Vol. I No. 3 Summer 1986 Columns Journal of Pain and Symptom Management 161

Behavioral Control of Symptoms

How to Treat A "Construct" Charles S. Clee land

Although pain, nausea, and other symptoms of distress are intensely real to the person expe- r iencing them, the person observing the expe- rience is faced with many difficulties when try- ing to describe its intensity and quality. It may be helpful to think of the obser~'er as trying to descr ibe a "cons t ruc t " A cons t ruc t is an abstraction, in this case an abstraction about the behaviors that generally go together when observing a person "in pa in" For the observer, "pain" might be thought of at a similar level of abstraction as such behavioral constructs as "anxiety:,' "fear;' or even "intellegence." In that light, the observer's problem is a serious one, for we all know how much controversy has been generated by the constructs o f anxiety and intell igence. Does def in ing the observer 's "pain" as a construct help us at all with how to solve our measurement and description prob- lems? Does it provide any helpful perspectives on treatment? Perhaps we should consider tak- ing some lessons from the massive effort Over the last several decades to deal with the mea- surement and t reatment o f other "constructs" expecially "anxiety" and "depression"

While anxiety and depression remain the topics of both theoretical debate and research effort, certain principlies or ground rules have emerged which may be helpful in the consider- ation of other symptoms of distress. First, and most importantly, even the best measures o f a construct are imperfectly correlated with one another. A person, for example, who describes him/herself as intensely anxious may not score at the high end of all anxiety measures or show all the somatic manifestations attr ibuted to anxiety, such as pallor, sweating, and high heart

Charles S. Cleeland, PhD, is a Professor of Neurol- ogy and Director of the Pain Research Group in the Deparunent of Neurology at the University of Wisconsin-Madison.

rate. Similarly, another person may score at the high end of some of these scales but repor t little anxiety. This is news to no one. Yet, the observer of the person in pain often expects a very high correlation o f verbal repor t with somatic manefestations and other expected behaviors in order to be convinced that "pain" is "really" present. Each patient will present with a profile or pat tern of observable behav- iors that characterize that person when in pain.

A related principle that can be derived from experience with other behavioral constructs is that they are best measured by observation of several of the dimensions that they are sup- posed to affect. We have certain expectations of the experience o f pain beyond the person's ver- bal report. We expect, for instance, that as pain increases, non-pain related interests and activ- ity will decrease, that the attention that the per- son can devote to events other than the pain will be diminished, and that reports of negative mood states will increase. We can expect that proport ionately greater energy will be invested in attempts to reduce the pain. One who makes clinical judgements o f both pain severity and the relative relief provided by clinical treat- ments, therefore, must be sensitive to the sev- eral dimensions of behavior which are our orfly. window to another 's experience of pain.

We also have certain expectations of what happens when pain is relieved, which should be confirmed by our observations before stat- ing that pain has been reduced. These expecta- tions usually include an improvement in mood, activity, sleep, and an increase in attention to the environment and to others, in addition to the patient's repor t that the pain has dimin. ished.

Just as with the pat ient who is anxious, the pat ient 's individual prof i le of the various dimensions that we observe as pain will dictate our treatment plan. An adequate clinical assess-

162 Vol. I No. 3 Summer 1986 Cleeland Journal of Pain and Symptom Management

ment will provide such a profile for each patient, and this profile will serve to define the "pain" that is to be treated. It will also set the criteria for judging the success or failure o f treatment. In selecting a treatment strategy, focusing on disturbed mood makes little sense when that dimension of pain is not present. Blindly applying relaxation training when there is not evidence to suppor t the hypotheses that the patient's pain could be relieved by this technique also seems ill-advised. In fact, if we keep the idea of a symptom profile in mind, it probably makes little sense to think that one particular strategy will be sufficient, that what will serve the patient best is an optimal combi- nat ion o f strategies designed to address the patient's particular pain expression.

The format ion o f mult idiscipl inary pain t reatment teams is a recognit ion of the several dimensions of pain, that each patient has a profile of symptom expression, and that opti- mal t reatment of pain must be multidimen- sional. Yet, when actual t reatment recommen- dations are made, too often the strategy offered by individual disciplines is unidimensional. This is frequently true of recommendat ions for the use o f behavioral control measures. What is often lost sight o f is that there is no single, effective behavioral control method for "pain~' but ra ther a set of techniques which may be o f benefi t for several o f the dimensions o f behav- ior that people in pain may express. Those treating the constructs o f anxiety and depres- sion are less prone to make this type of error.

Compare, for instance, the literature on the t reatment of depression with the literature on the treatment of pain (both behavioral and medical). The former is more often character- ized by measuring the improvement o f the pat ient on several dimensions. The literature on depress ion is more liable to carefully describe the specific dimensions o f depression that the specific t reatment is targeted for, and o f the groups which serve to evaluate the effec- tiveness of the treatment. It is also more likely to specify the severity, of the symptom dimen- sions o f the target groups and o f the groups who ser~'e in evaluation studies.

It should be recognized that the literature on the behavioral control o f pain is showing increasing sophistication in evaluation studies. More frequently, one encounters outcome stud- ies that utilize measures o f multiple dimen- sions, such as improvement in mood, activity,

and sleep, in addition to verbal report of pain severity. This level o f sophistication would be welcome in studies of pharmacological relief o f pain. Unfortunately, many o f these same behav- ioral studies can still be faulted by the lack of careful description o f the dimensions of pain prominent in their groups, or by the evaluation of groups which show only modest levels o f these dimensions.

Thinking o f pain as a behavioral construct may also be of some use when trying to untan- gle its relationship with o ther behavioral con- structs, such as anxiety and depression. I have already stated that disturbed mood is viewed by most of us as a componen t of pain, at least o f pain which is of moderate to severe intensity. It is a common-place observation that anxiety often accompanies pain when it first occurs. Patients whose pain has become chronic often show symptoms of depression. Depression and anxiety often are manifest in tile same individ- ual, yet those who deal with these constructs are circumspect about saying that depress ion "causes" anxiety, or vice versa. Although it makes intuitive sense for a pa t ient to be depressed because he or she is anxious, there is ample evidence that anxiety can be present without depression. Similarly, one rarely hears argument about whether or not anxiety is really depression, or depression is really anxiety. To make such statements, one must assume that the constructs are identical, that they have little separate utility.

I f we pursue our idea o f pain as a construct, it suggests that we should be more cautious about stating that pain causes anxiety, or that pain causes depression. Although pain and these other constructs can occur together, they don' t do so by necessity. Stating causa l i ty . implies an unders tanding o f "pain" that we do not have, at least at this point in time. Further- more, arguments about whether or not pain (especially chronic pain) is really depression are bound to generate more heat than light.

I doubt that this abstract concept of pain as a behavioral construct will gain much currency. Those who work with persons in pain certainly don't think of themselves as dealing with an abstraction. But I hope that this exercise has been o f some use, if only to remind us of ou r relatively primitive unders tanding of what pain means, and the complexity of what we assess and treat.