In this issue of the Scandinavian Journal of Pain, Sündermann and coworkers  report on body image concerns in people with persistent pain. Through a small qualitative study they investigate body image concerns and coping in seven volunteers suffering from persistent pain.
2 Body image distortions in persistent pain is largely unknown
Body image distortions is a well-known phenomenon in clinical psychology, particularly relating to patients with eating disorders and body dysmorphic disorders (BDD) . Somewhat surprisingly, though, this phenomenon has not received much attention within persistent pain research, besides from studies of cortical (mis)representations associated with conditions such as phantom limb pain and complex regional pain syndrome. The subjective experience of body image in patients with persistent pain, however, is largely unknown, and is therefore in great need of further scientific scrutiny.
3 All were dissatisfied with their appearance, but no evidence of distorted body image
The findings in the study by Sündermann and coworkers did indeed support the significance of appearance concerns in people with persistent pain. All of the seven participants reported appearance concerns, primarily involving their weight. The participants reported that they were dissatisfied with their appearance, and engaged in appearance-related coping, such as avoidance of mirrors, exercising or dieting. Whilst no support were found for the existence of a distorted view of their painful body parts similar to people with BDD, the authors speculate whether body image distortions may take a different form in pain patients than in patients with BDD. As indicated in the findings, some participants seemed to have unrealistic imagery of their bodies as old, frail or handicapped. Meanwhile, other patients were concerned that their painful body part was indeed not displaying any distortions, making it harder for other people to empathize and understand their pain condition. This duality may be a reflection of heterogeneity within the group of persistent pain patients, and may imply that both is true – a specific type of body image distortions may be evident in some patients, but not in others.
4 Important first step to understand body image in persistent pain
The rationale for the study is by and large based on anecdotal evidence from the clinical practice of the authors. This could be considered a weak foundation to form a scientific rationale for an empirical study. On the other hand, it is indeed one way of acquiring new knowledge and insights. For that particular purpose, a small qualitative study appears to be the first logical step to test the anecdotal evidence further. As such, this was the first study to systematically examine appearance-related body image concerns in people with persistent pain. Besides from demonstrating that body image concerns probably is a relevant factor in persistent pain, the findings further indicate that the experience of persistent pain had a significant impact on appearance perception, possibly via pathways of mood and fatigue. This makes perfect clinical sense and resembles the negative perception bias in people with depression ; when in a depressed mood, we tend to selectively attend to the negative features of experience, and even interpret neutral stimuli as negative. It is very possible that a similar mechanism is playing out in patients with persistent pain in relation to their body image.
5 Questions for future research
One of the main purposes of explorative qualitative studies is to generate hypotheses for further research. More than providing authoritative answers to specific questions, the current study thus provides us with several pertinent questions and hypotheses to follow up, such as: How do body image concerns interact with pain over time? How does pain catastrophizing aggravate the body image of persistent pain patients? Is in fact low mood the mediator between pain and appearance concerns? Are there body image distortions, but in a different form than in BDD, in persistent pain patients? And finally, should body image concerns and distortions be targeted in treatment of patients with persistent pain?
6 Conclusion and implications
In conclusion, the current study provides preliminary support for the significance of body image concerns in people struggling with persistent pain. Although body image distortions as seen in BDD could not be detected among the participants in this study, it is too soon to dismiss the value of body image distortions in persistent pain as the distortions could take other forms than in BDD. The clinical implications of body image concerns and distortions are largely unknown, and so is the potential for addressing them in clinical practice. However, given the modest effect sizes in psychological treatments for chronic pain , new aspects and approaches in treatment is highly warranted. Body image could be one such aspect and should be studied further in both epidemiological and clinical studies.
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About the article
Published Online: 2018-06-05
Published in Print: 2018-07-26
Conflict of interest: None declared.
Citation Information: Scandinavian Journal of Pain, Volume 18, Issue 3, Pages 339–340, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1515/sjpain-2018-0086.