In chronic pain conditions, the presenting symptoms of pain and disability can sometimes appear to correlate poorly with the patient’s medical status. Over the past two decades, this widespread observation has been backed up with a good deal of research.1 One psychological variable that’s been shown to be a significant determinant of pain and disability is catastrophic thinking.
Also referred to as maladaptive coping, pain catastrophizing has emerged as the most powerful psychological predictor of pain-related outcomes.2 More than 800 studies have been published documenting its adverse effects. Pain catastrophizing has been defined as an exaggerated negative response to actual or anticipated pain2 that includes elements of rumination (i.e., excessive focus on pain sensations), magnification (i.e., exaggerating the threat value of pain sensations), and helplessness (i.e., perceiving oneself as unable to cope with pain symptoms).
Catastrophizing has been associated with increased pain and pain behaviour, increased use of healthcare services, longer hospital stays, increased use of analgesic medication, and higher rates of unemployment.2 In samples of chronic pain patients, catastrophizing has predicted the risk of chronicity and the severity of disability better than illness-related variables or pain itself.3 Recent research suggests that catastrophizing individuals show poorer response to a variety of interventions including analgesics, surgery and rehabilitation.4 A relation between catastrophizing and pain-related outcomes has been observed in children as young as 7 years.5
Spotting the catastrophizing patient
High catastrophizers display more pain behaviour such as holding, rubbing, and guarding, as well as vocalizations such as moans and sighs. The catastrophizing patient will respond less favourably to pain medication and will complain of more severe side effects. Recent findings even suggest that the catastrophizing patient will show more complicated and prolonged recovery from surgical procedures such as knee replacement. The catastrophizing patient will be the one who has searched the internet for information about his or her conditon, and present the physician with a folder of reading material that might facilitate proper diagnosis or treatment. Longer consult times with the catastrophizing patient leave other patients waiting longer for their appointment times.
The catastrophizing patient can sound like a broken record, reporting the same symptoms with each visit. Even for the long-term patient, each visit seems like the first. The broken record scenario unfolds because the catastrophizing patient is not convinced that the doctor truly understands or cares about the suffering.
Assessment of catastrophizing
The Pain Catastrophizing Scale (PCS)6 is currently the most widely used measure of pain catastrophizing. The PCS is a self-report questionnaire that assesses three dimensions of catastrophizing: rumination (“I can’t stop thinking about how much it hurts”), magnification (“I worry that something serious may happen”), and helplessness (“It’s awful and I feel that it overwhelms me”). Electronic copies of the PCS can be downloaded in various languages from the website: http://sullivan-painresearch.mcgill.ca/pcs.php .
Respondents are asked to rate the frequency with which they experience different catastrophic thoughts and feelings. The reliability and validity of the PCS has been well established.7 The PCS yields a total score and subscale scores for rumination, magnification and helplessness. Total scores above 20 are considered to fall within the risk range.8 Individuals who obtain scores above 20 are more likely to follow a problematic course of recovery.
Techniques for working with catastrophizing patients
The key to developing a strong working relationship with the patient is to proceed through a series of interview questions that will cross different levels of intimacy. At the lowest level of intimacy, the physician can question the patients about the onset of the symptoms (e.g. “Tell about how the injury occurred”); at a higher level of intimacy, the physician can question the patients about current symptoms (e.g. “How are you feeling now? Do you think that the pain has improved or worsened with time?”). At the next level of intimacy, the physician can question the patient about the life impact of his or her health condition (e.g, “How has all this affected your life? What has been most difficult to deal with?”). By crossing different levels of intimacy in the interaction with the patient, the physician essentially mimics what occurs in the development of human relationships. As the patient shares information at different levels of intimacy, the patient will begin to perceive the physician as a caring person, a person interested in his or her life situation, and a person motivated to help. It’s critical that during this interaction, the doctor maintain eye contact with the patient. Relationships are developed between people who are looking at each other, not when one is looking at a notepad.
The physician will likely consider that questioning the patient about symptom onset and symptom profile is normal practice. But questioning the patient about the life impact of his or her health condition often isn’t.
As the physician listens to the patient’s responses it’s important to interject with empathic reflection statements such as “I can imagine that you got worried when your symptoms got worse” or “I can imagine that this was very difficult for you”. Such statements provide the patient with needed feedback. By using disclosure techniques such as those described above, the probability is increased that the catastrophizing patient will consider that his or her story has been heard and understood.
Treatments aimed at reducing catastrophizing
Research suggests that a variety of intervention approaches can be used to reduce catastrophic thinking. For example, following multidisciplinary treatment for pain, significant reductions in catastrophizing are often noted.9 Reductions in catastrophizing have also been observed following physiotherapy.10 It’s not clear, however, that such non-targeted approaches reduce catastrophizing enough to change clinical outcomes. Given the treatment-resistant nature of persistent pain conditions, it’s likely that multi-pronged approaches will be required, using techniques that aim to reduce the frequency of catastrophic thinking and its correlates, such as fear, depression and disability beliefs.
Our centre has described a 10-week program (Progressive Goal Attainment Program; PGAP)11 designed to target catastrophic thinking. The program consists of a maximum of 10-weekly contacts between a trained PGAP provider and a pain patient. PGAP incorporates a variety of techniques that have been shown to either reduce catastrophizing, or blunt its negative impact. Disclosure techniques are used to reduce perceived pain severity and emotional distress that might be maintaining high levels of catastrophizing.
Off the couch
Activity mobilization techniques are used to decrease downtime. The worst possible place for the catastrophizing patient is to be at home resting on the couch. In the absence of competing stimuli, the patient’s attention will be drawn to his or her symptoms. Since fear of movement and disability beliefs are significant correlates of catastrophizing, fear reduction techniques and belief change techniques are incorporated to indirectly target catastrophic thinking. Thought monitoring and cognitive re-structuring are also used to directly target catastrophic thinking.
Research with PGAP suggests that a variety of primary and allied health professionals (e.g., physicians, physiotherapists, nurses, occupational therapists) can be trained in these intervention techniques. By incorporating assessment and intervention tools into his or her clinical approach to the management of the pain patient, the medical practitioner will be better equipped to maximize the impact of treatment.
Michael Sullivan is Professor of Psychology, Medicine and Neurology at McGill University and holds a Canada Research Chair in Behavioural Health. He developed the Pain Catastrophizing Scale and was co-developer of the Progressive Goal Attainment Program.
Heather Adams is Project Coordinator with the Faculty of Medicine at the McGill University Health Centre. Her research addresses psy- chosocial factors that im- pede recovery following joint replacement surgery.
For the catastrophizing patient whose symptoms stem from an accident, perceptions of injustice are also likely. These might take the form of statements such as “If only he could see what he has done to my life” or “Nothing will ever make up for what I’ve gone through.” To the catastrophizing patient, the source of injustice might be a driver, an employer who failed to heed to safety concerns, the insurance company, or a health professional. Perceptions of injustice may be evidenced as anger reactions, non-compliance or missed appointments. Some of our recent research shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury.
For the treatment physician, validation techniques can be useful in reducing the negative impact of the catastrophizing patient’s perceptions of injustice. The following is an example of an interaction that might follow the patient’s description of an injury sustained at work:
Here the physician immediately validates the patients’ perspective (“It sounds like this has been a horrible experience”). It’s therefore not necessary for the patient to continue to “prove” to the physician that he or she has lived a significant injustice. The physician also attempts to assist the individual in looking forward by noting that damage can’t be undone. One of the ways in which perceptions of injustice impede recovery is that the patient is frozen in time at the injustice event. The doctor uses the language of recovery to emphasize forward movement and identifies himself as one who will be working to facilitate the patient’s recovery. Even though it might seem implicit that the physician role is that of a helper, it’s important to state it. Perceptions of injustice promote a style of dichotomous thinking where individuals are viewed as allies or enemies. To play an effective role as a helper, the doctor must be seen as an ally.