Friday, February 8, 2013

The Role of Catastrophizing in Pain Care

Winnie Dawson, MA, RN, BSN

Patients who react to pain in a manner that appears to magnify or exaggerate their pain experience may be experiencing the cognitive-affective response called catastrophizing. It is important for practitioners to understand this anxiety-related condition, utilize available screening tools, and refer patients for specialized help when it is appropriate.

Chronic pain management can be more challenging in patients who display a magnified response to pain and some patients may not even be aware of their tendency to over-react or to dwell on the potential of a worst-possible outcome. While the pain experience is real, catastrophizing can add to the patient's discomfort, reduce the potential for pain control, and challenge the practitioner's treatment plan. Some patients may also reduce their level of physical activity out of fear or adopt coping strategies that are unhealthy.

Recent studies have explored the influence of catastrophizing on the pain experience and the potential for increased pain intensity, depressive symptoms, and even chronic pain conditions.

Researchers at Maastricht University Medical Center in The Netherlands reviewed 52 years of literature to attempt to learn whether higher levels of preoperative anxiety or pain catastrophizing were associated with a greater risk of chronic postsurgical pain [Theunissen et al. 2012]. The 29 studies of adult surgical patients that met review criteria were evaluated using 14 assessment instruments to rate anxiety or pain catastrophizing.

Results showed that a statistically significant relationship between preoperative catastrophizing and chronic postsurgical pain was identified in 16 studies, including 67% of studies of patients who had musculoskeletal surgery and 36% for other types of surgery. They concluded that pain catastrophizing could play a role in chronic postsurgical pain and suggested that interventions aimed at reducing preoperative anxiety might be helpful.

In another study, investigators in the Psychology Department of Arizona State University evaluated the pain diary records of 230 adult patients with rheumatoid arthritis for a 30-day period [Sturgeon et al. 2012]. The study aimed to identify the existence of a relationship between state pain catastrophizing (ie, temporary emotional reaction to a specific condition like pain or injury) and trait pain catastrophizing (ie, a relatively permanent personal characteristic) and daily pain intensity, its positive or negative influences, and depression.

The investigators concluded that their analysis confirmed that state pain catastrophizing was a significant variable in the patient's daily pain intensity and emotional distress. Furthermore, exacerbations in patients' pain were often found to be related to changes in the intensity of catastrophizing. Additional analyses showed that people who demonstrated higher levels of trait pain catastrophizing had significantly greater challenges in their ability to adapt to daily pain fluctuations.

COMMENTARY: Because it isn't always evident whether a patient's emotional distress actually reflects catastrophizing, healthcare professionals are encouraged to utilize screening tools. When pain catastrophizing is suspected, timely patient assessment is important because experts recommend early intervention.

While there are a variety of instruments available for assessment, two such tools are the Pain-Related Self Statements Scale (PRSS-Catastrophizing) developed by Herta Flor and colleagues [Flor et al. 1993] and the Pain Catastrophizing Scale from Michael Sullivan, PhD at McGill University, Montreal, Canada [available here].

Many cognitive-behavioral interventions are being used to reframe emotional reactions to pain and reduce catastrophizing. Two recent studies have reported such interventions with outcomes that were successful in reducing anxiety-related catastrophizing behavior.

Lead researcher Lara Gallagher and her colleagues at 2 major universities in Australia implemented a study designed to teach patients the basics of pain biology using metaphors and story [Gallagher et al. 2013]. In this controlled study, 79 patients with chronic pain were randomly assigned to receive a booklet of metaphors and stories relating important pain physiology concepts or a booklet containing advice using common cognitive-behavioral principles to manage chronic pain. Study results supported the researcher's hypothesis that a metaphor booklet would increase a patient's knowledge about the physiology of pain as a way to reconceptualize the pain and decrease catastrophic thought processes.

A study by researchers from Uppsala University in Sweden investigated an experimental internet-based cognitive-behavioral intervention as a technique for reducing pain catastrophizing in patients with chronic back pain [Buhrman et al. 2011]. After an assessment using the catastrophizing subscale of the Coping Strategies Questionnaire, 54 participants were randomized to either 12 weeks of online cognitive skills education and acquisition, or a listing on the program waiting list. While several outcome measures did not show a positive treatment outcome, treated participants showed significant improvement in measures of pain catastrophizing when compared with the control group (58% vs. 18%) as well as improved quality of life scores.

While it is not possible to identify whether the exact mechanisms responsible for the reductions in pain catastrophizing are due to reconceptualization of pain, increased feelings of control, distraction, or other factors, these studies do show that cognitive-behavioral techniques can offer benefits for these patients.

  • Buhrman M, Nilsson-Ihrfeldt E, Jannert M, et al. Guided internet-based cognitive behavioral treatment for chronic back pain reduces pain catastrophizing: a randomized controlled trial. J Rehabil Med. 2011;43(6):500-505.
  • Flor H, Behle DJ, Birbaumer N. Assessment of pain-related cognitions in chronic pain patients. Behav Res Ther. 1993;31(1):63-73.
  • Gallagher L, McAuley J, Moseley GL. A randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease catastrophizing in people with chronic pain. Clin J Pain. 2013;29(1):20-25.
  • Sturgeon JA, Zautra AJ. State and trait pain catastrophizing and emotional health in rheumatoid arthritis. Ann Behav Med. 2012(Aug 23); online Epub ahead of print.
  • Theunissen M, Peters ML, Bruce J, et al. Preoperative anxiety and catastrophizing: a systematic review and meta-analysis of the association with chronic postsurgical pain. Clin J Pain. 2012;28(9):819-841.

About the Author: Winnie Dawson, MA, RN, BSN is the Research Editor for Pain Treatment Topics and the director of MedSearch Inc., a biomedical literature research service founded in 1993. As a medical information specialist, she researches and provides relevant background literature for presentations on a wide variety of medical topics, including pain management. Ms. Dawson has worked as a hospital staff nurse and a health educator in corporate, community, and hospital environments. She received her Master of Arts in Health Education from the University of Alabama. Visit the MedSearch website at: