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Appearance-based information about coping with pain: Valid or biased?
Soc. Sci. Med. Vol. 40, No. 4, pp. 537-543, 1995
Pergamon
0277-9536(94)E0100-7
Copyright © 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/95 $9.50 + 0.00
A P P E A R A N C E - B A S E D I N F O R M A T I O N A B O U T COPING WITH PAIN: V A L I D OR BIASED? THOMAS HADJISTAVROPOULOS,HEATHERD. HADJISTAVROPOULOSand KENNETH D. CRAIG Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, B.C., Canada V6T IZ4 Abstract--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. Key words--physical attractiveness, pain, non-verbal expressiveness
INTRODUCTION
Visible attributes of patients influence clinical judgments, as clinicians incorporate in their decisions information concerning demographic characteristics (e.g. age, gender, racial and ethnic information) and immediate evidence of how the person presents himself or herself [1, 2]. As well, patients' physical attractiveness and non-verbal expressiveness have been shown to affect clinical judgments [2]. For example, physically attractive pain patients were perceived by physicians as experiencing less pain than physically unattractive pain patients [2]. It is uncertain whether the impact of such appearance-based information on judgments reflects unwarranted judgments or discerning clinical acumen. The appearance-based information may be entirely unrelated to how pain is experienced or it could provide valid information about the nature of the person's experience. The literature suggests that physical attractiveness and non-verbal expressiveness may be related to important dimensions of psychological functioning [3, 4]. The goal of the present study was to determine whether physical attractiveness and non-verbal expressivity are also related to the way patients cope with pain. Coping mechanisms are of interest because they are instructive about how a person experiences pain [5]. Physical attractiveness and nonverbal expressivity were examined because past research [2] has shown them to affect clinical judgments about pain patients. Coping with pain Knowledge of a person's usual strategies and effectiveness in coping with pain may have considerable
clinical utility. Coping has been defined as purposeful efforts to manage or reduce the negative impact of stress [6], with physical pain perhaps the most universal form of stress [7]. People use a variety of coping strategies, including, for instance, efforts to distract themselves and the use of calming self-statements, or prayer. Several key dimensions of the coping strategies used by pain patients have been identified through factor analytic work [8]. These dimensions include use of active cognitive tactics, self-evaluative coping, passive coping, behavioural coping and catastrophizing. Several theoretical formulations of coping also are available [9, 10], with the distinction between active and passive coping strategies particularly useful [6]. Active strategies require the person to initiate instrumental action to manage pain (e.g. engage in a pleasant activity) whereas passive strategies involve assigning control to some external agent (e.g. medication or divine intervention). Passive strategies have been associated with lower levels of adjustment [11]. Catastrophizing, or self-alarming thinking [12], often represents a maladaptive effort to cope with pain [11] and has been associated with increased depression, pain severity, psychological distress and more severe disability [13]. Physical attractiveness as a possible influence on coping style Publicly visible, personal characteristics may reflect or determine the coping response of pain patients. Of these, physical attractiveness appears important. Physical attractiveness has a substantial influence on interpersonal behaviours in a wide variety of settings, including courts, the workplace, schools and health settings [2, 14]. Physically attractive persons tend to 537
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have more positive social experiences and, as a result, more control over their lives [15]. They also tend to be sought out as friends, mates and employees [16], and receive assistance in a variety of settings more often than physically unattractive people [17, 18]. These differences in the control and quality of social experiences may lead to differences in psychological functioning. Feingoid's [3] meta-analytic review supported the position that attractive and unattractive people differ psychologically. Physically attractive persons are not only frequently perceived to be more sociable, dominant, sexually warm, mentally healthy, intelligent and socially skilled than unattractive people, but measures of psychological functioning largely confirm they are more socially skilled, popular, sexually experienced and less lonely and socially anxious than unattractive people. Thus, it would not be unreasonable to posit that some of the notorious individual differences in coping with painful events would be determined by patient physical attractiveness. We hypothesized that: (a) given that the social environment is generally less responsive to unattractive people, they would rely on passive coping strategies; and (b) attractive patients would be less likely to catastrophize as their more positive social experiences would make them less susceptible to psychological distress. Non-verbal expressiveness as a possible influence on coping style People also vary in their disposition to react with vivacity and vigor, or lack thereof, to situational events. Nonverbal expressiveness could influence impressions of both clinicians and other observers [2, 19, 20]. For example, untrained judges reliably assessed the amount of distress experienced by subjects exposed to painful electric shocks on the basis of observations of non-verbal behaviour alone [19]. Additional evidence suggested that patients who express pain non-verbally are more likely to be viewed as credible and suffering than patients who do not [21, 22]. Whether non-verbal expressions of pain also provide information regarding how patients are coping with pain is less certain. Being expressive of one's pain gives a patient more control over some situations [23], for example, increasing the likelihood that caregivers will attend to the patient. As well, to the extent that a higher degree of non-verbal expressiveness would elicit a response from others, expressive people may be less likely to select passive coping strategies (such as praying and simply hoping) than non-expressive people. Finally, to the extent that non-verbal expressiveness predisposes people to improved psychological functioning by attenuating autonomic activity [4], we also predicted that expressive people would be less likely to catastrophize than non-expressive people.
While verbal expression of pain is also important and has been the focus of the majority of relevant research papers, it has numerous limitations such as susceptibility to setting demand characteristics and reporting biases [24]. Non-verbal expressiveness is considered to be less susceptible to such influences and observers often attach greater credibility to non-verbal expressions than they do to verbal report [24]. Since the sources of confound and bias for verbal expressiveness are difficult to control in the clinical setting [24], this study focuses solely on non-verbal expressiveness. Demographics as a possible influence on coping style Finally, we considered the role of demographic variables in the selection of coping strategies used by patients. Research has shown, for example, that variables such as age, level of education and income affect peoples' reactions to cancer pain [25]. More specifically, it has been shown that those who are older, with lower incomes and less education were more likely to have painrelated concerns [25]. We wished to determine whether socioeconomic status and education would also affect low back patients' reactions to pain. Gender was also viewed as a possible correlate of coping style. Women often use coping strategies that are less active than those used by men and are more likely to engage in self-blame about stressful situations [26]. As well, women have been shown to be more likely than men to use emotion-focused coping when dealing with psychosomatic symptoms [27]. Given such findings, we anticipated that gender differences in coping style may also exist in low back pain patients. Because the wide range of physical impairment (organic pathology) in the patients could also be related to coping capabilities, this was also assessed. Summary of purpose and hypotheses Health care professionals are influenced by appearance-based information, such as physical attractiveness and nonverbal expressiveness in their judgements of another's pain [2]. The present study examined whether these variables are informative about how patients are coping. It was hypothesized that: (a) unattractive patients will be more likely than attractive patients to rely on passive coping strategies and to catastrophize; (b) non-verbally expressive patients will be less likely than non-expressive patients to select passive coping strategies and to catastrophize; (c) the selection of coping strategies will be influenced by demographic characteristics of the patients (e.g. gender and age).
Appearance-based information about coping METHOD
Subjects Ninety-six patients experiencing low back pain for an average of 4.36 years (SD = 6.73; range = 3 days to over 27 years) and receiving treatment from one of two physiotherapists at a community-based clinic volunteered for study. Data from six of the patients was incomplete and they were discarded as subjects. The mean age of the sample was 44.11 years ( S D = 14.95 years; r a n g e = 2 0 - 7 0 years) and 61% were married. Half the patients were male and half were female. Socioeconomic status was rated using Blishen, Carroll and Moore's index [28], based on the 1981 census, and was 36.61 ( S D = 13.18; range 21-72). This is within the average range for the Canadian population. Thirty-one percent of the patients were temporarily off work because of the injury, while the remainder continued with their regular work activities. The majority (67%) of patients were not receiving financial aid or compensation.
Observers A total of five female and three male university students and faculty served as judges of physical attractiveness. All judges were unfamiliar with the patients. Past research has shown that males and females do not differ in the way in which they judge attractiveness [14, 29].
Procedure Patients were interviewed and filled out a battery of questionnaires while receiving physiotherapy treatment (e.g. heat or TENS). Subsequently, the physiotherapist assessed the patient for physical impairment (described further below). Patients then rested in a supine position on a standard examining table while their responses to a standard protocol were recorded on videotape. The camera was mounted on a tripod at the end of the table and focused upon their head and shoulders.The protocol began by asking patients to hold a neutral expression on their face and to move their toes, in order to obtain baseline facial activity. Patients then expressed pain while lifting either both or one (22% of the patients were unable to lift both legs) of their legs 10 inches off the examination table. The leg raise is a standard range of motion activity that is requested routinely during physical examinations and is experienced as discomforting by low back patients. The segments of the videotapes used in the present study were: (1) still clips of the neutral facial expressions, used to judge patient physical attractiveness; and (2) four second clips of the patients' response to the leg movement, used to rate patient non-verbal pain expressiveness.
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The pain segment corresponded to the two seconds preceding and the two seconds succeeding the moment patients were judged to be showing maximal facial movement. Two independent coders agreed almost fully as to when maximum movement was occurring (ct = 0.99). The facial expressions during the painful movement were coded using the Facial Action Coding System (FACS) [30].
Judges' ratings Physical attractiveness. Eight judges, all unfamiliar with the subjects, rated static, neutral video clips of the subjects along a seven point scale anchored by the bipolar opposites 'physically attractive' vs 'physically unattractive'. The intraclass correlation was 0.88 suggesting that physical attractiveness was assessed reliably. Instrumen ts Physical impairment inventory [31]. This standard set of reliable indices of organic impairment and physical limitation was scored by the physiotherapists. Interjudge reliability on 20% of the patients was high (r = 0.88). The coping strategy questionnaire (CSQ) [12]. Five scores were derived from the patients' responses to the CSQ [8], examining: (1) behavioural coping; (2) catastrophizing; (3) active cognitive coping (tendencies to ignore pain sensations, use coping self statements, and reinterpret pain sensations); (4) passive coping (tendencies to pray, hope and divert attention); and (5) evaluative dimensions (the patient's belief that he or she can control and decrease pain).
Facial action coding system (FACS) [30]. The pain segment was scored for the frequency of 46 facial action units (AUs). Following a precedent [32], the descriptions of several action units were combined: (1) orbit tightening (AUs 6 and 7); (2) levator contraction (AUs 9 and 10); and (3) mouth opening (AUs 25, 26 and 27). For the majority of AUs, a five point rating scale was used to code intensity. For mouth opening, however, a three point rating scale was used (I = lips parted; 2 = jaw drop; 3 = mouth stretched), as in Prkachin and Mercer [33]. Two FACS proficient research assistants coded the data. Percent agreement [30] for 25% of the patients was 84%. A composite measure of painful facial expression was derived by summing the AUs which were weighted by their intensity rating. Only AUs which have previously been found to be associated with pain in the literature were included in the measure [34]. These were inner (1) and outer (2) brow raise, brow lower (4), eye orbit tightening (6, 7), levator contraction (9, 10), lip corner pull (12), chin raise (17), lip stretch (20), lip
THOMASHADJISTAVROPOULO~et al.
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Table 1. Means and standard deviationsof the subjects in all variables X SD Non-verbalexpressiveness 4.77 5.06 Physical attractiveness 3.80 0.88 Age 44.I 1 14.95 Socioeconomicstatus 36.61 13.18 Physical impairment 7.86 8.22 Catastrophizing 1.37 1.21 Passive coping 2.21 1.22 Cognitivecoping 2.38 0.99 Evaluative dimension 3.07 1.13 Behaviouralcoping 2.83 1.29
press (24), mouth-opening (25, 26, 27), eyes closed (43) and eyes blinking (45). RESULTS The means and standard deviations obtained by the patients on all variables are presented in Table 1. To determine whether physical attractiveness, nonverbal expressiveness and demographic characteristics were related to the five coping dimensions assessed by the Coping Strategies Questionnaire (passive, evaluative, active cognitive, catastrophizing and behavioural coping) five regression equations were performed each predicting one of the five coping dimensions. A Bonferroni correction controlled for family-wise error rates for each coping dimension. That is, the full regression model in each analysis was tested at an ~ level of 0.01 (0.05/5). The group of predictors in each equation included the patients' physical attractiveness and non-verbal expressiveness, age, gender and socioeconomic status. Because the wide range of physical impairment represented in our sample could relate to the specific coping mechanisms, the degree of physical impairment also was included in each regression equation. In each equation, if the full model was significant, each variable's unique contribution to the regression was examined. A conservative approach was used that examined each predictor's ability to account for unique variance after all other predictors have been entered into the equation. The intercorrelations of the regression variables are presented in Table 2. Two of the five full regression models were significant. The significant regression results are presented in Table 3.
The full model was significant for passive coping, F(6, 8 3 ) = 4.63, P < 0.0004, R 2 = 0.25. An examination of each variable's unique contribution to the prediction equation suggested that physical attractiveness, non-verbal expressiveness and socioeconomic status each accounted for a significant and unique portion of the variance. The full model was also significant for catastrophizing, F(6, 83) = 4.97, P < 0.0002, R 2 = 0.26. Age, socioeconomic status and gender made significant unique contributions. The unique contribution of physical attractiveness to catastrophizing approached but did not reach statistical significance (P < 0.08). The results of the equations predicting active cognitive (R 2 = 0.05, F = 0.72, P < 0.64), behavioural (R 2 = 0.12, F = 1.93, P < 0.09) and evaluative coping (R 2 = 0.06, F = 0.90, P < 0.49) were not significant. Although not directly related to the hypotheses of the present study, we explored the association of physical attractiveness and non-verbal expressiveness after demographic factors were controlled for. Specifically, we entered physical attractiveness, demographic variables and degree of physical impairment of the patient in a regression equation predicting non-verbal expressiveness (dependent variable). These variables were not significantly associated with expressiveness [R 2 = 0.05, F(6,83) = 0.83, P < 0.54]. DISCUSSION The data support the hypothesis that the physical appearance of the individual relates to characteristic patterns of coping with pain. Similarly, the vigor of the expressive display during pain also reveals qualities of the subjective experience of the individual. Physical attractiveness and non-verbal expressiveness were not significantly related.
Physical attractiveness Physical attractiveness was related to individual differences in coping with pain. Specifically, the less physically attractive the patient, the more likely he or she was to engage in passive coping strategies such as praying and hoping. The significant contribution of patient physical attractiveness to the prediction of passive coping was over and above that of other
Table 2. Intercorrelationsof the variables involvedin the two significantregressionequations Passive
Attractiveness 1.00
Expressiveness Age SES~ Impairment Genderb --0.02 -0.44 0.02 -0.24 0.09 1.00 -0.05 -0.13 0.10 0.15 1.00 0.08 0.33 -0.02 1.00 -0.07 -0.23 1.00 0.04 1.00
Attractiveness Expressiveness Age SES• Impairment Genderb Catastrophizing~ Passive coping~ ~Highcr numbers imply a higher SES (socioeconomicstatus) level.
Catastrophizing~ -0.02 0.09 -0.32* -0.31" 0.05 0.25* 1.00
coping¢ -0.20* -0.15" -0.05 -0.37* 0.09 0.16 0.50 1.00
bl = male; 2 = female.
CDependentvariable. *These bivariatc correlationscorrespond to predictors that made significantand unique contributionsin the regressionequations.
Appearance-based information about coping
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Table 3. Regression analyses examining the unique variance accounted for by the predictors ofcoping style for each of the two significant full regression models Beta
F(6, 83)
P (<)
R 2 Change
- 0.27 -0.23 -0.18 -0.34 0.08 0.14
6.33 5.61 2.60 11.82 0.55 1.87
0.01 0.02 0.11 0.001 0.46 0.18
0.06 0.05 0.02 0. I 1 0.01 0.02
-0.19 - 0.01 -0.42 -0.22 0.13 0.20
3.21 0.00 14.82 4.98 1.52 4.31
0.08 0.96 0.00 0.03 0.22 0.04
0.03 0.00 0.13 0.04 0.01 0.04
Passive Coping Attractiveness Expressiveness Age SES Physical Impairment Gender
Catastrophizing Attractiveness Expressiveness Age SES Physical Impairment Gender
variables such as age. This finding can be explained with reference to well-established findings indicating that the social environment is less responsive to unattractive than to attractive people [16]. Consequently, unattractive people could utilize passive coping strategies because more active strategies (e.g. socializing and actively seeking assistance) proved less effective for them. Further research is needed to establish that active coping strategies may be more effective for physically attractive patients. The attractive and unattractive patients did not differ in their use of other, more active strategies (e.g. behavioural coping). This finding may reflect intermittent reinforcement of these effective tactics which would maintain use of active coping strategies at a relatively high level for unattractive people. Approaching statistical significance was the finding that more attractive persons were less likely to catastrophize than were unattractive persons. Since this finding did not reach conventional significance, it should be replicated by future research. The result suggests, however, that attractive people are less likely to catastrophize possibly because they may tend to experience more positive outcomes in their lives [15]. It is worth noting that the bivariate relationship of catastrophizing and physical attractiveness is low because of the suppressing effects of other variables (e.g. age) that overlap with physical attractiveness and are controlled for in the regression equations [35]. The Coping Strategies Questionnaire [12] used in the present investigation assessed five types of psychometrically valid coping styles. There may be other differences in the ways in which physically attractive and unattractive people differ in terms of coping with pain. Such differences may be more specifically focused on the utilization of social interaction as a means of coping with pain. The identification of such additional differences in the coping styles of physically attractive and unattractive people appears to be a fruitful area for future investigation. The issue of the causal relationship between the predictor (attractiveness) and the criterion (coping style) is not difficult to address because it cannot be
argued easily that the utilization of passive coping strategies makes people less physically attractive. As a result, the opposite causal direction seems more plausible. It is also possible, however, that physical attractiveness and coping style are related because people who utilize active coping also attend to their appearance more (and appear more attractive). Third variable determinants remain to be researched.
Non-verbal pain expressiveness Non-verbal expressiveness was predictive of passive coping with more expressive people being less likely to utilize strategies such as praying and hoping. This was consistent with the view that a high degree of non-verbal expressiveness would be more likely to elicit responses from others and, thus, expressive people may be less likely to select passive coping strategies. This finding has potential theoretical implications. Specifically, Berry and Pennebaker [4] recently suggested that there may be health differences between people who differ in the degree to which they are non-verbally expressive. It is possible that these health differences, if present, are mediated by differences in the coping styles employed by non-verbally expressive and inexpressive people. It is argued here that the degree to which a person is non-verbally expressive plays a role in the determination of coping style. Although we were able to demonstrate a relation of coping style with expressiveness, it is difficult to find proof in the clinical setting for our argument concerning the direction of causality. The possibility that the coping style of the patient affects the degree of expressiveness exists. Future research in the experimental laboratory, rather than the clinical setting may address this possibility.
Demographic characteristics The results indicate that persons who are younger, female and of lower socieconomic status are more likely to catastrophize. The finding concerning socieconomic status is consistent with previous research involving patients with other types of pain [25] and confirms that low back pain patients of lower socio-
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economic groups are more likely to engage in catastrophizing as means of coping with pain. The finding concerning a higher incidence of catastrophizing among younger people was not anticipated because previous results showed that older people have more pain related concerns [25]. Nonetheless, to the extent that catastrophizing is a characteristic of clinical depression [36], all findings concerning the relationship of demographic characteristics and catastrophizing are consistent with the psychopathology literature. That is, depression is more common in younger adults [37, 38] and women [39]. In addition, with some inconsistencies, the literature also suggests that depression is more common in persons of lower socioeconomic groups (e.g. Eiseman [40]). Certain demographic groups may be predisposed to depression and catastrophizing by the relatively higher level of stress they are believed to experience [41, 42]. Additionally, the identified gender difference is likely related to differences in the socialization of males and females in this culture [43]. The finding that people in higher socioeconomic groups are less likely to engage in passive coping may be due to the possibility that such persons may have broader opportunities to engage in active coping strategies (e.g. vacations, attending entertainment events) as a result of higher incomes.
As a result of the complex interplay of the determinants of coping style, a clinician may not readily observe coping styles of patients that can be accounted for by any one determinant. From a research point of view, however, subgroups of influences on coping style may be studied separately. Once a significant number of determinants of coping style are identified, future work could incorporate them into theoretical models that would account for the interplay of many of the variables. With reference to clinical practices, it can also be argued that individuals are not always aware of the variables that affect their judgements and attitudes [44,45]. As such, clinicians may be "perceiving but not always noticing" [46] relations such as the ones identified here. It is also worth noting that our study focused on patients with low back pain. Since people do not show the same type of reaction to all types of pain [5], it is important for future research to investigate the extent to which our findings generalize to patients who experience other types of pain. The extent to which studies of pain perception tap the concomitants of pain within a particular social context, as opposed to pure pain perception, must be understood and studied further. There are other inherent errors and biases of human judgements about other humans in pain that need to be studied and rectified. Such bias may be based, for example, on the race and socioeconomic status of patients [1].
Conclusions
In summary, it can be concluded that social, appearance-based characteristics of pain patients may provide some information about the nature of the coping strategies patients use as their illness progresses. Thus, the previously identified stereotype subscribed to by professionals that attractive and unattractive patients differ in psychological functioning during pain [2] does not serve as a pervasive error but carries a grain of truth. This should not be taken to imply, however, that health professionals should not be encouraged to examine and discount (appearance-based) biases because the stereotypes may imply differences that are more global than those identified here. In fact, Feingold [3] concluded in his meta-analytic study that, while there are differences in the psychological functioning of healthy attractive and unattractive persons, the physical attractiveness stereotype serves to greatly exaggerate these differences. In clinical populations, a patient's selection of coping style has multiple determinants. Patient physical attractiveness, non-verbal expressiveness and the demographic characteristics, examined here, only represent a piece of the puzzle. Additional contextual variables that could play a role in coping with pain might include factors such as the client's social support network, the nature of the treatment received, and cultural influences. Each determinant of reaction to pain could make a contribution to the type of coping style used by a patient.
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A P P E A R A N C E - B A S E D I N F O R M A T I O N A B O U T COPING WITH PAIN: V A L I D OR BIASED? THOMAS HADJISTAVROPOULOS,HEATHERD. HADJISTAVROPOULOSand KENNETH D. CRAIG Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, B.C., Canada V6T IZ4 Abstract--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. Key words--physical attractiveness, pain, non-verbal expressiveness
INTRODUCTION
Visible attributes of patients influence clinical judgments, as clinicians incorporate in their decisions information concerning demographic characteristics (e.g. age, gender, racial and ethnic information) and immediate evidence of how the person presents himself or herself [1, 2]. As well, patients' physical attractiveness and non-verbal expressiveness have been shown to affect clinical judgments [2]. For example, physically attractive pain patients were perceived by physicians as experiencing less pain than physically unattractive pain patients [2]. It is uncertain whether the impact of such appearance-based information on judgments reflects unwarranted judgments or discerning clinical acumen. The appearance-based information may be entirely unrelated to how pain is experienced or it could provide valid information about the nature of the person's experience. The literature suggests that physical attractiveness and non-verbal expressiveness may be related to important dimensions of psychological functioning [3, 4]. The goal of the present study was to determine whether physical attractiveness and non-verbal expressivity are also related to the way patients cope with pain. Coping mechanisms are of interest because they are instructive about how a person experiences pain [5]. Physical attractiveness and nonverbal expressivity were examined because past research [2] has shown them to affect clinical judgments about pain patients. Coping with pain Knowledge of a person's usual strategies and effectiveness in coping with pain may have considerable
clinical utility. Coping has been defined as purposeful efforts to manage or reduce the negative impact of stress [6], with physical pain perhaps the most universal form of stress [7]. People use a variety of coping strategies, including, for instance, efforts to distract themselves and the use of calming self-statements, or prayer. Several key dimensions of the coping strategies used by pain patients have been identified through factor analytic work [8]. These dimensions include use of active cognitive tactics, self-evaluative coping, passive coping, behavioural coping and catastrophizing. Several theoretical formulations of coping also are available [9, 10], with the distinction between active and passive coping strategies particularly useful [6]. Active strategies require the person to initiate instrumental action to manage pain (e.g. engage in a pleasant activity) whereas passive strategies involve assigning control to some external agent (e.g. medication or divine intervention). Passive strategies have been associated with lower levels of adjustment [11]. Catastrophizing, or self-alarming thinking [12], often represents a maladaptive effort to cope with pain [11] and has been associated with increased depression, pain severity, psychological distress and more severe disability [13]. Physical attractiveness as a possible influence on coping style Publicly visible, personal characteristics may reflect or determine the coping response of pain patients. Of these, physical attractiveness appears important. Physical attractiveness has a substantial influence on interpersonal behaviours in a wide variety of settings, including courts, the workplace, schools and health settings [2, 14]. Physically attractive persons tend to 537
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have more positive social experiences and, as a result, more control over their lives [15]. They also tend to be sought out as friends, mates and employees [16], and receive assistance in a variety of settings more often than physically unattractive people [17, 18]. These differences in the control and quality of social experiences may lead to differences in psychological functioning. Feingoid's [3] meta-analytic review supported the position that attractive and unattractive people differ psychologically. Physically attractive persons are not only frequently perceived to be more sociable, dominant, sexually warm, mentally healthy, intelligent and socially skilled than unattractive people, but measures of psychological functioning largely confirm they are more socially skilled, popular, sexually experienced and less lonely and socially anxious than unattractive people. Thus, it would not be unreasonable to posit that some of the notorious individual differences in coping with painful events would be determined by patient physical attractiveness. We hypothesized that: (a) given that the social environment is generally less responsive to unattractive people, they would rely on passive coping strategies; and (b) attractive patients would be less likely to catastrophize as their more positive social experiences would make them less susceptible to psychological distress. Non-verbal expressiveness as a possible influence on coping style People also vary in their disposition to react with vivacity and vigor, or lack thereof, to situational events. Nonverbal expressiveness could influence impressions of both clinicians and other observers [2, 19, 20]. For example, untrained judges reliably assessed the amount of distress experienced by subjects exposed to painful electric shocks on the basis of observations of non-verbal behaviour alone [19]. Additional evidence suggested that patients who express pain non-verbally are more likely to be viewed as credible and suffering than patients who do not [21, 22]. Whether non-verbal expressions of pain also provide information regarding how patients are coping with pain is less certain. Being expressive of one's pain gives a patient more control over some situations [23], for example, increasing the likelihood that caregivers will attend to the patient. As well, to the extent that a higher degree of non-verbal expressiveness would elicit a response from others, expressive people may be less likely to select passive coping strategies (such as praying and simply hoping) than non-expressive people. Finally, to the extent that non-verbal expressiveness predisposes people to improved psychological functioning by attenuating autonomic activity [4], we also predicted that expressive people would be less likely to catastrophize than non-expressive people.
While verbal expression of pain is also important and has been the focus of the majority of relevant research papers, it has numerous limitations such as susceptibility to setting demand characteristics and reporting biases [24]. Non-verbal expressiveness is considered to be less susceptible to such influences and observers often attach greater credibility to non-verbal expressions than they do to verbal report [24]. Since the sources of confound and bias for verbal expressiveness are difficult to control in the clinical setting [24], this study focuses solely on non-verbal expressiveness. Demographics as a possible influence on coping style Finally, we considered the role of demographic variables in the selection of coping strategies used by patients. Research has shown, for example, that variables such as age, level of education and income affect peoples' reactions to cancer pain [25]. More specifically, it has been shown that those who are older, with lower incomes and less education were more likely to have painrelated concerns [25]. We wished to determine whether socioeconomic status and education would also affect low back patients' reactions to pain. Gender was also viewed as a possible correlate of coping style. Women often use coping strategies that are less active than those used by men and are more likely to engage in self-blame about stressful situations [26]. As well, women have been shown to be more likely than men to use emotion-focused coping when dealing with psychosomatic symptoms [27]. Given such findings, we anticipated that gender differences in coping style may also exist in low back pain patients. Because the wide range of physical impairment (organic pathology) in the patients could also be related to coping capabilities, this was also assessed. Summary of purpose and hypotheses Health care professionals are influenced by appearance-based information, such as physical attractiveness and nonverbal expressiveness in their judgements of another's pain [2]. The present study examined whether these variables are informative about how patients are coping. It was hypothesized that: (a) unattractive patients will be more likely than attractive patients to rely on passive coping strategies and to catastrophize; (b) non-verbally expressive patients will be less likely than non-expressive patients to select passive coping strategies and to catastrophize; (c) the selection of coping strategies will be influenced by demographic characteristics of the patients (e.g. gender and age).
Appearance-based information about coping METHOD
Subjects Ninety-six patients experiencing low back pain for an average of 4.36 years (SD = 6.73; range = 3 days to over 27 years) and receiving treatment from one of two physiotherapists at a community-based clinic volunteered for study. Data from six of the patients was incomplete and they were discarded as subjects. The mean age of the sample was 44.11 years ( S D = 14.95 years; r a n g e = 2 0 - 7 0 years) and 61% were married. Half the patients were male and half were female. Socioeconomic status was rated using Blishen, Carroll and Moore's index [28], based on the 1981 census, and was 36.61 ( S D = 13.18; range 21-72). This is within the average range for the Canadian population. Thirty-one percent of the patients were temporarily off work because of the injury, while the remainder continued with their regular work activities. The majority (67%) of patients were not receiving financial aid or compensation.
Observers A total of five female and three male university students and faculty served as judges of physical attractiveness. All judges were unfamiliar with the patients. Past research has shown that males and females do not differ in the way in which they judge attractiveness [14, 29].
Procedure Patients were interviewed and filled out a battery of questionnaires while receiving physiotherapy treatment (e.g. heat or TENS). Subsequently, the physiotherapist assessed the patient for physical impairment (described further below). Patients then rested in a supine position on a standard examining table while their responses to a standard protocol were recorded on videotape. The camera was mounted on a tripod at the end of the table and focused upon their head and shoulders.The protocol began by asking patients to hold a neutral expression on their face and to move their toes, in order to obtain baseline facial activity. Patients then expressed pain while lifting either both or one (22% of the patients were unable to lift both legs) of their legs 10 inches off the examination table. The leg raise is a standard range of motion activity that is requested routinely during physical examinations and is experienced as discomforting by low back patients. The segments of the videotapes used in the present study were: (1) still clips of the neutral facial expressions, used to judge patient physical attractiveness; and (2) four second clips of the patients' response to the leg movement, used to rate patient non-verbal pain expressiveness.
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The pain segment corresponded to the two seconds preceding and the two seconds succeeding the moment patients were judged to be showing maximal facial movement. Two independent coders agreed almost fully as to when maximum movement was occurring (ct = 0.99). The facial expressions during the painful movement were coded using the Facial Action Coding System (FACS) [30].
Judges' ratings Physical attractiveness. Eight judges, all unfamiliar with the subjects, rated static, neutral video clips of the subjects along a seven point scale anchored by the bipolar opposites 'physically attractive' vs 'physically unattractive'. The intraclass correlation was 0.88 suggesting that physical attractiveness was assessed reliably. Instrumen ts Physical impairment inventory [31]. This standard set of reliable indices of organic impairment and physical limitation was scored by the physiotherapists. Interjudge reliability on 20% of the patients was high (r = 0.88). The coping strategy questionnaire (CSQ) [12]. Five scores were derived from the patients' responses to the CSQ [8], examining: (1) behavioural coping; (2) catastrophizing; (3) active cognitive coping (tendencies to ignore pain sensations, use coping self statements, and reinterpret pain sensations); (4) passive coping (tendencies to pray, hope and divert attention); and (5) evaluative dimensions (the patient's belief that he or she can control and decrease pain).
Facial action coding system (FACS) [30]. The pain segment was scored for the frequency of 46 facial action units (AUs). Following a precedent [32], the descriptions of several action units were combined: (1) orbit tightening (AUs 6 and 7); (2) levator contraction (AUs 9 and 10); and (3) mouth opening (AUs 25, 26 and 27). For the majority of AUs, a five point rating scale was used to code intensity. For mouth opening, however, a three point rating scale was used (I = lips parted; 2 = jaw drop; 3 = mouth stretched), as in Prkachin and Mercer [33]. Two FACS proficient research assistants coded the data. Percent agreement [30] for 25% of the patients was 84%. A composite measure of painful facial expression was derived by summing the AUs which were weighted by their intensity rating. Only AUs which have previously been found to be associated with pain in the literature were included in the measure [34]. These were inner (1) and outer (2) brow raise, brow lower (4), eye orbit tightening (6, 7), levator contraction (9, 10), lip corner pull (12), chin raise (17), lip stretch (20), lip
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Table 1. Means and standard deviationsof the subjects in all variables X SD Non-verbalexpressiveness 4.77 5.06 Physical attractiveness 3.80 0.88 Age 44.I 1 14.95 Socioeconomicstatus 36.61 13.18 Physical impairment 7.86 8.22 Catastrophizing 1.37 1.21 Passive coping 2.21 1.22 Cognitivecoping 2.38 0.99 Evaluative dimension 3.07 1.13 Behaviouralcoping 2.83 1.29
press (24), mouth-opening (25, 26, 27), eyes closed (43) and eyes blinking (45). RESULTS The means and standard deviations obtained by the patients on all variables are presented in Table 1. To determine whether physical attractiveness, nonverbal expressiveness and demographic characteristics were related to the five coping dimensions assessed by the Coping Strategies Questionnaire (passive, evaluative, active cognitive, catastrophizing and behavioural coping) five regression equations were performed each predicting one of the five coping dimensions. A Bonferroni correction controlled for family-wise error rates for each coping dimension. That is, the full regression model in each analysis was tested at an ~ level of 0.01 (0.05/5). The group of predictors in each equation included the patients' physical attractiveness and non-verbal expressiveness, age, gender and socioeconomic status. Because the wide range of physical impairment represented in our sample could relate to the specific coping mechanisms, the degree of physical impairment also was included in each regression equation. In each equation, if the full model was significant, each variable's unique contribution to the regression was examined. A conservative approach was used that examined each predictor's ability to account for unique variance after all other predictors have been entered into the equation. The intercorrelations of the regression variables are presented in Table 2. Two of the five full regression models were significant. The significant regression results are presented in Table 3.
The full model was significant for passive coping, F(6, 8 3 ) = 4.63, P < 0.0004, R 2 = 0.25. An examination of each variable's unique contribution to the prediction equation suggested that physical attractiveness, non-verbal expressiveness and socioeconomic status each accounted for a significant and unique portion of the variance. The full model was also significant for catastrophizing, F(6, 83) = 4.97, P < 0.0002, R 2 = 0.26. Age, socioeconomic status and gender made significant unique contributions. The unique contribution of physical attractiveness to catastrophizing approached but did not reach statistical significance (P < 0.08). The results of the equations predicting active cognitive (R 2 = 0.05, F = 0.72, P < 0.64), behavioural (R 2 = 0.12, F = 1.93, P < 0.09) and evaluative coping (R 2 = 0.06, F = 0.90, P < 0.49) were not significant. Although not directly related to the hypotheses of the present study, we explored the association of physical attractiveness and non-verbal expressiveness after demographic factors were controlled for. Specifically, we entered physical attractiveness, demographic variables and degree of physical impairment of the patient in a regression equation predicting non-verbal expressiveness (dependent variable). These variables were not significantly associated with expressiveness [R 2 = 0.05, F(6,83) = 0.83, P < 0.54]. DISCUSSION The data support the hypothesis that the physical appearance of the individual relates to characteristic patterns of coping with pain. Similarly, the vigor of the expressive display during pain also reveals qualities of the subjective experience of the individual. Physical attractiveness and non-verbal expressiveness were not significantly related.
Physical attractiveness Physical attractiveness was related to individual differences in coping with pain. Specifically, the less physically attractive the patient, the more likely he or she was to engage in passive coping strategies such as praying and hoping. The significant contribution of patient physical attractiveness to the prediction of passive coping was over and above that of other
Table 2. Intercorrelationsof the variables involvedin the two significantregressionequations Passive
Attractiveness 1.00
Expressiveness Age SES~ Impairment Genderb --0.02 -0.44 0.02 -0.24 0.09 1.00 -0.05 -0.13 0.10 0.15 1.00 0.08 0.33 -0.02 1.00 -0.07 -0.23 1.00 0.04 1.00
Attractiveness Expressiveness Age SES• Impairment Genderb Catastrophizing~ Passive coping~ ~Highcr numbers imply a higher SES (socioeconomicstatus) level.
Catastrophizing~ -0.02 0.09 -0.32* -0.31" 0.05 0.25* 1.00
coping¢ -0.20* -0.15" -0.05 -0.37* 0.09 0.16 0.50 1.00
bl = male; 2 = female.
CDependentvariable. *These bivariatc correlationscorrespond to predictors that made significantand unique contributionsin the regressionequations.
Appearance-based information about coping
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Table 3. Regression analyses examining the unique variance accounted for by the predictors ofcoping style for each of the two significant full regression models Beta
F(6, 83)
P (<)
R 2 Change
- 0.27 -0.23 -0.18 -0.34 0.08 0.14
6.33 5.61 2.60 11.82 0.55 1.87
0.01 0.02 0.11 0.001 0.46 0.18
0.06 0.05 0.02 0. I 1 0.01 0.02
-0.19 - 0.01 -0.42 -0.22 0.13 0.20
3.21 0.00 14.82 4.98 1.52 4.31
0.08 0.96 0.00 0.03 0.22 0.04
0.03 0.00 0.13 0.04 0.01 0.04
Passive Coping Attractiveness Expressiveness Age SES Physical Impairment Gender
Catastrophizing Attractiveness Expressiveness Age SES Physical Impairment Gender
variables such as age. This finding can be explained with reference to well-established findings indicating that the social environment is less responsive to unattractive than to attractive people [16]. Consequently, unattractive people could utilize passive coping strategies because more active strategies (e.g. socializing and actively seeking assistance) proved less effective for them. Further research is needed to establish that active coping strategies may be more effective for physically attractive patients. The attractive and unattractive patients did not differ in their use of other, more active strategies (e.g. behavioural coping). This finding may reflect intermittent reinforcement of these effective tactics which would maintain use of active coping strategies at a relatively high level for unattractive people. Approaching statistical significance was the finding that more attractive persons were less likely to catastrophize than were unattractive persons. Since this finding did not reach conventional significance, it should be replicated by future research. The result suggests, however, that attractive people are less likely to catastrophize possibly because they may tend to experience more positive outcomes in their lives [15]. It is worth noting that the bivariate relationship of catastrophizing and physical attractiveness is low because of the suppressing effects of other variables (e.g. age) that overlap with physical attractiveness and are controlled for in the regression equations [35]. The Coping Strategies Questionnaire [12] used in the present investigation assessed five types of psychometrically valid coping styles. There may be other differences in the ways in which physically attractive and unattractive people differ in terms of coping with pain. Such differences may be more specifically focused on the utilization of social interaction as a means of coping with pain. The identification of such additional differences in the coping styles of physically attractive and unattractive people appears to be a fruitful area for future investigation. The issue of the causal relationship between the predictor (attractiveness) and the criterion (coping style) is not difficult to address because it cannot be
argued easily that the utilization of passive coping strategies makes people less physically attractive. As a result, the opposite causal direction seems more plausible. It is also possible, however, that physical attractiveness and coping style are related because people who utilize active coping also attend to their appearance more (and appear more attractive). Third variable determinants remain to be researched.
Non-verbal pain expressiveness Non-verbal expressiveness was predictive of passive coping with more expressive people being less likely to utilize strategies such as praying and hoping. This was consistent with the view that a high degree of non-verbal expressiveness would be more likely to elicit responses from others and, thus, expressive people may be less likely to select passive coping strategies. This finding has potential theoretical implications. Specifically, Berry and Pennebaker [4] recently suggested that there may be health differences between people who differ in the degree to which they are non-verbally expressive. It is possible that these health differences, if present, are mediated by differences in the coping styles employed by non-verbally expressive and inexpressive people. It is argued here that the degree to which a person is non-verbally expressive plays a role in the determination of coping style. Although we were able to demonstrate a relation of coping style with expressiveness, it is difficult to find proof in the clinical setting for our argument concerning the direction of causality. The possibility that the coping style of the patient affects the degree of expressiveness exists. Future research in the experimental laboratory, rather than the clinical setting may address this possibility.
Demographic characteristics The results indicate that persons who are younger, female and of lower socieconomic status are more likely to catastrophize. The finding concerning socieconomic status is consistent with previous research involving patients with other types of pain [25] and confirms that low back pain patients of lower socio-
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economic groups are more likely to engage in catastrophizing as means of coping with pain. The finding concerning a higher incidence of catastrophizing among younger people was not anticipated because previous results showed that older people have more pain related concerns [25]. Nonetheless, to the extent that catastrophizing is a characteristic of clinical depression [36], all findings concerning the relationship of demographic characteristics and catastrophizing are consistent with the psychopathology literature. That is, depression is more common in younger adults [37, 38] and women [39]. In addition, with some inconsistencies, the literature also suggests that depression is more common in persons of lower socioeconomic groups (e.g. Eiseman [40]). Certain demographic groups may be predisposed to depression and catastrophizing by the relatively higher level of stress they are believed to experience [41, 42]. Additionally, the identified gender difference is likely related to differences in the socialization of males and females in this culture [43]. The finding that people in higher socioeconomic groups are less likely to engage in passive coping may be due to the possibility that such persons may have broader opportunities to engage in active coping strategies (e.g. vacations, attending entertainment events) as a result of higher incomes.
As a result of the complex interplay of the determinants of coping style, a clinician may not readily observe coping styles of patients that can be accounted for by any one determinant. From a research point of view, however, subgroups of influences on coping style may be studied separately. Once a significant number of determinants of coping style are identified, future work could incorporate them into theoretical models that would account for the interplay of many of the variables. With reference to clinical practices, it can also be argued that individuals are not always aware of the variables that affect their judgements and attitudes [44,45]. As such, clinicians may be "perceiving but not always noticing" [46] relations such as the ones identified here. It is also worth noting that our study focused on patients with low back pain. Since people do not show the same type of reaction to all types of pain [5], it is important for future research to investigate the extent to which our findings generalize to patients who experience other types of pain. The extent to which studies of pain perception tap the concomitants of pain within a particular social context, as opposed to pure pain perception, must be understood and studied further. There are other inherent errors and biases of human judgements about other humans in pain that need to be studied and rectified. Such bias may be based, for example, on the race and socioeconomic status of patients [1].
Conclusions
In summary, it can be concluded that social, appearance-based characteristics of pain patients may provide some information about the nature of the coping strategies patients use as their illness progresses. Thus, the previously identified stereotype subscribed to by professionals that attractive and unattractive patients differ in psychological functioning during pain [2] does not serve as a pervasive error but carries a grain of truth. This should not be taken to imply, however, that health professionals should not be encouraged to examine and discount (appearance-based) biases because the stereotypes may imply differences that are more global than those identified here. In fact, Feingold [3] concluded in his meta-analytic study that, while there are differences in the psychological functioning of healthy attractive and unattractive persons, the physical attractiveness stereotype serves to greatly exaggerate these differences. In clinical populations, a patient's selection of coping style has multiple determinants. Patient physical attractiveness, non-verbal expressiveness and the demographic characteristics, examined here, only represent a piece of the puzzle. Additional contextual variables that could play a role in coping with pain might include factors such as the client's social support network, the nature of the treatment received, and cultural influences. Each determinant of reaction to pain could make a contribution to the type of coping style used by a patient.
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