Pain: Diagnostic Uncertainty Breeds Cognitive Biases

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By Palanisamy Vijayanand

A frequent cause for excitement in the pain clinics is the pregnant potato chips pack look alike folder of spinal MRI’s the low back pain sufferer brings in. Neatly packed and bulging at its seams, there will be one for every year for the past ten years. Yet, without a solution. Opening the MRI folder, like the potato chips pack, is a frequent cause for disappointment. Full of air, only a few degrees Fahrenheit hotter. It seems like everyone have had their fair share of ordering the scans, from the genial GP to the quirky quack. At age sixty, every human has changes in the MRI of the spine. To identify the sub group of back pain sufferers, where the MRI changes could be clearly correlated with their symptoms is a tough ask. Studies have shown that precise causes and diagnostic labels could be found only in about 5%-10% of patients – an unhappy paradox of scientific advances and therapeutic standstill. Such diagnostic uncertainty affects the clinician – by triggering a sense of impotency which results in invasive procedures, done more out of desperation than realistic chances of success; as well as the sufferer – by way of negative social, cognitive and emotional functioning.

The study by Serbic and Pincus explored the relationship between specific beliefs about the diagnosis and the specific cognitive processes in a cohort of patients with chronic low back pain. With a 2 (between group, levels of certainty about the diagnosis) x 4 (within group, word type) multi factorial design, they set out to find whether an uncertain diagnosis would result in selective recall of words related to illness, which in turn would reflect the sufferers preoccupation with the meaning and consequences of pain. The between group question was, I think there is something else happening with my back which the doctors have not found out about yet (yes/no). The groups were then categorized on the basis of self-report answers to

a) I have been given a clear label/ diagnosis for my back pain (yes/no) and

b) I have been given a clear explanation about why I have back pain (yes/no).

The four levels of within-group factor were word category

a) pain-related – pounding, sore, pricking etc.

b) depression-related – feeling guilty, withdrawn, unlovable etc.

c) illness-related – suffering, disabled, dependent etc.

d) neutral – nosey, obnoxious, crude etc.

A computer generated, timed questionnaire was used for endorsing the self-descriptor words. This was followed by a filler task to prevent the participants from rehearsing the information. They were then asked to complete a surprise, non-time limited, recall test. The primary outcome measure was the number of words recalled for each word category by each participant. They also measured the number of words endorsed as self-descriptors and the mean reaction time for each word category.

More pain words were recalled than depression, illness and neutral words in both groups, and there was a significant interaction between word type and group. In the diagnostic uncertainty group, the participants recalled both pain and illness words as opposed to participants in the diagnostic certainty group who selectively recalled pain words. These biases remained after adjusting for depression and disability, and were not found on endorsement or reaction time data. ‘Together,’ they write that ‘the results demonstrate an association between diagnostic uncertainty and recall bias towards negative health-related stimuli, which has been previously conceptualized as evidence for the presence of maladaptive schemas and poor coping.’

An additional, interesting finding was that 40% of participants who thought there was something else going on in their back that had yet been found also reported having received a clear diagnosis. This suggests that patient’s beliefs and subsequent behaviour might depend on variables such as doctor-patient communication, trust, clear explanations, and manageable expectations. The study provides tentative evidence for the hypothesis that greater certainty may help patients to shift their attention to non-pain and non-illness aspects of life. The challenge, however, is offering effective reassurance in the context of uncertain aetiology and prognosis. Moreover, the extent to which recall bias interact with, and influenced by, other cognitive biases is poorly understood.

A simplistic biological approach to persistent pain is negligence through wilful blindness. The rich web of cognitions and emotions that pain weaves in an individual makes listening to his or her pain story imperative in its management. Many times, the story helps one discover the social dimensions of pain and that the sufferers are not just falling behind, but are falling apart. Other times, the emotional upheavals, of the sufferer as well as his family, point to a life of misery and discontent. And more often than not, it would be revealed that the diverse psychological issues make it increasingly impossible for a comfortable existence. When a one-size-fits-all biological approach could only produce an intense but narrow beam of light, a truly beneficial treatment would be the one that brightens up life from a whole person perspective – a biopsychosocial approach. Without guidance, even the most discerning patients are terrible at judging treatment efficacies. They could assume that the larger, expensive and attractive treatment packages with a pure biological focus – new and improved potato chips, now with 33% more air – means greater benefit. In this era of relationship-centred, team-based care and increasing demands of chronic illnesses, pain management thus may be the ideal platform on which to build and expand interprofessional collaboration.


Serbic D, et al.Diagnostic uncertainty and recall bias in chronic low back pain. Pain. 2014 Apr 30. pii: S0304-3959(14)00209-7. doi: 10.1016/j.pain.2014.04.030. [Epub ahead of print]


Dr. Palanisamy Vijayanand

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FCARCSI, DPainMed (RCSI), MSc (Pain), FFPMCAI, FFPMANZCA | Hyderabad, India

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