High Levels of Vicarious Exposure Bias Pain Judgments


      The present study evaluated the effects of exposure to facial expression of pain, on observers' perceptions of pain expression. Participants were undergraduates shown brief video clips of the facial expressions of shoulder-pain patients displaying no pain or moderate pain. Participants were randomly allocated to either a high preexposure condition in which each clip was preceded by 10 other clips showing strong pain or a no-exposure control. On each test trial, participants indicated whether they thought the person they saw was in pain or not. Data were analyzed using signal detection theory methods. High prior exposure to pain was unrelated to sensitivity to pain expression, but did significantly diminish the likelihood of judging the other to be in pain. Results are discussed in terms of their implications for pain judgments of health-care professionals, adaptation-level theory, and the psychophysical method of selective adaptation.


      This paper provides an experimental demonstration that, when people have large amounts of exposure to others' expressions of pain, their estimation of others' pain is reduced. The findings offer 1 explanation for the widely observed underestimation bias in pain judgments and may suggest ways of changing it.

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        • Bergh I.
        • Sjostrom B.A.
        Comparative study of nurses' and elderly patients' ratings of pain and pain tolerance.
        J Gerontol Nurs. 1999; 25: 30-36
        • Botvinick M.
        • Jha A.P.
        • Bylsma L.M.
        • Fabian S.A.
        • Solomon P.E.
        • Prkachin K.M.
        Viewing facial expressions of pain engages cortical areas involved in the direct experience of pain.
        Neuroimage. 2005; 25: 312-319
        • Brody L.R.
        Gender differences in emotional development: A review of theories and research.
        J Pers. 1985; 53: 102-149
        • Chibnall J.T.
        • Tait R.C.
        • Ross L.R.
        The effects of medical evidence and pain intensity on medical student judgements of chronic pain patients.
        J Behav Med. 1997; 20: 257-271
        • Choinière M.
        • Melzack R.
        • Girard N.
        • Rondeau J.
        • Paquin M.J.
        Comparison between patients' and nurses' assessment of pain and medication efficacy in severe burn injuries.
        Pain. 1990; 20: 143-152
        • Ekman P.
        • Friesen W.V.
        Manual for the Facial Action Coding System.
        Consulting Psychologists Press, Palo Alto, CA1978
        • Goubert L.
        • Craig K.D.
        • Vervoort T.
        • Morley S.
        • Sullivan M.J.L.
        • Williams AC de C.
        • Cano A.
        • Crombez G.
        Facing others in pain: The effects of empathy.
        Pain. 2005; 118: 285-288
        • Grier J.B.
        Nonparametric indexes for sensitivity and bias: computing formulas.
        Psychol Bull. 1971; 75: 424-429
        • Hall J.A.
        Gender effects in decoding nonverbal cues.
        Psychol Bull. 1978; 85: 845-857
        • Helson H.
        Adaptation-level theory.
        Harper & Row, New York, NY1964
        • Jackson P.L.
        • Rainville P.
        • Decety J.
        To what extent do we share the pain of others? Insight from the neural bases of pain empathy.
        Pain. 2006; 125: 5-9
        • Kappesser J.
        • Williams AC de C.
        • Prkachin K.M.
        Testing two accounts of pain underestimation.
        Pain. 2006; 124: 109-116
        • Lenburg C.B.
        • Glass H.P.
        • Davitz L.J.
        Inferences of physical pain and psychological distress. II. In the relation to the stage of the patient's illness and occupation of the perceiver.
        Nurs Res. 1970; 19: 392-398
        • Lundquist L.M.
        • Higgins N.C.
        • Prkachin K.M.
        Accurate pain detection is not enough: Contextual and attributional style biasing factors in patient evaluation and treatment choice.
        J Appl Biobehav Res. 2002; 7: 114-132
        • Olden A.
        • Jordan E.
        • Sakima N.
        • Grass J.
        Patients' versus nurses' assessments of pain and sedation after Cesarean section.
        J Obstet Gyn Neonat Nurs. 1995; 24: 137-141
        • Parker P.D.
        • Prkachin K.M.
        • Prkachin G.C.
        Processing of facial expressions of negative emotion in alexithymia: The influence of temporal constraint.
        J Pers. 2005; 73: 1087-1107
      1. Perreault K, Dionne CE: Does patient-physiotherapist agreement influence the outcome of low back pain? A prospective cohort study. BMC Musculoskelet Disord 7:76-10, 2006

        • Perry S.
        • Heidrich G.
        Management of pain during debridement: A survey of U.S. burn units.
        Pain. 1982; 13: 267-280
        • Pollack I.
        • Norman D.A.
        A non-parametric analysis of recognition experiments.
        Psychon Sci. 1964; 1: 125-126
        • Prkachin G.C.
        The effects of orientation on detection and identification of facial expressions of emotion.
        Br J Clin Psychol. 2003; 94: 45-62
        • Prkachin K.M.
        The consistency of facial expressions of pain: A comparison across modalities.
        Pain. 1992; 51: 297-306
        • Prkachin K.M.
        • Berzins S.
        • Mercer S.
        Encoding and decoding of pain expressions: A judgement study.
        Pain. 1994; 58: 253-259
        • Prkachin K.M.
        • Mass H.
        • Mercer S.R.
        Effects of exposure on perception of pain expression.
        Pain. 2004; 111: 8-12
        • Prkachin K.M.
        • Mercer S.
        Pain expression in patients with shoulder pathology: Validity, coding properties and relation to sickness impact.
        Pain. 1989; 39: 257-265
        • Prkachin G.C.
        • Prkachin K.M.
        Adaptation to facial expressions of emotion.
        Cogn Emot. 1994; 8: 55-64
        • Prkachin K.M.
        • Solomon P.
        • Hwang T.
        • Mercer S.R.
        Does experience affect judgements of pain behaviour? Evidence from relatives of pain patients and health-care providers.
        Pain Res Manag. 2001; 6: 105-112
        • Prkachin K.M.
        • Solomon P.A.
        • Ross A.J.
        The underestimation of pain among health-care providers.
        Can J Nurs Res. 2007; 39: 88-106
        • Regan D.
        • Beverley K.
        • Cynader M.
        The visual perception of motion in depth.
        Sci Am. 1979; 241: 136-151
        • Solomon P.
        Congruence between health professionals' and patients' pain ratings: A review of the literature.
        Scand J Caring Sci. 2001; 15: 174-180
        • Swets J.A.
        Signal detection theory and ROC analysis in psychology and diagnosis: Collected papers.
        Erlbaum, Mahwah, NJ1996
        • Teske K.
        • Daut R.
        • Cleeland C.
        Relationships between nurses' observations and patients' self-reports of pain.
        Pain. 1983; 16: 289-296