tives (e.g., not happy–very happy, not content-very content). This measure has been used previously asabriefbut

reliable checkon laboratory induced joy and sorrow (e.g.,

82).

The following measures served as theprimary dependent variablesin this experiment:

(a) Recall of painful incident. Subjects were asked to

recall a recent event (from the past year) in which they

experienced physical pain. Subjects were then asked several questions concerning the pain. They were to describe

briefly the incident, report how long the pain lasted and

when it occurred. Subjects were asked to rate the maximum level of pain experienced during this incident by

marking an X on a 100-millimeter (mm) visual analog

scale (VAS) (“no pain” to “pain as bad as it can be”),

Similarly, they were asked to rate on the 100-mm VAS the

“average” amount of pain experienced, how much this

pain interfered with daily activities, and how vividly the

incident could be recalled. Subjects also reported on the

pain’s temporal qualities (e.g., constant, rhythmic, or brief)

and its severity using the Pain Rating Index (PRI) and

pain adjectives of the McGill Pain Questionnaire (MPQ)

(12).

(b) Pain scenarios and judgments. Subjects read six

scenarios describing hypothetical situations in which pain

was experienced by the protagonist. After reading each

scenario, subjects rated the intensity of the hypothetical

pain (on a 100-mm VAS) one would experience immediately following the incident, the intensity of pain that

would be experienced 10 minutes later, and the quali~ of

pain on the MPQ pain adjectives. The order of presentation of the six stories was randomized and responses

averaged across them.

(c) Pain during past year. Subjects indicated which of

seven types of pain they had experienced in the past year:

headaches, backaches, stomach aches, joint pains, muscle

pains, dental pains, and pain for other reasons, For each

type of pain, subjects estimated the number of days on

which it was experienced in the previous 12 months, the

20

usual severity of the pain (on a O-5 scale), and the

maximum pain experienced (also on a O-5 scale).

Results

A two-way (gender x assigned mood induction condition) multivariate analysis of variance (MANOVA) was

conducted across the variables that were measured prior

to the mood induction procedure. These included the

Differential Emotions Scale, the measures of present

symptoms, symptoms from the past week, and discomfort

due to symptoms, The purpose of this analysis simply was

to demonstrate that prior to mood induction, there were

no differences in either mood or symptom reporting across

the three groups. Neither the main effect for mood,

gender, nor the mood by gender interaction approached

significance. Means for these measures are provided in

table R.

A two-way ANOVA (gender x mood) was conducted

on the six-item mood check to ensure that happy and

sad moods had been properly induced. As can be seen

in table S, subjects reported the most positive affect in

the happy condition and the least in the sad condition

(F (2,88) = 42.00, p < .0001). According to Tukey’s

Multiple Comparison Procedure, both the happy and sad

conditions produced significantly more and less positive

affect, respectively, than the neutral condition, Neither

the main effect for gender nor the mood x gender interaction was significant.

Subjects next recalled a recent painful episode, rated

its intensity on the several visual analog scales and rated

the quality of the painful experience on the McGill Pain

Questionnaire adjectives. The means for these ratings are

also displayed in table S. A two-way MANOVA across

this set of dependent variables revealed no main effect for

mood (Wilks’s lambda = 0.84, F (16, 162) = 0,92), but a

significant main effect for gender (Wilks’s lambda = 0.70,

F (8,81) = 4.42, p c .0005). The mood x gender interaction was not significant (Wilks’s lambda = 0,80,

F (16, 162) = 1.22).
Table S, Experiment 6A-Ratings of recent painful experience after mood induction by mood and gender

Mood induction condition

Happy Neutral Sad

Measure Ma/a Female Male Female Male Female

Mood check:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard davlatlon . . . . . . . . . . . . . . . . . . . . . .

Pain maximum (100-mm VAS):

30.67

8.36

26.07

9.22

23.76

5.38

27.07

5.64

15.47

6.40

i 3.29

3.79

Mean, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard devlatlon, ...,..... . . . . . . . . . . . .

Pain average (100-mm VAS):

78.53

25,05

66.67

23.07

53.47

29.04

76.57

18.26

68.53

22.72

60.21

20.49

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard devlatlon, ...,.... . . . . . . . . . . . . .

Pain Interference (100-mm VAS):

Mean. , . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddevlatlon . . . . . . . . . . . . . . . . . . . . . .

Pain vividness (100-mm VAS):

Mean . . . . . . . . . . . . . . . . . . . . . . ,., ,.,.,,

Standarddevlatlon, ,,, . . . . . . . . . . . . . . . . . .

MPQ senso~ adjectives:

Mean. ,, . .,, . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation, ,. .,.... . . . . . . . . . . . . .

MPQ affective adjectives:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . .

MPQ evaluative adjective:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . .

MPQ total score:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddev[atlon . . . . . . . . . . . . . . . . . . . . . .

56.27

24.34

4a.a7

23.39

35.16

23.04

51.64

23.05

54.53

23.56

35.71

20.27

47.33

35.82

54.13

37.69

25.a8

27.la

5a.43

36.69

45.37

30.91

45.a6

27,98

81.93

24.67

67.27

24.47

55.71

33.27

77.79

32.55

66.79

27.96

64.50

31.33

16.47

7.31

12.73

6.36

12.76

5.34

14.71

7.93

16.47

6.25

14.64

5.00

3.47

3.34

3.87

4.16

1.24

f .95

3.29

2.76

3.66

3.56

1.43

1.28

2.67

1.45

3.13

1.41

1.76

1.39

3.50

1.34

2.42

1.26

2.21

1.19

30.13

13.64

24.26

11.92

20.82

6.62

25.79

13.16

31.47

14.33

22.14

6.71

Table T. Experiment 6A-Pain ratingsof hypothetical storlesby mood and gender

Mood induction condition

Happy Neutral Sad

Measure Male Female Male Female Male Female

Pain now

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pain 10 minutes Iatec

Mean, , . ., . .,, . . . . . . . . . . ,,, ,, .,,,...,,,,,,

Standarddevlatlon . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MPQ sensory adjectives:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddeviat[on . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MPQ affective adjectives:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MPQ evaluative adjectives:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddevlatlon . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MPQ total score:

59.54

15.70

57.93

14.48

60.93

14.20

63.60

13.60

61.65

14.06

59.64

12.25

50.49

13.63

43.00

12.49

42.69

16.33

49.19

14.19

47.06

15.50

54.75

8.04

15.06

6.05

12.04

4.47

13.26

5.11

13.61

4.65

16.72

5.87

15.64

4.50

3.32

2.09

1.3a

1,20

2.11

1.36

2.55

1.65

2.66

2.50

2.63

1.66

2.60

.54

2.26

.61

2.66

.47

2.69

.55

2.55

.67

2.60

.40

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26.84

9.23

19.57

7.04

22.84

6.26

23.33

7.61

27.45

10.66

26.71

6.92

21
Table U. Experiment 6A-Recall of frequency of painful episodes from previous year by mood and gender

Mood induction condition

Happy Neutral Sad

Measure Male Female Male Female Male Female

Types of painful experiences during past year (o-7):

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation, . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sum of number of painful days during past yeac

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddeviation . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mean rating of “usual” pain intensity

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mean rating of “maximum” pain intensity

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation, . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.40

1.24

4.73

1.10

4.59

1.28

4.36

1.50

4.53

1.40

4.93

0.92

227

353

170

129

112

100

197

224

175

176

272

283

1,50

.83

1.41

.41

1.35

.56

1.36

.58

1.36

.48

1.42

.24

2.35

1.23

2.36

.61

2.24

.76

2,27

.97

2.35

.85

2.32

.52

Followup two-way ANOVAs revealed that the main

effect for gender was due to women rating their recalled

pain experience as more interfering with daily routines

than men(F(l,88) = 3.80, p c .05), and, onthe McGi11

Pain Questionnaire, women chose more evaluative adjectivesthan men(F(l,88) =5.70,p e .05). However, there

were no other significant differences on ratings of the

recalled painful episode.

There were no systematic differences for story version

on the ratings of the six hypothetical stories so data were

averaged across them, Means by mood and gender for

these averaged ratings are displayed in table T. A twoway (mood x gender) MANOVA was conducted across

the six story ratings. There was no mood main effect

(Wilks’s lambda =0.88, F(12,166) =0.87), norasignificant gender main effect (Wilks’s lambda = 0.96, F(6,83)

= 0.64), but there was a borderline significant mood x

gender interaction (Wilks’s lambda = 0.80, F(12,166) =

L59, p -= .10).

Two-way univariate ANOVAs revealed significant or

close to significant mood x gender interactions on the

following variables: level of pain expected after 10 minutes

(F(2, 88) = 2.81, pc .06), affective adjectives on the

McGill Pain Questionnaire (F(2, 88) = 3,62, p< .05),

and evaluative adjectives on the McGill Pain Questionnaire (F (2, 88) = 3.38, p c .05). On these variables, there

were no systematic trends across the mood conditions

among men. However, for women, significant linear trends

(representing mood congruent pain reporting with lowest

pain reported in the happy condition and highest in the

sad condition) emerged for level of pain expected after 10

minutes (F (1, 40) = 7.09, p = .01) and on all of the MPQ

adjective scales (F (1,40) = 4.56, 4.97, and 5.13, respectively, for sensory, affective, and evaluative adjectives, all

p < ,05). (These results should be interpreted with caution. Recall that the interaction term in the MANOVA

was only significant at .10 in the first place, and we have

not adjusted the alpha level here for the multitude of tests

conducted.) Finally, subjects were asked to indicate whether

they had experienced each of seven different kinds of pain

22

during the past year (yes/no), to estimate the number of

days on which the pain was experienced (O–365), to rate

the usual level of intensity associated with each pain type

(O-5), and to rate the maximum level of pain associated

with each pain type (O-5). The ratings across the seven

kinds of pain were then summed into indices for the first

two measures and averaged for the latter two. Means on

these indices by mood condition and gender are depicted

in table U.

A two-way (mood x gender) MANOVA revealed no

systematic effects for mood, gender, nor a significant mood

x gender interaction. Inspection of the means for the sum

of the number of painful days during the past year reveals

Table V. Experiments 6A and 6B- Correlations of baseline

(nonInduced) mood and pain ratings across all experimental

conditions

Experiment 6A Experiment 6B

Measure (n= 94) (n= 89)

Recent pain experience ratings

Pain maximum . . . . . . . . . . . . . . .

Pain average . . . . . . . . . . . . . . . .

Pain interference, . . . . . . . . . . . . .

Painvividness. . . . . . . . . . . . . . . .

MPQ sensory . . . . . . . . . . . . . . . .

MPCfaffective . . . . . . . . . . . . . . . .

MPQ evaluative.........,.. . . .

MPQtotal ..,....,.......,,.

-.01

–.12

-.01

-.06

-.15

–.10

.04

-.10

*-.23

-.15

-.06

W_.za

-.13

–.03

-.12

-.06

Pain story ratings

Pain now . . . . . . . . . . . . . . . . . . . -.11 .06

Pain later. . . . . . . . . . . . . . . . . . . .00 .02

MPQsensory . . . . . . . . . . . . . . . . -.02 .06

MPQ affective . . . . . . . . . . . . . . . . -.11 .05

MPQevakrative . . . . . . . . . . . . . . . .01 .01

MPQtotal . . . . . . . . . . . . . . . . . . -.03 .03

Frequency of pain episodes

Types of pain . . . . . . . . . . . . . . . . -.03 *-.21

Number ofpain days . . . . . . . . . . . .01 -.12

Usual pain intensity . . . . . . . . . . . . -.07 -.13

Maximum pain Intensity. ., , , . . . . . .01 *-,23

Note: ‘p c .05; ‘*p <.01.
Table W. Experiment 6B - Means on mood and symptom scales prior to mood induction by mood and gender

Assigned mood condition

Happy Neutral Sad

Male Female Male Female Male

Scale

Female

(n = 15) (n= 15) (n= 14) (n = 15) (n= 15) (n= 15)

Dlfferentlal emotions scale:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . .

Present symptoms and pain - past 24 hours:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . .

Present symptoms and pain - past week:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . .

Present symptoms and pain – discomfort:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . .

4.74

1.24

4.75

0.93

4.54

0.87

4.47

1.21

4.55

0.92

4.40

1.05

11.20

15.99

5.67

4.61

6.93

6.37

14.14

17.54

5.07

3.47

7.67

5.29

13.20

15.46

18.07

19.34

15.36

16.19

8.33

5.43

10.80

5.52

9.47

5.00

.62

.56

.68

.57

.56

.26

.45

.33

.59

.32

.70

.40

Table X, Experiment 6B-Recall offrequency of painful episodes from previous year by mood and gender

Mood induction condition

Happy Neutral Sad

Measure Male Female Male Female Male Female

Mood check

Mean, . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation, ..,....,. . . . . . . . . .

Types of painful experiences during

past year (O-7):

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddeviation . . . . . . . . . . . . . . . . . . .

Sum of number of painful days during

past year:

Mean, ,, .,, ,, .,, ,, .,..... . . . . . . . .

Standard deviation ...,..... . . . . . . . . .

Mean rating of “usual” pain intensity

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddevlation . . . . . . . . . . . . . . . . . . .

Mean rating of “maximum” pain intensity:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . .

30.33

7.57

31.07

7.82

25.79

5.91

24.53

7.78

17.40

5.15

13.13

5.91

4.00

1.41

4.60

2.61

4.07

1.69

3.53

1.55

3.60

1.92

3.80

1.61

345

436

113

199

150

165

237

303

196

244

234

281

1.10

.84

1.00

.70

1.11

.66

1.09

.61

.98

.74

1.30

.69

1.67

1.10

1.19

.89

1.91

1.12

1.69

1.05

1.55

1.17

1.87

1.04

weaksupportfor mood congruent recallamongthe women

(i.e., sad high, happy low) for these ratings, but, these

differences, alas, were not significant,

We were able to explore one other issue in the present

study, Others have conjectured that induced mood might

have a differential impact on pain judgments depending

on the “baseline” mood in which subjects entered the

experimental situation, We examined whether baseline

mood correlated with pain ratings across mood induction

conditions. As shown in table V, it did not. Multiple

regression analyses were conducted to determine the contribution of baseline mood and induced mood to pain

ratings, An interaction term was included in these analyses to test whether induced mood has differential impact

on pain judgments depending on the level of baseline

mood. R2 was not significant for any of these regression

equations, nor were any of the betas for individual independent variables significant, The interaction terms were

also not statistically significant.

Discussion

We hypothesized that pain ratings, whether based on

autobiographical incidents or in reaction to fictitious vignettes, should be mood sensitive. In particular, we expected that sad moods would inflate pain ratings of all

kinds and happy moods would suppress them. We had no

a priori expectations regarding gender differences in these

processes.

The data collected in this experiment revealed a

somewhat disappointing pattern of results. First of all,

although mood seemed to be adequately induced, it did

not have systematic effects on pain ratings. Moreover,

what few significant differences were revealed indicated

23
Table Y. Experiment 6B- Ratings of recent painful experience after mood induction by mood and gender

Mood induction condition

Happy Neutral Sad

Measure Male Female Male Female Male Female

Pain maximum (100-mm VAS):

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . .

Pain average (100-mm VAS):

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddeviation . . . . . . . . . . . . . . . . . . . . .

Pain interference (100-mm VAS):

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddeviation . . . . . . . . . . . . . . . . . . . . .

Pain vividness (100-mm VAS):

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddeviation . . . . . . . . . . . . . . . . . . . . .

MPQ sensory adjectives:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

62.07

31.51

63.47

27.63

71.93

28.77

68.87

24.83

63.26

28.49

75.60

28.45

50.13

31.96

51.87

34.56

43.29

20.84

54.53

29.87

45.33

26.06

61.20

21.83

49.13

33.71

42.47

30.76

36.64 42.27

33.78

51.27

32.75

51.53

33.93 33.73

72.67

30.77

69.67

26.41

72.07

31.97

72.00

30.65

64.93

32.03

77.53

30.71

15,87

7.86

15.00

5.11

19.67

9.03

18.00

9.67

16.93

7.69

16,14

Standarddeviat[on . . . . . . . . . . . . . . . . . . . . . 9.04

MPQ affective adjectives:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddeviation . . . . . . . . . . . . . . . . . . . . .

MPQ evaluative adjectives:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standarddeviation . . . . . . . . . . . . . . . . . . . . .

MPQ total score:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviation . . . . . . . . . . . . . . . . . . . . .

5.53

3.34

3.67

4.24

3.07

3.87

2.93

3.51

2.73

3.03

4.93

3.45

1.93

1.49

2.50

1.70

2.07

1.44

2.20

1.57

3.20

1.37

3.33

1.83

35.27

17.85

29.40

16.50

30.43

16.70

26.93

14.18

24.87

11.07

35.47

13.23

that men and women differed in the way in which mood

influenced their painratings. Women, forexample,showed

a weak trend in the direction of the predicted mood

congruent pattern ofpain ratings when theyjudgedhypotheticaI pain vignettes. Men, however, showed no consistent influenceof mood on these or any other ratings.

Experiment 6B: Subjects recruited from

community

Because the results ofexperiment6A were so weak,

the experiment was replicated with 89 subjects recruited

from the New Haven community and randomly assigned

to the three mood induction conditions. Dependent variables were measured in the same way, however, the

frequency ratings were moved closer to themoodinduction procedure, andonly halfas many hypothetical stories

were utilized in order to minimize deterioration of induced mood.

Results

A two-way (gender x assigned mood induction condition) MANOVAwas conducted across the variables that

were measured prior to the mood induction procedure.

These included the Differential Emotions Scale, the measures of present symptoms, symptoms from the past week,

and discomfort due to symptoms. Once again, there were

no differences in either mood or symptom reporting across

the three groups prior to mood induction. Neither the

main effect for mood, gender, nor the mood by gender

24

interaction approached significance. Means for these measures are provided in table W.

A two-way ANOVA (gender x mood) was conducted

on the six-item mood check to ensure that happy and sad

moods had been properly induced, As can be seen in

table X, subjects reported the most positive affect in the

happy condition and the least in the sad condition

(F (283) = 39.80,p < ,0001). According to Tukey’s Multiple Comparison Procedure, both the happy and sad conditions produced significantly more and less positive affect,

respectively, compared with the neutral condition. The

main effect for gender and the mood x gender interaction

were not significant.

In this version of the study, subjects completed the

pain frequency measures first. They were asked to indicate

whether they had experienced each of seven different

kinds of pain during the past year (yes/no), to estimate the

number of days on which the pain was experienced (O-365),

to rate the usual level of intensity associated with each

pain type (O–5), and to rate the maximum level of pain

associated with each pain type (O-5). The ratings across

the seven kinds of pain were then summed into indices for

the first two measures and averaged for the latter two.

Means on these indices by mood condition and gender are

depicted in table X.

A two-way (mood x gender) MANOVA revealed no

systematic effects for mood, gender, nor a significant mood

x gender interaction across the frequency measures. As

the means in table X indicate, the sum of the number of

painful days during the year varied quite a bit both within
Table 2, Experiment 6B- Pain ratings of hypothetical stories by mood and gender

Mood induction condition

Happy Neutral Sad

Measure Male Female Male Female Male Female

Pain now:

Mean, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56.67 57.33 44.25 44.13 42.90 50.77

Standarddevlatlon . . . . . . . . . . . . . . . . . . . . . 22.51 17.74 21.85 25.24 22.16 29.79

Palnl O minutes later:

Mean, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.63 30.07 21.21 24.30 14.87 25.83

Standarddevlatlon . . . . . . . . . . . . . . . . . . . . . 15.34 18.58 15.22 23.99 13.10 20.14

MPQ sensory adjectives:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.47 14.70 12.18 10.03 10.47 14.57

Standard deviation ...,..... . . . . . . . . . . . . 9.65 a.i3 6.14 5.90 5.40 6.84

MPQ affective adjectives:

Mean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.53 2.87 1.89 2.47 1.53 3.57

Standarddevlation . . . . . . . . . . . . . . . . . . . . . 4.09 2.92 2.25 3.44 2.05 2.95

MPQ evaluative adjectives:

Mean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.20 1.67 1,64 1.77 1.63 2.37

Standard deviation . . . . . . . . . . . . . . . . . . . . . 1.15 .66 .72 .84 ,81 1.39

MPQ total score:

Mean, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.63 23.23 18.96 17.37 16.60 26.97

Standarddavlatlon . . . . . . . . . . . . . . . . . . . . . 17.94 14.39 10.64 12.52 10.23 13.43

and across conditions. Happy women reported relatively

fewer painful days, but happy men reported the most,

thoughwe should not make too much of these findings

given the nonsignificant MANOVA (the ANOVA for this

variable revealed a marginally significant mood xgender

interaction (F(2S3) = 2.69, p c .08). Little support for

any mood congruent trend in these data, however, was

revealed.

Subjects next recalled arecent painful episode, rated

its intensity on the several visual analog scales and rated

the quality of the painful experience on the McGill Pain

Questionnaire adjectives. The means for these ratings are

displayed intable Y, Atwo-way MANOVAacross thisset

of dependent variables revealed no main effect for mood,

gender, nor a significant interaction,

The final task presented to subjects was the ratings of

pain in the hypothetical stories, There were no systematic

differences for story version so data were averaged across

them. Means by mood and gender for these ratings are

displayed in table Z. A two-way (mood x gender)

MANOVA was conducted across the six story ratings.

Neither mood nor gender main effects nor the interaction

was significant.

As in our first mood study, we also explored whether

pain ratings were related to baseline (reinduction) levels

of mood, as shown in table V. By and large they were not,

although sadder subjects did report pain memories that

were more vivid and whose maximums were rated as more

intense. Also, sadder subjects recalled more types of

painful days during the previous year. However, given the

number of correlations calculated (and the number that

were not significant), the importance of these effects

seems rather limited. Multiple regression analysis did not

reveal any interactions behveen baseline and induced

mood in influencing pain ratings.

Discussion

In terms of demonstrating a systematic influence of

mood on pain ratings, the only fair conclusion is that this

experiment was a dismal failure. Despite adequate sample

sizes based on power analyses conducted prior to the start

of the experiment, no reliable evidence for mood congruent pain reporting was demonstrated by this study. The

lack of influence of mood on judgments about pain in

experiments 6A and 6B is surprising. The influences of

mood on judgment are fairly robust (a whole volume

,dedicated to such effects was recently published, for

example, 83). Mood has been shown to affect judgments

about the likelihood of future catastrophic events (84),

becoming sick in the future (63, 85), one’s athletic and

romantic prowess (86), the quality of consumer products

(87), and impressions of other people (88), However, at

least for the kinds of pain ratings measured here, induced

mood does not have a significant impact on them, and

naturally occurring mood seems to affect them rather

minimally as well.

25
Conclusions

The accurate reporting of information about physical

pain on health surveys was the focus of this program of

research. Three potential sources of error in such selfreports were explored in six experiments: (a) the complexity of the lexicon used to describe pain, (b) the focus of

survey questions on recollections about the intensity and

severity of pain versus changes in daily activities brought

on by pain or observable pain related behaviors, and (c)

ongoing mental states such as experienced pain at the time

of the survey itself and transient mood states during recall.

On the basis of these experiments, several conclusions

and recommendations can be offered:

The pain lexicon is enormous and relatively vague,

There is considerable variability in how pain descriptors are assigned to painful experiences. Yet, there

seems to be considerable consensus in the understanding of the meaning of a subset of pain descriptors

across individuals with varying levels of experience

with pain. Fifteen descriptors that show considerable

stability in the way in which they are organized mentally are throbbing, shooting, stabbing, sharp, cramping, gnawing, hot, aching, heavy, tender, splitting,

tiring, sickening, fearful, punishing. Although we have

no way of knowing whether these descriptors are more

or less stable than any other set of 15, we feel confident that the relative meaning of these words is shared

widely by most potential survey respondents.

Compared with the literature reviewed at the start of

this paper, which reported, for the most part, considerable inaccuracy in recall of pain among small samples of patients undergoing treatment in pain clinics,

recall among our subjects across most of the studies

would be better characterized by its accuracy. Overall,

we were impressed by how well subjects could report

on their pain retrospectively, When biases in retrospective accounts were observed, they tended to be in the

●

●

●

●

direction of overestimating rather than underestimating prior levels of pain.

Keeping a diary in which individuals track daily severity of pain, pain-related behaviors, or both seems to

have little impact on subsequent accuracy in recall of

pain. Hence, studies (and clinics) using diarykeeping

procedures are probably not compromising the accuracy of subsequent pain data collected from these

subjects.

The severity of prior pain, its impact on daily activities,

and behaviors related to the pain problem are all

recalled approximately equally well and seem to be

equally stable over time among individuals with chronic

pain problems. Survey researchers who seek more

informative data than that provided by mere intensity

ratings should feel comfortable querying respondents

about these other pain related behaviors (or even

consider rating respondents’ observable pain behaviors).

One systematic source of bias in pain ratings is created

by severity of pain at the time of recall. Controlling for

original levels of pain and the amount that pain

fluctuates during the applicable time period, greater

pain at recall was associated with overestimating of

prior pain experience. Survey researchers asking questions about prior experiences with pain may wish to

include questions about current levels of pain as well.

Although transient (induced) mood states have a systematic effect on various kinds of judgment tasks

explored in other contexts, they did not affect the

recall of painful experiences, frequency of painful

days, or judgments about other people’s pain among

the healthy subjects tested in our experiments, Moreover, ongoing, naturally occurring mood states were

not associated with judgments about pain either. Mood

may not be a major influence on pain recall, at least

not under the specific conditions investigated here.

26
References

1. Turk DC, Meichenbaum D, Genest M. Pain and behavioral 20. Richards JS, Nepomuceno C, Riles M, Suer Z. Assessing

medicine: A cognitive-behavioral perspective, New York: pain behavior: The UAB pain behavior scale. Pain 14393-98.

Guilford, 1983. 1982.

2, Arthritis Foundation. Arthritis, the basic facts. Atlanta: 21. Turk DC, Wack JT, Kerns RD. An empirical examination of

Arthritis Foundation. 1976. the “pain behavior” construct. J of Beh Med 9:119-30.1985.

3. paulley JW, Haskell DJ. Treatment of migraine without 22. Turk DC, Rudy TE. Towards a comprehensive assessment

drugs. J Psychosomatic Res 19:367-74.1975. of chronic pain patients. Beh Res and Therapy 25:237-49.

d. Clark M, Gosnell M, Shapiro D. The new war on pain. 1987.

Newsweek 89(April 25):48-58. 1977. 23. Erskine A, Morley S, Pearce S. Memory for pain: A review.

5, Bresler DE. Free yourself from pain. New York: Simon &

Pain 41:255-65.1990.

Schuster. 1979. 24. Linton SJ, Melin L. The accuracy of remembering chronic

6, Koenig p. The placebo effect in patent medicine. Psychology pain, Pain 13:281-5.1982.

Today 7:60.1973.

25. Hunter M, Philips C, Rachman S. Memory for pain. Pain

7, American pain Sociev, Minutes of the new board of direc6:3546.1979.

tors of the American Pain Society. Nutley, NJ: American

26. Skowronski JJ, Betz AL, Thompson CP, Shannon L, Social

Pain Society, 1980.

memory in everyday life: Recall of self-events and other8, Jobe JB, Mingay DJ. Cognition and survey measurement:

events, J of Personality and Soc Psychology, 60:831-3.1991.

27. Roche PA, Gijsbers K. A comparison of memory for inHistory and overview. Applied Cognitive Psychology 5:175- duced ischemic pain and chronic rheumatoid pain. Pain

92, 1991. 25:337-43.1986.

9, Fienberg SE, Loftus EF, Tanur JM. Recalling pain and 28. Linton SJ, Gotestam KG. A clinical comparison of hvo pain

other symptoms. Milbank Mem Fund Q 63:582-97.1985, scales: Correlation, remembering chronic pain, and a mea10. Melzack R, Torgerson VJS. on the language of pain. Anes- sure of compliance. Pain 17:57-65.1983.

thesiology 34:50-9, 1971, 29. Kent G. Memory for dental pain. Pain 21:187–94. 1985.

11, urban BJ, Keefe FJ, France RD. A study of psychophysical 30. Guerra F, Awareness and recall. International Anesthesiolscaling in chronic pain patients. Pain 20:157-68. 1984. ogy Clinics 24:75-99.1986.

12. Melzack R. The McGill pain Questionnaire: Major proper- 31. Norvell KT, Gaston-Johansson F, Fridh G. Remembrance

ties and scoring methods. Pain 1:277-99.1975. of labor pain: How valid are retrospective pain measure- >

13. Byrne M, Troy A, Bradley LA, Marchisello PJ, Geisinger ments? Pain 31:77-86. 1987.

KF, Van der Heide LH, Prieto EJ. Cross-validation of the 32. Eich E, Reeves JL, Jaeger B, Graff-Radford SB. Memory

tlctor structure of the McGill Pain Questionnaire. Pain for pain: Relation between past and present pain intensity.

13:193-201.1982, Pain 23:375-80.1985,

1~. Leavitt FG, Garron DC, Whisler WW, Sheinkop MB. A.tfec- 33. Bower GH. Mood and memory. Am Psychologist 36:129-48.

tive and sensory dimensions of back pain. Pain 4:273–81.

1981.

1978.

34. Singer JA, Salovey P. Mood and memory Evaluating the

15, McCreary C, Turner J, Dawson E. Principal dimensions Of

network theory of affect. Clin Psychology Review S:211–51.

1988.

the pain experience and psychologicaldisturbance in chronic 35. Eich E, Rachman S, Lopatka C. Affect, pain, and autobioIOWback pain. Pain 11:85-92.1982.

16. Turk DC, Rudy TE, Salovey P. The McGill Pain Questiongraphical memory. J of Abnormal Psychology 99:174-8.

1990.

naire reconsidered: Confirming the factor structure and 36. Jamison RN, Sbrocco T, Parris WCV. The influence of

examining appropriate uses, Pain 21:385-97.1985.

17. Kerns RD, Turk DC, Rudy TE. The West Haven–Yale

physical and psychosocial factors on accuracy of memory for

Multidimensional Pain Inventory (WHYMPI). Pain

pain in chronic pain patients. Pain 37:289-94.1989.

37, Takane Y, Young FW, DeLeeuw J. Nonmetric individual

23:345-56, 1985. differences multidimensional scaling: An alternating least

1S. Fordyce WE, Behavioral methods for chronic pain and squares method with optimal scaling features. Psyillness. St, Louis: Mosby. 1976. chometrika 427–67. 1977.

19. Keefe FJ, Block AR, Development of an observation method 38. Smith AF. Structural relationships of perceived and imagfor assessing pain behavior in chronic low back pain pa- ined letters. Paper presented at the annual meeting of the

tients, Beh Therapy and Res 13:363-75.1982. Midwestern Psychological Association. Chicago, IL. 1987.

27
39. Carroll JD, Chang JJ. Analysis of individual differences in

multidimensional scaling via an N-way generalization of

“Eckart-Young” decomposition, Psychometrika 35:283-319,

1970.

40. Turk DC, Rudy TE, Salovey P. Health protection: Attitudes

and behaviors of LPNs, teachers, and college students,

Health Psychology 3:189-210.1984.

41. MacCallum RC. Effects of conditionality on INDSCAL and

ALSCAL weights. Psychometrika 42:297-305.1977.

42. Fordyce WE, Lansky D, Calsyn DA, Shelton JL, Stolov WC,

Rock DL. Pain measurement and pain behavior. Pain

18:53-69.1984.

43. McDaniel LK, Anderson KO, Bradley LA, Young TD,

Turner RA, Agudelo CA, Keefe FJ. Development of an

observation method for assessing pain behavior in rheumatoid arthritis patients. Pain 24:165-84.1986.

44. Teske K, Daut RL, Cleeland CS. Relationship between

nurses’ observations and patients’ self-report of pain. Pain

16:289-96.1983,

45. Smith AF, Jobe JB, Mingay DJ. Concerning the suitability

of diarykeeping to validate report of dietary information,

Unpublished Manuscript. 1991,

46, Turk DC, Flor H. Pain > pain behaviors: The utility and

limitations of the pain behavior construct. Pain 31:277-95.

1987.

47. Keefe FJ, Brantley A, Gerdenio M, Crisson JE, Behavioral

assessment of head and neck cancer pain. Pain 23:327-36.

1985.

48. Keefe FJ, Gil KM. Behavioral concepts in the analysis of

chronic pain syndromes. J of Consulting and C1in PsycholOg)J54:776-83.1986.

49. Keefe FJ, Hill RW. An objective approach to quanti&ing

pain behavior and gait patterns in low back pain patients.

Pain 21:153-61.1985.

50, Keefe FJ, Wilkins RH, Cook WA. Direct observation of

pain behavior in low back pain patients during physical

examination. Pain 20:59-68.1984,

51. Cinciripini PM, Floreen A. An assessment of chronic pain

behavior in a structured interview. J of Psychosomatic Res

27:117-24.1983.

52. Feuerstein M, Greenwald M, Gamache MP, Papciak AS,

Cook EW. The pain behavior scale: Modification and validation for outpatient use. J of Psychopathology and Beh

Assessment 4:301–15. 1985.

53. Nisbett RE, Ross L. Human inference: Strategies and shortcomings of social judgment. Englewood Cliffs, NI PrenticeHall. 1980.

54. Turk DC, Salovey P. Clinical information processing: Bias

inoculation. In: Ingram RE, ed. Information processing

approaches to clinical psychology. Orlando: Academic press,

305-23.1986.

55. Tversky A, Kahneman D. Judgment under uncertainty

Heuristics and biases. Science 185:1124-31.1974.

56. Blaney PH. Affect and memory. Psychological Bulletin

99:229-46.1986.

57. Isen AM. Positive affect, cognitive processes, and social

behavior. In: Berkowitz L, ed. Advances in experimental

social psychology. San Diego: Academic Press, 20:203-53.

1987.

58. Mayer JD, Salovey P. Personality moderates the interaction

of mood and cognition. In: Fiedler K, Forgas J, eds. AfTect,

cognition, and social behavior. Toronto: Hogrefe, 87-99.

1988.

59. Gilligan SG, Bower GH. Cognitive consequences of emotional arousal. In: Izard C, Kagan J, Zajonc R, eds, Emotions, cognition, and behavior. New York: Cambridge

Universi~ Press, 547-88, 1984.

60. Katon W. Depresion: Relationship to somatization and

chronic mental illness. J of Clin Psychiatry 45:4-11.1984.

61, Tessler R, Mechanic D, Psychological distress and perceived

health status. J of Health and Soc Beh 19:254-62.1978,

62. Croyle RT, Uretsky MB. Effects of mood on self-appraisal

of health status. Health Psychology 6:239-53.1987.

63. Salovey P, Birnbaum D, The influence of mood on healthrelevant cognition. J of Personality and Soc Psychology

57:539-51.1989.

64. Eich JE. The cue-dependent nature of state-dependent

retrieval. Memory and Cognition 8:157-73.1980,

65. Eich JE, Weingartner H, Stillman RC, Gillin JC. Statedependent accessibility of retrieval cues in the retention of a

categorized list. J of Verbal Learning and Verbal Beh

14:408-17.1975.

66. Bower GH, Monteiro KP, Gilligan SG. Emotional mood as

a context of learning and recall. J of Verbal Learning and

Verbal Beh 17:573-85.1978,

67. Schare ML, Lisman SA, Spear NE. The effects of mood

variation of state-dependent retention. Cog Therapy and

Res 8:387-408.1984.

68, Brockner J, Hjelle L, Plant RW. Self-focused attention,

self-esteem, and the experience of state depression, J of

Personality 53:425-34.1985.

69. Ingram RE, Smith TW. Depression and internal versus

external focus of attention. Cog Therapy and Res 7:139-52.

1984.

70. Pyszczynski T, Greenberg J. Depression and preferences for

self-focusing stimuli following success and failure. J of

Personality and Soc Psychology 49:1066-75.1985.

71. Pyszczynski T, Greenberg J. Evidence for a depressive selffocusing style. J of Res in Personality 20:95-106.1986,

72. Pyszczynski T, Greenberg J. Self-regulatory perseveration

and the depressive self-focusing style: A self-awareness

theory of depression. Psychological Bulletin 102:122-38,

1987.

73. Salovey P, Rodin J. Cognition about the selfi Connecting

feeling states and social behavior, In: Shaver P, ed, Self,

situations, and social behavior: Review of personality and

social psychology. Beverly Hills, CA Sage, 6:143-66.1985.

74. Smith TW, Greenberg J. Depression and self-focused attention, Motivation and Emotion 5:323-31.1981.

75, Smith TW, Ingram RE, Roth DL. Self-focused attention

and depression: Self-evaluation, affect, and life-stress. Motivation and Emotion 9:381–9. 1985,

76. Strack S, Blaney PH, Ganellen RJ, Coyne JC. Pessimistic

self-preoccupation, performance deficits, and depression, J

of Personality and Soc Psychology 49:1076-85, 1985.

77. Wood JV, Saltzberg JA, Goldsamt LA. Does affect induce

self-focused attention? J of Personality and Soc Psychology

58:899-908.1990.

78. Wright J, Mischel W. Influence of affect on cognitive social

learning personal variables, J of Personality and Soc Psychology 43:901-14.1982.

79. Salovey P, Singer JA. Mood congruency effects in recall of

childhood versus recent memories. J of Soc Beh and Personality 4:99-120.1989.

80. Izard CE. The face of emotion. New York: Appleton-CenturyCrofts. 1971.

28
81. Wahler HJ. The Physical Symptoms Inventory: Measuring

levels of somatic complaining behavior. J of Clin Psychology

24:207-11.1968.

82, Rosenhan DL, Salovey P, Hargis K. The joys of helping:

Focus of attention mediates the impact of positive affect on

altruism. J of Personality and Soc Psychology 40:899–905.

19s1.

83. Forgas JP, ed, ARect and social judgments. Oxford: Pergamon Press, 1991.

S4, Johnson EJ, Tversky A. Affect, generalization, and the

perception of risk. J of Personality and Soc Psychology

45:20-33, 19S3.

S5. Salovey P, O’Leary A, Stretton MS, Fishkin SA, Drake CA.

Influence of mood on judgments about health and illness.

In: Forgas JP, ed. A.lYect and social judgments. Oxford:

Pergamon Press, 241-62.1991.

86. Kavanagh DJ, Bower GH. Mood and self-efficacy Impact of

joy and sadness on perceived capabilities. Cog Therapy and

Res 9:507-25.1985.

87. Isen AM, Shalker TE, Clark M, Karp L. Affect, accessibility

of material in memory, and behavio~ A cognitive loop? J of

Personality and Soc Psychology 36:385-93.1978.

88. Forgas JP, Bower GH, Mood effects on person-perception

judgments. J of Personality and Soc Psychology 53:53-60.

1987.

29
Appendixes

Contents

1, Further analyses of experiment 3 data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . !. ..., 31

II. Materials Used in Experiments. . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . , . . , . . . . . . . . . . . . . ., . . . , ,.. . ,. ,. . . . . . . . . . 33

Experiment 1 materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. 33

Experiment 2materia1s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,,. 41

Experiment 3 materials . . . . . . . . . . . ,., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,, .,,.. 43

Experiment 4 materials . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,., . . . . . ., .,..,. ,,.. 46

Experiment 5 materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,.,.,. 57

Experiment 6materia1s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Appendix tables

I. Experiment 3: Recall ofbehaviors collapsed across diary-versus-no diary conditions . . . . . . . . . . . . . . . . .,. ,..$. . 31

II. E~eriment 3: Mean deviation scores (actual-recalled) bydia~condition (net error) . . . . . . . . . . . . . . . . . . . . . . . . 31

111,Experiment 3: Mean absolute deviation scores (absolute value of actual-recall) by condition (gross error) ,. .,,, 32

30
Appendix I

Further analyses of

experiment 3 data

The purpose of this appendix is to extend the behaviorby-behavior analysis reported for experiment 3. Recall

that in that experiment the reporting of pain intensity and

pain behaviors was revealed to be quite accurate. There

were simply no significant discrepancies between actual

and recalled levels of pain or pain behaviors, The only way

we could produce a few significant differences, and we

were clearly capitalizing on chance to some extent in order

to do so, was to combine the two conditions in which

behavior diaries were kept and compare them to the two

conditions, combined, in which such diaries were not kept.

These means are provided in table I. There were significant differences in the absolute level of recall on one pain

behavior and three control behaviors. Subjects who did

not keep diaries recalled complaining about pain more

frequently than subjects who kept diaries (F (1,105) = 4.75,

p c ,05), They remember eating chicken and writing letters less frequently (F (1,105) = 3.72, p <.06 and

F (1,105) = 5.4S, p <.05,respectively), and talking on the

phone more frequently (F (1,105) = 4.14, p c ,05). There

seems to be no particular pattern to these four differences,

and they occur in the context of 12 comparisons in which

no significant differences were found (in fact, a multivariate analysis of variance (MANOVA) across all 16

behaviors was not significant, Wilks’s lambda = 0.78,

F (16,89) = 1.49, P = .12).

Another way of thinking about these data is provided

in table II. Here, each entry in the table is the mean

difference score between subjects’ actual and recalled pain

intensity and behavior frequencies. These difference scores

can be considered the net error for each item. We were

interested in two aspects of these means. Do they differ

according to diary condition? Are they significantly different from zero? The only entry significantly different

from zero (by t-test) was complaining about pain by

subjects in the behavior only diary condition, as described

Table H. Experiment 3- Mean deviation scores (actuai-recaiied),

by diary condition (net error)

Behavior Pain Both All

diary diary diaries diary

Behavior (n = 26) (n = 23) (n = 23) conditions

Table i. Experiment 3- Retail of behaviors coilapsed across

diary-versus-no diary conditions

Pain intensity

Average pain . . . . . . . . . . . . . . . . . 0.09 0.16

Condition

Behavioral No behaw”oral

diary diary

Behavior (n = 49) (n= 58)

Pain behaviors

Take aspirin . . . . . . . . . . . . .

Take other . . . . . . . . . . . . . .

Take prescription. . . . . . . . . .

Use heating pad . . . . . . . . . .

Use hot water bottle. . . . . . . .

Take nap. . . . . . . . . . . . . . .

Use crutch . . . . . . . . . . . . . .

Ask for help . . . . . . . . . . . . .

Complaln about pain . . . . . . .

Avoid physical activity. . . . . . .

e.06

7.53

16.41

8.73

o.6e

10.47

5.35

10.76

13.37

12.50

6.03

5.79

15.59

8.03

I I .e3

1.74

5.57

13.26

*17.97

12.26

Other behaviors

Playbil l . . . . . . . . . . . . . . . 5.33 4.57

Read newspaper. . . . . . . . . . 20.51 20.69

Eatchicken . . . . . . . . . . . . . 7.33 *5.18

Talk on phone . . . . . . . . . . . 23.88 ●26.57

Use postage stamp . . . . . . . . 7.39 7.16

Wrlteletter. ., . . .. l...... 2.92 *1.12

●p <.05(the two conditions differ significantly).

Pain behaviors

Ali pain behaviors . . . . . . . . . . . 1-5.51

Take aspkin. . . . . . . . . . . . . . . -1.77

Take other . . . . . . . . . . . . . . . . 0.60

Take prescription . . . . . . . . . . . 1.06

Use heating pad . . . . . . . . . . . . -0.04

Usehotwater bottle . . . . . . . . . . 0.12

Take nap . . . . . . . . . . . . . . . . 0.60

Use crutch . . . . . . . . . . . . . . . . 0.81

Ask for help . . . . . . . . . . . . . . . –1.66

Complain . . . . . . . . . . . . . . . . *-3.64

Avoid physical activity. . . . . . –1.36

.,.

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

Other behaviors

All other behaviors. . . . . . . . . . . 3.45 . . .

Play bil l . . . . . . . . . . . . . . . . 1.12 . . .

Read news . . . . . . . . . . . . . . . -0.60 . . .

Eatchicken . . . . . . . . . . . . . . . -0.21 . . .

Talk on phone . . . . . . . . . . . . . -0.13 . . .

Use stamp . . . . . . . . . . . . . . . . 2.23 . . .

Write letter . . . . . . . . . . . . . . . . 1.03 .

-3.81

1.44

-2.60

-0.15

-0.66

0.11

1.82

-0.09

–2.02

-0.98

-0.66

-4.66

0.10

0.13

-2.30

-0.98

-1.18

-0.42

0.12

-4.70

-0.26

-0.90

0.49

-0.33

0.11

1.17

0.39

*-1 .83

*-2.39

–1.02

-0.36

0.84

-0.26

-1.19

-0.53

0.63

0.35

Note Obviously, there are no “actual” scores for the no diary condition, so daviation scores

cannot bs calculatedforthiscell.

tMissingdatain onesubjsct’sdiarycreatsda discrepancybetween this score and the

aggregated reCSll and aCIUal scores reported in table J. If we eliminate this subject, the

value for ell pain behavmrs would ba -7.10. Naither this velua nor the ona reported above is

statistically significant.

*DaviatiOn scora is significantly different from zerq p<.05.

31
in the main text. When we combined all diarykeeping

subjects together, there was also a significant tendency to

recall asking for help more frequently than reported in the

diary. But once again, the more profound finding is the

fact that these discrepancy scores are not significant on

most of the behaviors or for the recall of pain intensity

(where they are especially small). Moreover, diary condition did not have a significant effect on the magnitude of

these discrepancy scores.

About the only challenge to the notion that recall of

pain and pain behaviors is quite accurate can be mounted

when recall error is compounded without attention to the

direction of that error, an assessment of the gross error in

each item. In table III, we report the mean absolute value

recall-actual deviation scores. These scores represent the

average subject’s error in either direction in recalling pain

intensities or behavior frequencies. Of course, absolute

discrepancy scores are statistically significant by definition.

But comparing the gross error reported in table 111with

the net error in table II suggests that this error in recall is

generally not systematic. That is, recalled intensity and

behaviors are as likely to be inflated as underestimated.

A final question: Is this gross error (absolute deviation) different depending on diary condition? A series of

ANOVAs comparing diary conditions reveaIed that, indeed, it

is not. (We would have been surprised to have observed diary

condition effects; the only difference between subjects assigned to these conditions is whether, for instance, they had to

track just the 16 behaviors daily for 30 days or the 16

behaviors plus a single pain intensity item.)

Table [11.Experiment 3-Mean absolute deviation scores

(absolute value of actual-recall), by condition (gross error)

Behavior Pain Both All

diary diary diaries diary

Behavior (n = 26) (n = 23) (n = 23) conditions

Pain intensity

Average pain . . . . . . . . . . . . . . . . . .

Pain behaviors

All pain behaviors . . . . . . . . . . . . 28.59

Take aspirin . . . . . . . . . . . . . . . . 3.08

Take other..,...........,.. 3.37

Take prescription. . . . . . . . . . . . . 2.75

Use heating pad . . . . . . . . . . . . . 1.73

Usehotwater bottle. . . . . . . . . . . 0,27

Take nap . . . . . . . . . . . . . . . . . 2.03

Use crutch . . . . . . . . . . . . . . . . . 0.88

Aekforhelp . . . . . . . . . . . . . . . . 3.84

Complain, . . . . . . . . . . . . . . . . 5.95

Avoid physical activity. . . . . . . . . . 3.26

Other behaviora

All other behaviors, . . . . . . . . . . . 18.30

Playbil l . . . . . . . . . . . . . . . . . . 3.00

Read news . . . . . . . . . . . . . . . . 2.60

Eatchlcken . . . . . . . . . . . . . . . . 2.45

Talk on phone ., . . . ...,,,... 3,44

Usestamp . . . . . . . . . . . . . . . . . 4.70

Write letter . . . . . . . . . . . . . . . . . 2.10

0.74 0.57

. . . 31.71

. . . 2.83

. . . 7.08

. . . 1.29

. . . 2.31

. . . 0.72

. . . 3.98

,.. 0.52

. . . 3.26

. . . 3.78

,.. 5.98

. . . 21.72

.,, 2,70

. . . 4.49

. . . 4,01

,,, 4.60

. . . 4.20

. . . 1.73

0,66

30.09

2.96

6,10

2,06

2,00

0.48

3.37

0.71

3.46

4,92

4.57

19.91

2.86

3.49

3.18

3,99

4.47

1.92

Note: Obviously, there ara no “actual” scoras for the no diary condition, so deviation scores

cannot be calculated for this cell,

32
Appendix 11:

Materials used in

experiments

Experiment 1 materials

Inte?Nic5tT Protou31

[Forhalf of the subjects,ask questions6-11priorto questions1-5]

We are going to ask you a serks of questions about your healti. There are no

rkjht or wrung answers,so you should feel free to be as ho- as you possibly

can. Scme of our questionswill concernyOUr health~y. At Other tines =

will ask questionsconcerningthe thcxqhtsand feelingsyou are hav~ at that

particularmment. Do you have any qgestionsbeforewe get started?

S-ion A

1. Describe an experiencethat happenedto you Rcently in which you feltpain.

what happened?

2. Whatdid the pain feel like at first?

3. What did the pain feel like aftera while?

4. If you had to use fiveW* to describewhat the pain felt like,what would

those fivewordsbe?

5. H(YNdid yOU go chasing these particularwords?

6. Nm describethe most pa~ expexieme you have ever had. What hap&med?

33
7. What did the pain feel like at first?

8. What did the pain feel like aftera while?

9. If yOU

those five

had to use

mrds be?

fivewordsto describewhat the pain felt like,what wul.d

10. Huw did ym go aboutchoosiq theseparticularwords?

11. Hw did you go aboutselectingthis painfulq?erience to tell m about?

12.

lmst

‘lhhlcfor a lnoment

painfulexperience

anltxyto desaibefor me what youthinkwould be the

imaginable?

13.

what

If you had to use five

would these fivewords

woziisto describe

~?

what this pain Might feel like,

34
Section B (for Pain Patients onlv}

14. Using ascalefrom Oto9wkre Omeansno painatalland9mmns 132emost

exoruciatimg pain you could imagine, what nunber wuld you use to rate tie anmmt

of pain you-a& f&Mng right n&?

15. HCW did y~ go about &ms@ this

~ your *?

particular number? what was going

16. Place an llX’!on the follmhg line to imlicate this amxnt of pain.

very little — — excruciatimj

pain pahl

17● How didycugo akmutchoosingthisparticularspt to placeyour“X’? What

was goingthroughyourlIlid?

18. Using the O to 9 scale again, what would you say is the average amount of

painyou Experienced during tie past seven days?

19. HCW did you go about choosiq this particular

~ your ~?

number? What was going

20. HCW didyou figureoutthe “average”?whatwas goingt.hmxjhyourIllirK3?

21. Didyou fti the qyestionaboutaverageammt of paineasyor hardto

answer?

35
22. Didymrpain varyverynu-xhdurhq thecmrse of the past swen days?

23. Huw did the way in whichyour pain variedaffectymr finalrating?

24. magine a day in whichyour pain was excruciatingin the mxnirq, Mt then

graduallyinpruvedduringthe day until it was barelynoticeable.UsingW O to

9 scale,rate your averageamunt of pain for that day.

25. HuJ did yOU go abmrtselectingthis mmber?

26. Imaginea day in whichyour pain was excruciatingso you took same

medicationW it got better. Using the

of pain for that day.

27. Huw did yOU go aboutselecting this

O to 9 scale,rateymr averageammt

number?

36
SectionC

28. Nwweamgo@ totellyousme wxdsthatpecplesometbuse to

describetheirpain. ~Itellyou eachword, I would likeyoubtellm

abouta time duringwhi& you experimced a @ of that type. So, for exanple,

if I said, “a lmrningpain,ffycmtid tellme &cut a time in which you

expericmceda pain that felt like it was Wrnhkg. If you have neverexprisuchapain, thinlcu p asituationhatcmld makeapexson experienceapain like

the one describd. Do you have any questions?

(a) A thrckbingpain.

(b)A shootingpain.

(C) A StabbiIXJ ~in.

(d)A sharppain.

37
(e) A cranpirq pain.

(f) A gnaWing @n.

(g) A hot pain.

.

.

(h) An aching pain.

(i) A heavy pain.

38
(k) A splitting pain.

(1) A tirimj pain.

(m)A sickeningpain.

(n) A fearful pain.

39
(0) A @ding pain. 

40 
Experiment 2 materials

Pain Word Task

Many differentwordshave keen used to describepain. W@ are goingto

presentyou with pairs of sane of thesewOrds. Wewmldlike you to use&

scalebel~ to Mcate hm similarin meaningthetmwords in~ch pair are.

Pleaserate the similarityin meaningof the tm words as follows:

5 = extremely Shih.r in llEadng

4 = Inodmtely similar in nEuYing

3 = ~t s~l= in ~

2 = a little bit similar in ~

1 = not at all similar in -

Rate each pair of words by placing a number from 1 to 5

next to theme

— —

First,here are a few practicewords :

Ann@-J9\mPricking/Tingling

Nw, go aheadand rate the remining word

!

g

4

5

‘5

i-

_!3-_

fi’

--L

-L

.

3

-L

-iShooting/Tiring

Hea~/Sickening

Shooting/Stabbing

sharp/cramping

Sickming/Punishing

-W?@/A&@

Throbbing/Hot

shcOtiq/cmmpjl’Fg

H=vy\Splittjng

Sta3Mng/Sickening

Sharp/Gnawing

*/splitting

!ChroMing/Sickening

Shooting/mmder

__(__Hot/Tiring

/

&-

\

-i-

-.

pairs:

SWbing/Heavy

Hot\Fearful

==@-W/F~

Throbbing/Tender

Tiring/F~

Hcmy/Tender

Aching/Sickening

Splitting\F~

stabbiI-?g/sharp

Gnawing/Tender

Hot/H~vy

Tirin@unishiq

Gnawing/Hot

Gnawing/Sick*

+

.-2

i

f

in the blank space

Phchin@ming

Nagging/Cuttjng

Gnawing/Punishilq

‘I&ileq/F~

Stabbing/Splitting

sharp/Hot

m*/sPlitt*

Gnawing/Heavy

sMMrlg/CElmping

-/-@

shooting/Hot

Fearful/RmisMmg

mrobbinqstabbjnj

Shootim@ickeniq

mrobbing/PunMimJ

SharP/F~

Hot/Splitting

41
\ StaMincyzai.n.g

.2 ‘mmkbing/sharp

_L_ Crq?irqmri-q

t SlmbbirqjFearful

4 mrobbing\shooting

/ Terder/Sickning

.+!- A-iK@--vY

/ Shmting/lWnishing

-L llhrobbing/Splitting

1 Stabbing/Gnaw@

I Tadeq/Pmishing I Shooting/Splitting

% Gnawing/TiriIq ] Hot/Sickening

~ Hot/Achincj i mrcbbiKj/mawing

Q=@wm-= L Stabbing/Hot

u

1 Shaq@mishing +% Shootiq/Shaq

( Gnawing/Splitting I Hot/Rinish@

J!i_‘mmbbLlg/Mliq q’ Cm@@k?avy

I ~iKWHIP&J J_ srW.tt*/~

-4- stabbirKyTeMer __/__ si~F~

1 -/a —\ Hot/Teriier

d_ HwY/F~ ! ‘ihrckbinc#Fearful

1. stabbing/Tirimg [ Gnawincj/Fearful

J_ -/*litt* I Ten5=.r\Splitti.ng

42
Experiment 3 materials

Daily Rating Form NarnG Date

At the end of the day, before going to &d, please answer the following questions:

The following is a list of behaviors. Please

place a check mark on the line next to any

behavior you engaged in at least once today:

_ Took 2 or mo~ asprins

_ Took another over-the-axmter remedy

- Paid a bill

_ Took a prescription pain remedy

_ Read the newspaper

_ Used a heating pad

_ Ate chicken for lunch or dinner

_ Used a hot water bottle

_ Took a nap

_ Talked on the telephone

_ Used a crutch or other device to assist in walking

- Asked a member of the family to do something I ususally do myself

_ Used a postage stamp

_ Complained about my pain to another person

_ Wrote a letter

_ Avoided routine physical activities

Use the scale below and

circle a number that indicates

the usual level of pain you

experienced today.

9 excruciating, incapacitating

intense, severe pain

8

7

6

5

4

3

2

1

0 none, no pain

Daily Rating Form NaIw: Date

At the end of the &y, befme going to bed, please answer ihe following question:

1. USCthescale below and circl++a number that indicates the usual level of pain you ex@enced

loday

9 excruciating, incapacitating, intense, severe pain

8

7

6

5,

4

3

2

I

Onone, no pain

Daily Rating Form Name: Date:

At the end of the day, before going to bed, please answer the following question:

The following is a list of behaviors. Please place a check mark on the line next to any behavior you

engaged in at least once tcx!ay:

_ Took 2 or more aspnns

_ Took another over-the-counter remedy

- Paid a bill

_ Tmk a prescription pain remedy

- Read the newspaper

- Used a heating pad

_ Ate chicken for lunch or dinner

- Used a hot water bottle

_ Took a nap “

_ Talked on the telephone

_ Used a crutch or other device to assist in walking

_ Asked a member of the family to do something I ususally do myself

- Useda postage stamp

- Complained about my pain to another person

_ Wrote a letter

- Avoided routine physical activities

43
Think back to

numberfrom O

(a)Your

9

8

7

6

5

4

3

2

1

0

(b)Your

9

8

7

6

5

4

3

2

1

0

(c)Your

9

8

7

6

5

4

3

2

1

0,

the past fourweeks endingon . Pleasecirclea

to 9 Jx210wto irklicate:

usuallevelof pain duringthe last fourweeks.

excruciating,inq?acitating,intense,severepain

none,no pain

pati at itsworstduringthe last fourweeks.

excruciatirq,incapacitating,intense,severepain

none,no pain

pain at its leastduringthe last fourweeks.

excruciating,incapacitating,intense,severepain

none,no pain

Usingthe same O to 9 scaleon whichyou ratedyour

last fourweeks,estimatethe numberof daysduring

your pail-1:

Was evergreaterthan a 2:

Was evergreaterthan a 5:

Was evergreaterthan an 8:

pain every day duringthe

the last fourweekson which
On how many days during the last four weeks did you:

Tmk 2 or nmre aspirins

Took anotherover-the-counterpain remedy

Paid a bill

Took a prescriptionpain ray

Read the newspaper

Used a heatingpad

Ate chickenfor lunchor dinner

Used a hot waterbottle

Tcok a nap

Talkedon the telephone

Used a crutchor otherdeviceto assistin walking

Askeda memberof my familyto do somethingI usuallydo myself

Used a postagestamp

Complainedaboutmy pain to anotherperson

Wrotea letter

Avoidedroutinephysicalactivities

45
Experiment 4 materials

The WHYMPI

CENTER FOR PALN EVALUATION AND TREATMENT

UNIVERSITY OF PI’lTSBURGH

MULTLAXIAL ASSESSMENT OF PAIN

(AXIS II: PV)

Instructions. An important part of our evaluationincludes “examinationof pain from your

perspective because you know your pain better than anyone else. The information that

you provide willbe of great assistance in’ our evaluation and in helping us to plan a

treatment program for you.

Please read each question carefully and then do your best to answer each one, Do not

skip over any questions. If you believe that any question does not apply to you, rather

than not.answering it,please note that this question does not apply to you by circling

the number of that question. After you have completed the entire questionnaire,check

your responses to make sure that you have answered each question. Please use the last

page to add any additional information or comments that you believe would be of help to

us in better understanding you pain problem.

Section 1

1. Today’s Date: -———. . .. ——-—-—.-—- ———--———-

2. Name:------------------------------------------------------------------

Last First Initial

3, Address:------------------------------------------------------------------

No. Street

4, Work

5, Age:

----------------------------------------------------------------

City State Zip Code

phone:————————-——————————————-——— Home Phone:—————-—————————-————————

(area code) (number) (area code) (number)

(in years) —-——-—----—-----

6. Date of Birth:Month: Day: _____ year:_________

7. Sex (check one): ____ Male ____ Female

8. Ethnic Group (check one):

-— White ___ Black ___ Asian American ___ Latin American

___ Other, specify

9. Education (check one):

____ 9th grade or less ——_- 10th to 12th grade __ High school graduate

____ tillege (number of years: ) __ Graduate or professionaltraining

.10. Living situation(check allthat apply):

.

-——- Live alone ____ Live with spouse/significant other

___ Live with children _ Live with others, specify ——— —- —--- ————-—--—

46
11.

12.

13.

14.

15.

160

17.

18.

19.

20.

21,

. .

Current maritalstatus (check one):

Single - never married ____ Separated/Divorced - how long? yrs. ----

____ Married - how long? yrs. ___ Widowed - how long? _____yrs.

If married, how would you describe your current.maritalrelationship

(circlea number)?

o 1 23456

Very poor Very good

Yearly family income (check one):

---- Less than $10,000 From $20,000 to $35,000

___ From $10,000 to $20,000

-—-

___ Greater than $35,000

Current exnpIoyment status,including homemaker (check allthat apply):

----

----

——--

--—

Working full-time(over 30 hours per week)

Working part-time (lessthan 30 hours per week)

Unemployed and on socialsecurity disabilityor worker compensation

Unemployed and @ on disabilityor receiving compensation

Currently enrolled in a job retraining program

Retired

If you are unemployed, or employed part-time,is this due to your present

pain condition (check one)?

----- yes -—- NO

If you are unemployed, or employed part-time,have you tried to return to

full-time work within the past year (check one)? .

---- y- ____ NO

Compared to you; abilityto

can you (circlea number):

How

----

--—

01

No longer

work

work before your pain began (including homemaking),

23456

Work as much

as before

did your pain begin (check one)?

Accident at work ____ Accident at home _ Following surgery

Following an illness Pain just began

Other reason, specify———____ ---- ———-— —__________

When did you pain firststart? Month:——————___________ Year:-——--——

How often do YOU have pain (check one)?

---— Daily,or almost every day ____ Two or three times a week Once a week

—— Less than once a week but more than once a month __ Les;=han once a month

On a day when you have pain, how long does the pain usually last (check one)?

—-- O-1 hours --— 1-2 hours 2-4 hours 4-8 hours

____ 8-12 hours ____ More than i~ours

———-

47
22. Which of the following conditions makes your pain worse (check all that apply)?

____ Lying down ___ Standing ___ Bending/twisting ___ Sitting ___ Walking

--- Lifting ___ Reaching/Stretching ___ Other, specify____________________

23. How often do you stay in bed because of your pain (circlea number)?

o 1 2 3 456

Never Very often

24. How often do you take medicine other than aspirin or over-the-counter drugs

for pain relief(check one)?

--—- Never -—- Several times a week

___ Less than once a week __ Once a day

---- Once a week -—- Several times a day (how often?-------— )

25. What medicines are you ~ taking for pain

Pain Medication How often

--—--—-- —------. -—-——-— ————-———————--

- -------- —--- —-—------- ———-————-——---

-———--—-———————_——_—_———-————-——-—— -

and how often for each?

Pain Medication How often

-—-—---- ——-—---— —--____ —- —---—----

———--—------- ————- ———-—————----— --

OTHER Medications - please indicatefor what problem or illness

---------------------------------------------------------------------

——————————---- ———— ————————-————-—-— ————-——————-— ———-——-——--—— ———

26. Have you ever been operated on for this pain (check one)?

_ Never -—- Once ___ Twice __ Three times _ More than three times

Section 2

This part asks questions to help us learn more about your pain and how it affects your

life. Under each question is a scale to mark your answer. Read each question carefully

and then circlea number on the scale under that question to indicate how that specific

question applies to you. An example may help you to better understand how you should

answer these questions.

Example

How nervous are you when you ride in a car when the trafficis heavy?

0123456

Not at all Extremely

Nervous Nervous

If YOU are not,at all nervous when riding in a car in heavy traffic,you would want b

circlethe number O. If you are very nervous when riding in a car in heavy traffic,You

would then circlethe number 6. Lower numbers would be used for less nervousness, and

higher numbers for more nervousness.
1. Rate the levelof your pain at the present moment.

o 1 23 4 5 6

No pain Very intense pain

2. In general, how much does your pain interfere with your day-to-day activities?

o 123 4

No interference

3. Since the time your pain began, how

work?

(_ Check here, if you have retired

01234

No change

56

Extreme interference

much has your pain changed your abilityto

for reasons other than your pain).

56

Extreme change

4. How much has your pain changed the amount of satisfaction

taking part in socialand recreationalactivities?

01

No change

5. How supportive

pain?

o 1

Not at all

supportive

23456

Extreme change

or helpful is your spouse (significantother)

2 3 4 5 6

Extremely

supportive

or enjoyment you get from

to you in relationto your

6. Rate your overallmood during the past week.

7. How

No

01

Extremely

low

much has your

01

interference

2345.6

Extremely

high

pain interfered with your abilityto get enough sleep?

23456

Extreme interference

8. On the average, how severe has your pain been during the ——last week?

0123456

Not at all Extremely

severe severe

49
9. How able are you to predict when your pain willstart,

o 123456

Not at all Very able

able to predict to predict

10. How much has your pain changed your abilityto take

get better,or get worse?

part in recreationaland other

socialactivities?

o 12345

No change

11. How much do You limityour activitiesin

0“1 234 5

Not at all

6

Extreme change

order to keep your pain from getting worse?

6

Very much

12. How much has your pain changed the amount of satisfactionor enjoyment you get

from family-relatedactivities?

o 1 234 56

No change Extreme change

13. How worried is your spouse (significantother) about you because of your pain?

01

Not ‘atall

worried

14. During the ~

life?

01

No control

23456

Extremely

worried

week how much control do you feel that you have had over your

23456

Extreme control

15. On an average day, how much does your pain vary (increaseor decrease)?

o 123456

Remains Changes

the same a lot

16. How much suffering do you experience because of your pain?

0123456

No suffering Extreme suffering
.-—. . .-

17.

18.

19.

20.

21.

22*

23.

24.

How often are you able to so something that helps to reduce your pain-:

o 1 2 3 456

Never Very often

How much has your pain changed your relationshipwith your spouse, family,or

significantother?

01 23456

No change Extreme change

How much has your pain changed the amount of satisfactionor enjoyment you get

from work?

(--- Check here, if you are not presently

012345

No change

How attentiveis your spouse (significant

01 2 3 4 5

Not at all

attentive

working).

6

Extreme change

other) to you because of your pain?

6

Extremely

attentive

During the past week how much do you feel that you’ve been able to deal with your

problems?

01 23456

Not at all Extremely well

How much control do you feel that you have over your pain?

o 12 3 456

No control A great deal

at all of control

How much has your pain changed your abilityto do household

o 1

No change

During the p@

your life?

01

Not at all

successful

2 3 4 5 6

Extreme change

week, how successful were you in coping with

2 3 456

Extremely

successful

chores?

stressful situationsin

51
25. How much has your pain interfered with your abilityto plan activities?

o 12 3 4 56

No change Extreme change

26. During the past week how irritablehave You been?

o 1 2 3 4 56

Not at all Extremely

irritable irritable

27. How much has your pain changed or interferedyour friendships with people other

than your family?

o 1 2 3 4 56

No change Extreme change

28. During the past week how tense or anxious have you been?

o 123456

Not at all Extremely

tense or anxious tense and anxious

Section 3

In this section, we are interested in knowing how your spouse (or significantother)

responds to you when he or she knows that you are in pain. On the scale listed below

each question, circle a number to indicate how often your spouse (or significantother)

responds to you in that particularway when you are in pain. Please answer allof the 14

questions.

1. Ignores me.

012345

Never

2. Asks me what he/she can do to help.

o 12 3 4 5

Never

3. Reads to me.

o 123 4 5

Never

4. Gets irritatedwith me.

o 12345

Never

6

Very Often

6

Very Often

6

Very Often

6

Very Often

52
5. Takes over my jobs or duties,

o 12 3 4

Never

6. Talks to me about something else

o 1234

Never

7. Gets frustrated with me.

o 1234

Never

8. Tries to get me to rest.

o 1234

Never

5 6

Very Often

to take my mind off the pain.

5

5

5

9. Tries to involve me in some activity,

o 1234’5

Never

10. Gets

11. Gets

angry with me.

012345

Never

me pain medication.

o 1 2“ 3 45

Never

12. Encourages me to work on a hobby.

13. Gets

o 12345

Never

me something to eat or drink.

o 12345

Never

14. Turns on the T.V. to take my mind off

o 1234 5

Never

6

Very Often

6

Very Often

6

Very Often

6

Very Often

6

Very Often

6

Very Often

6

Very Often

6

Very Often

my pain.

6

Very Often

53
Section 4 - Am”s IIIa - Daily Behaw”or8

Listed below are 18 daily activities. Please indicate how often you do each of these by

circlinga number on the sale listedbelow each activity. Please complete all 18 questions.

1. Wash diehes.

o 12 34 5 6

Never Very Often

2. Mow the lawn (.-— Check here, if you do not have a lawn to mow).

0123

Never

3. Go out to eat.

0123

Never

4. Play cards or other games.

0123

Never

5. Co grocery shopping,

o 12 3

Never

45

45

4 .5

45

6

Very Often

6

Very Often

6

Very Often

6

Very Often

6. Work in the garden (__ Check here, if you do not have a garden).

0123456

Never Very Often

7. Go to a movie.

8. Visit

9. Help

0123456

Never Very Often

friends.

0123456

Never Very Often

with the house cleaning.

o 12 3 4 5 6

Never Very Often

10. Work on the car (__ Check here, if you do not have

01234 56

Never Very Often

a car).

54
11. Take a ride in a car or bus.

o 12 3 4 5 6

Never Very Often

12. Visitrelatives

(___ Check here, if You do not have relativeswithin 100 miles).

0123456

Never Very Often

13. Prepare a meal.

o 12 3456

Never Very Often

14. Wash the car (___ Check here, if you do not have a car).

o 12 3 4 5

Never

15. Take a trip.

o 12 3 “4 5

Never

16, Go to a park or beach.

012345

Never

17. Do the laundry.

o 12345

Never

18. Work on a needed household repair.

o 12 3 4 5

Never

19, Engage in sexual activities.

012345

Never

6

Very Often

6

Very Often

6

Very Often

6

Very Often

6

Very Often

6

Very Often

55
Pain Behavior Rating Form

Verbal Behaviors

1. Mentions having pain

2. Complains about pain

3. Gives lively descriptions of pain

4. Groans, moans, or sighs

5. Cries

6. Asks for help from others

o = Present

1 = Not Present

Ratinq

o 1

0 1

0 1

0 1

0 1

0 1

Grimaces and Rubbina

7. Grimaces

8. Rubs painful parts of body

~Sittin

9. Braces while sitting down into chair

10. Changes positions while sitting

11. Braces while rising after sitting

12. Stands in an unusual posture

Walkinq

13. Moves rigidly and stiffly

14. Walks with an abnormal gait

15. Walks guardedly and carefully

o

0

0

0

0

0

0

0

0

1

1

1

1

1

1

1

1

1

56
Experiment 5 materials

Haurlv Rin Diary C!arikand Instmcb “Ons

Instructions

our goal

this goal, he

14 ~,

is quite easy

tie ~.

is to 11’km-e fully Urda’stard the nature of your pain. Zb achieve

-d like yOU to keep an hourly record of y= ~. Attache3 are

me card for eati day during the next 2 weeks. The remrd-keepiq

arflstraightforward. It consists of rata yOW pain each hum on

On the card you will see, first, the hours of the day are

irdicatedon the top, goiq frm 6 a.m. to 5 a.m. This covers the ‘fll 24 hours

of one day. ~

‘Secoti, under eachhol.lrofthe dayam numbers fromoto9. These refer to

the severity of your pain:

9 Mkates excruciating, incapacitating, intense pain. !Ihe @,II is so

severe YOU can do ahmst no- else.

o represents no pain present.

We would like you to rate your pain each waking ham of the day. That is, at the

- of each ham, rate the amount of pain you are experiencing at that nmmak on

the 0t09 scale. If ycu forget to make a rat~ for a particular hcur, leave it

blank, donotgobackti~ti ~ pain frcm an hour when yOU forgot to

make your xatirq. Howw~, txy to remen&r torateyour paineveryhcmr on the

hour.

If your took a pain medication during that hcur, in addition to circling a

xat~ between O and 9, @ an ‘lX1lthrough the number. You should only rate your

pain for the hours durirg which ya are awake. Just leave blank tie houxs during

which you were asleep. Finally, besureto put your name @date on=ch of the

14 cuds. You shculd begin your ratings at 6:00 a.m. tomxmw, for the next 14

days. Please mail your pxtmrds to us (they are already pre-addresed ariipre-

-) after -let* them every day. Do not “save them up. ”

DailyPainDiary Name Date

AM PM AM

6 8 9 10 11 12 1 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5

999999999999 999999999999

888888888888 888888888888

77777777777 77777777777 77

666666666666 66666666666 6

5~ 5555555555 555555555555

444444444444 444444444:444

333333333333 333333333333

22222222222 22222222222 22

111111111111 illlllllllll

0000” 00000000 000000000000

Circle your level of pain each hour thal you are awake:

9indicatesexcruciating, incapacitating, intensepain.

Orqxesents no pain present.

Put an X through the times you take pain medication.

57
1. ThinMng back on the last 14 days,pleasecirclea nmiberbelcwto indicate:

(a)Your

9=

8

7

&

4

3

2

1

o=

(b)Your

9 =

9

6

5

4

3

2

1

(,)=

(c)Your

9=

8

7

6

5

(ii

2

1

0 =

usual level of pain

excruciating,incapacitat~, intense,severe

none,no pain

pain at its worst

excruciating,incapacitat~, intense,severe

none,no pain

pah at its least

excruciating,incapacitating,intmse, severe

none,

2. Think aboutthe

duringthe last two

whichyour pain:

no pain

O to 9 scaleon whichyou ratedyour pain on the postcaxd.s

weeks● Estimte the nmber of days duringthe last 14 on

Was ever greaterthan a 2: ~~

Was ever greaterthan a 5: ‘1

Was ever greaterthan an 8: .3
3. Ushg the same O to 9 pointscaleon whichyou ratedyour pain everyhour for

the past 14 days,pleasecirclea numberbelowto indicatethe severityof pin

that you are currentlyexperiencing.

9 = excruciating,incapacitatiq,intense,severe

8

7

6

+

2

1

0 = none,no pain

4. Some of the followingwozdsdescribeyour presentmin. Circlethe words

that best describeit. Use at m+ a singleword in

that appliesbest. Leaveout any

1 Flickering

2 Quiveriq

3 Fulsing

*:&%~

6 Pounding

4

5

..Pin.l_.r-KJ

F&F&sj

Gnawing

Cral-ping

Crushing

1 Dull

2 Sore

3 Hurtincj @j-&:~

5 Heavy

1 Fearful

2 Frightful

3 Terrifying

1 Spreading

,’2--timEij@

rlisiiisiititing

4 Piercing

1 Jumping

2 Flash@

p-sh~ig

1 Tugging

2.F&llil?g

<s_Wr&i%iEj>

1 Tender

2 Taut

3 Raspil’Kj

4 Splittimj

1 Fljnishing

2-Gruelli@

3 Cruel

4 Vicious

5 Killing

1 Tight

2 Numb

3 Drawing

4 squeezing

5 Tearing

word group that is

1 Pricking

2 Bor*

&ch word group, the one

not suitable.

al>=

2 cutting

3 Drilling 3 Lacerating

a:—s-mbl>

5 Lancfi-ting

1 Hot

2 Burning

3 Scalding

4 searing

LTir_~

2 Exhausting

1 Wretched

2 Blirdq

1 cool g-m@

3 Freezing

1 Tir@ing

2 Itchy

3 -inq

Q_xm@3iij

1 Sickeniny

2 suffocating

1 AnnoyilxJ

2 Troublesome

3 Miserable

f~~

5 Unbearable

( ~3@j’GJ)

2 Nauseating

3 Agonizing

4 Dreadful

5 Totiuring

59
Experiment 6 materials

Witive Affect Sub6cale of IE3

Please circle the number on each of the scales below to Mcate hw vou are

feeling right m.

not dlarated

not jqful

not sad

not downhearted

not delighted

not lonely

not happy

not ascOuraged “

not excited

not upset

not mergetic

not distressed

not warmhearted

not blissful

not self-reflective

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3

3

3

3

3

3

3

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

5

5

5

5

5

5

5

5

5

5

5

5

5

5

5

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

7

7

7

7

7

7

7

7

7

7

7

7

7

7

7

Vay exhilarated

very joyful

V~ sad

Vq downhearted

vay delighted

VW lonely

very happy

very discourageld

very excited

very upset

very energetic

very distressxa

very warmhEErrted

very blissful

very self-reflective

60
Present sensationsardl?ainalestl “or-main

Belm is a list of physiml trembles.Pleaseilxli=tewhim of theseym

havee.xperiemedduringthepastweelc,andalsowhichof theseyouhave

experiencedti the last24 h-. !Ihenratehm mu~ d3.scmfortr “ on average,

eachof thesesymptomshas causedyouduringtiepastweek.

Thenmkers of thediscomfortratimjsqzesent the followingphrases:

o =None I= Little 2=Som 3= Moderate 4= Severe

1. Nausea

2. Headache

3. Necksties-pains

4. Flashesof hot or cold

5. Aches/painsin arm/kcjs

6. Shakhess

7. Difficul@in sleep~

8. Backaches

9. stomch troubles

10. Nasal congestion

11.soreth?mat

12.Excessiveperspiration

13.Runnynose

14. Fwer

15.Feel- tixed

16.It&y or wa’&q eyes

17.MuscularWezhess

18.Dizzyspells

19.Difficultyin breathing

20.Slemim to acess

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

.

yes

yes

..< Ves .

no

no

no

no

no

no

no

no

no

no

no

no

no

no

no

no

no

no

m

no

past7davs

yes no

yes m

yes m

yes m

yes no

yes no

yes no

yes no

yes no

yes no

yes no

yes m

yes no

yes no

yes no

yes no

yes no

yes no

yes no

yes no

amount of disccmlfort

01234

01234

01’ 234

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234
21. Difficulty swallcwhg yes no

22. Muscular tension yes

23. Appetiti chamjes yes

24. Buwel trouble yes

25. Vcanithq yes

26. Chest @m yes

27. Recent bums or cuts yes

28. Strain@/sprain&i muscles yes

29. Cranq@ muscles yes

30. Injured (bruised) joint yes

31. soreness yes

32. Fcx)t~in yes

33. Dental ormuth pain yes

no

no

I-m

m

no

no

no

no

no

no

m

no

yes no

yes m

yes no

yes no

yes no

yes m

yes no

yes no

yes no

yes m

yes’ no

yes m

yes no

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234

01234

62
Mod InductionInstructions

General Instructions(written)

The firstpart of this experimentinvolvesan imaginationexercise. You will

receivespecificinstructionsabout this exerciseby listeningto a taped

messagein a few minutes. First,however,I would like to tell you what we are

tryingto accomplishin the imaginationprocedure. We are lookingat the

abilityto become involvedwith a past event, to

and to respondto it just as if it were real.

You will be listeningto a tape that asks you

from your past. As you rememberthis event, try

thoughtsand feelingsthat you had at the time.

feelinqsand react in the same ways. Right now,

createa picturein your mind

to remembera specificevent

to recreatein your mind the

Try to experiencethe same

you don’t have to do anything

but li~ten to the tape. It is ve~ importantthat you try to imaginethe past

event as vividlyas possible, re-live the experienceonce again, and then

respondas you might have at that time.

To a large extent,this imaginationtask is similarto techniquesused in a

schoolof drama calledmethod acting. Accordingto the method,actors try to

immersethemselvesin the charactersthey are playing to such a degree that they

are almost‘thesame people. That is what you shouldtry to do here. It is up

to you to immerseyourselfin the past event; feel the feelingsthat you once

felt. The situationmay be powerful. Relax and forget that the rest of the

world exists,and experienceonly-theworld that you createwhile listeningto

:he tape. .

We have found that people are better able to get into this imaginationtask

when they are left alone. There aren’totherpeople around to distractthem

from theirown thoughts,or to hurry them along. For this reason,I’m going to

leaveyou to finish the rest of the experimentat your own pace. I’ll turn the

tape on from anotherroom and it will shut itselfoff. I don’t want to

interferewith you in any way, so I will not be seeingyou again until you are

finishedwith the experiment. The tape will instructyou aboutwhat to do next.

When you are completelythroughwith the experiment,exit throughthe door

marked “EXITHERE,” and I will speakwith you brieflyand give you an experiment

creditcard. .

When you have finishedreadingthis,pleaseplace the headphonesover your

ears, and the tape will startwithin a few minutes. Remember, just relax and

try to recreatethe incidentin your mind as vividlyas possible. About five

minutesafter this tape ends, you will hear anothertapedmessage instructing

you to begin workingon the remainingtasks in this packet of papers.

PLEASEDO NOT TURN THIS PAGE UNTIL INSTRUCTEDTO DO SO BY THE EXPERIMENTER.

63
Imiucticn ImtnEtioml set

Sit back. close your eyes. Relax. Listentothescurd of my voice. Try

to do the US I am tellingyOU to do. I wmld lik for you to begin imagining

a situationwhi~ you thinkwuld make you feel [happy,sad,~1 ● IllBgine

~the sitition as vividlyas you can. Picturethe eventshaPl?=@J to You* ~

all We detailsof the situation. Picturein ymr %&x3’s eye!!the surmmmqs

as clearlyas possible. see the peopleor the cbjects;hear the somiis;

experieme the eventhappeningto ycu. Thinkthe thoughtsyou muld actually

think in this situation. Feel the same [happy,sad, neutral]feelingsycu would

feel. Let yourself reactas if ycur were actuallythere.
m- n-duction Mood cheek

Pleasecimle the nurberon each of the scalesbelowto indicatehow ym are

feelingrightnew.

not - 1

not exhilarated 1

not sad 1

not satisfied 1

not content 1

not disappointed 1

2

2

2

2

2

2

3

3

3

3

3

3

4

4

4

4

4

4

5

5

5

5

5

5

6

6

6

6

6

6

7 very W

7 very exhilarated

7 VW sad

7 very satisfied

7 vexy content

7 Vexy disappointed

65
llecallof~ Imident ClueskL “Ons

Think for a mommt about a recentexperiencethat involvedphysicalpain,an

=~ Wt YOU had sometime duringthe past year. linagimthat experieme

nomentand then answerthe followingqx2stions:

1. Ihasmteme ortm, describethis

a) What happened? What causedthe

b) Hw low did it last?

c) WkI did it hzqqxmto you?

2. Pl~ place an ‘IX!!on the followinglinesin orderto indicatewhat this

pain

(a)

very

pain

(b)

Vezy

pzckl

(c)

experiencewas like for you:

Rate the maximumlevelof pain you experimced:

little — excruciating

pain

Rate tie averageamountof @rI you fdt duringthis experience:

little -— excruciating

pin

HmJ mud did the pain interferewith your day to day activities?

no interference-—— -.— —- —extreme

interfermce

(d) How vividlycouldyou recallthis past painfulexperience?

not at all — — very vividly

vividly

3. Choosethe Lm word groupthat best describesthe pah you experienced.

Cmkhuous, steady,constant

Rhythmic,pe%dic, intermittmt

or

Brief,momentary,transient

66
4. The folld-ng words represent pain of increasingintmsity:

1

Mild

Choosethe

2 3 4 5

DiscomfortingD”~m Horrible Excruciating

nunberof the word that best describes:

The averagepain you -ienced duringthis episode

The worst

The least

‘lTieworst

The worst

The worst

painyou experiencedduringthis episode

pain you -i- durhg this episde

headadheyou everhad

stomatiacheyou everhad

toothacheym ever had

5. Some of the folluwhg wordsdescribethe pain you experience duringtie

episodeyou describedon the previcuspage. Cixclethe words that best describe

it. Use at mst a singleword in eachwoti group,

Leaveout any wozd groupthat is not suitable.

1 Flickering

2 Qlivering

3 R&ii-q

4 mrobbing

5 Beatilxj

6Rxndin9

1 Pkhing

2 Pressing

3 Gnawing

4 -ml

s~

1 mm

2 Sore

3 Hurtilxj

4 Aching

5 Heavy

1 Fearful

2 Rightful

3 Terrifying

1 spreading

2 Radiating

3 Rmetmtixxj

4 Piercing

1 Jump@ 1 Pricking

2 Flashiq 2 Boring

3 shooting 3 Drilling

4 Stakbing

the one that appliedbest.

lshaxp

2 Cutthg

3 Lacemting

5 Lancinating

1 ** 1 Hot 1 Tingling

2 Pulling 2* 2 Itchy

3Wre@mlg.

3 Scaldimj 3 Smartil’lg

4 searing 4 stinging

1 Telxkr 1 Tiring 1 Sickening

2 Taut 2 Exhausting 2 suffocating

3 R=Ping

4 Splitting

1 Punishing

2 Gmelliq

3 cruel

4 Vicious

5 Killilq

1 Tight

2 Numb

3 Dmwing

4 squeezing

5 Tearirq

1 weld-led

2 Blindimj

1 cool

2 Cbld

3 m?ezing

1 Annoying

2 TrouMesume

3“lbserable

4 Intense

5 Unbarable

1 Nagging

2 Nausea’t@

3 Mjonizir’q

4 Dreadful

5 lbrturing

67
Pain scenan“osard J

Now we wuld likeyou to -d severalstories. After readingeach story,

pl~ answerthe questionson the page follmd-ngit.

story 1:

Johnwaks q?onemrning and goestohis kitchentimaksme coffee. He

Imrnsthe electricbuxnerof his stmeon, 3xtthen realizesthat hehas lenthis

coffeeput to his next door neighbor. so instead,he goes to the refrigerator

cud takesout a mrton of orangejuioe. Whileholdiq the juioecartonin his

righthard,John accidentally places his left himiidirectly on W hot burner.

He pullshis haM away and dropstie cartonof juiceon the floor.
Questions forStory1:

1. Ratethe levelof painJohn experimces inm&iiately:

vexylittle excruciating

pain pain

2. Ratethe levelof painJ&n experiences after ten minutes:

veq little excnlciating

pain @

3. Saneof the follcwingwordsdescribethepin John experiences at the start

of thisepisode.Circlethewordsthatbestdescribeit. Use at mcst a single

word h each word group, the one that applies best. Leave out any word group

that is not suitable.

1 Flickering

2 Quivering

3 Pulsing

4 !mroMng

5 Beating

6 Pounding

1 Pinching

2 Pressing

3 Gnawing

4 --

s~

1 Dull

2 sore

3 Humiq

4 Aching

5 H=vy

1 Fearful

2 Frightful

3 Terrifying

1 spreading

2 Radiating

3 Penetmting

4 Pieming

1 Jun@ng 1 Pricking 1-

2 Flashimj 2 Ebring 2 cutting

3 Shootiq 3 Drilling 3 Iacemting

4 stabbing

5 Iancinating

1 W@9

2 Pulling

3Wen&ing

1 Tem3er

2 Taut

3 R=P*

4 Splitting

1 Punishing

2 Gruell~

3 cruel

4 Vicious

5 Killing

1 Tight

2 Numb

3 Drawing

4 we-w

5 ‘xEaring

1 Hot

2-

3 scalding

4 searing

1 Tiring

2 Exhausting

1 wretched

2 BliJ@@

1 cool

2 Cold

3 Freezing

1 Tiql@

2 Itchy

3 smarting

4 Stil-ging

1 Sickening

2 Suffmting

1 -*

2 Troublesome

3“Mu5erable

4 Intense

5 Unbearable

1 Naggiq

2 Nauseating

3 Agonizing

4 Dreadful

5 ‘Imturing

69
story 2:

After a long, hard day, John drives his car h-, parks it, W turnsoff

the motor. Unfortunately,Jchn is tind ard does not realizethat while slamiq

the frontdoor closed,his fingersam holdingon to We framearom3 the door.

The door slamsshut,axd all five of his fingersare caughtbetweenthe door and

the fram. He can~t pull them out. He must open the door to releasetiem.

story 3:

Stevegces on a six-hmr climbin the muntains with bran+= hikingboots.

The next morning,he noticeslarge,whiteblisterscoveringthe balls @ heels

of buth feet● They are brokenand peeling. He wears IfxklCsocksaxiitennis

dims to work.

story4:

While Steve is workingat his desk,a piece of paper floatsdum tuwardhis

feet. He pushes his &air back ZITX3reaches UIXIerthe desk to grab the paper. He

liftshishead upalittle too soon iudbangs itonthebottm of the desk

drawer.

Stozy5:

Bob flies hm from a trip, arxiwhile the plane mkes its fimal ~mach to

lax-ii,pressure builds in his ears. He tries to yawn, even starts chewing SCUE

g-m, buthecan’t seemto@cp’ hisears. The plane 1EUX5S,@ his ears still

haven’t qmppd~ .

Story6:

Whereridiq his bicycle dwn a hill, Bob hits a bump W falls off. He

slides a few feet dwn the hill on his shins and knees.
For =*

blankspaces:

R3inmriml Fast Year

of the follmhg experimces, pleaseiriii=tein the *rqriate

1. Whether or not it happenedto ycu in

2. Huw many days duringthe past twelve

guess)●

the past twelve mnths.

monthsyou experienced it (your best

3. ‘he

on

intensi~ of the pain typicallyassociatedwith the experi~

avexage:

no pain

mild pain

discomfortingpain

distressing pain

horriblepain

excmciatingpain

4. ‘Ihemaximum intensity the pain reached, on the same O-5 scale as in #3.

Ea2erience

1.

2.

3.

4.

5.

6.

7.

Headaches

Baokaches

Stoinachpains

Jointpains

Musclepains

Dentalpains

Fati for other

1. G&

(O to 365)

reasons

3. 4.

usual Pain Max.Pain

(o to 5) (o to 5)

~{ (J,=,, GOVERNMEW PRINTING OFFICE: 1922-3 1 2 -0 S 2 r 6 0 0 1 3
—-. ..——- .

Vital and Health Statistics

series descriptions

SERIES 1.

SERIES 2.

SERIES 3,

SERIES 4.

SERIES 5.

SERIES 6,

SERIES 10,

SERIES 1

SERIES 12.

SERIES 13.

Programa and Collection Procedures–These reports

describe the data collection programs of the National Center

for Health Statistics. They include descriptions of the

methods used to collect and process the data, definitions,

and other material necessary for understanding the data,

Data Evaluation and Methods Research –These reports

are studies of new statistical methods and include anal~lcal

techniques, objective evaluations of reliability of collected

data, and contributions to statistical theory. These studies

also include experimental tests of new survey methods and

comparisons of U.S. methodology with those of other

countries.

Analytical and Epidemioiogical Studies–These reports

present anal~ical or Interpretive studies based on wtal and

health statistics. These reperk carry the analyses further than

the expository types of reports in the other series,

Documents and Committee Reports–These are final

reports of major committees concerned with vital and health

statistics and documents such as recommended model vital

registration laws and revised birth and death certificates,

International Vital and Health Statistics Reports – These

reports are analfiical or descriptwe reports that compare US,

vital and health statistics with those of other countries or

present other international data of relevance to the health

statistics system of the United States,

Cognition and Survey Measurement–These reports are

from the National Laboratory for Collaborate Research in

Cogrwtion and Survey Measurement. They use methods of

cognitiva science to design, evaluate, and test survey

instruments,

Data From the National Health Interview Survey– These

reports contain statistics on illness; unintentional injuries;

disability; use of hospital, medical, and other health services;

and a wide range of special current health topics covering

many aspects of health behaviors, health status, and health

care utilization. They are based on data collected in a

continuing national household /ntewiew survey,

Data From the National Health Examination Survey, the

National Health and Nutrition Examination Surveys, and

the Hispanic Health and Nutrition Examination

Survey–Data from direct examination, testing, and

measurement on representative samples of the civilian

noninstitutlonalized population provide the basis for (1)

medically defined total prevalence of specific diseases or

conditions In the United States and the distributions of the

population with respect to physical, physiological, and

psychological characteristics, and (2) analyses of trends and

relationships among various measurements and between

survey periods.

Data From the Institutionalized Population

Surveys– Discontinued in 1975. Reports from these surveys

are included in Series 13,

Data From the National Health Care Survey– These

reports contain statistics on health resources and the Public’s

use of health care resources including ambulatory, hospital,

and long-term care services based on data collected directly

from health care providers and provider records,

SERIES 14.

SERIES 15.

SERIES 16,

SERIES 20,

SERIES 21.

SERIES 22.

SERIES 23.

SERIES 24,

Data on Health Resources: Manpower and

Facilities–Discontinued in 1990. Reports on the numbers,

geographic distribution, and characteristics of health

resources are now included in Series 13.

Data From Special Surveys–These reports contain

statistics on health and health-related topics collected in

special surveys that are not part of the continuing data

systems of the National Center for Health Statistics.

Compilations of Advance Data From Vital and Health

Statistics – Advance Data Reports @vide early release of

lnformatton from the National Center for Health Statistics’

health and demographic surveys, They are compiled in the

order in which they are published. Some of these releases

may be followed by deta!led reports in series 10–13,

Data on Mortality –These reports contain statistics on

mortality that are not included in regular, annual, or monthly

reports, Special analyses by cause of death, age, other

demographic variables, and geographic and trend analyses

are included,

Data on Natality, Marriage, and Divorce–These reports

contain statistics on natality, marriage, and divorce that are

not included in regular, annual, or monthly reports. Special

analyses by health and demographic variables and

geographic and trend analyses are included.

Data From the National Mortality and Nataiity

Surveys – Discontinued in 1975, Reports from these sample

surveys, based on vital records, are now published in series

200r 21,

Data From the National Survey of Family Growth –These

reports contain statistics on factors that affect birth rates,

Including contraception, infertility, cohabitation, marriage,

divorce, and remarriage; adoption; use of medical care for

family planning and infeflility; and related maternal and infant

health topics. These statistics are based on national surveys

of childbearing age,

Compilations of Data on Natality, Mortality, Marriage,

Divorce, and Induced Terminations of Pregnancy–These

include advance reports of births, deaths, marriages, and

divorces based on final data from the National Mtal Statistics

System that were published as supplements to the Month/y

Vita/ Statistics Reporf (M VSR). These reports provide

highlights and summaries of detailed data subsequently

published in Viral Statistics of the United Sta(es, Other

supplements to the MVSR published here provide selected

findings based on final data from the National Vital Statistics

System and may be followed by detailed reports in series 20

or 21.

For answers to questions about this report or for a list of reports published

in these series, contact:

Scientific and Technical Information Branch

National Center for Health Statistics

Centers for Disease Control

Public Health Sewice

6525 Belcrest Road, Room 1064

Hyattsville, MD 20782

(301 ) 436-8500
DEPARTMENT (3F

HEALTH &.HUMAN SERVICES

Public Health Service

Centers for Disease Control

fi!ationd Center for Health Statistics

6525 ~ 21Cf6St i?Q?d

Hyattwi[le, Marjrlartd 20782

CIFFICIAL EKJSlidESS

PENALTY FOR PRIVATE USE, $300

ISBN 0-16 -033072-3

II I~II

90000

9 780160380723

1

1

I

I

r

I

For sale by [IN U.S. Gowmmcnt Priming 01 Iiw I

Supmintendcnt of Docunmmh, hhil Stop: SSOP. Wu!lqmym. D(7 2(!-!! 12-IJ.32;; I

ISBN 0-16 -03 S072-3

DHHS Publication No. (PHS) 92-1081, Series 6, No. 6