Defeating the stigma of chronic pain.
Venue: Pain

De Ruddere and Craig, in their Topical Review, 6 describe the stigma applied to and felt by people with chronic pain in a psychosocial context: as deviance from expected behaviour, both in medical settings, where symptoms should be independently verifiable and curable, and in broader social settings, where adults are expected to be autonomous and productive until old age. Stigma is a distressing experience for the target and risks exacerbating social withdrawal, undermining attempts to manage despite pain, and depleting self esteem. Furthermore, stigma is internalized by people with chronic pain, who may themselves endorse stigmatizing statements, along with statements expressing alienation and reporting discrimination. The extent to which stigma is internalized in chronic pain is similar to that in people with severe mental illness. Furthermore, the discrimination is very real: in a study in which students thought they were rating 2 remote potential exercise partners, shown just in light dot displays of an outline of the body in movement, the one with pain behavior was rated less warm and less competent than the healthy one. Perhaps, though, stigma matters most in clinical settings, where it is associated with underassessment and underestimation of pain by health care staff, with discounting of self report of pain, disbelief and suspicion concerning the reality and the extent of suffering, and consequent undertreatment (and overpsychologization) of pain. All these processes of dismissing and discounting patients' reports affect their encounters, from consultation with a known primary care doctor, to presentation to the Emergency Department with an injury, to report of postoperative pain to a ward nurse, and to agitated crying in an elderly person with cognitive impairment. In a study examining social media accounts of chronic pain, many representations on Tumblr (a microblogging and social networking site) described the lack of fit with medical models of pain and described illness as "excommunication," a term expressing social exclusion for deviance from socially accepted norms. There are plenty of studies demonstrating stigma in practice: there are few that attempt to change the beliefs and behaviors of health care staff. The Topical Review by De Ruddere and Craig maps the areas in which research on stigma and pain is seriously lacking. Existing studies are overreliant on descriptive methods and on self report, whether in standardized or nonstandard forms. They tend to focus on the impact of stigma rather than on causes and mechanisms, or on interventions to mitigate stigma and its effects. DeRuddere andCraig are to be congratulated for tackling the difficult topic of possible mechanisms of stigma since, without theory driven research, as they emphasize, we are likely to make little progress. They hint at some of the broader social forces that put people with chronic pain at a disadvantage, such as the sanctioned deviance of the "sick role" that recognizes the rights of acutely ill people not to fulfil their usual societal roles, but only if theymake every effort to acquire and comply withmedical advice, a counterproductive pursuit for many with chronic painful disorders. Much of the rhetoric of self management instantiates this moral dynamic, despite the lack of evidence that it supports patients or enables them to achieve the desired autonomy. Invoking evolution as the dynamic that made us as we are now suspicious of possible freeloaders, doubtful of what we cannot see ourselves but only hear reported is only part of the picture. Evolution has equipped us with contextual rules of thumb that are so fundamental to our experience of the world that we often fail to investigate them. The "cheater detection mechanism" the sensitivity to possible exploitation of our resources or common goods is demonstrated by our difficulty with abstract logical tasks but ease when the same logical problem is expressed in social terms. It is our alertness to possible freeloaders, those who take a common good without earning or deserving what they take, that allows us, in general, to be reasonably altruistic. We make rapid estimations of trustworthiness that, although they generally agree with others' estimations, may have no basis in fact: these, too, affect judgments of authenticity in patients with pain. We are quick to make alliances based on similarity, such as of age, gender, or perceived preferences, but similarity is defined by contrast to outgroups who are different, perhaps inminor ways, including even external allocations such as membership of a temporary team. Thus, members of the outgroup may be stigmatized and marginalized for trivial reasons. Many of the paradigms used to investigate evolved cognitive, emotional, and social biases could usefully be extended to the pain field, whether with human subjects (eg, Ref. 12) or in silico (eg, Ref. 22) At an individual level, the proposal of fostering resilience to stigma through emotion regulation in people with chronic pain is promising, aiming to protect them from internalizing or accepting the attributions of stigma, although it leaves stigma itself unchanged. Using clinicians' report of gaps in understanding and in treatment options, De Ruddere and Craig make a good argument for better pain education. But education is not by itself likely to reverse deeply entrenched biases in thinking, adverse automatic judgments, rejecting behaviors, or societal values that underpin them. Eccleston has defined ours as "an analgesic culture, defined by the dominant belief that pain should be short lived, diagnostically meaningful, and denote a fixable problem" (p140) Chronic pain does not fit the model: diagnoses often add little Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.