Psychosomatic interactions in spinal diseases are of interest both to physicians and to psychologists. The literature on the subject is extensive (Waddell and Turk 1992, Katz 2000, Pfingsten et al. 2001, Blumenstiel et al. 2005, Hildebrand et al. 2005, Dersh et al. 2006, Clays et al. 2007, Heneweer et al 2007, Becker et al. 2008). Studies have shown that cortical processing is abnormal in patients with chronic low back pain and illness behavior (Findlay 2006).

The term “psychosomatic,” derived from the Greek words psychē(soul) and sōma (body), refers both to the emotional/cognitive and to the physical aspects of the individual. The psychosomatic approach to the diagnosis and treatment of disease is based on the principle that these two aspects always function in tandem. The contribution of emotional factors to disease processes such as bronchial asthma, duodenal ulcer, migraine, and eczema is well known. Some diseases, such as gastric ulcer, meet the strict definition of a psychosomatic condition in that they are associated with a specific organic pathoanatomical lesion. In other, so-called functional disorders, there is no evident organic abnormality: these include, for example, cardiac neurosis, headache, and disturbances of gastrointestinal peristalsis. The organic/functional distinction is not always easy to apply to spinal disorders, because the pathological substrate underlying them is often poorly defined (as inchronic low back pain).

Over the last 15 years, interdisciplinary research on the etiology and pathogenesis of chronic pain has increasingly centered on the gradual process of transition from acute to chronic (Pfingsten 2005). Many prospective studies, some of them specifically concerned with back pain, have convincingly shown that psychosocial mechanisms are generally much better predictors of symptoms becoming chronic than are somatic factors (Linton 2000).

Beck (1975), writing about the personality type of individuals with psychosomatic pain localized to the musculoskeletal system, emphasized the role of pentup aggressive conflicts causing muscle spasm and chronic pain.

Weintraub (1975) viewed pent-up strong emotions and an excessively rigid approach to life as the causes of static postural abnormalities and painful muscular hypertonia. He considered these painful states to be the neuromuscular equivalents of conflict-evoked behavioral and defense mechanisms. Psychosomatic low back pain, in particular, is in this view an expression of long-standing excessive mental stress and of the subjective inability to cope with the demands of one’s family or occupation. These patients typically have difficulty dealing with their internal and external problems.

Sternbach (1974) found that patients with low back pain had significantly elevated values on scales for hysteria, depression, hypochondria, and hypomania. Male patients were significantly more depressed, irritable, passive, and anxious than female patients. We explain these findings as probably resulting from the higher demands placed by society on men in terms of their occupational and social function, which constitute an additional stressor over and above their actual organic illness.

Although there is a great deal of individual variation, it is clear that chronic pain must be viewed as the result of a process that can be influenced by psychological factors (Pfingsten 2005). The patient’s behavior is chiefly guided by factors of perception, attention, cognitive interpretation, and general emotional condition. Caldwell and Chase (1977) postulated that patients with abnormal emotional behavior obtain “secondary gain” from chronic low back pain.

Pain expectation anxiety is a condition characterized by the avoidance of potentially pain-producing situations. Thus, a patient’s desire for early retirement may be motivated by a desire to avoid the further pain that might result from a resumption of heavy manual labor, including lifting. Beals and Hickman (1972) studied patients who had had disk surgery and found the severity of their emotional disturbance to be correlated with the number of disk operations they had undergone. A control group consisted of patients with limb injuries. We think that, in such cases, a type of neurosis was probably already present before the onset of disk disease and was then exacerbated by surgery and persistent postoperative symptoms.

Blumetti and Modesti (1976) carried out a follow-up study comparing patients with low back pain who did and did not improve 6 months after the initiation of treatment with various medical modalities. The unimproved group had significantly higher hysteria and hypochondria scores than the improved group.

Personality tests. Wiltse and Rocchio (1975) found that patients with high hysteria and hypochondria scores on the Minnesota Multiphasic Personality Inventory (MMPI) consistently responded less well to chemonucleolysis than patients with normal scores on these two scales whom the treating physicians judged to have no psychosomatic disturbance. These results have since been replicated a number of times (Hasenbring 1992, Hasenbring et al. 1994). Croft et al. (1996) showed, in a prospective population-based study, that individuals suffering from serious emotional problems (depression) were twice as likely to develop back pain over the course of 1 year as individuals with mild or no psychosocial impairment. A currently depressive mood was also found to be a significant risk factor for acute, nonspecific back pain becoming chronic. The cognitive, emotional, and behavioral aspects of pain processing and coping are very important. The processes of classical and operant conditioning play a central role in the maintenance of these factors (Hasenbring and Pfingsten 2005).

Spring and Wörz (1976) studied patients with discogenic low back pain pre- and postoperatively with the MMPI, a symptoms questionnaire, and a scale assessing the overall emotional state. Patients with a neurotic personality type were found to develop new symptoms after surgery significantly more frequently than patients who did not have a neurotic personality type.

Many other authors have discussed the interactions of the spine and the mind, including Waring et al. (1976), Cailliet (1978), Frymoyer and Pope (1980), Pope et al. (1980), Aronoff and Evans (1982), Blumer (1982), Leavitt (1982), von Bayer (1983), Cameron and Shepel (1983), Bradley and van der Heide (1984), Hendler (1984), McCulloch (1984), Weber and Niethard (1984), Feuerstein et al. (1985), Ryden et al. (1985), Adams et al. (1986), Crisson et al. (1986), France et al. (1986), Keefe et al. (1986), Schofferman (1986), Villard et al. (1986), Watkins et al. (1986), Love (1987), Dvořàk et al. (1988), Manucher (1988), Waddell and Reilly (1988), Stein and Floman (1990), Greenough and Fraser (1991), Hazard et al. (1991), Hasenbring (1992), Basler (1998), Pfingsten (2004, 2005), Waddell (2004), Kovacs et al. (2006), Clays et al. (2007), Heneweer et al. (2007), and Becker et al. (2008).

Our own comparative study of 93 patients with chronic lumbar syndrome in our institution and in the outpatient offices of our colleagues in private practice showed that their scores on a number of sub-scales of the Freiburg Personality Inventory (FPI-A) differed significantly from those of a control group of patients with gonarthrosis (Bösken 1986).

Two basic questions emerge from our review of the literature and our own studies:

One question concerns the extent to which psychosomatic processes contribute to spinal symptoms, i.e., the extent to which mental disturbances can be transferred to the spine.

The other question concerns the somatopsychic aspect, i.e., the extent to which chronic, recurrent disk disease with an overtly organic pathogenesis can affect the patient’s mental functioning.

In the following section, we will present and interpret the findings of studies carried out on our own patients regarding these two questions. Further information on the subject is found in Chapters 8 and 11.