Anesth Prog 37:76-81 1990
Behavioral Assessment of Chronic Orofacial Pain Francis J. Keefe and Jean C. Beckham Duke University Medical Center
Orofacial pain is usually evaluated and treated from a biomedical perspective. There is no question that the large majority of individuals having acute orofacial pain benefit from timely and appropriate medical intervention. When orofacial pain persists, however, the likelihood that this pain can influence and be influenced by behavioral factors increases. While some individuals are able to adapt and cope with chronic orofacial pain, others develop significant behavioral problems. These problems may include an overly sedentary lifestyle, dependence on habit-forming narcotic medications, or severe depression or anxiety. The hallmark of the behavioral perspective on chronic pain is the insistence that a careful assessment and treatment of such behavioral problems is just as important as appropriate biomedical intervention.1
for use with chronic orofacial pain patients. The focus of the first section of the paper is on the theoretical foundations of behavioral assessment. The second section provides an overview of behavioral assessment methods. In this section, we discuss the use of behavioral interviewing, diary methods, behaviorally-oriented questionnaires, and direct observation with chronic orofacial pain patients. The final section of the presentation will provide suggestions for future behavioral assessment research on orofacial pain.
THEORETICAL FOUNDATIONS OF BEHAVIORAL PAIN ASSESSMENT The theories and constructs underpinning behavioral assessment methods differ substantially from those of traditional psychology or psychiatry.2 Traditional, psychodynamically oriented theorists maintain that the problematic behaviors of patients having chronic pain are symptoms of longstanding, underlying traits or conflicts. According to this viewpoint, personality traits (e.g. hostility or pessimism) or unresolved conflicts (e.g. those related to dependency needs) cause the patient having chronic pain to behave in a maladaptive fashion. Behavioral change is viewed as unlikely to be achieved unless the underlying conflict or personality problem can be resolved. Treatment, in the form of psychotherapy, is often prolonged and expensive. Behavioral theories, in contrast, view the behavior of the chronic pain patient as significant in its own right.2 Behavioral problems are viewed as being acquired and maintained in much the same way as any other behavior. Established principles of behavioral science are used to help understand and modify problematic behavior. These principles direct attention toward current factors influencing behavior (e.g. dissatisfaction with his job or wife), rather than toward the remote causes of behavior (e.g. early childhood experiences) viewed as critically important by traditional psychodynamic theorists. Behavioral treatment, in the form of individual, group or specialized inpatient programs, is time-limited in nature and often very cost-effective. The behavioral perspective on chronic pain views assessment as a continuing and integral part of treatment.2
T he application of behavioral assessment methods to orofacial pain is a relatively recent development. Although some early research studies examined personality traits and psychodynamic conflicts in patients having chronic orofacial pain, these studies were based on constructs from traditional psychological theories rather than behavioral theories. It is only in the last decade that assessment methods developed by behavioral and cognitivebehavioral therapists have begun to be systematically applied to chronic pain populations. Behavioral assessment methods have been applied primarily to low back pain and arthritic pain, and relatively few studies have been carried out with chronic orofacial pain patients. The purpose of this paper is twofold: 1) to provide an overview of behavioral methods for assessing chronic pain, and 2) to discuss how these methods can be adapted Address correspondence to Francis Keefe, Department of Medical Psychology, Duke University Medical Center, Box 3159, Durham, NC 27110. © 1990 by the American Dental Society of Anesthesiology
ISSN 0003-3006/90/$3.50
76
Anesth Prog 37:76-81 1990
Assessment is not simply an activity carried out during early contacts with a patient to provide a preliminary evaluation before treatment commences. Instead, behavioral assessment methods are used throughout treatment in order: 1) to pinpoint presenting problems, 2) to identify probable controlling variables, 3) to match treatment to the needs of the patient, 4) to assess ongoing therapy, and 5) to evaluate the long-term maintenance of generalization of treatment gains. Two models have had a major impact on behavioral assessment strategies for chronic pain: the behavioral and cognitive-behavioral model.3 Fordyce' 4 is the major proponent of the behavioral model. According to this model, assessment efforts for chronic pain should focus on pain behavior-those overt behaviors that communicate to others the fact the patient is having pain. Pain behaviors are overt and, because of this, can become conditioned by environmental influences. A facial pain patient, for example, may learn that when she complains of pain or rubs her head while frowning that her family provides her with assistance with household chores and attention. This patient also may find that when she engages in well behavior, i.e. carries out her normal activities, that she gets little in a way of a positive or meaningful family responses. In this case the positive responses to pain behavior, unwittingly, may serve to reinforce and maintain pain behavior. The behavioral model directs assessment efforts towards: 1) the measurement of overt behaviors such as activity level, medication intake, visits to doctors, and certain body postures and facial expressions indicative of pain, and 2) an analysis of how these behaviors relate to stimuli and consequences in the patient's environment. The cognitive-behavioral model of pain agrees as to the importance of behavioral variables, but maintains that in analyzing these variables one also needs to consider cognitive factors such as patient beliefs and expectations. The major proponents of this model5 have argued that, in many chronic pain patients, irrational thoughts (cognitions) may be a more important determinant of pain and disability than biomedical or environmental factors. The cognitive-behavioral model directs assessment efforts towards: 1) the measurement of cognitive variables such as beliefs, expectations, coping strategies, and 2) an analysis of how these variables control patient behavior.
BEHAVIORAL ASSESSMENT METHODS FOR CHRONIC OROFACIAL PAIN A variety of methods can be used for behavioral assessment of chronic pain. In this section we describe four methods that can be applied in clinical settings: 1) behavioral interviewing, 2) diary methods, 3) behaviorally-oriented questionnaires, and 4) direct observation methods.
Keefe and Beckham 77
Each method is described and an example of the use of this method in chronic orofacial pain research is presented. Behavioral Interviewing. The interview is probably the most commonly used behavioral assessment method. The interview can be applied to a variety of assessment tasks. One of the most important applications of the interview when working with chronic orofacial pain is establishing a therapeutic relationship. Orofacial pain patients who are referred for behavioral assessment can be cautious, guarded and even resentful. Patients often view such referrals as an indication that their pain is psychologically based or imaginary.' It is important in the early stages of the interview to uncover such beliefs and to correct them by providing a rationale for behavioral analysis. We find that presenting a simplified version of the gate control model5 that emphasizes the effects that thoughts, feelings and behaviors can have on the chronic pain experience is quite helpful. Patients report this model fits with their own experiences with chronic pain, and because of this they often are more open and receptive to participating in behavioral evaluation. A second major application of behavioral interviewing is gathering information. In addition to the typical questions about pain and treatment history, the behavioral interviewer attempts to gather information on behavioral or cognitive factors likely to affect the pain experience. Fordyce4 has prepared an interview guide for behavioral assessment that focuses on a number of key areas. These include: 1) pain behavior (How do those around the patient know when pain is experienced?), 2) environmental responses (How do those around the patient respond when pain is signalled?), 3) pain activators (What increases pain or causes it to occur?), 4) pain diminishers (What actions or events, in addition to the response of others are pain contingent?), 5) tension-relaxation (What effects does tension or relaxation have on pain?), and 6) changes in activity as a result of pain (What changes in the patient's way of life have occurred and are these changes reinforcing or aversive?). One of the major advantages of the behavioral interview is its' flexibility. Patient responses can be followed up and important areas explored in detail by the skilled interviewer. This is particularly important in chronic orofacial pain patients who may be functioning well overall, but show very specific deficits in pain coping skills. It is also important in the assessment of cognitive factors such as beliefs about pain, since patients may hold very idiosyncratic beliefs about the cause and likely future trajectory of their pain. Although behavioral interviews are a practical and commonly used method of behavioral assessment of orofacial pain, relatively little has been written about its use. One exception is a recent article by Funch and Gale6 in which
78 Chronic Orofacial Pain
a structured behavioral interview was used to gather information about patients' perceptions of the reaction by family members during pain episodes. Patient responses to open-ended questions about family reactions to pain were rated as supportive, neutral or non-supportive by a rater who was blind with respect to other assessment and treatment data. Patients were also asked two true-false questions about general family responses: 1) Do people feel sorry for you when you are ill?, and 2) Do you get the feeling that people are not taking your illness seriously? Answers to the open-ended and true-false questions predicted to a highly significant degree which patients completed their treatment course. Patients who reported that their families were non-supportive, irritated or upset with them during pain episodes were much more likely to complete the full treatment course of EMG biofeedback and/or progressive relaxation training. It is interesting that these behavioral factors were much more predictive of treatment outcome than demographic and clinical factors. Taken together, the results of this study support the clinical utility of structured behavioral interview methods with orofacial pain patients. Diary Methods. Behavioral diaries can provide a systematic record of behavior (e.g. activity level or medication intake) relevant to chronic orofacial pain. Behavioral diaries typically consist of a single, printed sheet that includes columns for entering information on behavioral antecedents, responses and consequences. Information derived from the diary is often helpful in identifying targets for treatment efforts. To identify antecedents of the patient's pain, the patient is often asked to record type and level of activity, level of perceived stress or anxiety, and social situation. Records may reveal that pain varies with fatigue (e. g. pain increases over the course of the day), with changes in stress or anxiety (e.g. pain increases during a stressful work day), or when interacting with specific individuals in a social situation (e.g. having an argument with a spouse). When pain is found to covary strongly with social or environmental antecedents, a number of behavioral interventions can be useful. Patients whose pain increases with fatigue can benefit from leaming how to schedule rest or relaxation breaks on a time-contingent, rather than pain contingent basis. Relaxation or biofeedback training is often helpful for patients whose pain appears to be stress or anxietyrelated. Communication or social skills training is often an effective means of increasing patients skill in social interactions and decreasing any associated tension that may be increasing their pain. Behavioral responses to pain that can be monitored through diary records include overt motor behaviors such as taking medications or resting in bed or cognitive responses such as frequency of use of coping skills (e.g. imagery, meditation) or frequency of negative thoughts
Anesth Prog 37:76-81 1990
(e.g. "I'll never be able to cope with this pain," "I'm worthless when I hurt like this".). Activation programs are often useful for patients who tend to respond to pain by resting excessively. Cognitive therapy methods such as cognitive restructuring are indicated for those patient who report frequent negative thoughts during pain episodes. Behavioral diary recording can also be utilized to identify environmental consequences that may serve to maintain pain behavior pattems. For example, the patient may be asked to record the spouse's response to them when they have increased pain.1 Reinforcing or solicitous responses by the spouse (e.g. taking over the patients duties, enforcing bedrest) have been associated with higher levels of pain behavior7 and increased perceived pain and lower activity levels in chronic pain patients.8 Despite the potential benefits of behavioral diary measures, this assessment technique has rarely been utilized in research studies of orofacial pain patients. If diary methods are used, it is typically as a method of assessing treatment outcome. For example, Crockett et al,9 in a study comparing biofeedback, TENS, and physiotherapy, had patients rate their pain in a daily diary on a 5-point Likert scale daily for three weeks prior and three weeks following treatment. Since research on retrospective reports in other areas such as life event monitoring indicates the most accurate time unit for clinically valid reports is no longer than a week,10 using daily diaries for outcome assessment is likely an important application in orofacial pain assessment. Behaviorally-oriented questionnaires. In contrast to traditional psychological measures, behaviorally-oriented questionnaires are designed to measure nonstatic, modifiable aspects of behavior and cognition.2 In the area of orofacial pain assessment, cognitive-behavioral questionnaires have received more empirical attention than behavioral questionnaires. Salter et al.," for example, utilized two questionnaires (the General Health Questionnaire-GHQ,12 and the Crown-Crisp Experiential Index-CCEI,13) to examine the relationship of psychological distress to symptoms in temporomandibular pain patients. The main purpose of this study was to compare the effects of physiotherapy to a no-treatment control condition in the management of pain symptoms. Interestingly, it was the initial level of psychological distress, rather than participation in treatment that predicted outcome at three months. Patients having mild to moderate levels of psychological disturbance had much better outcomes than patients having either high or very low levels of psychological disturbance. The authors hypothesized that mild psychological distress may facilitate adaptation, whereas excessive distress or denial of psychological distress may be maladaptive and impair recovery. Although psychological distress was measured in this study, no behaviorally-oriented measures were included.
Anesth Prog 37:76-81 1990
Kerns, Turk and Rudy14 have developed the West Haven-Yale Multidimensional Pain Inventory (MPI), a comprehensive, psychometrically sound inventory designed to measure multiple aspects of pain. The MPI consists of three sections with 13 empirically divided scales. Part one is comprised of five scales designed to assess chronic pain patients' reports of pain severity, how pain interferes with their lives, social support, life control and affective distress. Part two assess patients' reports of behavioral responses by significant others and Part three is an activities checklist. Rudy and Turk15 have examined the use of the MPI along with other instruments to derive an empirical taxonomy of temporomandibular patients and have cross validated their results. Cluster analyses revealed three patient profiles: (1) dysfunctional, (2) interpersonally distressed and (3) adaptive coping. Dysfunctional patients indicated higher pain severity and reported pain had interfered to a great extent with their lives. Interpersonally distressed patients reported their families and significant others were not supportive of them. Adaptive coping patients reported lower pain levels, less affective distress and less interference with their lives along with higher levels of daily activity and life control. Use of reliable empirical classification for temporomandibular patients has important clinical implications in that future investigations may reveal what type of patients may benefit most from particular treatment procedures. Pain coping strategies recently have been assessed in chronic orofacial pain patients using questionnaire methods. For example, we have utilized the Coping Strategies Questionnaire (CSQ) to compare the pain coping strategies utilized by myofascial pain dysfunction and chronic low back pain patients. 6 The CSQ is a 48 item questionnaire that measures the frequency that patients report using various cognitive and behavioral strategies to cope with pain. The strategies assessed by the CSQ include: 1) diverting attention, 2) coping self-statements, 3) praying or hoping, 4) increasing behavioral activities, 5) reinterpretation of pain sensations, 6) ignoring pain sensations, 7) pain behavior and 8) catastrophizing. Rosenstiel and Keefe"6 identified three coping factors from the CSQ: 1) cognitive coping and suppression, 2) helplessness, and 3) diverting attention and praying/hoping. In our study of myofascial pain patients15 we found that these patients made much less frequent use of attention diversion and praying/hoping and also that they relied on a more restricted range of coping strategies than chronic low back pain patients. These results suggest that myofascial pain patients, indeed, may use different coping strategies than other chronic pain patients. Further investigation is needed to determine whether the use of specific coping strategies predisposes orofacial pain patients to poor treatment outcomes.
Keefe and Beckham 79
Another cognitive variable that potentially could be useful in understanding chronic orofacial pain is patient beliefs about pain. Williams and Thomr7 have recently developed the Pain Beliefs and Apperceptions Inventory which provides a practical and systematic method for assessing pain beliefs. This 16 item inventory has three factor analytically-derived scales: 1) time-the belief that pain is and will be enduring, 2) mystery-the belief that pain is a poorly understood experience and will be a mystery to the patient, and 3) self-blame-the belief that somehow the patient is to blame for the pain. Williams and Thorn'7 reported that in a sample of chronic pain patients, the time and mystery scales were predictive of poor adherence to both physical therapy and behavior therapy interventions. Patients who viewed their pain as enduring and as a mystery showed much poorer adherence to treatment than those who did not. Although cognitive factors that affect pain have been assessed by means of questionnaires, behavioral factors have not received as great attention. We are currently developing a new instrument, the Behavioral Analysis Questionnaire, that is designed to provide a functional analysis of behavioral pattems in chronic pain patients. This questionnaire will measure behavioral deficits and excesses, inappropriate contingency arrangements and problems in environmental stimulus control that may affect the pain experience. Direct Observation Methods. Pain behaviors such as reductions in activity or body posturing are clearly observable and, because of this, can be systematically recorded and quantified.' Methods for observing pain behaviors initially developed for low back pain patients18 have recently been extended for the purpose of recording pain behavior in chronic myofascial pain-dysfunction subjects'9 The basic procedure involves having the patient engage in a series of activities designed to elicit pain behavior such as standing, sitting, walking, rotating the head right and left and drinking water. The patient is videotaped as they perform these activities and the videotapes are subsequently scored to determine the occurrence and non-occurrence of five motor pain behaviors: guarding, bracing, rubbing of the painful area, sighing and grimacing. Two studies on pain behavior observation in myofascial pain dysfunction patients have been published. The first study'9 compared pain behaviors of facial pain patients to those observed in low back pain patients. The results of this study indicated that facial pain patients tend to exhibit their pain primarily through grimacing. In addition, while the facial pain patients and back pain patients tended to be similar in the degree to which they displayed pain through the facial expression of grimacing, the facial pain patients displayed much lower levels of guarding, bracing and rubbing than the back pain patients. The second
80 Chronic Orofacial Pain
study20 examined the relationship between observed pain behavior and masseter muscle tension using the same sample of myofascial pain dysfunction patients studied in the first investigation. This study found that patients having high levels of guarding, bracing and total pain behavior had high levels of masseter muscle tension. These patients were prone to have high tension levels not only during simple tasks such as sitting, but also during a stressful mental arithmetic task. The results of this study suggest that patients who exhibit excessive pain behavior during clinical examination may well have high levels of tension, and because of this, may be candidates for behavioral interventions (such as EMG biofeedback and progressive relaxation training) designed to reduce muscle tension. Given that facial expressions are likely to be one of the major observable pain behaviors in orofacial pain patients, detailed observation of facial expressions may be a very beneficial behavioral assessment method. Leresche and Dworkin21 have been exploring the utility of the Facial Action Coding System and a global pain rating method as a means of analyzing facial expressions from photographs. These investigators are currently examining whether the global rating system could be useful clinically in the analysis of pain-related facial expressions in chronic orofacial pain patients. FUTURE RESEARCH DIRECTIONS As we have seen, there are relatively few research studies examining behavioral assessment methods in orofacial pain patients. The few studies that have been conducted are interesting and further research appears warranted. Behavioral assessment methods have been found to be quite useful in the assessment of a variety of chronic pain conditions, and there is no reason to expect that these methods would not be just as useful with orofacial pain patients. Several important research areas need attention. First, there is a need for systematic research on behavioral pain diaries in chronic orofacial pain patients. These diaries do appear to be in wide use clinically because they enable therapists to carefully monitor daily changes in pain and related behavioral factors. Studies are needed to identify common problematic behavior pattems from diary records, and to examine changes in diary recorded behaviors that occur following various treatment programs for orofacial pain. Second, there is a need for additional research on cognitive-behavioral questionnaires for assessing orofacial pain. There is a particular need for questionnaire studies designed to gather information on environmental factors (e.g. social support, family environment, physician/health care professional behaviors) likely to affect chronic orofacial pain. Finally, further research
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on behavioral observation of orofacial pain patients appears to be warranted. In clinical settings there are many opportunities to observe the pain behavior of orofacial pain patients. The samples of behavior that can be observed in clinical settings may be useful in identifying patients having particular problems (e.g. tension) and in predicting the outcome of certain behavioral interventions (e.g. biofeedback or relaxation methods). Behavioral assessment methods for orofacial pain undoubtedly will be developed and refined in the coming years. As this happens, our ability to understand and treat the behavioral problems experienced by chronic orofacial pain patients is likely to be significantly increased.
REFERENCES 1. Fordyce WE: Behavioral methods for Chronic Pain and Illness. St. Louis, MO: Mosby, 1976. 2. Keefe FJ, Kopel S, Gordon SB: A Practical Guide to Behavioral Assessment. New York, Springer. 1978. 3. Keefe FJ: Behavioral measurement of pain, CR Chapman & JD Loeser (Eds.) Issues in Pain Measurement., New York, Raven Press, 1989, pp. 405-424. 4. Fordyce WE: Treating chronic pain by contingency management. In J Bonica (Ed.) Advances in Neurology, Vol. 4, International Symposium on Pain. New York: Raven, 1974 pp. 585-587. 5. Turk DC, Meichenbaum D, Genest M: Pain and Behavioral Medicine: A Cognitive-Behavioral Perspective, 1983, New York: Guilford. 6. Funch DP, Gale EN: Predicting treatment completion in a behavioral therapy program for chronic temporomandibular pain. Journal of Psychosomatic Research. 1986;30:57-62. 7. Block AR, Kremer EF, Gaylor M: Behavioral treatment of chronic pain: the spouse as a discriminative cue for pain behavior. Pain, 1980;9:243-252. 8. Flor H, Kerns RD, Turk DC: The role of spouse reinforcement, perceived pain, and activity levels of chronic pain patients. Journal of Psychosomatic Research, 1987;31:251-259. 9. Crockett DJ, Foreman ME, Alden L, Blasber B: A comparison of treatment modes in the mangement of myofascial pain dysfunction syndrome. Biofeedback and Self-Regulation, 1986; 11:279-291. 10. Horowitz M, Wilner N, Alvarez W: Impact of event scale: A measure of subjective stress. Psychosomatic Medicine,
1979;41:209-218. 11. Salter MW, Brooke RI, Merskey H: Temporomandibular pain and dysfunction syndrome: The relationship of clinical and psychological data to outcome. Journal of Behavioral Medicine, 1986;9:97-109. 12. Goldberg DP, Hillier VF: A scaled version of the General Health Questionnaire. Psychological Medicine, 1979;9: 139-145. 13. Crown S, Crisp AH: A short clinical diagnostic self-rating scale for psychoneurotic patients: The Middlesex Hospital Questionnaire (M.H.Q.) British Journal of Psychiatry, 1966; 112:917-923.
Anesth Prog 37:76-81 1990 14. Kerns RD, Turk DC, Rudy TE: The West Haven-Yale Multidimensional Pain Inventory (WHYMPI), Pain, 1985;23:345-356. 15. Rudy TE, Turk TC, Aacki HS, Curtin AD: An empirical taximetric alternative to traditional classification of temporomandibular disorders. Pain. (in press). 16. Rosenstiel AK, Keefe FJ: The use of coping strategies in chronic low back pain patients: Relationship to patient characteristics and current adjustment. Pain, 1983;17:33-44. 17. Williams DA, Thorn BE: Empirical assessment of pain beliefs. Pain, 1989;36:351-358. 18. Keefe FJ, Block AR: Development of an observation
Keefe and Beckham 81 method for assessing pain behavior in chronic low back pain patients. Behavior Therapy, 1982;13:363-375. 19. Keefe, FJ, Dolan E: Pain behavior and pain coping strategies in low back pain and myofascial pain dysfunction syndrome patients. Pain 1986;24:49-56. 20. Keefe FJ, Dolan EA: Correlation of pain behavior and muscle activity in patients having myofascial pain dysfunction syndrome. Joumal of Craniomandibular Disorders Facial & Oral Pain, 1988;2:181-184. 21. LeResche L, Dworkin SF: Facial expression accompanying pain. Social Science and Medicine, 1984;19:13251330.
Behavioral Assessment of Chronic Orofacial Pain Francis J. Keefe and Jean C. Beckham Duke University Medical Center
Orofacial pain is usually evaluated and treated from a biomedical perspective. There is no question that the large majority of individuals having acute orofacial pain benefit from timely and appropriate medical intervention. When orofacial pain persists, however, the likelihood that this pain can influence and be influenced by behavioral factors increases. While some individuals are able to adapt and cope with chronic orofacial pain, others develop significant behavioral problems. These problems may include an overly sedentary lifestyle, dependence on habit-forming narcotic medications, or severe depression or anxiety. The hallmark of the behavioral perspective on chronic pain is the insistence that a careful assessment and treatment of such behavioral problems is just as important as appropriate biomedical intervention.1
for use with chronic orofacial pain patients. The focus of the first section of the paper is on the theoretical foundations of behavioral assessment. The second section provides an overview of behavioral assessment methods. In this section, we discuss the use of behavioral interviewing, diary methods, behaviorally-oriented questionnaires, and direct observation with chronic orofacial pain patients. The final section of the presentation will provide suggestions for future behavioral assessment research on orofacial pain.
THEORETICAL FOUNDATIONS OF BEHAVIORAL PAIN ASSESSMENT The theories and constructs underpinning behavioral assessment methods differ substantially from those of traditional psychology or psychiatry.2 Traditional, psychodynamically oriented theorists maintain that the problematic behaviors of patients having chronic pain are symptoms of longstanding, underlying traits or conflicts. According to this viewpoint, personality traits (e.g. hostility or pessimism) or unresolved conflicts (e.g. those related to dependency needs) cause the patient having chronic pain to behave in a maladaptive fashion. Behavioral change is viewed as unlikely to be achieved unless the underlying conflict or personality problem can be resolved. Treatment, in the form of psychotherapy, is often prolonged and expensive. Behavioral theories, in contrast, view the behavior of the chronic pain patient as significant in its own right.2 Behavioral problems are viewed as being acquired and maintained in much the same way as any other behavior. Established principles of behavioral science are used to help understand and modify problematic behavior. These principles direct attention toward current factors influencing behavior (e.g. dissatisfaction with his job or wife), rather than toward the remote causes of behavior (e.g. early childhood experiences) viewed as critically important by traditional psychodynamic theorists. Behavioral treatment, in the form of individual, group or specialized inpatient programs, is time-limited in nature and often very cost-effective. The behavioral perspective on chronic pain views assessment as a continuing and integral part of treatment.2
T he application of behavioral assessment methods to orofacial pain is a relatively recent development. Although some early research studies examined personality traits and psychodynamic conflicts in patients having chronic orofacial pain, these studies were based on constructs from traditional psychological theories rather than behavioral theories. It is only in the last decade that assessment methods developed by behavioral and cognitivebehavioral therapists have begun to be systematically applied to chronic pain populations. Behavioral assessment methods have been applied primarily to low back pain and arthritic pain, and relatively few studies have been carried out with chronic orofacial pain patients. The purpose of this paper is twofold: 1) to provide an overview of behavioral methods for assessing chronic pain, and 2) to discuss how these methods can be adapted Address correspondence to Francis Keefe, Department of Medical Psychology, Duke University Medical Center, Box 3159, Durham, NC 27110. © 1990 by the American Dental Society of Anesthesiology
ISSN 0003-3006/90/$3.50
76
Anesth Prog 37:76-81 1990
Assessment is not simply an activity carried out during early contacts with a patient to provide a preliminary evaluation before treatment commences. Instead, behavioral assessment methods are used throughout treatment in order: 1) to pinpoint presenting problems, 2) to identify probable controlling variables, 3) to match treatment to the needs of the patient, 4) to assess ongoing therapy, and 5) to evaluate the long-term maintenance of generalization of treatment gains. Two models have had a major impact on behavioral assessment strategies for chronic pain: the behavioral and cognitive-behavioral model.3 Fordyce' 4 is the major proponent of the behavioral model. According to this model, assessment efforts for chronic pain should focus on pain behavior-those overt behaviors that communicate to others the fact the patient is having pain. Pain behaviors are overt and, because of this, can become conditioned by environmental influences. A facial pain patient, for example, may learn that when she complains of pain or rubs her head while frowning that her family provides her with assistance with household chores and attention. This patient also may find that when she engages in well behavior, i.e. carries out her normal activities, that she gets little in a way of a positive or meaningful family responses. In this case the positive responses to pain behavior, unwittingly, may serve to reinforce and maintain pain behavior. The behavioral model directs assessment efforts towards: 1) the measurement of overt behaviors such as activity level, medication intake, visits to doctors, and certain body postures and facial expressions indicative of pain, and 2) an analysis of how these behaviors relate to stimuli and consequences in the patient's environment. The cognitive-behavioral model of pain agrees as to the importance of behavioral variables, but maintains that in analyzing these variables one also needs to consider cognitive factors such as patient beliefs and expectations. The major proponents of this model5 have argued that, in many chronic pain patients, irrational thoughts (cognitions) may be a more important determinant of pain and disability than biomedical or environmental factors. The cognitive-behavioral model directs assessment efforts towards: 1) the measurement of cognitive variables such as beliefs, expectations, coping strategies, and 2) an analysis of how these variables control patient behavior.
BEHAVIORAL ASSESSMENT METHODS FOR CHRONIC OROFACIAL PAIN A variety of methods can be used for behavioral assessment of chronic pain. In this section we describe four methods that can be applied in clinical settings: 1) behavioral interviewing, 2) diary methods, 3) behaviorally-oriented questionnaires, and 4) direct observation methods.
Keefe and Beckham 77
Each method is described and an example of the use of this method in chronic orofacial pain research is presented. Behavioral Interviewing. The interview is probably the most commonly used behavioral assessment method. The interview can be applied to a variety of assessment tasks. One of the most important applications of the interview when working with chronic orofacial pain is establishing a therapeutic relationship. Orofacial pain patients who are referred for behavioral assessment can be cautious, guarded and even resentful. Patients often view such referrals as an indication that their pain is psychologically based or imaginary.' It is important in the early stages of the interview to uncover such beliefs and to correct them by providing a rationale for behavioral analysis. We find that presenting a simplified version of the gate control model5 that emphasizes the effects that thoughts, feelings and behaviors can have on the chronic pain experience is quite helpful. Patients report this model fits with their own experiences with chronic pain, and because of this they often are more open and receptive to participating in behavioral evaluation. A second major application of behavioral interviewing is gathering information. In addition to the typical questions about pain and treatment history, the behavioral interviewer attempts to gather information on behavioral or cognitive factors likely to affect the pain experience. Fordyce4 has prepared an interview guide for behavioral assessment that focuses on a number of key areas. These include: 1) pain behavior (How do those around the patient know when pain is experienced?), 2) environmental responses (How do those around the patient respond when pain is signalled?), 3) pain activators (What increases pain or causes it to occur?), 4) pain diminishers (What actions or events, in addition to the response of others are pain contingent?), 5) tension-relaxation (What effects does tension or relaxation have on pain?), and 6) changes in activity as a result of pain (What changes in the patient's way of life have occurred and are these changes reinforcing or aversive?). One of the major advantages of the behavioral interview is its' flexibility. Patient responses can be followed up and important areas explored in detail by the skilled interviewer. This is particularly important in chronic orofacial pain patients who may be functioning well overall, but show very specific deficits in pain coping skills. It is also important in the assessment of cognitive factors such as beliefs about pain, since patients may hold very idiosyncratic beliefs about the cause and likely future trajectory of their pain. Although behavioral interviews are a practical and commonly used method of behavioral assessment of orofacial pain, relatively little has been written about its use. One exception is a recent article by Funch and Gale6 in which
78 Chronic Orofacial Pain
a structured behavioral interview was used to gather information about patients' perceptions of the reaction by family members during pain episodes. Patient responses to open-ended questions about family reactions to pain were rated as supportive, neutral or non-supportive by a rater who was blind with respect to other assessment and treatment data. Patients were also asked two true-false questions about general family responses: 1) Do people feel sorry for you when you are ill?, and 2) Do you get the feeling that people are not taking your illness seriously? Answers to the open-ended and true-false questions predicted to a highly significant degree which patients completed their treatment course. Patients who reported that their families were non-supportive, irritated or upset with them during pain episodes were much more likely to complete the full treatment course of EMG biofeedback and/or progressive relaxation training. It is interesting that these behavioral factors were much more predictive of treatment outcome than demographic and clinical factors. Taken together, the results of this study support the clinical utility of structured behavioral interview methods with orofacial pain patients. Diary Methods. Behavioral diaries can provide a systematic record of behavior (e.g. activity level or medication intake) relevant to chronic orofacial pain. Behavioral diaries typically consist of a single, printed sheet that includes columns for entering information on behavioral antecedents, responses and consequences. Information derived from the diary is often helpful in identifying targets for treatment efforts. To identify antecedents of the patient's pain, the patient is often asked to record type and level of activity, level of perceived stress or anxiety, and social situation. Records may reveal that pain varies with fatigue (e. g. pain increases over the course of the day), with changes in stress or anxiety (e.g. pain increases during a stressful work day), or when interacting with specific individuals in a social situation (e.g. having an argument with a spouse). When pain is found to covary strongly with social or environmental antecedents, a number of behavioral interventions can be useful. Patients whose pain increases with fatigue can benefit from leaming how to schedule rest or relaxation breaks on a time-contingent, rather than pain contingent basis. Relaxation or biofeedback training is often helpful for patients whose pain appears to be stress or anxietyrelated. Communication or social skills training is often an effective means of increasing patients skill in social interactions and decreasing any associated tension that may be increasing their pain. Behavioral responses to pain that can be monitored through diary records include overt motor behaviors such as taking medications or resting in bed or cognitive responses such as frequency of use of coping skills (e.g. imagery, meditation) or frequency of negative thoughts
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(e.g. "I'll never be able to cope with this pain," "I'm worthless when I hurt like this".). Activation programs are often useful for patients who tend to respond to pain by resting excessively. Cognitive therapy methods such as cognitive restructuring are indicated for those patient who report frequent negative thoughts during pain episodes. Behavioral diary recording can also be utilized to identify environmental consequences that may serve to maintain pain behavior pattems. For example, the patient may be asked to record the spouse's response to them when they have increased pain.1 Reinforcing or solicitous responses by the spouse (e.g. taking over the patients duties, enforcing bedrest) have been associated with higher levels of pain behavior7 and increased perceived pain and lower activity levels in chronic pain patients.8 Despite the potential benefits of behavioral diary measures, this assessment technique has rarely been utilized in research studies of orofacial pain patients. If diary methods are used, it is typically as a method of assessing treatment outcome. For example, Crockett et al,9 in a study comparing biofeedback, TENS, and physiotherapy, had patients rate their pain in a daily diary on a 5-point Likert scale daily for three weeks prior and three weeks following treatment. Since research on retrospective reports in other areas such as life event monitoring indicates the most accurate time unit for clinically valid reports is no longer than a week,10 using daily diaries for outcome assessment is likely an important application in orofacial pain assessment. Behaviorally-oriented questionnaires. In contrast to traditional psychological measures, behaviorally-oriented questionnaires are designed to measure nonstatic, modifiable aspects of behavior and cognition.2 In the area of orofacial pain assessment, cognitive-behavioral questionnaires have received more empirical attention than behavioral questionnaires. Salter et al.," for example, utilized two questionnaires (the General Health Questionnaire-GHQ,12 and the Crown-Crisp Experiential Index-CCEI,13) to examine the relationship of psychological distress to symptoms in temporomandibular pain patients. The main purpose of this study was to compare the effects of physiotherapy to a no-treatment control condition in the management of pain symptoms. Interestingly, it was the initial level of psychological distress, rather than participation in treatment that predicted outcome at three months. Patients having mild to moderate levels of psychological disturbance had much better outcomes than patients having either high or very low levels of psychological disturbance. The authors hypothesized that mild psychological distress may facilitate adaptation, whereas excessive distress or denial of psychological distress may be maladaptive and impair recovery. Although psychological distress was measured in this study, no behaviorally-oriented measures were included.
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Kerns, Turk and Rudy14 have developed the West Haven-Yale Multidimensional Pain Inventory (MPI), a comprehensive, psychometrically sound inventory designed to measure multiple aspects of pain. The MPI consists of three sections with 13 empirically divided scales. Part one is comprised of five scales designed to assess chronic pain patients' reports of pain severity, how pain interferes with their lives, social support, life control and affective distress. Part two assess patients' reports of behavioral responses by significant others and Part three is an activities checklist. Rudy and Turk15 have examined the use of the MPI along with other instruments to derive an empirical taxonomy of temporomandibular patients and have cross validated their results. Cluster analyses revealed three patient profiles: (1) dysfunctional, (2) interpersonally distressed and (3) adaptive coping. Dysfunctional patients indicated higher pain severity and reported pain had interfered to a great extent with their lives. Interpersonally distressed patients reported their families and significant others were not supportive of them. Adaptive coping patients reported lower pain levels, less affective distress and less interference with their lives along with higher levels of daily activity and life control. Use of reliable empirical classification for temporomandibular patients has important clinical implications in that future investigations may reveal what type of patients may benefit most from particular treatment procedures. Pain coping strategies recently have been assessed in chronic orofacial pain patients using questionnaire methods. For example, we have utilized the Coping Strategies Questionnaire (CSQ) to compare the pain coping strategies utilized by myofascial pain dysfunction and chronic low back pain patients. 6 The CSQ is a 48 item questionnaire that measures the frequency that patients report using various cognitive and behavioral strategies to cope with pain. The strategies assessed by the CSQ include: 1) diverting attention, 2) coping self-statements, 3) praying or hoping, 4) increasing behavioral activities, 5) reinterpretation of pain sensations, 6) ignoring pain sensations, 7) pain behavior and 8) catastrophizing. Rosenstiel and Keefe"6 identified three coping factors from the CSQ: 1) cognitive coping and suppression, 2) helplessness, and 3) diverting attention and praying/hoping. In our study of myofascial pain patients15 we found that these patients made much less frequent use of attention diversion and praying/hoping and also that they relied on a more restricted range of coping strategies than chronic low back pain patients. These results suggest that myofascial pain patients, indeed, may use different coping strategies than other chronic pain patients. Further investigation is needed to determine whether the use of specific coping strategies predisposes orofacial pain patients to poor treatment outcomes.
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Another cognitive variable that potentially could be useful in understanding chronic orofacial pain is patient beliefs about pain. Williams and Thomr7 have recently developed the Pain Beliefs and Apperceptions Inventory which provides a practical and systematic method for assessing pain beliefs. This 16 item inventory has three factor analytically-derived scales: 1) time-the belief that pain is and will be enduring, 2) mystery-the belief that pain is a poorly understood experience and will be a mystery to the patient, and 3) self-blame-the belief that somehow the patient is to blame for the pain. Williams and Thorn'7 reported that in a sample of chronic pain patients, the time and mystery scales were predictive of poor adherence to both physical therapy and behavior therapy interventions. Patients who viewed their pain as enduring and as a mystery showed much poorer adherence to treatment than those who did not. Although cognitive factors that affect pain have been assessed by means of questionnaires, behavioral factors have not received as great attention. We are currently developing a new instrument, the Behavioral Analysis Questionnaire, that is designed to provide a functional analysis of behavioral pattems in chronic pain patients. This questionnaire will measure behavioral deficits and excesses, inappropriate contingency arrangements and problems in environmental stimulus control that may affect the pain experience. Direct Observation Methods. Pain behaviors such as reductions in activity or body posturing are clearly observable and, because of this, can be systematically recorded and quantified.' Methods for observing pain behaviors initially developed for low back pain patients18 have recently been extended for the purpose of recording pain behavior in chronic myofascial pain-dysfunction subjects'9 The basic procedure involves having the patient engage in a series of activities designed to elicit pain behavior such as standing, sitting, walking, rotating the head right and left and drinking water. The patient is videotaped as they perform these activities and the videotapes are subsequently scored to determine the occurrence and non-occurrence of five motor pain behaviors: guarding, bracing, rubbing of the painful area, sighing and grimacing. Two studies on pain behavior observation in myofascial pain dysfunction patients have been published. The first study'9 compared pain behaviors of facial pain patients to those observed in low back pain patients. The results of this study indicated that facial pain patients tend to exhibit their pain primarily through grimacing. In addition, while the facial pain patients and back pain patients tended to be similar in the degree to which they displayed pain through the facial expression of grimacing, the facial pain patients displayed much lower levels of guarding, bracing and rubbing than the back pain patients. The second
80 Chronic Orofacial Pain
study20 examined the relationship between observed pain behavior and masseter muscle tension using the same sample of myofascial pain dysfunction patients studied in the first investigation. This study found that patients having high levels of guarding, bracing and total pain behavior had high levels of masseter muscle tension. These patients were prone to have high tension levels not only during simple tasks such as sitting, but also during a stressful mental arithmetic task. The results of this study suggest that patients who exhibit excessive pain behavior during clinical examination may well have high levels of tension, and because of this, may be candidates for behavioral interventions (such as EMG biofeedback and progressive relaxation training) designed to reduce muscle tension. Given that facial expressions are likely to be one of the major observable pain behaviors in orofacial pain patients, detailed observation of facial expressions may be a very beneficial behavioral assessment method. Leresche and Dworkin21 have been exploring the utility of the Facial Action Coding System and a global pain rating method as a means of analyzing facial expressions from photographs. These investigators are currently examining whether the global rating system could be useful clinically in the analysis of pain-related facial expressions in chronic orofacial pain patients. FUTURE RESEARCH DIRECTIONS As we have seen, there are relatively few research studies examining behavioral assessment methods in orofacial pain patients. The few studies that have been conducted are interesting and further research appears warranted. Behavioral assessment methods have been found to be quite useful in the assessment of a variety of chronic pain conditions, and there is no reason to expect that these methods would not be just as useful with orofacial pain patients. Several important research areas need attention. First, there is a need for systematic research on behavioral pain diaries in chronic orofacial pain patients. These diaries do appear to be in wide use clinically because they enable therapists to carefully monitor daily changes in pain and related behavioral factors. Studies are needed to identify common problematic behavior pattems from diary records, and to examine changes in diary recorded behaviors that occur following various treatment programs for orofacial pain. Second, there is a need for additional research on cognitive-behavioral questionnaires for assessing orofacial pain. There is a particular need for questionnaire studies designed to gather information on environmental factors (e.g. social support, family environment, physician/health care professional behaviors) likely to affect chronic orofacial pain. Finally, further research
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on behavioral observation of orofacial pain patients appears to be warranted. In clinical settings there are many opportunities to observe the pain behavior of orofacial pain patients. The samples of behavior that can be observed in clinical settings may be useful in identifying patients having particular problems (e.g. tension) and in predicting the outcome of certain behavioral interventions (e.g. biofeedback or relaxation methods). Behavioral assessment methods for orofacial pain undoubtedly will be developed and refined in the coming years. As this happens, our ability to understand and treat the behavioral problems experienced by chronic orofacial pain patients is likely to be significantly increased.
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Anesth Prog 37:76-81 1990 14. Kerns RD, Turk DC, Rudy TE: The West Haven-Yale Multidimensional Pain Inventory (WHYMPI), Pain, 1985;23:345-356. 15. Rudy TE, Turk TC, Aacki HS, Curtin AD: An empirical taximetric alternative to traditional classification of temporomandibular disorders. Pain. (in press). 16. Rosenstiel AK, Keefe FJ: The use of coping strategies in chronic low back pain patients: Relationship to patient characteristics and current adjustment. Pain, 1983;17:33-44. 17. Williams DA, Thorn BE: Empirical assessment of pain beliefs. Pain, 1989;36:351-358. 18. Keefe FJ, Block AR: Development of an observation
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