Chronic nonmalignant pain makes individuals prone to stigmatizing reactions of others.Stigmatizing responses are devaluing and discrediting responses of observers toward individuals who possess a particular characteristic that deviates from societal norms [16]. In the context of chronic nonmalignant pain, an absence of clear tissue damage deviates from the widely held biomedical model, which presumes that clear physiological pathology underlies the pain experience [22]. As well, most people understand pain through acute pain experience, which resolves relatively rapidly over time, leading to uncertainty about pain that does not diminish [48,63]. These and other processes must be understood to explain the substantial evidence that individuals with chronic pain commonly suffer from stigmatization by others [32].The stigma associated with chronic pain are not well understood, with research lacking accounts of determinants, including underlying mechanisms in stigmatizing persons and details concerning vulnerabilities and the impact on stigmatized persons. Furthermore, prevention strategies for teaching how to deal with others' stigmatizing reactions and programs aimed at minimizing stigmatizing behaviors of observers are scarce. This topical review briefly describes the current understanding of stigma attached to chronic pain and has the intent to provide some thought provoking ideas and highlight future directions that will inspire both researchers and clinicians.
2.Stigma and chronic pain
Stigma perceived by the patientAbundant evidence highlights the ubiquity of stigma in the lives of individuals with chronic pain [1,21,25,26,32,34,52,54,55,62,73,74,76]
Impact of stigma on the wellbeing of pain patientsAlthough thorough research into the consequences of both perceived stigma and public stigma on the wellbeing of pain patients is lacking, preliminary evidence shows that the discounting
A C C E P T E D
A C C E P T E Dexploited by others [35]. In particular, the absence of a clear medical explanation for the pain might function as a threat for the observer regarding availability of reciprocity (i.e., the social exchange) to be expected from individuals in pain [35].There is a substantial literature demonstrating that individuals stigmatize individuals from the "out group" [58]. "In group" people include those similar to the observer, e.g., kin, friends, age peers, whereas "out group" people likely include those with different skin colors, ideological persuasions, etc. In the context of pain, observers feel less empathy and less altruistic motivation towards members of social out-groups than members of in-groups [29,47] and the pain complaints of "out group" members tend to be discounted [65]. This is consistent with findings that observers attribute lower pain to patients who are considered responsible for their pain condition [17,68].A final useful explanatory approach arises from the considerable research which indicates that healthcare practitioners often feel uncertain or unprepared to manage patients with c...