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Observer's Willingness to Express Pain Behaviors Influences the Accuracy of Estimating Pain in Others


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OBSERVER’S WILLINGNESS TO EXPRESS PAIN BEHAVIORS INFLUENCES THE ACCURACY OF ESTIMATING PAIN IN OTHERS By S. KAREN CHUNG A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2004

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Copyright 2004 by S. Karen Chung

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iii ACKNOWLEDGMENTS This project could not have been carrie d out without the supp ort and guidance of my adviser, Michael E. Robinson, Ph.D., and th e valuable contributi on of Emily A. Wise, Ph.D.

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iv TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iii ABSTRACT....................................................................................................................... ..v CHAPTER 1 INTRODUCTION........................................................................................................1 2 MATERIALS AND METHODS..................................................................................7 Participants................................................................................................................... 7 Procedures..................................................................................................................... 7 Measures....................................................................................................................... 9 3 RESULTS.................................................................................................................. .11 4 DISCUSSION.............................................................................................................13 LIST OF REFERENCES...................................................................................................16 BIOGRAPHICAL SKETCH.............................................................................................19

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v Abstract of Thesis Presen ted 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 ESTIMATI NG PAIN IN OTHERS By S. Karen Chung May 2004 Chair: Mike E. Robinson Major Department: Clini cal and Health Psychology This study examined specific variables th at may account for individual differences in the accuracy of estimating pain intensity in others undergoing an experimental pain task (cold pressor). Previous personal pain e xperiences, family history of pain, and belief in the appropriateness of expressing pain beha viors 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 be lief 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 appropria te 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 ar e 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

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vi influence the perception of pain in others, health care providers can ultimately be more objective and accurate in their medical decisions concerning their patients.

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1 CHAPTER 1 INTRODUCTION Within the last few years, there has b een an expanding interest in research on individual differences in pain perception. One of the most widely st udied variables is sex differences and pain with previous research demonstr ating the exis tence of sex differences in the experience of pain. Sim ilarly, a number of other factors including family models (Edwards et al., 1985; F illingim 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 di fferences in the prevalence of migraine, headache, facial pain, back pa in, 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 conditio ns. Rollman (1997) acknowledged that the evidence favoring sex differences in pain seems compelling and cons idered the role of ot her factors such as anxiety, somatosensory amplification, and c oping style to account for the differential response to pain. He noted that somatose nsory amplification was much stronger in women than in men, which may predict the pr opensity to seek medical care, which in turn is correlated with hypochondriaca l symptomatology (Barsky & Wyshak, 1990). Furthermore, women reported higher levels of catastrophizing ideation when describing

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2 thoughts or feelings related to pain (S ullivan & Pivik, 1995). Next, Rollman and Lautenbacher (2001) speculated that a state of increased pain sensitivity, with a peripheral or central origin pr edisposes individuals to chroni c muscle pain conditions and that there are sex differences in the oper ation 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 concl ude 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 professi onals. Polkki et al. (2003) f ound that a pediatric patients’ surgical pain relief in the hospital wa s affected more by the nurses’ personal characteristics (age, education, work expe rience) than by work related factors or characteristics of the child or the child’s pare nts. 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 experiment al 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 lo wer physiological arousal and subjective pain ratings during the cold pressor task. Clinically, Fillingi m 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.

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3 Lester et al. (1994) found that subjects with a strong family history of pain problems reported a greater number of pain sites, and hi gher levels of pain re lated interference. Sex differences have also been implicated in the role of family models with women reporting significantly more pain m odels 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 seconda ry gains associated with the evidence of pain may foster a link between familial pain models and current complaints of pain. Previous personal pain expe rience is another variable th at 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 th eir perception of the patients’ physical suffe ring 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’ pr evious personal pain experiences were negatively related to their initial pain management know ledge (Wessman & McDonald, 1999). These findings suggest that a nurses’ personal experience has some influence in estimating patient pain, but the exact natu re 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 (R obinson et al., 2001). Similarly, Klonoff et al. (1993) found that males were less likely to disclo se pain to others and associated feelings of embarrassment with having to admit pain. Furthermore, women rated their response to

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4 pain as entailing more irritability and worrying when compared to men, and a higher likelihood of disclosing their distress. Kout antji 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 ot hers’ pain, thus learning to model their behavior after those in their environment. Expressiveness is an important variable because higher non-verbal expressiveness is asso ciated with higher ratings of patient pain and distress and observer concer n (von Baeyer et al., 1984). Accurate pain assessments are crucial to health care professionals. However, there is evidence that nurses are inaccurate in asse ssing pain and often underestimate the pain experience of others. Zalon (1993) examin ed 119 nurses’ assessments of pain in postoperative patients using a visual analog scale (VAS). Re sults indicated that although nurses’ assessments were correlated with th eir patients’ pain, the majority of nurses underestimated more severe pain and overestimated milder pain. Zalon found that patients’ reported pain ratings contributed the largest porti on 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 car e 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 re latively consistent with small correlations between nurses’ estimation and patients’ pain ratings. (Choi niere et al., 1990; Sa lmon & Manyade, 1996) However, other studies, where verbal cues we re not used, found that nurses were not very

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5 accurate in their estimat ion of patients’ reported pain (Thomas et al, 1998). Katsma and Souza (2000) found that older nur ses 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 thirdand four thyear nurses of a hospital based program and registered nurses attributed more pain when test results of physical pathology were positive. Additionally, thirdand fourthyear student nurses also attributed more pain to depr essive patients. Nursing experi ence was also found to be an important predictor of pain ratings in Halfens and collea gues’ study. First-year student nurses attributed less pain to the hypothetical patient than th irdand fourthyear 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 treat ment procedure that was most stressful for dentists. Based on the previously mentioned res earch we hypothesized that (1) the more incidences of painful conditions a person's bi ological 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 expr ess pain, the more accurate he/she will be in assessing others’ pain intens ity. (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

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6 study conducted by Robinson and Wise (2003). We predict that appropriateness of pain expression, personal pain history, and family hi story of pain will sign ificantly predict the accuracy of pain intensity and that sex will not be a significant independent predictor with the previously mentioned variables in th e 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, a nd family history of pain.

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7 CHAPTER 2 MATERIALS AND METHODS Participants Subjects were recruited from the underg raduate psychology pool and from flyers posted on campus requesting volunteers for resear ch at the University of Florida. The sample consisted of 28 subjects, 14 females a nd 14 males. The mean age of the sample was 21.7 years (SD = 3.1 years; age range, 1833 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 subj ects 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. Procedures Upon arrival, all subjects read and sign ed an Institutional Review Board approved consent form acknowledging that the experime ntal procedures had been explained and that they could withdraw, wit hout prejudice, from the experiment at any time. Prior to the video presentation, subjects were read a st andardized set of inst ructions, including a description of the cold presso r task and instructio ns on the brief packet they were asked to complete after viewing each video clip. Al l subjects were then seated at a large table in front of a projection screen to watch te n randomly ordered video clip presentations.

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8 A randomly selected half of the subjec ts 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 thei r estimation of the pain intensity. Each presentation consisted of 10 video c lips. 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 pr ior 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 ma le and 5 female participants. Mean age was 20.4 years (SD = 0.97) and mean years of form al 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 s eated in front of a video camera. Beside them was the cold water immersion device (c old 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 ra tings for pain unpleasantn ess (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 a nd to withdraw their hand when they could no longer tolerate the sensation. Th ey were then asked to provid e ratings of pain intensity and pain unpleasantness of the cold-water task, using the scales described above.

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9 Measures Demographics Questionnaire: Provided in formation concerning the participants' sex, age, marital status, race, work status, and education. Previous Pain Experience Questi onnaire (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 sp linter) to major (i.e. gun shot, advanced cancer, serious burns, and heart attack) events. The partic ipants 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 particip ant had not experienced the event, they were asked to rate how painful they would imagin e the event to be. This measure has been used in previous studies, however it not been published and its psychometric properties are unknown. Family History Questionnaire (FHQ): The FHQ lists numerous chronic pain and psychological conditions. The participants are asked to report whether their biological mother, father, sister(s), brothe r(s) or the participants them selves have ever experienced the 17 listed conditions (i.e., rheumatoid ar thritis, irritable bowel syndrome, chronic fatigue syndrome, menstrual pain, fibr omyalgia, reflex sympathetic dystrophy, arthritis/joint pain, chronic headaches, bac k, neck, leg, and dental pain, other chronic pain, depression, anxiety disorder, Post Trau matic Stress Disorder, and other psychiatric diagnosis). To determine the number of pain exposure from the subject’s family, their reports for their mother, father, sister(s), a nd brother(s) were totaled. Multiple siblings were not distinguished from single siblings. This measure has been used in previous studies; however, it has not been publishe d and its psychometric properties are unknown.

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10 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 exis tence of sex differences wher e American men believed that expressive pain behavior wa s 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 statem ents (i.e. It is acceptable for me to cry when in pain, I believe I should k eep 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 disagr ee and 7 = strongly agree) that assesses the participant’s personal beliefs about appropriate pain behavior.

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11 CHAPTER 3 RESULTS 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 partic ipants. A hierarchical regres sion was conducted to determine whether the number of previous painful experiences (PPEQ), previous family history of pain (FHQ), and the Appropriate Pain Beha vior Questionnaire (APB Q-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 ques tionnaire. The APBQ-Y score was calculated by totaling ratings were after the responses were weighted according to the statement’s positive and negative valences. Block 1 consisted of, the PPEQ, FHQ a nd APBQ and predicted approximately 40.8% of the variance in accuracy of obser ved pain intensity (F(3,24)=5.507, p=.005). However, the regression revealed that the APBQ-Y was the only measure that significantly predicted th e pain intensity accuracy (st. beta=-.649, p=.001). This indicates an inverse relationship betw een the accuracy of pain intensity estimation and how appropriate the participant felt about expressing painful behavior s. In other words, higher willingness to express pain was associated with smaller difference scores, therefore higher accuracy.

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12 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 di fferences found in previous studies could be explained by family history, previous pain experience and willingness to express pain behaviors (Wise & Robinson, 2003). The additi on of sex in block 2 predicted an additional 4.9% of the variance in pain in tensity accuracy but was not statistically significant (F(4,23)=4.841, p=.006). Table 3-1. Results from hierarchical regression Measure Standardized Beta P R F APBQ -.649 .001 (F(3,24)=5.507, p=.005) PPEQ -.036 -.218 Block 1 FHQ .118 .715 .408 APBQ -.574 .003 PPEQ -.039 .810 FHQ .082 .500 Block 2 Sex .234 .234 .457 (F(4,23)=4.841, p=.006)

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13 CHAPTER 4 DISCUSSION The results of this study strengthen the c onclusion that personal expectations such as the belief in the appropriateness of expr essing 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 percepti on by their pain related gender stereotypes under laboratory-based experi mental paradigms. Nayak et al. (2000) found cultural and sex differences in beliefs about appropriate pain behaviors between participants in India and the United States. Indi an participants and male participants were less accepting of overt pain expression a nd had higher pain tolerances than their American and female counterparts, respectiv ely. 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 anothe r 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, persona l pain experiences were not found to be a significant predictor of accu racy of pain intensity estimation in this study. Additionally, previous studies indicated a relationship betwee n 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

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14 estimating pain in others. However, family history of pain was not found to be a significant predictor of estim ating pain in others. Interestingly, beliefs in the appropria teness 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, fam ily 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 intens ity in others. Results demonstrated that the more a person believe d 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. (2002). The data revealed that ob servers generally underestimat ed 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 estima tion. 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 gend er 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 ar e gender related, these roles appear to be involved in not ju st the subjective pain experience but also play a factor for those who view and estimate the pain experience in others.

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15 It is important to recognize that certain characteristics or beliefs of the observer affect their accuracy of es timating pain in others. Most health care providers make frequent medical decisions about people in pa in, especially in sett ings where prescribing or administering pain medications is required. However, these biases have not been fully explored in a heath care cont ext. By targeting these factor s, it becomes possible to allow health care providers to understand that these characteristics are influencing their perception of others. This can ultimately prov ide assistance for those in such professions to be more objective and accurate in their me dical 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.

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16 LIST OF REFERENCES Baron RS, Logan H, Kao CF: Some variables affecting dentists’ a ssessment 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, R ondeau 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. Per ceptual and Motor Skills 61:1053-1054, 1985 Fillingim RB, Edwards RR, Powell T: Sex-dependent effects of reported familial pain history on recent pain comp laints and experimental pain responses. Pain 86(12):87-94, 2000 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, Alle n 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 Mana gement Nursing 1(3): 88-95, 2000. Klonoff EA, Landrine H, Brown M. Appraisal an d response to pain may be a function of its bodily location. J Psychosoma tic Research 37(6): 661–670, 1993 Koutantji M, Pearce SA, Oakley DA: The rela tionship between gender and family history of pain with current pain experience and awareness of pain in others. Pain 77: 2531, 1998. Krivo S, Reidenberg, MM: Assessment of patie nts’ pain. Massachuse tts Medical Society 334(1): 59, 1996.

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17 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: Cult ure 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 in fluencing nurses’ use of nonpharmacological pain alleviation met hods 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, 1998 Robinson ME, Riley JL, Myers CD, Papas RK Wise EA, Waxenberg LB, Fillingim RB: Gender role expectations of pain: relationship to sex di fferences in pain. J Pain 2:251-257, 2001 Robinson ME, Wise EA: Gender bias in the obs ervation of experimental pain. Pain, 104: 259-264, 2003. Rollman GB: Sex differences in pain do exis t: The role of biol ogical and psychosocial factors. Behavioral and Br ain 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 w ith their pain: postoperative analgesia and nurses’ perceptions of their pa tients’ pain. Pain 68:63-68, 1996 Sheiner EK, Sheiner E, Shoham-Vardi I, Mazo r 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 Catastr ophizing Scale: Development and validation. Psychological Assessment 7(4):524-532, 1995 Thomas T, Robinson C, Chamption D, McKe ll M, Pell M: Prediction and assessment of the severity of post-operative pain and of satisfaction with management. Pain 75:177-185, 1998 Unruh AM: Gender variations in clinical pain experience. Pain 65(2-3):123-167, 1996 Von Bayer CL, Johnson ME, McMillan MJ: Co nsequences of nonverb al expression of pain: patient distress and observer co ncern. Soc Sci Med 19(12): 1319-1324, 1984 Wise EA, Price DD, Myers CD, Heft MW, R obinson ME: Gender role expectations of pain: Relationship to experimental pain perception. Pain 96:335-342, 2002

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18 Wessman AC, Mc Donald DD: Nurses’ pers onal pain experiences and their pain management knowledge. J Contin Educ Nurs 30(4): 152-157, 1999 Zalon ML: Nurses’ assessment of postopera tive patient’s pain. Pain 54: 329-334, 1993

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19 BIOGRAPHICAL SKETCH S. Karen Chung graduated from the Universi ty of California, Los Angeles in June of 2002 with a Bachelor of Science de gree in psychobiology. In August 2002, Karen Chung began her doctoral training in the Depart ment of Clinical a nd Health Psychology at the University of Florida. Her clinical and research interests are in the area of clinical health psychology.


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Permanent Link: http://ufdc.ufl.edu/UFE0004246/00001

Material Information

Title: Observer's Willingness to Express Pain Behaviors Influences the Accuracy of Estimating Pain in Others
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0004246:00001

Permanent Link: http://ufdc.ufl.edu/UFE0004246/00001

Material Information

Title: Observer's Willingness to Express Pain Behaviors Influences the Accuracy of Estimating Pain in Others
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0004246:00001


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OBSERVER'S WILLINGNESS TO EXPRESS PAIN BEHAVIORS INFLUENCES
THE ACCURACY OF ESTIMATING PAIN IN OTHERS















By

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


2004

































Copyright 2004

by

S. Karen Chung















ACKNOWLEDGMENTS



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,

Ph.D.
















TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ......... ................................................................................... iii

A B STR A C T ......... ..... ............................................................................... ......

CHAPTER

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

By

S. Karen Chung

May 2004

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.














CHAPTER 1
INTRODUCTION

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

dentists.

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






6


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.














CHAPTER 2
MATERIALS AND METHODS

Participants

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.

Procedures

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.









Measures

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

are unknown.

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.














CHAPTER 3
RESULTS

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

negative valences.

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

higher accuracy.









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
Beta
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)














CHAPTER 4
DISCUSSION

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.

(2002).

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.















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BIOGRAPHICAL SKETCH

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

health psychology.