|UFDC Home||myUFDC Home | Help|
This item has the following downloads:
OBSERVER'S WILLINGNESS TO EXPRESS PAIN BEHAVIORS INFLUENCES
THE ACCURACY OF ESTIMATING PAIN IN OTHERS
S. KAREN CHUNG
A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
UNIVERSITY OF FLORIDA
S. Karen Chung
This project could not have been carried out without the support and guidance of
my adviser, Michael E. Robinson, Ph.D., and the valuable contribution of Emily A. Wise,
TABLE OF CONTENTS
A C K N O W L E D G M E N T S ......... ................................................................................... iii
A B STR A C T ......... ..... ............................................................................... ......
1 IN T R O D U C T IO N ................... .... .......................... .. ............ ............. ....
2 M ATERIALS AND M ETH OD S............................................. ........................... 7
P participants ............................................................. . 7
P rocedu res ................................................................................... . 7
M e a su re s ............................................................................... 9
3 R E S U L T S .......................................................................................................1 1
4 D ISC U SSIO N .......................................................................................... ............... 13
L IST O F R E FE R E N C E S ....................................................................................... ............16
B IO G R A PH IC A L SK E T C H ........................................................................................ 19
Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science
OBSERVER'S WILLINGNESS TO EXPRESS PAIN BEHAVIORS INFLUENCES
THE ACCUACY OF ESTIMATING PAIN IN OTHERS
S. Karen Chung
Chair: Mike E. Robinson
Major Department: Clinical and Health Psychology
This study examined specific variables that may account for individual differences
in the accuracy of estimating pain intensity in others undergoing an experimental pain
task (cold pressor). Previous personal pain experiences, family history of pain, and belief
in the appropriateness of expressing pain behaviors were tested as predictors. Analyses
revealed that these three variables accounted for over 41% of the variance in accuracy
scores when combined. However, only the belief in the appropriateness of expressing
pain behaviors was found to be significant in predicting accuracy. Results demonstrated
that the more a person believed it was appropriate for him/her to express pain behaviors,
the more accurate he/she was in estimating pain in others. Previous literature indicates
that health care professionals' estimations of patient pain are often different from patient
ratings. Likewise, the present study revealed that observers generally underestimated the
pain intensity ratings of those they were observing. By targeting specific factors that
influence the perception of pain in others, health care providers can ultimately be more
objective and accurate in their medical decisions concerning their patients.
Within the last few years, there has been an expanding interest in research on
individual differences in pain perception. One of the most widely studied variables is sex
differences and pain with previous research demonstrating the existence of sex
differences in the experience of pain. Similarly, a number of other factors including
family models (Edwards et al., 1985; Fillingim et al., 2000; Robinson et al., 2001),
personal experience of pain (Holm et al., 1989), and expressiveness and willingness to
report (Nayak et al., 2000), have been associated with sex differences in pain responding.
The existence of sex differences in the pain experience has been established in
numerous previous studies. Unruh (1996) conducted a review of research examining
gender variations in clinical pain experience. She found sex differences in the prevalence
of migraine, headache, facial pain, back pain, musculoskeletal pain, and abdominal pain
as well as different pain experiences from similar diseases. Unruh suggested that women
seem more likely than men to have persistent and recurrent pain due to chronic but not
life-threatening conditions. Rollman (1997) acknowledged that the evidence favoring sex
differences in pain seems compelling and considered the role of other factors such as
anxiety, somatosensory amplification, and coping style to account for the differential
response to pain. He noted that somatosensory amplification was much stronger in
women than in men, which may predict the propensity to seek medical care, which in
turn is correlated with hypochondriacal symptomatology (Barsky & Wyshak, 1990).
Furthermore, women reported higher levels of catastrophizing ideation when describing
thoughts or feelings related to pain (Sullivan & Pivik, 1995). Next, Rollman and
Lautenbacher (2001) speculated that a state of increased pain sensitivity, with a
peripheral or central origin predisposes individuals to chronic muscle pain conditions and
that there are sex differences in the operation of these mechanisms which account for
some of the previously found sex differences in pain responsivity. Additionally, Fillingim
and Maixner (1995) reviewed the literature in sex differences, which was followed by a
meta-analytic review by Riley et al. (1998). These reviews conclude that there is
consistent evidence that the sexes differ in their response to experimental pain.
Researchers have explored additional variables in addition to sex, particularly
involving health care professionals. Polkki et al. (2003) found that a pediatric patients'
surgical pain relief in the hospital was affected more by the nurses' personal
characteristics (age, education, work experience) than by work related factors or
characteristics of the child or the child's parents. Sheiner et al. (1999) also concluded that
the ethnic background of the care provider is an important determinant in estimating the
suffering of the patients. These studies illustrate the role of numerous factors in play for
estimating pain in other people.
Several studies have investigated the role of family history and pain models in
relation to pain behavior. In an experimental setting, a high frequency of family pain
models was found to be associated with higher frequency of pain episodes, more types of
pain, greater intensity, and lower physiological arousal and subjective pain ratings during
the cold pressor task. Clinically, Fillingim et al. (2000) found that a positive family
history of pain was associated with increased reports of pain over the previous month and
poor general health, in addition to enhanced sensitivity of thermal stimuli among women.
Lester et al. (1994) found that subjects with a strong family history of pain problems
reported a greater number of pain sites, and higher levels of pain related interference.
Sex differences have also been implicated in the role of family models with
women reporting significantly more pain models than men (Koutanji et al., 1998).
Edwards et al. (1985) offered one possible explanation for the mechanism of relating
family models and pain behavior. He suggested that frequent secondary gains associated
with the evidence of pain may foster a link between familial pain models and current
complaints of pain.
Previous personal pain experience is another variable that may be related to pain
intensity assessments. In one of the few studies, Holm et al. (1989) examined the effect of
personal pain experiences on the assessment of patient pain in 134 nurses. Results
indicated that the intensity of pain experienced by the nurse was the only variable that
significantly predicted their perception of the patients' physical suffering and distress. In
general, nurses who have experienced intense pain seemed to be more sympathetic to
patients in pain, which may influence their accuracy of assessment of other's pain.
However, another study found that nurses' previous personal pain experiences were
negatively related to their initial pain management knowledge (Wessman & McDonald,
1999). These findings suggest that a nurses' personal experience has some influence in
estimating patient pain, but the exact nature of its influence seems unclear.
Gender differences have been found in terms of expressiveness in pain in that men
are generally less willing to report pain (Robinson et al., 2001). Similarly, Klonoff et al.
(1993) found that males were less likely to disclose pain to others and associated feelings
of embarrassment with having to admit pain. Furthermore, women rated their response to
pain as entailing more irritability and worrying when compared to men, and a higher
likelihood of disclosing their distress. Koutantji and colleagues (1998) hypothesize that
social roles for women are more supportive of pain expression and pain awareness,
making them more cognizant of their own and others' pain, thus learning to model their
behavior after those in their environment. Expressiveness is an important variable
because higher non-verbal expressiveness is associated with higher ratings of patient pain
and distress and observer concern (von Baeyer et al., 1984).
Accurate pain assessments are crucial to health care professionals. However, there
is evidence that nurses are inaccurate in assessing pain and often underestimate the pain
experience of others. Zalon (1993) examined 119 nurses' assessments of pain in
postoperative patients using a visual analog scale (VAS). Results indicated that although
nurses' assessments were correlated with their patients' pain, the majority of nurses
underestimated more severe pain and overestimated milder pain. Zalon found that
patients' reported pain ratings contributed the largest portion of the variance (9.25%) to
nurses' assessments of pain. Krivo (1996) even concluded that many physicians and
nurses may be aware of patients perceptions of pain intensity, but think that they
overstate the intensity of their pain. So what cues could these nurses and physicians be
using to assess their patients?
Previous findings suggest that health care professionals such as nurses use more
than just a patient's reported pain ratings when estimating their pain. When verbal cues
were used, the findings were relatively consistent with small correlations between nurses'
estimation and patients' pain ratings. (Choiniere et al., 1990; Salmon & Manyade, 1996)
However, other studies, where verbal cues were not used, found that nurses were not very
accurate in their estimation of patients' reported pain (Thomas et al, 1998). Katsma and
Souza (2000) found that older nurses with more experience were less likely to believe or
document their patient's self-repot of pain than younger nurses with fewer years of
experience. Halfens et al. (1990) found that third- and fourth- year nurses of a hospital
based program and registered nurses attributed more pain when test results of physical
pathology were positive. Additionally, third- and fourth- year student nurses also
attributed more pain to depressive patients. Nursing experience was also found to be an
important predictor of pain ratings in Halfens and colleagues' study. First-year student
nurses attributed less pain to the hypothetical patient than third- and fourth- year student
nurses and registered nurses.
The accuracy of pain estimates may also be affected by a health care
professionals' gender. A study by Baron et al. (1990) found that there was a tendency for
female dentists to demonstrate greater accuracy than male dentists, but this effect was
nonsignificant. In addition, dentists' accuracy in assessing overall patient discomfort was
significantly lower in that segment of the treatment procedure that was most stressful for
Based on the previously mentioned research we hypothesized that (1) the more
incidences of painful conditions a person's biological parents and siblings have had, the
more accurate he/she will be in assessing other people's pain intensity. (2) The more a
person considers it to be appropriate to express pain, the more accurate he/she will be in
assessing others' pain intensity. (3) The more painful experiences a person has had in
his/her past, the more accurate he/she will be in assessing other people's pain intensity.
Sex was found to be a significant predictor of accuracy of pain intensity in a previous
study conducted by Robinson and Wise (2003). We predict that appropriateness of pain
expression, personal pain history, and family history of pain will significantly predict the
accuracy of pain intensity and that sex will not be a significant independent predictor
with the previously mentioned variables in the model. In other words, sex differences as
found in previous studies will be explained by the three variables: willingness to express
pain, personal pain history, and family history of pain.
MATERIALS AND METHODS
Subjects were recruited from the undergraduate psychology pool and from flyers
posted on campus requesting volunteers for research at the University of Florida. The
sample consisted of 28 subjects, 14 females and 14 males. The mean age of the sample
was 21.7 years (SD = 3.1 years; age range, 18-33 years), of whom 96.0% were single.
Most of the sample reported their race as Caucasian (85.7%), with 10.7% reporting their
race as Hispanic, and 3.6% as African American. Mean years of formal education were
14.7 (SD = 1.6). Approximately, 75% of the subjects were recruited from flyers and thus
were compensated volunteers while 25% of the subjects were recruited from
undergraduate psychology courses. Robinson and Wise (2003) previously used a portion
of this data set.
Upon arrival, all subjects read and signed an Institutional Review Board approved
consent form acknowledging that the experimental procedures had been explained and
that they could withdraw, without prejudice, from the experiment at any time. Prior to
the video presentation, subjects were read a standardized set of instructions, including a
description of the cold pressor task and instructions on the brief packet they were asked
to complete after viewing each video clip. All subjects were then seated at a large table
in front of a projection screen to watch ten randomly ordered video clip presentations.
A randomly selected half of the subjects completed a battery of psychological
questionnaires prior to the video presentation and the other half filled the packet out after
the video presentation. In the packet, subjects were asked to complete a series of Visual
Analogue Scales (VAS) measuring their estimation of the pain intensity.
Each presentation consisted of 10 video clips. Each video clip lasted 30 seconds,
and consisted of a participant in the cold pressor task (described below). The time for
each video clip presented was the 30 seconds prior to the participant's self-report of pain
tolerance. The participants in the videos were recruited from undergraduate courses at
the University of Florida. There were 5 male and 5 female participants. Mean age was
20.4 years (SD = 0.97) and mean years of formal education were 15.0 (SD = 1.25). Nine
of the participants were Caucasian and 1 was African American. Each of the participants
described themselves as single. After completing a consent form and filling out a brief
demographics form, they were escorted to a small laboratory and seated in front of a
video camera. Beside them was the cold water immersion device (cold pressor). Pain
was induced with a NESLAB RTE Series Refrigerated Bath/Circulator maintaining a
constant water temperature of 1-3 degrees Celsius for a maximum of three minutes. The
participants were read a standardized set of instructions regarding the pain ratings. They
were asked to provide pain intensity ratings ranging from 0 ("no pain sensation") to 100
("the most intense pain imaginable") and ratings for pain unpleasantness (0 "not at all
unpleasant" to 100 "most unpleasant imaginable"). They were instructed to leave their
hand in the water as long as they could and to withdraw their hand when they could no
longer tolerate the sensation. They were then asked to provide ratings of pain intensity
and pain unpleasantness of the cold-water task, using the scales described above.
Demographics Questionnaire: Provided information concerning the participants'
sex, age, marital status, race, work status, and education.
Previous Pain Experience Questionnaire (PPEQ): The PPEQ includes 79
examples of potentially painful events ranging from mild (i.e. mosquito bite, dust in eye,
bright light, paper cut and splinter) to major (i.e. gun shot, advanced cancer, serious
burns, and heart attack) events. The participants rate the number of times they
experienced a specific event and how painful that event was on a 10-point scale from no
pain to the worst possible pain. If the participant had not experienced the event, they were
asked to rate how painful they would imagine the event to be. This measure has been
used in previous studies, however it not been published and its psychometric properties
Family History Questionnaire (FHQ): The FHQ lists numerous chronic pain and
psychological conditions. The participants are asked to report whether their biological
mother, father, sisterss, brothers) or the participants themselves have ever experienced
the 17 listed conditions (i.e., rheumatoid arthritis, irritable bowel syndrome, chronic
fatigue syndrome, menstrual pain, fibromyalgia, reflex sympathetic dystrophy,
arthritis/joint pain, chronic headaches, back, neck, leg, and dental pain, other chronic
pain, depression, anxiety disorder, Post Traumatic Stress Disorder, and other psychiatric
diagnosis). To determine the number of pain exposure from the subject's family, their
reports for their mother, father, sisterss, and brothers) were totaled. Multiple siblings
were not distinguished from single siblings. This measure has been used in previous
studies; however, it has not been published and its psychometric properties are unknown.
Appropriate Pain Behavior Questionnaire Y (APBQ-Y): The APBQ was created
to assess beliefs about the appropriateness of pain behaviors. The APBQ-Y was revised
from the APBQ-M and APBQ-F developed by Nayak et al. (2000). The APBQ-M and
APBQ-F has revealed the existence of sex differences where American men believed that
expressive pain behavior was more appropriate in females than males while American
women did not believe that different levels of pain expression are acceptable in males and
females (Nayak et al, 2000). The APBQ-Y includes 14 statements (i.e. It is acceptable
for me to cry when in pain, I believe I should keep pain in private, It is appropriate for me
to ignore my pain, and I should be able to tolerate pain in most circumstances) on a 7
point scale (1= strongly disagree and 7 = strongly agree) that assesses the participant's
personal beliefs about appropriate pain behavior.
To analyze viewer accuracy, the accuracy of pain intensity was calculated by
subtracting the estimated pain intensity of the viewers from the actual reported pain
intensity of the video participants. A hierarchical regression was conducted to determine
whether the number of previous painful experiences (PPEQ), previous family history of
pain (FHQ), and the Appropriate Pain Behavior Questionnaire (APBQ-Y) predicted the
accuracy of observed pain intensity (Table 1).
The PPEQ score was calculated by adding all of the pain ratings of those events the
participant had experienced. This sum was divided by the total number of experienced
events. The FHQ score was calculated by adding all the all of the health problems that
were indicated in the questionnaire. The APBQ-Y score was calculated by totaling
ratings were after the responses were weighted according to the statement's positive and
Block 1 consisted of, the PPEQ, FHQ and APBQ and predicted approximately
40.8% of the variance in accuracy of observed pain intensity (F(3,24)=5.507, p=.005).
However, the regression revealed that the APBQ-Y was the only measure that
significantly predicted the pain intensity accuracy (st. beta=-.649, p=.001). This indicates
an inverse relationship between the accuracy of pain intensity estimation and how
appropriate the participant felt about expressing painful behaviors. In other words, higher
willingness to express pain was associated with smaller difference scores, therefore
Sex was added in block 2 of the model to determine if it predicted any variance in
pain intensity accuracy above and beyond that accounted for by block 1. This analysis
was conducted to determine whether the sex differences found in previous studies could
be explained by family history, previous pain experience and willingness to express pain
behaviors (Wise & Robinson, 2003). The addition of sex in block 2 predicted an
additional 4.9% of the variance in pain intensity accuracy but was not statistically
significant (F(4,23)=4.841, p=.006).
Table 3-1. Results from hierarchical regression
Measure Standardized P R2 F
Block 1 APBQ -.649 .001 .408 (F(3,24)=5.507, p=.005)
PPEQ -.036 -.218
FHQ .118 .715
Block 2 APBQ -.574 .003 .457
PPEQ -.039 .810
FHQ .082 .500
Sex .234 .234 (F(4,23)=4.841, p=.006)
The results of this study strengthen the conclusion that personal expectations such
as the belief in the appropriateness of expressing pain behaviors influence the perception
of pain in others. Previous studies (Robinson et al., 2001; Wise et al., 2002) have
demonstrated that people are influenced in their own pain perception by their pain related
gender stereotypes under laboratory-based experimental paradigms. Nayak et al. (2000)
found cultural and sex differences in beliefs about appropriate pain behaviors between
participants in India and the United States. Indian participants and male participants were
less accepting of overt pain expression and had higher pain tolerances than their
American and female counterparts, respectively. Furthermore, Robinson and Wise (2003)
showed that given the same sex video to view, men and women rated the observed pain
differently with women rating the observed pain higher than men.
Results of this study suggest that another construct, in addition to sex, may play
an important part in accurately estimating pain intensity in others. Previous studies have
indicated that personal pain experiences may be associated with rating pain intensity in
others (Holm et al., 1989). However, personal pain experiences were not found to be a
significant predictor of accuracy of pain intensity estimation in this study.
Additionally, previous studies indicated a relationship between subjective ratings
of pain and family history of pain (Edwards et al., 1985; Fillingim et al., 1999), possibly
due to modeling, heredity, or other factors. We attempted to expand on this concept to
estimating pain in others. However, family history of pain was not found to be a
significant predictor of estimating pain in others.
Interestingly, beliefs in the appropriateness of expressing pain behaviors, as
measured by the APBQ-Y, were significantly related to more accurate ratings of pain.
The entire model consisting of personal pain experiences, family history of pain and the
APBQ-Y accounted for approximately 41% of the variance, however only the APBQ-Y
was found to be significant in the accuracy of estimating pain intensity in others. Results
demonstrated that the more a person believed it was appropriate for him/her to express
painful behaviors, the more accurate they were in estimating pain in others. These results
appear to be consistent with Nayak et al. (2000), Rollman et al. (2001), and Wise et al.
The data revealed that observers generally underestimated the amount of pain of
those they were observing. This led to an interesting phenomena where, the higher the
observer's estimation, the more accurate they were in their estimation. This leads to a
second, but very similar interpretation of our results: beliefs in the appropriateness of
pain behaviors as measured by the APBQ-Y were related to more accurate of pain
ratings. Previous researchers have found that gender roles appear to be related to the pain
experience (Robinson and Wise, 2003; Wise et al., 2002). It can be hypothesized that the
willingness to express pain behaviors may be related to perceived gender roles as found
by Nayak et al. (2000). Whether or not the perceived roles are gender related, these roles
appear to be involved in not just the subjective pain experience, but also play a factor for
those who view and estimate the pain experience in others.
It is important to recognize that certain characteristics or beliefs of the observer
affect their accuracy of estimating pain in others. Most health care providers make
frequent medical decisions about people in pain, especially in settings where prescribing
or administering pain medications is required. However, these biases have not been fully
explored in a heath care context. By targeting these factors, it becomes possible to allow
health care providers to understand that these characteristics are influencing their
perception of others. This can ultimately provide assistance for those in such professions
to be more objective and accurate in their medical decisions concerning their patients.
Future research employing similar methodology including clinically relevant scenarios
need to be examined in order to determine the influence of other factors in health care
providers estimates of patient's pain.
LIST OF REFERENCES
Baron RS, Logan H, Kao CF: Some variables affecting dentists' assessment of patients'
distress. Health Psychology 9(2), 143-153, 1990.
Barsky AJ, Wyshak G: Hypochondriasis and somatosensory amplification. British
Journal of Psychiatry 157: 404-409, 1990
Choiniere M, Melzack R, Girard N, Rondeau J, Paquin M: Comparisons between
patients' and nurses' assessment of pain and medication efficacy in severe burn
injuries. Pain 40:143-152, 1990
Edwards PW, O'Neill GW, Zeichner A, Kuczmierczyk AR: Effects of familial pain
complaints and coping strategies. Perceptual and Motor Skills 61:1053-1054, 1985
Fillingim RB, Edwards RR, Powell T: Sex-dependent effects of reported familial pain
history on recent pain complaints and experimental pain responses. Pain 86(1-
Fillingim RB, Maixner W: Gender differences in response to noxious stimuli. Pain
Forum 4(4): 209-221, 1995
Halfens R, Evers G, Abu-Saad H: Determinants of pain assessment. Int J Nurs Stud
27(1): 43-49, 1990.
Holm K, Cohen F, Dudas S, Medema P, Allen B: Effect of personal pain experience on
pain assessment. Journal of Nursing Scholarship 21:72-75, 1989
Katsma DL, Souza CH: Elderly pain assessment and pain management knowledge of
long-term care nurses. Pain Management Nursing 1(3): 88-95, 2000.
Klonoff EA, Landrine H, Brown M. Appraisal and response to pain may be a function of
its bodily location. J Psychosomatic Research 37(6): 661-670, 1993
Koutantji M, Pearce SA, Oakley DA: The relationship between gender and family history
of pain with current pain experience and awareness of pain in others. Pain 77: 25-
Krivo S, Reidenberg, MM: Assessment of patients' pain. Massachusetts Medical Society
334(1): 59, 1996.
Lester N, Lefebvre JC, Keefe FJ: Pain in young adults: I. Relationship to gender and
family pain history. Clinical Journal of Pain (10)4: 282-289, 1994
Nayak S, Shiflett SC, Eshun S, Levine FM: Culture and gender effects in pain beliefs and
the prediction of pain tolerance. Cross-Cultural Research: The Journal of
Comparative Social Science 34(2): 135-151, 2000
Polkki T, Laukkala H, Vehvilainen-Julkunen K, Pietila A: Factors influencing nurses' use
of nonpharmacological pain alleviation methods in paediatric patients. Scand J
Caring Sci 17: 373-383, 2003
Riley JL, Robinson ME, Wise EA, Myers CD, Fillingim RB: Sex differences in the
perception of noxious experimental stimuli: a meta analysis. Pain 74(2-3):181-187,
Robinson ME, Riley JL, Myers CD, Papas RK, Wise EA, Waxenberg LB, Fillingim RB:
Gender role expectations of pain: relationship to sex differences in pain. J Pain
Robinson ME, Wise EA: Gender bias in the observation of experimental pain. Pain, 104:
Rollman GB: Sex differences in pain do exist: The role of biological and psychosocial
factors. Behavioral and Brain Sciences 20(3):464-465, 1997
Rollman GB, Lautenbacher S: Sex differences in musculoskeletal pain. The Clinical
Journal of Pain 17:20-24, 2001
Salmon P, Manyande A: Good patients cope with their pain: postoperative analgesia and
nurses' perceptions of their patients' pain. Pain 68:63-68, 1996
Sheiner EK, Sheiner E, Shoham-Vardi I, Mazor M, Katz M: Ethnic differences influence
care giver's estimates of pain during labour. Pain 81:299-305, 1999
Sullivan MJL, Pivik J: The Pain Catastrophizing Scale: Development and validation.
Psychological Assessment 7(4):524-532, 1995
Thomas T, Robinson C, Chamption D, McKell M, Pell M: Prediction and assessment of
the severity of post-operative pain and of satisfaction with management. Pain
Unruh AM: Gender variations in clinical pain experience. Pain 65(2-3):123-167, 1996
Von Bayer CL, Johnson ME, McMillan MJ: Consequences of nonverbal expression of
pain: patient distress and observer concern. Soc Sci Med 19(12): 1319-1324, 1984
Wise EA, Price DD, Myers CD, Heft MW, Robinson ME: Gender role expectations of
pain: Relationship to experimental pain perception. Pain 96:335-342, 2002
Wessman AC, Mc Donald DD: Nurses' personal pain experiences and their pain
management knowledge. J Contin Educ Nurs 30(4): 152-157, 1999
Zalon ML: Nurses' assessment of postoperative patient's pain. Pain 54: 329-334, 1993
S. Karen Chung graduated from the University of California, Los Angeles in June
of 2002 with a Bachelor of Science degree in psychobiology. In August 2002, Karen
Chung began her doctoral training in the Department of Clinical and Health Psychology
at the University of Florida. Her clinical and research interests are in the area of clinical