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Psychiatria Danubina, 2016; Vol. 28, No. 4, pp 357-362 View point article
© Medicinska naklada - Zagreb, Croatia
IDIOPATHIC SCOLIOSIS FROM PSYCHOPATHOLOGICAL
AND MIND-BODY MEDICINE PERSPECTIVES
Goran Talić1, Ljerka Ostojić2, Snježana Novaković Bursać1,
Tatjana Nožica-Radulović1 & Đurđica Stevanović-Papić1
1Institute of Physical Medicine and Rehabilitation ''Dr Miroslav Zotovic'', Banja Luka, Bosnia and Herzegovina
2School of Medicine, University of Mostar, Mostar, Bosnia and Herzegovina
received: 2.5.2016; revised: 10.8.2016; accepted: 17.8.2016
SUMMARY
Idiopathic scoliosis, defined as a three-dimensional spine and trunk deformity, which appears in otherwise healthy subjects,
exhibits complex relations with various forms of personal well-being and psychopathology. Most research studies have documented a
higher proportion of psychological disturbances (e.g., self-criticism, negative body image, low self-esteem) and mental disorders
(e.g., anxiety and depressive disorders, personality disorders) among idiopathc scoliosis patients compared to healthy controls. In
addition, there are some reports, although more systematic research is warranted, on the role of mental health and personality traits
in relation to the adherence to conservative treatment. Given the increasing role of surgical treatment in the management of
scoliosis, as well as several reports on negative psychological outcomes of such interventions, there is a growing need for ongoing
screening and mental health care in this population. It seems this also holds true for non-operative treatments, particularly bracing
therapy. One should keep in mind that these scoliosis-psychopathology relations are deduced from a limited number of empirical
studies, usually conducted on small sample sizes, suggesting the need for further large-scale investigations, preferrably those with
longitudinal research designs. Understanding the complex interplay between personality/psychopathology and spinal deformities
within the framework of personalized mind-body medicine, should help clinicians tailor more individualized and specific treatments
and predict therapeutic outcomes in this clinical population.
Key words: idiopathic scoliosis – psychopathology – personality - mind-body medicine – psychosomatic
''There is no health without mental health'' (WHO 2005)
* * * * *
INTRODUCTION
Idiopathic Scoliosis (IS) is a multilevel process of a
three-dimensional spine and trunk deformity, which
appears in otherwise healthy subjects, and can progress
in relation to multiple factors, during any period of rapid
growth (Rigo & Griwas 2010). Formally, the main
diagnostic criterion is a coronal curvature exceeding 10°
on an anteroposterior X-ray image. Idiopathic scoliosis
is classified as infantile, juvenile, or adolescent depen-
ding on the age at which it is first noted. A fourth
category is that of adult scoliosis, which may be either a
continuation of adolescent idiopathic scoliosis or a de
novo development owing to degenerative changes or
other causes. In elderly patients, de novo scoliosis is
often hard to tell apart from pre-existing idiopathic
scoliosis with superimposed degenerative changes.
Scoliosis, in its most frequent adolescent idiopathic
form diagnosed in about 80% of the cases (Aebi 2005,
Weinstein et al. 2008), is the most prevalent orthopedic
condition affecting children and may have lasting
consequences (Asher & Burton 2004, Danielsson et al.
2001). In the overall adult population, the prevalence of
scoliosis may exceed 30% (Aebi 2005). It ranges from
nearly 9% in 40-year-olds to 68% in 70-year-olds
(Schwab et al. 2005, Trobisch et al. 2010) and increases
almost linearly from the 6th to the 8th decade of life
(Kebaish et al. 2011). In contrast to adolescents where it
is significantly more frequent among girls, no asso-
ciations with gender have been observed in adult
samples (Weinstein et al. 2008). As is the case with
most chronic medical conditions, etiopathogenesis of
idiopathic scoliosis is still poorly understood and is
known to influence numerous segments of one's life,
including physical, emotional and societal conse-
quences. Most prior research in this area have neglected
the role of psychological and behavioral factors as
relevant components of the development and prognosis
of this disease. Thus, there is a growing need to educate
various scoliosis-related experts and clinicians (i.e.,
medical doctors, physiotherapists, nurses, occupational
therapists, etc.) on the relations between idiopathic
scoliosis and psychological well-being, including
subjective quality of life and mental disorders.
IDIOPATHIC SCOLIOSIS
AND PSYCHOPATHOLOGY
Spinal deformities may significantly exert influence
on the general health and one’s health-related quality of
life, with a poor association between the radiographic
and clinical findings (Asher & Burton 2004, Tones et al.
2007). Empirical reports have described reduced partici-
pation in social life and interpersonal relationships,
Goran Talić, Ljerka Ostojić, Snježana Novaković Bursać, Tatjana Nožica-Radulović & Đurđica Stevanović-Papić:
IDIOPATHIC SCOLIOSIS FROM PSYCHOPATHOLOGICAL AND MIND-BODY MEDICINE PERSPECTIVES
Psychiatria Danubina, 2016; Vol. 28, No. 4, pp 357–362
358
lower marriage rates, poor self-image, difficulties on the
labor market, and mental/psychiatric disorders (Aebi
2005, Weinstein et al. 2008, Tones et al. 2007). Surgery
or brace treatment may also lead to psychological side
effects (Matsunaga et al. 2005, Sapountzi-Krepia 2001).
Long-term outcome reports (e.g., Danielsson et al. 2012,
Goldberg et al. 1994, Noonan et al. 1997, Weinstein et
al. 2003), suggested that deformity causes psychopatho-
logical effects or demonstrated positive coping mecha-
nisms. Furthermore, the available papers focus on the
assessment of health-related quality of life and utilize
generic or condition-specific measures with their physi-
cal, social, and emotional roles, mental functioning,
bodily pain, and body image components, incorporated
to produce a measure of a person’s perceived general
health status (Schwab et al. 2005, Tones et al. 2005).
For this reason, specific instruments for patients with IS
have been created, such the Scoliosis Research Society-
22 (SRS) and the Quality of Life in Spinal deformities
(QLSD). Compared to all other questionnaires, the SRS-
22 is the most frequently used and adapted into nume-
rous languages (Asher et al. 2003, Climent et al. 1995).
Misterska et al. (2010) demonstrated the absence of
psychopathological traits in non-treated adolescent girls
but a high level of self-criticism was ascertained. A
Korean study with only male patients (Oh et al. 2014)
obtained different results. When evaluating a population
of 19-year-old boys with adolescent idiopathic scoliosis,
they found out that these patients presented a higher
incidence of anxiety, depression, schizophrenia and
personality disorders compared to a control group.
Chang et al. (2016) recently conducted a nationwide
population-based cohort study in Taiwan, in order to
investigate the relationship between scoliosis and
depression. During the 5-year follow-up period, the
adjusted hazard ratios of depression in patients with
scoliosis (N=1409) were higher than that of the gender-
and age-matched controls (N=7045). The risk of
depression also demonstrated to be age-dependent for
scoliosis patients. The middle-age (41-65 years old) and
young adults (18-40 years old) scoliosis patients had
higher hazard ratios of depressive disorders.
However, studies interested in investigating the
personality traits of patients with scoliosis are limited.
To know the personality of these patients may be useful
to identify changes over treatment, modify the intensity
of brace treatment, indicate a supportive psychological
therapy and reduce dropout in conservative treatment
(Misterska et al. 2010, Oh et al. 2013). In fact, through
the application of scoliosis personality questionnaires,
interesting results have been found. In this sense, Rivett
et al. (2014) have demonstrated the existence of signi-
ficant differences with reference to personality in rela-
tion to the adherence to conservative treatment: patients
who adhered to treatment had a superior quality of life
than the noncompliant ones and showed different
psychological profiles. More specifically, a poorer quality
of life in the noncompliant group was possibly caused
by personality traits of the group, being more emo-
tionally immature and unstable, as well as less realistic.
Future studies are required to further investigate the role
of personality traits with regard to treatment adherence
in these patients, as it was done among some other
clinical populations, such as type 2 diabetes patients
(Milicevic et al. 2015).
With reference to the application of projective tests,
two studies reached similar results. Using Rorschach
and Bender test, Bengtsson et al. (1974) found a
difference in psychosocial adjustment in women with
scoliosis. Superficially, the subjects seemed well adap-
ted but from further analysis, they presented hyper-
sensitivity and insecurity, with a tendency to dysphoric
mood. Similarly, an Italian study (Saccomani et al.
1998) documented a discrepancy between a conscious
body image and a deeper aspect of feelings of
inferiority and insecurity through several projective
tests (Human Figure Drawing (HFD) and Sacks’
battery of tests). Finally, there is a lack of studies
linking health-related qulity of life with the personality
of scoliosis patients. However, in other areas, the
existence of a relationship between personality and
quality of life has been shown, such as in pediatric
cancer patients (DeClercq et al. 2004), young adults
with asthma (Axelsson et al. 2009) or schizophrenia
patients (Aukst Margetic et al. 2011).
PSYCHOLOGICAL ASPECTS OF
SCOLIOSIS PHYSICAL TREATMENT
With regard to specific physical interventions in
patients suffering from idiopathic scoliosis, spinal fu-
sion surgery with instrumentation successfully reduces
severe scoliotic curves and minimizes the risk for curve
progression (Tolo 1991). However, the results of treat-
ment also depend on the patient’s ability to cope with
stress of chronic disability, and the surgical outcome
may be unrelated to patient satisfaction (White et al.
1999). The psychological impact of spinal fusion
surgery, then, is of special concern. Any conclusion
about treatment effects on health and self-image should
also be based on age- and sex-matched control groups.
In one such study mental health was investigated in 30
young adults who were operated on for idiopathic
scoliosis, 2–3 years after surgery, and the results
compared to an age- and sex-matched control group of
40 individuals (Kibsgard et al. 2004). Overall, this study
showed that young adults operated on for idiopathic
scoliosis were satisfied, and that their mental health was
even better than the normal group, but their physical
health was somewhat poorer. Thus, the surgical proce-
dure was well tolerated and had not traumatized the
patients. On the other hand, a study by Plaszewski et al.
(2014) showed that the presence of scoliosis and
participation in the exercise program manifested
Goran Talić, Ljerka Ostojić, Snježana Novaković Bursać, Tatjana Nožica-Radulović & Đurđica Stevanović-Papić:
IDIOPATHIC SCOLIOSIS FROM PSYCHOPATHOLOGICAL AND MIND-BODY MEDICINE PERSPECTIVES
Psychiatria Danubina, 2016; Vol. 28, No. 4, pp 357–362
359
association with the symptoms of depressive disorder.
These findings correspond to some reports of a negative
impact of the diagnosis of scoliosis and treatment on
mental health. Therefore, the decision to introduce a
therapeutic program in children with mild deformities
should be made with judgment of potential benefits,
risks, and harm. For example, another study conducted
by Matsumoto et al. (2014) examined psychosocial
effects of repetitive surgeries in 34 children with early-
onset scoliosis. A higher prevalence of abnormal psycho-
social scores in multiple domains was found in multio-
perated patients as compared with national norms.
Moreover, the number of repetitive surgeries also
correlated positively with 3 problematic behavioral
dimensions: aggression, rule-breaking, and misconduct.
Misterska et al. (2010) investigated 35 scoliosis patients
who were treated surgically and found that patients
treated operatively, when compared to conservative
treatment and healty controls, manifested more symp-
toms of high neuroticism.
In addition to standardized psychopathological dis-
turbances after scoliosis treatment, studies have also
shown a lower body image that may persist for several
years in surgical patients (Noonan et al. 1997). Because
body image disturbances have been linked to various
negative life outcomes (e.g., academic performance, job
stability, marital status), a group of researchers have
recently developed the first self-report questionnaire
aimed at assessing body image disturbance in adoles-
cent idiopathic scoliosis (Auerbach et al. 2014). As
expected, the scores of patients with scoliosis indicated
greater back-related body image disturbance compared
with healthy controls.
Special attention has been paid to the experience of
brace-wearing in children/adolescents with scoliosis, as
long-standing observations have indicated lowered body
image and higher levels of stress for these individuals.
Sapountzi-Krepia et al. (2006) have observed intense
subjective experiences of stress, denial, fear, anger, and
shame in 12 children/adolescents undergoing bracing
therapy, indicating the need for psychological and social
support during the long period of bracing. Indeed,
numerous authors have called for additional psycho-
logical interventions for patients within the context of
in-patient rehabilitative treatment. Here, within the
setting of psychological group sessions and individual
discussions, the possibility exists for preventing psycho-
social impairment (Reichel & Schanz 2003).
Interestingly, a recenty study investigated stress
symptoms among adolescents before and after scoliosis
surgery, and explored correlations with postoperative
pain (Rullander et al. 2016). Although rates of
anxiety/depression and internalizing behavior were
significantly higher before surgery than six months
after, preoperative anger, social problems and attentions
deficits correlated significanlty with postoperative pain
at follow-up. It was concluded that more focus should
be put on the implementation of interventions to reduce
perioperative stress and postoperative pain in order to
improve the quality of nursing care. However, another
similar study has not detected the negative impact of
preoperative depression on 2-year clinical outcomes
following adult spinal deformity surgery after adjusting
for baseline differences in comorbidities, health-related
quality of life, and spinal deformity severity (Theologis
et al. 2016). Additional research is required to elucidate
psychological and psychopathological factros that could
influence the long-term outcomes of scoliosis treatment.
In general, physical exercises in the treatment of
scoliosis remain a matter of debate (Mordecai & Dabke
2012) and high-level evidence for or against these
procedures is lacking (Romano et al. 2012). Given the
increasing role of surgical treatment modality in the
management of scoliosis, as well as several reports on
negative psychological outcomes of such interventions,
there is a growing need for ongoing screening and
mental health care in this high-risk population.
INTEGRATIVE MIND-BODY
MEDICINE PERSPECTIVE
The above discussion on the varios findings in the
field of scoliosis-psychopathology relationship can be
more thoroughly understood within the framework of
mind-body medicine. Also known in the literature as
psychosomatic or psychological medicine, it can be
regarded as a theory of relations between the mind and
body, a theory of psychosomatic illnesses that explains
comorbidities of somatic and mental disorders, and a
holistic treatment approach that includes both medical
and psychological devices (Jakovljevic et al. 2010,
Jakovljevic & Ostojic 2013). It encompasses related
fields such as psychoneuroimmunology or psycho-
endocrinology, and in this particular case, psycho-
reumatology. The central premise of the psycho-
somatic paradigm is the awareness of complex and
simultaneously multidirectional associations and influ-
ences among numerous body and mind systems, also
evolving within a broader social and cultural contexts.
In the case of idiopathic scoliosis, traditional empirical
literature has mostly been concerned with psycho-
logical and psychiatric consequences in individuals
suffering from this somatic illness, which have been
thorougly described in this paper. This is of utmost
importance because in somatic patients mental vulner-
abilities and disorders may: 1. modify subjective reac-
tions to somatic symptoms (amplification), 2. reduce
motivation to care for somatic illness (demoralization),
3. lead to maladaptive direct physiological effects on
bodily symptoms, and 4. reduce the ability to cope
with somatic illness through limitation of energy, cog-
nitive capacity, affect regulation, perception of shame
or social stigma (Jakovljevic et al. 2010, Kennedy et
al. 2016). For example, research has shown how
Goran Talić, Ljerka Ostojić, Snježana Novaković Bursać, Tatjana Nožica-Radulović & Đurđica Stevanović-Papić:
IDIOPATHIC SCOLIOSIS FROM PSYCHOPATHOLOGICAL AND MIND-BODY MEDICINE PERSPECTIVES
Psychiatria Danubina, 2016; Vol. 28, No. 4, pp 357–362
360
rumination and anger influence central and autonomic
nervous system function and impair functioning of the
hypothalamic-pituitary adrenal cortical axis (stress
system), whereas promoting forgiveness can lead
todecreased musculoskeletal pain (Lee & Enright
2014), including chronic back pain typical for spinal
deformity illnesses (Carson et al. 2005).
However, an additional perspective of the mind-
body medicine includes a relationship where mental
(psychological, psychiatric) and related behavioral
factors might promote the development of deformed
spinal curvatures and accompanying chronic pain.
Misalignment of certain body segments as a result of
postural deviation will cause compensatory effort by
other segments to maintain body balance, resulting in
muscular strains and stress on the neurological system
and resulting in back pain. For example, some research
has shown that happy thoughts lead to more upright
postures, while sad thoughts lead to slumped and
hunched positions. In turn, uprightposture can alleviate
depression by improving breathing, which lleads to
increased oxygen levels in the blood and subsequently
relieves muscular tension in the shoulders (Ono et al.
2000). In addition, Guimond & Massrieh (2012) have
demonstrated associations between postural deviations
(e.g., kyphosis-lordosis, flat-back, and sway-back
postures), back pain and specific types of personality
structures (extraverted and introverted personalities). It
seems that the body shapes itself into different pos-
tures depending on the underlying mental and emo-
tional states, thus confirming the basic tenants of
psychosomatic medicine by establishing a direct link
between aspects of the mind (personality types) and
body (posture and back pain). Finally, it should be
noted that certain forms of psychodynamic theory and
psychotherapy have long argued for specific postural
deviations in individuals with immature and disturbed
personalities, such as oral (depressive) or masochistic
personality types (Lowen 2015), although these
premises need to be further tested in empirical settings.
For example, some authors have described postural
deviations among psychiatric patients (e.g., slumped
and hunched positions) in relation to their supressed
negative emotions and intrapsychic conflicts (Lowen
2015). Similarly, John E. Sarno (2006) has been a
proponent of a popular, albeit not universally accepted,
theory on the so called tension myositis syndrome that
causes chronic back, neck and limb pain, mostly serving
as unconscious distraction from deep and repressed
emotional issues. Overall, it is imperative to properly
understand the physical aspects that contribute to pain
and spinal deformities along with the emotional factors
contributing to such deviations, in order to appro-
priately modify behaviors andprevent/cure back pain.
In other words, personalized mind-body/psychoso-
matic medicine promotes the idea that each patient is a
unique individual in health and disease, and should get
highly specific and personally adjusted treatment for
her or his health problems, including both mental and
somatic health protection and promotion (Jakovljevic
2012, Jakovljevic & Ostojic 2013).
CONCLUSION
Idiopathic scoliosis, defined as a three-dimensional
spine and trunk deformity, which appears in otherwise
healthy subjects, exhibits complex relations with
various forms of personal well-being and psycho-
pathology. Most research studies have documented a
higher proportion of psychological disturbances (e.g.,
self-criticism, negative body image, low self-esteem)
and mental disorders (e.g., anxiety and depressive
disorders, personality disorders) among idiopathc
scoliosis patients compared to healthy controls. In
addition, there are some reports, although more
systematic research is warranted, on the role of mental
health and personality traits in relation to the adherence
to conservative treatment. Given the increasing role of
surgical treatment in the management of scoliosis, as
well as several reports on negative psychological out-
comes of such interventions, there is a growing need for
ongoing screening and mental health care in this
population. It seems this also holds true for non-
operative treatments, particularly bracing therapy. One
should keep in mind that these scoliosis-psycho-
pathology relations are deduced from a limited number
of empirical studies, usually conducted on small sample
sizes, suggesting the need for further large-scale
investigations, preferrably those with longitudinal
research designs. Understanding the complex interplay
between personality/psychopathology and spinal
deformities within the framework of personalized mind-
body medicine, should help clinicians tailor more
individualized and specific treatments and predict
therapeutic outcomes in this clinical population.
Acknowledgements: None.
Conflict of interest: None to declare.
Contribution of individual authors:
All the authors have substantially contributed to the
conception and writing of this manuscript,
and have approved the revised and final version of
the paper.
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Correspondence:
Goran Talić, MD
Institute of Physical Medicine and Rehabilitation ''Dr Miroslav Zotovic''
Banja Luka, Bosnia & Herzegovina
E-mail:
kancelari
j
a.direktora@zotovicbl.com
