Catastrofarea Si Durerea La Pacientii ali

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Catastrophizing and Pain in Arthritis,Fibromyalgia, and Other Rheumatic DiseasesROBERT R. EDWARDS, CLIFTON O. BINGHAM III, JOAN BATHON, ANDJENNIFER A. HAYTHORNTHWAITE

Objective. Pain is among the most frequently reported, bothersome, and disabling symptoms described by patients withosteoarthritis, rheumatoid arthritis, fibromyalgia, and other musculoskeletal conditions. This review describes a growingbody of literature relating catastrophizing, a set of cognitive and emotional processes encompassing magnification ofpain-related stimuli, feelings of helplessness, and a generally pessimistic orientation, to the experience of pain andpain-related sequelae across several rheumatic diseases.Methods. We reviewed published articles in which pain-related catastrophizing was assessed in the context of one or

more rheumatic conditions. Because much of the available information on catastrophizing is derived from the moregeneral chronic pain literature, seminal studies in other disease states were also considered.Results. Catastrophizing is positively related, in both cross-sectional and prospective studies across different musculo-skeletal conditions, to the reported severity of pain, affective distress, muscle and joint tenderness, pain-related disability,poor outcomes of pain treatment, and, potentially, to inflammatory disease activity. Moreover, these associationsgenerally persist after controlling for symptoms of depression. There appear to be multiple mechanisms by whichcatastrophizing exerts its harmful effects, from maladaptive influences on the social environment to direct amplificationof the central nervous systems processing of pain.Conclusion. Catastrophizing is a critically important variable in understanding the experience of pain in rheumatologicdisorders as well as other chronic pain conditions. Pain-related catastrophizing may be an important target for bothpsychosocial and pharmacologic treatment of pain.

KEY WORDS. Pain; Coping; Catastrophizing; Fibromyalgia; Arthritis.

Introduction

Pain is a nearly ubiquitous experience, and a cardinalsymptom of many rheumatologic conditions. Catastroph-izing, a set of negative emotional and cognitive processes(1), is increasingly implicated in the experience of pain inrheumatoid arthritis (RA), osteoarthritis (OA), and fibro-myalgia (FM). The construct of catastrophizing incorpo-rates magnification of pain-related symptoms, ruminationabout pain, feelings of helplessness, and pessimism about

pain-related outcomes. The recognition that pain is a con-sistent risk factor for mortality (25) highlights the impor-tance of better understanding the biopsychosocial natureof pain and identifying groups at high risk for adversepain-related consequences. This review summarizes evi-dence that catastrophizing represents an important targetfor investigation and intervention in the rheumatic dis-eases.

Catastrophizing

Catastrophizing is typically measured using a self-report

inventory: the 6-item catastrophizing subscale of the Cop-ing Strategies Questionnaire (CSQ) (6) or the Pain Cata-strophizing Scale (PCS) (7), which expanded the original 6CSQ items to include 7 others. Individuals rate the extentto which they experience (when they are in pain) thethought or feeling described by each item (Figure 1). Eachscale has good psychometric characteristics (1); the PCShas 3 subscales, magnification, rumination, and helpless-ness (7), which have similar psychometric properties inpatients with FM and controls (8).

Although individuals are sometimes dichotomized as

Drs. Edwards and Haythornthwaites work was supported

by grants from the NIH (grants AR-051315 and DE-13906,respectively).

Robert R. Edwards, PhD, Clifton O. Bingham III, MD, JoanBathon, MD, Jennifer A. Haythornthwaite, PhD: Johns Hop-kins Medical Institutions, Baltimore, Maryland.

Address correspondence to Robert R. Edwards, PhD, De-partment of Psychiatry & Behavioral Sciences, Johns Hop-kins University School of Medicine, 600 N Wolfe Street,Meyer 1-101, Baltimore, MD 21287. E-mail: redwar10@ jhmi.edu.

Submitted for publication August 8, 2005; accepted inrevised form September 15, 2005.

Arthritis & Rheumatism (Arthritis Care & Research)Vol. 55, No. 2, April 15, 2006, pp 325332DOI 10.1002/art.21865 2006, American College of Rheumatology

REVIEW ARTICLE

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catastrophizers and noncatastrophizers, most researchtreats catastrophizing as a continuous, normally distrib-uted variable (1). In our database of patients with pain,there is wide variability around the mean catastrophizingscore (Figure 2). Catastrophizing also exists on a contin-uum in healthy, pain-free individuals (9); indeed, highercatastrophizing, assessed in pain-free adults, predicts thefuture development of chronic pain and pain-relatedhealth care utilization (10,11). A rich area of debate hascentered on whether catastrophizing is best conceptual-

ized as a stable and enduring trait, such as a dimension of

personality, or as a modifiable characteristic (1,12), withsome evidence supporting both positions. Several studiesreport a high testretest stability of catastrophizing mea-sured over time frames of up to a year in patients with RAand in other samples (7,13). In contrast, catastrophizingoften decreases when patients undergo cognitive-behav-ioral therapy (CBT; a set of psychologist-delivered inter-

ventions designed to facilitate the development of self-management skills, including regulating ones thoughts,emotions, and behaviors) (14,15), indicating that cata-strophizing can be altered by treatment.

Adverse Outcomes of Catastrophizing

Pain severity. Cross-sectionally, catastrophizing relatesto higher pain severity among patients with RA (1618)and OA (19,20). High levels of catastrophizing are alsoassociated with more severe and widespread pain andmore emotional disturbance among individuals with FM(2124) and scleroderma (25). In general, these associa-

tions persist even after statistically controlling for depres-sion, anxiety, or neuroticism (20,26). Several prospectivestudies have illustrated the longitudinal association ofcatastrophizing with pain in RA. In daily diary studies,patients with RA who exhibited greater catastrophizingreported more day-to-day pain and attention to pain thanlow catastrophizers (26,27). Findings from another pro-spective study suggested that baseline catastrophizingscores predicted enhanced pain and depression in patientswith RA at 1-year followup (28). Catastrophizing may alsoinfluence the success of pain-related treatments in patientswith musculoskeletal disease. In studies of patients withOA recovering from knee surgery (29,30), higher preoper-ative levels of catastrophizing were associated with more

pain and disability up to 6 months postoperatively.Whether catastrophizing predicts the onset of painfulrheumatic conditions is not known, although high cata-strophizing was shown to be a risk factor for the onset oflow back pain and disability in a population-based study(10,11).

Pain sensitivity. Catastrophizing shows positive associ-ations with tender point counts in both population studiesof musculoskeletal tenderness and clinic-based samples ofpatients with FM (24,3133). Hyperalgesia, or enhancedresponsiveness to painful stimuli, is a defining feature ofFM but has also been noted in patients with RA (3439)and OA (4042). Catastrophizing may be correlated withsome of these hyperalgesic responses. For example, cata-strophizing was associated with decreased heat painthreshold and tolerance in women with FM (43), reducedpain tolerance during a cold pressor test in patients withjuvenile rheumatoid arthritis (JRA) (44,45), and lower painthreshold and tolerance in response to electrical stimula-tion among patients with OA (46). Recent evidence fromour laboratory suggests that higher catastrophizing relatesto greater central nervous system (CNS) sensitization dur-ing sustained pain (47), which may account for the con-sistent positive relationship between catastrophizing andpain sensitivity.

Figure 2. Distribution of Coping Strategies Questionnaire (CSQ)catastrophizing subscale scores in a sample of 2,257 patientsexperiencing heterogeneous chronic pain syndromes (unpub-lished data). Scores on the CSQ catastrophizing subscale rangefrom 0 to 6.

Figure 1. The Pain Catastrophizing Scale (7). Total scores rangefrom 0 to 52.

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Depression. In general, catastrophizing is strongly asso-ciated with measures of negative affect (1). Multiple inves-tigators have documented positive associations betweencatastrophizing and depressive symptoms in FM (21,23,43). Similar findings have been reported in patientswith RA (16), and we have observed a significant Pearsonscorrelation (r 0.65) between catastrophizing and scores

on the Beck Depression Inventory in several hundred in-dividuals with scleroderma. Prospective studies have doc-umented the association of high catastrophizing at base-line with increases in depressive symptoms over periodsof up to 1 year in patients with RA (13) and FM (28). In arecent diary study of patients with OA, catastrophizingshowed concurrent and prospective relationships withmore intense negative mood (i.e., increases in catastroph-izing on a given day related to worsened mood that sameday and on the next day) (19). Taken together, these find-ings suggest that in the context of chronic pain, catastroph-izing may contribute to depressed mood on a short- andlong-term basis. Interestingly, virtually no research to datehas examined associations between pain-related cata-strophizing and formally assessed (e.g., by structured in-terview) psychiatric diagnoses such as posttraumaticstress disorder, generalized anxiety disorder, etc., whichrepresents an important avenue for future catastrophizingresearch.

Disability. Catastrophizing shows robust associationswith self-reported disability and with more objective indi-ces of function such as returning to work. In patients withOA, catastrophizing relates to higher levels of observedpain behaviors and functional limitations during standard-ized activity tests (20). Among patients with OA undergo-ing knee surgery, catastrophizing prospectively predicted

postsurgical disability, even after controlling for other psy-chosocial factors (29). Importantly, although pain severityis often a primary determinant of disability, RA studieshave established that catastrophizing predicts disabilityeven after controlling for pain severity (16,48). Finally,catastrophizing and other indices of poor pain coping areprospectively associated with reductions in objectivelymeasured mobility and muscle strength over periods of upto 5 years in patients with RA (49,50). These findings areconsistent with studies of low back pain (5153) in whichcatastrophizers reported more pain and reduced functionduring standardized physical tasks (e.g., range-of-motionexercises, etc.).

Physiologic indices of disease activity in RA. MultipleRA studies have reported positive relationships betweencatastrophizing (or helplessness, one component of cata-strophizing) and elevated disease activity (5458). Al-though much of this research is cross-sectional, at least 1longitudinal RA study has shown that catastrophizing pro-spectively predicted worsening disease activity (defined

by erythrocyte sedimentation rate [ESR] and joint counts)(26). Among patients with JRA, catastrophizing directlyinfluences physicians global assessments of disease (59),with higher catastrophizing predicting more severe dis-ease assessment. Whereas most of these studies did not

control for symptoms of anxiety or depression, a recent RAstudy concluded that although helplessness was stronglypositively associated (i.e., 15% shared variance) with ele-vated high-sensitivity C-reactive protein (CRP) levels, anx-iety and depression were either unrelated or only mod-estly related to CRP (60). Finally, prospective RA researchhas also revealed that baseline helplessness predicts future

increases in ESR (61) as well as mortality (62,63), evenwhen controlling for baseline disease severity. Whethercatastrophizing directly impacts other physiologic systemssuch as the sympathetic nervous system or the hypotha-lamicpituitaryadrenal axis is uncertain; cold pressorstudies have demonstrated that high catastrophizing doesnot predict cortisol reactivity to pain (64), but does predictsustained increases in myocardial contractility (65), a po-tential index of sympathetic activity. Although it is un-clear how catastrophizing influences disease severity,helplessness does correlate with less effective medicationuse (66) and less positive health behavior such as exercise(67), suggesting several plausible pathways by which cata-strophizing could enhance disease, reduce physical

health, and promote mortality.

Additional outcomes. The impact of catastrophizing onoutcomes can be fairly broad (i.e., not limited to pain). Forexample, catastrophizing is related to greater reports offatigue among women with breast cancer (68,69), in-creased constitutional symptoms such as nausea in indi-viduals with infections (70), reduced maternal social in-volvement among new mothers (71), and dissatisfactionwith treatment among patients being treated for gastroin-testinal symptoms (72). From a societal perspective, cata-strophizing is an important variable to understand becauseit relates to greater health care utilization and use of pain-related medications in the general population (11,73),even after controlling for pain intensity.

Hypothesized Mechanisms of Action

Catastrophizing interferes with pain-coping and bene-ficial health behaviors. Perceptions of helplessness andpessimism may diminish the likelihood that high cata-strophizers anticipate positive outcomes from other cop-ing efforts, which may therefore be underutilized (1). In 2experimental pain studies, individuals who were highcatastrophizers reported using fewer active coping strate-gies (e.g., distraction, relaxation, etc.) during a cold pressortest (7,74). Catastrophizing also relates to lower copingefficacy in patients with OA (19) and RA (18); indeed, inthis latter study, higher levels of catastrophizing were as-sociated with reduced perceptions of coping self efficacyon the part of both the patient and his or her spouse.Finally, as noted above, helplessness (one component ofcatastrophizing) correlates with reduced adherence tomedication regimens (66) and less positive health behav-iors such as exercise (67), each of which could potentiallylead to increases in musculoskeletal pain symptoms.

Catastrophizing increases attention to pain. Some re-search has also examined the hypothesis that catastroph-izing enhances the experience of pain via its effects on

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attentional processes. That is, high levels of catastrophiz-ing may lead individuals to attend selectively and in-tensely to pain-related stimuli. Catastrophizers experiencemore difficulty controlling or suppressing pain-relatedthoughts than do noncatastrophizers, they ruminate moreabout their pain, and their cognitive and physical perfor-mance are more disrupted by anticipation of pain (51,75

77). In patients with FM, catastrophizing is strongly cor-related with increased attention to pain (78) and greatervigilance to bodily sensations (36,79).

Catastrophizing amplifies pain processing in the CNS.Incoming signals in the CNS are subject to modulation at avariety of sites from the spinal cord to the cortex (80). Onehypothesized mechanism by which catastrophizing im-pacts the experience of pain promotes sensitization orinterfering with pain inhibition in the CNS (1,21,43,47).An early study suggested that reducing catastrophizingresulted in the activation of descending endogenous opi-oid systems that inhibited nociception (81). A more recentfunctional magnetic resonance imaging study of patientswith FM indicated that high catastrophizers showed en-hanced activity in cortical regions involved in the affectiveprocessing of pain, such as the anterior cingulate cortexand insular cortex, during the experience of acute pain(21). Recent data from our laboratory also suggest thatcatastrophizing may be directly associated with CNS pain-facilitatory processes in the spinal cord (82). Overall, pre-liminary evidence indicates that catastrophizing may am-plify pain processing at multiple CNS loci, with someresearchers postulating that bidirectional relationships be-tween catastrophizing and nociceptive processing maycontribute to the chronicity of many pain conditions (1).

Catastrophizing has a maladaptive impact on the socialenvironment. The communal coping model of catastroph-izing postulates that expressions of catastrophizing func-tion to maximize access to supportive responses from oth-ers, and that these social responses may then reinforcedisplays of pain and expressions of catastrophizing(1,83,84). In support of the model, catastrophizers are per-ceived by others as less able to manage pain, and are morelikely to seek social support (18,48,85,86). It is interestingto consider that daily diary studies of patients with RAsuggest that expressing emotions and seeking social sup-port, which may reflect catastrophizing, are prospectivelyassociated with greater arthritis pain (8790). Also note-worthy is the finding that high levels of catastrophizing are

associated with greater perceived stress and less nonpain-related social support within the social network(86,91), suggesting that more frequent catastrophizing mayhave paradoxical effects by both eliciting more solicitousresponses to pain (92) and reducing the general availabil-ity of support, potentially by enhancing distress in others(93).

Implications for Treatment

Screening for psychosocial risk factors that predict poortreatment outcome is not widespread, but it may holdpromise as a low-cost means to identify individuals who

would benefit most from adjunctive treatments. For exam-ple, given that catastrophizing is a risk factor for poorsurgical outcomes (29,30), long-term treatment successmay be maximized by offering CBT either presurgery orconcurrently with surgery to those who exhibit high levelsof catastrophizing. We should also note that reducing cata-strophizing is particularly important in the context of pre-

venting disability. As several RA studies have demon-strated, the degree of physical disability exhibited bypatients is a function not solely of pain frequency or in-tensity, but also of the degree of catastrophizing, suggest-ing that simple pain reduction is not an adequate treat-ment goal. In this regard, exposure paradigms are animportant part of behavioral treatments for painful condi-tions such as FM, RA, and OA; interventions designed toincrease physical activity levels may result in greater painin the short term, but by reducing catastrophizing andenhancing self efficacy, these interventions are likely toreduce long-term pain and disability (94,95).

Chronic pain and disability are increasingly managed bymultidisciplinary means; analgesic regimens are fre-

quently supplemented by physical therapy or psychologi-cal interventions for individuals experiencing persistentpain from rheumatic diseases (9698). Indeed, for patientswith FM, nonpharmacologic adjunctive therapies maydemonstrate benefits superior to those provided by anal-gesic medications (96,99). Emerging evidence indicatesthat catastrophizing may be an important mediating vari-able contributing directly to the outcomes of such treat-ments. In 2 previous studies, decreases in catastrophizingcorrelated with reductions in levels of depression and pain

behaviors (such as distorted mobility and verbal and non-verbal complaints) among patients undergoing pain treat-ment (14,100). Subsequent work using more sophisticatedanalytic techniques has extended these findings; duringmultidisciplinary pain treatment, early reductions in cata-strophizing are associated with greater improvements inpain later in treatment, whereas individuals whose cata-strophizing does not change demonstrate few or no bene-fits from multidisciplinary interventions (15,101103).Previous studies of cognitive and behavioral interventionsfor pain suggest that these methods are effective in de-creasing pain-related catastrophizing (14,15,104), and

based on these findings, it may be of great importance totarget catastrophizing early in the multidisciplinary man-agement of pain. Future treatment studies in patients withrheumatic disease may benefit from the assessment of cata-strophizing pre- and posttreatment, the consideration ofcatastrophizing as a mediator or moderator of treatmenteffects, and a more fine-grained analysis of the pathways

by which catastrophizing impacts important outcomes.A crucial unanswered question is whether catastrophiz-

ing is a cause or consequence of chronic pain (1,12). Someindirect evidence bears on this issue, although no longitu-dinal studies have yet examined whether catastrophizingchanges following the development of chronic pain. First,catastrophizing tends to be stable over time in both healthyadults and patients with pain, showing high testretestreliability measured over weeks or months (7,13). Recentdata have also suggested that catastrophizing, measuredinitially when patients were experiencing acute pain and

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remeasured several weeks later when they were pain free,did not change when patients pain was alleviated (47). Incontrast, as noted above, self report of catastrophizingoften decreases when patients undergo CBT (14,15), indi-cating that it may be substantially modifiable. Finally,

studies using daily diary methodologies offer a uniqueopportunity to examine the dynamic properties of cata-strophizing because these methodologies allow assess-ment of variability both within persons (i.e., variation fromtime point to time point) and between persons. A recentdiary study in patients with chronic pain highlighted theshort-term stability of catastrophizing: individuals dif-fered substantially in how much they catastrophized, but agiven person was likely to show similar levels of cata-strophizing across the 2-week period, despite fluctuationsin pain (105). Collectively, catastrophizing appears to de-velop relatively early in life (106,107) and to possess manystable, trait-like characteristics, but it is clearly also ame-nable to reduction by certain types of psychosocial treat-

ment.

ConclusionsCatastrophizing shows strong influences on many pain-related outcomes in patients with rheumatic disease, withmultiple mechanisms of action accounting for its effects(Figure 3). Because it is robustly correlated with treatmentsuccess, catastrophizing represents an appealing target formultidisciplinary pain-management interventions. Be-cause catastrophizing may act via numerous pathways,multimodal treatments incorporating pharmacologic, cog-nitive, behavioral, and potentially social interventions areperhaps most likely to succeed in ameliorating its effects.Unfortunately, no published studies have evaluated theefficacy of pharmacologic interventions in the reduction ofcatastrophizing, which represents an important area forfuture research. However, CBT and multidisciplinarytreatments consistently reduce catastrophizing, even insamples of patients with long-standing complaints. Forexample, in patients reporting chronic pain for 12 years,a 4-week group CBT intervention delivered by a psychol-ogist improved PCS scores by40% from pre- to posttreat-ment (108). At present, little information is available onthe management of catastrophizing in patients with rheu-matic disease, although based on the broader chronic painliterature, patients with high levels of catastrophizing are

likely to benefit from referrals to a pain psychologist or toother health professionals with expertise in CBT. Finally,given that catastrophizing relates to enhanced inflamma-tory processes and disease activity in RA, the refinementand application of cognitive, behavioral, and other inter-ventions designed to diminish catastrophizing in patientswith arthritis would potentially represent an important

development in disease management.

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