Journal of Behavioral Medicine

, Volume 31, Issue 4, pp 309–317 | Cite as

Pain judgements of patients’ relatives: examining the use of social contract theory as theoretical framework

  • Judith Kappesser
  • Amanda C. de C. Williams


Observer underestimation of others’ pain was studied using a concept from evolutionary psychology: a cheater detection mechanism from social contract theory, applied to relatives and friends of chronic pain patients. 127 participants estimated characters’ pain intensity and fairness of behaviour after reading four vignettes describing characters suffering from pain. Four cues were systematically varied: the character continuing or stopping liked tasks; continuing or stopping disliked tasks; availability of medical evidence; and pain intensity as rated by characters. Results revealed that pain intensity and the two behavioural variables had an effect on pain estimates: high pain self-reports and stopping all tasks led to high pain estimates; pain was estimated to be lowest when characters stopped disliked but continued with liked tasks. This combination was also rated least fair. Results support the use of social contract theory as a theoretical framework to explore pain judgements.


Pain underestimation Pain judgements Significant others Vignettes Social contract theory Cheating detection mechanism 



This study is part of the first author’s PhD funded by the National German Merit Foundation. Authors wish to thank all participants, patients and staff at INPUT Pain Management Programme for their help and support, as well as to thank Raymond Tait for kindly providing original materials of vignette studies by himself and his colleagues.


  1. Chibnall, J. T., & Tait, R. C. (1995). Observer perception of low back pain: effects of pain report and other contextual factors. Journal of Applied Social Psychology, 25, 418–439. doi: 10.1111/j.1559-1816.1995.tb01597.x.CrossRefGoogle Scholar
  2. Chibnall, J. T., & Tait, R. C. (1999). Social and medical influences on attributions and evaluations of chronic pain. Psychology & Health, 14, 719–729. doi: 10.1080/08870449908410760.CrossRefGoogle Scholar
  3. Chibnall, J. T., Tait, R. C., & Ross, L. R. (1997). The effects of medical evidence and pain intensity on medical student judgements of chronic pain patients. Journal of Behavioral Medicine, 20, 257–271. doi: 10.1023/A:1025504827787.PubMedCrossRefGoogle Scholar
  4. Clark, J. A., Potter, D. A., & McKinlay, J. B. (1991). Bringing social structure back into clinical decision making. Social Science & Medicine, 32, 853–866. doi: 10.1016/0277-9536(91)90241-4.CrossRefGoogle Scholar
  5. Cosmides, L. (1989). The logic of social exchange: Has natural selection shaped how humans reason? Studies with the Wason selection task. Cognition, 31, 187–276. doi: 10.1016/0010-0277(89)90023-1.PubMedCrossRefGoogle Scholar
  6. Cosmides, L., & Tooby, J. (1992). Cognitive adaptations for social exchange. In J. H. Barkow, L. Cosmides, & J. Tooby (Eds.), The adapted mind: Evolutionary psychology and the generation of culture (pp. 163–228). Oxford: Oxford University Press.Google Scholar
  7. Cosmides, L., & Tooby, J. (2004). Knowing thyself: the evolutionary psychology of moral reasoning and moral sentiments. In R. E. Freeman, & P. Warhane (Eds.), Business, science, and ethics: The Ruffing series (pp. 91–127). Charlottesville, VA: Society for Business Ethics.Google Scholar
  8. Craig, K. D., Hill, M. L., & McMurtry, B. W. (1999). Detecting deception and malingering. In A. R. Block, & E. F. Kremer (Eds.), Handbook of pain syndromes: biopsychosocial perspectives (pp. 41–58). Mahwah, NJ: Lawrence Erlbaum.Google Scholar
  9. Craig, K. D., Prkachin, K. M., & Grunau, R. E. (2001). The facial expression of pain. In D. C. Turk, & R. Melzack (Eds.), Handbook of pain assessment (pp. 153–169). New York: Guilford Press.Google Scholar
  10. Cremeans-Smith, J. K., Stephens, M. A. P., & Franks, M. M., et al. (2003). Spouses’ and physicians’ perceptions of pain severity in older women with osteoarthritis: dyadic agreement and patients’ well-being. Pain, 106, 27–34. doi: 10.1016/S0304-3959(03)00268-9.PubMedCrossRefGoogle Scholar
  11. Dudley, S. R., & Holm, K. (1984). Assessment of the pain experience in relation to selected nurse characteristics. Pain, 18, 179–186. doi: 10.1016/0304-3959(84)90885-6.PubMedCrossRefGoogle Scholar
  12. Eisenberg, J. M. (1979). Sociologic influences on decision-making by clinicians. Annals of Internal Medicine, 90, 957–964.PubMedGoogle Scholar
  13. Everett, J. J., Patterson, D. R., & Marvin, J. A., et al. (1994). Pain assessment from patients with burns and their nurses. Journal of Burn Care & Rehabilitation, 15, 194–198. doi: 10.1097/00004630-199403000-00018.CrossRefGoogle Scholar
  14. Gigerenzer, G. (2000). Adaptive thinking. Rationality in the real world. New York: Oxford University Press.Google Scholar
  15. Gigerenzer, G., & Hug, K. (1992). Domain-specific reasoning: Social contracts, cheating, and perspective change. Cognition, 43, 127–171. doi: 10.1016/0010-0277(92)90060-U.PubMedCrossRefGoogle Scholar
  16. Gillmore, M. R., & Hill, C. T. (1981). Reactions to patients who complain of pain: effects of ambiguous diagnosis. Journal of Applied Social Psychology, 11, 14–22. doi: 10.1111/j.1559-1816.1981.tb00819.x.CrossRefGoogle Scholar
  17. Hadjistavropoulos, H. D., Ross, M., & von Baeyer, C. (1990). Are physicians’ ratings of pain affected by patients’ physical attractiveness?. Social Science & Medicine, 31, 69–72. doi: 10.1016/0277-9536(90)90011-G.CrossRefGoogle Scholar
  18. Hadjistavropoulos, T., LaChapelle, D., & Hale, C., et al. (2000). Age- and appearance-related stereotypes about patients undergoing a painful medical procedure. The Pain Clinic, 12, 25–33. doi: 10.1163/156856900750228060.CrossRefGoogle Scholar
  19. Hadjistavropoulos, T., McMurtry, B., & Craig, K. D. (1996). Beautiful faces in pain: biases and accuracy in the perception of pain. Psychology & Health, 11, 411–420. doi: 10.1080/08870449608400268.CrossRefGoogle Scholar
  20. Halfens, R., Evers, G., & Abu-Saad, H. (1990). Determinants of pain assessment by nurses. International Journal of Nursing Studies, 27, 43–49. doi: 10.1016/0020-7489(90)90022-B.PubMedCrossRefGoogle Scholar
  21. Halligan, P., Bass, C., & Oakley, D. (2003). Malingering and illness deception. Oxford: Oxford University Press.Google Scholar
  22. Hamers, J. P. H., van den Hout, M. A., Halfens, R. J. G., Huijer Abu-Saad, H., & Heijltjes, A. E. G. (1997). Differences in pain assessment and decisions regarding the administration of analgesics between novices, intermediates and experts in pediatric nursing. International Journal of Nursing Studies, 34, 325–334. doi: 10.1016/S0020-7489(97)00024-2.PubMedCrossRefGoogle Scholar
  23. Idvall, E., & Brudin, L. (2005). Do health care professionals underestimate severe pain more often than mild pain? Statistical pifalls using a data simulation model? Journal of Evaluation in Clinical Practice, 11, 438–443. doi: 10.1111/j.1365-2753.2005.00554.x.PubMedCrossRefGoogle Scholar
  24. Jensen, M. P., & Karoly, P. (2001). Self-report scales and procedures for assessing pain in adults. In D. C. Turk, & R. Melzack (Eds.), Handbook of pain assessment (pp. 15–34). New York: Guilford Press.Google Scholar
  25. Kappesser, J., Williams, A. C. d. C., & Prkachin, K. M. (2006). Testing two accounts of pain underestimation. Pain, 124, 109–116. doi: 10.1016/j.pain.2006.04.003.PubMedCrossRefGoogle Scholar
  26. Krokosky, N. J., & Reardon, R. C. (1989). The accuracy of nurses’ and doctors’ perceptions of patient pain. In S. G. Funk, E. M. Tornquist, M. T. Champagne, L. A. Cropp, & R. A. Wiese (Eds.), Key aspects of comfort: management of pain, fatigue and nausea (pp. 127–134). New York: Springer.Google Scholar
  27. Lenburg, C. B., Glass, H. P., & Davitz, L. J. (1970). Inferences of physical pain and psychological distress. II. In the relation to the stage of the patient’s illness and occupation of the perceiver. Nursing Research, 19, 392–398.PubMedGoogle Scholar
  28. Madison, J. L., & Wilkie, D. J. (1995). Family members’ perceptions of cancer pain. Comparisons with patient sensory report and by patient psychologic status. Nursing Clinics of North America, 30, 625–645.PubMedGoogle Scholar
  29. Mason, D. J. (1981). An investigation of the influences of selected factors on nurses’ inferences of patient suffering. International Journal of Nursing Studies, 18, 251–259. doi: 10.1016/0020-7489(81)90038-9.PubMedCrossRefGoogle Scholar
  30. Miaskowski, C., Zimmer, E. F., Barrett, K. M., Dibble, S. L., & Walhagen, M. (1997). Differences in patients’ and family caregivers’ perceptions of the pain experience influence patient and caregiver outcomes. Pain, 72, 217–226. doi: 10.1016/S0304-3959(97)00037-7.PubMedCrossRefGoogle Scholar
  31. Newton-John, T. R. O., & Williams A. C. de C. (2006). Chronic pain couples: perceived marital interactions and pain behaviours. Pain, 123, 53–63. doi: 10.1016/j.pain.2006.02.009.PubMedCrossRefGoogle Scholar
  32. Oberst, M. T. (1978). Nurses’ inferences of suffering: the effects of nurse-patient similarity and verbalisations of distress. In M. J. Nelson (Ed.), Clinical perspectives in nursing research (pp. 38–60). New York: Teachers College Press.Google Scholar
  33. Perry, S., & Heidrich, G. (1982). Management of pain during debridement: a survey of U. S. burn units. Pain, 13, 267–280. doi: 10.1016/0304-3959(82)90016-1.PubMedCrossRefGoogle Scholar
  34. Poole, G., & Craig, K. D. (1992). Judgements of genuine, suppressed, and faked facial expressions of pain. Journal of Personality and Social Psychology, 5, 797–805. doi: 10.1037/0022-3514.63.5.797.CrossRefGoogle Scholar
  35. Riemsma, R. P., Taal, E., & Rasker, J. J. (2000). Perceptions about perceived functional disabilities and pain of people with rheumatoid arthritis: differences between patients and their spouses and correlates with well-being. Arthritis Care Research, 13, 255–261. doi: 10.1002/1529-0131(200010)13:5≤255::AID-ANR3≥3.0.CO;2-3.CrossRefGoogle Scholar
  36. Tait, R. C., & Chibnall, J. T. (1997). Physician judgement of chronic pain patients. Social Science & Medicine, 45, 1199–1205. doi: 10.1016/S0277-9536(97)00033-6.CrossRefGoogle Scholar
  37. Taylor, A. G., Skelton, J. A., & Butcher, J. (1984). Duration of pain condition and physical pathology as determinants of nurses’ assessments of patients in pain. Nursing Research, 33, 4–8. doi: 10.1097/00006199-198401000-00002.PubMedCrossRefGoogle Scholar
  38. van der Does, A. J. W. (1989). Patients’ and nurses’ ratings of pain and anxiety during burn wound care. Pain, 39, 95–101. doi: 10.1016/0304-3959(89)90179-6.PubMedCrossRefGoogle Scholar
  39. Wilkinson, G. S. (1990). Food sharing in vampire bats. Scientific American, 262, 76–82.CrossRefGoogle Scholar
  40. Williams, A. C. d. C. (2002). Facial expression of pain: an evolutionary account. Behavioral and Brain Sciences 25, 439–488. doi: 10.1017/S0140525X02000080.PubMedGoogle Scholar
  41. Zalon, M. L. (1993). Nurses’ assessment of postoperative patients’ pain. Pain, 54, 329–334. doi: 10.1016/0304-3959(93)90033-L.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Institute of PsychologyJohannes-Gutenberg UniversityMainzGermany
  2. 2.University College LondonLondonUK

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