Suffering from pain is optional: Pain catastrophizing and your brain

Experts agree that the experience of pain is influenced by a large number of biological, social, and psychological factors.  The state of our physical body, the amount and quality of support we get from our family and friends, and our beliefs about pain all work together to influence the intensity and quality of all of our sensations, including pain.  Of all of the psychological factors that have been studied and shown to be associated with pain and its impact on our lives, the single most consistent (and to date – among the strongest) factor associated with pain is catastrophizing [1-3].

Catastrophizing can be defined as extremely negative thoughts and beliefs about pain.  They include such thoughts as “It is terrible!”, “It is never going to get better”, and “I can’t stand this pain any more”.  Researchers have not only found that these types of thoughts are consistently associated with current pain, but that when people with chronic pain think such thoughts, this is followed by increases in pain and suffering [4, 5].  Thus, while catastrophizing thoughts have not yet been proven to always lead to more pain and suffering, all of the evidence we have so far is consistent with the theories that argue that catastrophizing about pain makes things worse.

Because of the role that catastrophizing is thought to play in pain and pain-related suffering, we are very interested in understanding what can lead to more (or less) catastrophizing.  We recently published a study that was designed to examine one factor that might underlie the development and maintenance of catastrophizing: the relative activity level of two specific areas of the brain [6].

Our reasons for looking at brain activity as a predictor of catastrophizing were as follows.  First, we know that there is a tendency for activity in the front right part of the brain (so-called “right anterior” area) to be involved in some “negative” feelings (like sadness and anxiety) and a tendency to slow down or withdraw, and activity in the front left part of the brain (actual brain region) to be involved in more “positive” feelings (like optimism, joy, and hope) and a tendency to engage in approach behaviors [7].  Second, we know that catastrophizing thoughts are associated – sometimes very strongly – with negative feelings and withdrawal.  Finally, the amount of a certain type of brain wave (so-called “alpha” waves on electroencephalogram or EEG) in an area of the brain is associated with less activity in that brain area, because the presence of this activity is associated with the release of chemicals in the brain that inhibit activity.

Based on all of these ideas, we hypothesized that if we measured (1) brain waves (using EEG) just over the right and left front areas of the brain at one point in time and then (2) catastrophizing thoughts two year later in a group of individuals with chronic pain, we would see more alpha (i.e., more suppression of activity) in the left front areas of the brain, relative to the right, among those with more catastrophizing.  Measuring brain waves is tricky, because so many things (including what you are feeling at the time of assessment, whether and how much coffee you have drunk, how much sleep you had) impact upon EEG.  So, in order to help ensure that we had a good and stable measure of brain activity, we performed five EEG assessments, with each one more than a week apart, and then averaged the amount of “alpha asymmetry” (that is, a ratio of left to right frontal alpha activity) across the assessments.  We then correlated this alpha asymmetry score with the measure of catastrophizing that we assessed two years later.

Our study hypothesis was supported.  Individuals with more alpha asymmetry (reflecting greater left than right sided frontal alpha; that is, a relative suppression of left frontal activity) reported more subsequent catastrophizing.  The findings are consistent with a model hypothesizing that brain activity in the front of the brain might make people with chronic pain more vulnerable to the development of catastrophizing thoughts, and therefore how much they might suffer from pain. We think that this finding is interesting in and of itself, because it helps us to understand how activity in the brain might (potentially) influence our response to chronic pain.  One of the strengths of this study is that the measure of brain activity was assessed before (well before, two years) the measure of catastrophizing, making it difficult to argue that catastrophizing assessed two years later “caused” the brain activity two years previously.  Still, it is important to acknowledge that the alpha asymmetry which was found to predict might or might not directly influence the development of catastrophizing; it remains possible that it merely reflected a process that is related to catastrophizing.  Research is needed to examine the effects of procedures that influence EEG activity on catastrophizing to determine the role that alpha asymmetry might play in this process.

More importantly, if this finding turns out to be reliable (that is, if other researchers using similar strategies get the same or similar results), it suggests some potentially interesting and innovative ways to treat pain. For example, it may be possible to “activate” the left frontal areas of our brain or “inhibit” the right frontal areas of our brain in order to catastrophize less – or to think more positively about pain. This could be accomplished by changing what we do (active exercise as an “approach” behavior that could activate left frontal areas), what we think (envisioning a positive future), or even how we feel (engaging in activities that bring us pleasure or that are meaningful to us).  There are even more direct ways that are being developed to activate or inhibit brain activity via low voltage electric or magnetic stimulation.  These “treatments”, perhaps even in combination with changes in behavior, thoughts, or feelings, could potentially influence catastrophizing.

As alluded to previously, because this was a correlational study, the results do not prove that the amount of left versus right frontal activity causes catastrophizing.  However, the findings are consistent with the alpha asymmetry hypothesis, and indicate that more research to explore and test this hypothesis further is warranted.  Ideally, research in this area will help us better understand how catastrophizing is maintained, and help us identify ways to decrease catastrophizing responses when they are posing problems for people with pain.

About Mark Jensen

 

Mark P JensenMark P. Jensen, is a Professor and Vice Chair for Research in the Department of Rehabilitation Medicine, University of Washington School of Medicine. Dr. Jensen’s research program focuses on the development and evaluation of psychosocial interventions for pain management.  He has been awarded a number of grants from the National Institutes of Health and other funding sources for this work, and is the author or co-author of over 400 articles and chapters.  He has received a number of awards from the American Psychological Association (2003 APA Division 30 Award for Best Clinical Paper and 2012 Award for Distinguished Contributions to Scientific Hypnosis), the Society for Clinical and Experimental Hypnosis (Roy M. Dorcus Award for Best Clinical Paper, 2004), and the American Society of Clinical Hypnosis (Clark Hull Award for Scientific Excellence in Writing on Experimental Hypnosis, 2009) for his scientific contributions.  He is the author of Hypnosis for chronic pain management, which won the 2011 Society for Clinical and Experimental Hypnosis Arthur Shapiro Award for Best Book on Hypnosis.  He is also the current Editor-in-Chief of the Journal of Pain.

References

[1] Pulvers, K. and A. Hood, The role of positive traits and pain catastrophizing in pain perception. Curr Pain Headache Rep, 2013. 17(5): p. 330.

[2] Quartana, P.J., C.M. Campbell, and R.R. Edwards, Pain catastrophizing: a critical review. Expert Rev Neurother, 2009. 9(5): p. 745-58.

[3] Jensen, M.P., et al., Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review. Arch Phys Med Rehabil, 2011. 92(1): p. 146-60.

[4 Burns, L.C., et al., Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. J Pain Res, 2015. 8: p. 21-32.

[5] Campbell, C.M., et al., Changes in pain catastrophizing predict later changes in fibromyalgia clinical and experimental pain report: cross-lagged panel analyses of dispositional and situational catastrophizing. Arthritis Res Ther, 2012. 14(5): p. R231.

[6] Jensen, M.P., et al., Pain Catastrophizing and EEG-alpha Asymmetry. Clin J Pain, 2015. 31(10): p. 852-8.

[7]  Davidson, R.J., What does the prefrontal cortex “do” in affect: perspectives on frontal EEG asymmetry research. Biol Psychol, 2004. 67(1-2): p. 219-33.

Comments

  1. John Quintner says:

    “Thus, while catastrophizing thoughts have not yet been proven to always lead to more pain and suffering, all of the evidence we have so far is consistent with the theories that argue that catastrophizing about pain makes things worse.”

    Mark, this sentence appears to contain a logical contradiction. Would you care to comment?

  2. Terry Osterhout says:

    As the wife of a person with Central Sensitization, I have observed this first-hand. While we didn’t understand or recognize that he was catastrophizing, once we became aware and understood that was what was happening, it has given him another tool to modify his pain. By recognizing it for what it is (a system problem), he is able to ‘see’ that it won’t last and he can get through it. It has made a tremendous difference in his ability to cope with his pain. Additionally, by recognizing how his thoughts and emotions affect the condition, he is learning to actively participate in recognizing when those things are having an effect also. In looking back, before all is happened, we discussed that he was always the type of person who ‘saw’ the big picture before others, often asking the ‘what if’ questions. Maybe the catastrophizing is a positive trait until pain is the component? Maybe as long as it doesn’t create undue anxiety? Maybe the person who tends to ‘catastrophize’ is more prone to CS?, CRPS? Pain? It raises many more questions to me but it definitely has a role in managing pain, from our perspective.

  3. John Quintner says:

    Mark, in my opinion, “pain catastrophizing” should be expunged from the lexicon of pain medicine. It began life as an idea that has since been reified and now said to play an important role as a psychological determinant of the experience of pain. When Sullivan et al. [2001] explored the relation between catastrophizing and pain, they made an important observation, which they then neatly side-stepped: “Although it is not readily apparent why individuals would adopt or persist in a cognitive style that leads them to experience heightened pain and emotional distress, fear-avoidance models of pain might be invoked as a potential explanation. Catastrophizing may contribute to pain-related fear, which then leads to avoidance of activity and subsequent disability.” Reference: Sullivan MJL, Thorn B, Haythornthwaite JA, Keefe F, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain 2001; 17: 52-64.

  4. Jan Carstoniu says:

    Hi John, it has been a while but I’m still following these discussions and I find this one particularly interesting and important because of the emphasis placed on the notion of catastrophizing in clinical practice recently.

    I’d greatly appreciate it if you could expand a bit on your objection. I admit to having discussed the idea with my patients but only as a way to explore their beliefs about pain and how these might affect behaviour. Thanks.

  5. John Quintner says:

    Jan, I find the term “pain catastrophizing” to be quite confusing and misleading. Use of the term in the clinical context carries a risk of unintentionally stigmatising our patients. If such a cognitive process as catastrophizing exists, to my way of thinking it would relate more to a person’s perception and evaluation of existential threat, as well as to the action(s) taken in responding to such a perceived threat. But there are other issues. For example, in their recent review, Quartana et al. [2009] suggest that: “Future studies will need to explore more rigorously the empirical distinctiveness of the pain catastrophizing construct apart from related constructs, such as fear of pain, as well as from more general constructs imbued with negative affectivity, such as depression, anxiety and neuroticism.” I would be interested in your comments on the above thoughts. Reference: Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Exp Rev Neurother 2009; 9: 745-758.

  6. Jan Carstoniu says:

    John, I don’t have a big problem with attempts to operationalize, as opposed to reifying the concept of catastrophization for purposes of research. However, my concern (perhaps similar to yours) is that such efforts may be interpreted as support for the idea that psychological factors are somehow causes of chronic pain. My impression is that when pain is considered psychogenic by many clinicians, it is trivialized and yes, the patients may be stigmatized or treated inappropriately. The idea is anathema to most of my patients. It also raises the specter of mind body dualism.

    As interesting as the research has been I don’t think it comes close to supporting a linear causal relationship between catastrophizing and pain. There seems to be a logical gap between the research findings and the notion of treating catastrophization in order to treat pain.

    There seems to be sufficient evidence to support the use of cognitive techniques to modify the experience of pain (for example Lorimer Moseley’s work on explaining pain) and I use them in my practice. But it is far from clear to me that addressing negative beliefs about pain is both necessary and sufficient for successful outcome.

  7. Kerima Furniss says:

    Quote from Beth Darnall, see below:
    “A quarter century of research has shown that higher catastrophizing scores are associated with greater pain intensity and disability in outpatient chronic pain patients. Catastrophizing is also associated with poorer response to multidisiciplinary and medical treatment for pain,2-4 thus underscoring the value of early screening and intervention.

    Studies in adult surgical patients have shown that pre-surgical pain catastrophizing predicts post-operative:

    pain intensity4,5
    opioid use4,6
    recovery7
    function7
    whether or not a person will have their pain persist after surgery.
    In other words, catastrophizing can predict the development of post-surgical chronic pain.5,8The good part is that we know that psychological interventions can impact catastrophizing right now.” http://www.practicalpainmanagement.com/treatments/psychological/cognitive-behavioral-therapy/targeting-saboteur-surgical-outcomes-pain

    Beth Darnall of Stanford University has developed a 2 hour class as an intervention for pain catastrophizing, with some good preliminary outcomes.
    watch a quick video discussion at http://www.bethdarnall.com

  8. Current approaches to chronic pain management include everything suggested in this paper (targeting thinking and defusion, encouraging approach behaviours, meaningful and pleasurable behaviours, paced exercise, mindfulness etc. not sure that we need to try to reproduce the benefits of this by using electrical or magnetic stimulation. Why not just continue to seek behaviour change?

  9. John Quintner says:

    Jan, I agree that people can and do have attitudes, beliefs, and thoughts that would merit the descriptor “catastrophizing,” but in my opinion to then attach this descriptor to “pain” only serves to reify what is a unique experience. Is this the logical gap to which you refer?

  10. Jan Carstoniu says:

    John, I think reification is definitely part of the logical gap but I would also include the fact that studies on catastrophizing to date are correlational and have yet to adequately address the issue of causality. It seems to me that when we talk about treating catastrophization, not only are we talking about treating a concept, but an assumption is being made about causality that it is not warranted given the current state of the evidence.

    Christine, although I use the same or similar techniques in my clinical practice and believe they can make a difference, the fact remains that most of my patients still have pain. Outcome research to date on these techniques has demonstrated improvements but no cures that I am aware of. Finally, focusing on behavior change alone may fail to address the experience of pain adequately. I believe therefore that it is necessary to continue our attempts to find better ways to treat it. Whether this particular line of research will prove fruitful remains to be seen.

  11. John Quintner says:

    “Thus, while catastrophizing thoughts have not yet been proven to always lead to more pain and suffering, all of the evidence we have so far is consistent with the theories that argue that catastrophizing about pain makes things worse.”

    Jan, I agree with you that the issue of causality is unresolved (and it may be irresolvable), which is why I asked Mark for a comment on his above statement by way of clarification.

  12. John Quintner says:

    To date there has been no response from Professor Jensen to my deliberately provocative comments on his post. Although “catastrophizing” came into existence as a psychologically constructed theoretical process, it appears to have taken on a life of its own, as a discrete material “thing” that can be measured and treated (i.e. it has been reified). However, a wide variety of psychological phenomena have been bundled under the term “pain” and this suggests to me that “catastrophizing” is likely to be embedded in a network of causal relationships with other cognitive processes, all of which form part of our evolutionarily determined repertoire of adaptive responses to threatening stimuli. Reference: Adolphs R. The biology of fear. Current Biology 23, R79-R83. Jan 21, 2013.

    stu Reply:

    Hi John, thanks for your insightful comments and pursuit of meaningful dialogue. I think it is important to get at the root of the right brain / left brain discussion. In a recent SciAmerican article by MacNeilage, Rogers and Vallortigara on origins of the left and right brain, it was proposed that specialization of each hemisphere is as old as all vertebrates – right hemisphere took primary control in potentially dangerous circumstances that called for a rapid reaction from the animal – detecting a predator for instance. Otherwise, control passed to left hemisphere. In humans, the relatively primitive avoidance and wariness behaviours that manifest right hemisphere attentiveness in nonhuman animals have morphed into a variety of negative emotions. Perhaps, catastrophizing is simply a more global (right brain) strategy to a number of exogenous and endogenous threats and highlights that there a multitude of pathways in humans leading to the output of pain. There are also a number of subcortical – cortical midline networks that are important with DMN disrupted with persistent pain.. Looking for insight / frameworks – despite pain being unique to the individual, are there themes? I think that signalling and even basic perception could be similar. Thoughts?

    John Quintner, Rheumatologist Reply:

    Stu, the evolutionary perspective does appeal to me. However, I would prefer to insert “perceived” before “exogenous and endogenous threats”. On the same theme, could you please expand upon your last sentence concerning a possible relationship between “signalling” and “perception”?

    stu Reply:

    John, I totally agree – after pushing reply, I realized it should be ‘perceived exogenous and endogenous threats.’ Thanks for the correction. In terms of perception, I think that there is support for the trans-species concept of the self and the subcortical-cortical midline system as proposed by Northoff and Panksepp. As they stated, I feel that mammals are capable of relating bodily states, intrinsic brain states (e.g. basic attentional, emotional and motivational systems) and environmental stimuli to various life-supporting goal-orientations. I realize that there are multiple factors that play into and many ways to emerge with the output of pain in humans but at the ‘core self’ level, I suspect that the ‘basic output’ of pain has been present for a long time. I am becoming more aware of the free energy principle of brain function, bayesian theory and predictive coding (but only to write it down in a sentence – I am still trying to process this). I think that these theories also need to embrace the evolutionary origins of the mind including hemispheric lateralization.
    Once you get to the cognitive self and higher order neocortical cognitive functions which are likely epigenetically created by experiences, the puzzle of pain in humans presents itself. I welcome your insight.

    In terms of previous discussions, the concepts of defensive peripersonal space in a visually dominated species may be different than other species who rely on hapsis and olfaction. At a social level, Mogil’s work has shown that rats have a DMN and that they have an elaborate social communication system when they experience pain. In a social group in which some members of the group act as sentries, those that are especially wary, may result in an earlier alarm system and protection for the group – when you get to humans, with the ability to confabulate, this cognitive-behavioural trait may be carried too far (catastrophizing). Thoughts?

  13. Michael Ward says:

    John Quintner – I agree re catastrophizing. Can we also add kinesiophobia, fear avoidance and other pejorative classifications and labels to the list to be abandoned. They may have relevance in the most extreme cases but for the most part have little accuracy or validity in describing the decision making process of patients, which more commonly reflects a rational extension of their understanding or operational knowledge (potentially reinforced by health professionals).

  14. John Quintner, Rheumatologist says:

    Michael, it seems to me there are complex issues of language in play whenever we use such evocative terms in our clinical discourse. In the words of Wittgenstein: “There is a lack of clarity about the role of imaginability (Vorstellbarkeit) in our investigation … namely about the extent to which it ensures that a sentence (Satz) makes sense. (Wittgenstein, PI §395)

    As Horst Ruthrof suggests: “If you are able to imagine what I am talking about and the way I am saying it, then there is meaning; if not, there is not”. And vice versa, “if I am able to imagine what others are talking about and the way they do so, an event of linguistic meaning has occurred; if not, it has not.”

    Reference: Ruthrof H. Language and Imaginability. Newcastle upon Tyne: Cambridge Scholars Publishing, 2014: 1.

  15. John Quintner, Rheumatologist says:

    Stu, your insightful comments have stimulated me to re-read Chapter 8 (Social Phenomena) in the amazing little book by Maturana and Varela. You have taken us far into the discussion initiated by Mark Jensen in the original post. It appears to me that Pain Medicine theorists might need to delve ever more deeply into the meaning of some of the psychological concepts that they have previously taken at face value.
    Reference: Maturana H, Varela FJ. The Tree of Knowledge: the Biological Roots of Human Understanding. Boston: Shambhala Publications, Inc. 1987: 179-201.

    Seamus Barker Reply:

    John,

    Regarding your objection to ‘pain catastrophising’ as a reification – surely such an objection can be made to any constructed model of the mind and its processes? From Freud’s tripartite theory to modern schema theories, any theory of mind depends upon positing constructs which are clearly not considered ‘things’ with some essence or matter; they are descriptive models of function. If you want to maintain this objection, I think you’d need to similarly aim to dispel any other models of the functioning of the mind that aren’t reductively neurological. Given the current gap between neuroscience and psychology (or indeed consciousness), it seems to me entirely reasonable to continuing using psychological constructs, so long as they are understood as constructs. I don’t see that it is necessary for this to amount to reification.

    You make the important point that the state of the science is not sufficiently advanced to demonstrate a causal relationship between catastrophising and phenomena like central sensitisation or chronic pain. Yet, it seems to me that there are sufficiently strong correlations to warrant continued use of the construct of ‘catastrophising’, and to continue investigating possible causal relationships. Even if cause is not yet proven, if we take Moseley’s conceptualisation of pain – as something emerging from the brain’s appraisal of danger – seriously, it seems that continuing to investigate psychological constructs such as catastrophising and fear-avoidance is highly worthwhile.

    I certainly agree that, especially given that no causal link is yet proven, we need to be extremely careful how we throw these ideas around when talking to patients themselves, as these terms can readily connote to notions of blame, and can be experienced by the sufferer as an attribution of moral responsibility.

    John Quintner, Rheumatologist Reply:

    Seamus, I am not sure that I can accept your interpretation of the views of Lorimer Moseley when you argue: “… if we take Moseley’s conceptualisation of pain – as something emerging from the brain’s appraisal of danger …”

    The other point I would like to raise concerns your implication that “catastrophising” is a model of the functioning of the mind. Mark Jensen refers to “catastrophising” as being a “factor” associated with pain rather than an established model of mental functioning.

    I heartily agree with the view expressed in your final paragraph.

    Seamus Barker Reply:

    John, Moseley says “we feel pain when the brain has more credible evidence of danger to the body than it has credible evidence of safety to the body”. This definition presupposes that the brain must appraise what counts as credible, what counts as evidence, and what counts as danger (none of these terms describe properties of the external world, they all require interpretation/appraisal/calculation, as per one’s favourite model of cognitive science/philosophy – hence my use of the term “the brain’s appraisal of danger”. I’m confident that I’m not misrepresenting LM here, though of course I stand to be corrected.

    Re: your second point, I don’t see that it’s a problem to refer to a model of mental functioning (catastrophising) as a “factor” associated with pain. I take it as implicit that the author is referring to a model of mental functioning (catastrophising), with the further assumption that such functioning can be roughly measured (accepting the epistemological limitations of this idea) and so identified as a ‘factor’ empirically associated with pain. These epistemological issues notwithstanding, I still don’t take that as reification, as I’m not convinced the author believes catastrophising is a ‘thing,’ although I suppose an unsuspecting reader might take it as such. Of course, we could all benefit from laying out explicitly such concerns, even if they’re not fatal to the research, more often.

  16. John Quintner, Rheumatologist says:

    Seamus, will you please provide me with a reference for Lorimer’s current definition of pain?

    As I commented above, catastrophising “appears to have taken on a life of its own, as a discrete material “thing” that can be measured and treated (i.e. it has been reified).”

    We will have to agree to disagree as to whether catastrophising is in fact a model of mental functioning.

    But it would have been helpful to this unsuspecting reader if the author had clarified the matter soon after the article was posted 2 months’ ago.