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Chronic Back Pain: Physiological Or Psychological?
(Part 2 of 3)

Depression

It is almost impossible to evaluate and treat patients with chronic back pain without seeing significant depression. Many patients were once active, self-sufficient people who now find themselves in dependent roles with a lifestyle transfixed by ever-present pain. Understandably, they have lost self-esteem and perhaps their standing in the workplace and community. Often, they cannot participate fully in family and personal activities. Many experience sleep disturbance, lack of energy, weight gain, weepiness, irritability, and feelings of hopelessness. Suicidal thinking may occur.

Chronic back pain may be the expression of an underlying depressive disturbance. This is called a masked depression or depressive equivalent. Treatment of the depressive symptoms is an important adjunctive goal in the management of back pain, especially since the depression will prevent the patient from feeling motivated towards recovery of the back injury.

The association between depression and chronic back pain has long been recognized. However, controversy still exists about which is the chicken and which is the egg; i.e., whether depression follows the pain or precedes it. Some interesting research observations have been made about this:

• People with depression do not necessarily have a greater sensitivity to pain; in fact, they may actually have a higher pain threshold.
• A prospective 10-year study from Finland, tracking more than 600 employees at metal industry plants, concluded that depressive symptoms predated musculoskeletal pain and that many patients with low-back pain had preexisting depression and other psychiatric disturbances.
• Chronic pain — particularly chronic back pain — is a variant of depressive disease in certain pain-prone individuals. Consequently, depression should not quickly be attributed to back pain on the assumption that it is always a secondary complication. Even though patients may blame pain for causing their depressed mood, the back pain is, at times, actually the manifestation of the depression.

Preexisting Personality Factors

Certain personality dynamics — e.g., the makeup of the body, the performance of bodily func-tions, past psychological conflict — appear to be related to the development of chronic pain. I am not speaking of the caricature often unfairly drawn of the “low-back loser” — difficult to treat, an apparent personality disturbance in the form of passivity and helplessness. Rather, I am speaking of certain personality features and personal histories that anyone who works with chronic back pain patients will recognize.

From an early age, pain-prone individuals typically have had unmet dependency needs. At some point, they concealed these needs and took on an outward personality style of independence, relentless activity, overinvestment in work, and perhaps excessive caring for others. Often, they were unable to appreciate or verbalize their own feelings, a condition known as alexithymia. Following a significant loss, disappointment, or injury, a shift occurred, and these individuals became invalids. As the theory goes, this transformation is an expression of those unrecognized dependency needs. Thus, even though they may appear externally distressed, their new helpless and passive role allows them to be dependent and cared for.

Of course, these personality features are not easy to subject to controlled research studies, and we cannot definitively reach generalized conclusions about the personalities of chronic back patients. Nonetheless, there is a continuing interest in the area of personality predisposition. It may be that different types of personality disturbance — and not just one type — can all lead to psychological maladjustment for which pain and disability serve as a pathological resolution.

Preexisting Life Factors

As with all traumatic events, back injury does not occur in a vacuum. Instead, there is a living, loving, working person carrying a mosaic of life experiences and surrounded by family, friends, and co-workers. Each person has a unique history of personal conflicts and earlier trauma to which the blow of back injury is now added. It is understandable, therefore, that an injured person’s responses will inevitably be influenced by his or her past experiences. Whether these experiences are incidental or critical to the back condition should be explored.

Watershed Events

Research shows that significant life events, whether positive or negative, appear to coincide with the development of illness. The more significant the life event and the shorter the time span in which the event occurs, the greater the likelihood of developing illness shortly thereafter. For example, if someone experiences the death of a parent, a new mortgage, or a job promotion, that person is at a greater risk not only for psychological stress, but also for a seemingly unrelated illness, including tuberculosis, diabetes, and cancer.

Research has shown that a significant excess of adverse life events is also associated with people who develop chronic back pain, even when there is no clear organic cause for the pain. In one study, there was an apparent association between experiencing an adverse life event and chronic back pain, although the adverse life event was not necessarily accompanied by depression or a specific psychiatric disorder. It may be that the tension intrinsic to these events has some nonspecific deleterious effect on the body, taking the form of reduced resistance or decreased motivation in dealing with life’s struggles.

Family Life

Preexisting familial factors also play an important role in determining which back injuries become chronic. One study indicated that there was a higher prevalence of back pain for those individuals who lost a spouse through death, divorce, or separation within the previous year compared with those who didn’t. In addition, patients who came from families where there was a greater degree of conflict and power struggle were more likely to be chronic back pain sufferers. Of course, it is not always easy to determine whether a topsy-turvy family life aggravates an already injured and distressed patient, or whether the family was the original source of the distress. What’s more, an even-tempered family life may lead to the same results. As mentioned above, a family overly solicitous in its caregiving may actually reinforce disability.

An association between traumatic family experiences and chronic back pain also appears to exist even when the trauma occurred much earlier in the patient’s life than the chronic back pain. Many patients who report chronic, unresolved pain have had a family history of dysfunctional relationships, e.g., parental separation or divorce, alcoholism, and emotional impoverishment. There is also increasing evidence of an association between chronic pain syndromes and past physical or sexual abuse.

Office Environs

Perhaps the most significant preexisting life factors are those seen in the workplace environment itself. In a very provocative and often cited study, Stanley Bigos and his colleagues longitudinally and prospectively followed three thousand aircraft employees at the Boeing Company in Washington state in order to identify risk factors for reporting acute back pain at work. They concluded that work perception is among the most predictive of factors for those patients who will develop pain. Workers who hardly ever enjoyed their job tasks reported back injuries two-and-a-half times more than those who almost always enjoyed their job tasks. These same indications of job dissatisfaction, a higher degree of worry, and fatigue at the end of the work day have been found by others as well. Furthermore, it has been shown that high rates of resignation and layoffs and fear of possible layoffs also lead to the likelihood of low-back injuries.

Read Chronic Back Pain: Physiological or Psychological? (Part 1)
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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May 2000