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

Psychiatry has long purported that physical symptoms, including pain, can be a manifestation of psychological disturbance. Early concepts of hypochondriasis and hysteria have received considerable attention in the literature. The older concept of psychosomatic (the influence of the mind on the functions of the body) illness has been replaced by the present concept of somatization, referring to the transformation of anxiety into bodily symptoms. Somatization may be the representation of masked depression, fears or phobias, a breakdown of psychological defenses with an autonomic nervous system reaction, a defense mechanism, a learned behavior, the expression of hostility or resentment, or a means of seeking attachment. No one mechanism can explain the process of somatization, and its end results ultimately depend on the psychological make-up of the individual.

Overuse of Health Care

Anxiety is an uneasy emotional state involving tension and apprehension, often with no clear stimulus. There is a recognized association between somatic (or bodily) symptoms and anxiety; therefore, back symptoms should be no exception. Some authors suggest that certain people have an amplifying somatic style. These people scrupulously monitor their own normal bodily sensations and functions. They may scrutinize trivial or transitory symptoms — symptoms which others would dismiss as insignificant. They tend to react to physical sensations with apprehension or alarm. Other investigators have labeled this a high private body consciousness, where individuals are more attentive to themselves and their bodies than their environment. They tend to report more aches and pains and to interpret these sensations as more distressing.

Patients with somatization tendencies and disorders have been shown to use health services to a greater extent than other populations. They have more office visits, diagnostic tests, hospital stays, and surgical procedures. They tend to experience major disabilities and recover slowly. Their symptoms are often poorly explained, and they have greater psychological and social impairment. This pattern is astoundingly similar to chronic back pain patients who also use an extraordinary amount of health services, often with poor results. Research shows that the large majority of chronic back pain patients — in one study, 75 to 80 percent — experience numerous bodily complaints in addition to the back pain. Consistent with patients who experience somatization, patients with chronic back pain generally report more bodily sensations than control subjects and appear to focus more attention on normal bodily sensations.

Psychological Illness Masquerading as Back Pain

Primary psychological illness can be present with back pain. The most common categories of these illnesses are depression and somatoform disorders. We have already discussed depression. There are some instances in which depression is the primary and only psychological illness and back pain is merely an incidental symptom. Usually, this is not seen following a traumatic injury, where the relationship between depression and back pain is more complex.

Somatoform disorders are those in which there are physical symptoms that cannot be explained without medical pathology. suggesting a psychological basis for the physical symptoms. These are not factitious disorders and do not represent malingering; symptom production is not intentional. There are a number of specific diagnoses of somatoform disorders.

Hypochondriasis

Here, individuals fear having — or believe they have — a serious disease that they do not have. Strictly speaking, this disorder is one of apprehension rather than an experience of pain. However, the attention that is focused on bodily function can easily lead to pain symptoms, and frequently, this disorder accompanies other functional (psychological) bodily syndromes. Studies have shown that chronic pain patients with hypochondriasis had higher incidence of early childhood trauma.

Somatization Disorder

With somatization disorder, the essential feature is recurrent and multiple physical complaints over a period of at least several years. It is not restricted to back pain. Where there is a history of many unexplained medical problems over the course of a lifetime, this disorder should be considered.

Pain Disorder Associated With Psychological Factors

Formerly known as somatoform pain disorder, this disorder is a more specific pain complaint. Although it often follows an injury, it is primarily a psychological condition. The patient may not have had a history of recurrent or diffuse complaints, but would all at once appear dramatically ill, despite nonexistent objective findings. A variant of this condition, known as conversion disorder, has sensory or motor symptoms that are sometimes accompanied by pain. In both cases, undisclosed psychological problems are responsible. These problems may be pre-existing, and the injury may provide an opportunity for a face-saving way to manifest these problems.

Malingering and Factitious Disorders

Malingering and factitious disease involve the intentional production of false or grossly exaggerated symptoms. There is no question that some patients who claim back pain are malingerers and that malingering probably occurs more frequently than it is diagnosed. However, malingering is a very difficult diagnosis to make. Often, clinicians who are frustrated with a difficult patient will make the diagnosis erroneously. Ultimately, malingering is a factual and not a medical determination, based on a review of all the evidence. Private investigators may be helpful in accumulating evidence. However, the variability of symptoms in non-malingerers requires very accurate and reliable reports. The modern use of video cameras has added a new level of sophistication to this difficult identification process.

Compensation-Driven Disability

Over the last century, it has been acknowledged that patients who seek compensation for their injuries have a prolonged recovery period and a less satisfactory response to treatment. While the increase in industrial low-back disability during the first part of the twentieth century may be explained by changing workplace conditions, the epidemic that has followed is not so easily understood and is often attributed to the availability of compensation. Military medical records of English forces in the first and second world wars show a five-fold increase in low-back pain complaints and a four-fold increase in the duration of disability for World War II versus World War I soldiers. In the United States, the incidence of disabling back pain between 1971 and 1981 increased 168 percent — 14 times that of the population growth. Clearly, increased disability initially led to the need for compensation, but now compensation may be driving up the disability rate.

Terms such as compensation neurosis or greenback poultice have been pejoratively used to describe this phenomenon and have influenced many physicians in the course of their dealings with workers compensation patients. Financial gain has been shown to be a powerful reinforcer of disability. Indeed, studies have shown that patients who have back pain and are receiving workers compensation do poorly in treatment and are disabled longer. One author described these con-ditions as “a state of mind, born out of fear, kept alive by avarice, stimulated by lawyers, and cured by a verdict.”

However, this description is not universally accepted, and in some studies, patients receiving workers compensation recover just as well as those who do not. In fact, a significant indicator of truthfulness on the part of workers compensation chronic back pain patients is that, even up to five years after the settlement of a claim, there is no significant reduction in their morbidity.

When no objective medical pathology exists, psychological and psychosocial factors may be primarily responsible for the back pain. In these cases, the reinforcing effect of compensation is greatest. In most cases, the phenomenon known as secondary gain takes over — it occurs when an original injury has an unexpected environmental response that assists in sustaining it. Examples include a doting family, excusal from unsatisfactory work conditions, and financial reimbursement through workers compensation or disability insurance.

A less common, but more troublesome phenomenon is primary gain, where a psychological conflict or need creates the physical symptom in the first place. Here the motivation may be the desire to avoid an unpleasant or threatening personal situation or the ability to gain an important environmental benefit. The physical symptom serves a significant psychological purpose and may resolve the conflict with which the individual was unable to deal. The psychological issue is the initiating and sustaining factor.

A Final Word

Back pain disability can have a number of psychological components, including a psychological conditioning process, numerous psychosocial variables, and compensation-driven factors. A thorough understanding of the patient and his or her history is necessary before determining how much these factors are contributing to the patient’s complaints and impairment. Psychological evaluations and psychological testing by an experienced clinician can make the difference in successful treatment or exposure of malingerers.

Read Chronic Back Pain: Physiological or Psychological? (Part 1)
Read Chronic Back Pain: Physiological or Psychological? (Part 2)

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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June 2000