Handbook of Psychology

Unidimensional Conceptualizations of Chronic Pain 297

husband provided extra attention, comfort, and the opportu-
nity to avoid an undesirable social obligation. Therefore, her
pain behaviors were rewarded.
Figure 13.1 describes examples of basic operant principles
in chronic pain. The operant learning paradigm does not un-
cover the etiology of pain but focuses primarily on the main-
tenance of pain behaviors and de“ciency in well behaviors.
Adjustment of reinforcement schedules will likely modify
the probability of recurrence of pain behaviors and well
behaviors.
Pain sufferers do not intentionallycommunicate pain to
obtain attention or avoid undesirable activities. It is more
likely to be the result of a gradual process of the shaping of
behavior that neither the sufferer nor her comforter (i.e., hus-
band) recognizes. Thus, a person•s response to life stressors
as well as how others respond can in”uence the experience
of pain in many ways, but are not the causeof the pain
condition.
It is important not to make the mistake of viewing pain
behaviors as being synonymous with malingering.Malinger-
ing involves the patient consciously and purposely faking a
symptom such as pain for some gain, usually “nancial. As
we noted earlier, in the case of pain behaviors, there is no
suggestion of conscious deception but rather the unintended
performance of pain behaviors resulting from environmental
reinforcement contingencies. The patient is typically not
aware that these behaviors are being displayed, nor is he or
she consciously intending to obtain a positive reinforcement
from the behaviors. Contrary to the beliefs of many third-
party payers, there is little support for the contention that out-
right faking of pain for “nancial gain is prevalent (e.g., Craig,
Hill, & McMurtry, 1999).

Social Learning Processes

Social learning has received some attention in acute pain and
in the development and maintenance of chronic pain states.
From this perspective, the acquisition of pain behaviors may
occur by means of observational learningand modeling
processes. That is, people can acquire behavioral responses

that were not previously in their repertoire by the observation

of others.

Children develop attitudes about health and health care,

and the perception and interpretation of symptoms and phys-

iological processes from their parents and social environ-

ment. They learn appropriate and inappropriate responses to

injury and disease and thus may be more or less likely to

ignore or overrespond to symptoms they experience based on

behaviors modeled in childhood. The culturally acquired per-

ception and interpretation of symptoms determines how peo-

ple deal with disease states. The observation of others in pain

is an event that captivates attention. This attention may have

survival value, may help to avoid experiencing more pain,

and may help us to learn what to do about acute pain.

There is ample evidence of the role of social learning from

controlled laboratory pain studies and from some evidence

based on observations of people•s behaviors in naturalistic

and clinical settings. For example, children of chronic pain

patients may make more pain-related responses during stress-

ful times than would children with healthy parents. These

children tend to exhibit greater illness behaviors (e.g., com-

plaining, days absent, visit to school nurse) than children of

healthy parents (Richard, 1988). Models can in”uence the

expression, localization, and methods of coping with pain

(Craig, 1986). Physiological responses may be conditioned

during observation of others in pain (Vaughan & Lanzetta,

1980). Expectancies and actual behavioral responses to noci-

ceptive stimulation are based, at least partially, on prior social

learning history. This may, along with classical conditioning

and operant learning history, contribute to the marked vari-

ability in response to objectively similar degrees of physical

pathology noted by health care providers.

The biomedical, psychogenic, secondary-gain, and behav-

ioral views are unidimensional. Reports of pain are ascribed

toeitherphysicalorpsychological factors. Rather than being

categorical, either somatogenic or psychogenic, both physi-

cal and psychological components may interact to create and

in”uence the experience of pain. Several ef forts have been

made to integrate physical, psychosocial, and behavioral fac-

tors within multidimensional models.

Figure 13.1 Operant conditioning in chronic pain.

Operant Maintenance of Pain Behavior in Chronic Pain: Example

Restricted Movement (RM)

RM

Exercise

Exercise

Pain

Pain

Pain

Pain

Sympathy (Positive Reinforcement)

Avoiding Activity (Negative Reinforcement)

Flare-Up (Punishment)

Apathy from Others (Neglect)

RM Likely to Recur

RM Likely to Be Maintained

Exercise Unlikely to Recur

Exercise Unlikely to Recur

Operant Conditioning Stage Chronic Stage: Even without Pain