THE PAIN BEHAVIOR CHECK LIST (PBCL): PSYCHOMETRIC PROPERTIES IN A COLLEGE SAMPLE AUGUSTINE OSMAN, FRANCISCO X, BARRIOS, BEVERLY KOPPER, JOYLENE R. OSMAN, LEE GRITTMANN AND JOSH A, TROUTMAN The University of Northern lowa WILLIAM J. PANAK Towa State University The Pain Behavior Check List (PBCL) was designed to assess the frequency of four dimensions of pain behavior: distorted ambulation, affective distress, facial/audible expressions, and seeking help. This study evaluated theoretical factor structure, internal consistency, and construct validity of the PBCL. in a nonclinical college sample. Results provided support for the four-factor oblique model, compared to the one-factor and the four-factor orthogonal models. The PBCL total and subscales showed satisfactory internal con- sistency. Support for convergent validity was demonstrated by high correla- tions between the PBCL and several measures of pain behavior and with other pain indices. In addition, results of the confirmatory factor analyses suggested that self-report measures of pain can be differentiated from self- report measures of anxiety and depression. Severe or chronic physical pain generally is accompanied by several maladaptive responses, including cognitive distortions, anger, anxiety, distorted ambulation, social withdrawal, and depression (Haythornthwaite, Sieber, & Kerns, 1991; Lefebvre, 1981; Romano & Turner, 1985; Turk & Rudy, 1992). Recently, several different self-report measures have been developed and validated for assessing specific cognitive and/or behavioral responses to pain (Gil, Williams, Keefe, & Beckham, 1990; Lefebvre, 1981; Osman, Bunger, Osman, & Fisher, 1993; Rosenstiel & Keefe, 1983; Vlaeyen et al., 1990). The Pain Behavior Check List (PBCL; Kerns, Haythornthwaite, et al. 1991) is a 17-item self-report measure specifically designed to assess the frequency of overt pain behaviors. Responses on the PBCL items are recorded on a 7-point frequency scale (0 = never to 6 = very often). Higher scores suggest higher levels of pain behavior. The PBCL consists of four empirically derived factor scales: distorted ambulation, affective distress, facial/audible expressions, and seeking help. A PBCL total score is based on the mean of ratings for the 17 items. The reported alpha coefficient values for the PBCL subscales range from .63 to .85, and the 2- to 3-week test-retest reliability coefficients range from .70 to .87. Kerns, Haythornthwaite, et al. (1991) have provided detailed descriptions of the development of the PBCL based on a sample of 126 chronic pain patients referred by physicians to a Comprehensive Pain Management Center. Also, in 1991, these authors (see Kerns, Southwick, et al., 1991) provided additional data in support of using the PBCL subscales as outcome measures in the assessment of pain. To date, no investigations have provided additional normative data to complement results previously reported by the developers of the PBCL. Additional research is needed to establish nonclinical normative data that might be useful to clinicians (Kendall & Grove, 1988; Nietzel & Trull, 1988). It also is important to validate the pain behavior Correspondence should be addressed to Augustine Osman, Department of Psychology, The University of Northern Iowa, 140 Baker Hall, Cedar Falls, IA 50614-0505. 775776, Journal of Clinical Psychology, November 1995, Vol. 51, No. 6 construct in subjects who experience only moderate, subclinical levels of pain. Finally, it is important to demonstrate that the construct of pain behavior is distinct from closely related constructs, such as depressive and anxious symptoms and cognitions. (See Gross & Collins, 1981; Turk & Rudy, 1992, for a review and critical comments.) Thus, the purposes of the present study were: (1) to validate the four-factor structure of the PBCL in a normative (nonclinical) sample, using confirmatory factor analyses (CFA); (2) to evaluate the internal consistency of the PBCL total and subscale scores in a normal college sample; and (3) to examine the construct validity of the PBCL scores in relation to other measures of pain and measures of negative affectivity (anxiety and depression). MerHop Subjects The subjects included 130 men and 293 women, aged 17 to 43 years (M = 19.6, SD = 2.86). Approximately 97.2% of the subjects were White, and 95.5% were single. All subjects were recruited from various undergraduate psychology classes at a medium- sized Midwestern university. The sample was heterogeneous with regard to their self- report of pain symptoms: 76 (17.9%) reported headache pain, 34 (8.1%) reported low- back and neck-pain, 33 (7.8%) reported a combination of headache, low-back pain and neck pain, and 280 (66.2%) did not report pain symptoms. For all subjects, the reported duration of pain was less than 6 months, None was under the care of health care pro- fessionals for pain-related problems or currently was using prescription pain medica- tion. However, approximately 27.7% reported current use of nonprescription pain medication. All participants received extra course credit for completing the measures. Measures and Procedure Each subject completed a self-report questionnaire packet that contained a brief background information questionnaire, the PBCL, the 21-item Inventory of Negative Thoughts in Response to Pain (INTRP; Gil et al., 1990), the 34-item Pain Coping Ques- tionnaire (PCQ; Kleinke, 1992), the 30-iterm Automatic Thoughts Questionnaire (ATQ; Hollon & Kendall, 1980), the 20-item State-Trait Anxiety Inventory-State (STAI-S; Spielberger, 1983), the 20-item Center for Epidemiological Studies-Depressed Mood Scale (CES-D; Radloff, 1977), and the 26-item Cognition Check List (CCL; Beck, Brown, Steer, Eidelson, & Riskind, 1987). Several studies have provided normative and satisfac- tory psychometric data for the above measures in nonclinical samples (e.g., Osman et al., 1993; Steer, Beck, Clark, & Beck, 1994). The participants also completed other pain- related measures, including a 10-item physical pain symptom scale (PSS—e.g., stomach pains, joint pains, chest/heart pain) with each item rated on a S-point scale (0 = not at all to $ = very much so). The coefficient alpha for the 10-item physical pain symp- toms scale was .76 (corrected item-total correlations = .35 to .58). Subjects also rated the worst pain experienced in the last month on an 11-point scale (0 = no pain to 10 = pain as bad as it can be); overall perception of pain control on a S-point scale (1 = no control to $ = total control); and 2 items that measure the use of prescription or nonprescription pain medications (yes = 1, no = 0). RESULTS Confirmatory Factor Analyses A maximum-likelihood confirmatory factor analysis that employed the LISREL 7 program (Jéreskog & Sérbom, 1989) was used to evaluate the adequacy of three theoretical factor models: (a) a one-factor model that specified that all 17 PBCL items load on a single factor of general pain behavior (PBCL-unidimensional); (b) an oblique four-factor model that postulated that the PBCL items load on their respective factors,The Pain Behavior Check List ™m and the four factors were allowed to correlate (PBCL-oblique); and (c) an orthogonal four-factor model that postulated that the items load on four independent factors (PBCL- orthogonal). Results showed that the four-factor oblique model yielded the best fit to the observed data and met the preestablished criterion of .90 or greater for the goodness- of-fit index (GFI = .915), the .80 or greater for the adjusted goodness-of-fit index (AGFI = .885), and less than the .100 root mean square residual (RMSR = .062). Results are presented in Table 1. Factor loadings for the oblique model are listed in Table 2. All factor loadings were statistically significant, although | item (Item 12: Use cane or prosthesis) had a loading of less than .300 on the corresponding Distorted Ambulation subscale. (Because only 8.7% of the subjects endorsed this item above a rating of zero, this low factor loading probably is due to a restriction of range within the normative sample on this item.) Table | Factor Models and Goodness-of-fit Indices on the PBCL OO Goodness-of-fit indices Model ¥ value a GFT AGFI_—-RMSR k 614.77 rr) 833785074 (PBCL-unidimensional) 2. Four-factor oblique 326.29 13 91S 885062 (Four Related Primary Factors) 3. Four-factor Orthogonal 780.61 19 so¢ 74928 (Four Unrelated Primary Factors) Note.~PBCL = Pain Behavior Check Lis chi-square value; RMSR FI = Goodness-of-fit Index; AGFI = Adjusted Goodness- root-mean-square residual, Table 2 Factor Loadings for a Four-factor Oblique Model of the Pain Behavior Check List ——$$$$$$$ rn Item # Abbreviated description Loading Factor 1 Distorted Ambulation 1 Walk with timp 633 2, Move slowly 784 3. Walk protective fashion 745 4 Stoop S44 7. Ask for help 2348 12, Use cane or prosthesis 239 Factor 2 Affective Distress $. Ask, “Why did this happen?” 608 6 Irritable 829 1 Angry 693 14. Others not bother me 644 17. Upset or sad 663 Factor 3 Facial/Audible Expressions 8. Grimace 760 9. Clench teeth 676 10. Moan 597 Factor 4 Seeking Help I, Pain Medication 603 1S. Talk about pain 309 16. Ask someone to help 697718 Journal of Clinical Psychology, November 1995, Vol. 51, No. 6 Table 2 (continued) Intercorrelations among Factor Scores and Subscales, and Reliabilities ‘Subscale 1 2 3 4 1 Distorted Ambulation (74) 62 6 43 2 Affective Distress I (8) 78 64 3 Facial/ Audible Expressions 54 60 «my 35 4. Seeking Help 31 44 an (s) ‘Note. —Factor score correlations are above the diagonal; factor subscale correlations are below the diagonal. Alpha values are in parenthesis on the diagonal Internal Consistency Reliability coefficients, the PBCL factor scores (based on the oblique solution CFA), and PBCL subscale intercorrelations also are listed in Table 2 (lower part). The Cron- bach alpha value for the PBCL total was .87. The alpha values were high for the PBCL subscales except one, Seeking Help (alpha = .51). This is consistent with previous research (Kerns, Haythornthwaite, et al., 1991) in showing that the Seeking Help subscale has a lower internal consistency than the other PBCL subscales. Relationship between PBCL Subscales and Demographic Characteristics Because our results closely replicated previous factor structure and internal con- sistency findings with the PBCL, subsequent analyses used the original factor subscales. ‘The mean scores and standard deviations of the PBCL subscales for men and women are listed in Table 3. A multivariate analysis of variance (MANOVA) for gender differences on the PBCL subscales was significant, Hotelling’s T* = .12, p < .001. Post hoc tests showed significant gender differences on two of the four subscales. Males scored significantly higher than females on the Distorted Ambulation subscale; females scored significantly higher than males on the Seeking Help subscale, Table 3 Means, Standard Deviations, and ¢-values Men Women ‘Subscale M sD M SD 11,421) 1, Distorted Ambulation 12 80 87 16 3.02% 2. Affective Distress 2.09 1.20 2.30 1.21 1.61 3. Facial/Audible Expressions 477 124 168 1.25 n 4. Seeking Help 1.94 LB 2.49 1.21 a.agees “tp < Ol. ***p < 001 Additional analyses were conducted to examine the correlations between PBCL subscales and demographic characteristics of age, educational level, and marital status. The PBCL Affective Distress and Secking Help subscales correlated negatively and significantly (all significant at p < .05) with demographic variables of age and educa- tional level. Only the Distorted Ambulation subscale correlated positively and significantly with marital status (r = .10, p < .05). Also, only the Facial/Audible ExpressionsThe Pain Behavior Check List 7719 subscale correlated negatively and significantly with ethnicity (r = —.10,p < .05). All of the significant correlations (range —.10 to —.16) were weak. Differences among Pain Subgroups on the PBCL Subscales Next, we examined the relation between different types of self-reported pain and Fesponses on the PBCL subscales. An exploratory factor analysis on the 10-item physical pain symptom scale (principal components extraction with varimax rotation) revealed two interpretable factors: (1) pain in the joints and extremities (3 items) and (2) internal pains, such as headache, stomach ache, throat ache, and body aches (4 items). A third, heterogeneous factor that contained 3 items (chest/heart pain, numbness and tingling, and back, side, or hip pain) was dropped from further analysis. Subscale scores were calculated for the first two sets of items, and the sample was split on the median scores for both scales. This resulted in four pain subgroups (no pain, joint pain only, internal pain only, and a combined joint-internal pain group). A2 x 2 x 2 (joint pain by inter- nal pain by sex) MANOVA was conducted in which the four PBCL subscales were the dependent variables. There were significant multivariate main effects for both types of pain. (See Table 4.) Univariate analyses showed that subjects who indicated higher levels of joint pain reported higher levels of distorted ambulation (p < .001) and higher levels of affective distress (p < .01). Subjects who reported higher levels of internal pain also reported higher levels of affective distress (p < .001), as well as higher levels of seeking help (@ < .01). However, subjects who reported higher levels of internal pain did not report higher levels of distorted ambulation (p > .10). Also, the multivariate joint pain by internal pain interaction approached significance (p = .12). Univariate analyses showed that subjects who reported both joint pain and internal pain also reported more affec- tive distress than would be expected given the main effects of each type of pain (p < .05). No other multivariate or univariate interactions were statistically significant at the P < .05 level. Table 4 Means and Standard Deviations on PBLC Subscales for Pain Subgroups Internal Joint Internal and joint Subscale M SD M sD M SD MSD 1. Distorted ‘Ambulation 6S 75 61 Losers 80 1g 83 2. Affective Distress Lal 11s 2ases 1.12 198) LAL 2.76" 11s 3. Facial/Audible Expressions 143 1.30 1.63 Laz Les 1.19 1971.25 4. Seeking Help 193 Las 261% 1.31 2.05 Lig 20313 *p < 0S. **p < .01.***p < .001. Significant differences were found among subgroups on these Pain Behavior Check List subscales: Distorted Ambulation, Affective Distress, and Seeking Help. Relationship of the PBCL to Pain Measures and Measures of Anxiety and Depression Pain, anxiety, and depression scale intercorrelations were calculated to examine the construct validity of the PBCL total score. (See Table 5.) The results show that the PBCL total score correlated positively and significantly with pain cognition (e.g., the INTRP), self-report of physical pain symptoms (¢.g., the PASS), and self-report of pain coping (e.g., the PCQ). The PBCL total score also correlated significantly with measures of depressive and anxious symptoms and cognitions (e.g., the ATQ, CES-D, CCL-A,780 Journal of Clinical Psychology, November 1995, Vol. 51, No. 6 Table 5 Relations of the PBCL to Pain Measures and Measures of Depression and Anxiety Measure M SD Pain measures 1. Negative Pain Cognition (INTRP) 173 ss 2. Physical Pain Symptoms (PSS) 133 76 3. Pain Coping (PCQ) 3.08 48 Measures of depression and anxiety 4. Automatic Depressive Thoughts (ATQ) 52:82 18,57 5S. Depressive Cognition (CCLD) 7.30 ia 6, Depressed Mood (CES-D) 8.96 7, Anxious Cognition (CCLA) 3.40 8. State Anxiety (STAI-S) 40.11 221 "p< 01. and STAIS-S), although these correlations were substantially smaller than the correla- tions between the PBCL total score and the measures of pain cognitions, symptoms, and coping. The issue of convergent and discriminant validity between measures of pain and negative affectivity (see Turk & Rudy's 1992 critical comments) was examined further using confirmatory factor analyses. (See Table 6.) The following models were tested: (1) a one-factor model in which the PBCL, INTRP, PSS, and the PCQ (Pain measures) were constrained to load on the same “negative affectivity” factor with the ATQ, CES-D, CCL-A, and the STAI-S (Depression and Anxiety measures); (2) a two-factor oblique model in which the pain measures were constrained to load on a general pain factor, and the depression and anxiety measures to load on a separate, but correlated, negative affectivity factor; and (3) a two-factor orthogonal model that specified that the pain and the negative affectivity factors were not correlated (orthogonal factor solution). Table 6 Analyses of Factor Models on the Pain, Depression, and Anxiety Measures Goodness-of-fit indices Model ¥ value af GFL AGFI_—- RMSR 1. One-factor (General Distress) 242.34 20 1862752092 2. Two-factor Oblique 132.43 9 927 861.069 (Two Related Primary Factors) 3. Two-factor Orthogonal 238,00 20 892 805.208 (Two Unrelated Primary Factors) Two-factor oblique model Variables Pain factor Depression-anxiety factor 1. Pain Behavior (PBCL) n 0 2. Negative Pain Cognition (INTRP) 3B 0 3. Physical Pain Symptoms (PSS) 49 00 4. Pain Coping (PCQ) so 00 5. Depressive Thoughts (ATQ) 00 83The Pain Behavior Check List 781 Table 6 (continued) ‘Two-factor oblique model Variables Pain factor Depression-anxiety factor 6. Depressed Mood (CES-D) 00 87 Anxious Cognition (CCLA) 00 9 State Anxiety (STAI-S) 0 6 Note.—GFI = Goodness-of-fit Index, AGF = Adjusted Goodness-of-fit Index; y? = chi-square; df = degrees of freedom; RMSR = Root-mean-square residual; PBCL = Pain Behavior Check List. The two-factor oblique model provided significantly better fit to the observed data than either of the alternate models: GFI = .927; AGFI = .861, and RMSR 069. The correlation between the pain and negative affectivity factors was moderate, r = .63. Taken together, the results of the three confirmatory factor analyses demonstrate con- vergent and discriminant validity of the pain measures and the negative affect measures. Discussion The present study examined the replicability of the PBCL, using confirmatory factor analysis. Results of the confirmatory factor analyses showed that the factor structure for the PBCL for a nonclinical population is quite similar to that of a previously reported sample of chronic pain patients. Examination of item-factor loadings showed that only one item (item 12) may be inappropriate for use with our sample. These results also confirmed the multidimensionality of the pain behavior construct (see Turk, Wack, & Kerns, 1985) as assessed by the PBCL in our subclinical sample. The results that concern the reliability of the PBCL were quite similar to those reported by Kerns and this colleagues. The coefficient alpha values were similar in mag- nitude. The study also examined whether measures of pain could be differentiated from measures of anxiety and depression. Results of the models tested provided evidence to suggest that although pain behaviors are related to anxiety and depression, these con- structs can be distinguished reliably. Additional evidence for discriminant validity also was obtained. Three of the PBCL subscales were useful in distinguishing among the responses of our subclinical samples. Also, correlational analyses showed negligible rela- tions between the PBCL subscales and several demographic variables. Finally, evidence of adequate convergent validity was obtained for the PBCL. The correlations between the PBCL total score and measures of pain responses were substantially higher than the correlations between the PBCL total scores and measures of anxiety and depression. Special caution should be taken in generalizing our findings to other clinic or nonclinic samples. 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