Dr James Alexander, PhD- Psychologist

The attached article describes some exciting research results which suggest that many cases of chronic back pain (between 20-40%) could be the result of a bacterial infection of spinal soft tissue, such as discs. I have already been asked my views on this finding by clients, and the implications which it has for the psychological treatment of chronic pain. Firstly, i welcome the results. If 20-40% of chronic back pain sufferers are able to find relief from a 100 day course of antibiotics, then the overall net benefit (when one considers the gut damage etc which antibiotics can wreak) may certainly be there for individuals (what it does for the rest of us in terms of reducing the effectiveness of antibiotics and the production of antibiotic resistant bacteria is another issue which somebody should consider). If this finding prevents many cases of spinal surgery (for which there is very little evidence of effectiveness), or if it prevents years of unproductive physical therapy, or even years of unnecessary psychotherapy, then i think this is a good thing.

Psychotherapists who treat psychogenic pain and TMS authors have always acknowledged that there are some genuinely physical causes of chronic pain, e.g undetected cancers, and undetected infections (see page xxiii of The Hidden Psychology of Pain). It is known that undetected tumours only account for a very small proportion of chronic pain- where a person experiences no relief from lying down, frequent and/or painful urination, unexplained weight loss, neurological deficits and a history of cancer, they should be thoroughly medically assessed. While the consequences of cancer can be extreme, the proportion of chronic back pain sufferers having undetected cancer is very low. Until now, no one has known what proportion of sufferers have undetected infections. The research reported below suggests that this could be around 20-40%. This figure sits close to Burton's (1995) estimate, in the medical journal 'Spine' (20)6, that around 70% of chronic back pain can be accounted for by psychological factors- leaving around 30% of cases that are more likely to be primarily physically caused. As research has made it clear that structural pathology of the spine is not responsible for most cases of chronic back pain, it would appear that the primary physical cause is the newly identified bacterial infection. This still leaves anywhere between 60-80% of cases of chronic back pain which are not attributable to undetected cancers, structural pathology of the spine, or bacterial infections. Which brings us to the psychological contributors, and the possibility of the remaining proportion being attributable to psychogenic factors. A diagnosis of TMS (ie. psychogenic causes) is largely a process of elimination. The sufferer should be assessed for recent injury (thereby excluded from the chronic pain definition); assessed for symptoms of cancer; and assessed for symptoms of undetected spinal infections. If these causes are diagnosed, then the appropriate medical treatment needs to follow. If these causes are not diagnosed, but in their place are indicators of psychological/emotional distress (at various levels of conscious awareness), then a conclusion of psychogenic pain can be arrived at. It is a medical enterprise to exclude the medical causes, not a psychological one.

Is there still a role for psychology in the biological process of a bacterial infection? Decades of research in psychoneuroimmunology would suggest so. It is clear from research that our emotional state (which takes in both conscious and unconscious forms of distress) plays a large role in the functioning of our immune system. Chronic emotional stress results in higher levels of stress hormones such as cortisol, which in turn results in the hampering of the immune system, making the person more susceptible to bacterial infections. This suggests that the emotional state of a person is still highly relevant to their chances of suffering a spinal infection, as it is for any other infection. Again, a whole-person treatment approach is necessary, taking into account their life stressors, traumas and social-emotional functioning. This reality makes the recently found bacteria very similar to the bacteria found to be important in the production of stomach ulcers. Prior to the discovery of the offending bacteria, the assumption was that stomach ulcers result purely from stress. With the discovery of the bacteria, this assumption was turned on its head and resulted in the predominant view that the ulcers resulted purely from the bacteria. The reality is that humans are both biological and psychological beings- it is an arbitrary quirk of Western science that these two areas of human functioning were ever separated. Many people in the symptom free population carry a wide range of bacteria. In order for this to result in an illness, psychological factors need to come into play. It is likely that the bacteria identified for chronic back pain is part of the equation for many people (20-40%); however it is also likely to only be part of the equation. The psychological history and stressors are the other part of the equation which need to be taken into consideration, even when the bacteria is identified as present.

For the remaining 60-80% who may not have such an infection, antibiotics may come to be used on them anyway, and a certain portion will get better via a placebo effect. Then, once the back pain has been "cured" by antibiotics, it is likely that the person for whom pain was generated in order to protect them from unconscious material, their mind/brain will come up with a different symptom to satisfy the same psychological need- perhaps not a pain symptom, but there are many other body systems to choose from, e.g skin, gastro-intestinal, etc. The same need is likely to be met by alternative symptoms. The history of psychology and medicine is littered with examples of epidemics which come and go for no apparent reason- trends in ill-health. The syndromes and associated symptoms change with time, but the underlying psychological causes for many people (not all) will remain the same, as human nature does not change with each trend. In Freud's day, 'hysterical paralysis' was a common disorder- not so now. During WWI, trauma manifested with very different symptoms to what are apparent now- but the experience of being traumatised is the same. Who knows what psychogenic pain will morph into in the future (for whatever proportion of the population are susceptible to it)?

http://www.guardian.co.uk/society/2013/may/07/antibiotics-cure-back-pain-patients