Styles of living with low back injury: The continuity dimension

Following back injury, many patients continue to experience their residual pain as totally debilitating, even though physicians consider them ready to return to work, albeit with some discomfort and at less demanding jobs. Through the years, many of these individuals have been characterized according to two traditional diagnostic categories: conversion reaction and psychophysiologic disorder. However, that identification does not lead to helpful understanding. This paper reports a case study analysis of how individuals from these non-adaptive groups live their back injury as compared to back patients with 'no psychological overlay'. Findings show 'conversion' and 'psychophysiologic' patients to be differentiable from the latter patients and from one another. The two clinical groups share the following nonadaptive style of living the injury: they regard their prior able-bodied lives as the only acceptable way of being; the spectre of ongoing limitation brings into question their past and future worthiness and uprightness; they remain stuck in the present, focusing on and thereby exaggerating their pain, which they see and present as temporary illness rather than as permananent partial disability. In contrast, adaptive patients were not inordinately preoccupied with issues of worth and were able to make modifications in their lives that enabled them to move forward. The manner in which all patients took up their injuries was in accordance with their efforts to maintain continuity in their way of being--their values, identities, senses of self. This continuity dimension should be incorporated into our multi-dimensional understandings of chronic pain. Guidelines for clinical differentiation of conversion (absolutely upright) and psychophysiologic (straining upright) styles are presented and implications for diagnosis, treatment, social policy and societal values are discussed.