Title Page
 Front Matter
 Table of Contents
 List of Tables
 Review of the literature
 Methodology and instrumentatio...
 Biographical sketch

Title: Personality and pain response
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00099474/00001
 Material Information
Title: Personality and pain response a componential analysis
Physical Description: xv, 189 leaves : ; 28 cm.
Language: English
Creator: Schoeffel, Joan Canal
Publication Date: 1986
Copyright Date: 1986
Subject: Pain -- Psychological aspects   ( lcsh )
Psychophysiology   ( lcsh )
Foundations of Education thesis Ph. D
Dissertations, Academic -- Foundations of Education -- UF
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
Abstract: The management of postoperative pain is related to a decreased incidence of postoperative complications and length of hospital stay. Pain theory claims that part of the response to pain is mediated by motivational-affective and cognitive-evaluative factors such as culture, personality, anxiety, attention, and suggestion. I investigated the role of personality in pain response, in particular, Jungian psychological types and the coping styles described by Million. Participants took the Myers-Briggs Type Indicator, Millon Behavioral Health Inventory, Wallston Health Locus of Control Scale, and completed a symptom checklist before surgery. Postoperatively, subjects completed the McGill Pain Questionnaire. Thirty-two of the volunteers had gastric bypass procedures, 12 were fresh postoperative hand surgical patients, and 11 were hand surgery patients of more than 1-week duration. The ANOVA revealed significant differences between the three groups in pain response. Findings for personality type indicated there are few significant differences in reports of pain response, and differences were not consistent for all groups. The findings on coping styles and pain response were also not consistent for all groups. In the gastric bypass group, feeling types and subjects with inhibited and sensitive coping styles reported significantly more pain. In the hand surgery group subjects with inhibited and sensitive coping styles had significantly higher scores on several of the pain scales. In the hand rehabilitation group extraverted subjects were significantly more external on the Health Locus of Control Scale, and previous studies indicate that this is related to pain response. Subjects with introversive, respectful, and sensitive coping styles had significantly higher scores on several of the pain scales. Implications for health professional education and future research are discussed.
Thesis: Thesis (Ph. D.)--University of Florida, 1986.
Bibliography: Bibliography: leaves 176-187.
General Note: Typescript.
General Note: Vita.
General Note: A dissertation presented to the graduate school of the University of Florida in partial fulfillment of the requirements for the degree of Doctor of Philosophy
Statement of Responsibility: by Joan Canal Schoeffel.
 Record Information
Bibliographic ID: UF00099474
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: alephbibnum - 000929073
notis - AEN9841
oclc - 016141361


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Table of Contents
    Title Page
        Page i
        Page ii
    Front Matter
        Page iii
        Page iv
        Page v
        Page vi
    Table of Contents
        Page vii
        Page viii
    List of Tables
        Page ix
        Page x
        Page xi
        Page xii
        Page xiii
        Page xiv
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    Review of the literature
        Page 17
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    Methodology and instrumentation
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    Biographical sketch
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Full Text







Copyright 1986


Joan Canal Schoeffel

In Memoriam

Alfred Canal


Catherine White Schoeffel

Non Omnis Moriar


At the completion of this project, I have a profound respect for

the amount of time and energy others have given to assist me in my

quest. To rank order my expressions of appreciation is impossible,

because the role of each person has been essential at some point.

Let me begin, then, by expressing my gratitude to the patients who

gave me their time and encouragement during a period of great stress to

themselves and to the surgeons who were convinced this was a worthwhile

study: Allen Y. DeLaney, Alex M. C. MacGregor, and A. Moneim Ramadam,

who kindly allowed me to interview their patients. Without the help of

Elizabeth Ward, this study would not have happened. The staff of North

Florida Regional Hospital, Alachua General Hospital, and the Lake Butler

Center for Hand Surgery were always helpful and interested. I owe

special thanks to Ann Smith, Director of Nursing at North Florida

Regional Hospital. Becky Evans was most helpful in organizing data

collection procedures for the hand surgery patients. The staff of the

Physical Therapy Department of the Lake Butler Center were especially


The chairman of my committee, Dr. Barry Guinagh, reviewed the

many versions of the various chapters and provided an oasis of serenity

as I took the many stressful hurdles toward completion of the project.

Dr. Robert Soar, cochairman of the committee, was always available to

listen, with or without an appointment. He is a true scholar and

studying with him has been a high point in my life.

Dr. Mary McCaulley has been most generous with her time and helped

me understand type theory to the point where I could comfortably attempt

this study. Her scholarship has always been an inspiration. To Dr.

Margaret Morgan, I can never adequately express my gratitude and

affection for her constant encouragement over my entire graduate

experience. Of all the things I have learned from Maggie, perhaps the

most important was her basic philosophy that "the impossible just takes

a little longer." To Dr. Gordon Lawrence I extend my gratitude for his

time. His knowledge of type and learning has been an inspiration to me.

Jerry Mcdaid was an invaluable help with the data analysis. I also

extend my thanks to the National Computer Systems of Minneapolis for

assistance in processing the Millon data and permission to copy the


The graduate school experience, rich as it has been, is not without

great cost to the student and her family. During these long years, my

children have learned to manage without me when library or class work

interferred. They have suffered through examinations, term papers, and

finally this dissertation, rejoicing with me when each was over. These

truly wonderful people have shown me much love and maturity through this

experience, and I can only hope that in their loss of my presence, they

have gained something.

What can I say about someone who voluntarily types all of my

dissertation and correspondence, my husband? After years of encourage-

ment in every phase of this research, when I was discouraged, it was he

who would say, "Take some time off, and let's go swimming." When I was

full of energy, he cleared the environment of seven children and their

friends and incessant projects, so I could work. Without Mike's

vigilence, reassurance, and urging, I would never have completed this

project. He believed in it professionally and personally and often told

me so. I will be forever grateful for his love and help.

I wish to thank the friends who have offered helpful words and

advice, especially Pauline Gregory, Claire Norton, Peg Thompson, Marcia

Skinner, and Pat Korb. Barbara Smerage provided invaluable formatting

and editorial assistance.

Finally, I wish to extend my thanks to the research librarians I

have hounded over the years. Their knowledge is profound, their

patience saintly.


ACKNOWLEDGMENTS ............................................. iv

LIST OF TABLES ............................................. ix

ABSTRACT ...................................................... xiv


1 INTRODUCTION ............... ....................... 1

Statement of the Problem ............................ 4
Significance of the Study ........................... 4
Background of the Study ............................. 6
Personality .......................................... 8
Coping Styles ....................................... 11
Pain Expression ..................................... 14
Hypotheses and Research Questions ................... 15
Limitations of the Study ............................ 16

2 REVIEW OF THE LITERATURE ........................... 17

Historical Perspective on Pain ...................... 17
Studies on Pain and Personality ..................... 20
The Independent Variables ........................... 26
The Myers-Briggs Type Indicator ................ 26
The Millon Behavioral Health Inventory ......... 36
Health Locus of Control ............................. 41
The Subjects ....................................... 45
Obesity .......................................... 46
The Dependent Variable .............................. 52

3 METHODOLOGY AND INSTRUMENTATION ..................... 57

Subjects ........................................... 59
Instruments ........................................ 59
The Myers-Briggs Type Indicator ................ 60
The Millon Behavioral Health Inventory ......... 63
The Health History Questionnaire ............... 68
The Health Locus of Control Scale .............. 68
The McGill Pain Questionnaire .................. 71
Hypotheses Tested ................................... 74

4 RESULTS ........................................... 76

Introduction ....................................... 76
Correlations ....................................... 82
Hypotheses Testing .................................. 82
Results of Hypothesis Testing ....................... 87
Summary .......................................... 117

5 DISCUSSION ........................................ 124

Introduction ........................................ 124
Summary of the Study .............................. 124
The Gastric Bypass Group ....................... 126
The Hand Surgery Group ......................... 129
The Hand Rehabilitation Group .................. 132
Conclusions ........................................ 134
Recommendation for Future Research .................. 136



B LETTER TO SURGEONS .................................. 149

C CONSENT FORM AND MEMORANDUM ......................... 151

STYLES SCALES, n=55 ................................ 153

E SELECTION RATIO TYPE TABLES (SRTT) .................. 156

REFERENCES .................................................. 176

BIOGRAPHICAL SKETCH ........................................... 188


Table Page

1-1 Comparison of Responses to Acute and Chronic Pain ... 3

1-2 Definitions ........................................ 5

1-3 The Four Preferences Scored to Generate Types ....... 12

3-1 Split-half Reliabilities of the Four Scales of the
Myers-Briggs Type Indicator from the CAPT Data Bank 62

3-2 MBHI Scale Descriptions .................. .......... 65

3-3 Estimate of Reliability for MBHI Scales ............. 69

3-4 Correlations of the Mean Scale Values and the Rank
Order Values of the Pain Rating Index ............... 72

3-5 Correlations Between the Present Pain Intensity
Scale (PPI) and the Total Number of Words Chosen
(NWCT) ............................................ 73

4-1 Analysis of Variance of the Whole Sample (n=55) and
the Dependent Variable (Scores on the McGill Pain
Questionnaire) ...................................... 77

4-2 Means by Group for McGill Pain Questionnaire Scale .. 78

4-3 Description of Sample by Group, Gender, Mean Age .... 78

4-4 Type Distribution of Total Sample ................... 79

4-5 Type Distribution of the Gastric Bypass Group ....... 80

4-6 Type Distribution of the Hand Surgical Group ........ 81

4-7 Type Distribution of the Hand Rehabilitation Group .. 83

4-8 Means and Standard Deviations of the Three Groups on
the Total Number of Symptoms ........................ 86

4-9 Means and Standard Deviations of the Three Groups on
the Health Locus of Control Scale ................... 86

4-10 t Test for Differences Between Bipolar Scales of the
MBTI on the NWCS (Bypass Group) ..................... 88

4-11 t Test for Differences Between Bipolar Scales of the
MBTI on the PRIS (Bypass Group) ..................... 88

4-12 Analysis of Variance of the Bipolar Scales of the
MBTI on the NWCS of the McGill Pain Questionnaire
(HPQ) (Hand Surgery Group) .......................... 89

4-13 Analysis of Variance of the Bipolar Scales of the
MBTI on the PRIS Scale of the McGill Pain
Questionnaire (Hand Surgery Group) .................. 89

4-14 Analysis of Variance of the Bipolar Scales of the
MBTI on the NWCS (Hand Rehab. Group) ................ 90

4-15 Analysis of Variance of the Bipolar Scales of the
MBTI on the PRIS (Rehab. Group) ..................... 90

4-16 SRTT Analysis: Below the Median on Number of Words
Chosen (Sensory) on the McGill Pain Questionnaire
(n=24) ............................................ 91

4-17 SRTT Analysis: Above the Median on Number of Words
Chosen (Sensory) on the McGill Pain Questionnaire
(n=31) ............................................ 91

4-18 SRTT Analysis: Below the Median on the Pain Rating
Index (Sensory) of the McGill Pain Questionnaire
(n=27) ............................................ 92

4-19 SRTT Analysis: Above the Median on the Pain Rating
Index (Sensory) of the McGill Pain Questionnaire
(n=28) ............................................ 92

4-20 t Test for Differences Between Bipolar Scales of
the MBTI on the NWCA (Bypass Group) ................. 94

4-21 t Test for Differences Between Bipolar Scales of
the MBTI on the PRIA (Bypass Group) ................. 94

4-22 Analysis of Variance of the Bipolar Scales of the
MBTI on the NWCA of the McGill (Hand Surgery Group) 95

4-23 Analysis of Variance of the Bipolar Scales of the
MBTI on the PRIA (Hand Surgery Group) ............... 95

4-24 Analysis of Variance of the Bipolar Scales of the
MBTI on the NWCA Scale of the MPQ (Hand Rehab.
Group) ............................................ 96

4-25 Analysis of Variance of the Bipolar Scales of the
MBTI on the PRIA Scale of the MPQ (Hand Rehab.
Group) ............................................ 96

4-26 SRTT Analysis: Below the Median on the Number of
Words (Affective) NWCA Scale of the McGill Pain
Questionnaire (n=27) ................................ 97

4-27 SRTT Analysis: Above the Median on the Number of
Words (Affective) NWCA Scale of the McGill Pain
Questionnaire (n=28) ................................ 97

4-28 SRTT Analysis: Below the Median on the Pain Rating
Index (Affective) PRIA of the McGill Pain
Questionnaire (n=28) ................................ 98

4-29 SRTT Analysis: Above the Median on the Pain Rating
Index (Affective) PRIA of the McGill Pain
Questionnaire (n=27) ................................ 98

4-30 t Test for Differences Between Bipolar Scales of the
MBTI on the NWCE (Bypass Group) ..................... 100

4-31 t Test for Differences Between Bipolar Scales of the
MBTI and the PRIE (Bypass Group) .................... 100

4-32 Analysis of Variance of the Bipolar Scales of the
MBTI on the NWCE Scales of the MPQ (Hand Surgery
Group) ............................................. 101

4-33 Analysis of Variance of the Bipolar Scales of the
MBTI on the PRIE Scale of the MPQ (Hand Surgery
Group) ........................................... 101

4-34 Analysis of Variance of the Bipolar Scales of the
MBTI on the PRIE Scale of the MPQ (Hand Rehab.
Group) ............................................ 102

4-35 Analysis of Variance of the Bipolar Scales of the
MBTI on the NWCE Scale of the MPQ (Hand Rehab.
Group) ............................................ 102

4-36 SRTT Analysis: Below the Median on the Number of
Words Chosen (Evaluative) NWCE Scale of the McGill
Pain Questionnaire (n=8) ............................ 103

4-37 SRTT Analysis: Above the Median on the Number of
Words Chosen (Evaluative) NWCE Scale of the McGill
Pain Questionnaire (n=47) ........................... 103

4-38 SRTT Analysis: Below the Median on the Pain Rating
Index (Evaluative) PRIE Scale of the McGill Pain
Questionnaire (n=27) ................................ 104

4-39 SRTT Analysis: Above the Median on the Pain Rating
Index (Evaluative) PRIE Scale of the McGill Pain
Questionnaire (n=28) ................................ 104

4-40 t Test Differences Between the Bipolar Scales of
the MBTI on the PRIT (Gastric Bypass Group) ......... 105

4-41 Analysis of Variance of the Bipolar Scales of the
MBTI on the PRIT Scale of the MPQ (Hand Surgery
Group) ............................................ 106

4-42 Analysis of Variance of the Bipolar Scales of the
MBTI on the PRIT Scale of the MPQ (Hand Rehab.
Group) ............................................ 106

4-43 SRTT Analysis: Below the Median on the Pain Rating
Index (Total) PRIT Scale of the McGill Pain
Questionnaire (n=29) ................................ 107

4-44 SRTT Analysis: Above the Median on the Pain Rating
Index (Total) PRIT Scale of the McGill Pain
Questionnaire (n=26) ................................ 107

4-45 t Test for Differences Between the Bipolar Scales of
the MBTI on the NWCT (Bypass Group) ................. 108

4-46 Analysis of Variance of the Bipolar Scales of the
MBTI on the NWCT Scale of the MPQ (Hand Surgery
Group) ............................................. 109

4-47 Analysis of Variance of the Bipolar Scales of the
MBTI on the NWCT Scale of the MPQ (Hand Rehab.
Group) ............................................ 109

4-48 SRTT Analysis: Below the Median on Number of Words
Chosen (Total) NWCT Scale of the McGill Pain
Questionnaire (n=25) ................................ 110

4-49 SRTT Analysis: Above the Median on Number of Words
Chosen (Total) NWCT Scale of the McGill Pain
Questionnaire (n=30) ................................ 110

4-50 t Test for Differences between the Bipolar Scales of
the MBTI on the Total Number of Symptoms (Bypass
Group) .............................................. I1 1

4-51 Analysis of Variance of the Bipolar Scales of the
MBTI on the Number of Symptoms Reported (Hand
Surgery Group) ...................................... 112

4-52 Analysis of Variance of the Bipolar Scales of the
MBTI on the Number of Symptoms Reported (Hand
Rehab. Group) ...................................... 112

4-53 SRTT Analysis: Below the Median on Number of
Symptoms (n=28) ..................................... 113

4-54 SRTT Analysis: Above the Median on Number of
Symptoms (n=27) ..................................... 113

4-55 t Test for Differences Between the Bipolar Scales
of the MBTI on the HLC Scale (Bypass Group) ......... 114

4-56 Analysis of Variance of the Bipolar Scales of the
MBTI on the HLC Scale (Hand Surgery Group) .......... 115

4-57 Analysis of Variance of the Bipolar Scales of the
MBTI on the HLC Scale (Hand Rehab. Group) ........... 115

4-58 SRTT Analysis: Below the Median on Health Locus
of Control (n=24) ................................... 116

4-59 SRTT Analysis: Above the Median on Health Locus
of Control (n=31) ................................... 116

4-60 One-way Analysis of Variance on Coping Styles on
the McGill Pain Questionnaire (Bypass Group) ........ 118

4-61 One-way Analysis of Variance on Coping Styles and
the McGill Pain Questionnaire (Hand Surgery Group) .. 119

4-62 One-way Analysis of Variance on Coping Styles and
the McGill Pain Questionnaire (Hand Rehab. Group) ... 120

Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy



Joan Canal Schoeffel

December 1986

Chairman: Dr. Barry Guinagh
Cochairman: Dr. Robert Soar
Major Department: Foundations of Education

The management of postoperative pain is related to a decreased

incidence of postoperative complications and length of hospital stay.

Pain theory claims that part of the response to pain is mediated by

motivational-affective and cognitive-evaluative factors such as culture,

personality, anxiety, attention, and suggestion.

I investigated the role of personality in pain response, in

particular, Jungian psychological types and the coping styles described

by Million. Participants took the Myers-Briggs Type Indicator, Millon

Behavioral Health Inventory, Wallston Health Locus of Control Scale, and

completed a symptom checklist before surgery. Postoperatively, subjects

completed the McGill Pain Questionnaire. Thirty-two of the volunteers

had gastric bypass procedures, 12 were fresh postoperative hand surgical

patients, and 11 were hand surgery patients of more than 1-week

duration. The ANOVA revealed significant differences between the three

groups in pain response.

Findings for personality type indicated there are few significant

differences in reports of pain response, and differences were not

consistent for all groups. The findings on coping styles and pain

response were also not consistent for all groups.

In the gastric bypass group, feeling types and subjects with

inhibited and sensitive coping styles reported significantly more pain.

In the hand surgery group subjects with inhibited and sensitive

coping styles had significantly higher scores on several of the pain


In the hand rehabilitation group extraverted subjects were

significantly more external on the Health Locus of Control Scale, and

previous studies indicate that this is related to pain response.

Subjects with introversive, respectful, and sensitive coping styles had

significantly higher scores on several of the pain scales.

Implications for health professional education and future research

are discussed.


The purpose of the study was to examine the relationship between pain

response and personality.

Every adult and most children have suffered from pain at one time or

another. Pain theory states that individual pain perception is

associated with "interrelated biological, psychological, and social

factors" (Monks & Taenzer, 1983, p. 233). This may include motivational-

affective and cognitive-evaluative dimensions described by Melzack and

Dennis (1978). Pain is partially a learned response to noxious stimuli.

The learning is influenced by personality, social, environmental, and

cultural factors. With this in mind, I attempted to examine the

phenomenon of acute pain from the perspective of personality. This

chapter includes the purpose of the study and some brief introductory

remarks outlining the differences between chronic and acute pain. Along

with the statement of the problem and significance of the study, the

chapter includes a brief background and other information on personality

type and coping styles. It also includes a table of definitions and a

section on the limitations of the study.

Because of the complexity of pain, scientists from many disciplines

study it. A recent Time (1984) cover story on pain stated that "pain

research is an orphan field that neither anesthesiology, neurology, nor

psychiatry can entirely claim as its own" (p. 59). Pain research and

management is a new field of study. Over the last decade many large

medical centers and some private institutions both nationally and

internationally have opened pain clinics or centers strictly for its

study. These centers and clinics generally focus on the chronic pain

patient. This study is about acute pain, and a good place to begin is by

reviewing the differences between chronic and acute pain. Identifying

the differences helps to explain why the two types of pain are not

studied together.

Sternbach's (1978) review of the experimental and clinical literature

reveals a significant difference between acute and chronic pain. Acute

pain is described as "pain of recent onset or of short duration" (p.

243). An example of this would be surgical pain. Chronic pain is "pain

of at least several months duration" (p. 243). An example of this would

be pain associated with chronic arthritis or recurrent migraine


Besides temporality, the differences between these two types of pain

are both physiological and psychological. Table 1-1 lists the basic

differences in response to the two types of pain. Acute pain is

generally accompanied by an increase in the release of epinephrine,

causing many physiological symptoms. Investigators have found that

medical or psychological intervention to reduce anxiety associated with

acute pain will diminish the pain response. Likewise, treatment of the

depression associated with chronic pain "frequently results in a signifi-

cant reduction of pain," and "the reduction or abolition of pain reverses

the neurotic depression caused by the pain" (Sternbach, 1978, p. 243).

Table 1-1

Comparison of Responses to Acute and Chronic Pain

Physiologic Response

Fight or Flight

increase heart rate
increase blood pressure
increase pupil size
increase muscle tension
decrease gut motility
decrease superficial capillar

Psychological Response


feeling tense, irritable, nervous
insecure, dread, malaise, jumpy,
excited, talkative, apprehensive

Autonomic Responses

sleep disturbances
Chronic appetite changes
decreased libido
Pain irritability
general withdrawal with
weakened relationships
increased somatic


insomnia, low energy, chronic
fatigue, guilt, feeling of
inadequacy, productivity
decreased attention, social
withdrawal, pessimistic
attitude, less talkative,

(Adapted from Sternbach, 1978)

In this study I examined the relationship between personality type

theory as described by Jung (1971), coping styles as described by Millon

(1973), and pain expression as described by Melzak (1975). Type theory

includes an explanation of how one perceives and judges the world.

Coping styles include degrees of cooperativeness, sociability,

confidence, inhibitions, and sensitivity. Pain expression is the

magnitude of perceived pain. All of these variables are explained in

depth in the Background of the Study.



Statement of the Problem

Although scientists agree that personality influences pain,

investigations of this influence generally focus on mood, neuroticism,

and anxiety (Lim, Edes, Kranz, Mendelsohn, Selwood, & Scott, 1983;

Merskey, 1978). The literature contains no studies on the relationship

between personality type, coping style, and acute pain.

Health care personnel, although aware of individual differences

among patients, generally are not taught to take these differences into

consideration when planning care. Clinicians and investigators who

design programs for postoperative pain management generally do not

consider personality, type, or coping style as a significant factor when

individualizing a program.

Significance of the Study

Because a "number of postoperative dysfunctions are related directly

or indirectly to postoperative pain" (Benedetti, Bonica, & Bellucci,

1984, p. 381), effective treatment of pain is an important issue in the

recovery of the patient and the prevention of these dysfunctions. The

treatment of postoperative pain includes appropriate analgesia and

psychological intervention. "The incidence, severity, and duration of

pain and suffering during the postoperative period can be decreased by

proper preoperative and postoperative psychologic care" (p. 388).

In recent years researchers have given much attention to pain

response. However, certain questions have not been answered. One

question relates to the role of personality type and coping style in

pain response (Table 1-2). Research indicates that certain types of

Table 1-2


Term Definition

1. Personality type

2. Coping styles

3. Sensory words

4. Affective words

5. Evaluative words

6. Locus of control

7. Organic pain

8. Functional pain

"A type is a characteristic specimen of a general
attitude occurring in many individual forms.
From a greater number of existing or possible
attitudes I have singled out four that are
primarily oriented by the four basic
psychological functions: thinking, feeling,
sensation, intuition. When any of these
attitudes is habitual, thus setting a definite
stamp on the character of an individual, I speak
of a psychological type" (Jung, 1971, p. 482).

is, ways
p. 89).

forms of instrumental behaviors, that
of achieving positive reinforcements and
negative reinforcements" (Millon, 1981,

"Words that describe the sensory qualities of the
experience in terms of temporal, spatial pres-
sure, thermal and other properties" (Melzak,
1975, p. 278).

"Words that describe the affective qualities, in
terms of tension, fear and autonomic properties
that are part of the pain experience" (Melzak,
1975, p. 278).

"Words that describe the subjective overall inten-
sity of the total pain experience, for example,
annoying, troublesome, miserable, intense, and
unbearable" (Melzak, 1975, p. 278-81).

"The perceived influence that one has on the
attainment of reinforcement" (p. 439). "Internal
control refers to the individual's belief that he
or she can significantly determine whether or not
a goal will be reached, while external control
refers to the belief that fate, or external agents
rather than personal factors, are the most impor-
tant determinants of goal attainment" (Feshback &
Weiner, 1982, p. 144).

Pain associated with organic disease or surgery.

Pain without associated evidence of organic

pain intervention programs are more effective than others. For example,

Anderson and Masur (1983) suggested that the most effective type of

psychological preparation "appears to be a combination of sensory and

procedural data" given to a patient prior to surgery (p. 10). They add

that although these approaches have been effective in terms of selective

outcome measures, "the underlying mechanism has remained elusive"

(Anderson & Masur, 1983, p. 10). Thus, in this study I analyzed two

components of personality: type and coping style as they relate to pain


By examining the relationship between pain response and personality, I

suggest additional components to the puzzle of pain. Findings may lead to

revision of the education of health care personnel and of pain interven-

tion programs. Today, government policy is aimed at decreasing health

care expense. I designed this study to generate knowledge that could

influence the length of hospital stay. Thus, this study has economic as

well as social ramifications.

Background of the Study

Pain is a subjective experience. This subjectivity has limited

attempts to quantify and study pain. Some investigators examine labora-

tory-induced pain and others study either chronic or acute pain. The

question arises as to the role cognitive factors play in pain and pain

expression. Does personality mediate pain expression? If so, how might

this information be useful in planning an appropriate intervention


Furthermore, since the study of the pain experience involves human

subjects, componential analysis is the most common approach for

investigators of the phenomenon. Some of the more common components are

cultural, social, physiological, medical, learning processes, behavioral

manifestations, clinical aspects, psychodynamic aspects, perception, and

personality (Sternbach, 1978). Studies involving pain expression

generally come under clinical, psychodynamic, perceptual, or personality

components. Studies of chronic or acute pain involve either observation

by the investigator or self-report. Both methods have advantages and

problems. Research involving behavioral observations has led to the

adoption of a behavioral perspective in the management of pain patients

(Fordyce, 1978). Some psychologists believe that this behavioral

emphasis has "retarded the discovery of other important conceptual

approaches in pain management" (Parker, Doerfler, Tatten, & Hewett,

1983, p. 208).

The concept that the etiology of pain can be entirely physical

or entirely psychogenic is only slightly more than 100 years old

(Mereskey, 1980). This insight occurred after advances in anatomy and

physiology led to the theory that pain was due to stimulation of

specific pain pathways. Prior to this enlightenment, health care

personnel treated pain more or less as an emotional response or a

response to something that occurred outside of the body. Mereskey

(1980) reviewed the history of the concept of pain from antiquity, when

society recognized some relationship between pain and physical

experience, to Freud, who developed the idea that bodily symptoms could

result from unconscious thought processes. Somewhere in this expanse of

history is the primitive concept that the origin of pain is purely

external. Mereskey (1980) suggested that as far as we have come in the

study of pain, "the ideas of Jeremiah and Aristotle still find a place

in thought after more than two millennia" (p. 6). Aristotle declared

pain to be one of the "passions of the soul" and separated it from the

five senses, giving it an identity of its own. Jeremiah gave it an

exogenous origin declaring "from above He sent fire into my bones"

(Lamentations 1, 12-13). Jeremiah would be considered to have believed

in an external locus of control, that is attributing pain to forces

outside the individual, such as fate, bad luck, or evil eye.


Jungian type theory postulates that "much seemingly chance variation

in human behavior is not due to chance; it is in fact the logical result

of a few basic observable differences in mental functioning" (Nyers,

1980, p. 4). Jung asserted that these differences were not gender

specific or related to social class nor were they "mere idiosyncrasies

of character peculiar to individuals" (cited in Campbell, 1976, p. 179).

He believed that the apparent random distribution of type was evidence

that "it cannot be a matter of conscious intention, but must be due to

some unconscious instinctive cause" (cited in Campbell, 1976, p. 180).

Jung's types are meant to be descriptive of normal behavior essentially

free of psychopathology. Differences lie in how people perceive the

world and how they judge what they perceive. The way people use these

functions, perception (P) and judgment (J), is related to their

preference for the outer world extraversionn) (E) or the inner world

(introversion) (I).

Perception can be either sensing (S) or intuitive (N). Sensing

individuals are described as very aware of their immediate environment.

They are the first to notice when the seasons change or when the birds

migrate. Intuitives, on the other hand, are less concerned with the

here and now and more aware of the potential of a given situation.

People familiar with Jung's theory and their own type claim that sensing

types, because of their awareness of the immediate environment, should

be more aware of physical changes in their bodies than intuitive types


Persons who are oriented to life primarily through sensing
perception typically develop acute powers of observation, a
memory for facts and detail, a capacity for realism and an
enjoyment of the pleasures of the immediate moment. Persons who
are oriented to life primarily through intuitive perception
typically are attuned to future possibilities, often creative
ones, and develop the ability to see patterns at theoretical or
abstract levels and to enjoy the play of imagination.
(McCaulley, 1981, p. 299)

Judgment can be either thinking (T) or feeling (F). Thinking types

tend to be analytical and logical. They prefer to react to a situation

objectively relying on factual evidence. McCaulley (1981) described

thinking as

the function that links ideas together by means of concepts,
making logical connections. Persons who are oriented to life
primarily through thinking typically develop strong powers of
analysis, objectivity in weighing events with regard to logical
outcomes, a time perspective concerned with connections from
past through present to future, and a tough-minded skepticism.
(p. 300)

Because of this objectivity, thinking types would be expected to use

more objective sensory type language regarding issues of their personal

health. Feeling types prefer to judge by personal values rather than by

impersonal logic. Feeling is described as "the function that arranges

the contents of consciousness according to their value. Persons who are

oriented to life primarily through feeling typically develop sensitivity

to questions of what matters most to people, a need for affiliation, a

capacity for warmth, a desire for harmony and a time orientation

emphasizing the preservation of the values of the past" (McCaulley,

1981, p. 300). Feeling types, because they use emotion, might be

expected to use more affective or evaluative language when talking about

their health.

While sensing, intuition, thinking, and feeling are orienting

functions that reflect perception and judgment, extraversion and

introversion are considered attitudes.

In the extroverted attitude, attention seems to flow out--to be
drawn out--to the objects and people of the environment. There
is a desire to act on the environment, to affirm its importance,
to increase its effect. In the introverted attitude, energy
seems to flow from the object back to the subject, who conserves
this energy by consolidating it within his own position.
(McCaulley, 1981, p. 297)

Some studies have been done on the extraversion-introversion orientation

and pain behavior, and these will be examined in the literature review.

In this study I examined this orientation in terms of response to pain

as opposed to pain behavior.

So far I have described two attitude types (extroverts and intro-

verts) and four function types (sensing/intuition and thinking/feeling).

The test used to measure these types, in this study the MBTI, also

includes a fourth preference: judgment/perception. This dimension was

not described by Jung but added by Myers (1980) who claimed that Jung

implied the existence of this dimension. Basically it describes whether

a person prefers to use judgment or perception in dealings with the

world. According to Myers, "This preference makes the difference

between the judging people who order their lives and the perceptive

people who just live them" (Myers, 1980, p. 9). McCaulley (1981)

summarized the four preferences in Advances in Psychological Assessment,

reproduced with the author's permission in Table 1-3.

According to Jung's theory, one of the four functions (sensing,

intuition, thinking, or feeling) becomes the dominant function and

provides direction and stability to the personality. If the dominant

function is a perceptive function (sensing or intuition), it will be

balanced by development of one of the judgment functions (thinking or

feeling). This second function is known as the auxiliary function.

Further balance in the personality is provided by the theoretical

assumption that for extraverts, the dominant function will be used

mainly in interactions with the outside world, while the auxiliary is

used mainly in the inner world of concepts and ideas. For introverts,

on the other hand, the dominant function is used mainly in the inner

world of concepts and ideas while the auxiliary is used with the outside

world. Each of the Jungian types has its own special relationships

postulated between the developed functions and the extraverted and

introverted attitudes (Myers & McCaulley, 1985).

Coping Styles

Coping styles, measured by the Millon Behavioral Health Inventory,

were derived from Millon's biosocial theory of personality development.

Table 1-3

The Four Preferences Scored to Generate Types

Does the person's interest flow mainly to

The outer world of actions The inner world of concepts
objects, and persons? and ideas?

E Extraversion Introversion I

Does the person prefer to Perceive

The immediate, real, The possibilities,
practical facts of experience relationships, and meanings
and life? of experiences?

S Sensing Intuition N

Does the person prefer to make Judgments or decisions

Objectively, impersonally, Subjectively and personally,
considering causes of events weighing values of choices
and where decisions may lead? and how they matter to

T Thinking Feeling F

Does the person prefer mostly to live

In a decisive, planned and In a spontaneous, flexible
orderly way, aiming to regulate way aiming to understand
and control events? life and adapt to it?

J Judgment Perception P

Note. Adapted from McCaulley, M. H. (1981), Jung's theory of
psychological type and the Myers-Briggs Type Indicator. In P.
McReynolds (Ed.), Advances in Psychological Assessment (p. 298). San
Francisco, CA: Jossey Bass. Used with permission.

According to Millon (1981), personality development is linked to

"periods of neurological maturation rather than psychosexual stages or

cognitive functions" (p. 79). He referred to these periods as

"neuropsychological stages." They are stage 1, sensory-attachment, which

comprises the first year of life; stage 2, sensorimotor-autonomy, gener-

ally occurring over the next 3 years of the child's life; and stage 3,

intracortical-initiative, what he called the peak period of neurological

maturation for certain psychological functions (p. 89). This stage

occurs between the ages of 4 and 18. It is within this last stage that

Million believes coping strategies are learned. Million developed a

theoretical model of the essential strategies that guide coping behavior

in terms of "what reinforcement the individual is seeking, where the

individual is looking to find them, and how the individual performs in

order to obtain them" (p. 91).

The theoretical model begins with two basic dimensions. The first

dimension has to do with an individual's possessive source of positive

or negative reinforcement and within this dimension there are four

distinct styles:

1. Detached. This group represents the people who experience few

rewards or satisfaction.

2. Dependent. People who measure their satisfaction or discom-

forts on how others react to them.

3. Independent. People whose satisfaction is in terms of their

own values and desires with little reference to the wishes of


4. Ambivalent. People in conflict over whether to be guided by

what others say or their own wishes.

The second dimension reflects the basic pattern of coping behavior,

with two distinct styles:

1. Active. People who arrange and manipulate their lives to

achieve satisfaction and avoid discomfort.

2. Passive. People who are restrained, resigned, or content to

allow events to take their own course (Millon, 1984).

Million combined the first dimension (sources of reinforcement) with the

second dimension (coping behavior) and came out with a four by two

matrix from which he derived his basic coping styles. Since he is a

psychopathologist, the original coping styles consisted of eight mildly

pathologic styles and three very severe styles. These styles are

measured by an instrument designed for that purpose and only suitable

for use in patients with suspected psychopathology. The coping styles

assessed in this study are normal variations based on the same model of

personality and measured by an instrument designed specifically for a

medical, not a psychiatric population (Meagher, 1986). These styles

consist of introversive, inhibited, cooperative, sociable, confident,

forceful, respectful, and sensitive (Millon, Green, & Meager, 1982, p.

2). A brief description of these styles can be found in Chapter 3 and a

more detailed description in Appendix A.

Pain Expression

Pain expression is a dimension of the magnitude of perceived pain.

This includes the quality and intensity of the experience. Melzak

(1975) believes that quality is unique and should not be limited to a

sensory description. He suggested also examining affective and

evaluative qualities of the experience. Sensory qualities include

temporal, spatial, pressure, and thermal aspects. Affective qualities

include tension, fear, and autonomic properties. Evaluative qualities

involve the overall intensity of the experience, from annoying to

unbearable (Melzak, 1975).

Other methods of defining pain expression involve observation by the

investigator of overt behaviors such as restlessness, grimacing,

groaning, and medication usage. Behaviors such as blood pressure,

pulse, EMG readings, and galvanic skin response are also used to define

pain expression.

The instrument I used to measure pain expression was the McGill Pain

Index. This self-report technique developed by Melzak (1975) measures

the sensory, affective, and evaluative qualities of the pain experience.

Hypotheses and Research Questions

I hypothesized that personality type is associated with pain

expression, and that coping styles are associated with responses on the

McGill Pain Questionnaire.

To test these hypotheses, I addressed the following research

questions: Is personality type associated with a particular type of

pain response? That is, is type associated with sensory, affective, or

evaluative responses? Additionally, is coping style associated with

pain response? If so, in what direction?

Limitations of the Study

Pain has many components, and to include all of these components in

this study even if they were fully understood, would be impossible.

Culture, for example, is not accounted for, and yet Zborowski (1969)

makes a good case for the role it plays in pain expression.

In addition, the sample of three groups of surgical patients is not

truly random. The first group was composed of patients who have had a

gastric bypass procedure for morbid obesity. All morbidly obese

patients did not have an opportunity to participate because selection

for surgery is not entirely up to the patient. Because of the risk,

involved patients are selected for this procedure after evaluation of

many other criteria, such as age, general physical and mental health,

and economic factors. Within the group that was selected, every patient

scheduled for surgery during a 5-month period did have an equal

opportunity to participate but not all chose to do so.

The second and third groups comprised hand surgery patients, and

this selection was also not random. Patients were volunteers who

presented with hand problems over a 3-month period.

Another limit of the study is in the sample size. Because of the

small number of participants, it is not be possible to discuss type in

terms of combinations of all four functions. In this case the

individual functions are be discussed. Thus, our understanding misses

something since "the whole is greater than the sum of the parts."


Historical Perspective on Pain

Ever since human beings have been recording the events of their

lives, they have been writing about pain. Efforts to understand and

control pain have brought western civilization from the healer and

shaman to the physician with a team of health professionals. The

Eastern practice of acupuncture for the prevention and treatment of pain

is considered to be more than 5,000 years old. A 20th century observer

visiting a museum or a ruin in North, Central, or South America can see

evidence in artifacts and hieroglyphics of pain intervention by Indian

medicine men.

Procacci and Maresca (1984), in their review of the pain concept in

western civilization, asserted that "prehistoric people had no

difficulty in understanding pain associated with injury, but they were

mystified by pain caused by disease" (p. 1), so they associated the

latter with magic and demons. These beliefs persist today in

subliterate societies in third world countries. Indeed, the education

of health professionals in the United States consists of at least one

lecture on the superstitious beliefs of such cultures within our

society. Fear of the "mal oho" among Latin Americans and "voodoo death"

among Haitians still exists in a society that can send men to the moon.

Another myth, that somehow pain is associated with demons and sin, also


comes form the ancient Assyrio-Babylonian and Hebrew civilizations.

This concept somehow became part of the Christian ethic and is "the

fundamental significance of the word 'pain' in English, derived from the

Latin word poena meaning punishment" (Procacci & Maresca, 1984, p. 4).

The ancient Greeks believed that pain was associated with pleasure

(Maresky, 1980; Procacci & Maresca, 1984) since the removal of pain was

pleasurable and also that pain was "an emotional experience rather than

merely a disturbance located in the body" (Maresky, 1980). This view

apparently prevailed until the 11th century. Aristotle believed that

the heart was the location of the soul and also the center of sensory

processes. Not until the fourth century B. C. did successors of

Aristotle provide anatomic evidence that the brain was part of the

nervous system.

The Roman writers considered pain "in relation to the phenomenon

of inflammation." Galen brought Greek and Egyptian teaching to Rome in

the second century. His own work included a description of the nervous

system and the concept that "the center of sensibility was the brain"

(Procacci & Maresca, 1984 p. 4). Nevertheless, Aristotle's idea that

pain was a "passion of the soul" that was felt in the heart remained

until the 19th century.

During the Renaissance, the ideas of Aristotle were scrutinized but

none the less they survived. The opposing theories, such as those of

Descartes, did not make their way into the medical textbooks of the

time. In the first half of the 19th century, German scientists demon-

strated that the brain was involved in sensory and motor activity. By

the end of the 19th century the Aristotelian view was no longer popular,

and the long journey toward a scientific understanding of the

physiological nature of pain had begun.

Modern approaches to the nature of the pain experience come from

many disciplines. The gate theory proposed by Melzack and Dennis (1978)

is perhaps the best known and most popular of the physiological

approaches. Gate control theorists only attempt to explain the activity

of the nervous system when pain is experienced. Gate control theory

proposes that "neural mechanisms in the dorsal horns of the spinal cord

act like a gate that can increase or decrease the flow of nerve impulses

from peripheral fibers to the spinal cord cells that project to the

brain" (Melzak & Dennis, 1978, p. 2). This adjustment of the nerve

impulses takes place before injury or somatic input invokes pain

perception and response. According to the theory, large fiber inputs

close the gate, and small fiber inputs open the gate. The mechanism for

the inhibition and facilitation is unknown. Since it is now known that

all dorsal horn cells are under the control of fibers that descend from

the brain, it is believed that descending influences such as motiva-

tional drive and cognitive evaluative activities will also affect the

gate. When the output of the spinal cord transmission exceeds a

critical level, the individual experiences pain. "The complex sequences

of behavior that characterize pain are determined by sensory, motiva-

tional, and cognitive processes that act on motor mechanisms" (p. 12).

Motor mechanisms are "all of the brain areas that contribute to overt

behavioral response patterns" (Melzak & Dennis, 1978, p. 12).

The affective influence espoused by the ancients seems consistent

with current research of scientists such as Melzack and Dennis.

Affective influences can include cultural and social influences,

cognitive influences including attention and past experience, and

personality influences. The focus of the remainder of the review will

be on (a) previous studies of pain and personality; (b) personality

components such as type, coping styles, and locus of control; and (c)

estimates of pain through the McGill Pain Questionnaire.

Studies on Pain and Personality

This review will cover components of personality and pain behavior

in medical, surgical, and obstetrical patients. No studies were found

which specifically discussed personality type based on Jung's theory and

pain response or pain behavior.

Most studies of surgical patients in acute pain have centered on

medication usage and anxiety. Although anxiety is certainly a factor,

to improve and expand approaches to pain management, investigators must

examine other aspects of personality. Pilowsky (1978) wrote, "It would

be patently foolish to hope to understand so complex a phenomenon as

pain without taking into account its interaction with the total

personality" (p. 203).

The surgical experience provides an ideal setting for the study of

individual variables such as personality type, coping style, and the

magnitude of perceived pain. A patient's anxiety, level of discomfort,

and concern for well being is considerably more realistic than in

experimentally induced pain research. "Surgery is a high stress

situation which evokes intense emotional reactions, involves

considerable physical danger, and is quite painful" (Scott, Clum, &

Peoples, 1983, p. 283).

Most researchers agree that there is a considerable difference

between experimentally induced pain and clinical pain, and because of

these differences, experimentally induced pain studies have come under

some criticism. Wolff (1978) summed this up as follows:

The major criticisms of experimental pain have been that (a)
there is no significant psychological involvement and implica-
tion for the subject so that there is no real "suffering,"
which is in sharp contrast to clinical pain; (b) the duration
of experimental pain--seconds, minutes, perhaps a couple of
hours--is much shorter than clinical pain, which may last many
years; and (c) the intensity of experimental pain is usually
much less than the severity of clinical pain. (p. 149)

In addition to the above criticisms there is the matter of per-

ceived control of the noxious stimuli. Ethics and the law demand that

experimental pain subjects be allowed to withdraw at anytime. Clinical

pain does not offer that option without the risk and side effects that

come with the use of analgesics.

In his examination of the differential pain tolerance of extraverts

and introverts during childbirth, Eysenck (1961) found that "the more

extraverted the patient, the more unbearable did the labor situation

seem to her in retrospect" (p. 422). He attributed the differences in

reported pain to the fact that extraverts are "the types, by and large,

who are given to voicing their grievances, while introverts . are

those who tend to play down the experience as not too painful" (p. 423).

He believes that the intrinsic experience of childbirth is the same for

extraverts and introverts and that the response of extraverts is

"behaviorally exaggerated." He also examined the effect of neuroticism

on behavior and attitude to labor and found that it was not predictive.

Two other investigators using Eysenck's instrument (Bond, 1971; Bond,

1973) did find "a low degree of neuroticism clearly linked with

limitation of the experience of pain" (Bond, 1973, p. 259) and the

extraversion/introversion factor related to complaint behavior, with the

extraverts complaining more.

Shacham, Reinhardt, Rauhutas, & Cleeland (1983), in a study of 95

patients with cancer referred to a pain clinic, found that pain severity

was significantly related to negative mood states. Lufkin and Ray

(1982), in an article titled "Personality Correlates of Pain Perception

and Tolerance," report that in a nonmedical population exposed to

laboratory-induced pain, tolerance was related to situation variables

such as cognitive focus and distraction rather than the personality

variables of self-esteem and depression.

As stated earlier, investigators of postoperative pain generally

consider anxiety and neuroticism. Scott et al. (1983) demonstrated that

preoperative anxiety was a significant predictor of postoperative pain

and trait anxiety was not predictive of any of the postoperative pain

measures. They also found that information about the surgery was

predictive of higher levels of pain. This finding is at odds with other

research on giving information prior to surgery (Langer, Janis, &

Walfer, 1975); however, it does suggest that cognitive factors do

mediate pain response in some way. Martinez-Vrrutia (1975) in a study

of hospitalized veterans also found an increase in state anxiety after

surgery but no significant increase in trait anxiety.

Chapman and Cox (1977) investigated changes over time in anxiety,

pain, and depression in a group of abdominal surgical patients. Their

results indicated that patients have more anxiety and less depression

preoperatively. "Patients donating kidneys or receiving kidneys from a

live donor had significantly higher pain composite scores and levels of

state anxiety than abdominal surgery patients" (p. 14).

Wallace (1985) found that preoperative pain expectancy was

positively associated with postoperative reports of pain and high levels

of anxiety. In a second study, she found that subjects given informa-

tion prior to surgery had significantly less postsurgery pain than

controls had. This also supports the concept of cognitive motivational

mediation in the pain process as suggested by Melzack.

Reading and Cox (1985) in their study of the psychological

predictors of labor pain found that pain ratings on the McGill Pain

Questionnaire were high when compared to other clinical pain groups.

The strongest predictor of the variance was drug use during labor

followed by anxiety measured at 32 weeks' gestation. A significant

association was found between pain ratings and ratings of postpartum

mood, suggesting to the author an association between pain perception

and personality.

A popular method of assessing postoperative pain is to examine

medication usage. Since 1981, patient-controlled analgesia (PCA) has

been available and in general use in most hospitals. This is a system

in which the patient controls the amount and time of morphine (or other

drug) usage by pressing a button. A preset computer prevents the

patient from taking a dangerous overdosage. Most of the literature

indicates that with this method patients use less morphine than when

they request it from the nursing staff (Bennett, Batenhorst, & Graves,

1982). Wilson and Bennett studied coping styles of general surgical

patients using the amount of self-administered medication as their

dependent variable and therefore their pain index. They found that

patients who were independent with high levels of emotional control and

who were passive consumed significantly less medication than patients

with dependent, highly aggressive, and highly arousable styles.

Taenzer, Melzack, and Jeans (1986) report a study of 40 patients

who had a surgical removal of the gall bladder. They used multiple

regression analysis to demonstrate the extent to which nonmedical

factors influenced pain perception and found that these factors

accounted for 46% of the variance. Significant predictors of pain

scores included trait anxiety, neuroticism, and coping styles, with the

latter accounting for 28% of the variance. The highest pain scores came

from the defensive high-anxious group. Of the demographic factors

studied, only educational level was negatively associated with pain

scores, with more educated subjects reporting less pain and accounting

for 10% of the variance. Gender and age were not related to pain

intensity. This study added to the evidence of the role of

psychological factors in the perceived intensity of postoperative pain,

and the results "suggest that the wide variability in postoperative

pain, distress, and analgesic requirements is evidence of the multiple

interacting influences known to underlie pain perception" (p. 340).

A study on the emotional reactions to surgery (Spielberger,

Auerbach, Wadsworth, Dunn, & Taulbee, 1973) indicated an increase in

state anxiety just prior to surgery and no change in trait anxiety.

Using an abbreviated version of the Minnesota Multiphasic Personality

Inventory, they found no differences in pre- and postsurgery means,

suggesting that the emotional stress of surgery does not affect

relatively stable personality characteristics.

Twenty-two years ago, Egbert, Battit, Welch, and Bartlett (1964,

cited in Egbert, Battit, Welch, & Bartlett, 1985) examined the influence

of preoperative instruction and information on the amount of analgesics

requested after surgery. Egbert's results showed that patients who were

told what to expect and what they could do about it required

significantly less morphine postoperatively than a control group

(p < .01). In addition, the preinstructed patients were discharged an

average of 2.7 days earlier than the control group (p < .01). This

study led Egbert and others to conclude that "each patient has his own

personal psychologic makeup; each patient needs "special" treatment,

tailored to meet the individual's particular psychologic needs" (p. 56).

In a recent review of his previous research on postoperative pain and

psychological factors, Egbert et al. (1985) wrote

Again and again over the years, research has clearly shown
that the physical recovery of surgical patients is exquisitely
sensitive to psychological factors. As far as I know, no one
has ever disputed this, so an intelligent person would
naturally assume that psychologic factors are likely to be a
major area of interest and concern among anesthetists and
surgeons, who obviously desire their patients to recover as
rapidly and as comfortably as possible. And yet it is only
too clear that this area of interest has not developed.
(p. 56)

In summary, there is substantial evidence that psychological

factors can influence pain perception and, in turn, recovery. The

question that Egbert brought up 23 years ago still remains to be

answered: What effect will this knowledge have on patient care?

Furthermore, in this technological age, are we sophisticated enough to

turn some of these findings into models for treatment plans based on

individual personality preferences and styles? Anderson and Masur

(1983) reviewed "the major psychological approaches designed to allevi-

ate preprocedural concern and enhance recovery" (p. 1). They summarized

outcome studies on commonly used preparatory techniques. These tech-

niques included informative, psychotherapeutic, modeling, behavioral,

cognitive behavioral, and hypnotic methods. The next logical step in

the evolution of this type of treatment should include evaluating the

individual for personality type prior to selecting the intervention.

Egbert (1985) expressed dismay that this kind of psychological interven-

tion was not coming from the ranks of anesthesiologists, yet the psycho-

logical literature has few such studies (as noted above). What is miss-

ing are reports of ongoing programs, not just limited research studies.

The Independent Variables

The Myers-Briggs Type Indicator

The Myers-Briggs Type Indicator (MBTI) was developed by Isabel

Briggs Myers to test Jung's theory of psychological type. Details of

the theory and the validity of the instrument are noted in Chapters 1

and 3. Since 1975, the MBTI has been available to qualified users and

has been used extensively in education, management, counseling, and

religion. An extensive survey of the literature revealed no use of the

MBTI in the areas of medical or surgical health care.

Because there are not any studies reported in the literature on

type theory and pain response, this review will address behaviors that

are perceptual and cognitive motivational in nature. Gate Control

theory (Melzack & Dennis, 1978) states that cognitive motivational

factors play a role in the pain experience, interacting with other

activities "to provide perceptual information regarding the location,

magnitude and spatio-temporal properties of the noxious stimulus" (p.

12). The studies reviewed here do demonstrate that personality type may

be associated with perceptual, cognitive motivational behavior so it is

not unreasonable to assert that type may also be associated with other

behaviors such as pain response that have a perceptual and/or cognitive

motivational dimension. After a brief discussion of type distribution,

cognitive motivational and perceptual studies in the areas of memory,

perceptual tasks and styles, burnout, conflict handling, reading

behavior, and learning styles will be reviewed.

McCaulley, Macdaid, and Kainz (1985) reported on the distribution

of type in the Center for Application of Psychological Type data bank

from March 1978 to December 1982. They found this sample evenly divided

between extraverts and introverts, but when separated by gender, more

females were extraverted than introverted. On sensing and intuition,

they found sensing in the majority. On the thinking, feeling preference

they found another distinction by gender, with males more likely to be

thinking types and females more likely to be feeling types. The

judging-perception dimension has more judging than perceptive

individuals. These findings differ from an earlier survey by Myers

(1962) only in the extraversion-introversion dimension when Myers

reported that 75% of the population in the United States were

extraverted. McCaulley, Macdaid, and Kainz suggested that this

difference may be due to a bias toward introverted intuitives in the

CAPT data bank.

The literature contains several studies of type and memory.

Carskadon (1979) studied memory for names as well as other variables.

He found a significant difference (p < .001) between extraverts and

introverts on memory for names, with the extraverts having the higher

mean. The other behaviors that he studied at the same time were inter-

personal spacing, gestures, and amount of silence in conversation. He

found no significant differences in the number of gestures used by

students. He did, however, find differences in the other behaviors.

Introverted students differed significantly (p < .05) on interpersonal

space from extraverted students, with the introverts taking more. As

would be expected, introverted students also differed significantly

(p < .01) on amount of silence.

In another study on memory Dunn (1985) found no differences in

differential memory capacity (recall data) or differing logical

strategies (clustering data) between various MBTI types using a one-way

ANOVA. He does not report if he controlled for theoretical congruence

and suggests that previously reported lower IQ tests and lower academic

performance between types may be due to some "cognitive or motivational

ability other than pure memory" (p. 32).

Carlson has published a series of studies on Jungian typology that

deserve attention. In the first study she reported the use of basic

memory processes. Based on the theory, the investigators (Carlson &


Levy, 1973) hypothesized that "introverted thinking types should be more

effective in remembering interiorized neutral stimulus material" (p.

564). To test this they used the digit span subtest of the Wechsler

Adult Intelligence Scale and found that this type was significantly

superior (p < .002) on this task. The second part of this study

hypothesized that "extroverted feeling types should be more effective in

remembering novel, social, emotionally-taxed stimulus material" (p.

564). For this stimulus, they used 12 pictures from the Lightfoot

Facial Expression Series. Results indicated that extroverted feeling

types were significantly (p < .002) more accurate in recognition of

facial expressions. The authors pointed out that this study did not

suggest which of the dimensions, extraversion introversion, or thinking

feeling, controlled the major variance. Another problem existed because

of the differences in the memory tasks used. To address this problem,

Carlson conducted a second study of the same hypothesis using a uniform

memory task designed to contain both types of content. This task

required subjects to recall numbers and names. The results were the

same as in the first study, with the introverted thinking types more

effective in "using memorial processes with objective impersonal

material" (p. 567) and extroverted feeling types responding to the

"social implications of the stimulus material" (p. 567).

In a third study reported in the same paper (Carlson & Levy, 1973),

the investigators hypothesized that, based on Jung's theory, "the

importance of the perceptual functions (judging versus perceiving) and

the quality of one's perception (sensation versus intuition)" (p. 568)

would play a role in how we interpret another person's experience. An

"emotional recognition task" (p. 568) appropriate for use with black

students was developed following the general procedures used in

developing other facial expression instruments. As predicted, they

found "intuitive perceptive types significantly more accurate in

interpreting emotional expressions than were sensing judging types;

women were significantly more accurate than men" (p. 569).

In the last study reported in this paper the investigators examined

the relationship between typology and volunteer service. The hypothesis

was that extroverted intuitives would have an empathetic approach to

others and therefore be "over represented among social service

volunteers as compared to a matched group of nonvolunteers" (p. 571).

The results confirmed this hypothesis.

The authors believe that the above four studies, although limited

in scope and carried out with small samples, have important implications

for social science research in the area of behavioral mediators or


They suggest that complex, enduring organizations--which go
beyond familiar alternatives of "state" or "trait" conceptions
--must be considered in posing questions or generalizations
about relationships of personality and social behavior. They
point to the usefulness of Jungian type theory as a conceptual
framework capable of generating new insights into person-
situation relationships. (p. 573)

In another paper that Carlson called "Representations of the

Personal World" (1980), she again addressed memory but this time in a

field study as opposed to the previous laboratory study, and the results

supported previous research. The author expressed the belief that

Jungian type theory is underutilized and that these studies "clearly

demonstrate that Jungian type theory need not remain an isolated

theoretical system. Its implications are translatable into more

familiar concepts and methods of psychological inquiry and are equally

capable of interfacing with other theoretical formulations" (p. 809-


Ware, Yokomoto, and Paul (1984), in a study extending the research

on behavioral construct validation of the MBTI, tested 50 subjects using

two standard laboratory perceptual motor tasks, the mirror star tracing

apparatus and the stylus or finger maze. They found extroverts

"consistently performed faster and with fewer errors on the star trac-

ing, though not on the maze" (p. 27). One important objective of this

study was to determine if theoretically congruent subjects differed from

theoretically incongruent subjects, and they found a significant

difference in the two groups (p < .01). This suggests that type

differences may influence performance in selected perceptual motor

tasks, and, more specifically, that the extent of the behavior may be

related to theoretical congruence.

Holsworth (1985) in a study of perceptual style correlates of the

MBTI examined "the relationship between the Jungian perceiving function

as measured by the Myers-Briggs Type Indicator (MBTI) and the perceptual

style of field dependence/independence as measured by the Group Embedded

Figures Test (GEFT)" (p. 32). Field-independent individuals are

"capable of overcoming the embedding context of stimulus presentation in

order to examine elemental aspects of the field in a novel or creative

manner" (p. 32). Results of this study suggest that behavioral cor-

relates of perceptual style do exist. Using regression analysis,

Holsworth found that "the more intuitive and introverted an individual

was, the more likely he or she was to employ a field independent style"

(p. 34). The opposite effect of field dependence was related to


Another perceptual study by Ware, Wilson, and Yokomoto (1986)

involved time spent looking at selected photographs by Jungian personal-

ity types. Previous investigations of this behavior had focused on the

extraversion/introversion dimension, and these investigators thought

that the thinking/feeling dimension might be related to this behavior.

Their hypothesis was based on Jung's theory that "thinking types with

their preference for logic and analysis and a tendency to weigh the

facts may take longer than feeling types" (p. 59). They found this to

be true and also found that it may be moderated by the extraversion/

introversion dimension with extroverted thinkers looking longer than

introverted thinkers and introverted feelers looking longer than extra-

verted feelers. The authors point out that this has significance in


Garden (1985) investigated burnout behavior in relation to

personality type. She was most interested in the thinking/feeling

dimension since most of the previous studies had been done in the human

services which are largely comprised of feeling types. She studied

students in an MBA program and examined their behavior during burnout.

The measure of burnout was chronic energy depletion that was "not

renewed by the usual means of rest or sleep," (p. 5). The behaviors she

tested were distancing, hostility, lack of concern for others, and not

needing others. Results indicated that during burnout, feeling types

have a more "negative reaction to people, the more depleted of energy

they are" (p. 6) and thinking types "could be described as more positive

than negative, as their energy depletion becomes more severe" (p. 6).

She concludes that "negative reaction to people during burnout is not a

generalizable finding" (p. 7). She addresses the issue that these

findings are the opposite of what would be predicted based on type

theory and suggests that a "reversion" takes place which "reflects an

inability or unwillingness to use the conscious function upon which one

has come to rely" (p. 8). When she examined the sample on the sensing-

intuitive dimension, she got similar results. Sensing types showed

decreasing groundedness, and groundedness in reality is one of the

distinguishing features of the sensing-intuitive dimension. This study

clearly supports the concept that psychological type influences behavior

in different ways for different types.

In light of the "reversion" reported above, the reliability of the

indicator is pertinent. McCaulley in her chapter in Advances In

Psychological Assessment (1980) reviewed the reliability studies. In

addition, in the latest version of the MBTI Manual (Myers & McCaulley,

1985) the authors have included a chapter on reliability. In both of

these sources the authors concluded that

Test-retest reliabilites of the MBTI show consistency over
time. When subjects report a change in type, it is most
likely to occur in only one preference, and in scales where
the original preference was low. (p. 171)

Carlyn (1977) reported that in a review of studies of the

independence of the categories, the El, SN, and TF scales appeared to be

independent of each other. She reported,

The findings with both type category scores and continuous
scores indicate that the Myers-Briggs Type Indicator measures
three dimensions of personality that are relatively

independent of each other: extraversion-introversion,
sensation-intuition, and thinking-feeling. The instrument
also measures a fourth dimension of personality, judgment-
perception which appears to be related to at least one of the
other dimensions. (p. 463)

Carlyn's report of the stability of the indicator using type category

scores and continuous scores is similar to McCaulley's (1981, 1985)

finding of test-retest agreement significantly higher than would be

expected by chance. Further data on reliability are reported in Chapter


Another behavior that appears to be influenced by psychological

type is that of conflict handling. Kilmann and Thomas (1975) did a

laboratory study of conflict handling behavior with 86 male management

students. They report that feeling types were more accommodating, less

assertive, less willing to compete, and more willing to be cooperative

than thinking types. They did not find differences in behavior on the

sensing-intuitive dimension or the judging-perceiving preferences.

However, they found the strongest and the most consistent correlations

on the extraversion-introversion dimension, with extraverts being more

integrative, more assertive, and more cooperative than introverts in

conflict-handling behavior. Although this study did support the concept

that psychological type as described by Jung influences behavior, a

reminder is in order that the study was limited because the population

was all male business students, and these findings may not generalize to

other populations.

Hicks (1984), in a study of the posited dichotomy of the sensing

intuition scale of the MBTI, used book reading behavior of adults as an

external variable that was theoretically relevant. The SN scale was

chosen because "among the four MBTI scales, SN has been shown to be the

one that behaves most like a cognitive style measure" (p. 120). Results

indicated that the distribution of the SN scores was not bimodal, and

intuitives ranked books first significantly more than did sensing types

(p < .001). Hammer (1985) in another study of media preference and type

also examined book reading behavior of an adult population. He found no

"significant main effects or interactions involving any of the MBTI

scales on number of fiction books read, total number of books read or

hours of television watched per day" (p. 22). These results differed

from those reported above by Hicks (1984). However, Hammer pointed out

that "Hicks herself suggested that the difference between sensing and

intuitive subjects on book reading might be reduced if subjects were

sampled from settings with richer leisure opportunities compared to the

isolated rural setting where her data were collected" (p. 25). These

two studies suggest that the behavior of book reading may be related to

type given certain conditions. More research is needed to define those


A review of perceptual and cognitive motivational studies and type

theory should not end without Lawrence's (1984) review of research on

learning style and type. Lawrence explained the aspects of

psychological make up of learning styles:

a) Cognitive style in the sense of preferred or habitual
patterns of mental functioning: information processing,
formation of ideas and judgments.
b) Patterns of attitudes and interests that influence what a person
will attend to in a potential learning situation.
c) A disposition to seek out learning environments compatible with
one's cognitive style, attitudes and interests, and to avoid
environments that are not congenial.
d) Similarly, a disposition to use certain learning tools and avoid
others. (p. 2)

From this paradigm Lawrence presented studies that show

"correlations of the MBTI with other measures" (p. 2), "studies that

have used the MBTI to identify style" (p. 5), "studies attending to

Types" (p. 11), and finally a series of tables that summarize the

findings. Briefly, extraverts prefer group learning, discussion, and

hands-on activity, as opposed to introverts' preference for reading and

working alone. Sensing types prefer step-by-step instruction while

intuitives like to "find their own way in new material" (p. 12).

Thinking types like objective material while feeling types want personal

rapport. Judging types will "work in a steady orderly way" (p. 12),

while perceptive types "work in a flexible way following impulses" (p.

12). The author pointed out the need to design programs with type in

mind, even in the most casual instructional situation, to maximize

learning. One of the major problems in health care today is

noncompliance, and patients are "blamed" for this behavior. Perhaps

they were never taught what they had to do in a way that was meaningful

to them.

The Millon Behavioral Health Inventory

The Millon Behavioral Health Inventory (MBHI) was developed over a

4-year span of research as a "general purpose instrument of a

psychological nature designed for use in a wide range of medical

settings" (Millon, Green, & Meagher, 1979, pp. 529-537). In the belief

that mind-body interactions could affect the outcome of disease and

treatment, the authors did an extensive review of the literature in

search of an instrument designed to assess patients in a medical

setting. They found instruments such as the Minnesota Multiphasic

Personality Inventory (MMPI) and the Sixteen Personality Factor

Questionnaire being used in medical settings even though they were

developed for use in psychiatric settings and at best "are only

tangentially related to medical issues" (p. 532). Another instrument,

the Cornell Medical Index, is not considered appropriate for research

because "the developers of the instrument did not intend to calculate

score totals or scales," (p. 531) and it is "naive in construction and

has not been recommended as especially incisive or illuminating as a

medical-behavioral tool" (p. 531).

As their research continued, the authors found many other

instruments that might be appropriate except for the fact that they were

single focused and not multidimensional in scope. The MBHI was

developed to reflect personality styles; "these were derived as "normal"

variants of personality from a theory of personality pathology" (p.

534); psychosocial stressors "selected on the basis of their support in

research literature as significant and salient factors that contribute

to the precipitation or exacerbation of physical illness" (p. 534);

psychosomatic correlates "empirically derived by differentiating

patients with the same physical syndrome in terms of whether their

illness was or was not substantially complicated by social or emotional

factors" (p. 534); and prognostic indices to "identity future treatment

problems or difficulties that may arise in the course of the patient's

illness" (p. 534). (A brief description of these scales appears in

Chapter 3, and a detailed description can be found in Appendix A.)


A review of the literature on the MBHI has revealed no studies of

the relation between scores on this instrument and postoperative pain

response. However, a few are marginally related in that they deal with

perceptual cognitive-motivational behaviors.

Foster (1977) studied psychiatric patients for inclusive behavior.

He believed that the "rigidity of coping styles in a psychiatric

population tends to perpetuate extreme styles which are found in a

lesser degree in a normal population" (p. 227). He hypothesized that

subjects with active personality profiles would "be more cautious--

select fewer words" (p. 228) than those with passive personality

profiles, and this was substantiated (p < .02).

Sweet, Breuer, Hazlewood, Taye, & Pawl (1985) report a study of the

MBHI in a chronic pain clinic. Fifty-two patients were tested and

evaluated independently for treatment outcome. Although the

investigators found that "individual MBHI scales were able to classify

positive and negative outcomes with comparable accuracy" (p. 224), they

cautioned the use of this instrument with chronic pain patients until

further research is available. "While the MBHI seems to have potential

for predicting treatment responsivity with chronic pain patients, the

lack of specificity of the scales and the degree to which MBHI responses

are affected by the presence of denial of psychological problems are

problematic" (p. 224).

In another study of chronic pain patients, Levine and Meager (1983,

cited in Sweet, Bruer, Hazlewood, Taye, & Pawl, 1985) examined the

scales in relation to response to biofeedback training and found that

patients with elevations on the sociable and confident style scales did


well and those with elevations on future despair and somatic anxiety did

poorly. The pain treatment response scale (in which high scores

indicate that psychological factors may maintain the pain behaviors) was

not related to biofeedback response. However, in another study of 30

cancer patients (Rozensky, cited in Sweet et al. 1985), high scores on

this scale were related to biofeedback response.

The treatment of cancer with chemotherapy often results in nausea

and vomiting. Psychologists are interested in the anticipatory

nausea/vomiting experienced by patients after a few chemotherapy

treatments. Van Komen and Redd (1985) reported a study of 100 patients

receiving chemotherapy in two clinics in Illinois. The MBHI was

administered to 59 of the patients. They found that high scores on the

future despair, social alienation, and inhibited personality style

scales of the MBHI was associated with higher anticipated nausea in this

group of patients.

Another study of nonsurgical pain was reported by Richter, Obrecht,

Bradley, Young, and Anderson (1985). Twenty patients with noncardiac

chest pain and 20 patients with irritable bowel syndrome (IBS) were

compared to three control groups. The noncardiac chest pain patients

had a "syndrome characterized by exceeding high amplitude peristaltic

contractions in the distal esophagus" (p. 132). This motility disorder

has been called the "nutcracker esophagus (NC)" (p. 132). These two

groups were evaluated for psychological problems associated with their

diseases using the MBHI. "The mean scores of the IBS and the NC groups

were greater than the control groups on the scales for gastrointestinal

susceptibility (p < .0001), somatic anxiety (p < .001), and future

despair (p < .02)" (p. 134). In general, although the two gastro-

intestinal syndromes yielded similar results on the MBHI, the IBS

patients had far more generalized psychological problems than the NC

patients. For this reason the investigators concluded that different

treatment modalities would be appropriate.

As stated above, the literature contains few published studies of

the MBHI, and most of those are only marginally relevant to this study.

Million developed the test because he felt that instruments developed and

normed on psychiatric patients are not appropriate for medical or

surgical patients. Others do not agree with him. In a recent review of

the MBHI, Rustad (1985) stated, "There is no convincing evidence that

the Minnesota Multiphasic Personal Inventory is, per se, inappropriate

for medical patients. Available research indicates that medical illness

is unlikely to change scales more than a few raw score points" (p. 281).

In addition, Rustad suggested that because of "lack of normative and

case history data and interpretive aids, the dearth of published cross-

validation data, and the resultant problems in interpretation, it is

difficult at present to recommend the use of this inventory (the MBHI)

as a clinical instrument without serious reservations" (p. 281).

At least two other reviewers agree with Rustad, stating that lack

of cross-validation studies and overlapping of test items make it

difficult to evaluate potential utility (Allen, 1985; Lanyon, 1985).

Another complaint is the lack of theory in the manual. The eight basic

coping styles are purportedly based on Millon's theory of biosocial

development, yet there is no explanation of the theory available. All

three reviewers (Allen, 1985; Lanyon, 1985; Rustad, 1985) suggested that


until there is some "empirical evidence for the validity of the computer

narrative interpretation and the usefulness of the test in medical

settings" (Allen, p. 983), use of this instrument should be limited.

Richter et al. (1985), on the other hand, suggested, "It may be

worth while to employ the MBHI or similar psychometric instruments as

screening devices to obtain some estimate of which patients might be

likely to suffer psychological difficulties that may adversely affect

the course of their illness" (p. 137). One would have to conclude that,

at best, the MBHI has mixed reviews, and certainly further research is

needed before it is used for substantive judgments.

Health Locus of Control

The basic concept of locus of control comes from social learning

theory as defined by Rotter (1954). He believed that "behavior

potential is a function both of the expectancy that reinforcement will

follow the behavior, and the perceived value of the expected reinforce-

ment," (cited in Maddi 1980, p. 625). Coming from this belief is

Rotter's construct on internal versus external locus of control. This

construct concerns an expectancy that people either have control over

events in their lives or that they are subject to manipulation and

control by outside factors. On a personal level, those with internal

control "are more individualistic, assertive, interested in gaining

knowledge, and willing to rely upon their skill in risky situations than

are persons believing they are externally controlled" (p. 632). In

spite of the fact that personologists have been enthusiastic about this

construct, calling it "an intuitively and rationally compelling concrete

peripheral characteristic" (p. 633), considerable conflict persists

regarding its validity. Factor analytic studies of this construct

(Lindbloom & Faw, 1982) have yielded more factors than the theory

accounts for on the generalized scale. Wallston, Wallston, Kaplan, and

Maedes (1976) suggest that an explanation of these contradictory

findings may be found in the theory.

According to this theory, it is assumed that increasing an
individual's experience in a given situation will lead to the
development of specific expectancies. These expectancies
subsequently play a greater role in determining one's future
behavior in that situation than more generalized expectancies.
It stands to reason that research whose aim is the prediction
of behavior in specific situations could profit from the use
of more specific expectancy measures. (p. 580)

The authors believed that a health-related locus of control scale would

provide more sensitive predictions of the relationship between locus of

control and health behavior.

Richard Lau (1982) conducted a study "to explore possible

determinants of health locus of control beliefs" (p. 323). Using a

multidimensional health locus of control battery, he found that early

health habits concerning self-care, such as brushing teeth, getting

exercise, getting enough sleep, proper nutrition, and other health

habits regarding utilization of the medical profession were positively

correlated with internal health locus of control. Recent illness was

not related to either internal or external control, suggesting that

health locus of control could be a stable trait. Another factor related

to internality is socio-economic status, with higher SES subjects being

positively correlated with internality. A surprising result of his

survey was that having a physician in the family was not a significant

factor in determining locus of control.

Williams and Stout (1985) studied assertiveness, locus of control,

and health problems. They found that "highly assertive participants

were significantly more internally controlled than were participants low

in assertiveness (p <. 05)" (p. 171). In addition, they found that

these highly assertive subjects also had significantly fewer health

problems (p < .05) than low assertive people.

Strickland (1978) did an extensive review of the research on

internal-external (I-E) locus of control expectancy and health attitudes

and behaviors. In the area of health knowledge and precautionary

measures she reported that,

With some exception, the bulk of the reported research on I-E
and the precautionary health practices lends credence to the
expected theoretical assumptions that individuals who hold
internal as opposed to external expectancies are more likely
to assume responsibility for their health. (p. 1194)

For those people who were already sick, internals were more likely to

comply with diet restrictions and keep appointments. Among the pre-

surgical patients internals have less anxiety. She cited another review

that stated "except in two cases in which internality was linked with

high anxiety, externality was always associated with undesirable

physical characteristics such as higher temperature and higher

sedimentation rates" (p. 1197). Other evidence of the relation between

the I-E construct and physiological adaptive responses can be found in

the biofeedback literature. "Results of several studies do show

internals to be generally superior to externals in responding to

biofeedback paradigms" (p. 1198).

On the other hand, Johnson and Thorn (1985) tested 48 subjects on

two perceptual tasks known to elicit changes in heart rate. The changes

did occur, but they were not related to locus of control. In the area

of psychological health Strickland reports that internals "are

significantly more likely to report themselves as content with their

life situations than externals" (p. 1200). Participants in a fitness

program tested by O'Connell and Price (1982) were also more likely to be


A study on locus of control and response to dental surgery

(Auerbach, Kendall, Cutler, & Levitt, 1976) found that internal subjects

who were given specific information about the surgery responded better

than internals given general information. Conversely, external subjects

responded more favorably to general information. Clum, Scott, and

Burnside (1979) studied patients having elective cholycystectomies.

They reported that the amount of information internal patients had about

the surgery was related to the number of analgesics taken and their

present pain index with the greater amount of information resulting in

an increase in these outcome measures. Externals, however, only had an

increase in the present pain index with increased information. Another

study on cholycystectomy patients (Wise, Hall, & Wong, 1978) found

externals were more depressed but used no more medication than


As stated above, the construct of locus of control is still under

investigation. If the construct is valid, internals are probably better

prepared to cope with matters pertaining to their health.

The Subjects

Subjects in this study were a mixed sample of gastric bypass and

hand surgery subjects. The psychological literature contained no

references to hand surgical patients in particular, only references to

surgical patients in general, and these are discussed elsewhere.

Benedetti, Bonica, and Bellacci (1984) reviewed the literature on post-

operative pain and published a chart comparing incidence, intensity, and

duration of pain for various types of operations. They admitted that

these are "rough estimates" (p. 374). However, they do provide a way of

comparing different surgeries. For an intraabdominal gastrectomy, a

procedure similar to the gastric bypass, the investigators say that 20-

30% of the patients have moderate steady wound pain, 50-75% have severe

steady wound pain, 25-35% have moderate pain on movement, and 65-75%

have severe pain on movement; the duration of the moderate to severe

pain is 3 days with a range of 2-6 days. For the hand surgery patients

they report that 15-20% of them have moderate steady wound pain and 65-

75% have severe steady wound pain; 40-50% have moderate pain on movement

and 50-60% have severe pain on movement; the duration of moderate to

severe pain is 3 days with a range of 2-6 days. Keeping in mind that

their review covered a number of published studies, done over several

years, by different surgeons, with different anesthesiologists and in

different hospitals, and not controlling for socioeconomic or

psychological variables, there may be little difference in incidence,

intensity, and duration of postoperative pain between patients who have

upper intraabdominal surgery and patients who have hand surgery.


The gastric bypass procedure is a surgical intervention for the

treatment of morbid obesity. Morbid obesity is defined by Charles

(1983) as "weight 100 pounds greater than, 100% over, or at least 200%

of, ideal body weight" (p. 122).

Several investigators have sought to answer the question of whether

the morbidly obese have a greater incidence of psychopathology than the

rest of the population. In a recent issue of Integrative Psychiatry,

eight psychiatrists and psychologists who treat and evaluate obesity and

other eating disorders reviewed the lead article by Charles (1983).

Below is a summary of Charles' article and the commentary of her peers.

In her review of the psychological status of the morbidly obese, she

made the following statement:

Because morbidly obese patients appear so "extreme" in terms
of body weight, the common assumption is that major psycho-
pathology plays some role in its development and/or
maintenance. Studies to date are conflicting and have not
established if such patients have a higher degree of psycho-
pathology than obese persons or the general population. A
contributing factor to the apparent discrepancy among study
findings may be the fact that there are subgroups of this
population who are more available for study and who are more
highly vulnerable to psychiatric disability. (p. 122)

The distinction between morbid obesity and other obesity was not

made until the late 1950s when surgical procedures were developed to aid

in weight loss. Psychologists and psychiatrists had decided that super-

obesity was an "extreme defense mechanism" (p. 123), and one study

reported that "97% of their 31 subjects had a psychiatric diagnosis"

(cited in Charles, 1983, p. 123). Since those early studies using

psychiatric diagnoses as a way of describing the problem, other studies

that have been done using this criterion producing mixed results.

Charles felt that since certain subgroups are more vulnerable to

psychiatric disability, some subsets of morbidly obese patients may

exist who have a greater degree of psychiatric disorders. She called

for "studies of nonsurgical morbidly obese patients not currently

registered in medical or psychiatric clinics and presumably functioning

well in society" (p. 124). She estimated that there are 600,000

morbidly obese people in the United States.

Blackburn (1983) makes the statement that "morbid obesity is a

serious mental disease that is generally poorly treated and currently

exists in epidemic proportions" (p. 126). He expressed the belief that

it is genetic in origin and that the most successful treatment is a

combination of exercise, gastric bypass, cognitive restructuring, educa-

tional training, and self-help. Despite his calling it a "very serious

mental disease," he added that "it would be a mistake to assume that

overweight people have psychological dysfunction in greater numbers than

the general population" (p. 127).

Hagan and Johnson's (1983) commentary on Charles' article cited

evidence that the morbidly obese and the moderately obese do not differ

on MMPI profiles. They concluded that the conflict of findings in the

literature supports Charles' hypothesis that subgroups among the

morbidly obese may exist.

Wise (1983) reported on 35 morbidly obese Fairfax Hospital patients

who underwent nonsurgical treatment using the modified protein fast.

He found that the group of patients exhibited "preoccupation with food

and emotional distress but not the emergence of major mental disorders"


(p. 128). He suggested other areas that should be investigated are the

availability of the surgery and "the role of obesity within the person's

social system" (p. 128).

Castelnuovo-Tedesco (1983) agreed with Charles that more research

on morbid obesity is needed and pointed out that most of the studies are

on white women who have sought bypass operations. He calls for more

studies involving men and minorities. Regarding the research on the

possibility of psychopathology, he wrote that

To the surprise of many, extreme psychopathology (psychosis,
crippling neurosis) has turned out to be rare among the super-
obese, who in fact often show substantial, at times
remarkable, personal and social effectiveness. (p. 129)

Schowalter (1983) expressed the belief that obesity is an eating

disorder like anorexia. He suggested that "people with eating disorders

appear at risk for depression, whether as cause or effect" (p. 130).

Pointing out that anorexia patients are more depressed and suicidal when

they are gaining weight, he suggested that perhaps the opposite is true

of the obese patient and that eating relieves depression in this group.

He did point out that he tended to "see only obese individuals troubled

enough to seek help" (p. 130).

Kral (1983), in a discussion of the limitations of epidemiologic

studies of the morbidly obese, agreed with the assumptions of Charles

that subgroups exist. Furthermore, he stated that because of inclusion

and exclusion processes in selecting subjects there are "no truly

randomized population studies from which morbidly obese patients have

been selected" (p. 131). The inclusion processes can include "criteria

related to weight, duration of overweight, age, treatment history,

medical complications, alcohol or drug abuse, informed consent, and

cooperation" (p. 131). Exclusion processes can be active or passive.

Patients can be actively excluded because "they do not meet the

inclusion criteria or passively because they are not referred or recom-

mended for such surgery, or because surgery is unavailable or because

they are unwilling to accept surgery out of fear or misinformation" (p.

131). Because of these and other reasons, he stated that we need "well

designed epidemiological studies to characterize the morbidly obese" (p.


Klykylo (1983) expressed doubts that neurotic conflicts necessarily

are involved in obesity. "The psychic utility of a condition or

behavior to an individual in no way establishes causality" (p. 133). He

added that because of its relation to nutrition, obesity could be a very

"utilitarian defense" (p. 133). Speaking of the possibility of

anticedents to adult obesity, he suggested comprehensive studies of

childhood obesity with the possibility of intervention and prevention.

Stunkard (1983) referred to 11 studies that "failed to find

subgroups of morbidly obese persons" (p. 126). He pointed out that the

reason psychological assessments are done at all is to determine

suitability for surgical intervention and that this determination "is

not likely to be greatly affected by the knowledge that in general,

morbidly obese persons have more, or less, psychopathology than others"

(p. 126).

Noppa and Hallstrom (1981) studied body weight changes and excess

weight over a 6-year period in 1,302 middle-aged Swedish women. They

found weight gain and excess weight more common among single women. The

Eysenck Personality Inventory and the Cesarec-Marke Personality Schedule

indicated that the weight change group had significantly higher order

scores than the excess weight group. Aggressive nonconformance was

lower in the weight change group (p < .05). No other significant

differences were found. In the mental health variables they found that

groups that gained more than 5 kilograms had higher psychopathology

ratings than groups that gained less. This was measured by disability

degree (p < .05), depth of depression (p < .05), and the Hamilton Rating

Scale (p < .31). The authors concluded that "in the long run, women

with depressive symptoms seem to run an increased risk of developing

obesity" (p. 86), and "the personality variables studied seem to be of

only minor importance for the development of obesity in adult life" (p.


Webb, Phares, Abram, Meixel, Scott, and Gerdes (1976) report on the

evaluation of 70 patients for "psychological features" prior to bypass

surgery (p. 83). The evaluation consisted of a psychiatric interview, a

short form of the WAIS, the MMPI, Rorshach, a sentence completion blank,

and the Tennessee Self-Concept Scale. Eight were considered unfavorable

for surgery. Only one of these was psychotic; the other seven had

severe personality or psychoneurotic disorders. The investigators

diagnosed 56 of the surgical candidates as having mild personality

disorders, 3 with psychoneurotic disorders, none as being psychotics,

and 6 as being normal. The authors concluded that on a "group basis,

their personality problems were within normal limits" (p. 85), "that

severe psychological problems are rare, but that mild emotional

immaturity is frequent, indeed modal" (p. 85).

Hutzler, Keen, Molinari, and Carey (1981), in an ongoing study to

"describe the type of person who seeks this radical measure (bypass

surgery)" (p. 461), reported that "they consider themselves

unattractive, manifest low self-esteem, and almost half of them have

significant psychopathology" (p. 461). In a later investigation Rosen

and Aniskiewicz (1983) found that bypass patients had significantly

"higher levels of psychosocial stressors, and lower levels of adaptive

functioning" (p. 53). They also had a significantly higher frequency of

past suicide attempts and higher levels of depression. Duckro, Leavett,

Beal, and Chang (1983) in a study of 199 morbidly obese patients,

identified three profile groups using the MMPI. Profile 1 had adequate

psychological resources and a positive self-image. Profile 2 were

"unhappy and tense with limited social skills and self-confidence" (p.

481), and Profile 3 were angry and hostile with a "history of problems

in close relationships" (p. 481).

In a study of bypass patients and pain Rand, Kuldau, and Yost

(1985) found that the bypass patients required significantly less

medication for pain postoperatively than a group of cholecystectomy

patients. The authors did not know the reason for this observation but

suggested that "if both eating and pain sensitivity are at least in part

under the control of endogenous opiates, then morbidly obese adults

should experience less postsurgical pain than normal weight adults" (p.


The implication in the above brief review of the literature on

morbid obesity is that the incidence of psychopathology in this

population is low and may not differ from that in the general population

or that among the morbidly obese who do not seek surgical intervention.

To date, no research either empirical or ethnographic has uncovered a

profile of patients psychologically at risk for gastric bypass

procedures. Certainly, physical risk of this condition may far outweigh

any psychological risk.

The Dependent Variable

The measurement of pain has intrigued clinicians and
researchers for centuries, but satisfactory quantification has
as yet not been entirely achieved. Major stumbling blocks are
the lack both of a generally accepted definition of pain and
of knowledge concerning the nature of the adequate stimulus
for pain. (Wolff, 1978)

In spite of the above problems, clinicians and researchers continue

to attempt to measure pain because it has such an important impact on

the patient, the family, and the general outcome of treatment.

Approaches to the measurement of experimental pain are psychological,

involving the measurement of different sensory modalities and more

recently a technique "for separating the purely sensory characteristics

of the pain response from the individual's attitudinal and judgmental

components of the pain response" (Wolff, p. 143). Clinical pain, on the

other hand, is measured by the patient's response, since the exact

stimulus is rarely known. The patient's response includes behaviors

such as blood pressure, pulse rate, galvanic skin response, body

posture, verbal reports, medication usage, and direct scaling

techniques. The McGill Pain Questionnaire (Melzack, 1975) is a direct

scaling technique. In the review of the literature on this instrument,

none of the studies relate to psychological type, but many relate to

other components of personality.

Melzack (1983), who proposed a motivational-affective dimension of

pain in his gate control theory reviewed above (Melzack & Dennis, 1980),

described the experience as follows:

Pain has a unique, distinctly unpleasant, affective quality
that differentiates it from sensory experiences such as sight,
hearing, and touch. It becomes overwhelming, demands
immediate attention, and disrupts ongoing behavior and
thought. It motivates or drives the organism into activity
aimed at stopping the pain as quickly as possible. To
consider only the sensory features of pain and ignore its
motivational and affective properties is to look at only part
of the problem, and not even the most important part at that.
(p. 3)

From this perspective he developed the McGill Pain Questionnaire to

measure the sensory, affective, and evaluative dimensions of pain, the

intensity of each dimension and the "patient's evaluation of the overall

intensity of the pain" (p. 4).

Gracely (1983) proposed five properties of an ideal pain measure.

They include (a) freedom from bias that would lead to overestimate or

underestimate the pain, (b) the provision of immediate feedback to the

patient, (c) separation of the sensory aspects from the affective and

evaluative aspects, (d) utility for measurement of clinical and/or

experimental pain, and (e) absolute measure to determine between- and

within-group changes. Gracely expressed the belief that the McGill Pain

Questionnaire has all of these properties.

In a study to determine the validity of using the McGill Pain

Questionnaire for assessing postoperative pain, Taenzer (1983) reported

"results indicate that the McGill Pain Questionnaire and the visual

analogue scale are valid and appropriate indices for assessing

postoperative pain. Both appear to reflect the clinical course of

postoperative pain and reflect the patient's affective state" (p. 117).

Significant correlations were found between pain scores, expected

anxiety, and the Beck Depression Inventory.

Burckhardt (1984) and Lichtenberg, Swensen, and Skehan (1986) used

the McGill Pain Questionnaire to study arthritis patients. Burckhardt

found that arthritis patients used similar sets of words to describe

sensory aspects but that most of the variance was accounted for by the

affective dimension. Lichtenberg, Swensen, and Skehan found "high pain

scores associated with abnormal concerns over bodily functions and vague

somatic complaints" (p. 334). In another study Kremer, Atkinson, and

Kremer (1983) found affective descriptors of the McGill Pain

Questionnaire associated with psychiatric disturbance in chronic pain

patients accounting for 44% of the variance while the sensory dimension

accounted for only 2% of the variance.

Parker, Doerfler, Tatten, and Hewett (1983) investigated the

relationship among the MMPI, the Beck Depression Inventory, and the

McGill Pain Questionnaire. The subjects were 30 male VA patients with

pain of longer than 3 months' duration. The investigators found that

depression was not related to any of the scales, and personality traits

were not related to the sensory or evaluative scales. They did find a

positive correlation between elevated Pt (psychasthenia) scale of the

MMPI and the affective dimension of the McGill suggesting that "pain

reports sometime function as outlets for psychologically based distress"

(p. 24).

In other studies Bradley (1983) and McCreary (1983) reported

relationships between the Neurotic Triad scales (depression,

hypochondria, and hysteria) of the MMPI and the affective dimension of

the McGill Pain Questionnaire.

Diller (1980) wrote that because of the variety of specific pain

terms, some type of cognitive sorting must take place when describing

the experience. The terms we use for pain may function on more than one

level so Diller finds the McGill Pain Questionnaire useful in

distinguishing the levels. "In this way it may become possible to

connect more certainly the tertiary and quaternary accounts of pain and

to associate linguistic descriptions with quantitative clinical

measurements" (p. 10).

Gaston-Johansson (1984), in a study to determine if the concepts

pain, ache, and hurt differ from each other in intensity, gave the

McGill Pain Questionnaire and a visual analogue scale (VAS) to 41

registered nurses and 12 chronic pain patients. She did a pairwise

comparison of pain versus ache and ache versus hurt using the visual

analogue scale, the number of words chosen scale, and the pain rating

index scale of the McGill Pain Questionnaire. The investigator found

significant differences between the words on all three scales for the

nurses' rating. The patients chose fewer words to rate intensity than

the nurses chose. She recommended using the word hurt on the lower end

of a scale and pain on the higher end, concluding that her findings

confirm a difference in intensity between the words.

A conclusion from the above studies is that the McGill Pain

Questionnaire is an appropriate instrument for measuring both acute and

chronic pain. Evidence exists that this instrument may also


discriminate between different diagnoses. The variety of terms and the

format discourage set response bias, and the rating of the word

intensities appears valid.

In this study the various scales of the McGill Pain Questionnaire

were the dependent variable. The Myers-Briggs Type Indicator and the

Million Behavioral Health Inventory were used to assess the personality

types and coping styles.


The basic research questions of this study were as follows: Is

personality type associated with a particular type of pain response?

That is, is type associated with sensory, affective, or evaluative

responses? Additionally, is coping style associated with pain response?

If so, in what direction?

Ten local surgeons were contacted by mail (see Appendix B for the

letter) and asked to assist in this study by allowing the investigator

to contact their patients. Five replied enthusiastically and were

willing to participate. However, because of their busy schedules, their

office staffs would have to become involved and actually make the

initial patient contact regarding possible participation. Because of

insurance regulations, surgeons do not schedule operations until

approval is received from the insurance companies (unless the operation

is an emergency). Therefore, patients initially visit a surgeon

primarily for consultation; if the decision to operate is made, the

office staff files the necessary papers with the insurance company, and

upon receiving the reply, schedules the surgery. After the surgery was

scheduled, the patients were contacted about my study. As a result of

these complications, the sample was drawn from the patient populations

of only two surgeons, one a general surgeon who specializes in gastric

bypass procedures and a hand surgeon who owns his own hospital. In each

case the data collection procedure differed slightly. For the general

surgeon, once they scheduled the surgery, I mailed to the patients a

packet containing all the research instruments, the consent form (see

Appendix C), and a letter of explanation with a stamped self-addressed

envelope for return. A member of the office staff kept a list of

patients who had received the packets, the date of the surgery, the

hospital, and the type of surgery. I visited the patients on the third

postoperative day (approximately 86 hours after surgery) to assess their

pain, using the McGill Pain Index.

Data from the hand surgery patients were collected in a slightly

different manner. The surgeon has two offices, one in Gainesville,

Florida, a university community classified as a standard metropolitan

statistical area, and the other 28 miles away in the small rural farming

and forestry community of Lake Butler. I divided my time between the

two offices, seeing patients in his conference room, explaining the

study, and asking them to participate. Because many of the patients had

accidental injuries to their hands, their surgery was done with

deliberate speed. When possible, these patients were seen before

their operation, or at least in the same day. Those who agreed to

participate and completed their questionnaires returned them in a few


Over an 8-month period 167 packets of research materials were

distributed. Of these, 103 were mailed from the general surgeon's

office and 40 were returned, a 39% return rate. Two of the 40 were

dropped because of incomplete data. Thirty-two of the remaining 38

subjects were gastric bypass patients. The remaining six were dropped

from the sample to have a more homogeneous group. The same physician

did all of the gastric bypass procedures. Of the 64 packets given to

the hand surgery patients, 25 were returned representing a 39% return,

and 3 were dropped for incomplete data. The 22 remaining subjects

included 12 patients who completed the McGill Questionnaire within 4

days of surgery, and 11 who were not recently postoperative but who were

being treated at the hand rehabilitation clinic after their surgery for

continued pain.


The 55 volunteers who had either a gastric bypass procedure or hand

surgery were divided into three groups. Group I consisted of the 32

morbidly obese patients who had gastric bypass. Group II comprised the

12 patients having hand surgery and completing the McGill within 4 days.

Group III consisted of 11 patients not recently postoperative but having

hand rehabilitation treatment for continued pain. The mean age of the

55 patients was 40.5 years, with a range of 17-82. The sample was made

up of 41 females and 14 males.


The instruments used in this study were the Myers-Briggs Type

Indicator (MBTI) to assess personality type, the Millon Behavioral

Health Inventory (MBHI) to control for psychogenic attitudes and assess

coping styles, the Health History Questionnaire (HHQ) to assess the

number of symptoms, the Wallston Health Locus of Control Scale to


control for locus of control, and the McGill Pain Index (MPI) to assess

perceptive response to pain. A description of the instruments follows.

The Myers-Briggs Type Indicator

This test measures personality constructs described by Jung. It

consists of four basic scales, each with two bipolar dimensions that,

when combined, result in 16 different categories of types. The theory

states that "the basic differences concern the way people prefer to use

their minds" (Myers, 1980, p.1). All of the functions are available to

each individual, but over time and with experience, each person develops

a preference. The following characteristics are measured by the four


1. Introversion (I), Extroversion (E): a measure of whether a

person prefers the inner world of ideas or the outer world of

people and things. Myers (1980) wrote that "when

circumstances permit, the introvert concentrates perception

and judgment upon ideas, while the extrovert likes to focus

them on the outside environment" (p. 7).

2. Intuition (N), Sensing (S): These are two kinds of

perception. Intuitives will tend to see the possibilities of a

situation and sensing types will notice all the immediate


3. Thinking (T), Feeling (F): These are two types of judgment.

Thinking types prefer to judge a situation by examining data

objectively. Feeling types will make decisions based on

personal values and emotion.

4. Judgment (J), Perception (P): This category describes the way

people prefer to deal with the world around themselves.

Judging types prefer to use thinking or feeling, and

perceptive types prefer to use intuition or sensing.

The MBTI produces two types of scores. The main scores are the

four preference scores. Preference scores are made up of a letter

showing the direction of a preference and a number showing consistency

of a preference (such as E 19, N 33). The four letters for the four

preferences combine to create 16 preference types, for example, INTP,

ESTJ, ISFJ, and so on. Although type theory assumes dichotomies, Myers

used a linear transformation of preference scores called continuous

scores for correlational analysis. Continuous scores are computer

generated by setting the midpoint at 100. If the letter portion of the

preference score is E, S, T, or J, the numerical portion is subtracted

from 100; if the letter portion is I, N, F, or P, the numerical portion

is added to 100. Thus, a preference score of E 21 becomes 79 and a

preference score of I 21 becomes 121.

The psychometric properties of the MBTI have been reviewed exten-

sively and suggest that the instrument is appropriate for both applied

and research usage. Based on empirical evidence that while the E-I,

S-N, and T-F dimensions are independent, while the J-P and S-N functions

are substantially related (Carlyn, 1977; Coan, 1978). Both test-retest

and internal consistency reliability estimates of the MBTI tend to be in

the .75 to .85 range (Carskadon, 1977; Myers, 1962). The consistently

lowest reliability estimate is typically found on the T-F function

(Myers, 1962), and, in general, the reliabilities of the continuous type


scores tend to be higher than those of the categorical type classifica-

tion (Carlyn, 1977).

Idiosyncratic reliability on the four scales has been determined by

the use of a "logically split-half procedure." Results of the adult

sample are reported in Table 3-1.

These split-half reliabilities were derived from the "product-

moment correlation between continuous scores for the X half on the Y

half of each index, and thus take no account of the type dichotomies

based on the scores" (Myers, 1960). (Phi correlation was not used

because the type categories are an end product, and the input data of

the indicator are not categorical.)

Table 3-1

Split-half Reliabilities of the Four Scales of the Myers-Briggs
Type Indicator from the CAPT Data Bank

n E-I S-N T-F J-P

Males 23,240 .82 .87 .84 .88

Females 32,731 .84 .86 .80 .87

(Myers & McCaulley, 1985, p. 166)

The construct validity of the MBTI has received the usual scrutiny

in the literature. Initially some authors claimed the instruments did

not measure the Jungian psychological typology (Mendelsohn, 1965;

Stricker & Ross, 1964). More recent reviewers claim that the instrument

is indeed an adequate representation of Jung's theoretical constructs

(Carlyn, 1977; Carskadon & Knudson, 1978; Coan, 1978; Steele & Kelly,

1976). In a comprehensive technical review of the MBTI Carlyn (1977)

reported that the instrument exhibited moderate predictive validity in

forecasting college major and academic achievement. In addition, the

MBTI was found to be significantly related to the Gray-Wheelwright

questionnaire (Gray & Wheelwright, 1946), an instrument developed by

Jungian analysts to measure the same properties as the MBTI. In

summary, the MBTI appears to be an acceptable empirical indicator of

psychological type differences among late adolescents and adults.

The Millon Behavioral Health Inventory

The Millon Behavioral Health Inventory was used in this study to

measure personality coping styles. According to Sweet et al. (1985),

this instrument is particularly sensitive to psychopathology in medical

populations; therefore, it was used instead of the Minnesota Multiphasic

Personality Inventory because of its suitability for this study and its

brevity. The instrument was developed specifically for use with

physically ill patients with medical-behavioral decision-making issues

required. The normative population of the MBHI consisted of several

groups of nonclinical subjects (n = 452) and numerous samples of medical

patients (n = 2,113) involved in diagnosis, treatment, or follow-up.

The MBHI contains 150 items that divide and overlap into eight

scales to measure basic coping styles, six scales to measure psychogenic

attitudes, and three scales to measure prognostic indices. The 20

scales and items are geared to an eighth-grade reading level.

Potentially objectionable statements were screened. A brief description

of each scale can be found in Table 3-2, and comprehensive descriptions

of the scales are found in Appendix A.

The author of the MBHI believes that validation is an on-going

process that should take place in phases of test construction rather

than assessing the accuracy of an instrument after its completion. The

validation process has three separate procedures: theoretical-

substantive, internal-structural, and external-criterion. A brief

description of these procedures and results follows.

Theoretical-substantive validation stage: The MBHI is derived from

Million's theory of personality. This stage examines the degree to

which the test items represent the theory. It consisted of con-

structing an item pool (1000 items), then reducing the list, and

finally asking 10 health professionals familiar with the Millon

personality theory to independently sort the items into Coping

Style and Psychogenic Attitudes categories. In order for an item

to be included, 7 of the 10 professionals had to have selected it.

Internal structure validation stage; This stage measured the

within-scale homogeneity of the instrument. The author believes

that coping style and psychogenic attitude are not discrete

psychological dimensions and "comprise complex characteristics,

sharing many traits as well as distinctive features" (Millon et

al., 1982, p. 24). He stated that factoriall purity is neither

clinically feasible, nor even theoretically preferred" (Millon et

al., 1982, p. 24) and adapted procedures to enhance the high item-

scale homogeneity.

Table 3-2

MBHI Scale Descriptions


Basic Coping Styles:

Characteristic Behaviors of High Scorers

1. Introversive Styles emotionally flat, lacking in energy
(32 items)

2. Inhibited Style shy, easily hurt, keep their problems to
(43 items) themselves

3. Cooperative Style do not take initiative, but follow advice
(33 items) closely

4. Sociable Style outgoing, talkative, fickle, not too dependable
(40 items)

5. Confident Style calm and confident, usually follow treatment
(33 items) plans may expect special treatment

6. Forceful Style domineering, tough minded, may not follow
(33 items) treatment plans

7. Respectful Style responsible, conforming and cooperative, hold
(42 items) feelings inside

8. Sensitive Style unpredictable and moody, erratic in treatment
(48 items) plans

Psychogenic Attitude Scales:

A) Chronic Tension disposed to suffer various psychosomatic and
(29 items) physical ills, constantly on the go, have
trouble relaxing

B) Recent Stress susceptible to serious illness; higher
(20 items) incidence of poor physical and psychological

C) Premorbid Pessimism
(40 items)

view the world in a negative manner and tend to
intensify their discomfort with real physical
and psychological difficulties

Table 3-2. (Continued)


Characteristic Behaviors of High Scorers

Psychogenic Attitude Scales (Continued):

D) Future Despair do not look forward to a productive future life
(38 items) and view medical difficulties as potentially
life threatening

E) Social Alienation poor adjustment to hospitalization and low
(33 items) levels of family and social support

F) Somatic Anxiety hypochondriacal and susceptible to various
(34 items) minor illnesses; abnormal amount of fear
concerning bodily functions

Psychosomatic Correlates Scales:

MN) Allergic emotional factors are significant precipitants
Inclination of disease processes
(34 items)

NN) Gastrointestinal react to psychological stress with increase of
Susceptibility symptomatology
(27 items)

00) Cardiovascular increase in complaint symptomatology under
Tendency conditions of psychic tension
(38 items)

Prognostic Indices Scales:

PP) Pain Treatment psychological factors may maintain pain
Responsivsity behaviors
(42 items)

QQ) Life Threat typical among patients with comparable
Reactivity illnesses
(42 items)

RR) Emotional severe disorientation, depression or frank
Vulnerability psychotic episodes
(12 items)

(Adapted from the test manual of the Millon Behavioral Health Inventory,

For development of the Coping Style Scale, Millon reduced the 1,000

items to 289. This version was administered to 2,500 subjects from

a variety of settings. Point biserial correlations were calculated

between each item and each personality scale. Only items that had

a high correlation with the scale to which they were originally

assigned were kept. Items with a correlation of <.30 were

eliminated. The mean biserial correlation for all items for all

personality scales was .47. This procedure reduced the Coping

Style inventory to 64 items.

The Psychogenic Attitude scales were developed on theoretical

substantive grounds. Thirty-five to 60 new items, based on

previous research into the characteristics being measured, were

developed for each of the six scales. These items were then rated

by clinicians with experience in assessing the role of psychologi-

cal influences upon physical illness. Only items selected by more

than 75% of the raters were retained.

External Criterion Stage: This step consisted of empirically

verified association of test items with a significant and relevant

criterion measure. In this case, investigators administered

preliminary items to two groups. The criterion group exhibited the

trait with which the item was to be associated. The second or

control group did not. Items that statistically differentiated the

criterion group from the comparison group were judged "externally

valid" (Millon et al., 1982, p. 24). Health professionals who knew

the patients selected the criterion group patients. In addition to

the above procedure, investigators subjected each of the empirical

scales developed for the MBHI to at least one cross-validated study

(Millon et al., 1982, p.25).

Reliability of the MBHI was assessed with both test-retest and KR-

20 procedures. Mean time elapsed between test and retest was 4.5

months. Table 3-3, from the test manual, gives the coefficients for

both procedures. The coping style scales have a mean reliability of .82

and the psychogenic attitude scale has a mean of .85.

The Health History Questionnaire

One page of this survey is devoted to basic demographic data,

health history, family history, and medication usage. The remainder

consists of 135 questions covering various common health problems

typically reviewed in a routine physical examination. Mitler

Communications Inc. of Norwalk, Connecticut, developed this instrument.

Statistical tests of reliability and validity would not be appropriate

for this instrument.

The Health Locus of Control Scale

Wallston, Wallston, Kaplan, and Maides (1976) developed this

instrument "to provide more sensitive predictors of the relationship

between internality and health behaviors" (Wallston et. al., 1976, p.

581). Proponents of the locus of control construct believe that life

experience leads to the development of expectancies that will influence

behavior. The Rotter Locus of Control Scale was not appropriate for

Table 3-3

Estimate of Reliability for MBHI Scales

Scale Test-retest KR-20

1. Introversive .79 .72
2. Inhibited .84 .84
3. Cooperative .81 .68
4. Sociable .83 .82
Coping 5. Confident .86 .66
Style 6. Forceful .77 .72
7. Respectful .78 .74
8. Sensitive .88 .86

a. Chronic tension .90 .77
b. Recent stress .87 .74
c. Premorbid pessimism .85 .90
Psychogenic d. Future despair .78 .86
Attitude e. Social alienation .85 .84
f. Somatic anxiety .79 .86

MN Allergic inclination .83 .81
Psychosomatic NN Gastrointestinal susceptibility .81 .83
Inclination 00 Cardiovascular tendency .79 .85

PP Pain treatment responsivity .82 .86
Prognostic QQ Life threat reactivity .76 .83
Index RR Emotional vulnerability .59 .82

(Millon, Green & Meagher, 1982)

Copyright 1982, National Computer Systems Inc. Adapted from the
Million Behavioral Health Inventory Manual by permission.

measuring expectancies that might predict health behavior so a more

idiosyncratic scale was necessary. In this study I used the Wallston

Scale to control for locus of control.

The scale consists of 11 items chosen from a 34-item pool following

appropriate statistical protocols. Alpha reliability of the 11-item

scale is .72. In developing the scale, the authors controlled social

desirability using the Marlow-Crowne Social Desirability Scale. The

correlation was -.01. Test-retest reliability on the Wallston Health

Locus of Control Scale was .91.

"Concurrent validity of the Health Locus of Control Scale (HLC) was

evidenced by a .33 correlation (p < .01) with the Rotter I-E Scale for

the original sample" (Wallston, Wallston, Kaplan, & Maides, 1976, p.

581). The authors reported two studies that suggest evidence of con-

struct validity. They predicted and found that internalss" with high

health values would seek more information about a given health situation

and found it to be true. The second study was based on the belief that

internalss would be more likely to take steps to better their

environmental condition than externals" (p. 583). This was a weight-

reduction program, and the results were as predicted. Internals lost

more weight on a "self-directed program and externals lost more on a

group program" (Wallston et al., 1976, p. 583).

In general, although the whole concept of locus of control is

currently under study, I believe that the area-specific assessment

instrument has met the criteria for inclusion in this study.

Controlling for this variable in any study on health behavior seems


The McGill Pain Questionnaire

This instrument was designed to provide quantitative measures of

clinical pain. It consists of three classes of descriptive words used to

evaluate pain. The classes are sensory, affective, and evaluative.

Research indicates that words in the sensory category are more

frequently chosen, and all subjects tested chose words in the evaluative

category. Investigators developed the instrument by asking subjects to

classify 102 words into groups that describe different aspects of the

pain experience. This effort yielded three categories. A fourth

category, called miscellaneous, was added as patients suggested

additional words.

The second part of the questionnaire development "was an attempt to

determine the pain intensities implied by the words within each sub-

class" (Melzack, 1975, p. 278). Physicians and patients were asked to

rate the words by intensity, and this resulted in a "high degree of

agreement on the intensity relationships among pain descriptions by

subjects who have different cultural, socio-economic and educational

backgrounds" (p. 278). The test authors reported that four types of

data can be ascertained from the questionnaire:

1. A pain rating index (PRI-S) based on mean scale score values.

2. A pain rating index (PRI-R) based on rank order values.

3. The number of words chosen (NWC).

4. The present pain intensity (PPI).

Initially the test authors did not report reliability per se and

validity. However, they examined internal consistency of the

instrument. They obtained correlations between mean scale values and

the rank order values and found them to be in the .91 to .94 range with

a correlation of .95 for all four scales (see Table 3-4).

Table 3-4

Correlations of the Mean Scale Values and the Rank Order Values of the
Pain Rating Index

Mean scale values

Rank order values S A E M T

S .94
A .92
E .93
M .91
T .95

The categories are S, sensory; A, affective; E, evaluative; M,
miscellaneous; T, total, based on n = 248 (Melzack, 1975).

The number of words chosen total scale has four subscales: (a) the

number of words chosen sensing (NWCS), (b) the number of words chosen

affective (NWCA), (c) the number of words chosen evaluative (NWCE), and

(d) the number of words chosen miscellaneous (NWCM). The pain rating

index total scale also has four subscales: (a) the pain rating index

sensory (PRIS), (b) the pain rating index affective (PRIA), (c) the pain

rating index evaluative (PRIE), and (d) the pain rating index

miscellaneous (PRIM).

Correlations between the number of words chosen (NWC) and the pain

rating index (PRIT) was r = .97 for the scale (S) value and r = .89 for

the rank order (R) value.

Correlations for present pain intensity (PPI) scales with the

number of words chosen (NWCT) and the Pain Rating Index scales were

significant (p < .01 in all cases) but very low (see Table 3-5). The

author expressed the belief that these low correlations indicate that "a

large part of the variance of the present pain intensity may be

determined by factors other than those indicated by the descriptors"

(Melzack, 1975, p. 285).

Table 3-5

Correlations Between the Present Pain Intensity Scale (PPI) and the
Total Number of Words Chosen (NWCT)


NWCT .32
PRI-R Sensory .29
PRI-R Affective .42
PRI-R Evaluative .49
PRI-R Miscellaneous .18
PRI-R Total .42

(Melzack, 1975)

Reading (1983a), in a recent review of the McGill Pain Question-

naire (MPQ), discussed the reliability and validity of the instrument.

Reliability of this type of measure is affected by "the inherent

fluctuating quality of the pain experience" (p. 56). He reports that

repeated administrations of the questionnaire to cancer patients yielded

a 75% consistency index (range 35-90%). In another study "the words

selected on the MPQ have been compared with those chosen from a

checklist format", and he obtained a broadly similar profile (p. 56).

Investigators examined construct validity by correlating McGill

Pain Questionnaire scores with assessments of psychological state and

found that "affective scores contributed to the prediction of MMPI

profiles, with intensity emerging as the best predictor" (p. 57). The

instrument is considered to have face validity because of the large

number of clinical studies, using the MPQ as a dependent variable.

Concurrent validity is demonstrated by the association of MPQ scores

with analgesia requirements, verbal rating and visual analog rating

scales, and ratings of headache intensity and duration. The distinctive

score profiles of certain groups provide evidence of discriminant

validity. As examples, Reading (1983b) reported that women in acute

pelvic pain show greater use of sensory word groups in contrast to

"chronic pain patients who use affective and evaluative groups with

greater frequency" (p. 58).

Pain researchers have used the McGill Pain Questionnaire since its

development in 1975. The high intercorrelations on the Pain Rating

Index (PRI) and the Number of Words Chosen (NWC) Scale and its validity

make it an acceptable instrument for quantitative evaluation of pain


Hypotheses Tested

1. Sensing types and Intuitive types will not score differently on

the sensory category of the McGill Pain Questionnaire.

2. Feeling types and Thinking types will not score differently on

the affective scale of the McGill Pain Questionnaire.

3. Judging types and Perceptive types will not score differently

on the evaluative scale of the McGill Pain Questionnaire.

4. Sensing types and Intuitive types will not score differently on

the intensity scale of the McGill Pain Questionnaire.

5. Sensing types and Intuitive types will not differ in the number

of words they choose on the McGill Pain Questionnaire.

6. Sensing types and Intuitive types will not differ in the number

of symptoms they report on the Health History Questionnaire.

7. Introverts and extroverts will not differ on the Health Locus

of Control Scale.

8. Coping styles will not account for differences on the McGill

Pain Questionnaire.

The .05 level of significance was used as the basis for rejecting a

null hypothesis.



The purpose of the study was to examine the relationship between

pain response and personality. I assessed personality type with the

Myers-Briggs Type Indicator, coping styles with the Millon Behavioral

Health Inventory, the Wallston Health Locus of Control Scale for

measuring expectancies, and pain response with the McGill Pain Question-

naire. Data were collected from 55 surgical patients. The patients

came from two surgical practices and made up three groups: (a) patients

having a gastric bypass for morbid obesity (bypass group), (b) immedi-

ately postoperative hand surgical patients (hand surgery group), and (c)

hand surgical patients 1 week or more postoperative who still had pain

(rehab. group).

An analysis of variance was done on the three groups on the scales

of the rlcGill Pain Questionnaire (HPQ) to determine if differences

existed. Because I found significant differences on four of the MPQ

scales, I treated this population as three groups. Table 4-1 contains

results of the ANOVA, and Table 4-2 is a summary of the group means.

Table 4-3 contains descriptive statistics of the three groups.

The Statistical Package for the Social Sciences (SPSS) version M,

release 9.0, was the recommended computer program. Type distribution of

the whole sample and of the three groups are in Tables 4-4, 4-5., 4-6,


Table 4-1

Analysis of Variance of the Whole Sample (n=55) and the Dependent
Variable (Scores on the McGill Pain Questionnaire)

Scale SS df MS F

between groups 81.587 2 40.794 1.36
within groups 1549.795 52 29.804

between groups 4.678 2 2.339 0.341
within groups 357.067 52 6.867

between groups 10.164 2 5.082 1.725
within groups 153.182 52 2.946

between groups 0.201 2 0.100 0.253
within groups 20.635 52 0.397

between groups 29.937 2 14.969 1.681
within groups 463.045 52 8.905

between groups 1224.504 2 612.252 3.613*
within groups 8810.878 52 169.440

between groups 236.463 2 118.232 2.129
within groups 2888.264 52 55.544

between groups 40.036 2 20.018 3.184*
within groups 326.946 52 6.287

between groups 7.656 2 3.828 1.631
within groups 122.053 52 2.347

between groups 125.974 2 62.987 5.851**
within groups 559.772 52 10.765

between groups 23.883 2 11.941 5.786**
within groups 107.317 52 2.064

*p < .05. **E < .01.

Table 4-2

Means by Group for McGill Pain Questionnaire Scales

Gastric Bypass Hand Surgery Hand Rehab.

Mean SD Mean SD Mean SD

NWC T 10.84 5.2 12.33 6.6 13.90 4.5

NWC S 6.53 2.5 6.58 3.2 7.27 2.0

NWC A 1.75 1.6 2.50 1.8 2.72 1.7

NWC E 0.96 0.7 0.83 0.3 1.0 0.0

NWC M 2.21 3.5 2.33 1.5 4.09 2.3

PRI T 21.46 11.9 28.00 16.5 33.09 11.6

PRI S 13.90 7.0 17.50 9.7 18.63 5.5

PRI A 2.34 2.2 3.50 2.9 4.45 2.8

PRI E 1.87 1.5 1.91 1.5 2.81 1.3

PRI M 3.34 2.8 5.08 3.9 7.18 3.5

PPI 0.84 1.6 2.08 1.6 2.27 1.8

Table 4-3

Description of Sample by Group, Gender, Mean Age

Groups n x age Female Male

Group (a)--Gastric Bypass Patients 32 37 27 5

Group (b)--Hand Surgical Patients 12 47 7 5

Group (c)--Hand Rehab. Patients 11 43 7 4

Table 4-4

Type Distribution of Total Sample

N = 55


N= 6 N= 6 N= 0 N= 2
%= 10.1 %= 10.91 %= 0.00 %= 3.64


N= 1 N= 8 N= 3 N= 0
I= 1.; %= 14.55 I %- 5.45 %= 0.00

N= 6 N= 4 N= 4 N= 0
%= 10.91 O 7.27 %= 7.27 %= 0.00

N= 4 N= 9 N= I N= 1
%= 7.27 %= 16.36 %= 1.82 %= 1.82

Note: EE = 1 E o f maple

Note: 2 = 1016 of sample

N 0o
E 29 52.73
I 26 47.27
S 44 SO.00
N 11 20.00
T 20 36.36
F 35 63.64
J 29 52.73
P 26 47.27
I J 14 25.45
IP 12 21.32
EP 14 25.45
EJ 15 27.27
ST 17 30.91
SF 27 49.09
NF 8 14.55
NT 3 5.45
SJ 25 45.45
SP 19 34.55
NP 7 12.73
NJ 4 7.27
TJ 13 23.64
TP 7 12.73
FP 19 34.55
FJ 16 29.09
IN 5 9.09
EN 6 10.91
IS 21 38.18
ES 23 41.82
ET 11 20.00
EF 18 32.73
IF 17 30.91
IT 9" 16.36
S dom 22 40.00
N dom 6 10.91
Tdom 6 10.91
Fdom 21 38.13

Table 4-5

Type Distribution of the Gastric Bypass Group

N = 32


N= 1 N= 3 N= 0 N= 2
%= 3.12 %= 9.38 %= 0.00 %= 6.25

N= I N= 4 N= 3 N= 0
%= 3.12 %= 12.50 %= 9.38 %= 0.00


N= 4 N= 3 N= 3 N= 0
%= 12.50 %= 9.38 /%= 9.38 %= 0.00


N= 2 N= 5 N= 1 N- 0
%= 6.25 %= 15.62 %= 3.12 %= 0.00

MN N ...

Note: M = 1% of sample

N 0O
18 56.25
14 43.75
23 71.87
9 23.13
10 31.25
22 68.75
14 43.75
18 56.25
6 18.75
8 25.00
10 31.25
8 25.00
8 25.00
15 46.S7
7 21.SS
2 6.25
11 34.38
12 37.50
6 18.75
3 9.38
5 15.62
5 15.62
13 40.62
9 23.13
5 15.62
4 12.50
9 28.13
14 43.75
6 18.75
12 37.50
10 31.25
4 12.50
11 34.33
5 15.62

Table 4-6

Type Distribution of the Hand Surgical Group

N = 12


N= 2 N- 2 N= 0 N= 0
%= 16.67 %= 16.67 %= 0.00 %= 0.00

N= 0 N= 3 N= 0 N= 0
%= 0.00 %= 25.00 %= 0.00 %= 0.00

a Ma ENamm E

N= I N= 0 N= 0 N= 0
%= 8.33 %= 0.00 %= 0.00 %= 0.00

N= 1 N= 3 N= 0 N= 0
%. 8.33 %: 25.00 %= 0.00 %= 0.00

Note: A = 1% of sample

N %
E 5 41.6"
1 7 58.33
S 12 100.00
N 0 0.00
T 4 33.33
F 8 66.67
J 8 66.67
P 4 33.33
SIJ 4 33.33
IP 3 25,00
EP 1 8.33
EJ 4 33.33
ST 4 33.33
SF 8 66.67
NF 0 0.00
NT 0 0.00
SJ 8 66.67
SP 4 33.33
NP 0 0.00
NJ 0 0.00
TJ 3 25.00
TP 1 8.33
FP 3 25.00
FJ 5 41.67
IN 0 0.00
EN 0 0.00
IS 7 58.33
ES 5 41.67
ET 2 16.67
EF 3 25.00
IF 5 41.67
IT 2 16.67
Sdom 5 41.67
Ndom 0 0.00
T dom 1 8.33
F dom 6 50.00

and 4-7. Scales of the independent and dependent variables are

summarized in Figure 4-1.


With the Pearson product moment correlation I examined the

relationship between the scales of the Myers-Briggs Indicator, the

coping style scales of the Millon Behavioral Health Inventory, and the

scales of the McGill Pain Questionnaire. Results of these correlations

are in Appendix D. The Sensing-Intuitive scale of the Myers-Briggs was

significantly related to the miscellaneous category of the McGill Pain

Questionnaire (r = .33, p < 0.05). None of the other scales of the MBTI

had a significant relationship with the McGill; in fact, the correla-

tions were low.

On the Millon scales, significant relationships appeared between

the Present Pain Intensity and the Introversive scale (r = 0.52, p <

.001), the Cooperative scale (r = 0.32, p < .05), and the Sensitive

scale (r = -0.47, p < .01).

Hypothesis Testing

I tested the hypotheses of the bipolar scales of the Myers-Briggs

Type Indicator (Ho 1 through Ho 7) using a t test for independent

samples with the bypass group and a one-way ANOVA with both hand groups.

These procedures were used for ease in computation. For statistical

analysis, I used the continuous scores of the MBTI bipolar groups,

choosing a significance level of .05.

The Selection Ratio Type Table (SRTT) analysis is a ratio of the

observed to expected frequency based on the proportion of the type in

Table 4-7

Tvoe Distribution of the Hand Rehabilitation Group

N = 71


N= 3 N= 1 N= 0 N= 0
-.= 27.27 o= 9.09 9= 0.00 %= 0.00

N= 0 N= 1 N= 0 N= 0
0= 0.00 .%= 9.09 % 0.00 %= 0.00

N= I N 1 N N= 0
%= 9.09 %= 9.09 %= 9.09 %= 0.00

mNEUEREE .mu****** uu**m***mE

N= N= N= 0 N= 1
%= 9.09 %= 9.09 %= 0.00 %= 9.09

Note: M = 1% of sample

N %0
E 6 54.55
I 5 45.45
S 9 81.82
N 2 1S.18
T 6 54.55
F 5 45.45
J 7 63.64
P 4 36.36
1 4 36.36
I P 1 9.09
EP 3 27.27
EJ 3 27.27
ST 5 45.45
SF 4 36.36
NF 1 9.09
NT 1 9.09
SJ 6 54.55
SP 3 27.27
NP 1 9.09
NJ 1 9.09
TJ 5 45.45
TP 1 9.09
FP 3 27.27
FJ 2 18.18
IN 0 0.00
EN 2 18.1S
IS 5 45.45
ES 4 36.36
ET 3 27.27
EF 3 27.27
IF 2 18.18
IT 3 27.27
S dom 6 54.55
N dom. 1 9.09
Tdom 2 18.18
Fdom 2 18.18


Type Indicator

Million Behavioral
Health Inventory

Health Locus
of Control

McGill Pain


Introversive Style
Inhibited Style
Cooperative Style
Sociable Style
Confident Style
Forceful Style
Respectful Style
Sensitive Style

Number of words chosen total
Number of words chosen sensing
Number of words chosen affective
Number of words chosen evaluative
Number of words chosen miscellaneous
Pain Rating Index Total
Pain Rating Index Sensing
Pain Rating Index Affective
Pain Rating Index Evaluative
Pain Rating Index Miscellaneous
Present Pain Intensity

Figure 4-1. Summary of scales and acronyms used in this study.




the total sample. In this case because of the small n, I compared the

groups above and below the median individually to the whole sample.

When the SRTT index is 1.00, the observed frequency in the sample tested

is what would be expected based on the whole population. When the index

or ratio is greater than 1.00, the cell contains more people than one

would expect from the numbers in the base population (McCaulley, 1985,

p. 50). The SRTT is based on the chi square statistic, or Fisher's

exact probability if the n is small, to determine if the overrepresenta-

tion or underrepresentation is significant.

Hypothesis testing of the Millon Behavioral Health Inventory coping

style scales was by analysis of variance using base rate scores, with a

significance level of .05. The computer-generated base rate scores,

described in the test manual, represent a conversion of the raw scores

predicated on estimated style or class prevalence data. A base rate

score of 75 or above is indicative of the presence of the coping style.

The dependent variable for hypotheses numbers 1, 2, 3, 4, 5, and 8

was the selected scales of the McGill Pain Questionnaire (MPQ). These

scales contain three basic types of measurement. First is the number of

words chosen total scale (NWCT) which is further broken down to the

number of words chosen sensory (NWCS), the number of words chosen

affective (NWCA), the number of words chosen evaluative (NWCE), and the

number of words chosen miscellaneous (NWCM). Second is the pain rating

index total (PRIT) scale, which is broken down to the pain rating index

sensory (PRIS), the pain rating index affective (PRIA), the pain rating

index evaluative (PRIE), and the pain rating index miscellaneous (PRIM).

The words are rank ordered within the groups, and this score is obtained

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