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Chronic Pain

Don’t Let Chronic Pain Throw You into the Future

Research identifies pain-based catastrophizing as a major risk factor.

The days when chronic pain had been dismissed by physicians as “mainly in your head (a.k.a. “psychosomatic”) are long gone. Chronic pain is not only real; it is a bad disease. Whether you are being diagnosed with fibromyalgia, chronic lower back pain, complex regional pain syndrome, diabetic neuropathy, or other forms of chronic pain, you are far from being alone, and the physical and mental suffering you are experiencing is formidable. So is likely to be the suffering of those around you, primarily your family members. Numerous studies demonstrate that living with a person who suffers from chronic pain is highly taxing, leading caregivers to experience their own emotional and physical distress. Finally, society also suffers due to patients’ substance abuse, patients’ and caregivers’ lost productivity, health care costs, and educational and academic impairments (particularly for the sufferers). Perhaps the most ominous consequence of pain, however, is that it increases suicidality. Specifically, suicidal ideation, intent, attempts, and even deaths by suicide are more prevalent in chronic pain sufferers than in the general population.

But is it pain severity that actually “drives” these adverse effects? A series of studies conducted across the world suggest that it is not pain per se that derails sufferers’ lives, but the way sufferers cope with the pain in their own mind (“cognitive coping”). More specifically, pain-based catastrophizing is depicted by psychological and medical science as a very serious risk factor for all the above-noted outcomes of chronic pain, including pain severity itself.

What is pain-based catastrophizing? It is sufferers’ tendency to exaggerate the potential adverse influence of pain on their lives. Namely, instead of “staying in the moment” and experiencing pain “as it is,” pain-based catastrophizers “launch themselves into the future,” imagining all sorts of horrid scenarios that will ensue from the mere fact of having chronic pain. Such a way of thinking amounts to a self-fulfilling prophecy, as pain-based catastrophizers find themselves more pained, disabled, and distressed than their non-catastrophizers counterparts.

Our own research program on Israeli chronic pain sufferers tells a sordid tale on the role of pain-based catastrophizing in chronic pain. We have entered this research program by way of an extension of our previous, year-long depression research, in an attempt to understand the effect of pain on clinical depression. Drawing from studies suggesting that chronic pain might lead to depression, we sought to identify factors that increase or decrease this effect of pain. Utilizing a longitudinal study of 428 patients treated in two tertiary pain clinics, we were surprised to find the inverse: it was “anxious depression” (i.e., depression comorbid with anxiety) that predicted an increase in chronic pain, but not vice versa. Moreover, anxious depression also predicted an increase of pain-related disability in this sample.

We then reanalyzed the data, this time focusing on pain-based catastrophizing. We found that it was pain-based catastrophizing, and not anxious-depression, that predicted an increase in pain severity. Anxious-depression still predicted an increase in pain-related disability.

In another study based on an independent sample of chronic pain sufferers, we were able to shed additional light on the alarming nature of pain-based catastrophizing. One hundred and 65 chronic pain patients were assessed twice, before and after military operation "Protective Edge," during which thousands of missiles landed on populated areas across the country. At the pre-operation measurement, we assessed—among other things—suicidal ideations, which are known to be prevalent in chronic pain. We found that pain-based catastrophizing was the strongest predictor of suicide ideations in this sample. Subsequent to operation “Protective Edge,” we assessed the effect of exposure to the missile attacks on the experience of pain among these chronic suffers. Again, we found that pain-based catastrophizing featured prominently. Specifically, in patients who, prior to the military operation, tended to catastrophize about their pain, exposure to the missiles through the media (watching news on T.V. or over the internet) predicted an increase in pain severity.

So, what is going on here? Why is pain-based catastrophizing so ominous? As humans, we appear to be evolutionarily programmed to contemplate the future. It makes sense that we do because such future-oriented thinking enables us to preempt against possible threats and reach our key goals. This tendency, however, backfires when we allow pain—a consensually adverse experience—to overshadow our future vision. When this happens, our catastrophic thoughts attack us much more formidable than the pain itself.

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Source: dreamstime

Fortunately, currently available psychological interventions address chronic pain patients’ tendency to dangerously throw themselves into the future. Chief among these interventions is Acceptance and Commitment Therapy (ACT), where patients are taught to accept their present-moment pain experience and proceed to pursue personally meaningful tasks despite the pain. While we applaud these treatments, we believe that a crucially important yet relatively overlooked avenue for intervention is prevention. Namely, upon being admitted to specialty pain clinics, patients should be educated on pain-based catastrophizing, and be trained to withstand the latter’s attempt to control patients’ future visions.

References

Amati, D., & Shallice, T. (2007). On the emergence of modern humans. Cognition, 103(3), 358-385. DOI: 10.1016/j.cognition.2006.04.002

Cloft, P., Blyth, F. M., & van der Windt, D. (2010). Chronic pain epidemiology: From Aetiology to public health. New York: Oxford Press.

Edwards, R. R., Smith, M. T., Kudel, I., & Haythornthwaite, J. (2006). Pain-related catastrophizing as a risk factor for suicidal ideation inchroic pain. Pain, 126(1–3), 272–279. doi:10.1016/j. pain.2006.07.004

Lerman-Zohar, S. F., Rudich, Z., Brill, S., Shalev, H., & Shahar, G. (2015). In chronic pain sufferers, depression/anxiety prospectively predicts pain: Support for the antecedent hypothesis. Psychosomatic Medicine, 77(3), 333-341. doi: http://dx.doi.org/10.1097/PSY.0000000000000158

Noyman-Veksler, G., Lerman, S. F., Brill, S., Rudich, Z., Shalev, H., Joiner, T. E., & Shahar, G. Role of pain catastrophizing in pain, distress, and suicidal ideation among chronic pain patients. Psychiatry: Interpersonal & Biological Processes, 80(2), 55-170. doi: 10.1080/00332747.2016.1230984.

Noyman-Veksler, G., Shalev, H., Rudich, Z., Brill, S., & Shahar, G. Chronic pain under missile attacks: The central role of media exposure. Psychological Trauma, Oct 9. doi: 10.1037/tra0000297. [Epub ahead of print]

Phillips, C. J. (2009). The cost and burden of chronic pain. Pain Reviews, 3(1), 2-5. doi: 10.1177/204946370900300102

Ranjan, R. (2001). Social relations and chronic pain. New York: Plenum.

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