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Pain Catastrophizing Predicts Pain Intensity, Disability, and Psychological Distress Independent of the Level of Physical Impairment

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Pain Catastrophizing Predicts Pain Intensity, Disability, and Psychological Distress Independent of the Level of Physical Impairment The Clinical Journal of Pain 17:165–172 © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia Pain Catastrophizing Predicts Pain Intensity, Disability, and Psychological Distress Independent of the Level of Physical Impairment *Rudy Severeijns, M.Sc., †Johan W. S. Vlaeyen, Ph.D., †Marcel A. van den Hout, Ph.D., and ‡Wim E. J. Weber, Ph.D. *Department of Medical Psychology and ‡Pain Management and Research Center, University Hospital of Maastricht; and the †Department of Medical, Clinical and Experimental Psychology, University of Maastricht, Maastricht, The Netherlands Abstract: Objective: The aim of the current study was to examine the relation between catastrophizing and pain intensity, pain-related disability, and psychological distress in a group of patients with chronic pain, controlling for the level of physical impairment. Furthermore, it was examined whether these relations are the same for three subgroups of chronic pain patients: those with chronic low back pain, those with chronic mus- culoskeletal pain other than low back pain, and those with miscellaneous chronic pain complaints, low back pain and musculoskeletal pain excluded. Design: Correlational, cross-sectional. Patients and Setting: Participants in this study were 211 consecutive referrals presenting to a university hospital pain management and research center, all of whom had a chronic pain problem. Results: Overall, chronic pain patients who catastrophize reported more pain in- tensity, felt more disabled by their pain problem, and experienced more psychological distress. Regression analyses revealed that catastrophizing was a potent predictor of pain intensity, disability, and psychological distress, even when controlled for physical impairment. No fundamental differences between the three subgroups were found in this respect. Finally, it was demonstrated that there was no relation between physical impairment and catastrophizing. Conclusions: It was concluded that for different subgroups of chronic pain patients, catastrophizing plays a crucial role in the chronic pain experience, significantly con- tributing to the variance of pain intensity, pain-related disability, and psychological distress. These relations are not confounded by the level of physical impairment. Some clinical implications of the results are discussed. Finally, the authors concluded that these results support the validity of a cognitive–behavioral conceptualization of chronic pain–related disability. Key Words: Back pain—Catastrophizing—Disability—Pain intensity— Psychological distress—Physical impairment. Recently, there has been a growing focus on the role of research, some consistent findings are emerging. First, in psychological factors in chronic pain research. From this chronic pain, pathophysiologic processes do not ad- equately explain the levels of pain and disability§1 that Received November 3, 2000; revised February 9, 2001; accepted February 21, 2001. §Disability is defined as any restriction or lack of ability to perform Address correspondence to Dr. R. Severeijns, Department of Medical an activity in the manner or within the range considered normal for a Psychology, University Hospital of Maastricht, PO Box 5800, 6229 HX human being that results from an impairment (World Health Organi- Maastricht, The Netherlands; email: [email protected] zation definition). 165 166 SEVEREIJNS ET AL. chronic pain patients report.2–7 In other words, there is pain problem, and experience more psychological dis- no strong relation between objective physical impair- tress. To rule out the possibility that physical impairment ment࿣ and pain and disability. Second, catastrophizing, is a confounding variable, we will analyze it as a covari- which is defined as “overappraisal” of the negative ate. For exploratory reasons, we will also examine aspects/consequences of an experience,8,9 appears to whether these relations apply to different subgroups of play an important role in the chronic pain experience10–16 chronic pain patients (i.e., whether there is an interaction and has been consistently linked to, among others, pain effect between catastrophizing and group membership). intensity, pain-related disability, and psychological dis- Confirming the aforementioned hypotheses across ho- tress.13,17–26 Third, there are some prospective studies mogeneous subgroups with different medical diagnoses that suggest that catastrophizing is a precursor of pain would signify additional support for the important role of problems rather than a consequence.27–30 These findings catastrophizing in the chronic pain experience. The fol- corroborate a cognitive–behavioral conceptualization of lowing subgroups are distinguished: a group of CLBP chronic pain, elaborated in a model by Vlaeyen et al.,3 patients, a group of patients with chronic musculoskele- which assumes that catastrophizing in relation to pain tal pain other than low back pain (e.g., chronic neck pain promotes fear of movement/(re)injury. The latter, in turn, or shoulder pain), and a group of patients with miscel- leads to avoidance behavior, disuse, disability, and laneous pain complaints, low back pain and other mus- depression. culoskeletal pain excluded (e.g., headache, abdominal Nevertheless, some questions remain to be resolved. pain, facial pain). Although there appears to be only a moderate relation between physical impairment and pain intensity and dis- METHODS ability, there are at least two studies that suggest a sig- nificant relation between catastrophizing and physical Participants and procedure 13,14 13 impairment. Main and Waddell found a significant Participants in this study were 211 consecutive refer- p < 0.001) between objective physical rals presenting to a university hospital pain management ,0.32 ס relation (r impairment and catastrophizing, as measured by the and research center. All participants had a chronic pain 31 Coping Strategies Questionnaire subscale. Reesor and problem (i.e., pain duration of at least 6 months). The 14 Craig found that patients with chronic low back pain sample consisted of 75 men and 136 women with a mean Three rather homogeneous .(14.3 ס CLBP) who displayed more nonorganic signs and age of 48 years (SD) symptoms¶ (termed “incongruent” patients) had greater subgroups of chronic pain patients could be distin- physical impairment and disability and catastrophized guished, taking into account the fact that the subgroups more about their pain than so-called “congruent” CLBP had to be large enough to permit statistical analyses (i.e., patients. In line with this, it cannot be ruled out that regression analyses). Of the total sample, 54 participants physical impairment is a confounding variable, however (25.6%) suffered from CLBP, 107 (50.7%) suffered from remote that possibility might be. In contrast, if the cog- chronic musculoskeletal pain other than low back, and 50 nitive–behavioral model of catastrophizing and fear of participants (23.7%) had miscellaneous chronic pain 3 movement/(re)injury is valid, it is to be expected that problems, back pain and musculoskeletal pain excluded the relation between catastrophizing and pain intensity, (e.g., headache, abdominal pain, facial pain, thoracic pain-related disability, and psychological distress holds, pain). The mean duration of the pain complaints was 6.8 Of the total sample, 9.5% were on sick .(8.4 ס irrespective of the level of physical impairment. This has years (SD yet to be demonstrated in research. leave, 28.9% received financial disability compensation, The aim then of the current study was to investigate and 61.6% received no compensation. In addition, 11.1% the relation between catastrophizing and pain intensity, of the participants used supportive equipment for ambu- pain-related disability, and psychological distress in a lation (brace, crutches, corset, etc.), and 1.9% of the group of patients with chronic pain. We hypothesized participants were dependent on a wheelchair or electric that overall, chronic pain patients who catastrophize ex- scooter for ambulation. As part of the standard intake perience more pain intensity, feel more disabled by their procedure, participants were asked to complete a number of questionnaires. ࿣Physical impairment is defined as “an anatomical or pathological abnormality leading to loss of normal body ability.” Measures ¶Nonorganic signs are defined as “behaviors elicited during an or- thopedic examination procedure which deviate from anatomical prin- Physical impairment ciples.” Nonorganic symptoms are defined as “endorsement of symp- toms which are exaggerated and do not conform to anatomy or disease The Medical Examination and Diagnostic Information course.” Coding System (MEDICS)32 was used. MEDICS is a The Clinical Journal of Pain, Vol. 17, No. 2, 2001 PAIN CATASTROPHIZING 167 method that is designed to quantify the extent of physical Pain catastrophizing findings in chronic pain patients. From this system, a In this study, we used the Dutch version (an unpub- pathology index can be computed, which is a weighted lished, 1996 translation by G. Crombez and JWS logit score based on 18 common biomedical procedures Vlaeyen) of the Pain Catastrophizing Scale (PCS).36 This (e.g., computed tomography scan, muscular function, is a 13-item scale in which participants are asked to neurologic examination) used in the assessment of the reflect on past painful experiences and indicate the de- causes of pain in chronic pain patients. For this purpose, gree to which they experienced thoughts or feelings dur-
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