Focus

The Facial Expression

Better Than a Thousand Kenneth D. Craig Words?

of Pain

A diverse pattern of verbal and nonverbal activity communicates distress to others and permits inferences about the nature and severity of pain. The professional and scientific literature have focused heavily upon self-report measures, despite known limitations, with the potential benefits of nonverbal measures, and the important role of nonverbal communication, left relatively unexamined. Successes in objective description of a relatively specific facial reaction during painful events are described for both adults and infants. Detailed coding of facial activity provides a mechanism for understanding biological, behavioral, cognitive, and social parameters of pain that self-report measures do not address. Facial activity appears to be the most consistent expression of pain in infants. Age-specific patterns are described. In both clinical and nonclinical settings, observers often attach greater credibility to nonverbal expression than to self-report. Key words: measurement, facial expression, nonverbal measures, self-report, infant pain, social judgment

guistic vocalizations, including voice qualities, crying, or moaning. These diverse reactions communicate distress to others and allow observers to make inferences about the presence of pain. In their absence, pain remains a wholly private experience and quite incomprehensible to the observer, no matter how poignant and severe it may be for the sufferer.

PAIN ASSESSMENT TASK

AS A JUDGMENTAL

he onset of pain from traumatic injury and disease, or aggravation of these states, usually provokes vigorous activity. The observer may witness at that moment, and for a period thereafter, nociceptive reflexes, physical efforts to withdraw from the source of trauma, protective or guarded movements and postures, and a characteristic pattern of facial wincing or grimaces. In the domain of vocalizations, speech may be observed, if the circumstances are appropriate, as well as paralin-

From the Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada. Reprint requests: Kenneth D. Craig, PhD, Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada V6T 124.

The task confronting the observer is complex. While actions and words represent immediate means of understanding another persons distress, the observers judgment also may incorporate other information, including evidence of tissue damage or physiological stress and knowledge of the persons health history and culture. The task is further compounded by the fact that all measures of pain represent diminished echoes of the experience itself and vary in fidelity to what may be an agonizing reality. The contributions of nonverbal behavior to the complex judgmental task have only recently attracted systematicattention by professionals and scientists interested in pain, l4 with the behavioral orientation to pain particularly directing concerted attention.26l43 The term systematic is used advisedly because the deficiency largely appears specific to the clinical and scientific literature. Both professionals and nonclinicians attending to the needs of people in pain always have attached considerable importance to the role of nonverbal signs of physical distress. Most people intuitively appreciate ShakeTheres no art to find the speares conclusion, minds construction in the face (Shakespeare W: Macbeth. Act I; Scene 4). Sensitivity to nonverbal behavior is essential for astute physical examinations. For instance, Johnson3 noted that clinicians as153

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signed greater importance to nonverbal expression than to self-report when judging the severity of patient pain. Similarly, Rosentha17* reported that physicians believed they could determine the location of pain more accurately through nonverbal pain expressions than through use of verbal information. In the everyday environment, it is the full complex of displays of distress that convey sensations, thoughts, and feelings and evoke empathic reactions.7 Clarification of the often intuitive use of nonverbal expression, facial activity in particular, is the focus of this paper.

SELF-REPORT

IN PAIN ASSESSMENT

In contrast to the apparent importance of nonverbal evidence in judgments of pain in clinical and everyday settings, self-report has been emphasized by investigators and writers and enjoys preponderant attention as the source of information about pain suffered by patients. The vast majority of research papers on pain devote themselves exclusively to verbal measures. Self-report often has been characterized as the gold standard for measuring pain, ostensibly because it provides access to subjective perception of pain (e.g., reference 50) and its use is feasible for the great majority of investigations.66 There has been a tradition of enjoining clinicians to assign particular importance to a patients self-report. For example, Meinhart and McCaffery57 state, The patients verbal report is the only way to determine the presence, intensity, and quality of pain. . . Gracely26 asserts that a stimulus only hurts when a human says it hurts. An example of the devotion to self-report measures would be the recent volume on The Design of Analgesic Clinical Triak5 This volume almost exclusively reports verbal measures (with few, passing, exceptions, e.g., chapters by Deyo, Fricton, and Max) and notes that nurse-observers are trained to accept the patients verbal reports of pain, suggesting important information may be missed in these investigations. The dependence on self-report derives from the belief that language permits direct access to subjective experiences, the usefulness of self-report in conveying the complexities of experience, and the need to have retrospective accounts of events. As well, speech is a fundamental source of communication in everyday social discourse. Methodological convenience undoubtedly contributes also. Collecting and using nonverbal information is a more complex and difficult task than asking for self-report. The numerous limitations of verbal report are often neglected. Many problems derive from the as-

sumption that self-report is equivalent to the subjective experience of pain itself. Self-report cannot wholly translate qualities of subjective experiences, as thoughts, feelings ,and images comingle, change rapidly, and may be incoherent. Gracely26 effectively summarizes critics of the subjective nature of verbal report by noting they are concerned by the presence of reporting biases. , by the modulation of verbal judgment by an individuals need to maximize or minimize suffering, by the external demand characteristic of the situation , and by variability (p. 211) in memory and verbal ability. Thus, pain selfreport is determined by far more than the subjective experience of pain alone and cannot be accepted as isomorphic to the experience. Careful planning of investigations (e.g., standardized measures, doubleblind crossover designs, and balanced placebo controls) and multiple convergent and divergent measures can compensate for some of these limitations. A promising alternative to self-report of pain and direct observation of behavior has been the use of disability measures or the report of interference with life activities.4,5

NONVERBAL ASSESSMENT

EXPRESSION

IN PAIN

Nonverbal expression of pain can vary with self-report in several ways, outlined below. 1. Nonverbal expression can complement self-report. Despite its limitations, when used properly, selfreport can be a sensitive, reliable, and valid focus for the investigator and can be consistent with nonverbal evidence concerning the nature of the persons distress. But, even in this case, nonverbal information provides collateral and confirmatory information. Self-report in the absence of, or contradicted by, nonverbal evidence of pain loses its credibiIity.64 2. Nonverbal expression may be discordant with self-report. For a proportion of people presenting with pain, different channels of information do not agree. Reports of acute and severe distress may be contradicted by a dispassionate manner, or displays of agony may be accompanied by denials of discomfort. Similarly, behavioral signs and symptoms of pain may not conform in pattern or time to expectations based upon an understanding of specific pathophysiological processes.70,75 Discordant information challenges those who must make decisions affecting the well-being of the person in pain. In most social situations, discrepancies between different communication channels signal a probability of concealment or deception. 78 As well, verbal behavior is more likely to be discounted than nonverbal behavior

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when they are inconsi.stent.34 This probably reflects an intuitive recognition that people self-monitor and control verbal activity to a greater extent than nonverbal activity, although attention certainly can be directed to bodily activitye6 Moinpour et al.5g noted that disagreement between a childs self-report rating of pain and an observers judgment often leads to the conclusion that the child is providing an inaccurate assessment. McGrath54 points out that discordance among measures of pain dictates further assessment. 3. Nonverbal information may replace verbal report in some cases. Certain people are unable to provide self-report, although the need to understand whether pain is being experienced may be urgent. Those never able to communicate their distress verbally include very young children, the seriously mentally handicapped, and people with language deficits or speech disabilities. In Margaret Meads preface to perhaps the best qualitative descriptions of patient behavior during pain, Zborowskis account of what people do and say about their pain experience, she notes that the response to pain can be so sharp, so unmistakable, so immediate, that members of any culture can recognize, empathize, or identify with another human in pain. Situational factors also may contribute to an absence of self-report. Adults and children awakening from general anesthetics during postoperative recovery fall in this category. Voluntary refusal to report pain, possibly through fear of the consequences of the report, or clear manipulation of self-report so as to lose credibility, again lead to heavy dependence on nonverbal expression.

relatively specific facial reaction pattern during painful events and investigations of the manner in which observers decode and assign meaning to nonverbal expression of pain, including the usefulness and relative importance of various channels of communication. These areas of research are described below.

THE STRUCTURE OF THE FACIAL EXPRESSION OF PAIN

Most people believe they can distinguish the facial expression of pain. They can discriminate facial expressions of pain from various emotional states3 and identify the degree of suffering.67l74 Undoubtedly, people use this information to deliver care successfully in both clinical settings and everyday environments. Surprisingly, however, informal efforts to describe facial expressions of pain have been inaccurate, failing to conform to systematic descriptions. This is the case for influential historical and contemporary accounts. Certain features of Charles Darwins 1872 description were in error. Thus, he suggested that in pain I. . . the mouth may be closely compressed, or more commonly the lips are retracted, with the teeth clenched or ground together. . . .I and I. . . the eyes stare in horrified astonishment, facial actions that are rarely observed and contrary to those that tend to be seen, such as narrowed or closed eyes and open lips or a dropped jaw.15 Similarly, several current rating scales provide behavioral definitions of facial grimaces of pain that include improbable movements. There are problems with descriptions referring to tightened lips, corners of mouth pulled back, and clenched teeth,14* bites lips, grits teeth, pulls back corners of mouth,25 clenched teeth,56 or clenched teeth, tightly shut lips, widely opened eyes, wrinkled forehead, biting of lower lip. These atypical actions may be confused with those that are seen because the former are occasionally (but rarely) seen with concomitant attentional (e.g., eyes wide open, as in surprise), emotional (e.g., clenched teeth, as in anger), or coping (biting of lower lip) states. As well, actions actually prominent in the facial display of pain, as described below, tend to omitted. Coders successful use of these scales probably depends upon intuitive appreciation of what actually constitutes a facial expression of pain rather than the behavioral definitions used to train them. The development of an objective, comprehensive, and anatomically based coding system, along with availability of recording and playback equipment, has permitted description of facial activity in terms of its actual components. The Facial Action Coding

FACIAL

ACTIVITY

IN PAIN

ASSESSMENT

Facial activity is demonstrably of great importance to observers in most life settings. Different communication channels can be characterized by their visibility, operating speed, and plasticity or the potential variety of different patterns that can be displayed.* Facial displays almost invariably can be seen and ordinarily change rapidly, and a remarkable range of different actions can be observed. These convey a broad range of information about the persons emotions, dispositions, intentions, and motives, thoughts. The usefulness of facial expression is appreciated at least intuitively by virtually all people. Deficiencies in reading others facial expressions can lead to grievous errors of social judgment. Accelerating attention has been recently devoted to the role of facial expression during painful events. There have been successes in objective description of a

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System (FACS) emerged from fine-grained measurement of emotional expression,* but its descriptive, theoretically neutral basis has made it strikingly useful and successful in pain research. FACS requires no preconceptions or subjective attributions in its use, hence it can be used to describe the face, and biological, intrapersonal, social, or situational correlates can be examined readily. It requires coders trained to a high degree of proficiency to examine videotaped or filmed facial reactions and to identify 44 specific facial actions and their temporal relationships, using very explicit coding criteria. Most facial actions also are subject to intensity coding due to variations in the strength with which they occur. Reported intercoder reliabilities in studies of the facial expression of pain have consistently been satisfactory.4g,6g

Adult

Facial

Expressions

of Pain

Initial studies sought to discover whether a relatively invariant subset of facial actions would permit a simple characterization of a prototypical facial grimace of pain. The reality was more complex.47,13 While a limited subset of facial actions usually is sufficient to describe the facial expression during acute phasic pain, the pattern appears to vary with the severity of distress and the type of pain being experienced, as well as with a range of individual difference and situational factors that have not yet been fully explained.15 To date, the majority of studies have examined intense, transitory pain (as instigated by invasive medical procedures, exacerbation of persistent clinical pain, or induced experimental pain), and chronic pain states need to be examined. Wilkie reported that FACS coding of the facial expressions of patients with lung cancer-related pain who were engaged in standardized activities of daily living indicated that their faces remained relatively quiescent. The fully involved facial display during short, sharp pain includes lowering the brow, fully closing the eyes or, more often, substantially narrowing them by tightening the lids and raising the cheeks, raising the upper lip and deepening the nasolabial fold, the cleft between the corners of the nostrils and the outer limits of the lips, and opening the lips and mouth in varying degrees. Separate studies do not always agree as to defining characteristics of the facial expression of pain as they vary in whether additional, relatively rare, specific actions were associated with pain (e.g. horizontally stretching the lips, oblique pulling at the corner of the lips, vertically stretching the mouth open, wrinkling the nose, drooping the eyelids). Temporal relationships among facial ac-

tions are also important. 4g Facial actions that are contiguous provoke judgments of more severe pain.46 LeResche and Dworkin4 propose that eye narrowing or closure and brow lowering provide the defining criteria for pain, but only when certain other facial actions are absent, as the latter could signal different subjective states (e.g., lip corners pulled horizontally often signal a pleasurable smile). Prkachin and Mercer6g have proposed that brow lowering and narrowing of eyes signal the probability that physical discomfort has surpassed some personal threshold of pain. Other specific facial actions and more intense expression of these actions become recruited as discomfort progresses toward and beyond tolerance levels, supporting the position that the severity of pain is encoded in the face. Prkachin66 reports consistency in the facial expression across different types of experimentally induced pain. Pictorial representations of the facial expression of pain usually depict a number of pain-associated facial actions, but the reality of observing people experiencing pain is different. One tends to observe segments of the broad pattern, with some individuals providing only glimpses in the form of microexpressions. It cannot be concluded that this full pattern of facial display must be observed for pain to be present. The validity of the measure has been demonstrated several ways. The magnitude of facial involvement is moderately correlated with the severity of pain reported. Patrick et al.61 reported that in over 30 subjects receiving painful electric shocks, the mean multiple correlation of the relationship between selfreported pain severity and the facial actions associated with pain was .43 (range, .28-55). The relationship between self-report of induced low back pain in chronic patients and facial activity ranged between .30 and .34. LeResche and Dworkin4g found moderate positive correlations among different self-report measures of pain resulting from palpation of the mastication muscles and temporomandibular joint in temporomandibular dysfunction patients and characteristics of the facial expression of pain. The relationship was strongest between facial expression measures and the affective components of self-report For example, the McGill Pain Questionnaire measure of affective distress correlated r = .69 with the duration of the pain expression. Prkachin and MercerO reported moderate (e.g., r = ,551) to strong (r = .71) univariate correlations between individual facial actions (e.g., cheek raising or mouth activity) and ratings of both sensory and affective qualities of pain in patients suffering from shoulder pathology. In general, the moderately strong relationship between

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subjective report and facial activity suggests the latter has concurrent validity insofar as it reflects the self-report of pain, but the far from complete relationship also indicates that there are other important determinants of the facial expression of pain. They would not serve as surrogates for the other and are probably under the control of different situational parameters and reinforcing events.26.43 One can also differentiate the expression of pain from other concurrent subjective states. LeResche47 compared objective descriptions of the facial activity in candid photographs of adults experiencing acute pain with descriptions of various emotional states. The pain display shared some common elements with the facial expressions of fear, anger, and sadness, but the overlap was minimal. LeResche and Dworkin4g found no relationship between self-report measures of anxiety and depression and measures of the facial expression of pain, although these were related to the self-report measures of pain. They concluded that pain facial expression uniquely taps relatively specific qualities of the pain experience, rather than other states of psychological distress. It is noteworthy that the relative specificity of facial expressions to particular emotional states provides a means of examining relationships between and interactions among pain and emotions. For example, LeResche and Dworkin4g observed that pain report and facial expression were greater for persons showing a greater number of different negative affects. Pain facial displays are subject to considerable personal control. Chronic low back pain patients enjoyed considerable success in either faking an expression of pain or suppressing the facial display in response to a request that they do so for research purposes. The faked reactions were very similar to the genuine reactions in terms of the specific facial action units observed, but the faked display appeared to be dramatized, or to represent more of an intensified caricature of the prototype of spontaneous expression than the genuine expression itself, although untrained judges do not treat the expressions as absurd.64 Efforts to suppress the pain display led to successful inhibition of most actions except for residual tension around the eyes. One cannot conclude that the facial expression of pain is invariably a spontaneous, reflexive manifestation of distress. It can be suppressed or enacted, perhaps as an attempt at purposeful control, or as an unintentional but well-learned habitual reaction to the situation. The facial response to painful events varies with the situation.68,44 In this sense, the facial grimace of pain may resemble smiling. This also is universally interpreted to reflect a subjective state,

pleasure in this instance, but it can become ritualized, even devoid of pleasure, and is highly subject to deliberate management.22 There would appear to be adaptive utility to being able to dissemble certain subjective states and to attenuate what are usually taken as involuntary, reflexive behavior for reasons of deception, economy, and privacy.27 Through observational learning and self-modeling7 people have ample opportunity to learn the particulars of facial displays and the cultural display rules and may come to perceive that a situation is best controlled through a smile, or an expression of distress, and react accordingly. Despite the impact of socialization and voluntary control, in the first instance the facial display of pain is innate, stereotyped, and reflexive.

Childrens

Facial

Expression

of Pain

The usefulness of fine-grained measurement of facial expression during adult pain led to exploration of pain in a population from whom self-report of pain is never available, young children and infants. The challenge of measuring pain in children has long been recognized as a serious problem, with the vulnerability of children to stress resulting from pain, and evidence of neglect and underutilization of available potent analgesics, adding to the urgency of discovering age-specific measures.6,54,56,73 Children ordinarily react vigorously to physical trauma,41 although there is considerable variability in the reaction pattern and the specificity of the complex behavioral response to pain and various emotional states often remains ambiguous. Detailed behavioral coding systems allow observation of the progressive development of different patterns of response. For example, Craig et al.* were able to characterize infants reactions to an invasive procedure, immunization injections, as developing from a pattern in the first year of life that was spontaneous and diffusing to one that included anticipatory reactions, descriptive language, and goal-directed movement in the second year of life. Facial expression appears to be the most consistent response to pain in infants.40 Facial activity is meaningful and salient from the first stages of life. Newborns display diverse facial expressions that appear to be specific to particular emotional states and adults derive important information from observing them.45 Within the first days of life infants also are able to discriminate and imitate adult facial expressions.23 There are ample opportunities in pediatric care settings to observe pain from injuries and diseases unobtrusively, and painful diag-

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treatment, and prophylactic procedures often must be used. An unobtrusive observational coding instrument was developed to study facial expression in the infant.2g~30 It was based upon, but had to differ from, FACS for several reasons. Anatomical differences between babies, older children, and adults necessitate adaptation of FACS when studying infants (Oster and Rosenstein, 1982, unpublished manuscript). As well, our studies with adults suggested that a substantially reduced number of facial actions might be sufficient to capture the facial display when infants sustain tissue damage. The Neonatal Facial Coding System (NFCS)2g.30 comprises 10 facial actions that trained coders can identify through study of videotaped facial activity using explicit coding criteria. A facial expression relatively specific to pain appears to have emerged. Investigators using the measure primarily have examined the immediate response to invasive procedures, for example, heel lancing,2g,52 h ypodermic syringe injections,32,40 finger sticks, and venipuncture.64 These studies have indicated that brow lowering, tightly closed eyes, deepening of the nasolabial cleft, opening the mouth in varying degrees, and a taut, cupped tongue represent the infants response to the sudden onset of invasive procedures. Study of longer-term pain, for example, postoperative pain and cancer pain, appears in order. Barr et al. found the system descriptive of the facial behavior of infants satisfying stringent criteria for colic when they engaged in problematic crying prior to feeding. Thus, the coding systems usefulness appears to extend to the apparent exacerbation of recurrent pain in the infant. One can also identify states incompatible with pain. Tongue protrusion, perhaps reflecting rooting and anticipatory feeding behavior, is associated with innocuous cutaneous stimulation.32 While the infant reaction pattern strongly resembles that of the adult, evidence that confirms the painful nature of the experience for most observers, certain differences are noteworthy as they suggest differences in the qualitative response. In particular, infants squeeze their eyes shut, whereas adults keep theirs open, albeit narrowed. This is consistent with the adult capacity to engage in escape or protective behavior and the infants inability to cognize the meaning of the situation and the limited protection afforded by closing the eyes. It is noteworthy that the pattern of facial response to painful events in infants appears more stereotyped than the reaction pattern in adults. The broad range of individual differences observed in adults has not been so extensive in infants. This suggests the shapnostic,

ing effects of experience on pain expression in older children and adults7 and the role of display rules in everyday social intercourse.ls However, individual differences in pain expression certainly are present in young children. Grunau and Craig2 observed that the severity of distress is reflected in the facial expression. Neonates asleep at the time of a heel lance were less responsive than infants who had been awake. Most responsive were infants who were awake and alert, but not active at the time of the lance. Infants also vary in the overall magnitude of the facial reaction, as do adults. Craig et al. had little difficulty selecting for further study infants who were either quite unresponsive or responsive to heel lancing. Perinatal factors (maternal obstetric medication, difficulty of the birth) also are related to these individual differences in the neonate.31 Other situational and temperamental factors deserve study. The measure has potential as a criterion measure for outcome trials of pharmaceutical and nonpharmaceutical analgesic interventions. For example, using facial activity as a criterion measure, McCrory52 found that a combined auditory/proprioceptive stimulation procedure was effective in reducing pain for newborns during the heel lance procedure. Developmental changes in the pattern of pain expression in children impose special demands on the parent or clinician confronted with the need to assess the presence and severity of pain accurately. Two studies now demonstrate systematic variations in the facial display of pain during the earliest stages of life, one contrasting preterm neonates of varying gestational age and full-term neonates, the other contrasting preterm neonates, full-term neonates, and infants 2 and 4 months of age. Craig et al.16 examined the facial reactions of 59 newborns ranging between 25 and 41 weeks gestational age using the NFCS during the heel lance procedure. The constellation of facial actions was responsive to the heel stick, even in the preterm infants, but the vigour of the response was positively correlated with gestational age. Johnson et al.40 similarly examined facial activity in preterm and full-term newborns, as well as 2- and 4-month-old infants. They found differences specific to age, including a decline in facial activity in the 2- to 4-month-olds, consistent with the position that as caretakers learn to read their own infants communicative signals of facial activity and crying, robust facial activities become less necessary. It appears clear that age-specific normative standards will be necessary to judge pain in very young children. Systematic variation in the magnitude of response specific to age lead one to question whether this re-

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fleets differences in the severity of pain being experienced. Do preterm infants become progressively more capable of experiencing pain, with pain during infancy at its peak during the neonatal period, then abating during succeeding months? Both empirical and logical considerations dictate the contrary. Fitzgerald et al.24 concluded that the preterm infant is, if anything, supersensitive to painful stimuli when compared with the full term infant (p. 442). They had observed that preterm infants subjected to point pressure on the skin in damaged tissue adjacent to wounds on the heel resulting from lancing displayed shorter latencies and more substantial flexion withdrawal reflexes than fullterm infants. It appears that infants suffer deficits in the capacity to communicate distress rather than a deficit in the capacity to experience pain. Biological immaturity includes inadequate development of the systems needed to signal physical distress to parents and other caretakers. Musculoskeletal and voice systems require differentiation and strength and are dependent upon metabolic resources that are particularly rapidly depleted in preterm infants. This expressive or encoding deficit deprives adults of the opportunity to fully comprehend pain in the infant. Pain measures that are suited to the very limited expressive capabilities of the infant must be constructed. Izard35 has developed a different coding system, the maximally discriminative facial movement coding system (MAX), that has provided valuable information on the emotional contexts of pain. Preconceived discrete emotional expressions, including anger, fear, surprise, and joy, as well as pain, are identified through scanning the face. During infancy, the early pattern of facial response to immunization injections predominantly suggests pain, but around 6 to 8 months the pattern becomes one of anticipatory fear prior to the injection, pain following the needle stick, and anger thereafter. The pain response decreases with age, whereas the anger response increases, such that the latter is the dominant pattern by 19 months.36*38 Individual differences were apparent on the infants faces: those who were slow to be soothed showed significantly more anger, while those who were soothed more quickly showed less physical distress3

OBSERVER SENSITIVITY EXPRESSION OF PAIN

TO FACIAL

While considerable information about painful experiences may be encoded in the face, the manner in which this information is decoded and used by observers remains uncertain. Assessors bring different

skills and judgmental strategies to the task and can be expected to be variably sensitive to particular cues and to attach varying meanings and importance to them. The specific facial actions associated with pain identified above appear to be salient and important in judgments of pain in both adults and children. Untrained judges assigned the task of rating pain while viewing videotapes use the facial cues. Patrick et aL60 reported a mean multiple correlation of .74 between the complex of facial actions associated with pain and untrained judges ratings of the severity of pain being experienced. The use of infant facial activity is of comparable magnitude. Adults estimates of the affective discomfort infants were experiencing as a result of the heel lance procedure had a mean multiple correlation of .70 with key NFCS facial actions.g The relative importance of facial activity and crying in adult judgments of pain in infants also has been examined. Craig et al.g found that both facial activity and cry pitch were related to adult judgments of infant pain, but the former was more strongly related to variations in the judgments. Craig et al.O found that adult judgments of pain in babies were more reliable when the adults had access to facial activity as well as crying, and that the facial activity contributed more to variation in the judgments than did crying. Crying is probably most important in attracting the attention of adults; it serves as a distant early warning device. When attention is grasped, more information as to the nature of the distress appears to be derived from infant facial expression. Of interest is the ability of judges to identify the severity of pain being experienced when people attempt to suppress pain behavior or to fake pain when it is not present. Poole and Craig64 had untrained judges rate the severity of pain being experienced by chronic low back pain patients when the subjects viewed videotapes of either spontaneous reactions to painful movements, attempts to inhibit expressions of distress to these same movements, or faked expressions of pain to a nonpainful movement. The patients were strikingly, but not wholly, successful in fooling the judges. They consistently attributed more pain to faked faces than to those that were genuine and less pain to the suppressed reactions, although they still discerned some pain. Untrained patients were more successful at feigning pain than judges were at identifying faked pain. This asymmetry may be balanced by the severity with which judges act when they believe a patient is malingering. Keefe and efforts to Dunsmore observe that: Conscious communicate pain through guarded movements, fa-

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cial expressions, or extreme ratings of pain upset and even enrage clinicians. Ekman and Friesen have observed that facial activity is more subject to purposeful dissimulation than other nonverbal channels and recommend that observers interested in detecting deception pay careful attention to behavioral activity below the head. Poole and Craig64 reported the impact on judgments of pain of combinations of verbal report and facial activity. Patient acknowledgment or denial of pain affected ratings based upon facial activity, as would be expected, but facial activity was the more salient source of information. For example, substantial pain was reported if there was a facial display of pain, even if pain was denied, but relatively low levels of pain were reported if there were a verbal report of pain, but a relatively neutral facial expression. Studies of judgments of facial expressions also permit analysis of the preconceptions and predispositions of the observer. For example, Hadjistavropoulos, Ross, and von Baeyer33 found that physicians incorporated physical appearance in their judgments of pain, consistent with general findings that on the basis of information about physical attractiveness alone, people make strong assumptions about others personalities and health. When viewing facial expressions, more attractive patients were judged by physicians to be experiencing less pain, to be more healthy, and to need less help, irrespective of the actual severity of pain being experienced.

CONCLUSION
The title of this paper pits facial expression against self-report as sources of information about the nature and severity of pain another person is experiencing. The comparison is probably inappropriate, as both provide important and often different information about the persons pain. When sources of confound and bias are properly controlled, self-report serves as a valuable index of the subjective experience of pain. Without verbal communication, the observer would have to have personal, visual contact, and accounts of episodes of pain would not be available after the fact. There certainly is no substitute when retrospective reports are required. Nevertheless, there has been an imbalance of attention devoted to self-report in the literature on pain, failure to consider use of nonverbal measures when they would prove valuable, and neglect of the important role of nonverbal communications in both clinical settings and the natural environment. In both clinical and everyday settings judges usually attach greater credence to nonverbal expression than to

self-report. Facial display and other nonverbal behavior are probably more successful in convincing somebody else that genuine pain is being experienced than are words. In this sense, people commonly assign greater credibility to facial expressions than they do to words, or, to use another old adage, Actions speak louder than words. Nonverbal expression, facial display in particular, can serve unique, important purposes. It permits relatively unobtrusive study of the individual. It is available in many circumstances when self-report is not available. Facial expressions may be more specific to the experience of pain, with self-report more subject to confound from nonpainful states of affective distress. The perspective presented here conceptualizes measures of both verbal and nonverbal behavior as permitting inferences of varying degrees of validity about related, but often different, features of the complex processes of pain. Different variables may control different measures. The social ramifications of activity in the different channels of communication differ. In many ways, the use of nonverbal information in clinical assessments remains at the level of development of self-report when clinicians would depend upon casual queries concerning whether pain was being experienced. The use of self-report in clinical and research settings has improved dramatically as a result of systematic attention to these limitations. The deficiency lies in the relatively undeveloped state on nonverbal measures. It seems likely that devoting comparable attention to nonverbal measures would yield comparable benefits.

Acknowledgments

Supported by grants from the Social Sciences and Humanities Research Council and the Natural Sciences and Engineering Research Council of Canada.

References
1. Abu-Saad H: Assessing childrens responses to pain. Pain 19:163-171, 1984 2. Barr RG, Rotman A, Yaremko J et al: The crying of infants with colic: a controlled empirical description. Pediatrics (in press) 3. Boucher JD: Facial displays of fear, sadness and pain. Percep Mot Skills 28;239-242, 1969 4. Bradley LA: Assessing the psychological profile of the chronic pain patient. pp. 251-262. In Dubner R, Gebhart GF, Bond MR (eds): Proceedings of the Vth World Congress on Pain. Elsevier, Amsterdam, 1988 5. Bradley LA, Lindblom U: Do different types of chronic pain require different measurement technologies? pp.

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