Shame Mediates the Relationship Between Pain Invalidation and Depression

The unmet mental health needs of U.S. adults living with chronic pain

ABSTRACT

Previous research suggests that individuals with mental health needs and chronic pain may be less likely to use mental health treatment compared with those with mental health needs only. Yet, few studies have investigated the existence of population-level differences in mental health treatment use. We analyzed data from the National Health Interview Survey (n = 31,997) to address this question. We found that chronic pain was associated with end-to-end disparities in the mental health journeys of U.S. adults: (1) Those living with chronic pain are overrepresented among U.S. adults with mental health needs; (2) among U.S. adults with mental health needs, those living with chronic pain had a lower prevalence of mental health treatment use; (3) among U.S. adults who used mental health treatment, those living with chronic pain had a higher prevalence of screening positive for unremitted anxiety or depression; (4) among U.S. adults living with both chronic pain and mental health needs, suboptimal mental health experiences were more common than otherwise-just 44.4% of those living with mental health needs and co-occurring chronic pain reported use of mental health treatment and screened negative for unremitted anxiety and depression, compared with 71.5% among those with mental health needs only. Overall, our results suggest that U.S. adults with chronic pain constitute an underrecognized majority of those living with unremitted anxiety/depression symptoms and that the U.S. healthcare system is not yet adequately equipped to educate, screen, navigate to care, and successfully address their unmet mental health needs.

Experiencing Pain Invalidation is Associated with Under-Reporting of Pain: A Social Psychological Perspective on Acute Pain Communication

Pain invalidation involves the dismissal or lack of understanding of another's pain, undermining their subjective experience. Frequent exposure to invalidation negatively impacts mental and physical health as well as pain-related behaviors, potentially leading people to conceal their pain from others in the future and/or withdraw from potential sources of support. It is therefore possible that experiencing pain invalidation may also impact pain-reporting behavior in clinical settings. Across 2 separate samples of emerging adults, we examined whether exposure to invalidation of one's pain was associated with cognizant modulation of one's subjective acute pain ratings within routine medical and dental settings. Drawing upon social psychological theories of impression management and self-presentation, we hypothesized that exposure to pain invalidation would be associated with the under-rating of one's pain. In Study 1, previous experiences of invalidation were associated with under-rating of one's pain when visiting the doctor and the dentist. Study 2 found that invalidation from family and medical professionals-but not from friends-was associated with under-rating pain in both settings. Findings provide further evidence for the harmful effects of pain invalidation, particularly for emerging adults, as the dismissal of one's subjective experience may sow self-doubt while reinforcing cultural stigmas against pain, leading to alterations in pain communication that ultimately creates barriers to efficacious clinical treatment and care and increase pain-related suffering. PERSPECTIVE: Pain invalidation imparts harm to those who already suffer from pain, be it mentally, physically, and/or behaviorally. We show that people who have encountered invalidation are more likely to under-rate their pain when seeking care, impeding assessment and treatment, and further highlighting the importance of clinical validation of pain experiences.

Understanding the link between pain invalidation and depressive symptoms: The role of shame and social support in people with chronic pain

Pain invalidation (e.g., having pain discounted) is a risk factor for depression among people with chronic pain, but the mechanisms remain unclear. Shame is a common, yet understudied, aspect of the pain experience. This study investigated whether pain-related shame helps explain the relationship between pain discounting and heightened depressive symptoms. The secondary aim was to examine whether social support can protect against the harmful effects of discounting. Patients with chronic pain (N = 305) were recruited from outpatient pain clinics. Participants completed an online cross-sectional survey and data were analyzed using moderated mediation analysis. Greater discounting was associated with greater depressive symptoms, and pain-related shame significantly mediated this relationship. Perceived social support attenuated the relationship between discounting and depressive symptoms. Greater attention towards pain-related shame as a treatment target is needed. Individual- and system-level interventions are required to address pain invalidation and bolster support for this population.

Longitudinal association of mindfulness with aggression and non-suicidal self-injury in adolescence: The mediating role of shame-proneness

The aim of the current study was to investigate the longitudinal association of facets of mindfulness with aggression and non-suicidal self-injury (NSSI) among adolescents and to explore whether shame-proneness can mediate the longitudinal association. The present longitudinal study investigated the associations between mindfulness, aggression, and NSSI in a sample of 706 Chinese adolescents (M = 15.33; SD = 1.34; 50.20% girls). Five facet mindfulness questionnaire was completed at baseline and middle school students' shame scale was completed at 6-month follow-up. The Chinese version of Buss-Perry aggression questionnaire and adolescents' self-harm scale were completed at both baseline and 6-month follow-up. Shame-proneness significantly mediated the longitudinal association between (a) describing and aggression (-0.107, 95% CI: [-0.151 to -0.067]), and NSSI (-0.041, 95% CI: [-0.069 to -0.019]). (b) Acting with awareness and aggression (-0.094, 95% CI: [-0.139 to -0.061]), and NSSI (-0.036, 95% CI: [-0.062 to -0.016]). (c) Nonjudging and aggression (-0.062, 95% CI: [-0.107 to -0.024]) and NSSI (-0.024, 95% CI: [-0.047 to -0.008]). Describing, acting with awareness, and nonjudging were predictive factors of aggression and self-injury in adolescents, and shame-proneness played a crucial role in the negative longitudinal association between them. Findings from the current study may offer some implications in the domains of clinical practice and education to improve mental health and further ameliorate the misbehavior among adolescents.

Medical invalidation in the clinical encounter: a qualitative study of the health care experiences of young women and nonbinary people living with chronic illnesses

BACKGROUND

Medical invalidation is a well-documented phenomenon in the literature on chronic illnesses, yet there is a paucity of research capturing the perspectives of young adults living with chronic illnesses, and especially of those who are gender diverse or from groups that face broader societal marginalization. Our study sought to answer the following question: How do young women and nonbinary adults living with chronic illnesses characterize their experiences of medical invalidation and its impact on their health and well-being?

METHODS

This was a patient-oriented qualitative study informed by feminist disability theory. Eligibility requirements included self-identifying as having a chronic illness, self-identifying as a woman or nonbinary person receiving health care in Manitoba, and being between the ages of 18 and 35 years. Participants took part in online arts-based workshops and subsequent focus group discussion in November 2021.

RESULTS

Eight women and 2 nonbinary individuals participated. Medical invalidation was experienced by all of the participants at different points in their illness journeys and took a variety of forms depending on their social location and their particular illness, positioning invalidation as an issue of in/visibility. We identified several consequences of medical invalidation, including internalizing invalidation, overcompensating for their illness, avoiding care and, ultimately, symptom intensification. We also present participants' recommendations to avoid medical invalidation.

INTERPRETATION

This study provides insight into the phenomenon of medical invalidation, understood as the act of dismissing, minimizing or otherwise not taking patient concerns seriously. We suggest person-centred care may not be enough, and critical reflexivity may help avoid unintentionally invalidating patient experiences.

[Modern ideas about the relationship between fibromyalgia and mental disorders]

Fibromyalgia (FM) is a pain syndrome with a high burden and an understudied etiology and pathogenesis. There is now considerable evidence that FM has a strong bidirectional relationship with psychiatric disorders and is associated with certain personality traits that contribute to the severity of key somatic symptoms and affect overall prognosis. In this article, the authors present data from recent epidemiological and neurobiological studies, discuss the multilevel relationship between FM and psychiatric disorders, and briefly review approaches to the treatment of co-morbid conditions.

Psychosocial factors associated with pain and health-related quality of life in Endometriosis: A systematic review

BACKGROUND AND OBJECTIVE

Endometriosis is associated with pain and impaired health-related quality of life (HRQoL). Psychosocial factors have been associated with pain and HRQoL in other conditions, suggesting their potential relevance in Endometriosis. However, the role of psychosocial factors in this population has not been systematically explored yet. This systematic review aims to explore the association of psychosocial factors with pain intensity/severity and HRQoL in women with Endometriosis.

DATABASES AND DATA TREATMENT

Observational and experimental studies that explored the association of psychosocial factors with pain and HRQoL in women with Endometriosis were eligible. The following databases were searched: Medline, Embase, Cochrane library, Web of Science, PsychInfo and Cumulative index of nursing and allied health literature. The methodological quality was assessed, and findings were synthesized using narrative synthesis.

RESULTS

Twenty-seven studies were eligible for inclusion, which included 5419 women with Endometriosis. Catastrophising and anxiety were the factors most consistently associated with greater pain, whilst depression, anxiety and stress were related to worse HRQoL. Findings regarding depression and pain were mixed, and research on social factors was limited.

CONCLUSIONS

This systematic review highlights the role of psychosocial factors in Endometriosis. Anxiety, depression and catastrophising are suggested as potential treatment targets. The review also indicates the lack of research on other potentially important psychosocial factors, such as avoidance, perceived injustice and social support.

SIGNIFICANCE

This systematic review explored the role of psychosocial factors in Endometriosis, suggesting that these are associated with pain and health-related quality of life (HRQoL). Among the psychosocial factors included, anxiety, depression and catastrophising were the factors most often associated with pain and HRQoL in Endometriosis. These findings highlight the need to target psychological factors in the treatment of women with Endometriosis.

Over-rating pain is overrated: A fundamental self-other bias in pain reporting behavior

Wide-spread cultural beliefs influence personal experiences and clinical treatment of pain, yet are often unexamined and unchallenged in the pain literature. The common cultural belief that people generally over-report or exaggerate pain is familiar, reflected in discordant patient-provider pain assessments, and compounded in the context of disparities in pain treatment. However, no studies have directly measured the prevalence of this belief among the general population, nor challenged the validity of this assumption by assessing normative pain reporting in clinical settings. Results of an initial and replication study suggest that reporting pain accurately "as-is" is the norm, yet most people still believe that others normatively over-report pain. We refer to the phenomenon by which most people report their pain as they experience it while paradoxically believing that others over-report their pain as the fundamental pain bias, and suggest this false perception may contribute to larger scale pain stigma and poor outcomes for people in pain. We also identify counter-stereotypical patterns of pain reporting among groups (i.e., women, Latinx Americans) that face more disparate care. Results reinforce the need for respecting patient pain reports, and suggest that distrust surrounding others' pain experiences is prevalent in society.