Psychosocial Factors in Pain

Psychosocial Factors in Pain: Critical Perspectives

Gatchel RJ, Turk DC, editors

New York: The Guilford Press; 1999. 510 pp. with index

ISGN 1-57230-285-2

The preface to this book stakes out its claim. We are told that 4 main developments, each involving psychologists, served as the impetus for a revolution in thinking about pain. This revolution consists in the rejection of a “medical model” in favour of a “bio-psychosocial approach.”

The volume comprises 30 chapters. Of these, the first 9 make up Part I, on biopsychosocial context. In Part II 11 chapters deal with special topics and populations, and Part III provides 10 more on issues in prevention and management. The book finishes with an overview on resolution and evolution. Three out of the 43 authors of the 30 chapters are physicians dealing with pain and AIDS (a magnificent review), the epidemiology of low-back pain, and work style and work-related upper extremity disorders. There is an epidemiologist or two, a dentist with qualifications in psychology, and almost all the rest are psychologists dealing with pain. These include 3 Canadians (Gagliese, Katz and Melzack), Flor from Germany, and Main (from Glasgow and now Manchester).

The great bulk of the material reflects the work and views of US psychologists and their special psychosocial context.

This is a long volume, well produced and full of information, often very well worked out. The text itself is easy to read and very solidly written for the most part. Some chapters are excellent in whole or in part, while others seem to exist only to disappoint.

It is an irritating pity that what could have been a superb volume is marred by 2 faults of emphasis. One is needless special pleading and the other is an ill-founded, albeit highly sophisticated, tendency to revise the understanding of what it means to favour a back-pain disability model.

The special pleading begins with the listing of 10 contributors to the psychological approach. Three of these were actually physicians but not identified as such. More important, and tellingly, there is a lack of understanding or recognition that psychosocial factors have always been strong in medicine. Psychologists now dwell in a field long inhabited and not relinquished by internists, family doctors, neurologists, psychiatrists and a host of others.

Psychologists are much more numerous than psychiatrists in the field of pain and have made great contributions, starting with Hebb and Melzack. But some of their contributions (e.g., behavioural therapy of pain) remain controversial, and the field in which they have gained most recognition and added most to the subject appears to be cognitive treatment, which, incidentally, was applied to pain by a psychiatrist, A.T. Beck. Thus, what should have been a friendly and sociable claim to have made a large contribution has been spoiled by exaggeration.

More important, the way in which the biopsychosocial construct is now treated serves to reduce the biological element and to suggest that pain is largely due to psychological causes. I partly made that mistake myself and can sympathize, but the fact is that we have very few genuine indications that pain for which physical explanations are lacking is due to psychological causes except when it occurs with or after the onset of an obvious affective disorder. In other cases, and especially with musculoskeletal pain that arises with questionable indications of psychological difficulty, there is insufficient evidence to support the view that pain is due to vaguely alleged “behavioural factors,” but there is growing evidence from systematic controlled investigations that the determining factor is the state of the facet joints or degeneration (not prolapse) of intervertebral disks.

One of the most insidious practices connected with rejecting the patient’s pain consists in describing correlated information as “predictive.” Every psychologist knows that correlations do not demonstrate a causal link, except when there is a serial position, and should not be thought of as a causal consequence. Yet the insinuating word “prediction” is used repeatedly to corroborate some argument for psychological causation.

I do not want to leave the impression that Gatchel and Turk, as editors, make no attempt to acknowledge evidence that complicates their message. They recognize much of it. However, overall the book states the problems softly when they relate to weaknesses in psychological achievement, and overstates the failures of the organic approach. This is the more distressing because the authors and editors have all made significant contributions in the past, and continue to do so. Unfortunately, as one of my colleagues puts it, those who state their adherence to the biopsychosocial approach most loudly do not appear to be as serious about the “bio-” element.