Catastrophizing

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Sullivan definition[edit]

Sullivan defines catastrophizing as: “an exaggerated negative mental set brought to bear during actual or anticipated painful experience” (Sullivan et al., 2001).

Key aspects[edit]

This term has general and specific connotations. Here is the author’s conception of it based on a combination of readings and clinical impressions: It is a situation in which people with a theatrical bent exaggerate the danger and importance of negative events. Catastrophizing is always partly evaluative because it involves an evaluative judgment that something is dangerous i.e. harmful. Lukkahatai N et al. define catastrophizing as “an exaggerated negative evaluation and attention to specific symptoms such as pain or fatigue”. (Association of catastrophizing and fatigue: a systematic review. Lukkahatai N et al. J Psychosom Res. 2013 Feb;74(2):100-9.) [Italics added.]

Catastrophizing also involves an element of intense interest in catastrophes or events that interpret to be catastrophes. One type occurs when an anxious person hears a little squeak and they make it out to be an impending disaster. Another type occurs when some people have a minor symptom, but they dramatize it into a story of event of momentous proportions. The catastrophe is often self-centered whereby there is a concern to the person that a great evil has or will befall them.

There appears to be a social-communicative aspect to catastrophizing whereby the speaker has a need to tell graphic stories to others to make an impression on them and to grab their interest.

Catastrophizing as a predictor of disability[edit]

A study by Sullivan et al. examined how catastrophizing can be used to predict levels of pain and disability in patients with “soft-tissue injuries to the neck, shoulders or back following work or motor vehicle accidents.” Catastrophizing, pain, and disability in patients with soft-tissue injuries. Sullivan MJ, Stanish W, Waite H, Sullivan M, Tripp DA. Pain. 1998 Sep;77(3):253-60.)

Results showed there was a significant correlation between “patients' reported pain intensity, perceived disability and employment status. The results of a regression analysis further showed that catastrophizing contributed to the prediction of disability over and above the variance accounted for by pain intensity.” They also found that “catastrophizing was associated with disability independent of the levels of depression and anxiety. The rumination subscale of the PCS was the strongest predictor of pain and disability.”

Role of evaluative processing in the brain in catastrophizing[edit]

Psychological mechanism[edit]

Catastrophizing involves making situations out to be worse than they are. Logically this must involve evaluative processing because the process of judging something as terrible is an evaluative judgment.

Effect on others[edit]

If others do not see through the catastrophizing they be inclined to be alarmed that something terrible has happened. They may also be inclined to feel sympathetic.

If others see through it and realize the person is exaggerating or even dramatizing, their natural inclination will probably be to try to discourage the behaviour.

Catastrophizing can create social tension others.

Relation to “danger mode”[edit]

It is obvious that making such judgments is conducive to emotional upheavals, and probably also to protective brain states, such as what is referred to in this wiki as “Danger mode”

Self-deception[edit]

One possible type of catastrophizing is an intentional falsehood, i.e. a lie in which the person is trying to manipulate another person into leniency or cooperation. For example, a person who is drug seeking and they tell their doctor that some catastrophe has befallen them through no fault of their own. This is not the type of catastrophizing that is found in fibromyalgia. The author’s impression is that in fibromyalgia the patient believes the catastrophe has happen but they take a set of facts and distort them into a catastrophe. Since the believe the catastrophe has happened but it has not, there is an element of self-deception.

Dramatic aspect[edit]

Based on the author’s clinical experience with some of his fibromyalgia patients, there appears to be a communicative social aspect to catastrophizing. In the experience of the author, catastrophizers tend to want to tell others about their pains in a dramatic manner which is likely to trigger emotional responses to them.

Catastrophizing place the person in the role of apparent victim, but if it exaggerated then they are to some degree fake victims.

Author’s comments on prospects to use catastrophizing as a treatment target[edit]

While there may or may not be studies showing that psychological treatments for pain catastrophizing, it would nonetheless be a reasonable treatment target for psychologically minded therapists working with catastrophizing fibromyalgia or chronic fatigue syndrome patients.

Catastrophizing-fatigue association[edit]

Lukkahatai N et al. define catastrophizing as “an exaggerated negative evaluation and attention to specific symptoms such as pain or fatigue”. Lukkahatai N et al note that: “A number of studies consistently support the significant role of catastrophizing in pain.” They conducted a review of articles and found that for the most part articles show a “large impact of catastrophizing on fatigue severity”. (Association of catastrophizing and fatigue: a systematic review. Lukkahatai N et al. J Psychosom Res. 2013 Feb;74(2):100-9. )

Pain catastrophizing[edit]

Gracely et al. definition[edit]

This is the characterization of pain “as awful, horrible and unbearable”. Gracely et al. note that it is “increasingly being recognized as an important factor in the experience of pain.” (Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Gracely RH1, Geisser ME, Giesecke T, Grant MA, Petzke F, Williams DA, Clauw DJ. Brain. 2004 Apr;127(Pt 4):835-43. Epub 2004 Feb 11.)

Fallon et al. definition[edit]

Fallon et al. state: “Pain catastrophising is an exaggerated cognitive attitude implemented during pain or when thinking about pain. Catastrophising was previously associated with increased pain severity, emotional distress and disability in chronic pain patients, and is also a contributing factor in the development of neuropathic pain.” (Pain Catastrophising Affects Cortical Responses to Viewing Pain in Others. Fallon N1, Li X1, Stancak A1. PLoS One. 2015 Jul 17;10(7):e0133504. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4505849/. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

When catastrophizing, some pain patients act to draw the attention of others to their pains and the harms they perceive have been done to their body. In so doing their behaviour is organized to focus the attention of others on these harms while interpreting them as being very serious.

Pain catastrophizing scale[edit]

This questionnaire is a major highly studied tool for testing catastrophizing that is available in many languages. It was developed by Dr. Michael Sullivan. It is available in full online at: http://sullivan-painresearch.mcgill.ca/pdf/pcs/Measures_PCS_Adult_English.pdf. The user manual is available at: http://sullivan-painresearch.mcgill.ca/pdf/pcs/PCSManual_English.pdf.

For an article by Sullivan that describes it see: The Pain Catastrophizing Scale: Development and validation. Sullivan, M.J.L., Bishop, S.R., Pivik, J. Psychological Assessment; 7: 524-532 (1995) available in full online at: http://sullivan-painresearch.mcgill.ca/pdf/abstracts/sullivanapr1995.pdf.

A review of the question in this tool reveals that it enquires into the following concerns: worry the pain will go forever and recovery won’t occur and that the person will deteriorate, hopelessness, worry all the time about whether the pain will end, judging one’s situation as awful, feeling overwhelmed by the pains, thinking too much (preoccupation)about one’s pain and painful events, concern a serious event will occur.

In the ordinary meaning of the word catastrophizing the idea is making something out to be more terrible than it is. It is a form of mis-evaluation or of evaluative thinking about oneself. The questionnaire does not test for this directly, but one gets the impression that this is what the questions as a whole were designed to do. If the underlying issue in catastrophizing truly is an evaluative problem then it stands to reason that the focus of treatment should be to correct this.)

Sullivan states that pain catastrophizing “affects how individuals experience pain”.

The test measures rumination about one’s pain i.e. the inability to stop thinking about it; the magnification of the deleterious significance of one’s pain, feelings of helplessness to manage one’s own pain and control the intensity of the experience. It is also a tool to study pain-related thoughts.

Theory that pain catastrophizing augments pain[edit]

France et al. 2002 stated that: “Catastrophizing is reliably associated with increas-ed reports of clinical and experimental pain.” They assessed pain catastrophizing “using the catastrophizing subscale of the coping strategies questionnaire (CSQ)”. They found that “catastrophizing was positively related to both NRS [numerical rating scale] and SF-MPQ [short-form McGill pain questionnaire] pain ratings, (Catastrophizing is related to pain ratings, but not nociceptive flexion reflex threshold, Christopher R. France,a,* Janis L. France,a Mustafa al’Absi,b Christopher Ring,c and David McIntyrec, Pain. 2002 Oct; 99(3): 459–463, available in full online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1364455/.)

Williams et al. state that pain catastrophizing is a “cognitive style” that influences the patient’s attentional focus on painful events. They further argue that catastrophizers have trouble shifting they attention away from painful or threatening stimuli and appraise stimuli as being more threatening or harmful. The former is often referred to in the literature as “pain focussed behaviour”. Williams et al. have opined that catastrophizing probably augments pain. (Corroborative evidence from fMRI studies of catastrophizing in FM support this observation. (Understanding fibromyalgia: lessons from the broader pain research community. Williams DA, Clauw DJ. J Pain. 2009 Aug;10(8):777-91, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2741022/.)

Coping Strategies Questionnaire Catastrophizing Subscale[edit]

This is a tool that has been used to measure pain catastrophizing. (Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Gracely RH1, Geisser ME, Giesecke T, Grant MA, Petzke F, Williams DA, Clauw DJ. Brain. 2004 Apr;127(Pt 4):835-43. Epub 2004 Feb 11.)

Brain imaging studies of pain catastrophizing in fibromyalgia[edit]

A study by Gracely et al. concluded that pain catastrophizing “is significantly associated with increased activity in brain areas related to anticipation of pain (medial frontal cortex, cerebellum), attention to pain (dorsal ACC, dorsolateral prefrontal cortex), emotional aspects of pain (claustrum, closely connected to amygdala) and motor control. These results support the hypothesis that catastrophizing influences pain perception through altering attention and anticipation, and heightening emotional responses to pain.”

Pain catastrophizing, EEG changes during[edit]

An EEG study by Fallon et al. investigated “the neural basis of how pain catastrophising affects pain observed in others”. (Pain Catastrophising Affects Cortical Responses to Viewing Pain in Others. Fallon N1, Li X1, Stancak A1. PLoS One. 2015 Jul 17;10(7):e0133504. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4505849/. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

They “acquired EEG data in groups of participants with high (High-Cat) or low (Low-Cat) pain catastrophising scores during viewing of pain scenes and graphically matched pictures not depicting imminent pain. The High-Cat group attributed greater pain to both pain and non-pain pictures. Source dipole analysis of event-related potentials during picture viewing revealed activations in the left (PHGL) and right (PHGR) parahippocampal gyri, rostral anterior (rACC) and posterior cingulate (PCC) cortices. The late source activity (600–1100 ms) in PHGL and PCC was augmented in High-Cat, relative to Low-Cat, participants. Conversely, greater source activity was observed in the Low-Cat group during the mid-latency window (280–450 ms) in the rACC and PCC. Low-Cat subjects demonstrated a significantly stronger correlation between source activity in PCC and pain and arousal ratings in the long latency window, relative to high pain catastrophisers.”

They concluded that their results “suggest augmented activation of limbic cortex and higher order pain processing cortical regions during the late processing period in high pain catastrophisers viewing both types of pictures. This pattern of cortical activations is consistent with the distorted and magnified cognitive appraisal of pain threats in high pain catastrophisers. In contrast, high pain catastrophising individuals exhibit a diminished response during the mid-latency period when attentional and top-down resources are ascribed to observed pain.” (Pain Catastrophising Affects Cortical Responses to Viewing Pain in Others. Fallon N1, Li X1, Stancak A1. PLoS One. 2015 Jul 17;10(7):e0133504, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4505849/. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Treatment of pain catastrophizing[edit]

In principle it is possible to treat catastrophizing in pain (and non-pain) patients using psychological interventions including CBT, insight-oriented psychotherapy and psychoanalysis. Patients may not fully be aware that the do it. It is hard to imagine how they might control it if they cannot find ways to catch themselves in the act of catastrophizing.

A study by Smeets et al. found that reducing the patient’s pain catastrophizing seems to mediate the improvement of functioning in patients with chronic low back pain. (Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. Smeets RJ1, Vlaeyen JW, Kester AD, Knottnerus JA. J Pain. 2006 Apr;7(4):261-71.)

A study by Thorn et al. outlined a cognitive-behavioral group treatment approach for chronic pain that was designed to reduce catastrophizing. Their paper includes a useful tool in Appendix A 1 called “Catastrophizing Thought Record” that includes adaptive responses that should be encouraged. (Targeted Treatment of Catastrophizing for the Management of Chronic Pain Beverly E. Thorn and Jennifer L. Boothby, The University of Alabama Michael J. L. Sullivan, Dalhousie University, Cognitive and Behavioral Practice 9, 127-138, 2002 1077-7229/02/127-13851.00/0 Copyright © 2002 by Association for Advancement of Behavior Therapy, available in full online at: http://sullivan-painresearch.mcgill.ca/pdf/abstracts/sullivanmar2002.pdf.)

Author’s comment on making the assessment of pain catastrophizing a standard part of chronic pain assessment[edit]

There is an argument in favour of adding pain catastrophizing testing to the basic assessment of some chronic pain patients such as fibromyalgia patients. If a patient scores high, it is logical to explain the results and to try to design interventions.\

Further information[edit]

Can pain catastrophizing be changed in surgical patients? A scoping review, Eric Gibson, Marlis T. Sabo, Can J Surg. 2018 Oct; 61(5): 311–318.

Disease related, non-disease related, and situational catastrophizing in sickle cell disease and its relationship with pain, Vani A. Mathur, Kasey B. Kiley, C. Patrick Carroll, Robert R. Edwards, Sophie Lanzkron, Jennifer A. Haythornthwaite, Claudia M. Campbell, J Pain. 2016 Nov; 17(11): 1227–1236.