The Pain-Invalidation Scale: Measuring Patient Perceptions of Invalidation Toward Chronic Pain


      • Invalidation of chronic pain through disbelief or over-attentiveness can be damaging.
      • To identify the source of pain invalidation, a multi-domain scale was developed and validated.
      • Subscales included the Self, Immediate Others, Healthcare Professionals and Over-attentive Others.
      • The subscales were psychometrically sound and correlated with related measures.
      • Addressing the source of pain invalidation may promote treatment adherence and progress.


      Increasing evidence reveals the damaging impact of having one's chronic pain symptoms invalidated through disbelief, discrediting, and critical judgement. In other instances, a caregiver's over-attentiveness to the daily tasks of individuals with pain can be problematic, potentially undermining rehabilitation. The aim of this study was to develop an instrument to measure different aspects of invalidation perceived by people with chronic pain. Item generation was informed through literature review and a thematic analysis of narratives from 431 peer-reviewed articles. The crowdsourcing platform Prolific was used to distribute survey items to participants. In Study 1A, Principal Component Analysis was performed on data from 302 respondents, giving rise to 4 subscales, including: Invalidation by the Self, Invalidation by Immediate Others, Invalidation by Healthcare Professionals, and Invalidation by Over-attentive Others. Confirmatory Factor Analysis of data collected from another 308 individuals in Study 1B supported the 4-factor model of the Pain-Invalidation Scale (Pain-IS) and identified a best-fit model with 24 items. The Pain-IS was further validated in another 300 individuals in Study 2. The Pain-IS demonstrates sound psychometric properties and may serve as a valuable tool for use by clinicians in the detection of pain-invalidation issues, as a first step in patient pain management.


      Links between pain-invalidation and pain levels, as well as functional detriment, highlight the importance of having one's chronic pain experience heard, believed, and accepted. The Pain-Invalidation Scale is designed to identify domains where invalidation of the patient's pain should be addressed to promote emotional processing, treatment adherence, and improved outcomes.

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


        • Adachi T
        • Nakae A
        • Maruo T
        • Shi K
        • Shibata M
        • Maeda L
        • Sasaki J
        Validation of the Japanese version of the pain self-efficacy questionnaire in Japanese patients with chronic pain.
        Pain Med. 2009; 15: 1405-1417
        • Ali A
        • Vitulano L
        • Lee R
        • Weiss TR
        • Colson ER
        Experiences of patients identifying with chronic Lyme disease in the healthcare system: a qualitative study.
        BMC Fam Pract. 2014; 15 (Available at): 79-86
        • Armentor JL
        Living with a contested, stigmatized illness: Experiences of managing relationships among women with fibromyalgia.
        Qual Health Res. 2017; 27: 462-473
        • Asbring P
        Chronic illness – a disruption in life: Identity-transformation among women with chronic fatigue syndrome and fibromyalgia.
        J Adv Nurs. 2001; 34: 312-319
        • Berry MP
        • Lutz J
        • Schuman-Olivier Z
        • Germer C
        • Pollak S
        • Edwards RR
        • Gardiner P
        • Desbordes G
        • Napadow V
        Brief self-compassion training alters neural responses to evoked pain for chronic low back pain: A pilot study.
        Pain Med. 2020; 21: 2172-2185
        • Birk LB
        Erasure of the credible subject: an autoethnographic account of chronic pain.
        Cult Stud. 2013; 13: 390-399
        • Bontempo AC
        The need for a standardized conceptual term to describe invalidation of patient symptoms.
        J Health Psychol. 2021;
        • Bowers H
        • Wroe A
        Beliefs about emotions mediate the relationship between emotional suppression and quality of life in irritable bowel syndrome.
        J Ment Health. 2016; 25: 154-158
        • Broom AF
        • Kirby ER
        • Adams J
        • Refshauge KM
        On illegitimacy, suffering and recognition: A diary study of women living with chronic pain.
        Sociology. 2015; 49: 712-731
        • Burger AJ
        • Lumley MA
        • Carty JN
        • Latsch DV
        • Thakur ER
        • Hyde-Nolan M
        • Hijazi AM
        • Schubiner H
        The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: A preliminary, uncontrolled trial.
        J Psychosom Res. 2016; 81: 1-8
        • Byrne BM
        Structural Equation Modeling With AMOS – Basic Concepts, Applications, and Programming.
        3rd ed. Routledge, New YorkNY2016
        • Cano A
        • Goubert L
        What's in a name? The case of emotional disclosure of pain-related distress.
        J Pain. 2017; 18 (Available at): 881-888
        • Carroll LJ
        • Rothe JP
        • Ozegovic D
        What does coping mean to the worker with pain-related disability? A qualitative study.
        Disabil Rehabil. 2013; 35: 1182-1190
        • Clark LA
        • Watson D
        Constructing validity: Basic issues in objective scale development.
        Psychol Assessment. 1995; 7: 309-319
        • Cleeland CS
        • Ryan KM
        Pain assessment: Global use of the Brief Pain Inventory.
        Ann Acad Med Singap. 1994; 23: 129-138
        • Costello AB
        • Osborne JW
        Best practices in exploratory factor analysis: Four recommendations for getting the most from your analysis.
        Prac Assess Res Eval. 2005; 10: 1-9
        • Duke D
        • Krishnan M
        • Faith M
        • Storch EA
        The psychometric properties of the brief fear of negative evaluation scale.
        J Anxiety Disord. 2006; 20: 807-817
        • Farin E
        • Gramm L
        • Schmidt E
        The patient-physician relationship in patients with chronic low back pain as a predictor of outcomes after rehabilitation.
        J Behav Med. 2013; 36: 246-258
        • Gallagher L
        • McAuley J
        • Moseley GL
        A randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease catastrophizing in people with chronic pain.
        Clin J Pain. 2013; 29: 20-25
        • Garcia-Campayo J
        • Navarro-Gil M
        • Andrés E
        • Montero-Marin J
        • López-Artal L
        • Demarzo MMP
        Validation of the Spanish versions of the long (26 items) and short (12 items) forms of the self-compassion scale (SCS).
        Health Qual Life Out. 2014; 12 (Available at): 1-9
        • Ghavidel-Parsa B
        • Maafi AA
        • Aarabi Y
        • Haghdoost A
        • Khojamli M
        • Montazeri A
        • Sanaei O
        • Bidari A
        Correlation of invalidation with symptom severity and health status in fibromyalgia.
        Rheumatology. 2015; 54: 482-486
        • Ghavidel-Parsa B
        • Bidari A
        Two sides on the fibromyalgia coin: physical pain and social pain (invalidation).
        Clin Rheumatol. 2021; 40: 841-848
        • Gibson PR
        • Leaf B
        • Komisarcik V
        Unmet medical care needs in persons with multiple chemical sensitivity: A grounded theory of contested illness.
        J Nurs Educ Prac. 2016; 6 (Available at): 75-83
        • Hayes JA
        • Lockard AJ
        • Janis RA
        • Locke BD
        Construct validity of the self-compassion scale-short form among psychotherapy clients.
        Couns Psychol Q. 2016; 29: 405-422
        • Hemphill RC
        • Martire LM
        • Polenick CA
        • Stephens MAP
        Spouse confidence and physical function among adults with osteoarthritis: The mediating role of spouse responses to pain.
        Health Psychol. 2016; 35 (Available at): 1059-1068
        • Holloway I
        • Sofaer-Bennett B
        • Walker J
        The stigmatisation of people with chronic back pain.
        Disabil Rehabil. 2007; 29: 1456-1464
        • Kelly AC
        • Carter JC
        • Zuroff DC
        • Borairi S
        Self-compassion and fear of self-compassion interact to predict response to eating disorders treatment: A preliminary investigation.
        J Soc Psychother Res. 2013; 23: 252-264
        • Kempke S
        • Luyten P
        • Claes S
        • Goossens L
        • Bekaert P
        • Van Wambeke P
        • Van Houdenhove B
        Self-critical perfectionism and its relationship to fatigue and pain in the daily flow of life in patients with chronic fatigue syndrome.
        Psychol Med. 2013; 43: 995-1002
        • Kempke S
        • Luyten P
        • Van Wambeke P
        • Coppens E
        • Morlion B
        Self-critical perfectionism predicts outcome in multidisciplinary treatment for chronic pain.
        Pain Pract. 2014; 14: 309-314
        • Kerns RD
        • Turk DC
        • Rudy TE
        The West Haven-Yale multidimensional pain inventory (WHYMPI).
        Pain. 1985; 23: 345-356
        • Kocovski NL
        • Endler NS
        Social anxiety, self-regulation, and fear of negative evaluation.
        Eur J Personality. 2000; 14: 347-358;2-7
        • Kool MB
        • van Middendorp H
        • Lumley MA
        • Schenk Y
        • Jacobs JWG
        • Bijlsma JWJ
        • Geenen R
        Lack of understanding in fibromyalgia and rheumatoid arthritis: The illness invalidation inventory (3I).
        Ann Rheum Dis. 2010; 69: 1990-1995
        • Lavie-Ajayi M
        • Almog N
        • Krumer-Nevo M
        Chronic pain as a narratological distress: a phenomenological study.
        Chronic Illn. 2012; 8: 192-200
        • Leary MR
        A brief version of the fear of negative evaluation scale.
        Pers Soc Psychol Bull. 1983; 9: 371-375
        • Lim HS
        • Chen PP
        • Wong TCM
        • Gin T
        • Wong E
        • Chan ISF
        • Chu J
        Validation of the Chinese version of pain self-efficacy questionnaire.
        Anesth Analg. 2007; 104: 918-923
        • Lovibond SH
        • Lovibond PF
        Manual for the Depression Anxiety Stress Scales.
        2nd Ed. Psychology Foundation, Sydney NSW1995
        • Lumley MA
        • Schubiner H
        • Lockhart NA
        • Kidwell KM
        • Harte SE
        • Clauw DJ
        • Williams DA
        Emotional awareness and expression therapy, cognitive behavioral therapy, and education for fibromyalgia: A cluster-randomized controlled trial.
        Pain. 2017; 158: 2354-2363
        • Lunde CE
        • Sieberg CB
        Walking the tightrope: a proposed model of chronic pain and stress.
        Front Neurosci. 2020; 14
        • Lutz J
        • Berry MP
        • Napadow V
        • Germer C
        • Pollak S
        • Gardiner P
        • Edwards RR
        • Desbordes G
        • Schuman-Olivier Z
        Neural activations during self-related processing in patients with chronic pain and effects of a brief self-compassion training – A pilot study.
        Psychiat Res-Neuroimaging. 2020; 304
        • Martin LR
        • Williams SL
        • Haskard KB
        • DiMatteo MR
        The challenge of patient adherence.
        Thera Clin Risk Manag. 2005; 1: 189-199
        • McManimen SL
        • McClellan D
        • Stoothoff J
        • Jason LA
        Effects of unsupportive social interactions, stigma, and symptoms on patients with myalgic encephalomyelitis and chronic fatigue syndrome.
        J Community Psychol. 2018; 46: 959-971
        • Meade AW
        • Craig SB
        Identifying careless responses in survey data.
        Psychol Methods. 2012; 17: 437-455
        • Molnar DS
        • Sirois FM
        • Flett GL
        • Janssen WF
        • Hewitt PL
        Perfectionism and health: The roles of health behaviors and stress-related processes.
        in: Stoeber J. The psychology of perfectionism: Theory, research, applications; The psychology of perfectionism: Theory, research, applications. Routledge/Taylor & Francis Group, New York, NY2018: 200-221
        • Mukhida K
        • Carroll W
        • Arseneault R
        Does work have to be so painful? A review of the literature examining the effects of fibromyalgia on the working experience from the patient perspective.
        Can J Pain. 2020; 4: 268-286
        • Neff KD
        The development and validation of a scale to measure self-compassion.
        Self Identity. 2003; 2: 223-250
        • Newton BJ
        • Southall JL
        • Raphael JH
        • Ashford RL
        • LeMarchand K
        A narrative review of the impact of disbelief in chronic pain.
        Pain Manag Nurs. 2013; 14: 161-171
        • Nicholas MK
        The pain self-efficacy questionnaire: Taking pain into account.
        Eur J Pain. 2007; 11: 153-163
        • Nicola M
        • Correia H
        • Ditchburn G
        • Drummond P
        Invalidation of chronic pain: A thematic analysis of pain narratives.
        Disabil Rehabil. 2019; 43: 861-869
        • Okur Güney ZE
        • Sattel H
        • Witthöft M
        • Henningsen P
        Emotion regulation in patients with somatic symptom and related disorders: a systematic review.
        PLoS ONE. 2019; 14: 29
        • Oosterhof B
        • Dekker JHM
        • Sloots M
        • Bartels EAC
        • Dekker J
        Success or failure of chronic pain rehabilitation: The importance of good interaction—A qualitative study under patients and professionals.
        Disabil Rehabil. 2014; 36: 1903-1910
        • Osman A
        • Barrios FX
        • Gutierrez PM
        • Kopper BA
        • Merrifield T
        • Grittmann L
        The pain catastrophizing scale: Further psychometric evaluation with adult samples.
        J Behav Med. 2000; 23: 351-365
        • Polit DF
        Getting serious about test-retest reliability: A critique of retest research and some recommendations.
        Qual Life Res. 2014; 23: 1713-1720
        • Pow J
        • Stephenson E
        • Hagedoorn M
        • DeLongis A
        Spousal support for patients with rheumatoid arthritis: Getting the wrong kind is a pain.
        Front Psychol. 2018; 9: 1760
        • Raes F
        • Pommier E
        • Neff KD
        • Van Gucht D
        Construction and factorial validation of a short form of the self-compassion scale.
        Clin Psychol Psychother. 2011; 18: 250-255
        • Rimé B
        Emotion elicits the social sharing of emotion: Theory and empirical review.
        Emot Rev. 2009; 1: 60-85
        • Romano JM
        • Jensen MP
        • Schmaling KB
        • Hops H
        • Buchwald DS
        Illness behaviors in patients with unexplained chronic fatigue are associated with significant other responses.
        J Behav Med. 2009; 32: 558-569
        • Romano JM
        • Jensen MP
        • Turner JA
        • Good AB
        • Hops H
        Chronic pain patient–partner interactions: Further support for a behavioral model of chronic pain.
        Behav Ther. 2000; 31: 415-440
        • Sánchez-Rodríguez E
        • Ferreira-Valente A
        • Pathak A
        • Solé E
        • Sharma S
        • Jensen MP
        • Miró J
        The role of perfectionistic self-presentation in pediatric pain.
        Int J Environ Res Pub Health. 2021; 18: 591-604
        • Santiago MG
        • Marques A
        • Kool M
        • Geenen R
        • da Silva JAP
        Invalidation in patients with rheumatic diseases: Clinical and psychological framework.
        J Rheumatol. 2017; 44: 512-518
        • Scott W
        • Yu L
        • Patel S
        • McCracken LM
        Measuring stigma in chronic pain: Preliminary investigation of instrument psychometrics, correlates, and magnitude of change in a prospective cohort attending interdisciplinary treatment.
        J Pain. 2019; 20: 1164-1175
        • Sibelli A
        • Chalder T
        • Everitt H
        • Workman P
        • Bishop FL
        • Moss-Morris R
        The role of high expectations of self and social desirability in emotional processing in individuals with irritable bowel syndrome: A qualitative study.
        Brit J Health Psychol. 2017; 22: 737-762
        • Sirois FM
        • Molnar DS
        • Hirsch JK
        Self-compassion, stress, and coping in the context of chronic illness.
        Self Identity. 2015; 14: 334-347
        • Slade SC
        • Molloy E
        • Keating JL
        Stigma experienced by people with nonspecific chronic low back pain: a qualitative study.
        Pain Med. 2009; 10: 143-154
        • Sloan M
        • Bosley M
        • Moira B
        • Holloway L
        • Colette B
        • D'Cruz D
        • Chanpreet W
        • Naughton F
        • Howard P
        • Sutton S
        • Gordon C
        But you don't look sick’: A qualitative analysis of the LUPUS UK online forum.
        Rheumatol Int. 2021; 41: 721-732
        • Soklaridis S
        • Cartmill C
        • Cassidy D
        Biographical disruption of injured workers in chronic pain.
        Disabil Rehabil. 2011; 33: 2372-2380
        • Street Jr., RL
        • Makoul G
        • Arora NK
        • Epstein RM
        How does communication heal? Pathways linking clinician-patient communication to health outcomes.
        Patient Educ Couns. 2009; 74: 295-301
        • Strunin L
        • Boden LI
        Family consequences of chronic back pain.
        Soc Sci Med. 2004; 58: 1385-1393
        • Sturgeon JA
        • Darnall BD
        • Kao MJ
        • Mackey SC
        Physical and psychological correlates of fatigue and physical function: A collaborative health outcomes information registry (CHOIR) study.
        J Pain. 2015; 16: 291-298
        • Sullivan MJL
        The communal coping model of pain catastrophising: Clinical and research implications.
        Can Psychol. 2012; 53: 32-41
        • Sullivan MJL
        • Bishop SR
        • Pivik J
        The pain catastrophizing scale: Development and validation.
        Psychol Assess. 1995; 7: 524-532
        • Teper R
        • Segal ZV
        • Inzlicht M
        Inside the mindful mind: How mindfulness enhances emotion regulation through improvements in executive control.
        Curr Dir Psychol Sci. 2013; 22: 449-454
        • Toye F
        • Barker K
        Could I be imagining this?' - the dialectic struggles of people with persistent unexplained back pain.
        Disabil Rehabil. 2010; 32: 1722-1732
        • Worthington RL
        • Whittaker TA
        Scale development research: A content analysis and recommendations for best practices.
        Couns Psychol. 2006; 34: 806-838
        • Wren AA
        • Somers TJ
        • Wright MA
        • Goetz MC
        • Leary MR
        • Fras AM
        • Huh BK
        • Rogers LL.
        • Keefe FJ
        Self-compassion in patients with persistent musculoskeletal pain: Relationship of self-compassion to adjustment to persistent pain.
        J Pain Symptom Manage. 2012; 43: 759-770
        • Yarns BC
        • Lumley MA
        • Cassidy JT
        • Steers WN
        • Osato S
        • Schubiner H
        • Sultzer DL
        Emotional awareness and expression therapy achieves greater pain reduction than cognitive behavioral therapy in older adults with chronic musculoskeletal pain: A preliminary randomized comparison trial.
        Pain Med. 2020; 21: 2811-2822
        • Ziadni MS
        • Carty JN
        • Doherty HK
        • Porcerelli JH
        • Rapport LJ
        • Schubiner H
        • Lumley MA
        A life-stress, emotional awareness, and expression interview for primary care patients with medically unexplained symptoms: A randomized controlled trial.
        Health Psychol. 2018; 37: 282-290