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Harvard Health Blog
The psychology of low back pain
Follow me at @srinipillay
Low back pain is the second most common cause of disability in the U.S. Over 80% of people will experience an episode of this pain at some point in their lives. The most common reasons for low back pain are disc injuries, sciatica, lifting heavy objects, or some other non-specific back injury.
Yet even though back pain is incredibly common, not all people respond in the same way to this often-disabling condition. In fact, even if two people have the same level of pain, their responses to that pain can be very different. These differing responses are due in part to different people's psychological attitudes and outlooks.
Even when you have low back pain that is being medically treated, it helps to understand the psychological factors that impact your pain — and your brain. It also helps to know what you can do about this.
Why chronic back pain is connected to "your head"
When your physical movement is limited, this can cause psychological distress, and the psychological distress can, in return, worsen the pain. Your personal health beliefs and coping strategies can influence both your level of distress and course of the pain. For instance, if you are anxiety-prone, expect the worst, and have catastrophic thinking, this can make the pain far worse. That's because those psychological vulnerabilities can change your brain and intensify the pain.
Often, if you have these pre-existing psychological attitudes, you also have abnormalities in the regulation of your brain's chemistry (particularly dopamine), and the usual brain functions in emotional control, anxiety, and attention are also disrupted. As a result, you can't control your distress; your become anxious; you expect the worst; and you can't focus on anything else. The pain becomes all-consuming.
But it's not just pre-existing attitudes that worsen back pain. The pain itself can rewire your brain. When pain first occurs, it impacts your pain-sensitivity brain circuits. But when pain lasts, the related brain activity switches away from the "pain" circuits to circuits that process emotions. That's why emotions like anxiety often take center stage in chronic back pain. And it's why emotional control becomes that much more difficult.
What you can do to tame chronic back pain
Fortunately, some psychological therapies can be really helpful with back pain. They help lessen pre-existing psychological vulnerabilities, change how you perceive the pain, and also alleviate the psychological factors (such as anxiety and anticipation) that maintain your pain.
The treatment with the greatest supporting evidence (for all chronic pain syndromes, not just back pain) is mindfulness. A recent study demonstrated that a technique called mindfulness-based stress reduction (MBSR) can help to reduce back pain and also improve emotional control by increasing brain blood flow to the frontal lobe. A full eight-week course in this technique may even improve anxiety and depressive symptoms as well. Practicing mindfulness involves activating a brain relaxation pathway by deliberately ignoring mental "chatter" and focusing on your breathing. When you do this, an "unfocus" circuit, called the default mode network, is activated. However, in some chronic pain patients, this circuit is disrupted. In these cases, MBSR may not work.
There are other forms of psychological treatment that can be helpful as well. Cognitive behavioral therapy (CBT) can be especially helpful. You can attend group or individual sessions either in person or via computer. Even a single episode of back pain can benefit from psychological treatments. CBT can also prevent an acute injury from progressing to chronic back pain.
Hypnosis may help relieve the pain as well. CBT and hypnosis have weaker evidence to support their effectiveness for back pain than MBSR does, but they are worth trying if MBSR fails.
Depending on the cause, low back pain can be treated with progressive muscle relaxation too. This is a technique in which you learn how to decrease your anxiety by becoming more aware of how you can tense and then relax your body.
And there is also some evidence that combining psychiatric medication with psychotherapies may be more helpful than either treatment alone.
But it's not simply "mind over matter"
So while it's clear that low back pain can be "in your head," that doesn't mean that you have to trivialize it. In this day and age, "mind over matter" makes little sense. "Mind" includes "matter," especially when you consider that the physical "matter" of the brain plays a major role in mindset changes. This is especially true when it comes to the brain-based changes related to low back pain. To that extent, changing your mindset and brain biology can help your brain — and lessen your pain.
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No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
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