The multifaceted nature of pain behavior

T he commentaries by Turk and Matyas, Merskey, and Craig on our focus article “Pain Behavior: Concepts and Controversies” raise a number of important issues. Each of these authors has made a major impact on the way pain behavior is conceptualized and measured, and we are delighted to have an opportunity to respond to their commentaries. In this article, we will address a number of points of agreement and disagreement. Turk and Matyas argue persuasively for the importance of functional analysis on pain behavior assessment. Their main point is that those conducting behavioral observations need to be more behavioral in their approach. Although this criticism is somewhat surprising (given that we are usually criticized for being too behavioral), we wholeheartedly agree. As we have noted elsewhere,3 research on pain behavior needs to move beyond the static analysis of behavior to emphasize the study of those variables controlling that behavior. As Turk and Matyas note, to date, research on functional analysis has tended to focus largely on the importance of social reinforcement in controlling pain behavior. We have previously identified other important research directions in the functional analysis of pain behavior.3 These include: (1) the development of ways to classify problematic pain behaviors based on the factors that control them; (2) the intensive analysis of sequences of antecedentspain behavior consequences; (3) sampling pain behavior in more naturalistic home or work settings; (4) observing pain behavior during the specific tasks the patient identifies as problematic, and; (5) expanding the scope of functional analysis to encompass both pain behaviors and well behaviors. Turk and Matyas maintain that current operational definitions of pain behavior focus on specific target behaviors at the expense of considering those variables that serve to control the behavior. There are several problems with this position. First, an operational definition of pain behavior is an important step in analyzing behavior. Once behavior is operationally defined it can be measured in a reliable fashion and also can serve as a target for a functional analysis designed to pinpoint the variables that control behavior. In a sense, an operational definition is a sine qua non in pain behavior assessment. Although one can criticize the way that pain behavior has been operationally defined, observational studies of pain behavior must specify which behaviors are to be recorded and what aspect of the behavior (e.g., its frequency, duration, intensity) is to be coded. Second, use of an operational definition of pain behavior does not mean that one ignores the variables that might explain or control that behavior. Researchers studying pain behavior, in fact, are not interested in simply cataloguing the frequency of a variety of pain behaviors. Rather, their focus tends to be on how the behaviors they have observed relate to a variables such as demographic (age, gender), medical (physical findings), and psychological variables (depression, coping skills) (e.g., reference 4). Third, there is a caveat in behavioral observation research that states that operational definitions should focus only on the observable characteristics of behavior.2 Asking observers to make judgments of the patient’s intent in engaging in pain behavior (to avoid pain, cope with pain, and obtain assistance or attention) is impractical and likely to lead to unreliable coding. Although From ‘the Duke University Medical Center and tDuke University, Durham, North Carolina.