Author: Avery Hurt
Practical Pain Management Jan 23
The World Health Organization describes stigma as “a mark of shame, disgrace, or disapproval that results in an individual being rejected, discriminated against, and excluded from participating in a number of different areas of society.”¹ Stigma can have very specific and detrimental effects when it is related to a health condition. Those who experience such stigma tend to avoid treatment, and when they do seek help, they often have worse treatment outcomes.²
Commonly stigmatized conditions include mental health conditions as well as physical illnesses and conditions, such as obesity, HIV/AIDS, and chronic pain.²
“We are in a society that really devalues people who have chronic pain,” Tina Doshi, MD, MHS, assistant professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, told PPM. “We talk about … things like no pain, no gain, or pain as weakness leaving the body. And we perceive it as some sort of character flaw in these patients who are suffering from chronic pain.”
With all this in mind, a team of researchers led by Perugino at Sapienza University of Rome, in Italy, assessed the literature on chronic pain and stigma and reported their findings in Pain and Therapy.³
Chronic Pain’s Stigmatic Factors and Pervasive Effects
Perugino et al identified several factors that contribute to the stigmatization of chronic pain, including the lack of evidence of tissue damage or other clear medical evidence for the pain, as well as the invisibility and subjectivity of pain.
Not surprisingly, they found that the effects of stigma are pervasive, being felt in almost every area of life: at home and at work, in social settings among colleagues and friends, and with family and romantic partners who do not understand the experience of chronic pain.
Perhaps more surprising, the researchers found that stigma about pain exists even in clinical settings, leading to under-assessment of pain by clinicians, skepticism and suspicion about the reality of the suffering, and lower pain ratings, which often lead to the undertreatment of pain and tendency to assume it’s exclusively a psychological illness.
The personal toll of stigma is high, according to these findings. While some individuals are resilient, other people with chronic pain who experience stigma may fall into depression, social withdrawal, insomnia, and lowered self-esteem. The literature reviewers pointed out that people with chronic pain are twice as likely to die by suicide, making it even more important for clinicians to take pain complaints seriously and treat patients with chronic pain appropriately.
Stigma comes in several different forms. According to the literature review:
- public stigma is the circulation among the general public of negative attitudes and stereotypes
- structural stigma refers to organizational attitudes and policies
- internalized or self-stigma occurs when individuals absorb these negative attitudes, apply them to themselves, and anticipate social rejection
The latter is surprisingly common. One study cited by the authors found that 38% of people affected with chronic pain “endorsed the experience of internalised stigma, including alienation, social withdrawal, and discriminatory experiences based on pain.”³ The researchers also found evidence that internalized stigma can contribute to catastrophic thinking, increase long-term disability, and interfere with recovery.
Gender Gaps in Pain Care
The review also looked at the gender gap in pain stigma experience as well. For several reasons, more women than men are diagnosed with chronic pain syndromes, yet women are taken less seriously and receive less pain medication and more antidepressants than men. “Several studies showed that women with chronic pain are often perceived as hysterical, emotional, complaining, not wanting to get better, malingerers, and fabricating the pain, as if it is all in their heads, and they are assigned psychological rather than somatic causes for their pain,” Perugino et al wrote.³
While little work has been done to identify potential mechanisms for the stigma associated with chronic pain, the researchers did find that response to another’s pain depends in part on input from the individual in pain. Whereas acute pain is generally accompanied by spontaneous reactions such as facial expressions and nonverbal vocalizations, chronic pain does not show these signs, so others may think the pain is not real.
The researchers also mention that response to another’s pain is influenced by personal beliefs and attitudes. People who are prone to think that others are likely to take advantage of them – for example, by not carrying their share of the workload – are more likely to doubt the authenticity of another’s pain.
The authors suggested that stigma may stem from causal attribution theory, the need to determine the causes of others’ behavior. When it comes to healthcare professionals, there may be a lack of education about chronic pain and chronic pain management. At least as far as the healthcare community is concerned, the authors say that first-line intervention should involve education about chronic pain and its assessment.
“The reality,” said Dr. Doshi, “is that patients who have chronic pain are suffering from a chronic disease, and it should be no different than if you have hypertension or diabetes. There’s a neurological, biochemical, pathophysiologic basis for this, and that’s not something that should have a stigma attached to it.”
- World Health Organization. Mental Health: New Understanding, New Hope. World Health Report, 2001.
- IASP. IASP Announces Revised Definition of Pain. July 16, 2020. Available at: https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/ Accessed December 2022.
- Perugino F, De Angelis V, Pompili M, Martelletti P. Stigma and Chronic Pain. Pain Ther. 2022;11(4):1085-1094. doi:10.1007/s40122-022-00418-5
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