Stigma perceived by patients with functional somatic syndromes and its effect on health outcomes - A systematic review

Fibromyalgia pain management effectiveness from the patient perspective: a qualitative evidence synthesis

PURPOSE

This qualitative evidence synthesis aimed to identify and integrate findings where adults with fibromyalgia discussed how they managed their pain, and their perceptions of prescribed treatments from healthcare professionals.

MATERIALS AND METHODS

A comprehensive search strategy was implemented in PubMed, Scopus, ISI Web of Science, and Cinahl Plus databases. The GRADE-CERQual framework was used to evaluate the findings confidence. The findings were analyzed using an inductive thematic analysis approach.

RESULTS

A total of 35 studies (N = 728) were included. The confidence in the findings ranged from high to low confidence. Patients with fibromyalgia often do not benefit from seeking medical attention due to provider stigma, and have varying views on medication effectiveness commonly reporting feeling like "walking chemists." They find mixed effects from exercise, and consider psychological support essential, although the benefits of cognitive-behavioral therapy were controversial. Combining cognitive-behavioral therapy with physical exercise appears more effective, while natural and complementary therapies have short-term benefits and high costs.

CONCLUSIONS

Pain management is a source for frustration and an unmet need for patients with fibromyalgia. The current findings provide crucial insight for providers and researchers; and support the need for fibromyalgia phenotyping and precision medicine approaches to pain management.Implications for RehabilitationChronic widespread pain is the defining feature of fibromyalgia, yet pain reduction is often an unmet need for these individuals.The lack of effective treatments resulting in long-term relief proves frustrating for patients and healthcare providers.Rehabilitation professional should consider the unique insight into this complex, heterogeneous condition that this qualitative synthesis provides to better understand their patient's perspective on pain management.Given the differing perspectives on pain treatment approaches individuals with fibromyalgia report, providers should discuss with each patient their current strategies and take a patient-centered, individualized approach to form an effective treatment plan.

Measuring persistent somatic symptom related stigmatisation: Development of the Persistent Somatic Symptom Stigma scale for Healthcare Professionals (PSSS-HCP)

OBJECTIVE

Persistent somatic symptoms (PSS) describe recurrent or continuously occurring symptoms such as fatigue, dizziness, or pain that have persisted for at least several months. These include single symptoms such as chronic pain, combinations of symptoms, or functional disorders such as fibromyalgia or irritable bowel syndrome. While stigmatisation by healthcare professionals is regularly reported, there are limited measurement instruments demonstrating content validity. This study develops a new instrument to measure stigmatisation by healthcare professionals, the Persistent Somatic Symptom Stigma scale for Healthcare Professionals (PSSS-HCP).

METHODS

Development was an iterative process consisting of research team review, item generation and cognitive interviewing. We generated a longlist of 60 items from previous reviews and qualitative research. We conducted 18 cognitive interviews with healthcare professionals in the United Kingdom (UK). We analysed the relevance, comprehensibility and comprehensiveness of items, including the potential for social desirability bias.

RESULTS

After research team consensus and initial feedback, we retained 40 items for cognitive interviewing. After our first round of interviews (n = 11), we removed 20 items, added three items and amended five items. After our second round of interviews (n = 7), we removed four items and amended three items. No major problems with relevance, comprehensibility, comprehensiveness or social desirability were found in remaining items.

CONCLUSIONS

The provisional version of the PSSS-HCP contains 19 items across three domains (stereotypes, prejudice, discrimination), demonstrating sufficient content validity. Our next step will be to perform a validation study to finalise item selection and explore the structure of the PSSS-HCP.

Do FIQR Severity Categories and Symptoms, Differentiate Between Continuous, Intermittent and Non-Opioid Users in the Treatment of Fibromyalgia?

BACKGROUND

Many fibromyalgia patients utilize opioids to treat symptoms. It is important to better understand nuances regarding this treatment option and any stigma associated with this treatment modality.

AIM

This study: (1) assessed the prevalence of opioid use among continuous, intermittent, and non-opioid users in fibromyalgia patients; (2) determined whether the Revised Fibromyalgia Impact Questionnaire (FIQR) was useful in distinguishing opioid use and symptom burden; and (3) assessed whether fibromyalgia patients encountered stigma and/or invalidation.

DESIGN

A cross-sectional, observational study of 1,105 participants' responses to validated fibromyalgia and invalidation scales and demographic questions.

METHODS

The study employed online survey methodology.

RESULTS

A total of 45% of patients reported utilizing opioids (27% continuous, 18% intermittent, 55% non-users). FIQR disease categories (mild to most severe) strongly distinguished between opioid and non-opioid users with 59% of users falling in the most severe category and 68% of non-users falling in mild disease category (p < .0001). Interestingly, intermittent users were similar to non-users on FIQR severity (65.9 versus 65.7; p <0.60, 0-100) while continuous users reported greater severity than the former (73.9, p < .0001). Continuous users particularly reported more problems with daily activities (p < .0001), being overwhelmed (p < .0001), and being unable to accomplish goals (p < .0001). Stigma related to being 'drug seeking' and being 'judged'. Invalidation was infrequent.

CONCLUSIONS

Opioid use is common in fibromyalgia and increases monotonically with FIQR severity. Multidisciplinary approaches which help patients perform daily activities, decrease feelings of overwhelm, accomplish goals, and reduce stigma may be beneficial.

Acquiring a new understanding of illness and agency: a narrative study of recovering from chronic fatigue syndrome

BACKGROUND

The condition known as chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) is poorly understood. Simplified medical models tend to neglect the complexity of illness, contributing to a terrain of uncertainty, dilemmas and predicaments. However, despite pessimistic pictures of no cure and poor prognosis, some patients recover.

PURPOSE

This study's purpose is to provide insight into people's experiences of suffering and recovery from very severe CFS/ME and illuminate understanding of how and why changes became possible.

METHODS

Fourteen former patients were interviewed about their experiences of returning to health. A narrative analysis was undertaken to explore participants' experiences and understandings. We present the result through one participant's story.

RESULTS

The analysis yielded a common plotline with a distinct turning point. Participants went through a profound narrative shift, change in mindset and subsequent long-time work to actively pursue their own healing. Their narrative understandings of being helpless victims of disease were replaced by a more complex view of causality and illness and a new sense of self-agency developed.

DISCUSSION

We discuss the illness narratives in relation to the disease model and its shortcomings, the different voices dominating the stories at different times in a clinically, conceptually, and emotionally challenging area.

Mental and physical health of adult patients affected by complex vascular anomalies

OBJECTIVE

We examined care and communication factors that affect physical and mental health for patients with complex vascular anomalies (VAs).

METHODS

VA patients (N = 135) completed an online survey with measures of ability to navigate healthcare, quality of information exchange, perceived stigma, and demographic variables. We performed linear regression to determine if these variables were associated with mental and physical health.

RESULTS

Physical and mental health were associated with information exchange (β = .41, 95% CI=.12 -.69; β = .33, 95% CI=.04 -.62), stigma (β = -.49, 95% CI=-.74 to -.24; β = -.63, 95% CI=-.89 to -.38), and education (β = 4.00, 95% CI=.63 - 7.38; β = 3.44, 95% CI=.06 to 6.82). Ability to navigate healthcare was associated with health outcomes in our bivariate model, but not significant in a multivariate model.

CONCLUSION

The results underscore the importance of effective information exchange. Poor information exchange was associated with worse physical and mental health. VA patients with lower education levels and higher perceived stigma reported poorer health outcomes and likely face many struggles accessing care.

PRACTICE IMPLICATIONS

Patient-centered information exchange between clinicians and patients is needed to address unmet information needs. Clinicians can also reduce perceived stigma by validating patients, and should provide resources to reduce disparities related to education.

A cognitive behavioural group treatment for somatic symptom disorder: a pilot study

BACKGROUND

Somatic symptom disorder (SSD) presents challenges to the healthcare system, including frequent medical visits, lack of symptom relief experienced by individuals with this condition, high associated medical costs, and patient dissatisfaction. This study examined the utility of a novel, low-barrier, brief cognitive behavioural therapy (CBT) group intervention for individuals with SSD.

METHODS

Participants were referred by their mental health providers or self-referral. Each participant underwent a telephone screen and in-person psychological and neuropsychological screen. Two cycles of the CBT-based group (n = 30), each consisting of six weekly two-hour sessions, were facilitated at a large outpatient mental healthcare facility in Ontario, Canada. The final sample consisted of 13 individuals of whom 11 completed the treatment. Clinical outcome measures were administered pre-, mid- and post-group, including the Generalized Anxiety Disorder-7, Perceived Stress Scale-4, Pain Self-Efficacy Questionnaire, Pain Disability Index, Revised Illness Perception Questionnaire, and sections of the Patient Health Questionnaire. Six healthcare utilization metrics were collected from electronic medical records at six months pre- and post-group. Paired samples t-tests were used to examine pre- to post-group differences in participants' somatic symptoms, psychological functioning, health, and degree of healthcare utilization.

RESULTS

When comparing pre- and post- group, we observed reductions in the mean scores for somatic symptom severity, depressive symptomatology, anxiety, perceived stress, and perceived disability related to pain. The change in depressive symptomatology yielded a small effect size (d = 0.30). Further, we observed downward trends across participants' pre- to post-group healthcare utilization, with small effect sizes observed for hospital admission (d = 0.36), days admitted to hospital (d = 0.47), and inpatient consults (d = 0.42). Differences between pre- and post-group measures of somatic symptom severity, psychological functioning, health, or healthcare utilization did not reach significance.

CONCLUSIONS

Current findings provide support for the potential effectiveness of an abbreviated CBT group for individuals with SSD in reducing psychiatric symptomatology. Further research is recommended, including randomized control trials, cost-benefit analyses, and comparisons between abbreviated versus longer-duration treatment programs for SSD.

TRIAL REGISTRATION

Not applicable.

Empathy among health science undergraduates toward the diagnosis of chronic pain: An experimental study

OBJECTIVES

To analyse the empathetic response of future health professionals toward people diagnosed with chronic pain differentiated by the degree of visibility and credibility of symptoms.

METHODS

A total of 203 undergraduates performed an experimental task using vignettes depicting different diagnoses of chronic pain and completed questionnaires measuring dispositional and situational empathy. A MANCOVA analysis was conducted.

RESULTS

The main effects of chronic pain diagnoses did not significantly affect situational empathy (p = .587, η2 = 0.007, d = 0.229). The dispositional empathy variables perspective-taking and personal distress affected the situational empathy scores (p = .002, η2 = 0.072, d = 0.906, and p = .043, η2 = 0.032, d = 0.547, respectively).

CONCLUSIONS

It would seem appropriate to foster intra-individual empathy factors among health science undergraduates such that they can more readily understand the process of individual adaptation to chronic pain and thus manage it more effectively.

PRACTICE IMPLICATIONS

It would be useful for dispositional empathy to form part of the transversal competences of the training programmes of future health professionals from the beginning of their studies.

Public Chronic Pain Stigma and the Role of Pain Type and Patient Gender: An Experimental Vignette Study

Research exploring the specific manifestations of chronic pain (CP) public stigma is scarce. One potential factor influencing public stigma manifestations may be the CP type, that is, the presence (secondary CP) or absence (primary CP) of a clearly identifiable pathophysiology. Furthermore, patient gender may play a key role, whereby pain-related gender stereotypes may evoke distinct gender role expectations towards men and women experiencing CP. The aim of the research was 2-fold. First, by means of an experimental vignette design, the general population's cognitive, affective, and behavioral responses were investigated, both towards primary versus secondary CP and towards men versus women. Second, a potential interaction was examined between CP type and patient gender. The research is divided into 2 separate samples: individuals with CP (N = 729) and individuals without CP (N = 283). Factorial ANOVA models were estimated with CP type, patient gender, and participant gender included as factors, age as control variable. The findings support, partly, the general hypothesis of higher (perceived) public stigma towards individuals with primary (vs secondary) CP. No main effects of patient gender were observed. Gender bias in stigmatizing manifestations only emerged in certain contextual circumstances (ie, pain type and participant gender). Different interaction effects (with a combination of gender, patient gender, or CP type) were significant for the distinctive outcome variables. Interestingly, throughout the findings, different patterns of results are found in both samples. The study contributes to the literature on CP stigma, as well as the psychometric examination of items assessing stigmatizing manifestations. PERSPECTIVE: This study examined the role of contextual factors chronic pain type and patient gender into cognitive, affective, and behavioral stigmatizing manifestations coming from the general population towards individuals with chronic pain through an experimental vignette study. The study contributes to the chronic pain stigma literature, as well as the psychometric examination of items assessing stigmatizing manifestations.

Public stigma toward fatigue-do social characteristics of affected persons matter? Results from the SOMA.SOC study

Objectives

Although public stigma imposes a great burden on those affected with manifold negative consequence there is not much known about public stigma related to fatigue. Therefore, this study addresses the following research questions: (1) What is the magnitude of public stigma toward individuals with fatigue? (2) Are there differences in public stigma depending on the social characteristics of the affected person (sex, occupation, and migration)?

Methods

Analyses are based on a national telephone survey in Germany (N = 1,209). A vignette describing a person with symptoms of fatigue was presented to the respondents. Vignettes were varied according to sex, occupational status, and migration status. Stigma toward the person presented in the vignette was measured by stereotypes and negative emotional reactions (anger).

Results

Of the stereotypes under study, "hypersensitive" was most frequently endorsed by the respondents (35.7%), followed by "weak will" (27.2%). About 15-20% of the respondents agreed that they react with anger, annoyance or incomprehension. There were considerable differences in fatigue stigma according to the social characteristics of the affected person. In two social groups public stigma was particularly pronounced: (1) male persons with a low occupational status and a migration background; (2) female persons with a high occupational status and without a migration status. In contrast, women with a low occupational status and a migration background were less stigmatized.

Conclusion

Individuals suffering from fatigue symptoms are confronted with stereotypes and negative emotional reactions by the public. Magnitude of public stigma considerably varies according to social characteristics of the afflicted person. Future studies should consider applying an intersectional approach to identify groups that are at risk of multiple stigma.

Burdens of disease and caregiver burden in complex vascular malformations

INTRODUCTION

Vascular malformations (VMs) are rare diseases that affect a wide age range of patients and require complicated care and management. The strain these conditions put on patients and their caretakers is not well understood. This study aims to characterize those burdens in young adult patients and parents of patients with VMs to improve communication, health-related quality of life, and caregiver burden.

METHODS

We performed semi-structured interviews with patients and parents of patients with VMs. Interviews were conducted via telephone or video-call software, recorded, and transcribed. The transcriptions were analyzed to identify burden themes through multiple rounds of codebook development and refinement. The final codebook was applied to all interviews.

RESULTS

Twenty-five young adult patients and 34 parent interviews were performed and led to the identification of four primary themes of disease burden that showed up in almost every interview: burdens of the disease process, logistical and financial burdens, psychological and emotional burdens, and social burdens. Persistent uncertainty was prominent and exacerbated all other burdens as well.

DISCUSSION

We found that patients and parents struggle with burdens in a wider breadth of life experiences than have been previously characterized in the literature. They feel stressors of isolation, struggles with their identity, and even traumatic experiences from prior medical encounters. It is critical for providers of these patients and families to be aware of the burdens that they face outside of the immediate medical context. Acknowledging and providing space to address these burdens has the potential to greatly improve therapeutic relationships.

High overlap in patients diagnosed with hypermobile Ehlers-Danlos syndrome or hypermobile spectrum disorders with fibromyalgia and 40 self-reported symptoms and comorbidities

Background

Joint pain is a common symptom in patients with hypermobile Ehlers-Danlos Syndrome (hEDS), hypermobility spectrum disorders (HSD) and fibromyalgia. The goal of this study was to determine whether symptoms and comorbidities overlap in patients diagnosed with hEDS/HSD and/or fibromyalgia.

Methods

We retrospectively examined self-reported data from an EDS Clinic intake questionnaire in patients diagnosed with hEDS/HSD, fibromyalgia, or both vs. controls with an emphasis on joint issues.

Results

From 733 patients seen at the EDS Clinic, 56.5% (n = 414) were diagnosed with hEDS/HSD and fibromyalgia (Fibro), 23.8% (n = 167) hEDS/HSD, 13.3% (n = 98) fibromyalgia, or 7.4% (n = 54) none of these diagnoses. More patients were diagnosed with HSD (76.6%) than hEDS (23.4%). Patients were primarily White (95%) and female (90%) with a median age in their 30s (controls 36.7 [18.0, 70.0], fibromyalgia 39.7 [18.0, 75.0], hEDS/HSD 35.0 [18.0, 71.0], hEDS/HSD&Fibro 31.0 [18.0, 63.0]). There was high overlap in all 40 symptoms/comorbidities that we examined in patients diagnosed with fibromyalgia only or hEDS/HSD&Fibro, regardless of whether they had hEDS or HSD. Patients that only had hEDS/HSD without fibromyalgia had far fewer symptoms/comorbidities than patients with hEDS/HSD&Fibro. The top self-reported issues in patients that only had fibromyalgia were joint pain, hand pain when writing or typing, brain fog, joint pain keeping from daily activities, allergy/atopy and headache. Five issues that significantly and uniquely characterized patients diagnosed with hEDS/HSD&Fibro were subluxations (dislocations in hEDS patients), joint issues like sprains, the need to stop sports due to injuries, poor wound healing, and migraine.

Conclusion

The majority of patients seen at the EDS Clinic had a diagnosis of hEDS/HSD plus fibromyalgia that was associated with more severe disease. Our findings indicate that fibromyalgia should be routinely assessed in patients with hEDS/HSD and vis-a-versa to improve patient care.

Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments

OBJECTIVE

Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use.

METHODS

A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments.

RESULTS

We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate.

CONCLUSION

No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.

Non-pharmacological strategies to treat irritable bowel syndrome: 2022 update

Irritable bowel syndrome (IBS) is a chronic functional disorder characterized by abdominal pain associated with changes in stool frequency or form, in absence of organic disease. The treatment of IBS is often challenging and should be individually adjusted according to the prevalent symptomatology. Pharmacological treatment for IBS with diarrhea includes peripheral opioid agonists, bile acid sequestrants and antibiotics, while IBS with constipation can be treated with soluble fibers, osmotic agents or prokinetics. In case of abdominal pain, the available pharmacological options are antispasmodics, peripheral opioid agonists or antidepressants. Along with pharmacotherapy, non-pharmacological interventions should be considered as they can play an important role in symptom control. The first-line approach includes lifestyle modifications and dietary advice. Microbiota manipulation through probiotics, prebiotics and symbiotics is a widely used strategy, although the evidence upon the most effective among these in specific IBS subtypes is still unclear. Fecal microbiota transplantation is still in experimental phase for IBS, but it is giving promising results. Psychological therapies may be effective in patients with IBS, despite their application can be limited by long duration, high costs and poor patient's acceptance. Alternative medicine approaches, such as acupuncture, body relaxation techniques, dietary supplements or Chinese herbs, have been proposed; however, the evidence upon their efficacy and safety is still controversial.

The Pervasive Impact of the Stigmatization of Gastrointestinal Diseases-A Patient's Perspective

Stigma is a centuries-old phenomenon that pervades chronic digestive diseases, regardless of classification. Patients with gastrointestinal (GI) illness perceive others hold stigmatizing beliefs about them and their illness, including from medical professionals, and may go on to internalize or believe these negative stereotypes as true. These perceptions seem to be based on the thought that the public views GI diseases negatively. The effects of GI stigma are substantial and influence quality of life, psychological distress, treatment adherence, disease severity, and health-care utilization. These realities underscore the need for stigma to be addressed by the GI community and measures taken to mitigate its impacts.

"It Really Is an Elusive Illness"-Post-COVID-19 Illness Perceptions and Recovery Strategies: A Thematic Analysis

A substantial number of patients report persisting symptoms after a COVID-19 infection: so-called post-COVID-19 syndrome. There is limited research on patients' perspectives on post-COVID-19 symptoms and ways to recover. This qualitative study explored the illness perceptions and recovery strategies of patients who had been hospitalised for COVID-19. Differences between recovered and non-recovered patients were investigated. Semi-structured in-depth interviews were held with 24 participating patients (8 recovered and 16 non-recovered) 7 to 12 months after hospital discharge. Data were interpreted using reflexive thematic analysis. Four overarching themes were identified: (I) symptoms after hospital discharge; (II) impact of COVID-19 on daily life and self-identity; (III) uncertainty about COVID-19; and (IV) dealing with COVID-19. Formerly hospitalised post-COVID-19 patients seem to have difficulties with making sense of their illness and gaining control over their recovery. The majority of non-recovered participants continue to suffer mostly from weakness or fatigue, dyspnoea and cognitive dysfunction. No notable differences in illness beliefs were observed between recovered and non-recovered participants.

UK healthcare services for people with fibromyalgia: results from two web-based national surveys (the PACFiND study)

Background

The UK’s “Getting It Right First Time” programme recommends that management of people with fibromyalgia should centre on primary care. However, it remains unclear as to how best to organise health systems to deliver services to optimise patient outcomes.

Aim

To profile UK healthcare services for people with fibromyalgia: provision of National Health Services (NHS) and use of non-NHS services by people with fibromyalgia.

Methods

Two online open surveys (A and B) incorporating questions about diagnosis, treatment and management of fibromyalgia and gaps in healthcare services were conducted between 11th September 2019 and 3rd February 2020. These were targeted to NHS healthcare professionals consulting with people with fibromyalgia (Survey A) and people ≥16 years diagnosed with fibromyalgia using non-NHS services to manage their condition (Survey B). Descriptive statistics were used to report quantitative data. Thematic analysis was undertaken for qualitative data.

Results

Survey A received 1701 responses from NHS healthcare professionals across the UK. Survey B received 549 responses from people with fibromyalgia. The results show that NHS services for people with fibromyalgia are highly disparate, with few professionals reporting care pathways in their localities. Diagnosing fibromyalgia is variable among NHS healthcare professionals and education and pharmacotherapy are mainstays of NHS treatment and management. The greatest perceived unmet need in healthcare for people with fibromyalgia is a lack of available services. From the pooled qualitative data, three themes were developed: ‘a troublesome label’, ‘a heavy burden’ and ‘a low priority’. Through the concept of candidacy, these themes provide insight into limited access to healthcare for people with fibromyalgia in the UK.

Conclusion

This study highlights problems across the NHS in service provision and access for people with fibromyalgia, including several issues less commonly discussed; potential bias towards people with self-diagnosed fibromyalgia, challenges facing general practitioners seeking involvement of secondary care services for people with fibromyalgia, and a lack of mental health and multidisciplinary holistic services to support those affected. The need for new models of primary and community care that offer timely diagnosis, interventions to support self-management with access to specialist services if needed, is paramount.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08324-4.

The Role of Neuro-Immune Interaction in Chronic Pain Conditions; Functional Somatic Syndrome, Neurogenic Inflammation, and Peripheral Neuropathy

Functional somatic syndromes are increasingly diagnosed in chronically ill patients presenting with an array of symptoms not attributed to physical ailments. Conditions such as chronic fatigue syndrome, fibromyalgia syndrome, or irritable bowel syndrome are common disorders that belong in this broad category. Such syndromes are characterised by the presence of one or multiple chronic symptoms including widespread musculoskeletal pain, fatigue, sleep disorders, and abdominal pain, amongst other issues. Symptoms are believed to relate to a complex interaction of biological and psychosocial factors, where a definite aetiology has not been established. Theories suggest causative pathways between the immune and nervous systems of affected individuals with several risk factors identified in patients presenting with one or more functional syndromes. Risk factors including stress and childhood trauma are now recognised as important contributors to chronic pain conditions. Emotional, physical, and sexual abuse during childhood is considered a severe stressor having a high prevalence in functional somatic syndrome suffers. Such trauma permanently alters the biological stress response of the suffers leading to neuroexcitatory and other nerve issues associated with chronic pain in adults. Traumatic and chronic stress results in epigenetic changes in stress response genes, which ultimately leads to dysregulation of the hypothalamic-pituitary axis, the autonomic nervous system, and the immune system manifesting in a broad array of symptoms. Importantly, these systems are known to be dysregulated in patients suffering from functional somatic syndrome. Functional somatic syndromes are also highly prevalent co-morbidities of psychiatric conditions, mood disorders, and anxiety. Consequently, this review aims to provide insight into the role of the nervous system and immune system in chronic pain disorders associated with the musculoskeletal system, and central and peripheral nervous systems.