Catastrophising, or thinking the worst, is one of those psychological factors that we know influences distress and disability in people with chronic pain. It’s quite a common phenomenon, and sometimes can stand us in good stead – after all, if we can think of the worst things that can happen, then plan to avert those possible disasters, then life will be sweet, yes? ermmmm – no, as a matter of fact. Catastrophising can actually function to narrow our thinking down, reducing the range of options we can come up with to manage situations, and it can also function to focus us on things that haven’t worked out while at the same time minimising our appreciation of things that are working well.
In chronic pain, catastrophising is often an outcome to measure – the thought is that if people learn to think more positively about what might happen when their pain is bad, they’ll be in a better position to cope with their pain. This is thought to reduce the level of distress by being more realistic about the potential for negative things to happen. People who can face difficult times with a greater sense of the real level of threat can harness resources more effectively and often avert negative situations before they happen.
There are a number of interesting theories about resilience and how people cope more positively with life’s situations. One of these theories is the ‘broaden and build’ theory first developed by Fredrickson, (2001). In the ‘broaden’ part of this theory, it’s thought that positive emotions serve to broaden what we attend to and think about, and in doing so, widen the range of things we consider and think about so that we can think of more options than we consider when we’re under stress. This is thought to help us cope better with stress because we can think of a greater range of things that might work to help us out of that particular difficulty.
Some of the other relevant discussions about resilience and positive emotions suggests that while resilience can be thought of as a trait, or a fairly stable ‘way of viewing the world’, one aspect of reslience that is important is the ability to generate and have positive emotions. Maybe having positive emotions is just a by-produce of resilience, or maybe it’s that if we can remain positive despite stressors being present, then we will be able to be resilient – but it’s certainly evident that when people are able to find something positive in a difficult situation, or if they can find something funny in their situation or even find something to comfort and therefore increase positive mood, they seem to cope better than people who ‘think the worst’ and then remain focused on these negative aspects of their situation.
How does this fit with catastrophising and chronic pain?
Well, in an interesting ‘daily process study’ by Ong, Zautra and Reid, people who were being seen for their chronic pain were asked to keep a daily diary and record catastrophising, pain intensity, and both positive and negative emotions over a period of 14 days. At the beginning of the study they were asked to complete a set of questionnaires including a measure of resilience, neuroticism, and the usual range of demographic details.
The aim of the study was to see how resilience characteristics related to catastrophising, positive and negative emotions, and pain. There were four main questions: (1) Is there a gender difference in catastrophising? (2) Is there a relationship between the level of resilience and the changes experienced in pain catastrophising? (3) Do positive emotions reduce pain catastrophising? and (4) Is the relationship between resilience and pain catastrophising influenced by positive emotion?
What did they discover?
Well, the first question about whether there is a relationship between gender and catastrophising found that yes, women in this study of 95 people, were more likely to catastrophise. Why this is, we don’t know. More research please!
The second question about resilience and catastrophising found that people who were identified as more resilient (using the scales in this study, anyway) were less likely to score as highly on the measure of catastrophising as people who were found to be less resilient. So it seems that if you have that tendency to bounce back, you’re also less likely to think the worst in a stressful situation. Which one comes first, we are not quite as certain.
The third question about whether positive emotions could influence catastrophising about pain also found that yes, if these participants felt positive on one day, they’d tend to score less on catastrophising the following day. (I guess you can see that maybe the reverse also applied – so it could easily become a downward spiral of feeling low in mood, then the next day, tending to think the worst – which is probably only going to increase the likelihood of feeling even lower that subsequent day!).
And lucky last, the question about whether positive emotions influenced the relationship between resilience and catastrophising (ie mediated that relationship) was also tested. In this rather complex set of calculations, it was found that the relationship between being generally resilient and the degree of catastrophising experienced on a daily basis was mediated by positive emotions. So if you’re generally resilient, but have a bad day, this can influence your catastrophising, but not to the same extent as if you’re generally less resilient, when it can lead to a really big increase in catastrophising.
What does this mean for us as clinicians?
The first thing that strikes me when I look at this is that if we can help people identify and pursue things that make them feel more positive, and they do this on a daily basis, it might help them be more able to think more realistically about their situation. So rather than freaking out about their pain, and being really concerned that their pain is going to overwhelm them, people who have had a couple of positive experiences through the day might be more likely to think that their pain is bothering them, but they can deal with it.
This leads me to consider the many ways in which we can help people generate positive events in their lives. Not everything we suggest to people needs to involve ‘hard work’! It’s actually OK to throw a ball for the dog and laugh at her antics. It’s fine to get out an old comedy movie and watch it for laughs. There could be merit in ‘laughing meditation’ where people are encouraged just to start laughing – it’s almost impossible to resist laughing when you see someone else chuckling away! Maybe even get people to look at my Friday Funnies? – oh, maybe not.
The next thing that comes to mind is that while women tend to be more likely to catastrophise, it was also found that positive emotions had a greater effect on catastrophising in women. The authors of this paper suggest that maybe women have more trouble regulating emotions (don’t talk to our menfolk will you? They’d only agree…sigh…), but add that perhaps a greater emphasis on using ways to increase positive emotions will pay dividends for women.
We have a long way to go to really understand what helps people look on the bright side or have bounce back when they experience life’s challenges. At least one thing we can draw from this study is that by increasing positive emotions there is a reasonable chance we can help people reduce their degree of catastrophising about their pain. I’ll post more about how to increase positive emotions shortly – but this is one area that is an especially important one for clinicians working in chronic pain, and especially for occupational therapists who are ‘expert’ in occupations that people enjoy. Having positive emotions seems to generate more options for coping, and increases the sense that life can go on – and this has got to be good for the people we work with.
Ong, A., Zautra, A., & Reid, M. (2010). Psychological resilience predicts decreases in pain catastrophizing through positive emotions. Psychology and Aging, 25 (3), 516-523 DOI: 10.1037/a0019384
Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56, 218–226. doi:10.1037/0003-066X.56.3.218
HealthSkills Blog 
I live with chronic neuropathic pain and I find i cope generally pretty well albeit with a lot of meds on board but when my pain gets out of hand due to stress or whatever I find that i would score high on a catastrophizing scale at this point so i think that sometimes it is not really catastrophizing it is a real picture of what is happening at that given time. I think I am like this until I have a med change or more psychology to get me through this period but that this feeling of hopelessness is real for the amount of pain i have. Then when the pain bothersomeness is decreased I would score lower not because i am no longer catastrophizing but the point of not coping is gone due to a change i have made. But i do wonder a lot what is the main factor of why i cope is it genetic( i know in my case I had a mom who lived and worked all her adult life with RA and the deformities).
The thing with catastrophising is to listen to the language – ‘I can’t cope’ and ‘I can’t go on’ may reflect how you feel – but are those thoughts working for you? Do they help you get through? And then – how accurate are they? What is the alternative to ‘not coping’? or ‘not going on’? To me the alternative is to give up – and that means living in a way that reduces my engagement with things that bring meaning into my life (like not dancing or taking photographs or blogging) – or it means dying. I’m not dying (people don’t die from chronic pain, they just feel like it!), and when I’m doing things that add fulfilment to my life I have a richer life ande one that I enjoy – and pain becomes a much smaller part of it.
So to deal with catastrophising thoughts I think it’s useful to do two things: Firstly check out the language and ask if it’s really true? What would ‘not coping’ look like? What would ‘not going on’ look like? Is that really happening? or are there things that you are still doing and coping with? Are you still ‘going on’ in some way at least?
Secondly, I really draw on mindfulness at this time: yes, my pain is high, yes my mind is chattering away saying I can’t go on, I shouldn’t have to put up with this pain, there must be something I can do – but that’s just what my mind does best: try to solve a problem, only this chronic pain is not a problem to solve, it’s an experience to move through. It will settle, it doesn’t stay at this level forever, and at the same time I feel the pain I also feel and experience other things. Those other things can be sounds, other skin-related sensations like pressure or texture, they might be tastes, scents and so on – and they are just as present as my pain sensations. I can acknowledge my thoughts, but I don’t choose to do anything about them, they just rattle on there while I get on with experiencing the rest of what is going on.
Then I get engaged in a small thing that gives meaning back to me – maybe I take a photograph and work on it, maybe I browse the internet and read something, maybe I potter in the garden – something relatively low key but aligned to my values. Somehow by doing this I end up moving through the negative period and slowly and gradually become more energised and at the same time more calm.
That’s my take on how to reduce catastrophising for me, and one of the ways I work with patients.
You’re right that scores on catastrophising go up and down in association with pain intensity – but as this study shows, by being engaged with what’s important in your life, it’s so much more possible to experience the pain AND go beyond it to do what means a lot to you.
There seems to be genetic components to positive affect, to resilience and to pain modulation. But at the same time we can develop effective ways of responding differently, and we do this from the time we’re tiny – until we stop breathing forever! Some of us use therapy to help learn to do things differently, some of us watch folks around us (family, friends), and some of us read blogs! To me this means hope is always there – and believe me, I’ve been in very low points and could well go there again, so knowing that there is hope is very important to me!
cheers
Bronnie
thank you for this. So far i have gotten through those times but if all I can do is relaxation and imaging i feel there is no point and I have been suicidal, But i guess I feel it is not really catastrophizing it is reality to me. I need to know that this pain will be lowered to go on and it needs to be very soon. I get by by knowing I can work and lead a life that has enjoyment in it and I use these things to go on as does my psychologist and I hope that I can give this to my patients as well but I guess i really have a problem with being told i am catastrophizing. For me I want to say take my pain at this moment and live with it for a day and then tell me i am catastrophizing. I know it is just a word but i guess what I get from this as a clinician is be careful what patients feel that the scale says to them and not just to the clinician. I don’t know where this came from but it has been a problem for me since i developed my pain 8 years ago.
I completely understand the reaction leslie speaks of. It seems to me that we try to use creative phrases to say the same things over and over. To me the word “catastrophizing” says “making a big deal out of nothing”. I just try to remember that if I am on a plane and it starts to go down the person next to me is not going to complain about my “intense emotional response” because they will be busy “screaming” (see, I can do it too!)
I’ve been dealing with chronic pain for over 10 years now, and the only people who don’t judge my response to my illness are the people who live with me,other chronic pain patients and my doctors. And I’m one of the luckier ones. Whatever the words you use to describe what’s going on with you, just use the truth. I think they are going to discover that chronic pain is a personal resource (hormones, endorphins, seratonin, dopamine etc) depleting illness that Can end in death. Not that attitude isn’t important, it is. Just like with cancer or diabetes.
Hi Jessica, My impression from what you’ve said is that you feel like the word ‘catastrophising’ is something of a judgement on you and your evaluation of your situation. Almost as if people are saying ‘so what are you making such a big deal of this for?’ or ‘pull yourself together’. And I agree that the word, used thoughtlessly, can be derogatory.
I guess I’d prefer to look at it another way.
What if we looked at the effect of having thoughts that, even if accurate, take a bleak evaluation of the situation? Does judging the situation in this way help you to cope better? To give you an example of the effect of thoughts, consider Olympic swimmers. When they line up on the starting line at the edge of the pool and look at the other swimmers, what would it be like to think ‘I’ve never been able to swim as fast as Joe Bloggs. AndyPandy there is so much taller and has longer arms than me. And that water looks so cold and uninviting. I’m scared because it’s my first competition and I’m shivering and my heart is pounding’ While each of these statements might well be accurate, it’s not going to help that swimmer compete effectively.
Instead, competitive athletes learn to stay focused on their performance, on what they can do, on the work they’ve put in to get to the competition, and on doing their best.
In the same way, even if your description of your pain is completely accurate, even if you feel like you’ll never make it through, or you feel like a hopeless case – or whatever your set of thoughts are – the effect is to reduce your ability to remain positive, to stay focused on getting through, and on what you can do despite pain.
Pain is undoubtedly a negative experience. It’s an emotional one, and it’s an enormously stressful experience. To get through it successfully means doing all you can to support yourself in a positive way. To me this means working hard on developing positive ways of coping, and doing whatever you can to reduce habits that don’t support living well. I know that the research shows the depleting effects of chronic pain on self regulatory resources – I don’t think it shows premature death from chronic pain, or increased risk of death. As someone said to me, it’s not a death sentence, it’s a life sentence – so it’s up to me, in my case, to develop all the ways I can to live a life as full as it can be.
I hope you visit again, and take the time to comment. It’s always a pleasure to know that what I write gets read!
cheers
Bronnie