Patients with Medically Unexplained Pain More Often Socially Excluded

Elderly in pain
Elderly in pain
Dr Buse said that in her practice, patients with chronic pain often report feeling isolated and misunderstood, and that others believe they are exaggerating their pain or somehow using it to their benefit.

Patients with chronic pain face a variety of burdens in addition to their symptoms, including depression, relational and occupational issues, and inadequate health care.1

According to a sizable body of research, another significant issue affecting such patients is stigmatization, of which social exclusion is a key feature.2 In a new study reported in the Journal of Pain, researchers at the University of Ghent in Belgium explored the social responses of observers toward individuals with medically unexplained pain.3

The study’s 59 participants were first presented with photos of 4 actual patients with chronic low back pain, along with vignettes indicating the medical evidence–or lack thereof–explaining each patient’s pain.

Participants then watched videos of the patients performing a back-straining activity. Using a visual analogue scale, observers were asked to estimate the amount of pain the patient felt, their own level of sympathy for each patient, and their willingness to help the patients with daily activities.

Next, they indicated their willingness to interact with each patient per the Social Distance Scale (SDS), which contains items such “How would you feel having someone like this person as a neighbor?” They were also asked to choose 2 patients as teammates for a social game.

As expected, multivariate analysis revealed that participants attributed less pain to patients with medically unexplained pain (F1,58 = 15.31; P <.001), and reported less sympathy (F1,58 = 7.49; P = .008) for such patients and lower willingness to help them (F1,58 = 12.68; P = .001).

In addition, they were less willing to engage interpersonally with patients who lacked a medical explanation for their pain vs patients whose pain was supported by medical evidence (mean = 54.97; SD = 19.34 vs mean = 59.36; SD = 18.92, respectively). They were also less likely to choose patients with unexplained pain as confederates in the social game.  

The authors explain that these responses may be due to the prevailing biomedical model of pain, which could lead observers to believe that individuals with no clear reason for their pain may be feigning it.

“Although the biopsychosocial perspective on pain is currently acknowledged in scientific literature, the biomedical model is still widely endorsed,” said Lies De Ruddere, PhD, one of the study’s authors.

“This model posits that pain is directly linked with tissue damage or injury. Accordingly, skepticism may occur in individuals when confronted with patients whose pain complaints are not understood in terms of clear physiological damage,” she told Clinical Pain Advisor.

Previous findings by Dr De Ruddere and colleagues suggests that healthcare providers similarly attribute less pain and feel less sympathy for patients with less medical evidence explaining their symptoms.4

Dawn C. Buse, PhD, associate professor of neurology at Albert Einstein College of Medicine of Yeshiva University, and director of behavioral medicine at the Montefiore Headache Center, said that in her practice, patients with chronic pain often report feeling isolated and misunderstood, and that others believe they are exaggerating their pain or somehow using it to their benefit.

“This is a common problem reported by people who experience ‘invisible illnesses’ or those that are not easily measured,” she told Clinical Pain Advisor.

Noting that social support is vital to physical and emotional health, Dr Buse said, “One of the most important things that friends, family, and healthcare professionals can do for someone with chronic pain, is to offer them support and validation, even if their condition cannot be medically explained.”

Summary and Clinical Applicability

Patients with medically unexplained pain are more likely to be socially excluded, to be perceived as experiencing less pain, and to receive less sympathy than patients with a clear medical reason for their pain.


The current results cannot be generalized to friends, family members, or healthcare providers, and future research should examine whether findings are different with individuals who have a positive relationship with the patient. Other limitations include the homogenous race of participants (all Caucasian) and the narrow social scenarios examined in the study.

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  1. Reid KJHarker J, Bala MM, et al. Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact. Curr Med Res Opin. 2011;27(2):449-462.
  2. De Ruddere L, Craig KD. Understanding stigma and chronic pain: a state of the art review. Pain. 2016; 157: 1607-1610.
  3. De Ruddere L, Bosmans M, Crombez G, Goubert L. Patients are socially excluded when their pain has no medical explanation. J Pain. 2016; 17(9):1028-1035.
  4. De Ruddere L, Goubert L, Stevens MA, Deveugele M, Craig KD, Crombez G. Health care professionals’ reactions to patient pain: impact of knowledge about medical evidence and psychosocial influences. J Pain2014; 15(3):262-270.