Pain, 11 (1981) 101--107 101

Elsevier/North-Holland Biomedical Press

ON "RATIO SCALES OF SENSORY AND AFFECTIVE VERBAL PAIN

DESCRIPTORS"

WAYNE HALL *
Rheumatic Diseases Centre, Hope Hospital, Eccles Old Rd, Salford M 6 . S H D (Great
Britain)
(Received 12 ~ovember 1980, accepted 12 February 1981)

SUMMARY

The cross-modality matching methods of Stevens [16] have been used by

Gracely and his colleagues [4--6] to provide numerical values for "verbal
pain descriptors." These numerical values, it is claimed, provide reliable,
objective and valid ratio-level measurement of the sensory and affective
dimensions of pain. Each of these claims is critically examined.

INTRODUCTION

In a recent series of papers Gracely, McGrath and Dubner [4--6] have

used the scaling methods developed by Stevens [16] to derive numerical
scales of adjectives which are alleged to distinguish the sensory and affective
dimensions of experimentally induced pain. Gracely et al. have claimed that
cross-modality matching (CMM) produces "relatively bias-free" scales that
achieve a ratio level of measurement, are reliable and objective, and provide
valid measures of the sensory and affective dimensions of pain. These claims
seem to have been accepted by the Panel on Pain which recently reported to
the National Institute of Neurological, Communicative Disorders and Stroke.
In its report the pmael states: "Pain scales utilizing verbal descriptor mea-
sures and derived from ratio-scaling procedures may provide the best method
of scaling different dimensions of the pain experience" [10, p. 43]. In view
of the authoritative support these claims have received they deserve close
scrutiny.
WHAT IS C R O S S - M O D A L I T Y MATCHING?

The CMM methods used by Gracely and his colleagues may seem unduly
complicated because of the profusion of judgments required of subjects and

* Applied Health Science Fellow, National Health and Medical Research Council of Aus-
tralia.

0 3 0 4 - 3 9 5 9 / 8 1 / 0 0 0 0 - - 0 0 0 0 / $ 0 2 . 5 0 1981 Elsevier/North-Holland Biomedical Press

102

the extensive manipulations that are performed on these judgments in order

to yield scale values. Researchers who are not acquainted with the literature
of psychophysics might suppose that the derivation of scale values is an
archane matter the details of which must remain mysterious to the un-
initiated. It would be unfortunate if this were to happen because the logic of
CMM is simple.
The most readily understood variety of CMM occurs when a subject
"matches" each stimulus with a number, that is, provides a numerical
estimate of stimulus magnitude. The procedure followed is to ask the subject
to arbitrarily assign a number to the first stimulus presented and then to
assign numbers proportionally to subsequent stimuli. When these estimates
are plotted against stimulus intensity the typical finding is that the relation-
ship can be conveniently fitted by a power function, e.g., R = KS n, where
R = the subject's magnitude estimate, S = stimulus intensity, K = a constant
and n = the exponent. When plotted on log-log coordinates the function is
linear, the slope providing the exponent of the power function. Different
stimulus dimensions have different but characteristic exponents [ 16 ].
There is no reason why subjects ought to be restricted to responding in
terms of number. In principle, subjects can use any response which can
express magnitude. Instead of giving a numerical estimate they can, for
example, adjust the length of a line or squeeze a dynamometer in proportion
to the intensity of each stimulus that is presented. The propriety of using
non-numerical responses can be checked by examining consistencies between
different stimulus-response matches. For example, if line length and hand-
grip matches are related by a power function with exponent x, and line
length and magnitude estimates are related by a power function with
exponent y, then the power function relating magnitude estimates and
handgrip responses should be given by the ratio of the exponents relating
each to line length, i.e., x/y. This prediction can be directly tested against
the exponent relating subjects magnitude estimates to their handgrip
responses. In many cases these predictions have been satisfied [16].
The major change that Gracely and his colleagues have made is to apply
these methods to the scaling of adjectives used to describe pain. Since words
are not usually regarded as metric they have sought to demonstrate the
propriety of scaling them by testing for consistencies between judgments in
a way that is analogous to cross-modality prediction of exponents. More spe-
cifically, they asked subjects to provide magnitude estimates and handgrip
responses to two lists of adjectives, putatively lists of "sensory" and "affec-
t i r e " descriptors. The consistency of these judgments was checked by com-
paring the ratio of exponents between magnitude estimates and handgrip
responses made to a common descriptor list and the ratio of exponents
betwe~ magnitude estimates and handgrip responses made to line length.
Identity of the two ratios was claimed to have "validated" the scaling of l:Le
adjectives: "A similarity between the non-metric (words) and metric (line
length} inter-response exponents shows that the verbal stimuli, although not
objectively measurable, are scaled as readily and reliably as physically mea-
surable stimuli" [5, p. 15].
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ARE THE SCALES PRODUCED BY CROSS-MODALITY MATCHING " R E L A T I V E L Y

BIAS-FREE"?

One of the virtues that Gracely et alo claim for CMM methods is that they
yield scales which are unbiased when compared with commonly used cate-
gory scaling methods (methods in which subjects are restricted to a fixed
number of categories by which to judge stimuli). In support of this argument
they cite evidence which indicates that category scaling methods are "sensi-
tive to bias effects such as stimulus frequency, range and distribution effects
and category end effects" [5, p. 7]. They err, however, in supposing that the
CMM scales are not similarly susceptible to bias. Stevens believed that his
scales were less biased than category scales but his belief was not shared by
other researchers in scaling. Zinnes [17], for example, after reviewing
Stevens' claims concluded: "A great number of papers show that the
exponent varies under a wide variety of experimental conditions or
m a n i p u l a t i o n s . . , that it is especially influenced by the range of s t i m u l i . . .
and that there are large differences in the exponents between subjects"
[17, p. 469]. A similar opinion has been expressed by Poulton [11--13] who
has developed models of the type of biases operating in cross-modality
matching. Poulton's models illustrate the way in which magnitude estimates
can be affected by: the range of stimuli, distribution of stimulus intensities,
choice of standard stimulus, and choice of modulus -- precisely, the sort of
biases that category scaling methods are susceptible to.

DO CROSS-MODALITY MATCHING METHODS P R O D U C E R A T I O SCALES?

The ratio scale is the highest level of measurement in Stevens' [15] 4-fold
classification of levels of measurement (nominal, ordinal, interval, ratio). It
requires a rational, non-arbitrary zero or origin, and equal intervals between
scale values; requirements which are only rarely satisfied in natural science
(e.g., the Kelvin scale of temperature). To assert, as did Stevens [16] that
CMM produces a ratio scale is to make a very strong claim; a claim that
sounds implausible when one examines the principal differences between
the procedures involved in producing a CMM scale and a category scale
which is only supposed to attain the interval level of measurement.
The major differences between category scaling methods and cross-
modality matching methods are in the type of response allowed the subject
in making a judgment, and in the type of judgment required of the subject.
In category scaling methods the subject is limited to a fixed set of response
categories. In cross-modality the subject is given greater discretion, being
allowed a scale that in unbounded at the top. The task of the subject in cste-
gory scaling is to compare each stimulus with standards represented by the
categories and to decide between which category boundaries the stimulus
belongs. The subject performing a CMM task is asked to "make an arbitrary
response to the first stimulus and then respond proportionally to successive
stimuli" [4, p. 7]; a task which p r e s u p p o s e s that subjects can judge ratios.
104

These procedural differences may explain the well-known non..linear rela-

tionship between category and CMM scales [16] but the evidence that the
differences are sufficient to produce a ratio scale is less than compelling.
Stevens [16] asserted two pieces of evidence in faver of the claim that
cross-modality matches produce ratio scales. The first was that a ratio scale
of judgments predicted a power function relating judgments to stimulus
intensity and that this relationship has been found to hold true for a large
number of stimulus attributes [16]. The second was the successful cross-
modality prediction of exponents, i.e., the finding that the exponent of the
power function relating dimensions A and C could be predicted by the ratio
of the exponents relating A to B and B to C.
Stevens' assertions have not been accepted by all psychophysicists. Against
the first Anderson [ 1 ] has countered that the fit of a power function to the
plot of judgments against stimulus intensity establishes nothing more than
the flexibility of the power function as is evident in its capacity to fit any of
the monotonically increasing curves common-sense would expect to describe
the relationship between numerical judgments and stimulus intensity. Ander-
son has also contested the claim that cross-modality predictions of expo-
nents have been successful [ 1 ].
Other arguments have also been brought against Stevens' second assertion.
Ekman [3] and Savage [14, p. 408] have pointed out that the successful
cross-modality prediction of exponents does not uniquely validate the
"power law" (on which the ratio scale depends). The same predictions are
derivable from a very different psychophysical law, namely Fechner's where
magnitude estimates are related to stimulus magnitude by a log function.
Zinnes [17 ] has dismissed cross-modality prediction of exponents as irrele-
vant. Whatever the merits and demerits of Stevens' case, the claira that CMM
produces a ratio scale is much more controversial than Gracely et al. have led
their readers to believe.

ARE THE " S E N S O R Y " AND " A F F E C T I V E " SCALES RELIABLE?

The correlations between the scale values obtained by a group of 8 sub-

jects in 2 sessions 1 week apart were 0.96 and 0.89 for sensory and affective
scales, respectively. These coefficients are gratifyingly large and seem to sup-
port the claims that Gracely et al. have made for the reliability of the scales.
That the scales are reliable seems likely. That they are as reliable as these
coefficients suggest is doubtful. Their size probably owes something to the
fact that each scale value represents the average of 128 responses.

ARE THE " S E N S O R Y " AND " A F F E C T I V E " SCALES OBJECTIVE?

The average correlations between the scale values of the group and the
scale values of the individuals who comprise it are also large. In fact the coef-
ficients are the same as the reliability coefficients: 0.96 and 0 8 9 for the sen-
sory and affective scales, respectively. Gracely et al. cite these ceJefficients as
 105

evidence that there is a substantial agreement between individuals in the

values they attach to each adjective and hence evidence that the scale values
are "objective".
It would be mistaken, however, to suppose that these correlations confer
any special status on the scale values of individual adjectives. Correlations of
this order are ensured if subjects only agree upon the rank ordering of the
adjectives; there need not be any agreement upon the relative spacing
between the adjectives. (Readers can verify this for themselves by calculating
the correlation between the scale values of the 15 pairs of sensory and affec-
tive pain descriptors [Table IV, 5].) These sets of values differ greatly in
range and spacing between adjacent descriptors yet they correlate to the
extent of 0.95--0.99. The "objectivity" coefficient may indicate little more
than the fact that normal volunteers of the same age and education agree
upon the way in which adjectives ought to be ranked in increasing order of
some underlying magnitude. Support for this interpretation is provided by
correlation coefficients of 0.99 between sensory and affective scale values
and the subjects' rank ordering of the adjectives [5, p. 15]. This finding
which Gracely et al. pass over in silence raises an interesting question: Why is
it necessary for subjects to perform a large number of judgments if after all
the transformations and linear regressions have been performed the scale
values obtained reproduce with great accuracy the subjects' rank ordering of
the adjectives? Why not use the rank orders as scale values?

ARE THE " S E N S O R Y " AND " A F F E C T I V E " SCALES VALID?

The claim that the two sets of adjectives provide valid measures of the
sensory and affective dimensions of pain presupposes that there are in fact
separable sensory and affective aspects of pain and that the scales do in fact
measure them.
In accepting the first presupposition Gracely and his colleagues are in
good company. As they point out, many pain researchers have found it con-
venient to draw a distinction between the sensory and affective attributes of
pain [e.g., 2, 7, 8]. Although the distinction is a popular one a sceptic might
argue that too much has been made of some speculative neuropsychology
[8] and a multidimensional scaling of adjectives used to describe pain [9].
Neurophysiological evidence on the role of the limbic system and spino-
thalamic tracts in pain perception, valuable as it is, does not establish that
the processes presumed to be subserved by these structures are straight-
forwardly represented in conscious experience. A multidimensional scaling
of adjectives may be instructive about the way people use words to describe
pain; it has no straightforward implications about the mechanisms that may
underly the choice of words. The one to one relationship which Gracely et
al. seem to assume exists between two of the classes of words revealed by
multidimensional scaling and two putative neurophysiological systems is an
appealing conjecture which would be extremely convenient if true. It would
be a mistake, however, to forget that it is a conjecture; one which is difficult
to test.
106

The strategy that Gracely et al. have chosen to follow in order to "validate"
their descriptor scales is one of investigating whether the scales are differ-
entially affected by manipulations presumed to have "sensory" and "affec-
t i r e " effects. Thus, they cite as validating evidence that diazepam affects
only the affective scale while fentanyl affects only the sensory scale [4,6].
The major difficulty with this strategy is that the presumptions about the
effects of diazepam and fentanyl are at least as controversial as the scaling
methods their effects are supposed to have validated. What, one might ask,
is validated by the observations that fentanyl affects the "sensory" scale and
diazepam the "affective" scale? Is it the distinction between the sensory and
affective scales or the presumption that fentanyl reduces sensitivity while
diazepam reduces affective response?

CONCLUSION

The arguments that have been adduced suggest several things: that the
claim that CMM produces relatively bias-free ratio scales is probably false but
at least controversial; that the scales owe part of their impressive reliability
to the number of judgments upon which they are based; that the "objectiv-
ity" of the scale values most likely resides in the agreement between subjects
upon the rank ordering of the adjectives rather than in agreement on the
scale values themselves; and that the evidence for the validity of the scales is
as provisional as the theories of mechanism upon which it depends. None of
these criticisms implies that the use of adjectives or the assignment to them
of scale values (e.g., average rank orderings) is devoid of merit. Scaling meth-
ods of this sort may be a useful alternative to numerical pain judgments. In
using such methods, however, we must remain cognisant of their imperfec-
tions, many of which they share with existing methods of pain measurement.

ACKNOWLEDGEMENTS

Preparation of this paper was undertaken while I was a research fellow in

the Department of Anesthesiology, University of Washington, during 1979
and in the Rheumatic Diseases Centre, University of Manchester during 1980.
The assistance of the staff of both departments is gratefully acknowledged.
Special thanks are due to Dick Chapman, Andrew Chen, and Green Gagliardi
for their comments on an earlier draft of this paper.

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