Meta-analysis of psychological interventions for chronic low back pain.

The purpose of this meta-analysis of randomized controlled trials was to evaluate the efficacy of psychological interventions for adults with noncancerous chronic low back pain (CLBP). The authors updated and expanded upon prior meta-analyses by using broad definitions of CLBP and psychological intervention, a broad data search strategy, and state-of-the-art data analysis techniques. All relevant controlled clinical trials meeting the inclusion criteria were identified primarily through a computer-aided literature search. Two independent reviewers screened abstracts and articles for inclusion criteria and extracted relevant data. Cohen's d effect sizes were calculated by using a random effects model. Outcomes included pain intensity, emotional functioning, physical functioning (pain interference or pain-specific disability, health-related quality of life), participant ratings of global improvement, health care utilization, health care provider visits, pain medications, and employment/disability compensation status. A total of 205 effect sizes from 22 studies were pooled in 34 analyses. Positive effects of psychological interventions, contrasted with various control groups, were noted for pain intensity, pain-related interference, health-related quality of life, and depression. Cognitive-behavioral and self-regulatory treatments were specifically found to be efficacious. Multidisciplinary approaches that included a psychological component, when compared with active control conditions, were also noted to have positive short-term effects on pain interference and positive long-term effects on return to work. The results demonstrated positive effects of psychological interventions for CLBP. The rigor of the methods used, as well as the results that reflect mild to moderate heterogeneity and minimal publication bias, suggest confidence in the conclusions of this review.     

The evolution of chronic back pain problems: a longitudinal study.

A longitudinal evaluation of the recovery from an acute back pain episode was undertaken on 117 sufferers, with assessments at the onset, 3 and 6 months. The number of individuals still reporting pain at 6 months, and therefore qualifying for 'chronic pain', was considerably higher than expected (40%). At 6 months, the persisting pain problems were found to be moderate to severe in intensity in approx. 20% of cases. Despite the pain, the chronic sufferers showed gradual continuing adjustments to it, re-establishing activities despite pain. Most of the change in the pain components (cognitive, subjective, behavioral, depression, anxiety) occur in the first 3 months, after which considerable stability is evident in the residual problem. In contrast, the impact of the pain and the consequent disability decline more markedly and continue to do so right up to the 6 month point. There was no evidence of chronic pain evolving and growing, but rather of a persistence of the acute presentation.     

An evolutionary analysis of psychological pain following rape. III: Effects of force and violence

Mental pain has been hypothesized to reflect psychological adaptation designed by selection to detect and cope with the occurrence of social problems that reduced individuals inclusive fitness in human evolutionary history. According to the hypothesis, mental pain is brought about by social tragedies in the lives of individuals and focuses an individual's attention on the events surrounding the pain, promoting correction of the pain-causing events and their avoidance in the future. The hypothesis applied to rape victims argues that in human evolutionary history raped females had increased fitness as a result of mental pain, because the pain forced them to focus their attention on the fitness-reducing circumstances surrounding rape, which are discussed. Some of the hypothesis' predictions about the psychological pain of rape victims are examined using a data set of 790 rape victims who were interviewed about their psychological traumatization within five days after the assault. Earlier analyses of these data have indicated that, as predicted, both a victim's age and marital status are proximate causes of the magnitude of psychological pain following rape: Reproductive-aged women appear to have been more severely traumatized by rape than older women or girls and married women more than unmarried women. The analyses herein indicate that, as predicted, reproductive-aged women are more likely to be victims of force and/or violence during rape than are older women or young girls. When force and/or violence was controlled, reproductive-aged women were still more psychologically traumatized by rape than were either older women or young girls. The results suggest that the psychology that regulates mental pain processes information about age and mateship status in the event of a woman's rape. The analyses reported here indicate that stranger rapes are more forceful and violent than either friend or family-member rapes.     

Use of verbal pain measurement in the detection of hidden psychological morbidity among low back pain patients with objective organic findings

Abstract

Patients with positive physical findings to explain low back pain arc believed lo belong to two organic subgroups. One group has organic disease alone: in the other, organic disease is accompanied by psychological disturbance. Separation of patients with medical findings into groups with varying levels of psychological disturbance is difficult, because emotional disturbance is often hidden. In this study, the pain report of 124 patients with organic findings alone, and 50 patients with organic and psychological findings was examined to determine whether pain measurement could he used to identify accurately patients belonging 10 the two groups. the pain groups differed in the use of 43 pain words from the Low Back Pain Symptom Check List. Using a set of weights derived From discriminant analysis. the 33 pain words predicted 99.2% of the patients with organic disease alone and 86.0% of the patients with organic disease and psychological disturbance. The results were replicated in a new sample of 140 patients. Cross-validation shrinkage in accuracy was 8.3%. The results of the two studies suggest that pain measurement may he a useful clinical indicator of psychological disturbance in patients with organic findings.     

Personality organization as an aspect of back pain in a medical setting.

The MMPI profiles of 74 low back pain patients who had previously been classified as "functional,"organic," or "mixed" were sorted into six profile groups. The six profile groups were those used by Pichot, Perse, Lekous, Dureau, Perez, and Rychewaert (1972); denial, "conversion V" without defensiveness, "conversion V" with defensiveness, depressed/anxious, psychotic and normal. Results indicate that all six profile types are well represented in the low back pain group. Evidence is also presented which shows that each of the pathological MMPI profile types examined across "functional," "organic," and "mixed" classification is significantly more elevated than a normal profile group on two scales (Lb, DOR) designed to measure functional aspects of pain. Pathological MMPI profile groups did not differ significantly from each other on the "functional" pain scales. The data presented in this study point to the relationship of various forms of psychopathology with "functional pain." The findings of this study would not support a homogeneous "pain personality" for low back pain patients. However, combined "conversion V" profiles accounted for 58% of the "functional" group, 45% of the "mixed" group and 35% of the "organic" group.     

Factorial analysis of the MMPI profiles of low back pain patients

To examine the interrelationships of MMPI scale scores among low back pain patients, 50 profiles were scored on the traditional 13 scales, Hanvik's Lb scale and seven subscales derived from Scales 1 and 3. The profiles were randomly divided into two equal samples and factor analyzed. Comparison of the two samples yielded three common factors. The first factor measured severity of the symptoms, the second assessed the level of anger and aggression and the third assessed the psychogenic components of the syndrome. The implications of the factors are discussed.     

Effects of different psychological interventions on neck,shoulder and low back pain in female hospital staff

Abstract

One hundred and eleven females volunteered to take part in this intervention study of musculoskeletal pain. They all completed a survey of pain among five hundred and eighty-six female hospital staff and presented mild to severe pain in the neck, shoulder and/or low back. They were randomly assigned to one of the following groups; Focus on job-stress and psychosocial coping (Cognitive), relaxation training (Relaxation), the combination of the two (Combined) or to a control group (Control). Musculoskeletal pain (intensity and duration) was assessed by self-report prior to interventions, immediately after interventions, and at a four months follow-up. Results from multivariate analyses of variance as well as covariance (pre-intervention levels of pain as covariate) showed that magnitude of pain reduction was dependent upon the interaction between area of the back and type of intervention. These trends were more significant for intensity than for duration scores. They were due to reductions of pain in (1) neck and shoulders for the Cognitive and Combined groups and (2) in the low back and shoulders for the Relaxation group. The four month follow-up assessment revealed a significant risk of relapse only for duration of low back pain among subjects in the Combined group. Results from the Cognitive approach to intervention may reflect a causal role for ability to cope with psychosocial job stress in the development of neck and shoulder pain in female hospital staff.     

Unexplained chest pain: a review of psychological conceptualizations and treatment efficacy

This review critically considers psychological theories and models used to understand unexplained chest pain, and efficacy of treatment strategies. It discusses the strengths and limitations of current perspectives, and highlights implications for future research and interventions. A comprehensive range of literature examining unexplained chest pain, and published over the last three decades, was thus reviewed finding that, although unexplained chest pain has been examined as a psychological phenomenon for over 100 years, explanatory models have emerged only in the last two decades. Neither psychophysiological nor psychodynamic models have been significantly advanced. Only cognitive-behavioural models have been explicitly derived to explain and manage the condition, and require further refinement to address conceptual and methodological limitations. Studies assessing treatment efficacy suggest cognitive-behavioural therapy as a first-line therapy, but have failed to establish whether the approach is acceptable and effective in routine care. Comprehensive psychological understanding of unexplained chest pain, and its management, is therefore developing but is far from complete. Cognitive-behavioural interventions show promise but are likely to be enhanced by greater theoretical clarity and understanding of resistance to their implementation.     

Operant-behavioural and cognitive-behavioural treatment for chronic low back pain.

Fifty-eight outpatients with chronic low back pain were randomly allocated to one of six experimental conditions. Four conditions were designated as treatment conditions and two as control conditions. The four treatment groups consisted of: cognitive treatment (either with or without relaxation training) and behavioural treatment (either with or without relaxation training). The cognitive and behavioural groups also received physiotherapy. The two control conditions consisted of: attention (physiotherapy plus discussion sessions) and no-attention (physiotherapy-only) conditions. All conditions, including the two controls, received the same physiotherapy back-education and exercise program. For the sample as a whole, improvements were obtained on measures of affective distress, functional impairment, medication use, pain-related dysfunctional cognitions and use of active coping strategies. These improvements were generally maintained at 6- and 12-month follow-ups. The combined psychological/physiotherapy treatment conditions improved significantly more than the physiotherapy-only conditions from pre to posttreatment on measures of pain intensity, self-rated functional impairment and pain-related dysfunctional cognitions. However, these differences were only weakly maintained at 6- and 12-month follow-ups. The behavioural conditions improved significantly more than the cognitive conditions from pre to posttreatment on the self-rated measure of functional impairment, but this difference was not maintained at 6- and 12-month follow-ups. Progressive relaxation training was found to make little contribution to either cognitive or behavioural treatments.     

Negative beliefs about low back pain are associated with persistent high intensity low back pain

While previous cross-sectional studies have found that negative beliefs about low back pain are associated with pain intensity, the relationship between back beliefs and persistent low back pain is not well understood. This cohort study aimed to examine the role of back beliefs in persistent low back pain in community-based individuals. A hundred and ninety-two participants from a previous musculoskeletal health study were invited to take part in a two-year follow-up study. Beliefs about back pain were assessed by the Back Beliefs Questionnaire (BBQ) at baseline and low back pain intensity was measured by the Chronic Pain Grade Questionnaire at baseline and follow-up. Of the 150 respondents (78.1%), 16 (10.7%) reported persistent high intensity low back pain, 12 (8.0%) developed high intensity low back pain, in 16 (10.7%) their high intensity low back pain resolved and 106 (70.7%) experienced no high intensity low back pain. While participants were generally positive about low back pain (BBQ mean (SD) = 30.2 (6.4)), those with persistent high intensity pain reported greater negativity (BBQ mean (SD) = 22.6 (4.9)). Negative beliefs about back pain were associated with persistent high intensity low back pain after adjusting for confounders (M (SE) = 23.5 (1.6) vs. >30.1 (1.7), p < .001). This study found negative back beliefs were associated with persistent high intensity low back pain over 2 years in community-based individuals. While further longitudinal studies are required, these findings suggest that targeting beliefs in programs designed to treat and prevent persistent high intensity low back pain may be important.     

Betrayal: A psychological analysis

Betrayal is the sense of being harmed by the intentional actions or omissions of a trusted person. The most common forms of betrayal are harmful disclosures of confidential information, disloyalty, infidelity, dishonesty. They can be traumatic and cause considerable distress. The effects of betrayal include shock, loss and grief, morbid pre-occupation, damaged self-esteem, self-doubting, anger. Not infrequently they produce life-altering changes. The effects of a catastrophic betrayal are most relevant for anxiety disorders, and OC D and PTSD in particular.Betrayal can cause mental contamination, and the betrayer commonly becomes a source of contamination. In a series of experiments it was demonstrated that feelings of mental contamination can be aroused by imagining unacceptable non-consensual acts. The magnitude of the mental contamination was boosted by the introduction of betrayal themes. Feelings of mental contamination can also be aroused in some ‘perpetrators’ of non-consensual acts involving betrayal. The psychological significance of acts of betrayal is discussed.     

Cognitive differentiation, back pain, and psychogenic pain drawings

Two groups of subjects with back pain were studied (n = 67). All subjects underwent a battery of psychological tests which included a test of psychological differentiation (the Rod-and-Frame Test), a test of psychological defenses (Meta-contrast Technique), and the Eysenck Personality Inventory. In addition, the subjects drew a pain picture and answered a questionnaire on pain-related issues. Each group of subjects was then subdivided into 4 groups depending on the judged abnormality of their pain drawings. The two main groups were compared overall and the subgroups of the two back-pain groups compared with each other. The Meta-contrast Technique results show that depression was quite common among back-pain subjects as a whole compared to a painless group of subjects. Differences were found on field-dependence; subjects with abnormal pain drawings were more field-dependent than those with "normal" pain drawings. Few other between-group statistical differences were noted between the two back-pain groups. Expected scores on hysteria were not noted among the abnormal drawing makers, neither were there differences between the groups on the items of pain duration, physical functionings, or of depression.     

Putting the psychology back into psychological models: Mechanistic versus rational approaches

Two basic approaches to explaining the nature of the mind are the rational and the mechanistic approaches. Rational analyses attempt to characterize the environment and the behavioral outcomes that humans seek to optimize, whereas mechanistic models attempt to simulate human behavior using processes and representations analogous to those used by humans. We compared these approaches with regard to their accounts of how humans learn the variability of categories. The mechanistic model departs in subtle ways from rational principles. In particular, the mechanistic model incrementally updates its estimates of category means and variances through error-driven learning, based on discrepancies between new category members and the current representation of each category. The model yields a prediction, which we verify, regarding the effects of order manipulations that the rational approach does not anticipate. Although both rational and mechanistic models can successfully postdict known findings, we suggest that psychological advances are driven primarily by consideration of process and representation and that rational accounts trail these breakthroughs.     

Exposure to physical movements in low back pain patients: restricted effects of generalization.

Whether the effects of exposure to 1 movement generalize to another dissimilar movement was investigated in 37 patients with low back pain (15 men, 22 women). Two movements were executed twice: bending forward while standing and lifting 1 leg while lying down. During each trial, baseline pain, expected pain, and experienced pain were recorded. Similar ratings for perceived harm were obtained. Analyses revealed an initial over prediction of pain, but after exposure the overprediction was readily corrected. This exposure effect did not generalize toward another dissimilar movement. These results were only characteristic for patients with catastrophic thinking about pain. Low pain catastrophizers did not overpredict pain. There were no effects of exposure on perceived harm. Exposure may profitably be conceived of as the learning of exceptions to a general rule.     

The concept of psychogenic pain: A psychological investigation of women with pelvic pain

Women with pain occurring in the absence of pathology have been reported to have personality and mood disturbances which account for their pain. These studies suffer from both methodological and theoretical difficulties. A common methodological problem is the absence of comparison groups of women with pain of equivalent chronicity yet with diagnosed pathology. This study compares women with and without pathology, matched for pain chronicity, on a range of psychological measures. No differences were observed between “pathology” and “no pathology” groups on global measures of personality or mood. Differences do emerge in specific attitudes and exposure to illness. The implications of these findings for our understanding of pain mechanisms are discussed and the limitations of the notion of “psychogenic” pain are considered.     

The consequences of pain: The social and physical pain overlap on psychological responses

Current theories suggest that social and physical pain overlap in their neurological and physiological outcomes. We investigated how social and physical pain overlap in their psychological responses by testing the hypothesis that both social and physical pain would thwart satisfaction on four human needs, worsen mood, and increase desire to aggress. In Experiment 1, recalling an experience of social or physical pain produced overlapping effects in the form of thwarted self‐esteem and control needs and increased negative affect and desire to aggress. In Experiment 2, we induced social (Cyberball ostracism) or physical pain (cold pressor) within the laboratory session, and found that both pain types produced feelings of being ignored and excluded, and thwarted belonging, self‐esteem, control, and meaningful existence. Our results provide further support to pain overlap theories and indicate that social and physical pain cause common psychological consequences, resulting in new ways to understand and manage pain. Copyright © 2011 John Wiley & Sons, Ltd.