MONTREAL – Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.
In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.
In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude toward their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.
In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, [and] guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, sponsored by the International Association for the Study of Pain.
“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).
For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”
By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.
First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.
Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; Pain 1999;79:155-63).
Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.
In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.
“When pain is controllable, assimilative coping works. But when it is not controllable, it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).
Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist.
“I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”