Up to 10% of U.S. adults have chronic low back pain that lasts three months or longer and is bad enough to limit what they can do. Globally, low back pain is the number one cause of disability, based on Years Lived with Disability—a standard metric used by researchers.
Coping with the pain is difficult enough. But people’s frustration is often magnified by the vagueness of their diagnosis. Chronic low back pain can be traced back to a single, specific injury or illness in only a minority of cases.
The inability to pinpoint an exact cause leaves room for doubt. A new study looked at the emotional impact of this diagnostic uncertainty—the belief that doctors have yet to discover something important that’s going on with your back. The study, published in Health Psychology, was led by Danijela Serbic, Ph.D., a teaching fellow in psychology at the University of London.
Dr. Serbic and her colleagues gave questionnaires to more than 400 individuals with chronic low back pain. They found that, in the absence of a clear-cut explanation, people often ended up feeling guilty about their pain. And that guilt, in turn, was linked to increased depression, anxiety and disability.
3 Types of Pain-Related Guilt
Dr. Serbic, along with Tamar Pincus, Ph.D., previously developed a pain-related guilt scale. The scale asks about three kinds of guilt:
Verification of pain guilt, which involves feeling guilty about being unable to provide a clear diagnosis or physical evidence of pain. Example: “I have experienced feelings of guilt about being unable to produce a clear diagnosis when asked.”
Managing condition/pain guilt, which involves feeling guilty about seeing a number of different doctors in search of help or failing to respond to treatments. Example: “I have experienced feelings of guilt about being unable to control the illness and pain.”
Social guilt, which involves feeling guilty about letting friends and family down by not being socially engaged and active due to pain. Example: “I have experienced feelings of guilt about not being able to help people close to me when they need me.”
Recently, I chatted with Dr. Serbic about her just-published study, which used this scale to assess guilt. Below, she discusses why people experience pain-related guilt and how to head off such feelings.
Why did you choose to study pain-related guilt in people with chronic low back pain?
Dr. Serbic: In spite of low back pain being the leading cause of disability worldwide, we know very little about pain-related guilt in this group of patients. For many patients, low back pain is a disabling, persistent and chronic condition, which can greatly limit what they can or cannot do for themselves and others. However, its impact is often underestimated by society, which can contribute to patients feeling guilty about having such limitations. Our research has shown that pain-related guilt is a common experience in low back pain patients.
You found that diagnostic uncertainty was moderately associated with pain-related guilt. How are these two factors related?
Dr. Serbic: In the majority of low back pain patients, clear causes for the back pain are unknown. For these patients, it’s difficult to justify the pain as well as their actions or inactions influenced by the pain. This is likely to result in a number of emotional and behavioral responses, and one of them is guilt.
It is likely that patients experience cognitive dissonance, or conflict, between having insufficient evidence for a physical cause of pain and their own experience of pain and suffering. This conflict may result in guilt in some patients.
You also found that pain-related guilt was associated with disability and negative moods. Can you please explain the connection?
Dr. Serbic: Past research findings showed that individuals with low back pain reported distancing themselves from other people to avoid feeling guilty about their pain-related behaviors. This explanation is in line with theoretical explanations of guilt, which describe it as a maladaptive state that motivates avoidance. Guilt might motivate avoidance of social situations and activity, and therefore increase disability and negative mood.
What are the practical implications of your findings? Are there things that people with chronic low back pain can do to prevent guilty feelings?
Dr. Serbic: There is no published research on this yet. But preliminary findings from our latest research show that increased pain-related guilt is related to decreased acceptance of pain. There is plenty of evidence showing that patients who are accepting of their pain have lower levels of disability, depression and anxiety. Overall, they cope better with pain.
Acceptance of pain is difficult. Mindfulness and ACT (acceptance and commitment therapy) might be useful for some. We don’t yet have a definite trial to investigate this in low back pain, although we do know that patients find these types of treatments credible.