Psychogenic Backache: The Missing Dimension John E. Sarno, M.D. New York, New York Experience with a population of patients with conversion pain and a third group with the common complaint of low back pain pain due to excessive muscle tension. The suggests that a substantial proportion of theoretical basis for these states is described these patients are suffering with pain of and a plea made for the inclusion of psychogenic causation. These patients appear these etiologic categories in the differential to fall into one of three categories: those diagnosis of low back pain. A brief whose somatic pain is intensified by psychic diagnostic and therapeutic modus operandi factors, those who have what has been called is presented. here is probably no group of disorders which afflict that much of the confusion which exists in the diagnosis T modern man that is more ubiquitous and more disturb­ and treatment of patients with backache results from the ing than the variety of pathologies which have low back widespread tendency to attribute back pain in every case to pain as their major symptom. Despite the scientific method­ some neurological or mechanical musculoskeletal derange­ ologies that characterize the investigative and therapeutic ment. This article will outline the evidence for psychogenic armamentarium of today's medical practice, this problem backache, describe our experience with this problem, and still eludes solution. Perhaps it does so because it is not one suggest some diagnostic and therapeutic approaches which but many diseases. Further, because the major manifesta­ should be helpful to family physicians caring for patients tion of these conditions is pain, the problem is more com­ with this.common problem. plicated than it looks. It is appropriate that family physicians should interest themselves in the ultimate solution of this problem since Psychogenic Basis of Backache they are usually the first to see the patient and may hold the key to its solution in a substantial percentage of cases. It is In 1946 a short article appeared in the New England jour­ common practice to refer intractable cases to specialists and nal of Medicine entitled “ Psychosomatic Backache" by Sar­ just as commonly appreciated that the usual therapeutic gent describing a population pf patients seen in an Army Air measures such as restriction of activity, bed rest, lumbar Force Convalescent Hospital, all of whom had backache corsets, a bed-board, a set of exercises, an injection, and associated with a wide variety of neurotic symptoms.’ even surgery often fail to solve the problem. If is proposed These patients were from a much larger group brilliantly that many cases of low back pain are psychic in origin, and studied and described by Grinker and Spiegel.2 Working with a concentrated population, a pure culture.as it were, of From the Department of Rehabilitation Medicine, New York University human beings subjected to severe stress, these authors de­ School of Medicine. New York. New York. This study was supported veloped some keen insights into how people react to stress, in part by the Social and Rehabilitation Service, Department of Health, who are the ones most likely to succumb to the strain, and Education and Welfare under the designation of New York University ,is what their personality patterns and social histories are. Sar­ a Rehabilitation Research and Training Center, and under Grant No. 21-P gent found that his patients with backache could be divided 55029/203. Requests for reprints should be addressed to Dr. lohn Sarno, Institute of Rehabilitation Medicine, 400 F.ast 34ih Street, New roughly into three categories: those with definite organic York, New York, 70076,. disease, a group with hysterical conversion symptoms and a large segment with backache due to "muscular tension," in­ have presented compelling arguments relating pain to psy­ terpreted as a somatic manifestation of nervous tension. chic states. A detailed psychodynamic explanation would Sargent, a surgeon, indicated that only four percent of an not be appropriate here, but certain major characteristics of undisclosed number of patients (not disclosed for military the pain-emotion process will be briefly mentioned. reasons) were found to have organic back disease after Viewed from, a basic psychological standpoint, all human thorough examination, X-rays and laboratory studies. beings develop associations between pain and certain emo Among those with hysterical conversion symptoms there tional states via the fundamental learning process which we were some with simple conversion symptoms and, more now call conditioning. In later life when a person experi­ commonly, patients with a previous history of a back disor­ ences an emotional state, such as guilt, it may evoke the der who developed the old symptoms again in association same painful state with which it was associated earlier in with the stress of combat. This striking phenomenon has life. Szasz has developed the thesis that the experience of been observed in our clinic on numerous occasions, as ex­ pain is itself an emotional or affective expression and as emplified by the insurance executive who suddenly devel­ such derives its specific character in a given individual from oped severe back pain of a type for which he had been that person's personality structure.5 An implication of this seen and treated two years previously, because the com­ view is that a person's response to a painful peripheral stim­ pany which he had created and which had gone public was ulus, such as a wound or an infection, will be determined being threatened with takeover by an outside syndicate. by his personality structure and in such cases represents a The present' state of the diagnostic and therapeutic situa­ warning that something is threatening the functional integ­ tion regarding backache was well summarized in an editori­ rity of that person's body. Szasz and others have pointed al in the British Medical lournal.3 It was pointed out that in out the communicative role of pain; the fact that it can be a most cases of back pain a specific abnormality is not found. cry for help, a complaint, an attack or retribution against When congenital vertebral deformities or spondylosis are someone. Anxiety may be stimulated by real or imagined demonstrated radiographically, for example, their signifi­ threats to the integrity of the self or body or by the presence cance in the production of pain is usually doubtful. Reflect­ of hostility or resentment within the person himself. Unre­ ing this situation, these are some of the terms used to de­ lieved strain may result in ego regression and increased de­ scribe backache: fibrositis, fibromyositis, postural backache, pendency. When hostility is turned inward against the ego, ligamentous strain, lumbosacral strain, sacroiliac strain, lum- depression results. Our experience and that of many other balgia, lumbosciatic pain, lumbosciatalgia, sciatica, lumbar workers is that depression is a frequent, almost universal, radiculalgia, low back pain, lumbar pain. It is of interest that concomitant of conversion pain. in this long list of diagnoses, none suggests either a primary Wolkind and Forrest reported the use of a questionnaire or secondary contribution of the patient's psyche to the to identify patients unlikely to respond to conventional pain syndrome. treatment for low back pain and who required extensive so The present state of the diagnostic art in backache is such cial or psychiatric investigation.9 They utilized a self-rating that no etiology, aside from degenerative disc disease, en­ scale of psychoneurotic symptoms and behavior known as joys the support of scientific data. We are reluctant to add the Middlesex Hospital Questionnaire. The subjects were to this confusion by suggesting yet another diagnostic possi­ 50 consecutive male patients without evidence of degen­ bility. Still, the clinical evidence, a review of the literature erative disc disease referred to a physiotherapy department and the growing awareness of the importance of the psyche for treatment of low back pain. There was a statistically valid in health and disease require that we re-examine the prob­ correlation between outcome of treatment and scores on lem of low back pain with this dimension in mind. In sup­ sub-tests measuring obsessionality, depression and the port of this point of view, it has been reasoned that if a pa­ somatic concomitants of anxiety. tient with backache of long duration in whom'the etiology Sparup has reported experience with 108 chronic back is suspected to be psychogenic can have alleviation of patients in a rehabilitation clinic geared to identify psycho­ symptoms through some form of psychotherapy, one is social problems. Forty-seven percent of them had a psychi­ justified in concluding that the etiologic diagnosis is correct. atric diagnosis and with appropriate diagnosis and treat­ It is becoming dear that pain is not simply a stimulus- ment, 70 percent were able to return to work.10 response process. The identification of neurological path­ In a comprehensive study of industrial injuries of the ways and the purely physiological parameters of the pain back and legs, Beals an'd Flickman concluded that "psycho- experience are not sufficient to explain the clinical phe­ pathological factors play an important and determinate role nomenon of pain. Adams has said, "I am convinced that the in the return to work of industrially injured workers" and sound medical approach to the chronic pain syndrome is that these factors were of greater importance in the back- yet to be discovered: further that we shall not achieve a full injured than in the leg-injured patient. After studying 180 understanding of the mechanism of chronic pain and the such patients they suggested the routine employment of way in which it disturbs the human organism until we ac­ psychological evaluations in both industrial and non­ quire more information concerning the anatomy and physi­ industrial back pain syndromes of a chronic nature.'1 ology of emotion.