THE BACK & NECK PAIN AND THE MIND
Dr. V. T. Ingalhalikar

DISCLAIMER There is a high incidence of Psycho-Somatic Back Pain. In one of the clinical research studies of chronic back pain sufferers that we carried out, upto 62 percent patients had major or minor contribution from psychological factors towards production and suffering of their back pain. Psychological and emotional factors can Influence and even Induce back pain. There could be a genuine objective physical cause for back pain suffering. But the pain may be increased or sometimes even relieved by psychological factors. ( Emotionally Influenced Back Pain ). In somebody, there may be no underlying objective physical cause whatsoever, but pain can be felt. ( Emotionally Induced Back Pain ) The focus of patient's attention is physical pain, i.e Back & Neck Pain, therefore the patients see doctors other than the psychiatrists. When the psychosomatic contribution to the patient's spinal pain goes unrecognized the treatment given may sometimes be ineffective.

Acute pain is often associated with Anxiety. Chronic pain usually associated with Depression. A Combination of anxiety and Depression is very common.

Back pain is very commonly blamed for the depression in a person. It is often thought that chronic back pain suffering produces Depression and, therefore, it is claimed that if the back pain is properly treated and cured, the depression will be cured. This is not always true. The back pain itself could be a presentation of the Depression. There are incidences of people commiting suicide from severe chronic depression and their chronic back pain is blamed for the person's ending his / her life.

Back Disability :

A large number of patients have chronic back pain but it does not produce any major disturbance in their own life or in the lives of those around them. Most often it is a simple back pain and whatever the suffering, is confined to the back pain sufferer alone. This can be likened to a person's taking alcohol regularly and leading perfectly normal life. If at all the alcohol is likely to produce any harm it will be to the person himself or herself. Nobody else suffers. On the other hand, a person's taking alcohol may affect not only his life but the lives of people around him. Such a person is not a simple alcohol taker, he could be appropriately termed as an Alcoholic. In a similar way, whenever the back pain in a patient significantly affects his / her life and the lives of others around him in terms of normalcy of life, we like to term this as a Back Disability.

This back disability is not necessarily a direct result of the underlying spinal disorder. It has more to do with patient's psychological and social resources available for coping with the life situations. These people often cease to live happy, fruitful and meaningful life. They often cease to exist as normal useful members of the society. In any community or country, in present times Stress is unavoidable. More and more people suffer from stress related Back & Neck pain. Stress induced chronic back pain sufferers have high tendency to become back disability persons.

Early diagnosis of psychosocial back pain is necessary since on-going back pain can produce Back Disability. Longer the duration of disabling back pain suffering, lesser are the chances of the patient resuming fruitful original functioning.

Psycho-Somatic Back Pain :
Presentation :

The Common associated findings are : -
- Multiple Bizzare Symptoms : symptoms belonging to various body systems presenting singally or in combintions in such a funny manner that it does not form any single medically rational and coherent clinical picture. Eg. ; headaches , tingling and numbness in body , chest pain , abdominal pain , difficulty in speaking swallowing , palpitations , apprehensions, Intolerance to noise, Persistent aerophagia ( burping ) etc. .
- Multiple physician contact : Because of the symptoms indicating multiple body systems affections , many physicians of different speciality are approached for treatment. Plenty of investigations may be carried out, many of them not revealing any significant or abnormal results.
- Verbosity of complaints : The patient may describe his suffering in vorbose , grandiose and mega-emphasized manner.
- Superlative response to clinical examination : exaggerated pain respones to even most gently carrried out examination.
- Most of these patients also have : -

- High urgency demands : They want to be treated out of turn on priority basis. The examination very often may not reveal enough objective physical disease commensurate with the expressed suffering . They expect many years of suffering to vanish in just a few days.
- Unrealistic expectations and frustrations over residual pain.
- Over reaction and misinterpretation over residual back pain.
- Somatic preoccupation : mind occupied with thoughts of body and illness all the time.
- Phobias : fears and apprehensions.
- Their Back and neck pain stimulation can be brought about by - loud noise, stress, fever, crowd etc.

Other important things to know about pain suffering :

- Early training of healthy pain habits is very important. A child who has during his developing years learnt incorrect attitude of looking at any body pain, is likely to grow into Pain Prone Personality as an adults.
- The Pain tolerance varies and also the resultant complaint behaviour varies.
- The Pain perception changes with mood.
- Sometimes the thought that pain is likely to be produced by something later, is enough to start pain perception now. This is to be termed as the Nocebo Effect of Pain Suggestion.
- It is commonly believed that whenever a person complains of pain, the pain is actually being produced at that moment in the body ( Real Time Pain Production ). This is not always true. Due to neurophysiological adaptations in the brain, the back pain can be a "Learnt Phenomena". The pain experience can be stored in the memory centres of the brain and this memory of pain can be aroused by situations similar to original pain producing episode. Thus the pain can be felt in the absence of actual pain production at that moment. It is like opening a file from the hard disc of a computor. The pain suffering on this memory arousal can be as real and vivid like the original experience. Though the back pain can be felt due to psychosomatic causes, the patient's suffering is not fake or unreal. Migrainous headaches are classic examples of this suffering. Anybody who has had such headaches knows how real the suffering is ! It is unfair to say that such a person suffering is "all in the head and imaginary".

Psycho-Somatic Back Pain And Surgery : -

The pain production could be entirely psycho-somatic. In these patients some investigations like MRI or CT myelogram etc. may reveal certain findings which may have no direct relevance to the patient's clinical suffering. It is often very difficult to ascertain the exact contribution made by psycho-somatic factors. Some of these patients may not be relieved after surgery . It is not unlikely to see a chronic back disability sufferer insisting on undergoing surgery to end his suffering. Very often this is an attempt to have his suffering authenticated and signatured by a surgical episode, especially if investigations are not strongly indicating a physical source of suffering. Like any new treatment modality in back care, a surgical episode may show temporary relief of pain in the immediate post-operative period for no real reasons. This is a Placebo effects of surgery. Poor post-operative results can be predicted in certain psychological disorders like Paranoid Schizophrenia and chronic Depression. Sometimes it is better to accept some morbidity with the back problem rather than operate upon these patients, since these patients have high chance of deteriorating psychologically or they using the surgical episode as an excuse for their ongoing complaining and Back Disability Behaviour.

Psychiatric Help and LBP :

During clinical evaluation most patients and their relatives strongly deny any psychosocial problems. Most would deny referral to psychiatrists or medico social counselor. A good physician always acknowledges the legitimacy of the patient's back pain. He always has a positive scientific rationale for referring the patient to the experts in psychological and social fields. Such a referral is routine and it does not necessarily indicate a transfer under psychiatrist care. The patients and their family members must understand this and comply with the treatment instructions to be benefited.

Care of Psycho-somatic Back & Neck Pain :

• Psychosocial counselors and psychiatrists are a great help.
• Scientifically educating the patient about the spine, the spinal disorders, their care, their prevention and about the psychological factors involved, is very important in getting the patient out of the difficulty. Back School is the most effective modality in achieving this.
• Active participation of a well motivated patient is a key to success.
• Psychotherapy and relaxation sessions bring about relief in many patients.
• Team Approach in Back Care : The patients are treated by a group of clinicians consisting of an Orthopaedic Surgeon, Neurologist, Physical Therapist, Occupational Therapist, Clinical Psychiatrist, Psycho-social counselor.
  • Such a team approach :
    
• Saves time and reduces risk of side tracked treatment.
  Prevents shunting of the patient.
  Different levels of expertise are available
  It eliminates individual clinician's bias.
  
• Contrary to the common belief, the patients do not mind team approach. They do not mind a group of clinicians discussing their case and are happy that more than one brains are working on their case.
  
• All drugs must be stopped eventually
  
  • Analgesics and Anxiolytics are habituating and it is preferable to give them for short courses
    Antidepressants are often needed. Their actions take effect slowly. They need to be given for prolonged periods. Some of them have side reactions like dryness of mouth etc.
    
• Medical illnesses like diabetes, hypertension, heart diseases etc. reduce pain tolerance. Their drugs sometimes cause reduced energy levels, mental blurring and psycho-physical addiction.
• Weaning of chronic analgesics and anxiolytics is difficult, but must be done. The chemical detoxification improves mental state and gives the patient a sense of control over his back-neck pain suffering.

PSYCHOSOCIAL MANAGEMENT OF BACK & NECK PAIN
Dr. Geeta Joshi.

The treatment of back disability is difficult and success is not always assured.

For best results Psychosocial treatment must be given simultaneously with physical care.

Psychosocial therapy strives to enhance the individuals coping capacities and mobilizes resources in the community, to enable him to achieve a better adjustment with himself and his environment.

When the patient comes for the first interview - he comes with some apprehension, diffidence and denial. Patients have little or no control over how they react to illness. They do not want to have pain. They do not choose to be psychologically disturbed and malingering is uncommon. The conversion of repressed emotion into a bodily symptom or exaggeration of the bodily symptom, in this case back pain , occurs at an unconscious level. Patients are pre-occupied with the pain and only want you to tell them how to get rid of the pain. Some of them even get hostile at the mention of psychosocial factors contributing to the pain.

The interview begins with an unconditional acceptance of the patient with his apprehension, diffidence, denial and even hostility. This unconditional acceptance is communicated through verbal and non verbal reassurance. The patient is then given the rationale for referral and treatment.

A detailed psychosocial study of the patient involves eliciting information about the patient and his immediate environment from the patient and one objective source i.e. spouse, parent.

Information needs to be collected and organized with regard to the following :
1] Personal data, 2] Family data, 3] Social data, 4] Childhood history, 5] Treatment history.

Information gathering and assessment is simultaneous. An individuals perception towards himself, others, life, the world and God. His sense of worth and esteem, his intellect, education, the defenses he uses and his overall ego functioning are taken into account for an assessment.

An assessment is a conceptual picture of the individual personality, the environment and the interaction between the two.

The common stressors that we have identified in working with back pain patients.

1] Interpersonal conflict.
2] Family role changes.
3] Joint family problem.
4] Financial stress.
5] Addiction in self / spouse.
6] Maltreatment by spouse.
7] Unemployment in self/spouse.
8] Job related problems.
9] Sterilization procedures/ hysterectomy.
10] Menopause.

Depression is often masked by the absorption in the somatic symptom.

The pain may protect the patient from intense depression and even suicide. Repression of emotions like anger, hatred, fears, grief and guilt is self destructive. These emotions are like dynamite buried alive. Repressed emotions unfortunately do not die. They refuse to be silenced. They find an outlet in somatic pain. They also influence the personality and behaviour of the individual.

An inability to cope creates feelings of helplessness and uselessness. These lead to a low self esteem and psychic pain. Psychic pain is unique and arises from the inner world when sense of self is diminished. The individual experiences a sense of worthlessness. Chronic pain is then the somatic expression of an unresolved psychic pain.

Without realizing it, the patient may subconsciously make his pain worse because of many primary and secondary gains. It gets him the added attention of family and friends. Pain can be used to avoid an unpleasant situation. After repeated failures pain can be a face saving reason for giving up a losing fight. The gain may be financial in terms of compensation. Rewards for pain behaviour re-inforce it and patients cling to this useful tool.

Taking time to talk to the patient and enabling him to voice feelings, fears, doubts and anxieties provides an emotional catharsis When emotional support , reassurance and encouragement is provided. The patient feels individualized. He feels accepted without criticism or judgment. as he gets a opportunity to express both thoughts and feelings and is reassured of confidentiality and help.

The therapist’s belief in his capacity for change and growth is communicated time and again till he begins to believe in himself. With his confidence boosted he is open now to move to the cognitive level. He is helped to understand how his cognitions are the determinants of his emotions and behaviour. With reflective discussion he is helped to become aware of his negative thinking and irrational beliefs that result in his inappropriate behaviour and as opposed to that if he can begins to practice positive and rational thinking he can use appropriate behaviour.

e.g. Irrational belief - It is necessary for an individual to be loved and approved by all in all situations.

Rational belief - It is not humanly possible to be loved and approved by all in every situations.

It is absolutely necessary to involve the family in the treatment process. They need support to develop more positive attitudes towards the patient that will enable positive behavioural changes. They may also need help to learn certain skills like communication skills especially In interpersonal conflict.

Knowing is not doing. An important aspect necessary for behavioural change is acquisition of Psychomotor skills. The patients coping can be enhanced when we empower him by training him in the adaptive skills that will enhance his ego functioning. e.g. Relaxation, Communication, Assertiveness and Problem Solving.

Insight into his illness and behaviour will reduce self defeating patterns of behaviour. The more he learns to value himself the less he will move towards psychic pain. Somatic pain will then be more proportionate to the actual organic lesion.

In the event that the disease has no cure the patient needs to learn to live with pain and discomfort without getting overwhelmed by it and rely less on medication. The therapeutic value of laughter is well known and the patient can be taught to appreciate and use the same. They need to be reminded about the joys in the simple things in life rather than waiting for something phenomenal to happen. The patient may need support if he needs vocational re-training or to go back to his job with some adjustment. An absorbing hobby or meaningful involvement in a social cause can be gratifying. All the treatment strategies discussed serve to correct perceptions and change attitudes, restore confidence, self worth and self esteem. The patient is lead to “feeling good” from within. He confidently uses adaptive skills for effective coping and we have found that patients can be happy and live a productive life despite pain.

DISCLAIMER

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