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Last updated: Sun, Jul 28, 2024
Pain behaviors are any behaviors that are influenced or might be influenced by a person's state of pain. By this broad definition behaviors such as limping or bracing are pain behaviors, as are a person's utterances about their pain, their answers to questions about their pain, their responses to physical examination, and just about any other behavior that an observer believes may be influenced by pain. Facial displays (Facial Expressions) are an instance of pain behavior in which substantial research has been done.
The term “pain behavior” probably originated with animal research into pain, where pain behaviors include such clearly defined things as the tail flick (Animal Research Models). W. E. Fordyce in 1976 authored a book, “Behavioral Methods for Chronic Pain and Illness.” In this book he took the perspective that researchers and clinicians should consider that any visible sign related to pain serves as a communication. Pain behaviors therefore can be influenced by the social environment and can influence the social environment of the patient. Further, pain behaviors may be shaped, consciously or not, by factors other than the biological condition.
Pain behaviors have been of persistent interest to both medical and behavioral pain practitioners. Sometimes the hope/expectation is that pain behaviors can provide a more reliable indicator of the “real” pain state of the patient, since some pain behaviors are more automatic and less filtered than verbal reports. At other times the interest is in what the pain behaviors can reveal about the psyche of the patient. Perhaps the astute observer can make valid inferences about the patient's beliefs and motivations based on observed pain behaviors.
Clinicians of course must develop an overall impression of the patient's level and quality of suffering, so these issues come up both in medical evaluations (see Medical Pain Treatment) and in behavioral evaluations (see Psychological and Psychiatric Treatments). I'll discuss these issues in the sections just refered to. If you look back at the earlier section on Provability of models (The Challenge of Provability), you can see the examiner's dilemma in trying to make inferences about the patient's pain state from partial knowledge of a large number of factors using an incomplete model of the causes of pain behaviors.
A 2003 meta-study examined 29 original studies in which pain behaviors were recorded along with the pain self-reports of the subjects. The meta-study found that there was an association between behaviors and self-report, but that the association was stronger with acute than with chronic pain, when a composite measure of pain behaviors was used, and when restricted to low back pain patients.1
An earlier (1986) study is one of many that indicate that social factors influence not only reporting but perhaps also perception of pain. The 1986 study applied alternating treatment of its subjects over seven consecutive days. One treatment was verbal reinforcement of “pain talk,” and the other treatment was reinforcement of “well talk.” The subjects' pain intensity ratings were higher after reinforcement of “pain talk,” and lower after reinforcement of “well talk.”2 Although this particular study was limited to a very small number of subjects, it seems to be well established that people's judgments of their own pain can be changed socially. It is less clear what implications this has for the practice of pain medicine.
Mr. Smith was having great difficulty tolerating the physical examination. Despite the fact that he had few physical findings, Mr. Smith complained bitterly of chronic back pain. He flinched visibly when the examiner palpated his back. His movements were slow, and he limped in an exaggerated fashion when asked to walk. He gave very detailed descriptions of his back pain and stated that he was not sure that he could cope with the pain much longer.
Most clinicians working in the pain management area have met patients like Mr. Smith. In a medical setting, the behavior of such a patient with chronic pain may influence decisions about the need for further assessment or treatment. Patients who show exaggerated or inconsistent pain behavior are often considered to be poor candidates for invasive diagnostic testing (e.g., electromyography), or medical or surgical interventions (Waddell, McCulloch, Kummel, & Venner, 1980). For a behavioral clinician, the behavior of a patient like Mr. Smith is interesting and important in and of itself.3
The preceding quotation is from the chapter about assessment of pain behaviors in the Handbook of Pain Assessment. It suggests what may be at stake for Mr. Smith based on his pain behaviors. The attitudes implied in this quotation aren't unique to the authors of this chapter, but are echoed in many ways in the pain literature. Consider how the author might know that Mr. Smith's behavior was “exaggerated” or “inconsistent,” and whether Mr. Smith could reasonably be expected to be able to protect himself from the consequences of the narrator's judgments.