Counterpoint: Catastrophizing Is Real by Any Name

Counterpoint: Catastrophizing Is Real by Any Name

By Ed Coghlan

Over this weekend in her column for the National Pain Report, For Grace founder Cynthia Toussaint openly cringed at the use of “catastrophizing” at a recent Stanford Twitter Chat on chronic pain. We reached out to Beth Darnall PhD, a pain psychologist at Stanford who organized the Twitter chat (and interestingly is writing a book on catastrophizing pain due out in 2017). Here’s our interview:

National Pain Report: “What is a simple definition of catastrophizing?”

Dr. Darnall: “A negative mental set brought to bear in the context of actual or anticipated pain. (MJ Sullivan).  You may wonder how one would not feel negatively about pain.  Pain automatically grabs your attention and can trigger negative emotional responses.  If you remain in that space of pain focus and negative emotions, it will serve to amplify pain in your spinal cord and brain.  The trick is to identify it early, then use strategies to redirect the brain in order to dampen pain processing.”

National Pain Report: “Cynthia Toussaint made the point that using the term is particularly offensive to women in pain–do you agree?”

Dr. Darnall: “The science shows that men and women catastrophize equally.  It is a gender-neutral experience, so I disagree at the surface.  When women have experiences of having been marginalized or judged by medical professionals—their pain was disbelieved—then the term may be experienced as offensive, absolutely.  The experience of being offended is predicated on one’s experience with the professional, and with how the term is used.  It should not be used pejoratively.  Women are more likely to have such pejorative experiences, as Cynthia correctly notes.  On the flip side, ignoring it altogether would be a tremendous and unethical disservice.

We need to be careful here.  Pain is a psychobiological experience with potentially greater implications for women.  I believe we should focus on better treatment that attends to all aspects of the pain experience.

I understand the label “catastrophizing” can be off-putting.  I would love for someone to create an alternative that is both accurate and engenders receptivity.”

National Pain Report: “Pain sufferers do get very defensive when it’s stated or implied that the pain “is in their head”, right?”

Dr. Darnall: “Rightly so.  I say this frequently:  Your pain is real and your pain is medically based.  And yet, psychological factors will either amplify or dampen pain processing in your nervous system.  Across multiple scientific studies and decades of research, catastrophizing turns out to be one of the most powerful predictors of pain outcomes.  Personal empowerment lies in understanding how to best modulate pain processing—these are learned skills.  To say someone has high levels of catastrophizing does not imply their pain isn’t real.  It tells me that I can help them reduce their suffering around pain—and decrease pain intensity—by treating it.”

National Pain Report: “The Twitter chat was promoting the importance of pain psychology in the continuum of care–talk about the progress being made in having both physicians prescribe and insurance companies pay for pain psychology.”

Dr. Darnall: “In the 2016 study put forward by the AAPM Pain Psychology Task Force (“Pain Psychology: A Global Needs Assessment and National Call to Action; Darnall BD et al.  Free and open access here:   http://www.ncbi.nlm.nih.gov/pubmed/26803844) survey respondents identified insurance coverage as being a barrier to good pain psychology care.  This report published 2 months ago, so I am not aware of policy progress in that short time lapse, but the information alone is progress toward our understanding of what needs to change.  Critically, we need better pain training and education for mental health professionals and psychologists in the U.S. to best equip them to treat the psychological and behavioral aspects of pain with their clients.  Our study showed that currently, many therapists feel ill-prepared to treat pain and thereby avoid it; it’s a huge missed opportunity to reduce suffering for men and women alike.”

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Authored by: Ed Coghlan

There are 9 comments for this article
  1. Alex Russell at 7:03 am

    getting annoyed… why can I find a thousand articles telling me my pain is all in my head, “catastrophising”, but I cant find a single reference to what if there is ACTUALLY SOMETHING CAUSING ME DAMN PAIN!

    Proper sick of being told the pain is in my head…. I’ve suffered hundreds of injuries, aches, stabs, and other pains in my life, I somehow managed to ignore all them and not “catastrophize” them, but all of a sudden because my doctors a retard and keeps throwing codeine at me and not dignosing, suddenly it must be all in my head.

    Last time I was “catastrohpizing” some ongoing discomfort, I pulled a piece of bone out of my leg where it had fractured and the hospital had missed it…. Im not just a freaking headcase, im 29 and all of a sudden have been crippled by RSI, my quality of life, mental health, and general ability to be self sufficient are all being demolished just because my doctor cant be bothered to (or more accurately probably doesn’t want to spend to) refer me to a specialist, call for an MRI, x-ray, ultrasound..

    what the hell am I supposed to do to prove that I AM IN PAIN, not just nuts….

  2. Teresa C at 6:20 pm

    I am bowing to y’all for your well thought out and informative answers, No BS artists have written here ‘yet’. I purely enjoy reading these posts. Made me think and contrary to my children’s opinions, I do love to think!
    This may sound off topic, but it is quite pertinent to this discussion.
    Words matter. Words can be perceived to have more than one meaning depending on what each persons experience of that word is. Before taking offense at a term, look in Webster’s for the correct definition. I.E. The United States is a democracy. Um, no it is not. It is a Representative Democracy. Two very different things, as the cesspool of darkness that is our government certainly demonstrates. Plus, in actuality it would be the Untied States Of America ARE(not is). Both common misconceptions that we all use and accept as correct.
    Catastrophizing is misused to denigrate and demean the pain patient, period. It connotes an out of control hysterical response. It should never be used in relation to any patient for any reason. Just because your experience of that word isn’t derogatory does not mean the word isn’t derogatory in truth.

    My little 2 cents of BS since I have a thing with how words are used and cannot substantially add to what has already been posted. Yep, up for days without pain relief makes me kinda funny.

  3. Dave at 6:11 am

    I will write to members of Congress to have the term “catastrophizer” eliminated. It is a thinly veiled effort at judgmentalism and meant to degrade and insult people who already suffer from not just pain but an unresponsive and ineffective pain care system. The term was meant to alienate and “other” people suffering pain.There is no such thing as “catastrophizing” – it has no referent in the physical world- it is a judgment used by professionals who have trouble dealing with the suffering of people in pain to label them as abnormal and defective mentally. It is as unprofessional, inhumane, insensitive as it is cruel and inconsiderate. Just imagine a person with rheumatoid arthritis being told their responses to pain is abnormal and they should not make mountains out of mole hills- ” go take a valium and get over it”- or go get some CBT and stop complaining about your pain. Its obvious the term is used because so called professionals just cant deal well with suffering. It is a great reflection on how far removed and insensitive professionals and the larger society has become with regard to peoples suffering. They just want people in pain to get over it and stop complaining( as if people in pain do much complaining).
    I keep in mind that professionals who deal with pain are often more inured then others. They get tired of dealing with pain- and don’t receive adequate education for dealing with the human and personal aspects of suffering- after all our society cares little for the “catastrophizers”- people with painful conditions.

  4. Danny at 10:12 am

    First off, I want to express my appreciation to psychologist Dr. Beth Darnell for her recognition of the gender-neutrality of pain. I completely understand and appreciate that Cynthia Toussaint writes on behalf of women and their shared experiences. However, when discussing pain, in general, and/or the issues that come with it (such as “catastrophizing”), there is nothing that divides the general population of pain sufferers. Certainly, there are pain issues specific to women. And men, for that matter.

    Secondly, I’m sure that Dr. Darnell knows that some pain sufferers have had access to alternative therapies and have been trained in how to use helpful tools to deal with our pain. Personally, I’ve tried the treatments of acupuncture, hypnosis and a chiropractor, all in the hope of eliminating, or lessening, the severity of my pain. Each was tried for a minimum of one year (except for acupuncture, where I was told that after 8 months, he knew know I wouldn’t have success). Fortunately for me, my family was able to help me with the financial costs associated with those treatments not covered by insurance. Unfortunately for me, none had any effect on my pain.

    22 years ago, I entered a “headache clinic” at Emory U. Hospital in Atlanta, GA, for one week. (I suffer from severe, chronic head pain as a result of an electrical accident. I do not have “migraines”.) I learned how to use biofeedback and relaxation techniques to “help” with the intense pain. These tools aren’t intended to eliminate pain (that’s what I was told, at least) but to help deal with the it. Tension is a result of pain. It’s a natural response to pain, especially severe, chronic pain (or “high impact pain” as I’ve been reading lately). WE know how bad it is getting, and how much worse it might be, and that knowledge makes us “brace ourselves”, resulting in tension.

    I still use biofeedback and relaxation techniques daily. They do help. I sometimes fall asleep, which is the greatest escape from pain! But, I want pain sufferers to have realistic expectations when they get the chance to learn how to use these tools.

    I do not disagree with Dr. Darnall that chronic pain sufferers experience emotional problems. When considering the highs and lows that come with hope of a different new medications, changing doctors, feeling like a pharmacy thinks we’re an addict… AGAIN! All of the things we all deal with at one time or another, it takes a toll on us and on our personal lives. These issues are not the cause of our pain, but they can certainly complicate our already complicated lives. It’s past time that insurance companies should be required to cover all things that can help the pain sufferer.

  5. Stephen Golder, Ph.D. at 8:57 am

    Good letter, Dr. Lawhern. Our profession, aside from hypnotherapeutic practioners, has been less than helpful in pain control. My experience has been that, unless the practitioner experiences the pain personally or, such as yourself, has a close family member in pain, one will probably be run through a few medication protocols and algorithms and shown the door. One finds that “pain management professionals” become technicians. Empathy…short supply.

  6. Dave at 8:43 am

    Ms Darnall- like her colleagues suffers a mind projection fallacy when referring to “catastrophizing and cant distinguish between maps and terrains. She shos no concern with reflexive practices or concerns about the harm to people in pain her epistemic community is doing by using such pejorative terms.
    Her use of :”negative mental set” has no physical referent. It is merely a form of discursive imperialism to denigrate and control people in pain- for clearly people in pain did not vote on using “catastrophizing” to characterize a “negative mental set” The term “catastrophizing” was created by a very small epistemic community- without the advice or consent of people in pain- it was not created by “science”. Ms Darnall also commits the naturalistic fallacy in assuming there is a reality known as ” catastrophizing”.
    It is unfortunate that there are epistemic communities that try to control what pain care is and what people in pain can and cant have- and that essentially is what the neologism “catastrophizing” is all about.

  7. Bob Schubring at 7:44 am

    Catastrophizing is the usual mental state of the human infant. As infants, we swing from ecstatically happy, to wailing and crying, most of our waking hours. And then we sleep a lot.

    It is as we gain the capacity to use our muscles to change our condition, that we become less overwhelmed by feelings of pain and frustration.

    The infant who sits on a pin-cushion experiences a painful catastrophe.

    The adult who sits on the same pin-cushion jumps up and figures out a safer place to sit.

    The process of learning to survive while having a painful disease, is exactly like maturing from an infant into an adult. We learn a lot of skills that help us cause ourselves less pain, and that learning is what makes the pain less catastrophic.

    Making our pain less catastrophic, means that we respond to social stimuli differently. In plain English, it means that folks who have arthritis or a neuromuscular ailment, appear sluggish and lazy and just don’t jump to rigid attention when someone shouts “Officer on deck!”…and moreover, we don’t really give a hoot that we look lazy and sluggish because if we moved any faster we’d hurt worse than we do already.

    Unfortunately, this causes certain of the people around us, to catastrophize about our altered behavior. They see us move 10% slower and have terrifying visions of us never obeying another command, ever.

    It is important to realize, in discussing catastrophizing, that it involves every relationship the patient is in. Some people easily adapt to a change in a friend’s status or needs…and some do not.

    I co-founded the #GivePainAVoice campaign for precisely this reason. People with pain, know our pain, our limits, and our current abilities, better than any outsider who guesses at our limits and abilities. Learning to advocate for ourselves effectively, removes the burdens imposed on us, by everyone who listens and adapts.

    There remain a significant number of toxic relationships with which we must deal. In many of those toxic relationships, we are viewed as “crazy” people who require an authority figure to set us “straight”. Usually the mental health professional who joins in our care, is taken to be that authority figure, who will dispense “tough love” and force us to stop imagining that we are sick…and it is a significant burden upon us, and upon that professional, to explain to the people who have these toxic relationships with us, that we have a disease and it limits our abilities…that there are things we used to do once, that we no longer do as well, and we have to conserve our energy because once we start hurting too much we become totally exhausted, thank you, and we want that event, which we call a pain crisis, not to happen today.

    Unfortunately, Americans have such a toxic relationship with many politicians and bureaucrats. Teaching those politicians and bureaucrats the importance of our access to strong pain medications like the opioids, with which to intervene in a pain crisis to halt the spread of breakthrough pain and enable us to rest and get back to our baseline condition of illness, is absolutely essential for every pain patient who ever has a pain crisis. The recent CDC Guidelines, issued in response to what CDC bureaucrats imagine to be an epidemic of opioid misuse, are a case of catastrophizing, most assuredly. If they want to continue in their delusional thinking they are free to do so, but we patients will constantly demand treatment when a pain crisis strikes, and CDC will not be free to continue making up rules that restrict us to a daily ration of drugs on the schedule that suits their desire to feel socially useful. We’re not going to validate their desire for self-importance, until they stop harming us and actually help us.

  8. Jean Price at 7:13 am

    Nice follow up, Ed! It’s amazing to me that all long term illnesses or accidents involving function changes, (really even acute illnesses and acute function changes), have psychological ramifications….yet pain is the only issue being targeted! Why is this? Changes for cardiac patients and diabetics and spinal cord injuries and a whole array of other life changing illnesses/injuries don’t seem to carry this stigma of the “catastrophizing” aspect of psychological needs. Why does pain warrant this any more than say MS or ALS or other disorders with equally profound impacts on mental health? And equally focused patients! We have always been a culture which places great emphasis on “doing”…so when the ability to do is altered, many mental health issues come into play. Our human state is comprised of body, mind, and spirit…so there is little argument what affects one can affect the others. Even in the short term. Yet, I’ve only heard the “C” word used in reference to pain (sorry but writing it out is difficult since spell check doesn’t even recognize it as a real word!). Is it because of the current false link between pain care and addiction, or something more sinister? Recently someone posted that addiction will no longer be the word of choice…it will be changed to “opioid dependent disease/condition” and will include those with chronic pain who take opioids to help with their daily lives along with those who take these meds illegally for totally different reasons and effects. So reducing pain will be lumped in with wanting to get high, wanting to escape life and society! I sincerely hope this doesn’t happen…those with pain don’t have opioid dependent conditions!! Most have a whole range of diseases and conditions which are characterized by pain…not dependency! If people are to accept the help needed to deal with life changing pain, the catastrophizing word has to go! It is clearly a judgement to say someone is too heavily focused on their pain when that’s what they are seeing the doctor about! Are they expected to talk about their high school prom, or their last shopping experience? So, we are asked to talk about our pain but not focus on it?! Hmm, does this really make sense? Who can say whether an exceptionally bad run of days of pain isn’t worthy of being focused on? Ues, we are involved with our pain…we live it! So wouldn’t a better “label”, if labels are even needed be simply “invasive pain dynamics” or “pain based grieving”, or some other type of words referencing the truth?! How about “future inclusive”, or “rational relay”, meaning we rationally relay our pain forward, since that’s what chronic pain is about, waking up with pain, going to bed with pain! This whole context of psychological help is lessened by labeling those in pain as broken, since the truth is we are normal people dealing with abnormal daily, life limiting medical issues involving pain…not broken, not unwhole, not mentally unable to function…but a little bludgeoned, a little worn around the edges, a little less able to “do”, a little more in need of cohesive medical support, a little more likely to live tenuously with our individual realities…of pain, not a made up or over stated problem but a real issue which can seriously threaten our livelihoods and our very lives. This is real, this is pain, this is not crying wolf or catastrophizing. And to truly support us, this is so important to understand!

  9. Richard A. Lawhern, Ph.D. at 6:13 am

    Beth Darnell’s interview poses a dilemma for me and for others who wish to exercise good will in our support to chronic pain patients. I have been closely engaged with chronic face pain patients for twenty years. My spouse deals with Trigeminal Neuralgia pain every week of her life. I have built websites on this subject, and interacted with well over 15,000 patients and family members in online forums or by email.

    From that background I would suggest that the following are facts that we must embrace if we are to be constructive on the issues involved. I would welcome substantive comments from Dr. Darnell.

    1. Women are disproportionately impacted by negative attitudes on the part of medical practitioners which discount, marginalize, or disbelieve medical pain symptoms which they report. There is an extensive literature supporting this observation.

    2. When a diagnosis code related to psychological factors or so-called “psychogenic” pain is entered into a patient’s medical records, thereafter they will have significantly more difficulty getting assistance from other medical practitioners. Some patients report being told explicitly that “the pain is all in your head” before being discharged. Since current practice standards permit this action, it cannot be called malpractice even though it almost certainly is that, in the perception of the patient.

    3. The medical evidence for psychiatric diagnoses such as “somatization” or “functional neurological symptom disorder [conversion disorder]” is very weak (some would say lacking). Most of what passes for evidence is in fact personal opinion or speculation on the part of financially or academically self-interested practitioners. See “Authors of Our Own Misfortune? Problems with Psychogenic Explanations for Physical Disease” by Angela Kennedy, available on Amazon.

    4. Professional psychiatry and psychology are presently weathering a crisis in public credibility. It is clear from the recently published “Replication Study” that a majority of published work in clinical and social psychology does not replicate or otherwise provides much weaker outcomes when re-performed by independent investigators. See https://en.wikipedia.org/wiki/Replication_crisis.

    5. The state of research advocating for brain-dysfunction models in acute psychiatric distress is equally abysmal. No less an authority than the National Institutes for Mental Health (NIMH) has chosen to drop the Diagnostic and Statistical Manual of Mental Disorders (5th edition) as an organizing framework for mental health research.

    6. Many once-praised drug treatments for ADHD, depression, anxiety, schizophrenia and psychosis are turning out to have disabling or deadly long term side effects. Some have been shown to have no better outcomes than placebo when re-analyzed by unbiased investigators. See among many other books, “Psychiatry Under the Influence — Institutional Corruption, Social Harms, and Prescriptions for Change” by Whitaker and Cosgrove, also available on Amazon.

    7. These things being said, we should also acknowledge that non-coercive psychological support and cognitive training can be positive factors for some pain patients, some of the time. A key factor in outcomes is creation of a relationship of trust between patient and trainer, with the patient leading their own treatment “team”. There is a substantive literature for “nocebo” effect, whereby patient outcomes are better when there is a strongly supportive and respecting relationship to the medical provider – and much worse when this relationship is lacking. This principle suggests that psychological treatment should seek to empower patients in the control of their own lives and pain levels, with the professional practitioner acting in the role of resource person, not “manager”.

    Finally, I must suggest that while access to psychological support may be helpful for some patients, an appearance of self-serving or conflict of interest is created when professionals lobby to broaden that access. We surely cannot expect insurance companies or government to subsidize professionals who lack consistent evidence for the efficacy of their tools. And that consistent evidence is presently lacking.