Annals of Indian Psychiatry

: 2022  |  Volume : 6  |  Issue : 1  |  Page : 38--43

Psychological correlates of disability among patients with chronic low back pain

Aditi P Chaudhari1, S Anukarthika1, Kaustubh Mazumdar2,  
1 Department of Psychiatry, BARC Hospital, Mumbai, Maharashtra, India
2 Department of Psychiatry, Medical Division, BARC Hospital, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Aditi P Chaudhari
Department of Psychiatry, BARC Hospital, Anushaktinagar, Mumbai - 400 088, Maharashtra


Background: Chronic low back pain (cLBP) is pain that lasts for more than 3 months after the first acute episode of back pain. There is evidence that psychological factors are involved in the response to pain and hence the development of disability. There are very few Indian studies on the subject. This study was conducted to study the prevalence of psychiatric morbidity in patients with cLBP, to study the fear avoidance and pain catastrophizing in these patients, and to determine if these factors impact disability due to cLBP. Methodology: One hundred consecutive patients of cLBP, aged 18 to 60 years, with no previous psychiatric illness were assessed for depression, anxiety, and somatization using the Patient Health Questionnaire-9 (PHQ), Generalized Anxiety Disorder -7, and PHQ -15, respectively. Fear-avoidance beliefs and pain catastrophizing were assessed with the Fear Avoidance Beliefs Questionnaire and Pain Catastrophizing Scale, respectively. The Roland-Morris Disability Questionnaire was used to assess the disability. The data were pooled and statistically analyzed using Pearson's Correlation test and multiple regression analysis. Results: The prevalence of anxiety, depression, and somatization was 28%, 38%, and 34%, respectively. Fear-avoidance beliefs related to work and physical activity were high among 60% and 26%, respectively. Pain catastrophizing was high among 8% of patients. 32% patients had high disability. Disability correlated significantly with depression, somatization, and fear avoidance (work and physical activity) but following multiple regression analysis, fear-avoidance related to physical activity was the only predictor of disability. Conclusions: Disability assessment must be an integral part of the management of cLBP, and patients with high disability may be screened for psychiatric morbidity and fear-avoidance beliefs. The role of targeted interventions for these factors could then be explored.

How to cite this article:
Chaudhari AP, Anukarthika S, Mazumdar K. Psychological correlates of disability among patients with chronic low back pain.Ann Indian Psychiatry 2022;6:38-43

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Chaudhari AP, Anukarthika S, Mazumdar K. Psychological correlates of disability among patients with chronic low back pain. Ann Indian Psychiatry [serial online] 2022 [cited 2023 Mar 27 ];6:38-43
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Full Text


Low back pain is pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without sciatica.[1] It is regarded as chronic when it continues for 12 weeks or more.[1]

Chronic low back pain (cLBP) is well documented to be extremely common and the leading cause of activity limitation and work absence throughout the world.[2] In clinical practice, an accurate pathoanatomical diagnosis of the cause of cLBP can be made in only 10% of the patients. In 90% of the cases, the etiology is unknown.[3]

Therefore, in recent decades, there has been increased emphasis on psychosocial factors in epidemiological studies of cLBP.[4] The biopsychosocial model emphasizes that the mechanical and physiological processes are involved in the generation of pain whereas the psychological and social conditions could contribute to the response to pain leading to the development of disability.[4]

There is evidence to show that psychiatric disorders such as anxiety, depression, and somatization are common in a setting of cLBP.[5],[6],[7] There is Indian research[8],[9],[10] that has attended to this association. However, psychological elements, namely fear avoidance[11],[12] and pain catastrophizing, can also affect pain-related outcomes and yet, there are virtually no Indian studies that have touched upon these aspects. The central concept in the fear-avoidance model is the fear of pain with a subsequent response of avoidance, which leads to the initiation and maintenance of long-term disability.[11] Pain catastrophizing is a tendency to magnify or exaggerate the threat value or seriousness of the pain situation.[12] Exploring the role of these parameters could help to bridge the gap in Indian literature.

Disability is an umbrella term, covering impairments, activity limitations, and participation restrictions.[13] The concept of disability has resulted in a paradigm shift in the management of chronic nonfatal conditions. It was adopted as an outcome measure for the present study because it is a reflection of the usefulness of any therapeutic intervention. Anxiety, depression, and somatization were regarded as indicators of distress. Fear-avoidance and pain catastrophizing were selected as measures of pain-related cognitions.

These parameters were chosen because they are well-defined constructs that are amenable to intervention. The study is therefore not one of only theoretical interest but also the findings of the study could have implications in patient management. To the best of our knowledge, this is the first comprehensive Indian study on psychiatric morbidity, psychological factors, and disability in cLBP.

The research question for the study was do psychiatric morbidity and psychological factors impact disability among patients with cLBP. The aims and objectives were to study the prevalence of psychiatric morbidity in patients with cLBP, to study the fear avoidance and pain catastrophizing in these patients, and to determine if these factors impact disability due to cLBP.


Sample selection

This was a cross-sectional, observational study conducted at the Department of Psychiatry in coordination with the Department of Orthopaedics at a general government hospital over a period of 1 year, following approval of the Ethics committee. The study population consisted of 100 consecutive patients diagnosed with cLBP from Orthopaedic outpatient department. Patients aged 18 to 60 years were enrolled after due informed consent.

Sample size

There have been vast differences in the sample sizes in other studies on this subject primarily due to differences in study design and methodology. Our study sample comprised of the beneficiaries of the Contributory Health Service Scheme. The sample size was estimated using OpenEpi version 3.0 (Emory University, Atlanta, United States of America). The proportion of cLBP with psychological comorbidity was estimated at 50% which is most conservative and gives the largest sample size. Using a 10% absolute precision and a confidence limit of 95%, and we got a sample size of 81 out of the estimated 500 patients expected to seek treatment during the study period of 1 year. However, we were able to obtain data from 100 patients during the study period which gives the study a 97% confidence level.

Inclusion criteria

Patients diagnosed with having low back pain (defined as having symptoms at T12 or lower, including radiating pain into the buttocks and lower extremity)Duration of pain being more than 3 monthsAge group from 18 to 60 yearsPatients willing to give informed consent for the study.

Exclusion criteria

Patients who have already been diagnosed as having a psychiatric illness by self-report and perusal of recordsThe presence of a medical illness concerning the spine or systemic involvement related to metastatic or visceral diseaseRecent spinal fractureOsteoporosisPregnancy.

Study instruments

Semistructured proforma was designed to collect the sociodemographic and illness-related variablesThe Patient Health Questionnaire (PHQ):[14],[15],[16] The patients were assessed using PHQ-9[14] for depression, Generalized Anxiety Disorder-7 (GAD-7)[15] for anxiety disorders, and PHQ-15[16] for somatization disorders. Cut points of 5, 10, and 15 represent mild, moderate, and severe levels of depressive, anxiety, and somatic symptoms, on the PHQ-9, GAD-7, and PHQ-15, respectively. A cutoff point of 10 or greater is considered a yellow flag on all 3 measures (i.e. drawing attention to a possible clinically significant condition) and was chosen for the present study. The internal consistency (Cronbach's α) of PHQ-15 is 0.82, GAD-7 is 0.91, and PHQ-9 is 0.88. This set of scales has been widely used across Indian studies and therefore well validated in our populationThe Roland-Morris Disability Questionnaire (RMDQ):[17] this 24-item scale was used to assess the extent of disability due to cLBP. It has a range of 0 (no disability) to 24 (maximum disability), with higher scores indicating higher disability. A score smaller than 15 is interpreted as low limitation, and a score equal to or higher than 15 is interpreted as high limitation in functioning. The internal consistency (Cronbach's α) is 0.83. While there are several scales to assess disability, this scale was chosen because it is specific to the disability caused by low back painThe Fear Avoidance Beliefs Questionnaire (FABQ):[18] this scale can help predict those that have a high pain avoidance behavior. The FABQ consists of 2 subscales – FABQ for physical activity (FABQ-PA) and for work (FABQ-W). The cutoff scores to interpret high fear-avoidance beliefs are 15 and 13 for the two subscales, respectively. The scale was chosen because it has demonstrated to be valid and reliable in a cLBP population with an internal consistency (Cronbach's α) of 0.93The Pain Catastrophizing Scale (PCS):[19] This is a 13-item scale to assess emotions of pain catastrophizing, namely rumination, magnification, and helplessness. A higher score indicates higher pain catastrophizing, and a cutoff of more than 30 points is associated with clinical relevance. This measure has been found to have good psychometric properties, including high test-retest reliability and high internal consistency. (Cronbach's alpha = 0.87–0.95). The choice of this scale was based upon the evidence that a significant amount of international literature studying pain catastrophizing has used this scale.

Data analysis

The data were pooled and statistically analyzed using the IBM SPSS Statistics for Windows, version XX (IBM Corp., Armonk, New York, United States of America. The sociodemographic variables have been expressed in terms of frequency and percentages. The scores on all the scales have been mentioned in terms of mean and standard deviation. Using the cutoff scores, cases were differentiated from noncases. The scores on the scales for depression, anxiety, somatization, fear-avoidance, and pain catastrophizing were correlated with the scores on the scale for disability using a Spearman's Correlation coefficient test. Those parameters which correlated significantly with disability were entered into a multiple regression analysis. A P = 0.05 was taken as the cutoff for significance.


Sociodemographic and clinical profile

A total of 100 patients were studied of which 31% (n = 31) were males and 69% (n = 69) were females.

There was a preponderance of patients in the age group of 46 to 60 with 63% (n = 63) coming from this range. About 44% (n = 44) of the study participants were having an education of graduation or above. Fifty-three percent (n = 53) women were homemakers. Thirty-two percent (n = 32) were employed while the rest had retired. Ninety-two percent (n = 92) were married. As regard to the duration of illness, 30% (n = 30) had suffered the illness for a duration of 1–2 years while 46% (n = 46) had been having the condition for more than 2 years.

Prevalence of psychiatric morbidity

Patients were screened using the PHQ, which has three modules: PHQ-9 for depression, GAD-7 for anxiety disorders, and PHQ-15 for somatization disorders.

The scores on the PHQ- 9 ranged from 0 to 18 and the mean was 7.18 ± 4.84. The prevalence of depression was found to be 38%. (n = 38) The scores on the GAD -7 ranged from 0 to 15 and the mean score was 5.83 ± 4.35. The prevalence of anxiety was found to be 28%. (n = 28) The scores on the PHQ – 15 ranged from 2 to 23 and the mean score was 8.4 ± 4.12. The prevalence of somatization was 34%. (n = 34) However, these groups were not mutually exclusive. 28% (n = 28) patients experienced anxiety, depression, as well as somatization. The overall prevalence of psychiatric morbidity in our sample was defined as the presence of at least one psychiatric diagnosis and that was noted to be 53% (n = 53).

Fear avoidance

Fear-avoidance beliefs were assessed using the FABQ. This scale has two subscales – FABQ-W (work subscale) and FABQ-PA (physical activity subscale). The mean scores of FABQ, FABQ-W, and FABQ-PA were 25.45 ± 13.44, 15.48 ± 8.66, and 10.07 ± 5.84, respectively. High fear avoidance for work was seen in 60% (n = 60) and for physical activity was seen in 26% (n = 26) of patients.

Pain catastrophizing

This was assessed using the PCS. The scores on this scale ranged from 0 to 40 and the mean score was 11.25 ± 9.18. High pain catastrophizing was found in 8% (n = 8) of the study participants.

Extent of disability

The extent of disability among the patients was assessed using the RMDQ. The scores on this scale ranged from 5 to 21 and the mean was 12.91 ± 3.86. Overall, 32% patients (n = 32) had a score >15 indicating significant disability

Association between psychiatric morbidity, psychological factors, and disability

Using a Spearman's correlation coefficient test, the scores on disability were correlated with the scores for depression, anxiety, and somatization. They were also correlated with the scores on the scales for psychological factors of fear avoidance related to work and physical activity as well as with pain catastrophizing. The results have been shown in [Table 1].{Table 1}

In our study, depression, somatization, fear avoidance – both subscales and pain catastrophizing – showed significant correlation with the scores on disability.

Correlations, however, are not indicators of causality. Subsequent to this finding, we adopted the statistical method followed by majority of studies on this subject. After confirming for the assumptions, regression analysis was performed to ascertain the effects of the significant variables on the likelihood that the patients experienced disability. The variables entered were the scores on depression, somatization, fear avoidance for work and physical activity and pain catastrophizing. The regression analysis model for the dependent variable disability is shown in [Table 2].{Table 2}

Table 2 Multiple regression analyses for dependent variable Disability and independent variables – depression, somatization, fear avoidance- work and physical activity and pain Catastrophizing.

None of the variables had to be excluded from the analysis. The variables explained 21.3% of the variability of our dependent variable, i.e. disability. The F-ratio in the ANOVA was 6.37 (P = 0.000, i.e. P < 0.05) indicating that the overall regression model is a good fit for our data and that some of the variables studied, significantly predicted the dependent variable, i.e. disability. From the significance seen, it was found that fear-avoidance physical activity subscale was the factor that predicted disability.


In our study, 100 patients with cLBP were evaluated for depression, anxiety, and somatization and psychological factors, namely fear avoidance and pain catastrophizing. The association of these factors with disability was assessed.

Prevalence of psychiatric morbidity

The overall prevalence of psychiatric morbidity in our study sample was 53%. Depression was present among 38%, anxiety was present in 28%, and somatization was present in 34% of patients with cLBP. About 28% of patients experienced all the three conditions, i.e. comorbid, depression, anxiety, and somatization.

There is robust evidence to support our findings.

A 2017 study from Togo[5] found the prevalence of anxiety and depressive disorders in their population to be 39%, while a 2016 Nigerian study[6] reported the prevalence of depression among patients of cLBP to be 39.5%. In 2012, authors from Brazil[20] reported that 36.7% of the study participants with cLBP had dysphoria or depression. Two recent Indian studies[7],[8] had conclusions similar to ours. The 2014 study from Kashmir[7] reported that 37.8% of patients with cLBP were suffering from somatization and 30.75% with depression. Another study done in Bengal[8] in 2011 identified GHQ caseness in 99 out of 100 patients with cLBP and a prevalence of depression in 33%, anxiety in 19%, and somatoform disorders in 37% of the cases.

However, there have been some Indian[9],[10] and international studies[21],[22] that have reported prevalence rates of different psychiatric conditions to be much higher than those seen in our study.

Conversely, a study done at Qatar, in 2013,[23] has reported a prevalence of only 9.5% for severe anxiety disorders, 13.7% for severe depression, and 14.9% for somatization disorders. A survey from Japan[24] and research from Texas, USA,[25] also reported a lower prevalence of psychiatric morbidity.

According to the statistics of the National Mental Health Survey of India[26] 2015–2016 implemented by NIMHANS, Bangalore, the current and lifetime prevalence of depression in India is 2.5% and 5.2%, respectively. The weighted risk for neurotic and other stress-related disorder is 6.93%. The findings of our study as well as other research thus highlight the higher prevalence of psychiatric morbidity among patients with cLBP as compared to the general population.

Psychological factors

In our study, 60% of patients had high fear avoidance at work and 26% had high fear avoidance related to physical activity. A Brazilian study done in 2010[27] had found that 61% of patients had high levels of fear-avoidance beliefs, which is similar to our findings. There are also two international studies that have reported scores on fear avoidance to be similar to ours.[28],[29] Research has shown that patients with fear avoidance were 2.5 times more likely to remain away from work for at least 2 months. Because these beliefs determine work-related behavior, they most likely negatively affect the income of these patients.[27]

In our study sample, the prevalence of significant pain catastrophizing was low and seen in only 8% of patients. There is not much abundance in literature on the prevalence rates of pain catastrophizing in clinical samples of cLBP. While there is evidence[28] that is in keeping with our findings, other studies[30],[31] have reported a much higher prevalence of this phenomenon. These authors[31] have inferred that people with pain catastrophizing ruminate and attend excessively to pain stimulus as a result of which they experience more pain.

Prevalence of disability

The mean scores of disability, on Roland-Morris Disability Questionnaire (RMDQ) in our study, were 12.91 ± 3.86. Significant disability was noted in 32% of patients. A recent scientific report from Punjab, India,[32] on the subject had used the Modified Oswestry questionnaire and reported that two-thirds of patients with low back pain reported mild-to-moderate disability. Different studies have adopted different disability concepts as well as different methods to measure this phenomenon. Hence, comparisons were difficult to construct.

We have compared our results with studies that have used the same measure of disability as our study, i.e. the RMDQ. We found that many of these studies[28],[29],[30],[33] had found mean scores on the RMDQ which were in keeping with our study.

Role of psychiatric morbidity and psychological factors in disability

In our study, depression, somatization, fear avoidance (both work and physical activity subscale) showed significant correlation with the scores on disability on the Spearman's correlation test. However, on application of the multiple regression analysis model, only fear-avoidance physical activity subscale was found to be significantly associated with disability.

Studies that have used correlations as the statistical test have reported significant correlations of disability with anxiety,[10],[22],[34] depression,[22],[34],[35] and fear avoidance.[36] Many authors have subsequently used the regression analysis model to study the effect of different psychiatric and psychological variables on disability due to cLBP.

In a cross-sectional 2008 Dutch study,[33] depression, psychological distress, and fear of movement significantly correlated with disability. However, when regression analyses were performed, the model could explain only 19% of variance in the data, with fear of movement being the only one psychological variable that contributed significantly. This is exactly in keeping with our findings. Our research also concurs with other research,[28],[37] which found that fear and avoidance behavior was the single predictor of disability in cLBP.

Most of the recent studies on this subject have also used multiple regression analysis and reported conflicting results. A 2020 study from Romania[38] showed that pain intensity, pain catastrophizing, and depression predicted disability in low back pain. Depression and fear-avoidance beliefs about work predicted disability in a Swiss study[30] while depression and pain intensity impacted disability in a recent 2016 study from Iran.[21] A 2012 study[29] from Turkey had reported that severity of pain, anxiety, and fear-avoidance behaviors were the predictors of disability while a 2015 Nigerian study[31] reported that patients with pain catastrophizing had significantly higher disability as compared to those who did not. Thus, almost all the factors discussed in the present study have emerged as significant and insignificant factors in past research.

Hence, we studied a systematic review[39] on psychosocial risk factors on cLBP that was done in 2010. The authors have reviewed 18 different studies on this subject and concluded that although depression and psychological distress impact cLBP outcome, this may involve only few people and large cohorts would be needed to demonstrate this. Other psychological factors studied (anxiety and somatization) seem not to be prognostic factors. Fear-avoidance beliefs, however, were found to be predictive of persistent disabilities. This is in keeping with the findings of our research.

It is possible that although many psychological variables may not be independent predictors of disability, they do correlate with disability. Rather than being primary predictors of outcome, they could be regarded as mediators that influence disability in conjunction with some other factors. Thus, diagnosing their presence could have some practical utility. Assessment and interventions targeted at fear avoidance may be useful in reducing the disability in these groups of patients but further systematic research would be required to ascertain this.


The study has been conducted in patients who were availing health care from the services provided by the organization in which either they themselves, their spouse or parent was employed. The sociodemographic characteristics of this sample may not reflect that of the general population. There was no control group for comparison with the study population. Since this study involved assessment of pain-related cognitions and disability, healthy controls could not be included. Hence, results had to be discussed with respect to the findings of previous studies. The intensity of pain and the frequency of pain were also not included in the study. Other factors that could impact the disability in this study group, namely duration of pain age of the patient, self-efficacy, and resilience, were beyond the scope of the study.


The prevalence of anxiety, depression, and somatization was 28%, 38%, and 34% (n = 28, 38, and 34), respectively. All three were present in 28% (n = 28) of patients. Nearly 60% (n = 60) had high fear-avoidance beliefs related to work and 26% (n = 26) had high fear-avoidance beliefs related to physical activity. Eight percent (n = 8) of total population had high pain catastrophizing. Three percent 32%(n = 32) of the patients had high disability. Disability showed significant correlations with depression, somatization, and fear avoidance. Fear avoidance (physical activity) was the only factor that significantly predicted disability.


We would like to thank Head of Department of Orthopaedics, Dr. Nandan Kamat and Dr. Praveen Bande for granting us the permission to conduct this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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