Last month, I had the flu. I didn’t seek a doctor, but instead spent four days watching episode after episode of “The Good Wife.” Annoyed at my incapacitation, I waited for the malaise to pass. I recovered and felt well for three days.
Then the pain started.
I woke up with a general achiness in my back. Thinking I’d slept funny, I began work untroubled. Throughout the day, the pain got increasing worse and I began to become increasingly distracted. I wondered what was wrong. Had I pulled a muscle? What else could it be? By evening, I was running a fever and the pain in my back, especially my lower back, was too intense for me to concentrate on anything else. What could be wrong? Was my flu coming back? I woke the next morning feeling yet worse. By the second evening, I was in the worst pain of my life.
I began to worry about the pain. Obsessively. Irrationally. Uncontrollably.
The term ‘catastrophizing’ appears to have been introduced for use in medical practice by Albert Ellis. Ellis was particularly interested in the interaction of thoughts and emotion. In particular, how thoughts could affect emotions in ways relevant for treatment. For Ellis, ‘catastrophizing’ was a term employed to refer to clusters of the repetitive, negative thoughts involved in anxiety and depression.
It is perhaps not surprising that the notion of catastrophizing became extended to pain experiences; this related phenomenon is called pain catastrophizing. Pains and unpleasant emotions like depression and anxiety are both unpleasant. This nasty shared quality of these experiences is sometimes called negative affect. There is good reason to think that negative thoughts interact with negative affect in particular. It is also increasingly recognized among pain researchers that what we think about our pains affects how they feel—indeed, some pain researchers have been urging for decades that we not only have thoughts about our pain experiences, but that some thoughts are part of pain experiences.
It is a matter of some dispute how best to characterize pain catastrophizing and our understanding of these negative, obsessive thoughts has become increasingly sophisticated. Currently, the dominate tool for evaluating pain catastrophizing is the pain catastrophizing scale (PCS). The PCS was developed by collaborators led by Michael Sullivan in 1995 and remains the most comprehensive and widely-used tool to determine whether and to what extent someone is catastrophizing their pain.
When using the PCS, the person in pain is invited to self-report concerning three main aspects of their pain experience: magnification, rumination, and helplessness. A five point scale from 0-4 is used: ‘0’ meaning not at all, ‘1’ meaning to a slight degree, ‘2’ meaning to a moderate degree, ‘3’ meaning to a great degree, and ‘4’ meaning all the time. The patient is to assign a number from 0-4 to the following 13 statements:
When I’m in pain….
- I worry all the time about whether the pain will end.
- I feel I can’t go on.
- It’s terrible and I think it’s never going to get any better.
- It’s awful and I feel that it overwhelms me.
- I feel I can’t stand it anymore.
- I become afraid that the pain will get worse.
- I keep thinking of other painful events.
- I anxiously want the pain to go away.
- I can’t seem to keep it out of my mind.
- I keep thinking about how much it hurts.
- I keep thinking about how badly I want the pain to stop.
- There’s nothing I can do to reduce the intensity of the pain.
- I wonder whether something serious may happen.
High scores on the PCS are correlated with negative pain treatment outcomes—in the lab and in the clinic, for both acute (short duration) and chronic (extended duration) pain. Exactly how pain catastrophizing works and the best interventions for it remain controversial. (If you’re interested in the details, you can check out this nice review.)
Further research is needed and underway, but despite the controversy and the gaps in our knowledge, we know enough now to know that minimizing pain catastrophizing is important. Unfortunately, it can also be very difficult not to catastrophize.
Realizing that I was catastrophizing about pain, I attempted to talk myself out of it. To calm myself down. I repeatedly told myself that the pain was temporary, and tried to focus on getting in to see my doctor. I told myself that I would get through it and that it was highly unlikely that it was anything fatal. I tried to distract myself from the pain and, above all, not to worry that it would get worse. My efforts were somewhat, but not entirely successful. As long as I was in such intense pain, I remained scared and worried. Pain catastrophizing was always only a thought away.
It turns out that I had a kidney infection. In a week, I was better. Three days after seeing my doctor, my pain had been reduced to an unpleasant twinge and, having discovered the cause, a twinge that I no longer worried about.
Unlike the acute pain associated with my kidney infection, pain catastrophizing is often thought to be most important for persons with chronic pain. Such people experience pain for months. For years. Even decades. Often, moreover, they are offered no satisfying diagnosis. One main goal of some cognitive-behavioral approaches to chronic pain, for instance, is to reduce and eliminate pain catastrophizing.
Though I was only in serious pain for a few days, I have a new appreciation both for pain catastrophizers and the difficulty eliminating it. In the face of pain, irrationally negative thoughts begin to appear rational. It is hard not to despair or feel helpless. I cannot imagine fighting against these thoughts in the face of pain for months, years, or decades.
It is my hope that as we better understand the role of pain catastrophizing in pain experiences, we will become better able to control and eliminate it. It is becoming increasingly clear that effective pain treatment requires adequately addressing not only any bodily damage that is involved, but any damaging thoughts that are involved. What we think and how we feel are not independent, and effective treatment requires addressing both.
In the meantime, if you know someone in pain, remember how easy it is to catastrophize. Be encouraging. Be patient. And if you are in pain and find yourself catastrophizing, remember that those negative thoughts play an important role in your pain experience that you can legitimately raise with your doctor—they are as worthy of treatment as any bodily damage you face.