ArticlePDF Available

Diagnostic Uncertainty, Guilt, Mood, and Disability in Back Pain

Authors:
Danijela Serbic at Royal Holloway, University of London
Danijela Serbic
Tamar Pincus at Royal Holloway, University of London
Tamar Pincus
Chris Fife-Schaw at University of Surrey
Chris Fife-Schaw
Helen Dawson at Imperial College Healthcare NHS Trust
Helen Dawson
Download full-text PDF
Read full-text
Download citation

Abstract and Figures

Objective: In the majority of patients a definitive cause for low back pain (LBP) cannot be established, and many patients report feeling uncertain about their diagnosis, accompanied by guilt. The relationship between diagnostic uncertainty, guilt, mood, and disability is currently unknown. This study tested 3 theoretical models to explore possible pathways between these factors. In Model 1, diagnostic uncertainty was hypothesized to correlate with pain-related guilt, which in turn would positively correlate with depression, anxiety and disability. Two alternative models were tested: (a) a path from depression and anxiety to guilt, from guilt to diagnostic uncertainty, and finally to disability; (b) a model in which depression and anxiety, and independently, diagnostic uncertainty, were associated with guilt, which in turn was associated with disability. Method: Structural equation modeling was employed on data from 413 participants with chronic LBP. Results: All 3 models showed a reasonable-to-good fit with the data, with the 2 alternative models providing marginally better fit indices. Guilt, and especially social guilt, was associated with disability in all 3 models. Diagnostic uncertainty was associated with guilt, but only moderately. Low mood was also associated with guilt. Conclusions: Two newly defined factors, pain related guilt and diagnostic uncertainty, appear to be linked to disability and mood in people with LBP. The causal path of these links cannot be established in this cross sectional study. However, pain-related guilt especially appears to be important, and future research should examine whether interventions directly targeting guilt improve outcomes. (PsycINFO Database Record
Figures - uploaded by Chris Fife-Schaw
Author content
All figure content in this area was uploaded by Chris Fife-Schaw
Content may be subject to copyright.
Content uploaded by Chris Fife-Schaw
Author content
All content in this area was uploaded by Chris Fife-Schaw on Dec 14, 2015
Content may be subject to copyright.
A preview of the PDF is not available
A preview of this full-text is provided by American Psychological Association.
Learn more
Content available from Health Psychology
This content is subject to copyright. Terms and conditions apply.
... This uncertainty is coupled to unclear cause, diagnosis, prognosis, and treatment. Unclear or unavailable diagnosis often correlates with disability, pain and depression (Serbic & Pincus, 2013;Serbic, Pincus, Fife-Schaw, & Dawson, 2015;Serbic, Pincus, & Holloway, 2014). Cognitive processing might be the key mechanism by which perceived uncertainty could impact on patient outcomes. ...
... disability). Study results provide a plausible explanation for the association between diagnostic uncertainty and poorer prognosis (Serbic, Pincus, Fife-Schaw, & Dawson, 2015). The narratives of CLBP patients (n = 20) suggested the absence of clear diagnosis not only has considerable negatively implications in terms of distress, uncertainty, and further health care seeking but also influenced patient's perception of their social relationships, since having no visible evidence and no clear diagnosis gave their pain less social credibility. ...
Consultation-based Reassurance for Patients with Musculoskeletal Lower Back Pain Consulting Orthopaedic Spine Teams
Book
Full-text available
  • Oct 2019
Research in primary care showed that consultation-based reassurance influences patient outcomes. It is strongly linked to short-term outcomes such as satisfaction, but certain types of reassurance are also associated with long-term outcomes, such as anxiety or further health care utilization. Nonetheless, there is gap in research examining the role of reassurance on people who consult in secondary care. Especially, for patients who are consulting in surgical settings, yet for whom surgery is not indicated as appropriate treatment option. There are several reasons why surgery might be ruled out as treatment, ranging from the resolution of symptoms to the exhaustion of available appropriate treatment options. To investigate consultation-based reassurance for patients with chronic musculoskeletal lower back pain consulting with orthopaedic spinal care teams for whom surgery is not recommended, a mixed-method design was adopted. Firstly, a qualitative study was conducted with 30 patients who had consulted and been discharged from orthopaedic spinal care. One-to-one interviews were conducted to examine how patients felt about being discharged without further treatment and how they perceived reassurance in their last specialist consultation. Findings indicated that patients felt dismissed and discouraged. Especially when no active treatment was offered, they required specific behaviours from their consultants to feel sufficiently reassured and encouraged to self-manage their condition. Subsequently, a prospective-cohort study (n = 605) was conducted to test the role of consultation-based reassurance on outcomes shortly after the consultation, and at 3- months follow-up. Findings showed that reassurance was associated with short- and long- term outcomes. Patients who were recommended surgery perceived higher levels of reassurance than those who were discharged or received other treatments. Specifically, after controlling for patients' clinical symptoms and individual differences, and adjusting for their hospital setting and type of practitioner, reassurance significantly and strongly predicted satisfaction, and significantly predicted how enabled patients felt directly after the consultation. In addition, more perceived cognitive reassurance and (partially) higher levels of perceived generic reassurance were associated with worst outcome in the long- term. Patients who perceived less relationship- building reported more GP visits at 3- months.
View
... Issues in the vignettes include common symptoms of both conditions with mood and cognitive facets. [62][63][64][65][66] Functional difficulties such as drop in study marks were selected to illustrate the impact both conditions have on academic work. 64,67 The vignettes described a young person as we were aware participant recruitment would primarily involve university students and we wanted to ensure participants could identify with the person in the vignette. ...
A Comparison of Social Exclusion Towards People with Depression or Chronic Back Pain
Article
  • Jan 2023
Objectives Research comparing mental and physical health stigma is scarce. The aim of this study was to compare social exclusion towards hypothetical males and females with depression or chronic back pain. Furthermore, the study investigated whether social exclusion is associated with participant’s empathy and personality traits, while controlling for their sex, age and personal exposure to mental/physical chronic health conditions. Design This study employed a cross-sectional questionnaire design. Methods Participants ( N = 253) completed an online vignette-based questionnaire and were randomly allocated to either a depression or chronic back pain study condition. Measures of social exclusion through respondents’ willingness to interact with hypothetical individuals, empathy and the Big Five personality traits were completed. Results Willingness to interact scores did not significantly differ depending on the diagnosis or sex of the hypothetical person in the vignette. For depression, higher levels of conscientiousness significantly predicted less willingness to interact. Whilst being a female participant and having higher empathy significantly predicted greater willingness to interact. For chronic back pain, higher empathy significantly predicted greater willingness to interact, with no significant predictors found from the Big Five personality traits. Conclusion Findings indicate that females and males with depression or chronic back pain face similar levels of social exclusion, with empathy being a core variable driving social exclusion behaviours. These findings enhance our understanding of potential variables driving social exclusion, in-turn informing campaign development to reduce public stigma towards depression and chronic back pain.
View
... Overall, findings related to depression and anxiety are supported by past research, which repeatedly finds a positive relationship between chronic pain and depression and anxiety in non-student samples. [53][54][55] Generally, university life is associated with poorer mental health compared to the general population. 20 Our findings suggest that this may be more prominent in students who experience chronic pain than those who do not, as indicated by elevated mental distress, suicidal intention and meeting criteria for psychiatric disorder in groups with chronic pain. ...
Psychological, social and academic functioning in university students with chronic pain: A systematic review
Article
Full-text available
  • Dec 2021
Objective: Chronic pain is a prevalent health issue among young adults; however, there is limited understanding on how it affects university students. This is the first systematic review of evidence relating to the association between chronic pain and psychological, social and academic functioning in university students. Participants: Four databases were searched for relevant published studies. Data from 18 studies including 10,069 university students, of which 2895 reported having chronic pain, were included in the synthesis. Methods: Due to heterogeneity of data and methodologies, meta-analysis was not possible; therefore, data were synthesized narratively. Results: Our findings showed that students with chronic pain have poorer psychological, social and academic functioning and quality of life, compared to students without chronic pain. Conclusions: These findings suggest that chronic pain presents a challenge in university settings. Research is urgently needed to enable an understanding of how universities can support students who experience chronic pain.
View
... However, there are some exceptions in this respect, e.g., studies describing the association of feelings of guilt related to punishing reactions from significant others with pain complaints among patients with chronic spinal cord injury pain (Conant, 1998). Furthermore, guilt was positively associated with the uncertainty about the diagnosis and disability among patients with low back pain (Serbic & Pincus, 2014;Serbic et al., 2016). Guilt and shame were also positively related to how the patients with hypercholesterolemia manage their condition (Frich et al., 2007) and to the belief that one caused one's own cancer (Abrams & Finesinger, 1953;LoConte et al., 2008). ...
Guilt, shame and their associations with chronic diseases in Czech adults
Article
Full-text available
  • Aug 2021
The interest in the association between feelings of guilt and shame and psychological health is growing. However, less attention so far has been paid to the associations with chronic disease. Therefore, the aim of this study was to explore whether feelings of guilt and shame are related to physical health in chronic disease and in selected ones. A nationally representative sample of Czech adults (n = 1000, age = 46.0 ± 17.3 years, 48.6% men) participated in the survey. Feelings of guilt and shame (items from The Positive and Negative Affect Schedule) and health problems in selected chronic diseases were measured. Respondents with higher feelings of guilt – but not of shame – were more likely to suffer from a chronic disease; we found this in arthritis, back pain, cardiovascular disease, asthma, cancer and depression or anxiety. The association was strongest in the case of cancer with odds ratios (OR) 5.83 (95% confidence interval (CI) 2.27–16.69). There were no significant associations in case of diabetes and stroke. Feelings of shame were not related to chronic diseases. Our findings suggest that feelings of guilt are associated with worse physical health. Further research is needed in this area.
View
Intolerance of uncertainty, pain catastrophizing, and symptoms of depression: a comparison between adults with and without chronic pain
Article
  • Jul 2023
Recent evidence suggests that individuals living with chronic pain demonstrate reduced tolerance of uncertainty compared to healthy individuals. Intolerance of uncertainty often lead to excessive worry, which may be related not only to the tendency to catastrophize pain, but also to increased distress. However, the specific nature of these relationships remains largely unexplored. The present study sought to investigate the associations between intolerance of uncertainty, pain catastrophizing, and symptoms of depression, while exploring how they differ between adults with and without chronic pain. Questionnaires were administered electronically to a community sample of 160 adults. All variables were significantly and positively correlated in the chronic pain group (n = 80), while only intolerance of uncertainty and symptoms of depression were positively and strongly correlated in the pain-free group (n = 80). Individuals in the chronic pain group reported higher levels of pain catastrophizing and symptoms of depression compared to the pain-free group, but both groups exhibited similar levels of intolerance of uncertainty. Intolerance of uncertainty and pain catastrophizing were significant predictors of the severity of depression in both groups, even after controlling for age and gender. However, intolerance of uncertainty was no longer statistically significant in the chronic pain group once pain catastrophizing was considered. These findings suggest that intolerance of uncertainty serves as a general vulnerability factor for psychological distress in adults, while pain catastrophizing acts as a specific vulnerability factor for individuals living with chronic pain. Enhancing knowledge about the role of cognitive factors in depression among individuals with chronic pain could help improve the management of this debilitating condition.
View
Persisting Pain Disorders: The Central Importance of Psychology in the Management of Pain and Its Impact
Chapter
  • Apr 2022
A brief history of pain and its assessment precedes a review of the influence of psychological factors on the perception of pain and its effects in a range of musculoskeletal and neuropathic pain disorders. Research into psychological factors, and models of pain and disability are then described. An overview of psychological interventions precedes a description of secondary prevention, the role of psychological targeting based on risk identification in stratified or matched care and the development of psychologically informed practice (PiP) in clinical and occupational settings. Finally, the importance of the social context and the nature of communication are highlighted.
View
Diagnostic Uncertainty in Patients, Parents, and Physicians: A Compensatory Control Theory Perspective
Article
  • Jun 2022
Medical diagnoses offer a structure by which psychological uncertainty can be attenuated, allowing patients to diminish imposing psychological threats and focus on health prognosis. Yet when no diagnosis can be made, patients may experience diagnostic uncertainty - their perceptions that the medical field is unable to provide an accurate explanation of the cause of their health problems. The present paper examines the psychological threat that diagnostic uncertainty imposes on the individual's need for control and understanding, and the resulting consequences experienced by patients, parents of pediatric patients, and physicians when the lack of diagnosis makes their worlds seem random. Using compensatory control theory (CCT) (Kay et al., 2008) as a framework, we propose a taxonomy of behaviors that people may adopt in order to regain control in the face of diagnostic uncertainty and to reaffirm that the world is not random and chaotic. To manage diagnostic uncertainty, these individuals may bolster their personal agency, affiliate with external systems that they see as acting in their interest, affirm clear connections between behaviors and outcomes, and affirm nonspecific epistemic structure. Diagnostic uncertainty is approached from the perspectives of patients, parents of pediatric patients, and physicians, demonstrating how each group responds in order to maintain a sense that the world has structure and is not random. Discussion centers on moderators, limitations, and implications for clinical practice.
View
Intolerance of Uncertainty in Pediatric Chronic Pain: Dyadic Relationships Between Youth and Parents
Article
  • Apr 2022
  • J PAIN
The current study used a dyadic analytic approach (actor-partner interdependence models) to assess the stability and interrelationships of intolerance of uncertainty (IU) among a cohort of youth with chronic pain and their parents (n = 156 dyads). Relationships between parent and youth IU, parent and youth pain interference, and parent and youth internalizing mental health symptoms were examined. At baseline and follow-up, youth and parents completed psychometrically-sound questionnaires to assess their respective IU, pain characteristics, and clinical outcomes (pain interference, anxiety, depressive, and posttraumatic stress symptoms). Our findings support the construct stability of IU over time, as well as intrapersonal (i.e., actor) effects of IU on follow-up youth pain interference and mental health symptoms and parents’ mental health symptoms (but not parent pain interference). There were no interpersonal (i.e., partner) effects over time between youth and parent IU or between youth and parent IU and pain interference or mental health symptoms. These findings align with previous research evidencing IU as a transdiagnostic risk factor for a range of mental health concerns and extend previous findings by showing the stability of parent and youth IU over time and its potential predictive relevance to outcomes in a clinical sample of youth with chronic pain. Perspective: This article presents dyadic analyses assessing intrapersonal and interpersonal associations between intolerance of uncertainty (IU) and pain and mental health symptoms in youth with chronic pain and their parents. Analyses evidenced short-term construct stability of IU and intrapersonal (but not interpersonal) effects of IU on pain and mental health symptoms.
View
Predicting pain and function outcomes in people consulting with shoulder pain: the PANDA-S clinical cohort and qualitative study protocol
Article
Full-text available
  • Sep 2021
Introduction People presenting with shoulder pain considered to be of musculoskeletal origin is common in primary care but diagnosing the cause of the pain is contentious, leading to uncertainty in management. To inform optimal primary care for patients with shoulder pain, the study aims to (1) to investigate the short-term and long-term outcomes (overall prognosis) of shoulder pain, (2) estimate costs of care, (3) develop a prognostic model for predicting individuals’ level and risk of pain and disability at 6 months and (4) investigate experiences and opinions of patients and healthcare professionals regarding diagnosis, prognosis and management of shoulder pain. Methods and analysis The Prognostic And Diagnostic Assessment of the Shoulder (PANDA-S) study is a longitudinal clinical cohort with linked qualitative study. At least 400 people presenting to general practice and physiotherapy services in the UK will be recruited. Participants will complete questionnaires at baseline, 3, 6, 12, 24 and 36 months. Short-term data will be collected weekly between baseline and 12 weeks via Short Message Serevice (SMS) text or software application. Participants will be offered clinical (physiotherapist) and ultrasound (sonographer) assessments at baseline. Qualitative interviews with ≈15 dyads of patients and their healthcare professional (general practitioner or physiotherapist). Short-term and long-term trajectories of Shoulder Pain and Disability Index (using SPADI) will be described, using latent class growth analysis. Health economic analysis will estimate direct costs of care and indirect costs related to work absence and productivity losses. Multivariable regression analysis will be used to develop a prognostic model predicting future levels of pain and disability at 6 months using penalisation methods to adjust for overfitting. The added predictive value of prespecified physical examination tests and ultrasound findings will be examined. For the qualitative interviews an inductive, exploratory framework will be adopted using thematic analysis to investigate decision making, perspectives of patients and clinicians on the importance of diagnostic and prognostic information when negotiating treatment and referral options. Ethics and dissemination The PANDA-S study has ethical approval from Yorkshire and The Humber-Sheffield Research Ethics Committee, UK (18/YH/0346, IRAS Number: 242750). Results will be disseminated through peer-reviewed publications, social and mainstream media, professional conferences, and the patient and public involvement and engagement group supporting this study, and through newsletters, leaflets and posters in participating sites. Trial registration number ISRCTN46948079 .
View
Taking patients to the ice cream shop but telling them that they cannot have ice cream: a qualitative study of orthopaedic spine clinicians’ perceptions of persistent low back pain consultations
Article
Full-text available
  • Sep 2021
Objective This study aimed to explore the perceptions of orthopaedic clinicians about consultations for people with persistent musculoskeletal low back pain (PMLBP) in which surgery is not recommended. Surgery is not recommended for the majority of PMLBP consulting in secondary care settings. Setting Secondary care sector in the UK. Participants Semi-structured qualitative interviews were conducted with 24 orthopaedic team clinicians from 17 different hospitals in the UK and Ireland. Interviews explored clinicians’ perceptions of the challenges in consultations where surgery is not indicated. Interviews were transcribed verbatim and analysed using thematic analysis. Results Two meta-themes, Difficulties and Enablers, each consisting of several subthemes were identified. Difficulties included challenges around the choice of appropriate terminology and labels for PMLBP, managing patients’ expectations, working with mentally vulnerable patients and explaining imaging findings. Enablers included early management of expectations, use of routine imaging, triaging, access to direct referral elsewhere, including other non-surgical practitioners in the team, training to improve communication skills and understanding of psychological issues. Conclusion The findings highlight clinicians’ perceived need for concordance in messages delivered across the care pathway and training of orthopaedic clinicians to deliver effective reassurance and address patients’ needs in circumstances where surgery is not indicated.
View
Guilt: Elaboration of a multidimensional model
Article
Full-text available
  • Dec 2003
This article expands on a model that conceptualizes guilt as a multidimensional construct with affective and cognitive dimensions. In the model, guilt magnitude is a function of the magnitudes of five variables posited as primary components of guilt: distress and four interrelated beliefs about one's role in a negative event. Originally proposed to account for guilt that emerges in the context of traumatically stressful events, the model may also help account for guilt that occurs in response to common-guilt evoking events. Eight contextual variables that promote distress and activate guilt cognitions are identified, drawing attention to social or situational factors that contribute to guilt. The contextual variables are used to explain why trauma-related guilt is common and usually more chronic and severe than commonplace guilt. Initial evidence for the model is summarized and directions for future research discussed.
View
View
View
View
View
Chasing the ghosts: The impact of diagnostic labelling on self-management and pain-related guilt in chronic low back pain patients
Article
  • Jan 2013
In the majority of chronic low back pain (CLBP) patients a clear diagnosis cannot be established; as a result patients are given labels such as non-specific low back pain. There is some evidence to suggest that lack of a clear diagnosis is associated with negative psychological, clinical and behavioural outcomes. The main aim of this study was to examine CLBP patients' understanding, feelings and behaviour in response to their diagnostic labels. Semi-structured interviews were conducted with twenty CLBP patients who were recruited from one osteopathic and one pain management clinic in the UK. Sampling, data collection and analysis were driven by a grounded theory approach. Data were analysed through four stages of coding: open, selective, axial and theoretical coding. Data collection and coding continued until data achieved saturation. Results indicated that lack of a clear diagnosis is associated with distress, further treatment seeking and uncertainty. It also influenced participants' perception of their social relationships; having visible evidence and a clear diagnosis gave patients'pain more social credibility. Participants reported feeling guilty about the consequences of their pain to themselves and others, and for failing to recover. Overall, participants' narratives suggest that at least for some, absence of a clear diagnosis has considerable negative implications. The goal of the study was to inform clinicians and policy makers about the impact of diagnosis on CLBP patients' adjustment and emotional burden; findings suggest that legitimising the pain experience is of prime importance to CLBP patients.
View
An Inventory for Measuring Depression
Article
  • Jun 1961
  • ARCH GEN PSYCHIAT
The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12 in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations."Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15 These have been well summarized in a review article by Lorr11 on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific
View
View
Pain-related Guilt in Low Back Pain
Article
  • Oct 2014
Objectives: Identifying mechanisms that mediate recovery is imperative to improve outcomes in low back pain (LBP). Qualitative studies suggest that guilt may be such a mechanism, but research on this concept is scarce, and reliable instruments to measure pain-related guilt are not available. Methods: We addressed this gap by developing and testing a Pain-related Guilt Scale (PGS) for people with LBP. Two samples of participants with LBP completed the scale and provided data on rates of depression, anxiety, pain intensity, and disability. Results: Three factors were identified using exploratory factor analysis (n=137): "Social guilt," (4 items) relating to letting down family and friends; "Managing condition/pain guilt," (5 items) relating to failing to overcome and control pain; and "Verification of pain guilt," (3 items) relating to the absence of objective evidence and diagnosis. This factor structure was confirmed using confirmatory factor analysis (n=288), demonstrating an adequate to good fit with the data (AGFI=0.913, RMSEA=0.061). The PGS subscales positively correlated with depression, anxiety, pain intensity, and disability. After controlling for depression and anxiety the majority of relationships between the PGS subscales and disability and pain intensity remained significant, suggesting that guilt shared unique variance with disability and pain intensity independent of depression and anxiety. High levels of guilt were reported by over 40% of participants. Discussion: The findings suggest that pain-related guilt is common and is associated with clinical outcomes. Prospective research is needed to examine the role of guilt as a predictor, moderator, and mediator of patients' outcomes.
View
Knowledge of and Agreement with Chronic Pain Diagnosis: Relation to Affective Distress, Pain Beliefs and Coping, Pain Intensity, and Disability
Article
  • Mar 1998
Many authors report that a high percentage of patients with chronic pain have no or insufficient underlying physical pathology to explain their pain. Even when patients do have an identified diagnosis, many patients profess to have little understanding of the source of their pain or fear that they may suffer from more severe pathology. This may be particularly true for patients with chronic musculoskeletal pain given the lack of “objective” findings for soft tissue pain complaints. In the present study, we examined whether chronic neck and back pain patients were able to identify the physiologic source of their pain, and based on their responses patients were placed in one of three groups: (1) patients who did not know the cause of their pain; (2) patients who did know the cause and agreed with their clinical diagnosis; and (3) patients who identified a cause for their pain that was different from their clinical diagnosis. The sample was comprised primarily of individuals with musculoskeletal pain problems (70%) referred to an outpatient chronic pain rehabilitation program. Each patient completed a pretreatment test battery, and group differences were examined on responses to the McGill Pain Questionnaire, Survey of Pain Attitudes, Brief Symptom Inventory, Coping Strategies Questionnaire, and Pain Disability Index. Upon initial evaluation, 47.2% (n = 85) of patients indicated that they did not know what was causing their pain. Of patients who articulated a cause for their pain, 20% (n = 36) attributed it to factors that did not agree with their diagnosis. Only 32.8% (n = 59) of persons in the entire sample were able to accurately identify the cause of their pain. Patients who disagreed with their clinical diagnosis were more likely to be diagnosed with musculoskeletal pain and reported the highest levels of pain (F(2,169) = 3.41, p .05) as well as the greatest levels of affective distress (F(2,169) = 3.54, p .05). Patients who were unsure of or disagreed with their diagnosis tended to report a greater belief in pain being a signal of harm (F(2,169) = 11.5, p .001) and described themselves as more disabled (F(2,169) = 8.43, p .001). In addition, both the “unsure” and “disagree” groups tended to use maladaptive pain strategies more frequently, and persons unsure of their diagnosis had the lowest levels of perceived control over pain. A hierarchical regression analysis examining a cognitive/behavioral model of pain disability indicated that lack of knowledge of pain etiology, a belief that pain is a signal of harm, catastrophizing and affective distress all significantly predicted increased disability, while pain intensity did not. The data suggests that lack of knowledge about the origin of pain is associated with maladaptive cognitions in relation to pain (i.e., fear of harming oneself and catastrophizing) and increased emotional distress which in turn are related to heightened disability due to pain. These data argue that educating patients regarding their diagnosis and the origin of their pain, thereby dispelling dysfunctional pain beliefs, may be an important component of pain treatment, particularly among patients with chronic musculoskeletal pain.
View