What are some of the indications that someone tends to catastrophise about their pain? How do we know? Do we have to use a questionnaire? Is it really my job to know about this if I’m not a psychologist – and what do I do about it?
These are the kinds of questions that have been posed to me as I’ve explored the topic of catastrophising, and I propose to answer the last question in my next post (sorry to keep stringing you along like this – I think many may know my take on that already!).
I work in a wonderful interdisciplinary team setting, in a centre where everyone who attends the Centre gets to complete a set of psychometrically sound questionnaires that all of the team are encouraged to use and interpret, so any of the team can be confident about identifying and working with a patient who catastrophises. BUT I know that many clinicians work alone, or work in a team that functions in a multidisciplinary way, and where patients don’t routinely complete questionnaires.
So, what can solo, primary care clinicians do?
As I mentioned before, questionnaires are not X-rays of the mind – they simply organise how information is obtained, and allow us to compare the responses from one person with the responses from many others so we can decide how similar or different this one person is. In other words, using a questionnaire is just another strategy to help assess where a person is at.
It’s possible and sometimes really helpful to just ask. With some proviso’s of course – asking the right questions and not just asking but also observing behaviour and putting this information together in some form of clinical reasoning about what is going on, and what this might mean for treatment.
Even if you decide to use a questionnaire (and maybe the Pain Catastrophising Scale is a useful choice), it’s important to decide who to give it to, when to give it, and most importantly, how to interpret it because numbers just don’t mean anything on their own – not even percentage change over time tells us very much if we don’t know the meaning of the domains they are representing.
Here’s another Healthskills Advice for NonPsychologists list on questionnaires and catastrophising!
- Some indications for considering the use of a measure of catastrophising are people who present as highly anxious or distressed about their pain, who describe their pain in dramatic metaphors or say things like “my back will snap” or “my bones and nerves are being ground away”, who say things like “I can’t stand it any more” or “it’s terrible and it can’t go on”, or who are fearful they will “end up in a wheelchair” for example. Particularly people who believe that moving will “do damage”, and those who seem completely helpless when they have pain “there’s nothing I can do when I have pain”.
- It’s probably not so helpful to administer a questionnaire for catastrophising in someone who is seeing you with acute pain (first episode, within the first two or three weeks), but more useful to give it to someone who has had their pain for six weeks or more (sub-acute), who has had episodes of pain that have lasted more than six weeks before and had a slow recovery.
- In primary care settings most people won’t demonstrate catastrophising – but there is some research that suggests up to 25% of people with acute pain hold catastrophic beliefs (Ciccone, Chandler & Kline, 2010), and this finding was in young, fit military people! Clearly not everyone who has catastrophic beliefs when they have acute pain go on to develop long-term disability, but the risks are higher, so a screening assessment like the Orebro Musculoskeletal Pain Questionnaire might be useful for routine administration in acute, primary care settings.
- It’s not very useful to use an English language questionnaire with someone who doesn’t speak English well – see if there is a questionnaire in that person’s language instead. Be wary of using a translator to help someone answer a questionnaire, because this can lead to unintended errors and invalidate scoring. The same applies if the person has limited comprehension.
- Make sure you read and understand the questionnaire, what it measures, how it’s interpreted, what the reference or normative group is, and how to score it. If you don’t know these things, you’d be far better off not to use the questionnaire! Kthx.
- If you’re going to ask about catastrophising, you can ask things like
- What goes through your mind when your pain gets bad?
- What do you think is happening then?
- What images go through your mind when you’re really sore?
- What can you do to help yourself when your pain is really bad?
- What do you think will happen in the future if your pain gets bad?
- What do you think is going on in your body when you’re really sore?
- What can you do to get by when your pain is bad?
Can you tell that this post is not the last in this series? But wait, there’s more! Come on back for more, and don’t forget to comment (they’re always welcome).
Ciccone DS, Chandler HK, & Kline A (2010). Catastrophic appraisal of acute and chronic pain in a population sample of new jersey national guard troops. The Clinical journal of pain, 26 (8), 712-21 PMID: 20664336