Diagnosis and treatment of personality factors in chronic low back pain.

The differentiation between primary versus secondary gains is useful for an understanding of the management of chronic low back pain. Primary gain is defined as the direct reduction of pain and emotional distress. Secondary gain is defined as the reduction of anticipatory pain-fear through the avoidance of the occasions of rearousal of pain. This differentiation helps to clarify the diagnosis as well as the treatment of back pain. A person's fear of pain is considered to be the central psychological factor that interferes with successful treatment of chronic low back pain. Research provides insight into how the person both internally and externally protects against pain-fear. The Hysterical Conversion Scale on the MMPI is interpreted to be a measurement of the current level of pain-fear rather than a statement about the physical versus psychological nature of the pain. The reduction of pain-fear is shown to explain the behavior of hysterical conversion patients. Treatment suggestions are made that focus on reducing the patient's fear of pain. These include: considerations for when to operate; a recommendation to give the patient accurate expectations about the pain he/she will experience during treatment; and a specialized pain counselor in hospitals and clinics in order to help manage the level of pain-fear among low back patients.