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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 November 3; 335(7626): 900.
PMCID: PMC2048899
Talk of Psychosocial Factors

Tell the whole story

Charles T Vivian, consultant occupational physician

Goldacre says he sounded like an ass when explaining the complex pathogenesis of back pain on radio, but he is unduly harsh on himself.1 His message is not wrong, and he is not an ass. However, the message might have been better gift wrapped.

Western medicine is based on the biomedical model. This model is reductionist—all symptoms can be explained by underlying pathology—and dualist—if there is no pathology, it's all in your head. This model was drilled into us at medical school and is the principal model for the National Health Service. Society largely accepts the model too.

But it's wrong. For up to 90% of people presenting to their general practitioner with genuine physical symptoms, the symptoms are not explained by pathology. It is also not appropriate to label most of these patients as anxious or depressed. I now explain this to patients, and tell them that the problem lies with the model, not with them. It is normal to have genuine physical symptoms that cannot be explained through radiographs or blood tests.

You can then help the patient understand that extensive research has proved what will help. The psychological yellow flags act as obstacles to recovery and return to work. These include catastrophising (fearing the worst), low mood, avoidance behaviour, and having an external locus of control (for example, make me better doctor). These all inhibit recovery. Cognitive behaviour therapy is excellent for tackling these obstacles ( When coupled with graded exercise programmes, the outcomes are excellent.


Competing interests: None declared.


1. Goldacre B. Beware of mentioning psychosocial factors. BMJ 2007;335:801. [PMC free article] [PubMed]

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