UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Pain perception in chronic pain patients : a signal detection analysis Mahon, Mary L. 1991

You don't seem to have a PDF reader installed, try download the pdf

Item Metadata

Download

Media
[if-you-see-this-DO-NOT-CLICK]
UBC_1991_A1 M38_5.pdf [ 6.69MB ]
[if-you-see-this-DO-NOT-CLICK]
Metadata
JSON: 1.0100512.json
JSON-LD: 1.0100512+ld.json
RDF/XML (Pretty): 1.0100512.xml
RDF/JSON: 1.0100512+rdf.json
Turtle: 1.0100512+rdf-turtle.txt
N-Triples: 1.0100512+rdf-ntriples.txt
Original Record: 1.0100512 +original-record.json
Full Text
1.0100512.txt
Citation
1.0100512.ris

Full Text

PAIN  PERCEPTION A SIGNAL  IN CHRONIC P A I N P A T I E N T S : DETECTION ANALYSIS by  MARY  LEONA  MAHON  B . S c . , T h e U n i v e r s i t y o± A l b e r t a , 1982 M.A., T h e U n i v e r s i t y o t B r i t i s h C o l u m b i a , 1986 A THESIS THE  SUBMITTED  IN PARTIAL  REQUIREMENTS DOCTOR  THE  F U L F I L L M E N T OF  FOR THE DEGREE OF  OF P H I L O S O P H Y  FACULTY  OF GRADUATE  STUDIES  ( P s v c ho 1og y )  We  accept to  THE  this  thesis  the required  UNIVERSITY  Mary  conforming  standard  OF B R I T I S H  July @  as  COLUMBIA  1991  Leona  Mahon,  1991  In presenting this thesis in partial fulfilment of the  requirements for an advanced  degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department  or  by his  or  her  representatives.  It  is  understood  that  copying or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department The University of British Columbia Vancouver, Canada  DE-6 (2/88)  ABSTRACT The  purpose  supposition pain  (i.e.,  models).  Both  research  but  presentations incongruent  medically matched  report  atiective  The a  iactors  lesser  to  extent  compare  pain  theory  sensory  were  their  ot  pain  in  to  was  and  appraisal  ot  and  mav  tvpe what  be  met.  have  present  to  radiant  without  in the  addition,  presentation  under  t h i r t v  used  pain  the  c l i n i c a l  pain-tree  indicated  report  and  the  thirty  order  altered  study  subjective  cognitive  and  past  medicallv  responses  In  paintul  stimuli  ditterent  s e n s i t i v i t v  assessed  this  paintul  (i.e.,  paintul.  bv  models  without  methodologv  as  two  presentation)  subjects  to  to  unclear  Thereiore,  with  altered  led  variation  to  the  the  adaptation-level  these  and  that  supported  patients  with  have  respond  remained  ot  (thirty  incongruent  on  has  symptoms').  CPPs  ot  and  been  examine  (CPPs)  would  patients-with  correlates  results  i t  to  examined  CPPs  have  those  and  sensations  medically  patients  tor  evaluate  psychological  how  pain  control  detection  separately to  oi  incongruent  normal  were  predictions  sought  sixty  patients  methodological  studied,  vary  signs  ot  to  ot  ( i . e .,  investigation stimuli  as  predictions  the  to  pain  hypervigilance  responses  tound  Signal  the  disorder  The  i n v e s t i g a t i o n was  models  because  circumstances  been  Two  predictions  stimuli  pain  this  chronic  perception.  opposing  oi  that  ot  to  heat  a  age  and  sex  individuals). order  to  response cognitive  i d e n t i i v  bias and  potential  perception. that  the  presence  distinguished  d i s a b i l i t v atiective  and  to  d i s t r e s s  a  ot  regarding  their  responses  to  CPPs  classitied  were  diagnostic and  the  pain  paintul  groups,  response  thresholds  compared  classiiied  as  sensations  as  stimuli.  The  threshold  than  to  the  two  models  atiective  /  had  ot  pain  patients  characteristics components.  and  pain  'tunctionai in  pain  higher  control  subjects  Ditterences by  the than  sensory had  a  group  results  are  discussed sensory,  pain patients  threshold to  report  two  lower  this  discussed  The  1  sensitivitv  but  to  the  pain  ditterence in  methods  according  where  Patients  pain  slightly  thei  threshold  and  response' bias  control  on  in  in  anaivsis  signi±icant1v  perception. are  hoc  ditter  iound.  rather  The  post  not  were  normal  normal  the  a  did  ditterences  ' t u n c t i o n a i ' group  signiticant.  orthogonal  In  report  represented paintul  They  'organic'  'tunctionai'.  not  pain  to  'organic'  was  classitv  into  bias  as  primarilv  stimuli.  signiiicant  classitied  were  condition.  to  cognitive,  light  ot  used  to  their and  iv  TABLE  OF  CONTENTS Page  Abstract List  of  i i Tables  Acknowledgements  INTRODUCTION LITERATURE  vi viii  1  REVIEW  The H y p e r v i g i l a n c e M o d e l The A d a p t a t i o n - 1 e v e 1 M o d e l Signal Detection Theory R e s e a r c h on P a i n P e r c e p t i o n i n C h r o n i c P a i n P a t i e n t s S i g n a l D e t e c t i o n Theory Studies Other I n v e s t i g a t i o n s A n a l y s i s o t R e s e a r c h on P a i n P e r c e p t i o n i n ChronicPainPatients Type ot P a i n S t i m u l u s Used D i t t e r e n c e s i n Type ot P a i n D i s o r d e r S t u d i e d C 1 a s s i t i c a t i o n ot Pain P a t i e n t s Medical Incongruity C1assitication Summary a n d P u r p o s e o t t h e P r e s e n t S t u d y Hypotheses and D e s i g n  6 8 IU 18 18 21 23 23 25 28 32 37 39  METHOD Subjects Group Assignment Eq u i pmen t Stimuli Procedure S i g n a l D e t e c t i o n Theory Measures ot D i s c r i m i n a b i 1 i t y and Response B i a s M e a s u r e s ot Impairment and D i s a b i l i t y Selt-Report Measures Statistical Analysis  42 46 49 49 51 53 55 57 60  RESULTS A n a l y s i s ot Demographic V a r i a b l e s A n a l y s i s ot P a t i e n t C h a r a c t e r i s t i c s A n a l y s i s o i Dependent Measures Group D i t t e r e n c e s : Pain Measures R e l a t i o n s h i p s Among t h e P a i n M e a s u r e s Group D i t t e r e n c e s : C o g n i t i v e Measures R e l a t i o n s h i p s Among t h e C o g n i t i v e M e a s u r e s Group D i f f e r e n c e s : A f f e c t i v e Measures R e l a t i o n s h i p s Among t h e A f f e c t i v e M e a s u r e s  63 64 68 68 73 75 78 79 80  V  Additional C o r r e l a t i o n a l Analyses 8i R e l a t i o n s h i p s Among t h e D e p e n d e n t M e a s u r e s 81 R e l a t i o n s h i p s Among t h e D e p e n d e n t M e a s u r e s a n d M e a s u r e s o f S e v e r i t y a n d Symptoms P r e s e n t a t i o n 83 P o s t Hoc A n a l y s e s 86 Group D i f f e r e n c e s : P a i n Measures 90 Group D i f f e r e n c e s : C o g n i t i v e Measures 92 Group D i f f e r e n c e s : A f f e c t i v e Measures 92 G r o u p D i f f e r e n c e s : M e d i c a l l y I n c o n g r u e n t S y m p t o m s 92 Summary o f F i n d i n g s 96 DISCUSSION Pain Perception i n Chronic Pain Patients M e d i c a l l y I n c o n g r u e n t Symptom P r e s e n t a t i o n , Disability, and D i s t r e s s The R o l e of C o g n i t i o n and A n x i e t y i n t h e Experience of Pain Gender D i f f e r e n c e s i n the E x p e r i e n c e of Pain Summary a n d C o n c l u s i o n s REFERENCES APPENDICES Appendix Appendix Appendix Append i x Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix  100 108 115 116 119 12 4  A . Nonorganic P h y s i c a l Signs Criteria B . The P a i n D r a w i n g and S c o r i n g c. I n a p p r o p r i a t e Symptom I n v e n t o r y D . C o n s e n t Form f o r P i l o t Study Subjects Subjects E - C o n s e n t Form f o r C h r o n i c P a i n F . I n s t r u c t i o n s f o r P a i n P e r c e p t i o n Task. G. D a t a S h e e t f o r S i g n a l D e t e c t i o n T a s k H . D e b r i e f i n g of P a r t i c i p a n t s I . C o n s e n t Form f o r C o n t r o l Subjects Index J . P h y s i c a l Impairment K . O s w e s t r y Low B a c k P a i n Disability Questionnaire L . G r a c e l y R a t i n g S c a l e s and S c o r i n g Questionnaire M. C o p i n g S t r a t e g y Scale N . Pain Experience 0. Trait Anxiety Inventory  135 136 1 38 139 140 142 144 145 1 46 148 149 15 1 153 156 159  vi  LIST  OF  TABLES Papc  Table  1 .  Decisional  Matrix  Table  2.  Percentage  ot M e d i c a t i o n  Table  3.  Percentage Breakdown Patient Samole  Table  Table  Table  Table  Table  Table  Table  Table  Table  Table  4.  5.  6.  7.  8.  9.  t o r Binary  R e l a t i o n s h i p s Among Pain  1 2  U s e by P a t i e n t G r o u p  ot D i a g n o s e s  in  45  the 45  Measures  ot  Incongruent 47  Percentage Occurrence the Incongruent Group Percentage Criteria  SDT T a a I'.  ot C r i t e r i a  Within 48  ot P a t i e n t s Meeting  Incongruent 49  Means and S t a n d a r d Demographic Data  Deviations:  Continuous 63  Percentage Breakdown Demographic Data  ot C a t e g o r i c a l 64  Patient Characteristics: Analvses  Means  and U n i v a r i a t e 66  1 0 . C o r r e l a t i o n s Among M e a s u r e s o t P h v s i c a l L i m i t a t i o n and I n c o n g r u e n t Signs  67  1 1 . Means and S t a n d a r d Measure s  68  Deviations  1 2 . MANOVA Summary T a b l e Pain P a t i e n t s Pooled  t o r Pain  13. U n i v a r i a t e A n a l y s e s : Pain P a t i e n t s Pooled  Pain  t o r Pain  Measures  with 70  Measures  with 7 1  14. MANOVA Summary T a b l e t o r P a i n M e a s u r e s with Pain Patients Separated into Medically C o n g r u e n t and Incongruent Groups  72  Table  15. U n i v a r i a t e  Table  16. C o r r e l a t i o n  Table  17. Means a n d S t a n d a r d Me a s u r e s  Table  Analvses:  Pain  Measures  73  Matrix:  Pain  Measures  75  Deviatioins tor Cognitive 76  1  Table  1 8 . MANOVA  Summarv  Table  torCognitive  Measures  76  vii  Table  19. U n i v a r i a t e  Analyses:  Table  2U . C o r r e l a t i o n  Table  21. Means and Me a s u r e s  Matrix:  Standard  Cognitive Cognitive Deviations:  Measures Measures  80  22. C o r r e l a t i o n  Table  23. R e l a t i o n s h i p s Between P a i n M e a s u r e s C o g n i t i v e and A t t e c t i v e Measures  Table  Table  Table  Table  Table  78  Attective  Table  Table  77  Matrix:  •Attective  Measures  80  and 82  2 4 . C o r r e l a t i o n s Among M e a s u r e s o t S e v e r i t v a n d Svmotom P r e s e n t a t i o n a n d D e n e n d e n t M e a s u r e s  85  25. P a t i e n t C h a r a c t e r i s t i c s : Deviations  88  Means  and  26. P a i n M e a s u r e s : Me a n s a n d U n i v a r i a t e bv D i a g n o s t i c Group  Standard  Analvses  27. C o g n i t i v e M e a s u r e s : Means a n d A n a l v s e s bv D i a g n o s t i c Groups  Univariate  28. A t t e c t i v e M e a s u r e s : Means a n d A n a l v s e s bv D i a g n o s t i c Groups  Univariate  89  91  29. Measures ot M e d i c a l l v I n c o n g r u e n t Symptoms: M e a n s a n d U n i v a r i a t e A n a l y s e s by D i a g n o s t i c Groups  93  94  V i i  ACKNOWLEDGEMENTS I ior  would  like  h i s advise  writing members.  oi this  to thank  and s u p p o r t project.  Dr. Stanley  invaluable  methodology,  my  i n the design,  particularlv  a p p r e c i a t i o n to Peter  encouragement.  completion,  Finally, Kemp  Craig and  the committee Linden  were o i  i n the design, Heather  was o i t r e m e n d o u s  and a n a l y s i s .  Dr. Kenneth  and Dr. W o l i g a n g  and a n a l y s i s o i d a t a .  Hadiistavro1opolous collection  supervisor.  Additionally,  Coren  assistance,  my  assistance  I would  like  t o r h i s support  i n the data to  and  express  1  INTRODUCTION  It altered major  has  been  in  chronic  tactors  argued oain  ot  the  1976).  opposing  the  perception  patients  responsible  maintenance Two  that  tor  chronic  and  the  pain  characterize  the  response  ot  chronic  sutterers  the  perspectives  been  pain  patients  model will  because  they  tend  paintul  sensations  adaptation-level will  be  the  less  will  be to  tocus  model  ot to  most  thev  or  iudged  to  be  less  in  the  stimulation.  "hvpervigilance"  perception.  to  and  The chronic  paintul  stimuli  a l l ot  their  attention  1986).  In  chronic  stimuli  been  been  p r e d i c t i o n that  that  paintul  the  Sternbach, have  paintul  pain  1978;  have  1978;  changes  the  the  oredicts to  to  responsive  ("Chapman,  oain  be  led  more  responsive  constant  stimuli  has  ot  called  " a d a p t a t i o n - l e v e l " models  hvpervigilance  to  have  nature  ot  and  perspectives  to  is  i s one  development  proposed  These  oain  this  (Chapman,  theoretical  pain  that  ot  contrast, pain  significant  the  patients  because,  experiencing,  on  relative  additional  (Rollman,  1979) . Despite tindings groups pain  can  of  the be  tound  patients  conditions.  which  physical  with  higher  pain  threshold  who  apparent  do  not  ot  presenting  tolerance pain.  have levels This  tvpes with  which  been'tound in  research  predictions,  ditterent  is unclear-and  anxiety  chronic  both  trom  patients  pathology  and  support  suttering Pain  levels  have  to  contradiction, various  has  ot  with  chronic  disorders  are to  comparison  tinding  but  in  associated have to  been  lower people  interpreted  as  evidence  hvpervigilance 198U;  Malow  model  position  patients  who  whom  al.,  These  pain  evidence  and  ot  categories:  tactors  reter  as  been  Yang  ot  ot a v o i d i n g  pain, and  i t  pain and t o r  pain  to have  people  without  interpreted model  as  (Naliborl  e t a l . , 1983; sets  ot  higher  a  ot  t i n dings-  should  be  and  the perception  talse  sense  noted  physiological  et  1983;  pathophysiological  ot  Medical  criticized  oi clear  tor classitying  and  thought  because  (Dorland's  than  determinants  "organic"  to d i s o r d e r s  causes,  disorders  their  tound  different  or absence  into  phvsical  has  chronic  ot duality-  that  tactors  ot  both  depend  the uoon  substrates.  the basis  been  The  tactors  provided  conditions  levels  to the r o l e s  presence  two  been  ot  et a l . ,  The  pathology  the a d a p t a t i o n - l e v e l  psychological  The  with  organic  have  ot t h e  1987; Maluw  et a l . , 1987).  teature  e t a l . , 1983;  the experience  biological  clear  salient  In the i n t e r e s t  dominant  & Schmidt,  supported  the t i n d i n g  attention  the p r e d i c t i o n s  Scudds  tolerance  supporting  psychological  in  with  et a l . , 1987).  attract  pain.  been  patients  and  1981; Cohen  Lipman  has  i s not a  threshold  chronic  1981;  present  anxiety  condition. pain  (Brands  & Olson,  opposing  supporting  as  ch r o n i c  pain  condi tions  ot  has  patients Organic  a t t r i b u t a b l e to  p r i m a r i l y cau sed  absence  pathology  "tunctionai".  primari ly  tunctionai  t o be an  and  organic  reter  bv  an a p p a r e n t This  Dictionary,  1989).  excessivelv  simpii stic  to  psvcho 1ogica 1 physical  cause  distinction  with  th e  has  acceptance Tunks, al.  ot  1984;  1980;  Turk,  1984;  considered  to  involving phvsical  multidimensional Meichenbaum,  Waddeli be  a  to  produce  In  the  the  past,  and  with  attective  organic  present  anv  in  both  physical  chronic  pathology  or  not),  differentiate  patients  psvchological  dystunction.  to  phvsical  etc.)  pain  and  who  as  i t  (Ranstord,  Cairns,  &  Mooney,  Waddeli  a l . , 1980;  1984).  basis  Craig  whether  exhibited  "medicallv  incongruent"  with  known  phvsiologv  using  evidence  of  cognitions,  established  Waddeli  et  a l . , 1980;  anxiety  and  is  ot  less  likelv  detailed  to  their &  disorder  Craig,  svmptoms  1988;  on  that  1984).  higher  They  the were  anatomy  procedures  strategies,  levels,  is  to  evidence  underlying  diagnostic  i n e f f e c t i v e coping high  there  made  are  i t  factors  ditterentiated patients  thev  a l . , 197b;  or  (1988)  an  because  been  Reesor  not  et  ot  &  be  surgerv,  more  relates  197b;  were  (whether  have  (i.e., a  to  1982).  to  psychological  patients  require  assessment  there  positive  treatments may  it  &  thought  condition  These  addition  Wall,  and  provide  now  interacting  However,  attempts  et  constantly  based'  pathology.  &  always  in  were  are  Reesor  components  conditions  that  et  phenomenon  a l l components  'psychologically  Waddeli  is  pain  recognized  psvchological  Pain  chronic  now  medication,  1984).  1983;  (Melzack  clear  to  Genest,  (Bellissimo  experience  absence  respond  pain  pain  or  phvsical  Main,  ot  final  functional ot  &  &  multidimensional  cognitive factors  models  or  (Ranstord found  catastrophic sensory  intensity  ratings  ot  a paintul  stimulus  in patients  medicallv  incongruent  symptoms  relative  to p a t i e n t s  not  exhibit  suggestive ditter  medically ot  t h e wavs  i n their  cognitions,  factors  that  Studies  or  that  and  (Malow 1981;  ot  have  pain  response  bias  support  have  generallv  ditterent wide The  medicallv  & Olson, Yang  ot  not c l e a r .  ranges purpose  ot  stimuli  this  incongruent  control  group.  Detection  svmptoms Signal  pain  Theory  evaluate  two  sensitivity  sensations  ot  painful  1981; N a l i b o t t  et a l . ,  Because  i n these  on  pain  ot  was  studies, and  which  model  and  those  model  patients, formats  ot  SDT,  trials.  to examine  patients  i n comparison Detection  ot  sensitivity  pain  stimulus  pain  to  as  ditterent  research  i n chronic  ot  the a d a p t a t i o n - l e v e l  stimuli,  i n t h e number  a r e met.  Investigations  types  pain  ot the  models  the h y p e r v i g i l a n c e  ditterent pain  two  employed pain  may  important  et a l . , 1985).  t h e p r e d i c t i o n ot used  be  the sensory  to report  tinding is  patients  models  Signal  who d i d  strategies,  may  to s e p a r a t e l y  chronic  is still  tvpes  painful  normal  ot  the p r e d i c t i o n ot  which  to  Malow  these  used  i n the procedures  the e t t e c t  and  bias  e t a l . , 1983;  however,  support  examined have  pain  Coping  levels  This  the p r e d i c t i o n s  perception,  e t a l . , 198U;  variations  anxiety  i n order  the response  Cohen  chronic  to pain.  whether  i n the past  components  symptoms.  the adaptation-1eve1  methodology  pain  and  determine  hypervigilance  (SDT)  i n which  response  related  perception  incongruent  with  with  responses and  to a  Theory  was  without  matched used  to  5 separately response  evaluate  bias  groups.  components  In a d d i t i o n ,  painful  stimuli  examined.  some  the sensory of pain  intended  sensitivity  reports  relationships  and c o g n i t i v e  I t was  elucidate of  both  between  and a f f e c t i v e  that  this  which  and a d a p t a t i o n - 1 e v e 1  these  three  responses  to  variables  research  of the c o n d i t i o n s under  the hypervigi1ance  among  and t h e  should the  were help  to  predictions  models  would  be  satisfied. The  review  description models  be  on  pain  from  classification be  by a  reviewed  separately  discussed.  literature  the hypervigi1ance  followed  Research then  of  of the r e l e v a n t  brief  summary  perception with  SDT  and  o f SDT  investigations.  of pain  patients with  with  methodology.  pain  presented  other  begin  adaptation-1eve1  in chronic  studies  will  patients and  Finally, nonorganic  will  critiqued the signs  will  a  6 LITERATURE The  Hvpervigilance . The  pain  discussion  of  some  signs  a  threshold  or  and  that  have  characterized movement,  e n v iro nm e n t , 1976;  Sternbach,  and  Melzack  the  physical  states  &  render  individual addition, and  and  to  limitations  continue  weakened  and  leaving  a f f l i c t i o n  (Fordyce,  Sternbach,  1976).  basic  with  social the  Anxiety  to  habit  their  to  proposed  a  pain  of  this  have  somatic  lower  to  also  evervday  having  their (Fordyce,  Bonica,  to  5> W a l l ,  1977;  recognized  with  that  painful  f o r the  a c t i v i t i e s .  alone  the  &  been  relationships  to  patients  preoccupation  (or impossible)  about  a b i l i t y  as  f o r  (1986)  pain  authors  associated  Melzack  account  Chapman  Chronic  Chapman,  It has  to  unique  attention  sufferer  1976;  proposed  perceptual  level,  numerous  often  i t d i f f i c u l t  family  a  been  Pilowsky,  1982).  a  i n the  levels.  decreased  1976;  Chapman  predicted  (pp. 160-161). by  chronic  vigilance  consequence  demonstrates  increased  Wall,  a  i n  (1978;1986)  attention  are  have  "often  attention"  restricted  develop  As  patients  At  Chapman's  their  tolerance  perception  condition.  d i s t r e s s .  shift.  pain  perceptual  patients  captivate been  of  pain  explanations  pain  of  from  a l lo f  these  attentional  reports  pain  somatic  Numerous this  chronic  most  hvpervigilance, pain  developed  chronic  of  model  the influence  of  d i r e c t i n g  and  has  of  development that  Model  hvpervigilance  patients  REVIEW  In  are often focus  on  1982;  and  significance  strained his/her  of the  7 pain  (i.e.,  whether  threatening attention  event)  attention  theories found  behavioural  because  (Fordyce,  focus of  provided  suffering.  experiences sets.  result These  malignant  condition  hypervigilant) The  research implies  disorders  overexaggerated reason  the  and  reported  painful  when  diminished  attention  when  Miller  on  Pain  subjects  that  that  past schemas  he/she  to search  has a ( o r be  in  with  recent  et a l . , 1987). patients  unrealistic. i t has been  sensations  are distracted  i s highly of the  found  the  that  results  in  ( S c h i f f , 1980;  are perceived  toward  This  Regardless  sensation  the s e n s a t i o n  e t a l . , 1979; A h l e s  reports  associated  these  is directed  habit  cues.  a particular of  the  attention)  of c o g n i t i v e  been  by  that  and  purports  and h y p o c h o n d r i a s i s  enhancement  et a l . , 1982).  suggests  the b e l i e f  has  the  (Pennebaker,  the p a t i e n t  somatic  model  of  include  the i n d i v i d u a l  perhaps,  of a t t e n t i o n  reported  Levine  1979;  involve  f o r the hypervigi1ance,  focussing  when  e t a l . , 1987; S c u d d s  the pain  focus  sympathy  i n the development  lead  attracting  as a p e r c e p t u a l  theory  for confirming  (Lipman that  (e.g.,  Cognitive  hypervigi1ance  somatization  theory  develops  others  and  as  the cognitive  Behavioural  schemas  life-style  suggested  patients  1976) and  significant  or  1986).  pain  of a t t e n t i o n  life  the i n t e r n a l  the reinforcement  by  his/her  (Chapman,  i n chronic  a  been  regarding  perspectives.  internal  or  has a l s o  to the pain  Other  1982)  i t indicates  them  as more  and a r e  (Leventhal  et a l . ,  e t a l . , 1983; M c C a u l  &  Malott,  1984).  techniques  involve  Meichenbaum, that  Many  of the c o g n i t i v e oain  some  & Genest,  of d i s t r a c t i o n  1983).  h v p e r v i g i l a n c e enhances  not  just  The  Adaptation-Level  the tendency  (1964)  to account  particular stimuli  change.  observer (e.g.,  makes  size,  personal  sensory  theory  was  vary  as  judgement  color,  a neutral relative  'more'  or  about  loudness,  adaptation-1eve1 internal  and e x t e r n a l  divided  these  focal,  background, i s currently those  stimulus  within  stimulus  intensities  include  factors  factors factors  being  that  being  into  that  a r e not under  stimuli  The  of  the  classes  observer. of  stimuli:  experimental  i s that stimuli  focal  (e.g.,  residual  are  are  stimulus  f o r the  that  a l l  background  situation  encountered).  intensity  The  The  an  decision.  judged).  the context  the experimental  the  they  focal  when  stimulus  (i.e.,  three The  of a  A l lother  surround  of a  establishes a  the combination that  that  t o base  point  evaluated.  provide  he/she  Helson  background  quality  response.  by  or  by  contends  which  and r e s i d u a l .  comprise  and  painful.  perceptions  to the stimulus  of the q u a l i t y  Helson  which  etc.),  reference  i s formed  that  some  upon  o r medium  to this  'less*  as  proposed  the theory  (subjective) scale  judged  first  the context  "adaptation-level" refers  elicits  sensations  to pain  Model  Basically, a  therefore,  sensitivity  f o r the observation  stimulus  (Turk,  It i s possible,  to report  Adaptation-1eve1  The  form  reduction  range  of  stimuli control, for  example,  past  states.  Thus,  relative  t o some  reflects  the observer's  factors  experience,  biological  and  perceptual  judgements  are proposed  facing  reference  by  pain  were  pain  levels.  external level  Rollman  based  exposure  He  to internal that  thresholds  and would  prediction The  to  chronic  their  pain  problem  appear Signal  different  pain  be  which of  patients  less  likely  by  pain  patients' there  patients  as  their  Theory  circumstances,  be  briefly  Before presented.  this  research  have  diversity of  well-being.  i n past  different  model.  and n a t u r e  Both  research  (SDT) methodology,  and w i t h  as  or  i s considerable  support  pain  opposite  models  as a g e n e r a l  to the o r i g i n  higher  sensations  i s the  psychological  Detection  will  have  to report  persistent l e d to the  the h y p e r v i g i l a n c e  however,  and  reasoning  This  judge  adaptation  of t h e i r  would  of  experienced  patients  and a d a p t a t i o n - l e v e l  received  populations.  pain  This  pain  judgements  to a higher  individuals.  to  previously  pain  t o have  pain  that  chronic  relative  proposed  'chronic group;  that  found  with  discomfort.  pain-free  among  level)  t o t h e gamut  extended  i n d i v i d u a l s because  chronic  to that  homogeneous  using  who  hypervigilance  referred  models  (1979)  stimuli  pain-free  than  has been  proposed  prediction  painful  adjustment  theory  on c o m p a r i s o n s  noxious  than  personal  (or adaptation  t o be  him/her.  Adaptation-1eve1 perception  point  psychological  types  but of  i s reviewed,  under chronic SDT  to  Signal  Detection  Signal perceptual influence report  of  sensory  events.  observer's  of  provides  The  factors.  are  evaluated  by  The  nonsensory  an  factors  attitude,  affect  observer  to give  measured  by a n  perceptual  depend  sensory  are reflected  judged  stimulus  stimulus  upon  factors  They  influence  expectancy, by  both include  and t h e  by t h e  or a c c u r a t e l y  intensities  and  judgements  motivation.  the tendency  response,  called  perceptual  l e a r n i n g , and  altering  a certain  index  the  of d i s c r i m i n a t i o n a b i l i t y ( d ' ) .  that  judgements  that  i s being  a  measuring  that  that  different  index  evaluates  contends  The  in detecting  between  of  the w i l l i n g n e s s to  decisions  of the o b s e r v e r .  discriminating  and  theory  the stimulus  accuracy  a method  separately  sensitivity  and n o n s e n s o r y  sensitivity  These  that  are s t a t i s t i c a l  intensity  include  (SDT)  Theory  judgements  judgements  the  Detection  sensory  sensory  Theory  a  tendency  the response  bias  f o r the that i s  or  criterion  (beta). Signal general et  mathematical  a l . , 1961).  decisions and  was  in  radar  since  The  a r e made  originally operations  become  measurement way  Detection  Theory theory  theory when  of  to examine  of  people  statistical a way  are faced  tool  (Swets  from  decisions  with  signal  a  (Swets how  ambiguous  data  detection  et a l . , 1961).  i n the  I t has  psychophysical  judgements  the c o n t r i b u t i o n of  derived  of e v a l u a t i n g  for evaluating  i n 1955  perceptual  originally  provides  adapted  a valuable  was  because  sensory  i t provides  sensitivity  a  and  11 decisional The  biases  theory  signals  (Swets  is  based  to  be  detected  background  of  sensory  distribution addition  of  greater,  but  of a  graphically  et  the  a l . , 1961).  upon  are  the  presented  'noise .  It  1  noise  signal  on  is  the  overlapping, presented  in  assumption  a  against  Figure  curve  produces  overall  a  i s assumed  normal  noise  that  sensory  fluctuating that  and a  the  the  that  the  normal  curve  of  activity.  This  is  1.  P a i n Report  Criterion  Sensory Continuum Figure  1.  Theoretical distributions responses  The  observer's  sensory  simply,  task  activity  superimposed the  on  is  a  is  signal  detection  to  decide  whether  background  an  noise  to  adopt  specified  level  of  sensation)  and  that  absence  of  a  i s due level  level  signal,  is  a  to of  itself.  ambiguous  having  below  an  a  experienced  background  distributions observer  in  of  zone  observer's task.  the  the  level  signal  sensory The  which  judged  to  respectively.  activity  overlap results  decision criterion whereby  sensory  indicate  of  the  in in  (i.e.,  or  the  to two  the a  activity presence  above or  1 2  Because possible or  t h e two d i s t r i b u t i o n s  outcomes  a correct  below  ot t h e d e c i s i o n :  rejection.  (see Table  overlap,  These  there  a h i t , miss,  are presented  are tour  talse  i n the  alarm, grid  1). Response "Yes" Signal Present  "No" S i g n a l Absent  Signal  +  MISS  HIT  Noise  Noise Alone  Table The  1.  level two  Decisional Matrix  proportion  degree  ot h i t s  ot o v e r l a p adopted  by  to talse  will  i s specified  evaluate  the observer's  signal.  A sensitive to t a l s e  represented  et  will  and h e l d  and t h e  Sensory  have  and i s q u a n t i f i e d  When  ot t h e  ot t h e the  a  to detect  larger  sensitivity  between  criterion  signal  i t i s p o s s i b l e to  sensitivity  will  upon t h e  ot o v e r l a p  the strength  constant,  sensory  observer  alarms.  by  depend  ot t h e o b s e r v e r .  by t h e d i s t a n c e  distributions  Task  The d e g r e e  be a f f e c t e d  and the s e n s i t i v i t y  hits  SDT  alarms  the observer.  strength  ot  tor Binary  o t t h e two d i s t r i b u t i o n s  distributions  signal  CORRECT REJECTION  FALSE  ALARM  the  proportion  i s graphically  t h e means  o t t h e two  i n the parameter,  d'  (Swets  will  also  a l . , 1961). The  attect  criterion  level  the p r o p o r t i o n  conservative  level  adopted  ot h i t s  by  the observer  to talse  i s employed,  alarms.  the observer  I*f a  tries  to  very  minimize the be  the talse  number  oi hits.  adopted  this  will  expectations presented, certain versus  and  the b e n e t i t bias)  parameter, This  ot  +  The  index to  the cost  can a l s o  the normally  as  two  observer's The  same  sensory  held  constant.  made  by  stimuli  on  decision. rating  The  ditterent being  in giving talse  The  a  alarm  criterion  (or  by t h e  task. ot  instead  presence  ot  noise  cautions  will  binary  retlect  with  a  judge ot  signal;  the their  t h e use ot  tewer  t h e number  are  decision  ot  out that  data  ot  ability  intensities  can a l s o  that  type  was  sensitivity  or absence  pointed  reliable  signal  tor this  to the c e r t a i n t y  et a l . (1961)  (N •+• ^ ^ , '  which  which  a  ot  presented  the observer's  i t the s t i m u l i  as  both  The  stimuli  B), subjects  scale  (1972)  signals,  are valid  t h e two  (i.e.,  to the assessment  background  i s a measure  can produce  McNicol  or  detection  stimulus  Swets  applied  i s to i n d i c a t e  In a d d i t i o n ,  a rating  scales  However,  hit.  would  alarms.  signal  a  reduce  but, i n turn,  quantitatively  stimuli  sensitivity  the subject or  be  task  d i s c r i m i n a t e between  A  a  giving  a  principles  (d ' ), however,  stimulus  oi hits  oi ialse  ot  also  criterion  t o r example,  ot  distributed  t o r the simple  his/her  liberal  the observer  ot o b t a i n i n g  against  task  so. w i l l  beta. theory  presented.  ot  i s represented  discriminability  S.j).  with,  the l i k e l i h o o d  the motivation  response,  response  t h e number  can change  about  doing  the p r o p o r t i o n  increase  level  b u t by  In c o n t r a s t , a  to maximize also  criterion  alarms  ot  trials.  categories and  the  their have  used  subject  cxocrimcnt.  been  iound  to  have  piven  to  and,  changes (Clark  Detection  in &  has  provided to  a D p l i e d  oain  a  report  with  evaluate  valuable  assessing One pain  in  the  however,  assumes  prior  researcher  to  specify  when  and  pain)  have  been  preceded  bv  pressure  which  a  blank  has  a  trial  not  as  been  (a  Pain  allow  tor  (McBurnev,  c i r c ii m v e n t e d  oain.  ot  as the  1976;  the  be  Traditional  contound  was  the  oain  ability  viewed  analgesics 1977;  as  definition allows  stimulus  19 » 3 ).  warmth, clear  are  by  SDT  a  the  not  to cause  usual!v  heat,  or  identitication  Rollman,  problem  ot  expected  does  w h i c h  i n  and  a p p l i c a t i o n or  sensations  such  and  can  SDT  which  signal  1972).  how  the  ( a  is  involving  vision  Chapman,  the  method  subseauentlv  ettects  in  icct:  psychoohvsics  theretore,  1974;  cub  (1974)  components  signal  trial  in  tolerance)  knowledge  sensations  does  have  two the  presented.  other  nonsignal  researchers  a  ot  and.  difficulties  It  pain)  oain  (Clark,  'signal'.  cause  and  this  used  Clark  in  several  McNicol,  such  i'.J  to  D r a c t i c c  methods  experimental  these  pain  main  research,  to  studying  clinical ot  first  senses,  threshold  sensitivitv  seoaratelv  highlv  ot  was  ot  using  SDT  limited  because  i s  1973;  explanation  assessment (e.g.,  in  than  1  a l . , 19 6 1 ) .  thorough  the  measures  et  This  Dillon,  Theorv  be  conseauently,  d  investigate exteroceotive (Swets  should  considerable  difficulty  simultaneouslv  iudgements  audition  to  be  the  sensitive  scale  should to  Signal  to  ratine  D r i o r  binarv  to  the  use  categories less  in  1977).  having  Pain  subiects  rate  the stimulus  1969;  1974).  stimulus  set  with  Dillon. This  'tailoring'  d'  ot  eL  ot  however,  ambiguitv  or changes  has  been  application Gracely, (1978)  as a r e s u l t and  pain  one  ot  1983; G r a c e l y , that,  d'  i t i s not accurate  tunctionallv  related.  examine  ditterence  intervention. separate  measures  and bias  ot  SDT  (Clark, in  i t s  1985; C o p p o l a  Rollman,  1977).  and  are  to say they pointed  &  Chapman  statisticallv are not out that  Lhese  i n pain  response  criterion-  increases)  results  i n i n t e r p r e t i v e problems  (Chapman,  1985;  1977).  However,  Gracelv  changes  i n these  measures  as d  situations  1  to change  group  criticisms  been  to  together  (i.e.,  tend  I t has  'floating  conseauence i s  as  beta  decreases,  i n which  thev  (1989)  remain  modulation  has n o t e d  are d i t t i c u l t t h e same  &  1981).  in a  response  (Chapman,  1989;  although  beta  based  the major  research  ot an  stimulus  1969; C l a r k  the a b i l i t v  sensitivity  or emotio n a l l y  the  set results  The  set oi  their  et a l . ,  i n t h e i n t e r p r e t a t i o n ot i n d'  ot  (Clark,  in sensitivitv.  independent,  measures  the basis  eliminates  (Clark,  a different  confounding  the stimulus  which  to pain  noted  on  ccalc  a l . , 1983; N a l i b o t t  p h y s i o l o g i c a l l y based  1974)  used  tactors  i n t e r p r e t a t i o n ot d'  psychologically  ratinp  have  subiect  subjects  ditterences  The  oain  t h r e s h o l d s , thus  1973; Cohen  greater  a  researchers  individual  baseline  on  t o r each  oain  baseline,  in  Some  levels  individual  levels  that  studies which  Rollman,  although  to i n t e r p r e t , i s confirmation  ot  16  similar  sensorv  P.ollman  abilities.  ( 1 976;  1977;  1 979b;  additional  concerns  with  research.  Brietly,  Rollman  variation  in  the  experimental  the  intensities  -judged,  number  -judgements,  tvoe  oain  SDT  oain  across  limiting  present  i n  has  Rollman  methodological thus  ot  research  labs.  the  study.  methodological  not  met  in  include: large  a  (1977)  the  large  Rollman  studies  number  number  ot  practice  particularly  it  several  scale  10),  (e.g.,  intensities these data  to  parameters in  SDT  These  rates,  are  stimulus  limited (i.e.,  necessary  results that  conditions  suggested ideal  that  SDT  manvof  studv  These  trials  are  in  parameters,  were  requirements  (e.g.,  250),  a  hundred),  used  in  number  ot  two).  Rollman  to  emnloved  out  the  an  and  tor  SDT  (several  categories  practice  etc.)  reviewed.  trials  iudged  requirements  result  produce  tor  a  SDT  study  tor  pain  research,  in  poor  subiect  compliance  studies  involving  especially  patients.  a  ot  ot  used  the  (1977)  he  that  stimulus  pointed  to  tor  D a i n  a  rating  stimulus purports  reliable,  that  accurate  experiments.  impractical would  and  be  validity  to  inconsistent  attect  reouirements  pain  number  -iudged,  turther  may  SDT  indicated  categories  to  expressed  ot  ditterent  contributed  external  the  ot ot  has  (e.g.,  stimulus  variations  the  (1977)  number  has  application  methodologies  trials,  1980)  Chapman  in  (1977)  however.  asserts  that  are The and  somewhat time h i g h  involved attrition  chronic  oain  Rollman  is  describing  determining  psychophysical  can  be  useiul  the  rigorous  because  i t  in  pain  provides  some  Finally,  precise  are  also  data  stimuli  tested In  reason  with  summary. to  assume  assumptions  ot  demand  that  other  t-test  or  used."  (p.  1987)  any  the  same  ot  data  experience  ot  pain.  is  not  the  that  process  ot  although  pain  more  are  provided  control  groups  judged, are  stimuli.  noted must  SDT  that  "there  precisely  model  than  is  t i t  there  no  is  to  parametric  statistical  test  SDT  is  currently  measures They pain  in  how  1983  do  ot  the  not  various  a  suggest  will  help  tactors  and  that  but  betore  Clark.  useful  sensory  measurement, that  ) and  only us  it  a is  ot  response is  that gain  attect  ot  (1974;  method  i t  more  the  requirements  ( 1 977 ;  in  suggests  stimuli  ot  SDT  applied  t i t a l l the  information  insight  i t  that  exactly  pain.  additional  considers  two  data  Chapman  to  into  only  He  Rollman  noted  (1977)  SDT  it  that  number  earliest  that  useful  it  used  Chapman  other  solution'  provides  be  separate  components 'final  may  299).  way  Chapman  that  even  insight  produced  the  maintain  providing  research  psychophysical  judgements.  multiple  functions.  the  the i t  bias  18  Research In one  on  Pain  general,  which  SDT  to  patients  are  methodology  from  other  area  of  in  Chronic  two  chronic  pain,  and  pain  the  patients.  will on  Research  perception  mvofascial  pain  thresholds  than  normal  al.,  1980).  Signal  have  shown  able  to  detection  although  pressure  pain  criterion  to  (suggesting report  control  subjects  1981).  After  successful  thresholds between  were  higher,  stimulus  report  criterion  of  MPD  the  normal chronic  patients  control pain  sensations  as  decreased  (Malow  group  of  this  their  &  pain  group  MPD  ability  Olson,  were  found  painful  than  people  is  to  was  to  and  their than &  Olson,  pain  their  responses  more  without  focal  discriminate  1981). be  MPD  of  Malow  post-treatment the  et  less  lower  patients'  improved  to  have  (Malow  intensities  a l . , 1980;  patients  disorder  has  i n v e s t i g a t i o n s of  et  These  (MPD)  subjects  painful  similar  (Malow  this  as  was  pain  sensitivity),  treatment,  higher. were  using  dysfunction  different  intensities was  chronic  control  chronic  sensations  normal  chronic  separately  analysis  with  theory  this  between  in  pain  patients  discriminate  an  the  Studies  critiqued  which  pain  that  are  indicating pain.  and  chronic  lower  that  investigations:  presented.  pain on  Patients  patients  to  reported  be  ot  other  underresponsive be  Pain  groups  investigations after  studies  revealed  are  that  will  research  S D T  there  reports  overresponsive pain  Perception  Thus, likely  chronic  pain responses  of  the these  to pain  report  19  despite  apparently  In  contrast  chronic  pain  stimulation studies  al. ,  ( 1983)  control that  than  pain.  subjects  pain  S i g.n a l  detection  patients heat  stimuli  control  to  than  as  they  did  find  not  pain  chronic They  higher  SDT  was  (Yang  inclined  than  pain et  are  Cohen  low  chronic  respiratory  nonpatient  reliable  group  found had  subjects.  back  and  lowered MPD  They  painful  patients  the  pain  patients  that  d i s c r i m i n a b i l i t y of  with  back  control  indicated  suggesting  et  nonpatient  stimulation.  respiratory  several  less  and  chronic and  painful  thermal  the  to  found  pain  radiant  nonpatient  sensitivity  patients.  to  However,  differences  for  a l . , 1983;  sensations  'painful'.  additional  finding  of  higher  chronic  pain  revealed pain  1985).  et  pain  relative  control  Yang  also  beta  that  thresholds.  d i s c r i m i n a b i l i t y for  that  report  normal  have  have  decreased  they  the  of  found  are  a l . , (1981)  analysis  patients  et  that to  patients  patients,  investigations  criterion  stimuli.  criterion).  reported  subjects  than  found any  pain  however,  and  again  report  back  also  heat;  the  subjects,  Other  pain  responsive  responses  painful  poorer  stimuli  (i.e.,  the  the  i n d i v i d u a l s , there  Naliboff  theory  pain  more  chronic  thresholds  showed  be  to  investigations  respiratory  back  higher  above  to  examined  the  sensitivity  pain-free  chronic  both  the  indicate  to  patients,  to  patients  that  responsive  lowered  That  group  to  al.(1985)  differences  in  the  to  radiant  patients normal  i s , they call  a  control were  the  attributed pain  had  report  the  less  20  criterion It pain  to  is  methodological  difficult  patients  respond  investigations employed.  et  of  Cohen  category  sensitive subjects  changes  were  found  categories  particularly  trials  were  were  given  trials  given  intensity  et  a l . , 1983;  in to  d' have  i f only  were  given  have the  not  to  the  estimates number  recorded  of  small  number  1972).  It  is  make (Naliboff  to  a l l  of  be  less  the &  Dillon,  practice  not  trials  The  because  consistently (Clark  number  et of  the  varying  pain  In  different for  each  of  trials  clear  how  even  i f  or  1981)  to  SDT  SDT  manyany  per  intensity  26  trials  Cohen  indices  et  studies  stimulus (Malow  per  a l . , 1983). gained  Therefore,  the  findings  numbers  experimental  of  addition,  stimulus  (Cohen  of  intensities  based et  some  on  et  stimulus  are  subject  threshold  above  given  per  a l . , 1981;  comparable.  task  3  trials.  greatly  selected SDT  &  (Naliboff  be  task  using  the  Olson,  may  to  judgements  among  Malow  these  methodologies  found  variation  al.,  with  been  binary  SDT  a l . , 1985).  studies  from  greater  SDT  these  ranging  reliable  a  the  in  intensity,  intensity  has  chronic  these  subjects  et  difficulty  and  in  their  Yang  SDT  than  (McNicol,  i s wide  respect  1980;  in  in  in  how  at a l l .  There with  required  of  about  pain  variation  studies  simultaneously  1973),  practice  the  judgements  to  conclusions  laboratory  of  the  judgements  a l . , 1981;  use  of  draw  to  because  Many  category  to  ditterences.  each  a l . , 1983;  the to  with  More a  obtained trials  studies be  used  person's Naliboff  et  in  21  al., set  1981).  Yang  of s t i m u l i  that for  d'  for a l l subjects.  values  each  obtained  subject  Finally,  with  two  focal  1981)  and  radiant  1981;  Yang  types  heat  et a l . , 1985).  i n comparing Thus,  different  methodologies  patients  between above  while  exhibit  painful  Recent  whether  chronic  (Brands  & Schmidt,  1987).  Brands  pain  their than  i s some  pain  have  states  with  had  no  lower  in  these  &  Olson, et a l . ,  suggested  using  different  pain  across  that  a l l  chronic  to discriminate sure  because  of the  patients,  subjects. there  pain  found  and e x a m i n a t i o n  levels  and  chronic  pathological to cold  arthritis  evidence  of of  low  pain  examined  pain  c o r r e l a t e s of  p a t i e n t s , and  i s a chronic  "absence  et a l . ,  basis for  pressor  personality  Fibrositis i s an  that  pain  to a s c e r t a i n  tolerance  e t a l . (1987)  rheumatoid  i n chronic  undertaken  tolerance  levels,  radiographic,  has  perception  apparent  tolerance  i n which  used  e t a l . , 1987; Scudds  (1987)  thresholds,  control  be  been  1987; L i p m a n  Scudds  condition  ability  affect  controls.  normal  were  consistency  cannot  normal  fibrositis  intensities  variations.  and Schmidt  condition  stimulus  i t appears  a reduced  studies  patients  has i n d i c a t e d  (1983)  studies  i n v e s t i g a t i o n s of pain  patients.  back  of  one  (1974)  e t a l . , 1983; N a l i b o f f  i n that  stimuli,  methodological Other  there  t h e same  e t a l . , 1980; Malow  Rollman  results  used  comparable.  stimuli  (Malow  (Cohen  stimuli.  pain  different  of p a i n  pressure  however,  Clark  are not d i r e c t l y  studies:  caution  and h i s c o l l e a g u e s ,  pain  laboratory, inflammatory  22  disease" group  (Scudds  was  reported  controls  on  these of  and  pain  and  fibrositis than  normal  depression,  anxiety,  and  social  showed  levels  patients.  be  significantly  than  The  with  the  the  normal  authors  lower  control  suggest  hypervigi1ance  radiant  heat  chronic of  in  that  model  the  volunteers.  of  In  general,  to  chronic  chronic  severe  have  the  pain  pain  resulting  however,  organic  pain  exhibited  thermal  they  chronic and  were  found pain  stimuli that group  similar  to  They  higher  than  the  the  etiologies  intervention.  patients  pain  group  neurosurgical  painful  interventions  The  experiencing  by  compared  stimuli  volunteers.  Furthermore,  decreased  a l . (1987)  a l l considered  levels  normal  et  disorders.  treatable  that  surgical  Lipman to  of  were  volunteers.  the  The  higher  tolerance  patients  variety  tolerance  levels  563).  significantly  they  consistent  normal  of  conditions  found  are  levels  consisted  to  addition,  and  contrast,  patients  a  score  p.  perception.  tolerance  from  to  rheumatoid  results  In  and  In  thresholds  subjects  a l . , 1987,  hypochondriasis,  introversion. pain  et  normal  pain  tolerance  following the  responses  of  23  Analysis  ot  Research  on  Pain  Perception  diiiicult  to  reach  in  chronic  pain  patients It pain  is  perception  method  in  variation  consistent  chronic  used  in  or  pain  patients  as,  type  of  pain  such  of  pain  difference  pain  in  pain  of  pain  induction  have  chronic  pain  Scudds been  prolonged found  pain  used  radiant  al.,  1987; study  was  induced)  shock)  simply  Malow  been  indicating in  chronic  used  and  the  to  et  used  low  et or  termed  et  the  general  induction  pain  In  contrast, high  (Cohen  et  questionnaire a l . , 1983). transient  pain  et  format  Radiant  1  methods deep,  to  pain  Lipman  et  a l . , 1985) ( i . e . , no  heat  (e.g.,  stimuli .  Olson,  produce  thresholds  Yang  &  investigations  a l . , 1983;  and  used  Malow  they  have  methods  induction  because  type  that  thresholds  a l . , 1980;  have  'phasic  underresponsiveness  pain  pain  a l . , 1981; a  finding  Investigations  stimuli'  stimuli  (Yang  some  consistent  concerns  These  sensations.  short-term  have  have  1987;  patients  heat  the are  pain  stimuli  studies  used.  pressor  Naliboff  one  to  'tonic  painful  A  patients  a l . , 1987).  termed  that  producing  et  There  to  altered  of  studies  pain  reporting  cold  Schmidt,  studies.  of  between  technique  and  because  between  used.  these  patients  pressure  1981;  above  type  stimulus  to  C  patients  regarding  studied.  and  (Brands  the  the  overresponsiveness  focal  pain  underresponsiveness  disorder  methodological  reported  conclusion  d i f f e r e n c e s , however,  overresponsiveness  Type  a  and  and pain  others  electric  24  Tonic nervous pain  and  phasic  svstem  in different  are believed 'C'  diffuse,  aching  fibres  pain  because  of  the s i m i l a r i t y  not  be  Detection brief  stimuli  which  intensity  administered  similar  1987).  heat  that are  of  This  pain and,  pain  source  ( i n contrast  only  3  although  (Clark,  of  induction  of  nature  i t takes  of  investigators conditions  type  of  of  stimulus  Signal  trials  per  of  tonic  some  pain  time f o r  seconds  trials  brief  chronic  or  given  more)  per  intensity  very  stimuli.  were  of  was  found  t h e two  1969;  and  considered  Phasic  &  widely  easily-  has  been  In a d d i t i o n ,  to conform  radiant  pain  to the  assumption  distribution This  as  Harris,  and  pain  mechanical  1976).  t o be  i t is a  reliable  underlying  Rollman,  seconds),  (Rollman  fibres.  to e l e c t r i c a l  to U  pain,  technique  i t is a  pain  (3  i t i s not  the A - d e l t a  techniques)  the v a r i a n c e s equal  These  presentations  ( e . g . , 60  involves  i s because  to s t i m u l a t e  induction  that  t h e number  to the experience  controlled found  heat  stimuli  form  The  administered  (e.g.,  some  slow,  i n Malow's i n v e s t i g a t i o n s ) .  Radiant discrete  1985).  limits  produce  pain  repeated  pressure  large  1986).  this  the  and  investigations.  many  i s such  t o be  necessarilv  stimulus  used  (Chapman,  by  However,  the  and  clinical  f o r SDT  requires  techniques  stimulus  with  t o a c t on  pressor  (Chapman,  are favored  1987).  appropriate Theory  induction each  induction  e t a l . , 1980;  Cold  stimulate  sensations  of  may  wavs.  of n o c i c e p t i o n  methods  (Malow  are believed  to p r i m a r i l y  unmyelinated and  stimuli  in  assumption  SDT is  25  important 1976). for  for  the  Finally,  stimulus  induction  parametric the  administered  in  a  Differences important  for  in  underresponsiveness  had  difference  an  obvious  that  is  area  was  no  for  for  (1986)  indicated  also  unknown.  This  Scudds  a l .  et  fibrositis were cause  was In  (1983)  is  contrast, used  disorder  without  1983,  p.  247).  study  using  who  were  or  of  pain  likely  Naliboff patients  Lipman  et  obtain  pain  not.  may  pain  be  the  the  &  Low  al. with  distinct  Laskin, in  has  been  the  and,  Taxonomy of  in  MPD  addition, between  tolerance  for  whom  no  was  levels organic  1987).  of  an  and  Cohen  also  obvious  et  al.  organically  problems."  from  on  association  (1981)  (1987)  relief  A  condition  pathology  pain  Schmidt,  "typical  studied.  the  Subcommittee  strong  al.  found  International  patients  et  by  fibrositis  a  that  pain  of  An  found  pathology  physical  for  studied.  patient  One  The  psychiatric  patients to  time  suitable  that  those  whether  Pain:  pain  (Brands  and  organic  reported  major  a  population  established  true  chronic  apparent  both  be  hypochondriasis. in  (Rollman,  trials  studies  of  1981).  that  also  the  to  of  Study  (1987)  and  reported  the  pain  type  MPD,  Scott,  Association  of  cause  evidence  (in  heat  more  patients  the  organic  criteria  affected  pain  appears  diagnostic there  type  between  in  d'  administration  radiant  because  ot  time.  the  distinction  brief  makes  SDT  given  overresponsiveness  general  relatively  presentation  technique  calculations  (Cohen  conducted  organic upcoming  based et  a l . ,  their  causes  and  surgical  interventions. nature Yang  or  et  the  with  a l . (1983) ot  their  indicated  herniated  less  oain  that  lumbar  were  clear  patients,  their  disks,  pain  a:  to  the  however  patients  mvoiascial  were  svndrome,  osteoarthritis. Malow  and  possibility syndromes with  people  pain  may  (198U)  people  ditter  who  that  do  not  or  stimulation  report  no  physical  have  comparison  temporarily  in  signs. for  They  chronic  more  sensitive  i n d i v i d u a l s . " (p. 71).  that  pain  cause  et  pain  causes  pain  (Leavitt  pain  organic  normal  the  caused'  organic  are  organic  to  on  obvious  found  i n t e n s i t y ot  etiologies  of  who  than  apparent  greater  response  exhibit  i n people  commented  'organically  in their  investigations  unclear  have  with  "the absence  result  paintul  Other  Olson  that  may  suggested  to  et  conditions  a l . (19 85)  diagnosed and  Yang  patients  tor their  than  patients  a l . , 1979;  with  discomfort with  Perry  clear  et a l .  1988). Cohen difference  et  in results  psychological Leavitt were  to  'non-organic' MPD  and  and  anxiety  1981;  (1979)  patients.  and  i n both  (Schwartz et  have  et  however, instead ot  the  tound  increased  tibrositis  Scudds  may  components  & Garron  related  unclear  a l . (1983),  have  "reflect  disorders."  that  pain  suggested  been  strongly  conditions,  a l . , 1979;  a l . , 1987).  (p. 251).  in either  It i s interesting  Malow  et  tactors 'organic'  to note  associated  the  physical  that  with  symptoms  or both  stress  cause  a l . , 198U;  Characteristic  the  the d i t t e r e n t  psychological  report  that  is  Scott, ot  anxiety  include  to  or  selt  (American  worry  others  and  Manual  Research  the  on  generally  threshold  and  Weisenberg  resulted  et  Davidson,  somatic  (1985)  Mendler  Watson,  a l . , 1977;  increased Elton  found  stimuli  improved  changes. sensory  They neural  pathways  applicable  who  are  attentive  to  significance will  to  follow  signs of in  the  is a  to  to  subgroup  to  about  1986;  anxiety (Bobey  &  a  to  to  of  that  their  the  the  in  of  the  subjects'  pain  review  patients and of  classification  review  heat  hvpervigilance  condition A  a l .  temperature  in  chronic  et  painful  changes  changes  (e.g.,  attention  Bushnell  distress.  with  1975;  capture  detect  organic/functiona1  conjunction  1965;  internal  attention  plausible  somatic  pain  tolerance  or  finding  not  anxious  of  and  has  is  a l . ,  reduce  1986).  ability  and  It  particularly  found  this  anxiety  decreased  to  1987).  anxiety  Sternbach,  external  selective  Revised,  and  et  mistortune  1976).  Chapman,  attributed  model  1984;  been  subjects'  criterion.  is  have  -  calamity  and  Klusman,  threshold  whether  the  decision  1966;  £> S t a n l e y ,  a l . , 1988; that  that  Techniques  pain  pain  (Lepanto  Kent,  1987).  stimuli,  et  &  possible  III  report,  levels  sensations),  (Williams  observation pain  possible  Diagnostic  Disorders  tolerance  1970;  Feared  the  increased  Clark, in  Mental  tor  r e l a t i o n s h i p between  with  1966;  &  hvpervigilance  ot  supported  associated  Wharton  a n t i c i p a t i o n ot  Psychiatric Association,  Statistical  Halsam,  and  the  role  are the system  of  28  cognitive  and  affective  factors  in  the  experience  of  chronic  pain.  Classification One  of  of  the  pain  major  patients ways  that  pain  has  been  on  classified  in  the  or  of  identifiable  absence  process  has  patients pain  yielded  with  have  been  pain'  identifiable  having  been  and  to  wake  type of  involve  to  based)  the  of  for  the  to  those of  whose  pain  reports  damage  have  been  were  classified  display  'unreal  (i.e.,  (Turk  Rudy,  mind-body  and  pain  have  that  is  1987).  dualism  formulations  display  patients  disorders,  &  their  or  absence  pain'  Those  of  has  been  pain  criticized  which  consider  in pain  sensory-discriminative, motivational-affective,  in  There  cognition pain  pain  presence  diagnostic  considered  However,  or  the  causes  1987 ) .  been  patients.  'organic'  been  in  of This  pain  physical  have  tissue  cognitive-evaluative  1982).  of  have  'psychogenic'  current  interacting  of  6. R u d y ,  basis  causes.  having  physical' causes  considered  This  to  and  ' f u n c t i o n a l ' or  emotionally  the  as  persistent  disproportionate as  organic  underlying  disorders  of  the  categories  classified  (Turk  complaining  two  obvious  'somatogenic' 'real  past  patients  the has  and  Meichenbaum,  experience been  affect  (Craig, &  components  Genest,  pain  substantial  as  1989;  of  mediating  Elton, 19 8 3 ) .  1987; In  which  are  constantly  (Melzack  support factors  for in  Thompson, addition,  &  the  the 1981; the  Wall, role  of  perception Turk,  organic/functional  distinction  has  is  organically  caused  rare  does  to  not  Tunks,  find  also  1984;  Orthopaedic apparently tendency  involve Turk  et  psychological a l . , 1983;  treatments  often  organically to  ignore  Garron,  1979;  Waddell  et  for  an  the  a l . , 1980).  'secondary  inappropriate gain'  compensation failed  to  find  compensation Melzack  et  or  or  (e.g.,  an  pain  report  financial  to  a l . , 1985;  claims  Reesor  &  Tullis,  explanation  tendency  et  1988;  or  however,  nonorganic  Craig,  to  through  studies,  (Leavitt  &  1986;  malingering  incentives  Several  the  (Leavitt  i n the  &  with  of  alternative  r e l a t i o n s h i p between litigation  &  that  1984).  because  factors  It  (Bellisimo  ineffective  i s apparent  litigation). a  been  Derebery  Finally,  condition  & Main,  disorders  1987;  problems.  variables  psychological  Leavitt,  pain  Waddell  have  caused  "functional" disorders  attribute  encountered  signs  have and  a l . , 1982;  Waddell  et a l . ,  19 8 0 ) . It degree the  i s becoming of  detectable  variance  pain  patients  emotional  physical  than  the  reaction 1987;  Main  & Waddell,  does to  and  et  Polatin  1987).  catastrophic  cognitions  helplessness  in controlling  Pain  (Barnes  the  Lee  a l . , 1989; patients  regarding  their  pain  in  appraisal  a l . , 1990; et  that  contributes  disability  cognitive  condition  Lacroix  1984;  Waddell,  the  research  pathology  perception  & Turk,  and  i n recent  i n pain  Flor  1987;  apparent  who pain  also  et  the less  to  chronic  and a l . , 1989;  et Turk  a l . , 1989; &  Rudy,  reported and  a  reported  sense higher  of  30 intensities for  of  patients  pain  with  clear  organic  1989;  and  Spinhoven  withstand pain  et  cold  Se1f-efficacy of  performance  is  apoears ;nc  that  release  a  of  h av e  increased  Hill  et  1987;  Spinhoven  exhibit  be  less  conform  the  biochemical  under  et  responsive to  by  the  to  opioid  in  et &  painful  could  be  or  which  who  stimuli the  pain  have  has  &  that  the  who  may  appear  to  to  model. to Animal  perception  analgesia  same  Turk,  reported  linked  pain  1963;  Watson, &  sensitivity.  altered  report  pain  been  who  been  with  as  patients  with  and  i t  (Bowers,  Flor  pain  of  Co g n i t i o r . s  Adaptation-level  pain  by  act  pa i n ) •  1976;  cope  levels Thus,  Mendler  Chronic  belief  associated  research  revealed  produced  is  to  Epstein,  systems.  certain  past  investigate  conditions  pain  to  person's  decreased  stress  to  et a l . ,  increased  events.  a l . , 1965;  affect  a  with  response that  over  sensitivity  patients  to  as  substances  control  of  Keefe  analgesic  achieve  over  a l . , 1989).  to  opioid  control  tolerance  to  true  patients  se1f-efficacy  authors  control  Szpiler  1987;  c o r r e l a t e d with  of  conducted  hyperalgesia  was  that  predictions  factors  stressful  found  Lepanto  and  was  1989).  associated  subgroup  Emotional  research  been  1966;  the  &  capable  of  self-efficacy  represent  Turk,  decrease  a l . , 1952;  HaIsam,  (Flor  maintain  pain  1966;  for  pain  endogenous  (i.e.,  and  findings  a l . ,  being  sense  of  organic  a c t i v a t i o n of  to  analgesics control  et  defined  as  and  This  a l . (1987)  and  him/herself  disability.  causes  pressor  tolerance  increased  limited  with  Bandura  and  and  situation  in  rats  (Jorum, these  1988a).  outcomes  behaviour  The  appeared  exhibited  situation. sensitive  Rats to  pain  and  refers is  further  investigated  mechanisms  be  threshold  results  in  suggested  that  suggested  is  anxiety  that  critical  factor  findings  lead  distressed somatic their  by  to  a  in  that  be  event  in  the  the  their  He  bases  hyperalgesic noradrenergic and  such  pain  Jorum  threshold. the  above  pain  and  patients  exhibit  (hvpervigilance) painful  may  hyperalgesia.  that  may  (1988b)  event,  hyperemotionality) of  the  nociceptive  unpleasant  in  be  the  produced  in  353).  that  that  earlier  decrease (p.  (1988b)  these  that  has  anxiety  Jorum  response  an  condition  to  of  for  the  found  which  implication  sensitivity  index  conditioned  development  pain  pain.  in  an  i m p l i c a t i o n of as  and  be  whether  of  less  agitated  a l . , 1983).  decreases  (presented  be  an  subsequent  the  to  agitation, defecation,  hyperalgesic  expectation  preoccupation  sensory  et  hyperalgesia"  result  further  to  seeing  an  with  may  motor  of  stressful  found  were  each  h y p e r s e n s i t i v i t y to  could  hyperemotionality  the  that  biochemical  to  response  were  to  emotional  nonnoxious  rats  Tanaka  the  leading  animal's  quietly  to  the  a n t i c i p a t i o n of  therefore,  the  conditioned.  mediated  hyperalgesic "mere  1988b;  addition  could  the  considered  (Jorum,  response  factor  be  exhibited  animals  in  lay  whereas  Hyperemotiona1ity  responses  to  during  that  "hyperemotional"  vocalization  critical  He  results be  These who  increased increasing  sensations.  a  are  3Z It  is  now  recognized  psychological condition. identify, who  may  factors  require  before  the  a  a  basis  e s t a b l i s h i n g the  signs et  a l . , 1980).  than  by  (Bigos  Waddeli, reports are  Battie, Main  1987). of  or  poorly  principles  1987;  absence  medically incongruent that  communication: pictorial.  medically  patients  Pain  on  the  incongruent pain  symptoms  refer  to  examination from  that  anatomical  et  termed  a l . ,  1984).  "medically  identified  congruent Reesor basis  &  by  (Ransford  signs  behavioural,  different verbal  were  vs  et  medically  Craig  of  the  and  presentation  involve  patients  Doxey  1988).  presentation.  pain  1986;  1980;  drawings  of  organic  a l . ,  pain  Craig,'  the  et  non-anatomical  classified  measures  Tullis,  been  &  on  of  Waddeli been  done  absence  also  Classification  three  best  have  Reesor  and  have  surgery  the &  or  assessment  as  Waddeli  signs  a l . , 1980;  and  Medically  1984;  patients  signs  deviate  exaggerated  of  Derebery  to  those  be  pain  non-organic  or  symptoms"  pain  of  localized,  incongruent  incongruent  to  physical  et  made  such  to  signs/symptoms  1976;  been  reactions  (Waddeli  chronic  psychological  appears  Waddeli,  and  any  examination,  determining  Non-organic  al. ,  in  have  presence  Non-organic  pain  vague,  &  physical  treatment  This  exclusion,  &  a l . , 1988;  efforts  physical  et  rather  present  detailed  (Waddeli of  be  physical  more  undergoing  both  will  Consequently, through  that  presence  or  symptoms.  was  assessed  modes  as  using  of  self-report,  classified  (1988)  and  exhibiting  a  medically signs  incongruent  that  surpassed  measures.  A  85%  patients  of  this  the  set  discriminant were  behavioural  nonorganic  examination signs  criterion function  if  for  they  at  exhibited  least  analysis  classified  (Waddeli  of  straight  and  pain leg  that  one  of  indicated  correctly  do  Nonorganic  treatments greater  the  that  according  Multiphasic  with  the  are  1988; a  do  the  to  strength  or  not et  signs  for  whom  in or  signs  were  hysteria  F  or  et  litigation  Two  scales  on  the  claims  did  the  not  (Doxey  studies  have  physical  (Leavitt  with  suggesting  malingering  nonorganic  or  Minnesota  but  scales  Other  be  medical  correlate  i n d i c a t i v e of  between  to  to  validity  a l . , 1980).  anatomical  likely  a l . , 1980).  (MMPI)  in  neighboring  found  Inventory K  more  conventional  (Waddeli  increase  sensation  were  symptoms:  distracted,  examination.  physical  to  tenderness,  tests, is  physical  correspond  based  patient  measure  physical  following  examination the  not  to  the  or  that  a  nonorganic  overreaction  relationship  compensation  The  a  neurological  and  Waddeli  pain  include  mock  Personality  correlate  during  to  failed  hypochondriasis  present  using  correspond  nonorganic  signs  of  when  patients had  assessed  non-anatomica11y  muscle  not  and  in  deep  was  a l . , 1980).  reports  during  of  substrates,  observed  et  raising  disturbances areas  of  signs  p r i n c i p l e s and  superficial report  component  physical  consist  anatomical  find  a  presentation  system. The  of  pain  et  that et  failed  signs  a l . ,  a l . ,  and  1982;  to  Melzack  et  a l . , 1985;  Cooper,  1983).  indicative surgerv  of  and  assessment Dzioba  The  who  may  was  The  d i d not  presentation  was  Symptom  list  specific  seven  symptoms  that  are  inconsistent  with  principles.  The  rater  discriminative patients (1986)  with  clear  symptoms  the  related  Finally,  to  the  high  from  psychological et  a l . , 1988; This  (Reesor  &  Craig,  discriminative with  & Waddell,  Waddell  1984).  incongruent et  measure  consists  q u e s t i o n s which  inquire  about  localized,  physiological has  been  (i.e.,  found  and to  and  generally  have  high  incidence  organic  pathology).  Derebery  measure  to  be  valuable  psychological  factors.  was  assessed  by  Reesor  and  the  Ransford  et  a l . (1976)  component Craig  with  scoring  of  a  are  inter-  high  low  pictoral  of  anatomical  jo < . 0 1 > a n d very  pain  a l . , (1984)  This  poorly  is  reliability  medically  the  signs  result  significantly  of  &  across  .86)  (Main  using  (K=.58-1.00,  validity  consider  and  Repco  a l . , 1980).  to  correlate  vague,  scale  reliability  .78  Inventory.  known  Doxey  test-retest  from  assessed  poor  detailed  et  and  nonorganic  reliability  component  Inappropriate of  and  a  1986;  impairment)  self-report  have  a more  a l . , 1980)  physical  to  high  1988;  multiple  Waddell  have  ranged  et  (i.e.,  objective  to  have  Waddell  validity  and  (inter-rater  coefficients  of  & Tullis,  1984;  found  & Craig,  likely  require  (Derebery  assessments  1988;  presence  patients  & Doxey,  measure  Reesor  in  system.  Pain The  &  Tullis  identifying  medical  the  in  incongruence Drawing patient  using is  35  required  to indicate  on an o u t l i n e  location  and q u a l i t y  of their  quantifies drawing. with  nonanatomica 1 A score  decreased  conventional Taylor  pain  organic  lesions  1988).  High  hypochondriasis  been  and h y s t e r i a  al.,  1976).  The R a n s f o r d  used  with  from  .70 t o . 8 9 ) a n d h i g h  high  (coefficients Uden  et a l ., The  i s rare  from  assessment  of incongruent  to s u r g i c a l  psychological  & Tullis,  would  Patients  has been  ( c o e f f i c i e n t s range reliability  pain  i s considered  emotional disability with  be r e a c t i n g  & C r a i g , 1988;  inappropriate  are likely  be h e l p f u l  to provide to their  (Waddeli,  presentation  stresses  t o have  a  (Bigos  &  Battie,  e t a l . , 1988; W a d d e l i Incongruent  pain  information illness  1987; W a d d e l i  pain  has  a n d f o r whom a  1987).  response  to l i f e ' s  who  1986; Doxey  a l . , 1980; 1984; W a d d e l i ,  presentation  to  treatment  consultation  Derebery  their  et  1988) .  result  of  with  (Ransford  system  .77 t o . 8 5 ) ( R e e s o r  poor  patient's  or  et a l . ,  o f t h e MMPI  test-retest  of use i n i d e n t i f y i n g p a t i e n t s  et  Exaggerated  with the  et a l . , scoring  been  1987;  respond to  & Doxey, 1984;  (Uden  correlated  inter-rater reliability  range  associated  i n patients  disk  scales  of the  will  (Dzioba  as a h e r n i a t e d have  has been  e t a l . , 1988).  presentation  such  scores  Uden  system  features  the patient  treatment  figure the  The s c o r i n g  or greater  l i k e l i h o o d that  orthopoedic  nonanatomica1  pain.  or exaggerated  of three  e t a l . , 1984;  o f a human  and  about the perception  et a l . ,  presentations  1989).  " c a n be  i n a maladaptive  way"  said  (Derebery  &  correlated more  Tullis, with  physical  1986).  higher  regarding  ability  control  to  exhibiting poor  on  to  the  MMPI  (Dzioba  al.,  1984;  1984;  et  patients  identifiable incongruent  the  signs  "The  effect  pain  may  patient  ... to  basis  of  to  or  to  a of  in  Reesor  &  Craig  ineffective (which exhibit  serve pain  coping to  a  to  marked  given  (Main  (1988)  of  the  Taylor  et  the may  be  medically  &  behaviours  out  of  their  the  inappropriate symptoms),  examination of  the  objective  1984,  that  and  of  to  exacerbation  suggested  of  chronic  events  leading  physical  level  techniques  from  (inappropriate  Waddell,  accentuate  relief  physiological  reports  and  impairment"  of  a  1980).  sensitizing  awareness)  responses  a  to  have  elevated  scales  perception  obtain  general  inappropriate  for  have  a l . ,  in  symptoms.  failure  perceptions  to  a l . , 1976;  et  presence  pain,  Patients  found  to  conform pain  been  helplessness  been  et  of  1988).  and  Ransford  altered  somatic  disability  also  to  of  of  Craig,  who  lead  resulting  &  have  appear  have  catastrophic  hypochondriasis  a l l sorts  (heightened  sense  Waddell  and of  a  a l . , 1988;  model  on  and  treatments  Doxey,  &  disability,  signs  physical  symptoms  intensity ratings  (Reesor  and  hvpervigilance  pain  pain  hysteria  Uden  Pain  and  pain,  nonorganic  response  scores  sensory  impairment  cognitions  Incongruent  p.  pain  extent  of  physical  40). patients  maladaptive suffering)  proportion  (signs)  to  with  cognitions  may the  come  to  underlying  pathology-  The  maladaptive  cognitions  attention  to  tendency  the  hvpervigilance) Furthermore, the  patient  a  and  feels  condition.  reactivity  to  in  show  effective In  whereby  the  in  pain,  a  would becomes or  patient's  may  draw  and  the  chronic reduced  likely  nonorganic exhibit  to  whereby  (i.e.,  more  positive cycle  self-efficacy  pain.  anxious  effect be  in  of  exacerbating  significant  a  engage  established  more  s t r a t e g i e s , and  case,  to  state  be  s t i m u l i ) would  without  and  h y p e r s e n s i t i v i t y to  adaptation-level  coping  this  create  maintaining  An  patients  anxious  catastrophizing)  circle  more  painful  seen  scores.  (i.e.,  result  thus  be  (e.g.,  vicious  hypervigilant, pain  pain  to  could  signs,  low be  control  to  be who  anxiety established  pain  is  reinforced.  Summary  and  Two  Purpose  models  patients  have  of  been  of  altered  adaptation-level  led  to  prediction  more  reactive  most  or  In  to  a l l of  contrast,  than  people  chronic  stimuli  pain  because  they  model  has  because  higher  without  patients  they  standard chronic  will  or  pain.  model  will judge  be  Both  direct  distress.  to  the  less  reactive  painful  adaptation-1eve1  be  to  somatic  and has  will  tend  led  pain  model  patients  adaptation-level  stimuli a  that  pain  chronic  hvpervigilance  of  to  to  The  chronic  in  hvpervigilance  signs  that  relative  perception  the  attention  Investigation  to  prediction painful  pain  model.  painful  their  the  Present  presented:  the  the  the  stimuli of  predictions  pain have  been  supported  display  who  anxiety  patients in  report  These  of  adaptive  efficacious to  painful  to  assess  do  sensory  In  cognitions  and  report  patients  have  been  identified  incongruent display  inappropriate  their Signal  predictions models  sensitivity  to  of  pain  the  order  pain  and  has  general, high  symptoms,  to  be  Theory  rendered  and  has  more reactive  been  used  and evaluate  bias.  the  engage  less  separately  response  the  However,  h y p e r v i g i 1 ance to  levels pain  by  anxious,  appear  Detection  in  variation  less  who  greater  symptoms.  s t r a t e g i e s , are  control  methodological  conditions.  also  not  adaptation-1eve1  patients  pain  stimuli. the  pain  with  their  coping to  of  but  catastrophic  medically  who  research  types  regarding  intensity. display  past  different  patients of  in  However,  conclusions  amb i g u o u s . The  purpose  of  evaluate  whether  the  perception  were  presentations incongruent assessed pain of  or  of  present  i n v e s t i g a t i o n was  predictions by  pain  the  patients  symptomatology  congruent  of  with  (i.e.,  symptoms).  two  Pain  SDT  methodology  in  addition  threshold  and  self  of  the  pain.  Cognitive were  conditions expected  and  affective  evaluated  under in  report  which  chronic  in  hypopain  order or  with  pain  medically  perception to  subjective  define  was  measures  of more  of  experience the  pain  clearly  h y p e r r e a c t i v i t y to  patients.  of  different  correlates to  to  models  those  using  responses  be  met  the  pain  the can  39  Hypotheses  and  Because previous  Design  this  study  (Reesor  &  classification  without Reesor  incongruent control An chronic  be  individuals  differences.  This  represented  by  Rather,  two  be  was  a  expected  to  adaptation-level  conform  report  less  without that and  effective and  report  incongruent • the  medically  feel  less  able  to  yield  the  patient  selection  patients medically  the  with  conform  to  hvpervigilance  model.  The  anticipated  be  by  a  high  be  expected  different  of  medically  pain  the incongruent  model  threshold  to  symptoms  predictions  adaptation-level  group  patients.  congruent  the  pain-  would  pain  were  predictions  to  than  group  of  perception  expected  reflected  no  pain  that  significant  by  with  hypothesis  to  with  to  with  medically  to  those  were  and  accordance  with  general  and  symptoms  model  In  with  differently  pain  supported  Patients  those  anxious  the  because  of  adequately-  expected  heterogeneous  differentially  were  of  expected  models  presentations.  patients  respond  was  the  pain.  assessment  patients  to  a  laboratory  catastrophizing,  more  their  two  patients  i t was be  that  symptoms.  to  r e p l i c a t i o n of  research  patients:  prone  would  same  expected  than  partial  produce  pain  were  a  expected  findings,  manage  initial  the  of  more  group  pain  i t was  addition,  or  the  would  intensity  In  by  incongruent  symptoms  pain  symptoms.  free  groups  styles,  greater  to  system  Craig's  incongruent coping  1988),  medically and  involved  conducted  Craig,  distinguished  study  for  of  the  was pain  and  40  by  a  high  criterion  analysis.  This  perceptual  stimuli  standard expect  or the  criterion  a  report  because  to  report or  normal  low  threshold  the  the  The  for  pain  criterion  in  the  report  relative  to  medically  congruent  groups.  This  somatic  vigilance.  In  attention,  heightened  speculated  that  sensitivity  the  (d')  of  the  anxiety  would  be  have  than  one a  would  higher  the  to  'medically  sensations  was  expected  and  normal  because  and  pain  detection higher  be  reflected  incongruent  hypothesized  addition,  signal  to  of  internal  medically  analysis  because  judgements  model,  expected  detection  is  to  detection  groups.  signal the  this  group  was  to  signal  refers  sensations  model  the  observer's  From  control  hypervigilance  from  to  painful  from  model  congruent'  The  group.  the  relative  'medically  pain  pain  adaptation-level.  incongruent'  by  is  to  as  painful  to  be  control increased  of  research  on  sensitivity,  measure  relative  low  to  of  i t  was  sensory  the  other  two  groups. A to  3  X  2,  evaluate  group  the  subjects  2  consisted  with,  3  medically  groups  were  design  (i.e.,  only, &  age  causal  Stanley,  sex,  between  hypotheses.  control and  by  (i.e., of  those  chronic  incongruent and  Group  sex  back, p a i n symptoms,  matched.  r e l a t i o n s h i p s may Demographic  not  design  1 consisted  without  quasi-experimental)  1963).  groups  chronic  of  normal  yields  type  assessed  and  All of  correlational  interpretted  variables  Groups  without  respectively. this  used  pain).  patients,  Because  be  was  data  (Campbell included  41 age,  marital  status,  Experimental  conditions  detection  task)  (duration  of  subjective  socioeconomic  and  the  (ambient  factors  and  and  temperature  related  condition,  disability,  status,  to  medication physical  ethnicity.  during  chronic use,  a  heat  pain  surgery,  impairment)  were  also  assessed. The  dependent  measures: anxiety of  the  Worry in  affective,  was  assessed  and  patients  1985).  including  the  Strategy  Coping  1983).  Finally,  threshold indices  of  subjective  et  of  for  descriptions  (d') of  Intensity  three  pain using  the  pain, and the and  the  Experience with  signal  using  Scale 1985).  was  assessed  Scale  chronic  (Turk  &  &  pain  assessed  measures  response pain  Trait  pain  of General  (Spielberger,  (Rosenstiel  pain  groups  measures.  s t r a t e g i e s were  following heat  of  chronic  Pain  Questionnaire  sensitivity  a l . , 1979).  the  to  associated  coping  radiant  Sensory  Inventory  specific  using  the  and  a l l subjects  Cognitions  conditions  Scales  in  emotionality  pain  consisted  cognitive,  S t a t e - T r a i t Anxiety  the  Rudy,  variables  with  Keefe,  were  taken:  detection  bias the  (B),  and  Gracely  Affective Distress  Rating  (Gracely  42  METHOD Subjects All  subjects  Shaughnessy Normal  Site,  control  hospital  and  eligible  to  30  and  not  60  were a  trom  medication.  Back  Back  Pain  with  the  Pain  Clinic  pain  patients  Clinic Back  and  Pain  the  compensation  midnight (d)  out  from  a  were  ages  of  asked 30  back to  and  or  litigation  agreeable  to  abstain  night  before  fluent  self-report  their the  (e)  of  duration  years, with  of  a  pain  and with Of  a  the  Back back  medical  by  one  of  physician,  who  the  not  their  back  from  the in  in  study,  order  to  understand chronic  those  an  the  study:  medication in  met  involved  to  language  to  (c)  chronic  patients  (b)  ot  physiotherapist.  respect  English  longer.  and  The  assessed  participation  presenting or  pain  from  inventories  and  months  in  Hospital.  and  ages  associated  participate in  60  the  through  practice  psychologist, of  were  p r a c t i t i o n e r s or  general  the  regular  physicians  routinely  a  any  B.C..  oi  language,  assessments  general are  They  recruited  Shaughnessy  of  admissions  instructions, six  at  consisting  sufficiently  f i l l  were  claims  the  taking  consulting  patients  criteria  or  stait  between  English  comprehensive  specialist,  between  (c)  Clinic  Pain  Consecutive  pain,  from  (a)  Hospital,  Vancouver,  the  hospital.  the  pain  in  trom  were:  patients  referred  each  orthopaedic  (a)  pain  in  University  hospital  the  thev  chronic  the  recruited  to  tluent  conducts  specialists.  following  were  visitors  (b)  trom  general  participate it  years,  teams,  large  subjects  s u f f e r i n g from  two  recruited  who  pain  problem  volunteered,  43  six  were  atter they  omitted  the  time  were  levels  unable  The  mean  in  age  patients  of  second  data.  were  outside  by  thirty  in  were  control in  married  11%  and  Moore  working. people  This  or  of  the  reported  for  ninety three group.  40.3  years  30%  to  the in  pain  were their  on  on  the  1981  entire  were  employed  consisted  of  students,  work,  and  patients,  the  mean  homemakers  census  sample  percent  seeking  married  common-law  rated  based  (SD=7.8,  were  E n g l i s h as  the  groups  each  sample  was  index  index  group  of  involved  status  Seventy-two  was  contrast  (1987)  socioeconomic  in  because  stimulus  ot  subjects,  percent  while  each  medication  omitted  tour  total  females sample  took  were  the A  entire the  ot  task.  Socioeconomic  mean  the  pain  pain  c o n d i t i o n was  percent  Physical was  Of  others  any  and  they  not  and  was 28%  seeking  wo r k.  Of  Thirty  SDT  data,  the  because  three  Eighty-nine  Carroll,  unemployed  the  of  (SD=14.30). not  the  males  anglophones  The  43.22  of  68%  language.  Blishen,  and  relationships,  whom  relationships. Caucasian  in  years).  common-law  sample  distinguish  valid  numbers  range=30-59 or  to  produced  equal  the  speciiied  administered  subjects with  trom  reported  impairment  assessed Waddeli  below.  The  (i.e.,  loss  by  and  the  9.0  years  having  (i.e.,  according  (1984)  which  measure  yields  a  are  previous  Mean  to  of  percentages  of  years').  surgery. limitations)  criteria  described  percentage  duration  range=.5-38  objective structural  physicians  function).  (SD = 9.3,  undergone  Main  of  self-reported  more  outlined thoroughly  bodily  impairment  for  sample  the  ot  44  pain  p a t i e n t s were  14.3% (SD=5.54)  (SD=8.2)  f o r women.  measured  by t h e O s w e s t r y  below.  Mean  was  28.56%  The  above  and  percentage  (SD=12.73) values  subjective Craig  Self  report  f o r t h e men  Disability  Inventory  who  also  of s u b j e c t i v e d i s a b i l i t y (SD=14.74)  forobjective physical  (1988)  are similar assessed  15.36%  of s u b j e c t i v e d i s a b i l i t y  and 38.63%  disability  and  pain  described  f o r t h e men  f o r t h e women.  impairment  to those  was  and  obtained  patients  from  by  Reesor  t h e same  facility. Medication effect Sixty  was  rank,  on t h e c e n t r a l five  percent  regularly. analgesics  psychotropic reported breakdown patients  nervous  percent  8% r e p o r t e d  and n o n n a r c o t i c  taking  opiate  of type  according  system  o f t h e sample  Fifteen only;  ordered  denied  reported taking  analgesic  i n Table  of  anxiolytic  or sedative  no  medication  taken  et a l . , 1985).  taking  taking  action;  medication.  Of i n t e r e s t  medication  f o r a l l four  with  a  combined  a n d 12%  The  f o r t h e sample 2.  medication  nonnar c o t i c  medication  analgesic  of medication  i s presented  (Yang  t o the s t r e n g t h ot  of  percentage pain  i s the absence  and t h e p r e p o n d e r a n c e of  groups.  45  Table  2:  Percentage  of M e d i c a t i o n  Use  by  Patient  Congruent Medication Anti-inflamma Analgesics  Males  Analgesics  exacerbating  6.2  0  6.2  6.2  12.5  31.2  14.3  0  0  14.3  56.2  56.2  42.8  62.5  and  subjects  was  secondary  secondary  factors),  i n Table  Primary  14.3  group  Primary  3.  18.8  0  Medication  Table  F ema 1 e s  6.2  Antidepressants  listed  Ma 1 e s  0  Opiate  per  Fema 1 e s  31.2  Relaxants  n-15  3.  missing  diagnostic  as d e t e r m i n e d  I t should a  be  primary  categories by  noted  chart that  diagnosis  and  (and/or  review,are  one  of the  15 w e r e  not  given  diagnoses.  Percentage Sample  Breakdown  Diagnoses  Clear Findings or P a i n Out o f P r o p o r t i o n to Pathology Mechanical Back P a i n Facet Joint Related Degenerative Disc Nerve Root Irritation Soft Tissue Injury Spondylosis Bursitis/Fibrositis Spondylolithesis Lumbarization Disc Protrusion  of Diagnoses  i n the P a t i e n t  S e c o n d a r y D i a g n o s e s &/or Exacerbating Factors  No  n=59  Incongruent  t o r y/  Muscle  No  Group  25 . 4 16 . 9 1 6. 9 1 1. 9 6.8 6.8 6.8 3. 4 1.7 1.7 1.7  Physical Deconditioning/ Inactivity/Obesity Facet Joint Related Degenerative Changes Discogenic Problem P a i n Out o f P r o p o r t i o n to PathologyArthritis Depression/Alcohol Abuse Spinal Stenosis/ Calc ificat ion Mechanical Back P a i n Psychological Overlay Nerve Root Irritation Soft Tissue Injury n=4  5  35 . 6 1 1. 1 1 1. 1 6. 7 6.7 6.7 6.7 4. 4 4.4 2 2 •) .2 2 2  46 Group The group,  Assignment  subjects  and  assigned  two  to  (Waddeli  et  (Ransford Symptom  Back  part  patients 20  were were  the  assessed  for  Pearson  correlation  measure  indicated  JJ<.00 1)  which  is  (1988).  The  Pain  (1976)  scoring  a  research  coefficient. the  form  of  Drawing  scored  an  inappropriate  to wa  two  as  calculate Inappropri  interview were  non-organic  i  by  assigned  were  and  Dy  s  fty  five  with  the to  a  is  included  44  of  the  Of  these  by  this  ( r = . 77 , and  (n= 3 3)  of  the  Craig et  a l .  these  author  reliability  Pearson  which The  Ransford  raters,  a  44  on  Reesor  the  percent  as  physicians  score  in  60  reliability.  using  Symptom  C).  physicians  reliability  Interrater  ate  the  total  independent  d  Inappropriate  only  obtained  scored  Signs  Drawing  measure.  nterrater  medically  (Appendix  measure  the  were  Physical  independent  on  that  or  the  interrater  ent  control  patients  Pain  1984)  this  two  p h y s i c a l s i gns  symptoms  the  B),  this  of  Fi  by  y  assistant.  The  Patients more  adequate  criteria.  D<.001)  b  coeffici  similar  were  A),  assessment, on  calculation  drawings  (r=.96,  clinic's  Pain  assessed  A l t h o ugh  normal  Nonorganic  a 1.,  we r e  assessed  allowed  female  et  signs  the  the  a  congruent  (Append ix  (Waddeli  Clinic. of  of  (Appendi x  a l . , 1976)  Pain  patients,  basis  physical  gro ups.  (medical ly  a l . , 1980)  Inventory  routine pain  the  groups:  three  patient  groups  on  et  Nonorganic the  pain  two  incongruent)  formed  was  and high  correlation  Inventory  was  given  in  experimenter. the  incongruent  were  reported;  present; or  group 3  or  patients  i f 2  or  more scored  5  or  47  greater (1976)  on  the Pain  scoring  system.  congruent  group  precedent  for this  Craig  (1988)  reported according  Pain  from  system.  indicated  pain  three  measures  presentation  (Reesor measures  Table  & Craig,  been  1988).  correctly  & Craig  presentation  verbal  found The  report,  of  of the  three  the pain i n  symptom  pictoral.  t o be m o d e r a t e l y  Among  Measures  these  i n Table  The  three  4.  of Incongruent  Non-organic Signs  or  correlated  r e l a t i o n s h i p s among  Relationships  report  modes o f  and  are presented  Non-organic  and  assigned  one  different  study  Measure  The  as p o s s i b l e .  i n the present  4:  to the  classified  (1988)  i f at least  three  a l .  s e t by R e e s o r  i n d i c a t e exaggerated  but i n v o l v e  have  was  et  function analysis,  were  as d i s t i n c t  behavioral,  measures  assigned  criteria.  system  group  an a b n o r m a l  the groups  communication: three  these  Reesor  measures  t o keep  were  a discriminate  to the incongruent  All  of  85% o f t h e p a t i e n t s  to this  to the Ranstord  patients  classification  patients  order  according  i n the absence  who,  that  Drawing  Pain  Inappropriate Symptoms  Pain Drawing  Signs  Inappropriate  Symptoms  -15 ( 44 )  Pain  Drawing  Score  .43*  .41)**  (44)  (60)  * p <.01 ; * * p < . 0 0 1 Of  note,  the Non-organic  Physical  correlated  with  the Pain  Drawing  correlated  with  the I n a p p r o p r i a t e  Signs  were  but were Symptom  not  moderately significantly  Inventory.  The  Pain  48  Drawing  and I n a p p r o p r i a t e  Table exceeding  5 lists each  group  by s e x .  Table  5:  Svmptoms  the percentage  criterion  within  Percentage Occurrence I n c o n g r u e n t Group  Sex  Non-organic S i g n s (>1)  were  moderatelv  occurrence  ot p a t i e n t s  the medically  of C r i t e r i a  correlated.  incongruent  Within  Inappropriate Symptoms ( > 2 )  the  Pain Drawing Score ( >4 )  Males  13  73  40  Females  33  80  73  n= l 5 Table medically of  6 represents incongruent  the c r i t e r i a .  group  Only  measures  were  subjects  met a l l t h r e e  data, of  more  women  only  nonorganic  than were  symptoms,  those  satisfied  patients  criteria men  met  signs  f o r whom  incongruent'  only. seven  Of  three  few o f t h e  those  were  i nthe  a l l three  b u t , as i n Reesor  on t h e b a s i s  a n d one on t h e b a s i s  Very  as i n c o n g r u e n t  criteria,  patients  o n e , two, o r  two o f t h e t h r e e  classified  physical  one o f t h e t h r e e  'medically  who  of pain  available are included.  the patients  the  the percentage  and  Craig's  criteria.  None  on t h e b a s i s o f identified  classified  by-  as  of the i n a p p r o p r i a t e  of the pain  drawing.  49  Tabic  fa:  Percentage  ot  Patients Number  Sex  Three  Males  Females (Males,  n=8;  Meeting  ot  Incongruent  Criteria  Two  One  0  25  75  15  69  15  Females,  Criteria  n=13)  Equipment Radiant  d e l i v e r ed  was  by  a  ( W i l l i a m s o n D e v e l opment  Dolorimeter calibrated  heat  using  Stimuli  were  patches  of  forearm  (four  a  india on  t o one to  ink. a p p l i e d each  Co.).  Sc i e n t i f i c  Fischer  administered  Hardy-Wolff-Goode11 The  Digital  dolorimeter  was  Thermoprobe.  of  eight  2.0  cm  diameter  the  volar  surface  of  each  arm).  S t imu1i The  stimuli  determined subjects groups  (i.e.,  used  recruited paid  was  pilot  for  form  the  SDT  SDT  involving  patients),  of  the  by  D), a  faint  experiment  were  a  20  age  group and  These  After  pain  staircase  of  sex  and  completing  of  to  to  the  were  Hospital  threshold  method  normal  matched  subjects  Shaughnessy  participation.  (Appendix  determined  the  experiment.  staff  their  for  study  non-pain  i n the  from  $5.00  consent heat  in a  selected  were  the  radiant  threshold  50  determination. stimulation pain  at  which  to  the  Hardy,  threshold  a  for  Method"  this The  (Dixon  accurate  the  increments  until  is  continues  in  this  Thresholds familiarized  faint  that pain  this  males  average  selected subjects. pain  for  the  and  the  These  on of  can  There  SDT  and  the  experiment  four  stimuli  that  two  be  253.14  (J^=.02,  1952, the  pain"  is  the  fast  easily  "Up-Down  and  involves  intensity  the  is  of  reported.  stimulus  The  changes  after  the  first  intensity an  level  accurate  subjects and  had  the  faintly  been  level  of  painful.  mcal/sec/cm  -  The  (SD=26.50,  significant  difference  p>.05).  the  On  basis  range,  four  stimuli  which  were  administered  spanned were  p.  calculated.  after  no  second  unit  responding,  to  of  mcal/sec/cm  final  stimuli  was  a  i t  trials  the  be  of  was  females  such  six  reported  threshold  threshold  Based  threshold  range=215.0-302.5). between  of  range  they  The  intensity  determined  the  10  pain  threshold  with  in  stab  that  called  Briefly,  no  pattern  were  is  of  Goodell,  "pricking  until  until  &  level  small  three  provides  reported.  manner  the  pain  stimulation  the  a  the  reported  used  intensity  recorded. and  of  Wolff,  and  to  very  of  (1952)  threshold.  is  end  called  1969)  decreased  which  estimate  (Hardy,  sensation,  pain  in  administered  exact  Goodell  stimulus  then  are  and  of  direction  reversal  the  Massey,  estimate  stimulus  at  refers  sharp,  s t a i r c a s e method  &  increasing  threshold  "distinct,  stimulus"  Wolff,  identified.  mean  pain  ( i s ) experienced  exposure 81).  Faint  the  above  average  and  two  of  were to a l l  'normal'  below  in  51  addition  to  encompassing  the  range.  Stimuli  intensities  were  2 spaced 210,  at  equal  240,  270,  likelihood four  and  that  stimuli  (1952)  intervals  the  for  reported  pricking  300  (30  mcal/sec/cm*"  mcal/sec/cm".  pain  threshold  a l l the  subjects.  that  would  and  was  increase  be  to  spanned  Hardy,  is  Back  Pain  were:  by  Wolff,  just  the  these  and  noticeable difference 2 7 mcal/sec/cm on average.  pain  the  This  apart)  Goodell  tor  Procedure The  consecutive eligible  days.  patients  requirements during were it  the  same  the  they  the  series  of  four,  2  cm  forearm. report  day  consent part  one  i f they of  in  hour  events.  While  was  the  on  dried,  followed  by  the  for  the  the  subject's  skin  of  the be  the  volar  pain  an  was  participate who  asked  to  used of  to  information  and  was  Symptom  paint  self-  then Inventory  While  (Appendix taken.  the  each  the  was  return  day.  completed  task  agreed  underwent  surface  interview.  temperature  to  following  condition  perception  two  and  Those  and  ink  subjects  of  study  subjects  india  the  E)  over  assessment,  willing  Inappropriate  form  pain  assessment  assessment.  Demographic their  in  would  study  First,  to  given  about  experiment,  spots  these  day  (Appendix  related  instructions the  their  form  their  first  informed  questionnaires.  collected,  read,  the  diameter  information  which  During  asked  took  During  conducts  were  second  given  when  and  Clinic  the F)  were  52  Atter an  hearing  ascending  describe  the  series  the  ot  the point  perceived,  i t was  that  we  required  hint  of  prickly of  sensation  pain.  the  subject  had  c o n f i d en ce  trying  to  subject  using  study.  This  which  faint them  to d e t e c t .  presented  more  When  this  was  I t was heat  randomly  in a  they  stressed and  the  t o be  what  that first  the  stimuli  faint  relatively  knew  was  the  presented  the reported  responded  they  sensation  i s considered  around  that  to v e r b a l l y  prickly that  given  pain  consistent  they  were  detect.  Threshold  of  asked  were  experiencing.  which  Several  level  and  were  to d i s t i n g u i s h between  were  fashion  a to  them  intensities until  and  were  at which  wanted  were  beginning  they  emphasized  they  a  stimuli  sensations  identified  'signal'  instructions, a l l subjects  the  for faint  pain  was  t h e Up-Down.Method was  followed  four  by  stimulus  then that  the  determined was  signal  levels  used  f o r each  i n the  detection  selected  pilot  experiment  ( 2 1 0 , 240,  270,  and  2 300  mcal/sec/cm*") from  random  blocks  of  eight  the p i l o t stimuli  study  each.  were  administered  Twenty  trials  administered  f o r each  stimulus  intensity  experimental  trials.  Prior  the a d m i n i s t r a t i o n  experimental  trials,  were  administered  (Appendix  G).  with  second  to  a  12  move  rotating  the heat among  4 practice  making  The  to  a  duration  total of  interstimulus gun  trials of  each  the eight  per  16  locations  and  spot the  was  total of  of  80  the intensity  trials 3  seconds  subjects  f o r each  10  were  stimulus  stimulus  on  a  practice  interval  to a d i f f e r e n t  making  in  were  trial,  forearms.  On  told thus  each  53  trial,  subjects  whether  they  exposure  to  Upon rated on  the  felt the  the  the  were  required  pain  or  stimuli  most  intense  Gracely  Rating  (Appendix  paid  The Signs the same  Pain  were  two  series  information  events  relevant  author  assistant assessed  35.  the  means  SDT  Measures  of  in  by  pain  of  the  designating  below. called  they  chronic  assessed  There  Initially,  included  Normal  except to  thoroughly  collected  sample  The  during  experiment and debriefed  Nonorganic  Pain  Clinic  Control  pain  the  subjects  participation.  of  did  complete  task,  thoroughly  their  to  minutes.  intensity  were  Back  to  as  not  Physical  Staff  Group  underwent  complete  conditions  during the  any  (consent  form,  I).  The  data  of  the  30  perception  Assessment  by  assessment.  for  decision  time  was  sensory  subjects  and  administered  day  Appendix  Drawing  binary  received  of  $20.00  a  task  pain  stimulus  Finally,  and  SDT  the  Scales  make  Approximate  the  of  unpleasantness. H)  not.  in  completion  to  'hits'  trained were  each  in  no  the  while  systematic  and  as  the  and  stimulus  used  'false  assessed  t-tests  on'  signal  those  to  be  as  the  above  'painful'  judged  to  be  by  detection  Response  alarms'.  intensities  judged  and  was  procedures the  threshold  study  research  between  the  pain  female  differences  and  average  a  experimental  experimenter  threshold  pilot  Stimuli  subjects  Discriminability  'hits'  two  25  Bias  for  the  cutoff By  this above  indices.  nonpatient  point  design,  for  the  threshold this  'painful'  level  below  study and  two  were  this  54 level  were  considered  cutotts  were  alarms'  in  beta  set  order  measures,  two  additional  and  the  level  other  and  be  the  that  D a i n i u l  'hits'  cutott were  were  the  stable three  three  'talse  senarate  Again,  stimuli  above  stimuli  to  be  method,  presence  or  ot  This  research.  The  use  comparison  level  highest  level  stimulus  judged  to  be  paintul  that  were  the  alarms'. and  less  These  beta  below  measures  measure  averaged spread  tor  each  measures  were  out)  stimuli i t was  the  allows  a  the  tor  on  bv  possible signal an  which the  than  anv  ot  assess  to  on  the  pain consistently  the  basis  ot  important ot  sets  basis  assumptions  the  to  chronic  application  method,  baseline) to  ot  was  s t u d v  represents  in  this  exactly  This  stimulus  to  this  absence  innovation  contorms  The  considered  resulting  paintul  methodological  Cor  beta.  were  d'  and  and  themselves.  group.  ot  one  the  purpose  control  be  and  d'  cutott  'talse  skewed  by  the  to  oroduce  ( i . e . less  that  specitied  judged  to  this  a  d'  the  'talse  original  lowest  three.  comparison  task.  the  lower  subjects,  SDT  tor  and  vs  a  measures  additional  and  the  levels  patients  group,  with  stimuli  ot  the  along  Two  'hits'  three  judgements  the  ot  between  relative  specity  alarms'.  detinition  c u t o t t s were  measures  Given  the  considered  By  be  calculate,  averaged  subject. more  to  were  and  then  tor  to  a  ot and  unambiguous  SDT  to  pain  tixed the  coioarison  requirements  interpretation  ot ot  / the  d's  and  betas  investigations  ot  i n a manner oain.  not  reallv  possible  in  past  SDT  55 Because cutott terms d'  the  the  D o i n t s ,  ot  the  measure,  the  more  in  subject  was  able  and  tirst  instructions  taint  to  pain  ot  in  ot  pain  background  beta,  sensations  such  that  the  needed  Measures  Impairment  1)  The  Physical  (Append i x  limitations  to  in  made.  The  ot  how  stimuli  constant  higher  set  the  were. well  discriminate  retlect or  to  the  between  levels  in  heat  and  this  the  the  greater  detect  noise  tendency  lower  to  the  (i.e.,  tirst  trace  heat).  report  criterion  stimulus  sensitivity  The  pain  set,  the  less  paintul.  Disability  Impairment  impairment  or  loss  pathophysiological percentage  a  interpretab1e  judgements  sensory  the  and  to  c o n s i s t e n t l y d i s t i n g u i s h heat  levels  call  relative  Index  (Waddell  &  Main,  1984)  J).  Phvsical  evidence  to  are  is  ret l e c t i o n  held  to  ot  reflects  stimulation  ot  the  Because  were  stimulus  stimuli  judgements  interpreted  ditterences  criterion,  measure  pain.  to  a  d'  is a  ability  is  the  consistent  subjects the  ot  d i s t i n g u i s h or  trace to  upon  ot  judgements  investigation, trom  averaged  consistency  Consistencv  the  ju d g ements  ot  the  tracture,  compression, distraction.  and  ability  pain  objective  because The  impairment  leg  combination  raising  is  time  physical  provides  based  ot  with  or a  o n objective  pattern,  signs both  structural  anatomical  measure  surgery,  ot  ot  which  pattern,  previous  straight  This  to  abnormality.  physical  including  previous  ot  refers  presence  ot  root and  without  characteristics  was  56 selected  bv  analvsis  which  ot i  Waddeli  ranged  1984).  them  patient  sample  (jr=.94)  as  Pearson  correlation  measure in  (n=11).  the  as  following  yielding  to was  the  best  same  as  that  ot  agreement  study  overall  regression  each  completed  present  coetticient.  the  the  tor  100%  a  on  total  This  reported  41%  ot  was  ot  by  the &  two the  high  scores  level  prediction  (Main  bv  Interrater reliability  c a l c u l a t e d on  was  77  trom  This  examiners  reliability  (1984)  Interrater reliability  characteristics  independent  Main  identiiied  impairment.  Waddeli,  and  using  a  interrater  Reesor  &  Craig  ( 1988).  2)  The  Oswestrv  (Fairbank,  Couper,  Disability tunction  due  inventory  ten  to  bv  everyday  living  personal  care,  sexual  one  increasing vield  a  pain  back the  back  social  six  measure  to  walking, lite,  ot has  and  (Appendix  report  This  selt  which  everyday  pain  problem.  assess need  Questionnaire  1980)  subjective  statements ot  O'Brien,  back  which  litting,  Disability  problem.  patient's  including:  levels  pain  the  extent  scales  percentage  This acute  ot  and  a  activity,  endorse  Davies, to  the  separate  Back. P a i n  reters  assesses  compromised ot  Low  ditterent  tor  each  disability.  The  area  inventory  reported  disability.  been  tound  reflect  problem  and  to  be  stable  activities It  are  consists ot  medication, sleeping,  Patients  reflecting  selt  to  ot  report  standing,  travelling.  in  loss  areas  analgesic  sitting,  ot  K).  is  scored  recovery  (i.e.,  trom  to  an  test-retest  57 jr=.99)  reliability, 1980).  Reesor  extensive  (1990)  from  demonstrated  al. ,  1980) .  physical  and  They  reported  half  of  the  Waddell  that  Self 1)  Report The  1979)  Subjects and  of  ratio  13  which  has  et  objective  can  accounts also  measure  (Fairbank  that  disability  be  compared.  for less  than  includes  i n chronic  Scale  (Gracely,  the  most  painful  u n p l e a s a n t n e s s on to  the  scales  and  been  preferred  that  f o r which  (Gracely  over  psychophysical  the  administration  descriptors  demonstrated  /  The  pain.  Dubner,  &  McGrath,  L).  been  their  pain.  suggested  impairment  involved  discriminate  consistency  subjective  disability  Rating  rated  retrospective has  back  to  Measures  (Appendix  scale  have  (Fairbanl; ct a l . ,  Oswestry  internal  physical  factors  Gracely  intensity  the  minimal  (1984)  and  reported  psychological  or  to have  impairment  conditions  reported  moderate  been  Main  in chronic  other  et  have  stimuli Gracely of  been  and  properties  rating  (Chapman  Scale  scales  Each  i n the  validity  These  et  i t s sensory  stimuli.  quantified  a l . , 1979). of  to  Rating  a l l the  reliability  types  as  have  scales because  a l . , 1985).  form  have of  58 2)  The  1983)  Coping (Appendix  cope  is  that  patients  with  Questionnaire  a  pain:  42  item  diverting  praying  a c t i v i t i e s ,  reinterpreting  sensations, of  pain  a b i l i t y  and  or  and  measures  coping  (alpha  the  internally  The has  factor  been  patient this  is  cross  (total  investigation,  coping  strategies  includes  sensations,  coping It  active  use  of  manage  pain.  their  on  =  self  .71  Keefe,  the five  factor  strategies dimension  inter-item  a l . ,  that  1983).  Questionnaire  chronic  pain  1990). of  f i r s t  From  cognitive  component  ignoring  pain  reinterpreting  reflecting coping  of  decrease  Keefe,  the  decrease  a  pain  conscious,  "processes"  identified  consisting and  &  the  two  indicating  scales:  or  to  Strategy  et  and  also  high  .85)  The  as  ignoring  are  structure  statements,  control  is  d i f f e r e n t  (Lawson  strategies  self-  a b i l i t y  Coping  characterized  to  There  -  the  behavioral  (Rosenstiel  following  second  seven  coping  There  recommended.  component  a b i l i t i e s  of  three  the  was  The  pain.  n=620)  cognitive  se1f-eva1uative of  a  was  i d e n t i f i e d  sensations.  &  assesses  sensations,  e f f i c a c y :  reliable  validated  samples  pain  coefficient  structure  of  increasing  the  control  that  one  attention,  hoping,  strategy to  using  catastrophizing.  correlation te s t  questionnaire  report  statements,  pain  (Rosensteil  M).  This frequency to  strategy  refers  to  patients' the  pain.  to a  ratings The  / third  factor  represents  coping  and  relate  coping  strategies  to  scales  r e f l e c t i n g  passive  the  s p e c i f i c  cognitive  ( i . e . ,  praying,  hoping,  styles  content  and  of  diverting  of the  59  attention  to other  books).  I t was  separate  measures  the  above  three  behavioural these as  more The  since  and  conditions Reesor  Thev  be  scale  behavioural  (Keefe  & Craig,  which  1988;  been  1986;  Rosentiel  i s not as  treated  related  surprising  (Lawson  t o be  since  as  being  1990).  related  to the  in chronic  e t a l . , 1987;  & Keefe,  to  constructs  et a l . ,  to pain  Keefe  as  assessing  cognitive  tound  adjustment  & Dolan,  be  music,  i s characterized  tactors  has  scales  are the scale  characterized  ot e m o t i o n a l  games,  not c o n s i s t e n t l y  s t r a t e g i e s , which  catastrophizing  emotional  two  were  catastrophizing  retlective  as m e n t a l  that  thev  tactors.  cannot  and  such  recommended  coping  reallv  such,  matters  1983;  and  pain  1989; Turner  &  Clancey,1986).  3)  The  Pain  Experience  Scale  (Turk  & Rudy,  1985)  (Appendix  N ). This  is a  19  item  s e l f - r e p o r t inventory  assess  the cognitive-eva1uative  Factor  analysis  emotionality  scale  about  the pain  worry  scale  concerns (e.g., (two  p<.001  a b o u t ^how  =  =  "This .74,  the pain  about  my  scale  two  to chronic  reliable  scales:  an  p<.001) r e p r e s e n t i n g  pain  i s d r i v i n g me  distress  crazy") long  Test-retest  ( r =.89,  respectively)  to cognitive-behaviora1  p. and  <.001  life  reliability  and  the s c a l e s  treatment.  and a  term  i s a f f e c t i n g the p a t i e n t ' s  family").  to  pain.  .91,  p<.001) r e p r e s e n t i n g  i n t e r v a l ) i s high  f o r each  sensitive  (alpha  (e.g.,  (alpha  "I worry  week  has r e v e a l e d  reaction  designed  r  =.81,, are  60  4)  The  S t a t e - T r a i t Anxiety  Inventory  (Spielberger,  1985)  (Appendix 0 ) . Onlv  the ' T r a i t '  administered. statements anxietv  and  The  i s an  has h i g h  construct  measure  validity  subject)  consistency,  anxiety  status)  testing  analysed  status)  were  This  characteristics.  absence  of previous  nonparametric  were  the respondent i s  the degree  to which  test-retest  each  The  reliability,  t o be a n e x c e l l e n t  impairment,  analvsed  using  was  using  3 X  by  X s e x ) ANOVAs.  by  ethnicity,  using Chi  or  using  (duration  o^f t h e  percentage  of s u b j e c t i v e  group  (room  each  (presence  analysed  medication,  and p e r c e n t a g e  nature  an a n a l y s i s of  data  data  of  status,  separately  again  Interval  (pain  (group  (marital  Categorical was  2  in  conditions  temperature  followed  of a n a l g e s i c  2 X 2  continuous  and t e s t i n g  analysed  surgery)  statistics.  strength  were  variables  patient  physical  o f 2U  1978).  and s k i n  first  demographic  statistics.  condition,  (Buros,  v a r i a b l e s which  during  employment  Square  consists  was  Analysis.  were  Categorical  indicates  and i s c o n s i d e r e d  and s o c i o e c o n o m i c  temperature  to which  measure  d e s c r i p t i o n of h i m / h e r s e l f .  internal  Demographic  and  subject  of t h i s  inventory  the degree  accurate  of t r a i t  Statistical  (age  self-report  to assess  prone.  statement scale  This  portion  pain  of  disability)  s e x ) ANOVAs.  Dependent groups:  pain,  measures  were  group  analysed  as  were  (group  (group  analyses, because  by  i t was  distinction  threshold assessed  was  i t i s considered  detection  measures,  and  measures were,  Gracely were  Rating  measure beta,  subjective  (jr=.58,  sample, pain  where  measures  were  analyzed  five  cognitive  cognitive  strategies, same  pain  were  Then to the  group i n  i n an  set of s t i m u l i . with  1987).  ANOVA  In  the  signal  The  remaining  s e t of  stimuli  multivariate analyses. I n t e n s i t y and and a v e r a g e d  rating'.  The  entered and were  SDT  pain  into  T h e mean  The  Unpleasantness as they  a  were  composite i n d i c e s , , d' and  threshold  a MANOVA  followed  up  of the  along  with  by u n i v a r i a t e  of the three  d' and  beta  similarly. variables  (cognitive  se1f-efficacy, behavioural  and c a t a s t r o p h i z i n g ) were  questionnaire,  pain  In the above  t h e same  t o t h e mean  appropriate.  content,  the c o n t r o l  p_<.001) t o p r o d u c e  rating  analyses  ^he  into  to z-scores  'subjective  control  from  patient  according  s e D a r a t e l v  (Clark,  of S e n s o r y  calculated relative  normal the  converted  of  entered  Scales  correlated  and b e t a  pain  ( n = 3 0 ) on  groups  t o be r e d u n d a n t  a l l derived  therefore,  first  highly  were  d*  The  of v a r i a n c e .  of v a r i a n c e . analysed  three  the e n t i r e  group  with  on a s e p a r a t e  addition,  pain  first,  as s e p a r a t e  into  measures.  sex) analyses  by s e x ) a n a l y s e s  pain  conceptually  to the c o n t r o l  analysed  ' congruent/incongruent' 3 X 2  divided  follows:  compared  in 2 X 2  patients  were  c o g n i t i v e , and a f f e c t i v e  ( n = 6 0 ) was  measures the  measures  the Coping  processes, coping  a l l derived  Strategy  from  Questionnaire.  the These  62 tive  v a r i a b l e s were  MANOVA  which  The  the  followed  atiective  ANOVAs. Anxietv  was  This  was  was  The  only  above  correlational descriptive measures  were  Scale,  medical  i n order  who as  a post  subgroups  had r e c e i v e d  complaining detectable females) groups, patients  no  were  of s u b j e c t s .  who  diagnosis  apparent  organic  identified. numbers  had r e c e i v e d  randomly-selected. above  were  Pain  completed  The on  conducted  m e a s u r e s ot  on  t h e Back  pathology  was  between  three  p a t i e n t s were  from  in a  dependent  measures.  a final  equivalent  and  the dependent  Eighteen  was  the dependent  the three  h o c a n a l y s i s was  pathology.  among  measures  that  selected  Pain  o r who  Clinic  were  "out of p r o p o r t i o n "  such  patients  (9  to the  males;  In o r d e r  to form  comparison  of normal  control  subjects  clear  first this  organic  series new  and  by a s e t o f  at the data  among  of discomfort  groups  as r e l a t i o n s h i p s  impairment  State-Trait  two m e a s u r e s ,  followed  to look  and the r e l a t i o n s h i p s  exhibiting  were  Interrelationships  i n c o n g r u i t y and  (The  separate  groups.  analyses  as w e l l  bv s e x )  i n three  to a l l three  yields  of analyses  examined  Finally, selected  which  series  disabi1ity/physica1 measures,  analysed  administered  group  analyses.  one o f t h e m e a s u r e s  to the patient  way.  (pain  by u n i v a r i a t e  because  Experience  administered  a 2 X 2  into  v a r i a b l e s were  Inventory)  Pain  entered  diagnoses  of analvses  grouping  9  and  pain  were described  of the s u b j e c t  pool.  63  RESULTS  Analysis  oi  Demographic  Continuous (SES),  were  demographic  analysed  signiticant  main  variables.  Testing  temperature) ditterences the  7:  using  eiiects  were were  demographic  Table  Variables. data, 3  or  X  age  2  and  (group  bv  interactions  conditions  similarly  (room  analysed  revealed.  Means  v a r i a b l e s are  sex)  emerged  on  and,  no  again,  standard in  skin systematic,  deviations  Table  Deviations:  No  these  and  and  status  ANOVAs.  temperature  presented  Means and S t a n d a r d Demographic Data  socioeconomic  tor  7.  Continuous  Group  Control  Congruent  Males  Incongruent  Females  Males  Pain  Variable  Males  Age (years) x sd  41.4 9.0  39.4 8.6  38.1 5.6  43.7 8.0  39.6 7.8  39.8 7.8  46.1 14.2  49.8 11.9  43.8 14.4  38.0 17.0  42.8 14.4  38.6 13.8  SES  Females.  Pain  Females  3  x sd  _n = 15 (a)  per  cell  higher  scores  Categorical employment Square  revealed in  data  status)  statistics.  marital  than  refer  status that the  higher  (marital  were A  to  patient  status,  analysed  by  significant  [ X " ( 2 ) = 11.97, more  levels  subjects groups.  No  the  SES  e t h.n i c i t y ,  group  group  p_< . 0 1 ] . in  of  and  effect  by  significant  sex  was  Examination  control  and  group group  using  found of  were  the  Chi  for data  single  effects  were  64  tound  tor  ethnicity  ditterences percentage  on  of  breakdown  demographic  Table  any  and  8:  data  is  employment  the  :  by  above  group  presented  Percentage  Breakdown  status  and  variables  and  sex  in  Table  of  no  sex  emerged.  for  The  categorical  8.  Categorical  Demographic  Data  Incongruent  Pain  Group  Congruent  Control  Variable  Males  Females  Males  Pain  Females  Males  Females  Mar i t a 1 Status (S i n g 1 e )  73  67  27  33  40  27  Ethnicity' (Caucasian)  100  87  80  100  100  93  33  33  33  40  Unemployed n= 15  per  20  cell  Analysis  of  The  Patient  patient  parameters (presence  of or  groups pain  absence  of  using  effects  emerged  of  condition,  Chi  from  objective  disability)  ANOVAs.  It  were  should  noted  to  Interval  or  data  sex  were main  (duration  medication,  using that  the  data  surgery)  group  impairment,  analysed be  No  analgesic  physical  respect  back-related  analysis. of  with  Categorical  statistics.  strength  subjective sex)  previous  this  of  assessed  conditionsi  Square  percentage  bv  were  their  analysed  pain  Characteristics.  2  54%  and  percentage  X  (pain  of  2  the  group  data  for  ot  65  the  measure  physicians the  No for  the  physical  did  means  addition  of  and to  not  complete  standard  the  results  duration  the  consumed, However,  and  found  were  Examination patients  of  incongruent  disability. functional  In  condition (Waddeli  have et  by  incongruent  Moderate  been  1984;  medical  (Waddeli  exception  of  and  the  The  relationships  that  Non-organic  Of  significantly  note,  correlated  of  for  both  comparison  to  to patients  more  found  group  disability.  symptoms,  were  found  physical  reported  function  &  has  in  were  functional  report  more  males.  to  of  been  the  a  1988).  of  in &  Craig,  Impairment  Craig, are Index  Drawing  and  1988).  measures  Impairment  study  as  previous  these  &  severity  condition,  Reesor  (Reesor  of  pain  function,  evaluated  among  back,  The  pain  loss  Pain  low  measures  the  present  the  to  Physical  Signs  Physical with  as  1984;  reported  the  due  Craig,  a l . ,  Physical  the  also  in  analyses.  strength  in  9  variables  subjective  females  between  found  lists  of  subjective  were  Table  effects  that  severity  et  the  interactions  congruent  Reesor  signs  because  main  measure  of  and  above  objective  referred  the  correlations  10.  than loss  objective  the  Table  the  between  investigations  of  symptomatology  also  a l . ,  relationship measured  of  or  revealed  addition,  the  univariate  degree  the  missing  conditions,  medically  disability  Measures  pain  data  exhibiting  of  significant  for  the  the  was  examinations.  effects  and  impairment.  with  of  main  of  the  deviations  significant  medication  sex  impairment  or  with  Index 1988).  presented is the  not Non-  in  Tabic  8.  Patient  Characteristic:: Pain  Congruent  Variable  Males  Females  Means  and  Univariate  Croup  Source  Incongruent  Males  Analyses  Croup  Females  F C1 ,56)  Sex  p  F(l,56)  Croup  £  X  F(l,56)  Sex  p  Duration (years) od Med i c a t i o n St rcngth x.  sd 0 swc strv Disability y. sd P h v s i c a l , Impairment y. sd n  8.1 7.5  .47 .83  6.0 8.6  .47 .92  10.3 8.2  .80 1.26  11.6 12.9  .93 1.16  2.49  .120  .02  .880  . '.9  2.14  .149  .06  .808  .06  .808  .007  .12  .728  .003  .955  22.5 31.3 1 1 . 5 1 1 . 0  34.6 14.0  45.9 18.5  13.51  .001  7.70  13.6 4.4 5  15.0 6.8 7  16.2 7.9 9  .31  .583  .15  14.5 8.5 6  n_= 1 5 p e r c e l l Ca) H i g h e r s c o r e s r e f l e c t g r e a t e r (b) Mote: u n e q u a l r\; F ( 1,23 )  strengths  of  analgesic  medication  .70  .6  89  67  organic  Physical  Questionnaire  Signs  whereas  i s moderately  the  Oswestrv  correlated  with  Disabilitv a l l  three  measures .  Table  10:  C o r r e l a t i o n s Among M e a s u r e s and I n c o n g r u e n t Signs Incongruent  ot  Physical Limitation  Pain  M e a s u r e s ot Physical Limitation  Pain Drawing  Physical Impairment Index (n=27)  .29  .24  Oswestry Disability Questionnaire (n=60)  .44***  .52***  *  p< . 0 5 ;  **  p<.01  ;  ***  p<.00 1  Measures  Non-organic Signs  Inappropriate Symptoms  .36*  .35**  68  Analysis  of Dependent  Group  Differences:  Means  and  threshold, threshold calculated rating)  Table  Measures.  standard  d' and b e t a  11.  deviations  control  the three  are presented  Means  Measures.  group,  cutoff  i n Table  and  f o r a l l pain  calculated relative  of the normal from  Pain  Standard  (pain  to the average  mean  levels,  measures  pain  d ' a n d mean  beta  subjective  pain  and  11.  Deviations f o r  Pain  Measures  Group  Control  Va r i a b 1 e  Ma 1 e s  Congruent  Fema1e s  Ma 1 e s  Pain  Incongruent  Pain  Females  Ma 1 e s  Fema1e S  282.99 2 6.08  268.19 33.51  27 1.56 45.90  Threshold  2 (mcal/sec/cm ) x 263.47 sd 24.77  2 6 0 . 10 40.04  273.95 39.80  d• X  sd Mean  2 . 38 . 79  2.38 .83  1.99 .61  2.62 .84  2.31 . 97  2.47 . 64  2.52 . 62  2.51 . 66  2.21 . 54  2.85 .63  2.20 .87  2.41 .47  d' X  sd Beta X  sd Mean  30.53 49.35  15.91 39.17  22.68 44.02  42.66 5 2.14  34.27 49.65  35.60 5 2.92  38.89 24.93  19.16 26.21  22.10 28.58  44.44 2 7.80  28.05 3 1.84  32.51 3 1.34  Beta X  sd Subjective P a i n Ra t i ng *  . 07 . 90  X  sd reported  as  z-scores;  . 22 . 64  -.41 .81  r\= 1 5 p e r  cell  . 20 .95  - . 35 . 68  . 28 1.12  69  Pain the  patients  control  numbers variance the  subjects  i n each was  variances  a 2 X  main  2  calculated subjects pain  d'  control  by  in a  beta  for lost  and b e t a  in  Table  12.  significant  measures  the groups.  t h e mean were  2 X  12).  power  measures. As  were  o f d' and b e t a  were  13).  this  when used.  unequal  of  revealed  then  no The  of normal with  yielded  that  analysed  significant SDT  indices  control  the s u b j e c t i v e  no  i n place  of the high  or sex e f f e c t s ; found  was  the negative used  of  to  differ  revealed  analyzed  The r e s u l t s  was  which  Threshold  which  Given  seen,  test  threshold  first  because  c a n be  group  pain  Because  d i d not  which  group  of homogeneity  (see Table  2 MANOVA  measures  sex i n t e r a c t i o n  measures  t h e Box M  s e x ) ANOVA  as a g e n e r a l  measures.  the assumption  or i n t e r a c t i o n s  (see Table  d'  by  between  compared  the pain  using  as a c u t o f f  a n d mean  tirst  f o r the pain  using  rating  findings  group,  (group  effects  on  assessed  significantly in  were  significant  result,  t h e mean  i n order  to  variability  of t h i s  analysis  also  MANOVA  revealed  no  however,  a  t h e more  stable  i n the  significant  appear  group  averaged  70  T a b 1e  12.  MANOVA Summary T a b l e Patients Pooled  Source  Wilks (S=l,  l o rP a i n  With  Pain  F  j  MANOVA U s i n g d ' a n d B e t a M e a s u r e s Group .97 Sex .94 Group X Sex .96  .79 1.65 1.10  .504 .183 .358  MANOVA U s i n g M e a n Group Sex Group X Sex  .60 2.09 3.10  .614 .108 .031  Given  d' and Beta .98 .93 .90  the s i g n i f i c a n t  averaged  d' and b e t a  analyses  were  analyses  revealed  represented of  t h e means  higher  report  that  by t h e mean indicated  within  painful  N=41)  Measures  finding  measures  conducted,  criteria  However,  Lambda M= 1/2 ,  Measures  o n t h e MANOVA  a r e used,  as p r e s e n t e d  t h e group  to report  sensations  within  group,  than  i n Table  measure  univariate  13.  (beta).  the control  sensations  the patient  follow-up  The  by s e x i n t e r a c t i o n i s  criterion that  when t h e  women.  group,  as p a i n f u l  men  Examination  s e t lower  than  men s e t women.  criteria  to  71  Table  13.  Univariate Analvses: Patients Pooled.  Pain  Measures  With  Pain  Source  Sex  Group  Variable  F(1,86)  £  Group  F ( 1 ,86)  p_  X Sex  F( 1 ,86)  £  Mean  d*  .41  .522  2.09  .152  2.31  . 132  Mean  Beta  .19  .667  .25  .621  6.76  .011  1.20  .275  4.03  .048  1.52  .222  2.42  .124  2.42  .124  .36  Subjective Pain R a t i n g Threshold (a) (b)  3  6  C a l c u l a t e d on z - s c o r e s Not i n c l u d e d as a p a r t The  absence  hypothesized patients' patients the  divided  was f i r s t  into  heterogeneity  two  equal  analyses  which (d  threshold  1  or  and beta  of normal  contro1  14).  A s c a n be s e e n ,  group  effects  rating  or group  this by  repeated.  i n Table  yielded  interactions.  oi  s i g n s and Threshold f o r by s e x )  evident  ANOVA.  f rom  these  S i g n a l D e t e c t i on  t o t h e mean  were  pain  pa i n  again  no  pain  anal ysed  a 3 X 2 MANOVA ( s e e  analysis s ex  15.  relative  subjects) using  were  the  on t h e ba s i s  i n a 3 X 2 (group  c a l c u 1ated  subjective pain  were  in  Therefore,  incongruent  i nteractions  are present ed  m e a s u r e s was  observed  groups  medically  a n a l y s ed  effects  f o rpain  pr esentation.  or absence of  no m a i n  indices  effect  the  of pain  t h e MANOVA  and the above ana 1 yses  pain  Again,  the  manner  presence  faint  grou P  to r e f l e c t  were  symptoms  o± a  of  .5 50  Table  signifi cant  However,  a  with  72  borderline  signit icant  differences. the  high  using  group  i n Table  s e x was  the  data  pooled have  Table  on p a i n  and s i g n i f i c a n t  with  respect  d' and b e t a  14.  power,  they  were  i n this  due t o  repeated  results  also overall effect  a n a l y s i s and,  according to of a trend i n  effect.  stable  be u s e d  was  the main  i s a suggestion  a r e more  power  no s i g n i f i c a n t  t o an i n t e r a c t i o n  measures  These  However,  significant  g u i d e l i n e s , there  sex  the analysis  revealed  measures.  tor  t o r lost  measures.  again  not s t a t i s t i c a l l y  greater  to control  d' and b e t a  stronger  conventional  was e v i d e n t  i n d' and b e t a ,  14 w h i c h  differences  although  i n order  variability  the averaged  appear  for  Again,  finding  Because the  and, t h e r e f o r e ,  i n subsequent  analyses.  MANOVA Summary T a b l e t o r P a i n M e a s u r e s W i t h P a i n Patients Separated i n t o M e d i c a l l y C o n g r u e n t and Incongruent Groups  Source  WiIks  Lambda  MANOVA U s i n g d ' a n d B e t a M e a s u r e s Group .97 Sex .91 GroupXSex .95  .42 2.63 .75  .865 .056 .611  MANOVA U s i n g M e a n Group Sex GroupXSex  .66 3.13 1.83  .679 .030 .0 97  Univariate significant indices. 15  d* a n d B e t a .95 .90 .89  follow-up  sex e f f e c t  The r e s u l t s  and i n d i c a t e  sensitivity)  Measures  tests  were  i n t h e MANOVA of these  a sex e f f e c t  and S u b j e c t i v e  examined using  analyses  the averaged  are presented  f o r the measures Pain  Rating.  given the  o f d'  Inspection  SDT i n Table  (sensory of the  73  means  ot these  distinguish stimuli  variables  the pain  as more  mentioned  signal  intense  above,  from  women  t h e heat  i t i s recognized  by s e x i n t e r a c t i o n  found  i n the analysis  found  that  and d i s t r e s s i n g  group  was  showed  that  t o be s i g n i f i c a n t  when  better  and a l s o  than  t h e men.  however, similar  the pain  able  to  rated the  a significant  was n o t f o u n d ;  i s qualitatively  were  As overall  the trend  to that  patients  which  were  pooled .  Table  15.  Univariate  Analvses:  Pain  Measures  Source  Sex  Group  Variable  F(2,84)  Mean  d'  Mean  Beta  (a) (b)  6  Table  16.  1.98  .144  .17  .840  .15  .696  4.10  .0 20  .63  .533  6.44  .013  . 74  .479  1.62  .203  .16  .69 1  . 22  . 799  Among t h e among  correlation  In t h i s  Gracely  Rating  sensory  intensity  note,  £  .040  Intercorrelations Pearson  F ( 2 , 84 )  4.36  C a l c u l a t e d on z - s c o r e s Not i n c l u d e d as a p a r t o f  with  £  .324  Relationships  Of  F(1,84)  X Sex  1.14  Sub i e c t i v e Pain Rating Threshold  £  Group  Pain  MANOVA Measures.  these  m e a s u r e s were  coefficients  table, the  Scale  the  subjective  i s presented  positive  are  pain  i n i t s two  and u n p l e a s a n t n e s s  a moderate  which  evaluated presented  rating  was  the  component s :  or a f f e c t i v e  correlation  from  i n  found  distress between  •  the  74  pain  threshold  significant  and  oain  report  was  found  association  discriminabi1ity. pain  the  threshold  represented  The  a  between  relationship  suggests  by  criterion  that  response  pain  bias  pain  between  report  no  threshold  the  threshold  to  but  is  and  criterion  and  primarily  sensations  as  painful. Also  found  was  a  discrimination)  and  beta  correlation set  a  higher  consistent criterion the  is  hits  in to  in  pain  pain.  between  affective would  pain.  report  pain  had  was  between  the  found  suggesting  tended a  (sensory distress a  to  low  i s , those  false but  painful  tendency  stimuli  to  of  those  who  set  relative  low  for also  and  those be  who  intensity found  more  of  pain. are  to  pain  self-report by  high  intensity  subjective  caused  a  negative  sensory  with  who  more  r e l a t i o n s h i p was  unpleasantness  slight  This  significant  greater  positive  also  alarms  rating  (sensory  subjects  That  discrimination) or  those  were  that  d'  criterion).  that  low  report  between  pain  fewer A  also  to  mean  pain.  suggest  sensitive  to  detecting  Finally, d'  report  judgements.  report  threshold-  thresholds of  their  to  correlation  (pain  interpretted  criterion  correlation and  moderate  This  more  distressed  by  the  75  Table  lb.  Correlation Mean d  Mean Beta  1  Mean  Matrix:  Measures Sensory Intensity  Threshold  Attective Distress  d'  Mean  50***  Beta  Threshold  12  Sensorv Intensity Affective Distress n=90;  The  .52***  16  -.14  -.20*  18*  -.04  -.02  *<.05;  Group  Differences:  means  and  Cognitive  standard  from  the Cooing  in  17.  The  Table  (i.e.,  active  pain  cognitive praying, control  and  five  coping coping  content  Strategy  measures  such  passive  the pain,  behavioural  cognitions. use of each  the f i v e  Questionnaire  se1f-statements)  (i.e.,  of  are cognitive  strategies  and d i v e r t i n g  catastrophizing  Measures.  deviations  hoping,  self-reported  .58***  ***< . 001  obtained  the  Pain  component.  presented  coping  , strategies  processes  with  strategies  attention),  Higher  are  as r e i n t e r p r e t a t i o n  coping  coping  measures  scores  specific  such  se1f-efficacy  strategies,  of  as to  and  reflect  greater  76  Table  17.  Means a n d S t a n d a r d Me a s u r e s  Deviations  for Cognitive  Group  Congruent  Variable  Males  Pain  Males  Females  4 5 .07 14 .80  39.67 15.30  47.33 16.95  23 .07 12 .09  21.47 10.94  29.87 14.29  6 .53 1 .36  4.80 2.60  1 7.93 6 .69  13.73 5.40  16.33 5.27  7 .13 7 .62  8.40 5.65  12.07 9.11  v a r i a b l e s were  entered  MANOVA ( s e e T a b l e 1 8 ) .  interactions there  is a  Table, 1 8 .  were  trend  revealed in  Wilks  11  was  decided  Lambda  to  examining  a 2 X  these  t o suggest  Table  to look  into  significant  through  .88 .83 . 95  Group Sex / GroupXSex  No  the data  MANOVA Summary  Source  view  5 . 40 2.06  per c e l l These  sex)  Pain  Females  Processes x 3 9. 73 sd 12. 34 Content x 1 7 . 00 sd 10 .7 1 Eff icacy x 4 .93 sd 2 .25 Behavioural Coping x 12. 40 sd 6 .8 1 Catastrophizing x 7 .47 sd 5 .76 n=15  Incongruent  2  (pain  g r o u p by  ma i n  e f f e c t s or  anal y se s  However,  some  sex  d i f f e r enc e s.  t o r C o g n i t i v e Me a s u r e s' F  £ .241 .08 1 .761  1 . 40 2.09 . 52  at the u n i v a r i a t e  analyses  the v a r i a b l e s f o r the apparent  trend  with  a  77  differentiating in  presented  Table  19.  the  Table  sexes-  Results  these  of  analyses  are  19.  Analyses:  Univariate  Cognitive  Measures  Source  Group  V a r i a b1e  Group  Sex  F ( 1 , 56)  Sex  F( 1 , 56)  F(1,56)  £  X  £  Content  3.26  .077  5.37  .024  . 14  .710  Process  .08  .777  2.84  .098  .09  .763  Eff icacy  1.34  .251  4.05  .049  . 84  .364  Catastrophi z i n g  2.50  .119  .81  .373  .933  6.70  .012  .0 1  Behaviour  The  apparent  variables: and  sex  cognitive  behavioural  admitted  activities)  by  Because  statistically only  be  t o be these  i n other  in a  to  More (such  on  not  . 87  manage  women as  behavioural  were  way.  .355  the  than  pain,  men  distracting or c o g n i t i v e t o manage  found  to  their  be  the m u l t i v a r i a t e t e s t s ,  qualitative  .285  following  self-efficacious  differences  significant  discussed  strategies  more  the  efficacy  strategies.  coping  engaging  and  a p p e a r s on  content,  coping  to using  themselves  pain.  difference  1.16  they  will  78  Relationships  Among  Interrationships assessed presented this  using in  matrix  which  is  reflects  Strategy  Table  among  Pearson  the  form  an  the  the  Measures.  c o g n i t i v e measures  Correlation coefficients of  a  overall  the  Cognitive  sum  of  matrix  in Table  composite a l l the  which  20.  score  are  Included  called  subscales  were  of  in  'coping'  the  Coping  Questionnaire.  20.  Correlation Matrix:  Content  Process  Cognitive  Measures  Catastrophizing  Efficacy  Behaviour  Coping  Content Process  .61***  "Efficacy  .18  .12  Cat a s t r o phizing  .26*  .08  Behaviour  .55***  .36**  .38***  Coping  .83***  .86***  .31**  n=60;  *£<.05;  High 'coping'  **£<.01;  positive  addition  to  the  weighted  more  measure  specific  reflects  how  and  well  and  coping  the  were the  on  the  for  reflects  the  overall  strategies processes  would  questionnaire  strategies  effect,  between  and  This  strategies  coping  catastrophizing, in  .89***  found  coping  strategies.  subscales  reflecting  .04  c o g n i t i v e content  behavioural  actually  -.01  ***£<.001  correlations  composite  representing  -.31**  pain.  are  in  suggest are  that  those  Efficacy  perceived  'non-coping'.  to  work  79  Moderate coping  to high  positive  subscales  including  negative  correlation  etticacy  which  about able  pain,  t o manage  the  The of  Inventory (Worry  and  ANOVA.  No  revealed  standard Scale  evaluates  significant  distress  t h e more  the  t o low  catastrophizes  he/she  feels  in  being  was main  specific  analysed  each  No  on  3 X  pain,  Two-way  significant  any of t h e  2  the Pain  to chronic  conducted  Experience 21.  Scale  The  (group  or i n t e r a c t i o n s  Because  measures  Anxiety  i n Table  in a  effects  group.  measure.  f o r the three  of the Pain  are presented  analyses.  emerged  Measures.  of the S t a t e - T r a i t  to the c o n t r o l  interactions  a person  deviations  administered on  among  c a t a s t r o p h i z i n g and  efficacious  subscales  (STAI)  i n these  tound  A moderate  between  Affective  and E m o t i o n a l i t y ) measure  were  pain.  t h e two  Anxiety  tound  the less  the T r a i t and  etticacy.  that  Differences:  means  affect,  was  suggests  his/her  Group  correlations  Trait  by s e x )  were  Experience  Scale  i t was n o t ANOVAs  main  variables.  were  effects  or  80  Table  2 1.  Means  and  Standard  Deviations:  Attective  Measures  Group  Control  Variable  Males  Trait Anx i e t y x 36.07 sd 7.04 Wo r r y x sd Emo t i o n a 1 i t y x sd Note: Higher n = 15 p e r c e l l  in  Table  High  three  measures.  Table  22.  Males  Females  33.47 6.52  34.80 9.06  35 47 9 20  35.73 8.66  3 6.53 6.66  2 .37 1.13  3 01 1 34  3 28 1 50  3.10 1.38  03 34  2 78 1 59  2.49 1 . 40  3.03 1 . 60  reflect  Among  higher  levels  the A f f e c t i v e  were  again  which  positive  (n=90) Anx i e t v  as  using a  Affective  66***  Emotionalitv  7 5* * *  p_< .00 1  Pearson  correlation found  matrix  among a l l  Measures  Pain Experience Scale (ri=60) Worrv Emotiona 1 i t v  Trait Anxiety Wo r r y  affect,  Measures.  assessed  appear  of  c o r r e l a t i o n s were  Correlation Matrix: STAI Trait  [  Pain  Fema1e s  coefficients  22.  Incongruent  Ma1e s  Interrationships correlation  Pain  Females  scores  Relationships  Congruent  76***  81  Additional  Correlational  Relationships It  was  different  of  interest  and  to  to  Dependent  examine  measures  Although  with  identify  the  the measures  presentation. liberal  Among  dependent  measures  Analyses.  number  of  possible  as  of  the  well  kind  of  correlations  trends  i n the  relationships  as  severity  this  Measures.  between  and  the  the  dependent  symptom  analysis  becomes  calculated, data  among  the  more  goal  was  for heuristic  purpo se s. Table between  23  the  and  affect.  the  Gracely  scales: is  the  Rating  with pain  with  strategies  sensory  significant exception  threshold  and  pain  small  cognitive  between  the  pain  a  positive  content  also  higher  was  sensory  note,  these  using In  that  coping  addition, and  found  about  Of  relationship  catastrophizing  stimuli  component  suggesting  report  content.  catastrophize  report  among  from  a  reported  suggesting  their  a  pain  intensity  of  stimuli.  the  affective  relationship of  a  cognitive  correlation  who  of  thresholds  specific  of  correlations  coping  derived  Distress.  to a l s o  exception  ratings,  Affective  condition  of  pain  cognitive  and  f o r those  absence  subjective  of  Intensity  tendency  Among  measures  in their  the  pain  the  coefficients  presented  intensity  external  and  correlation  are  higher  positive  the  Pearson  Scales",  of  with  the  measures  Again,  absence  between  low  pain  Sensory  measures  those  presents  low  measures, with  positive  the  again  pain  correlations  there  is a  notable  measures  with  the  between  the  self-report  82  of  sensory  Scale. those  intensity  These who  external  to also pain  T a b 1 e 2 3.  the subscales  relationships  a r e more  condition  and  worried report  suggest and  of  a slight  emotional  higher  the Pain  sensory  Experience  tendency f o r  about  their  intensity  pain  r a t i n g s of  stimuli.  Relationships and A f f e c t i v e  Between Pain Measures Pain  Threshold  Mean d'  Content  - . 22*  Processes  Measures  and  Cognitive  Me a s u r e s Mean Beta  Sensory Intensity  Af t e c t i v e Distress  .02  - . 01  .17  - . 08  -.14  -.10  - . 10  -.01  -.12  Eff icacy  -.11  - . 02  -.18  -.18  -.17  Catastrophi z ing  -.12  .15  .02  Behav i o u r a 1 Coping  - . 04  . 00  . 04  - . 09  -.15  Overall Coping  -.14  - . 02  .02  -.01  -.12  Trait Anxiety  - . l>4  - . 01  - . 03  Wor r y  - . 04  Cogn i t i ve Measures  .33**  .04  Affective Measures  Emot i o n ality n=60;  .06  *£<.05;  . 08  . 12  .00  . 28**  . 10  .14  .0 5,  .31**  . 18  **£<.01  Relationships variables,  . 13  between  as e v a l u a t e d  t h e c o g n i t i v e and  with  Pearson  affective  correlation  coefficients,  83 revealed and at  moderate  a l l three .68  to  with  the were  variables  the  and  the  cognitive  The  scale  symptom  evaluated in  Table  24.  associated the  negative  organic  Low  coping  both  is  a  ot  et  supports  that  a  current  the  tactors  a l . ,  .50  cognitive  and  not  a  1990).  Measures  and  Measures  the  ot  severity  ot  Disability dependent  severity  Questionnaire)  measures  were  which  not  appear  at a l l  was  also  presentation  with  the  exception  between  That  pain  i s . the  threshold  lower  physical  the  signs  and  specitic symptom  subscales other  positive association  and  were  cognitive  ot  a  Non-  tound  between  content  and  This  praying/hoping  activities. between  tor  displayed.  presentation.  assessing  mental  true  pain  p o s i t i v e c o r r e l a t i o n s were  to  were  This  non-organic  the  (Physical  variables.  severity  attention  consistent  ot  reflecting  ot  This  at  signiticant  Correlation coetticients  Signs.  tactor  consists  diverting  and  pain  more  other  measures  Oswestry  measures  moderate  measures  tactor  (Lawson  and  No  emotional  Dependent  correlation  the  to  the  symptom  Physical  threshold,  the  and  the  ot  the  correlated  Presentation.  Pearson  with  STAI.  Questionnaire  such  Between  The  measures  small  as  presentation  using  ot  represents  Symptom  Index  Emotionality  the  any  r e l a t i o n s h i p s between  Impairment and  Strategy  construct  and  tor  and  ot  catastrophizing  Catastrophizing  a t t e c t i v e measures.  Relationship Severity  Worry  Scale  found  Coping  Catastrophizing  both  Trait  relationships  ot  c o r r e l a t i o n s between  a t t e c t i v e measures.  (p_<.001) w i t h  (j3<.001)  view  high  the  Ot Pain  and  interest Drawing  84  as  scored  measures Coping that  by of  this  measures  Ransford  affect  Strategy  including  of  component of  et  symptom  Inappropriate  scoring of  Symptoms)  positive  association  apparent  positively physical  worry  absence  Emotionality  is  of  regarding  associated impairment.  would  pain  drawing  unrelated  the  association the with  pain  seem  to  to  note  The  pain  a  low  to  strong two  Signs ot moderate  physical  condition  subjective was,  the  other  measures  objective  condition  subjective  a  of  indicate  Physical  to  and  scale  reflects  (Nonorganic  between to  method  conditions.  i n t e r e s t i n g to  specific  scoring  This  pain  were  level  an  catastrophizing  presentation  i t  and  the  chronic  Finally,  impairment  (1976)  the  affect. of  al.  Questionnaire.  method  affective  and  the  itself  disability.  however,  disability  but  but  not  85  Table  2 4.  Correlations Presentation  Measures  Dependent Variable  Impairment  ot  3  Among M e a s u r e s o t S e v e r i t y and Dependent Measures  Severitv  Disability  Measures  ot  SvmDtom  Pain Draw  Non-organic Signs  and  SymDtom  Presentation  Inappropriate Symptoms  Pain Measure s Threshold  -.12  .13  -.04  -.29*  -.16  Meand'  -.14  .14  -.08  -.05  -.0 7  Mean  -.20  .19  -.07  -.09  -.12  .15  .20  .12  .22  .18  .30  .14  .14  .12  .08  .33*  .44***  .30*  .36**  .30*  Processes  .03  .22*  .29*  .28*  .01  Etticacy  .22  Catastrophizing  .13  .25*  .33**  .27*  Behaviour  .24  .14  .12  .21  Coping  .17  .29*  .19  .30*  .04  Anxiety  .15  .09  .32**  .00  .03  Worry  .3 5*  .18  .31**  .09  .17  Emotionality  .13  .30**  .30**  .11  .11  Beta  Sensorv Intensity Af-f e c t i v e Distress Cognitive Measures Content  -.09  -.07  -.06  -.24*  .24* -.05  Affective Measure s Trait  n=60 ; ( a) n= 2 7 *£<.05; **£<.01;  ***£<.001  86  Post  the  Hoc  Analyses.  The  c1 a s s i t i c a t i o n  'inc1usionary  which  sought  tactors Craig, two  criteria  1  to i d e n t i t y  played  a  1988) .  groups  larger  This  ot  pain  earlier  study  such  catastrophic  etticacy pain  role  pain,  and  group  were  presentation  ditterences  i n the present  condition  (Reesor  The  with  two  &  pain,  and  groups  psychological  i n the  tactors  low  subjective  on  That  i s ,patients  diagnosed  complaints  proportion"  ot  patients).  diagnoses an  which  and  'functional'  patients  diagnosis  "no  ot  deemed  selt-  ratings  proportion  no  ot  males at  surgeon,  to the detectable  were  in this  nine  through  general  received  cause". and  " o u t ot  team  ot  the  The  pathology  (i.e.,  females  the  conferences physician, 18  remaining  Five  received  primary  disability  pathology".  criteria.  practice  Fifteen  sample  organic  were  pain  symptom  selected  and  the  their  apparent  discomfort  identified  when  'exclusionary'  arrived  discomtort  ot  patients  pathology  organic  found  basis  psychologist.  clear  to report  with  Nine  were  orthopaedic  physiotherapist,  ot  physical  to detectable  'functional'  involving  the basis  not  the  study,  reclassified  whose  were  d i f f e r e n t i a t e d on  were  were  psychological  those  regarding  higher  on  in distinguishing  as  symptoms.  based  intensity.  patients  such  pain  was  investigation  t o r whom  designated  cognitions  study  previous  successful  d i f f e r e n t i a t e d on  to c o n t r o l  Because  or  in a  in their  incongruent  were  in this  patients  was  patients  medically  used  used  pain  system  without  as  scheme  three  " o u t ot ot  the  temales  87  and  s i x ot the males  identitied  classitied  as d i s p l a y i n g  svmptoms.  The r e s t  symptoms absence  and thus,  ot m e d i c a l l y  These to  received  organic  ditterences the a  were  variables.  patients control  diagnoses analysed  were  group  (i.e., using  examination  to explore  possible  signs  by  and  also  and signs  or  symptoms. on a l l  and a p a i n  group  'organic'  measures who h a d  patients).  univariate that  and  the presence  compared  this  ot the data,  trends  were  incongruent  signs  It i s recognized  conservative  was  medically  incongruent  selected  congruent  not d i t t e r e n t i a t e d  'tunctionai'  a randomly  'tunctionai'  medically  displayed were  as  Group  analyses  tora l l  does  represent  not  however,  and t o g e n e r a t e  the  new  intention  research  goals.. Continuous (3  X 2 ) ANOVAs  statistics. emerged  demographic  and c a t e g o r i c a l  No  signiticant  on any ot t h e s e  socioeconomic  data  status,  were  data  main  analysed  with  which  and e t h n i c i t y .  two-way  C h i Square  ettects  variables  using  or  interactions  included  Marital  age,  status,  however,  2  again  emerged  retlecting  that  Patient medication disability) continuous categorical or  as a group  the normal  by  control  characteristics  strength, were  variables variable  fX~(2)=y.45, group  (duration  physical  analysed  sex d i t t e r e n c e s  group  ditterence  similarly  (presence  sex i n t e r a c t i o n  ot  with  and  two-way  ot p r e v i o u s  tound  single.  subjective ANOVAs t o r  statistics  on any ot t h e s e was  mostly  condition,  impairment,  and n o n p a r a m e t r i c  arose  were  p<.U1 1  t o r the  surgery).  analyses,  t o r the reported  No  group  however, duration  a  88  of  the  the  oain  means  diagnoses than  conditions  revealed  that  reported  longer  t h e men.  Within  organic  diagnoses,  problem  than  with  respect  objective of  [F(l,32)=4.37,  i n the group  durations  the group  men  t h e women.  reported  there  Means  characteristics  who  were  organic  the pain  of their  2 5.  Patient Characteristics: Deviations  disability  and s t a n d a r d are presented  Diagnostic  Func t i ona1  Var i a b l e  Durat ion (years') x sd Medicat ion Strength x sd Sub j e c t i v e Disability x sd P h y s i c a1 Impairment' x sd n=9  per c e l l ;  Means  and  or deviations i n Table  Standard  Groups  Organi c  Males  Females  Males  Females  70 28  14.07 14.52  14.56 9.02  8.95 12.23  44 73  .33 .7 1  1.22 1.39  .67 . 87  26.56 17.73  36.00 15.94  30 . 00 12.00  37.67 7.94  16.25 4.65  13.00 7 .80  15.50 5.45  12.00 12.73  (a) unequal  n  pain  no d i f f e r e n c e s  2 5.  T a b 1e  problem  had r e c e i v e d  durations  of s u b j e c t i v e  impairment.  patient  of having  longer  Examination of  without  of p a t i e n t s  Of n o t e ,  to the levels  physical  t h e above  women  p_< . 0 5 ) .  Table  2 6.  Pain  Measures:  Means  and  Univariate  Analyses  by  Diagnostic  Group  Variable  Source  Functional  Control  Groups  Group  Organic  Males  Females  Males  Females  Males  Females  2 (mcal/sex/cm ) x 2b2.68 sd 29.00  261.94 42.43  248.77 25.60  244.80 31.33  277.60 52.88  297.00 29.54  2.49 . 69  2 .26 78  2.40 . 64  2 .09 44  2.84 . 70  9.74 2 5.60  1 9 36 3 1 33  24.02 5 2.88  F(2,48)  Sex  £  Group  F(l,48)  £  X  Sex  F(2,48)  £  Threshold  -  x sd  2 . 38 .65  5.68  .006  .22  .623  .54  .584  20  .820  3.57  .065  1.41  .255  3.43  .040  .49  .486  3.50  .038  .35  .708  3.68  .061  .64  .538  Beta 40.43 x 29.00 sd Sub j e c t i v e P a i n Rat i n g 17 x 78 sd n=9 (a)  per c e l l presented  as  20.38 42.43  09 7 1  31 74  - . 04 .7 1  - . 35 .99  49.43 29.54  . 48 1.19  z-scores  oo  9 0  Group The  Ditterences:  results  measures  was  found  t o r t h e mean  j> <.U5 1 .  was  mean  control  pain  however,  the  greater  group  lower  were  no  discrimination) heat  differentiating the pain  slightly  significant  intense  group  that  likely  by  normal  t o r the group,  The  'organic'  to report  the normal  pain  control  t h e two  significant on d'  pain.  appeared  patient  sex  slightly  better  able  An  additional  on  the s u b j e c t i v e  rating  than  men  chronic  sensations  ratings as  the males. with  than  A  the  i n the t i r s t pain  to  trend  the s t i m u l i  as  without  ditterences,  (sensory  suggesting,  paintul  and  significant.  being  females  existed.  control  criterion  inbetween  (two-  was  threshold  sex i n t e r a c t i o n appeared  although  to report  mean  and d i s t r e s s i n g  (beta)  procedure  group  the normal  existed  taint  with  pain  not  females  the sexes  criterion  analyses,  trend  trom  stimuli  more  were  group  the d i t t e r e n c e s  Although  level  pain  fF(2,48)=3.43,  not s i g n i f i c a n t .  statistically  with  (beta)  the ' f u n c t i o n a l '  higher  criterion  a possible  distinguish  was  the  [ F( 2 ,4 8 )=5 .6 8 , D<.U1) ]  Comparison  than  group.  the d i t t e r e n c e s  however,  less  criterion  both  on  significant  threshold  T h e mean  significantly  'functional'  There  report  than  was  A  t o r the 'organic'  (jp_<.U5).  h a d a mean  groups,  ot  2 6.  t o i d e n t i t y where  the d i f f e r e n c e  set a  group  report  threshold  groups  'tunctionai'  than  t o r pain  pain  used  significantly  group  i n Table  analyses  The Newman-Keuls M u l t i p l e  tailed) The  Measures  the u n i v a r i a t e  are presented  difference and  ot  Pain  s e t ot  tend  women,  pain  t o be men  with  Table  2 7.  C o g n i t i v e Measures: Patient  Functional  Variable  Means  and  Univariate Analyses  Group  by  Diagnostic  Group  Source  Organic  Group  F(l,22)  Group  Sex  £  F(l,22)  £  X  F(l,22)  Sex  £  Males  Females  Males  Females  20.22 11.64  30.89 12.44  16.89 9.35  24.00 11.40  1.85  .18 3  5.60  .024  .22  .639  41.11 16.19  54.56 14.29  39.33 8.57  45.78 11.71  1.48  .233  5.26  .029  .65  .426  6.33 2.29  6.22 2.54  4.33 2.45  6.22 1.39  1.83  .185  1.45  .238  1.83  .185  8.33 7.62  8.67 8.23  7.33 4.61  9.22 9.34  01  .933  .18  .673  09  .768  11.89 2.47  18.67 5.07  12.44 8.03  13.56 6.25  1.38  .249  4.14  .050  2.13  .154  Content x sd Process x sd Efficacv x sd Catas t r o phizing x sd Behaviour x sd n=9  per  cell  92  chronic  pain  a r e more  sensations.  No  likely  than  women  i n t e r a c t i o n s were  to report  evident  paintul  on any ot t h e o t h e r  variables . Group  Ditterences:  Means  and r e s u l t s  Coping  Strategy  ditterences the  se1t-reported content,  are  strategies.  more  measures  than  coping  women  and u n i v a r i a t e i n Table  appeared report  group  on any o t on t h e  specitic  cognitive  o t t h e means using  revealed  the coping  No  a possible  levels  Measures  analyses  28.  on e m o t i o n a l i t y  higher  No  27.  s t r a t e g i e s , and the use ot  reported  Atiective  by s e x i n t e r a c t i o n s w e r e However,  the  men.'  Means  measures.  tor  emerged  s t r a t e g i e s with  Examination  Ditterences:  presented  i n Table  sex d i t t e r e n c e  ot c o g n i t i v e  Group  group  pain  significant  on a l l t h r e e  strategies  appear  analyses  by s e x i n t e r a c t i o n s a p p e a r e d  use ot coping  styles  behavioural that  A  Measures  ot the u n i v a r i a t e  Questionnaire  or group  measures.  Cognitive  with  t o r the a t t e c t i v e  signiticant evident trend women  ot e m o t i o n a l i t y  main  measures  e t t e c t s or  on a n y o t t h e t h r e e  ditterentiating slightly  more  regarding  the sexes  inclined  their  to  chronic  problem. Group  Ditterences:  Measures  ot M e d i c a l l y  Incongruent  Symptoms It  was o t i n t e r e s t  medically  incongruent trom  to see i t the three  symptoms those  distinguished  organic  diagnoses  with  ettects  or i n t e r a c t i o n s appeared  organic  measures ot patients  diagnoses.  on any ot t h e t h r e e  without No  main  measures  Table  28.  Attective  Measures:  Means  and  Univariate  Analyses  by  Diagnostic  Group  Variable  Source  Functional  Control  Group  Organic  Males  Females  Males  Females  Males  Females  35.89 7.86  31.89 5.35  33.33 6.12  36.22 9.44  39.56 10.04  37.33 . 6.44  2.63 1.31  2.78 1.80  3.27 .74  3.10 1.40  Group  F(l,22)  Sex  £  Group  F(l,22)  £  X  Sex  F(1,22)  £  Trait a Anxiety x sd Wo r r y  Emo a  (a) n=9  x sd tion1 ity x sd F calulated per c e l l  with  1.73 2.80 1.12 1.68 (2,48) degrees of  2.58 3.24 1.26 1.28 freedom, f o r group  1.75  .184  .28  .600  .96  .390  1.10  .302  .00  .980  .12  .732  2.03  .164  3.64  .065  .21  .646  and  (1,48)  t o r sex  u>  Table  28.  Measures ot M e d i c a l l y D i a g n o s t i c Group Patient  Func t i ona1  Males  Variable  Females  Incongruent  Symptoms:  Means  Univariate  Analyses  by  Source  Group  Organic  Males  and  Group  Females  F(l,32)  Group  Sex  £  F(l,32)  £  X  F(l,32)  Sex  £  Pain D r aw i ng x sd Non-organi c Physical Signs x sd Inappropriate S ym p t oms x sd n=9  per  2.67 3.27  3.38 3.25  1 . 00 1.16  5.20 4.38  .12  .735  1.86  .182  46  .500  .67 1.03  .88 1.46  1 4 38  40 89  1.43  .245  .31  .586  .00  .954  2 .00 1.79  2.25 1.67  1.86 1 . 68  3.20 1.64  04  .836  1.08  .306  39  .537  cell  4>-  95  suggesting ot  a  chronic  small may  that  n  be  and  pain  are indeed  problem  obvious  trend. clear  nonorganic  physical  power,  Physical  Examination  organic  ot  diagnoses  signs.  assessing  (see Table  lack, ot  the Nonorganic  possible without  they  ditterent  29).  Given  the only  Signs  which  t h e means tend  the  possible seems  constructs very exception  to i n d i c a t e  shows  that  to e x h i b i t  more  the  a  group  96  Summary  and  ot  Findings  The  results  1)  There  the  normal  (age,  ot  were  tor  largely mostly  married The  patients group  single  The  without  as  tor  differences  Those  patients reported not  coping  on  did  the  and  'functional'  'organic'  The  signiticant pain  diagnoses  on  had  medically  incongruent  ditterences or  system  diagnostic ot  higher  pain  were  with  those  than  The  patients  were  pain  physical  and  symptoms  the  There  distress.  with  disability.  incongruent  ot  pain  significant  subjective  measures  the  significant  yielded  distinguish  consisted  no  perception,  groups  also  impairment  between  pain  patients  'organic'  diagnostic on  (beta).  according  groups  measures  ot  Patients  thresholds  and  to  yielded pain with  higher  threshold 'organic'  pain  did  nor  groups.  differences  criterion  groups  into  symptoms.  objective  group  no  disability  on  attective ot  ot  status)  relationships.  revealed  measure  groups  variables  individuals  symptoms  pain  employment  patient  patients  subjective  'functional'  report  a  exhibited  measure  group  pain  follows:  chronic  control  common-law  measures.  distinction  vs  the  pain  classification  4)  and  a  normal  pain-tree  ot  as  demographic  the  only  strategies,  the  group  greater  ditter  in  ot  summarized  between  general  who  not  The  incongruent  group  be  a  exhibit  signiticant  on  whereas  distinction  group  may  e t h n i c i t y , and  status.  involved  medically  did  status,  comparison  effects 3)  group  people  or  pooled  study  ditterences  control  marital  ot  2)  who  no  socioeconomic  except  also  this  report  97  criteria patient report pain  than group,  longer  chronic 5)  evident  than  i s , women  were  trom  the f i r s t  trace  where  cognitions  behavioural reported  coping  more  there  pain  organic  ot  on  reported  disability,  medically  was a  strategies significant  duration  ot t h e pain  diagnoses  conditions  by  sex i n t e r a c t i o n  with  Gender  than  longer  reported  men,  whereas  durations  ot p a i n than  men.  ot  the pain  found  reporting  also  rating  ot  otten their  Finally,  were  coping  mental  heat  t o be m o r e was a  strategies,  men.  pain  (i.e.,  ot pain into  and  Women decrease  a significant  pooled  pain.  activities,  than  t o r t h e measure  patients  were  the stimuli  cognitive  t o manage  found  greater  in distinguishing  to other  men.  tor selt-  A d d i t i o n a l l y , there  to using  than  was  women  and judged  s t r a t e g i e s more  the pain)  were  ditterences  consistent  etticacy  control  when  clear  are diverted  or  criterion  the presence  ot d' and s u b j e c t i v e  t o admit  greater  ditterences  Finally,  men.  and u n p l e a s a n t  t o r women  groups  sex d i t t e r e n c e s  t o r the measures  trend  t h e two p a t i e n t  disability  That  intense  between  to  women.  subjective  ot f u n c t i o n  to report  diagnoses  Signiticant  reported  and c r i t e r i a  The c r i t e r i o n  t o r the reported  ot t h e i r  than  thresholds  s e l t - r e p o r t e d use ot coping  Women w i t h o u t  pain  pain  and t h e ' f u n c t i o n a l '  group-  impairment,  'organic'  group  no g r o u p  ot a n x i e t y .  durations  with  loss  were  by s e x i n t e r a c t i o n  conditions.  men  There  symptoms,  on measures  group  the control  physical  incongruent  had lower  signiticantly  however.  objective  the control  which  p a i n—- t h a n  dittered  only,  or  both  one  group  report group.  98  Within  the normal  criteria set  than  higher 6)  men  pain  report  show  were  some  variables.  association  catastrophizing  and, The  retlecting  the conscious  small  negative  perception decrease)  the pain.  positively (general chronic  associated  anxiety,  Signs  way w i t h  coping  with  and worry  events.  were strategies  such  as  ignoring  coping  Inventory  tormed  selt a  ot t h e p a t i e n t ' s (i.e.,  the Pain  a l l three  hoping,  and u s i n g  t o manage only  with  mental  Physical  a measure  but  c o n t r o l and  Drawing  measures  and e m o t i o n a l i t y  was  ot a t t e c t specitic  to  pain).  7) (Physical  The measures Impairment  Questionnaire) However, with  Ot n o t e ,  perception  as p r a y i n g ,  to other  Symptom  symptom  strategies  such  sensations  etticacy  women  and a t t e c t i v e  use ot c o p i n g . s t y l e s  a s s o c i a t i o n with  ot h i s / h e r  ot pain  associated  content  The I n a p p r o p r i a t e  report  groups,  incongruent  the use ot coping  r e i n t e r p r e t i n g the pain  statements.  positively  i n a small  pain  men.  t o measures  and Non-organic  associated  pain  ot m e d i c a l l y  cognitive  positively  and  than  diverting attention  Drawing  s e t lower  to the cognitive  were  and with  specitic  generally Pain  unrelated  women  the chronic  criteria  measures  A l l three  retlecting  group,  but w i t h i n  The t h r e e  presentation did  control  were  ot s e v e r i t y Index  and Oswestry  unrelated  hoping,  strategies  and d i s t r a c t i o n  condition  Disability  to measures  a p o s i t i v e a s s o c i a t i o n was  t h e use ot coping  (praying,  ot t h e p a i n  tound  ot p a i n t o r both  ot s p e c i t i c to other  perception. measures  mental  matters).  content There  99  was  a  small  and  catastrophizing  styles.  Finally,  associated about  positive association  my  to  tamily") to  pain  driving  8) to  ot  The  greater other  subjective stimuli.  pain, tormed ot  attect  ot  about  the  pain  with  strong  and  pain  with  perception  lower  hoping,  their  and  a  ot  pain the  also  pain  "I  worry  positively "I  think,  ratings  lesser  degree.  anxiety,  worry,  the  'This  to  unrelated  exception  other  thresholds  inclined  the  pain  sensory  Finally,  and  concentrate  on  to  greater  intensity the  use  reported  who  reported  the  a  mental  to  were  ot  and  attempts  about  ot  mostly  threshold  p o s i t i v e a s s o c i a t i o n with  (general  was  were  with  sensory  emotionality  higher to  positively  (e.g.,  (e.g.,  diverting attention  experiences  although a  disability  A d d i t i o n a l l y , those  Worry  associated  ot  praying,  matters.  pain  was  coping  crazy'").  i s , those  ot  catastrophize  about  disability  cognitive  impairment  chronic  r e l a t i o n s h i p between  That use  physical to  subjective  conscious  attective variables  tactics  content.  ot  subjective  measures  negative  coping  and  me  and  use  specitic  emotionality  cognitive  small  the  objective  worry  related is  and  between  ot  the  were  pain  also  intensity  ot  catastrophizing  a l l three  measures  emotionality).  IDO DISCUSSION Pain  Perception The  results  expectation sample  in  altered  in  pain  pain-tree  ot  that  terms  Chronic the  (sensorv  sensitivity),  subjective  unpleasantness. mixed and  in  ot  diagnostic  altered pain  pain  example, organic  some  trom  et  selected  patients  1980; 1987;  the  Past in  (Cohen  and  with  have  been  (Brands  Olson,  1981;  not  ot  ot  ot  as  found  to  pain  physical  Peters  et  1987;  selected  For clear  a l . ,  1985)  a l . . 1989;  others  and  associated Malow  1987;  and  pathology  highly  report  have  et  a l . , 1983;  Schmidt,  did  with  Lipman  was  presentation  samples.  patients  be  paintul,  patients  patients  homogeneous  clear  pain  and  pain  patterns  et  between  discriminabilitv  intensity  pain  have  chronic  i n v e s t i g a t i o n s which  Yang  &  do  sensations  a l . , 1983;  less  heterogeneous  ditterences  sample  sample  chronic  et  no  report  pain  a  the  whose with  et a l . ,  Scudds  et a l . ,  1989). Because  and  emotional  and  anxiety)  in  &  to  relatively  anxiety  Malow  entire  patients'  a l . . 1981;  conditions and  the  were  threshold,  ot  noted,  as  presentation,  investigators selected  diagnoses  stress  bias  groups.  Naliboif  pain  pain  perception  patients  the  ratings As  terms  ot  i n v e s t i g a t i o n contirm  patients,  There  i n d i v i d u a l s and measures  Patients  clinical  perception.  on  the  pain  their  patients  or  present  chronic ot  Pain  pain  of  literature  reactions to  chronic  perception  and  suggesting  (i.e., pain  that  cognitive  helplessness,  contribute  disability  than  more does  appraisal  catastrophizing, to the  the  variance  degree  of  101 apparent  physical  distinction  of  presentation yield  referred  to  patients  of  results  pathology, into  medically  similar  above  to  the  (Barnes  et  a l . , 1990;  Lee  Polatin  et  a l . , 1989;  Turk  were  exhibiting  expected  be  be  more  to  have  pain  lower  sensations signs  and  as  physiology stimuli to  were  (i.e.,  label  predictions  of  However, and  without  the the  the  hypothesized. based  organic to  cause  painful  Rather, on  the  to  for to  pain  patients  'organic'  symptoms  sensations  stimuli  criteria who  to  did  label not  exhibit  less  responsive  to  thresholds in  accordance  pain  painful  higher with  patients  symptoms of  criteria  the  of  with  clear  thresholds  patients  patients  their  both  as into  responses  findings  the  organic  conformed  with  diagnosable  organic  than  apparent  perception  a in  those  not  pain  of  patients  into  did  pain  absence  the  and  model.  distinction or  and  and  (i.e.,  anatomy  measures  without  and  underlying  of  Patients  signs  1984;  1987).  with  painful)  the  1987;  Waddell,  painful  patients  pain  on  and  painful  lower  be  differentiated  the  1987;  incongruent  and  presence  group  of  Waddell,  incongruent  higher  responses  &  Those  groups  stimuli.  the  Main  distinction  significantly and  a l . , 1989; Rudy,  would  investigations  et &  the  symptoms  Turk,  adaptation-1eve1  medically  differentiate  groups  as  and  of  &  higher  sensations  basis  Flor  incongruent  have  of  the  a l . , 1989;  responsive  expected  the  signs  groups  hypervigilant  painful).  on  that  et  thresholds  symptoms  groups  two  medically  to  therefore,  two  expected  incongruent  Lacroix  Patients  i t was  to  had  control  etiology. the  The  1 0 2  prediction patients  of  the  with  patients)  no  were  adaptation-level clear  found  thresholds  relative  those  organic  with  patients group,  had  but  Because  this  the  different the  lower  Signal  (i.e., than for  the  the  groups;  less  normal  indicates  that  sensitivity  to  correlation  between  report  but  that  propensity supported Clark  &  to by  Yang,  the  no  to  group  the for  did  'functional control  significant.  not  the  1  significantly  prediction  of  supported. the  The  was  data  indicated  higher  mean  report  patients  that  response  sensations  between to  the  (i.e.,  normal  were  sample,  report  two  the  statistically  of  criterion  as  two  pain  groups  criteria  painful  response the  criterion  patient  differed only.  No  d i s c r i m i n a b i l i t y measure not  differ  in  the  their  which  sensory  stimuli. analyses the  revealed  pain  report previous  pain  to  measure rather  et  high and  positive response  bias  discriminability.  to  The  is  largely  reflected  than  sensory  sensitivity  investigations Yang  a  threshold  relationship  threshold  1983;  not  patients.  groups  the  Correlational  pain  was  the  patients  pain  pain  group  addition,  significantly  found  the  not  lower  patient  than  control  inclined)  between  were  was  analysis  set  the  In  these  normal  control  however,  differences  'organic'  contrast,  ('functional'  significantly  thresholds  of  'functional'  significantly  finding  pain  In  pathology  diagnoses).  detection  were  the  model  patients  the  to  have  difference  hypervigilance  'organic'  to  responses  from  physical  model.  (Clark.  a l . , 1985).  &  This  by  Mehl,  1971;  result  has  the is  been  103 interpreted beta  t o r t h e SDT  independent  link  between  i n previous  chronic been  support  represent The  found  as  pain,  investigations.  higher  pathology  Naliboff  parameters  pain  threshold  Yang  other  i n v e s t i g a t i o n s have  with  clear  organic  pathology  and  tolerance  levels.  patient  group  had  control  sample  significant.  hvpervigilance clear  by  conditions, vigilance pattern patients  of  tonic they  may  results  t o any  a  stimulus  research  induction  be  more  sensations.  clear pain  used  levels with  pain  obvious  In  patients  normal  may  i n the  was  used  present f o r the  pain  patients  tonic  pain  the experience  of  to chronic  i t . seems may  but p a r t i c u l a r l y  be  pain  pain  anxiety  the consistency  diagnosis  not  be  support  chronic  research,  have  pain  the  to heighten  Given  organic  stimuli  of  without  1985).  finding  techniques  likely  to previous  than  but a l s o  been  the ' f u n c t i o n a l '  providing  the s i m i l a r i t y  has  the d i f f e r e n c e  assessed  and  e t a l . , 1987;  lower  Although  study,  pathology,  pain  reported  significant  of  Lipman  thresholds  not only  organic  without  vulnerable s t imu1i.  model  f o r those  of  of  Previous  Because  produced  lack  to the type  investigation.  stimuli.  pain  i n the present This  attributable  without  lower  patients  t o have  d'  to people  e t a i . , 1983;  contrast,  thresholds  report  tolerance  pain  e t a l . , 1983;  and  pain  and  that  et a l , 1985).  Relative  i n chronic  (Cohen  e t a l . , 1981;  less  (Yang  ' o r g a n i c i t y ' and  c o n s i s t e n t l y found  organic  supposition  and i n the  likely  that  more  to t o n i c  pain  *  104  Signal  Detection  chronic  pain  present  study  dysfunction control  people 1980;  i n the  have  finding  higher and  chronic  pain  & Olson, 1 985 ) .  The  with  sensations  as  populations stimuli.  with A l l of  differences chronic  on  patients  Naliboff  et  The between number greater  chronic  less  a l . , 1981;  present  discrepancy this  of  factors.  There  over  of  than  obvious  than et  and  Yang  present  study  were  primarily bias  results  studies  studies  of  on  and  a l . , 1983;  not  found  the  present pain  the  pain  significant  people  without chronic  between  stimuli  S. O l s o n ,  1985).  on  et  report  chronic  Malow  a l . ,  revealed  to  found  patients  a l . , 1980;  et  were  physical  Malow  a l . , 1981;  to d i s c r i m i n a t e  et  normal  d i s c r i m i n a b i l i t y , with  In  1981;  contrast,  the d i s c r i m i n a b i l i t y  investigation. in findings  research  control  research.  pain  Yang  differences  SDT  organic  criterion  response  the  SDT  able  Malow  et  the  the d i s c r i m i n a b i l i t y of  the measure  being  i n the  to  previous  a l . , 1983;  significant measure  the  between  pain  et  respect  past  less  in  clear  a l . , 1983;  the  i n the  However,  from  et  threshold  differences  differ  of  with  with  report  Naliboff  i n pain  painful.  investigation  (Cohen  perception  criterion  with  pain  results  pain  patients  report  lower  1981;  ot  consistent  patients  without  the d i f f e r e n c e s  (Cohen  that a  Malow  that  pain  to have  associated  pain  a  are generally  tend  a l . , 1983; that  patients  subjects,  pathology  investigations  and  past  First,  the  medication  i s good  reason  concerning  t h e d'  investigations present than  may  measure be  due  investigation  was  done  to believe  in  that  exerted  previous a  lack  to a  of  105 control (1979)  over  medication  found  that in  the  bias  increase  in  d i s c r i m i n a b i l i t y of  radiant  to  result  threshold  response  as  painful  increased  only  and  a  findings.  administration  an  in  pain  could  and  placebo  of  criterion  significant  alterations  in  Most  SDT  investigating  of  the  chronic their  pain  pain  patients time  of  did  not  population  and  i t cannot  not  testing et  Yang  taking  (Cohen  a l . ,  et  were  day  testing  requested and  of  in  was  tested  in  regular sample. (i.e.,  nine the  who  did  not  volunteer). medication  a  was  for  in time. in by  medication  that  their et  found  sensations  over  of  in  decrease  perception use  Malow  and  result  assumed  the  pain  a l . ,  at  the  1980;  the  that- the  pain  any  medication  pain  that  eight  hours.  at  a l l and  be  an  majority  the  medication  oain  thus,  artifact  were  the  The  investigation the  may of  anyway  the to  before were  possible  Dooulations  not  of  for of  the  uast  SDT  amount  patients any  a  take  testing,  existence  the  medication  selection  more  they  were  taking  not  on  minimum  represent  requested night  patients  a l l patients  i n v e s t i g a t i o n were  Therefore, in  take  however,  midnight  take  to  estimated  patients  from  be  a l . , 1983;  present  hours;  could  because  the  medication  least  the  medication  medication  at  present  This  mention  reported  not  they  for  lapsing  pain  resulted  report  not  ,  1981).  medication-free  intake  et  a l . , (1985)  tested  time  any  to  did  a 1.  et  Valium  responsiveness  patients  were  Naliboff  of  studies  bias  stimuli.  control  pain  morphine  response  heat  Yang  likely of  'cleaner' criteria their patients to  analgesic  studies  mav  106 have  contributed  stimuli A in  in  results  in  for  were  between for  the  measure  (_r = - . 2 5 ,  d'  has  may  were  the  of  In  was  £ < . 01 , n = 9 0 )  30 a  tested  chronic  of  patients  (s.d.=9.1)  and  compared  whose  age  was  19  years  Yang  et  al.  tested  in  the  to  70  years  to  65  years.  their The  whereas Other  subjects  tendency  for  and  past  group  and  compared  control  group  may  have  age  intake  for  lack  of  The for  the  study SDT use  for  the  measure  methodology of  a  control  used  to  the  et  a  age in  18  ages  of  1980). older  found  study  definition  in  medication  findings  the  the  from  an  and  in  in  the  26  younger  discriminability.  sample  age  a l . ,  of  present  patients from  differences  differences  groun  pain  tested  significant  (1980)  control  in  to  study  years  report  have  were  showed  al.  28  ranged  not  who  negative  et  the  Malow  to  over  current  did  study  present  was  and &  groups  Chronic  responses  contributed  the  to  subjects  Control  account  age  age  (Clark  subjects  ranged  a l . , 1981;  their  the  Malow  .2 ) .  study  discriminability. may  in  older  responses  ( s . d.=1  the  significant  mean  investigations  patient  selection  present  and  stimuli.  investigations et  differences  research  the  d'  that  control  (Naliboff  for  but  age  (1985)  to  the  past  years  whose  their  the  in  small  the  painful  r e l a t i o n s h i p between  60  suggesting  discriminability  mean  and  between  poorer  pain  a  of  study.  concerns  selected  fact,  found  also  this  contributed  reported  subjects ages  of  have  Because  been  discriminability  results  that  age.  correlation  the  subjects.  1971),  matched  to  poorer  factor  discriminability Mehl,  their  contrast  second  criteria  to  is of  in  the  notable hits  and  107 false  alarms.  other  researchers  signal  detection  current were  were  pain  perception  group  finding more  differences  valid  normal  control  provide  pain  support  clear  pain  The  incongruent  (i.e.,  signs  i n pain  and  to p a i n f u l  hypothesized  t o be  criterion  comparison  of  investigation  model  of  pain  for a  of p a t i e n t s  by  subgroup  assessing  d i d not r e s u l t  as h y p o t h e s i z e d ,  criteria  (i.e.,  absence  the pain  condition)  pain  patients  i n terms  by  adaptation-1eve1 a higher  se n s a t i o n s This  as  pain  of in  however,  for  represented  people.  research.  symptoms)  The  to report  to the  the presence  stimuli,  to p a i n - f r e e  i n previous  a  of  identifying  ' e x c l u s i o n a r y'  of  is likely  relative  but only  percep t i o n  causes  studies  current  meas u r e  present  patients,  i n the d i s t i n c t i o n  responses  the  point s.  the  stimuli  reported  d i s t i n c t ion  pathophysiological  higher  of  heat  adaptat i o n - l e v e l  criteria  the use of  resulted  a  that  f o r the  differences  Rather,  than  the r e s u l t s  patients.  medically  radiant  1  sensit i v i t y  the sensory  subjects  interpretation  unambiguous Thus,  The  d s and  SDT  previous  i n t h e d*  to  i n chronic  'inc1usionary'  group  group  summary,  perception of  differences  patients  in  by  of the  the  the  and a l l of  t o t h e same c u t o f f  f o r the  of  of  since a l l  d' and b e t a .  representation  pain  In  in  group  levels  not found  and a H o w s  used  investigations.  SDT  problem  relative  characteristic  o f no  chronic  this  ba s e l i n e  the i n t e r p r e t at i o n  i n past  stimulus  calculated  is a  or i n d i v i d u a l  compromised  a v o i ds  t h e same  This  of  has  meas u r e s  paradigm  given  betas  The " f l o a t i n g  of  of  their  model  was  threshold  and  painful in  p r e d i c t i o n was  met  by  108  patients  with  a  clear  organic  hypervigi1ance  model  was  pain  and  lower  threshold  painful  relative  pattern  of  patients control  a  to  results  without sample,  basis  hypothesized criterion  pain-free is  the  to to  organic  with  differences  were of  these  discussion  the  significance  of  the  Medically  symptomatology  Incongruent  Psychological The without group  Craig  classification medically  This  of  physical  on  objective  The  a  sensations  the  low as  the  prediction  between  normal  statistically findings  and  evaluation  addressed  also  in  to  of  a medically  below.  Disability,  of  no  of  and  after  pain  presentation  maladaptive  cognitions  (i.e.,  by  group  data  be  due  to  were  found  the with to  Reesor  & on  physical on  objective  the  54%).  s i g n i f i c a n t group  Patients  and  differences  or  (i.e.,  out  with  disability  differences  may  partially  impairment.  incongruent  group  of  reported  limitations  missing  those  in significant  report  clear  study  found  into  resulted  that  reported  this  Craig  measures  physical  signs  structural  finding  &  patients  subjective  similar  percentage  Reesor  cognitive  by  Although  Presentation,  pain  their  is  They  impairment  significant addition,  on  objective  impairment.  of  incongruent  result  (1988).  measure  be  The  Distress  differences  only.  will  Symptom  reflected  and  not  implications  condition.  report  diagnoses  The  incongruent  be  this  significant. of  their  individuals.  consistent  clear  for  In  differences  variance a  medically  engage  catastrophizing),  due  in  more  i n e f f e c t i ve  to  a  109 coping  strategies  lower  sense  patients Craig,  (e.g.,  of. s e l f - e f f i c a c y  who  did  1988).  not  in  the  related  cognitions, with  incongruent pain, more and  less  inclined  &  on  to  efficacy  use  of  significant  of  group  Patients  report  relative  control  coping  and  pain-  about  pain,  strategies  was  medically  more  the  &  not  differences with  a  to  (Reesor  coping  catastrophize  to  passive  pain  to  symptoms  measures  Craig.  tended  the  and  s i g n i f i c a n c e was  d i r e c t i o n of  to  and  the  were  (i.e.,  praying  hoping ). lack  present  study  subjects  tested  patients  in  present  with Other  each  differences  volunteered  on  cognitive  attributable  to  the  in  that  may  the  power  each for  to  group  (power of  compensation/litigation  not  study  taking  unlike  Reesor  resulted  in  selection  more  self-reliant  were  less  on to  &  and  Craig's of  a  many  or  on  of  the  at  .94).  group  were  who for  their  may  have  patients  depend  in  populations  strategies to  pain  achieved  patients  This  of  their  been  patients  sample.  e f f e c t i v e coping  tested  pain  medication  sample  catastrophize  have  forty  estimated  different  regular  assessed  based  in  number  significant  No  present  measures  smaller  thirty  should  lack  slightly  the  analysis  power  the  Craig  that  problem,  likelv  &  be  were  the  a  enough  in  reasons  Reesor contrast  However,  assessed. in  findings  group.  subjects  possible  be  group  revealed  thirty  assessed  may  per  study.  findings  were  control  incongruent  study  Reesor  hoping),  statistical  the  symptoms  reported  The the  present  and  to  display  Although  reached  consistent  praying  on  who and  pain  were thus,  passive  110 coping  strategies  The  finding  primarily is  by  presentation symptoms,  Main  &  of  the  patients'  Waddeli  (1984);  the  and  presentation low  impairment styles pain of  of  study.  both  a  of was  other  the  low  in  past  be  their  degree  was  cognitive  Waddeli  &  Main  not or  a  1984;  disability  and  of  the  Reesor  physical  present  Further,  to  that  and  the  physical  with  passive  'worry'  about  associated  variables  symptoms  study  impairment  significantly  found  pain  Although  correlation  affective  200  inappropriate  between  low  of  by  physical  research.  of  reported  sample  of  s t r a t e g i e s and  (1984)  to  statistically  incongruent  a  but  mostly  significant.  found  coping  be  and  a s s o c i a t i o n was  symptoms.  have  pain  i n v e s t i g a t i o n (_r=.27,  report  results  to  Waddeli,  c o r r e l a t i o n s between  correlation  to  &  between  medically  self  the  the  found  marginally  with to  incongruent  disability  inappropriate  cognitive  condition  the  of  clear  drawing,  only  report  not  of  found  significant  and  pain  revealed self  was  and  disability  inappropriate  (Main  present  degree  of  been  of  found  however,  measures  is  but  impairment the  the  same  result  was  r e l a t i o n s h i p between  impairment  and  in  The  The  small  correlation  n = 27).  have  report  pain  self-perceived  signs,  impairment A  incongruent  Measures  drawing)  a l . , 1989).  impairment  of  on  physical  pain  et  patients,  found  research.  physical  hoping.  measures  the  insignificant  p_= . 0 8 ,  past  and  patients  (nonorganic  degree,  physical  the  and  predictive  Waddeli  that  praying  distinguished  supported  lesser  like  in  "most  the of  with  the any  present the  111 psychometric  variables  inappropriate  signs,  but  a l l with  hardly  32).  at  Additionally  between  the  pain  Reesor  &  Craig  Main's  (1984)  patients  inappropriate two  between  incongruent there  may  signs  be  assessed  a  with  psychological Physical assess  "I  last").  a  and  view  factors  to  about worry  In  covarying  feelings  of  of  and of  about  my  a  chronic  which  more  of  to  less be  than  than  less five  relationship medically clear.  the  i t  Because  should  analyses  family";  cognitions  and  investigators  disability  pain  was  be of  "I was  have  how  In  a  long  this  (manifested  will  with  anxiety, link  the  concerns  emotionality  anger,  to  associated  term  associated  reported  depression  long  wonder  heightened  appear  condition.  primarily  reflects  disability  and  had  found  the  divided  of  who  entirely  subjective  impairment  pain  disability  sum  i t out  f r u s t r a t i o n , depression,  Other  the  &  appropriate.  the  contrast,  not  Waddell  of  Thus,  is  unlike  (1989)  had  (p.  association  al.  r e l a t i o n s h i p , however,  if  physical  from  l i m i t a t i o n s and  symptoms  impairment  catastrophizing  report  structural  impairment."  et  were  who  symptoms.  systematic  study,  worry  pity).  and  data  Patients  symptoms  disability,  impairment,  basis  patients  d i f f e r e n t aspects  present  (e.g.,  and  and  significant  same  symptoms.  than  signs  objective  and  a  Waddell  the  with  physical  find  the  however, on  of  physical  Using  signs  impaired  not  and  groups  symptoms,  degree  did  (1988).  signs  inappropriate  with  they  inappropriate  physically  the  drawing  two  significantly  inappropriate  study,  into  correlate  (i.e.,  and  self-  between  self-  mainly  as  112  frustration pain  and a n g e r ) ,  drawings,  schemas  regarding  continuous  pain  1989;  Leavitt,  1989;  Polatin  1990;  Bigos  and  pain,  reports 1990;  are e s s e n t i a l l y  and  the  severity  about  are said  This  assessment  distinguished separate signs,  associated drawing  (i.e.,  the p a t i e n t  is a reflection Measures  drawings  primarily  by  on  distress  incongruent self  t o have (trait  et a l . ,  and  drawing,  result which  was  a consistent  catastrophic supports report  the  of, t h e  physician. the  to  study  illness disability et a l . ,  as,  although  primarily  disability,  each  nonorganic found  physical  t o be  distress.  association  worry  and  cognitions) of  level  patients'  (Waddeli  also  the f i n d i n g s  The  pain  to  emotionality i n the  present  previous  a r e l a t i o n s h i p between  the h y s t e r i a  t o be a  of  symptoms  perceived  anxiety,  and  associated  the present  the pain  measures  and  Fraser,  of m a g n i f i e d  of p s y c h o l o g i c a l  This  &  incongruent  expression  with  distress  et a l . ,  behaviour)  symptoms)  investigations pain  t o be  patients'  about, t h e p a i n , study.  which  medically  illness  emphatic  of m e d i c a l l y  found  naive  u s e , and  1989; L a c r o i x  inappropriate  was  affective  a more  supported  measure  and  between  to p s y c h o l o g i c a l  was  professionals,  i n t e n s i t y (Barnes  consider  the problem.  secondarily  1989).  medication  (or magnified  They  behaviour  increased  abnormal  1991).  of communication  distress  care  et a l . , (1989)  symptoms  disease  of h e a l t h  of high  vigilance,  L e e e t a l . , 1989; G r e e n o u g h  form  of  somatic  e t a l . , 1989; G a l l o n ,  et a l . ,  Waddeli signs  mistrust  increased  and h y p o c h o n d r i a s i s  abnormal scales  of  113 the  MMPI  (Dzioba  Ransford  et  the  drawing  pain  response  &  Doxey,  a l - , 1976;  to  has  1984;  and been  treatment  Murphy  Taylor found  (Polatin  et  to et  &  Cornish,  1984;  a l . , 1984).  be  In  p r e d i c t i v e of  a l . , 1989;  Uden  addition, a  poor  et a l . ,  1988). The use  of  nonorganic  various  attention,  and  catastrophize the  the  about  and  of  (1984)  inappropriate  symptoms  with  and  control  pain,  and  study.  Thus,  i t  incongruent perception  The  pain and  catastrophic reasonable  presentation  expression  concern patient  and  groups  as  the  present  the  of  incongruent  study pain  the as were  to  to  reported  lower  they  suggested  physical  in  of the  mood  which  is  &  and  and were  praying, efficacy  to  present  measures of  Main  signs  symptoms  (i.e.,  assessments  disability  tendency  condition.  sense  consider  identified  in  low  cognitions to  a  depressed  strategies  d i s t r e s s about  'functional' measures  of  their  Inappropriate  coping  self-  behavioural  nonorganic  diverting attention), a  is  and  the  diverting  a l . (1990)  pain  to  to  related  the of  related  awareness.  passive  hoping,  were  regarding  the  et  reflect  coping  also  Lacroix  reflect  were  but  to  hoping,  sensations,  signs  that  found  (praying,  understanding  reported  associated  may  were  pain),  pain.  schemas  poor  somatic  the  physical  signs  heightened  his/her  the  naive  physical  consequences Waddell  strategies  ignoring  nonorganic  education that  coping  signs  r e i n t e r p r e t i n g pain  statements,  that  physical  the  of patient's  reflective  of  problem. 'organic' not  and  distinguished  presentation  or  on  any  on of  the  114  cognitive that &  or  affective  reported  Garron,  previous  1979).  correlation organic  in  measures. research  Waddeli  between  etiology  the  et  presence  although  the  in  cases  with  obvious  (1988)  reported  that  patients  not  necessarily  but  that  psychological  important  role  The  in  variables  lead  of to  relationships. research  organic  the  with  with  nature data,  diagnosis  may  perceived  and  medically  incongruent  that  if  of  the  In  this  in  to  and  status  reflections  of  the  patients  concern  to  an  and  disability.  alteration  attention  in  signs  of  a  clear  organic  of  lead  increased  patient either  has  a  naive  physical  or  somatic  somatic schema  study  and  due  vigilance,  psychological)  the and  an  that  in  of  group.  causal  absence how  (which  a  be  more  particularly (i.e.,  clear is  of to  be  are  regarding model  shift  (Chapman,  with  a  appear  patient)  to  pain  of pain  distress  may  those  conjunction  hypervigi1ance  diagnosis  distress  presentation  the  distress  about  in  al.  pathology  prevents  or  the  of  perception  to  absence to  pain  The  et  play  nature  symptoms  physical  less  Doxey  may  alterations in  the  pain  were  clear  r e l a t i o n s h i p s among  presence  of  Leavitt  and  physical  study  the  this  independent  his/her  signs  disability  to  significant  psychological  contrast,  signs  1987;  no  signs  present,  of  as  of  result  reported.  found  unclear  more  similar  Turk,  nonorganic  however,  findings  suggests  is  pathophysio1o1ogy.  speculations  The  &  nonorganic  maintenance  the  (Flor  of  distress,  correlational  interpretations  past  present  finding  a l . (1980)  common  may  This  refers  in  1986).  The  likely if  the  that  i s determined  to  to  i t is find  physical  depression, result  in  related  Psycholog i c a l  pathology. poor  coping  increased  to  individual's  daily  life  rather  cause  pain.  In  judgements  principles  of  The  the  role  of  the of  than  abs ence pain  cognition  and  not  are  anxiety,  necessarily they  may  be  affecting  the  e s t a b l i s h i n g the of  appear  a d a p t a t i o n - 1 eve 1  (i.e.,  since  disability  and  vigilance,  may  vigilance  somatic pain  the  etc.)  skills  the  of  how  factors  increased to  be  specific  somatic  based  on  the  model.  emotion  in  the  experience  of  pain. It  is  between  of  pain  response  As  be  to  the  the  threshold patients  cognitions report  More  to  a  of  than  was  found.  and or  to  clinical  used  and  the  SDT  i s , i t  are  appears  unrelated  discriminabi1ity It  involving  the  relationship  That  anxiety  related  pain  no  cognitions  stimuli).  task  should  be  to  (i.e.,  noted,  however  cognitions  and  anxiety  condition  and  may  laboratory here  supra-thresho1d  were  simply  induced  concerned  the  pain.  pain  levels  of  pain  the  manage.  interesting  catastrophizing of  pain  pain  measure  measures  intensity  of  essentially  related  patient's  rather must  pain  painful  related  well,  between  to  to  that  perception  measures  relevant not  pain  bias  the  of  related  sensitivity that  interest  measures  measures that  of  of and  pain.  is  the  pain the  presence  related  worry,  subjective  Those  of  patients  an  emotionality,  ratings who  association  of  the  reported  and  sensory  higher  levels  of  affective  the  painful  finding  distress stimuli  i s similar  catastrophic pain  have  intensity pain  1989;  functional  & Watson,  while  are associated  with  the subjective  pain  management  decreased  result  medication  no c l e a r  cognitive  associated  that  with  increased 1987; F l o r  6. E p s t e i n , and  experience  i n pain  itself  of  This 1  pain,  may  programs  increased  functional  1976).  pain  pain.  mood,  &  affective  cognitive-behavioura  u s e , and l e s s  et a l . ,  1966; R e e s o r  general  to report  i n improved  improvement  sensory  e t a l . , 1952; K e e f e  that  bias  of  to control  (Bandura,  e t a l . , 1989; S z p i l e r  or the response  where  disability,  tolerance  e t a l . , 1965; M e n d l e r  f o r the findings  despite  ratings  rated  This  helplessness  higher  pain  also  intense.  therefore,  sensitivity  for  with  1966; H i l l  are not n e c e s s a r i l y  account  condition  i n the past  and p e r c e i v e d  and d e c r e a s e d  1988; S p i n h o v e n  factors  pain  reported  increased  1987; Halsam,  appears,  they  to that  associated  of pain,  Lepanto  Craig, It  been  their  a s s u b j e c t i v e l y more  cognitions  report,  & Turk,  about  coping,  disability  (Skinner  et a l . ,  19 9 0 ) .  Gender  Differences  The  results  differences  However,  better  able  In  threshold  within  that women  they  generally  showed  more rated  pain heat  group,  the pain  Pain gender  to report women  and f a i n t  sensitive  of  no o v e r a l l  or the c r i t e r i o n  between  were  and E x p r e s s i o n  study  the chronic  to discriminate  suggesting addition,  of the present  f o r pain  pain.  men  i n the Experience  were  pain  than  to the s t i m u l i . stimuli  as more  117 intense  and unpleasant  present  study,  the  control  sensations  to report group,  than  more  inclined  None  of the previous have  Research the  past  evaluating  tolerance  levels  Sherman lower et  thresholds  Stevens,  1967).  t o have  including Rollman  touch,  & Harris  perception, direction  (1976)  most  men  hearing, noted  of the data having  f o r heat,  levels  reported  taste,  that  lower  smell,  shock  a s s u b j e c t i v e l y more however,  men  t o have  (Brennem  females  1987 ; were  modalities  and r o d v i s i o n .  there  a r e some  differences  i n pain  a sex d i f f e r e n c e  shock,  electric  1967; and  women  sensory  thresholds  electric  1950;  6. H a r r i s ,  that  on g e n d e r  indicates  perception i n  & King,  than  although  A d d i t i o n a l l y , they  (1987),  pain  & Tophooff,  Rollman,  pain.  & Harris  women.  t h r e s h o l d and  reporting  f o r many  i n the research  of females  than  19 5 4;  thresholds  (1987)  men  investigators  1971; C l a u s e n  pressure  Rollman  some  f o r pain  and t o l e r a n c e  pain,  painful  groups,  than  i n pain  1952; Notermans  Archer  inconsistencies  levels  & Mehl,  & Stride,  lower  pain  sensations  sex d i f f e r e n c e s  & Goodell,  the  to report  the chronic  & R o b i l l a r d , 1967) and o t h e r s  pain  Within  sex d i f f e r e n c e s .  differences  (Clark  a l . , 1989; H a l l  found  inclined  painful  i nthe  by s e x i n t e r a c t i o n f o r  sensations.  i n c o n s i s t e n t , with  no g e n d e r  ot i n t e r e s t  i n v e s t i g a t i o n s of chronic  evaluated  has been  Wolff,  SDT  group  less  but within  to report  reporting  Hardy,  Finally,  painful  men w e r e  women  were  populations  men.  i s the s i g n i f i c a n t  inclination  normal  than  found  and  i nthe  tolerance  and m e c h a n i c a l that  females  rated  painful  than  males.  indicated  that  i t remains  118 unclear  t o what  contribute The  results  complex  between  a n d more  the self  functional  research  report  outspoken  about  supported  by o t h e r  chronic  their  differences  than  men.  research  self  observed  trends  differentiating  cognitive  co.ping  diverting  attention  strategies greater There  sense  disclosure  Women w e r e  strategies  often  than  of s e l f - e f f i c a c y  to catastrophize.  little  credence  suggestive  of o v e r a l l  experience  of pain  may  women  gender found  praying,  has been greater for  using  them.  the  use of  passive  h o p i n g , and  women  the pain  f o r sex d i f f e r e n c e s  disability.  The  and b e h a v i o u r a l  these  more more  f o r the reported  t o manage  be g i v e n  study  t o be  account  In a d d i t i o n ,  Because  the r e s u l t s .  reporting  tend  may  perception  i n this  to report  sex d i f f e r e n c e s  and  women  i n women  matters)  men.  trend  found  and d i s a b i l i t y  (i.e.,  to other  was n o a p p a r e n t  tendency only,  more  and p a i n  ( L e e et a l . , 1989).  toward  strategies.  with  perception.  that the  to c l a r i f y  were  That  discomfort  tendency  coping  i n pain  pain,  i s needed  of d i s a b i l i t y ,  disability  tactor:  i n v e s t i g a t i o n suggest  gender,  gender  and n o n s e n s o r y  sex d i t t e r e n c e s  ot the present  Significant for  sensory  to the reported  relationship is  extent  coping  reported  than  in  men.  the  findings  are  However,  they a r e  i n the expression  trends  and  a  Summary  and  The  purpose  supposition patients.  of  that Two  predictions The  Conclusions this  pain  perception  models  were  regarding  hvpervigilance  pain  patients  more  likely  how  led  have  report  because  1986).  adaptation-1eve1  prediction  that  thresholds  and  sensations  as  because, painful Both of  painful  relative stimuli  models  had  methodological  conditions painful under  pain  stimuli.  what  be  to  would  prediction  that  chroni  thresholds  and  received  judged  as  support  would label  The  would  present  circumstances  the  be  over-  study  to  th  higher  pa  somatic  discomfort,  was  This  (Rollman,  1979). because  under  which  underresponsive  designed  predictions  but  unclear  or  is  additional  research  i n c o n s i s t e n c i e s , i t was patients  (Chapma  individuals.  past  b  pain-  led  have  innocuous  in  would  vigilance  contrast,  to  pain-free  pain  d i s t r e s s than  in  likely  be  of  opposing altere  less  internal  pai  is  patients  their  chronic  yield  pain  than  the  which  somatic  lodel,  evaluate  in  somatic  increased  chronic would  the pain  of  individuals The  to  to  altered  perception  lower  signs  of  is  presented the  model  would  to  i n v e s t i g a t i o n was  of  to  each  to  examine  model  are  met. The with  results  clear  pain-free higher  of  physical  this  investigation revealed  pathology  i n d i v i d u a l s which  criterion of  by  The  responses  the  adaptation-1eve1  which  these  to  had  was  pain  primarily  report  patients  model.  higher  represented  Patients  with  to  patients  thresholds  sensations  conformed  that  as  the  by  than a  painful. prediction.of  unclear  physical  120 pathology, pain  however,  thresholds  painful  relative  significantly control model  was  of  were  more  Thus,  in  that  this  significantly to  in  this  used  label  patients  responses  p r e d i c t i o n of  finding  stimulus  have  pain  their  the  supported  to  inclined  'organic'  different  not  pain  found  to  sample.  however, type  and  were  study.  may  be  in  this  as  not  normal  hypervigi1ance  should  partially study  were  the  the It  sensations  but to  lower  be  noted,  dependent  (i.e.,  a  upon  phasic  the  pain  stimulus). The in  findings  their  responses  perception rather  may  than  reflective painful.  be  a  differences  in of  It  is  have  a  increased may  has  been  were  bias  of  signs cause. the  use  of  pain  report.  The  greater  statistical found  in  distress support  previous  to  in  for  that  be  stimuli, primarily  sensations of  an  shift  distress  That  somatic of  a  to  their in  an  shift  research.  judge  effort  may  tonic  pain  in  the  they  may  painful  stimulus  patients  h y p e r v i g i 1 ance  to  result  distress results  vulnerable the  as  organic  i s , although  which  pain However,  adaptation-1eve1  from  use  to  attentional an  on  painful  report  somatic  adaptation-1eve1 focus  to  patients  patients.  absence  stimuli.  intense  pain  people  This  pain  suggesting  found  to  the  of  their  engender  yielded  to  pain  perceptual  higher  stimuli,  threshold  response  physical  of  sensitivity  leads  overriding  judgement  chronic  the  focus  the  in  in  differentiated  stimuli  that  attentional a  painful  possible  for  identify  study  altered  pain the  this  to  change  explanation  in  of  may  model  in which have as  The and  presence  psychological  strategies, pain  and  perception  psychological (i.e., the  exception  found  report  and as  to  be  more  praying  and  incongruent of  to  of  a  to  psychological  how  In  Finally,  with  the  past  categorization medically in  appears  terms  and,  chronic  of,  be  pain  to  to  be  the  are  more  to  bias)  patients pain  symptoms than  is  of  more  the  of  pain,  with  pain  measures  problems.  supports into  these  those  affecting  with  appears  subjective of  regarding  the  such  medically  exaggerated  reflective  problem  not  strategies  degree  experiencing an  were  those  presentation  the  of  Rather,  primarily, their  of  with  ratings  associated  which  fact,  and  control  coping  on  response  catastrophize  patients'  pain  In  although  measures  secondarily,  expression to  the  incongruent  d i s t r e s s they the  addition,  research of  and  disability  passive  found  patients  pain  higher  stimuli.  tended  hoping.  were  to  efficacy  use  to  response  signs  functional  to  coping  emotionality,  incongruent  less  presentation  hypotheses.  unrelated  painful  they  pain  the  related  inclined  Thus,  presentation about  the  report  disability  condition.  were  symptoms.  d i s t i n g u i s h them  report  mostly  distress regarding  the  without  of  greater  conjunction  findings,  to  heightened  cognitions  symptoms  emotional In  and  worry,  pain  d i s t i n g u i s h pain  contrary  significant,  pain,  not  d i s c r i m i n a b i 1 i t y , and  incongruent  the  incongruent  (cognitions,  were  medically  statistically about  measures  intensity  with  without  variables  that  patients to  medically  distress) did  threshold,  sensory  a  variables  catastrophizing the  of  their  pain concerns  the  122 individual's to  express  These  daily  his/her  concerns  vigilance without  clear  depression), that  addition, stimuli rated  significant  pain  than  than  The  pain  more  likely  t o have  i s needed  lower  remains  to c l a r i f y  of this  i n the l i t e r a t u r e problems.  was  less  to label  these  likely  the the  to  label  the chronic  however, and  gender, a n d more  as  women a r e tolerance  chronic controlled  results.  multidimensional  It i s recognized  A  differences in  i n v e s t i g a t i o n support toward  Within  thresholds  unclear  men.  for  sensations  mixed;  pain  women  than  within  on g e n d e r  In  painful  found  However,  been  pain  with  men.  Finally,  The r e l a t i o n s h i p between  perception  results  have  than  as p a i n f u l .  research  of  investigation  and u n p l e a s a n t  men w e r e  women.  and  intense.  sensitive.  than  Past  of  anxiety,  disability  sensations  or  the experience  i n this  interaction  somatic  with  to discriminate  intense  and r e p o r t  men.  and p a i n  research  were  reported  able  individuals,  women.  experience  levels  trend  to report  men  found  a r e more  by g r o u p  ability,  more  functional  better  i n patients  to affect  as being  were  professional.  The e x i s t e n c e  coping  appears  a s more  as p a i n f u l  groups,  generally  pain,  they  of pain-free  painful pain  were  gender  bias  sensations  (poor  greater  result  to occur  pathology.  differences  the stimuli  group  i n increased  i s rated  implying  response  not n e c e s s a r i l y  however,  women  individual  care  distress  reporting  by t h a t  d i s t r e s s to the health  organic  the pain  Gender women  may  and i s an a t t e m p t  and a r e as l i k e l y  psychological  in  life  that  the current assessments of  two-dimensional  models  of  pain  adopt  are  overly  multidimensional  socioeconomic, pain  and  1987b;  and  Waddeli  et  medically  need  (Main  schemes  in  and  are  more  a d d i t i o n a l help  the  cognitive  physiological patients sole  so  cause  explanations  for  that  pain  altered  maintenance the  of  correlational establish vigilance, report  of  alleviate  how pain,  excessive  1987a;  dichotomous  chronic  or  pain  are  of  medically  symptoms  is  valuable by  learning  affective  do  and  to  or  continued  causal For  what  is  in be  rather,  the  kinds  somatic  an a of  may  explanations  in  addition  given  to  a l l  upon  any  is  It  an  patient's  finding  in  be in  out  of  research of  this  valuable  to  somatic  experience  preventive  a  the  indication  arising  increase  pain  is unlikely  Future  i t would  to  other  factor  problem.  vigilance.  who  pain  dependent  major  and  (i.e.,  discomfort.  example,  affect  identifying  plight  pain  speculations  to  in  problem  cope.  reject  a  but of  lead  may  of  become  resent  pain  to  roles  need  not  their  how  explanations  factors  and  Rudy,  assessment  perception  this  &  to  the  study.  what  Turk  relate  However,  their  the  they  the  chronic  address  to  of  individual's appraisal  should  as  organic/functiona1 for  made  dimensions  explanations)  physical  being  psychological,  1984;  Simple  distressed  they  are  the  in  and  that  assess  Waddeli,  (whether  Multidimensional of  &  characterizing  signs  who  attempts  that  a l . , 1989).  individual.  incongruent patients  models  incongruent/congruent)  insufficient that  and  physiological factors  chronicity  classification  for  simplistic  and  strategies  would  124 REFERENCES A h l c s . T.A., B l a n c h a r d , E.B., & L e v e n t h a l , C o g n i t i v e c o n t r o l ot p a i n : Attention a s p e c t s ot t h e c o l d p r e s s o r s t i m u l u s . a n d R e s e a r c h , 7_, 1 5 9 - 1 7 8 .  H. (1983). to the sensory Cognitive Therapy  American P s y c h i a t r i c A s s o c i a t i o n ( 1 9 8 7 ) . D i a g n o s t i c and S t a t i s t i c a l Manual of Mental D i s o r d e r s (3rd. e d i t i o n , revised). W a s h i n g t o n , D.C.: author. Archer, J. (1976). Biological explanations of p s y c h o l o g i c a l sex d i f f e r e n c e s . I n B. L l o y d & J . A r c h e r (Eds.), E x p l o r i n g Sex D i f f e r e n c e s ( p p . 2 4 1 - 2 6 6 ) . New Y o r k : Academic Press. B a n d u r a , A . , O ' L e a r y , A., T a y l o r , C. 3 . , G a u t h i e r , J., & G o s s a r d , D. ( 1 9 8 7 ) . P e r c e i v e d s e l f - e f f i c a c y and p a i n control: O p i o i d and n o n o p i o i d mechanisms. J o u r n a l of P e r s o n a l i t y and S o c i a l P s y c h o l o g y , 5 3 , 5 6 3 - 5 7 1 . B a r n e s , D., S m i t h , D. G a t c h e l , R. J . , & M a y e r , T. G. (1989). P s y c h o s o c i o e c o n o m i c p r e d i c t o r s of t r e a t m e n t s u c c e s s / f a i l u r e i n c h r o n i c low-back pain p a t i e n t s . Spine ,  _14.< >r 4  427-430.  B e l l i s s i m o , A. & T u n k s , E . ( 1 9 8 4 ) . Chronic psychotherapeutic spectrum. New Y o r k :  pain: The Praeger.  B i g o s , S. J . & B a t t i e , N. C. ( 1 9 8 7 ) . Acute care to prevent back d i s a b i l i t y . C l i n i c a l Orthopaedics and R e l a t e d R e s e a r c h , 22 1 , 121-128. B i g o s , S. J . , B a t t i e , M. C., S p e n g l e r , D. M., F i s h e r , L . D., F o r d y c e , W.E., H a n s s o n , T . H., N a c h e m s o n , A . L . , & W o r t l e y , M. D. ( 1 9 9 1 ) . A p r o s p e c t i v e s t u d y o f work perceptions and p s y c h o s o c i a l f a c t o r s a f f e c t i n g t h e r e p o r t of back i n j u r y . Spine, 1 6( 1 ) , 1-6 B l i s h e n , B. R., C a r r o l l , W. K . , Se M o o r e , socioeconimic index f o r occupations C a n a d i a n S o c i o l o g y and A n t r o p o l o g y , B o b e y , M. J . & D a v i d s o n , P. 0 . a f f e c t i n g pain tolerance. Research, 14, 371-376.  (1970). Journal  C. ( 1 9 8 7 ) . The 1981 i n Canada. Review of 24(4) , 465-488 . Psychological factors of Psychosomatic  Bowers, K . ( 1 9 6 8 ) . P a i n , a n x i e t y , and p e r c e i v e d c o n t r o l . J o u r n a l of C l i n i c a l and C o n s u l t i n g P s y c h o l o g y , 3 2, 596602  .  125 B r a d i s h , D. F . , L l o y d , G. J . , A l d a m , C. H., A l b e r t , J . , D y s o n , P., D o x e r , N. C., & M i t s o n , G. L . ( 1 9 8 8 ) . Do n o n o r g a n i c s i g n s h e l p to p r e d i c t the r e t u r n t o a c t i v i t y of p a t i e n t s with low-back pain. S p i n e , 1_3 ( 5 ) , 5 5 7 - 5 6 0 . B r a n d s , A. E . & S c h m i d t , A. J . ( 1 9 8 7 ) . Learning processes the p e r s i s t e n c e b e h a v i o u r o f c h r o n i c low back p a i n p a t i e n t s with repeated acute pain s t i m u l a t i o n . Pain, 329-337.  in 3 0,  B r e n n u m , J . , K j e l d s e n , M., J e n s e n , K., & J e n s e n , T. S. ( 1 9 8 9 ) . M e a s u r e m e n t o f human p r e s s u r e - p a i n t h r e s h o l d s on f i n g e r s and t o e s . P a i n , 38, 2 1 1 - 2 1 7 . B u r o s , 0. Vol.  K. 1.  (1978). The E i g h t h M e n t a l M e a s u r e m e n t s New J e r s e y : The G r y p h o n P r e s s .  Yearbook,  B u s h n e l l , M. C., D u n c a n , G. H., D u b n e r , R., J o n e s , R. L . , a n d M a i x n e r , W. ( 1 9 8 5 ) . A t t e n t i o n a l i n f l u e n c e s on n o x i o u s a n d i n n o c u o u s c u t a n e o u s h e a t d e t e c t i o n i n humans a n d monkeys. J o u r n a l o f Neu r o s c i e n c e , _5_( 5 ) , 1 1 0 3 - 1 1 1 0 . C a m p b e l l , D. T . & S t a n l e y , J . C. ( 1 9 6 3 ) . Experimental and quasi-experimental designs for research. Boston: H o u g h t o n M i f f l i n Company. C h a p m a n , C. R. ( 1 9 7 7 ) . Sensory d e c i s i o n pain research: A reply to Rollman.  theory Pain,  methods i n _3, 2 9 5 - 3 0 5 .  C h a p m a n , C. R. ( 1 9 7 8 ) . Pain: The p e r c e p t i o n o f n o x i o u s events. I n R. A. S t e r n b a c h ( E d . ) , The P s y c h o l o g y of Pain (pp. 169-202). New Y o r k : Raven Press. C h a p m a n , C. R. ( 1 9 8 6 ) . P a i n , p e r c e p t i o n , and i l l u s i o n . A. S t e r n b a c h ( E d . ) , T h e P s y c h o l o g y o f P a i n (second e d i t i o n ) (pp. 153-179). New Y o r k : R a v e n P r e s s . C h a p m a n , C. R., C a s e y , K. L . , D u b n e r , R., F o l e y , K. G r a c e l y , R. H., & R e a d i n g , A. E . ( 1 9 8 5 ) . Pain measurement: An o v e r v i e w . P a i n , 2 2 , 1-31.  In  R.  M.,  C l a r k , W. C., ( 1 9 6 9 ) . Sensory-decision theory a n a l y s i s of the placebo effect on t h e c r i t e r i o n f o r p a i n a n d t h e r m a l sensitivity (d ' ). J o u r n a l o f A b n o r m a l P s y c h o l o g y , 7 4, 363-371. C l a r k , W. C. ( 1 9 7 4 ) . P a i n s e n s i t i v i t y a n d t h e r e p o r t An i n t r o d u c t i o n t o s e n s o r y decision theory. Anesthesiology, 40, 2 7 2 - 2 8 7 .  of  pain:  C l a r k , W. C. ( 1 9 8 7 ) . P a i n m e a s u r e m e n t by s i g n a l d e t e c t i o n theory. I n G. A d e l m a n ( E d . ) , E n c y c l o p e d i a o f Neuroscience, V o l . II (pp. 911-913). Boston: Birkhauser.  126 C l a r k , W. C. & D i l l o n , D. J . ( 1 9 7 3 ) . SDT a n a l y s i s o f b i n a r y d e c i s i o n s and s e n s o r y i n t e n s i t y r a t i n g s to n o x i o u s thermal s t i m u l i . P e r c e p t i o n a n d P s y c h o p h y s i c s , 13, 491493 . C l a r k , W. C. S. M e h l , L . ( 1 9 7 1 ) . Thermal pain: A sensory d e c i s i o n t h e o r y a n a l y s i s o f t h e e f f e c t of age and sex d', v a r i o u s r e s p o n s e c r i t e r i a , and 50% threshold. J o u r n a l o f A b n o r m a l P s y c h o l o g y , 7 8 , 2 13-22 1 .  on  C l a r k , W. C. & Y a n g , J . C. ( 1 9 8 3 ) . A p p l i c a t i o n s of s e n s o r y d e c i s i o n t h e o r y to problems i n l a b o r a t o r y and clinical pain. I n R. M e l z a c k ( E d . ) , P a i n M e a s u r e m e n t and A s s e s smen t ( p p . 15-25). C l a u s e n , J . & K i n g , H. E . ( 1 9 5 0 ) . D e t e r m i n a t i o n of the p a i n t h r e s h o l d on u n t r a i n e d s u b j e c t s . J o u r n a l of Psychology, 30 , 2 9 9 - 3 0 6 . C o h e n , M. J . , N a l i b o f f , B. D., S c h a n d l e r , S. L . , & H e i n r i c h , R. L . ( 1 9 8 3 ) . S i g n a l d e t e c t i o n and t h r e s h o l d m e a s u r e s to l o u d t o n e s and r a d i a n t h e a t i n c h r o n i c low back p a i n p a t i e n t s and c o h o r t c o n t r o l s . P a i n , 16, 245-252. Coppola, SDT  R. & G r a c e l y , R. pain assessment?  H. ( 1 9 8 3 ) . P a i n , 17 ,  Where i s t h e 257-266 .  noise  in  C r a i g , K. D. ( 1 9 8 9 ) . E m o t i o n a l a s p e c t s o f p a i n . I n P. D. & R. M e l z a c k (Eds.), Textbook of P a i n (pp.220-230). York: Churchill Livingstone.  Wall New  C r a u f o r d , D. I . , C r e e d , F . , J a y s o n , M. I . ( 1 9 9 0 ) . Lite events and p s y c h o l o g i c a l d i s t u r b a n c e i n p a t i e n t s w i t h l o w - b a c k pain. S p i n e , j_5_( 6 ) , 4 9 0 - 4 9 3 . D e r e b e r y , V. J . & T u l l i s , W. H. ( 1 9 8 6 ) . Low back p a i n e x a c e r b a t e d by p s y c h o l o g i c a l f a c t o r s . T h e We s t e r n J o u r n a l o f M e d i c i n e , 14 4 ( 5 ) , 5 7 4 - 5 7 9 . D i x o n , W. J . & M a s s e y , F . J . ( 1 9 6 9 ) . I n t r o d u c t i o n to S t a t i s t i c a l A n a l y s i s , 3rd e d i t i o n . USA: McGraw-Hill Company ( p p . 3 7 7 - 3 9 4 ) . D o x e y , N. C., D z i o b a , R. B., M i t s o n , G. L . , L a c r o i x , (1988). P r e d i c t o r s of outcome i n back s u r g e r y candidates. J o u r n a l of C l i n i c a l Psychology, 44 622 .  J.  Book  M.  (4),  611-  D z i o b a , R. B. & D o x e y , N. C. ( 1 9 8 4 ) . A p r o s p e c t i v e i n v e s t i g a t i o n i n t o t h e o r t h o p a e d i c and psychological p r e d i c t o r s of outcome of f i r s t lumbar s u r g e r y f o l l o w i n g industrial injury. S p i n e , _9 , 6 1 4 - 6 2 3 .  127 E l t o n , D. ( 1 9 8 7 ) . Emotional v a r i a b l e s and c h r o n i c p a i n . In G. D. B u r r o w s , D. E l t o n , & G- V. S t a n l e y ( E d s . ) , H a n d b o o k of C h r o n i c P a i n Management. The N e t h e r l a n d s : Elsevier Science. E l t o n , D. & S t a n l e y , G. V. ( 1 9 7 6 ) . R e l a x a t i o n as a method of pain control. A u s t r a l i a n J o u r n a l of P h y s i o t h e r a p y , 2 2, 121-123. F a i r b a n k , J . C., Couper, J . , Davies, J . B., & O'Brien, (1980). T h e O s w e s t r y Low Back P a i n Disability Questionnaire. Physiotherapy, 66(8), 279-273. Flor,  J.  P.  H. & T u r k , D. C. ( 1 9 8 7 ) . C h r o n i c back p a i n and r h e u m a t o i d a r t h r i t i s : P r e d i c t i n g p a i n and d i s a b i l i t y from cognitive variables. J o u r n a l of B e h a v i o u r a l M e d i c i n e , 11 ( 3 ) , 251-265.  Fordyce, and  R. A. ( 1 9 7 6 ) . Illness. St.  B e h a v i o u r a l Methods Louis: Mosby.  for  Chronic  Pain  G a l l o n , R. (1989). P e r c e p t i o n of d i s a b i l i t y i n c h r o n i c back pain p a t i e n t s : A long-term follow-up. P a i n , 3 7 , 67-7 5 . G r a c e l y , R. H. ( 1 9 8 9 ) . Pain psychophysics. I n C. R. Chapman & J . D. L o e s e r ( E d s . ) , Advances i n Pain Research and T h e r a p y ( V o l . 12) ( p p . 2 1 1 - 2 2 9 ) . New York: Raven Press. G r a c e l y , R. H., D u b n e r , R., & M c G r a t h , P. A. ( 1 9 7 9 ) . Narcotic analgesia: F e n t a n y l r e d u c e s the i n t e n s i t y but not the unpleasantness of p a i n f u l t o o t h p u l p sensations. S c i e n c e , 203 , 1 2 6 1 - 1 2 6 3 . G r e e n o u g h , C. G. & F r a s e r , R. c o m p e n s a t i o n on r e c o v e r y 14( 2 ) , 9 4 7 - 9 5 5 . H a l s a m , D. R. (1966). pain thresholds.  D. ( 1 9 8 9 ) . The e f f e c t s of from low-back p a i n . Spine,  The e f f e c t o f t h r e a t e n e d shock upon Psychonomic S c i e n c e , £, 309-310.  H a r d y , J . D . , W o l f f , H. G., 5. G o o d e l l , H. ( 1 952 ) . Pain Sensations and R e a c t i o n s . Baltimore: The W i l l i a m s W i l k i n s Company. Helson, H. ( 1 9 6 4 ) . and S y s t e m a t i c and Row. Hill,  &  Adaptation-Level Theory; An Experimental Approach to B e h a v i o u r . New York: Harper  H. E . , K o r n e t s k y , C. H., F l a n a r y , H. G., & Winkler, A. (1952). S t u d i e s of a n x i e t y a s s o c i a t e d w i t h anticipation of p a i n . I. E f f e c t s of morphine. A r c h i v e s of N e u r o l o g i c a l P s y c h i a t r y , 6 7, 612-619.  128 I n t e r n a t i o n a l A s s o c i a t i o n f o r the Study of P a i n : Subcommittee on T a x o n o m y ( 1 9 8 6 ) . C l a s s i f i c a t i o n of chronic pain: D e s c r i p t i o n s of c h r o n i c p a i n s y n d r o m e s and d e f i n i t i o n of pain terms. P a i n , S u p p . 3, S 5 9 - S 6 0 . Jorum, E. ( 1 9 8 8 a ) . Analygesia or hyperalgesia following s t r e s s c o r r e l a t e s w i t h emot i o n a l b e h a v i o u r i n r a t s . P a i n , 32, 3 4 1 - 3 4 8 . Jorum, E. ( 1 9 8 8 b ) . stress-induced K e e f e , F. J . , Brown, (1989). Coping Catastrophizing 56 .  Noradrenergic hyperalgesia  mechanisms i n m e d i a t i o n of in rats. P a i n , 32 . 349-355.  G. K. W a l l s t o n , K. A., & C a l d w e l l , D. S. with rheumatoid a r t h r i t i s pain: as a m a l a d a p t i v e s t r a t e g y . P a i n , 37, 51-  K e e f e , F . J . , C a l d w e l l , D. S., Q u e e n , K. T., G i l , K. M., Martinez, S., C r i s s o n , J . E . , O g d e n , W. & N u n l e y , J . Pain coping s t r a t e g i e s i n o s t e o a r t h i t i s p a t i e n t s . Journal o f C l i n i c a l a n d C o n s u l t i n g P s y c h o l o g y . 5 5 , 2 0 8 - 2 12 . K e e f e , F. J . & D o l a n , E. ( 1 9 8 6 ) . P a i n b e h a v i o u r and p a i n c o p i n g s t r a t e g i e s i n low b a c k p a i n and m y o f a s c i a l pain d y s f u n c t i o n syndrome p a t i e n t s . P a i n , 2 4, 4 9 - 5 6 . L a c r o i x , J . M. P o w e l l , J . , L l o y d , G. J . , D o x e y , N. C., M i t s o n , G. L . , & A l d a m . C. F. ( 1 9 9 0 ) . Low b a c k p a i n : F a c t o r s of value i n p r e d i c t i n g outcome. Spine, 15(6), 495-499. t  Kee f e , F . J . , & T u r n e r , J . A. L a w s o n , K., Re e s o r , K. A. D i mens i o n s o f p a i n - r e l a t e d c o g n i t i ve c o p i n g : (1990) C r o s s - v a 1 i d a t i o n o f t he f a c t o r s t r uc t u r e o f t h e C o p i n g S t r a t egy Que s t i o n n a i r e . P a i n , 43 ( 2 ) , 1 9 5-20 4. L e a v i t t , F. ( 1 9 8 7 ) . Use o f v e r b a l p a i n m e a s u r e m e n t i n t h e d e t e c t i o n o f h i d d e n p s y c h o l o g i c a l m o r b i d i t y among l o w back p a i n p a t i e n t s w i t h o b j e c t i v e o r g a n i c finding. P s y c h o l o g y and H e a l t h , 1_, 3 1 5-326 . L e a v i t t , F. ( 1 9 9 0 ) . The r o l e o f p s y c h o l o g i c a l d i s t u r b a n c e i n extending d i s a b i l i t y t i m e among c o m p e n s a b l e b a c k i n j u r e d i n d u s t r i a l workers. J o u r n a l of Psychosomatic R e s e a r c h, 3_4(4), 4 4 7 - 4 5 3 . L e a v i t t , G. & G a r r o n , D. C. ( 1 9 7 9 ) . Psychological disturbance and p a i n r e p o r t d i f f e r e n c e s i n b o t h o r g a n i c a n d n o n o r g a n i c low back p a i n p a t i e n t s . P a i n , 7_, 187-1 95 . L e a v i t t , F . , G a r r o n , D. C , D ' A n g e l o , C. M., (1979). Low b a c k p a i n i n p a t i e n t s w i t h demonstrable organic disease. Pain, ^,  & M c N e i l l , T. and without 191-200.  W.  129  L e a v i t t , F . , G a r r o n , D. C., M c N e i l l , T. W., & W h i s t l e r , W. W. (1982). Organic status, psycholgical disturbance, and p a i n r e p o r t c h a r a c t e r i s t i c s i n l o w - b a c k p a i n p a t i e n t s on compensation. S p i n e , 7_, 398-402. Lee,  P. W., Chow, S. P., Lieh-Mak, (1989). Psychosocial factors p a t i e n t s with low-back p a i n .  F . , C h a n , K. C , & Wong, i n f l u e n c i n g outcome i n Spine, 14(8) , 838-843.  L e p a n t o , R., M o r o n e y , W., & Z e n h a u s e n , R. (1965). The c o n t r i b u t i o n of a n x i e t y to l a b o r a t o r y i n v e s t i g a t i o n s pain. P s y c h o n o m i c S c i e n c e , 3^, 475 .  S.  of  L e v e n t h a l , H., B r o w n , D., Shacham, J . , & E n g q u i s t , G. (1979). E f f e c t s of p r e p a r a t o r y i n f o r m a t i o n about sensations, t h r e a t o f p a i n , a n d a t t e n t i o n on c o l d p r e s s o r distress. J o u r n a l o f P e r s o n a l i t y a n d S o c i a l P s y c h o l o g y , 3 7, 6887 14. L e v i n e , J . D., G o r d o n , N. C., S m i t h , R., & F i e l d s , H. L. (1982). Post-operative pain: E f f e c t of e x t e n t of injury and a t t e n t i o n . B r a i n R e s e a r c h , 2 3 4, 500-504. L i p m a n , J . J . , B l u m e n k o p f , B., & Parris, W. C. ( 19 8 7 ) . Chronic p a i n a s s e s s m e n t u s i n g h e a t beam d o l o r i m e t r y . P a i n , 30 , 5 9 - 6 7 . Main,  C. J . & W a d d e l i , G. (1984). Chronic p a i n , d i s t r e s s , and i l l n e s s behaviour. I n C. J . M a i n & W. R . L i n d s a y ( E d s • N' j C l i n i c a l P s y c h o l o g y and M e d i c i n e . New Y o r k : P1enum Press .  M a l o w , R. M., G r i m m , L . & O l s o n , R. E . (1980 ) . Differences p a i n p e r c e p t i o n between m y o f a s c i a l p a i n dy s f u n c t i o n p a t i e n t s and n o r m a l s u b j e c t s : A s i g n a l d e t e c t i on analysis. J o u r n a l of P s y c h o s o m a t i c R e s e a r c h , 24, 3033 10. M a l o w , R. M. S. O l s o n , perception after 65-72 .  R. E . ( 1 9 8 1 ) . treatment for  C h a n g e s i n pa i n Pain, chronic pain  i n  11  M a l o w , R. M. , W e s t , J . A., 6. S u t k e r , P. B. ( 1 9 8 7 ) . A sensory d e c i s i o n t h e o r y a n a l y s i s of a n x i e t y and p a i n r e s p o n s e s i n c h r o n i c drug abusers. J o u r n a l of Abnormal Psychology, 96, 18 4 - 1 8 9 . M c B u r n e y , D. H. (1976). Anesthesiology, 44 M c C a u l , K. D. & with pain.  Signal detection ( 4 ) , 356-358.  theory  and  M a l o t t , J . M. (1984). D i s t r a c t i o n and P s y c h o l o g i c a l B u l l e t i n , 9 5 , 5 16-533.  pain.  coping  130 McNicol, D. ( 1 9 7 2 ) . London: George M e l z a c k , R. Second  A Primer of S i g n a l A l l e n & Unwin.  & W a l l , P.D. ( 1 9 8 2 ) . Edition. New Y o r k :  Detection  Theory.  The C h a l l e n c e of P a i n , Basic/Harper Torchbooks.  M e l z a c k , R., K a t z , J . , & J e a n s , M. E . ( 1985"). The r o l e of compensation i n chronic pain: A n a l y s i s u s i n g a new method of s c o r i n g t h e M c G i l l P a i n Q u e s t i o n n a i r e . Pain, 23, 101-112. M e n d l e r , G. & W a t s o n , D. L . ( 1 9 6 6 ) . A n x i e t y and t h e i n t e r r u p t i o n of behaviour. I n C. D. S p i e l b e r g e r (Ed.), A n x i e t y and B e h a v i o u r . New Y o r k : Academic Press (pp.166-173).. M i l l e r , S. M. ( 1 9 7 9 ) . C o n t r o l l a b i l i t y a n d human s t r e s s : Method, evidence, and t h e o r y . B e h a v i o u r R e s e a r c h and T h e r a p y , 17, 2 8 7 - 3 0 4 . M u r p h y , K. A. & C o r n i s h , R. D. ( 1 9 8 4 ) . P r e d i c t i o n of c h r o n i c i t y i n a c u t e low back p a i n . Archives of Physical M e d i c i n e R e h a b i l i t a i o n , 6 5, 3 3 4 - 3 3 7 . N a l i b o f f , B. D., C o h e n , M. J . , S c h a n d l e r , S. L . , & H e i n r i c h , R. L . ( 1 9 8 1 ) . S i g n a l d e t e c t i o n and t h r e s h o l d measures f o r c h r o n i c back p a i n p a t i e n t s , c h r o n i c i l l n e s s p a t i e n t s , and c o h o r t c o n t r o l s t o r a d i a n t h e a t s i m u l i . J o u r n a 1 of A b n o r m a l P s y c h o l o g y , 90, 271-274. N a l i b o f f , B. D. & C o h e n , M. J . ( 1 9 8 9 ) . Psychophysical l a b o r a t o r y methods a p p l i e d t o c l i n i c a l p a i n . I n C.R. C h a p m a n & J . D. L o e s e n ( E d s . ) , A d v a n c e s i n P a i n R e s e a r c h and T h e r a p y , V o l . 12 ( p p . 3 6 5 - 3 8 6 ) . New Y o r k : R a v e n Press. N o t e r m a n s , S. L . & T o p h o f f , M. ( 1 9 6 7 ) . Sex d i f f e r e n c e s i n p a i n t o l e r a n c e and p a i n a p p e r c e p t i o n . Psychiatria, N e u r o l o g i a , a n d N e u r o c h i r u g i a , 7 0, 2 3 - 2 9 . P e n n e b a k e r , J . W. ( 1 9 8 2 ) . Symptoms • New Y o r k :  The P s y c h o l o g y of P h y s i c a l Springer-Verlag, Inc.'.  P e r r y , F . , H e l l e r , P. H., & L e v i n e , J . D. ( 1 9 8 8 ) . Differing c o r r e l a t i o n s between p a i n measures i n syndromes with or without explicable organic pathology. P a i n , 3 4 , 185-189. P e t e r s , M. L . , S c h m i d t , A. J . , & V a n d e n H o u t , M. A. ( 1 9 8 9 ) . Chronic low b a c k p a i n a n d t h e r e a c t i o n t o r e p e a t e d acute p a i n s t i m u l a t i o n . P a i n , 3 9 , 69-76. Pilowsky, I . , C h a p m a n , C. R., & B o n i c a , J . J . ( 1 9 7 7 ) . Pain, d e p r e s s i o n and i l l n e s s b e h a v i o u r i n a p a i n population. P a i n , <*_, 18 3-192 .  131  Arens, D ., M a y e r , H. , A p s y c h o s oc i o n e d i c a1 p r e d i c t i o n T. G. < 1 9 8 9 ) . C. , d i s ab1e d by ch r o n i ca11y mode 1 of re s p o n s e t o t r e a t m e n t pain. S p i n e , 1 _ 4 ( 9 ) , 9 5 6 - 9 6 1. low-b ack work e rs w ith  Polat i n ,  R a n s f o r d , A . 0. , draw ing a s pat ient s Reesor,  K.  Pain  Ca i r n s an  »  (1990).  pain.  The  pain  The V. ( 1 9 7 6 ) . evaluation psychologic  Moone y,  the  back  low  D i s a b i l i t y  G. , B a r n e s ,  D. , & to  a i d  wi th  A.  R.  Gatche 1  P . B. , May e r ,  _1_  Pain,  v a l i d i t y  Questionnire.  of  of  1 2 7 - 1 34 .  (2) ,  the Oswestry  R e h a b i l i t a t i o n  Low  Back  Research,  103-111. Reesor,  K.  A.  chronic  &  Craig,  back  i n e f f e c t i v e  K.  pain:  D.  (1988).  Physical  coping.  Pain,  32 ,  C o o p e r , R. ( 1 9 8 3 ) . R e p c o , G. R. & case W o r k e r ' s Compens a t i o n P a v c h o 1 o RY. Ro11man,  G.  B .  3  9  «  4  (1976)  (pp.  incongruent  s u f f e r i n g ,  and  35-45 . A  study  Journal  of of  the  average  C l i n i c a l  287-295. Signal  detection  theory  assessment  In J . J . Bonica A c r i t i q ue. in Pain Research and Advances  pain mo d u 1 a t i o n : Fe s s a r d ( E d s . ) , Vol .  Medically  l i m i t a t i o n ,  355-362).  R o l l m a n , G. B. ( 1 9 7 7 ) . pain: A review and  New  York:  Raven  Signal detection c r i t i q u e . Pain,  of  & D. Albe Therapy,  Press.  theory measurement 3^, 1 8 7 - 2 1 1 .  of  R o l l m a n , G. B . Empirical effects.  (1979). Signal detection theory and measures: v a l i d a t i o n studies and a d a p t a t i o n - l e v e l Pain, 6, 9-21.  R o l l m a n , G. B. of signal 379 .  (1980). Letters detection theory  to the editor: pain measures.  R o l l m a n . G. B. ( 1 9 8 3 ) . Measurement chronic pain patients: Methodo factors. I n R. M e l z a c k (Ed.), Assessment (pp. 251-257). New Rollman,  G.B.  &  Harris,  d i s c r i m i n a b i l i t y , e l e c t r i c a l  shock.  G. and  (1987).  Perception  of experimental pain i n logical and i n d i v i d u a l Pain Measurement and York: Raven Press. The  perceived  On t h e u t i l i t y P a i n , j) , 3 7 5 -  detectabi1ity,  magnitude  and  of  painful  Psychophysics,  43(3) ,  25 7 - 2 6 8 . Rosensteil.  A.  &  strategies  Keefe,  F.  i n chronic  Relationship  to  adjustment.  Pain,  (1983).  The  low  pain  patient 17,  back  use  of  coping  patients:  c h a r a c t e r i s t i c s and 33-44.  currect  132 S c h w a r t z , R. A., G r e e n e , C. S., & L a s k i n , D. M. (19 7 9 ) . P e r s o n a l i t y c h a r a c t e r i s t i c s of p a t i e n t s w i t h myofascial p a i n d y s f u n c t i o n (MPD) syndrome u n r e s p o n s i v e to conventional therapy. J o u r n a l o f D e n t a l R e s e a r c h , 5 8, 1435-1439. S c o t t , D. S. ( 1 9 8 1 ) . M y o f a s c i a l p a i n d y s f u n c t i o n syndrome: psychobio1ogica 1 perspective. J o u r n a l of Behavioural Med i c i ne , 4^, 4 5 1 - 4 6 5 . S c h i f f , W. York:  (1980). Perception: An a p p l i e d Houghton M i f f l i n Company.  Schiffman, H. R. (1976). integrated approach.  approach.  S e n s a t i o n and p e r c e p t i o n : New York: Wiley.  New  An  S c u d d s , R. A., M c C a i n , G. A., R o l l m a n , G. B., & Harth, M. (1989). Improvements i n p a i n r e s p o n s i v e n e s s in patients with f i b r o s i t i s after successful treatment with amitripty1ine. J o u r n a l o f R h e u m a t o l o g y , 16, 98-103. S c u d d s , R. A., R o l l m a n , G. B., H a r t h , M., & M c C a i n , G. A. (1987). P a i n p e r c e p t i o n and p e r s o n a l i t y m e a s u r e s as d i s c r i m i n a t o r s i n the. c l a s s i f i c a t i o n o f fibrositis. J o u r n a l o f R h e u m a t o l o g y , 14, ( 3 ) , 563-569. Skinner, J . B., E r s k i n e , A., P e a r c e , S., Rubenstein, I., T a y l o r , M., & F o s t e r , C. ( 1 9 9 0 ) . The e v a l u a t i o n of a cognitive behavioural t r e a t m e n t programme i n o u t p a t i e n t s with chronic pain. J o u r n a l of P s y c h o s o m a t i c R e s e a r c h , 34 , 1 3 - 1 9 . S p e i l b e r g e r , C. D. ( 1 9 8 5 ) . A s s e s s m e n t of s t a t e and trait anxiety: C o n c e p t u a l and m e t h o d o l o g i c a l issues. The S o u t h e r n P s y c h o l o g i s t , 2_, 6-16. A. c Spinhoven, P. , T e r k u i 1 e , M. M. , L i n s s e n , , Pain coping s t r a t e 8 i e s i n a Du tch ( 1989). P a i n , 37, c h r o n i c low b a c k p a i n patien t s •  & Gazendam, B population of 77-83.  In S t e r n bac h, R. A. ( 1 9 7 6 ) . Psycho 1o g i c a 1 f a c t o r s in pain. J. J. Bonica & D. A l b e - F e s s a r d ( E d s . ) , Adv a n c e s i n P a i n Raven Press . R e s e a r c h and T h e r a p y , V o l . 1 . N e w Y o r k : S t e r n b a c h , R. A. ( 1 9 8 6 ) . A. S t e r n b a c h ( E d . ) , (pp. 223-239). New  C l i n i c a l a s p e c t s of p a i n . The P s y c h o l o g y o f P a i n , 2nd York: Raven Press.  S w e t s , J . A., T a n n e r , W. P., & B i r d s a l l , T. G. (1961) Decision processes in perception. Psychological B u l l e t i n , 68, 301-340.  In: R. Edition  A  133 S z p i l e r , F . A. & E p s t e i n , S. ( 1 9 7 6 ) . A v a i l a b i l i t y of an a v o i d a n c e r e s p o n s e as r e l a t e d t o a u t o n o m i c arousal. J o u r n a l o f A b n o r m a l P s y c h o l o g y , 8 5 , 73-82 . T a n a k a , M., K o h n o , Y., T s u d a , A., N a k a g a w a , R., Yoshishige, I . , I i m o r i , K., H o a k i , Y., & N a g a s a k i , N. (1983). D i f f e r e n t i a l e f f e c t s o f m o r p h i n e on n o r a d r e n a l i n e r e l e a s e i n b r a i n r e g i o n s of s t r e s s e d and n o n - s t r e s s e d r a t s . B r a i n R e s e a r c h , 2 7 5, 105-115. T a y l o r , W. P., S t e r n , W. Predicting patients f o r low-back p a i n .  R., K u b i s z y n , T. W. (1984). p e r c e p t i o n s of r e s p o n s e to t r e a t m e n t S p i n e , _9, 3 1 3 - 3 1 6 .  T u r n e r , J . A. & C l a n c e y , S. ( 1 9 8 6 ) . Strategies for coping w i t h c h r o n i c low b a c k p a i n : R e l a t i o n s h i p t o p a i n and disability. P a i n , 24, 355-304. T h o m p s o n , S. C. ( 1 9 8 1 ) . W i l l i t h u r t l e s s i f I can it? A complex answer to a s i m p l e q u e s t i o n . P s y c h o l o g i c a l B u l l e t i n , 90, 89-101.  control  Turk,  D. C , M e i c h e n b a u m , D. H., & G e n e s t , M. ( 1 9 8 3 ) . and B e h a v i o u r a l M e d i c i n e : T h e o r y , R e s e a r c h , and GuideNew York: Guilford.  Pain Clinical  Turk,  D. C. & R u d y , T. C. ( 1 9 8 5 ) . Pain experience: the c o g n i t i v e component. F i f t h Annual Meeting American Pain Society.  Turk,  D. C. & R u d y , T . E . ( 1 9 8 7 ) . Towards assessment of c h r o n i c p a i n p a t i e n t s . and T h e r a p y , 25 ( 4 ) , 2 3 7 - 2 4 9 .  Turk,  D. C. & R u d y , T . E . ( 1 9 8 8 ) . T o w a r d an empirically d e r i v e d taxonomy of c h r o n i c p a i n p a t i e n t s : Integration of p s y c h o l o g i c a l a s s e s s m e n t data. J o u r n a l of C o n s u l t i n g a n d C l i n i c a l P s y c h o l o g y , 5_6 ( 2 ) , 2 3 3 - 2 3 8 .  Uden,  A. & B e r g e n u d d , H. ( 1 9 8 8 ) . Pain drawings back p a i n . S p i n e , 13 ( 4 ) , 3 8 9 - 2 9 2 .  Assessing of the  a comprehensive Behaviour Research  in  chronic  W a d d e l i , G. ( 1 9 8 7 ) . C l i n i c a l assessment of lumbar impairment. C l i n i c a l O r t h o p a e d i c s a n d R e l a t e d R e s e a r c h , 2 2 1, 1 1 0 - 1 2 0 . W a d d e l i , G., Main, low-back p a i n  C. J . ( 1 9 8 4 ) . Assessment of s e v e r i t y disorders. S p i n e , 9/2 ) , 2 0 4 - 2 0 8 .  in  W a d d e l i , G., M a i n , C. J . , M o r r i s , E . W., D i P a o l o , M., & Gray, I. ( 1 9 8 4 ) . Chronic low-back pain, p s y c h o l o g i c d i s t r e s s , and i l l n e s s b e h a v i o u r . S p i n e , J9 ( 2 ) , 209-213 .  134 W a d d e l l , G., M c C o l l o u g h , J . A., Kummel, (1980). Nonorganic physical signs Spine, 5 ( 2 ) , 117-125.  E., & Venner, R.M. i n low-back. p a i n .  W a d d e l l , G., Pilowsky, I . , & B o n d , M. R. (1989). Clinical a s s e s s m e n t and i n t e r p r e t a t i o n of abnormal illness b e h a v i o u r i n low b a c k p a i n . P a i n , 3 9, 4 1 - 5 3 . W e i s e n b e r g , M. Bulletin,  (1977). P a i n and 84, 1008-1044.  pain  control.  W h a r t o n , R. N. & C l a r k , W. C. ( 1 9 8 7 ) . Patterns anxiety with pain a m p l i f i e r s . P a i n , Supp. W i l l i a m s , J . M., Watts, (1988). Cognitive New York: Wiley.  Psychological  of 4,  persistent 318.  F . N., M a c L o e d , C., & M a t h e w s , A. P s y c h o l o g y and E m o t i o n a l Disorders.  Yang,  J. C , W a g n e r , J . M., & C l a r k , W. C. (1983). P s y c h o l o g i c a l d i s t r e s s a n d mood i n c h r o n i c p a i n and surgical patients: A sensory decision analysis. In J . J. Bonica, V. L i n d b l o m , & A. I g g o ( E d s . ) , A d v a n c e s i n P a i n R e s e a r c h a n d T h e r a p y , V o l . 5 ( p p . 901 -906 ) .  Yang,  J . C., R i c h l i n , D., B r a n d , L . , W a g n e r , H., & Clark, W. C. ( 1 9 8 5 ) . Thermal sensory d e s i c i o n theory i n d i c e s and p a i n t h r e s h o l d i n c h r o n i c p a i n p a t i e n t s and healthy volunteers. Psychosomatic Medicine, 47, 461-468.  135 APPENDIX  A  Nonorganic P h y s i c a l Signs (Waddell et a l . , 1980) Note: These examination. A.  B.  signs are evaluated during I f p r e s e n t , any individual  O v e r r e a c t i o n to examination Facial expression M u s c l e t e n s i o n and Co 1 l a p s i n g Sweating  routine sign is  physical s c o r e d as  tremor  Tenderness Superf i c i a l N o n a n a t omi c  C.  Pain  D.  Distraction  E.  R e p o r t e d on S i m u l a t i o n Axial loading Rotation  Regional  Tests Straight  leg  Tests  raising  Disturbances W i d e s p r e a d Weakness Sensorv Disturbances  (i.e.,  bogus  tests)  1.  APPENDIX  Scoring  Criteria (Ranslord  B  t o r the Pain Drawing e t a l . , 19 7 6")  Unreal Drawings (poor anatomic l o c a l i z a t i o n , scores 2 unless indicated) a. t o t a l l e g p a i n lateral b. l a t e r a l w h o l e l e g p a i n ( t r o c h a n t e r i c a r e a a n d thigh allowed) c. c i r c u m f e r e n t i a 1 t h i g h p a i n (unilateral d. b i l a t e r a l anter i o r t i b i a l area pain allowed) 1) e. c i r c u m f e r e n t i a 1 f o o t p a i n ( s c o r e s 1) f. b i l a t e r a l foot pain (scores g. use o f a t l e a s t f o u r m o d a l i t i e s s u g g e s t e d i n 1) instructions ( scores pain Drawings showing " e x p a n s i o n " or " m a g n i f i c a t i o n " of a. b a c k p a i n r a d i a t i n g t o i i i ac c r e s t , g r o i n , o r a n t e r i o r perineum (each scores 1 ) b. a n t e r i o r knee p a i n ( s c o r e s 1 ) ankle pain ( s c ore s 1 ) c . anterior d . p a i n drawn out s i d e t h e out l i n e ( s c o r e s 1 or 2 d e p e n d i n g on e x t e n t ) "I a. b. cd. e.  p a r t i c u l a r l y hurt here" i n d i c a t o r s (each scores 1) add e x p l a n a t o r y notes c i r c l e p a i n f u l areas draw l i n e s to d e m a r c a t e p a i n f u l a r e a s use arrows go t o e x c e s s i v e t r o u b l e a n d d e t a i l i n d e m o n s t r a t i n g the p a i n areas u s i n g the symbols suggested  " L o o k how b a d I am" indicators A d d i t i o n a l p a i n f u l areas i n the trunk, head, upper e x t r e m i t i e s drawn i n . Tendency toward p a i n ( s c o r e s 1 o r 2 d e p e n d i n g on extent)  neck, total  or body  137 APPENDIX B The P a i n D r a w i n g  On t h e human f o r m b e l o w , m a r k w h e r e y o u r n u m b n e s s o r p a i n i s , u s i n g t h e k i n d o f marks t h a t c o r r e s p o n d t o what y o u f e e l i n e a c h a r e a . Numbness Aching  A A A  P i n s and N e e d l e s ooooo A A  A A " \ A A  Burning xxxxx  Stabbing  /////  138 APPENDIX  C  I n a p p r o p r i a t e Symptom (Waddeli et a l . , Interview  Questions  ("yes" s c o r e s indicated)  1 unless  1.  Do  2.  Does  your  whole  l e g ever  become  3.  Does  your  whole  leg ever  go  4.  Does  your  whole  l e g ever  give  5.  In the little  6.  Have any o f t h e y o u i n a n y way?  7.  Have you e v e r had t o because of your back  you  get  pain  at  the  t i p of  past y e a r , have you pain? ("no" s c o r e s  Inventory 1984)  your  tailbone?  painful?  numb?  had 1)  way? any  treatments you've ("no" s c o r e s 1) go t o pain?  otherwise  the  spells  had  with  f o r the  emergency  very  pain  department  helped  139 APPENDIX  Consent Heat  Form  D  tor Pilot  Study  Discrimination  K e n n e t h D. C r a i g , P h . D . Department ot P s y c h o l o g y UBC ph. 228-3948  Subjects  Study-  M a r y L . M a h o n , M.A. Department ot P s y c h o l o g y UBC ph. 228-5581  The p u r p o s e o f t h i s s t u d y i s t o f i n d o u t what t h e a v e r a g e f a i n t pain t h r e s h o l d i s f o r heat s t i m u l i . Faint pain t h r e s h o l d r e f e r s t o t h e p o i n t where you f e e l a s m a l l , d i s t i n c t , p r i c k i n g sensation at the e n d o f a three second exposure to a heat source. H e a t w i l l be g e n e r a t e d by a l i g h t beam t h a t i s s h o n e o n t h e s k i n o f y o u r f o r e a r m w h i c h w i l l be p a i n t e d b l a c k w i t h an e a s i l y removed w a t e r - b a s e d paint. I n t e n s i t i e s w i l l r a n g e f r o m warm t o f a i n t l y p a i n f u l . Stimuli l a s t t h r e e seconds or l e s s i f you choose to stop i t sooner. A f t e r each s t i m u l u s , you s i m p l y have t o i n d i c a t e whether you f e l t a p r i c k l y s e n s a t i o n o r n o t a n d y o u w i l l h a v e 12 s e c o n d s b e t w e e n s t i m u l i t o make t h i s j u d g e m e n t . This experiment will t a k e 20 m i n u t e s o f y o u r t i m e f o r w h i c h y o u w i l l be p a i d $5.00. You a r e f r e e t o w i t h d r a w f r o m t h e e x p e r i m e n t a t a n y t i m e a n d y o u w i l l s t i l l be p a i d f o r v o u r participation. Data o b t a i n e d i n t h i s experiment w i l l be k e p t c o n f i d e n t i a l a n d u s ed f o r r e s e a r c h o n l y . To e n s u r e a n o n y i t y . v o l u n t e e r s w i l l be i d e n t i f i e d by a n u m b e r . T h a n k y ou f o r y o u r t i m e a n d i f y o u h a v e a n y q u e s t i o n s a b o u t t h i s s t u d y , do n o t  I agree to p a r t i c i p a t e i n t h i s study subject to the c o n d i t i o n t h a t t h e i n f o r m a t i o n i s kept i n c o n f i d e n c e and used for research only. I am a w a r e t h a t I c a n s t o p my p a r t i c i p a t i o n a t any time w i t h o u t p e n a l t y . I also acknowledge t h a t I have r e c e i v e d a C O D V o f t h i s form. Signature Date  140  APPENDIX Consent  Form  tor  Heat  D i s c r i m inat. i o n  K e n n e t h D. C r a i g , Ph.D D e p a r t m e n t ot Psychology UBC ph. 228-3948  C h r on i c  E Pain  Participants  5 c a ci  v  M a r y L . M a h o n , M. A. D e p a r t m e n t ot Psycho logy UBC ph. 228-5581  We a r e i n t e r e s t e d i n how d if f erent chronic pain c o n d i t i o n s a f f e c t a p e r s o n s ab i 1 i t y t o d i s c r i m i n a t e b e t w e en d i f f e r e n t heat intensities We are a l s o i n t e r e s t e d i n whe t h e r p e r c e p t i o n s of v a r i o u s l e v e l s of he a t a r e a f f e c t e d by y o u r t h o u g h t s and moods. T h i s r e s e a r c h may c o n t r i b u t e t o more e f f e c t i v e t r e a t m e n t s f o r c h r o n i c pa i n c o n d i t i o n s . For t h i s r e a s o n , we a r e r e q u e s t i n g 1 hou r of y o u r t i m e f o r w h i c h yo u w i l l be p a i d $ 2 0 . 0 0 f o r y o u r participation. 1  Your p a r t i c i p a t i o n w i l l i n v o l v e h a v i n g f o u r black, s p o t s p a i n t e d on e a c h f o r e a r m . The black paint i s easily removed w i t h s o a p and w a t e r . H e a t w i l l be g e n e r a t e d by a l i g h t beam t h a t i s s h o n e on o n e o f t h e s e b l a c k s p o t s a n d intensities will r a n g e f r o m warm t o m i l d l y . p a i n f u l . Stimuli will last three s e c o n d s or l e s s i f you c h o o s e t o s t o p i t s o o n e r . Your task i s to d i s t i n g u i s h b e t w e e n h e a t s e n s a t i o n s and the f i r s t h i n t of faint pain. T h i s f a i n t p a i n s e n s a t i o n f o r h e a t has been d e s c r i b e d as a d i s t i n c t , sharp., p r i c k i n g s e n s a t i o n . After e a c h s t i m u l u s , you s i m p l y have t o i n d i c a t e w h e t h e r you f e l t a p r i c k l y s e n s a t i o n o r n o t a n d y o u w i l l h a v e 12 s e c o n d s b e t w e e n s t i m u l i t o make t h i s j u d g e m e n t . You w i l l a l s o be a s k e d t o f i l l o u t some s h o r t q u e s t i o n n a i r e s t h a t e v a l u a t e your t h o u g h t s , moods, and p a i n e x p e r i e n c e . In o r d e r to evaluate d i f f e r e n t p a i n c o n d i t i o n s , we n e e d t o l o o k a t d i a g n o s t i c , l a b o r a t o r y , and m e d i c a l e x a m i n a t i o n d a t a r e l a t e d to your back problem from the Shaughnessy H o s p i t a l . We w i l l be h a p p y t o a n s w e r any f u r t h e r q u e s t i o n s you h a v e a b o u t t h e s t u d y and a d e t a i l e d e x p l a n a t i o n of t h e h y p o t h e s e s and r e s e a r c h w i l l be g i v e n a t t h e end o f y o u r participation. A l l o f t h e i n f o r m a t i o n y o u p r o v i d e w i l l be kept c o n f i d e n t i a l and u s e d f o r r e s e a r c h o n l y . To e n s u r e a n o n y m i t y , v o l u n t e e r s w i l l be i d e n t i f i e d by a n u m b e r . We would a p p r e c i a t e y o u r h e l p and c o o p e r a t i o n but you a r e f r e e t o r e f u s e o r s t o p y o u r p a r t i c i p a t i o n a t any time. You w i l l be p a i d $ 1 0 . 0 0 f o r p a r t i c i p a t i n g e v e n i f y o u d e c i d e p a r t way that y o u do n o t w a n t t o f i n i s h the e x p e r i m e n t . Since t h i s study is i n d e p e n d e n t of the S h a u g h n e s s y H o s p i t a l , w h e t h e r you c h o o s e to p a r t i c i p a t e or not w i l l i n no way a f f e c t your t r e a t m e n t at the hospital. Thank you f o r y o u r time.  141  I a g r e e t o p a r t i c i p a t e i n t h i s s t u d y and g i v e permission to the S h a u g h n e s s y H o s p i t a l to r e l e a s e m e d i c a l information s o l e l y f o r t h e p u r p o s e s of t h i s i n v e s t i g a t i o n and subject to the c o n d i t i o n t h a t t h i s i n f o r m a t i o n i s kept i n s t r i c t confidence. I am a w a r e t h a t I c a n s t o p my participation at any time without jeopardy to m e d i c a l care. I a l s o acknowledge t h a t I have r e c e i v e d a copy of t h i s form. Signature Date  142 APPENDIX Instructions We trom  a prickly  trace ot  are i n t e r e s t e d  how  much  This  pain  to p e r c e i v e  painful  feeling  you  pricking  just  seconds  feel that  sensation heat.  arm. also you  will  be  closely  Some w i l l feel  like  felt  only  warm,  for  exactly  three  seconds.  gun d i r e c t l y  heat  gun i s c o v e r e d  feel  hot a g a i n s t  the  light  change spot  will  the heat  because  on  Your  just  by  gun  on  skin.  f o r three  t o the next  otherwise,  one  spot  to  to your  and  some  skin  i s to simply  bulb  of your  press  seconds. spot. will  will  goon  The end o f t h e  so i t w i l l  not  red button  For each  become  stimulus  t h e end of the  this  Always  given  judge  that  skin. ring  will  and  a t t h e end o f t h e  by a l i g h t  I will  three  experiencing.  hotter,  resistant  when  this  be a p p l i e d  You a r e t o p l a c e  a heat  means  have  i n on y o u r  task  the surface  your  stay  others  has f o c u s s e d  i s produced  heat  will  very  t o t h e warmth and  you a r e  the p i n prick  The h e a t  i s detect  in addition  intensities  sharp,  end of t h e  the sensations  a b i t of a p i n p r i c k .  not.  task  your  faintly  of t h i s  you w i l l  the heat  you f e l t  trace  ability of  This  as a d i s t i n c t ,  at the exact  first  i s a test  of p a i n .  first  Your  the  ot your  and, t h e r e f o r e ,  on  feel  but r a t h e r trace  i s on.  t o be  i s not a test  The  the p i n - p r i c k  Task  you can d i s t i n g u i s h heat  consider  described  sensation.  v a r i e t y of heat  whether or  the f i r s t  It i s not easy  A  we  procedure  the heat  Perception  well  that  has been  which  concentrate  i n how  you c a n t a k e ,  ability  small  t o r Pain  sensation  ot p a i n .  F  move  and  stimulus, to a  sensitive.  next  143  Because to  be  familiar  feeling. warmth. warmer  with  I will  one.  give  not the  start  an  easy  type  of  at  you at  the  more  end  uncomfortable,  task,  low  level.  at  the  end  at of  the  simply  Now  the  the  I  will  for If  heat  you  you  be feel  you  some you  feel  a a  O.K.  seconds?  the  gun  for  give  Did  three  Look  will  should  240).  stimulus.  take  important  you  You  150).  examples.  of  i t is  sensations  stimulus  toward  some  a  stimulus  (administer  sensation  sensation too  is  (Administer  prickly will  this  prickly  find  away  any  of  from  them  your  skin. (Administer where  the  subject  Good, some  more  heat  gun  you of  trace  of  the  pain  reports to  same  on  on  each  range  seem  mouth  concentrate between  a  a  the  (Administer determination).  stimuli,  the  have  pin  the  thing.  idea.  A l l you black  sensation.  You  to  judge  pin-prick)  two  runs  of  emphasizing  the  We  will  have  to  spot will  whether or  the  ones  prick)  different  stimulus (the  of  each have  you  now do  just is  time 12  felt  put  do the  and  seconds that  not. Up-Down  I  Threshold  first  APPENDIX G  1  Data Sheet f o r SDT Task SDT  DATA  SHEET  SEX S K I N TEMPERATURE AGE ROOM T E M P E R A T U R E CONTROL GROUP E X P E R I M E N T A L GROUP MEDICATIONS: TYPE DOSAGE D E M O G R A P H I C S •• MARITAL STATUS E N G L I S H SECOND LANGUAGE EMPLOYMENT S T A T U S HAD P R E V I O U S S U R G E R Y MULTIPLE SURGERIES F I N A N C I A L COMPENSATION PRACTICE  TRIALS-  1. 2. 3. 4. 5. 6. 7. 8.  9. 10. 11. 12. 13. 14. 15. 16.  2 3 1 4 4 2 1 3  2 3 1 4 3 1 4 2  EXPERIMENTAL  17. 18. 17. 20. 21. 22. 23. 24.  . . .  . . .  ; -  . .  1 2 3 4 4 1 2 3  25. 26. 27. 28. 29. 30. 31. 32.  3 4 1 2 3 4 2 1  TRIALS'  1. 2. 3. 4. 5. 6. 7. 8.  3 2 1 4 3 4 2 1  9. ID. 11. 12. 13. 14. IS. 16.  2 3 1 4 3 1 4 2  17. 18. 19. 20. 21. 22. 23. 24.  1 4 3 2 2 4 3 1  25. 26. 27. 28. 29. 30. 31. 32.  2 3 4 1 1 3 4 2  33. 34. 35. 36. 37. 38. 39. 40.  3 4 1 2 1 2 4 3  41. 42. 43. 44. 45. 46. 47. 48.  3 4 1 2 2 1 4 3  49. 50. 51. 52. 53. 54. 55. 56.  2 1 4 3 4 2 1 3  57. 58. 59. 60. 61. 62. 63. 64.  4 2 1 3 4 1 3 2  65. 66. 67. 66. 69. 70. 71. 72.  2 4 1 3 1 4 2 3  73. 74. 75. 76. 77. 78. 79. 80.  1 2 3 4 4 1 2 3  145 APPENDIX Debrieting Heat  ot  H  Participants  Discrimination  K e n n e t h D. C r a i g , Ph.D. D e p a r t m e n t ot P s y c h o l o g y UBC ph. 228-3948  Study  Mary L. Mahon, M.A. D e p a r t m e n t ot Psychology UBC oh. 228-5581  T h a nk you f o r y o u r pa r t i c i p a t i o n i n purpose of t h i s s t u d y wa s t o t e s t your t p a i n us i ng r a d i a n t h e a t . Therefore, we i d e n t i f y the po i n t w h e r e y ou f e l t a d i s t the end of a t h r e e s e c o n d e x p o s u r e to a  this study. The hr e sho l d f o r f a i n t a s k e d you to i nc t p i n - p r i c k a t l i g h t beam.  There i s r e s e a r c h to suggest pain p e r c e p t i o n i s a l t e r e d i n c h r o n i c p a i n p a t i e n t s b u t i t i s u n c l e a r a s t o how it d i f f e r s from people without chronic pain. This study is a p r e l i m i n a r y study f o r a major r e s e a r c h p r o j e c t that i s designed to look at d i f f e r e n c e s i n p a i n s e n s i t i v i t y among d i f f e r e n t t y p e s o f c h r o n i c p a i n p a t i e n t s . The sensitivity ot p a i n p a t i e n t s w i l l be c o m p a r e d t o t h e s e n s i t i v i t y o f p e o p l e who do n o t e x p e r i e n c e chronic pain. On t h e b a s i s , o f the a v e r a g e p a i n t h r e s h o l d t h a t we e s t a b l i s h i n t h i s preliminary study, d i f f e r e n t l e v e l s o f h e a t i n t e n s i t i e s w i l l be s e l e c t e d f o r a s u b s e q u e n t t e s t o f b o t h c h r o n i c p a i n p a t i e n t s and a non-pain group. T h i s r e s e a r c h w i l l c o n t r i b u t e to our understanding o f how pain perception i s a f f e c t e d i n people who experience chronic pain.  be  I f you happy to  are i n t e r e s t e d i n f u r t h e r answer your questions.  information,  we  would  146 A P P E N D I X  Consent Heat K e n n e t h D. C r a i g , Ph.D. D e p a r t m e n t ot Psychology UBC ph. 228-3948  Form  tor  I  Control  Discrimination  Subject Study  Mary L. Mahon, M.A. D e p a r t m e n t ot Psychology UBC ph. 228-5581  We a r e i n t e r e s t e d i n w h e t h e r p e o p l e e x p e r i e n c i n g chronic p a i n d i f f e r f r o m p a i n - f r e e i n d i v i d u a l s as t o t h e i r a b i l i t y to d i s c r i m i n a t e between d i f f e r e n t heat i n t e n s i t i e s . In o r d e r to do t h i s , we n e e d t o t e s t t h e h e a t d i s c r i m i n a t i o n a b i l i t y in why y o u a r e people w i t h o u t c h r o n i c pa i n c o n d i t i o n s w h i c h i s being asked to vo1unt e e r . We a r e a l s o i n t e r e s t e d i n wh e t h e r perceptions of v a r i o u s l e v e 1 s of h eat are a f f e c t e d b y V o u r t h o u g h t s and mo o d s . F o r t h i s r e a s o n , we a r e r e q u e s t i ng 1 h o u r o f y o u r t ime f o r wh i c h y o u w i 11 be p a i d $ 2 0 . 0 0 f o r y o u r T h i s r e s ea r c h w i l l c o n t r i b u t e to a g r ea t e r participation. understanding o f c h r o n i c p a i n a n d may l e a d t o more e f f e c t i v e t r ea tmen t s. You r p a r t i c i p a t i o n w i l l i n vo 1 V e h a v i n g f o u r b l a c k s P o t s p a i n t e d on e a c h f o r e a r m . T h e b 1 a c k p a i n t i s e a s i i y r e mo v e d w i t h s oa p and H e a t w i 11 by a 1 i g h t b e am wat e r . be g e n e r a t e d t h a t i s s h o n e on one of i n t ens i t i e s w i l l t h e s e b 1 ac k s p o t s and r a n g e f r om warm t o m i l d l y p a i n f u 1 . w i l l l a s t thr e e S t i mu1 i s e c o n d s or l e s s i f you c h o o s e t o s t op i t s o o n e r . Yo u r t a s k i s to d i s t i n g u i s h and t h e f i r s t h i n t of be t w e e n h e a t s e n s a t i o n s faint pain. T h i s f a i n t p a i n s e n s a t i o n f o r h e a t has been d e s c r i b e d a s a d i s t i n c t , s h a r p , p r i c k i "8 s e n s a t io n . Afte r e a c h s t i m u l u s , y o u s i m p l y h a v e t o i nd i c a t e whe t h e r y o u f e l t a p r i c k l y s e n s a t i o n o r n o t and you w i 11 ha v e 12 s e c o n d s be t w e en s t i m u l i t o make t h i s j u d g m e n t . You w i 11 a 1 s o be a s k e d t o f i l l o u t some s h o r t q u e s t i o n n a i r e s t h a t e v a 1 ua t e y o u r t h o u g h t s , moods, and p a i n e x p e r i e n c e . We w i l 1 b e h a P p y t o a n s w e r an V further questions you have a b o u t t h e s t u d y and a d e t a i 1 ed e x p l a n a t i o n o f t h e h y p o t h e s e s a n d r e s e a r c h w i l l be given a t t h e end o f y o u r participation. A l l o f t h e i n f o r m a t i o n y o u p r o v i d e w i l l be k e p t c o n f i d e n t i a l and u s e d f o r r e s e a r c h o n l y . To e n s u r e a n o n y m i t y , v o l u n t e e r s w i l l be i d e n t i f i e d by a n u m b e r . We would a p p r e c i a t e y o u r h e l p and c o o p e r a t i o n but you a r e f r e e t o r e f u s e o r s t o p y o u r p a r t i c i p a t i o n a t any time. You w i l l be p a i d $ 1 0 . 0 0 f o r p a r t i c i p a t i n g e v e n i f y o u d e c i d e p a r t way that y o u do n o t w a n t t o f i n i s h t h e e x p e r i m e n t . T h a n k you f o r your time.  I agree to p a r t i c i p a t e i n t h i s study s u b j e c t to the used c o n d i t i o n t h a t t h e i n f o r m a t i o n i s k e p t i n c o n f i d e n c e and s t o p my for research only. I am a w a r e t h a t I c a n I a l s o acknowledge p a r t i c i p a t i o n a t any t i m e w i t h o u t penalty, t h a t I have r e c e i v e d a copv of t h i s form. Signature Date  148 APPENDIX  J  P h y s i c a l Impairment Index (Waddell & M a i n , 1984) Mathematic Pain  Time  28  constant  pattern  Low b a c k p a i n Back and r e f e r r e d leg pain Roo t p a i n  pat t e r n  Previous  Previous  Root  fracture  back,  surgery  compression-  0 8 _ 2  Recurring Chroni c  4 3  Transverse process Wedge compression Fracture dislocation  1 2 6  None One More  0 3 6  than  one  0 1  None Doubtful De f i n a t e  o  Subtotal  Lumbar  flexion  cms  Straight with  leg raising, distraction)  left  Straight with  leg raising, distraction)  right  Approximate  total  bodily  (checked  (checked  X 2  -  /10  -  /10  -  Subtotal  -  impairment  Note: Spinal stenosis with neurogenic claudication should be c o d e d a s B a c k •+• r e f e r r e d l e g p a i n a n d s c o r e d a s 8. The l e f t hand column l i s t s t h e c l i n i c a l observations for which the corresponding l o a d i n g f o r each o b s e r v a t i o n i s e n t e r e d i n t h e r i g h t h a n d c o l u m n , w h i c h i s a d d e d up t o g i v e approximate t o t a l b o d i l y impairment.  X  149  APPENDIX Oswestrv  The  following  attected everv  aDolv  1.  are  vour  to  to  Pain I  statements to  and m a r k  It  vou.  vou,  Back P a i n D i s a b i l i t v Questionnaire (Fairbanketal.. 1y 8 U )  ability  section,  aDDlies  Low  Dick  K  as  to  h o w vour  back  m a n a g e  in  everyday  lire-  in  each  section  two statem en ts one w h i c h most  in  only  anv  closely  the  o n e  Dain has  Please one  box  section  describes  answer which  seem  to  vour problem  Intensity can tolerate  the  oain  I have  without  havine  to  use  nain  killers.  The D a i n i s bad b u t I manage without taking p a i n P a i n killers give moderate reliet trom Dain. P a i n killers give very l i t t l e reliet trom Dain. P a i n killers have no ettect on t h e nain and I do  killers.  not  use  them.  P e r s o n a l Care (Washing, D r e s s i n g , etc.) I can look a t t e r myselt normally without causing extra oain. I can l o o k a t t e r myselt normally but i t c a u s e s e x t r a D a i n It i s p a i n t u l t o l o o k a t t e r m y s e l t and I am s l o w and c a re t u1 . I n e e d some h e l D b u t manaee m o s t o t mv personal care. I n e e d h e l D e v e r y day i n m o s t a s D e c t s o t s e l t care. I do n o t g e t d r e s s e d , w a s h w i t h d i t t i c u l t v and s t a y i n bed . 3.  Lilting I c a n l i f t h e a w weights w i t h o u t e x t r a Dain. I can l i t t h e a v y w e i g h t s but i t g i v e s e x t r a p a i n . P a i n prevents m e trom l i t t i n g heavv weights o t t the tloor b u t I c a n manage it t h e y a r e conveniently Dositioned, e g . on a t a b l e . P a i n p r e v e n t s me trom l i t t i n g h e a v y w e i g h t s but I can manage l i g h t t o medium w e i g h t s i t t h e v are conveniently  I I Wa1  /  can  positioned.  litt  cannot  o n l y v e r y light w e i g h t s . litt o r carrv a n y t h i n g a t a l l .  king P a i n d o e s n o t D r e v e n t me w a l k i n g anv distance. P a i n p r e v e n t s me w a l k i n g more t h a n 1 m i l e . P a i n D r e V e n t s me w a l k i n g more t h a n 1/2 mile. P a i n D r e v e n t s me w a l k i n g more t h a n 1/4 mile. I can o n l v walk u s i n g a s t i c k or crutched. I am i n bed m o s t o t t h e t i m e and h a v e t o c r a w l toilet.  to  the  150 Sitting I can I can ?ai n D Pa i n D Pai n D Pa i n D  s e t i n a n v c h a i r a s l o n g a s I 1 i rte . o n 1 v s i t i n m v t a v o u r i t e c ha i r a s l o n e a s I 1 r e v e n t s m e s i t t in g more t h a n 1 ho u r . r e v e n t s me t r om s i 1 1 i ng more t h a n 1 / 2 hour. r e v e n t s me t roni s i 1 1 i ng more t h a n 1 0 minutes. r e v e n t s m e t r o m s it t i ng a t a 1 1 .  S tanding I c an s t a n d as I c a n s t and as Pain prevent s Pain prevent s Pain prevent s Pain prevent s  on g as I on g a s I me t r o m s t me t r o m s t me t r o m s t me t r o m s t 1  Sleeping P a i n d o e s no t D r e v e n t I c a n s l e e p w e l l on 1 v E v e n when I t a k e t a b l e E v e n when I t a k e t a b l e sleep. E v e n when I t a k e t a b l e sleep. P a i n p r e v e n t s me t r o m Sex  extra pain, g i v e s me e x t r a  1  Lite My s e x l i t e i s n o r m a l My s e x l i t e i s n o r m a l My s e x l i t e i s n e a r 1 v Mv s e x l i t e i s s e v e r e My s e x l i t e i s n e a r 1 v P a i n p r e v e n t s any s e x  pain  m e trom s l e e p i n g w e l l , by u s i n g tablets. t s I have l e s s t h a n s i x hours s l e e p t s I have l e s s t h a n t o u r h o u r s ts  I  have  less  than  two  h o u r s ot  s1  a n d c a u s e s no e x t r a pain. b u t c au s e s some e x t r a pain. no rma 1 bu t i s v e r y paintul. by p a i n . 1v r e s t r i c t e d a b s e n t be c a u s e o t p a i n . l i t e at a 1 1 .  Social Lite Mv s o c i a l l i t e i s n o r m a l a n d g i v e s me no e x t r a p a i n . Mv s o c i a l l i t e i s n o r m a l b u t i n c r e a s e s t h e d e g r e e o t p a i n P a i n h a s no s i g n i t i c a n t ettect o n my s o c i a l l i t e apart t r o m l i m i t i n g mv m o r e e n e r g e t i c i n t e r e s t s , e . g . danc i n g , etc.' P a i n has r e s t r i c t e d bv s o c i a l l i t e a n d I d o n o t go o u t a s o t ten. P a i n h a s r e s t r i c t e d mv s o c i a l l i t e o t mv home. I h a v e no s o c i a l l i t e b e c a u s e o t p a i n . Travelling I c a n t r a v e l a n v w h e r e w i t ho u t e x t r a P a i n . I c a n t r a v e l a n v w h e r e bu t i t g i v e s me e x t r a pa i n . P a i n i s b a d b u t I man age 1 ou r n e v s o v e r two h o u r s . P a i n r e s t r i c t s me t o i ou r ne y s ot 1 e s s t h a n o n e h o u r . P a i n r e s t r i c t s me t o s ho r t n e c e s s a r v i o u r n e v s u n d e r JJ U minutes. P a i n p r e v e n t s me t r o m t r a v e 1 1 i n g e X c e p t t o t h e d o c t o r o r hospital  151  APPENDIX Gracely (Gracelv  From each column the most p a i n t u l  L  Rating Scale e t a l . , 1979")  below, c h o o s e one word stimulus presented.  M.  Very  Extremely  L.  Very  K.  Intense  K.  Very  J.  Strong  J.  Slightly  I.  Slightly  I.  Very  H.  Barely  G.  Moderate  G.  Very  F.  Mild  F.  Slightly  E.  Very  E.  A n n o y i ng  D.  Weak  C.  Very  A.  Intense  Intense  Strong  Mild  Weak  Faint No  Sensation  L.  H.  best  describes  Intolerable  M.  B .  Intense  that  Intolerable Distressing Intolerable  Annoying  Distressing Unpleasant Distressing  D.  Unpleasant  C.  Slightly  Annoying  B.  Slightly  Unpleasant  A.  No  Discomiort  152  Scoring SENSORY  tor  Gracely  Rating  Scales  UNPLEASANTNESS  INTENSITY 59.5  Very  43.5  Intolerable  32.3  Intense  34.6  Very  18.3  Strong  2 2.9  Slightly  21.3  Very  12.6  Distressing  11.4  12.4  Very  10.7  Extremely Very  Intense  Intense  Slightly Barely  Intense  Strong  Moderate Mild Very  Mild  Weak. Verv  Weak  Faint No  Sensation  Intolerable  Distressing Intolerable  Annoying  Unpleasant  13.6 12.1  5.5  Slightly  3.9  Annoying  5.7  2.8  Unpleasant  5.6  2.3  Slightly  Annoying  3.5  1.1  Slightly  Unpleasant  2.8  0  No  Distressing  44.8  Discomfort  6.2  0  153 APPENDIX  M  COPING STRATEGY QUESTIONNAIRE I n d i v i d u a l s who experience p a i n have developed a number ot wavs to cope, or d e a l w i t h , t h e i r p a i n . These i n c l u d e s a y i n g t h i n g s to themselves when thev e x p e r i e n c e p a i n , or engaging i n d i t t e r e n t a c t i v i t i e s . Below are a l i s t ot t h i n g s t h a t p a t i e n t s have r e p o r t e d d o i n g when they t e e l p a i n . For each a c t i v i t y , p l e a s e i n d i c a t e , u s i n g the s c a l e below, how much you engage i n that a c t i v i t y when you f e e l p a i n , where a 0 i n d i c a t e s you never do t h a t when you a r e e x p e r i e n c i n g p a i n , a 3 i n d i c a t e s that you sometimes do t h a t when you experience p a i n , and a 6 i n d i c a t e s you always do i t when vou e x p e r i e n c e p a i n . Remember, you can use any p o i n t along the s c a l e .  0 Never do  1  2  3 Sometimes do t h a t  4  5  6 Alwavs do that  WHEN I FEEL PAIN... 1. I t r y to f e e l d i s t a n t from the p a i n , almost as i f the p a i n was i n somebody e l s e ' s body. 2. I leave the house and do something, such as going to the movies or shopping. 3. I t r y to t h i n k of something p l e a s a n t . 4. I don't t h i n k of i t as p a i n but r a t h e r as a d u l l or warm f e e l i n g . 5. I t i s t e r r i b l e and I f e e l i t i s never going t o get any b e t t e r . 6. I t e l l myself to be brave and c a r r y on d e s p i t e the p a i n . 7. I read. I 8. I t e l l myself that I can overcome the p a i n . 9. I count numbers i n my head or r u n a song through my mind. 10. I just t h i n k of i t as some o t h e r s e n s a t i o n , such as numbness. 11. I t i s awful and I f e e l i t overwhelms me. 12. I play mental games w i t h myself t o keep my mind o f f the p a i n . 13. I f e e l my l i f e i s n ' t worth l i v i n g . 14. I know someday someone w i l l be here t o h e l p me and i t w i l l go away f o r awhile. 15. I pray to God i t won't l a s t l o n g . 16. I t r y not to t h i n k of i t as my body, but r a t h e r as something separate from me. 17. I don't t h i n k about the p a i n . 18. I t r y to t h i n k years ahead, what e v e r y t h i n g w i l l be l i k e a f t e r I've gotten r i d of the p a i n . 19. I t e l l myself i t doesn't h u r t . 20. I t e l l myself I can't l e t the p a i n stand i n the way of what I have to do. i l . I don't pay any a t t e n t i o n t o i t . 22. I have f a i t h i n d o c t o r s t h a t someday there w i l l be a cure f o r my pain. 23. No matter how bad i t g e t s , I know I can handle i t . 24. I pretend i t i s not t h e r e . 25. I worry a l l the time about whether i t w i l l end. 26. I r e p l a y i n my mind p l e a s a n t e x p e r i e n c e s i n the p a s t .  154 27. 28.  29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40 41. 42.  I t h i n k ot people I enjoy doing t h i n g s w i t h . pray f o r the p a i n t o s t o p . I imagine t h a t the p a i n i s o u t s i d e of my body. I j u s t go on as i f n o t h i n g happened. I see i t as a c h a l l e n g e and don't l e t i t bother me. A l t h o u g h i t h u r t s , I j u s t keep g o i n g . I f e e l I can't stand i t any more. I t r y t o be around o t h e r people. I ignore i t . I r e l y on my f a i t h i n God. I f e e l l i k e I can't go on. I t h i n k of t h i n g s I enjoy d o i n g . I do anything t o get my mind o f f the p a i n . I do something I enjoy, such as watching TV o r l i s t e n i n g t o music. I p r e t e n d i t i s not a p a r t ot me. I do something a c t i v e , l i k e household chores o r p r o j e c t s . I  Based on a l l the t h i n g s you do t o cope, o r d e a l w i t h , your p a i n , on an average day, how much c o n t r o l do you f e e l you have over i t ? P l e a s e c i r c l e the a p p r o p r i a t e number. Remember, you c a n c i r c l e any number a l o n g the scale. 0 No c o n t r o l  1  2 3 Some c o n t r o l  4  5 6 Complete c o n t r o l  Based on a l l the t h i n g s you d o t o cope, o r d e a l w i t h p a i n , on an average day, how much a r e you a b l e t o decrease i t ? Please c i r c l e the a p p r o p r i a t e number. Remember, You can c i r c l e any number along the s c a l e . r  0 1 Can't decrease i t at a l l  2 Can it  3 4 decrease somewhat  5  6 Can decrease i t completely  155 Key Cognitive  to  coping  Coping  Strategy  strategies:  1.  Diverting  2.  Reinterpreting  3.  Catastrophizing:  4.  Ignoring  5.  Praying  6.  Coping  Behavioural  coping  1.  Questionnaire  a t t e n t i o n : 3, the  5,  hoping:  12,  26,  27,  38  1,  4,  pain sensations: 16, 29 , 41 11,  sensations: or  9,  13,  17,  14,  se1f-statements:  25,  19,  15, 6,  21,  18, 8,  33,  20,  37  24,  22,  30,  28, 23,  35 36  31,  32  strategy  Increased  behavioural  activities:  2,  7, 40 ,  Effectiveness  10,  ratings  1.  Control  over  2.  Ability  to  pain  decrease  pain.  34, 42  39,  APPENDIX PAIN  N  EXPERIENCE  SCALE  Many p e o p l e r e p o r t h a v i n g t h e f o l l o w i n g k i n d s o t thoughts a n d f e e l i n g s when t h e i r p a i n i s v e r y s e v e r e . We w o u l d like t o know how f r e q u e n t l y you e x p e r i e n c e each of the t h o u g h t s a n d f e e l i n g s l i s t e d b e l o w when y o u r p a i n i s v e r y s e v e r e . R e a d e a c h a n d t h e n c i r c l e a n u m b e r on t h e s c a l e u n d e r the s t a t e m e n t t o i n d i c a t e how o f t e n y o u h a v e t h a t t h o u g h t o r feeling. 1.  I  feel  frustrated  0 Never 2.  I  think  about  0 Never 3.  I  feel  I  am  I wonder 0 Never  6.  I  feel  I  feel  I  feel  my  pain 2  5  4  getting  6 Very  Often  worse.  3  4  5  6 VeryOften  1  what 1  2  3  4  5  6 VeryOften,  because 2  of  3  i t would  my  pain. 5  4  be  6 Very  like  to  never  Often have  2  3  4  5  6 VeryOften  1  2  3  4  5  6 Very  Often  overwhelmed.  0 Never 8.  3  angry.  0 Never 7.  1  depressed  0 Never 5.  1  2  irritable.  0 Never 4.  1  1  afraid  0 Never  1  2  that 2  3  my  pain 3  5  4  will 4  6 VeryOften get  5  worse.  6 Verv  Often  any  pain.  157 9.  I  10.  I  think,  "This  0 Never  1  feel  1  I worry  about  0 Never 12.  I  think  about  I  feel  I feel pain  I  feel  '  19.  I  0 Never feel 0 Never  4  5  4  5  life  Often  6 VeryOften  6 Very  i s worth  3  4  5  2  3  4  5  2  1  Often  living.  6 VeryOften  3  myself  4  is getting 2  3  6 Very  5  on  4  " I t i s so  1  2  how 1  of  long  this  2  sorry 1  2  for 2  to  3  do  4  will  3  nothing 1  hard  other 3  Often  for giving  6 Very  nerves.  5  6 VeryOften  anything  5  6 Very  when  Often  last.  4  5  6 VeryOften  than  my  pain.  4  5  6 Very  Often  myself. 3  4  5  6 Verv  in  the  Often  my  '  I wonder  think  6 Very  2  everyone  I think, pain.  I  whether  1  0 Never 18.  3  disappointed with  0 Never 17.  5  family.  2  1  0 Never 16.  crazy".  everybody.  3  my  me  anxious.  0 Never 15.  4  with  2  1  0 Never 14.  is driving 3  1  0 Never 13.  2  impatient  0 Never 11.  pain  Often  I  have  the  158  Scoring  Scale  1:  2:  the  Pain  ExDcricncc  Scale  Emotionalitv (01  Scale  tor  +  03 015  + +  04 + Ob + 07 + 09 016 + 0 1 9 ) / 13  05  +  08  +  010  +  Worrv (02  +  +  Oil +  014  +  017)  /  b  012  +  013  +  159 APPENDIX Trait  0  Anxietv Questionnaire (Speilberger , 1985)  A number ot s t a t e m e n t s w h i c h p e o p l e have u s e d t o d e s c r i b e themselves are g i v e n below. Please read each statement and t h e n p u t a c h e c k m a r k i n t h e a p p r o p r i a t e box t o t h e r i g h t o f the s t a t e m e n t t o i n d i c a t e how you g e n e r a l l y f e e l . There are no r i g h t o r w r o n g a n s w e r s . Do n o t s p e n d t o o m u c h t i m e o n a n y one s t a t e m e n t but g i v e t h e a n s w e r w h i c h seems t o d e s c r i b e how you g e n e r a l l y feel. Almost never  I  feel  pleasant_  I  tire  quickly  3.  I  feel  like  4.  I wish I happy as to be  crying  c o u l d be a s o t h e r s seem  I am l o s i n g o u t o n things because I can't make up my m i n d soon enough 6.  I  feel  rested  7.  I am " c a l m , collected"  cool,  and  I feel that d i f f i c u l t i e s are p i l i n g up s o t h a t I c a n n o t o v e r c o m e them I w o r r y t o o much o v e r something that really doesn't matter 10.  I  am  happy  11.  I am i n c l i n e d things hard  12.  I  lack  s e 1 f - c o n f i d e n e e_  13.  I  feel  secure  to  take  Some t i m e s  Of t e n  Almost a 1wa v s  160 A1mo s t never  14.  I try to avoid facing a c r i s i s or d i f f i c u l t y  15.  I feel  16.  I am  17.  Some u n i m p o r t a n t thoughts run t h r o u g h my m i n d a n d b o t h e r me  18.  I take disappointments so k e e n l y t h a t I c a n ' t p u t t h e m o u t o f mv m i n d  19.  I am  20.  I get i n a state of t e n s i o n of t u r m o i l as I t h i n k o v e r my r e c e n t concerns and i n t e r e s t s  blue content  a  steady  person  Some t i m e s  Often  Almost always  

Cite

Citation Scheme:

    

Usage Statistics

Country Views Downloads
China 8 8
Japan 5 0
United States 2 1
Spain 2 0
Australia 1 0
City Views Downloads
Beijing 8 0
Tokyo 5 0
Ashburn 2 0
Manresa 2 0
Unknown 1 10

{[{ mDataHeader[type] }]} {[{ month[type] }]} {[{ tData[type] }]}
Download Stats

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0100512/manifest

Comment

Related Items