When does normal concern about relentless pain become excessive and catastrophizing? Who has the power to make this decision?
I’m exasperated and offended by the recent over-promotion and over-simplification of the latest popular theory about chronic pain, which uses the derogatory term “catastrophizing” to describe our well-founded concerns about our pain.
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.
(Pain catastrophizing: a critical review; Phillip J Quartana, PhD, Claudia M Campbell, PhD, and Robert R Edwards, PhD | 2009 May)
First, researchers created a list of “catastrophizing” traits in pain patients:
Nine frequently used psychometric scores which measure pain catastrophizing: negative affect, general trait anxiety, depression and anxiety, fear of illness, pain-specific anxiety, fear of pain, fear of negative evaluation and anxiety sensitivity.
(Pain catastrophizing: an updated review | Lawrence Leung | 2012)
Then the researchers ran studies looking for these tendencies in pain patients – and found them. This seems a blatant case of confirmation bias.
When researchers announced their findings that “catastrophizing is related to worsened pain”, the media hype machine went into action and either implied or stated outright that “catastrophizing causes pain”. It seems like the perfect story: it’s an extension of the self-help movement (and victim-blaming) and it fits right in with the cultural imperative to “tough it out” and “don’t be a wimp”.
No one seems to notice the data from the study shows only that “catastrophizing is correlated with worsened pain.” All this proves is that more pain is more distressing.
Our pain has indeed become a catastrophe as we lose access to the effective pain relief of opioids. Shifting the blame from physical nociception to mental “catastrophizing” confirms what many patients have suspected of our doctors: if they can’t find a physical cause, doctors tend to believe our pain is a psychological problem instead.
The public is more than happy to hear that we’re causing our own pain with our “bad attitude”. Better yet, treatment for catastrophizing requires no opioids, just talk therapy. And best of all, if our pain still does not improve, then it’s our own fault.
The popular media touts the psychological treatment of catastrophizing as a virtual cure for chronic pain. Countless articles explain over and over how we pain patients are worsening (or even causing) our own pain by catastrophizing and we don’t even know it. If only we would stop “catastrophizing”, they say, our pain would be manageable, and we would not need opioids.
Placing the blame for our chronic pain on a “bad attitude” gives everyone license to bludgeon us with accusations of mental weakness or addiction. It allays any guilt for letting pain patients suffer without opioids: if we don’t respond to their suggested psychological treatment, then we are either weak or addicted and it becomes *our* problem. They can wash their hands of us, write us off as hopeless drug-seeking addicts.
Diagnosing patients with intractable pain as “catastrophizing” is an attack on the legitimacy of our pain, an attempt to weasel out of the difficult job of medically treating our pain, and even a ruse to blame us for our own misfortune.
Another study specifically addressed the issue of whether catastrophizing causes pain. Although the healthy participants used for this study cannot substitute for people who have been in pain for years and decades, the study makes an important point:
“We cannot yet rule out the possibility that at least some aspects of catastrophization may actually be the product of an intense pain experience, rather than its cause.
That is, the more intense the pain feels to the person, the more likely they are to have thoughts about it that fit the definition of catastrophization.”
(Quote from full text of study: The causal status of pain catastrophizing: an experimental test with healthy participants. | Severeijns R, van den Hout MA, Vlaeyen JW. | Eur J Pain. 2005 Jun)
According to experts on this topic, I should be able to reduce my pain by having a positive attitude and minimizing catastrophizing. However, looking over the detailed pain, activity, and medication diary I’ve kept for years, I can see that my pain level does not correspond to my levels of distress.
My pain can be low during the worst days of depression and can become crippling on my happiest days. I’ve had to leave or cancel several significant joyous events, like a wedding and a large family gathering, that I’d looked forward to for weeks and months. My pain unpredictably flared on just those days.
I skipped the wedding and went to the reception despite my pain, believing that my happiness and the positive energy of the crowd would surely ease my perception of pain. But standing or sitting around was killing my low back and a little bit of dancing set off my mysterious and excruciating visceral pain. An hour later I had to concede defeat and go back home.
People want to believe that chronic pain is an attitude issue and congratulate themselves for not being the fearful worriers they assume we are. They don’t want to know that even the “best” attitude cannot protect them and, even more frighteningly:
Chronic pain can happen to anyone, anytime, anywhere… even YOU.
Feeling fearful or distressed can certainly make any pain more noticeable and “uncomfortable”, but even the best attitude, the strongest will, and the greatest courage provide no guarantee of relief from chronic pain.