Changing the Way We Think About Pain: Insights From Beth Darnall, PhD
A negative pain mindset undermines pain treatment effectiveness and facilitates structural brain changes that serve to maintain pain and distress.
A negative pain mindset – catastrophizing – undermines pain treatment effectiveness and facilitates structural brain changes that serve to maintain pain and distress.
In short, catastrophizing makes pain more painful, last longer, and much harder to treat. Researchers are focusing on treating catastrophizing efficiently and early on to prevent persistence of pain.
The national emphasis on opioid reduction is forcing healthcare systems and clinicians to take stock of alternative options to treat pain. It has long been known that pain is a subjective experience, but the role of psychology in an individual's pain experience is perhaps less appreciated by non-experts. There is wide variability in reported pain intensity, even in standardized pain experiments. Research findings indisputably reveal that psychological factors are major drivers of pain intensity, duration, and suffering.
These results led to something of a renaissance in the fields of psychology and behavioral medicine. Treatment of formal psychopathology — such as major depression and anxiety disorders like posttraumatic stress disorder — remain vitally important in the context of pain. Beyond this, there is increasing appreciation for the power of an individual's mindset to direct the trajectory of a pain experience. Pain catastrophizing is the negative expectation of actual or anticipated pain, and is comprised of persistent rumination on pain, mental magnification of pain, and feelings of helplessness.1 Recovery depends heavily on a positive mindset, especially in the context of negative circumstances such as pain. After all, nobody wants to feel pain, and individuals are highly motivated to escape it.
Shaping a Positive Mindset in Painful Circumstances
Cognitive behavioral therapy (CBT) effectively reduces pain catastrophizing, and typically involves 6 to 12 individual or group treatment sessions in which participants learn about and acquire skills that improve pain regulation. These skills include stopping negative thoughts in their tracks and changing mental focus (cognitive restructuring), as well as understanding how thoughts, emotions, and choices can be optimized for pain relief. Applying mind-body relaxation response skills are a mainstay of CBT for pain and other treatments that effectively reduce catastrophizing. The relaxation response is particularly effective because it extinguishes catastrophizing and related distress, and serves to reveal the control an individual has over mind and body. Shaping a positive mindset is an active process.
While CBT for pain has the most science behind it, there are other treatments that reduce pain catastrophizing. Mindfulness-based stress reduction, acceptance and commitment therapy (ACT; a variant of CBT), and even some forms of yoga that include enhanced focus on psychological distress and application of relaxation. Newer treatment strategies are combining cognitive behavioral strategies with physical therapy sessions.
In 2014 we published our pilot results for a single-session class that targets pain catastrophizing.2 The goal of the class is to extinguish a negative pain mindset — even in patients who may have no underlying psychological disorders. The point is that everyone can benefit from optimizing the power of their mind to gain relief and live more actively. This class is a compressed form of longer-course CBT and allows greater access to care because its brief format dismantles many of the current barriers to CBT for pain. Our results exceeded expectations, and we showed preliminary efficacy — a strong signal that a 2-hour class could teach patients how to reduce a negative pain mindset. At Stanford University in California, we are now running a large randomized controlled trial of the treatment of catastrophizing funded by the National Institutes of Health. In this study, we are comparing a single-session catastrophizing class with longer course CBT and with a health education control group in patients with chronic low back pain.
Shift Towards Prevention
Pain catastrophizing exerts a powerful influence on surgical outcomes. Research suggests that what patients bring to the surgical table can be more powerful than the surgeon or the type of surgery they are undergoing. Foremost among post-surgical predictors is the presurgical pain mindset: catastrophizing. The International Association for the Study of Pain has designated 2017 the Global Year Against Pain After Surgery. There is burgeoning research focused on delivering presurgical psychobehavioral interventions as a pathway to reduce postsurgical pain and opioid use, and including combined physical therapy-CBT and ACT- and CBT-based interventions. Our group recently completed a randomized controlled trial of an internet-based treatment for pain catastrophizing in 90 women undergoing surgery for breast cancer, and data are being analyzed. The treatment is an adaptation of the targeted class we are studying. Of note, there is no therapist involved with this online treatment, so it can be made available at no charge to anyone who has internet access. Millions of Americans undergo surgery each year. Delivering targeted, low-cost psychobehavioral treatments before surgery may be an efficient and economical way to improve post-surgical outcomes — and prevent the chronification of pain after surgery.
Beth Darnall, PhD, is a member of Clinical Pain Advisor's advisory board.
- Sullivan MJ, Stanish W, Waite H, Sullivan M, Tripp DA. Catastrophizing, pain, and disability in patients with soft-tissue injuries. Pain. 1998;77(3):253-260.
- Darnall BD, Sturgeon JA, Kao MC, Hah JM, Mackey SC. From Catastrophizing to Recovery: a pilot study of a single-session treatment for pain catastrophizing. J Pain Res. 2014;7:219-226.