Pain Catastrophizing and Your Headache

Some people have strange ideas about – well, people. Human beings.

Some people seem to think that we’re just MINDS. And since we’re just MINDS, if we think we have no pain, we have no pain.

Other people believe that we are merely SOULS. Perhaps, then, the pain is not even real.

And other people think we’re just BODIES walking around. If we have pain, we have pain. It’s just the way our BODIES work. Period.

But many people realize that we’re complex beings. It’s just not as simple as “just deal with it”. It’s not going to work to “just take a pill”.

And that brings us to one of the current “cool” terms in pain treatment, pain catastrophizing. (Say it out loud once or twice. It’s fun.)

Pain catastrophizing has been defined in various ways, but here’s the basic idea. Everyone seems to think differently about pain (and think differently at different times, in response to different types of pain, and so on). Some thoughts may be positive (“It will be over in a few hours”) and some thoughts may be negative (“There’s nothing I can do to make things better”).

If those thoughts are on a basically negative path, it can make things even worse than the pain would by itself. That’s pain catastrophizing.

I’ve often said that how you think about pain is directly related to disability. In other words, if I’m constantly thinking about my pain, I am more disabled. I may have more pain another day, but if I find a way to think about it less, it affects how disabled I am.

This may not mean that thoughts affect the pain – actually making it more or less. But it does affect – as I said – disability. It affects behaviour. It may change even the treatments I choose, or how productive I am, to some extent.

Because thoughts are so personal, and pain is so personal, this is a very slippery topic. Many researchers believe pain catastrophizing exists (let’s call it PC from now on in this article), but here are some of the big questions that we have.

1. What causes PC? Is it simply caused by too much pain too often? Or is it more a matter of culture, or point of view, or behaviour?
2. Can PC actually directly make symptoms worse? How?
3. Can PC actually be treated directly?
4. Do different types of pain change how PC works?

Various methods have been used to measure PC, or related things like your anxiety regarding your pain, or fear avoidance. For example, PC is measured using rumination, magnification and helplessness. Rumination is a focus on your symptoms, causes, and consequences (for example, continually thinking about the pain). Magnification is an exaggeration of your symptoms or circumstances (“what if I’m dying?”). Helplessness is – well, you can guess! Things like saying “there’s nothing I can do about these symptoms!”

But trying to measure responses to pain are difficult when someone else can’t really measure your pain. And how accurately do we even understand our thoughts over the past 24 hours?

Treating Pain Catastrophizing?

That’s the question, isn’t it? Can it be treated?

Some researchers thought, if it’s all about positive attitude, could an anti-depressant pill treat it? Results have been less than positive on that front.

No silver bullet has been found to “treat” PC. As Dr. Steven Z. George (associate professor of physical therapy at the University of Florida in Gainesville) put it,

Other studies have shown SSRIs [common antidepressants] not to be very effective or to be less effective. For now, the mainstay of treatment is cognitive-behavioral therapy (CBT). This may include learning better coping skills, and practicing acceptance and mindfulness. But we still have to treat the pain. It is a bit of the chicken and the egg. Which comes first? If we reduce that pain, catastrophizing gets better. If we reduce the catastrophizing, pain gets better. [source]

In other words, it’s just what we’ve been saying all along. You have to treat the whole, complex, human being. Positive thinking doesn’t generally make pain vanish (and would we want that? If you convince yourself you have no pain, you put yourself in serious danger of not listening to your body’s warning signals). But your thoughts do work together with your behaviour to make your treatment work.

It’s also tempting to rely on the power of placebo. “Who cares if xyz isn’t a treatment with any scientific evidence whatsoever? If you think it works for you, it does.” But – wouldn’t it be all the better if you “thought” that a treatment with good evidence behind it worked?

In the end, both doctors and patients need to be aware of PC. We need to stop ignoring the fact that our thoughts do make a big difference in our level of disability. No, that’s not the answer to all our problems. But it is a part of the complex picture.

If you’d like to learn more, check out these articles:

• Pain Catastrophizing: An Updated Review (from 2012, but lots of information)
• Pain Catastrophizing: What Clinicians Need to Know (2015, from Practical Pain Management)
• Pain 101: The Latest Thinking About Pain Catastrophizing and Why It Matters for Chronic Pain (2017, from the IASP Pain Research Forum (PRF) of the International Association for the Study of Pain)
• See some of the questionnaires that are used related to PC – most importantly, the Pain Catastrophizing Scale, but also the FACS and PASS.