Pain Catastrophising
The example statements and sayings used in this article are an attempt to ‘bring alive’ the concepts they are illustrating. However, obviously, within themselves, the statements and sayings can hold a broader meaning that may challenge the concepts they are attempting to illustrate here, but that is not their intention.
Introduction
“I wonder what our role should be with patients whose very attitude toward disease has become a disease itself. I wonder what we can do about an all-too-common undercurrent in the modern medical visit, at least in the West: a sense of entitlement and a never-ending search for perfection ….. do we have an obligation to point out to them (as practitioners wanting to help them develop their own sense of well-being) that things actually could be so much worse?” David Ponka MD CM CCFP(EM). Patient-centred care in a self-centred world (2008)
The complete psychology of catatsrophisation would be beyond the scope of myself, and a single article, as it would involve an array of psychotherapeutic models that I couldn’t give justice to. However, a literature review of pain catastrophisation does highlight areas of interest that maybe informative when being presented with such patients in clinic. Whilst an awareness of these concepts maybe beneficial, the application of these principles to individual patients should obviously be done in context of the individual practitioner’s training in this field.
Catastrophising allows individuals to approach problems at a superficial level, using overgeneralised verbal thinking (Hirsch et al 2019) to get stuck in rut with abstract, overgeneralised thoughts that are comforting in their familiarity but are unconstructive, unclear and broad/ill defined (Paucsik et al 2021). Whist being convenient in its ability to avoid emotionally processing, and confronting, clear aversive images and intense negative emotions, these highly valued benefits of catastrophising are only temporary in offering a short-term distraction as emotional distress only increases in the longer-term (Tenti et al 2022).
Therefore, when pain catastrophising and lowered pain acceptance in Fibromyalgia patients forms their illness representations fear avoidance is not necessarily due to pain intensity, or the fear of pain, but is due to their poor pain acceptance (Tenti et al 2022). Poor pain acceptance favours an absolute, blinkered need to avoid painful activities, even if the pain from these activities fails to surpass the rewarding experience of being self-defining by showing that there is more to life than ‘this’. This can lead to the distinction between the individual’s identity and their illness representation, as two separate entities, merging ever closer so that eventually their individual identity becomes swallowed up and defined by their illness representation (Tenti et al 2022). It is this ‘swallowing up’ of their individual identity by their illness representation in Fibromyalgia, not the pain, that accounts for (i) the sense of disownership, that a body part doesn’t belong to them feeling ‘alien’ which accounts for feeling strange sensations such as illusionary movements or a low level of acceptance with a morbid dislike for a body part (Scandola et al 2022); (ii) mediating the association between the rigid, non-adaptable characteristic traits of catastrophisation and Fibromyalgia symptoms (Paschali et al 2021).
When an individual’s identity becomes consumed by how catastrophisation shapes their illness representation they may engage in more social behaviours that are aligned with this identity, for example, trying to elicit empathy from others by communicating the severe and uncontrollable nature of their pain using facial displays and vocalisations for a longer duration compared to when they are alone (Bastion et al 2014). How the individual perceives these characteristic traits are projected out into society, and then reflected upon by social and cultural norms, determines how they are transmitted back to, and experienced by the individual through their own frame of reference.
Therefore, catastrophising, as an egocentric ineffective problem solving tool, approaching problems at an overgeneralised superficial level lends itself to poor critical thinking. Poor critical thinking (Hill & Garner 2021) and an egotistical fixation on a self-manufactured unique and stable identity (Vu & Burton 2021) triggers decisions that are in-line with this self-constructed, self-idealised identity (Vu & Burton 2021). This can result in polarisation, resentment, anger and radicalisation (Hill & Garner 2021) allowing the catastrophiser to virulently cling on to their beliefs so that they can protect and experience the familiarity of their self-narrative that is their perceived illness representation. Using cognitive resources to find flaws in others who fail to tread the narrow path so that they can experience the comforting familiarity of their rigid, non-adaptable self-narrative they resist turning their attentions inwards as to be independently creative through self-reflection and feeling a responsibility to treat individuals with conflicting perspectives as partners in search for more innovative ideas to broaden their perspectives and help find solutions, especially when they feel part of a group where collective responsibility diminishes their individual responsibility.
What is catastrophising? Pre-empt, prevent and protect
Catastrophisers are highly stressed and anxious about obtaining certainty over an uncontrollable future. Dwelling on their predictions that the worst will happen causes catastrophisers to define setbacks, not as a productive learning experience, but as catastrophic “if I fail this exam I’ll never get a job and end up miserable for the rest of my life”.
Therefore, catastrophising, as an emotional regulatory strategy replaces the anxiety from the need to obtain certainty over a cloudy future, with a crystal clear certainty that the worst will happen. By being able to prepare for the worst and ‘brace for impact’ catastrophisers regain a level of certainty and control that provides a particular kind of security and optimism.
When preparing to ‘brace for impact’ catastrophisers obtain certainty and reduce anxiety further by gaining comfort from familiar, rigid, inflexible styles of thinking. As a form of avoidance it preoccupies the individual with an anxiety driven desire to overgeneralise and misshape perspectives in order to avoid confronting the complexity and enormity of a problem with a more broader, flexible style of thinking (Flink et al 2013).
Another common catastrophising strategy to lower anxiety is to seek reassurance as to feel a deep sense of relief when rescued from the depths of despair by being told their anxious feelings are unfounded.
By quenching the anxiety fuelled distress with these unhealthy, but positively comforting emotions it validates this behaviour and continues the cycle. This means the next time catastrophisers feel anxious or the need to feel certain they, may, ramp up these emotions to the feel the warmth and comfort that ensues from protecting themselves by pre-empting the worst and seeking reassurance.
Once this process becomes well ingrained and established, these catastrophic, negative patterns of thinking, can easily be reactivated through only minor triggers such as subtle changes in mood (Barnhofer & Chittka 2010).
What is pain catastrophising?
Pain allows us to instantly respond to physical threats and help us predict potential harm (Lim et al 2020). This triggers swift instinctive action enabling us to escape from this harm or potential harm. However, pain can also be a normal or healthy experience associated with enjoyment e.g. some sports, eating chilli, or the “that’s it, right there” sensation during a massage (Bastian et al 2014).
Pain catastrophisation however, is a highly sensitive distorted, exaggerated, negative interpretation, towards actual, or anticipated pain that turns it into a catstrophe. It is one of the most important psychological correlates of pain and disability (Petrini & Arendt-Nielsen 2020).
Pain catastrophising occurs when the individual can’t make sense of, or accurately anticipate (Lim et al 2020), the physical and emotional aspects of pain; becoming overwhelmed they loose control either of the pain or life as a whole e.g. putting lives on hold for fear of ‘hurting the fragile body’ (Brunzli et al 2017).
Based on catastrophic beliefs, that follow a faulty, but can be quite logical, thought process, the individual attempts to make sense of the pain by asking (Brunzli et al 2017):
What is the pain? How can I identify it? This shapes beliefs about the structure and function of the body “my spine is the core, it holds everything together, all the nerves come from there”.
What caused the pain? “I don’t know what caused it, what’s exacerbating it, and that’s scary”.
What are the consequences to this pain? “I’m fearful of damaging my back, I won’t be able to walk, I’ll be an invalid and useless”.
How well can I control this pain? “I can’t cope, the pain overwhelms me”.
How long will it last? “I won’t be able to cope with the pain in the future. What will I do workwise to support my family?”
The answers to these questions determine how we feel about the pain, and, what we can do to make ourselves feel better about it. When the answers lend themselves to pain being perceived as unpredictable and uncontrollable, and/or as having intense consequences, it elicits a threat and a fear response (Brunzli et al 2017) associated with catastrophising.
This catastrophising response is characterised by worry and anxiety resulting in (Petrini & Arendt-Nielsen 2020):
Heightened sense of pain.
Difficulty in shifting attention away from pain.
Feeling helplessness in controlling pain.
Imaginative negative consequences, and thoughts about more severe situations.
This results in the individual being stuck in rut with abstract, overgeneralised thoughts that are comforting in their familiarity but are unconstructive, unclear and broad/ill defined (Paucsik et al 2021) in an attempt to try and create solutions to e.g. “what can I do prevent this pain?”
Lacking grounded, concrete logical thinking (“I’ll entertain more broadly a professional’s advice”) this abstract, reflex, emotional thinking is open to being distorted by prejudice or bias (“it feels to me as though I got bone on bone, my spine must be crumbling” “this treatment will ruin my life”); this catastrophising, mindset, that values perceptions, tainted by biases, creates a blindspot in our imagination making it hard to see how complexity and conflicting points of view paints a different picture from the one we perceive.
Dwelling on pain experiences in these exaggerated terms, without considering other more likely consequences, (Petrini & Arendt-Nielsen 2020), causes feelings of helplessness and rumination (Royle et al 2020) and a strong sense of injustice (Bissell et al 2018).
Catastrophisers attempt to regulate negative emotions by (Petrini & Arendt-Nielsen 2020):
Control. Loosing control makes pain more difficult to make sense of making it threatening, frustrating and scary. This makes the individual feel ‘stuck’ and uncertain what to do next (Petrini & Arendt-Nielsen 2020) especially when treatment doesn’t meet expectations and reinforces an inability to make sense of the pain (Brunzli et al 2017).
Loss of control and unpredictability can be from the uncontrollable nature of the pain (e.g. severe pain out of the blue without a ‘warning twinge’); catastrophising perceptions of a condition with petrifying damage beliefs e.g. degeneration = uncontrollable deterioration or “something breaking down getting worse over time”; catastrophising treatment outcomes “there’s no cure” “if it’s just a ligament why is it not healing up?” (Brunzli et al 2017).
Catstrophising regains control and clarity by providing answers that predict the worst scenario and make the individual feel they can prevent, pre-empt and protect themselves from future distress by suppressing any contradictory input that challenges their perceptions (Lim et al 2020) as well as giving a sense of relief when these feelings are unfounded (Petrini & Arendt-Nielsen 2020).
Suppression and avoidance. Suppressing emotions ignores challenging, contradicting points of view and bottles emotions up so you don’t experience or express them how you want (e.g. put a brave face on). It involves distracting oneself from these emotions, by, for example, catastrophising, whilst constantly checking that these emotions don’t surface. This drains self-control so (i) emotions fail to be suppressed and become fixated on; (ii) less self-control for other tasks (Litvin et al 2012). This reduced sense of self-control, as well as how suppressing emotions effects other aspects of health, drains our resources and influences how an individual engages with more challenging therapeutic interventions in the face of a more tempting, safer option of reduced engagement.
Communal coping. Pain catastrophisers exaggerate their communicative pain behaviours to elicit assistance or empathic responses from others (Petrini & Arendt-Nielsen 2020) e.g. longer facial displays or vocalisations when in the presence of others. Whilst they are more effective in communicating their pain they are less likely to engage in strategies that could minimise their pain (Gorczyca et al 2020).
This results in:
Inability to inhibit pain-related thoughts in anticipation of, during, or following a painful event (Petrini & Arendt-Nielsen 2020).
Inappropriate activation of Behavioural Inhibition and Behavioural Activation Systems (BIS/BAS) (Petrini & Arendt-Nielsen 2020).
Interoceptive sensitivity (Petrini & Arendt-Nielsen 2020).
Fear-anxiety-avoidance behaviour (Petrini & Arendt-Nielsen 2020).
Physically impede healing by promoting pro-inflammatory and anti-immune responses (Finan & Garland 2015).
Magnifying emotional-pain related thoughts, and re-enforcing them by continuously dwelling on them perpetuates an everlasting ‘worry cycle’; this worry cycle is characterised by frustration, helplessness and dysfunctional beliefs (Petrini & Arendt-Nielsen 2020).
The four characteristics of catastrophising that causes and reinforces the catastrophic worry cycle are (Petrini & Arendt-Nielsen 2020):
Catastrophic worry (repetitive negative thinking).
Rumination.
Magnification of the threat value of pain and the nature of the condition causing it, and, intern the downplaying of the harmless facets to pain. “Is something serious going to happen with my back?” “Is the pain going to get worse?” “I keep thinking of my last bad bout of pain”.
Helplessness. “I can’t stand it anymore, I can’t go on, there’s nothing I can do, it’s never going to get better. I spend all my time worrying about it, I feel it overwhelmed”.
Models used to explain pain catastrophising
Theoretical models that have been used to explain pain catastrophising including:
Worry (Petrini & Arendt-Nielsen 2020).
Rumination (Petrini & Arendt-Nielsen 2020).
Suppression (Petrini & Arendt-Nielsen 2020).
Behavioural Inhibition and Activation Systems (BIS/BAS) (Petrini & Arendt-Nielsen 2020).
Interoceptive sensitivity (Petrini & Arendt-Nielsen 2020).
Fear-anxiety-avoidance behaviour (Petrini & Arendt-Nielsen 2020 & Flink et al 2013).
These models are not only effected by a person’s relationship with their pain and their condition but also by how they regulate their emotions in other aspects of their life. For example, people that suppress anger direct valuable resources to this task having less resources to regulate other emotions that relate to their perceptions of pain and their condition making them more susceptible to pain (Toledo et al 2019).
Worry
When grounded by literal and pragmatic thinking worry is a healthy and productive problem-solving tool. In truly worrying situations that pose a literal, not perceived threat, from uncertainty and danger worry uses a “what if ... happens" style of thinking to openly confront the situation, whilst at the same time, creating a proportionate level of drama that beneficially stresses the importance of an upcoming threatening situation; this motivates the individual to find a solution to the worrying situation whilst monitoring the progress of the individual in implementing this solution; this enables the individual to successfully make sense of, and navigate, uncertainty and danger (Meeten et al 2016).
However, when worry spirals out of control, and isn’t grounded by literal and pragmatic thinking, it becomes overly dramatic by developing a disproportionate desire to seek certainty, and avoid, what is perceived to be, dangerous threatening situations. Uncontrollable worry shifts the emphasis away from using grounded, concrete, pragmatic thinking that is open to directly confronting and processing complexity to using an anxiety-driven desire to misshape and overgeneralise in order to protect against confronting the enormity of a problem and its solution.
The three key processes that trigger and maintain worry are (Hirsch et al 2019):
Automatic emotional-processing biases. When perceptions are shaped from anticipation and worry the individual places a high value on hypervigilant threat appraisal and negative thoughts about an up-coming event. The value placed on these intrusive negative thoughts in order to obtain certainty about an upcoming threat means the individual is less sensitive to updating their perceptions from any contradicting, positive, information that may presents itself; engaging in this self-fulfilling prophecy with blinkered autonomic hyperarousal constructs a negative-bias towards future thoughts that blocks out any pleasantly surprising, less threatening, contradicting information (White et al 2016).
Verbal thinking. Overgeneralised verbal thinking (i) suppresses vivid mental imagery that would otherwise encourage a less prejudice and more encompassing mindset using concrete, logical thinking (Teng et al 2016); (ii) easily moves from one negative topic to another making positive resolution of specific problems difficult or impossible.
Impaired intentional control of attention. When worry and rumination cumulates in high levels of threat and uncertainty the individual becomes highly motivated to pre-empt and avoid errors by focusing on negative, threat-related information. This traps the individual in a worry cycle preventing them from moving on and re-focusing on something else. Generating more benign interpretations of ambiguous information using mental imagery“the noise outside was probably a cat not a burglar” can help break the worry cycle.
Therefore, being anxiety driven, the individual becomes reliant on uncontrollable worry to provide a convenient, understandable, overgeneralised perception of the problem and its solution (Flink et al 2013). It muddies any clear visual images of the problem or its solution by thinking verbally (Ehring et al 2008) to predict ‘impending doom’. This creates a convenient illusion so the individual (i) feels secure of no surprises e.g. worrying about the results of a medical prepares you so you will be less upset if you hear bad news than if you had not have worried at all; (ii) cling on to inflexible, generic beliefs that suppress and avoid any conflicting points of view.
By avoiding grounded, concrete, pragmatic thinking to entertain these conflicting points of view there is a failure to embody a clear vision of the true complexity, and conveniently, blur perspectives as to narrow emotional engagement (Hochli et al 2018). This helps the individual distance themselves from the problem and shift blame (Kyung et al 2010) and responsibility, either on to themselves or others, and develop dysfunctional beliefs (Petrini & Arendt-Nielsen 2020). This makes uncontrollable worry an ineffective problem-solving tool when confronting, for example, problems such as “how can I make sure my back doesn’t ‘go’ again?’.
The most common problems pain-related worry tries to work around is (i) uncertainty “is this a new pain?” “why has the intervention made it no better (or worse?)”; followed by (ii) disability “I can’t do my normal activities”; (iii) pain experience “this pain just keeps hurting”; and lastly (iv) negative affect “I am useless” “I feel helpless” (Petrini & Arendt-Nielsen 2020).
However, in an attempt to obtain certainty and work around disability and negative affect to prepare for the worst and to protect against further pain worrying is notoriously ineffective. It is ineffective because it avoids grounded, concrete, pragmatic thinking that entertains complexity and conflicting points of view that would otherwise challenge biases and preconceived notions making the individual come face to face with negative emotion. At the expense of draining self-control (Litvin et al 2012), worrying attempts to avoid and suppress these negative emotions, which only draws more attention to them creating further anxiety, future disability, a deteriorating condition and dysfunctional beliefs. “It can’t just be a tight muscle because I feel my pelvis is twisted and that always causes my discs ‘blow’”.
Therefore, by magnifying emotional-pain related thoughts (“is something serious happening? will the pain will get worse?”) and re-enforcing these thoughts by continuously, anxiously dwelling on them (“I want the pain to go away”, “I can’t get it out of my mind”, “I keep thinking about how much it hurts, how badly I want the pain to stop”) perpetuates an everlasting ‘worry cycle’.
This ‘worry cycle’ is characterised by an inability to inhibit pain related thoughts (Quartana et al 2009), frustration, helplessness (“I can’t go on”, “I can’t stand it anymore”, “there’s nothing I can do”, “it’s never going to get better”, “I feel overwhelmed”) and dysfunctional beliefs (Petrini & Arendt-Nielsen 2020).
Consequently, individuals predisposed to more positive moods predict more positive outcomes and reappraise events as to promote a sense of coherence and ability to integrate stressful events within a more positive context (Finan & Garland 2015) without down-playing the complexity or emotional consequences of an event.
Catastrophic worry (Repetitive Negative Thinking)
How stuck someone gets in a cycle of repetitive negative thinking, or how unable someone is to stop worrying once they have started, is dependent upon whether they have a low mood and positive beliefs about a need to worry in order to find a solution (Flink et al 2013). When someone is more optimistic they are less likely to get stuck in a cycle of repetitive negative thinking e.g. having recovered previously from mild back pain leads to reduced fear and optimism over future back pain events (Brunzli et al 2017).
Repetitive negative thinking may include thoughts about personal shortcomings, failings, faults, mistakes; unwanted intrusive images and thoughts; inability to control obsessive thoughts; having thoughts about a situation and wishing it would go better (McEvoy et al 2014).
Examples of how dysfunctional beliefs perpetuate catastrophic worry in low back pain are (Brunzli et al 2017):
Previous experiences of back pain. Severe, debilitating back pain creates worry and a need for certainty over whether the pain will go away or if it is a sign of a deteriorating condition. This reinforces beliefs about the weakness of the spine, vulnerability and measures to prevent re-injury. This influences negative expectations of suffering/loss of function associated with pain. “I am just really cautious … I don’t want to blow another disc”.
Societal beliefs and attitudes that attempt to reduce further risk of injury by reinforcing the ‘fear of damage’ “if I hurt my spine I’m not going to be able to walk”.
Even once the perceived threat has past e.g. there is no more pain, individuals that have learnt to be reliant on repetitive negative thinking, will still exhibit these nuances in everyday thinking (McEvoy et al 2014). This blocks any perceived potential benefits and rewards from engaging with activities (Flink et al 2013) that encourage a more open minded inquisitive engagement with life in general.
Repetitive negative thinking is associated with a range of negative emotions including (McEvoy et al 2014):
Anxiety and depression.
Shame, anger, distress and neuroticism.
Believing thoughts are uncontrollable and dangerous.
Punishing oneself for having particular thoughts.
Greater emphasis should be placed on educating and challenging patients on the uncontrollable engagement associated with repetitive negative thinking, rather than the cognitive content (McEvoy et al 2014) e.g. placing emphasis on informing patients about catastrophising not just the biological strength of their spine; refer to ‘treatment for pain catastrophisation’.
Rumination
“I feel as though I’m being swallowed up by constantly thinking about my feelings of fatigue and achiness” (McEvoy et al 2014).
“I keep thinking about how badly I want the pain to stop” (Quaranta et al 2009).
Brooding or dwelling on past events or negative personality traits makes you fixate on problems and feelings so they swallow you up; this prevents effective problem solving making you idle and inactive.
A non-threatening, controllable pain is typically used to reduce rumination by distracting you from dwelling on unrelated thoughts and refocuses the mind (Bastian et al 2014). For example, the pain from slapping yourself on the head can distract you from being side-tracked with unrelated thoughts as to refocus your attention back onto completing the task in hand.
Chronic pain in contrast, is threatening and uncontrollable. This pain doesn’t distract you from unhealthy thoughts it draws your attention towards them; it increases rumination by screaming about potential threat and harm and so encourage catastrophising behaviours (Bastian et al 2014).
Individuals dwell on things (ruminate) by using:
Abstract rumination: getting stuck in a rut with repeatedly having the same few negative thoughts. These thoughts are characterised as unconstructive, unclear and broad/ill defined (Paucsik et al 2021). Abstract rumination tries to be creative but is distorted by prejudice or bias; this creates a blindspot in our imagination making it hard for us to see how the world could be different from how we assume it to be; this influences our assumptions on the hypothetical interpretation of things, their meaning, why something’s being done, the cause, the purpose, the overall goal and the implications and consequences. Example: “why did I react in a particular way?” “why do my problems exist?” “why do I feel a particular way?” and thinking about feelings and recent situations wishing it had gone better (McEvoy et al 2014).
Concrete rumination: repeated thoughts that focus on the experiences in the present moment e.g. sights, smells, sounds, etc. These thoughts aim to grasp and respond to situations and how to keep pace with how these situations change. These thoughts aren’t elaborate or hypothetical but distinct, clear and asks specific questions to get specific answers that leave no doubt (Paucsik et al 2021). Example: “how did I fail? How did all this unfold? How can I get round this? How can I change the outcome? How can I break things down into smaller steps and move forwards?” Concrete rumination typically results in a less depressed mood (Watkins et al 2012) and less regret once a decision has been made (Deya et al 2018).
Unhealthily dwelling on things in either style of rumination constitutes an unhealthy coping mechanism. However, abstract rumination, (i) draws elaborate conclusions from one situation forming a sweeping rule of thumb for all situations (Watkins et al 2012), this overgeneralisation typically predicts never-ending patterns of defeat (ii) proposes an imaginative ‘reality’, distorted by prejudice, encouraging a measure of self-worth against ‘perfection’ leading to stress, depression, anxiety and lower levels of self-compassion (Paucsik et al 2021) that can, in turn, lower self-esteem (Zhang et al 2018); (iii) ponders on things using vague, ill-defined imaginative thoughts that lack the clarity of vision to focus on confronting problems and the issues around their solution. In contrast, ruminating on past events being focused on more concrete details e.g. where you were, sights, sounds, how what you felt related to what you done, forms a clear vision in the minds eye that openly confronts problems and their solution (Stober 1998); (iv) results in a depressed mood (Watkins et al 2012) as individuals feel hopeless by becoming exhausted and loosing a sense of control over the overwhelming enormity of their emotions; (v) experience regret once a decision has been made (Deya et al 2018).
Despite this, chronic pain patients with a tendency to catastrophise hold a number of positive beliefs about rumination (e.g. it helps them cope, problem-solve, and avoid repeating mistakes by preparing them to handle future threats) as well as negative beliefs (e.g. acknowledging that they have no control over their rumination) (Petrini & Arendt-Nielsen 2020).
Suppression
Bottling up emotions by not experiencing or expressing them how you want involves distracting oneself from them and constantly checking that these emotions don’t surface. However, this results in these emotions failing to be suppressed and so, paradoxically, becoming fixated on. This is common in individuals who are hyper-vigilant of their public self-presentation and so suppress thoughts, feelings, and behaviours for fear, or shame, of eliciting disapproval from others. By trying to suppress and conceal emotions, there develops an egotistical inauthenticity between what is truly felt internally and what is manifested externally (Zhang et al 2019) so that, for example, the patient may not be fully ‘on board’ when striving for success in a therapeutic intervention. Developing self-compassion, can enhance participation by promoting optimism and the authenticity of the therapeutic intervention in truly reflecting the individual’s open minded, non-suppressed self-compassionate mindset.
When worry and rumination form a rigid, inflexible mindset that is intolerant to being challenged by contradicting information, then this information is suppressed or actively changed in order to constrain what we ‘feel’ within safe, predicted, boundaries (Bohlen et al 2021) i.e. a self fulfilling prophesy. This is typically done by using overgeneralised verbal thinking that suppresses any vivid mental imagery that would otherwise encourage a less prejudice and more encompassing mindset using concrete, logical thinking (Teng et al 2016). At this point suppression mediates the relationship between emotional distress (e.g. anxiety, sadness, fear, anger, guilt, shame) and pain catastrophising.
In antipathy to the notion ‘all models are wrong but some are useful’ this rigid, inflexible mindset centres the individual around an unreasonable belief that their model is correct and their expectations and predictions will manifest themselves (e.g. the expectation of pain and disability). There is also a problem adjusting these unyielding high expectations to the fluidity of the real world (Paulus et al 2019).
This results in ‘true’ bottom-up afferent information being suppressed by overbearing, rigid inflexible top-down beliefs. These top-down beliefs from the cortical hierarchy suppress bottom-up afferent information by shouting about what should be felt, rather than accepting what the bottom-up information is saying is actually being felt. This blurring of reality means the individual is unable to differentiate between an array of bodily sensations e.g. a simple bottom-up stretching sensation gets misinterpreted as pain, surprise gets interpreted as fear; difficulties recognising cues related to feeling hungry or full contribute to eating disorders (Brewer et al 2021). This can create an urge to perform compulsions in an attempt to reduce anxiety and cement inaccurate associations and is why by suppressing negative emotions individuals experience increased pain, prolonged recovery and increased muscle tension at the site of injury (Petrini & Arendt-Nielsen 2020).
Suppressing or actively changing (interoceptive) information that challenges or contradicts preconceived notions creates a delusional reality that comforts us by making us believe that we know our body and can predict the consequence of our actions in order to regain a sense of control and predictability and foster a sense of self (Liesner & Kunde 2021). However, when an individual becomes consciously preoccupied with this, they imprison themselves in a self-sustaining loop, constantly anticipating what this rigid mindset, formed from uncontrollable worry and rumination, predicts (Di Lernia et al 2016).
Therefore, to help promote pain tolerance, contextualise worry about pain sensations and foster a healthy emotional awareness, there should be an emphasis on developing an appropriate open-minded inquisitive attention towards bodily information (Joshi et al 2021) as not to catastrophise in order to find comforting, convenient, over-generalised ‘solutions‘ that are supported by dysfunctional beliefs.
Actively suppressing emotions also drains self-control so there is less for other tasks requiring self-control (Litvin et al 2012). This hasn’t got to be suppressing pain related emotions, but suppressing, for example, anger and feelings of injustice in other aspects of your life can drain your overall resources (Toledo et al 2019) and can be associated with greater sensations of pain.
Encouraging people to actively change their physical lifestyle and emotional perspectives involves using self-control; this self-control prevents us from succumbing to our natural desire to, on a whim, feel exacerbated and indulge in activities and mindsets that effortlessly and superficially think in away that appeals to the prejudices and biases that form the cornerstone of a catastrophic mindset “everytime there’s a twinge I know my back will go”.
Therefore, by reappraising situations with an open-minded curiosity, trying not to suppress emotions across the board, means we don’t drain our self-control and other emotional resources, and can keep site on working towards our longer term goals (Duckworth et al 2017) “I’m having familiar thoughts that ‘everytime there’s a twinge I know my back will go’, I know this thinking will produce a protective response that is comforting and makes me feel safe, but I can remember times when I felt a twinge and was surprised that my back didn’t go, so I should be cautious, but not overly cautious so that I set up more problems”.
Behavioural Inhibition and Behavioural Activation Systems (BIS/BAS)
Behavioural Inhibition System (BIS) and Behavioural Activation System (BAS) predicts pain responses and behaviours to determine if an individual is prone to pain catastrophisation through their susceptibility to anxiety and impulsivity (Petrini & Arendt-Nielsen 2020).
Behavioural Inhibition System screams “be cautious”. It is sensitive to signals of danger and punishment by detecting potential threat and enhances avoidance behaviour (e.g. suppression) (Petrini & Arendt-Nielsen 2020). It predicts the future and compares it to the present. By encouraging the avoidance of potential threat the individual evaluates risks and ruminates that can lead to anxiety (Merchan-Clavellino et al 2019).
In contrast, the Behavioural Activation System screams “let’s go for it”. The BAS is sensitive to signals of reward and escaping from punishment by encouraging approach behaviours (e.g. re-appraisal) (Petrini & Arendt-Nielsen 2020). Use of the BAS leads to the experience of hopeful excitement, it drives persistence to achieve the desired goals and a sense of joy when they are attained. It is fearless experiencing low levels of frustration, or sadness (Merchan-Clavellino et al 2019).
As the brain permits the simultaneous processing of positive and negative information both the BIS and BAS systems can be activated independently (i.e., either one), and together simultaneously so that an individual perceives a situation as an opportunity both for gain and loss (Uphill et al 2019). Therefore, being able to regulate emotions and behaviours effectively involves the positive use of both BIS and BAS. For example, individuals should concentrate on achieving goals and be receptive to rewarding their efforts (BAS) without acting impulsively with no regard for the long term consequences (BIS) (Merchan-Clavellino et al 2019).
Since pain is usually perceived as a threatening and/or punishing stimulus, it is the BIS system that is involved in pain (Petrini & Arendt-Nielsen 2020) screaming “be cautious” worrying about, and conjuring up danger, centred around, for example, how you’re feeling, what your condition is and what you can’t do.
Behavioural Inhibition System (BIS)
Situations where pain is present is commonly defined by uncertainty, risk to health and safety and competing behavioural responses. A normal healthy response to make headway through this panic, confusion and noise is to possess control and an inhibition of certain behaviours one hand (BIS) and an appreciation of the rewards associated with a proactive approach on the other (BAS); this determines, what is perceived to be, an optimal course of action for us to achieve our long-term goals.
As chronic pain, is perceived as threatening and uncontrollable the threat of harm induces catastrophising behaviours that turn the volume up on our BIS (Bastian et al 2014) that is screaming for us to “be cautious”. Due to the excessive attention to negative events the BIS interrupts and inhibits behaviour (Petrini & Arendt-Nielsen 2020) that is trying to be proactive in enabling us to achieve our longer-term goals.
People with a sensitive BIS are passive and fearful, constantly looking out for, detecting or creating threat. They have a tendency to suppress emotions, worry and ruminate. This can lead to introversion, depression, anxiety, and pain catastrophising as well as a reduced vagal tone (Petrini & Arendt-Nielsen 2020).
Behavioural Activation System (BAS)
BAS reactivity is associated with an orientation toward positive affect i.e. reward and impulsivity (Petrini & Arendt-Nielsen 2020) without adequately appraising the long-term effects (Merchan-Clavellino et al 2019). The BAS can be inhibited with patients suffering from repetitive negative thinking who fail to see potential rewards when engaging with proactive therapeutic interventions (Flink et al 2013).
People with highly sensitive BAS are particularly vulnerable to having to alleviate emotional numbness and to developing addictive behaviours as they constantly crave reward. However, people with a lowered BAS, in the form of a lowered reward responsiveness is prevalent in chronic pain and fibromyalgia patients (Petrini & Arendt-Nielsen 2020).
Acute pain that is short lived, involves no threat and you have control over can increase activation of the BAS through facilitating pleasure. This pleasure can be from (i) a heightened sensitivity to bodily sensations or (ii) euphoric relief from pain. This is why pain can generally, when it feels as though it has been endured, lead to a desire to seek pleasure (Bastion et al 2014) e.g. I deserve this treat:
Heightened sensitivity to bodily sensations: acute pain captures our attention. It shifts attention away from our evaluations and self-awareness and draws it not only to the pain but other bodily sensations at the onset of pain. For example: having an itch and scratching the skin till it’s red raw.
Relief from acute pain, or the ‘treat of pain’: this also causes a heightened sensitivity to bodily sensations enhancing the capacity to savour and enjoy positive sensory experiences. For example cool water after having been in the hot sun.
In contrast, chronic pain, that is marked by threat and lack of control, also increases sensitivity, but it increases sensitivity to the negative effects e.g. central sensitisation in CRPS.
Whilst relief of chronic pain may occur this euphoria is dulled down or over ridden by the constant predicted threat of it reoccurring leading to activation of the BIS (Bastian et al 2014). When this relief of pain is attributed to measures taken off the back of a catastrophic belief system it validates, and re-enforces the need for activation of the BIS.
However, in response to this activation of the BIS pain facilitates pleasure seeking and activation of the BAS, for example, when painful experiences trigger ideals associated with injustice e.g. “I’m being punished with this pain so I’ll make it up to myself and have a reward”. This is particularly prevalent in people who are sensitive to being the victims of perceived injustice where their righteous indignation towards ‘unfair’ pain makes them feel justified in being entitled to indulge in immediate gratification that may have poorer long term consequences (Bastian et al 2014).
Fear-anxiety-avoidance behaviour
Catastrophising is the thinking element in generating fear, anxiety or avoidance behaviours. Catastrophising involves elaborately, vividly and disproportionately appraising the threat of pain related thoughts. These threatening pain related thoughts maybe centred around, for example, the threat of movement, the threat from a lack of personal ability, the threat from a condition.
Appraising pain related thoughts in this way increases fear of future pain, leading to avoidance of activities and ultimately to disuse and disability (Miller et al 2018). Therefore, pain catastrophising is the turning point at which individuals either enter or don’t enter the fear-anxiety-avoidance cycle (Petrini & Arendt-Nielsen 2020).
From this perspective fear-avoidance behaviour may therefore be perceived as a ‘common-sense’ problem-solving response to avoiding pain especially when these beliefs are reinforced by professional advice (“I got told not to lift anything heavy” ) and this advice appears to work e.g. by avoiding everything, nothing hurts, and that’s a good thing (Brunzli et al 2017).
However, long-term avoidance of physical activity has several consequences. It impairs functioning making an individual more physically weak and increases negative mood that contributes to psychological feelings of disability, which when protracted, can lead to depression (Petrini & Arendt-Nielsen 2020).
Communal coping model
Communal coping model (CCM) states that catastrophising is a coping strategy employed by individuals experiencing pain to elicit support from others (Quartana et al 2009). This can be seen when tired or sick babies seek the proximity of a primary caregiver and when social support is beneficial in chronic pain (Bastion et al 2014).
An argument against the CCM as a cause of pain catastrophising is that, in some patients, wanting to elicit social support comes after, as a consequence of, catastrophising and therefore is not the cause of it (Flink et al 2013).
However, CCM may be a cause of pain catastrophising in patients characterised by submissiveness and high levels of dependency and support seeking, insecure adult attachment style characterised by beliefs that others will not provide support in times of distress and perceptions of the self as incapable of coping with distress. For this reason, CCM positively reinforces pain and illness behaviours and undermines successful adaptation to pain (Quartana et al 2009).
Typically, when patients employ the CCM, carers tend to be supportive in the short term but more dismissive in the long term (Quartana et al 2009). This is because empathy for pain “hurts” as it activates both the sensory and affective components of pain experience (Bastion et al 2014). The net result of this is that it can reinforce these characteristic traits associated with being dependent on support and insecurity as they pre-empt that it won’t be provided.
Using CCM to elicit social support can come from (Bastion et al 2014):
Eliciting empathy.
Attempting to amplify or simulate pain, or the suppression of pain, reminds others of an individual’s capacity for pain. This attempts to increase the motivation of others to protect them from harm.
Pain catastrophisers try to communicate their pain behaviours (e.g., facial displays, vocalisations) for a longer duration when another person is present compared to when they are alone. If others don’t see the individuals pain as severe, and their pain is deemed to be controllable, this may elicit less empathy from others.
This ‘cry for help’ can lead individuals to taking on a victim role. This victim role attempts to reduce guilty judgements from others that may attribute blame (e.g. “you’re lazy you can help yourself”) which can trigger motivation for retribution (e.g. looking down on someone for not helping themselves).
Ironically, although social support can enhance psychological well-being for persons with chronic pain, when it is excessive and becomes solicitous (i.e. expressions of concern, support, and provision of assistance), it can lead individual’s to display more pain and disability.
Could this be the reason why, even though the CCM encourages individuals to use prosocial behaviour, chronic pain can lead to antisocial responses e.g. anger and aggression?
Increase solidarity.
When pain is experienced in the presence of other people or shared with others, it can be a powerful force in drawing people together creating a sense of ‘oneness’. This shared experience can facilitate a ‘team spirit’ marked by a liking and feelings of closeness and attachment to others, especially when those experiences are significantly challenging.
In us all, evolution has not produced ‘neutral truth seekers’, but loyal tribal members of competitive groups who are more inclined to find flaws in rival groups than be independently self-reflective when appraising our own (Hill & Garner 2021). When poor critical thinking (Hill & Garner 2021) and an egotistical fixation on a self-manufactured unique and stable identity (Vu & Burton 2021) exacerbates our natural deviance from being a ‘neutral truth seeker’, any perceived attack on our personal beliefs and identity, from a rival group, triggers decisions that are in-line with our self-constructed, self-idealised identity (Vu & Burton 2021) resulting in, for example, polarisation, resentment, anger and radicalisation (Hill & Garner 2021). Therefore, catastrophisers may create a group to virulently cling on to their beliefs, protecting and self-projecting their personal identity by using cognitive resources to find flaws in others who question the rationale for their behaviour, rather than turn their attentions towards being independently creative through self-reflection and feeling a responsibility to treat individuals with conflicting perspectives as partners in search for ideas to release their grip on comforting, but unhelpful thought processes.
Display virtuous qualities to others.
People who experience pain as a challenge, i.e. when their perceived resources outweigh the demands of pain, will be more receptive to positive outcomes, especially when feeling self-compassion and non-egotistical authenticity when making these sacrifices (i.e. when these sacrificial outer expressions reflect a true inner self) (Zhang et al 2019). Conversely, people who experience pain as a threat i.e. when the demands of pain are greater than their perceived resources will be less receptive to positive outcomes.
By showing others how they ‘rise to the challenge’ places a greater value in overcoming major personal challenges and establish control over their pain. This demonstrates virtues of self-control and personal strength to others, and increases social connectedness. This can be seen in ‘virtue signalling’ towards, for example, pain, or a condition, whereby publicly expressing opinions or sentiments is motivated by a self-satisfaction from appearing virtuous in order to achieve a perceived moral status (Hill & Garner 2021).
Treatment for Pain Catastrophisation
The treatment for pain catastrophising has been centred around promoting more positive moods, even if they are experienced just transiently. These positive associations aim to find the exceptions to the patient’s problems and distress to minimise the fixation on pain and negative mood. This enables them to widen their gaze and broaden their mindset to a range of ideas and suppressed emotions, to identify and savour the experience associated with well-being and positive change. This intern diminishes their inherent attentional bias to pain associations and enhances their perceived flexible problem-solving abilities and control over pain to promote resilience (Finan & Garland 2015). Even though a level of resilience, that returns an individual to a baseline function is common, rather than extraordinary, even in the face of substantial adversity, a lowered resilience, or to the other extreme, an ability to thrive in the face of adversity and develop greater resilience, requires more measured personality characteristics (Seery et al 2010).
The personality traits fostering a higher sense of resilience means the individual will ‘bounce back’ in the face of adversity and not enter a prolonged state of self-perpetuating persistent symptom activation (Lunansky et al 2020) whereby, for example, an injury inducing a symptom of pain will self-perpetuate another symptom, e.g. anxiety, that will in turn self-perpetuate another symptom e.g. insomnia, that will in turn self-perpetuate another symptom e.g. depression and loss of interest, that will in turn self-perpetuate another symptom e.g. guilt; it is important to note that unless resilience steps in to prevent symptoms from triggering other symptoms, vulnerability will keep this ‘self-perpetuating network’ active long after the initial injury induced pain, that triggered its activation, has waned (Borsboon 2017).
Disengaging from the fixation on pain and negative mood, promotes mindfulness principles, as to savour non-painful, enjoyable and meaningful experiences. Being aware of positive emotions, draws a new context in which to reframe or reappraise circumstances to be less overwhelming, more meaningful and beneficial in order to promote a motivation and readiness to change (Finan & Garland 2015).
Positive reappraisal involves distancing yourself from a situation to generate a new perspective and lessen its emotional impact, especially when an entire self-identity (e.g. ‘me and my pain’) is based on perceived, or actual, shortcomings. For example, stepping back and reassessing a ‘degenerative’ back from the perspective of normal ageing as opposed to ‘deterioration’.
Positively reappraising emotions should use terminology that is honest, not suppressed, and reflects grounded, concrete, logical thinking; it is not about suppressing the negative whilst focusing on the positive, but enables the individual to acknowledge and validate perceptions without labelling them e.g. altering phrases like “my back is weak” to “I’m having familiar thoughts ‘my back is weak’ but there must be some strength in it to carry my weight around all day”. This helps ascertain how situations unfold by ‘talking to the individual’, in an autobiographical context, so they can openly accept complexity and contradictions in order to foster a new ‘sense of self’; this slows us down, provokes less reflex, abstract, blinkered emotional responses that skewer memory and cast unjust moral judgements (Kyung et al 2010).
A constellation of appraisals, of which any one might be appropriate depending on the situation, allows for adaptability and flexibility when evaluating stimuli (Uphill et al 2019):
A challenge appraisal: where an individual perceives sufficient (or nearly sufficient) personal resources to meet or exceed the demands of the task. This is associated with higher levels of perceived control and self-efficacy along with positive emotions and the adoption of approach goals that anticipate opportunities for gain or growth.
A threat appraisal: where an individual perceives insufficient personal resources to meet the demands of the task. This is associated with lower perceived control and self-efficacy along with negative emotions and the adoption of avoidance goals that anticipate opportunities for harm or loss.
A simultaneous challenge and threat appraisal: this open minded appraisal anticipates opportunities for growth and loss when challenge and threat are similar in magnitude. For example, obtaining a future positive outcome whilst avoiding a future negative outcome, or using a challenge appraisal (i.e approach behaviour) to extinguish a threat. Being less blinkered and more pliable this appraisal involves systematic processing in order to derive meaning from contradicting information, so, for example, we can be pulled in more than one direction and feel a mixed bag of contradicting emotions about a situation.
Being able to positively reappraise emotions in a psychologically and physiologically stable way, without being overwhelmed by them, promotes a sense of mastery and control that facilitates future perceptions of control; this in turn enhances coping capabilities and psycho-physiological toughness to develop self-esteem, self-efficacy (Seery et al 2010), self-confidence (Cook & Artino 2016) and resilience (Babic et al 2020).
An example is optimistic individuals, who not only accept, but elaborate on, negative health information (Aspinwall & Brunhart 2000). Despite ‘ramping-up’ this negativity it fails to make a dent on the optimist due to their ability to openly reframe and reappraise pessimism to remain confident and persistent in pursuing their goals (Pacheco & Kamble 2016). This process of ‘bouncing back’ from negative exposure promotes a sense of resilience (Babic et al 2020) and self-efficacy (Finan & Garland 2015).
In contrast, individuals with a perceived lack of control and mastery to cope with adversity have lower self-esteem, self-efficacy (Seery et al 2010), self-confidence (Cook & Artino 2016) and resilience (Babic et al 2020). Typically, through suffocation and control, their autonomy is undermined (Loeb et al 2021), so they can’t effectively appraise distressing situations leaving them feeling vulnerable and easily overwhelmed. This vulnerability creates pessimism, a sense that things will never get better, and that they have no control and are automatically to blame when things go wrong (Rubenstein et al 2016). Without a sense of ability to control, or steer, a distressing situation to a favourable outcome, adversity can feel unpredictable and traumatic (Richter-Levin & Sandi 2021); this makes adversity a negative learning experience as without resilience, the individual predicts, and fails, to ‘bounce back’ to a psychological and physiological baseline function.
From a more open, less blinkered, self-evaluative perspective the individual can handle setbacks and failures with relative calm and acceptance, they develop an awareness towards positive and negative personal experiences, and an awareness of how these experiences are shared by others; these traits are essential for fostering self-compassion, a sympathy towards oneself that genuinely cares about well-being. Self-compassion is not only essential in directly modulating pain, but develops self-esteem and optimism, increases engagement by reducing the fear and shame of being looked upon unfavourably by others and enhances authenticity so that the sacrificial outer expressions, i.e. striving for success in a therapeutic intervention, reflects a non-egotistical true inner self characterised by an open, self-compassionate mindset (Zhang et al 2019).
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