Advertisement

Measuring Stigma in Chronic Pain: Preliminary Investigation of Instrument Psychometrics, Correlates, and Magnitude of Change in a Prospective Cohort Attending Interdisciplinary Treatment

  • Whitney Scott
    Affiliations
    Health Psychology Section, Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK

    INPUT Pain Management Unit, Guy's and St Thomas’ NHS Foundation Trust, London, UK
    Search for articles by this author
  • Lin Yu
    Affiliations
    INPUT Pain Management Unit, Guy's and St Thomas’ NHS Foundation Trust, London, UK
    Search for articles by this author
  • Shrina Patel
    Affiliations
    INPUT Pain Management Unit, Guy's and St Thomas’ NHS Foundation Trust, London, UK
    Search for articles by this author
  • Lance M. McCracken
    Correspondence
    Address reprint requests to Whitney Scott, Health Psychology Section, King's College London, Guy's Hospital Campus, London SE1 9RT.
    Affiliations
    Health Psychology Section, Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK

    INPUT Pain Management Unit, Guy's and St Thomas’ NHS Foundation Trust, London, UK
    Search for articles by this author

      Highlights

      • The Stigma Scale for Chronic Illness 8-item version is a psychometrically sound measure of stigma in chronic pain.
      • Stigma was uniquely associated with depression and daily functioning.
      • Total stigma scores did not change after interdisciplinary treatment.

      Abstract

      Chronic pain is a potentially stigmatizing condition. However, stigma has received limited empirical investigation in people with chronic pain. Therefore, we examined the psychometric properties of a self-report questionnaire of stigma in people with chronic pain attending interdisciplinary treatment. Secondarily, we undertook an exploratory examination of the magnitude of change in stigma associated with interdisciplinary treatment in a prospective observational cohort. Participants attending interdisciplinary treatment based on acceptance and commitment therapy completed the Stigma Scale for Chronic Illness 8-item version (SSCI-8; previously developed and validated in neurological samples), and measures of perceived injustice, pain acceptance, and standard pain outcomes before (n = 300) and after treatment (n = 247). A unidimensional factor structure and good internal consistency were found for the SSCI-8. Total SSCI-8 scores were correlated with pain intensity, indices of functioning, and depression in bivariate analyses. Stigma scores were uniquely associated with functioning and depression in multiple regression analyses controlling for demographic factors, pain intensity, pain acceptance, and perceived injustice at baseline. SSCI-8 total scores did not significantly improve after treatment, although an exploratory subscale analysis showed a small improvement on internalized stigma. In contrast, scores on perceived injustice, pain acceptance, and pain outcomes improved significantly. Taken together, these data support the reliability and validity of the SSCI-8 for use in samples with chronic pain. Further research is needed optimize interventions to target stigma at both the individual and societal levels.

      Perspective

      This study supports the use of the SSCI-8 to measure stigma in chronic pain. Stigma is uniquely associated with worse depression and pain-related disability. Research is needed to identify how to best target pain-related stigma from individual and societal perspectives.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Bock RD
        • Mislevy RJ
        Adaptive EAP estimation of ability in a microcomputer environment.
        Appl Psychol Measure. 1982; 6: 431-444
        • Brown L
        • Macintyre K
        • Trujillo L
        Interventions to reduce HIV/AIDS stigma: What have we learned?.
        AIDS Educ Prev. 2003; 15: 49-69
        • Buenaver LF
        • Edwards RR
        • Haythornthwaite JA
        Pain-related catastrophizing and perceived social responses: Inter-relationships in the context of chronic pain.
        Pain. 2007; 127: 234-242
        • Cano A
        • Corley AM
        • Clark SM
        • Martinez SC
        A couple-based psychological treatment for chronic pain and relationship distress.
        Cogn Behav Pract. 2018; 25: 119-134
        • Cano A
        • Leong LE
        • Williams AM
        • May DK
        • Lutz JR
        Correlates and consequences of the disclosure of pain-related distress to one's spouse.
        Pain. 2012; 153: 2441-2447
        • Cano A
        • Williams ACdC
        Social interaction in pain: Reinforcing pain behaviors or building intimacy?.
        Pain. 2010; 149: 9-11
        • Cella M
        • Sharpe M
        • Chalder T
        Measuring disability in patients with chronic fatigue syndrome: Reliability and validity of the Work and Social Adjustment Scale.
        J Psychosom Res. 2011; 71: 124-128
        • Cleeland C
        • Ryan K
        Pain assessment: Global use of the Brief Pain Inventory.
        Ann Acad Med Singapore. 1994; 23: 129-138
      1. Cohen J Statistical Power Analysis for the Behavioral Sciences. 2nd ed. L. Erlbaum Associates, Mahwah, NJ1988
        • Daly-Eichenhardt A
        • Scott W
        • Howard-Jones M
        • Nicolaou T
        • McCracken LM
        Changes in sleep problems and psychological flexibility following interdisciplinary Acceptance and Commitment Therapy for chronic pain: An observational cohort study.
        Front Psychol. 2016; 7: 1326
        • De Ruddere L
        • Craig KD
        Understanding stigma and chronic pain: A state of the art review.
        Pain. 2016; 157: 1607-1610
        • De Ruddere L
        • Goubert L
        • Stevens M
        • Williams ACdC
        • Crombez G
        Discounting pain in the absence of medical evidence is explained by negative evaluation of the patient.
        Pain. 2013; 154: 669-676
        • De Ruddere L
        • Goubert L
        • Stevens MAL
        • Deveugele M
        • Craig KD
        • Crombez G
        Health care professionals' reactions to patient pain: Impact of knowledge about medical evidence and psychosocial influences.
        J Pain. 2014; 15: 262-270
        • Dunlap WP
        • Cortina JM
        • Vaslow JB
        • Burke MJ
        Meta-analysis of experiments with matched groups or repeated measures designs.
        Psychol Methods. 1996; 1: 170-177
        • Dworkin RH
        • Turk DC
        • Farrar JT
        • Haythornthwaite JA
        • Jensen MP
        • Katz NP
        • Kerns RD
        • Stucki G
        • Allen RR
        • Bellamy N
        • Carr DB
        • Chandler J
        • Cowan P
        • Dionne R
        • Galer BS
        • Hertz S
        • Jadad AR
        • Kramer LD
        • Manning DC
        • Martin S
        • McCormick CG
        • McDermott MP
        • McGrath P
        • Quessy S
        • Rappaport BA
        • Robbins W
        • Robinson JP
        • Rothman M
        • Royal MA
        • Simon L
        • Stauffer JW
        • Stein W
        • Tollett J
        • Wernicke J
        • Witter J
        Core outcome measures for chronic pain clinical trials: IMMPACT recommendations.
        Pain. 2005; 113: 9-19
        • Eccleston C
        • Williams ACDC
        • Rogers WS
        Patients' and professionals' understandings of the causes of chronic pain: Blame, responsibility and identity protection.
        Soc Sci Med. 1997; 45: 699-709
        • Edelen MO
        • Reeve BB
        Applying item response theory (IRT) modeling to questionnaire development, evaluation, and refinement.
        Qual Life Res. 2007; 16: 5-18
        • Edmond SN
        • Keefe FJ
        Validating pain communication: Current state of the science.
        Pain. 2015; 156: 215-219
        • Fish RA
        • McGuire B
        • Hogan M
        • Morrison TG
        • Stewart I
        Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in an Internet sample and development and preliminary validation of the CPAQ-8.
        Pain. 2010; 149: 435-443
        • Froud R
        • Fawkes C
        • Foss J
        • Underwood M
        • Carnes D
        Responsiveness, reliability, and minimally important and minimal detectable changes of 3 electronic patient-reported outcome measures for low back pain: Validation study.
        J Med Internet Res. 2018; 20: e272
        • Garthwaite K
        Fear of the brown envelope: Exploring welfare reform with long‐term sickness benefits recipients.
        Soc Policy Admin. 2014; 48: 782-798
        • Garthwaite K
        Becoming incapacitated? Long‐term sickness benefit recipients and the construction of stigma and identity narratives.
        Sociol Health Illn. 2015; 37: 1-13
        • Goffman E
        Stigma and social identity.
        in: Goffman E Stigma: Notes on the Management of Spoiled Identity. Prentice-Hall Inc, Englewood Cliffs, NJ1963: 1-40
        • Guildford BJ
        • Daly-Eichenhardt A
        • Hill B
        • Sanderson K
        • McCracken LM
        Analgesic reduction during an interdisciplinary pain management programme: Treatment effects and processes of change.
        Br J Pain. 2018; 12: 72-86
        • Guildford BJ
        • Jacobs CM
        • Daly-Eichenhardt A
        • Scott W
        • McCracken LM
        Assessing physical functioning on pain management programmes: The unique contribution of directly assessed physical performance measures and their relationship to self-reports.
        Br J Pain. 2017; 11: 46-57
        • Hadjistavropoulos T
        • Craig KD
        • Duck S
        • Cano A
        • Goubert L
        • Jackson PL
        • Mogil JS
        • Rainville P
        • Sullivan MJ
        • Williams ACdC
        • Vervoort T
        • Fitzgerald TD
        A biopsychosocial formulation of pain communication.
        Psychol Bull. 2011; 137: 910-939
        • Hann KE
        • McCracken LM
        A systematic review of randomized controlled trials of Acceptance and Commitment Therapy for adults with chronic pain: Outcome domains, design quality, and efficacy.
        J Contextual Behav Sci. 2014; 3: 217-227
        • Hayes SC
        • Villatte M
        • Levin M
        • Hildebrandt M
        Open, aware, and active: Contextual approaches as an emerging trend in the behavioral and cognitive therapies.
        Annu Rev Clin Psychol. 2011; 7: 141-168
        • Horn JL
        A rationale and test for the number of factors in factor analysis.
        Psychometrika. 1965; 30: 179-185
        • Karos K
        • Williams ACdC
        • Meulders A
        • Vlaeyen JW
        Pain as a threat to the social self: A motivational account.
        Pain. 2018; 159: 1690-1695
        • Keller S
        • Bann CM
        • Dodd SL
        • Schein J
        • Mendoza TR
        • Cleeland CS
        Validity of the Brief Pain Inventory for use in documenting the outcomes of patients with noncancer pain.
        Clin J Pain. 2004; 20: 309-318
        • Kool M
        • Van Middendorp H
        • Lumley M
        • Schenk Y
        • Jacobs J
        • Bijlsma J
        • Geenen R
        Lack of understanding in fibromyalgia and rheumatoid arthritis: The Illness Invalidation Inventory (3* I).
        Ann Rheum Dis. 2010; 69: 1990-1995
        • Kool MB
        • van Middendorp H
        • Boeije HR
        • Geenen R
        Understanding the lack of understanding: Invalidation from the perspective of the patient with fibromyalgia.
        Arthritis Care Res. 2009; 61: 1650-1656
        • Krafft J
        • Ferrell J
        • Levin ME
        • Twohig MP
        Psychological inflexibility and stigma: A meta-analytic review.
        J Contextual Behav Sci. 2018; 7: 15-28
        • Kroenke K
        • Spitzer RL
        • Williams JB
        The PHQ‐9.
        J Gen Intern Med. 2001; 16: 606-613
        • Ledesma RD
        • Valero-Mora P
        Determining the number of factors to retain in EFA: An easy-to-use computer program for carrying out parallel analysis.
        Practical Assessment, Research & Evaluation. 2007; 12: 1-11
        • Leong LE
        • Cano A
        • Wurm LH
        • Lumley MA
        • Corley AM
        A perspective-taking manipulation leads to greater empathy and less pain during the cold pressor task.
        J Pain. 2015; 16: 1176-1185
        • Li AT-W
        • Fung KP-L
        • Maticka-Tyndale E
        • Wong JP-H
        Effects of HIV stigma reduction interventions in diasporic communities: Insights from the CHAMP Study.
        AIDS Care. 2018; 30: 739-745
        • Lorenzo-Seva U
        • Ferrando PJ
        FACTOR: A computer program to fit the exploratory factor analysis model.
        Behav Res Methods. 2006; 38: 88-91
        • Luoma JB
        • Kohlenberg BS
        • Hayes SC
        • Bunting K
        • Rye AK
        Reducing self-stigma in substance abuse through Acceptance and Commitment Therapy: Model, manual development, and pilot outcomes.
        Addict Res Theory. 2008; 16: 149-165
        • McCracken LM
        • Vowles KE
        Acceptance and Commitment Therapy and mindfulness for chronic pain: Model, process, and progress.
        Am Psychol. 2014; 69: 178-187
        • McCracken LM
        • Vowles KE
        • Eccleston C
        Acceptance of chronic pain: Component analysis and a revised assessment method.
        Pain. 2004; 107: 159-166
        • Mislevy RJ
        Recent developments in the factor analysis of categorical variables.
        J Educ Stat. 1985; 11: 3-31
        • Molina Y
        • Choi SW
        • Cella D
        • Rao D
        The Stigma Scale for Chronic Illnesses 8-item version (SSCI-8): Development, validation and use across neurological conditions.
        Int J Behav Med. 2013; 20: 450-460
        • Mundt JC
        • Marks IM
        • Shear MK
        • Greist JM
        The Work and Social Adjustment Scale: A simple measure of impairment in functioning.
        Br J Psychiatry. 2002; 180: 461-464
        • Nakagawa S
        • Cuthill IC
        Effect size, confidence interval and statistical significance: A practical guide for biologists.
        Biol Rev. 2007; 82: 591-605
        • Nyblade L
        • Stangl A
        • Weiss E
        • Ashburn K
        Combating HIV stigma in health care settings: What works?.
        J Int AIDS Soc. 2009; 12: 15-21
        • Rao D
        • Choi SW
        • Victorson D
        • Bode R
        • Peterman A
        • Heinemann A
        • Cella D
        Measuring stigma across neurological conditions: The development of the Stigma Scale for Chronic Illness (SSCI).
        Qual Life Res. 2009; 18: 585-595
        • Rao D
        • Feldman BJ
        • Fredericksen RJ
        • Crane PK
        • Simoni JM
        • Kitahata MM
        • Crane HM
        A structural equation model of HIV-related stigma, depressive symptoms, and medication adherence.
        AIDS Behav. 2012; 16: 711-716
        • Rao D
        • Molina Y
        • Lambert N
        • Cohn SE
        Assessing stigma among African Americans living with HIV.
        Stigma Health. 2016; 1: 146-155
        • Reckase MD
        The difficulty of test items that measure more than one ability.
        Appl Psychol Measure. 1985; 9: 401-412
        • Rovner GS
        • Årestedt K
        • Gerdle B
        • Börsbo B
        • McCracken LM
        Psychometric properties of the 8-item Chronic Pain Acceptance Questionnaire (CPAQ-8) in a Swedish chronic pain cohort.
        J Rehabil Med. 2014; 46: 73-80
        • Scott W
        • McEvoy A
        • Garland R
        • Bernier E
        • Milioto M
        • Trost Z
        • Sullivan M
        Sources of injustice among individuals with persistent pain following musculoskeletal injury.
        Psychol Injury Law. 2016; 9: 6-15
        • Scott W
        • Trost Z
        • Milioto M
        • Sullivan M
        Further validation of a measure of injury-related injustice perceptions to identify risk for occupational disability: A prospective study of individuals with whiplash injury.
        J Occup Rehabil. 2013; 23: 557-565
        • Scott W
        • Trost Z
        • Milioto M
        • Sullivan MJ
        Barriers to change in depressive symptoms following multidisciplinary rehabilitation for whiplash: The role of perceived injustice.
        Clin J Pain. 2015; 31: 145-151
        • Sullivan MJ
        • Scott W
        • Trost Z
        Perceived injustice: A risk factor for problematic pain outcomes.
        Clin J Pain. 2012; 28: 484-488
        • Sullivan MJL
        • Adams H
        • Horan S
        • Maher D
        • Boland D
        • Gross R
        The role of perceived injustice in the experience of chronic pain and disability: Scale development and validation.
        J Occup Rehabil. 2008; 18: 249-261
        • Veehof M
        • Trompetter H
        • Bohlmeijer E
        • Schreurs K
        Acceptance-and mindfulness-based interventions for the treatment of chronic pain: A meta-analytic review.
        Cogn Behav Ther. 2016; 45: 5-31
        • Wadley AL
        • Mitchell D
        • Kamerman PR
        Resilience does not explain the dissociation between chronic pain and physical activity in South Africans living with HIV.
        PeerJ. 2016; 4
      2. Wadley AL, Pincus T, Evangeli M: A preliminary analysis of the association between perceived stigma and HIV-related pain. Available at: www.biorxiv.org/content/biorxiv/early/2017/09/27/194191.full.pdf. Accessed September 28, 2018

        • Waugh OC
        • Byrne DG
        • Nicholas MK
        Internalized stigma in people living with chronic pain.
        J Pain. 2014; 15 (550.e551-550.e510)
        • Werner A
        • Malterud K
        It is hard work behaving as a credible patient: Encounters between women with chronic pain and their doctors.
        Soc Sci Med. 2003; 57: 1409-1419
        • Williams ACdC
        Defeating the stigma of chronic pain.
        Pain. 2016; 157: 1581-1582
        • Williams ACdC
        • Craig KD
        Updating the definition of pain.
        Pain. 2016; 157: 2420-2423
        • Wirth R
        • Edwards MC
        Item factor analysis: Current approaches and future directions.
        Psychol Methods. 2007; 12: 58-79