• Nigel Peek MSc (chiro) PGDip (pain) PGCert (acu)

The Psychology of Back Pain

Back pain is an area that has been extensively researched, and this is largely because back pain is the world's most disabling disorder placing extensive impact on our economic welfare and social fabric. Unfortunately, despite all that we have learned, the epidemic and burden of back pain is increasing.

Why is this?

Back pain is predominantly treated as physical problem. A slipped disc, a sprain or strain, or some sort of degenerative issue. However, we also know that "damage or degenerative changes" are common in people who do not have pain (see here). Only approximately 20% of people with back pain relate their pain to a physical or traumatic event. So, what is being missed here? Pain is not always an expression or representation of physical damage (see here), pain acts as mechanism to protect us from danger or harm (see here).

"It is NOT always necessary to have physical damage to experience pain"
(see video clip)

Why does this matter?

If we continue to treat back pain solely as biological manifestation without addressing the other dimensions (psychological and social) that are fundamentally embedded within the pain experience, then we are only doing part of the work - might this explain why we have yet to develop more effective treatments for back pain?

The psychology of pain

When we experience an episode of disabling back pain we try to "weigh up what the pain means" (particularly if that pain is intense). Our thoughts act to assess, attempt to solve, and predict the consequences of this issue in our lives. For example, “will I be able to go to work?”, “how serious is this”, “will I do more damage if I move”, etc.

These thought processes may also be enhanced by our often-negative societal portrayal of “the meaning of back pain”, thoughts like – “I must be careful, I don’t want to be an old person with a bad back” or “back pain is serious”, or “be careful with your back”, “don’t bend like this”, “don’t lift like this”, or “don't sit like this”

All this self-talk is in part a reasoned response to an unpleasant experience; however, this “reasoning” may become wired into the experience such that we become consumed with fear and dread. This is called pain catastrophising and is defined as;

“an exaggerated negative mental set brought to bear during
actual or anticipated painful experience” (1)

Research tells us that people who catastrophise (overanalyse, over-think, or think the worst) have a much greater tendency to develop persistent pain. This association has been demonstrated extensively (2-6).

Persistent back pain sufferers also have a greater tendency towards depression, this association seems to be intertwined with the cascade of worrying thoughts, catastrophic notions and spiralling distress (7). However, it is still debated as to whether depression is a predisposition to chronic pain or a consequence of the pain itself (possibly both).

Another psychological entity that is also associated with back pain is “fear of movement”, i.e., people who fear that movement will increase pain or induce further damage are more likely to experience persistent disabling low back pain (3). Fear of movement can lead to reduced enjoyment in life activity, deconditioning and further protection. Likely resulting in more pain and more disability.

Despite the research illustrating to us that back pain is rarely dangerous and non-specific (see here), we continue to dispense advice that reinforces beliefs that are not helpful or in keeping with current understandings. Overemphasising the need to over-protect our backs is not helpful, this is clearly an area that needs to change.

The important thing to remember is that the magnitude of the experience does NOT always equate to the extent of damage. This is particularly important with back pain. The spine has neural and mechanical complexity, making it more sensitive but not necessarily more vulnerable.

"The human frame is a by-product and marvel of hundreds of thousands of years of evolutionary sculpturing, it is not fundamentally weak or vulnerable"

It's all in my head!

Aside from the fact that pain is an experience, and hence an output of brain processing, pain is not either “real” or “a fabrication of one’s mind”. There is always a “biological, psychological and social self” embedded in the pain experience. These things are NEVER mutually exclusive and should NEVER be separate. It is the “the person, in the dynamic and ever-changing context of their life” that is relevant and central to our understanding of pain.

"Our relationship with pain is extremely relevant, and may be even
more important than the pain itself"


1. Sullivan MJL, Bishop SR, Pivik J. The Pain Catastrophizing Scale: Development and Validation. Psychological Assessment. 1995;7(4):524-32.

2. Ramírez-Maestre C, Esteve R, Ruiz-Párraga G, Gómez-Pérez L, López-Martínez AE. The Key Role of Pain Catastrophizing in the Disability of Patients with Acute Back Pain. International journal of behavioral medicine. 2017;24(2).

3. Ranger TA, Cicuttini FM, Jensen TS, Manniche C, Heritier S, Urquhart DM. Catastrophization, fear of movement, anxiety, and depression are associated with persistent, severe low back pain and disability. The spine journal : official journal of the North American Spine Society. 2020;20(6).

4. Lecca LI, Fabbri D, Portoghese I, Pilia I, Meloni F, Marcias G, et al. Manual handling of patients: role of kinesiophobia and catastrophizing in health workers with chronic low back pain. European journal of physical and rehabilitation medicine. 2020;56(3).

5. Pierobon A, Policastro PO, Soliño S, Andreu M, Novoa G, Raguzzi I, et al. Beliefs and attitudes about low back pain in Argentina: A cross-sectional survey using social media. Musculoskeletal science & practice. 2020;49.

6. Pierobon A, Raguzzi I, Soliño S, Salzberg S, Pierobon G, Vuoto T, et al. Disability is associated with catastrophizing and not with pain intensity in patients with low back pain: A retrospective study. Physiotherapy research international : the journal for researchers and clinicians in physical therapy. 2020.

7. Spada MM, Gay H, Nikčevic AV, Fernie BA, Caselli G. Meta‐cognitive beliefs about worry and pain catastrophising as mediators between neuroticism and pain behaviour. Clinical Psychologist. 2016;20(3):138-46.

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