Pain Catastrophizing and in the Chiropractic Patient Population: A Literature Review

Author: Terence Crowley

Faculty Advisor: Rodger Tepe, PhD

A senior research project submitted in partial requirement for the degree Doctor of Chiropractic

March 22, 2011

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ABSTRACT

Objective: In this review, the author discusses the concept of catastrophizing as it is related to depression and low mood disorders.

Methods: A computer search using PubMed and the Rehabilitation Reference Center generated articles relevant to pain catastrophizing, depression and multidisciplinary pain treatment programs.

Discussion: “Pain catastrophizing is characterized by the tendency to magnify the threat value of pain stimulus and to feel helpless in the context of pain, and by a relative inability to inhibit pain-related thoughts in anticipation of, during or following a painful encounter” (6). The author then reviews the current assessment measurements of pain catastrophizing. Then the author discusses the proposed mechanisms of pain catastrophizing; cognitive, psychosocial, central nervous system mechanisms, cortical changes and physiological. The author concludes the review with a discussion of the importance on implementing a multidisciplinary treatment program for pain that involves a cognitive-behavioral approach.

Conclusion: The current literature recognizes a significant correlation between pain catastrophizing and depression that exists within the general population. The researchers in this field have developed assessment tools to quantify a measure of pain catastrophizing. In addition, several mechanisms have been proposed to explain the pain catastrophizing experience. The researchers describe a mutually inclusive model of pain catastrophizing that includes cognition, psychosocial, central nervous system changes, neural correlates and physiological responses. Furthermore, the literature states the importance and effectiveness of implementing a multidisciplinary approach to treating that includes a cognitive-behavioral approach.

Key Words: Pain catastrophizing, depression, pain.

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INTRODUCTION

It is apparent to physicians that pain catastrophizing and depression exist within our patient population. And, that these two constructs are not mutually exclusive. It is estimated that depression has a combined prevalence varying between countries but is over 10% in most

Western countries (1,2). The majority of such patients are treated in a primary care setting (3).

In 2002, the U.S. Preventive Services Task Force (USPSTF) recommended screening adults for depression in clinical practices that have systems to ensure accurate diagnosis, effective treatment, and follow-up (4). A major depressive episode is characterized by the presence of a severely depressed mood that persists for at least two weeks. The signs and symptoms of a major depressive episode is a patient who exhibits a very low mood, which pervades all aspects of life, and an inability to experience pleasure in activities that were formerly enjoyed.

Depressed people may be preoccupied with thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness, hopelessness and self-hatred (5). The current management of depression includes psychotherapy, antidepressant medication, electroconvulsive therapy, deep brain stimulation, physical exercise and nutrition. There are myriads of causes for depression some of which include chronic disease, chronic fatigue, genetics, psychosocial factors, sedentary lifestyle and chronic pain (6).

For the Chiropractic physician the perception of pain and its subsequent catastrophization is possibly the most significant cause of depression in our patient population. Pain as a symptom, now considered the fifth vital sign, accounts for approximately 80% of physician visits and an estimated $100 billion annually between healthcare expenditures and lost productivity (7). Pain- related catastrophizing is broadly conceived as a set of exaggerated and negative cognitive and

3 emotional schema brought to bear during actual or anticipated painful stimulation (8). Campbell and Edwards stated that pain-coping strategies influence perceived pain intensity and physical functioning, and individual differences in styles of pain coping even shape the persistence of long-term pain complaints in some populations (8).

This literature review will focus on the relationship between pain catastrophizing and depression, the assessment measures of catastrophizing, the proposed mechanisms of catastrophizing and the management strategies for pain catastrophizing.

For this review, articles were searched in PubMed and the Rehabilitation Reference Center. A selective search strategy was used with the combination of “depression”, “mental health”,

“catastrophizing”, “prevalence”, “diagnosis” and “management”.

In PubMed when the phrase “pain catastrophizing” was limited to randomized control trial there were 67 results. A further refined search with the combined phrase “pain catastrophizing and depression” yielded 19 results. When the phrase “pain-catastrophizing + depression + prevalence” was searched it yielded 20 results.

DISCUSSION

Depression and Pain

A recent study reported the prevalence of pain in depressed patients was 59.1% (9). Quartana et al found that pain catastrophizing has been cross-sectionally and prospectively linked to exaggerated negative mood and depression (6) Furthermore, Beck et al reported that initial

4 conceptualizations of pain catastrophizing considered maladaptive thoughts to be latent in depressed patients suffering from chronic pain (10).

Miro et al (2009) conducted a study to assess the role of biopsychosocial factors in patients with type 1 myotonic and facioscapulohumeral muscular dystrophy (MMD1/FSHD) with chronic pain. The researchers found an association between both psychological functioning and pain interference in a sample of 182 patients suffering from chronic pain. Participants completed surveys assessing pain interference and psychological functioning, as well as psychosocial, demographic, and injury-related variables. The researchers concluded that greater catastrophizing was associated with increased pain interference and poorer psychological functioning, pain attitudes were significantly related to both pain interference and psychological functioning, and coping responses were significantly related only to pain interference (11).

This relationship between depression and pain catastrophizing is a crucial point given the high rates of suicide amongst people suffering from chronic pain (12). A study by Edwards et al suggested that pain catastrophizing was related to increased suicidal ideation in a large sample of chronic pain patients (13).

Pain Catastrophizing

In 2009, Quartana et al reviewed the literature on pain catastrophizing and devised the following definition of pain catastrophizing:

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“Collectively, pain catastrophizing is characterized by the tendency to magnify the threat value of pain stimulus and to feel helpless in the context of pain, and by a relative inability to inhibit pain-related thoughts in anticipation of, during or following a painful encounter (6).”

Furthermore, he noted two distinct assessments of pain catastrophizing; the Coping Strategies

Questionnaire (CSQ) and the Pain Catastrophizing Scale (PCS). The CSQ, developed by

Rosentiel and Keefe (12) included a six-item subscale tapping dimensions of helplessness and pessimism in the context of pain. The PCS was developed by Sullivan et al and it elaborated on the CSQ by incorporating items explicitly designed to assess other elements of catastrophizing such as helplessness, rumination and magnification (13). Quartana et al state that the PCS is the most comprehensive assessment instrument to date of the catastrophizing construct. However, he states that an area of assessment that is currently underdeveloped is that considering the behavioral elements of pain catastrophizing.

Campbell et al (2010) reiterated the importance of developing a precise and accurate measurement of pain catastrophizing. The study states the importance of the multidimensional assessment of pain-related catastrophizing, and suggests a role for measuring catastrophizing related to specific, definable painful events (14).

Proposed Mechanisms of Pain Catastrophizing

There are four essential mechanisms that may explain the evolution of pain catastrophizing behaviors; cognitive, psychosocial, central nervous system, and physiological.

The cognitive mechanism is also referred to as the attention/information bias mechanism. Some researchers have proposed that pain catastrophizing might be characterized by attention and

6 information processing biases analogous to those observed in individuals with anxiety and depressive disorders (17). Adding to this point, Quartana et al remarks that “pain catastrophizing is rooted in traditional cognitive–behavioral conceptualizations of anxiety and depression, and is characterized substantially by a relative inability to suppress or inhibit pain- related cognitions” (6).

The psychosocial model of pain catastrophization is characterized by a communal positive and negative reinforcement of a person‟s perception of pain. Sullivan and colleagues advanced a communal coping model, suggesting that catastrophizing represents an interpersonal style of coping with pain and suffering (18). The model hinges on the notion that catastrophizing represents a behavioral coping strategy employed by individuals experiencing pain to elicit emotional and/or tangible support from others, thereby positively reinforcing pain and illness behaviors and undermining successful adaptation to pain (18).

Pain catastrophizing research has uncovered some potential central nervous system involvement in the perception of pain and its magnification. In this area of research two possible mechanisms are being studied; diffuse noxious inhibitory control (DNIC) and temporal summation. Quartana et al describes DNIC as a phenomenon in which the activity of pain-signaling neurons in the dorsal horn is attenuated in response to noxious stimuli applied to a remote site of the body (6).

A recent study by Weissman-Fogel et al identified negative relationships between pain catastrophizing and DNIC, wherein when the DNIC system was non-functional then pain catastrophizing was manifested (19). Temporal summation or „wind-up‟ is a commonly employed measure of pain facilitation, and it has been conceptualized as a psychophysical marker of central sensitization-like processes (20). Quartana et al suggest that pain

7 catastrophizing might be associated with diminished endogenous inhibition of pain coupled with central sensitization, which may represent a CNS mechanism by which pain catastrophizing is associated with the development, maintenance and aggravation of persistent pain (6).

For years investigators have been studying the effects of neuroplastic changes in the context of pain and pain catastrophizing. Investigators have focused particularly on those brain regions involved in processing and regulation of the unpleasantness dimension of pain (21). The research has identified the anterior cingulate cortex (ACC), and the dorsolateral and ventromedial prefrontal cortex (PFC) as the primary regions of neuroplastic change.

In 2006, Seminowicz and Davis found that during mild and intense pain, pain catastrophizing was not significantly associated with activation in primary or secondary somatosensory cortices.

However, during mild pain, pain catastrophizing was associated with exaggerated activity in the

PFC, insular cortex and caudal ACC, suggesting exaggerated processing of the affective dimension of pain. Furthermore, during more intense pain a different pattern emerged, pain catastrophizing was negatively associated with caudal ACC and insular cortex activity, which may suggest a failure of activation of the top-down inhibitory control, or DNIC, in response to severe pain (22).

Another study by Oscner et al showed a similar pattern of correlations using functional neuroimaging with painful and non-painful thermal stimuli, but with measures of pain-related fear and anxiety sensitivity. The authors found that fear of pain correlated positively with pain- related activation in the ventral lateral PFC; believed to be involved in affect regulation, and the

8 posterior ACC; believed to be involved in monitoring and evaluation of affective states in the context of and pain. Oschner et al suggest that fear of pain and pain catastrophizing are likely to activate highly overlapping neural circuits (23).

A new area of study into the mechanism of catastrophizing is in the area of physiology. Flor et al proposed the notion of „symptom-specificity,‟ the researchers suggest that pain catastrophizing might be related to greater chronic low back pain severity and disability via specifically exaggerated muscular responses near the site of injury (24). Furthermore, Quartana et al showed that pain catastrophizing was positively correlated with lower paraspinal, but not trapezius muscle responses, to cold pain in a sample of chronic low back pain patients (25).

Multidisciplinary Approach to the Management of Pain Catastrophizing

In addition to treating the patient‟s injury, a core component of a multidisciplinary pain treatment program is a cognitive–behavioral technique that involves reducing catastrophizing and enhancing adaptive pain-coping skills (6). The use of such techniques is based on the well- documented notion that the manner in which a patient assesses their pain and contextual surroundings has a profound influence on pain, disability and emotional wellbeing (26).

In 2010 Meeus et al conducted a double-blind randomized control study to observe the effectiveness of a pain education program on 48 patients suffering from chronic fatigue syndrome and chronic pain. They concluded that a 30-minute educational session on pain physiology imparts a better understanding of pain and brings about less rumination in the short term. Pain physiology education can be an important therapeutic modality in the approach of

9 patients with chronic fatigue syndrome and chronic pain, given the clinical relevance of inappropriate pain cognitions (27).

Angst et al (2009) conducted a naturalistic prospective controlled cohort study, where they compared 164 chronic pain patients who participated in an interdisciplinary pain program and

143 who underwent standard rehabilitation. The interdisciplinary pain program patients reported greater improvement on pain (multivariate p = 0.034), social functioning (bivariate p = 0.009), and an ability to decrease pain. The researchers concluded that an intensive interdisciplinary rehabilitation program with more behavioral therapies was accompanied by a greater improvement in patients who were severely affected by pain, compared with standard rehabilitation (28).

Jensen et al conducted two studies that indicates that multidisciplinary pain treatment programs, of which cognitive–behavioral intervention are a core ingredient, can lead to reductions in pain catastrophizing concurrent with reductions in pain, disability and depression. In the first, Jensen et al found that decreases in pain catastrophizing were associated with 6- and 12-month improvements in disability, pain intensity and depression in a heterogeneous sample of pain patients (29). The second found that increases in depression and disability from immediately post-treatment to 12-months post-treatment were associated concurrently with changes in pain beliefs and catastrophizing(30).

CONCLUSION

The pain catastrophizing research, to date, has demonstrated a significant correlation between pain catastrophizing and depression. However, the research requires further study in several key

10 areas. First, in the assessment of pain catastrophizing, Quartana et al states that the current models of pain catastrophizing do not adequately address the behavioral aspects of catastrophizing (6). Moreover, the researchers suggest that using paradigms that manipulate intensity of pain and concomitantly assess pain catastrophizing (i.e., product) and attentional bias

(i.e., process) may shed additional light on the processes that characterize the catastrophizing construct. Second, mechanisms for the process of pain catastrophizing range from the cognitive to the physiological. However, researchers suggest that these mechanisms are not mutually exclusive and future research should focus on a more comprehensive model of multiple processes (6, 17-22). Lastly, Quartana et al suggests that researchers in the field of pain catastrophizing should focus their efforts in the context of psychiatric disorders such as major depression and generalized anxiety disorder as it relates to pain perception, fear of pain and magnification of pain (6). Moreover, researchers suggest that a multidisciplinary approach to the treatment of pain and pain catastrophizing is needed, wherein; a focus of the treatment is cognitive-behaviorally based (6, 26-30).

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