Assessment 307includes 20 questions. As a preliminary screening, the briefer
measures may provide a reasonable and adequate overview
of functional limitations.
Assessment of Coping and Psychosocial
Adaptation to Pain
Historically, traditionalpsychological measures that are de-
signed to evaluate psychopathological tendencies have been
used to identify speci“c individual dif ferences associated
with reports of pain, even though these measures were usu-
ally not developed for, or standardized on, samples of med-
ical patients. Thus, it is possible that responses by medical
patients may be distorted as a function of the disease or the
medications that they take. For example, common measures
of depression ask patients about their appetites, sleep pat-
terns, and fatigue. Similarly, the commonly used MMPI
includes items related to physical symptoms such as the
presence of pain in the back of the neck, the ability to work,
feelings of weakness, beliefs regarding health status in com-
parison with friends. Since disease status and medication can
affect responses to such items, patients• scores may be ele-
vated distorting the meaning of the responses.
More recently, a number of assessment instruments have
been developed for use speci“cally with pain patients. Instru-
ments have been developed to assess psychological distress;
the impact of pain on patients• lives; feeling of control; cop-
ing behaviors; and attitudes about disease, pain, and health
care providers and the patient•s plight (Turk & Melzack,
1992, 2001).
A sample of an instrument developed to assess both psy-
chosocial and behavioral factors associated with chronic pain
is the West Haven-Yale Multidimensional Pain Inventory
(MPI) (Kerns, Turk, & Rudy, 1985). This 60-item question-
naire is divided into three sections with the “rst assessing the
patients• perception of pain severity, the impact of pain on
their life, affective distress, feelings of control, and support
from signi“cant people in their lives. The second section as-
sesses the patients• perceptions of the responses of signi“cant
people to their complaints of pain. The third section exam-
ines the change in patients• performance of common activi-
ties such as household chores and socializing. The MPI and
many other assessment measures are reviewed and critiqued
in Turk and Melzack (1992, 2001).
For many patients, there are no objective physical “ndings
to support the complaints of pain. In other instances, the
reports of pain severity seem excessive in light of physical
“ndings. The dif“cult task is to know how to evaluate these
patients in a comprehensive fashion. In instances where pain
persists beyond the expected period of healing of an injury or
where pain is associated with a progressive disease, it may be
appropriate to refer patients for assessment to psychologists
or psychiatrists who specialize in the evaluation of chronic
pain patients.
Because of the subjectivity inherent in pain, suffering and
disability are dif“cult to prove, disprove, or quantify in a
completely satisfactory fashion. As discussed, response to the
question, •How much does it hurt?Ž is far from simple. The
experience and report of pain are in”uenced by multiple fac-
tors such as cultural conditioning, expectancies, current so-
cial contingencies, mood state, and perceptions of control.
Physical pathology and the resulting nociception are impor-
tant, albeit, not the sole contributors to the experience of pain.
It is important to acknowledge the central importance of
patients• self-reports along with their behavior in pain assess-
ment. It is highly unlikely that we will ever be able to evalu-
ate pain without reliance on the person•s perceptions. The
central point to keep in mind is that it is the patientwho
reports pain and not the pain itself that is being evaluated.Assessment of Overt Expressions of PainPatients display a broad range of responses that communicate
to others that they are experiencing pain, distress, and suffer-
ing„pain behaviors. Some of these may be controllable by
the person whereas others are not. For example, in the acute
pain state autonomic activity such as perspiring may indicate
the presence of pain. Over time, however, these physiological
signs habituate and their absence cannot be taken as an indica-
tion of the nonexistence of pain or signi“cant pain reduction.
Pain behaviors include verbal reports, paralinguistic vo-
calizations (for example, sighs, moans), motor activity, facial
expressions, body postures and gesturing (for example, limp-
ing, rubbing a painful body part, grimacing), functional
limitations (reclining for extensive periods of time), and
behaviors designed to reduce pain (for example, taking med-
ication, use of the health care system). Although there is no
one-to-one relationship between these pain behaviors and
self-report of pain, they are at least modestly correlated.
A number of different observational procedures have been
developed to quantify pain behaviors. Several investigators
using the Pain Behavior Checklist (Turk, Wack, & Kerns,
1985) have found a signi“cant association between these
self-reports and behavioral observations. Behavioral obser-
vations scales can be used by patients• signi“cant others as
well. Health care providers can use observational methods to
systematically quantify various pain behaviors and note the
factors that increase or decrease them. For example, observ-
ing the patient in the waiting room, while being interviewed,
or during a structured series of physical tasks.