Tuesday, December 11, 2012

Pain Doubted if Medical Basis is Missing

Briefly NotedMany chronic pain sufferers often feel that their maladies are misunderstood, disbelieved, or unaccepted by others. New research confirms that if there is no clear and convincing biomedical cause identified to satisfactorily explain the pain other people tend to discount it and have little sympathy toward the patient.

Researchers at Ghent University in Belgium conducted a pair of studies to investigate the impact of medical and psychosocial information on estimations of another person’s pain, along with observers’ emotional responses and their behavioral tendencies toward the person with pain [De Ruddere et al. 2012]. Study participants were recruited from the community: Study 1: N = 29 women, 10 men; Study 2: N = 29 women, 12 men.

Participants variously viewed photographs of 4 alleged patients (2 men, 2 women; ages 44 to 57 years) described as having shoulder pain conditions. With each photograph there was a written brief vignette describing 2 of 4 different circumstances: either the presence or absence of a medical explanation for the pain, along with either the presence or absence of psychosocial influences attributed to the pain experience.

  • For example, pain was medically explained as associated with either “a little fracture,” “an inflammation,” or a “muscle strain”; in the no-cause condition the vignette simply stated that “based upon medical examination there appeared to be no injury to the shoulder.”

  • Psychosocial influences were described in Study 1 vignettes from the patients’ perspectives: eg, “[Fictitious patient name] reports having more pain when experiencing job stress” or “…more stress at home.” In Study 2, these influences were more authoritatively attributed to medical opinion: eg, “…the doctor decided that psychosocial factors have an impact upon the pain, in particular job stress and feelings of anxiety” or “…in particular relationship problems and a depressive mood.”

    If psychosocial influences did not exist, in Study 1 they simply were not mentioned. In Study 2, however, there was a more explicit declaration that “…the doctor decided that psychosocial factors do not have an impact upon the pain.” Thus Study 1 and 2 were similar, except for a much stronger attribution of psychosocial factors, or lack thereof, in the second study.

After examining each vignette/photo, study participants were shown a brief video segment (8 seconds) displaying the respective patient having his/her shoulder examined and expressing facial signs of moderate pain. Then, on 4 different 100mm visual analog scales (VAS), participants rated each patient’s pain, their own distress upon viewing the patient in pain as well as their sympathy toward the patient, and their inclination to help the patient.

Writing in the December 2012 edition of the Journal of Pain, the researchers report that, in both Studies 1 and 2, results indicated significantly lower ratings on all measures when medical evidence for pain was absent. That is, when a medical explanation for a patient’s pain was missing, participants rated the pain as lower and their own distress at viewing the patient as lower, as well as less sympathy toward the patient and less willingness to help.

Surprisingly, there was no overall effect found on any of the 4 outcome measures due to claimed psychosocial influences on patients’ pain. The one small exception was in Study 2, in which participants indicated feeling less personal distress when psychosocial factors were explicitly indicated (ie, noted by examining physicians as having an impact).

The researchers conclude that the findings suggest pain is taken less seriously when there is no medical evidence to help explain it, and psychosocial influences on the patient — eg, stress at work or home, anxiety, relationship issues — are not considered as important contributors to pain. This line of investigation is important, the researchers note, for better understanding how patients’ pain for which there is no clear medical explanation is interpreted and judged by other persons.

COMMENTARY: Research in the social psychology field is often most interesting when it confirms — more or less scientifically — what most people already think they intuitively know. This present study confirms what many patients already have expressed in prior comments to various UPDATES articles; that is, when chronic pain is unexplained by a diagnosis of some severe biopathology patients often face significant obstacles to being taken seriously by their families, friends, and healthcare providers.

In the study by De Ruddere et al. it was somewhat puzzling that psychosocial factors appeared to have so little influence on participants’ perceptions. It seemed that medical evidence for the pain superseded all other information when judging the genuineness of pain and consequent feelings of sympathy or helpfulness toward the patient.

As often is the case in the pain management field, more research is needed before leaping to any firm conclusions. For one thing, patients in the video segments displayed what had been determined as representing moderate pain; expressions of more severe pain might have had much greater impact on assessments — evoking higher ratings of pain (whether or not medically explained) and greater empathy by study participants.

Another important limitation was that participants had no personal relationships or direct interactions with the fictitious patients; completely unlike what would be the case in clinical settings or among family/friends. Essentially, the researchers attempted to create a laboratory setting for assessing human variables that are far more complex in everyday life or clinical practice.

Participant-group sizes — Group 1, N= 39; Group 2, N=41 — were probably adequate to provide reasonable statistical power for detecting significant differences, avoiding Type II (false negative) findings. [Readers should note that numbers of participants indicated in the study abstract and the article text itself are grossly discordant; we are using numbers from the text.]

However, composition of the participant groups must be considered: overall, the two groups were unequally balanced toward women, average participant age was significantly lower than the test patients (roughly 28 vs 51 years), and approximately half of participants were college students. So, generalizing the findings at this time to how older persons, healthcare providers, or family/friends might react could be erroneous.

Therefore, there are still unanswered questions about how the qualities of patients and those interacting with them, as well as available information about patient medical condition and/or psychosocial influences, affect judgments when it comes to pain assessment, sympathy, and helping behavior. The researchers, themselves, acknowledge most of these limitations; yet, this study is an important step toward a better understanding of several factors that might significantly bias perceptions of patients’ pain and impact the care that they receive in medical settings and at home.

REFERENCE: De Ruddere L, Goubert L, Vervoort T, et al. We Discount the Pain of Others When Pain Has No Medical Explanation. J Pain. 2012(Dec);13(12):1198-1205 [abstract here].

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