Facing others in pain: the effects of empathy.
Explore the source record for details and available documents.
Adaptation, Psychological↗
Biomedical subjects
K D Craig
Publications and source records attributed to K D Craig.
A theoretical framework for understanding self-report and observational measures of pain: a communications model.
Self-report and observational measures of pain are examined from the perspective of a model of human communication. This model examines the experience of pain as affected by intrapersonal and contextual factors, the process whereby it is encoded into expressive behaviour, and the process of decoding by observers prior to their engaging in action. Self-report measures primarily capture expressive pain behaviour that is under the control of higher mental processes, whereas observational measures capture behaviour that is less subject to voluntary control and more automatic. Automatic expressive behaviours are subject to less purposeful distortion than are behaviours dependent upon higher mental processes. Consequently, observational measures can be used and have clinical utility as indices of pain when self-report is not available, for example, in infants, young children, people with intellectual disabilities or brain damage, and seniors with dementia. These measures are also useful when the credibility of self-report is questioned and even when credible self-report is available. However, automatic behaviours may be more difficult for observers to decode. The model outlined herein takes into account the role of various human developmental stages in pain experience and expression and in understanding the utility of self-report and observational measures. We conclude that both observational and self-report measures are essential in the assessment of pain because of the unique information that each type contributes.
Humans↗
Nonneurologic hand pain versus carpal tunnel syndrome: do psychological measures differentiate?
OBJECTIVE: To determine whether psychological measures would differentiate a group of patients with physician-diagnosed nonneurologic hand pain from patients with carpal tunnel syndrome (CTS). Many patients, who also displayed symptoms of psychological distress, were referred to an electrodiagnostic clinic with a diagnosis of possible CTS; they subsequently had normal nerve conduction studies. DESIGN: Sixty patients with hand pain were referred to either of two university clinics for electrophysiologic testing, were assigned to either the CTS or nonneurologic group, and were compared on a series of psychometric tests. RESULTS: The Beck Depression Inventory and McGill Pain Questionnaire showed that the physician-assigned nonneurologic patients have a greater degree of depression, use more affective adjectives, and choose more words on the McGill Pain Questionnaire than the physician-assigned CTS group. The nonneurologic group also scored higher on indices of self-reported disability on the Pain Disability Inventory in five of seven categories. Although the CTS group perceived more control over their pain, no differences were observed in the types of coping strategies used on the Coping Strategy Questionnaire. Finally, the nonneurologic group had more Workers' Compensation Board claims. CONCLUSION: Evidence of important psychological issues in some patients with hand pain suggests a need for greater awareness among treating physicians.
Adolescent↗
Facial expression of children receiving immunizations: a principal components analysis of the child facial coding system.
OBJECTIVE: To identify the structure of facial reaction to procedural pain and to determine the subset of facial actions that best describe the response. DESIGN: Observational. SETTING: Five rural and five urban physicians' offices. PATIENTS: One hundred twenty-three children aged 4 to 5 years undergoing routine diphtheria, pertussis, tetanus, and polio immunization. OUTCOME MEASURES: The Child Facial Coding System, comprising 13 discrete facial actions, was used to code each second of five 10-second phases from videotape: baseline, preneedle, needle, postneedle, and posthandling. Parents and a technician provided visual analog scale ratings of children's pain. Children provided a self-report using a Faces Pain Scale, and parents and nurses rated the children's pain and anxiety using visual analog scales. RESULTS: A "pain face" similar to that reported in adults emerged with the onset of pain. Principal component analyses revealed the frequency and intensity of facial action during the needle phase could be represented by components reflecting pain sensation, a "brave face," and the children's expectations for pain. Children's Faces Pain Scale and adult visual analog scale ratings were best predicted by components reflecting pain sensation and expectations of high pain. CONCLUSIONS: These results provide a preliminary indication that the Child Facial Coding System can be reduced to components that reflect several aspects of children's acute pain experience and predict self-reports and observer reports of children's pain.
Acute Disease↗
Measuring movement-exacerbated pain in cognitively impaired frail elders.
OBJECTIVE: Prior research examining the utility of nonverbal measures of pain in persons with cognitive impairments has focused on acute procedurally-induced phasic pain (i.e., venipuncture and needle injections). The goal of the current project was to examine the utility of both self-report and nonverbal measures of pain in frail elders experiencing exacerbations of chronic musculoskeletal pain. These were assumed to be more representative of the day-to-day pain experience of elderly patients. DESIGN: Participants were 58 frail elders, 29 of whom had been found to have significant cognitive impairments. All were filmed as they undertook a series of structured activities (e.g., walking and reclining), and pain was assessed using self-report. Trained coders identified the incidence of pain-related behaviors using the videotapes. The various pain measures (i.e., self-report and nonverbal indices) were compared across both patient groups and the several activities. RESULTS: Consistent with our hypotheses, more pain was identified (using both self-report and nonverbal measures) when patients engaged in more physically demanding activities. Facial reactions varied as a function of patient cognitive status, with those participants who were cognitively impaired more responsive. Of the various nonverbal indices that we examined, guarded behavior appeared to be especially sensitive. The various pain indices were only modestly correlated with one another. CONCLUSIONS: This study supports the validity of self-report and behavioral measures of pain in frail elders with and without cognitive impairments. Each of the measures used contributed different information to pain assessment, suggesting that investigations of pain in elders with cognitive impairments should employ varying types of pain assessment tools.
Aged↗
Morphine pharmacokinetics and pain assessment in premature newborns.
OBJECTIVES: To determine morphine pharmacokinetics in premature neonates varying in postconceptional age (PCA) and evaluate behavioral pain response in relationship to serum morphine concentrations. METHODS: Premature neonates (n = 48), stratified by weeks of PCA (group 1 = 24-27 weeks, group 2 = 28-31 weeks, group 3 = 32-35 weeks, and group 4 = 36-39 weeks) received morphine infusions. Blood samples were drawn at 48, 60, and 72 hours and at discontinuation of morphine, followed by 3 samples obtained during the next 24 hours. Newborns were videotaped during heel lances and restful states, with morphine at steady-state concentrations and without morphine. Pain was assessed by using the Neonatal Facial Coding System (NFCS). Statistical analysis included regression between NFCS score changes from baseline to painful procedure with and without morphine. RESULTS: Morphine clearance for groups 1, 2, 3, and 4 was calculated as 2.27 +/- 1.07, 3.21 +/- 1.57, 4.51 +/- 1.97, and 7.80 +/- 2.67 mL/kg/min, respectively, and correlated with PCA (r = 0.63, P <.001). Pain measured by facial expression was diminished; however, it did not correlate with morphine concentrations. CONCLUSION: Morphine clearance in premature neonates is less than reported, increasing with PCA. Facial activity discloses morphine analgesia; however, it is unrelated to morphine concentrations.
Analgesics, Opioid↗
A comparison of faces scales for the measurement of pediatric pain: children's and parents' ratings.
Faces scales have become the most popular approach to eliciting children's self-reports of pain, although different formats are available. The present study examined: (a) the potential for bias in children's self-reported ratings of clinical pain when using scales with smiling rather than neutral 'no pain' faces; (b) levels of agreement between child and parent reports of pain using different faces scales; and (c) preferences for scales by children and parents. Participants were 75 children between the ages of 5 and 12 years undergoing venepuncture, and their parents. Following venepuncture, children and parents independently rated the child's pain using five different randomly presented faces scales and indicated which of the scales they preferred and why. Children's ratings across scales were very highly correlated; however, they rated significantly more pain when using scales with a smiling rather than a neutral 'no pain' face. Girls reported significantly greater levels of pain than boys, regardless of scale type. There were no age differences in children's pain reports. Parents' ratings across scales were also highly correlated; however, parents also had higher pain ratings using scales with smiling 'no pain' faces. The level of agreement between child and parent reports of pain was low and did not vary as a function of the scale type used; parents overestimated their children's pain using all five scales. Children and parents preferred scales that they perceived to be happy and cartoon-like. The results of this study indicate that subtle variations in the format of faces scales do influence children's and parents' ratings of pain in clinical settings.
Adult↗
Pain measurement in persons with intellectual disabilities.
OBJECTIVE: The goal was to study the utility of nonverbal facial expressions as a research tool for assessing pain in persons with intellectual disabilities. Biases and stereotypes related to age, gender, physical attractiveness, and intellectual disability that may influence the ability of observers to evaluate pain reactions were also examined. DESIGN: Facial reactions to an intramuscular injection of 40 adults (mean age = 49.6 years) with an intellectual disability were videotaped and objectively examined using the Facial Action Coding System. Self-reported pain ratings were obtained using a Colored Visual Analogue Scale for pain. Pain reactions were also rated by untrained observers. RESULTS: A significant proportion of participants (35%) was unable to provide valid self-report. The intensity of objectively coded facial activity as well as observer-rated pain intensity showed significant increases from baseline to injection segments. Observers' pain ratings were primarily determined by the intensity of facial activity and were not significantly affected by stereotypes based on perceived level of intellectual disability, gender, age, or physical attractiveness. CONCLUSIONS: The findings support the validity of both objectively coded and observer-rated facial expressions of pain as research tools in treatment outcome studies involving persons with intellectual disabilities. Self-report has substantial limitations for the assessment of pain in this population.
Age Factors↗
Postoperative pain expression in preschool children: validation of the child facial coding system.
OBJECTIVE: The purposes of the study were threefold: (a) to determine whether a measurement system based on facial expression would be useful in the assessment of post-operative pain in young children; (b) to examine construct validity in terms of structure, consistency, and dynamics of the facial display; and (c) to evaluate concurrent validity in terms of associations with global judgments of the children's pain. PATIENTS: One hundred children between the ages of 13 and 74 months were video-taped for a maximum of 1 hour after arrival in the postanesthesia care unit (PACU) at British Columbia's Children's Hospital. OUTCOME MEASURES: Videotapes were edited into 20-second blocks, randomly selected from each 2-minute time period taped during the hour following surgery, and coded for the presence or absence of 13 facial actions in the Child Facial Coding System (CFCS). RESULTS: Facial expressions were characterized primarily by the following constellation of actions: open lips, lowered brows, a deepened nasolabial furrow, mouth stretched wide in both horizontal and vertical directions, eyes squeezed shut or squinted, and raised cheeks. A principal components analysis indicated that these actions comprised a single factor, accounting for 55% of the variance in CFCS actions. Facial action summary scores were correlated with a visual analog rating of global pain, confirming that the CFCS has convergent validity. Facial action summary scores, i.e., pain displays, were at their lowest immediately after admittance to the PACU and just before the child's release from the PACU. CONCLUSIONS: The present study demonstrated that the CFCS serves as a valid measurement tool for persistent pain in children.
Child↗
Biobehavioral responses to acute pain in adolescents with a significant neurologic impairment.
OBJECTIVE: To further understand acute pain response in children with a significant neurologic impairment (SNI), we undertook a descriptive hypothesis-generating study of the response to a routine vaccine among adolescents with SNI. DESIGN: Within-subject crossover design. SETTING: Tertiary care facility for children and adolescents with SNI. PATIENTS: Eight adolescents (mean age = 15 years). INTERVENTIONS: Mock and real vaccine injections. OUTCOME MEASURES: Quantitative measures of heart rate, videotaped facial action, Child Facial Coding System (CFCS), and Facial Action Coding System (FACS); observer ratings visual analog scale (VAS) were obtained before, during, and after a mock injection and routine annual influenza vaccine injection presented in a counterbalanced order. RESULTS: VAS scores were significantly higher during the injection phase than during the other time periods; however, there were no significant differences across study time periods when using the other outcome measures. CONCLUSIONS: Although the dampened behavioral and physiologic reactions to an acute noxious stimulus were similar to those of previous work with developmentally delayed children and frail elderly, it remains unclear what underlies the apparent reduced pain response in this setting. These findings have potentially important implications for the daily care of individuals with significant neurologic impairment and illustrate the compelling need tor further study of the unique character of the pain experience in this setting.
Acute Disease↗
Cognitive and behavioral responses to illness information: the role of health anxiety.
The cognitive-behavioral theory of health anxiety predicts atypical responses in health anxious individuals when exposed to health related information. Systematic research is still needed to support the theory. This investigation examined 192 participants varying a subclinical levels of health anxiety, who were randomly given feedback on an ostensible diagnostic measure, indicating positive, negative or ambiguous risk for health complications. Responses to a cold pressor task were then measured. The results indicated that regardless of the type of feedback patients were given, health anxious individuals displayed the predicted cognitive (e.g. negatively interpreted information) and behavioral responses (e.g. increased reassurance seeking). Important and perhaps central cognitions to health anxiety were identified. Health anxious individuals regarded themselves to be at greater risk for disease overall, and attached greater accuracy to health related information. Extending the cognitive-behavioural theory, health anxiety was found to be associated with decreased usage of positive somatic monitoring of symptoms, suggesting health anxiety may be associated with a failure to engage in protective strategies. Health anxiety did not result in cognitive or behavioural avoidance of illness information. Clinical implications and future directions for research are described.
Adaptation, Psychological↗
Agreement between child and parent reports of pain.
OBJECTIVE: Parents are often the primary source of information regarding their children's pain in both research and clinical practice. However, parent-child agreement on pain ratings has not been well established. The objective of the present study was to examine agreement between child- and parent-rated pain following minor surgery. SETTING: Tertiary care children's hospital. PARTICIPANTS: A total of 110 children (56.4% male) aged 7-12 years undergoing surgery and their parents. OUTCOME MEASURES: Parents and children independently rated pain intensity by using a 7-point Faces Pain Scale on the day of the child's surgery and the following 2 days. RESULTS: Correlations (both Pearson's and intraclass correlation coefficients) indicated a highly significant relationship between child and parent ratings. However, kappa statistics indicated only poor to fair agreement beyond chance. Parents tended to underestimate their children's pain on the day of surgery and the following day, but not on the second day following surgery. When children's and parents' pain ratings for each of the 3 days were collapsed into a no-pain/low-pain group or a clinically significant pain group, kappa statistics indicated fair to good agreement. Parents demonstrated low levels of sensitivity in identifying when their children were experiencing clinically significant pain. CONCLUSIONS: Correlations between parent and child pain reports do not accurately represent the relationship between these ratings and in fact overestimate the strength of the relationship. Parents' underestimation of their child's pain may contribute to inadequate pain control.
Adult↗
The expression of pain in infants and toddlers: developmental changes in facial action.
Age-related changes in the facial expression of pain during the first 18 months of life have important implications for our understanding of pain and pain assessment. We examined facial reactions video recorded during routine immunization injections in 75 infants stratified into 2-, 4-, 6-, 12-, and 18-month age groups. Two facial coding systems differing in the amount of detail extracted were applied to the records. In addition, parents completed a brief questionnaire that assessed child temperament and provided background information. Parents' efforts to soothe the children also were described. While there were consistencies in facial displays over the age groups, there also were differences on both measures of facial activity, indicating systematic variation in the nature and severity of distress. The least pain was expressed by the 4-month age group. Temperament was not related to the degree of pain expressed. Systematic variations in parental soothing behaviour indicated accommodation to the age of the child. Reasons for the differing patterns of facial activity are examined, with attention paid to the development of inhibitory mechanisms and the role of negative emotions such as anger and anxiety.
Child Development↗
Social barriers to optimal pain management in infants and children.
OBJECTIVE: To examine the social barriers that lead to less than optimal management of pain in children. DESIGN: Recognizing the vulnerabilities of infants and children and their dependence on caring adults, a model of pain communication is proposed. The model examines (a) the pain experiences of children, including social determinants; (b) developmental variations in the capacity to encode the severity and qualities of pain as expressive behavior; (c) adult skills and deficiencies in decoding pain; and (d) the actions of adults predicated on the meaning and significance attached to children's actions. Limitations in care were examined. DATA SOURCES: The current research and professional literature were accessed through searches of the Psyclit and Medline databases for relevant investigations on the basis of our working knowledge of the literature. CONCLUSION: Numerous deterrents to optimal care are identified in the domains of commonplace beliefs about the nature of pain in infants and children: failure to recognize the impact of socialization in familial and cultural modes of experience and expression; needs for age-specific assessment instruments; the limited capacity to use available evidence concerning pain; the need to employ clinicians, parents, and other adults more effectively in delivering care; and structural problems in the health care system.
Child↗
Appearance-based information about coping with pain: valid or biased?
Previous research led to the conclusion that patient characteristics such as physical attractiveness and non-verbal expressiveness affected judgements of patient pain and distress. This study investigated whether this represents an intrusive bias or whether there indeed are psychological differences between physically attractive vs physically unattractive and expressive vs inexpressive pain patients. The findings led to the conclusion that both variables are related to the types of coping strategies pain patients use. Specifically, physically attractive and nonverbally expressive patients were found to be less likely to utilize passive coping strategies. Coping style also was found to be related to demographic characteristics of the patients. Theoretical reasons for the identified relationships are discussed as are the implications of these findings for the assessment of pain.
Adaptation, Psychological↗
Flying therapy for flying phobia.
INTRODUCTION: Optimum treatment for aircrew who have developed anxiety associated with flight includes a flying phase for desensitization. However, standardized flight profiles are not found in the literature. In this study, a method of desensitization flying, which may increase the probability of a return to productive flying, was devised and assessed. METHOD: Seven aircrew were referred for flying desensitization. Behavioral therapy (relaxation training, imaginary flying, and thought switching) was usually continued by the Medical Officer (Pilot) (MOP). These aircrewmen flew 2-16 sorties in the RAF IAM Hawk or Hunter aircraft with the MOP. Each flight was structured with three purposes: to approach by increments the flight conditions in each victim's anxiety hierarchy, to regulate the amount of low workload, anxiety-vulnerable time during each sortie, and to practice relaxation techniques in the air. RESULTS: In all referred aircrewmen, anxiety was controllable in flight at IAM. Somatic signs diminished and no sortie was terminated early. All returned to operational flying. Anxiety recurred in one fast jet pilot while flying solo, and in one navigator, both of whom requested a change to transports. A transport pilot had recurrent uncontrollable anxiety at high altitude and is grounded. At 9-24 months follow-up, 5/7 were flying comfortably with rare, controllable anxiety. We conclude that actual exposure to flying is usually necessary for aircrew to recover from anxiety associated with flight.
Adult↗
Acute and chronic low back pain: cognitive, affective, and behavioral dimensions.
Despite strong suppositions concerning differences between patients suffering acute and chronic low back pain, relatively few data-based comparisons have been made. In this study, affective, cognitive, behavioral, and demographic contrasts were conducted. Chronic patients were divided into those who demonstrated signs and symptoms that were either congruent or incongruent with underlying anatomical and physiological principles. Low socioeconomic status, compensation claims, use of opiate analgesics, greater disability, catastrophizing cognitions, stronger emotionality, and passive coping were more characteristic of both acute and chronic incongruent patients than chronic congruent patients. A relatively stereotyped, spontaneous facial expression of pain was observed in all groups when responding to painful movements during a physical examination. The similarities between acute and chronic incongruent patients have implications for the assessment and treatment of low back pain.
Adult↗
A comparison of two measures of facial activity during pain in the newborn child.
Facial activity is strikingly visible in infants reacting to noxious events. Two measures that reduce this activity to composite events, the Neonatal Facial Coding System (NFCS) and the Facial Action Coding System (FACS), were used to examine facial expressions of 56 neonates responding to routine heel lancing for blood sampling purposes. The NFCS focuses upon a limited subset of all possible facial actions that had been identified previously as responsive to painful events, whereas the FACS is a comprehensive system that is inclusive of all facial actions. Descriptions of the facial expressions obtained from the two measurement systems were very similar, supporting the convergent validity of the shorter, more readily applied system. As well, the cluster of facial activity associated with pain in this sample, using either measure, was similar to the cluster of facial activity associated with pain in adults and other newborns, both full-term and preterm, providing construct validity for the position that the face encodes painful distress in infants and adults.
Age Factors↗