Pain Catastrophizing Not Just Psychological

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Resisting temptation to label these patients difficult is key to treating them.
Resisting temptation to label these patients difficult is key to treating them.

Medical experts used to believe that pain level depends on the amount of tissue damage, but it is now known that how much pain a person experiences depends on many factors. And it may depend as much on psychosocial factors as it does on physiology. 

The term 'pain catastrophizing' was first used to describe a maladaptive style of coping with pain that people with anxiety and depression used. 

Although pain catastrophizing may coexist with these conditions, pain catastrophizing also exists independent of these conditions.1

Defining Pain Catastrophizing

“Pain catastrophizing can be defined as a maladaptive coping style that includes hopelessness, expanded rumination, and pain magnification,” said Claudia M. Campbell, PhD, associate professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine in Baltimore, Maryland.

These three components of catastrophizing are captured in the Pain Catastrophizing Scale (PCS), which is often used to screen for pain catastrophizing. The PCS includes these assessments:

When I am in pain:

  • I can't stop thinking about how much it hurts.
  • I worry something bad might happen.
  • There's nothing I can do to reduce the intensity of the pain.

“It is hard to say how common pain catastrophizing is. To some extent, it is expected in people with pain. It is rare to have no catastrophizing, common to have some, but uncommon to have lots of catastrophizing. It may depend on the type of pain and how threatening it is,” explained Steven Z. George, PhD, associate professor of physical therapy at the University of Florida in Gainesville.

“Our data suggest that it may affect 5 to 10% of people with chronic pain. But we don't have one set of accepted criteria to diagnose it. Different people use different questionnaires. There are also so many variables that contribute to it. It may be more common in people with insomnia, but we know that insomnia also causes increased pain sensitivity,” said Campbell. 

The Causes and Consequences of Pain Catastrophizing

The short answer is we don't know the cause, and certainly multiple factors contribute.1

“Physiologic components may include inflammation and inflammatory mediators like cortisol. Functional MRI studies tell us that catastrophizers have increased activity in parts of the brain that are responsible for anticipation and emotion,” said Campbell.

“There may also be a genetic component. Pain catastrophizing may run in families. But is that genes or learned behavior? A person who catastrophizes pain may have a parent or spouse that also catastrophizes pain. It may be a family or cultural coping style,” added George.

The consequences of pain catastrophizing are better known than the cause. Catastrophizing has been associated with increased severity of acute and chronic pain, more postoperative pain, longer recovery, exaggerated usage of the healthcare system, increased disability, and a destructive influence on a person's support network.1

Risk factors for pain catastrophizing need further research. The only risk factor that consistently shows up in studies is being female. Some studies show that age is a risk factor and some don't.1

“We see poor outcomes in general,” said Campbell. “We also see more depression. Depression and pain catastrophizing seem to be bidirectional.” 

Treatment for Pain Catastrophizing

A 2015 placebo-controlled study, published in the journal Anesthesiology, looked at the possible usefulness of prescribing a selective serotonin reuptake inhibitor (SSRI) to treat pain catastrophizing after surgery. The researchers hypothesized that if pain catastrophizing has a physiologic basis then downregulating serotonin pain receptors might help.2

In this study, 120 patients diagnosed with pain catastrophizing were randomized to perioperative SSRI or placebo before and after total knee surgery. Overall pain upon ambulation and at rest was lower in the SSRI group than the placebo group in postoperative days two through six. There was no difference in pain 24 hours after the operation. The authors suggest that further studies are needed.2

“Other studies have shown SSRIs not to be very effective or to be less effective. For now, the mainstay of treatment is cognitive behavioral therapy (CBT). This may include learning better coping skills, and practicing acceptance and mindfulness,” said Campbell. 

George agrees that CBT is the best option currently available. 

“But we still have to treat the pain. It is a bit of the chicken and the egg. Which comes first? If we reduce that pain, catastrophizing gets better. If we reduce the catastrophizing, pain gets better,” said George.

Bottom Line on Pain Catastrophizing

“The key takeaway is that pain catastrophizing is not just a psychological experience. Doctors need to resist the temptation to label these patients as negative or difficult. This is a real condition that needs to be recognized and managed. As we include it in more studies, we will learn more about how to treat it,” Campbell said.

“It is an important condition, but it is hard to fit into a traditional medical model. The pain experience is different for different people. We need to accept that, George said.

Medically reviewed by: Pat F. Bass III, MD, MS, MPH      

References

1. Quartana PJ, et al. Exp Rev Neurother. 2009; 9(5):745-758.

2.  Lunn TH. Anesthesiology 2015; 122:884–94.

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