pain experience. For example, in the experimental study described above, James and
Hardardottir (2002) illustrated this association using the cold pressor task. Eccleston
and Crombez have carried out much work in this area which they review in 1999. They
illustrate that patients who attend to their pain experience more pain than those who are
distracted. This association explains why patients suffering from back pain who take to
their beds and therefore focus on their pain take longer to recover than those who carry
on working and engaging with their lives. This association is also reflected in relatively
recent changes in the general management approach to back pain problems – bedrest is
no longer the main treatment option. In addition, Eccleston and Crombez provide a
model of how pain and attention are related (Eccleston 1994; Eccleston and Crombez
1999). They argue that pain interrupts and demands attention and that this interrup-
tion depends upon pain-related characteristics such as the threat value of the pain and
environmental demands such as emotional arousal. They argue that pain causes a shift
in attention towards the pain as a way to encourage escape and action. The result of this
shift in attention towards the pain is a reduced ability to focus on other tasks resulting in
attentional interference and disruption. This disruption has been shown in a series of
experimental studies indicating that patients with high pain perform less well on difficult
tasks which involve the greatest demand of their limited resources (e.g. Eccleston 1994;
Crombez et. al. 1998a; 1999).Behavioural processes
Pain behaviour and secondary gains
The way in which an individual responds to the pain can itself increase or decrease
the pain perception. In particular, research has looked at pain behaviours which have
been defined by Turk et al. (1985) as facial or audible expression (e.g. clenched teeth
and moaning), distorted posture or movement (e.g. limping, protecting the pain area),
negative affect (e.g. irritability, depression) or avoidance of activity (e.g. not going to
work, lying down). It has been suggested that pain behaviours are reinforced through
attention, the acknowledgment they receive and through secondary gains, such as not
having to go to work. Positively reinforcing pain behaviour may increase pain perception.
Pain behaviour can also cause a lack of activity and muscle wastage, no social contact
and no distraction leading to a sick role, which can also increase pain perception.
Williams (2002) provides an evolutionary analysis of facial expressions of pain and
argues that if the function of pain is to prioritize escape, recovery and healing, facial
expressions are a means to communicate pain and to elicit help from others to achieve
these goals. Further she argues that people often assume that individuals have more
control over the extent of their pain induced facial expressions than they actually do and
are more likely to offer help or sympathy when expressions are mild. Stronger forms of
expressions are interpreted as amplified and as indications of malingering.The interaction between these different processes
The three process model describes the separate components that influence pain per-
ception. However, these three processes are not discrete but interact and are at times294 HEALTH PSYCHOLOGY