One reason I love blogging is the discussion between me and readers. I wrote about the language of pain recently, and out of that discussion I’ve spent a few days digging around the literature to look at what is known about the relationship between language, pain and catastrophising. I’d argued in my post that metaphoric language can reflect distress both in the communicator and the listener, and that this is supported by fMRI studies in which various parts of the brain are activated when emotion-laden communication about pain is being carried out, while one of my readers thought I might be taking this interpretation too far.
My reason for being interested in how we communicate about pain is that talking about pain (including describing it) is a pain behaviour. Pain behaviours are a range of behaviours that occur when we are sore and seeking help, and can include voluntary and involuntary actions. There can be an assumption that people are fully aware of the behaviours they do in relation to pain, so when a person demonstrates a lot of pain behaviour some clinicians believe the person “must” know that this is what they’re doing. This is sometimes the case, but there are numerous factors that can influence the behavioural responses we have to an experience of pain.
Pain behaviours occur on a continuum, however, from involuntary such as the withdrawal reflex, through more voluntary actions such as swearing (yes, it does seem to help!) and ultimately to very complex behaviour such as seeking treatment for pain. And from an evolutionary point of view, pain behaviours are there primarily to communicate to others that we need or want help.
Pain behaviour and catastrophising
There is a relationship between catastrophising, or “an exaggerated negative “mental set” brought to bear during actual or anticipated pain experience” (Sullivan, Thorn, Haythornthwaite, Keefe, Martin, Bradley and Lefebvre, 2001), and pain behaviours – including verbal reports of pain intensity, seeking treatment including hospital stays, use of medications, and has been posited as one reason health professionals may pursue more intensive and invasive approaches to pain assessment and treatment. Catastrophising is thought to influence the ways in which people interpret their pain – there are several theories identifying how this might occur. But first, let’s have a look at how catastrophising is identified.
As I’ve mentioned in an earlier post, there are several pen and paper measures of catastrophising. Questionnaires are simply standardised, or repeatable sets of questions that have been tested and thought to measure some underlying concept – they’re not “x-rays of the mind” and while they’re helpful and allow researchers and clinicians to do statistics on the findings and establish how similar or different one person’s answers are from “the rest”, they are based on language. The words and phrases that people use reflect the way they interpret a situation, and while the actual wording differs depending on the vocabulary the person commonly uses, the way the person appraises or judges a situation underpins what they say.
There are several problems levelled at questionnaire measurement of catastrophising. Because catastrophising as a concept is “invisible” – we can’t measure it directly and have to use statements that are believed to be associated with it – some critics have identified that the Coping Strategies Questionnaire, for example, might confuse measurement of catastrophising with measurement of depression. Others have suggested that catastrophising is so closely related to fear of pain or anxiety or even perceived disability that it might not be worth measuring it as a distinct entity. The conclusion currently, however, is that catastrophising is a distinct concept, and the most favoured assessment tool is the Pain Catastrophising Scale.
This scale has been found to have three subscales – rumination (or “repetitively (and passively) focusing on the symptoms of distress, and on its possible causes and consequences” – thanks to Wikipedia), magnification, and helplessness.
Three possible theories
Appraisals – Lazarus and Folkman proposed a general model of the ways people respond to situations. Primary appraisal involves determining whether a situation represents a threat, positive or irrelevant. Secondary appraisal involves determining coping options and likelihood of success. The PCS magnification and rumination subscales might form part of primary appraisal, while helplessness might be related to secondary appraisal.
Attention – People who demonstrate elevated levels of catastrophising also seem to focus on pain more than those with lower levels. This suggests that one of the pathways from catastrophising to the experience of pain might be via hypervigilance, or increased tendency to quickly attend to pain – and from there to negatively appraise pain as something difficult to deal with.
Coping – One form of coping is to obtain help from other people. A model that could explain the usefulness of catastrophising might be that by communicating distress, help might be obtained from other people, so that the individual doesn’t have to cope alone. The experimental and clinical evidence supporting this function of catastrophising, as demonstrated through pain behaviour and verbalisations, seems to be reasonably compelling – and my thoughts are that one way in which catastrophising language “works” is through empathy, which itself seems to be related to those darned mirror neurones.
The question nonpsychologists might have is – so do I need to use the PCS to identify people who catastrophise? And if I know someone tends to catastrophise, what does it have to do with me?
And that is for another post, so y’all come back now!
Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, & Lefebvre JC (2001). Theoretical perspectives on the relation between catastrophizing and pain. The Clinical journal of pain, 17 (1), 52-64 PMID: 11289089