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Diagnostic uncertainty and pain-related guilt: new treatment targets for low back pain?



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Low back pain (LBP) is a highly prevalent condition, with a devastating impact on society and it is now recognized as the leading cause of disability worldwide (Lim et al., 2012). Research suggests that several psychological factors play an important role in LBP, and among the most robust factors are depression, catastrophic cognitions, fear of movement and activity, and beliefs about recovery (Pincus & McCracken, 2013).  Despite this, psychological interventions targeting these factors have delivered only small improvements in trials (Williams, Eccleston, & Morley, 2012). This might suggest that additional factors should be identified and studied. Our recent research (Serbic et al., 2016) focused on two less studied psychological factors: diagnostic uncertainty and pain-related guilt.

So, why diagnostic uncertainty?  In the majority of patients a definitive cause for LBP cannot be established (Krismer & van Tulder, 2007) and many patients report feeling uncertain about their diagnosis. Diagnostic uncertainty may impact how patients feel and cope with their pain and they may continue searching for the causes of their back pain instead of focusing on other important aspects of their lives. But – here comes the interesting part about this construct – research (Serbic & Pincus, 2014a) has shown that patients’ perception of their diagnosis is not clearly related to the diagnostic labels received from their health care providers, even when patients agree with the label. For example, many patients who believe that there is something wrong (structurally) with their backs, yet undetected, also report having agreed with their diagnosis and/or explanation. This might reflect patients’ belief that the diagnosis is correct but does not capture the true severity of their condition; that it fails to capture other factors beyond the , or possibly that they believe the diagnosis is inaccurate, but are not comfortable disagreeing with their provider. As a consequence of this, in the current study we assessed ‘perceived’ diagnostic uncertainty.

Why pain-related guilt? In the absence of a clear cause for their pain patients  may feel that their pain is not legitimized and  may feel guilty about this. Feeling guilty about their pain may not only increase depression, but may result in increased disability-related behaviours. Previous research (Rhodes et al., 1999; Serbic & Pincus, 2013; Serbic & Pincus, 2014b) has shown that pain-related guilt is a common experience among LBP patients and that it includes several aspects. These include: feeling guilty about being unable to provide a diagnosis and justification for pain (verification of pain guilt); being unable to control and manage pain better (managing condition/pain guilt); and failing to engage more in social situations and letting down family and friends (social guilt). Therefore, one hypothesised mechanism via which diagnostic uncertainty might be linked to disability and mood is through feelings of guilt. We wanted to examine this hypothesized pathway, and alternative models in which pathways between these variables were reversed (e.g. in one of them mood preceded guilt, rather than the other way round, which in turn lead to diagnostic uncertainty and disability). To examine these models we used structural equation modelling (SEM), which is used to evaluate whether theoretical models are plausible when compared to observed data.

Our results showed that all tested models were viable, which may suggest a cyclical relationship between diagnostic uncertainty, guilt, mood and disability, but further (longitudinal) research is needed to confirm and clarify this.   Overall, in all tested models, guilt, and especially social guilt, was associated with disability. Diagnostic uncertainty was associated with guilt, but only moderately. mood (increased anxiety and depression) was also associated with guilt. Alternative models were tested and found additional other possible associations and directionality, please see the published manuscript for more details. The important questions for future research arising from the current findings focus on the need to reduce disability in LBP. Evidence from studies that attempt to reduce disability by reducing negative mood and cognitions in LBP populations, are only partially successful (Pincus & McCracken, 2013). As previously indicated, there is a need to identify and intervene on additional factors; our findings suggest that two of these factors may be diagnostic uncertainty and in particular pain-related guilt.  Social guilt, in particular, has strong associations with disability. While the causal path between these two variables is unknown, the possibility of a ‘vicious cycle’ in which disability increases social guilt, and the response to social guilt is further withdrawal from social engagement, in turn increasing isolation, disability and depression, warrants further investigation. Several other studies have suggested that an important focus of pain-related guilt is social. For example, patients have reported feelings of guilt about letting their family down and about family members undertaking their responsibilities  Available interventions only partly address diagnostic uncertainty in that they include elements of education about LBP, and there is no explicit goal or method of intervening on pain-related guilt. As all tested models support a link between pain-related guilt and disability, new directions for research include addressing two key questions: a) can interventions be designed to specifically address pain-related ; and b) will reductions in pain-related guilt improve outcomes in these patients? In addition, it is important to examine how practitioners can effectively reassure patients, for example by targeting diagnostic uncertainty through validation/legitimization of patients’ suffering.

About Danijela Serbic 

Danijela SerbicDr Danijela Serbic is a teaching fellow at Royal Holloway, University of London, UK where she is involved in the teaching of psychological research methods and analysis, abnormal psychology and other undergraduate and postgraduate courses. The broad area of her research is the role of psychology in chronic pain. She is in particular interested in the impact of diagnostic uncertainty and pain-related guilt on clinical outcomes such as depression, anxiety and disability in chronic low back pain patients.

About Tamar Pincus

Tamar Pincus

Professor Tamar Pincus holds a PhD (University College London), as well as Masters degrees in experimental research methods in psychology (UCL), and epidemiology (Cambridge University). Her research has embraced a variety of methodologies, including experimental, epidemiological and qualitative. The research has included investigation of attention and recall in pain patients; the psychological predictors for poor outcome in low back pain, and the study of clinicians’ beliefs and attitudes in low back pain. Recently the focus of her research has moved to investigating the effectiveness of interventions through randomised controlled trials, and throughout she has collaborated closely with researchers from many disciplines, including doctors, physiotherapists, osteopaths, chiropractors and clinical psychologists, from a multitude of institutions, including Warwick, Keele, QMW, Leeds, Manchester, The British School of Osteopathy and many others. She also convened the international consensus group to establish what factors and measures should be included in prospective cohorts investigation the transition from early to persistent back pain. Most recently her research has focused on delivering effective reassurance to patients in primary care.


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Serbic, D., & Pincus, T. (2014a). Diagnostic uncertainty and recall bias in chronic low back pain. Pain, 155(8), 1540-1546.

Serbic, D., & Pincus, T. (2014b). Pain-related Guilt in Low Back Pain. Clinical Journal of Pain, 30(12), 1062-1069.

Serbic, D., Pincus, T., Fife-Schaw, C., & Dawson, H. (2016). Diagnostic Uncertainty, Guilt, Mood and Disability in Back Pain. Health Psychology, 35(1), 50-59.

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