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Chronic Back Pain: Physiological Or Psychological?
(Part 1 of 3)

Back pain disability is the greatest industrial health problem in the United States and is growing at staggering rates in Western society as a whole. Research shows that back pain will afflict most of us, at least briefly, during the course of a lifetime. Of those who suffer, 90 percent will recover within the first three months and resume leading productive lives. The remaining 10 percent will be less likely to recover at all and will be the cause of the largest portion of all funds expended for back pain. In the majority of cases, a specific cause for the back pain will not be found.

If back pain disability is increasing in our society — and if there is no determinable medical cause for a majority of these cases — then there is the intuitive suggestion that physical disease is not solely responsible for back pain. This is not to say that a patient’s perception of pain is not real. Nor that most back pain is due to psychiatric illness — it is not. Rather, there is an association between suffering and the psychology of the sufferer. For instance, when compared with other patients, psychiatric patients have a high degree of pain complaints. And psychiatric symptoms, such as anxiety and worry, can aggravate pain. For this reason, we speak of the psychosocial variables (variables involving both psychological and social aspects) and the psychological overlay (the psychological component of an organic disability) when diagnosing and treating back pain. In many ways, these terms are as amorphous and subjective as the more “medical” descriptions of lumbar strain (a strain relating to the loins or the part of the back and sides between the ribs and the pelvis) and lumbago (pain in mid and lower back).

To understand the psychology of back pain, we must look more closely at the interplay between pain and the mind.

Chronic Pain Syndrome

Chronic pain syndrome is the most widely used term to describe the back pain of a patient whose pain and disability are out of proportion with any quantifiable medical disease. It arises when pain creates stress and, through a conditioning process, the pain magnifies and persists long after healing should have taken place. Psychologists have demonstrated this cascading effect of pain following serious injury, and pain clinics have used it as the foundation of their practices. Three types of conditioning effects occur with chronic pain syndrome: respondent conditioning, operant conditioning, and conditioned fear of reinjury.

Respondent Conditioning

Respondent conditioning occurs when the initial injury causes an activation of the sympathetic nervous system — or in layman’s terms, stress. This stress response includes muscular spasm, constriction of blood vessels, and the release of pain-producing chemicals, all of which take place at the local site of injury. There is a general state of physiological arousal. This is known as the fight or flight response to danger. This physiological response can actually increase pain symptoms. If a person anticipates pain from a non-pain-producing injury, the physiological response can even lead to the genesis of pain. This secondary pain in turn creates more physiological arousal, and the cycle continues. In plain terms: Pain causes stress, which then causes more pain, which then causes more stress, and so on.

Look for patients who are visibly distressed, anxious, perspiring, tremulous, or fearful. They may be having an autonomic physiological response that aggravates the pain symptoms.

Operant Conditioning

Operant conditioning is based on behavioral reinforcement, a theory first articulated by B.F. Skinner. Under the theory, a patient’s pain and behavior produce a favorable response from the environment, which, in turn, reinforces the patient’s pain and behavior. When a patient receives extra attention from relatives, compensation or disability benefits, supervisory approval to stay at home and avoid unpleasant work activities, sympathy from co-workers, and maybe even narcotics as a result of the back pain, the patient is being conditioned to associate feeling pain with being treated well. With time, the original sources of pain may recover, but the patient may consciously or subconsciously desire the favorable environmental responses to the pain — and thus the pain — to continue.

Look for patients who show dramatic behavior (grimacing, rubbing, sighing, or wincing) when exhibiting their pain.

Conditioned Fear of Reinjury

The third type of conditioning takes place when a patient develops a conditioned fear of reinjury. The patient recalls experiencing the pain at its worst and can become immobilized in an effort not to experience the pain again. Typically, this results in musculo-skeletal inactivity and physical deconditioning. As a consequence, natural healing forces are crippled and rehabilitation does not occur.

Look for patients who show extreme bracing or guardedness in their bodily movements and may be slowly physically deteriorating.

Read Chronic Back Pain: Physiological or Psychological? (Part 2)
Read Chronic Back Pain: Physiological or Psychological? (Part 3)

ABOUT THE AUTHOR

The Journal of Workers Compensation is a quarterly review of risk management and cost containment strategies published by Standard Publishing in Boston, Massachusetts. For more information, please visit standard-pub.com, or contact the editor at 800-682-5759, extension 222, or subscription services at extension 228.

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April 2000