Elsevier

The Spine Journal

Volume 1, Issue 2, March–April 2001, Pages 88-94
The Spine Journal

Original submission
Chronic spinal disorders and psychopathology: research findings and theoretical considerations

https://doi.org/10.1016/S1529-9430(01)00017-1Get rights and content

Abstract

Background context: Numerous studies have documented a strong association between chronic spinal disorders and psychopathology. However, there have been methodological shortcomings associated with much of this.

Purpose

This article reviews the relevant research literature, including methodological refinements that have resulted in improved measurement of psychopathology, in order to provide the most updated conclusions concerning the links between spinal disorders and psychopathology.

Study design

A systematic review of all Medline referenced articles on this subject during the past three decades.

Methods

Previous research has shown that chronic spinal disorders are most often associated with depressive disorders, somatoform disorders, anxiety disorders, substance use disorders, and personality disorders. In addition to reviewing this research, the relationship between chronic spinal disorders and depressive disorders is examined in more detail.

Results

Although the relationship between spinal disorders and psychopathology is complex, a diathesis-stress model is emerging as the dominant overarching theoretical model. In this model, diatheses are conceptualized as pre-existing semidormant characteristics of the individual before the onset of chronic spinal disorders, which are then activated by the stress of this chronic condition, eventually resulting in a diagnosable depressive disorder.

Conclusions

In the present review, a diathesis-stress model was applied specifically to the relationship between chronic spinal disorders and depressive disorders. Such a model may also be applicable to the relationship between chronic spinal disorders and other types of psychopathology, such as anxiety and substance use disorders. However, conclusive empirical support will require a prospective research design, given that these diatheses could be validly assessed only before the onset of the chronic pain condition.

Introduction

Chronic spinal disorders are an increasingly costly and debilitating medical condition in industrialized countries. As more has been learned about this condition, the importance of psychological and social factors in understanding chronic spinal disorders has become increasingly recognized. Indeed, such disorders are now widely viewed as a biopsychosocial phenomenon, in which biological, psychological, and social factors dynamically interact with one another. As psychological (i.e., behavioral, cognitive, and affective) factors have been explored, it has become increasingly evident that chronic spinal disorders are associated with high rates of diagnosable psychopathology.

There are several reasons why it is important to identify psychopathology in patients with chronic spinal disorder. Most importantly, unrecognized and untreated psychopathology can significantly interfere with successful rehabilitation of these patients [1]. Rehabilitation programs without an adequate mental health component may therefore be “doomed to failure” [1]. Psychopathology may also increase pain intensity and disability, thus serving to perpetuate pain-related dysfunction 2, 3. For example, anxiety has been found to decrease pain threshold and tolerance 4, 5, anxiety and depression have been associated with magnification of medical symptoms 6, 7, 8, 9, depression has been associated with less successful treatment outcomes 10, 11, and emotional distress has been linked to physical symptoms by means of autonomic arousal, vigilance, and misinterpretation [12] or somatic amplification [13].

Section snippets

Historical overview

Research on psychopathology in the chronic spinal disorder population, conducted mostly on patients with chronic low back pain (CLBP) in the 1980s, documented increased prevalence of depression, anxiety, substance abuse/dependence, “somatization,” and personality disorders compared with the general population 14, 15, 16, 17, 18, 19, 20. For example, rates of major depressive disorder (MDD) ranged from 34% to 57% in these studies, compared with rates of 5% to 26% in the general population [21].

DSM diagnostic criteria and structured clinical interviews

More recent studies have addressed the limitations of earlier ones by using structured clinical interviews based on DSM diagnostic criteria. As early as 1983, Reich et al. [22] recommended the DSM as the most accurate means for classifying patients with chronic pain in a uniform manner. The multiaxial classification format allows users to consider both physiological and psychological components of chronic pain in a systematized manner. The first two DSM axes are comprised of the psychiatric

Psychopathology and rehabilitation

Additional research has focused on determining whether psychiatric disorders are a limiting factor in the successful rehabilitation of patients with CLBP. Gatchel et al. [35] used the SCID to assess the prevalence of current and lifetime DSM diagnoses in a sample of 152 patients with CLBP beginning an intensive 3-week rehabilitation program. These patients were then followed over time, with treatment outcome being defined as return-to-work status 1 year after program completion. Despite high

Psychopathology and chronic pain

The research findings reviewed above have answered many questions regarding psychiatric disorders and chronic spinal disorders. However, important unresolved issues remain, including the precise nature of the causal relationship between chronic pain and psychopathology. It should be noted that research investigating the relationship between chronic pain and psychopathology has not been limited to patients with CLBP. High rates of psychiatric disorders have also been found to be associated with

The diathesis-stress model

Returning to the Fishbain et al. [66] study, these authors concluded that the consequence hypothesis is most strongly supported, with additional support for the cognitive-behavioral mediation and scar hypotheses. A recent theoretical proposal by Banks and Kerns [51], when placed within the framework of Fishbain et al.'s [66] study, may help to clarify further the relationship between chronic pain and depression. After demonstrating that rates of depression appear to be higher in chronic pain

Conclusions

A large body of research has consistently documented elevated rates of psychopathology in chronic spinal disorder patients. Depressive disorders, somatoform disorders, anxiety disorders, substance use disorders, and personality disorders have been identified as the most common diagnostic categories. Although the relationship between chronic spinal disorders and psychopathology is complex, a diathesis-stress model is emerging as the dominant overarching theoretical perspective. In this model,

Acknowledgements

This work was supported in part by Grants 2 R01-M446452 and 2 KO2-MH01107 from the National Institutes of Health.

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    The writing of this article was supported in part by grants No. 2K02-MH01107, 2R01-MH46452, and 2R01-DE010713 from the National Institutes of Health.

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