Catastrophising and pain (i)
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.

Pain behaviour
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.

Measuring catastrophising
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


  1. And if I know someone tends to catastrophise, what does it have to do with me?

    Well, as an acupuncturist, quite a lot, actually. I am also a nurse, with over 30 years NHS experience behind me, so I can come at this from a number of angles. My nursing background is largely in paediatrics, where pain is a very interesting phenomenon, and not assessed/managed in the same way as with adults.

    Now I work mainly with adults, I see quite a few people who catastrophise their pain experience – I have one particular patient with an anal fissure (not fun, admittedly) who is now on Morphine, Amytriptiline, and Diazepam – all to no effect. And she has regular acupuncture, and had four surgical interventions. All my clinical observations show my treatment is the correct one, and the medical teams dealing with her have all done the appropriate things in time but, as far as she is concerned she is disabled with this: now anorexic, bed-ridden and off sick from work, she certainly is (at age 34).
    And I reckon it’s by choice.
    Some people get many benefits from being in a position that requires great sympathy and means relinquishing day to day responsibilities. Now we are more tolerant of most mental illnesses, and now physical disability is becoming more accepted, the need to turn to other areas to gain that benefit frequently means ‘intolerable’ pain.
    When I did my Sociology degree, I learned that The Sick Role is well recognised, and of the various parts all agencies play in supporting that role. Many people have a vested interest in managing pain (acupuncturists included, I have to say), and not all will happily confront the deep-seated disturbance their patient is experiencing – after all, it might mean the loss of a nice earner or appearing to be incompetent. Additionally, if the patient IS confronted, the vast majority will cease consulting the clinician.
    So – what’s to be done? Advertising bombards us with a plethora of OTC pain relief, getting stronger and faster all the time. Prescriptions for stronger pain relief are increasing year-on-year. It would seem the catastrophising is a signal that something is sick at more than just the level of an individual person. IMHO.
    Great article.

    1. I agree very much that the problem of pain, particularly chronic pain, is not simply about “this individual” and “this event” but is a complex, multidimensional experience made up of at least biopsychosocial aspects – and I’ve briefly mentioned before that I believe we have had a swing away from biomedical towards what is now a psychological model rather than a balanced biopsychosocial model.

      There is a slightly worrying tendency though, for some people who start to review pain from a biopsychosocial model, to suggest that people voluntarily choose and are aware of their adoption of “the sick role”. I see it as a far more complex situation in which there are probably some deliberate choices to “be disabled” at some points, but many other contributory factors such as early learning experiences, family inadvertently reinforcing dependence and disability, health care providers responding to distress, cultural messages about what is and isn’t an appropriate treatment (or level of suffering), modelling from others in the community and whanau/family, media messages – the list goes on! And as you say, for some health care providers it simply doesn’t pay to attempt to untangle all those knots and help the person do things differently.

      But I see it as a problem that most people unwittingly become swallowed up in, rather than any conscious attempt to fulfil emotional needs for being cared for. And as I’ll show later, catastrophising may be something people inherit, or has some element of neurobiological underpinning, and as a result they may have a greater vulnerability towards this type of cognitive bias. And of course, the research is still relatively young.

      Thanks for taking the time to comment – I hope the next post helps to provoke more discussion!

      1. Oh, I was not implying that this is a conscious or intentional choice. No! My point was that pain behaviours are, as you indeed say, the result of a complex series of influences. By ‘choice’, however, I mean that some people do consciously reject many interventions that might help them manage their pain. I have seen patients who, when realising that acupuncture is working, decide to stop coming. A common complaint is that the needles hurt – despite maybe 5 or 6 sessions without a murmur from them. And even if the needles did hurt, clearly the chronic back pain/headache/arthrits is preferrable!!
        I have only just discovered this site, and it is full of very interesting articles – I certainly look forward to new posts.. Thank you!

      2. It’s curious that people do reject effective treatment or management, and I suppose it is about balancing the benefits against the drawbacks – something that I think motivational interviewing approaches can draw out and make explicit. I know I’m not keen on needles (not that many people are!!) so I can appreciate the concern about having them inserted, but for me the main problem I would have with acupuncture is that it hasn’t helped me! And that it takes time out from normal routines to go and have the treatment, so it is difficult for me to recommend acupuncture for people who want to self manage their pain. I’m glad you found the site – and let me know if there are any topics you’d like me to write about, I’m more than happy to scout around the research (sad, I know!!).

  2. Thank you for addressing pain “language”. I believe that the subconscious things that we do when we are in pain often affect those around us thus making the pain more valid, or larger, than suffering alone. Those actions also can make our loved ones become part of the cycle of pain by focusing on what we can’t do instead of what we can and watching for signs that we are in pain so they can “help”.
    I now tell people to ignore me if I am doing anything that conveys pain; the last thing I want to hear is “are you ok?”. I am fine, I will be fine, and the pain just is. Refusing invasive treatment and getting on with life WITH the pain has made me a happier person AND has actually reduced my pain (or perception of) because I pay less attention to it.

    Thank you again,

    Yvonne Henderson

  3. I agree. When I work with people in a one on one session, or in an emergency response situation, I always, every time, get them to stop and breathe. I actually teach them that part of the biodirectional communication of pain, is coming from the brains memory of pain, and that if I can turn the volume down on that story, then i can more accurately assess the actual tonality and volume of the pain – scaled 1-10. Every time, the volume is decreased by creating a safe nurturing environment, we can get the “red alert” system response level to decrease and actually better define what is going on. Thanks.

  4. I have enjoyed reading this thoughtful post. As this is a topic with extremely broad implications I think folks could make connections ad infinitum. One thing I would like to add to the conversation is the obvious connection of a fear based mind set. The positive changes I have witnessed when I challenge a patient’s relationship with fear have been substantial.
    The relationship between pain, fear , and substantial health crises should not be minimized because it does not fit into the insurance driven medical model of care. Fear of pain has immediate and long term psychological and physical repercussions. When fear is decoupled from pain, and the patient can realign their relationship to pain, real healing and a return, to at least a more normal life, can ensue.
    Excellent String, thanks for posting!
    BJ Erkan, LMP

    1. I totally agree – fear/anxiety (specifically about health in particular) are associated with greater use of health resources, greater disability, greater distress etc. And I suppose that’s partly why I’m exploring catastrophising because of the relationship catastrophising has with fear/anxiety. I’m not sure that the treatment of pain-related fear or anxiety is altogether clear yet, although mindfulness, cognitive techniques such as reframing and graded exposure all seem to have a role – more to come on each of these! Thanks for taking the time to comment, it’s great to know there are readers out there.

      1. Today I began doing something that I haven’t done before (partly do to a string of thoughts inspired by this blog :). I began teaching my most recently hired therapists about how to speak with patients in acute pain about their pain and the psychological and physical responses to the pain. One theme I keep coming back to with patients that are in the Pain-fear-more pain cycle is to move the body in a relaxed gentle manner versus a rigid guarded manner. I ask them how they may need to think about the body to accomplish this change. It seems to be conceptually easy to grasp and the patients report this focus seems to lower the instance and severity of pain. I believe the wordplay we build into the treatment session can do as much good as the skillful and effective soft tissue manipulation.
        I look forward to your future posts!
        BJ Erkan, LMP

  5. I rum a ptsd clinic at our school and am developimg protocols for Bethesda, Cook County Hospital, and would like more infoto work “between the ears” since we work on the eara with acupunture.

  6. Re: painful acupuncture/needle phobia
    Just as a note, I treat many needle phobic people (after all, who DOES like them?). I still treat some children.
    If acupuncture is being done properly, by fully trained practitioners (min 3000 hours supervised training) it should not hurt.
    Make sure anyone who does acupuncture is a fully trained specialist!

    1. The only people who like needles are people who probably have an unhealthy obsession with giving themselves acute pain!! Unless you’re on the giving end rather than receiving of course…

  7. Well, I have been inspired by some of the information on this site. I learned CBT a number of years ago, and I felt there were few situations relevant to my work that I could really use it. I have followed up some of the suggestions on here and am using them with the patient I described above. Then I realised I was using a number ot techniques that were familiar through my work with children. I think the discussion about fear is highly relevant to this point, as children are so good at expressing their fears, and it was not possible to work with them unless that was taken on board.
    One of the most useful tools was distraction – not covering up or denying but, engaging the child in something that interested him/her – especially if it carried some promise for the future. So, finding out what they were doing ar school or nursery, what they liked about it, and setting up a scheme for them to access it in hospital – that sort of conversation only took a few minutes but in the meantime, all sorts of blood tests and examinations could take place. The child would be involved with the procedure but, not distressed.
    Using some of this, with the advice here, has already made a big difference in how my patient ‘sees’ their situation. I am actually looking forward to planning a schedule of treatment, with her on board, too, and am feeling far less frustrated and hopeless. I assume my patient is, too!
    Thanks, all!

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