Quantifying Catastrophizing About Pain Can Lead to More Effective Patient Management

LAS VEGAS—Research increasingly is focusing on whether negative cognitive and emotional factors, such as catastrophizing, can predict patient response to pain, said Robert R. Edwards, PhD, MSPH, of Brigham and Women's Hospital Department of Anesthesiology, Boston, Massachusetts, to attendees at PAINWeek 2014.

The goal: by improving assessment and targeting of pain-related catastrophizing, healthcare providers can offer more effective pain management to patients with many different persistent pain conditions, such as fibromyalgia, osteoarthritis, and postoperative pain. “Variability in pain is the rule rather than the exception,” he said, and this is related to its biopsychosocial aspects.

Catastrophizing, considered one of the most important psychological factors that shape pain perception, is defined as a set of negative cognitions, emotions, attitudes, and beliefs related to pain that include magnification, rumination, and helplessness.

Catastrophizing can easily be assessed in patients using the PCS, or Pain Catastrophizing Scale, which asks patients to rate 13 questions beginning with, “When I'm in pain…”, on a scale of 0 (not at all) to 4 (all the time). Examples include: 

  • I worry all the time about whether the pain will end.
  • I feel I can't stand the pain anymore.
  • I wonder whether something serious may happen.

Overall, Dr. Edwards said, higher catastrophizing is a risk factor for long-term pain and for disproportionately negative consequences of pain, including worsening physical disability, medication misuse, and higher healthcare costs.

Catastrophizing appears to exert its effects via numerous pathways, including amplifying pain processing in the brain, increasing distress. For example, a higher percentage of patients with chronic pain who rated themselves as “high catastrophizing” (versus low or average), embraced active suicidal ideation and intent.

In addition, studies in patients with musculoskeletal pain conditions have found catastrophizing to be the most important pretreatment risk factor that impairs the effectiveness of pain-relieving interventions.

He described familial catastrophizing, a phenomenon in which early parent catastrophizing predicted chronic postoperative pain in children undergoing major surgery. In one study in which 83 children were followed for 12 months, parent and child catastrophizing became more strongly linked over time. In a second study of 107 families of children with chronic pain, after controlling for children's pain duration and intensity, parental catastrophizing was associated with parental stress, parental anxiety, a child's functional disability, and school attendance.

Although to date no genetic factors have been linked to catastrophizing, emotional—but not physical—abuse in childhood has been found to predict adult catastrophizing.

One of the most effective nonpharmacological treatment approaches to the treatment of catastrophizing is cognitive behavioral therapy (CBT), he said. Recently, a pilot study has found that CBT reduces catastrophizing in patients with fibromyalgia and high PCS scores, with a short-term change in catastrophizing at posttreatment prospectively associated with reduction in pain severity at 6 months.

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