Catastrophising is a popular concept in pain management. It’s been associated with poor outcomes in major joint replacement (Riddle, Wade, Jiranek and Kong, 2010); spinal fusion (Abbott, Tyni-Lenne & Hedlund, (2010); in experimental pain modulation (Bartley & Rhudy, 2008); in cancer pain (Bishop & Warr, 2003); and influences interpersonal relationships (Buenaver, Edwards & Haythornthwaite, 2007).
I’m often asked: so, what do I do about it? Can it be treated? What does it really mean? Should I (any kind of non-psychologist) try to treat it, or should I leave it to the psychologists?
The short answer is, I think, yes we need to be aware of catastrophising, yes we can do something to help people become less likely to catastrophise, and yes I firmly believe any and all health professionals have a contribution to make to reduce the tendency to catastrophise simply because it can be so influential for distress, function and disability.
What does catastrophising really mean?
Catastrophising is, basically, the tendency to think the worst about a situation. It probably has some adaptive function in that it helps people identify all the things that can go wrong so they can do something to reduce that risk. On the other hand, it’s not such a wonderful thing when it leads to ruminating (brooding), feeling helpless, and to magnify (or emphasise) all the disasters that could happen, when the probability is really quite low (Sullivan, Bishop & Pivik, 1995).
It’s likely that most of us will have, at one time or another, anticipated the worst. Most of the time the worst doesn’t happen, and we go our way, reassured that we’ve planned for, and managed the situation more effectively than if we’d carried out regardless. But for people who tend to catastrophise about their pain, the risk is fairly high that they’ll experience more distress, depression and disability than those who don’t.
I want to point out that identifying that someone tends to catastrophise does not mean their fears should be dismissed out of hand. The person who tends to catastrophise is likely to disagree with you, feel their concerns are being trivialised, feel rejected and less likely to talk to you about their concerns. Not the way to maintain a therapeutic relationship!
How can you tell if someone’s catastrophising?
The main assessment measure of catastrophising is Sullivan, Bishop & Pivik’s “Pain Catastrophising Scale“. It’s not the only measure, but it’s one of the most well-known. It’s relatively brief, and has excellent psychometric properties. But if you’re not comfortable using a pen and paper measure, how else can you decide if someone’s tending to think this way?
Some good questions to ask are:
“What do you think is the most likely outcome of this [procedure/painful event]?”
“How are you feeling about this pain?”
“What can you do to help yourself when your pain is like this?”
“How much can you distract yourself from the pain?”
“What do you think this pain means? What’s your theory about this pain?”
If the person answers negatively – for example, they say they can’t even think about an outcome it’s so bad, or they don’t think it’s ever going to get better, or it’s “terrible”, or “awful”; if they say they can’t distract themselves from the pain, they keep thinking about it all the time; and if they think there’s nothing they can do to help themselves, they feel helpless or hopeless; and if they think the pain means something sinister or bad – then you’re likely to have identified someone who is appraising their situation more fearfully than is helpful.
If the person says “Oh but it really is that bad!”
Remember when you were a kid and were terrified of the dark, or bugs, or things under the toilet lid? or when you were really upset and someone said “Calm down!” – remember that flash of anger that the other person was just not aware of how terrified you were? Simply disagreeing or correcting someone is not going to reduce their anxiety.
I find that first of all it’s important to reflect to the person that you understand they are really worried by their pain. Saying something like “It seems that your pain is really bothering you, and you’re really worried about what it means now and might mean in the future. Have I understood you correctly?”
I then find it useful to unpack the specifics of what the person is really worried about. I might ask “When you say the pain is terrible, what does that mean? What do you think might happen?”
What I’m trying to do is reduce the global appraisal the “everything” is “awful”. I want to find out the details, the underlying beliefs that are underneath the fearful appraisal. So, for example, if the answer to the question above is “I feel like I’m going to die, I can’t breathe and it’s frightening” or “I think it’s never going to end, it’s going to be there all the time, forever”, I can begin to gently reality test these beliefs and also provide some skills to help the person get through them. I firstly reflect what I’ve heard: “It sounds so scary, not to be able to breathe – no wonder you’re feeling afraid” or “I’d be worried too, if I thought my pain was going to be there all the time, forever”.
Then I might begin suggesting we work on ways to handle the emotions associated with this belief (it’s very hard to reality test if the person is very distressed). “I wonder if we could just spend a minute looking at some ways to help you deal with your feelings, so they don’t wind your nervous system up more? Even if it’s frightening, it’s hard to deal with when your body is getting very stressed, so tell me, what do you find works well to help you calm down?” I might either use what the person says, or teach some diaphragmatic breathing and mindfulness.
Then it’s often a good time to work through a nonthreatening explanation of pain. There are so many ways to present this – YouTube videos of Lorimer Moseley “explain pain”, or Mike Stewart “Know Pain”, or the 5 minute pain video by Hunter Integrated Pain Service. Or you can use your own explanations and metaphors that are meaningful to the person. A case formulation can be helpful too.
When should you refer to a psychologist?
I think most people with chronic pain are fine just learning simple skills like breathing, mindfulness and gently approaching movements that they’ve been worried about doing. Even better if this is carried out with a strong eye to what the person can do and wants to be able to do in their everyday life. Success does breed success.
But there are a percentage of people who really struggle with catastrophising. If you find that the person you’re working with can’t use breathing to calm down, finds it really difficult to stop brooding (especially if this is going on all night!), or finds it very hard to accept a different way of viewing pain, then it’s time to work together with a psychologist to develop an approach that combines what you do (restoring occupational engagement or function) with cognitive therapy or ACT (Acceptance and Commitment Therapy). I personally find it’s people who have very rigid beliefs about their pain, about how the world works, and who find it difficult to experiment and try new things that need this kind of input.
So – should we think about catastrophising in our clinical work? Definitely yes. It’s too important to omit. Should we help people who tend to think this way? Definitely yes, it’s not necessarily the remit only of a psychologist, and I’d argue that we ALL need to contribute.
Abbott, A.D., Tyni-Lenne, R., & Hedlund, R. (2010). The influence of psychological factors on pre-operative levels of pain intensity, disability and health-related quality of life in lumbar spinal fusion surgery patients. Physiotherapy, 96(3), 213-221. doi: 10.1016/j.physio.2009.11.013
Bartley, E.J., Rhudy, J.L. (2008). The influence of pain catastrophizing on experimentally induced emotion and emotional modulation of nociception. Journal of Pain, 9(5), 388-396.
Bishop, S.R., & Warr, D. (2003). Coping, catastrophizing and chronic pain in breast cancer. Journal of Behavioral Medicine, 26(3), 265-281.
Buenaver, L.F., Edwards, R.R., & Haythornthwaite, J.A. (2007). Pain-related catastrophizing and perceived social responses: Inter-relationships in the context of chronic pain. Pain, 127(3), 234-242.
Riddle, D.L., Wade, J.B., Jiranek, W.A., & Kong, X. (2010). Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clinical Orthopaedics & Related Research, 468(3), 798-806.
Sullivan, M.J., Bishop, S.R., & Pivik, J. (1995). The pain catastrophizing scale: Development and validation. Psychological Assessment, 7(4), 524. doi: dx.doi.org/10.1037//1040-3522.214.171.1244