Division of Health Psychology

Diagnostic Uncertainty in Chronic Low Back Pain

Dr Danijela Serbic, CPsychol, FHEA, Teaching Fellow at Department of Psychology, Royal Holloway, University of London

Low back pain (LBP) is a highly common and disabling condition; it is now recognised as the leading cause of disability in the world. Pain and disability in LBP are associated with a number of psychosocial factors, for example depression, catastrophic thinking and fear of pain. A problem that has been less studied but appears relevant to many LBP patients is diagnostic uncertainty. Many LBP patients report feeling uncertain about their condition, pain and diagnosis. This is because in about 85% of patients a definitive cause for LBP cannot be established. So, it is not surprising that many patients continue searching for the causes of their back pain, instead of focusing on how to better manage their condition and pain. This inevitably results in numerous and unnecessary visits to health professionals. In the absence of a clear cause and diagnosis for their pain problem, many LBP patients report feeling that their pain is not legitimised. Some patients go as far as feeling guilty about being unable to provide a clear diagnosis and concrete evidence for their pain. 

Research has shown that pain-related guilt is a common experience among LBP patients, who also report feeling guilty about being unable to control and manage pain better, failing to engage more in social situations and letting down family and friends. Diagnostic uncertainty and associated feelings of guilt may negatively impact on mood and increase both withdrawal from social engagement and disability-related behaviours. Indeed, recent research evidence has shown that diagnostic uncertainty is associated with depression, anxiety, cognitive biases (e.g., recall bias for negative health stimuli) and disability in LBP. Therefore, there is a need to address diagnostic uncertainty. Health practitioners only partly do this when providing education about LBP; however, more targeted education and reassurance is needed. Some of these issues will be discussed in the next annual meeting of the Society for Back Pain Research, which is taking place on 2nd and 3rd November in Northampton, UK. There will also be a lively debate on the following: ‘This house believes we should target the system not the person with back pain '. This is a great meeting for all involved in chronic (back) pain research including students, clinicians, basic scientists, clinical scientists and psychologists.

We have made many medical advances in the treatment of back pain, but we still do not know how we can effectively reassure patients, without delegitimising their suffering. This question poses a challenge to practitioners and requires further research from health psychologists working in this area