Well-being and Perceived Stigma in Individuals With Rheumatoid Arthritis and Fibromyalgia: A Daily Diary Study.

INTRODUCTION: The presence or absence of clearly defined symptoms and underlying pathophysiology may be a crucial variable related to variability in well-being and stigmatization in individuals with chronic pain (ICPs). In the context of pain, absence of clearly defined symptoms and pathophysiology deviates from the widely endorsed biomedical model and as such, may lead to stigmatization, which in turn could be related to ICPs' well-being. OBJECTIVES: The present study compared physical, psychological, social well-being, and perceived stigmatization in individuals with clearly defined symptoms and underlying pathophysiology (rheumatoid arthritis, RA) and individuals with less well understood symptoms and pathophysiology (fibromyalgia, FM) using daily diaries. Furthermore, the association between daily perceived stigmatization and daily well-being was examined. MATERIALS AND METHODS: Seventy-nine participants with FM, 86 participants with RA, and 33 participants with both diagnoses completed a diary for 14 consecutive days. RESULTS: Compared to individuals with RA, individuals with FM and individuals with both diagnoses reported worse daily well-being. After controlling for age, pain duration, and daily pain, differences between FM and RA remained significant for social well-being and completion of plans. Differences between RA and the dual diagnosis group remained significant for completion of plans, negative affect, and isolation. Furthermore, results suggested more stigmatization in individuals with FM than in individuals with RA. Individuals with both diagnoses reported equal stigmatization as individuals with FM, but more stigmatization than individuals with RA. Finally, increased levels of perceived stigma were associated with lower well-being. DISCUSSION: Findings highlight that the absence of clearly defined symptoms and pathophysiology could be contributing to greater feelings of stigmatization, which may be detrimental for ICPs' well-being.

Pain Intensity And Attribution Mediate The Impact Of Patient Weight And Gender On Activity Recommendations For Chronic Pain.

BACKGROUND AND PURPOSE: Despite the notable benefits of physical activity for chronic pain, a large proportion of patients with chronic pain report that they do not receive activity-related recommendations from their providers. Research suggests that patient factors such as weight and gender influence activity-related recommendations for chronic pain. Research also suggests that appraisals of the intensity and cause of pain may explain these weight and gender effects. We investigated the influence of patient weight and gender on observers' likelihood of recommending activity-related treatments for pain. We also explored the mediating effects of observers' ratings of pain severity and the extent to which pain was due to medical and lifestyle factors (pain attribution). PATIENTS AND METHODS: Healthy young adults (N=616; 76% female) viewed videos (Ghent Pain Videos of Daily Activities) and vignettes of 4 patients with chronic back pain performing a standardized functional task. Patients varied by gender (female, male) and weight (normal, obese), but were otherwise equivalent on demographic characteristics and pain behaviors. Participants rated how much pain they perceived the patients to be experiencing, the extent to which they attributed the pain to medical and lifestyle factors, and their likelihood of recommending exercise, physical therapy (PT), and rest. RESULTS: Patient weight and gender significantly interacted to influence exercise, PT, and rest recommendations. Both pain intensity and pain attribution mediated the relationships between patient weight and activity recommendations; however, these mediation effects differed across gender and recommendation type. CONCLUSION: Patient weight and gender influenced laypeople's activity recommendations for chronic pain. Moreover, the results suggest that observers' perceptions of pain intensity and pain attributions are mechanisms underlying these effects. If these findings are replicated in providers, interventions may need to be developed to reduce provider biases and increase their recognition of the benefits of physical activity for chronic pain.

Classism in Pain Care: The Role of Patient Socioeconomic Status on Nurses' Pain Assessment and Management Practices.

OBJECTIVE: Research on social disparities in pain care has been mainly focused on the role of race/racism and sex/sexism. Classism in pain assessment and management practices has been much less investigated. We aimed to test the effect of patient socioeconomic status (SES; a proxy of social class) on nurses' pain assessment and management practices and whether patient SES modulated the effects of patient distress and evidence of pathology on such practices. DESIGN: Two experimental studies with a two (patient SES: low/high) by two (patient distress or evidence of pathology: absent/present) between-subject design. SUBJECTS: Female nurses participated in two experimental studies (N = 150/N = 158). METHODS: Nurses were presented with a vignette/picture depicting the clinical case of a female with chronic low back pain, followed by a video of the patient performing a pain-inducing movement. Afterwards, nurses reported their pain assessment and management practices. RESULTS: The low-SES patient's pain was assessed as less intense, more attributed to psychological factors, and considered less credible (in the presence of distress cues) than the higher-SES patient's pain. Higher SES buffered the detrimental impact of the presence of distress cues on pain assessment. No effects were found on management practices. CONCLUSIONS: Our findings point to the potential buffering role of SES against the detrimental effect of certain clinical cues on pain assessments. This study contributes to highlighting the need for further investigation of the role of SES/social class on pain care and its underlying meanings and processes.

Differential Effect of Patient Weight on Pain-Related Judgements About Male and Female Chronic Low Back Pain Patients.

Compared with men, women report more pain and are at increased risk for having pain discounted or misattributed to psychological causes. Overweight individuals experience high rates of pain and may receive suboptimal care because of provider bias. Research suggests the social consequences of being overweight are worse for women than men, and that gender and weight uniquely and interactively affect pain experience and care. Healthy participants (n = 616) viewed 6 videos of back pain patients (1 female and 1 male of normal weight, overweight, and obese categories) performing a functional task. Participants provided judgements/ratings regarding patient pain (intensity, interference, exaggeration), potential sources of patient pain (medical, psychological), and treatment recommendations (opioids, psychological therapy, seek workplace accommodations). Results suggest that the pain of normal and overweight women and obese men was discounted (judged as less intense, less interfering, more exaggerated, and less attributable to medical factors) and judged as less in need of treatment (treated with less opioids and workplace accommodations). Across all weight categories, women's pain was attributed more to psychological factors and was more likely to receive recommendations for psychological therapy than men's pain. These findings highlight the differential effect of patient weight on pain-related judgements about women and men. PERSPECTIVE: This article examines the relationships among patient weight, patient gender, and observers' pain appraisals and treatment recommendations. These findings highlight the differential effect of patient weight on pain-related judgements about women and men and indicate the need for research to determine how these judgements affect treatment decisions in clinical settings.

Patients Are Socially Excluded When Their Pain Has No Medical Explanation.

UNLABELLED: This study investigated whether observers socially exclude patients who experience pain that is not medically explained by means of an experimental design. Fifty-nine participants (individuals from the general population) viewed videos of 4 patients, each accompanied by a vignette describing the presence or absence of a medical explanation for their pain. Participants estimated patient's pain, and rated the sympathy felt for and the inclination to help the patient. To measure social exclusion, participants indicated their willingness to interact with the patients in several situations (Social Distance Scale). Furthermore, the participants were invited to select 2 of the 4 patients as confederates to play a game against another duo. When no medical explanation for the pain was provided, participants attributed less pain, reported feeling less sympathy, and were less inclined to help the patients with daily activities. Of particular importance to this study, participants were less willing to interact with patients with medically unexplained pain and selected less often patients with 'medically unexplained' pain than patients with 'medically explained' pain as confederates in the social game. These results are indicative of social exclusion of patients with pain for which there is no clear medical explanation. PERSPECTIVE: Observers socially exclude patients with pain for which there is no clear medical explanation. These findings have important clinical implications. In particular, social exclusion might have detrimental effects on the mental and physical well-being of patients with pain.

Health care professionals' reactions to patient pain: impact of knowledge about medical evidence and psychosocial influences.

UNLABELLED: This study examined the impact of evidence concerning the presence of 1) a biomedical basis for pain and 2) psychosocial influences on practitioner appraisals of patient pain experiences. Furthermore, the potential moderating role of patient pain behavior was examined. In an online study, 52 general practitioners and 46 physiotherapists viewed video sequences of 4 patients manifesting pain, with accompanying vignettes describing presence or absence of medical evidence and psychosocial influences. Participants estimated pain intensity, daily interference, sympathy felt, effectiveness of pain medication, self-efficacy, their likability, and suspicions of deception. Primary findings indicated lower perceived pain and daily interference, less sympathy, lower expectations of medication impact, and less self-efficacy when medical evidence was absent. The same results were found when psychosocial influences were present, but only when the patient displayed higher levels of pain behavior. Furthermore, absence of medical evidence was related to less positive evaluations of the patients and to higher beliefs in deception in both professions. The presence of psychosocial influences was related to less positive evaluations and higher beliefs in deception in both professions. In sum, a range of contextual factors influence health care practitioner responses to patient pain. Implications for caregiving behavior are discussed. PERSPECTIVE: The present study indicates that in the absence of clear medical evidence and in the presence of psychosocial influences, patient pain might be taken less seriously by health care practitioners. These findings are important to further understand the difficulties that relate to the clinical encounter between pain patients and health care practitioners.

Discounting pain in the absence of medical evidence is explained by negative evaluation of the patient.

This study investigated the effect on observer responses of the presence/absence of information about medical evidence for pain and psychosocial influences on the patient's pain experience. Additionally, the moderating role of the patient's pain expressions and the mediating role of the observer's belief in deception and evaluation of the patient was examined. Sixty-two participants were presented with videos of 4 patients, each accompanied by a vignette describing the presence or absence of both medical evidence for the pain and psychosocial influences on the patient's pain. Participants estimated patients' pain and rated their own sympathy and inclination to help; they re-estimated patients' pain when the patient's self-report of pain was provided. Finally, participants evaluated each patient as positive or negative and the likelihood that the patient was feigning pain. Participants gave lower ratings on pain, sympathy, and help when medical evidence was absent. Further, in the presence of psychosocial influences, participants took patients' self-reported pain less into account. Next, only for patients expressing high-intensity pain, information about both medical evidence and psychosocial influences was taken into account. Finally, the observer's evaluation of the patient and his/her belief in deception fully, respectively partially, explained the effect of medical evidence. The results indicate that discounting pain in the absence of medical evidence may involve negative evaluation of the patient. Further, the patient's pain expression is a moderating variable, and psychosocial influences negatively impact the degree to which patients' self-reports are taken into account. The results indicate that contextual information impacts observer responses to pain.

Impact of being primed with social deception upon observer responses to others' pain.

This study examined whether priming with social deception affects responses (pain estimates, self-reported sympathy, inclination to help) towards others' pain. We further explored whether the priming effect is mediated by the valence of the patients (positive/negative), as indicated by the participants. First, participants (N=55) took part in an 'independent' delayed memory study in which they read either a neutral text about the use of the health care system (neutral condition) or a text about its misuse (social deception condition). Second, participants watched videos of pain patients performing pain-inducing activities. Participants rated the patients' pain, the sympathy felt for the patients, and the inclination to help the patients. Third, the participants re-estimated patients' pain when patients' self-report of pain was provided. Fourth, pictures of the patients were shown and participants indicated the valence of the patients (positive/negative). Results revealed no direct effect of priming with social deception. However, priming with social deception was related to less positive rating of the valence of the patients, that were related to lower ratings on pain and sympathy, and to larger discrepancies between the ratings of the patients and the observers. The results indicate that observers attribute less pain, feel less sympathy, and take patients' self-reported pain intensity less into account when the patients are evaluated less positively, which is likely to occur when a cognitive scheme of social deception is primed.

We discount the pain of others when pain has no medical explanation.

UNLABELLED: The present studies investigated the impact of medical and psychosocial information on the observer's estimations of pain, emotional responses, and behavioral tendencies toward another person in pain. Participants were recruited from the community (study 1: N = 39 women, 10 men; study 2: N = 41 women, 12 men) and viewed videos of 4 patients expressing pain, paired with vignettes describing absence or presence of 1) medical evidence for the pain and 2) psychosocial influences on the pain experience. A similar methodology was used for studies 1 and 2, except for the explicit manipulation of the presence/absence of psychosocial influences in study 2. For each patient video, participant estimations of each patient's pain and their own distress, sympathy, and inclination to help were assessed. In both studies, results indicated lower ratings on all measures when medical evidence for pain was absent. Overall, no effect of psychosocial influences was found, except in study 2 where participants indicated feeling less distress when psychosocial influences were present. The findings suggest that pain is taken less seriously when there is no medical evidence for the pain. The findings are discussed in terms of potential mechanisms underlying pain estimations as well as implications for caregiving behavior. PERSPECTIVE: The present studies indicate that observers take the pain of others less seriously in the absence of clear medical evidence for the pain. These findings are important to further understand the social context in which pain for which there is no clear medical explanation is experienced.

Negative emotional responses elicited by the anticipation of pain in others: psychophysiological evidence.

UNLABELLED: Limited evidence is available about factors influencing observers' anticipatory emotional responses to another's pain. We investigated fear and distress towards the threat of pain in others, and the moderating role of observers' psychopathic traits and catastrophizing about their own or others' pain. Thirty-six dyads of healthy participants were randomly assigned to either the role of observer or observed participant. Both participants were instructed that 1 colored slide (blue or yellow) signalled that a pain stimulus could possibly be delivered to the observed participant (=pain signal), whereas no pain stimulus would be delivered when a differently colored slide was presented (=safety signal). Observers' self-reported fear, fear-potentiated startle, and corrugator electromyography activity during pain and safety signals were measured. Furthermore, observers rated the presence of pain after each trial allowing assessment of observers' perceptual sensitivity to others' pain. Results indicated that self-reported fear, fear-potentiated startle, and corrugator electromyography activity were augmented during pain signals compared to safety signals. Moreover, these negative emotional responses were heightened in observers highly catastrophizing about others' pain, but reduced in observers with heightened psychopathic traits. Psychopathic traits were also related with a diminished perceptual sensitivity to others' pain. The results are discussed in light of affective-motivational perspectives on pain. PERSPECTIVE: This study investigated observers' negative emotional responses in anticipation of pain in another, and the moderating role of observers' psychopathic traits and pain catastrophizing. Knowledge about characteristics influencing observers' emotional response to others' pain may provide insight into why observers engage in particular behaviors when faced with another in pain.

When you dislike patients, pain is taken less seriously.

This study examined the influence of patients' likability on pain estimations made by observers. Patients' likability was manipulated by means of an evaluative conditioning procedure: pictures of patients were combined with either positive, neutral, or negative personal traits. Next, videos of the patients were presented to 40 observers who rated the pain. Patients were expressing no, mild-, or high-intensity pain. Results indicated lower pain estimations as well as lower perceptual sensitivity toward pain (i.e., lower ability to discriminate between varying levels of pain expression) with regard to patients who were associated with negative personal traits. The effect on pain estimations was only found with regard to patients expressing high-intensity pain. There was no effect on response bias (i.e., the overall tendency to indicate pain). These findings suggest that we take the pain of patients we do not like less seriously than the pain of patients we like.