Psychosocial aspects of persistent pain

Abstract

The biopsychosocial model posits that biological, psychological, and sociocultural variables interact in a dynamic manner to shape an individual's response to persistent pain. Yet while this model is widely accepted in the formulation and management of pain, psychosocial factors are neglected in much of the persistent pain literature. As such, this program of research presents an examination of psychosocial factors, chiefly through considering internalised stigma from the perspective of people with pain, but also through examining pain judgments from the perspective of future healthcare providers. Internalised stigma reflects a process where the anticipation or experience of negative sociocultural reactions based on pain are essentially turned inward, leading to negative feelings about self, identity transformation, or maladaptive behaviour. Study 1 presents a community based study that assessed the prevalence of internalised stigma and its interrelationships with self-concept and psychological well-being among people with pain (n = 92). Results demonstrated that a large percentage of participants (38%) endorsed the experience of internalised stigma. Internalised stigma had a negative relationship with self-esteem and pain self-efficacy, after controlling for depression. It was also associated with cognitive responses to pain, in terms of greater catastrophisation and a reduced sense of personal control over pain. Study 2 employed a longitudinal design to consider whether internalised stigma predicted the pain self-efficacy and self-esteem of people with pain (n = 57). Main findings suggested that an aspect of internalised stigma, social withdrawal, predicted reduced self-esteem six months later, when taking baseline self-esteem into account. While findings are tentative, they provide evidence of the vicious cycle that can arise from experiencing internalised stigma in terms of isolation and decreased confidence in oneself. Study 3 utilised a quasi-experimental design to consider the modifiable nature of internalised stigma and its capacity to be targeted in treatment. Participants in a cognitive-behavioural pain management program provided pre- and post-program measures (n = 45). Main results indicated that participation in the rehabilitation program was associated with decreased internalised stigma and increased stigma resistance in people with persisting pain. Disability and pain self-efficacy, but not depression, were identified as correlates of change. Finally, Study 4 examined the role of contextual variables in judgments of medical and nursing students (n = 116) by employing a within-subjects experimental vignette paradigm. Main findings suggested that psychosocial factors can have an important influence on perceptions of patients and their pain, including perceived malingering, but this often occurred in interaction with other patient variables. Findings of the four studies are discussed within the context of a biopsychosocial pain formulation. Both socio-cognitive and socio-psychological theories are utilised in the interpretation of findings. Furthermore, discussion considers how this program of research augments qualitative work and builds upon research on internalised stigma in the mental health field. Promising implications for clinical practice, particularly the assessment and tailored targeting of internalised stigma as part of pain management, are discussed. This thesis presents novel findings in an area that has little existing evidence, and provides the empirical beginnings of a fruitful area of research.