Pain Catastrophizing: An Updated Review | Indian J Psychol Med. 2012 | free full-text PMC article
Pain catastrophizing has been described for more than half a century which adversely affects the pain coping behavior and overall prognosis in susceptible individuals when challenged by painful conditions.
This is the first time I’ve heard that catastrophizing only affects “susceptible individuals”. It makes me wonder what they mean by “susceptible”.
It seems that any patient who needs opioids is assumed to be catastrophizing – otherwise, their pain wouldn’t be “that bad”.
It is a distinct phenomenon which is characterized by
- feelings of helplessness,
- active rumination and
- excessive magnification of cognitions and feelings toward the painful situation.
Various models of pain catastrophizing have been proposed which include attention-bias, schema-activation, communal-coping and appraisal models. Nevertheless, consensus is still lacking as to the true nature and mechanisms for pain catastrophizing.
Recent advances in population genomics and noninvasive neuroimaging have helped elucidate the known determinants and neurophysiological correlates behind this potentially disabling behavior.
PAIN CATASTROPHIZING: HISTORY AND DEFINITION
Catastrophizing was first coined by American psychologist Ellis in 1962 and later refined by Beck in 1987 to describe a maladaptive cognitive style originally seen in patients with anxiety and depressive disorders with an irrational negative forecast of future events.
Pain is a common negative experience which signifies injury, illness, danger and possible doom.
When my ability to earn a living is stolen from me by constant pain, it does signify possible doom: my life savings are being used up during the years I should have been earning the most.
Taken together, pain catastrophizing refers to a set of exaggerated and ruminating negative cognitions and emotions during actual or perceived painful stimulation.
Table 1- Pain catastrophizing scale
PAIN CATASTROPHIZING AND PHYSICAL DISABILITY
Clinically, pain catastrophizing is a recognized phenomenon which is often considered within the context of depression.
There are numerous experiments conducted for the research of pain catastrophizing and they can be broadly divided into three categories according to the nature of the subjects:
- healthy volunteers (e.g., undergraduate students),
- patients with acute pain (e.g., whiplash injury after motor vehicle accidents) and
- patients with chronic pain (e.g., fibromyalgia and low back pain).
Selected studies with their methodologies, variables and predicted outcome are summarized in Table 2.
Table 2 – Summary of selected clinical studies on pain catastrophizing looking at three research sample groups:
Per se, pain catastrophizing is an independent risk factor for predicting[?] chronicity of pain and poorer prognosis
Here, even a researcher is fooled and wrongly believes that catastrophizing can cause or predict worse outcomes for pain patients.
Only an association between catastrophizing and worsened pain has been proven, not a cause.
How well does pain catastrophizing translate to physical disability?
Crombez et al. studied 104 subjects with chronic low back pain and measured the association of pain-related fear, actual pain level and pain catastrophizing with performance of a physical task (Trunk-Extension-Flexion). He found that fear of pain, but not pain catastrophizing, is the best predictor of self-reported disability and performance degradation
However, the Sullivan camp held an opposing view.
In his study of 72 subjects with chronic musculoskeletal pain,
- physical tolerance,
- communicative pain behaviors (facial and verbal expressions like grimace, grunts, words and sighs) and
- protective pain behaviors (guarding, holding, touching or rubbing)
were studied as the subjects sequentially lifted 18 paint canisters partially filled with sand at three standardized weights.
The group found significant associations between pain catastrophizing and physical intolerance and also with both types of pain behaviors.
In particular, the group found no association of fear of pain and suggested the reasons to be due to differences in patient population, parameters of tolerance task and pain measurements
The statement above seems to negate what was said before.
The same “differences in patient population” would cause all the other findings of this study to be problematic as well, but they only consider them to explain away findings that didn’t fit their preconceived ideas.
MEASURING PAIN CATASTROPHIZING: SITUATIONAL OR DISPOSITIONAL?
Being a mental set, pain catastrophizing can be assessed in two different ways—
- either as a reaction measured during or immediately after exposure to a noxious stimulation
(situational or state assessment),
- or, through recall of most negative feelings and cognitions related to painful events
(dispositional or trait assessment)
Although pain catastrophizing is often conceptualized as a trait which is only manifests with a noxious encounter, it has been argued that dispositional assessment of pain catastrophizing often fail to correlate with actual pain ratings as the recall events(s) may either be too distal in the past or too weak in impact, or the items in the assessment tool are not rigorous enough to capture the variances.
Everything that didn’t turn out as expected is excused non-relevant causes like study design or population variation, while desired outcomes with the same flaws are supposedly more valid.
Campbell et al. compared situational versus dispositional PCS across multiple samples of healthy subjects, subjects with short-term pain and with chronic pain and found that except for short-term pain, there is no significant correlation between situational and dispositional pain catastrophizing in healthy subjects and patients chronic pain, and that situational PCS predicts higher pain ratings across all three groups. This calls into question the logic and validity of studies using dispositional type of assessment for pain catastrophizing.
PAIN CATASTROPHIZING: A DISTINCT ENTITY OR REDUNDANT CONSTRUCT?
Implicit in the three domains of pain catastrophizing are negative affect constructs which are shared by a number of conditions like worry, anxiety and in particular, depression.
Finally, Mounce et al. performed a dispositional study amongst pain-free subjects who completed nine frequently used psychometric scores which measure pain catastrophizing,
- negative affect,
- general trait anxiety,
- depression and
- fear of illness,
- pain-specific anxiety,
- fear of pain,
- fear of negative evaluation and
- anxiety sensitivity.
Component analysis of all the constructs in these nine scores revealed commonality which can be summarised into three core components:
- general distress,
- fear of pain from injury/insult and
- cognitive intrusion of pain which is shared by depression and pain catastrophizing.
Overall evidence for pain catastrophizing as a unique construct distinct from others of negative affectivity is still conflicting, and better research methodologies and tools are needed to enable spectrum analysis of pain-catastrophizing trait in response to standardized painful event, and vice versa.
THEORIES FOR PAIN CATASTROPHIZING AND APPROACH ANALYSIS
The attention bias models states that pain catastrophizing results of a preferential and dysfunctional bias of attention toward pain and its related cognition and mental processes.
Taken for grant as a normal human reaction, any painful stimulus interrupts and demands attention of the subject.
Eccleston et al. elaborated a model consisting of seven components
- multiple demands from the environment,
- sensory system,
- action programs,
- focal task,
- threat mediation and
- moderating factors
to address why and how pain interrupts attention to motivate an urge to escape.
He opined that the interruptive function of pain depends on the pain-related characteristics (e.g., threat level of pain) and the environmental demands (e.g., emotional arousal).
Authors did mention briefly that pain catastrophizing is a variable of pain characteristics in the interruptive process; hence pain catastrophizers may have their attention maladaptively interrupted to a state of cognitive and behavioral immobilization whenever a painful stimulus occurs.
Sullivan et al. (2001 Theoretical perspectives on the relation between catastrophizing and pain) proposed that pain catastrophizers possess s special pain schema which consisted of a distorted cognition with excessively pessimistic beliefs about pain, pain-related experiences and actual ability to cope.
When confronted with the minimally noxious stimulus, this schema is activated and heightens the pain experience which eventually over time, translates to a learned expectancy (or self-fulfilled prophecy) regarding the high threat of pain and their own inability of management.
This model is strong is explaining the cognitive processes that contribute to pain catastrophizing but do not address the conditions and their interactions that lead to activation of the schema.
Also existing methodologies cannot test whether and to what degree the schema has been activated during the pain-catastrophizing process.
Whenever a pain stressor comes along,
- the subject initially assess the relevance and levels of harm as the primary appraisal,
- then continue to contemplate upon the coping options and formulate the beliefs regarding the possibility of success as the secondary appraisal.
In the contact of pain catastrophizing, researchers proposed that
- magnification and rumination domain stems from a dysfunctional focus and evaluation in the primary appraisal stage,
- while helplessness is a maladaptive and negative secondary appraisal
In a study of professional dancers who are sued to cope with pain due to performance or injury, Anderson et al found that their appraisal of pain did not differ according to the type or severity of pain they experience, except when perceived as a threat, would associate with pain-catastrophizing behavior.
Communal coping model
Advocated by Sullivan et al., the communal coping model states that pain catastrophizing is a behavior strategy of coping where subjects communicate their painful experience to elicit emotional and social support from others, hence reinforcing the pain and illness behavior and subsequently undermining their normal adaptability to cope with the pain itself
Living with a partner or spouse leads to higher probability of catastrophizing for subjects with chronic pain, and the partners or spouse would also perceive higher pain levels from the pain catastrophizers and provide more instrumental support.
CAN PAIN MODELS EXPLAIN PAIN CATASTROPHIZING?
Transactional model of stress
First described in 1980’s by Lazarus and Folkman,
- stress is viewed as a relational product between the person and the environment, and
- stress arises when the individual judges that the environmental demands exceed the individual’s own resources.
It involves two appraisal processes:
- the primary appraisal occurs when the individual makes sense of the encounter and determines its nature as challenging, harmful or threatening;
- the secondary appraisal evaluates the coping resources and decides on what can be done.
It has been shown in patients with fibromyalgia, the level of perceived stress has a significant bearing on the symptoms severity and illness impact, lending support to this transactional model which states that when pain (stressor) is initially appraised as way beyond the individual’s coping mechanisms, then secondary appraisal as to what can be done will be defective and the individual will feel helpless and pessimistic without a solution and revert to primary appraisal of the stressor in a detrimental feedback loop, resulting in a positive amplification of the pain sensation and gravity of the problem—hence catastrophizing.
Moreover, some researchers consider self-regulation as an adaptive capacity which can be trained up with repeated exercises of both the mind and the body, with the added concept that it is a limited resource dependent upon blood sugar and physical stamina.
When they say self-regulation is “a limited resource dependent on blood sugar and physical stamina”, they mean it takes a tremendous amount of energy to self-regulate. It’s been proven that we use up our “self-control muscle” during the day, to the point that we only fall into our bad habits late in the day.
Those of us with chronic pain are constantly expending this energy to resist the pain and self-regulate unless we’re lying in bed alone, and this is exhausting.
Gate control theory and neuromatrix theory
First described by Melzack and Wall in 1965, the gate-control theory is an epoch-marking theory in the field of neuroscience which states that:
pain signals, as primarily mediated by the A-δ and C-fibers, can be modulated by intermediate interneurons which act as gates either to enhance or suppress the pain signal per se.
This provides an explanation for most, if not all scenarios of chronic and neuropathic pain where noxious sensory input is invariably absent from the equation.
In the context of pain catastrophizing, the cognitive and emotional domians of input become so dominating that the neuromatrix outputs become disproportinaland maladaptive.
Conclusions and food for thought
Pain catastrophizing is a specific mindset with direct impact on the subject’s behavior, functional ability and quality of living.
One questionnaire study on healthy volunteers asking them to reflect on past painful experiences suggest that pain catastrophizing tendency may be pain-type specific and may associate with emotional responses to pain in younger subjects as compared to association with the actual pain intensity in older subjects
Our understanding of pain catastrophizing may well be summarized as a black-box–we have good knowledge of the inputs and outputs but the processes and mechanisms that constitute the box are still unclear.
Moreover, experimental attempts to manipulate the process of pain catastrophizing has concluded without success.
However, there is still a logical snag: from a philosophical perspective, pain is always an internal subjective sensation which despite numerical or graphical rating, remains a feeling uniquely relating to the individual.
When we attempt to use descriptives to represent the feeling in a logical form, it is instantaneously constraint by the lexicographic rules and logic implicit in the words used, which in turn would differ tremendously between different languages.
Quoting the logic of famous philosopher Ludwig Wittgenstein: “the limits of my language means the limits of my world” (Tractatus: 5.6) and, “we cannot think what we cannot think; so what we cannot think we cannot say either”(Tractatus: 5.61)
Hence, using a reference scoring tool like the PCS to assess the complex mental set of pain catastrophizing will philosophically distort the true nature and limit the boundary of its ramifying affectivity and cognitions.
Also trying to describe a mindset that is not experienced or contained in the own self is always a logical and philosophical debate, albeit how scientifically rigorous it would seem.
It’s impossible to look from the outside into a pain patient and determine how “bad” their pain is or how “sad” or “mad” they are. And even asking the patients themselves assumes the right questions are being asked.
You can’t ask “Are you worried about your pain?” without also asking “Do you expect to learn how to get over your worries about your pain?”. That’s what those fancy pain clinics are supposed to be doing, and if they were successful, patients would naturally taper their opioids because they would no longer need them.
It seems arrogant to assume that a researcher without pain can determine whether a pain patient’s response to pain is an “excessive magnification of cognitions and feelings” or just an appropriate response to a dismal situation.
Catastrophizing was already being debunked in 2009:
Pain catastrophizing: a critical review