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Pain Catastrophizing and Depression in the Chiropractic Patient Population: a Literature Review

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Pain Catastrophizing and Depression in the Chiropractic Patient Population: a Literature Review Pain Catastrophizing and Depression 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 1 ABSTRACT Objective: In this review, the author discusses the concept of pain 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 chronic pain that includes a cognitive-behavioral approach. Key Words: Pain catastrophizing, depression, pain. 2 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: 5 “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
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