Pain catastrophizing: a critical review | Expert Rev Neurother. 2009 May | free full-text PMC article
This article points out that pain catastrophizing has not been sufficiently studied to make it a certain *cause* of increasing pain. I, and others, believe the catastrophizing could just as easliy be caused by pain.
It may be a completely realistic response to crippling, disabling, torturous unrelieved pain.
Pain catastrophizing is conceptualized as a negative cognitive–affective response to anticipated or actual pain and has been associated with a number of important pain-related outcomes.
In the present review, we first focus our efforts on the conceptualization of pain catastrophizing, highlighting its conceptual history and potential problem areas.
We then focus our discussion on a number of theoretical mechanisms of action: appraisal theory, attention bias/information processing, communal coping, CNS pain processing mechanisms, psychophysiological pathways and neural pathways.
We then offer evidence to suggest that pain catastrophizing represents an important process factor in pain treatment.
In this updated and comprehensive review of the pain catastrophizing research literature, we critically evaluate the pain catastrophizing construct, positioning catastrophizing in its historical context and detailing a number of unresolved, yet critical, conceptual and measurement issues
Subsequently, we explicate the dominant theories of pain catastrophizing and evaluate the current empirical status of each, then follow with a concise overview of the importance of pain catastrophizing in the context of pain treatment.
Pain catastrophizing: conceptual & measurement considerations
The term catastrophizing was formally introduced by Albert Ellis  and subsequently adapted by Aaron Beck  to describe a mal-adaptive cognitive style employed by patients with anxiety and depressive disorders
Other researchers focused on the development of psychometrically sound self-report instruments that could be readily and reliably used with a variety of populations.
The Coping strategies Questionnaire (CSQ), developed by Rosentiel and Keefe , included a six-item subscale tapping dimensions of helplessness and pessimism in the context of pain.
Sullivan et al. elaborated on the CSQ by developing the Pain Catastrophizing Scale (PCS) , which incorporates items explicitly designed to assess other elements of catastrophizing
Initial factor analytic work indicated that the PCS yielded three second-order factors (i.e., helplessness, rumination and magnification).
An area of assessment that is currently underdeveloped is that considering the behavioral elements of pain catastrophizing.
Collectively, pain catastrophizing is characterized by the tendency to magnify the threat value of pain stimulus and to feel helpless in the context of pain, and by a relative inability to inhibit pain-related thoughts in anticipation of, during or following a painful encounter
Trait (dispositional) versus state (situational) assessment
Although pain catastrophizing has most typically been conceptualized and assessed as a trait-like or dispositional variable, a handful of recent investigations have assessed pain catastrophizing in a state-like, situation-specific manner.
However, a more recent study demonstrated that state pain catastrophizing was not related to pain threshold, pain tolerance or ratings of cold pain
There are a number of shortcomings associated with the state pain catastrophizing literature that are in desperate need of empirical attention
First, the validity and reliability of state pain catastrophizing measures has not been adequately established
Second, correlations between state and trait measures of pain catastrophizing have ranged from small to moderate in magnitude [Campbell CM et al., Manuscript Submitted; 19–22]
This pattern of relationships is somewhat troubling given that each measure is designed to assess the same underlying cognitive processes.
Third, because state pain catastrophizing is assessed following painful stimulation, it is difficult to determine whether the stronger magnitude of relationship for state versus trait pain catastrophizing is not attributable in large part to confounding with the pain experience itself.
This is a big unwieldy paragraph that questions whether pain catastrophizing might not be due to the severity of the pain itself.
Subsequent studies will need to carefully determine whether state pain catastrophizing is a construct apart from pain and its affective constituent.
Pain catastrophizing is but one of a number of variables that tap into a negative pain schema, including pain anxiety, fear of pain and pain helplessnes
Moreover, pain catastrophizing shares significant variance with broader negative affect constructs, such as depression, anxiety, anxiety sensitivity, worry and neuroticism. A handful of recent studies call into question the extent to which pain catastrophizing is conceptually distinct from these other measures.
Since we already know that depression and anxiety are *caused* by chronic pain, these components of catastrophizing might as well be *caused* by pain.
In summary, there are some conflicting evidence as to the uniqueness of the pain catastrophizing construct above and beyond negative affectivity in general, or with regard to other negative pain-related cognitive process variables, such as fear of pain.
Nonetheless, substantial empirical evidence highlights the importance of pain catastrophizing in shaping the experience of acute and chronic pain.
Association of pain catastrophizing with pain-related outcomes
Pain catastrophizing has been associated with a number of indices of pain sensitivity in the context of experimental pain testing paradigms, both among healthy, pain-free participants and individuals with various chronic pain conditions
The literature also points to consistent and generally robust associations observed between pain catastrophizing and an array of clinical pain-related outcomes, including measures of clinical pain severity, pain-related activity interference, disability, depression (and other negative mood indices) and alterations in social support networks
Moreover, catastrophizing has been linked to increased behavioral expressions of pain, as well as a variety of illness behaviors (e.g., more frequent visits to healthcare professionals). It is important to note that the magnitude of these relationships is variable, with catastrophizing accounting for minimal variance in pain severity in some studies, and up to 31% of the variance in pain severity in others
Importantly, pain catastrophizing is also related prospectively to adverse pain-related outcomes.
Indeed, pain catastrophizing-assessed presurgery has been shown to account for significant variance in postsurgical pain ratings, narcotic usage, depression, pain-related activity interference and disability levels
a study by Edwards et al. suggested that pain catastrophizing was related to increased suicidal ideation in a large sample of chronic pain patients
In summary, pain catastrophizing has emerged as a rather potent predictor of a variety of pain-related outcomes, both in pain-free and chronic pain patient samples. We next address some of the postulated mechanisms by which pain catastrophizing might be associated with adverse outcomes (Table 1).
Theoretical mechanisms of action & supporting evidence
Some have framed pain catastrophizing in the context of Lazaraus and Folkman’s transactional model of stress and coping , at the core of which are the notions of primary and secondary appraisals
Primary appraisal concerns judgments regarding whether a potential stressor is irrelevant, benign-positive or stressful-negative.
Secondary appraisals are beliefs about coping options and the extent to which they will be successful or not.
there are threads of evidence suggesting that catastrophizing is associated with other appraisal processes, such as self-efficacy concerning one’s ability to control their pain
Attention bias/information processing
Some researchers have proposed that pain catastrophizing might be characterized by attention and information processing biases analogous to those observed in individuals with anxiety and depressive disorders
Specifically, it has been argued that pain catastrophizing amplifies the experience of pain via exaggerated attention biases to sensory and affective pain information.
Indeed, pain catastrophizing is rooted in traditional cognitive–behavioral conceptualizations of anxiety and depression, and is characterized substantially by a relative inability to suppress or inhibit pain-related cognitions.
Even in noncatastrophizers, pain demands attention, interrupts ongoing activity and interferes with mental processes
If this is true of patients who are not catastrophizing, it seems such heightened focus on the pain is generated by the severity of the pain itself.
These attentional and behavioral consequences of pain are largely adaptive, given that pain signals threat.
However, in persons who tend to catastrophize, pain might demand attention to the point of cognitive and behavioral immobilization.
In summary, preliminary studies using diverse experimental methods have suggested that pain catastrophizing is associated with a heightened attentional bias to pain-relevant stimuli (perhaps its negative affective element in particular) and an inability to disengage from pain or pain cues.
Catastrophizing in a communal context
Sullivan and colleagues advanced a communal coping model, suggesting that catastrophizing represents an interpersonal style of coping with pain and suffering
The model hinges on the notion that catastrophizing represents a behavioral coping strategy employed by individuals experiencing pain to elicit emotional and/or tangible support from others, thereby positively reinforcing pain and illness behaviors and undermining successful adaptation to pain.
Pain catastrophizing has also been associated with exaggerated punishing and critical responses from spouses and partners
Specifically, Cano’s analysis suggested that pain catastrophizing is associated with supportive response among patients with short pain duration, but punishing/negative responses among those with longer pain duration.
The relation between interpersonal problems and pain catastrophizing remained significant even after statistically controlling for general symptomatic distress.
These data suggest that pain catastrophizing is related to an interpersonal style characterized by submissiveness and high levels of dependency and support seeking. It was more recently shown that pain catastrophizing is associated with an insecure adult attachment style
More specifically, pain catastrophizing was linked to beliefs that others will not provide support in times of distress.
Pain catastrophizing, as well as fear of pain and hypervigilance to pain, were associated with perceptions of the self as incapable of coping with distress.
This is not catastrophizing, this is simply the reality for pain sufferers.
A handful of studies have examined whether pain catastrophizing is associated with alterations in endogenous pain modulation pathways
several studies of the nociceptive flexion reflex, a polysynaptic spinal reflex that subserves withdrawal from potentially noxious stimuli, suggest that pain catastrophizing is not associated with nociceptive flexion reflex threshold
By contrast, pain catastrophizing is associated with alterations in supraspinal endogenous pain-inhibitory and -facilitatory processes
Temporal summation is assessed by administering repetitive, identical, phasic noxious stimuli.
Typically, pain ratings increase across successive stimuli, reflecting a ‘summation’ process.
Temporal summation is quantified as the difference between the highest-rated stimulus and the initial stimulus of a given sequence.
A handful of studies using repetitive thermal stimulation have revealed correlations between pain catastrophizing and the degree of temporal summation
This sounds very true. For me, the amount of pain is not as burdensome as its persistence. A headache of hours or a day feels much worse on it’s 5th consecutive day.
These findings suggest that pain catastrophizing might be associated with diminished endogenous inhibition of pain coupled with central sensitization, which may represent a CNS mechanism by which pain catastrophizing is associated with the development, maintenance and aggravation of persistent pain
Although investigation of the physiological consequences of catastrophizing is a relatively new area of study, some interesting data have surfaced that suggest that pain catastrophizing might be related to altered physiological responses to stress and pain.
Aberrant patterns of muscle tension have received some initial investigation as potential meditational pathways
The relationship between catastrophizing and lower paraspinal or symptom-specific muscle responses to pain was augmented by efforts to suppress thoughts of pain.
Some data also suggest that pain catastrophizing is associated with altered hypothalamic–pituitary–adrenal axis activity.
The arthritis literature has identified helplessness as a potentially important factor in shaping some measures of disease activity
suggesting the possibility that pain catastrophizing might be related to altered neuroimmunologic responses to pain.
The advent of noninvasive brain imaging techniques has made possible the identification of various top-down and bottom-up neural circuits involved in the experience of pain, and hundreds of functional MRI studies have examined the brain’s processing of pain-related information
Seminowicz and Davis found that during mild and intense pain, pain catastrophizing was not significantly associated with activation in primary or secondary somatosensory cortices
During mild pain, pain catastrophizing was associated with exaggerated activity in the PFC, insular cortex and caudal ACC, suggesting exaggerated processing of the affective dimension of pain in particular.
While I do believe our mental attitude greatly affects the amount of suffering our pain causes us, I do not believe this response should be criticized since it’s a natural reaction to disabling pain.
Instead of being told that our catastrophizing is *causing* our pain, it should be clearly stated that psychological treatment is just another tool to prevent us from being utterly defeated by our pain.