BMJ Column – Beware of mentioning psychosocial factors

November 8th, 2007 by Ben Goldacre in acupuncture, medicalisation | 34 Comments »

How doctors describe the many interactions between a person, their illness, and society has little purchase in the crudely dualistic world of popular culture.

Ben Goldacre
Observations – Media watch
BMJ 2007;335:801 (20 October)

Although we are constantly told to “engage with the public,” many doctors and academics avoid the media like the plague. This month, like many doctors before me, I walked into a broadcast studio a man and came out an ass.

The story was acupuncture. A major study had been published showing that acupuncture is more effective for back pain than conventional medical treatment, and as I sometimes write about complementary medicine and research methodology I was invited to discuss the study on BBC Radio 4, where nobody can tell that I look about 14.

The paper was extremely interesting (Archives of Internal Medicine 2007;167:1892-8) and had three arms. Results from the “sham” and “real” acupuncture arms were indistinguishable—make of that what you will—but both outperformed conventional medical treatment. The patients in the study, I should mention, were people who had already been failed by conventional medical treatment for an average of eight years.

If you’re a doctor, you can probably imagine what I said. The important background information missing from the news reports didn’t concern the study’s methodological details or anything to do with acupuncture: what was missing was a wider understanding of back pain. Back pain isn’t like tuberculosis or a fracture; it’s one of the leading causes of sick leave and misery, but the simple fact that no clear cause is found itself exacerbates distress and causes conflict.

And just as many of the big risk factors for a niggle turning into chronic, longstanding back pain are personal, psychological, and social—things such as working conditions, depression, job dissatisfaction, unavailability of light duty on return to work, and so on—so are many of the interventions.

Anti-inflammatory drugs are undeniably better than placebo, at the cost of possible side effects, but if you were going to look at the evidence beyond pills, then resting in bed is actively harmful (specific exercises can be too), and trial data show that simple educational interventions such as giving advice to “stay active” can speed recovery, reduce chronic disability, and reduce time off work. In fact, in Australia they even put money into that notion, and a simple public information campaign (“Back pain: don’t take it lying down”) was shown to reduce back pain significantly in the whole target population (Medical Journal of Australia 2001;175:456-7).

I talked about this kind of stuff, although I suspect that the Radio 4 people may have been hoping for some old duffer to say that acupuncture is “poppycock.” The acupuncture study raised important issues, I agreed. It’s very important to think about whether and when doctors should go beyond merely prescribing pills, and we often do. But if we accept, in the case of back pain, that acupuncture may in part be a surrogate psychosocial intervention or theatrical placebo, then it’s a pretty expensive one. Maybe we could consider pushing for other options, less expensive and less fashionable, such as brief education interventions, public health information programmes, perhaps cognitive behavioural therapy, and so on.

This all felt pretty sensible. Much of it was lifted from a bog standard review on back pain in the BMJ (2006;332:1430-4 doi: 10.1136/bmj.332.7555.1430). Working doctors are accustomed to thinking beyond the prescription pad, after all, and it’s a peculiar side effect of the branding of alternative therapists that medicine is portrayed in mainstream media as crudely biomechanical.

So I was a bit surprised three days later to hear this read out, in a very angry voice, in the letters slot of BBC Radio 4’s afternoon news programme PM, to a million people: “I would take issue with your speaker Ben Goldacre, who, if I recall correctly, said that 90% of back problems are psychosomatic disorders. What planet is he on? Whilst I would agree that there are a lot of schmucks out there that want to sit around and skive off work every day (and thereby make the problem even worse) . . . never tell me my backache of 20 years is imaginary. OKAY?”

Now I’m quite prepared to accept that I may not have expressed myself very clearly—obviously I don’t think back pain is “psychosomatic,” and I accuse nobody of malingering—but something more interesting is happening here. The finer distinctions between concepts that doctors use to describe the multiple interactions between a person, their illness, and society have little purchase in the crudely dualistic world of popular culture, and sometimes it can seem that there is a hypersensitivity to anyone even mentioning psychosocial risk factors or interventions.

Perhaps it is a matter of who is permitted to discuss them: patients shop for advice, after all, and you don’t go to a crystal therapist for steroids, any more than you go to a urologist for marital guidance. Perhaps even a biomedical doctor merely raising the question is seen as questioning the legitimacy of symptoms and suffering. Perhaps the problem is magnified because we live in a country with millions of people receiving sickness benefit, where many people perceive at least some claimants simply as rebranded “unemployed” people.

But this is a dark corner, framed only by the crude marketing claims of quacks and their notions of “holism.” In a culture where “psychosocial risk factors” can be heard as “psychosomatic illnesses,” and with a popular media where “psychosomatic” simply means “imaginary” and “malingering” (Psychosomatics 2004;45:287-90), these negotiations will never be easy.

Ben Goldacre, doctor and writer, London

Here is the audio, so you can decide for yourself:

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I’m not fishing for sympathy, by the way: I genuinely think that the piece, lined up against the letters, tells a fascinating story about what people hear, and what they expect to hear (especially the first letter they read out). The paradox of course is that doctors are far more likely to be discussing psychosocial factors with an unsuspecting patient than any so-called “holistic” practitioner wheeling out the gadgets and the sugar pills.

If you like what I do, and you want me to do more, you can: buy my books Bad Science and Bad Pharma, give them to your friends, put them on your reading list, employ me to do a talk, or tweet this article to your friends. Thanks! ++++++++++++++++++++++++++++++++++++++++++

34 Responses

  1. Acleron said,

    November 8, 2007 at 2:11 pm

    The ability of people to misrepresent what you said and then get annoyed about it doesn’t surprise me. The presenters, though, should have screened out the listener who claimed his back pain was psychsomatic as being irrelevant to what you actually said.
    On the subject of the trial, perhaps more emphasis should be made about the group on conventional treatment. The CAM woos will just point out that acupuncture is more effective than conventional treatment. They are already obfuscating the sham vs non-sham by vague comments of closeness of needles and depth. The real message is that the conventionally treated group were designed to fail having being chosen from a group of people who had previously failed on receiving exactly the same treatment.

  2. censored said,

    November 8, 2007 at 2:59 pm

    From a quackery point of view, it would’ve been nice to perhaps see a fourth group: those treated with a revolutionary new (sham and made up) holistic therapy.

    I suspect they might’ve done rather well too…

    More on topic, it’s this same gap between language and understanding that the EM lobby thrive on.

  3. briantist said,

    November 8, 2007 at 5:19 pm


    I heard both your interview on “PM” and the complainant on “Freeback” and I wasn’t in the slightest bit surprised.

    The whole way that “these programmes” work – and you see the same fault with any Climate Change discussion – is that they pretend that the argument is black and white and evenly balanced.

    You were EXPECTED to rubbish the report, it’s findings and it’s author.

    No-one was listening to what you actually said – they had already decided how you fitted into their programme before you arrived.

    What you actually said would have made no difference. Usually everybody involved is too busy to listen to their own programme.

  4. monstermunch said,

    November 8, 2007 at 6:13 pm

    Can anyone explain why this study is interesting? My take is:

    1. Back pain has no objective measurements we can check and we must rely purely on the subjective reporting of the patient.

    2. The patients had been using conventional treatment A (Pills? Told to get exercise?) previously for a long time and it had not been working.

    3. Patients in the treatment A will be convinced it doesn’t work because of 2 so will suffer a very low placebo effect.

    4. Acupuncture patients will be experiencing a new treatment that will have a heightened placebo because they haven’t tried it before and they think it might work.

    5. By 1, 3 and 4, the acupuncture group will report relieved back pain even though the cause is still there.

    What was the conventional treatment by the way?

  5. pun1sh3r said,

    November 8, 2007 at 6:39 pm

    This reminds me of a great scene in the movie Memento: (Spoiler Warning). Sammy Jenkins suffers from short term memory loss. The doctors tell his wife that his memory loss is psychological which she takes to mean that he’s faking it. So she gets Sammy to repeatedly give her insulin injections – figuring that sooner or later he’ll confess to making it all up or else he’ll kill her. She dies. I think the point was that people hear “psychological” and infer “faking”.

  6. kingshiner said,

    November 8, 2007 at 7:29 pm

    Monstermunch, I agree the first group were set up to fail, for the reasons you say. I found the fact that fake acupuncture works as well as the real thing more interesting. This does not support the traditional explanation of how acupuncture works (meridians, acupuncture points, flowing of energy and so on).

    By the way, somebody, what does ‘woo’ mean?

  7. emilypk said,

    November 8, 2007 at 7:40 pm

    I asked the same question a few posts ago 🙂 I think it is getting a little in-groupy as slang goes?

  8. ephemera said,

    November 8, 2007 at 9:12 pm

    I work as a Clinical Hypnotherapist and NLP Master Practitioner, and have had clients come to me for pain relief interventions. After checking with their GP that there is no physical cause for their pain, or that if there is a cause that it is not curable, then in most cases relief is possible without drugs, or at least reducing the need for drugs. However, in some cases clients have become ‘victims’ of their pain and / or have secondary gains such as sympathy, extra help from their partner, etc, and removing the pain would mean this attention then disappears. In these cases the pain relief interventions are temporary at best. The whole person, their environment and family, etc need to be taken into account. Sometimes it is just easier to have the symptoms than deal with the real, underlying problem – and the client, armed with this understanding can at least know they potentially have a choice…!

  9. maninalift said,

    November 8, 2007 at 9:47 pm

    There have been a series of programs about ME on radio 4 this week and there seems to exist a similar attitude amongst the ME sufferers advocate organisations. They get very angry at the idea that anyone could suggest that CBT might be effective because ME is a “real, physical” disease.

  10. jackpt said,

    November 8, 2007 at 10:05 pm

    Good article. I hope some of the people that wrote in to the show with negative comments read it because they may change their mind.

    I think as a society we’ve got empathy blind spots for anything perceived to be psychological or that has a psychosocial element. As a result the context of treatment and the terms in which it is related to a patient are all important. For the Pro-Woo, telling someone they have negative energy or an allergy to nightshades is probably a good bedrock or (fictional) backstory for a placebo treatment. It’s also easier for the patient to be told a woo explanation than been told they’re in a rut, in part because of the social stigma attached to psychosocial problems.

    I think people confuse what you’re saying about intervention with telling someone to ‘pull yourself together’ or ‘snap out of it’. Maybe because they’re ignorant of the types of intervention you’re talking about and because of the social stigma attached to the psychosocial. I think if people were more aware of the treatments you talked about they’d be less likely to get the wrong end of the stick. I think the stigma attached to such things needs to be tackled too. I don’t think such stigma is originating from the medical world.

  11. Quixotematic said,

    November 8, 2007 at 11:42 pm

    “”From a quackery point of view, it would’ve been nice to perhaps see a fourth group: those treated with a revolutionary new (sham and made up) holistic therapy.””

    I’m not sure that one would make it past the Research Ethics Committee . . .

  12. Dr Aust said,

    November 9, 2007 at 12:31 am

    Mrs Dr A was “hear hear-ing” this one, Ben – working in OH part of the time she sees a lot of people referred for back pain where it is quite clear that many of the roots of the problem lie in the “personal, psychological, social” causes you list.

    Interestingly, the reaction of Mrs Dr A’s patients to exploration of these “issues” is often quite positive (to hear her tell it), not the umbrage I might have cynically predicted based on reading things like the ME fora, or the grumblings of the radiosensitivity crew, or your BBC letter.

    I guess this could be testimony to Mrs Dr A’s top-notch one-to-one caring sharing skills (I would say that, of course), but maybe it is suggesting that the reaction of the patient depends on the, er, “narrative” of their particular condition they have bought into. For instance, perhaps for ME or electrosensitivity this is far more statistically likely to be “oppositional” to the psychosocial explanations than is the case for a bad back. What do you reckon? The interesting Q then might be whether that was a reflection of “received narrative” (including what people find online?), or of prevailing personality types among those reporting symptoms. Or both plus loads of other stuff.

    Know any more good refs down this sort of line?

  13. Ben Goldacre said,

    November 9, 2007 at 12:38 am

    i’m not sure there are very many clear answers, but i have to say i think medically unexplained symptoms and the mechanisms of psychological factors in ill health are officially the most interesting thing in medicine right now, a huge amount of very real distress, little clear knowledge, and i’m totally moving into it as a dayjob, research if not clinical.

  14. Bass Tyrrell said,

    November 9, 2007 at 8:56 am

    I listened to this on the podcast, and I am afraid I cringed and was not at all surprised at the reactions – before I read this follow-up. It came across as begrudgery: a “yes-but” response to a positive bit of research. From reading your stuff I know this is not generally your view of placebos. Were you being asked to present the case against acupuncture? (A poisoned chalice under the circumstances when a study has just shown it as effective, even if pseudo-acupuncture is just as effective).

    Another comment in the feedback seems to me worthy of a follow up (column?), and that was the old saw about children and animals. The whole “how can be a placebo if it works on c & a” debate has a basic (flawed) assumption at its centre: that the placebo effect occurs entirely in the conscious brain. It would seem far more probable that such reactions have a long evolutionary history. So it would be really surprising if placebos didn’t work on children or animals as it would imply a very late adaptation. What research exists on this, if any? (I seem to remember something showing that placebos work at approximately 1/2 the effective “strength” if the subject knows its a placebo, which in itself indicates a fascinating interplay between the “conscious” and “unconscious” mind.

    Personally, while my neighbours rushed to pop out the arnica for any child with a mild bump, my kids got a rub and a kiss better. The crying and upset seemed to stop just as quickly. Anecdotal I know, but acknowledgement, reassurance and removal of stress seem to be key.

  15. Gramlin said,

    November 9, 2007 at 9:35 am

    If possible, I would like some clarification – it is clear what a psychosomatic illness is NOT (imaginary, malingering) but I still feel rather confused as to what it IS.

    I know it is a mysterious set of phenomena, but are there any proposed mechanisms for it at all?

    I only ask because all too often, on site devoted to debunking quackery, the term psychosomatic is wheeled out as a glib explanation as if that ends all debate. It seems rather like an argument from ignorance. What can we confidently claim to know about psychosomatic illness, for certain?

  16. Gramlin said,

    November 9, 2007 at 10:29 am

    I’ve just listened to the audio – not to put too fine a point on it, but that Dr. David Whoever came over as rather pig-witted: he repeatedly ignored the most important part of the trial! The interviewer asked the same question twice, Dr. David ignored it twice and repeated himself stubbornly instead.

    I thought Ben sounded balanced and reasonable, and that chap who wrote the letter about him totally got the wrong end of the magical stick.

    The interviewer was fair and seemed to understand the issues, but the way the producers tried to offer a balanced audience response actually seemed to give more prominence to those who support acupuncture. However, all the pro-acupuncture responses seemed emotive and poorly argued, so perhaps the producers knew what they were doing all along.

  17. misterjohn said,

    November 9, 2007 at 12:15 pm

    The BBC refers to some more research about treatment of lower back pain on this link;-

    It’s interesting how the chiropractor leaps in to say “We don’t just do spinal manipulation”, having been told that it has a negative impact on recovery!

  18. Harlequin said,

    November 9, 2007 at 12:24 pm

    TB was considered by some to be psychosomatic before the discovery of the bacillus. And many present-day patients with debilitating but unexplained symptoms are used to being fobbed off with variants of the ‘psychosocial’ diagnosis. In such cases, the attitude of the Department for Work and Pensions to unexplained illness can be as or more crucial to patients’ wellbeing than the opinions of the doctors and the media.

  19. phayes said,

    November 9, 2007 at 1:31 pm

    “Another comment in the feedback seems to me worthy of a follow up (column?), and that was the old saw about children and animals.” (Bass Tyrell).

    I agree. What, if anything, is known about this? I’d guess placebo could work on at least some non-human species and the only claims I recall seeing about acupuncture or homeopathy working on animals were anecdotal and looked like the association implies causality fallacy anyway.

  20. Bass Tyrrell said,

    November 9, 2007 at 2:55 pm

    What has happened over the years to all the “r”s people (who possibly don’t know their “r”s from their elbows?) drop out of my name? There must be a pile of them around somewhere! Still it is an illustration of the general effect, phayes saw what he expected to see (though why it is generally expected is another question: we outnumber the one r’d variant by about 20 to 1) not what was actually there: just as the complainer on the show heard what he expected to hear (“faker”) rather than “complex psychological causes”. Grr. (Actually, it was also interesting that he was quite happy for other people to be considered a “lot of schmucks out there that want to sit around and skive off work every day” he just wanted to be clear that he wasn’t!

  21. Squander Two said,

    November 9, 2007 at 6:53 pm


    > They are already obfuscating the sham vs non-sham by vague comments of closeness of needles and depth.

    While their comments may be vague, surely they’re not irrational. No-one’s seriously suggesting (are they?) that sticking a needle into someone’s flesh has no effect, so it seems reasonable to suppose that how deep you stick the needles, how many needles you stick in, and how closely together you stick them should affect that effect. If suggestions of what the effect is are vague, then I’d’ve thought more research would be a better idea than outright dismissal. After all, pretty much every bit of scientific knowledge we have started out as vague, then got more precise as a result of experimentation.


    > It’s interesting how the chiropractor leaps in to say “We don’t just do spinal manipulation”, having been told that it has a negative impact on recovery!

    Purely anecdotal, but a chiropractor cured my back pain where all my GP was interested in doing was prescribing me ibuprofen. (Regardless of the efficacy of ibuprofen, I still resent being given a prescription for it, enabling me to buy for a mere 6 quid what would usually cost me 50p.) Certainly didn’t have a negative impact on my recovery, and I know it wasn’t purely psychosomatic for the simple reason that my hamstrings are now demonstrably longer than they were, demonstrated through simple before-and-after trying-to-touch-my-toes experiments. (Took me bloody months of stretching).

    Anyway, like I said, I know that’s anecdotal, but it still illustrates a point. I think a big problem with back pain is the same as with the common cold: there is no such thing as the common cold; it is merely a catch-all phrase for a very large number of different viruses, all of which provoke similar reactions from our immune systems and therefore appear the same if you look at symptoms instead of causes. This is why science, as we are so often told, “has yet to come up with a cure for the common cold”. Same with “back pain”: that’s not a disease, it’s a symptom. So talk of whether chiropractic — or anything else — works on it is doomed to inaccuracy. Chiropractic certainly does work on some problems which lead to back pain, and probably doesn’t work on some others. Same as ibuprofen. Looking at a group of patients with back pain and discovering that cure A makes 80% of them worse and 20% of them better tells you that you have at least two different causes of back pain, not that cure A doesn’t work.

    As for people’s tendency to think that “psychological” means “not real”, I blame that Descartes. The problem is that most people don’t think that what goes on in their minds is a part of their body. Whereas, in fact, psychological is a subclass of physical.

  22. raygirvan said,

    November 9, 2007 at 7:24 pm

    Harlequin > TB was considered by some to be psychosomatic before the discovery of the bacillus

    Citation? Spitting blood and observable lung damage were a bit of a giveaway that it wasn’t. The psychosomatic angle came after the discovery of the bacillus, particularly through the work of Thomas Holmes. His studies – still valid, I think, looked at the role of stress in infection: (a) why not everyone infected with the bacillus got ill, and b) how mindset and stress factors affected the chance of recovery.

  23. LadyHP said,

    November 9, 2007 at 8:47 pm

    “But if we accept, in the case of back pain, that acupuncture may in part be a surrogate psychosocial intervention or theatrical placebo, then it’s a pretty expensive one. Maybe we could consider pushing for other options, less expensive and less fashionable, such as brief education interventions, public health information programmes, perhaps cognitive behavioural therapy, and so on.”
    That’s an interesting suggestion, but hasn’t it also been proved:
    a) that an expensive placebo works better than a cheap one?
    b) that a placebo that focuses on the patient as a specific person (listens to him, as most good acupuncturists and homeopaths would) works better than an impersonal one (such as “public health information programmes”, or to a lesser extent, the 20-minute check-out where your GP ticks a few boxes)?

  24. Harlequin said,

    November 10, 2007 at 10:11 am

    *raygirvan > Citation?*
    “Is tuberculosis psychogenic in origin? Can we compare it in this regard with schizophrenia? Certainly, from ancient times until well into the nineteenth century, tuberculosis was considered, at least in part, a result of grief, anxiety, and mental upset. …. The discovery of a specific bacterial etiology produced a lull in the desire to demonstrate a psychogenic factor in tuberculosis.”
    “In the 1950’s, however, there were important alterations in this picture. Following the introduction of specific mycobactericidal therapy, Psychosomatic Medicine, a journal which for its first 15 years had largely ignored tuberculosis, began to accept frequent articles on psychogenic factors in tuberculosis. Mere possession of “magic bullets” had not abolished the disease.”
    VAILLANT, GE. Tuberculosis: An Historical Analogy to Schizophrenia Psychosom Med. 1962 May-Jun;24:225-33.

  25. SteveG said,

    November 10, 2007 at 1:34 pm

    Sensible, practical advice for clinicians working with functional complaints, including a generic model, can be found here:

  26. ips said,

    November 12, 2007 at 9:56 am

    Thanks for the link …its a lot harder than following guidelines when dealing with ‘functional somatic symptoms’.
    I have no answers but this ‘grey zone’ probably makes up a substantial percentage of work in many health care settings(particularly in General Practice).

    This book and the reviews may be interesting. I found it fascinating with explanations and likely mechanisms for many ‘traditional healing’ practices. One of the best ‘treatments’ for these ongoing connundrums is meditation –lots of valid research –costs nothing and does not require anyone else to do it . I am not advocating this as a panacea due to the obvious social factors that can’t be eliminated by sitting still !

  27. ChrisR said,

    November 12, 2007 at 3:27 pm

    I heard the live interview and thought that unfortunately Ben did not come across well. He sounded as if he had a pre-prepared point and was going to make it regardless, which to be fair the other interviewee also did. But then Ben used this term “psychosocial” – a word which I, and I imagine many other listeners, was not familiar with. It sounded like the kind of technical jargon that one might hear in a conversation between medics in a hospital. So it rather irritated and turned me off, particularly as Ben didn’t explain clearly what it meant. The audience was left to guess as to its meaning, and clearly some listeners guessed wrongly.

    The whole episode was a shame because in general I admire Ben’s communication of medical and scientific issues.

  28. Jon Newman said,

    November 12, 2007 at 6:06 pm

    Hi Ben,

    As a physical therapist I frequently encounter medically unexplained pain. More commonly, I see erroneously explained pain symptoms, usually in the guise of (or together with) a medical diagnosis. I can definitely feel your pain of being misperceived.

    I concur with your thoughts that “medically unexplained symptoms and the mechanisms of psychological factors in ill health are officially the most interesting thing in medicine right now”. I look forward to see what your research and clinical practice produces.

  29. Camp Freddie said,

    November 14, 2007 at 9:49 am

    I’m afraid “psychosocial” and “congnitive behaviour therapy” are meaningless words to the vast majority of people.

    So people just insert their own definitions based on what the words sound like.

    Psychosocial sounds like psychosomatic, which we all know means that someone is not really ill.

    Cognitive behaviour therapy sounds like seeing a psychiatrist, which people only do if they’ve got something wrong with their thoughts not their bodies.

    Plus, most people can’t accept that something can be ‘real’ and ‘(partly) in the mind’. The cognitive dissonance makes misinterpreting the facts very easy.

  30. buffalo66 said,

    November 14, 2007 at 1:09 pm

    I’m not at all surprised that listeners didn’t know the difference between psychosocial and psychosomatic. In fact, I’m not sure what the difference is myself. The Concise Oxford Dictionary (8th edition) has these definitions:

    psychosocial: of or involving the influence of social factors or human interactive behaviour.

    psychosomatic: 1 (of an illness, etc.) caused by or aggravated by mental conflict, stress, etc. 2 of the mind and body together.

    Now, Table 1 in the BMJ paper that Ben cited ( lists the following risk factors as “psychosocial”:
    Stress; anxiety; negative mood or emotions; poor cognitive functioning; pain behaviour.

    Number 1 in this list of “psychosocial” risk factors is “stress”, which is not mentioned in the Oxford dictionary’s definition of “psychosocial”, but is specifically mentioned in the dictionary’s definition of “psychosomatic”. So I don’t think you could blame anyone for thinking that the terms “psychosocial” and “psychosomatic” are virtually synonymous.

    Perhaps medical professionals use a different definition of “psychosomatic” from that used in everyday language typified by the Oxford Dictionary definition (like the way “significant” has a precise meaning to statisticians which can be at odds with the definition used in ordinary language)?

    Ben – it would be really helpful if you could define precisely what you mean by “psychosomatic” and “psychosocial”.

  31. tronador said,

    November 17, 2007 at 7:44 am

    It sounds like the many listeners/readers are confused about the definition of “psychosomatic”. The vast majority of chronic back pain is psychomatic and is simply myofascial pain related to unconscious emotion such as repressed anger or possibly conscious emotional stress. The average person seems to accept the concepts of other myofascial conditions such as “tension headache”, colloquialisms such as “pain in the neck” and “pain in the ass.” Why not tension backache? Most people seem to understand other mind-body conditions such as the sensory components of “heartache”, “gut feelings”, “butterflies in the stomach”, and the like. Clinical experience shows that when people finally make the connections between back pain and their emotions, give up the fear of injuring themselves, and realize that the majority of people without any back pain have some level of demonstratable pathology on MRI,they quickly get better!

  32. scotlyn said,

    November 23, 2007 at 4:25 pm

    Two words very heavily laden with associations and undertones – “psychosocial” or “psychosomatic” for many people equate to “not a real disease”, while “placebo” – for many people equates to “not a real medicine.” Hard for people to listen properly to what you want to say when these undertones are what they hear. It would move us on considerably if we could agree on a value-free terminology to discuss the intricate interworkings of mind and body, and to discuss the multitude of ways in which people find relief from their suffering.

  33. Harlequin said,

    November 26, 2007 at 9:14 am

    “…the Journal of Psychosomatics now uses the terms ‘psychosomatic’ and ‘biopsychosocial’ interchangeably.” McLaren N. The biopsychosocial model and scientific fraud. Paper presented to annual congress, RANZCP, Christchurch May 2004 available from the author at

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