Persistent pain: not a medically unexplained symptom

Well-being and Perceived Stigma in Individuals With Rheumatoid Arthritis and Fibromyalgia: A Daily Diary Study

INTRODUCTION

The presence or absence of clearly defined symptoms and underlying pathophysiology may be a crucial variable related to variability in well-being and stigmatization in individuals with chronic pain (ICPs). In the context of pain, absence of clearly defined symptoms and pathophysiology deviates from the widely endorsed biomedical model and as such, may lead to stigmatization, which in turn could be related to ICPs' well-being.

OBJECTIVES

The present study compared physical, psychological, social well-being, and perceived stigmatization in individuals with clearly defined symptoms and underlying pathophysiology (rheumatoid arthritis, RA) and individuals with less well understood symptoms and pathophysiology (fibromyalgia, FM) using daily diaries. Furthermore, the association between daily perceived stigmatization and daily well-being was examined.

MATERIALS AND METHODS

Seventy-nine participants with FM, 86 participants with RA, and 33 participants with both diagnoses completed a diary for 14 consecutive days.

RESULTS

Compared to individuals with RA, individuals with FM and individuals with both diagnoses reported worse daily well-being. After controlling for age, pain duration, and daily pain, differences between FM and RA remained significant for social well-being and completion of plans. Differences between RA and the dual diagnosis group remained significant for completion of plans, negative affect, and isolation. Furthermore, results suggested more stigmatization in individuals with FM than in individuals with RA. Individuals with both diagnoses reported equal stigmatization as individuals with FM, but more stigmatization than individuals with RA. Finally, increased levels of perceived stigma were associated with lower well-being.

DISCUSSION

Findings highlight that the absence of clearly defined symptoms and pathophysiology could be contributing to greater feelings of stigmatization, which may be detrimental for ICPs' well-being.

Treatment of persistent pain from torture: review and commentary

Torture and the conditions under which it is inflicted often leave persistent painful disorders. Because there may be no lasting signs, persistent pain is often misconceived as a somatic representation of psychological distress, also common after torture. This serious failure to understand the nature of persistent pain means that pain is largely overlooked and untreated in torture survivors. We carried out a systematic review on treatments for pain from torture, but found few studies and little use of current understanding and evidence. We discuss this in the context of treating pain associated with psychological distress and of the broader problems faced by the refugee and torture survivor that may take priority over pain. We propose clinical and research implications for this neglected field.

Assessment and management of neuropathic pain in primary care

SUMMARY Most patients with neuropathic pain present and are managed in primary care. It is generally a long-term condition associated with poor physical, psychological and social health. Assessment and pharmacological treatment algorithms, specifically designed for primary care, are now available. The focus should be on taking a good medical history and clinical examination, and with the knowledge of the patient's current and past medical history, the general practitioner can diagnose possible neuropathic pain and initiate treatment while awaiting specialist assessment (if required). Specific nonpharmaceutical interventions, though popular with patients, have thus far demonstrated limited effectiveness. General practitioners, with their long-term relationship with patients, have a central role in improving the diagnosis and management of neuropathic pain.

Medically unexplained symptoms and pain: misunderstanding and myth

PURPOSE OF REVIEW

The recent resurgence of the notion of psychosomatic disorders, grouping together as 'medically unexplained symptoms' all those without organic diagnosis and associated with distress, has included all chronic (persistent) pain within its remit. As pain is reasonably well explained, within an integrated biopsychosocial model, critical analysis of the position is required.

RECENT FINDINGS

Neuroscientific and translational studies of pain mechanisms have strengthened the understanding of pain, providing stronger connections between abstract psychological concepts corresponding to observation and studies of human clinical populations, neuroscientific findings in clinical and analogue studies, and animal research. This situation is contrasted with even the most recent reviews of medically unexplained symptoms providing only vague and patchily supported mechanisms, with little cognate human analogue or animal research.

SUMMARY

The implication of subsuming chronic pain under medically unexplained symptoms is that the primary care/community physician will try to persuade the patient that the symptoms indicate underlying depression, which her or she may offer to treat. When pain is instead recognized as a problem in its own right, it would be referred for specialist opinion and care, or treated directly with evidence-based pain interventions.