Internalized Stigma in People Living With Chronic Pain

Published:February 19, 2014DOI:


      Although persistent pain occurs in a sociocultural context, the influence of personal devaluation and invalidation is often neglected. As such, the present study sought to consider whether individuals' experience, perception, or anticipation of negative social reactions to their pain may become internalized and affect the self. To examine this issue, 92 adults with chronic pain responded to a questionnaire exploring the presence of internalized stigma and its association with a range of psychological consequences. As predicted, a large percentage of people with chronic pain (38%) endorsed the experience of internalized stigma. The results showed that internalized stigma has a negative relationship with self-esteem and pain self-efficacy, after controlling for depression. Internalized stigma was also associated with cognitive functioning in relation to pain, in terms of a greater tendency to catastrophize about pain and a reduced sense of personal control over pain. Overall, this study presents a new finding regarding the application of internalized stigma to a chronic pain population. It offers a means of extending our understanding of chronic pain's psychosocial domain. Implications are discussed in terms of the potential to inform clinical treatment and resiliency into the future.


      This article presents a novel finding regarding the presence of internalized stigma among people living with chronic pain. Internalized stigma is strongly associated with indicators of patient outcome. It presents an area for future work with the aim to improve our understanding and treatment of people living with pain.

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        • Ajzen I.
        Perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior.
        J Appl Soc Psychol. 2002; 32: 665-683
        • Blyth F.M.
        • Macfarlane G.J.
        • Nicholas M.K.
        The contribution of psychosocial factors to the development of chronic pain: The key to better outcomes for patients?.
        Pain. 2007; 129: 8-11
        • Börsbo B.
        • Peolsson M.
        • Gerdle B.
        The complex interplay between pain intensity, depression, anxiety and catastrophising with respect to quality of life and disability.
        Disabil Rehabil. 2009; 31: 1605-1613
        • Boyd Ritsher J.
        • Otilingam P.G.
        • Grajales M.
        Internalized stigma of mental illness: Psychometric properties of a new measure.
        Psychiatry Res. 2003; 121: 31-49
        • Brohan E.
        • Gauci D.
        • Sartorius N.
        • Thornicroft G.
        Self-stigma, empowerment and perceived discrimination among people with bipolar disorder or depression in 13 European countries: The GAMIAN Europe study.
        J Affect Disord. 2011; 129: 56-63
        • Camp D.L.
        • Finlay W.M.L.
        • Lyons E.
        Is low self-esteem an inevitable consequence of stigma? An example from women with chronic mental health problems.
        Soc Sci Med. 2002; 55: 823-834
        • Cohen J.
        Statistical Power Analysis for Behavioral Sciences.
        2nd ed. Lawrence Erlbaum, Hillsdale, NJ1988
        • Corrigan P.W.
        • Larson J.E.
        • Rúsch N.
        Self-stigma and the “why try” effect: Impact on life goals and evidence-based practices.
        World Psychiatry. 2009; 8: 75-81
        • Corrigan P.W.
        • Watson A.C.
        • Barr L.
        The self-stigma of mental illness: Implications for self-esteem and self-efficacy.
        J Soc Clin Psychol. 2006; 25: 875-884
        • Crocker J.
        • Major B.
        • Steele C.
        Social stigma.
        in: Gilbert D. Fiske S.T. Lindzey G. The Handbook of Social Psychology. McGraw-Hill, New York1998
        • Dumit J.
        Illnesses you have to fight to get: Facts as forces in uncertain, emergent illnesses.
        Soc Sci Med. 2006; 62: 577-590
        • Foster N.E.
        • Bishop A.
        • Thomas E.
        • Main C.J.
        • Horne R.
        • Weinman J.
        • Hay E.
        Illness perceptions of low back pain patients in primary care: What are they, do they change and are they associated with outcome?.
        Pain. 2008; 136: 177-187
        • Foster N.E.
        • Thomas E.
        • Bishop A.
        • Dunn K.M.
        • Main C.J.
        Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care.
        Pain. 2010; 148: 398-406
        • Frohm K.D.
        • Beehler G.P.
        Psychologists as change agents in chronic pain management practice: Cultural competence in the health care system.
        Psychol Serv. 2010; 7: 115-125
        • Gatchel R.J.
        • Peng Y.B.
        • Peters M.L.
        • Fuchs P.N.
        • Turk D.C.
        The biopsychosocial approach to chronic pain: Scientific advances and future directions.
        Psychol Bull. 2007; 133: 581-624
        • Glenton C.
        Chronic back pain sufferers—Striving for the sick role.
        Soc Sci Med. 2003; 57: 2243-2252
        • Goffman E.
        Stigma: Notes on the Management of Spoiled Identity.
        1st ed. Penguin, Harmondsworth1964
        • Goldberg D.
        Jobs and the stigmatization of chronic pain.
        Perspect Biol Med. 2010; 53: 425-438
        • Hadjistavropoulos T.
        • Craig K.D.
        • Duck S.
        • Cano A.
        • Goubert L.
        • Jackson P.L.
        • Mogil J.S.
        • Rainville P.
        • Sullivan M.J.L.
        • Williams ACdC
        • Vervoort T.
        • Fitzgerald T.D.
        A biopsychosocial formulation of pain communication.
        Psychol Bull. 2011; 137: 910-939
        • Henry J.D.
        • Crawford J.R.
        The short-form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large non-clinical sample.
        Br J Clin Psychol. 2005; 44: 227-239
        • Holloway I.
        • Sofaer-Bennett B.
        • Walker J.
        The stigmatisation of people with chronic back pain.
        Disabil Rehabil. 2007; 29: 1456-1464
        • Kool M.B.
        • van Middendorp H.
        • Lumley M.A.
        • Schenk Y.
        • Jacobs J.W.
        • Bijlsma J.W.
        • Geenen R.
        Lack of understanding in fibromyalgia and rheumatoid arthritis: The Illness Invalidation Inventory (3*I).
        Ann Rheum Dis. 2010; 69: 1990-1995
        • Lennon M.C.
        • Link B.G.
        • Marbach J.J.
        • Dohrenwend B.P.
        The stigma of chronic facial-pain and its impact on social relationships.
        Soc Prob. 1989; 36: 117-134
        • Link B.G.
        • Phelan J.C.
        Conceptualizing stigma.
        Annu Rev Sociol. 2001; 27: 363-385
        • Link B.G.
        • Struening E.
        • Dohrenwend B.P.
        • Cullen F.T.
        • Shrout P.E.
        A modified labeling theory approach to mental disorders: An empirical assessment.
        Am Sociol Rev. 1989; 54: 400-423
        • Linton S.J.
        • Bergbom S.
        Understanding the link between depression and pain.
        Scand J Pain. 2011; 2: 47-54
        • Livingston J.D.
        • Boyd J.E.
        Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis.
        Soc Sci Med. 2010; 71: 2150-2161
        • Lovibond S.H.
        • Lovibond P.F.
        Manual for the Depression Anxiety Stress Scales.
        2nd ed. Psychology Foundation, Sydney1995
        • Lucksted A.
        • Drapalski A.
        • Calmes C.
        • Forbes C.
        • DeForge B.
        • Boyd J.
        Ending self-stigma: Pilot evaluation of a new intervention to reduce internalized stigma among people with mental illnesses.
        Psychiatr Rehabil J. 2011; 35: 51-54
        • Lysaker P.H.
        • Roe D.
        • Yanos P.T.
        Toward understanding the insight paradox: Internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders.
        Schizophr Bull. 2007; 33: 192-199
        • Marbach J.J.
        • Lennon M.C.
        • Link B.G.
        • Dohrenwend B.P.
        Losing face: Sources of stigma as perceived by chronic facial pain patients.
        J Behav Med. 1990; 13: 583-604
        • Moss-Morris R.
        • Weinman J.
        • Petrie K.
        • Horne R.
        • Cameron L.
        • Buick D.
        The Revised Illness Perception Questionnaire (IPQ-R).
        Psychol Health. 2002; 17: 1-16
        • Munoz M.
        • Sanz M.
        • Perez-Santos E.
        • Quiroga M.D.
        Proposal of a socio-cognitive-behavioral structural equation model of internalized stigma in people with severe and persistent mental illness.
        Psychiatry Res. 2011; 186: 402-408
        • Ng F.
        • Trauer T.
        • Dodd S.
        • Callaly T.
        • Campbell S.
        • Berk M.
        The validity of the 21-item version of the Depression Anxiety Stress Scales as a routine clinical outcome measure.
        Acta Neuropsychiatr. 2007; 19: 304-310
      1. Nicholas MK: Self-efficacy and chronic pain. Presented at the Annual Conference of the British Psychological Society, St. Andrews, UK, 1989

        • Nicholas M.K.
        The pain self-efficacy questionnaire: Taking pain into account.
        Eur J Pain. 2007; 11: 153-163
        • Nicholas M.K.
        • Asghari A.
        • Blyth F.M.
        What do the numbers mean? Normative data in chronic pain measures.
        Pain. 2008; 134: 158-173
        • Nielsen M.
        Comment on Blyth FM, Macfarlane GJ, Nicholas MK. The contribution of psychosocial factors to the development of chronic pain: The key to better outcomes for patients? Pain 2007;129:8-11.
        Pain. 2007; 131: 348-349
        • Osman A.
        • Barrios F.
        • Gutierrez P.
        • Kopper B.
        • Merrifield T.
        • Grittmann L.
        The Pain Catastrophizing Scale: Further psychometric evaluation with adult samples.
        J Behav Med. 2000; 23: 351-365
        • Padurariu M.
        • Ciobica A.
        • Persson C.
        • Stefanescu C.
        Self-stigma in psychiatry: Ethical and bio-psycho-social perspectives.
        Revista Romana De Bioetica. 2011; 9: 76-82
        • Quartana P.J.
        • Campbell C.M.
        • Edwards R.R.
        Pain catastrophizing: A critical review.
        Expert Rev Neurother. 2009; 9: 745-758
        • Rahman A.
        • Reed E.
        • Underwood M.
        • Shipley M.E.
        • Omar R.Z.
        Factors affecting self-efficacy and pain intensity in patients with chronic musculoskeletal pain seen in a specialist rheumatology pain clinic.
        Rheumatology. 2008; 47: 1803-1808
        • Ritsher J.B.
        • Phelan J.C.
        Internalized stigma predicts erosion of morale among psychiatric outpatients.
        Psychiatry Res. 2004; 129: 257-265
        • Robins R.W.
        • Hendin H.M.
        • Trzesniewski K.H.
        Measuring global self-esteem: Construct validation of a single-item measure and the Rosenberg Self-Esteem Scale.
        Personality Soc Psychol Bull. 2001; 27: 151-161
        • Roland M.
        • Morris R.
        A study of the natural-history of back pain. Part 1: Development of a reliable and sensitive measure of disability in low-back-pain.
        Spine. 1983; 8: 141-144
        • Rosenberg M.
        Society and the Adolescent Self-Image.
        revised edition. Wesleyan University Press, Middletown, CT1989
        • Slade S.C.
        • Molloy E.
        • Keating J.L.
        Stigma experienced by people with nonspecific chronic low back pain: A qualitative study.
        Pain Med. 2009; 10: 143-154
      2. Stevelink SAM, Wu IC, Voorend CGN, van Brakel WH: The psychometric assessment of internalized stigma instruments: A systematic review. Stigma Res Action 2: 2012

        • Sullivan M.J.L.
        The communal coping model of pain catastrophising: Clinical and research implications.
        Can Psychol. 2012; 53: 32-41
        • Sullivan M.J.L.
        • Thorn B.
        • Haythornthwaite J.A.
        • Keefe F.
        • Martin M.
        • Bradley L.A.
        • Lefebvre J.C.
        Theoretical perspectives on the relation between catastrophizing and pain.
        Clin J Pain. 2001; 17: 52-64
        • Thomas S.P.
        A phenomenologic study of chronic pain.
        West J Nurs Res. 2000; 22: 683-699
        • Tsang HW-h
        • Fung KM-t
        • Chung RC-k
        Self-stigma and stages of change as predictors of treatment adherence of individuals with schizophrenia.
        Psychiatry Res. 2010; 180: 10-15
        • Turk D.C.
        • Okifuji A.
        Psychological factors in chronic pain: Evolution and revolution.
        J Consult Clin Psychol. 2002; 70: 678-690
        • Van Brakel W.H.
        Measuring health-related stigma: A literature review.
        Psychol Health Med. 2006; 11: 307-334
        • van Dirk R.
        • Haslam S.A.
        Stress and well-being in the workplace: Support for key propositions from the social identity approach.
        in: Jetten J. Haslam C. Haslam S.A. The Social Cure: Identity, Health and Well-Being. Psychology Press, Hove, East Sussex2012: 175-195
        • Watson A.C.
        • Corrigan P.
        • Larson J.E.
        • Sells M.
        Self-stigma in people with mental illness.
        Schizophr Bull. 2007; 33: 1312-1318
        • World Health Organization
        Promoting Mental Health: Concepts, Emerging Evidence and Practice.
        World Health Organization, Geneva2004
        • Yanos P.T.
        • Roe D.
        • Lysaker P.H.
        Narrative enhancement and cognitive therapy: A new group-based treatment for internalized stigma among persons with severe mental illness.
        Int J Group Psychother. 2011; 61: 576-595
        • Yanos P.T.
        • Roe D.
        • West M.L.
        • Smith S.M.
        • Lysaker P.H.
        Group-based treatment for internalized stigma among persons with severe mental illness: Findings from a randomized controlled trial.
        Psychol Serv. 2012; 9: 248-258