통증환자가 최악의 상황을 상상하느냐가 통증치료 예후에 중요하다는 논문Pain-Related Catastrophizing.

[문형철]

통증환자가 최악의 상황을 상상하느냐가 통증치료 예후에 중요하다는 논문

Pain-Related Catastrophizing.

Pain-Related Catastrophizing.pdf

참고논문) 

Theoretical Perspectives on the Relation Between catastrophizing and pain.pdf

Abstract:

Progress in advancing understanding of the role of “catastrophizing” in pain and associated physical and psychosocial disability may be furthered by 

(1) consideration of the construct of catastrophizing, 

(2) eval‎uation of the extent to which currently available measures of pain catastrophizing tap into that construct, 

(3) investigation of the relation of catastrophizing to personal trait variables (e.g., neuroticism and worry), and 

(4) identification of the conditions (or states) under which catastrophizing is most likely to occur. 

-  통증 최악상황의 구조고려

- 

In this article, the authors discuss these issues and suggest directions for future research.

The term catastrophizing was used by Albert Ellis, the founder of rational–emotional therapy, almost four decades

ago. 1962년. 

-  catastrophizing 개념은 1962년 알버트 엘리스에 의해 처음 제시

What do pain catastrophizing scales really measure?

How do these definitions of catastrophizing, developed in cognitive models of anxiety and other psychologic

disorders, fit with the available measures of pain catastrophizing? 

Table 1 lists items on these measures.

Cognitive Errors Questionnaire

CATASTROPHIZING SUBSCALE

- 만약 이 상태가 지속되면, 나는 심각한 상태가 될것이고, 직장생활을 계속하지 못할 것이다. 또는 걷지 못할 것이다.

- 지금 나의 허리가 아파서, 나는 더이상 스포츠 활동(운동)을 못할 것이다.

- 언젠가 나는 섹스를 못할 수도 있다.

- 곧, 나는 수영조차 못할 수도 있다.

- 만약 하루동안 이완하지 못한다면 나는 자리를 보전하고 누을 수 있고, 일을 하지 못할수 있다.

- 만약 내가 가족, 친구, 운동동료와 함께 시작하지 못한다면, 나는 그들과 함께 하지 못할 것이다. 

Coping Strategies Questionnaire

CATASTROPHIZING SUBSCALE

- 최악이어서 나는 더이상 나아지지 않을 것이라고 느낀다

- 너무 두려워서 나는 나자신을 어떻게 해볼수가 없다고 느낀다.

- 나는 내 삶을 살 가치가 없다고 느낀다

- 지금 이 상황이 끝날 것인지에 대해서 항상 걱정한다.

- 나는 더이상 참을 수 없음을 느낀다. 

- 나는 더이상 나아갈 수 없다고 느낀다.

Pain Catastrophizing Scale

HELPLESSNESS SUBSCALE

- 최악이어서 나는 이 상황이 나아지지 않을 것이라고 생각한다.

- 너무 두려워서 나는 나자신을 어떻게 해볼수가 없다고 느낀다.

- 지금 이 상황이 끝날 것인지에 대해서 항상 걱정한다.

- 나는 더이상 참을 수 없음을 느낀다. 

- 나는 더이상 나아갈 수 없다고 느낀다

- 나는 통증의 강도를 줄이기 위해 내가 할 수 있는 것이 없다. 

RUMINATION SUBSCALE

- 나는 걱정스럽게 이 통증이 사라지기를 원한다.

- 나는 나의 마음에서 없앨수 없...

- 나는 얼마나 아플까에 대해서 계속 생각한다

- 나는 내가 얼마나 많이 이 통증이 멈추기를 생각하는지 모른다. 

MAGNIFICATION SUBSCALE

- 나는 통증이 더 나빠질 것에 대해서 계속 걱정한다.

- 나는 다른 통증 질환(상황)에 대해서 계속 생각한다

- 나는 심각한 일이 일어날 것인지 아닌지 걱정한다.

Pain Anxiety Symptoms Scale

FEAR SUBSCALE

- 만약 나의 통증이 너무 심하게 된다면, 그것은 절대 완화되지 않을 것이라고 생각한다.

내가 통증을 느낄때, 나는 나에게 생길 수 있는 어떤 심각한 일에 대해 걱정한다.

그것이 아플지라도, 나는 내가 괜찮아 질것이라는 것을 안다.

내가 통증을 느낄때, 나는 죽음에 대해 걱정하기 시작한다.

내가 아무리 고통을 유발하는 행동을 할지라도, 나는 나중에 그 통증이 줄어들 것이라는 것을 안다. 

나는 의사가 회복시킬 수 없는 심각한 질병을 가졌다고 생각한다.

내가 통증을 느낄때 나는 그것이 심각한 질병이라고 생각한다.

통증은 무섭다.

나는 통증을 느끼는 것을 몹시 무서워 한다. 

큰 통증이 찾아올때, 나는 내가 마비되거나 불구가 될것 같다고 생각한다.

COGNITIVE ANXIETY SUBSCALE

-내가 통증을 느낄때 나의 마음은 고요하다.

통증이 올때 나의 마음은 뒤흔들리고 긴장한다.

내가 아플때 나는 혼란스러움을 느낀다.

내가 아플때 나는 올바르게 생각할 수 없다. 

통증이 올라올때 나는 통증 외에는 어떤 것도 생각하기 어렵다.

내가 아플때 나는 그 통증이 계속될것 이라고 생각한다. 

나는 내가 통증이 있을 때에 원하지 않은 생각에 의해서 괴로움을 느낀다.

내가 아플때 나는 집중하기 힘들다.

나는 아플때 걱정한다,

나는 내가 심각한 고통을 겪는 동안 어떤 생각도 할 수 없다. 

The first measure developed to assess pain-related catastrophizing was the Cognitive Error Questionnaire.8 The

Cognitive Error Questionnaire consists of 24 vignettes, each followed by a dysphoric cognition(불쾌감). Respondents

indicate how similar the cognition is to how they would think in that situation. Six items form the catastrophizing scale (the others reflect other cognitive errors: overgeneralization, personalization, and selective abstraction).

The Cognitive Error Questionnaire has not been widely used; the majority of research in the area has involved the

six-item catastrophizing scale of the Coping Strategies Questionnaire (CSQ).9 However, Sullivan et al.10 sought to develop a broader measure of pain catastrophizing and in 1995 published the Pain Catastrophizing Scale (PCS). This measure has three subscales: rumination, helplessness, and magnification. The helplessness scale includes five of the six CSQ Catastrophizing scale items, plus one additional item. 

Although not labeled as a pain catastrophizing measure, the Pain Anxiety Symptoms Scale,11 developed to measure fear and anxiety associated with pain, has two subscales that are closely related to catastrophizing: fear (fearful thoughts and ruminations about the consequences of pain) and cognitive anxiety. 

These two subscales are highly correlated with one another and with the CSQ Catastrophizing scale (r
0.66–0.74) and with a measure of trait anxiety(상태불안).11,12 Examining the various items in Table 1, the question arises as to whether the definition of catastrophizing typically used by psychologists is fully exemplified in the most commonly used pain catastrophizing scales. Although the example given by Ellis2 is similar to items on the CSQ Catastrophizing scale and helplessness scale of the Pain Catastrophizing scale, do items on these scales (reflecting appraisals(평가) that the pain is terrible and intolerable) fully encompass the construct of catastrophizing should a measure of pain catastrophizing also include items that depict worst-case scenarios for patients with chronically painful conditions; for example: “I might end up paralyzed,” “I might become totally disabled,” “I will lose my job and not be able to support my family”? Such items might increase the face, content, and construct validity of pain catastrophizing scales by capturing an additional dimension of catastrophizing. 

As can be seen in Table 1, the Cognitive Errors Questionnaire catastrophizing scale items and some of the items on the Pain Anxiety Symptoms Scale fear subscale come closer than the other scale items to these catastrophic thoughts. At

this stage of our knowledge acquisition, it may be useful to broaden the area of inquiry to determine whether our

current measures of pain-related catastrophizing adequately reflect the concept of catastrophizing as it was originally conceived and as it has been applied to anxiety and other psychologic disorders. The addition of items reflecting worry about worst possible outcomes to existing or new measures would appear to be a potentially fruitful area for future research.

Catastrophizing: stable personality disposition or situational response?

The review by Sullivan et al.1 indicates that measures of pain-related catastrophizing consistently are associated

positively with measures of physical and psychosocial disability among patients with a variety of pain conditions.

The evidence also suggests that catastrophizing represents something other than solely a manifestation of depression.13 However, before we can attempt to apply existing theoretical frameworks to explain the relation of catastrophizing to pain and adjustment, it may be useful to consider whether pain-related catastrophizing is a stable personality disposition or a situational response that varies over time, elicited by certain stimuli/ conditions. 

That is, is catastrophizing related to a dispositional (e.g., schema- or personality-based) construct that is present across situations and acts as a filter through which one develops appraisals of pain as a threat with which one cannot cope? Or is catastrophizing a response that varies according to situational circumstances?

This question is touched upon by Sullivan et al.1 in the section on “Stability and Situational Specificity of Catastrophizing.” We would like to highlight this distinction here because clarification may prove to be heuristic in further research and delineation of the construct of catastrophizing. This may, in turn, result in certain theoretical models emerging as more applicable than others or, alternatively, necessitate the creation of a new model altogether. In the next two sections, we consider each possibility.

Catastrophizing as a stable, dispositional characteristic

In the review by Sullivan et al.1 and more generally in the pain literature, the term “catastrophizer” is used commonly to refer to one who catastrophizes, which suggests that we believe it to be a person-based construct. In support of this argument, a study examining the stability of the CSQ Catastrophizing scale over time reported a high (0.81) 6-month test–retest stability coefficient.14 Similarly, the Pain Catastrophizing Scale has been found to have a high test–retest correlation (r
0.75) across a 6-week period.10 With regard to exploring the possibility that catastrophizing is a stable, person-based characteristic, it would seem important to eval‎uate the relation of catastrophizing to other global or relatively stable dispositional variables, such as neuroticism. 

Although Sullivan et al.1 conclude that catastrophizing is distinct from neuroticism, there is evidence that measures of

catastrophizing and measures of neuroticism are highly correlated. For example, one study15 found the CSQ

catastrophizing scale to be highly correlated with the NEO16 Neuroticism scale. Another study found that significant

associations between CSQ catastrophizing scores and measures of physical and psychosocial disability disappeared when scores on the NEO Neuroticism scale were controlled.17 These results suggest that the CSQ catastrophizing scale provides similar information, as does this measure of neuroticism. Persons high in neuroticism may be prone to catastrophizing, and catastrophizing may mediate the relation between neuroticism and pain intensity ratings.18

Research investigating the relation of pain catastrophizing measures to neuroticism and other personality characteristics

(e.g., hypochondriasis, somatization, anxiety, worry, and negative affectivity) would seem to hold considerable

potential for increasing our understanding of what dispositional traits or psychologic disorders are associated with catastrophizing responses to pain. For example, one investigation found that patients with psychiatric diagnoses of somatization disorder and hypochondriasis had higher scores on a measure of catastrophizing interpretations of bodily complaints than did behavioral medicine center patients without these diagnoses.19

It might also prove informative to explore the relation between pain catastrophizing scales and measures of worry,

such as the Penn State Worry Questionnaire,20 a selfreport instrument for the trait assessment of clinically significant, pathologic worry. Studies of people without chronic pain have shown that worry is related to catastrophizing

thoughts, and that chronic worriers believe that worry has an adaptive function (e.g., to help avoid failures, mistakes, and catastrophes).5 Worry and catastrophizing have also been found to be associated with a sense of personal inadequacy and lack of confidence in problem-solving skills,5 which suggests other areas to explore in research and treatment involving patients with chronic pain problems.

Another potentially interesting area for study might be the relation of pain catastrophizing to pain-related beliefs,

which are generally viewed as fairly stable, although amenable to change (e.g., through education). Similar to catastrophizing, pain beliefs are strongly associated with physical and psychosocial disability. Sullivan

et al.1 state that, “in a recent study by Turner et al.21 it was found that pain beliefs mediated the relation between

catastrophizing and disability, suggesting that catastrophizing may influence disability indirectly, through other pain appraisals.” Although the study did not involve tests of mediation, the results suggested that catastrophizing may explain unique variance in depression, but not in physical disability, beyond that accounted for by age, sex, pain intensity, and measures of beliefs and coping. 

The findings of the study are consistent with a view of catastrophizing as significantly associated with one’s beliefs about one’s pain. Some of the beliefs most importantly associated with physical disability seem to be views of one’s pain as

disabling, views that pain is a signal of physical harm, and belief that one has little control over pain.21 Factor analytic studies have shown that the belief that one can control or decrease pain loads onto the same factor as catastrophizing, and that control and catastrophizing are inversely related.22 Such beliefs may influence cognitive (e.g., thoughts such as those listed in Table 1) and behavioral (e.g., continuing vs. discontinuing activity when in pain) responses to pain. In turn, these responses may influence subsequent pain experience and physical and psychosocial disability. For example, belief that pain is a signal of physical harm and that one has little control over pain may result in catastrophizing thoughts and verbalizations during pain flare-ups. Catastrophizing thoughts may lead to choices to rest and avoid activity, which can lead to deconditioning and failure to return to work, which may in turn lead to further pain, depression, and additional problems. 

Catastrophizing verbalizations may elicit sympathetic offers of help and suggestions to rest from significant others, in turn leading to decreased patient participation in customary activities and perhaps reinforcing the patient view that pain is disabling and a signal of harm.

Catastrophizing as a variable, situation-based response to pain

As an alternative to the view that catastrophizing is a disposition that is fairly stable over time, it is useful to consider the possibility that catastrophizing is a response to pain that varies over time and is determined by situational factors. As Sullivan et al.1 note, catastrophizing has been shown to change with targeted interventions.

This raises the question of whether there are contextual determinants of catastrophizing and, if so, what they are

and how they vary across time and persons with pain. It should be noted that variations in either internal (e.g.,

sensory or affective states) or external (e.g., environmental cues) conditions may provide the “context” in which

catastrophizing thoughts or behaviors are frequently observed. 

Therefore, for example, it may be the case that even psychologically healthy (e.g., non-neurotic, nondepressed)

individuals who do not typically “catastrophize” may have catastrophizing thoughts when experiencing severe pain (an internal sensory state). With regard to external factors, Sullivan et al.1 propose in the “Coping Model” section that catastrophizing may be used instrumentally, via exaggerated verbal reports and pain behaviors, to elicit social support. From this perspective, it would be expected that the extent to which one engages in catastrophizing may change over time as a function of stimulus cues and social responses (e.g., solicitous or punishing) present in the individual’s environment.

However, complex interactions may affect the relations between catastrophizing and psychologic distress or physical disability. For example, suppose that communications of catastrophizing are observed only in the presence of certain environmental conditions (e.g., a sympathetic spouse) and when one holds the belief of low control over pain. Such a finding would be consistent with the view that catastrophizing functions as a coping behavior and would lead to a prediction that catastrophizing fluctuates over time, depending on environmental conditions and the internal states of the person (e.g., certain beliefs or mood states). 

Unfortunately, very

little is known about the various conditions in which

catastrophizing may increase, decrease, or even disappear

in response to pain. Daily process methodologies

that have been used to eval‎uate daily fluctuations of coping

responses (e.g., studies by Affleck et al.23,24) and

direct observational methodologies (e.g., as used by Romano

et al.25–27) may be helpful in addressing these

types of questions.

Catastrophizing as both dispositional and

situation-influenced

As a final alternative to consider, catastrophizing may

be found to represent a fairly stable tendency in some

individuals, but with manifestations varying in intensity

as a function of certain stimuli/conditions. Analogously,

it has been argued that patients with panic disorder have

a tendency to catastrophically misinterpret bodily sensations,

even when they are not anxious, and that this relatively

enduring cognitive trait is amplified when the patient

is in an anxious state.6 Similarly, it is possible that

certain individuals have a tendency to catastrophize in

response to pain but that this tendency is amplified under

certain internal conditions, such as when the individual is

depressed or anxious or highly stressed, and in certain

situations, such as in the presence of a solicitous spouse.

Some methodological considerations

Difference between pain experience and pain report

We comment on more specific aspects of the article by

Sullivan et al.1 First, we point out that the authors use the

terms “pain” and “pain experience” when it would be

more accurate to use terms such as “measures of pain

intensity” or “patient ratings of pain intensity.” For example,

the first sentence in the “Catastrophizing and

Pain” section states, “One of the most consistent findings

has been that catastrophizing is associated with heightened

pain experience.” Similar statements are found in

other sections of this article. It must be kept in mind that

we cannot know the pain experience of others; we can

only observe their behaviors (including verbal reports of

pain and ratings of pain intensity). A more accurate conclusion

would be that self-report measures of the tendency

to have catastrophizing thoughts when in pain are

correlated with self-report measures of pain intensity.

Correlation does not prove causation

These correlational studies do not prove causal relations.

Attention may be called to the first sentence of the

fourth paragraph, which states that “...the tendency to

‘catastrophize’ during painful stimulation contributes to

more intense pain and increased emotional distress.”1

We must not make the mistake of assuming that catastrophizing

“contributes to” more intense pain based on

statistical associations between individual ratings of pain

intensity and ratings of catastrophizing thoughts. Shared

method variance and response/reporting biases may explain

these associations to some extent, and causal relations

between catastrophizing and pain are unknown. As

the authors acknowledge, individuals may be more likely

to catastrophize when pain is more intense.

Similarly, further research is needed before concluding

that “the pattern of findings appears to support the

causal or, at least, antecedent status of catastrophizing”

(statement in the Catastrophizing and Pain section).1

Three articles are cited in support of this statement. In

one article, students classified as catastrophizers reported

more pain than did noncatastrophizers in an experimental

pain procedure, and patients classified as catastrophizers

reported more pain during an electrodiagnostic procedure

than did noncatastrophizers.10 Although these findings

are consistent with a model of catastrophizing as

causing increased pain (or at least, higher pain ratings),

studies in which pain is assessed after experimental manipulations

of catastrophizing would provide even stronger

support for such a model.

In another of the cited studies, undergraduate students

completed a pain catastrophizing measure before a dental

procedure involving mild to moderate pain.28 Individuals

were assigned randomly to two conditions in which they

were asked to write just before the procedure. In the

disclosure condition, they were asked to write about the

thoughts and feelings they typically experienced during

dental treatment, focusing on the aspects of dental treatment

they found to be most distressing. In the control

condition, they were asked to describe their activities from the previous day. “Catastrophizers” rated their pain

during the procedure significantly higher than did “noncatastrophizers”

in the control condition, but the two

groups did not differ in the disclosure condition. Furthermore,

catastrophizers in the control condition reported

significantly more pain than did catastrophizers in the

disclosure condition. This is a fascinating study; however,

because there was not a convention with no writing

intervention prior to the dental procedure, we do not

know whether catastrophizers would have rated their

pain as higher than noncatastrophizers under normal dental

procedures. Furthermore, the comparisons between

catastrophizers and noncatastrophizers in this study did

not account for age, extent of periodontal disease, gender,

and other factors that might have influenced pain

ratings.

In the third study14 cited as evidence that catastrophizing

plays a causal (or antecedent) role in pain, patients

with rheumatoid arthritis completed questionnaires assessing

catastrophizing, physical disability, depression,

and pain intensity at time 1 and 6 months later (time 2).

Catastrophizing at time 1 explained a statistically significant

proportion of the variance in pain ratings, physical

disability, and depression scores at time 2, even after

controlling for time 1 scores on these outcome measures.

However, the amount of variance explained was very

modest and of questionable clinical significance. Further

research is needed to shed light on sequential and causal

relations between catastrophizing, pain, physical disability,

and depression.

CONCLUSIONS

In summarizing the current state of knowledge, Sullivan

et al.1 have provided a strong foundation to build on

in future investigations involving catastrophizing and

pain. There are many exciting possibilities for exploration.

In this article, we outlined potential directions we

believe to hold the most promise to advance our understanding

of the nature and function of catastrophizing.

These include the following: (1) questioning how current

measures of pain catastrophizing relate to the original

construct of catastrophizing and whether current measures

should be broadened; (2) examining how pain catastrophizing

relates to such stable, dispositional characteristics

as neuroticism and worry; (3) exploring sequential

relations and causal pathways between personality

characteristics, pain beliefs, catastrophizing, pain reports,

and physical and psychosocial disability; and (4)

identifying conditions under which catastrophizing may

function as a variable response to pain. It is our hope that

these suggestions will lead to even greater debate and

inquiry into the nature of a construct that we do know to

be associated importantly with patient reports of pain and

with pain-related physical and psychosocial dysfunction.

Cognitive Errors Questionnaire

CATASTROPHIZING SUBSCALE

If this keeps up, I’ll be crippled and won’t be able to work or even walk. 

Now that I hurt my back, I can’t play sports anymore.

Someday, I won’t be able to have sex.

Pretty soon, I won’t be able to swim at all.

If I don’t get some time to relax during the day, I’m going to be bedridden and unable to work.

Unless I start going with them [my family, to a baseball game], I won’t have a family to go out with.

Coping Strategies Questionnaire

CATASTROPHIZING SUBSCALE

It is terrible and I feel it is never going to get any better.

It is awful and I feel that it overwhelms me.

I feel my life isn’t worth living.

I worry all the time about whether it will end.

I feel I can’t stand it anymore.

I feel like I can’t go on.

Pain Catastrophizing Scale

HELPLESSNESS SUBSCALE

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 worry all the time about whether the pain will end.

I feel I can’t stand it anymore.

I feel I can’t go on.

There’s nothing I can do to reduce the intensity of the pain.

RUMINATION SUBSCALE

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.

MAGNIFICATION SUBSCALE

I become afraid that the pain will get worse.

I keep thinking of other painful events.

I wonder whether something serious may happen.

Pain Anxiety Symptoms Scale

FEAR SUBSCALE

I think that if my pain gets too severe, it will never decrease.

When I feel pain, I am afraid that something terrible will happen.

Even though it hurts, I know that I’m going to be O.K. (reverse scored)

When I feel pain, I become afraid of dying.

Even if I do an activity that causes pain, I know it will decrease later. (reverse scored)

I think I have a serious medical problem that my physician has failed to uncover.

When I feel pain I think that I might be seriously ill.

Pain sensations are terrifying.

I dread feeling pain.

When pain comes on strong, I think that I might become paralyzed or more disabled.

COGNITIVE ANXIETY SUBSCALE

My mind is calm when I am in pain. (reverse scored)

My thoughts are agitated and keyed up as pain approaches.

I feel disoriented and confused when I hurt.

I can’t think straight when in pain.

During painful episodes it is difficult for me to think of anything besides the pain.

When I hurt, I think about the pain constantly.

I am bothered by unwanted thoughts when I’m in pain.

I find it hard to concentrate when I hurt.

I worry when I am in pain.

I can think pretty clearly even while experiencing severe pain. (reverse scored)

[박수홍]

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