Pain Catastrophizing: What Clinicians Need to Know
A recent survey of Practical Pain Management readers revealed that 66% of the respondents were unfamiliar with the construct of pain catastrophizing. The purpose of this article is to explain what it is, how to identify it, and how to treat it.
As will become apparent, it is extremely important to understand this construct to prevent and treat chronic pain. Indeed, during the past 2 decades, chronic pain clinical researchers began to emphasize the important role that certain specific sets of negative beliefs (such as catastrophizing and fear avoidance) play in the maintenance and exacerbation of chronic pain.1
Gatchel et al define pain catastrophizing as “an exaggerated negative orientation toward actual or anticipated pain experiences…current conceptualizations most often describe it in terms of appraisal or as a set of maladaptive beliefs.”1 Moreover, there is a great deal of evidence for the role it plays in chronic pain.1-3
Origins of Catastrophizing
Catastrophizing is a cognitive process characterized by a lack of confidence and control, and an expectation of negative outcomes.4 The origins of this construct can be traced to early work in cognitive psychology. Albert Ellis originally developed what came to be known as Rational-Emotive Therapy (RET), based on the assumption that psychosocial disorders, such as anxiety, were caused by irrational or faulty patterns of thinking.5,6 Basically, Ellis asserted that the focus of treatment should be directed at changing the internal negative thoughts/sentences that people say to themselves that produce negative emotional responses.
Indeed, there usually is a strong connection between how you think and how you feel. It may not be what happens to you that causes you to become anxious or tense but what you tell yourself about what happens. We all have thoughts constantly going through our minds as we take in and evaluate events around us. These are called “automatic thoughts” because we often do not notice them consciously.
Based on Ellis’ RET technique, an A-B-C Model for constructive thinking was developed. When a stressful situation (an Activating event) results in anxiety (a Consequence), there often are distorted thoughts (Beliefs) that mediate the anxiety. Distorted belief systems often involve catastrophic thoughts (exaggeration/magnification of the noxious properties of an activating event, or “blowing one’s concerns out of proportion”).
Effective cognitive behavioral therapy approaches have been developed by Ellis and others7,8 to change non-constructive thinking and replace it with more constructive, positive self-talk that will reduce negative emotional components.9 Cognitive restructuring techniques have been effective in treating depression, anxiety, and stress in general.10 They also may be effective in allowing patients to deal more successfully with stressors that are closely associated with the precipitation or exacerbation of physical symptoms.
Subsequently, health psychologists recognized catastrophizing as a general pattern of emotional thoughts/beliefs in which chronic pain patients overestimate the degree of emotional distress and discomfort that may be caused by a stressful experience, such as being injured, and then overly focus on the negative aspects of pain caused by the injury.11
Besides the initial work by Ellis,5,6 Beck7 and Miechenbaum8 also reported success using cognitive restructuring techniques to treat anxiety and depression. In this approach, the therapist determines the specific thoughts or negative self-statements that are assumed to produce an increase in anxiety or depression and helps the patient modify these negative self-thoughts or self-statements and replace them with positive self-statements.9
A key component of catastrophizing is the role that one’s imagination can play in anticipating negative outcomes. Pain catastrophizing is a negative cascade of cognitive and emotional responses to actual or anticipated pain—magnification, rumination, and feelings of hopelessness.12
Pain-related catastrophizing was recognized in the late 1970s and 1980s, as clinical researchers began to evaluate cognitive-behavioral treatment (CBT) interventions for pain. Several components of pain catastrophizing have been delineated, such as excessive worry, rumination, and the inability to shift attention away from pain-related thoughts; negative expectations based on previous memories of pain; negative self-statements; feelings of helplessness; and the inability to cope effectively with pain.13-15 Pain catastrophizing has been found to intensify the experience of pain and depression.4,16 A recent meta-analysis concluded that higher pain catastrophizing often is associated with higher self-reported pain and disability, and may lead to delayed recovery in patients with low back pain.17 A separate meta-analysis determined that decreased catastrophizing during treatment for low back pain was associated with better outcomes.18
It is essential for successful chronic pain management to understand that patients with painful medical disorders commonly have high levels of self-reported pain, disability, catastrophizing, and fear-avoidance behaviors. Because pain catastrophizing and fear avoidance can be related to negative therapeutic outcomes, clinicians need to be aware of these behaviors in clinical settings.
Pain Catastrophizing and Fear Avoidance
Pain catastrophizing is a major component of current theories of pain-related fear avoidance.19-21 In the basic fear-avoidance model, if one interprets pain as especially threatening and begins to catastrophize, this can lead to feelings of pain-related fear, avoidance of daily activities, and hypervigilance or overmonitoring of bodily sensations.22 Negative beliefs about pain, and/or negative illness information, can lead one to imagine the worst outcomes, during actual or anticipated painful experiences.18 This type of pain catastrophizing is believed to be a precursor for fear-avoidance behaviors, which can result in physical deconditioning, depression, as well as disability from work, recreation, and/or family activities. Indeed, as highlighted by Gatchel et al, there is clear evidence that fear avoidance is closely related to increased pain, physical disability, and long-term sick leave in chronic pain patients.1
The Pain Catastrophizing Scale was introduced in 1995.23 It is a self-report measure, consisting of 13 items scored from 0 to 4, resulting in a total possible score of 52.24 The higher the score, the more catastrophizing thoughts are present. Previous studies have shown a cutoff of more than 30 points to be associated with clinical relevance. This measure has been found to have good psychometric properties, including high test-retest reliability and high internal consistency (Chronbach’s alpha = 0.87-0.95).25-27