Citation
Sex and Race Differences in Rating Others' Pain, Pain-Related Negative Mood, Pain Coping, and Recommending Medical Help

Material Information

Title:
Sex and Race Differences in Rating Others' Pain, Pain-Related Negative Mood, Pain Coping, and Recommending Medical Help
Creator:
Alqudah, Ashraf F
Place of Publication:
[Gainesville, Fla.]
Florida
Publisher:
University of Florida
Publication Date:
Language:
english
Physical Description:
1 online resource (62 p.)

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Psychology
Clinical and Health Psychology
Committee Chair:
Robinson, Michael E.
Committee Members:
Riley, Joseph L.
Bauer, Russell M.
Price, Donald D.
Graduation Date:
8/11/2007

Subjects

Subjects / Keywords:
African Americans ( jstor )
Chronic pain ( jstor )
Descriptive statistics ( jstor )
Emotional expression ( jstor )
Facial expressions ( jstor )
Multilevel models ( jstor )
Pain ( jstor )
Ratings ( jstor )
Sex linked differences ( jstor )
Women ( jstor )
Clinical and Health Psychology -- Dissertations, Academic -- UF
african, americans, assessment, caucasians, coping, differences, females, help, human, males, medical, mood, pain, race, recommending, sex, virtual
Genre:
bibliography ( marcgt )
theses ( marcgt )
government publication (state, provincial, terriorial, dependent) ( marcgt )
born-digital ( sobekcm )
Electronic Thesis or Dissertation
Psychology thesis, Ph.D.

Notes

Abstract:
Sex and race influence pain ratings. We studied these influences in ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommending medical help. Seventy-five undergraduates viewed virtual human virtual humans expressing pain, and provided computerized ratings via VASs. A series of Mixed ANOVAs was performed. Male and female participants rated female virtual humans higher than male virtual humans on pain intensity, (p < 0.05), pain unpleasantness, (p < 0.01), pain-related negative mood, (p < 0.05), poor pain coping, (p < 0.05), and recommending medical help, (p < 0.05). Male and female virtual humans need for medical help was rated higher by male participants compared to female participants, (p < 0.05). Males also rated African American and Caucasian virtual humans need for medical help higher than females' ratings, (p < 0.05). African Americans and Caucasians rated female virtual humans higher on pain intensity, (p < 0.05) and pain unpleasantness, (p < 0.05). Caucasians and African Americans viewed Caucasian virtual humans pain-related negative mood as higher than African Americans, (p < 0.05). Caucasians' ratings of male and female virtual humans pain-related negative mood were higher than African Americans' ratings, (p < 0.05). Caucasians rated females' pain-related negative mood higher than males', (p < 0.05). Caucasians' and African Americans' ratings for poor coping were higher for Caucasian virtual humans compared to African American virtual humans, (p < 0.05). African Americans' ratings for African American virtual humans' pain intensity were higher than for Caucasian virtual humans. In summary, both sexes and races had higher ratings for females' pain. Both races rated female virtual humans higher on each variable. Both races rated Caucasians as having more negative mood and poorer coping than African Americans. Females' higher negative mood and poorer coping might be explained the relationship between pain, mood, and coping. Results show that races may differ in sensitivity to pain expressions. Males' tendency to seek more pain medications may explain their high levels of recommending virtual humans to seek medical help. Technology used in this study (virtual humans) is discussed along with its possible future use and applicability. ( en )
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis:
Thesis (Ph.D.)--University of Florida, 2007.
Local:
Adviser: Robinson, Michael E.
Statement of Responsibility:
by Ashraf F Alqudah.

Record Information

Source Institution:
UFRGP
Rights Management:
Copyright Alqudah, Ashraf F. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Classification:
LD1780 2007 ( lcc )

Downloads

This item has the following downloads:


Full Text






Table 3-1. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain intensity made by male and female participants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Male 40.6 15.8 4.92 0.063 0.03
Female 37.8 14

Female Male 41.6 14.7
Female 40.9 13.6
Pain Intensity Ratings for sex of 1.23 0.017 0.27
virtual human sex of participants

Between Participants Effect 0.24 0.003 0.62

Table 3-2. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain intensity made by Caucasian and African American
parti cipants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Caucasian 38.7 14.4 6.93 0.087 0.01
African American 38.6 15.9

Female Caucasian 40.9 14.2
African American 42.3 12.8
Pain Intensity Ratings for sex of 0.41 0.006 0.52
virtual human race of participants

Between Participants Effect 0.03 0.000 0.88

Table 3 -3. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain intensity made by Caucasian and African American
parti cipants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian Caucasian 39.4 13.7 2.62 0.035 0.11
African American 42.6 15.6

African American Caucasian 40 14.8
African American 38.3 12.9
Pain Intensity Ratings for race of 4.73 0.061 0.033
virtual human race of participants

Between Participants Effect 0.03 0.000 0.86










Table 3-17. Descriptive statistics and mixed model ANOVA results of the effect of race of
virtual humans on ratings of recommending medical help made by male and female
participants
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian Male 52.8 24.8 0.11 0.00 0.74
Female 42.9 19.3

African American Male 52.9 24.2
Female 42.1 18.4
Recommending medical help ratings for 0.21 0.00 0.65
virtual humans' race participants' sex

Between Participants Effect 4.06 0.53 0.048

Table 3-18. Descriptive statistics and mixed model ANOVA results of the effect of race of
virtual humans on ratings of recommending medical help made by Caucasian and
African American participants
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian Caucasian 45.3 21.7 1.44 0.02 0.24
African American 48.1 20.1

African American Caucasian 45.3 21.5
African American 45.3 17.2
Recommending medical help ratings 1.36 0.02 0.25
for virtual humans' race *
participants' race

Between Participants Effect 0.05 0.00 0.85

Table 3-19. Correlations between the dependent variables
Pain Pain Pain-related Pain Recommending
Intensity Unpleasantness negative coping medical help
mood
Pain Intensity 1 0.87 0.72 0.68 0.53
Pain Unpleasantness 0.87 1 0.82 0.75 0.51
Pain-related negative 0.72 0.82 1 0.71 0.42
mood
Pain coping 0.68 0.75 0.71 1 0.35
Recommending medical 0.53 0.51 0.42 0.35 1
help

































O 2007 Ashraf Faris Alqudah









that in standard instructional sets, pain report would differ between males and females. And these

differences would decrease when females and males were given similar sex role expectations for

pain tolerance. Their work was the first to show that sex differences in pain report decrease when

sex role is experimentally manipulated. Results also supported the notion that assessments of sex

differences in pain responding, in laboratory settings, are influenced by sex role-related

expectations of pain. That is, pain tolerance can be manipulated by altering sex role-based

expectations for pain.

There are few studies examining how individuals view others in pain, either

experimentally or clinically. Robinson et al. (2001) have found that males and females differ

significantly in their pain expectations for self and others. Investigators examined how both

sexes observe experimentally induced pain in male and female participants. They found that,

regarding virtual humans' sex, viewers rated male virtual humans as having less pain than female

virtual humans. Regarding sex of the observer, however, female viewers rated observed pain

intensity significantly higher than did male viewers. In a more recent study, Robinson & Wise

(2004) found that participants rated female subj ects as experiencing greater pain intensity when

undergoing a cold pressor task compared to males. Parental observation, sociocultural norms,

acuity in observing overt behaviors, and beliefs regarding roles were suggested by the

investigators to play a part in the explanation of how one perceives another in pain.

Sex Differences in Pain-Related Negative Mood

The current definition of pain by the International Association for the Study of Pain as "an

unpleasant sensory and emotional experience associated with actual or potential tissue damage,

or described in terms of such damage." reflects the subj ective, multidimensional nature of pain.

A better understanding of the experience of clinical pain highlights the importance of









CHAPTER 1
INTTRODUCTION

Pain is an individual subj ective experience that is known to have psychological

components. Almost a fifth of American adults experience chronic pain (a total of 50 million).

Persistent pain is experienced by 17% of patients in the United States seen by primary care

physicians. And people who seek treatment for chronic pain each year are estimated to be about

4.9 million. Significant pain accompanies the maj ority of more than 23 million surgical

procedures that are performed each year in the United States. Direct and indirect costs for the

treatment of pain and the pain-related losses are estimated to be more than $125 billion per year

(Turk & Melzack, 2001).

Sex Differences in Pain Perception and Rating

Empirical investigations support the presence of sex differences in pain (Robinson, Riley,

Myers, Papas, Wise, Waxenberg, & Fillingim, 2001; Frot, Feine, & Bushnell, 2004; Robinson &

Wise, 2003; Ellermeier & Westphal, 1995; Vallerand & Polomano, 2000; Hawthorn &

Redmond, 1998; Unruh, 1996; Dao & LeResche, 2000; Robinson & Wise, 2004). However, the

degree to which sex influences pain perception is not completely clear. Although a number of

studies have shown that females perceive and express higher levels of pain than males, other

studies have found no differences between the sexes (Hawthorn & Redmond 1998). A number of

researches have shown that females are more likely to experience pain in a range of medical

conditions compared to males. For example, females report more frequent tension and migraine

headaches than males (Unruh, 1996), and have higher prevalence rates for orofacial (Dao et al,

2000) and musculoskeletal pain (Unruh, 1996). Sex-related differences in pain perception have

also been found in experimental pain settings (Frot et al. 2004).









CHAPTER 3
RESULTS

A series of mixed model ANOVA models was performed where sex and race of

participants and virtual humans served as independent variables, and ratings of pain intensity,

pain unpleasantness, pain-related negative mood, pain coping, and the extent to which the

[virtual humans] are recommended to seek medical help for their pain as dependent variables.

The willingness to report pain, and pain endurance are two factors of the GREP that are

being considered to be included in the model as covariates. However, correlation analysis was

conducted on these two factors as well as male and female participants' ratings of pain intensity

and pain unpleasantness for male and female virtual humans. Results showed that correlations

are not significant. Therefore, willingness to report pain, and pain endurance were dropped from

the model because the assumptions of covariance analysis were not met.

Analysis of Pain Intensity Ratings

Sex Effects

Both male and female participants rated pain intensity for female virtual humans

significantly higher than that for male virtual humans, F (1, 73) = 4.92, p < 0.05. Between

participants main effects, and sex of virtual human by sex of participant interactions were non-

signifieant (see table 3-1). Both Caucasian and African American participants rated pain

intensity for female virtual humans significantly higher than that for male virtual humans, F (1,

73) = 6.93, p < 0.05. Between participants' main effects or the sex of virtual human by race of

participant interaction effects were non-signifieant, (see table 3-2).










(2000) Found that African Americans rated the thermal stimuli as more unpleasant and more

intense than Caucasians. Edwards et al (1999) found that African Americans had a lower thermal

pain tolerance and greater pain severity than Caucasians. Edwards et al (2001) also found that

African Americans report significantly greater pain severity and pain-related disability than

Caucasians. These studies investigated participants' ratings of their own pain conditions. The

current study, however, investigated participants' ratings of others' pain. Since Caucasians did

not rate African Americans' pain as high as African Americans did, results may indicate

differences between race-related cultures in terms of sensitivity to facial pain expressions, that' s

is, African Americans might be more sensitive to African Americans' facial expressions of pain

than Caucasians. Rahim-Williams, Riley III, Herrera, Campbell, Hastie & Fillingim (2007)

studied ethnic identity to determine whether it associates with experimental pain intensity in

three groups including African Americans. They found that African Americans scored the

highest on the ethnic identity measure. Researchers suggested that higher scores on the ethnic

identity measure would mean higher ethnic-specific socio-cultural influence on the pain

experience. Since African Americans scored higher on the ethnic identity measure, and that

means higher influence of their culture on pain experience, it is possible that they have rated

African American virtual humans' pain intensity as higher than that for Caucasian virtual

humans because they (the African American participants) are more sensitive to pain behaviors,

including facial pain expressions, exhibited by individuals of the same race-related culture. In the

Study mentioned above, Non-Hispanic Whites scored the lowest on the ethnic identity measure,

suggesting that it is possible that Caucasians are not as influenced by their racial culture. This

might suggest that Caucasians are less sensitive to pain behaviors, including facial pain

expressions, exhibited by individuals of the same race. However, further investigation of this









Several studies indicate that patients with a variety of chronic pain conditions report

anxiety levels significantly greater than published norms and that a significant amount of the

variance in pain report can be explained by anxiety (Gaskin, Greene, Robinson, & Geisser, 1992;

Brown, Robinson, Riley, & Gremillion, 1996; Holzberg, Robinson, Geisser, & Gremillion,

1996). Gaskin et al. (1992) used regression methodology to ascertain relationships between

clinical pain measured by the McGill Pain Questionnaire and measures of depression, anxiety,

and anger and found that 33% of the McGill affective dimension of pain was associated with

state anger and state anxiety, and 19% of the McGill sensory dimension was associated with state

anxiety. Anger is considered as an affective state that may be related to pain and styles of

inhibiting anger have been found to be the strongest predictor of pain intensity (Kerns,

Rosenberg, & Jacob, 1994). The development of depression in general has been linked to the

suppression of anger in general, as well as specifically among pain patients (Beutler, Engle,

Oro'-Beutler, Daldrup, & Meredith, 1986).

Sex-specific relationships between pain and negative affect have been evidenced in both

community and clinical samples (Riley, Robinson, Wade, Myers, & Price, 2001). In the National

Health and Nutrition Examination Survey, pain and depressive symptoms tended to be more

evident in females than in males (Magni, Caldieron, Rigatti-Luchini, & Merksey, 1990). In pain

clinic patient samples, prevalence of depression and anxiety is typically higher for females

(Unruh, 1996), although at least one study reported more depression and anxiety in males

(Buckelew, Shutty, Hewitt, Landon, Morrow, & Frank, 1990). In within-day assessments of pain,

pain coping, and mood in males and females having Osteoarthritis, a study aimed to analyze sex

differences in dynamic relations between pain, mood, and pain coping. Participants rated their

pain, pain coping, and mood two times each day for 30 days using a booklet format. One Einding










REFERENCES


Adamson, J., Ben-Shlomo, Y., Chaturvedi, N., & Donovan, J. (2003). Race, socio-economic
position and sex-do they affect reported health-care seeking behaviour? Social Science &
Medicine, 57 (5), 895-904.

Affleck, G., Tennen, H., Keefe, F. J., Lefebvre, J. C., Kashikar-Zuck, S., Wright, K., Starr, K., &
Caldwell, D. S. (1999). Everyday life with osteoarthritis or rheumatoid arthritis:
Independent effects of disease and sex on daily pain, mood, and coping. Pain, 83, 601-
609.

Ambadar, Z., Schooler, J., & Cohn, J (2005). Deciphering the enigmatic face: the importance of
facial dynamics in interpreting subtle facial expressions. Psychological Science. 16, 403-
410.

Anderson, K., Palos, G., Gning, I., Mendoza, T., Sanchez, M., Valero, V., Richman, S., Nazaria,
A., Hurley, J., Payne, R. & Cleeland, C. (2003). Multi-site randomized trial of pain
management education for minority outpatients with cancer pain. Pain 4, 95.

Bassili, J (1979). Emotion recognition: the role of facial movement and the relative importance
of upper and lower areas of the face. Journal of Personality and Social Psychology. 37,
2049-258.

Bates, M. S. (1996). Biocultural dimensions of chronic pain: implications for treatment of
multiracialpopulations. Albany, NY: State University of New York Press.

Beutler, L.E., Engle, D., Oro'-Beutler, M.E., Daldrup, R. & Meredith, K. (1986). Inability to
express intense affect: a common link between depression and pain? Journal of
Consulting and Clinical Psychology, 54 (6), 752-759.

Bombardier, C.H., D'Amico, C., & Jordan, J. S. (1990). The relationship of appraisal and coping
to chronic illness adjustment. Behavior Research and 7herapy 28, 297-304.

Boothby, J. L., Thorn, B. E., Stroud, M. W., & Jensen, M. P. (1999). Coping with Pain. In
Gatchel, R. G., & Turk, D. C. (Eds.), Psychosocial Factors in Pain. New York: Guilford
Press.

Boyatzis, C., Cazan, E., & Ting, C (1993). Preschool children' s decoding of facial emotions.
Journal of General Psychology. 1 54, 3 75-3 82.

Brodsgaard, M. R. (1999). Cross-cultural investigations of pain. In: Crombie IK, editor.
Epidemiology of pain. Seattle: IASP Press.

Brown, F. F., Robinson, M. E., Riley, J. L. & Gremillion, H. A. (1996). Pain severity, negative
affect, and microstressors as predictors of life interference in TMD patients. CRANIO,
14:63-70.









BIOGRAPHICAL SKETCH

Ashraf Faris Alqudah was born on November 11, 1975 in Ajloun, Jordan. He grew up in

Ajloun until he graduated from Aj ouln High School in 1993. He moved to Amman, the capital

city of Jordan, to study at the University of Jordan (JU). He earned his B. A. and M. A. in

Psychology in 1997 and 2000, respectively. He worked as a teaching assistant for 1 year at JU

upon receiving a scholarship to pursue his Ph. D. degree in Clinical Psychology.

Upon finishing the teaching assistant year at JU, he was admitted to the Graduate School at

the University of Florida (UF) to work on his Ph. D. in Clinical Psychology at the UF Health

Science Center, College of Public Health and Health Professions, Department of Clinical and

Health Psychology. Upon completion of his Ph. D. program, Ashraf will j oin the faculty of the

Department of Psychology at JU. He has a 4-year-old daughter whose name is Sarah.









Racial differences in pain related coping were also found between African Americans and

Whites on every Coping Strategies Questionnaire-Revised scale dimensions after including sex

and age as covariates in the model (Hastie, Riley, & Fillingim, 2004).

Pain coping strategies generally vary widely between cultures. Cultural differences in pain

coping strategies might be as important as the differences in the prevalence pain or its reported

severity (Brodsgaard, 1999). Racial differences in pain coping within clinical samples might not

be the result of a long chronic pain experience, but might be present even in the absence of

chronic pain. So, racial differences in pain coping might indicate an exacerbation of stress

management styles that are inherited, such as pain. Coping is not individualistic but is folded in

the influences of the person' s ethno-cultural environment and sub-cultural context (Hastie et al.,

2004).

Racial Differences in Pain-Related Negative Mood

Race may have a maj or influence on the emotional and behavioral responses to pain and

pain appraisal (Edwards, Fillingim & Keefe, 2001). Socio-cultural factors related to racial

background may influence the meaning of the pain experience (Bates, 1996). Consequently, pain

appraisals can have a maj or influence on pain-related emotional responses such as depression

and anxiety, as well as behavioral responses such as the decision to seek treatment, adherence to

treatment regimens (Edwards et al., 2001).

Associations have also been reported between depression and emotion-focused coping

strategies in chronic pain (Weickgenant, Slater, Patterson, Atkinson, Grant, & Garfin, 1993; de

Ridder, & Schreurs, 2001; Endler, Corace, Summerfeldt, Johnson, & Rothbart, 2003). Studies on

patients coming to pain centers for initial assessment found that higher pain intensity and

depression were associated with being African American, younger, and having a pain duration of

more than 30 months (Anderson, Palos, Gning, Mendoza, Sanchez, Valero, Richman, Nazaria,









finding is needed to further understand and explain the existence and the implications of between

races differences in sensitivity to facial pain expressions.

The International Association for the Study of Pain defines pain in a way that highlights

the importance of understanding of the negative emotional experiences of pain. Part of that

emotional experience is the negative mood that accompanies pain experience. Although all facial

expressions of pain were digitally controlled to be similar for males and females in this study,

female virtual humans' pain-related negative mood was rated significantly higher than that for

male virtual humans' by both male and female participants. These results might be explained by

the positive relationship between pain and negative mood found and is consistent with the

findings of the National Health and Nutrition Examination Survey, where pain and depressive

symptoms tended to be more evident in females than in males (Magni et al, 1990). Turk &

Okifuji (1999) also found that females were viewed as more depressed than males when in pain.

These results also highlight the role of the expectations males have regarding the effects of

females' high levels of pain on their moods. Current data also indicate that Caucasians and

African Americans differ in their ratings of pain-related negative mood. Although Caucasian

participants' ratings of pain-related negative mood for male and female virtual humans were

significantly higher than African Americans' ratings, they even rated females' pain-related

negative mood as significantly higher than males' pain-related negative mood. This highlights

the role that culture might play in perceiving pain effects on the mood of females and males.

Caucasian virtual humans were rated by both African American and Caucasian participants

as having higher pain-related negative mood. However, this is not consistent with the positive

relationship between pain level and negative mood experiences. These results indicate that race

might moderate the relationship between pain and pain-related negative mood.









of FACS was used in this study focusing on 4 action units: brow lowering, tightening of the

orbital muscles surrounding the eye, nose wrinkling/upper lip raising, and eye closure.

Each virtual human the participants observed consisted of a vignette and a virtual reality

virtual human of the observed patient of each sex and race. Each virtual human contained three

cues: sex (two levels: male or female), race (two levels: Caucasian or African American), and

pain (two levels, and were manipulated only in the observed virtual human and was inferred by

the participants based on the virtual humans' facial pain expressions). Pain-related negative

mood, pain coping, and the virtual humans need to be recommended to seek medical help was

also inferred by the participants based on and related to the pain facial expressions of the

observed virtual human of both sexes and races.

In order to minimize the impact of social desirability on participants' ratings, participants

were instructed to completely respond to virtual humans in the order presented, complete one

virtual human before going to the next, and not to revisit a previously completed virtual human.

For each virtual human (of both sexes and races), participants (of both sexes and races) used

computerized VASs to (1) rate the level of pain intensity they think the observed virtual human

is experiencing, (2) rate the level of pain unpleasantness they think the observed virtual human is

experiencing, (3) rate the level of pain-related negative mood the observed virtual human is

experiencing due to his/her observed pain, (4) rate how well they think that the observed virtual

human is coping with the pain experience, and (5) rate the extent to which they would

recommend the observed virtual human to seek pain-related medical help. Participants also

completed a computerized version of the Sex Role Expectations of Pain questionnaire (GREP)

(appendix A) using computerized VASs to assess for the degree to which sex role expectations

of pain may contribute to their ratings.










Hurley, Payne, & Cleeland, 2003; Green, Anderson, Baker, Campbell, Decker, Fillingim,

Kaloukalani, Lasch, Myers, Tait, Todd, & Vallerand, 2003; Green, Baker, Sato, Washington, &

Smith, 2003; and Green, Baker, Sato, Washington, & Smith, 2003). One study aimed to explore

relationships between chronic pain and race. The researchers asked the participants to rate the

degree to which their chronic pain interferes with their lives, and found that African Americans

had significantly higher rating than Caucasians on irritability, disturbed sleep, inability to

participate in pleasurable activities, and loss of appetite due to their pain condition (Portenoy,

Ugarte, Fuller, & Haas, 2004). Research on pain related mood has shown that African Americans

with chronic pain had higher pain severity, depression, and disability when compared to whites

with chronic pain (Carmen, Green, Ndao-Brumblay, Nagrant, Baker, & Rothman, 2004).

Riley, Wade, Myers, Sheffield, Papas, & Price (2002) found that African Americans

experience greater emotional suffering compared to white participants on similar levels of pain

intensity. The researchers identified depression, anxiety, frustration, anger, and fear as the

components of the emotional factor in their study. Researchers used VASs to assess for the

components of the emotional factor. In a retrospective analysis of persons younger than 50 years

of age presenting for chronic pain management in a multidisciplinary pain center, Green et al.

(2003) found that African American participants were more depressed, anxious, and irritable

compared to white participants.

Facial Expression of Emotions

Charles Darwin was one of the first who talked about facial expressions of emotion. In his

1872 book, Expression of the Emotions in Man and Animals, he suggested that humans'

expressive movements are remnants of earlier ones. Taking the expression of grief in adult as an

example, it is a toned down version of crying in the infants (Woodworth, 193 8). The wide-open

mouth of crying involves muscles of the corner of the mouth, and the slight movement of these









The ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain

coping, and recommending medical help showed significant intercorrelations. Relationships

between these dependent variables have a pattern that might add to the explanation of some of

the current results. For example, the high correlation between pain intensity, pain unpleasantness,

pain-related negative mood, and pain coping might add to the explanation as to why female

virtual videos were rated high on all of them, if pain rating influenced the other ratings.

The results of this study have exciting implications, however, this study has some

advantages and disadvantages worth noting. One limitation of this study is that only one African

American male participated in it. Efforts to recruit more African Americans through study

announcements to specifically target African American undergraduates were not successful.

The use of computerized virtual humans with digitally controlled facial expressions of pain

based on the FACS, and digitally controlled pain levels across sexes and races of virtual humans,

is innovative. This enables greater control over unifying facial pain expressions and levels of

pain than if we had used human virtual humans. This technique, by the high control it provides

over the ecology, also enables greater confidence in focusing on biases and variance brought to

the ratings by participants.

Furthermore, the virtual human technology used in this study, has the potential to develop

to be an educational assessment and intervention tool. Students, health care providers, and other

individuals can use this technology to assess for their own biases regarding pain expressed by

others and regarding specific variables of interest assigned to the observed virtual humans. This

technology is also accessible from almost everywhere in the world via the Internet. One

advantage of the easy access to this technology is that it makes, for example, cross-cultural

studies much easier to conduct if same stimuli were to be used. Such an example provides wider










Wehrle, T., Kaiser, S., Schmidt, S., & Scherer, K (2000). Studying the dynamics of emotional
expression using synthesized facial muscle movements. Journal ofPersonality and'
Social Psychology. 78 (1), 105-119.

Weickgenant, A. L., Slater, M.A., Patterson, T. L., Atkinson, J. H., Grant, I. & Garfin, S. R.
(1993). Coping activities in chronic low back pain: relationship with depression. Pain,
53, 95-103.

Weir, R., Browne, G., Tunks, E., Gafni, A., & Roberts, J. (1996). Sex differences in psychosocial
adjustment to chronic pain and expenditures for health care services used. Clinical
Journal of Pain, 12, 277-290.

Weisse, C. S., Sorum, P. C., & Dominguez, R. E. (2003). The influence of sex and race on
physicians' pain management decisions. The Journal ofPain, 4 (9), 505-510.

Woodworth, R. S. (1939). Experimental Psychology. New York: Holt.

Woodworth, R. S., & Schlosberg, H. (1954). Experimental Psychology. New York: Holt.

Zatzick, D. F. & Dimsdale, J. E. (1990). Cultural variations in response to painful stimuli.
Psychosomatic M~edicine. 52, 544-557









praying/hoping as coping strategies, whereas, Caucasians reported greater use of ignoring pain

and coping statements (Jordan, Lumley, & Leisen, 1998).

Many researchers concluded that race is an important predictor of pain-related

symptomatology and pain coping (Edwards & Fillingim, 1999; Greenwald, 1991; Novy, Nelson,

Hetzel, Squitieru, & Kennington, 1998; Sheffield, Biles, Orom, Maixne, & Sheps, 2000; Zatzick

& Dimsdale, 1990). Others such as Edwards, Doleys, Fillingim, & Lowery (2001) highlighted

that future investigations may benefit from assessment of coping strategies as a potential

mediator or moderator of relationships between race and pain responses. Previous research has

suggested that coping, social learning, and attitudes might play an important role that is yet

unstudied in racial differences in health conditions, particularly pain (Folkman & Moskowitz,

2000; Moore & Brodsgaard I, 1999). Jordan et al (1998) compared racial groups on pain coping

strategies and control beliefs and the relationships of these variables to health status among

women with rheumatoid arthritis. They found that Racial groups did not differ in pain severity or

negative affect, but African-Americans used more coping techniques involving diverting

attention and praying/hoping. And that Caucasians used more coping techniques involving

ignoring pain. The relationships of praying/hoping and reinterpreting pain to RA adjustment

differed by racial group. Whereas, ignoring pain, coping statements, and stronger control beliefs

predicted better health status, diverting attention predicted more pain for all patients. These

findings suggest that there are racial differences in the use of coping strategies that should be

acknowledged when helping patients cope with their pain.

Campbell, Edwards, & Fillingim (2005), Examined racial differences in responses to

multiple experimental pain stimuli, including heat pain, cold pressor pain, and ischemic pain and

found that African Americans reported greater use of passive pain coping strategies.











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

SEX AND RACE DIFFERENCES IN RATING OTHERS' PAIN, PAIN-RELATED
NEGATIVE MOOD, PAIN COPING, AND RECOMMENDING MEDICAL HELP

By

Ashraf F ari s Al qudah

August 2007

Chair: Michael E. Robinson
Major: Psychology

Sex and race influence pain ratings. We studied these influences in ratings of pain

intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommending

medical help. Seventy-five undergraduates viewed virtual human virtual humans expressing

pain, and provided computerized ratings via VASs. A series of Mixed ANOVAs was performed.

Male and female participants rated female virtual humans higher than male virtual humans on

pain intensity, (p < 0.05), pain unpleasantness, (p < 0.01), pain-related negative mood, (p <

0.05), poor pain coping, (p < 0.05), and recommending medical help, (p < 0.05). Male and

female virtual humans' need for medical help was rated higher by male participants compared to

female participants, (p < 0.05). Males also rated African American and Caucasian virtual

humans' need for medical help higher than females' ratings, (p < 0.05). African Americans and

Caucasians rated female virtual humans higher on pain intensity, (p < 0.05) and pain

unpleasantness, (p < 0.05). Caucasians and African Americans viewed Caucasian virtual

humans' pain-related negative mood as higher than African Americans', (p < 0.05). Caucasians'

ratings of male and female virtual humans' pain-related negative mood were higher than African

Americans' ratings, (p < 0.05). Caucasians rated females' pain-related negative mood higher










Table 3-8. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain pain-related negative mood made by Caucasian and
African American participants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Caucasian 39 15.2 0.55 0.01 0.46
African American 32.5 16.2

Female Caucasian 42.2 14.3
African American 31 16.2
Pain-related negative mood ratings 4.11 0.05 0.05
for virtual humans' sex *
participants' race

Between Participants Effect 4 0.52 0.05

Table 3 -9. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain pain-related negative mood made by male and female
parti cipants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian Male 42.8 15.8 1.29 0.02 0.26
Female 38.6 14.6

African American Male 42.6 15.8
Female 36.3 15.9
Pain-related negative mood ratings for 0.9 0.01 0.35
virtual humans' race participants' sex

Between Participants Effect 1.95 0.03 0.17

Table 3-10. Descriptive statistics and mixed model ANOVA results of the effect of race of
virtual humans on ratings of pain pain-related negative mood made by Caucasian and
African American participants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian African American 41 14.3 5.34 0.068 0.024
Female 34.4 17.5

African American Caucasian 40 15.4
African American 29.2 16.6
Pain-related negative mood ratings 2.47 0.03 0.12
for virtual humans' race *
participants' race

Between Participants Effect 3.87 0.05 0.053









SEX AND RACE DIFFERENCES IN RATING OTHERS' PAIN, PAIN-RELATED
NEGATIVE MOOD, PAIN COPING, AND RECOMMENDING MEDICAL HELP

















By

ASHRAF FARIS ALQUDAH


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

UNIVERSITY OF FLORIDA

2007









A correlation analysis was conducted between dependent variables. All dependent

variables in this study (ratings of pain intensity, pain unpleasantness, pain-related negative mood,

pain coping, and recommending medical help) were intercorrelated. Correlations ranged between

0.35 (pain coping and recommending medical help) to 0.87 (pain intensity and pain

unpleasantness (see table 3-19).









Affleck, Tennen, Keefe, Lefebvre, Kashikar-Zuck, Wright, Starr, & Caldwell (1999) found

that females reported more problem solving, social support, positive self-statements, and

palliative behaviors than males. When the effects of disease and sex on daily pain, mood, and

coping were compared in 71 patients with Osteoarthritis and 76 patients with rheumatoid

arthritis, females had daily pain levels of 72% higher than the daily pain levels of males. Females

used more problem-focused and emotion-focused strategies every day than males. This suggests

the female participants endorsed more coping strategies than males.

The perceived seriousness of the pain experience may increase by the anticipated and

actual interference of pain on one's perceived responsibilities. Multiple primary role

responsibilities of females such as childcare or care for elderly parents, household management,

and paid employment may contribute to the appraisal of pain as threatening. They may attend to

pain earlier in an effort to minimize its' intrusiveness. Females may also be more worried and

irritated about pain. Role interference and perceived effectiveness or ineffectiveness of coping

strategies may contribute to the emotional response to pain. Normal biological processes that

result in troublesome pain experiences, recurrent pains with little or no pathological significance,

and pain experiences that are symptomatic of pathological, increase the complexity of female' s

pain experience and may lead to some frustration with self-management and assessment of pain.

Risks of depression and disability associated with pain may be increased due to irritability and

worry. Paid work remains the dominant occupational role for males although their involvement

in childcare and household responsibilities is slowly increasing. Risk of work disability may be

partially reduced by the greater opportunity to recover from pain if responsibilities for childcare,

household management and relationships are considered secondary and possibly assumed by a

partner. For males, unless the pain experience is interfering with work, they may perceive that










Table 3-14. Descriptive statistics and mixed model ANOVA results of the effect of race of
virtual humans on ratings of pain coping made by male and female participants
Virtual humans Participants' MSD F (1, 73) rl 2 P
Caucasian Male 34.6 14.6 0.79 0.01 0.38
Female 34.4 13.3

African American Male 35.5 15
Female 31.7 13.8
Pain-coping ratings for virtual 3.27 0.04 0.08
humans' race participants' sex

Between Participants Effect 0.35 0.01 0.56

Table 3-15. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of recommending medical help made by male and female
participants
Virtual humans Participants M~ SD F (1, 73) rl 2 P
Male Male 51.9 25.1 5.98 0.076 0.017
Female 40.8 18.6

Female Male 53.8 24.2
Female 44.4 19
Recommending medical help ratings for 0.64 0.01 0.43
sex of virtual human sex of participants

Between Participants Effect 4.02 0.052 0.049

Table 3-16. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of recommending medical help made by Caucasian and African
American participants
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Caucasian 43.7 21.6 3.63 0.05 0.06
African American 45.8 20

Female Caucasian 47.1 21.7
African American 47.6 17.5
Recommending medical help ratings 0.37 0.01 0.54
for virtual humans' sex *
participants' race

Between Participants Effect 0.04 0.00 0.84










Table 3 -6. Descriptive statistics and mixed model ANOVA results the effect of race of virtual
humans on ratings of pain unpleasantness made by male, female, Caucasian, and
African American participants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian Males 45.15 16.7 1.17 0.02 0.28
Females 44 13.3

African American Males 45 16.8
Females 42 14.7
Pain unpleasantness ratings for race of 0.77 0.01 0.38
virtual human sex of participant

Between Participants Effect 0.32 0.00 0.58

Caucasian Caucasian 44.58 14 2.55 0.03 0.11
African 43 16
American

African American Caucasian 43.4 15.4
African 40.4 14.9
American
Pain unpleasantness ratings for race of 0.38 0.01 0.54
virtual human race of participant

Between Participants Effect 0.268 0.00 0.61

Table 3-7. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain-related negative mood made by male and female
parti cipants.
Virtual humans Participants M~ SD F (1, 73) r 2 P
Male Male 41.2 15.9 6.76 0.085 0.011
Female 36.5 15.2

Female Male 44.2 15.3
Female 38.6 14.9
Pain-related negative mood ratings for 0.19 0.00 0.67
sex of virtual human sex of participants

Between Participants Effect 1.89 0.03 0.17









than males', (p < 0.05). Caucasians' and African Americans' ratings for poor coping were higher

for Caucasian virtual humans compared to African American virtual humans, (p < 0.05). African

Americans' ratings for African American virtual humans' pain intensity were higher than for

Caucasian virtual humans. In summary, both sexes and races had higher ratings for females'

pain. Both races rated female virtual humans higher on each variable. Both races rated

Caucasians as having more negative mood and poorer coping than African Americans. Females'

higher negative mood and poorer coping might be explained the relationship between pain,

mood, and coping. Results show that races may differ in sensitivity to pain expressions. Males'

tendency to seek more pain medications may explain their high levels of recommending virtual

humans to seek medical help. Technology used in this study (virtual humans) is discussed along

with its possible future use and applicability.










Table 3-4. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain unpleasantness made by male and female participants.
Virtual humans Participants M~ SD F (1, 73) rl 2 P
Male Male 43.2 16.8 7.61 0.095 0.007
Female 42 14.6

Female Male 46.9 16.9
Female 44 13.5
Pain unpleasantness ratings for sex of 0.57 0.008 0.454
virtual human sex of participants

Between Participants Effect 0.32 0.004 0.575

Table 3-5. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain unpleasantness made by Caucasian and African American
part cipants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Caucasian 42.7 14.6 4.17 0.054 0.045
African American 40.4 18.1

Female Caucasian 45.3 14.7
African American 43 14.2
Pain unpleasantness ratings for sex 0.00 0.00 0.99
of virtual human race of
participant

Between Participants Effect 0.267 0.00 0.61











Green, C. R., Baker, T. A., Smith, E. M. & Sato, Y. (2003). The effect of race in older adults
presenting for chronic pain management: A comparative study of African and Caucasian
Americans. Journal ofPain, 4, 82-90.

Green, C. R., Wheeler, J. R. & LaPorte, F. (2003). Clinical Decision Making in Pain
Management: Contributions of Physician and Patient Characteristics to Variations in
Practice. The Journal of Pain, 4 (1), 29-39.

Greenwald, H. P. (1991). Interracial differences in pain perception. Pain. 44, 157-163.

Hall, J (1978). Gender effects in decoding nonverbal cues. Psychological Bulletin. 85, 845-857.

Hamers, J. P., van den Hout, M., Halfens, R. J., Abu-Saad, H. H., & Heijltjes, A. E. (1997).
Differences in pain assessment and decisions regarding the administration of analgesics
between novices, intermediates and experts in pediatric nursing. International Journal of
Nursing Studies. 34 (5), 325-334.

Harwood, N., Hall, L., & Shinkfield, A (1999). Recognition of facial emotional expressions from
moving and static displays by individuals with mental retardation. American Journal of
Mentally Retarded. 104 (3), 270-278.

Hastie, B. A., Riley, J. L. & Fillingim, R. B. (2004). Racial differences in pain coping: Factor
structure of the coping strategies questionnaire and coping strategies questionnaire-
revised. The Journal ofPain. 5 (6), 304-316.

Hassenbusch, S. J. & Portenoy, R. K. (2000). Current Practices in Intraspinal Therapy: A Survey
of Clinical Trends and Decision Making. Journal of Pain and Synapton; Management, 20
(2), S4-S 11.

Hawthorn, J. & Redmond, K. (1998). Pain : Causes and2anageenten. Maiden, Mass. Blackwell
Science.

Hazelett, S., Powell, C., & Androulakakis, V. (2002). Patients' behavior at the time of injury:
Effect on nurses' perception of pain level and subsequent treatment. Pain Management
Nursing, 3 (1), 28-35.

Holm, K., Cohen, F., Dudas, S., Medema, P. & Allen, B. (1989). Effect of personal pain
experience on pain assessment. Journal of Nursing Scholarship, 21, 72-5.

Holzberg, A. D., Robinson, M. E., Geisser, M. E. & Gremillion, H. A. (1996). The effects of
depression and chronic pain on psychosocial and physical functioning. Clinical Journal
ofPain 12, 118-125.

Jasso, G., & Opp, K. (1997). Probing the Character of Norms: A Factorial Survey Analysis of the
Norms of Political Action. American Sociological Review. 62 (6), 947-964.










scope of races to be easily studied, as well as other cultures. Although the virtual human

technology used in this study focused only on facial pain expressions without sound, future

considerations might add other pain expressions to this technology, such as, verbal pain

expressions, body gestures that are pain related, and adding background environments that

determine context in which the pain is being experienced.

One other advantage of using virtual humans in this study is that it eliminates the biases in

the making of the stimuli. These stimuli are basically made digitally identical except for the

variables at interest in this study. One other advantage to this study is the focus on how others

perceive and rate others' pain and other dependent variables in this study. Most research

investigating pain perception focused on self-reports. Although self-reports of pain experience

are an important component in the quest of understanding the nature of pain, it is also important

to investigate how others perceive and view the experience of pain communicated to them by

other individuals. This contributes significantly to the overall understanding of the nature of pain

including how others appraise and respond to others' experiences of pain.










The presence of sex differences in the appraisal of pain might arise for two reasons. First,

males and females have differences in their pain experience over the lifespan, suggesting the

presence of meaning constructs of pain and related coping styles. Second, sex-based social role

expectations are different for males and females. Subsequently, the interference of the pain

experience differs with the roles and responsibilities for females and males. Pain-related

emotional and affective responses might also be affected by differences in social role

expectations (Unruh, 1996).

It is relatively well established that differences do exist between the sexes. However, the

underlying mechanisms are not clear yet. It has been suggested that sex differences in pain

perception are driven by both biological and socially learned factors, and also by the possible

interaction between them. Different expectations were found between males and females in

terms of the typical male' s and female' s pain responding. Males are viewed as less willing to

report their pain and more able to endure it. A manipulation of sex- related pain expectancy in

experimental setting eliminated the sex differences in cold pressor pain (Robinson et al., 2004).

Males and females endorse different predispositions to willingness to report their pain

significantly (Robinson et al. 2001). That is, males are less willing to report pain. Robinson,

Riley, & Myers (2000) have argued that the differences reported in many laboratory

investigations could largely be explained by the sex-related expectations of pain. Robinson,

Gagnon, Riley, & Price (2003) attempted to explicitly manipulate the sex role stereotypes for

males and females to further determine the effects of these stereotypes and related expectations

on different psychophysical responses to experimental pain. One of their hypotheses was that

manipulating the expected performance for males and females would influence their subsequent

pain report and reduce or eliminate the documented sex differences in pain. They hypothesized










3-13. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain coping made by Caucasian and African American
participants ................. ...............44.................

3-14. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain coping made by male and female participants ................... .....45

3-15. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of recommending medical help made by male and female
participants ................. ...............45.................

3-16. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of recommending medical help made by Caucasian and African
American participants .............. ...............45....

3-17. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of recommending medical help made by male and female
participants ................. ...............46.................

3-18. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of recommending medical help made by Caucasian and African
American participants .............. ...............46....

3-19. Correlations between the dependent variables .............. ...............46....










Hassenbusch et al, 2000). Since research has shown that sex and race differences in pain-related

negative mood and pain coping exist, the importance of investigating how males and females of

different races differ in perceiving other's pain-related negative mood and pain coping may in

turn lead to better understanding of the differences in the way males and females of different

races perceive, rate and respond to others' pain coping, pain-related negative mood, and better

pain management strategies.

This study adds to the determination of whether differences between males and females,

and differences between races exist in terms of perceiving and rating other peoples' pain. In

addition, this study contributes to the investigation of whether sex differences and/ or race

differences exist in perceiving and rating other's pain-related negative mood, pain coping, and

the extent of recommending seeking pain-related medical help.

Study Aims

The initial aim of this study is to determine whether sex and/or racial differences exist in

regard to rating other people's pain, pain-related negative mood, pain coping, and the extent of

recommending medical help for pain. Second, in this study, the sex role expectations of pain are

investigated as a possible mediator to the relationship between sex and the perceived others'

pain.

Hypotheses

There will be significant differences in participants' ratings for male and female virtual
humans' pain intensity, pain unpleasantness, pain-related negative mood, coping with
pain, and the extent in which virtual humans will be recommended to seek medical help
for their pain. Ratings made by male, female, Caucasian, and African American
participants for female virtual humans will be higher than their ratings for male virtual
humans.

There will be significant differences in participants' ratings for Caucasian and African
American virtual humans' pain intensity, pain uncleanness, pain-related negative mood,
coping with pain, and the extent in which the virtual humans will be recommended to











Rahim-Williams, B., Riley III, J, L., Herrera, D., Campbell, C, M., Hastie, B, A., & Fillingim, R,
B. (2007). Ethnic identity predicts experimental pain sensitivity in African Americans
and Hispanics. Pain, 129 (1-2), 177-184.

Riley, J. L., Wade, J. B., Myers, C. D., Sheffield, D., Papas, R. K. & Price, D. D. (2002).
Racial/racial differences in the experience of chronic pain. Pain. 100 (3), 291-298.

Riley, J. L., Robinson, M. E., Wade, J. B., Myers, C. D. & Price, D. D. (2001). Sex Differences
in Negative Emotional Responses to Chronic Pain. The Journal ofPain, 2 (6), 3 54-3 59.

Robinson, M. E., Gagnon, C. M., Riley, J. R. & Price, D. D. (2003). Altering sex role
expectations: effects on pain tolerance, pain threshold, and pain ratings. The Journal of
Pain, 4 (5), 284-288.

Robinson M. E. & Riley J. L. (1998). Role of negative emotions in pain, in Gatchel R. J. & Turk
D. C. (eds): Psychosocial Factors in Pain. New York, NY, Guilford Press, pp 74-88.

Robinson, M. E., Riley, J. L., & Myers, C. D. (2000). Psychosocial contributions to sex related
differences in pain responses. In: Fillingim, R. B. Sex, sex, and pain, Progress in pain
research and' management, 17. Seattle, WA: IASP Press, 41-68.

Robinson, M. E., Riley, J. L., Myers, C. D., Papas, R. K., Wise, E. A., Waxenberg, L. B. &
Fillingim, R. B. (2001). Sex role expectations of pain: Relationship to sex differences in
pain. Journal of Pain 2, 251-257.

Robinson, M. E. & Wise, E. A. (2004). Prior pain experience: influence on the observation of
experimental pain in men and women. The Journal ofPain, 5 (5), 264-269.

Robinson, M. E. & Wise, E. A. (2003). Sex bias in the observation of experimental pain. Pain,
104 (1-2), 259-264.

Robinson, M. E., Wise, E. A., Gagnon, C., Fillingim, R. B. & Price, D. D. (2004). Influences of
sex role and anxiety on sex differences in temporal summation of pain. The Journal of
Pain, 5 (2), 77-82.

Romano, J. M., & Turner, J. A. (1985). Chronic pain and depression: does the evidence support a
relationship? Psychological Bulletin, 97 (1), 18-34.

Rotter, N & Rotter, G (1988). Sex differences in encoding and decoding of negative facial
emotion. Journal ofNonverbal Behavior. 12, 139-148.

Sheffield, D., Biles, P. L., Orom, H., Maixne, W. & Sheps, D. S. (2000). Race and sex
differences in cutaneous pain perception. Psychosomatic M~edicine. 62 (4), 517-523.









other studies have used vignette format in medical and health settings (Mitchell and Owens,

2004; Weisse, Sorum, & Dominguez, 2003; Adamson, Ben-Shlomo, Chaturvedi, & Donovan,

2003; Hazelett, Powell, & Androulakakis, 2002; Hamer, van den Hout, Halfens, Abu-Saad, &

Heijltjes, 1997; Tait & Chibnall, 1997; Carey, Hadler, Gillings, Stinnett, & Wallsten, 1988; and

Cohen, 1980).

In terms of medication practices, research using vignettes that were identical, except for

the sex of the patient indicates that different amounts of analgesic medication were chosen based

on the patients' sex, with nurses' choosing less pain medication for female patients experiencing

pain than when compared to males (Cohen, 1980; McDonald & bridge, 1991). Campbell (2002)

found that in prospective vignette studies, some nurses have indicated the intention to spend less

time engaged in pharmacological pain management of female patients, and to select less pain

medication for female patients. She also found, using lens model and vignette format, that patient

pain report appears to play an early predispositional role in the clinical decision making process.

She also found that patient sex, age, and race play smaller predispositional roles in the clinical

decision making process (Campbell, 2002).

Study Rationale

Relatively little is known about how males and females of different races vary in respect to

perceiving and rating pain, pain-related negative mood, pain coping, and the extent to which

each would recommend seeking medical help for males, females, Caucasians, and African

Americans when experiencing pain. Some research has been done on sex differences in rating

other individual's pain. Previous research has shown that differences in perceiving and rating

other' s pain lead to differences in judgments and decisions relative to pain management, drug

prescriptions and health care providing (Tamayo-Sarver et al, 2004; Campbell, 2002; Cohen,

1980; McDonald et al, 1991; Holm, Cohen, Dudas, Medema, & Allen 1989; Green et al, 2003; &










Table 3-11i. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain coping made by male and female participants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Male 34.1 14.6 6.37 0.08 0.014
Female 31.8 13.3

Female Male 36 15
Female 34.2 13.4
Pain-coping ratings for virtual 0.08 0.00 0.78
humans' sex participants' sex

Between Participants Effect 0.35 0.01 0.56

Table 3-12. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain coping made by Caucasian and African American
parti cipants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Caucasian 32.7 13.8 2.84 0.04 0.096
African American 31.6 13.4

Female Caucasian 35.2 13.5
African American 32.5 15.5
Pain-coping ratings for virtual 0.63 0.01 0.43
humans' sex participants' race

Between Participants Effect 0.21 0.00 0.65

Table 3-13. Descriptive statistics and mixed model ANOVA results of the effect of race of
virtual humans on ratings of pain coping made by Caucasian and African American
participants
Virtual humans Participants' MSD F (1, 73) rl 2 P
Caucasian Caucasian 34.5 13.3 6.86 0.086 0.011
African American 34.5 15.3

African American Caucasian 33.6 14
African American 28.9 14.5
Pain-coping ratings for virtual 3.7 0.05 0.058
humans' race participants' race

Between Participants Effect 0.34 0.01 0.56









The most prominent nonverbal pain behavior has been considered to be the facial

expressions of pain (Craig & Patrick, 1985). In general, sex differences in facial expressions

have hardly been studied. And sex was rarely included as a factor in facial pain expressions

limited research (Kunz, Gruber, & Lautenbacher, 2006). Some research found no differences

between males and females in pain facial expressions (Craig, Hyde, & Patrick, 1991., and

Prkachin, 1992). However, Guinsburg, Peres, de Almeida, Balda, Bereguel, Tonelotto,

&Kopelman (2000) found increased facial pain responses in female neonates compared to male

neonates. Robinson et al. (2001) have found that males and females differ significantly in their

pain expectations for self and others. Viewers rated male virtual humans as having less pain than

female virtual humans and female viewers rated observed pain intensity significantly higher than

did male viewers. Robinson et al. (2004) found that participants rated female subj ects as

experiencing greater pain intensity when undergoing a cold pressor task compared to males.

Vignettes Research

This study used vignettes and virtual humans of virtual humans experiencing pain.

Vignettes, pioneered by Peter Rossi (Leahey, 2004) combine forms of survey research and

experimental designs. The vignette technique is applied to studies of problems in which

participants make evaluations regarding complicated objects. Desirable features included an

avoidance of real world multi-collinearity and the ability to isolate the independent variable of

interest. The vignette format is particularly appropriate for studying norms, attitudes, and beliefs

(Leahey, 2004). Jasso & Webster (1997); Jasso & Opp (1997); and Morrill, Snyderman, &

Dawson (1997) used the vignette format to explore normative judgments, sexed double

standards, and moral gaps in business settings.

Other researchers also used vignette formats in medical and health settings. Green,

Wheeler, & LaPorte (2003) used nine clinical vignettes to examine potential differences in the









families. Research on facial expressions yielded the possibility of separate discrete emotional

states such as fear and anger. Contraction of specific facial muscles provides the information as

to whether the expression represents anger, fear, sadness, disgust, enjoyment, or surprise

(Ekman, 1993).

Some research has argued that the dynamic facial expressions are necessary for complete

emotional information extraction derived from faces (Caron, Caron, & Myers, 1985). The

dynamics of expression is a factor that facilitates recognition of expressions. Researchers used

different stimuli such as computer generated schematic movies (Wehrle, Kaiser, Schmidt, &

Scherer, 2000), Natural movies (Harwood, Hall, & Shinkfield, 1999), subtle displays of emotion

(Ambadar, Schooler, & Cohn, 2005), and point-light displays (Bassili, J, 1979) argued for the

importance of dynamics in the perception of facial expressions of emotions.


Sex differences in recognition of facial expressions and facial pain expressions

Males and females show differences in perception of facial expressions. The maj ority of

the literature shows that females are better in identifying different affects expressed through face

(Hall, 1978., Kirrouac & Dore, 1985., Nowicki & Hartigan, 1988., and Tylor & Johnsen, 2000).

However, some research suggest that sex differences depend on the type of facial expression

being observed. Nowicki et al. 1988 found that females are better in recognizing expressions

such as fear and sadness. Whereas, Wagner, McDonald, Manstead, 2986., Mandal &

Palchoudhury, 1985., and Rotter & Rotter, 1988, found that males are better in identifying

displays of anger. The sex differences in recognizing facial expressions seem to hold true even at

an early age. Boyatzis, Cazan, & Ting, 1993, found that 3.5 year-old girls accuracy in

recognizing facial expression matched 5-year-old boys' accuracy.









CHAPTER 2
IVETHOD S

Participants

Recruitment

75 University of Florida undergraduate students of both sexes (53 females, 22 males) and

races (62 Caucasians, 13 African Americans) were recruited through flyers and posters

requesting volunteers to participate in this study.

Inclusion/Exclusion Criteria

Eligibility for participation required being at least 18 years old and English speaking. Only

males and females of African American or Caucasian background were included. Participation

was also contingent upon ability to give consent.

Procedure

Each participant was asked to read a description of the study including the time required to

complete the study and a reminder that the study is voluntary. After reading the study

description, all participants read and sign a computerized consent form acknowledging that the

study procedures were explained and that they could withdraw, without prejudice, from the study

at any time. Next, the participants filled out a demographic questionnaire. The following

demographic information was collected: sex, race, and age. After that, participants read a set of

instructions that provided information on how to approach the task and how to use Visual

Analogue Scales (VASs) to give ratings. Then, participants viewed the vignettes and the virtual

humans of both sexes and races. The virtual humans participants observed expressed pain

through facial expressions. These facial expressions of pain were digitally coded based on the

Facial Action Coding System (FACS). The FACS is based on anatomic analysis of facial muscle

movements and distinguishes 44 different action units (AUs). However, an abbreviated version










responses an important, if not central, role in understanding and predicting adjustment to pain

and illness (Boothby, Thorn, Stroud, & Jensen, 1999).

Given that individuals develop their own strategies for coping with painful experiences,

and since males and females differ in the experience of pain, it is likely that males and females

will develop different coping styles (Jensen, Turner, Romano, & Lawler, 1994; Weir, Browne,

Tunks, Gafni, & Roberts, 1996; Robinson et al, 2000). Unfortunately, little research has

investigated whether sex moderates or mediates the effectiveness of pain coping strategies

(Sullivan, Tripp, & Santor, 2000; Keefe, Lefebvre, Egert, Affleck, Sullivan, & Caldwell, 2000).

Unruh, Ritchie, & Merskey (1999), for example, presented results from a community based

telephone survey of people who reported pain in the two weeks before the interview. Researchers

found that females reported significantly more intense pain, as well as used a greater range of

coping strategies, i.e. greater social support seeking, problem-solving, positive self-statements

and palliative behaviors compared to males.

Another study aimed to determine whether sex differences would be found in the effect

that sensory-focused and emotion-focused coping instructions have on cold pressor pain

experiences. In this study, participants consisted of healthy adults, all of whom reported no

current pain. Compared to females, males showed less negative pain responses when focusing on

the sensory component of the pain experience, and compared to sensory focusing, emotional

focusing was found to increase the affective pain experience of females (Keogh & Herdenfeldt,

2002). Keefe et al. (2004) found that females used more problem focused coping than males, and

females who catastrophized were less likely than males to report negative mood. They also found

that males were more likely than females to use emotion-focused coping when their mood was

more negative.









Consistent with the pain-related negative mood results, male and female participants rated

female virtual humans as coping poorer with their pain, and Caucasian virtual humans were rated

by both Caucasian and African America participants as coping poorer with their pain. These

results mirror the pain-related negative mood ratings. These results suggest that when females

and Caucasians are viewed as having higher levels of pain than males and African Americans,

they are more likely to be viewed as experiencing higher levels of pain-related negative mood

and higher levels of poorer pain-related coping strategies.

When someone's pain level, pain-related negative mood, and pain-maladaptive coping is

rated high, it is expected that he/she is more likely to be recommended to seek medical help for

his/her pain. In this study, female virtual humans were rated higher on all of those variables than

male virtual humans, they also were recommended to seek medical help for their pain

significantly more than male virtual humans. However, it was not expected for male participants'

recommendations to be higher than female participants'. Males recommended female virtual

humans to seek medical help for their pain significantly more than the recommendation made by

female participants. Male participants also recommended Caucasian and African American

virtual humans to seek medical help for their pain significantly more than the recommendations

made by female participants. One possible explanation to why males' recommendations are

higher than females' recommendations is the difference between males and females in pain-

related medication seeking behaviors. Males have been shown to request more drugs than

females after surgery when given access to patient controlled analgesia (Macintyre & Jarvis,

1995. Burns, Hodsman, McLintock, Gillies, Kenny, & McArdle (1989) and Stinshoff, Lang,

Berbaum, Lutgendorf, Logan & Berbaum (2004) also found that males tend to seek more

medications for their pain compared to females.










experience as having limited importance. While females may be more irritated and worried about

pain, males may be more embarrassed by pain. Embarrassment may cause males to minimize

pain unless pain increases in severity or interferes with work. Social and cultural norms that

accept insensitivity to pain and pain endurance as measures of virility may minimize the pain

expression or reporting (Unruh, 1996). Klonoff, Landrine, & Brown (1993) found that male

undergraduate students were significantly more likely than females to rate their emotional

response to common pain problems as embarrassment regardless of the location of the pain.

Participants of both sexes identified the greatest threats to be the overall interference of pain and

the emotional distress when asked about their appraisal of pain (Unruh et al., 1999).

Racial Differences in Coping with Pain

The literature concerning chronic pain has shown that active coping, such as problem-

focused coping, tends to be associated with better physical and psychological functioning. And

passive coping, such as emotion-focused coping, tends to be associated with poorer physical and

psychological functioning (Jensen, Turner, Romano, & Karoly, 1991; Boothby et al., 1999).

Furthermore, patients who used problem-focused coping were better in adapting to chronic

disease than those who used emotion-focused strategies (Bombardier, D'Amico, & Jordan, 1990;

Maes, Leventhal, & de Ridder, 1996).

Little is known about racial differences in coping with pain as well as racial differences in

perceiving others' coping strategies when experiencing pain. It is possible that different coping

styles used by African Americans and Caucasians may impact the pain experience. For example,

in a study of pain coping among patients with rheumatoid arthritis, racial differences were

present in the use of pain coping strategies although no racial differences in pain were noted.

African Americans with rheumatoid arthritis reported significantly higher use of distraction and










participants (male and female) served as independent variables. The same process was repeated

for ratings of pain unpleasantness, pain-related negative mood, pain coping, and recommending

medical help. Then, ratings of pain intensity served as a dependent variable, and race of virtual

humans (Caucasian and African American), and sex of participants (male and female) served as

independent variables. The same process was repeated for ratings of pain unpleasantness, pain-

related negative mood, pain coping, and recommending medical help. After that, ratings of pain

intensity served as a dependent variable, and race of virtual humans (Caucasian and African

American), and race of participants (Caucasian and African American) served as independent

variables. The same process was repeated for ratings of pain unpleasantness, pain-related

negative mood, pain coping, and recommending medical help. Finally, ratings of pain intensity

served as a dependent variable, and sex of virtual humans (male and female), and race of

participants (Caucasian and African American) served as independent variables. The same

process was repeated for ratings of pain unpleasantness, pain-related negative mood, pain

coping, and recommending medical help.

Willingness to report pain and pain endurance (taken from the GREP), were investigated to

determine whether they meet the criteria to serve as covariates in the analyses of sex of virtual

humans and participants main effects on ratings of pain intensity and pain unpleasantness.










stays as a sign of grief after vocal crying has decreased as a response. Darwin described the

facial expression of disgust as a combination of closing off the nose to keep out unpleasant odor

and opening the mouth as if to spit out the contents (Woodworth & Schlosberg, 1954).

Having people judge facial expressions of emotions from photographs was introduced by

Darwin. Because the muscles and skin of the face are very mobile, the face was a logical choice.

In addition, the face is visible to others and is an important source of information in both verbal

and nonverbal social communications (Woodworth & Schlosberg, 1954).

Piderit also talked about the facial expressions of emotions in the 19th century. He argued

that mental images of obj ects should produce the same facial response as when the obj ect was

actually viewed. Therefore, when unpleasant thoughts exist, the mouth moves as if to avoid a

bitter taste, the eye region as if to avoid an unpleasant sight, the nose as to react to an unpleasant

odor. Piderit mentioned also the open mouth of attention and the appraising mouth, with lips

protruding. Piderit illustrated his arguments with simple line drawings. Boring and Titchener in

the 1920s used his drawings in studying judgments of emotional expressions by participants

(Woodworth & Schlosberg, 1954).

One way facial expressions were viewed is that it represents a psychobiological

phenomenon influenced by the humans' evolutionary heritage along with current circumstances.

This helped developing an evolutionary perspective on emotions. A perspective that would

suggest that emotion-specific changes in autonomic physiology have evolved to help that

adaptation processes that are presented as emotions, such as anger and fear. Ekman (1992)

proposed that each emotion state (emotion family) constitutes a family of affective states that

share commonalities in the way they are expressed. These commonalities between emotion

families are characteristic of that specific family and distinguishes it from other emotion









was that males were more likely than females to experience an increase in negative mood and a

decrease in positive mood in the morning after an evening of increased pain (Keefe, Affleck,

Emery, Waters, Caldwell, Stainbrook, Hackshaw, Fox, & Wilson, 2004). Riley et al. (2001)

proposed a sequential model of pain processing with pain intensity as stage 1, pain

unpleasantness as stage 2, pain-related emotions (depression, anxiety, frustration, anger, fear) as

stage 3, and overt behavioral expression of pain as stage 4. Investigators tested hypotheses about

relationships between sex and the first 3 stages of pain processing in both sexes participants with

chronic pain and one of the findings was that pain-related emotions were more strongly related to

pain for males. Anxiety was one of the emotions most highly related to pain. Recent research

results highlight sex differences in the experience of pain and the importance of assessing pain-

related negative mood and sex differences.

Sex Differences in Coping with Pain

Lazarus & Folkman (1984) define coping as "constantly changing cognitive and behavioral

efforts to manage specific external and/or internal demands that are appraised as taxing or

exceeding the resources of the person". They also identified the person' s health status and energy

as one of the most pervasive coping resources in that they are relevant to coping in many, if not

all, stressful encounters. They suggest that a person who is weak, ill, tired or otherwise

debilitated has less energy to apply to coping than a healthy person and that it is easier to cope

when one is feeling well than when one is not. This notion implies that people who are in pain

will cope differently than people who are not and that pain would only be considered as a

stressor when, and if, a person believes or appraises the pain as taxing or exceeding his/her

recourses and abilities to manage it. Coping is a construct that many of the variables that

influence pain and disability fall under, and many models of pain and illness give coping










Buckelew, S. P., Shutty, M. S., Hewitt, J., Landon, T., Morrow, K. & Frank, R. G. (1990).
Health locus of control, sex differences and adjustment to persistent pain. Pain, 42: 287-
295.

Burns, J., Hodsman, N., McLintock, T., Gillies, G., Kenny, G., & McArdle, C. (1989). The
influence of patient characteristics on the requirements for postoperative analgesia.


Campbell, L. (2002). Predispositions Towards Pharmacological Pain Management: A policy
capturing study. University of Florida.

Carey, T. S., Hadler, N. M., Gillings, D., Stinnett, S., & Wallsten, T. (1988). Medical disability
assessment of the back pain patient for the social security administration: The weighting
of presenting clinical features. Journal of Clinical Epidemiology. 41 (7), 69 1-697.

Carmen, R., Green, S., Ndao-Brumblay, K., Nagrant, A. M., Baker, T. A. & Rothman, E. (2004).
Race, age, and sex influences among clusters of african american and white patients with
chronic pain. The Journal ofPain, 5 (3), 171-182.

Caron, R. F., Caron, A. J., & Myers, R. S (1985). Do infants see emotional expression in static
faces? ChildDevelopment. 56, 1552-1560.

Campbell, C. M., Edwards, R. R. & Fillingim, R. B. (2005). Racial differences in responses to
multiple experimental pain stimuli. Pain, 113 (1-2), 20-26.

Cohen F. (1980). Post-surgical pain relief: patient's status and nurse's medication choice. Pain,
9, 265-74.

Cooksey, R. W. (1996). Judgment Analysis: Theory, methods, and applications. San Diego, CA:
Academic Press.

Craig, K., Hyde, S., & Patrick, C (1991). Genuine, suppressed and faked facial behavior during
exacerbation of chronic low back pain. Pain. 46, 161-171.

Craig, K., & Patrick, C (1985). Facial expression during induced pain. Journal ofPersonality
and Social Psychology. 48, 1080-1091.

Dao, T. T. & LeResche, L. (2000). Sex differences in pain. Journal of Orofacial Pain, 14, 169-
84.

de Ridder, D. & Schreurs, K. (2001). Developing interventions for chronically ill patients: is
coping a helpful concept? Clinical Psychology Review, 21, 205-240.

Dennis, C. K. & Akiko O. (1999). Does sex make a difference in the prescription of treatments
and the adaptation to chronic pain by cancer and non-cancer patients? Pain, 82, 139-149.












TABLE OF CONTENTS


page

ACKNOWLEDGMENTS .............. ...............4.....


LIST OF TABLES ................. ...............7..____ .....


AB S TRAC T ......_ ................. ............_........9


CHAPTER


1. INTTRODUCTION ................. ...............11.......... ......


Sex Differences in Pain Perception and Rating ................. ...............11........... ..
Sex Differences in Pain-Related Negative Mood ................. ...............13...............
Sex Differences in Coping with Pain............... ...............17..
Racial Differences in Coping with Pain .............. .. ...............20...
Racial Differences in Pain-Related Negative Mood ................. ...............22...............
Facial Expression of Emotions ................. .......... .. .......... ..... ........2
Sex differences in recognition of facial expressions and facial pain expressions ................. .25
Vi gnettes Research .............. ...............26....
Study Rationale............... ...............2
Study Aim s .............. ...............29....
Hypotheses............... ...............2

2. METHOD S ................ ...............31........... ....


Participants .............. ...............3 1....
Recruitm ent ................... .......... ...............3.. 1....
Inclusion/Exclusion Criteria............... ...............3
Procedure ................. ...............3.. 1..............

A analysis .............. ...............33....

3. RE SULT S .............. ...............3 5....


Analysis of Pain Intensity Ratings ................. ...............35........... ...
Sex Effects ................. ...............35.................
Race Effects ............... ... ............ ...............36.......

Analysis of Pain Unpleasantness Ratings ................. ...............36........... ...
Sex Effects ................. ...............36.................
Race Effects .................. .... ...... ... ....... ...............36...

Analysi s of Pain-Related Negative Mood Ratings ................ ...............36........... ..
Sex Effects ................. ...............36.................
Race Effects ................... ...............37.......... ......

Analysis of Pain-Coping Ratings ................. ...............37................
Sex Effects ................. ...............37.................
Race Effects ................. ...............37.................









and anger-hostility, and found that pain patients rated themselves significantly more anxious,

depressed, and hostile. Another study investigated the associations between a chronic pain

condition and common mood and anxiety disorders in a sample representative of the general US

civilian population utilizing the National Comorbidity Survey. Researchers found significant

positive associations between chronic pain and individual 12-month mood and anxiety disorders

(McWilliams, Cox, & Enns, 2003).

Individuals experiencing chronic pain have higher incidences of depression, lower levels of

physical functioning, and a poorer response to treatment (Geisser, Robinson, Keefe, & Weiner,

1994). Depression is a significant issue among pain patients. Prevalence rates for depression of

30% to 60% in clinic-based chronic pain samples highlight the significance of depression among

pain patients (Robinson & Riley, 1998). Romano & Turner (1985) reviewed the literature on the

relationship between pain and depression and concluded that research support can be found for

almost all hypotheses about the nature of the relationship between the two constructs:

"depression leads to pain by increasing pain sensitivity and decreasing pain threshold; pain

becomes a virtual equivalent of depression among patients with certain dispositions; pain serves

as a stressor that leads to subsequent depression; and that pain and depression occur

simultaneously, but are related only due to coincidentally similar psychological and/or biological

mechanisms". This highlights the importance of further investigation of the relationship between

pain and depression, and to include factors that are expected to have variant contributions to that

relationship such as the person's sex, how well the person is coping with his/her pain, the level

of pain the person is reporting, and sex differences in perceiving the person's mood, coping, pain

level, and his/her expected sex role.










Race Effects

There was no main effect of race of virtual human on ratings of pain intensity. However,

African American participants rated African American virtual humans significantly higher than

Caucasian virtual humans, F (1, 73) = 4.73, p < 0.05, (see table 3-3).

Analysis of Pain Unpleasantness Ratings

Sex Effects

Both male and female participants rated pain unpleasantness for female virtual humans

significantly higher than that for male virtual humans, F (1, 73) = 7.61, p < 0.01. Main effect of

sex of viewer, and main effect and sex of virtual human by sex of viewer interaction were non-

signifieant, (see table 3-4). Both Caucasian and African American participants rated pain

unpleasantness for female virtual humans significantly higher than that for male virtual humans,

F (1, 73) = 4. 17, p < 0.05. Between participants' main effect and sex of virtual human by race of

participants' interaction were non- significant, (see table 3-5). These results mirrored the

intensity effects.

Race Effects

Race of virtual human did not have an effect on ratings of pain unpleasantness. Sex of

participant and race of participant did not have an effect on ratings of pain unpleasantness (see

table 3-6).

Analysis of Pain-Related Negative Mood Ratings

Sex Effects

Both male and female participants rated pain-related negative mood for female virtual

humans significantly higher than that for male virtual humans, F (1, 73) = 6.76, p < 0.05. No

significant interactions or between participants' effects were found, (see table 3-7). However, a

between participants main effect was found for race of participants; Caucasian participants'










LIST OF TABLES


Table page

3-1. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain intensity made by male and female participants. .................. ..40

3-2. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain intensity made by Caucasian and African American
participants. .............. ...............40....

3-3. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain intensity made by Caucasian and African American
participants. .............. ...............40....

3-4. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain unpleasantness made by male and female participants. ..........41

3-5. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain unpleasantness made by Caucasian and African American
participants. .............. ...............41....

3-6. Descriptive statistics and mixed model ANOVA results the effect of race of virtual
humans on ratings of pain unpleasantness made by male, female, Caucasian, and
African American participants. .............. ...............42....

3-7. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain-related negative mood made by male and female
participants. .............. ...............42....

3-8. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain pain-related negative mood made by Caucasian and
African American participants. .............. ...............43....

3-9. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain pain-related negative mood made by male and female
participants. .............. ...............43....

3-10. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain pain-related negative mood made by Caucasian and
African American participants. .............. ...............43....

3-11i. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain coping made by male and female participants. ................... ....44

3-12. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain coping made by Caucasian and African American
participants. .............. ...............44....











Jasso, G. & Webster, M. (1997). Double standards in just earning for male and female workers.
Social Psychology Quarterly, 60 (1), 66-78.

Jensen, M. P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: a
critical review of the literature. Pain. 47, 249-283.

Jensen, M. P., Turner, J. A., Romano, J. M., & Lawler, B. K. (1994). Relationship of pain-
specific beliefs to chronic pain adjustment. Pain, 57, 301-309.

Jordan, M., Lumley, M., & Leisen, J. (1998). The relationships of cognitive coping and pain
control beliefs to pain and adjustment among African-American and Caucasian women
with rheumatoid arthritis. Arthritis Care and Research. 11, 80-8.

Keefe, F. G., Affleck, G., France, C. R., Emery, C. F., Waters, C., Caldwell, D. S., Stainbrook,
D., Hackshaw, K. V., Fox, L. C. & Wilson, K. (2004). Sex differences in pain, coping,
and mood in individuals having osteoarthritic knee pain: a within-day analysis. Pain, 110
(3), 571-577.

Keefe, F. J., Lefebvre, J. C., Egert, J. R., Affleck, G., Sullivan, M. J., & Caldwell, D. S. (2000).
The relationship of sex to pain, pain behavior, and disability in osteoarthritis patients: the
role of catastrophizing. Pain, 87, 325-334.

Keogh, E., & Herdenfeldt, M. (2002). Sex, coping and the perception of pain, Pain, 97 (3), 195-
201.

Kerns, R. D., Rosenberg, R. & Jacob, M. C. (1994). Anger expression and chronic pain. Journal
ofBehavioral M~edicine, 17 (1), 57-67.

Kirrouac, G & Dore, F (1985). Accuracy of the judgment of facial expressions as a function of
sex and level of education. Journal ofNonverbal Behavior. 9, 3-7.

Klonoff, E.A., Landrine, H. & Brown, M.A. (1993). Appraisal and response to pain may be a
function of its bodily function. Journal of psychosomatic research, 37, 661-670.

Kunz, M., Gruber, A., & Lautenbacher, S (2006). Sex differences in facial encoding of pain. The
Journal of Pain. 7 (12), 915-928.

Lazarus, R. S., & Folkman, S. (1984). Stress, Appraisal, and' Coping. New York: Springer
Publishing Company.

Leahey, E. (2004). The role of status in evaluating research: the case of data editing. Social
Science Research, 33 (3), 521-537.

Macintyre P, Jarvis D. (1995). Age is the best provider of postoperative morphine
requirements. Pain, 64, 357-364.










Analysis of Recommending Medical Help Ratings


Sex effects

A main effect for sex of virtual humans on sex of participants was found; both male and

female participants' ratings were significantly higher for female virtual humans than that for

male virtual humans, F (1, 73) = 5.98, p < 0.05. A sex of participants' main effect was also found

indicating that male participants' ratings were significantly higher than female participants'

ratings, F (1, 73) = 4.02, p < 0.05, (see table 3-15). Race of participant did not have an effect on

ratings of recommending medical help (See table 3-16).

Race effects

Sex of participant did not have an effect on ratings of recommending medical help.

However, male participants' ratings for both Caucasian and African American virtual humans

were significantly higher than that of female participants, F (1, 73) = 4.06, p < 0.05 (see table 3-

17). Sex of participant did not have an effect on ratings of recommending medical help (see table

3-18).

In summary, male and female participants rated female virtual humans' pain intensity, pain

unpleasantness, pain-related negative mood, poorer pain coping, and the need to seek medical

help as higher than male virtual humans. However, Caucasian and African American

participants' ratings for female virtual humans were higher than that for male virtual humans

only on pain intensity and pain unpleasantness. Caucasian virtual humans were viewed as having

higher pain-related negative mood and cope poorer with their pain than African American virtual

humans. African American virtual humans' pain intensity was rated higher only by African

American participants. Ratings made by male participants tended to be higher than ratings made

by female participants.













Analysis of Recommending Medical Help Ratings ................. ...............................38
Sex effects .............. ...............38....

Race effects .............. ...............38....


4. DI SCUS SSION ............. ...... .__ ...............47..


References............... ...............5


BIOGRAPHICAL SKETCH .............. ...............62....









The Gender Role Expectations of Pain questionnaire (GREP) consists of visual analog

scales to assess for participants' view of the typical male and female regarding pain sensitivity,

pain endurance, and willingness to report pain. It also assesses the participants' personal

attribution of his/her pain sensitivity, pain endurance, and willingness to report pain relative to

the typical male and female. The psychometric properties of the GREP factor structure are close

to the theoretical formulation of the scales, accounting for 76% of the variance in scores. The

questionnaire has good test-retest reliability with individual item correlations ranging from 0.53

to 0.93. The sex differences in the endorsement of items on the GREP were large, with the

largest differences (46% of variance) shown for willingness to report pain items. (Robinson et al,

2001). Wise et al (2002) found that the GREP was a significant predictor of experimental pain

ratings in undergraduate males and females, and that a significant proportion of sex differences

in pain report was accounted for.

Task duration was approximately 1 hour. Following completion of the task, participants

were asked to respond, in writing, to a task validity probe, in which they were asked to guess

what the study hypotheses were. Then, participants were briefed regarding the variables of

interest and the study hypotheses.

Analysis

All data analyses were performed using SPSS for windows (Version 15). Mixed model

ANOVA analyses were performed where sex and race, of participants and virtual humans,

served as independent variables, and ratings of pain intensity, pain unpleasantness, pain-related

negative mood, pain coping, and the extent to which the virtual humans were recommended to

seek medical help for their pain as dependent variables.

The 2 X 2 Mixed model ANOVAs were conducted as follows: ratings of pain intensity

served as a dependent variable, and sex of virtual humans (male and female) and sex of



































To my parents who provided me with endless love. To my brothers Abdulghafour and
Mohammad who planted gardens in the deserted land of my dreams. To my daughter Sarah who
is the candle of my life and the meaning of my smile.










physician' s pain management based on the type of pain and patient demographic characteristics,

and found that that the preparation of adequate pain management may be influenced by patient

characteristics and physician variability. In another study, Hassenbusch & Portenoy (2000)

investigated practice patterns via an internet-based survey distributed to physicians who manage

implantable infusion pumps for pain management. The survey used a standard questionnaire

format and two clinical vignettes to assess decision-making practices and found evidence of wide

variations in clinical practice among physicians. Goubert, Crombez, & Danneels (2004)

investigated whether pain catastrophizing and pain-related fear is related to a reluctance to

generalize an experience of lesser pain than expected to other similar situations. Researchers

used a series of vignettes to assess catastrophizing, overgeneralization, personalization and

selective abstraction related to general life experiences and to low back pain (LBP) experiences.

They also used three vignettes to assess the lack of generalization of corrective experiences

related to LBP. Researchers found that dysfunctional cognitions related to general life

experiences were the strongest predictor of the self-denigration subscale of the Beck Depression

Inventory (BDI). However only dysfunctional cognitions related to LBP accounted for a unique

contribution in predicting the somatic and physical function subscale of the BDI. Moreover,

dysfunctional cognitions related to LBP were significantly correlated with interference with daily

life due to pain.

In a study aimed to determine what factors influence emergency physicians' decisions to

prescribe an opioid analgesic for three common painful conditions, Tamayo-Sarver, Dawson,

Cydulka, Wigton, & Baker (2004) developed a baseline vignette, and items expected to influence

the decision for each of the three pain conditions: migraine, back pain, and ankle fracture, and

found that Physicians' likelihood of prescribing an opioid showed marked variability. Many











Maes, S., Leventhal, H., & de Ridder, D. T. (1996). Coping with chronic diseases. In: Zeidner,
M., Endler, N.S. (Eds.), Handbook of Coping. Theory, Research, Applications. Wiley,
New York.

Magni, G., Caldieron, C., Rigatti-Luchini, S. & Merksey, H. (1990). Chronic musculoskeletal
pain and depressive symptoms in the general population: An analysis of the 1 st National
Health and Nutrition Examination Survey data. Pain. 43, 299-307.

Mandal, M & Palchoudhury, S (1985). Perceptual skill in decoding facial affect. Perceptual and
Motor .\d// 60, 96-98.

McDonald, D. & Bridge, R. G. (1991). Sex stereotyping and nursing care. Research in Nursing
and Health. 14, 373-8.

McWilliams, L. A., Cox B. J. & Enns M. W. (2003). Mood and anxiety disorders associated with
chronic pain: an examination in a nationally representative sample. Pain, 106 (1-2), 127-
133.

Mitchell, K., & Owens, R. (2004). Judgments of laypersons and general practitioners on
justifiability and legality of providing assistance to die to a terminally ill patient: a view
from New Zealand. Patient Education and Counseling, 54 (1), 15-20.

Moore, R. & Brodsgaard, I. (1999). Cross-cultural investigations in pain. in Crombie IK (ed):
Epidemiology ofPain. Seattle, WA, IASP Press.

Morrill, C., Snyderman, E., & Dawson, E. J. (1997). It' s not what you do, but who you are:
informal social control, social status, and normative seriousness in organizations.
Sociological Forum, 12, 519-543.

Novy, D. M., Nelson, D. V., Hetzel, R. D, Squitieru, P. & Kennington, M. (1998). Coping with
chronic pain: sources of intrinsic and contextual variability. Journal of Behavioral
Medicine. 21 (1),19-34.

Nowicki, S & Hartigan, M (1988). Accuracy of facial affect recognition as a function of locus of
control orientation and anticipated interpersonal interaction. Journal of Social
Psychology. 128, 363-372.

Portenoy, R. K., Ugarte, C., Fuller, I. & Haas, G. (2004). Population-based survey of pain in the
United States: Differences among white, African American, and Hispanic subjects. The
Journal ofPain. 5 (6), 317-328.

Price, D. D. (1999). Psychological M~echanisms of Pain and Analgesia. Seattle, WA, IASP.

Prkachin, K (1992). The consistency of facial expression of pain: a comparison across
modalities. Pain. 51, 297-306.










Edwards, R. R., Doleys, D. M., Fillingim, R. B. & Lowery, D. (2001). Racial differences in pain
tolerance: clinical implications in a chronic pain population. Psychosomatic M~edicine 63:
316-323.

Edwards, R. R. & Fillingim, R. B. (1999). Racial differences in thermal pain responses.
Psychosomatic M~edicine 61 : 346-3 54.

Edwards, C. L., Fillingim, R. B. & Keefe, F. J. (2001). Race, race and pain. Pain, 94, 113-137.

Ekman, P (1993). Facial Expression of Emotion. American Psychologist. 48 (4), 384-392.

Ellermeier, W. & Westphal, W. (1995). Sex differences in pain ratings and pupil reactions to
painful pressure stimuli. Pain, 61 (3), 435-439.

Endler, N. S., Corace, K. M., Summerfeldt, L. J., Johnson, J. M. & Rothbart, P. (2003). Coping
with chronic pain. Personality and'Individ'ual Differences, 34, 323-346.

Feldman, S., Downey, G., & Schaffer-Neitz, R. (1999). Pain, Negative Mood, and Perceived
Support in Chronic Pain Patients: A Daily Diary Study of People With Reflex
Sympathetic Dystrophy Syndrome. Journal of Consulting and' Clinical Psychology, 67
(5), 776-785.

Folkman S, & Moskowitz, J. T. (2000). Positive affect and the other side of coping. American
Psychologist. 55 (6), 647-654.

Frot, M., Feine, J. S. & Bushnell, M. C. (2004). Sex differences in pain perception and anxiety.
A psychophysical study with topical capsaicin. Pain, 108 (3), 230-236.

Gaskin M. E., Greene A. F., Robinson M. E. Geisser & M. E. (1992). Negative affect and the
experience of chronic pain. Journal ofPsychosomatic Research, 36 (8), 707-713.

Geisser, M.E., Robinson, M. E., Keefe, F. J. & Weiner, M. L. (1994). Catastrophizing,
depression and the sensory, affective and evaluative aspects of chronic pain. Pain, 59 (1),
79-83.

Goubert, L., Crombez, G., & Danneels, L. (2004). The reluctance to generalize corrective
experiences in chronic low back pain patients: a questionnaire study of dysfunctional
cognitions. Behaviour Research and' Therapy, 43 (8), 105 5-1067.

Green, C. R, Anderson, K., Baker, T., Campbell, L., Decker, S., Fillingim, R., Kaloukalani, D.,
Lasch, K., Myers, C., Tait, R., Todd, K. & Vallerand, A. (2003). The unequal burden of
pain: Confronting racial and racial disparities in pain. Pain M~edicine, 4, 277-294.

Green, C. R., Baker, T. A., Sato, Y., Washington, T. L. & Smith, E. M. (2003). Race and chronic
Pain: A comparative study of young black and white Americans presenting for
management. Journal ofPain, 4, 176-183.









CHAPTER 4
DISCUSSION

Although pain levels were digitally controlled to be equal among male, female, Caucasian,

and African American virtual humans, these data indicate that participants of both sexes and

races still view females' pain, with both of its components, sensory (intensity) and affective

(unpleasantness), as significantly higher than that for male virtual humans. This is consistent

with other research findings. Robinson et al. (2001) found differences in participants' pain

ratings for observed males and females experiencing experimentally induced pain. They found

that viewers rated female virtual humans as having more pain than observed male virtual

humans. One possible explanation for why female virtual humans were viewed as having higher

pain levels than male virtual humans is the difference in pain expectations, that is, females are

expected to report higher levels of pain than males in general. Although willingness to report

pain, and pain endurance did not correlate significantly with pain ratings in this study, a sizable

literature shows that both males and females expect females to experience higher levels of pain

compared to males (Unrah, 1996, and Robinson et al, 2001). This study also suggests that

differences in expecting females to experience higher levels of pain are also true across races

(Caucasians and African Americans). Although between races rating did not differ, they both

rated female virtual humans to have higher pain levels.

African American participants viewed African American virtual humans' pain intensity as

significantly higher than Caucasian virtual humans' pain intensity. The ratings of African

Americans as having higher pain intensity than Caucasians is consistent with previous studies;

Walsh, Schoenfield, Ramamurthy, & Hoffman (1989) investigated pain tolerance to the cold

pressor test in Anglo-Saxons, Hispanics, and African Americans and found that African

Americans and Hispanics had lower pain tolerance. Sheffield, Biles, Orom, Maixner, & Sheps









ACKNOWLEDGMENTS

I thank my supervisory committee chair (Michael E. Robinson) and committee members

for their mentoring. I thank my department for its genuine and continuous guidance and

generosity. I thank the members of the Center for Pain Research and Behavioral Health for their

help and support.










ratings for both male and female virtual humans pain-related negative mood were significantly

higher than African American participants' ratings, F (1, 73) = 3.99, p = 0.05. An interaction of

sex of virtual human by race of participants was also found; Caucasian participants ratings for

female virtual humans were significantly higher than African American participants ratings for

female virtual humans, F (1, 73) = 4. 11, p < 0.05, (see table 3-8).

Race Effects

Race of virtual human did not have an effect on ratings of pain-related negative mood

made by male and female participants. (see table 3-9). However, both Caucasian and African

American participants viewed Caucasian virtual humans as having significantly higher levels of

pain-related negative mood, F (1, 73) = 5.34, p < 0.05. (see table 3-10).

Analysis of Pain-Coping Ratings

Sex Effects

Both male and female participants viewed female virtual humans as coping poorer than

male virtual humans, F (1, 73) = 6.37, p < 0.05. No significant between participants effect, and

sex of virtual human by sex of participant interactions were found, (see table 3-11). No

significant main effect for sex of virtual human on race of participants was found. Also, no

interaction or between race of participants effects were found (see table 3-12).

Race Effects

Both Caucasian and African American participants viewed Caucasian virtual humans as

coping poorer with their pain than African American virtual humans, F (1, 73) = 6.86, p < 0.05.

Race of participant did not have an effect on ratings of pain coping. (see table 3-13). Sex of

participant did not have an effect on ratings of pain coping (see table 3-14).










seek medical help for their pain. Male, female, Caucasian, and African American
participants will rate African American virtual humans higher.

There will be significant differences between male and female participants' ratings of
virtual humans' pain intensity, pain unpleasantness, pain-related negative mood, coping
with pain, and the extent in which the virtual humans will be recommended to seek
medical help for their pain. Female participants' ratings for male, female, Caucasian, and
African American Virtual humans will be higher than the ratings made by male
parti cipants.

There will be significant differences between Caucasian and African American
participants' ratings for virtual humans' pain intensity, pain unpleasantness, pain-related
negative mood, coping with pain, and the extent in which the virtual humans will be
recommended to seek medical help for their pain. Caucasian participants' ratings for
male, female, Caucasian, and African American virtual humans will be higher than the
ratings made by African American Participants.

Sex and race differences on rating others' pain, pain-related negative mood, pain coping,

and the extent of recommending medical help experiencing pain provides a broader range of

variables that may affect the way males and females of both races perceive and rate others' pain,

mood, and coping. This study provides baseline information regarding the role of the person's

pain, mood, and coping taken together on decisions and judgments regarding people who are

experiencing pain. It also provides initial data to explore sex and race differences on dealing with

other people's pain from both sexes and races, and its expected effects on a wider range of

behaviors including expected sex and race effects on health care behaviors toward pain patients.









understanding the negative emotional experiences that accompany and contribute to the overall

pain experience (Robinson & Riley, 1998).

Previous research shows that pain is associated with negative mood (Gaskin, Green,

Robinson, & Geisser, 1992). Chronic pain patients show high psychological distress, including

depressed mood, anxiety, and anger (Feldman, Downey, & Schaffer-Neitz, 1999). Wade,

Dougherty, Hart, Rafli, & Price (1992); Wade, Dougherty, Archer, & Price (1996); and Price

(1999) proposed a sequential stage model of pain processing. The Perceived intensity of the pain

sensation was suggested to be the first stage. The second stage is the immediate pain

unpleasantness, which reflects an individual's immediate affective response to the pain sensation

and to the context of its occurrence. The immediate pain unpleasantness dimension involves

limited cognitive processing and is often linked to the physical sensation of pain. The third stage

involves long-term reflective or cognitive processing related to the meanings and implications of

pain on the individual's life (Price, 1999). Therefore, negative emotions such as depression,

anxiety, and anger, are thought to be characteristics of this third stage. The fourth and final stage

of the model is the apparent behavioral expression of pain.

Gaskin et al (1992) analyzed the ability of anxiety, anger, and depression to predict self-

report of clinical pain as indicated by the McGill Pain Questionnaire (MPQ). Researchers found

support for the hypothesis that chronic pain has a predisposing factor in the development of

negative mood. Feldman et al. (1999) investigated the relationship between daily pain, negative

mood, and social support in 109 participants with reflex sympathetic dystrophy syndrome and

found that pain led to increased depressed, anxiety, and anger. Slocumb, Kellner, Rosenfeld and

Pathak (1989) matched gynecologic patients with the abdominal pelvic pain syndrome with other

gynecologic patients. They administered to both groups self-rating scales of anxiety, depression,










Slocumb, J. C., Kellner, R., Rosenfeld, R. C. & Pathak, D. (1989). Anxiety and depression in
patients with the abdominal pelvic pain syndrome. General Hospital Psychiatry. 11 (1),
48-53.

Stinshoff, V. J., Lang, E. V., Berbaum, K. S., Lutgendorf, S., Logan, H. & Berbaum, M. (2004).
Effect of sex and gender on drug-seeking behavior during invasive medical procedures
Academic RadiRRR~~~~~RRRRR~~~~ology 11 (4), 390-397.

Sullivan, M. J., Tripp, D. A., & Santor, D. (2000). Sex differences in pain and pain behavior: the
role of catastrophizing. Cognitive 7herapy and'Research, 24, 121-134.

Tait, R. C., & Chibnall, J. T. (1997). Physician judgments of chronic pain patients. Social
Science & M~edicine. 45 (8), 1199-1205.

Tamayo-Sarver, J. H., Dawson, N. V., Cydulka, R. K., Wigton, R. S. & Baker, D. W. (2004).
Variability in Emergency Physician Decisionmaking About Prescribing Opioid
Anal gesics. Annals of Emergency M~edicine, 43 (4), 483-493.

Tayler, J & Johnsen, B (2000). Sex differences in judgment of facial affect: a multivariate
analysis of recognition errors. Scand'inavian Journal ofPsychology. 41, 243-246.

Turk, D. C. & Melzack, R. (2001). Handbook ofPain Assessment. New York: Guilford Press.

Unruh, A. M. (1996). Sex variations in clinical pain experience. Pain, 65 (2-3), 123-67.

Unruh, A. M., Ritchie, J., & Merskey, H. (1999). Does sex affect appraisal of pain and pain
coping strategies? ClinicalJournal ofPain, 15, 31-40.

Vallerand, A. H. & Polomano, R. C. (2000). The relationship of sex to pain. Pain Management
Nursing, 1 (3), 8-15.

Wade, J. B., Dougherty, L. M., Archer, C. R., & Price, D. D. (1996). Assessing the stages of pain
processing: A multivariate analytical approach. Pain. 68, 157-167.

Wade, J. B., Dougherty, L. M., Hart, R. P., Rafli, A. & Price, D. D. (1992). A canonical
correlation analysis of the influence of neuroticism and extraversion on chronic pain,
suffering, and pain behavior. Pain. 51, 67-73.

Wagner, H., McDonald, C., & Manstead, A (2986). Communication of individual emotions by
spontaneous facial expression. Journal ofPersonality and Social Psychology. 50, 737-
743.

Walsh N, Schoenfield L, Ramamurthy S, & Hoffman J. (1989). Normative model for cold
pressor test. American Journal ofPhysical M~edicine and Rehabilitation, 68, 6-11.




Full Text

PAGE 1

SEX AND RACE DIFFERENCES IN RA TING OTHERS PAIN, PAIN-RELATED NEGATIVE MOOD, PAIN COPING, AND RECOMMENDING MEDICAL HELP By ASHRAF FARIS ALQUDAH 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 UNIVERSITY OF FLORIDA 2007 1

PAGE 2

2007 Ashraf Faris Alqudah 2

PAGE 3

To my parents who provided me with endle ss love. To my brothers Abdulghafour and Mohammad who planted gardens in the deserted land of my dreams. To my daughter Sarah who is the candle of my life a nd the meaning of my smile. 3

PAGE 4

ACKNOWLEDGMENTS I thank my supervisory committee chair (Mic hael E. Robinson) and committee members for their mentoring. I thank my department for its genuine and c ontinuous guidance and generosity. I thank the members of the Center for Pain Research and Behavioral Health for their help and support. 4

PAGE 5

TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 ABSTRACT.....................................................................................................................................9 CHAPTER 1. INTRODUCTION................................................................................................................ ..11 Sex Differences in Pain Perception and Rating......................................................................11 Sex Differences in Pain-Related Negative Mood...................................................................13 Sex Differences in Coping with Pain......................................................................................17 Racial Differences in Coping with Pain.................................................................................20 Racial Differences in Pain-Related Negative Mood...............................................................22 Facial Expression of Emotions...............................................................................................23 Sex differences in recognition of facial expressions and facial pain expressions..................25 Vignettes Research.................................................................................................................26 Study Rationale.......................................................................................................................28 Study Aims.............................................................................................................................29 Hypotheses..............................................................................................................................29 2. METHODS..................................................................................................................... ........31 Participants.............................................................................................................................31 Recruitment.................................................................................................................... .31 Inclusion/Exclusion Criteria............................................................................................31 Procedure................................................................................................................................31 Analysis....................................................................................................................... ...........33 3. RESULTS..................................................................................................................... ..........35 Analysis of Pain Intensity Ratings..........................................................................................35 Sex Effects.......................................................................................................................35 Race Effects.....................................................................................................................36 Analysis of Pain Unpleasantness Ratings...............................................................................36 Sex Effects.......................................................................................................................36 Race Effects.....................................................................................................................36 Analysis of Pain-Related Negative Mood Ratings.................................................................36 Sex Effects.......................................................................................................................36 Race Effects.....................................................................................................................37 Analysis of Pain-Coping Ratings............................................................................................37 Sex Effects.......................................................................................................................37 Race Effects.....................................................................................................................37 5

PAGE 6

6 Analysis of Recommending Medical Help Ratings................................................................38 Sex effects.......................................................................................................................38 Race effects.....................................................................................................................38 4. DISCUSSION.................................................................................................................. .......47 References......................................................................................................................................53 BIOGRAPHICAL SKETCH.........................................................................................................62

PAGE 7

LIST OF TABLES Table page 3-1. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain intensity ma de by male and female participants.....................40 3-2. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain intensity ma de by Caucasian and African American participants.........................................................................................................................40 3-3. Descriptive statistics and mixed model ANO VA results of the effect of race of virtual humans on ratings of pain intensity ma de by Caucasian and African American participants.........................................................................................................................40 3-4. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain unpleasantness made by male and female participants...........41 3-5. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain unpleasantness made by Caucasian and African American participants.........................................................................................................................41 3-6. Descriptive statistics and mixed model ANOVA results the effect of race of virtual humans on ratings of pain unpleasantness made by male, female, Caucasian, and African American participants...........................................................................................42 3-7. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain-related negative mood made by male and female participants.........................................................................................................................42 3-8. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain pain-relat ed negative mood made by Caucasian and African American participants...........................................................................................43 3-9. Descriptive statistics and mixed model ANO VA results of the effect of race of virtual humans on ratings of pain pain-related negative mood made by male and female participants.........................................................................................................................43 3-10. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain pain-relat ed negative mood made by Caucasian and African American participants...........................................................................................43 3-11. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain coping made by male and female participants........................44 3-12. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain coping made by Caucasian and African American participants.........................................................................................................................44 7

PAGE 8

8 3-13. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain coping made by Caucasian and African American participants................................................................................................................... ......44 3-14. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain coping made by male and female participants........................45 3-15. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of recommending medi cal help made by male and female participants................................................................................................................... ......45 3-16. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of recommending medical help made by Caucasian and African American participants........................................................................................................45 3-17. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of recommending medi cal help made by male and female participants................................................................................................................... ......46 3-18. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of recommending medical help made by Caucasian and African American participants........................................................................................................46 3-19. Correlations between the dependent variables.....................................................................46

PAGE 9

Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy SEX AND RACE DIFFERENCES IN RA TING OTHERS PAIN, PAIN-RELATED NEGATIVE MOOD, PAIN COPING, AND RECOMMENDING MEDICAL HELP By Ashraf Faris Alqudah August 2007 Chair: Michael E. Robinson Major: Psychology Sex and race influence pain ratings. We studied these influences in ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommending medical help. Seventy-five undergraduates view ed virtual human virtual humans expressing pain, and provided computerized ratings via VAS s. A series of Mixe d ANOVAs was performed. Male and female participants rated female virtual humans higher than male virtual humans on pain intensity, ( p < 0.05), pain unpleasantness, ( p < 0.01), pain-related negative mood, ( p < 0.05), poor pain coping, ( p < 0.05), and recommending medical help, (p < 0.05). Male and female virtual humans need for medical help was rated higher by male participants compared to female participants, ( p < 0.05). Males also rated African American and Caucasian virtual humans need for medical help higher than females ratings, ( p < 0.05). African Americans and Caucasians rated female virtual humans higher on pain intensity, ( p < 0.05) and pain unpleasantness, ( p < 0.05). Caucasians and African Americans viewed Caucasian virtual humans pain-related negative mood as higher than African Americans, ( p < 0.05). Caucasians ratings of male and female virtual humans pain -related negative mood were higher than African Americans ratings, ( p < 0.05). Caucasians rated females pain-related negative mood higher 9

PAGE 10

10 than males, ( p < 0.05). Caucasians and African Americans ratings for poor coping were higher for Caucasian virtual humans compared to African American virtual humans, ( p < 0.05). African Americans ratings for African American virtua l humans pain intensity were higher than for Caucasian virtual humans. In summary, both sexe s and races had higher ratings for females pain. Both races rated female virtual huma ns higher on each variable. Both races rated Caucasians as having more negative mood and poorer coping than African Americans. Females higher negative mood and poorer coping might be explained the relationship between pain, mood, and coping. Results show that races may diffe r in sensitivity to pain expressions. Males tendency to seek more pain medications may expl ain their high levels of recommending virtual humans to seek medical help. Technology used in this study (virtual humans) is discussed along with its possible future use and applicability.

PAGE 11

CHAPTER 1 INTRODUCTION Pain is an individual subj ective experience that is known to have psychological components. Almost a fifth of American adults experience chronic pain (a total of 50 million). Persistent pain is experienced by 17% of patie nts in the United States seen by primary care physicians. And people who seek treatment for chr onic pain each year are estimated to be about 4.9 million. Significant pain accompanies the majo rity of more than 23 million surgical procedures that are performed each year in the United States. Direct and indirect costs for the treatment of pain and the pain-r elated losses are estimated to be more than $125 billion per year (Turk & Melzack, 2001). Sex Differences in Pain Perception and Rating Empirical investigations suppor t the presence of sex differe nces in pain (Robinson, Riley, Myers, Papas, Wise, Waxenberg, & Fillingim, 2001; Frot, Feine, & Bushnell, 2004; Robinson & Wise, 2003; Ellermeier & Westphal, 1995; Vallerand & Polomano, 2000; Hawthorn & Redmond, 1998; Unruh, 1996; Dao & LeResche, 2000; Robinson & Wise, 2004). However, the degree to which sex influences pain perception is not completely clear. Although a number of studies have shown that females perceive and express higher levels of pain than males, other studies have found no differences between the sexes (Hawthorn & Redmond 1998). A number of researches have shown that females are more lik ely to experience pain in a range of medical conditions compared to males. For example, females report more frequent tension and migraine headaches than males (Unruh, 1996), and have highe r prevalence rates for or ofacial (Dao et al, 2000) and musculoskeletal pain (Unruh, 1996). Sex-re lated differences in pain perception have also been found in experimental pa in settings (Frot et al. 2004). 11

PAGE 12

The presence of sex differences in the appraisa l of pain might arise for two reasons. First, males and females have differences in their pa in experience over the lifespan, suggesting the presence of meaning constructs of pain and rela ted coping styles. Second, sex-based social role expectations are different for males and female s. Subsequently, the in terference of the pain experience differs with the roles and responsib ilities for females and males. Pain-related emotional and affective responses might also be affected by differences in social role expectations (Unruh, 1996). It is relatively well established that differe nces do exist between the sexes. However, the underlying mechanisms are not clear yet. It has been suggested that sex differences in pain perception are driven by both biological and socially learned f actors, and also by the possible interaction between them. Different expectati ons were found between males and females in terms of the typical males and females pain responding. Males are viewed as less willing to report their pain and more able to endure it. A ma nipulation of sexrelate d pain expectancy in experimental setting eliminated the sex differen ces in cold pressor pain (Robinson et al., 2004). Males and females endorse different predisposi tions to willingness to report their pain significantly (Robinson et al. 2001). That is, males are less willing to report pain. Robinson, Riley, & Myers (2000) have argued that th e differences reported in many laboratory investigations could largely be explained by th e sex-related expectati ons of pain. Robinson, Gagnon, Riley, & Price (2003) attempted to explicit ly manipulate the sex role stereotypes for males and females to further determine the effect s of these stereotypes a nd related expectations on different psychophysical respons es to experimental pain. On e of their hypotheses was that manipulating the expected performance for males and females would influence their subsequent pain report and reduce or eliminate the documen ted sex differences in pain. They hypothesized 12

PAGE 13

that in standard instructional sets, pain report would differ between males and females. And these differences would decrease when females and male s were given similar sex role expectations for pain tolerance. Their work was the first to show that sex differences in pain report decrease when sex role is experimentally manipulated. Results also supported the notion th at assessments of sex differences in pain responding, in laboratory settings, are influenced by sex rolerelated expectations of pain. That is, pain tolerance can be manipulat ed by altering sex rolebased expectations for pain. There are few studies examining how indi viduals view others in pain, either experimentally or clinically. R obinson et al. (2001) have f ound that males and females differ significantly in their pain expectations for se lf and others. Investig ators examined how both sexes observe experimentally induced pain in male and female participants. They found that, regarding virtual humans sex, view ers rated male virtual humans as having less pain than female virtual humans. Regarding sex of the observer, however, female viewers rated observed pain intensity significantly higher than did male viewers. In a more recent study, Robinson & Wise (2004) found that participants rated female subject s as experiencing greater pain intensity when undergoing a cold pressor task compared to male s. Parental observation, sociocultural norms, acuity in observing overt behavi ors, and beliefs regarding roles were suggested by the investigators to play a part in the explan ation of how one perceives another in pain. Sex Differences in Pain-Related Negative Mood The current definition of pain by the Internati onal Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or po tential tissue damage, or described in terms of such damage. reflects the subjective, multidimensional nature of pain. A better understanding of the experience of c linical pain highlights the importance of 13

PAGE 14

understanding the negative emotional experience s that accompany and contribute to the overall pain experience (Robinson & Riley, 1998). Previous research shows that pain is a ssociated with negative mood (Gaskin, Green, Robinson, & Geisser, 1992). Chronic pain patien ts show high psychological distress, including depressed mood, anxiety, and anger (Feldm an, Downey, & Schaffer-Neitz, 1999). Wade, Dougherty, Hart, Rafii, & Price (1992); Wade, Dougherty, Archer, & Price (1996); and Price (1999) proposed a sequential stage model of pain processing. The Pe rceived intensity of the pain sensation was suggested to be the first stag e. The second stage is the immediate pain unpleasantness, which reflects an individuals immediate affective re sponse to the pain sensation and to the context of its occu rrence. The immediate pain unp leasantness dimension involves limited cognitive processing and is often linked to the physical sensation of pain. The third stage involves long-term reflective or cognitive processing related to the meanings and implications of pain on the individuals life (P rice, 1999). Therefore, negative emotions such as depression, anxiety, and anger, are thought to be characteristics of this third stage. The fourth and final stage of the model is the apparent be havioral expression of pain. Gaskin et al (1992) analyzed th e ability of anxiety, anger, and depression to predict selfreport of clinical pain as indicated by the Mc Gill Pain Questionnaire (MPQ). Researchers found support for the hypothesis that chronic pain has a predisposing factor in the development of negative mood. Feldman et al. (1999) investigated the re lationship between daily pain, negative mood, and social support in 109 pa rticipants with reflex sympathetic dystrophy syndrome and found that pain led to increased depressed, anxiety, and anger. Slocumb, Kellner, Rosenfeld and Pathak (1989) matched gynecologic patients with the abdominal pelvic pain syndrome with other gynecologic patients. They administered to both groups self-rating scales of anxiety, depression, 14

PAGE 15

and anger-hostility, and found that pain patients rated themselves significantly more anxious, depressed, and hostile. Another study investigated the associat ions between a chronic pain condition and common mood and anxiet y disorders in a sample repres entative of the general US civilian population utilizing the National Como rbidity Survey. Researchers found significant positive associations between chronic pain and individual 12-month mood and anxiety disorders (McWilliams, Cox, & Enns, 2003). Individuals experiencing chronic pain have higher incidences of depression, lower levels of physical functioning, and a poorer response to tr eatment (Geisser, Robinson, Keefe, & Weiner, 1994). Depression is a significant issue among pain patients. Prevalence rates for depression of 30% to 60% in clinic-based chronic pain samp les highlight the significance of depression among pain patients (Robinson & Riley, 1998). Romano & Turner (1985) reviewed the literature on the relationship between pain and depression and conc luded that research support can be found for almost all hypotheses about the nature of the relationship between the two constructs: depression leads to pain by increasing pain se nsitivity and decreasing pain threshold; pain becomes a virtual equivalent of depression among patients with certain dispositions; pain serves as a stressor that leads to subsequent depr ession; and that pain and depression occur simultaneously, but are related only due to coincidentally similar psychol ogical and/or biological mechanisms. This highlights the importance of further investigat ion of the relationship between pain and depression, and to include factors that are expected to have variant contributions to that relationship such as the persons sex, how well th e person is coping with his/her pain, the level of pain the person is reporting, and sex differences in perceiving the persons mood, coping, pain level, and his/her expected sex role. 15

PAGE 16

Several studies indicate that patients with a variety of chronic pain conditions report anxiety levels signifi cantly greater than published norms and that a significant amount of the variance in pain report can be explained by a nxiety (Gaskin, Greene, Robinson, & Geisser, 1992; Brown, Robinson, Riley, & Gremillion, 1996; Holzberg, Robinson, Geisser, & Gremillion, 1996). Gaskin et al. (1992) used regression methodology to ascertain relationships between clinical pain measured by th e McGill Pain Questionnaire and measures of depression, anxiety, and anger and found that 33% of the McGill affective dimension of pain was associated with state anger and state anxiety, and 19% of the McG ill sensory dimension was associated with state anxiety. Anger is considered as an affective state that may be related to pain and styles of inhibiting anger have been found to be the st rongest predicto r of pain intensity (Kerns, Rosenberg, & Jacob, 1994). The development of de pression in general has been linked to the suppression of anger in general, as well as spec ifically among pain patients (Beutler, Engle, Oro-Beutler, Daldrup, & Meredith, 1986). Sex-specific relationships between pain and ne gative affect have been evidenced in both community and clinical samples (Riley, Robins on, Wade, Myers, & Price, 2001). In the National Health and Nutrition Examination Survey, pain and depressive symptoms tended to be more evident in females than in males (Magni, Caldie ron, Rigatti-Luchini, & Me rksey, 1990). In pain clinic patient samples, prevalence of depres sion and anxiety is typically higher for females (Unruh, 1996), although at least one study reported more depre ssion and anxiety in males (Buckelew, Shutty, Hewitt, Landon, Morrow, & Fra nk, 1990). In within-day assessments of pain, pain coping, and mood in males and females having Osteoarthritis, a study aimed to analyze sex differences in dynamic relations between pain, mood, and pain coping. Participants rated their pain, pain coping, and mood two times each day fo r 30 days using a booklet format. One finding 16

PAGE 17

was that males were more likely than females to experience an increase in negative mood and a decrease in positive mood in the morning after an evening of increased pain (Keefe, Affleck, Emery, Waters, Caldwell, Stainbrook, Hacksh aw, Fox, & Wilson, 2004). Riley et al. (2001) proposed a sequential model of pain processi ng with pain intensity as stage 1, pain unpleasantness as stage 2, pain-relat ed emotions (depression, anxiet y, frustration, anger, fear) as stage 3, and overt behavioral expr ession of pain as stage 4. Inves tigators tested hypotheses about relationships between sex and the fi rst 3 stages of pain processing in both sexes participants with chronic pain and one of the findings was that pain-related emotions were more strongly related to pain for males. Anxiety was one of the emotions most highly related to pain. Recent research results highlight sex differences in the experience of pain and the importance of assessing painrelated negative mood and sex differences. Sex Differences in Coping with Pain Lazarus & Folkman (1984) define coping as co nstantly changing cognitive and behavioral efforts to manage specific exte rnal and/or internal demands th at are appraised as taxing or exceeding the resources of the person. They also identified the persons health status and energy as one of the most pervasive copi ng resources in that they are re levant to coping in many, if not all, stressful encounters. They suggest that a person who is weak, ill, tired or otherwise debilitated has less energy to apply to coping than a heal thy person and that it is easier to cope when one is feeling well than when one is not. This notion implies that people who are in pain will cope differently than people who are not a nd that pain would only be considered as a stressor when, and if, a person believes or appr aises the pain as taxing or exceeding his/her recourses and abilities to mana ge it. Coping is a construct th at many of the variables that influence pain and disability fall under, and many models of pain and illness give coping 17

PAGE 18

responses an important, if not cen tral, role in understanding and predicting adjustment to pain and illness (Boothby, Thorn, Stroud, & Jensen, 1999). Given that individuals develop their own strategies for coping with painful experiences, and since males and females differ in the experien ce of pain, it is likely that males and females will develop different coping styles (Jensen, Tu rner, Romano, & Lawler, 1994; Weir, Browne, Tunks, Gafni, & Roberts, 1996; Robinson et al 2000). Unfortunately, little research has investigated whether sex moderates or mediates the effectiveness of pain coping strategies (Sullivan, Tripp, & Santor, 2000; Keefe, Lefebvre, Egert, Affleck, Sullivan, & Caldwell, 2000). Unruh, Ritchie, & Merskey (1999), for example, presented results from a community based telephone survey of people who repor ted pain in the two weeks befo re the interview. Researchers found that females reported significantly more inte nse pain, as well as used a greater range of coping strategies, i.e. greater social support seeking, problem-solving, positive self-statements and palliative behaviors compared to males. Another study aimed to determine whether se x differences would be found in the effect that sensory-focused and emotion-focused copi ng instructions have on cold pressor pain experiences. In this study, participants consis ted of healthy adults, all of whom reported no current pain. Compared to females, males showed less negative pain responses when focusing on the sensory component of the pa in experience, and compared to sensory focusing, emotional focusing was found to increase the affective pain experience of females (Keogh & Herdenfeldt, 2002). Keefe et al. (2004) found that females used more problem focused coping than males, and females who catastrophized were less likely than males to repo rt negative mood. They also found that males were more likely than females to use emotion-focused coping when their mood was more negative. 18

PAGE 19

Affleck, Tennen, Keefe, Lefebvre, Kashikar-Z uck, Wright, Starr, & Caldwell (1999) found that females reported more problem solving, social support, positive self-statements, and palliative behaviors than male s. When the effects of disease and sex on daily pain, mood, and coping were compared in 71 patients with Oste oarthritis and 76 patients with rheumatoid arthritis, females had daily pain levels of 72% hi gher than the daily pain levels of males. Females used more problem-focused and emotion-focused st rategies every day than males. This suggests the female participants endorsed mo re coping strategies than males. The perceived seriousness of the pain expe rience may increase by the anticipated and actual interference of pain on one's perceive d responsibilities. Multiple primary role responsibilities of females such as childcare or care for elderly parents, household management, and paid employment may contribute to the appraisa l of pain as threaten ing. They may attend to pain earlier in an effort to minimize its' intrus iveness. Females may also be more worried and irritated about pain. Role interference and perc eived effectiveness or in effectiveness of coping strategies may contribute to the emotional response to pain. No rmal biological processes that result in troublesome pain experiences, recurren t pains with little or no pathological significance, and pain experiences that are symptomatic of pathological, increase the complexity of females pain experience and may lead to some frustrati on with self-management and assessment of pain. Risks of depression and disability associated with pain may be in creased due to i rritability and worry. Paid work remains the dominant occupatio nal role for males although their involvement in childcare and household responsib ilities is slowly increasing. Risk of work disability may be partially reduced by the greater opport unity to recover from pain if responsibilities for childcare, household management and relationships are co nsidered secondary a nd possibly assumed by a partner. For males, unless the pa in experience is interfering with work, they may perceive that 19

PAGE 20

experience as having limited importance. While fe males may be more irri tated and worried about pain, males may be more embarrassed by pain. Embarrassment may cause males to minimize pain unless pain increases in severity or interf eres with work. Social and cultural norms that accept insensitivity to pain and pain endurance as measures of virility may minimize the pain expression or reporting (Unruh, 1996). Klonoff, Landrine, & Br own (1993) found that male undergraduate students were significantly more likely than females to rate their emotional response to common pain problems as embarrassme nt regardless of the location of the pain. Participants of both sexes identifi ed the greatest threats to be th e overall interference of pain and the emotional distress when asked about th eir appraisal of pain (Unruh et al., 1999). Racial Differences in Coping with Pain The literature concerning chronic pain has shown that active coping, such as problemfocused coping, tends to be associated with be tter physical and psychol ogical functioning. And passive coping, such as emotion-focused coping, tends to be associated with poorer physical and psychological functioning (Jensen, Turner, Romano, & Karoly, 1991; Boothby et al., 1999). Furthermore, patients who used problem-focused coping were better in adapting to chronic disease than those who used emotion-focused st rategies (Bombardier, DAmico, & Jordan, 1990; Maes, Leventhal, & de Ridder, 1996). Little is known about racial differences in copi ng with pain as well as racial differences in perceiving others coping strategi es when experiencing pain. It is possible that different coping styles used by African Americans and Caucasians may impact the pain experience. For example, in a study of pain coping among patients with rh eumatoid arthritis, r acial differences were present in the use of pain copi ng strategies although no racial di fferences in pain were noted. African Americans with rh eumatoid arthritis reported signifi cantly higher use of distraction and 20

PAGE 21

praying/hoping as coping strategi es, whereas, Caucasians reported greater use of ignoring pain and coping statements (Jordan, Lumley, & Leisen, 1998). Many researchers concluded that race is an important predic tor of pain-related symptomatology and pain coping (Edwards & Fillingim, 1999; Greenwald, 1991; Novy, Nelson, Hetzel, Squitieru, & Kennington, 1998; Sheffield, Biles, Orom, Maixne, & Sheps, 2000; Zatzick & Dimsdale, 1990). Others such as Edwards, Doleys, Fillingim, & Lowery (2001) highlighted that future investigations may benefit from assessment of coping strategies as a potential mediator or moderator of relationships between race and pain responses. Previous research has suggested that coping, social lear ning, and attitudes might play an important role that is yet unstudied in racial differences in health cond itions, particularly pain (Folkman & Moskowitz, 2000; Moore & Brodsgaard I, 1999). Jordan et al (1998) compared racial groups on pain coping strategies and control be liefs and the relationships of thes e variables to health status among women with rheumatoid arthritis. They found that R acial groups did not diffe r in pain severity or negative affect, but African-Americans used more coping techniques involving diverting attention and praying/hoping. And that Caucas ians used more coping techniques involving ignoring pain. The relationships of praying/hoping and reinterpreting pain to RA adjustment differed by racial group. Whereas, ignoring pain, coping statements, and stronger control beliefs predicted better health status, di verting attention predicted more pain for all patients. These findings suggest that there are racial differences in the use of coping strategies that should be acknowledged when helping pati ents cope with their pain. Campbell, Edwards, & Fillingim (2005), Examin ed racial differences in responses to multiple experimental pain stimuli, including heat pain, cold pressor pain, and ischemic pain and found that African Americans reported greater use of passive pain coping strategies. 21

PAGE 22

Racial differences in pain related coping we re also found between African Americans and Whites on every Coping Strategies Questionnaire-Revised scale dimensions after including sex and age as covariates in the mode l (Hastie, Riley, & Fillingim, 2004). Pain coping strategies generall y vary widely between cultures. Cultural differences in pain coping strategies might be as important as the di fferences in the prevalen ce pain or its reported severity (Brodsgaard, 1999). Racial differences in pain coping w ithin clinical samples might not be the result of a long chronic pain experience, but might be present ev en in the absence of chronic pain. So, racial differences in pain c oping might indicate an exacerbation of stress management styles that are inherited, such as pain Coping is not individuali stic but is folded in the influences of the persons ethno-cultural envi ronment and sub-cultural context (Hastie et al., 2004). Racial Differences in Pa in-Related Negative Mood Race may have a major influence on the emotional and behavioral responses to pain and pain appraisal (Edwards, Fillingim & Keefe, 2001). Socio-cultural factor s related to racial background may influence the meaning of the pain experience (Bates, 1996) Consequently, pain appraisals can have a major influence on pain-related emotional responses such as depression and anxiety, as well as behavioral responses such as the decision to seek treatment, adherence to treatment regimens (Edwards et al., 2001). Associations have also been reported between depression and emotion-focused coping strategies in chronic pain (Weickgenant, Slat er, Patterson, Atkinson, Grant, & Garfin, 1993; de Ridder, & Schreurs, 2001; Endler, Corace, Summ erfeldt, Johnson, & Rothbart, 2003). Studies on patients coming to pain centers for initial a ssessment found that highe r pain intensity and depression were associated with being African American, younger, and having a pain duration of more than 30 months (Anderson, Palos, Gni ng, Mendoza, Sanchez, Valero, Richman, Nazaria, 22

PAGE 23

Hurley, Payne, & Cleeland, 2003; Green, Anderson, Baker, Campbell, Decker, Fillingim, Kaloukalani, Lasch, Myers, Tait, Todd, & Valle rand, 2003; Green, Baker, Sato, Washington, & Smith, 2003; and Green, Baker, Sato, Washingt on, & Smith, 2003). One study aimed to explore relationships between chronic pain and race. The researchers asked the participants to rate the degree to which their chronic pain interferes with th eir lives, and found that African Americans had significantly higher rating th an Caucasians on irritability, disturbed sleep, inability to participate in pleasurable activit ies, and loss of appetite due to their pain condition (Portenoy, Ugarte, Fuller, & Haas, 2004). Research on pain re lated mood has shown that African Americans with chronic pain had higher pain severity, depr ession, and disability when compared to whites with chronic pain (Carmen, Green, Ndao-Brumblay, Nagrant, Baker, & Rothman, 2004). Riley, Wade, Myers, Sheffield, Papas, & Price (2002) found that African Americans experience greater emotional suffering compared to white participants on similar levels of pain intensity. The researchers identified depression, anxiet y, frustration, anger, and fear as the components of the emotional factor in their st udy. Researchers used VASs to assess for the components of the emotional factor. In a retros pective analysis of persons younger than 50 years of age presenting for chronic pain management in a multidisciplinary pain center, Green et al. (2003) found that African American participants were more de pressed, anxious, and irritable compared to white participants. Facial Expression of Emotions Charles Darwin was one of the first who talked about facial expressi ons of emotion. In his 1872 book, Expression of the Emotions in Man a nd Animals, he suggested that humans expressive movements are remnants of earlier ones Taking the expression of grief in adult as an example, it is a toned down version of cryi ng in the infants (Woodwor th, 1938). The wide-open mouth of crying involves muscles of the corner of the mouth, and the slight movement of these 23

PAGE 24

stays as a sign of grief after vocal crying has decreased as a response. Darwin described the facial expression of disgust as a combination of closing off the nose to keep out unpleasant odor and opening the mouth as if to spit out the contents (Woodworth & Schlosberg, 1954). Having people judge facial expr essions of emotions from photographs was introduced by Darwin. Because the muscles and skin of the face are very mobile, the face was a logical choice. In addition, the face is visible to others and is an important sour ce of information in both verbal and nonverbal social communications (Woodworth & Schlosberg, 1954). Piderit also talked about the facial expression s of emotions in the 19th century. He argued that mental images of objects should produce th e same facial response as when the object was actually viewed. Therefore, when unpleasant thoughts exis t, the mouth moves as if to avoid a bitter taste, the eye region as if to avoid an unpleasant sight, the nose as to react to an unpleasant odor. Piderit mentioned also the open mouth of attention and th e appraising mouth, with lips protruding. Piderit illustrated hi s arguments with simple line dr awings. Boring and Titchener in the 1920s used his drawings in studying judgmen ts of emotional expressions by participants (Woodworth & Schlosberg, 1954). One way facial expressions were viewed is that it represents a psychobiological phenomenon influenced by the humans evolutionary heritage along with current circumstances. This helped developing an evolutionary pers pective on emotions. A perspective that would suggest that emotion-specific changes in aut onomic physiology have evolved to help that adaptation processes that are presented as em otions, such as anger and fear. Ekman (1992) proposed that each emotion state (emotion family) c onstitutes a family of affective states that share commonalities in the way they are ex pressed. These commonalities between emotion families are characteristic of that specific family and distinguishes it from other emotion 24

PAGE 25

families. Research on facial expressions yielded the possibility of separate discrete emotional states such as fear and anger. Contraction of specific facial mu scles provides the information as to whether the expression repres ents anger, fear, sadness, disgust, enjoyment, or surprise (Ekman, 1993). Some research has argued that the dynamic f acial expressions are necessary for complete emotional information extraction derived fr om faces (Caron, Caron, & Myers, 1985). The dynamics of expression is a factor that facilitates recognition of expressions. Researchers used different stimuli such as computer generated sc hematic movies (Wehrle, Kaiser, Schmidt, & Scherer, 2000), Natural movies (Harwood, Hall, & Shinkfield, 1999), subtle displays of emotion (Ambadar, Schooler, & Cohn, 2005), a nd point-light displays (Ba ssili, J, 1979) argued for the importance of dynamics in the perception of facial expressions of emotions. Sex differences in recognition of facial ex pressions and facial pain expressions Males and females show differences in percep tion of facial expressions. The majority of the literature shows that female s are better in identifying different affects expressed through face (Hall, 1978., Kirrouac & Dore, 1985., Nowicki & Hartigan, 1988., and Tylor & Johnsen, 2000). However, some research suggest that sex differences depend on the type of facial expression being observed. Nowicki et al. 1988 found that females are better in recognizing expressions such as fear and sadness. Whereas, Wa gner, McDonald, Mans tead, 2986., Mandal & Palchoudhury, 1985., and Rotter & Rotter, 1988, found that males are bette r in identifying displays of anger. The sex differences in recogniz ing facial expressions seem to hold true even at an early age. Boyatzis, Cazan, & Ting, 1993, found that 3.5 year-old girls accuracy in recognizing facial expression matc hed 5-year-old boys accuracy. 25

PAGE 26

The most prominent nonverbal pain behavior has been considered to be the facial expressions of pain (Craig & Patrick, 1985). In ge neral, sex differences in facial expressions have hardly been studied. And sex was rarely in cluded as a factor in f acial pain expressions limited research (Kunz, Gruber, & Lautenbach er, 2006). Some research found no differences between males and females in pain facial expressions (Craig, Hyde, & Patrick, 1991., and Prkachin, 1992). However, Guinsburg, Peres, de Almeida, Balda, Bereguel, Tonelotto, &Kopelman (2000) found increased f acial pain responses in female neonates compared to male neonates. Robinson et al. (2001) have found that males and female s differ significantly in their pain expectations for self and others. Viewers ra ted male virtual humans as having less pain than female virtual humans and female viewers rated observed pain intensity significantly higher than did male viewers. Robinson et al. (2004) found that participants rated female subjects as experiencing greater pain intensity when undergoing a cold pressor task compared to males. Vignettes Research This study used vignettes and virtual humans of virtual humans experiencing pain. Vignettes, pioneered by Peter Rossi (Leahey, 200 4) combine forms of survey research and experimental designs. The vignett e technique is applied to st udies of problems in which participants make evaluations regarding complicated objects. De sirable features included an avoidance of real world multi-collinearity and the ability to isolate the independent variable of interest. The vignette format is particularly appr opriate for studying norms, attitudes, and beliefs (Leahey, 2004). Jasso & Webster (1997); Jass o & Opp (1997); and Morrill, Snyderman, & Dawson (1997) used the vignette format to explore normative judgments, sexed double standards, and moral gaps in business settings. Other researchers also used vignette format s in medical and health settings. Green, Wheeler, & LaPorte (2003) used nine clinical vignettes to examine potential differences in the 26

PAGE 27

physicians pain management based on the type of pain and patient demogr aphic characteristics, and found that that the preparation of adequate pain management may be influenced by patient characteristics and physician variability. In another study, Hassenbusch & Portenoy (2000) investigated practice patt erns via an internet-based survey di stributed to physicians who manage implantable infusion pumps for pain management The survey used a standard questionnaire format and two clinical vignett es to assess decision-making pract ices and found evidence of wide variations in clinical pr actice among physicians. Goubert, Crombez, & Danneels (2004) investigated whether pain catas trophizing and pain-related fear is related to a reluctance to generalize an experience of lesse r pain than expected to other similar situations. Researchers used a series of vignettes to assess catast rophizing, overgeneralization, personalization and selective abstraction related to general life expe riences and to low back pain (LBP) experiences. They also used three vignettes to assess the l ack of generalization of corrective experiences related to LBP. Researchers found that dysf unctional cognitions re lated to general life experiences were the strongest predictor of the self-denigration subscale of the Beck Depression Inventory (BDI). However only dysfunctional c ognitions related to LBP accounted for a unique contribution in predicting the somatic and phys ical function subscale of the BDI. Moreover, dysfunctional cognitions related to LBP were significantly correlated with interference with daily life due to pain. In a study aimed to determine what factors influence emergency physicians decisions to prescribe an opioid analgesic for three comm on painful conditions, Tamayo-Sarver, Dawson, Cydulka, Wigton, & Baker (2004) developed a baselin e vignette, and items expected to influence the decision for each of the three pain conditions : migraine, back pain, and ankle fracture, and found that Physicians likelihood of prescribing an opioid show ed marked variability. Many 27

PAGE 28

other studies have used vignette format in me dical and health setti ngs (Mitchell and Owens, 2004; Weisse, Sorum, & Dominguez, 2003; Ad amson, Ben-Shlomo, Chaturvedi, & Donovan, 2003; Hazelett, Powell, & Androulakakis, 2002; Ha mer, van den Hout, Halfens, Abu-Saad, & Heijltjes, 1997; Tait & Chibnall, 1997; Carey, Hadler, Gillings, Stinnett, & Wallsten, 1988; and Cohen, 1980). In terms of medication practices, research us ing vignettes that were identical, except for the sex of the patient indicates that different am ounts of analgesic medication were chosen based on the patients sex, with nurses choosing less pain medication fo r female patients experiencing pain than when compared to males (Cohen, 1980; McDonald & bridge, 1991). Campbell (2002) found that in prospective vignette studies, some nurses have indicated the intention to spend less time engaged in pharmacological pain management of female patients, and to select less pain medication for female patients. She also found, usi ng lens model and vignette format, that patient pain report appears to play an early predispositio nal role in the clinical decision making process. She also found that patient sex, age, and race play smaller predispositional roles in the clinical decision making process (Campbell, 2002). Study Rationale Relatively little is known about how males and fema les of different races vary in respect to perceiving and rating pain, pain-related negative mood, pain coping, and the extent to which each would recommend seeking medical help fo r males, females, Caucasians, and African Americans when experiencing pain. Some resear ch has been done on sex differences in rating other individuals pain. Previous research has shown that diff erences in perceiving and rating others pain lead to differences in judgments and decisions re lative to pain management, drug prescriptions and health care providing (Tamay o-Sarver et al, 2004; Campbell, 2002; Cohen, 1980; McDonald et al, 1991; Holm, Cohen, Dudas, Medema, & Allen 1989; Green et al, 2003; & 28

PAGE 29

Hassenbusch et al, 2000). Since research has shown that sex and race differences in pain-related negative mood and pain coping exist, the importan ce of investigating how males and females of different races differ in perceiving others pain -related negative mood and pain coping may in turn lead to better understanding of the differenc es in the way males and females of different races perceive, rate and respond to others pa in coping, pain-related negative mood, and better pain management strategies. This study adds to the determination of whet her differences between males and females, and differences between races exist in terms of perceiving and rating other peoples pain. In addition, this study contributes to the investigation of whether sex differences and/ or race differences exist in perceiving and rating others pain-related negative mood, pain coping, and the extent of recommending seek ing pain-related medical help. Study Aims The initial aim of this study is to determine whether sex and/or racial differences exist in regard to rating other peoples pain, pain-related negative mood, pain coping, and the extent of recommending medical help for pain. Second, in this study, the sex role expectations of pain are investigated as a possible mediator to the re lationship between sex and the perceived others pain. Hypotheses There will be significant diffe rences in participants ratings for male and female virtual humans pain intensity, pain unpleasantne ss, pain-related negative mood, coping with pain, and the extent in which virtual humans will be recommended to seek medical help for their pain. Ratings made by male, fe male, Caucasian, and African American participants for female virtual humans will be higher than their ratings for male virtual humans. There will be significant diffe rences in participants rati ngs for Caucasian and African American virtual humans pain intensity, pa in uncleanness, pain-related negative mood, coping with pain, and the extent in which the virtual humans will be recommended to 29

PAGE 30

30 seek medical help for their pain. Male, female, Caucasian, and African American participants will rate African American virtual humans higher. There will be significant diffe rences between male and fema le participants ratings of virtual humans pain intensity, pain unpleas antness, pain-related negative mood, coping with pain, and the extent in which the virtual humans will be recommended to seek medical help for their pain. Female participan ts ratings for male, female, Caucasian, and African American Virtual humans will be higher than the ratings made by male participants. There will be significant differences between Caucas ian and African American participants ratings for virtual humans pain intensity, pain unpleasantness, pain-related negative mood, coping with pain, and the exte nt in which the virtual humans will be recommended to seek medical help for thei r pain. Caucasian part icipants ratings for male, female, Caucasian, and African American virtual humans will be higher than the ratings made by African American Participants. Sex and race differences on rating others pa in, pain-related negativ e mood, pain coping, and the extent of recommending medical help ex periencing pain provides a broader range of variables that may affect the way males and female s of both races perceive and rate others pain, mood, and coping. This study provide s baseline information regard ing the role of the persons pain, mood, and coping taken toge ther on decisions and judgme nts regarding people who are experiencing pain. It also provides initial data to explore sex and race differences on dealing with other peoples pain from both sexes and races, and its expect ed effects on a wider range of behaviors including expected sex and race effects on health care behaviors toward pain patients.

PAGE 31

CHAPTER 2 METHODS Participants Recruitment 75 University of Florida undergraduate students of both sexes (53 females, 22 males) and races (62 Caucasians, 13 African Americans) were recruite d through flyers and posters requesting volunteers to pa rticipate in this study. Inclusion/Exclusion Criteria Eligibility for particip ation required being at least 18 y ears old and English speaking. Only males and females of African American or Ca ucasian background were included. Participation was also contingent upon ability to give consent. Procedure Each participant was asked to read a descrip tion of the study includi ng the time required to complete the study and a reminder that the study is voluntary. After reading the study description, all particip ants read and sign a computerized consent form acknowledging that the study procedures were explained an d that they could withdraw, w ithout prejudice, from the study at any time. Next, the participants filled out a demographic questionnaire. The following demographic information was collected: sex, race, a nd age. After that, participants read a set of instructions that provided information on how to approach the task and how to use Visual Analogue Scales (VASs) to give ratings. Then, pa rticipants viewed the vignettes and the virtual humans of both sexes and races. The virtual humans participants observed expressed pain through facial expressions. These facial expressions of pain we re digitally coded based on the Facial Action Coding System (FACS). The FACS is based on anatomic analysis of facial muscle movements and distinguishes 44 di fferent action units (AUs). Howe ver, an abbreviated version 31

PAGE 32

of FACS was used in this study focusing on 4 action units: brow loweri ng, tightening of the orbital muscles surrounding the eye, nose wr inkling/upper lip raising, and eye closure. Each virtual human the participants observed consisted of a vignette and a virtual reality virtual human of the observed patient of each se x and race. Each virtual human contained three cues: sex (two levels: male or female), race (t wo levels: Caucasian or African American), and pain (two levels, and were manipulated only in the observed virtual human and was inferred by the participants based on the virtual humans facial pain expressions). Pain-related negative mood, pain coping, and the virtual humans need to be recommended to seek medical help was also inferred by the participants based on and re lated to the pain facial expressions of the observed virtual human of both sexes and races. In order to minimize the impact of social desi rability on participants ratings, participants were instructed to completely respond to virt ual humans in the order presented, complete one virtual human before going to the next, and not to revisit a previously completed virtual human. For each virtual human (of both sexes and races), participants (of both sexes and races) used computerized VASs to (1) rate the level of pain intensity they think the observed virtual human is experiencing, (2) rate the level of pain unplea santness they think the observed virtual human is experiencing, (3) rate the level of pain-related negative mood the obs erved virtual human is experiencing due to his/her observed pain, (4) rate how well they think that the observed virtual human is coping with the pain experience, a nd (5) rate the extent to which they would recommend the observed virtual human to seek pa in-related medical help. Participants also completed a computerized version of the Sex Role Expectations of Pain questionnaire (GREP) (appendix A) using computerized VASs to assess for the degree to which sex role expectations of pain may contribut e to their ratings. 32

PAGE 33

The Gender Role Expectations of Pain questi onnaire (GREP) consis ts of visual analog scales to assess for participants view of the t ypical male and female regarding pain sensitivity, pain endurance, and willingness to report pain. It also assesses the pa rticipants personal attribution of his/her pain sensitivity, pain e ndurance, and willingness to report pain relative to the typical male and female. The psychometric prope rties of the GREP fact or structure are close to the theoretical formulation of the scales, accounting for 76% of the variance in scores. The questionnaire has good testretest reliability wi th individual item correlations ranging from 0.53 to 0.93. The sex differences in the endorsement of items on the GREP were large, with the largest differences (46% of variance) shown for willingness to report pain items. (Robinson et al, 2001). Wise et al (2002) found that the GREP was a significant pr edictor of experimental pain ratings in undergraduate males and females, and that a significant proportion of sex differences in pain report was accounted for. Task duration was approximately 1 hour. Following completion of the task, participants were asked to respond, in writing, to a task valid ity probe, in which they were asked to guess what the study hypotheses were. Then, participan ts were briefed regarding the variables of interest and the study hypotheses. Analysis All data analyses were performed usi ng SPSS for windows (Version 15). Mixed model ANOVA analyses were performed where sex and race, of participants and virtual humans, served as independent variables, and ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and the extent to which the virtual humans were recommended to seek medical help for their pa in as dependent variables. The 2 X 2 Mixed model ANOVAs were conducted as follows: ratings of pain intensity served as a dependent variab le, and sex of virtual humans (male and female) and sex of 33

PAGE 34

34 participants (male and female) served as independent variables. The same process was repeated for ratings of pain unpleasantness, pain-relat ed negative mood, pain coping, and recommending medical help. Then, ratings of pain intensity serv ed as a dependent variable, and race of virtual humans (Caucasian and African Amer ican), and sex of participants (male and female) served as independent variables. The same process was rep eated for ratings of pain unpleasantness, painrelated negative mood, pain coping, and recommending medical help. After that, ratings of pain intensity served as a dependent variable, and race of virtual humans (Caucasian and African American), and race of participants (Caucasian and African American) served as independent variables. The same process was repeated for ratings of pain unpleas antness, pain-related negative mood, pain coping, and recommending medical help. Finally, ratings of pain intensity served as a dependent variable and sex of virtual humans (mal e and female), and race of participants (Caucasian and African American) served as independent variables. The same process was repeated for ratings of pain unpl easantness, pain-related negative mood, pain coping, and recommending medical help. Willingness to report pain and pain endurance (taken from the GREP), were investigated to determine whether they meet the criteria to serve as covariates in the analyses of sex of virtual humans and participants main effects on ratings of pain intensity a nd pain unpleasantness.

PAGE 35

CHAPTER 3 RESULTS A series of mixed model ANOVA models was performed where sex and race of participants and virtual humans served as independent variables, and ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and the extent to which the [virtual humans] are recommended to seek medical help for their pain as dependent variables. The willingness to report pain, and pain endur ance are two factors of the GREP that are being considered to be included in the model as covariates. Howe ver, correlation analysis was conducted on these two factors as well as male and female participants rati ngs of pain intensity and pain unpleasantness for male and female virt ual humans. Results showed that correlations are not significant. Therefore, willingness to report pain, and pain endurance were dropped from the model because the assumptions of covariance analysis were not met. Analysis of Pain Intensity Ratings Sex Effects Both male and female participants rated pain intensity for female virtual humans significantly higher than that for male virtual humans, F (1, 73) = 4.92, p < 0.05. Between participants main effects, and sex of virtual human by sex of pa rticipant interactions were nonsignificant (see table 3-1). Both Caucasian and African American participants rated pain intensity for female virtual humans significantl y higher than that for male virtual humans, F (1, 73) = 6.93, p < 0.05. Between participants main effects or the sex of virtual human by race of participant interaction effects were non-significant, (see table 3-2). 35

PAGE 36

Race Effects There was no main effect of race of virtual human on ratings of pain intensity. However, African American participants rated African American virtual humans significantly higher than Caucasian virtual humans, F (1, 73) = 4.73, p < 0.05, (see table 3-3). Analysis of Pain Unpleasantness Ratings Sex Effects Both male and female participants rated pa in unpleasantness for female virtual humans significantly higher than that for male virtual humans, F (1, 73) = 7.61, p < 0.01. Main effect of sex of viewer, and main effect and sex of virt ual human by sex of viewer interaction were nonsignificant, (see table 3-4). Both Caucasian a nd African American par ticipants rated pain unpleasantness for female virtual humans significantly higher than that for male virtual humans, F (1, 73) = 4.17, p < 0.05. Between participants main effect and sex of virtual human by race of participants interaction were nonsignificant, (see table 3-5) These results mirrored the intensity effects. Race Effects Race of virtual human did not have an effect on ratings of pain unpleasantness. Sex of participant and race of participant did not have an effect on ratings of pain unpleasantness (see table 3-6). Analysis of Pain-Related Negative Mood Ratings Sex Effects Both male and female participants rated pa in-related negative m ood for female virtual humans significantly higher than that for male virtual humans, F (1, 73) = 6.76, p < 0.05. No significant interactions or between participants effects were f ound, (see table 3-7). However, a between participants main effect was found for race of participants; Caucasian participants 36

PAGE 37

ratings for both male and female virtual humans pain-related negative mo od were significantly higher than African American participants ratings, F (1, 73) = 3.99, p = 0.05. An interaction of sex of virtual human by race of participants was also found; Caucasian participants ratings for female virtual humans were significantly higher than African American participants ratings for female virtual humans, F (1, 73) = 4.11, p < 0.05, (see table 3-8). Race Effects Race of virtual human did not have an eff ect on ratings of pain-related negative mood made by male and female participants. (see ta ble 3-9). However, both Caucasian and African American participants viewed Caucasian virtual hu mans as having significantly higher levels of pain-related negative mood, F (1, 73) = 5.34, p < 0.05. (see table 3-10). Analysis of Pain-Coping Ratings Sex Effects Both male and female participants viewed female virtual humans as coping poorer than male virtual humans, F (1, 73) = 6.37, p < 0.05. No significant between participants effect, and sex of virtual human by sex of participant interactions we re found, (see table 3-11). No significant main effect for sex of virtual hum an on race of participants was found. Also, no interaction or between race of participants effects were found (see table 3-12). Race Effects Both Caucasian and African American partic ipants viewed Caucasian virtual humans as coping poorer with their pain than African American virtual humans, F (1, 73) = 6.86, p < 0.05. Race of participant did not have an effect on ra tings of pain coping. (see table 3-13). Sex of participant did not have an effect on ratings of pain coping (see table 3-14). 37

PAGE 38

Analysis of Recommendin g Medical Help Ratings Sex effects A main effect for sex of virtual humans on sex of participants was found; both male and female participants ratings were significantly higher for female virtual humans than that for male virtual humans, F (1, 73) = 5.98, p < 0.05. A sex of participants main effect was also found indicating that male participants ratings were significantly higher than female participants ratings, F (1, 73) = 4.02, p < 0.05, (see table 3-15). Race of partic ipant did not have an effect on ratings of recommending medical help (See table 3-16). Race effects Sex of participant did not have an effect on ratings of recommending medical help. However, male participants ratings for both Caucasian and African Am erican virtual humans were significantly higher than that of female participants, F (1, 73) = 4.06, p < 0.05 (see table 317). Sex of participant did not have an effect on ratings of recommending medical help (see table 3-18). In summary, male and female participants rate d female virtual humans pain intensity, pain unpleasantness, pain-related nega tive mood, poorer pain coping, and the need to seek medical help as higher than male virtual humans. However, Caucasian and African American participants ratings for female virtual humans we re higher than that for male virtual humans only on pain intensity and pain unpleasantness. Ca ucasian virtual humans were viewed as having higher pain-related negative mood and cope poorer w ith their pain than Af rican American virtual humans. African American virtual humans pa in intensity was rated higher only by African American participants. Ratings made by male part icipants tended to be higher than ratings made by female participants. 38

PAGE 39

A correlation analysis was conducted between dependent variables. All dependent variables in this study (ratings of pain intensity, pain unpleasa ntness, pain-related negative mood, pain coping, and recommending medical help) were intercorrelated. Correla tions ranged between 0.35 (pain coping and recommending medical he lp) to 0.87 (pain intensity and pain unpleasantness (see table 3-19). 39

PAGE 40

Table 3-1. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain intensity ma de by male and female participants. Virtual humans Participants M SD F (1, 73) 2 P Male Male 40.6 15.8 4.92 0.063 0.03 Female 37.8 14 Female Male 41.6 14.7 Female 40.9 13.6 Pain Intensity Ratings for sex of virtual human sex of participants 1.23 0.017 0.27 Between Participants Effect 0.24 0.003 0.62 Table 3-2. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain intensity ma de by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Male Caucasian 38.7 14.4 6.93 0.087 0.01 African American 38.6 15.9 Female Caucasian 40.9 14.2 African American 42.3 12.8 Pain Intensity Ratings for sex of virtual human race of participants 0.41 0.006 0.52 Between Participants Effect 0.03 0.000 0.88 Table 3-3. Descriptive st atistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain intensity ma de by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Caucasian Caucasian 39.4 13.7 2.62 0.035 0.11 African American 42.6 15.6 African American Caucasian 40 14.8 African American 38.3 12.9 Pain Intensity Ratings for race of virtual human race of participants 4.73 0.061 0.033 Between Participants Effect 0.03 0.000 0.86 40

PAGE 41

Table 3-4. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain unpleasantness made by male and female participants. Virtual humans Participants M SD F (1, 73) 2 P Male Male 43.2 16.8 7.61 0.095 0.007 Female 42 14.6 Female Male 46.9 16.9 Female 44 13.5 Pain unpleasantness ratings for sex of virtual human sex of participants 0.57 0.008 0.454 Between Participants Effect 0.32 0.004 0.575 Table 3-5. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain unpleasantness made by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Male Caucasian 42.7 14.6 4.17 0.054 0.045 African American 40.4 18.1 Female Caucasian 45.3 14.7 African American 43 14.2 Pain unpleasantness ratings for sex of virtual human race of participant 0.00 0.00 0.99 Between Participants Effect 0.267 0.00 0.61 41

PAGE 42

Table 3-6. Descriptive st atistics and mixed model ANOVA results the effect of race of virtual humans on ratings of pain unpleasantness made by male, female, Caucasian, and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Caucasian Males 45.15 16.7 1.17 0.02 0.28 Females 44 13.3 African American Males 45 16.8 Females 42 14.7 Pain unpleasantness ratings for race of virtual human sex of participant 0.77 0.01 0.38 Between Participants Effect 0.32 0.00 0.58 Caucasian Caucasian 44.58 14 2.55 0.03 0.11 African American 43 16 African American Caucasian 43.4 15.4 African American 40.4 14.9 Pain unpleasantness ratings for race of virtual human race of participant 0.38 0.01 0.54 Between Participants Effect 0.268 0.00 0.61 Table 3-7. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain-related negative mood made by male and female participants. Virtual humans Participants M SD F (1, 73) 2 P Male Male 41.2 15.9 6.76 0.085 0.011 Female 36.5 15.2 Female Male 44.2 15.3 Female 38.6 14.9 Pain-related negative mood ratings for sex of virtual human sex of participants 0.19 0.00 0.67 Between Participants Effect 1.89 0.03 0.17 42

PAGE 43

Table 3-8. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain pain-relat ed negative mood made by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Male Caucasian 39 15.2 0.55 0.01 0.46 African American 32.5 16.2 Female Caucasian 42.2 14.3 African American 31 16.2 Pain-related negative mood ratings for virtual humans sex participants race 4.11 0.05 0.05 Between Participants Effect 4 0.52 0.05 Table 3-9. Descriptive st atistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain pain-related negative mood made by male and female participants. Virtual humans Participants M SD F (1, 73) 2 P Caucasian Male 42.8 15.8 1.29 0.02 0.26 Female 38.6 14.6 African American Male 42.6 15.8 Female 36.3 15.9 Pain-related negative mood ratings for virtual humans race participants sex 0.9 0.01 0.35 Between Participants Effect 1.95 0.03 0.17 Table 3-10. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain pain-re lated negative mood made by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Caucasian African American 41 14.3 5.34 0.068 0.024 Female 34.4 17.5 African American Caucasian 40 15.4 African American 29.2 16.6 Pain-related negative mood ratings for virtual humans race participants race 2.47 0.03 0.12 Between Participants Effect 3.87 0.05 0.053 43

PAGE 44

Table 3-11. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain coping made by male and female participants. Virtual humans Participants M SD F (1, 73) 2 P Male Male 34.1 14.6 6.37 0.08 0.014 Female 31.8 13.3 Female Male 36 15 Female 34.2 13.4 Pain-coping ratings for virtual humans sex participants sex 0.08 0.00 0.78 Between Participants Effect 0.35 0.01 0.56 Table 3-12. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain coping made by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Male Caucasian 32.7 13.8 2.84 0.04 0.096 African American 31.6 13.4 Female Caucasian 35.2 13.5 African American 32.5 15.5 Pain-coping ratings for virtual humans sex participants race 0.63 0.01 0.43 Between Participants Effect 0.21 0.00 0.65 Table 3-13. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain coping made by Caucasian and African American participants Virtual humans Participants M SD F (1, 73) 2 P Caucasian Caucasian 34.5 13.3 6.86 0.086 0.011 African American 34.5 15.3 African American Caucasian 33.6 14 African American 28.9 14.5 Pain-coping ratings for virtual humans race participants race 3.7 0.05 0.058 Between Participants Effect 0.34 0.01 0.56 44

PAGE 45

Table 3-14. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain coping made by male and female participants Virtual humans Participants M SD F (1, 73) 2 P Caucasian Male 34.6 14.6 0.79 0.01 0.38 Female 34.4 13.3 African American Male 35.5 15 Female 31.7 13.8 Pain-coping ratings for virtual humans race participants sex 3.27 0.04 0.08 Between Participants Effect 0.35 0.01 0.56 Table 3-15. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of recommending medi cal help made by male and female participants Virtual humans Participants M SD F (1, 73) 2 P Male Male 51.9 25.1 5.98 0.076 0.017 Female 40.8 18.6 Female Male 53.8 24.2 Female 44.4 19 Recommending medical help ratings for sex of virtual human sex of participants 0.64 0.01 0.43 Between Participants Effect 4.02 0.052 0.049 Table 3-16. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of recommending medical help made by Caucasian and African American participants Virtual humans Participants M SD F (1, 73) 2 P Male Caucasian 43.7 21.6 3.63 0.05 0.06 African American 45.8 20 Female Caucasian 47.1 21.7 African American 47.6 17.5 Recommending medical help ratings for virtual humans sex participants race 0.37 0.01 0.54 Between Participants Effect 0.04 0.00 0.84 45

PAGE 46

Table 3-17. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of recommending me dical help made by male and female participants Virtual humans Participants M SD F (1, 73) 2 P Caucasian Male 52.8 24.8 0.11 0.00 0.74 Female 42.9 19.3 African American Male 52.9 24.2 Female 42.1 18.4 Recommending medical help ratings for virtual humans race participants sex 0.21 0.00 0.65 Between Participants Effect 4.06 0.53 0.048 Table 3-18. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of recommending medical help made by Caucasian and African American participants Virtual humans Participants M SD F (1, 73) 2 P Caucasian Caucasian 45.3 21.7 1.44 0.02 0.24 African American 48.1 20.1 African American Caucasian 45.3 21.5 African American 45.3 17.2 Recommending medical help ratings for virtual humans race participants race 1.36 0.02 0.25 Between Participants Effect 0.05 0.00 0.85 Table 3-19. Correlations between the dependent variables Pain Intensity Pain Unpleasantness Pain-related negative mood Pain coping Recommending medical help Pain Intensity 1 0.87 0.72 0.68 0.53 Pain Unpleasantness 0.87 1 0.82 0.75 0.51 Pain-related negative mood 0.72 0.82 1 0.71 0.42 Pain coping 0.68 0.75 0.71 1 0.35 Recommending medical help 0.53 0.51 0.42 0.35 1 46

PAGE 47

CHAPTER 4 DISCUSSION Although pain levels were digitally controlled to be equal among male, female, Caucasian, and African American virtual humans, these data indicate th at participants of both sexes and races still view females pain, with both of its components, sensory (intensity) and affective (unpleasantness), as significantly hi gher than that for male virtua l humans. This is consistent with other research findings. Robinson et al. (2001) found diffe rences in participants pain ratings for observed males and females experien cing experimentally induced pain. They found that viewers rated female virtual humans as ha ving more pain than observed male virtual humans. One possible explanation for why female virtual humans were vi ewed as having higher pain levels than male virtual humans is the diffe rence in pain expectati ons, that is, females are expected to report higher levels of pain than males in general. Although willingness to report pain, and pain endurance did not correlate significantly with pain ratings in this study, a sizable literature shows that both males and females expect females to experience higher levels of pain compared to males (Unrah, 1996, and Robinson et al, 2001). This study also suggests that differences in expecting females to experience highe r levels of pain are also true across races (Caucasians and African Americans). Although be tween races rating did not differ, they both rated female virtual humans to have higher pain levels. African American participants viewed African American virtual humans pain intensity as significantly higher than Caucas ian virtual humans pain inte nsity. The ratings of African Americans as having higher pain intensity than Ca ucasians is consistent with previous studies; Walsh, Schoenfield, Ramamurthy, & Hoffman (1989) investigated pain tolerance to the cold pressor test in Anglo-Saxons, Hispanics, a nd African Americans and found that African Americans and Hispanics had lower pain toleran ce. Sheffield, Biles, Orom, Maixner, & Sheps 47

PAGE 48

(2000) Found that African Americans rated the thermal stimuli as more unpleasant and more intense than Caucasians. Edwards et al (1999) found that African Americans had a lower thermal pain tolerance and greater pain severity than Caucasians. Edwards et al (2001) also found that African Americans report significantly greater pain se verity and pain-related disability than Caucasians. These studies invest igated participants ratings of their own pain conditions. The current study, however, investigated participants ratings of othe rs pain. Since Caucasians did not rate African Americans pain as high as African Americans did, results may indicate differences between race-related cultures in terms of sensitivity to facial pain expressions, thats is, African Americans might be mo re sensitive to African Americans facial expressions of pain than Caucasians. Rahim-Williams, Riley III, He rrera, Campbell, Hastie & Fillingim (2007) studied ethnic identity to determine whether it associates with experimental pain intensity in three groups including African Americans. Th ey found that African Americans scored the highest on the ethnic identity measure. Research ers suggested that higher scores on the ethnic identity measure would mean higher ethnic-spec ific socio-cultural influence on the pain experience. Since African Americans scored high er on the ethnic identity measure, and that means higher influence of their culture on pain ex perience, it is possible that they have rated African American virtual humans pain intensity as higher than that for Caucasian virtual humans because they (the African American participants) are more sensitive to pain behaviors, including facial pain expressions, exhibited by individuals of the sa me race-related culture. In the Study mentioned above, Non-Hispanic Whites scored the lowest on the ethni c identity measure, suggesting that it is possible that Caucasians are not as influen ced by their racial culture. This might suggest that Caucasians are less sensitiv e to pain behaviors, including facial pain expressions, exhibited by individuals of the same race. However, further investigation of this 48

PAGE 49

finding is needed to further understand and explai n the existence and the implications of between races differences in sensitivity to facial pain expressions. The International Association for the Study of Pain defines pain in a way that highlights the importance of understanding of the negative emotional experien ces of pain. Part of that emotional experience is the nega tive mood that accompanies pain experience. Although all facial expressions of pain were digita lly controlled to be similar for males and females in this study, female virtual humans pain-related negative mo od was rated significantly higher than that for male virtual humans by both male and female pa rticipants. These result s might be explained by the positive relationship between pain and nega tive mood found and is consistent with the findings of the National Health and Nutrition Examination Surve y, where pain and depressive symptoms tended to be more evident in female s than in males (Magni et al, 1990). Turk & Okifuji (1999) also found that females were view ed as more depressed than males when in pain. These results also highlight the role of the expectations males have regarding the effects of females high levels of pain on their moods. Cu rrent data also indicate that Caucasians and African Americans differ in th eir ratings of pain-related negative mood. Although Caucasian participants ratings of pain-related negative mood for male and female virtual humans were significantly higher than African Americans ratings, they even rated females pain-related negative mood as significantly higher than males pain-related negative mood. This highlights the role that culture might play in perceiving pain effects on the mood of females and males. Caucasian virtual humans were rated by both Af rican American and Caucasian participants as having higher pain-related negative mood. However, this is not consistent with the positive relationship between pain level a nd negative mood experiences. Thes e results indicate that race might moderate the relationship between pain and pain-related negative mood. 49

PAGE 50

Consistent with the pain-related negative mood re sults, male and female participants rated female virtual humans as coping poorer with thei r pain, and Caucasian virtual humans were rated by both Caucasian and African Am erica participants as coping poorer with their pain. These results mirror the pain-related negative mood rati ngs. These results suggest that when females and Caucasians are viewed as having higher leve ls of pain than males and African Americans, they are more likely to be viewed as experien cing higher levels of pain-related negative mood and higher levels of poorer pa in-related coping strategies. When someones pain level, pain-related ne gative mood, and pain-maladaptive coping is rated high, it is expected that he /she is more likely to be recommended to seek medical help for his/her pain. In this study, female virtual humans were rated higher on all of those variables than male virtual humans, they also were recommended to seek medical help for their pain significantly more than male virt ual humans. However, it was not e xpected for male participants recommendations to be higher than female par ticipants. Males recommended female virtual humans to seek medical help for their pain si gnificantly more than the recommendation made by female participants. Male participants also recommended Caucasian and African American virtual humans to seek medical help for their pa in significantly more than the recommendations made by female participants. One possible explanation to why males recommendations are higher than females recommendations is the di fference between males and females in painrelated medication seeking behaviors. Males ha ve been shown to request more drugs than females after surgery when given access to patie nt controlled analgesia (Macintyre & Jarvis, 1995. Burns, Hodsman, McLintock, Gillies, Ken ny, & McArdle (1989) and Stinshoff, Lang, Berbaum, Lutgendorf, Logan & Berbaum (2004) also found that males tend to seek more medications for their pain compared to females. 50

PAGE 51

The ratings of pain intensity, pain unpleas antness, pain-related negative mood, pain coping, and recommending medical help showed significant intercorrelations. Relationships between these dependent variables have a pattern that might add to the ex planation of some of the current results. For example, the high correlat ion between pain intensity, pain unpleasantness, pain-related negative mood, and pain coping might add to the explanation as to why female virtual videos were rated high on all of them, if pain rating influenced the other ratings. The results of this study have exciting implications, however, this study has some advantages and disadvantages worth noting. One lim itation of this study is that only one African American male participated in it. Efforts to recruit more African Americans through study announcements to specifically target African American undergra duates were not successful. The use of computerized virtual humans with di gitally controlled facial expressions of pain based on the FACS, and digitally controlled pain levels across sexes and races of virtual humans, is innovative. This enables greate r control over unifying facial pa in expressions and levels of pain than if we had used human virtual humans. This technique, by the high control it provides over the ecology, also enables gr eater confidence in focusing on biases and variance brought to the ratings by participants. Furthermore, the virtual human technology used in this study, has the potential to develop to be an educational assessment and intervention tool. Students, health care providers, and other individuals can use this technol ogy to assess for their own biases regarding pain expressed by others and regarding specific variables of interest assigned to the observed virtual humans. This technology is also accessible from almost ever ywhere in the world via the Internet. One advantage of the easy access to this technology is that it makes, for ex ample, cross-cultural studies much easier to conduct if same stimuli we re to be used. Such an example provides wider 51

PAGE 52

52 scope of races to be easily studied, as we ll as other cultures. Although the virtual human technology used in this study focused only on f acial pain expressions without sound, future considerations might add other pain expressions to this technology, such as, verbal pain expressions, body gestures that are pain rela ted, and adding background environments that determine context in which the pain is being experienced. One other advantage of using virt ual humans in this study is that it eliminates the biases in the making of the stimuli. These stimuli are basically made digitally identical except for the variables at interest in this study. One other advantage to this study is the focus on how others perceive and rate others pain and other dependent variables in this study. Most research investigating pain perception focused on self-repo rts. Although self-reports of pain experience are an important component in the quest of unders tanding the nature of pai n, it is also important to investigate how others perc eive and view the experience of pain communicated to them by other individuals. This contributes significantly to the overall understanding of the nature of pain including how others appraise and respond to others expe riences of pain.

PAGE 53

REFERENCES Adamson, J., Ben-Shlomo, Y., Chaturvedi, N ., & Donovan, J. (2003). Race, socio-economic position and sex-do they affect reported health-care seeking behaviour? Social Science & Medicine, 57 (5), 895-904. Affleck, G., Tennen, H., Keefe, F. J., Lefebvre, J. C., Kashikar-Zuck, S., Wright, K., Starr, K., & Caldwell, D. S. (1999). Everyday life with osteoarthritis or rheumatoid arthritis: Independent effects of disease a nd sex on daily pain, mood, and coping. Pain 83, 601609. Ambadar, Z., Schooler, J., & Cohn, J (2005). Deciphe ring the enigmatic face: the importance of facial dynamics in interpreting subtle facial expressions. Psychological Science 16, 403410. Anderson, K., Palos, G., Gning, I., Mendoza, T., Sanchez, M., Valero, V., Richman, S., Nazaria, A., Hurley, J., Payne, R. & Cleeland, C. (2003). Multi-site randomized trial of pain management education for minority outpatients with cancer pain. Pain 4, 95. Bassili, J (1979). Emotion recognition: the role of facial movement and the relative importance of upper and lower areas of the face. Journal of Personality and Social Psychology 37, 2049-258. Bates, M. S. (1996). Biocultural dimensions of chronic pai n: implications for treatment of multiracial populations Albany, NY: State University of New York Press. Beutler, L.E., Engle, D., Oro-Beutler, M.E., Daldrup, R. & Meredith, K. (1986). Inability to express intense affect: a common link between depression and pain? Journal of Consulting and Clinical Psychology 54 (6), 752. Bombardier, C.H., DAmico, C., & Jordan, J. S. (1990). The relationship of appraisal and coping to chronic illness adjustment. Behavior Research and Therapy 28, 297. Boothby, J. L., Thorn, B. E., Stroud, M. W., & Jensen, M. P. (1999). Coping with Pain. In Gatchel, R. G., & Turk, D. C. (Eds.), Psychosocial Factors in Pain New York: Guilford Press. Boyatzis, C., Cazan, E., & Ting, C (1993). Preschool childrens decoding of facial emotions. Journal of General Psychology 154, 375-382. Brodsgaard, M. R. (1999). Crosscultural investiga tions of pain. In: Crombie IK, editor. Epidemiology of pain Seattle: IASP Press. Brown, F. F., Robinson, M. E., Riley, J. L. & Gremillion, H. A. (1996). Pain severity, negative affect, and microstressors as predictors of life interference in TMD patients. CRANIO, 14:63-70. 53

PAGE 54

Buckelew, S. P., Shutty, M. S., Hewitt, J., Landon, T., Morrow, K. & Frank, R. G. (1990). Health locus of control, sex differences and adjustment to persistent pain. Pain, 42: 287295. Burns, J., Hodsman, N., McLint ock, T., Gillies, G., Kenny, G., & McArdle, C. (1989). The influence of patient characteristics on the requirements for postoperative analgesia. Anaesthesia 44, 2 6. Campbell, L. (2002). Predispositions Towards Pharmacol ogical Pain Management: A policy capturing study. University of Florida. Carey, T. S., Hadler, N. M., Gillings, D., Stinnett, S., & Wallsten, T. (1988). Medical disability assessment of the back pain patient for the so cial security administ ration: The weighting of presenting clinical features. Journal of Clinic al Epidemiology. 41 (7), 691-697. Carmen, R., Green, S., Ndao-Brumblay, K., Nagrant, A. M., Baker, T. A. & Rothman, E. (2004). Race, age, and sex influences among clusters of african american a nd white patients with chronic pain. The Journal of Pain 5 (3), 171-182. Caron, R. F., Caron, A. J., & Myers, R. S (1985). Do infants see emotional expression in static faces? Child Development 56, 1552-1560. Campbell, C. M., Edwards, R. R. & Fillingim, R. B. (2005). Racial differences in responses to multiple experimental pain stimuli. Pain, 113 (1-2), 20-26. Cohen F. (1980). Post-surgical pain relief: pa tients status and nurse s medication choice. Pain 9, 265. Cooksey, R. W. (1996). Judgment Analysis: Theory, methods, and applications San Diego, CA: Academic Press. Craig, K., Hyde, S., & Patrick, C (1991). Genuine suppressed and faked facial behavior during exacerbation of chronic low back pain. Pain 46, 161-171. Craig, K., & Patrick, C (1985). Facial expression during induced pain. Journal of Personality and Social Psychology 48, 1080-1091. Dao, T. T. & LeResche, L. ( 2000). Sex differences in pain. Journal of Orofacial Pain, 14, 169 84. de Ridder, D. & Schreurs, K. ( 2001). Developing interventions for chronically ill patients: is coping a helpful concept? Clinical Psychology Review, 21, 205. Dennis, C. K. & Akiko O. (1999). Does sex make a difference in the pr escription of treatments and the adaptation to chronic pain by cancer and non-cancer patients? Pain, 82, 139-149. 54

PAGE 55

Edwards, R. R., Doleys, D. M., Fillingim, R. B. & Lowery, D. (2001). Racial differences in pain tolerance: clinical implicati ons in a chronic pain population. Psychosomatic Medicine 63: 316-323. Edwards, R. R. & Fillingim, R. B. (1999). R acial differences in thermal pain responses. Psychosomatic Medicine 61: 346-354. Edwards, C. L., Fillingim, R. B. & Keefe, F. J. (2001). Race, race and pain. Pain 94, 113-137. Ekman, P (1993). Facial Expression of Emotion. American Psychologist. 48 (4), 384-392. Ellermeier, W. & Westphal, W. (1995). Sex differences in pain ratings and pupil reactions to painful pressure stimuli. Pain 61 (3), 435-439. Endler, N. S., Corace, K. M., Summerfeldt, L. J., Johnson, J. M. & Rothbart, P. (2003). Coping with chronic pain. Personality and Individual Differences 34, 323. Feldman, S., Downey, G., & Schaffer-Neitz, R. (1999). Pain, Negative Mood, and Perceived Support in Chronic Pain Patients: A Da ily Diary Study of People With Reflex Sympathetic Dystrophy Syndrome. Journal of Consulting and Clinical Psychology 67 (5), 776-785. Folkman S, & Moskowitz, J. T. (2000). Po sitive affect and the other side of coping. American Psychologist 55 (6), 647-654. Frot, M., Feine, J. S. & Bushnell, M. C. (2004) Sex differences in pain perception and anxiety. A psychophysical study with topical capsaicin. Pain, 108 (3), 230-236. Gaskin M. E., Greene A. F., Robinson M. E. Ge isser & M. E. (1992). Negative affect and the experience of chronic pain. Journal of Psychosomatic Research 36 (8), 707-713. Geisser, M.E., Robinson, M. E., Keefe, F. J. & Weiner, M. L. (1994). Catastrophizing, depression and the sensory, affective and evaluative aspects of chronic pain. Pain 59 (1), 79-83. Goubert, L., Crombez, G., & Danneels, L. ( 2004). The reluctance to generalize corrective experiences in chronic low back pain patie nts: a questionnaire study of dysfunctional cognitions. Behaviour Research and Therapy, 43 (8), 1055-1067. Green, C. R Anderson, K., Baker, T., Campbell, L., Decker, S., Fillingim, R., Kaloukalani, D., Lasch, K., Myers, C., Tait, R., Todd, K. & Vallerand, A. (2003). The unequal burden of pain: Confronting racial and racial disparities in pain. Pain Medicine 4, 277-294. Green, C. R., Baker, T. A., Sato, Y., Washington T. L. & Smith, E. M. (2003). Race and chronic Pain: A comparative study of young black and white Americans presenting for management. Journal of Pain 4, 176-183. 55

PAGE 56

Green, C. R., Baker, T. A., Smith, E. M. & Sato, Y. (2003). The effect of race in older adults presenting for chronic pain management: A comparative study of African and Caucasian Americans. Journal of Pain 4, 82-90. Green, C. R., Wheeler, J. R. & LaPorte, F. (2003). Clinical Decision Making in Pain Management: Contributions of Physician and Patient Characteristics to Variations in Practice. The Journal of Pain, 4 (1), 29-39. Greenwald, H. P. (1991). Interracial differences in pain perception. Pain. 44, 157-163. Hall, J (1978). Gender effects in decoding nonverbal cues. Psychological Bulletin 85, 845-857. Hamers, J. P., van den Hout, M., Halfens, R. J., Abu-Saad, H. H., & Heijltjes, A. E. (1997). Differences in pain assessment and decisions regarding the administration of analgesics between novices, interm ediates and experts in pediatric nursing. International Journal of Nursing Studies. 34 (5), 325-334. Harwood, N., Hall, L., & Shinkfield, A (1999). Rec ognition of facial emotional expressions from moving and static displays by indi viduals with mental retardation. American Journal of Mentally Retarded. 104 (3), 270-278. Hastie, B. A., Riley, J. L. & Fillingim, R. B. (2 004). Racial differences in pain coping: Factor structure of the coping strategies questi onnaire and coping stra tegies questionnairerevised. The Journal of Pain. 5 (6), 304-316. Hassenbusch, S. J. & Portenoy, R. K. (2000). Current Practices in Intraspinal Therapy: A Survey of Clinical Trends and Decision Making. Journal of Pain and Symptom Management, 20 (2), S4-S11. Hawthorn, J. & Redmond, K. (1998). Pain : Causes and Management. Malden, Mass. Blackwell Science. Hazelett, S., Powell, C., & Androulakakis, V. (2 002). Patients' behavior at the time of injury: Effect on nurses' perception of pain level and subsequent treatment. Pain Management Nursing, 3 (1), 28-35. Holm, K., Cohen, F., Dudas, S., Medema, P. & Allen, B. (1989). Effect of personal pain experience on pain assessment. Journal of Nursing Scholarship 21, 72. Holzberg, A. D., Robinson, M. E., Geisser, M. E. & Gremillion, H. A. (1996). The effects of depression and chronic pain on psyc hosocial and physical functioning. Clinical Journal of Pain 12, 118-125. Jasso, G., & Opp, K. (1997). Probing the Character of Norms: A Factorial Survey Analysis of the Norms of Political Action. American Sociological Review. 62 (6), 947-964. 56

PAGE 57

Jasso, G. & Webster, M. (1997). Double standards in just earning for male and female workers. Social Psychology Quarterly, 60 (1), 66-78. Jensen, M. P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: a critical review of the literature. Pain. 47, 249. Jensen, M. P., Turner, J. A., Romano, J. M., & Lawler, B. K. (1994). Relationship of painspecific beliefs to chronic pain adjustment. Pain 57, 301. Jordan, M., Lumley, M., & Leisen, J. (1998). Th e relationships of cognitive coping and pain control beliefs to pain and adjustment among African-American and Caucasian women with rheumatoid arthritis. Arthritis Care and Research. 11, 80. Keefe, F. G., Affleck, G., France, C. R., Emer y, C. F., Waters, C., Caldwell, D. S., Stainbrook, D., Hackshaw, K. V., Fox, L. C. & Wilson, K. (2004). Sex differences in pain, coping, and mood in individuals havi ng osteoarthritic knee pain : a within-day analysis. Pain 110 (3), 571-577. Keefe, F. J., Lefebvre, J. C., Egert, J. R., Af fleck, G., Sullivan, M. J., & Caldwell, D. S. (2000). The relationship of sex to pain, pain behavior, and disability in osteoarthritis patients: the role of catastrophizing. Pain, 87, 325. Keogh, E., & Herdenfeldt, M. (2002). Sex, coping and the perception of pain, Pain 97 (3), 195201. Kerns, R. D., Rosenberg, R. & Jacob, M. C. (1994). Anger expression and chronic pain. Journal of Behavioral Medicine 17 (1), 57. Kirrouac, G & Dore, F (1985). Accuracy of the judg ment of facial expressions as a function of sex and level of education. Journal of Nonverbal Behavior 9, 3-7. Klonoff, E.A., Landrine, H. & Brown, M.A. (1993) Appraisal and response to pain may be a function of its bodily function. Journal of psychosomatic research 37, 661-670. Kunz, M., Gruber, A., & Lautenbacher, S (2006). Sex differences in facial encoding of pain. The Journal of Pain 7 (12), 915-928. Lazarus, R. S., & Folkman, S. (1984). Stress, Appraisal, and Coping New York: Springer Publishing Company. Leahey, E. (2004). The role of status in ev aluating research: the case of data editing. Social Science Research 33 (3), 521-537. Macintyre P, Jarvis D. (1995). Age is th e best provider of postoperative morphine requirements. Pain 64, 357. 57

PAGE 58

Maes, S., Leventhal, H., & de Ridder, D. T. ( 1996). Coping with chronic diseases. In: Zeidner, M., Endler, N.S. (Eds.), Handbook of Coping Theory, Research, Applications. Wiley, New York. Magni, G., Caldieron, C., Rigatti-Luchini, S. & Merksey, H. (1990). Chronic musculoskeletal pain and depressive symptoms in the general population: An analysis of the 1st National Health and Nutrition Examination Survey data. Pain. 43, 299-307. Mandal, M & Palchoudhury, S ( 1985). Perceptual skill in decoding facial affect. Perceptual and Motor Skills 60, 96-98. McDonald, D. & Bridge, R. G. (1991) Sex stereotyping and nursing care. Research in Nursing and Health .14, 373. McWilliams, L. A., Cox B. J. & Enns M. W. ( 2003). Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample. Pain 106 (1-2), 127133. Mitchell, K., & Owens, R. (2004). Judgments of laypersons and gene ral practitioners on justifiability and legality of providing assistan ce to die to a termina lly ill patient: a view from New Zealand. Patient Education and Counseling 54 (1), 15-20. Moore, R. & Brodsgaard, I. (1999). Cross-cultural investigations in pai n. in Crombie IK (ed): Epidemiology of Pain Seattle, WA, IASP Press. Morrill, C., Snyderman, E., & Dawson, E. J. (1997). Its not what you do, but who you are: informal social control, social status, and normative seriousness in organizations. Sociological Forum, 12, 519. Novy, D. M., Nelson, D. V., Hetzel, R. D, S quitieru, P. & Kennington, M. (1998). Coping with chronic pain: sources of intrin sic and contextual variability. Journal of Behavioral Medicine. 21 (1),19-34. Nowicki, S & Hartigan, M (1988). Accuracy of facial affect recognition as a function of locus of control orientation a nd anticipated interp ersonal interaction. Journal of Social Psychology. 128, 363-372. Portenoy, R. K., Ugarte, C., Fuller, I. & Haas, G. (2004). Population-based survey of pain in the United States: Differences among white, Afri can American, and Hispanic subjects. The Journal of Pain. 5 (6), 317-328. Price, D. D. (1999). Psychological Mechanisms of Pain and Analgesia Seattle, WA, IASP. Prkachin, K (1992). The consistency of faci al expression of pain: a comparison across modalities. Pain 51, 297-306. 58

PAGE 59

Rahim-Williams, B., Riley III, J, L., Herrera, D., Ca mpbell, C, M., Hastie, B, A., & Fillingim, R, B. (2007). Ethnic identity predicts experimental pain sensitivity in African Americans and Hispanics. Pain 129 (1-2), 177-184. Riley, J. L., Wade, J. B., Myers, C. D., Sheffi eld, D., Papas, R. K. & Price, D. D. (2002). Racial/racial differences in th e experience of chronic pain. Pain. 100 (3), 291-298. Riley, J. L., Robinson, M. E., Wade, J. B., Myers, C. D. & Price, D. D. (2001). Sex Differences in Negative Emotional Responses to Chronic Pain. The Journal of Pain 2 (6), 354-359. Robinson, M. E., Gagnon, C. M., Riley, J. R. & Price, D. D. (2003). Altering sex role expectations: effects on pa in tolerance, pain thre shold, and pain ratings. The Journal of Pain 4 (5), 284-288. Robinson M. E. & Riley J. L. (1998). Role of nega tive emotions in pain, in Gatchel R. J. & Turk D. C. (eds): Psychosocial Factors in Pain New York, NY, Guilford Press, pp 74-88. Robinson, M. E., Riley, J. L., & Myers, C. D. (2000). Psychosocial contri butions to sex related differences in pain responses. In: Fillingim, R. B. Sex, sex, and pain, Progress in pain research and management 17. Seattle, WA: IASP Press, 41. Robinson, M. E., Riley, J. L., Myers, C. D., Pa pas, R. K., Wise, E. A., Waxenberg, L. B. & Fillingim, R. B. (2001). Sex role expectations of pain: Relationship to sex differences in pain. Journal of Pain 2, 251-257. Robinson, M. E. & Wise, E. A. (2004). Prior pa in experience: influence on the observation of experimental pain in men and women. The Journal of Pain 5 (5), 264-269. Robinson, M. E. & Wise, E. A. (2003). Sex bias in the observation of experimental pain. Pain 104 (1-2), 259-264. Robinson, M. E., Wise, E. A., Gagnon, C., Fillingim, R. B. & Price, D. D. (2004). Influences of sex role and anxiety on se x differences in temporal summation of pain. The Journal of Pain 5 (2), 77-82. Romano, J. M., & Turner, J. A. (1985). Chronic pain and depression: doe s the evidence support a relationship? Psychological Bulletin 97 (1), 18. Rotter, N & Rotter, G (1988). Sex differences in encoding and decoding of negative facial emotion. Journal of Nonverbal Behavior. 12, 139-148. Sheffield, D., Biles, P. L., Orom, H., Mai xne, W. & Sheps, D. S. (2000). Race and sex differences in cutaneous pain perception. Psychosomatic Medicine. 62 (4), 517-523. 59

PAGE 60

Slocumb, J. C., Kellner, R., Rosenfeld, R. C. & Pathak, D. (1989). Anxiety and depression in patients with the abdominal pelvic pain syndrome. General Hospital Psychiatry 11 (1), 48-53. Stinshoff, V. J., Lang, E. V., Berbaum, K. S., Lutgendorf, S., Logan, H. & Berbaum, M. (2004). Effect of sex and gender on drug-seeking beha vior during invasive medical procedures Academic Radiology 11 (4), 390-397. Sullivan, M. J., Tripp, D. A., & Santor, D. (2000). Sex differences in pain and pain behavior: the role of catastrophizing. Cognitive Therapy and Research 24,121. Tait, R. C., & Chibnall, J. T. (1997). Phys ician judgments of chronic pain patients. Social Science & Medicine 45 (8), 1199-1205. Tamayo-Sarver, J. H., Dawson, N. V., Cydulka, R. K., Wigton, R. S. & Baker, D. W. (2004). Variability in Emergency Physician D ecisionmaking About Prescribing Opioid Analgesics. Annals of Emergency Medicine, 43 (4), 483-493. Tayler, J & Johnsen, B (2000). Sex differences in judgment of facial affect: a multivariate analysis of recognition errors. Scandinavian Journal of Psychology. 41, 243-246. Turk, D. C. & Melzack, R. (2001). Handbook of Pain Assessment New York: Guilford Press. Unruh, A. M. (1996). Sex variations in clinical pain experience. Pain, 65 (2), 123. Unruh, A. M., Ritchie, J., & Merskey, H. (1999). Does sex affect appraisal of pain and pain coping strategies? Clinical Journal of Pain 15, 31. Vallerand, A. H. & Polomano, R. C. (2000) The relationship of sex to pain. Pain Management Nursing, 1 (3), 8-15. Wade, J. B., Dougherty, L. M., Archer, C. R., & Pr ice, D. D. (1996). Assessing the stages of pain processing: A multivariate analytical approach. Pain. 68, 157-167. Wade, J. B., Dougherty, L. M., Hart, R. P., Rafii, A. & Price, D. D. (1992). A canonical correlation analysis of the in fluence of neuroticism and extraversion on chronic pain, suffering, and pain behavior. Pain. 51, 67-73. Wagner, H., McDonald, C., & Manstead, A (2986) Communication of individual emotions by spontaneous facial expression. Journal of Personality and Social Psychology 50, 737743. Walsh N, Schoenfield L, Ramamurthy S, & Hoffman J. (1989). Normative model for cold pressor test. American Journal of Physical Medicine and Rehabilitation 68, 6. 60

PAGE 61

61 Wehrle, T., Kaiser, S., Schmidt, S., & Schere r, K (2000). Studying the dynamics of emotional expression using synthesized facial muscle movements. Journal of Personality and Social Psychology 78 (1), 105-119. Weickgenant, A. L., Slater, M.A., Patterson, T. L ., Atkinson, J. H., Grant, I. & Garfin, S. R. (1993). Coping activities in chronic low back pain: relationship with depression. Pain, 53, 95. Weir, R., Browne, G., Tunks, E., Gafni, A., & Robe rts, J. (1996). Sex differences in psychosocial adjustment to chronic pain and expend itures for health care services used. Clinical Journal of Pain 12, 277. Weisse, C. S., Sorum, P. C., & Dominguez, R. E. (2003). The influence of sex and race on physicians' pain management decisions. The Journal of Pain 4 (9), 505-510. Woodworth, R. S. (1939). Experimental Psychology New York: Holt. Woodworth, R. S., & Schlosberg, H. (1954). Experimental Psychology. New York: Holt. Zatzick, D. F. & Dimsdale, J. E. (1990). Cultu ral variations in res ponse to painful stimuli. Psychosomatic Medicine 52, 544-557

PAGE 62

BIOGRAPHICAL SKETCH Ashraf Faris Alqudah was born on November 11, 1975 in Ajloun, Jordan. He grew up in Ajloun until he graduated from Ajouln High School in 1993. He moved to Amman, the capital city of Jordan, to study at the University of Jordan (JU). He earned his B. A. and M. A. in Psychology in 1997 and 2000, respectively. He worked as a teaching assistant for 1 year at JU upon receiving a scholarship to pursue hi s Ph. D. degree in Clinical Psychology. Upon finishing the teaching assistant year at JU he was admitted to the Graduate School at the University of Florida (UF) to work on his P h. D. in Clinical Psychology at the UF Health Science Center, College of Public Health and Health Professions, Department of Clinical and Health Psychology. Upon completion of his Ph. D. program, Ashraf will join the faculty of the Department of Psychology at JU. He has a 4-year-old daughter whose name is Sarah. 62