catastrophising

fishing

Empathy and catastrophising influence pain inhibition


When I went to occupational therapy school I was introduced to nociception and the biological underpinnings of pain. I wasn’t, at that time, taught anything about the brain, attention, emotions or any social responses to pain behaviour. Like most health professionals educated in the early 1980’s, pain was a biological and physical phenomenon. I suppose that’s why it can be so hard for some of my colleagues to unlearn the things they learned way back then, and begin to integrate what we know about psychological and social aspects of our pain experience. Because pain is a truly biopsychosocial experience. Those pesky psychosocial factors aren’t just present in people who have difficulty recovering from pain, they’re actually integral to the entire experience.

Anyway, ’nuff said.

Today I stumbled across a cool study exploring two of the psychosocial phenomena that we’ve learned are involved in pain. The first is catastrophising. And if you haven’t got your head around catastrophising it’s probably time to do so. It’s one of the strongest predictors of disability (Edwards, Dworkin, Sullivan, Turk & Wasan, 2016). Catastrophising is the tendency to “think the worst” and consists of ruminating (brooding on), magnifying (over-estimating the negative impact) and helplessness (feeling as if there’s nothing you can do).  The second is empathy, or the ability to sense other people’s emotions, coupled with the ability to imagine what someone else might be thinking or feeling. Empathy is not the same as sympathy which seems to be about the emotions a person experiences while observing another’s emotional state. In fact, separate parts of the brain are involved in the two experiences (Cuff, Brown, Taylor & Howat, 2014).

Back to the study. This study examined conditioned pain modulation in partners observing their partner undergoing a painful experience. It was carried out by Gougeon, Gaumond, Goffaux, Potvin and Marchand (2016) in an attempt to understand what happens to the pain experience of people watching their loved ones in pain. The experimental protocol was (1) baseline; (2) assessing pain VAS 50; (3) pre-CPT heat pain testing (thermode preimmersion at a fixed temperature); (4) CPT (either at 201Cor71C); and (5) post-CPT heat testing (thermode postimmersion at the same fixed temperature). What they did was ask the participants to submerge their right hand in a freezing cold waterbath while video recording them. They then asked their partners to place their right hand in lukewarm water while watching the video recording. Participants were asked to rate their pain intensity.

What they found was the higher the catastrophizing score was, stronger was their descending pain inhibition when they were watching either themselves or their spouse in pain. In women, the more empathic the women were, the better was their descending pain inhibition when they observed their spouse in pain.

This is extraordinary. Firstly, the finding that there was a correlation between catastrophising score and descending inhibition contradicts other research studies – Gougeon, Gaumond, Goffaux, Potvin and Marchand suggest that although cognitive and emotional processes underlying catastrophising increase pain perception and decrease inhibition, their experimental design may have increased pain perception during the conditioned stimulus which may have triggered more conditioned pain modulation. They also suggest that the catastrophising level of participants increases their perceived pain, explaining why it correlates with conditioned pain modulation efficiency.

Secondly, women were more distraught than men by observing pain in others. Adopting the perspective of a loved-one elicited stronger activation in regions involved in the “pain” matrix than adopting the stranger’s perspective (Cheng et al), and the authors suggest that empathy is a powerful factor involved in pain modulation while observing someone in pain. This shows that descending inhibition is influenced by physical stimulus characteristics (such as intensity or location), as well as personal cognitive dimensions. A far cry from the notion that psychosocial factors play little part in modulating our pain experience.

What does this actually mean for us?

Well, to me it suggests that we need to be aware of our own empathic response to observing someone else who is experiencing pain. Let’s put it this way: if I’m an especially empathic person (and especially if I tend to catastrophise) and I see people who are experiencing pain in my clinical practice, my own emotional and cognitive response to seeing people may influence my behaviour and practice. For example, I might be less willing to tell people that I don’t have a way to reduce their pain. I might pursue more “heroic” healthcare – send people off for more treatments, try for longer with unsuccessful treatments “just in case”, I might even send people away from my care because I find it hard to tolerate being around someone who “doesn’t respond”.

You see, being empathic and catastrophising tends to elevate feelings of distress in the presence of pain. If we don’t have effective ways to manage our own distress when we are in the presence of someone who is indicating they’re sore, we’re at greater risk of developing burnout and of feeling frustrated (Gleichgerrcht & Decety, 2014).

For this reason I’m a fan of using mindfulness because it does help people to step back from the emotional judgements of experience, and in particular the negative impact such judgements have on both interactions and emotions (Dobkin, Bernardi & Bagnis, 2016).

 

Cheng Y, Chen C, Lin CP, et al. Love hurts: an fMRI study. Neuroimage. 2010;51:923–929.

Cuff, B. M. P., Brown, S. J., Taylor, L., & Howat, D. J. (2014). Empathy: A review of the concept. Emotion Review, 8(2), 144-153. doi:10.1177/1754073914558466

Decety, J., Yang, C.-Y., & Cheng, Y. (2010). Physicians down-regulate their pain empathy response: An event-related brain potential study. Neuroimage, 50(4), 1676-1682.

Dobkin, P. L., Bernardi, N. F., & Bagnis, C. I. (2016). Enhancing clinicians’ well-being and patient-centered care through mindfulness. Journal of Continuing Education in the Health Professions, 36(1), 11-16.

Edwards, R. R., Dworkin, R. H., Sullivan, M. D., Turk, D. C., & Wasan, A. D. (2016). The role of psychosocial processes in the development and maintenance of chronic pain. The Journal of Pain, 17(9, Suppl), T70-T92.

Gleichgerrcht, E., & Decety, J. (2014). The relationship between different facets of empathy, pain perception and compassion fatigue among physicians. Frontiers in behavioral neuroscience, 8, 243.

Gougeon, V. M., Gaumond, I. P., Goffaux, P. P., Potvin, S. P., & Marchand, S. P. (2016). Triggering descending pain inhibition by observing ourselves or a loved-one in pain. Clinical Journal of Pain, 32(3), 238-245.

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… a little more about Pain Catastrophising subscales


I’ve been writing about the Pain Catastrophising Scale and how to use this instrument in clinical practice these last two posts here and here because the construct of catastrophising (thinking the worst) has become one of the most useful to help identify people who may have more distress and disability when dealing with pain. Today I want to continue with this discussion, but looking this time at a large new study where the subscales magnification, rumination and hopelessness have been examined separately to understand their individual impact on pain severity and disability.

Craner, Gilliam and Sperry looked at the results of 844 patients with chronic pain prior to taking part in a group programme (a heterogeous sample, rather than a single diagnosis, so this group probably look at lot like those admitted to high intensity tertiary chronic pain management services such as Burwood Pain Management Centre here in Christchurch).  Most of the participants were female, European/white and married, and had chronic pain for an average of 10.7 years. Just over half were using opioid medication to manage their pain.

Along with the PCS, participants also completed some very common measures of disability (Westhaven-Yale Multidimensional Pain Inventory – MPI) and quality of life (SF-36), and the CES-D which is a measure of depression.

Now here comes some statistical analysis: multiple hierarchical regression! Age, sex, duration of pain and use of opioids were entered into the equation and found to account for only 2.0% variance of the pain severity subscale of the MPI – but once the PCS was added in (subscales entered separately) an additional 14% of the variance was accounted for, but the helplessness subscale was the only one to contribute significantly to the overall variance.

When Pain Interference was  entered as the dependent variable, all the same demographic variables as above contributed a meagre 1.2% of the variance, but when the Pain Severity subscale scores were added, 25.5% of the variance was explained – while the combined PCS subscales contributed 6.5% of the variance. Again, helplessness was the only subscale to contribute to Pain Interference.

Moving to quality of life – the physical subscale of the SF-36 was used as the dependent variable, and once again the demographic variables accounted for only 1.5% variance in physical QOL, with Pain Severity accounting for 23%. PCS subscales contributed only 2.6% of the variance, with only the magnification subscale being identified as a unique contributor. When the mental health subscale was used, again demographics only accounted for 1.2% of variance, with pain severity accounting for 12.4% of the variance. This time, however, the PCS subscales contributed 19.5% of the variance with both Magnification and Helplessness contributing to the variance.

Finally, examining depression, demographics contributed a small amount of variance (3.3%), with pain severity additing 9.8% of variance. The PCS subscales were then entered and contributed a total of 21% to the prediction of depression with both Magnification and Helplessness contributing to the overall depression variance.

The so what factor

What does this actually mean in clinical practice? Well first of all this is a large group of patients, so we can draw some conclusions from the calculations – but we need to be a little cautious because these participants are a group who have managed to get into a tertiary pain management facility. They’re also a group with a large percentage using opioids, and they were pretty much all European – and from North America, not New Zealand. I’m not sure they look like the people who might commonly come into a community-based facility, or one where they’d be referred directly from a GP or primary care centre.

At the same time, while this group may not look like the people most commonly seen for pain management, they share some similar characteristics – they tend to magnify the “awfulness” of pain, and then feel helpless when their pain is bothering them. Surprisingly, I thought, ruminating or brooding on pain wasn’t a unique contributor and instead the helplessness scale contributed the most to pain severity, pain-related interference (disability associated with pain), poor mental health quality of life, and low mood, while magnification scale contributed to poorer physical health quality of life, mental health quality of life and low mood.

What this means for practice

The authors suggest that the construct measured by the helplessness subscale might be a factor underlying poor adaptation to life’s difficulties in general, leading to passivity and negative emotions. They also suggest that magnification might be a unique contributor to perceiving obstacles to doing the things we need to do every day, while hopelessness might mean people are less likely to participate in enjoyable activities and then in turn contribute to feeling low.

Importantly, the authors state: “We offer that simply collapsing the 3 dimensions of this phenomenon (ie, rumination, magnification, helplessness) may actually conceal nuanced relationships between specific dimensions of catastrophizing and outcomes that would might inform treatment approaches.” Looking at the overall scores without thinking about the subscales is going to give you less information to use for individualising your treatment.

In a clinical setting I’d be reviewing the individual subscales of the PCS alongside both disability and mood measures to see if the suggested relationships exist in the scores this person has given.

I’d be taking a look at the repertoire of coping strategies the person can identify – and more, I’d be looking at how flexibly they apply these strategies. Extending the range of strategies a person can use, and problem-solving ways to use these strategies in different activities and contexts is an important part of therapy, particularly occupational therapy and physiotherapy. Another approach you might consider is helping people return to enjoyable activities that are within their tolerance right here, right now. By building confidence that it’s possible to return to things that are fun we might counter the effects of helplessness, and help put pain back where it belongs – an experience that we can choose to respond to, or not.

I’d also be taking a look at their tendency to avoid feeling what their pain feels like, in other words I’d like to see if the person can mindfully and without judging, complete a body scan that includes the areas that are painful. This approach is intended to help people notice that alongside the painful areas are other nonpainful ones, and that they can successfully be with their pain and make room for their pain rather than attempting to block it out, or over-attend to it. The way mindfulness might work is by allowing people to experience the sensations without the judgement that the experience is bad, or indicates some terrible catastrophe. It allows people to step back from the immediate reaction “OMG that’s BAD” and to instead take time to view it as it actually is, without the emotional halo around it.

Pain catastrophising is a useful construct – but I think we need to become more nuanced in how we use the scores from the questionnaire.

Craner, J. R., Gilliam, W. P., & Sperry, J. A. (2016). Rumination, magnification, and helplessness: How do different aspects of pain catastrophizing relate to pain severity and functioning? Clinical Journal of Pain, 32(12), 1028-1035.

solving the problems of the world

…but I thought a new knee would fix my pain!


ResearchBlogging.org
Working in an orthopaedic surgery department is quite enlightening. Along with discussions about ceramic vs metal implants and cartilage regeneration (I work with a team of researchers looking at how to create replacement cartilage), the topic of what counts as a surgical success in knee surgery also comes up from time to time. Knee joint replacement isn’t as successful as hip joint replacement for a number of reasons including the complex nature of the joint, the way the joint capsule is disrupted during surgery, and the knee can apparently feel quite different from the original knee.

What this means is there can be quite a mismatch of expectations for people who believe very strongly that there should be no pain and they should have a completely normal knee joint after surgery. In fact, in the NZ National Joint Registry, the main reason recorded for knee joint revision is pain.

Naturally, the problem of pain after surgery is something surgeons and researchers are also interested in. Many studies have shown psychological factors such as catastrophising (thinking the worst) and low mood are associated with poorer outcomes (Riddle, Wade. Jiranek, & Kong, 2010; Roth, Tripp, Harrison, Sullivan & Carson, 2007; Shelby, Somers, Keefe, Pells, Dixon & Blumenthal, 2008).  The outcomes looked at so far include length of stay in hospital at the time of surgery, analgesia use during surgery, increased disability after surgery and revision rates.

Now, one solution to this problem could be simply not performing joint replacement surgery in people who are depressed and tend to think the worst. The problem is that two of the strongest predictors for looking for treatment are – you guessed it: low mood and catastrophising (and disability). Another solution is to provide intervention after surgery to target the people who tend to become fearful – perhaps an enhanced level of physiotherapy for this group, while the less vulnerable may even require less. Some studies have also looked at giving better education about what the surgery entails and the expected outcomes, and doing this before the person undergoes surgery, while another study has looked at providing a pain coping skills training course prior to surgery (Riddle, Wade, Jiranek & Kong, 2011). The outcomes from this last approach were promising, although it was a very small sample size, and the follow-up was for only two months.

There are a number of problems with implementing any of these approaches in clinical practice, at least in the system I’m most familiar with (NZ):

  1. Many orthopaedic surgeons still discount the importance of psychological factors, and consider the information they provide completely adequate for presurgical preparation
  2. It’s difficult to give someone different or special treatment based on psychological factors within a usual clinical setting without also inadvertently giving people a label that may change how they are responded to
  3. Any additional intervention will have an up-front cost (not good for cost accountants!)
  4. These treatments need specially trained clinicians who understand the measures being used, the rationale for treatment, and the type of treatment needed – and because these are psychological factors and surgery is conducted in a “physical” hospital, this is unfamiliar territory for many
  5. Patients may not be very comfortable with a treatment that focuses on thoughts, emotions and pain

It seems to me, and from the results from a recent study looking at analgesic use after surgery, that an argument simply based on the cost of failing to go ahead with effective management of psychosocial factors would make sense. Here’s the detail:

Fuzier, Serres, Bourrel, Palmaro, Montastruc and Lapeyre-Mestre (2014) conducted a large study of patients in the Midi-Pyrenees region of France. They examined the medical records of all 1939 patients who had knee arthroplasty, and compared the drug use (what was dispensed) at four times – 12 months before surgery, 2 months before surgery, and 10 months before and after the knee surgery.  What they found was an increase in analgesic, antineuropathic and opioid drug use in the 12 months after surgery. The actual percentage of patients requiring more medication is astonishing: 47% of people needed more analgesia, 8.6% needed more antineuropathic medications, and 5.6% needed more opioids. That’s a whole lot of drugs!

These researchers also analysed a number of other variables associated with the medication changes, and made some more understandable findings:

  • people having total knee replacement surgery were at a greater risk of using more medication than those having unicompartmental surgery (half a joint)
  • people with high levels of preoperative pain along with “psychiatric vulnerability” were at greater risk of having increased neuropathic medications prescribed
  • but older people were less likely to be prescribed additional medications

Unfortunately, this study didn’t identify the particular “psychiatric vulnerabilities” of the patients who participated – from the paper it looks like data was extracted from clinical records, so psychiatric disorders such as depression, anxiety and so on are the likely culprits. We don’t therefore know whether catastrophising contributed to the medication use – but given the results from at least 20 studies I have in my database, I think it’s probably likely.

Medications are not cheap. While they’re quick to prescribe, dispense and take, they cost not only in fiscal terms (which is a serious consideration, nevertheless), but also in side effects – and more importantly, in loss of personal locus of control. What I mean by this is that these are people who haven’t been given the opportunity to develop pain self management skills. They will continue to catastrophise, and perhaps even more so after surgery because their fears have been confirmed. Maybe it’s cheaper and more humane to bite the bullet and begin giving people appropriate psychosocial treatment before, during and after surgery.

Fuzier, R., Serres, I., Bourrel, R., Palmaro, A., Montastruc, J., & Lapeyre-Mestre, M. (2014). Analgesic drug consumption increases after knee arthroplasty: A pharmacoepidemiological study investigating postoperative pain PAIN®, 155 (7), 1339-1345 DOI: 10.1016/j.pain.2014.04.010

Riddle, D. L., Keefe, F. J., Nay, W. T., McKee, D., Attarian, D. E., & Jensen, M. P. (2011). Pain coping skills training for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty: a quasi-experimental study. Archives of Physical Medicine & Rehabilitation, 92(6), 859-865.

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.

Roth, M. L., Tripp, D. A., Harrison, M. H., Sullivan, M., & Carson, P. (2007). Demographic and psychosocial predictors of acute perioperative pain for total knee arthroplasty. Pain Research & Management, 12(3), 185-194.

Shelby, Rebecca A., Somers, Tamara J., Keefe, Francis J., Pells, Jennifer J., Dixon, Kim E., & Blumenthal, James A. (2008). Domain specific self-efficacy mediates the impact of pain catastrophizing on pain and disability in overweight and obese osteoarthritis patients. Journal of Pain, 9(10), 912-919.

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The language of pain


ResearchBlogging.org
Have you ever wondered about the ways we communicate our pain? Pain behaviour doesn’t just include nonverbal communication – one of the main ways we communicate our pain is through speech. Words are an incredibly powerful aspect of pain behaviour that strikes me as something we haven’t really studied much. When I was searching for the article to refer to in this post, I looked in PsychInfo under the terms “linguistics” and “pain” – and out of the tens of thousands of articles under each term, and total of 16 included both words. Sixteen!

The stimulus for this post comes from someone who said the term “catastrophising” is a misnomer – a way for health professionals to dismiss or minimise the suffering and distress someone who has pain is experiencing. In this person’s words “Now its no longer just a buzzword but a label that pain docs like to attach to everyone in chronic pain who indicates they are suffering. And of course as most pain docs dont particularly care for hearing about suffering of those in pain they then attempt to get them to go for some cbt or psychotropics.”

Now, I preface this next section with the notice that I’m no linguist (although it’s something I’d love to learn about!).  But in a paper by Elena Semino, it’s absolutely fascinating to read about the ways in which people describe pain – she starts by saying “sensations conveyed by the English word pain tend to be described via expressions that refer to potential causes of bodily damage.”  Note the word “causes”.  She gives the example of someone describing their pain as “sharp“, “like a rake over my eyes and head, digging in and scraping away”, noting that “expressions such as “sharp pain” function metonymically when they describe pain that directly results from physical damage, and metaphorically when no such damage is involved”.  (BTW Metonyms are figures of speech that replace a word with a word that is intimately associated with that thing or concept.  For example, in New Zealand “the Beehive” refers to Parliament, because that is the name of the building in which Parliament is housed.)

The reason we use terms like “sharp” or “stabbing”, argues Semino, is that “that these uses of metaphor may facilitate some form of internal embodied simulation of pain experiences on the part of listeners/readers, which may in turn provide the basis for an empathic response.”

Pain behaviour of all types functions in the same way – evolutionary psychologists suggest that they are remnants of early signalling behaviour designed to elicit a response from those around the individual.  It makes sense that if a group of prehistoric people are hunting, someone who has pain can signal to others through crying or groaning that “something’s wrong”, hopefully eliciting some sort of caring behaviour from the rest of the troup, with the withdrawal response later helping the individual remain still and quiet in the back of the cave so as to minimise the potential for sabretooth snacking!

What Semino and others postulate is that the language we use when describing pain draws upon the neurophysiological aspects of shared experience or empathy – the “mirror neurones”.   fMRI studies of the anterior cingulate cortex, the bilateral anterior insula, rostral anterior cingulate cortex and the sensorimotor areas of the neuromatrix (aka “pain” matrix – but this is probably a misnomer) show these are activated when individuals observe another person experiencing a painful procedure or hear words describing these procedures. 

Semino quotes Avenanti et al., (2005) who suggests that there are “two forms of empathy linked to one another in an evolutionary and developmental perspective.  A comparatively simple form of empathy, based on somatic resonance, may be primarily concerned with mapping external stimuli onto one’s body.  A more complex form of empathy, based on affective resonance, may deal with emotional sharing and with the evaluation of social bonds and interpersonal relations. p.958”.

Semino therefore proposes that metaphorical descriptions of pain that allude to causes of physical damage may trigger embodied simulations of similar experiences – and that both types of empathy are enacted when we use descriptive metaphors when talking about pain.

OK, where does this leave us when thinking about “catastrophising”? Catastrophising is the tendency to “think the worst” in a situation.  An example might be saying “my headache is killing me”.  Catastrophising influences an individuals appraisal of their situation.  Although this way of describing their situation does convey an individuals level of distress, catastrophic interpretations actually impede effective problem solving and active coping.  Catastrophising is associated with increased disability, high distress, low mood and high helplessness.

Is it normal to catastrophise?  At times, yes.  Most of us will do a little catastrophising from time to time, if we’re honest with ourselves.  But even if it’s normal, catastrophising isn’t helpful.  Again, most of us will catastrophise for a short while, then change our thinking and begin to speak differently and approach our situation differently – usually with a view to taking steps to exert some level of control over our situation.

I think it’s important to consider our use of language as health professionals, and it’s one reason for thinking about how we write reports, for example.  While we have our own technical language and use it amongst ourselves (and the term catastrophising is one of them) we need to be aware that people who don’t know the meaning of these terms can misconstrue them.  And in the case of some patients, feel misunderstood and sometimes offended.  We need to think about this and avoid using jargon where practicable.

More importantly, we need to be incredibly careful not to use terms in a pejorative or dismissive way.  We’ve moved a long way from describing a woman with pain as being “hysterical” – but terms like “functional pain” or “supratentorial” or “malingering” can still be found in some reports.

I think the best thing we can do when we’ve been talking with someone who does “catastrophise” is make it clear that we are not dismissing their pain as less than what they say it is, but instead to be sensitive to their language and reflect that their pain is very distressing and difficult to deal with.  Because in the end, that’s what the language used when sone tends to catastrophise is intended to elicit from us. 

Descriptions of Pain, Metaphor, and Embodied Simulation Metaphor and Symbol, 25 (4), 205-226 DOI: 10.1080/10926488.2010.510926

Avenanti, A., Bueti, D., Galati, G., & Aglioti, S. (2005). Transcranial magnetic stimulation highlights the sensorimotor side of empathy for pain. Nature Neuroscience, 8, 955-960.

Recovering from a wrist or ankle fracture: pain-related fear, catastrophising and pain influences outcome


ResearchBlogging.org
I have no idea how many wrist and ankle fractures occur every year, but I can bet it’s not a small number by any imagination. For most of us, I’m guessing we’d expect to have a fracture, wield a wonderfully-autographed cast, get it removed and go on our merry way – but after reading this article, and having seen some very sad people over the years, perhaps my expectations of speedy return to normal might be over-inflated!

This paper by Linton and colleagues from Orebro, Sweden, is a novel one in that most of our knowledge about chronic pain comes from observing people recovering from low back pain. After all, low back pain is one of the most common pains, it’s the one that produces the most long-term work disability, and treatments for it eat up health budgets like little else. BUT, in a fracture, we have a nice clear-cut incident that begins the process of recovery, a well-known pathophysiology, and a well-understood recovery process from a biophysical perspective, so it provides us with a great opportunity to see what the risk factors are for longterm pain and disability.

Methodology

I’ll just briefly describe the methodology here – 79 participants were sequentially recruited to the study if they had a distal fracture, were aged between 18 – 70 years, without any other fractures and not experiencing dementia. Nine dropped out and these were older and female. Each participant completed a modified Fear Avoidance Beliefs Questionnaire, completing this in respect of their beliefs about pain before their injury; the Pain Catastrophising Scale, numeric rating scale for pain before the injury, expected recovery at six months, and actual recovery at six months. Mobility and strength were also tested a time one and six months later.

Results
Pain and worry reduced over time, as expected. Pain level started at 4 (ranging between 0 – 8), and dropped at T2 and T3. The number of people reporting no pain or no worry increased from T1 to T3 from 4% to 46% and from 30% to 57%.
69% of patients thought they should be fully recovered within six months when they were first asked. 36% thought this at T2, but the percentage who actually thought they were fully recovered at T3 were only 29%. That means that although most people thought they would be recovered within 6 months, actually less than 1/3 actually were. I certainly didn’t expect that!

Mobility and strength ratings at T3 showed 45% were not fully recovered at six months if they had a wrist fracture, while 33% of people with ankle fractures were not fully recovered. And yes, they do describe the processes used to measure mobility and strength.

Looking at fear-avoidance and catastrophising, there was a bit of work to get the groups divided into high and low levels of fear.
The proportion of patients with low fear at T1 and T2 was 54%, while for catastrophising was 56%. 29% of the participants had a high fear and pain profile at T2. What this lead to, after looking at an odds ratio analysis examining the relationship between fear and catastrophising, was that higher fear-avoidance beliefs increased the risk for pain , but high fear wasn’t significantly related to future self-rated recovery, mobility or strength. For catastrophising, there was a relationship only for strength.

What can we conclude?
OK, apart from the small sample size, and the need to use the strength of the noninjured limb as a substitute for the fractured one at T1, and the authors suggest that taking more frequent repeated measures might have helped; we can conclude a couple of interesting things:

  1. People over-estimate how rapidly they will recover from distal fractures, and expect to be fully recovered within six months, when 2/3 of people won’t be
  2. Higher-than-average scores, or increasing scores on pain-related fear and catastrophising are linked with future pain and recovery levels.  This is similar to the repeated findings in back pain and other types of pain, so shouldn’t be unexpected.
  3. As catastrophising and pain-related fear drop over time, this could mask those who are at risk of failing to recover.

Linton and colleagues suggest that close monitoring of fear-avoidance beliefs and catastrophising over the first few weeks of recovery would help health professionals intervene with psychological input designed to reduce fear and normalise expectations.  In other words, reassure patients that it’s normal for distal fractures to take a lot longer than 6 months to fully settle down.

One problem with this for me is that I don’t know anywhere in New Zealand where fear-avoidance and catastrophising is measured in people who have distal fractures! Most orthopaedic departments are singularly lacking in psychologists, and provided the fracture is uniting, patient’s fears and worries rarely get a look-in!  I can’t speak for GP’s who might have some ongoing input with a person who has a distal fracture, but I’d expect that unless the person attends and asks for help, their worries and fears won’t be identified.  This then means the physiotherapist who might be involved to help improve function (and maybe the occupational therapist) are the ones who may be left trying to address the patient’s fears.

Do we need to introduce another layer of psychological input delivered by psychologists for this group of people?

I think not – I do think maybe occupaitonal therapists and physiotherapists could be mindful of the natural healing process, the time it takes to recover, and be aware of how fear-avoidance and catastrophising interact to produce disability – and start to structure graded activities to increase the  confidence a person can have in their own ability to move.  And perhaps encouraging gradual return to functional activities rather than ‘exercises’ per se could be a better approach.  No gadgets please OT’s!  Learning to use the limb, attending to fear and catastrophising and addressing these quickly are well within the clinical skills of occupational therapists, physiotherapists, nurses and GP’s – so watch, listen and respond, even in these acute and so-called ‘simple’ injuries.

Linton, S., Buer, N., Samuelsson, L., & Harms-Ringdahl, K. (2010). Pain-related fear, catastrophizing and pain in the recovery from a fracture Scandinavian Journal of Pain, 1 (1), 38-42 DOI: 10.1016/j.sjpain.2009.09.004

Health Anxiety


We used to call it hypochondriasis – and that’s a term loaded with unhelpful meanings if ever there was one!  What hypochondriasis meant was ‘it’s in your head, there’s nothing wrong with you, go away and pull yourself together’.  Ask someone who has had an episode of noncardiac chest pain to ‘go away and pull yourself together’!

The definition of heath anxiety is:

– preoccupation with, and fear of developing or having a serious illness

– it persists despite medical reassurance

– this worry interferes with everyday life

– it’s been going on for 6 months or so

Health anxiety is about misinterpreting body sensations and changes and thinking that they are evidence of underlying serious illness – despite reassurance and lack of confirmatory findings from investigations.  What it can lead to is high distress, more medical appointments, more investigations, more visits to the Emergency Department, and reduction of both quality of life and engagement in life.

Salkovskis and colleagues have been workiung with people experiencing health anxiety within a general medical setting as well as people with chronic pain.  I attended a workshop run by Dr Helen Seivewright, a Senior Clinical Research Fellow in a programme run at Imperial College & King’s Mill Hospital, on health anxiety and immediately saw the parallels between people who experience problems with chronic pain and those who have health anxiety.

Health anxiety persists because of:

selective attention leading to bias in processing information about the person’s health condition – for example, the person may only hear parts of the ‘reassurance’ that a doctor gives, so the advice to ‘keep active because you won’t need surgery until you’re much worse than this’ becomes ‘you’ll inevitably become much worse than this even if you keep active’

safety seeking behaviours that may include avoidance (we know about this in terms of pain!), reassurance seeking, and checking (how many MRI’s does a person need?)

physiological arousal causing symptoms of anxiety such as pounding heart, tingling fingers and tight chest

– eventually low mood which can lead to, and reinforce, rumination or thinking, thinking, thinking about what might be going wrong

The model Salkovskis and colleagues uses is a CBT one developed by Beck.  This is where anxiety is = to the likelihood of something horrid multipled by the ‘awfulness’ is divided by the ability to cope + rescue factors.  To help a person with health anxiety means learning to understand their perception of the ‘something horrid’ and the ‘awfulness’, and reality testing the likelihood of that happening, while at the same time helping to increase their ability to cope by developing their own resources, and identifying ‘rescue factors’.

The process of learning to understand the person’s perception of what is going on is fundamental to developing a formulation.  A formulation will include predisposing factors, precipitating factors (for this presentation), perpetuating factors and protective factors – and I use a biopsychosocial model to flesh out the relevant factors for this individual.

The actual strategies introduced as part of the workshop are quite familiar to those who have been using CBT for some time, but I don’t think I’ve mentioned these ones on the blog before.

The first is a pie chart.

Angie has headaches.  She is convinced the headaches are a sign of a tumour but despite lots of reassurance and and MRI, she isn’t ready to accept that there is no sign of a tumour.  In a pie chart, all the possible causes for headaches are listed – making sure there are plenty of low threat examples in there like dehydration, hunger, fatigue, hangover and so on.

Then, starting with the low threat examples first, we ask Angie to tell us what percentage of people in the local supermarket would have a headache from fatigue – maybe 40%.  We mark this in on the pie chart.  Then we go on to stress, and ask how many might have a headache from stress – she might say ‘around 25%’ – so we mark this in on the pie chart.  We work through all the common causes for headaches, using Angie’s percentages (and we ask her to ‘have a guess’ if she’s uncertain), until we come to the ‘serious’ factors like stroke, tumour and so on.  By this time the pie chart has very little room left for these – so it starts to reality test Angie’s belief that her headache is definitely a tumour.  We let her draw her own conclusions about her own headache, but we ask her to go away and think about the pie chart.  The aim of this activity is to normalise what is a common experience, but which Angie has misperceived as a highly threatening and personalised problem.

Causes for headaches
moar funny pictures

You can also do this as a pyramid – where at the bottom are all the people who have been seen by a GP for headache, then maybe 20% of them are seen again (this can be the next layer on the pyramid), then maybe 5% might need further investigation as another layer, 2% of these might come back as abnormal on the next layer, 1% of these need to be referred to hospital as the next layer, half of the people referred to hospital might have a disease that is significant, and finally on top of that a teeny tiny proportion have something really nasty.

Again this is one way of normalising and reducing the threat value of the belief that the person has. It won’t remove their anxiety, but it might help reality test it a little, and help them start to look at their problem in a slightly less catastrophic way.

More about this tomorrow!