Catastrophizing and Pain-Coping in Young Adults: Associations With Depressive Symptoms and Headache Pain

The Journal of Pain, Vol 9, No 4 (April), 2008: pp 311-319 Available online at www.sciencedirect.com

Catastrophizing and Pain-Coping in Young Adults: Associations With Depressive Symptoms and Headache Pain Luis F. Buenaver,* Robert R. Edwards,* Michael T. Smith,* Sandra E. Gramling,† and Jennifer A. Haythornthwaite* *Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland. † Department of Psychology, Virginia Commonwealth University, Richmond, Virginia.

Abstract: Cognitive and behavioral pain-coping strategies, particularly catastrophizing, are important determinants of the pain experience. Most studies of pain-coping are performed in samples of treatment-seeking patients with longstanding pain complaints. Individual differences in pain-coping styles may also significantly affect day-to-day pain and quality of life in nonclinical samples, though this has rarely been investigated. In particular, headache pain is common in the general population, and little is known about how pain-related coping affects pain and quality of life among headache sufferers from a nonclinical setting. In this study, 202 generally healthy subjects were divided into 2 groups, those who reported problem headaches and pain-free control subjects. Reports of painrelated catastrophizing and the use of active pain-coping strategies did not differ between the groups, but differential associations between pain-coping strategies and emotional functioning were observed. Specifically, within the headache group only, those reporting higher levels of pain catastrophizing and lower levels of active pain-coping showed the highest level of depressive symptoms. Further, higher catastrophizing was associated with greater headache pain and pain-related interference. These findings suggest that catastrophizing has little influence on emotional functioning in those without ongoing pain complaints and highlight the importance of coping in modulating the consequences of pain on day-to-day functioning, even in samples from nonclinical settings. Moreover, these findings indirectly suggest that interventions that increase adaptive coping and decrease catastrophizing may help to buffer some of the deleterious functional consequences of headache pain. Perspective: This study adds to a growing literature that conceptualizes catastrophizing as a diathesis, or risk factor, for deleterious pain-related consequences. These data suggest that catastrophizing may require the presence of a pain condition before its detrimental effects are exerted. © 2008 by the American Pain Society Key words: Chronic pain, pain, catastrophizing, headache, pain-coping, active coping.

C

ognitive, affective, and behavioral pain responses are important features of the pain experience; they shape long-term pain-related outcomes and serve as prime targets for psychosocial interventions Received March 30, 2007; Revised October 23, 2007; Accepted November 1, 2007. Supported by NIH grants F32 DE017282 (L.F.B.), AR 051315 (R.R.E.), NS 051771 (M.T.S.), and NS 02225 (J.A.H.). Address reprint requests to Dr. Luis F. Buenaver, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Meyer 1-108, Baltimore, MD 21287. E-mail: [email protected] 1526-5900/$34.00 © 2008 by the American Pain Society doi:10.1016/j.jpain.2007.11.005

aimed at improving pain-related quality of life.31,39 Catastrophizing, generally classified as a passive and maladaptive pain-coping strategy, is a negative cognitive and affective process involving magnification of pain-related symptoms, helplessness, pessimism, and rumination about pain. Catastrophizing is a consistently-important predictor of pain-related outcomes,13,46 showing associations with day-to-day pain symptoms and with the development of persistent pain, even in initially healthy samples.15,41 Though the specific nature of catastrophizing is under debate,49,50 one hypothesis about catastrophizing is that it may function as a diathesis, varying widely between individuals but not manifesting its detrimental effects until a pain condition is present. Data from community 311

312 samples indicate a fairly normal distribution of catastrophizing scores, and a statistically significant, though slight, elevation in catastrophizing in those experiencing moderate pain compared with pain-free adults.5 Moreover, catastrophizing measured before surgery predicts post-operative pain severity.24 These findings suggest that catastrophizing about pain may not act in isolation, but rather, requires the presence of a significantly painful event or condition to be activated and exert its effects. For example, 2 hypothetical individuals, 1 with a pain condition and 1 without, might report similar degrees of catastrophizing; however, the negative effects of catastrophizing would only be manifested in the individual with pain. This conceptualization has not been previously tested, though in a recent couples study, catastrophizing among spouses of individuals with chronic pain was only associated with depressive symptoms when the spouse themselves experienced pain.32 This relationship was observed despite no differences in mean levels of pain catastrophizing between spouses with and without pain. Such findings indirectly suggest that the negative effects of catastrophizing (on depressive symptoms) may be observed exclusively in the context of a personal experience of pain, which serves as a catalyst for catastrophizingrelated cognitive and affective processes. Headache offers an attractive model in which to investigate this hypothesis, because it is an intermittent pain condition that is common in the general population, allowing investigation of these hypotheses in a sample of individuals from a nonclinical setting (ie, relatively healthy young adults surveyed during daily life vs previous studies of patients suffering from chronically, disabling headache surveyed at a tertiary care facility). Compared with headache-free control subjects, individuals with headaches report greater catastrophizing in laboratory studies,25,51 and in reports of daily coping processes.20,27 In addition to simply evaluating differences in catastrophizing between headache sufferers and control subjects, our study also compares the relationship between catastrophizing and negative mood among individuals who experience headache pain to that relationship in pain-free individuals. In this way, we hope to shed light on the conceptualization of catastrophizing as a diathesis for deleterious outcomes. We hypothesized that (1) individuals with headache pain would report higher degrees of catastrophizing and lower levels of active pain-coping compared with painfree control subjects, and that (2) higher levels of catastrophizing and lower levels of active coping would be associated with depressive symptomatology only in the individuals reporting headache pain. Lastly, in the context of the larger body of literature linking catastrophizing and pain-related outcomes independent of depression, it was hypothesized that (3) greater catastrophizing and lower degrees of active coping would be associated with greater headache pain and pain-related life interference among individuals with headache pain.

Catastrophizing and Headache

Methods Participants Participants were undergraduate students attending a large, public, urban, mid-Atlantic university; they received course credit in exchange for participating in the study. We defined 2 mutually exclusive groups of undergraduate students: Those with problem headaches and pain-free control subjects (see procedure section for inclusion/exclusion criteria). A total of 202 individuals met criteria and were included in one of these groups. The mean age of the participant sample was 21.3 years, with a range of 17 to 59 years (SD ⫽ 6.2). The majority of the sample was female (ie, approximately 70%). The racial breakdown of the sample was approximately 49% Caucasian, 32% African-American, and 10% Asian-American with relatively small percentages of patients representing other racial groups. The majority of the research participants were single (87%). The average duration of headache pain for individuals comprising the problem headache group was 11 years (SD ⫽ 8.7). The characteristics of these participants are relatively typical for a college student population (ie, single, young, and relatively healthy). See Table 1 for a breakdown of demographic information by group status (ie, control versus problem headache).

Measures Demographics Demographic information was collected from all participants for descriptive purposes. Specifically, informa-

Table 1. Descriptive Data Presented by Group Status (ie, Headache Group Versus Control Subjects) Including Means and Standard Deviations VARIABLES Age Female sex White ethnicity Number of physician visits (per year) BDI Total Score CSQ Active Coping CSQ Catastrophizing Headache-free days/ month Headache Severity Score BPI Pain Interference

HEADACHE GROUP CONTROL GROUP (N ⫽ 85) (N ⫽ 117) P VALUE 22.3 ⫾ 6.7 83.5% 72.6% 1.3 ⫾ 3.1 10.5 ⫾ 8.8 2.3 ⫾ 1.0 1.5 ⫾ 1.2 HEADACHE INDICES 19.8 ⫾ 6.9

20.5 ⫾ 5.7 59.8% 32.2% 1.1 ⫾ 5.4

.04* .001† .00† .78*

4.8 ⫾ 5.6 2.4 ⫾ 1.1 1.3 ⫾ 1.2

.000‡ .64‡ .10‡

4.8 ⫾ 1.7 3.7 ⫾ 1.9

Abbreviations: BDI, Beck Depression Inventory; BPI, Brief Pain Inventory; CSQ, Coping Strategies Questionnaire. *t test. †␹2 test. ‡Analysis of covariance.

CLINICAL REPORT/Buenaver et al tion was gathered about sex, age, ethnicity, marital status, pain duration, and level of education.

Headache and Facial Pain Screening Questionnaire The self-report Headache And Facial Pain Screening Questionnaire (HAFPSQ) is a 63-item questionnaire, previously used in published reports,36-38 that includes separate items for migraine and tension-type headache (TTH) based on the International Headache Society (IHS) classification system 26 to allow for independent diagnosis of each headache type. Specific items used for diagnosis include frequency of headache episodes (past month and year), duration of typical episode, location of pain, quality of pain, intensity of pain, nausea/vomiting, photophobia, and phonophobia.

The Beck Depression Inventory The Beck Depression Inventory (BDI) is 1 of the most commonly-used measures of depressive symptomatology; it assesses the frequency and severity of a variety of cognitive, affective, physiological, and motivational symptoms of depression.1 Each item is scored on a 4-point scale (0 –3) with higher scores reflecting more severe symptoms. The BDI has well-established psychometric properties.2

The Coping Strategies Questionnaire The Coping Strategies Questionnaire (CSQ) is a 50-item self-administered questionnaire designed to measure the frequency with which patients report the use of a variety of pain-coping strategies.43 The CSQ is comprised of 7 subscales that assess particular cognitive and behavioral coping strategies: (1) Diverting attention, (2) coping self-statements, (3) praying or hoping, (4) reinterpreting pain sensations, (5) ignoring pain sensations, (6) catastrophizing, and (7) increasing activity level. Subjects use a 7-point Likert scale that ranges from 0 (never) to 6 (always) to indicate how often they use each strategy when they experience pain. In the present study, the catastrophizing subscale was used, along with a composite measure of multiple “active coping” subscales. The catastrophizing subscale is a well-validated, 6-item scale, which is the most frequentlyused measure of catastrophizing.46 In the present study, the catastrophizing subscale was slightly modified by dropping 1 item (ie, “I feel my life isn’t worth living.”) for 3 reasons: (1) To be consistent with previous research32 utilizing the helplessness subscale of the Pain Catastrophizing Scale (PCS),45 which corresponds to the remaining 5 items of the CSQ catastrophizing subscale, (2) because the study sample is a young, nonclinical, relatively healthy population it was not expected that that there would be a high degree of suicidal ideation, and (3) to provide a more conservative estimate of the correlation with BDI depressive symptoms. Regarding active coping, similar to previous studies,19,33 multiple CSQ subscales thought to reflect “active” cognitive and behavioral pain-coping processes (ie, diverting attention, coping self-statements, reinterpreting pain sensations, and ignoring pain sensations) were intercorrelated ranging from 0.35 to 0.70 and P ⬍ .01 (mean intercorrelation ⫽ 0.48, P ⬍ .001) and were combined to

313 form an active coping composite score. All of the subscales were found to be reliable in the 2 groups of participants with Cronbach ␣ coefficients of 0.85, 0.82, 0.92, 0.85, and 0.82 for the diverting attention, coping self-statements, reinterpreting pain sensations, ignoring pain sensations, and catastrophizing subscales within the headache sample, and 0.81, 0.83, 0.83, 0.87, and 0.81 for the diverting attention, coping self-statements, reinterpreting pain sensations, ignoring pain sensations, and catastrophizing subscales within the control group.

The Brief Pain Inventory The Brief Pain Inventory (BPI) is a widely-used pain-rating instrument that provides information on the intensity of pain as well as the degree to which pain interferes with function.11,48 Respondents rate their worst, least, average, and immediate pain severity (on a numerical 0 –10 scale), pain relief ranging from 0% to 100%, and functional interference caused by pain in the areas of daily activity, mood, relationships with others, and so forth.

Procedure Research participants enrolled in various undergraduate psychology courses were recruited to participate in a large questionnaire study in exchange for course credit. The questionnaire packet consisted of various psychological measures, including a demographics questionnaire, and the HAFPSQ. Before completing the questionnaires, research participants gave informed consent and were assured their responses would be anonymous and confidential and not affect their course grade. To be classified as having “problem headache”, individuals were required to have an ongoing history of either TTH or migraine headache diagnosis or both (this information was obtained from the HAFPSQ), to have experienced at least 5 or more headaches in the past year (this information was obtained from the HAFPSQ), and endorse having “pain other than everyday pain” on the BPI as well as an average BPI pain severity rating of 4 or greater, indicating the perception of a significant pain problem. Individuals classified as painfree control subjects were required to have no diagnosis of TTH, no diagnosis of migraine headache, no diagnosis of temporomandibular joint disorder (TMD) (this information was obtained from the HAFPSQ), answer “no” to the question about “pain other than everyday pain” on the BPI, and report no more than mild everyday pain (ie, an average BPI pain severity rating of less than 4). Based upon these criteria, 85 individuals were identified as having problem headache and 117 participants were classified as control subjects. Thus, of 565 subjects sampled, analyses were conducted on 202 research participants who met inclusion criteria. Of the individuals who were not included in the analyses, most had some pain symptoms, but did not fully meet criteria for problem headaches. For example, 31% reported symptoms consistent with TMD and 28% met some of the criteria for TTH or migraine headache. All study procedures were approved by the university institutional review board.

314

Catastrophizing and Headache

Data Analysis Plan Preliminary analyses included t tests, chi square tests, and analysis of covariance to investigate group (ie, problem headache versus control) differences on various measures including catastrophizing, active coping, depressive symptoms, sex, and ethnicity. Bivariate relationships were also examined to assess for possible covariates. Next, hierarchical regression analysis was conducted to test the moderating effects of headache diagnosis (the presence or absence of headache pain) on the relationship between pain coping (ie, catastrophizing and active coping) and depressive symptoms. Therefore, regression analysis tested the main effects of catastrophizing and active coping as well as their interaction with headache diagnosis following the recommendations of and Holmbeck,6 which included centering catastrophizing and active coping to reduce multicollinearity and using these centered scores to compute interaction terms. The regression included sex and ethnicity as covariates entered in the first step along with headache diagnosis, which served as a predictor variable. Sex was included as a covariate in light of significant sex differences on depressive symptoms (t[152] ⫽ ⫺3.05, P ⬍ .01) with females reporting more depressive symptoms (M ⫽ 8.16, SD ⫽ 8.14 and M ⫽ 5.02, SD ⫽ 5.91, respectively) than males. Ethnicity was also included as a covariate because analyses revealed that ethnic differences approached significance for depressive symptoms (t[178] ⫽ ⫺1.70, P ⫽ .09) with Caucasians reporting more depressive symptoms (M ⫽ 8.09, SD ⫽ 8.63 and M ⫽ 6.23, SD ⫽ 6.47, respectively) than nonCaucasians. Further, the groups were found to differ on measures of sex (␹2 (1, n ⫽ 202) ⫽ 12.02, P ⫽ .001) and ethnicity (␹2 (1, n ⫽ 202) ⫽ 30.17, P ⬍ .001) with the problem headache group having a greater proportion of females and Caucasians relative to the control group. The second step of the regression analysis included catastrophizing and active coping. The interactions of pain coping (ie, catastrophizing and active coping) with headache diagnosis were entered in the third step. Significant interactions were subjected to post hoc probing,28 where multiple regression is used to estimate the expected value of the dependent variable (ie, depressive symptoms) at high (⫹1 SD) and low levels (⫺1 SD) of the independent variables (ie, catastrophizing and active coping) for individuals with and without headache. Table 2.

Lastly, hierarchical multiple regression was also used to investigate the association between pain-coping strategies and headache severity and pain-coping strategies and headache pain-related life interference within the problem headache group. Sex, ethnicity, and headache duration were included in the first step as covariates, whereas headache-free days and depressive symptoms were entered as predictors in the second step [both headache-free days and depressive symptoms were significantly related to headache pain severity; r(85) ⫽ ⫺0.29, P ⬍ .01 and r(85) ⫽ 0.29, P ⬍ .01, respectively]. Depressive symptoms were also controlled for due to the well documented relatively strong relationship with catastrophizing. Headache severity was included as a covariate when it was not being treated as a dependent variable [both headache severity and depressive symptoms were significantly related to pain-related life interference; r(85) ⫽ 0.37, P ⬍ .001 and r(85) ⫽ 0.45, P ⬍ .001, respectively]. In the third and final step, catastrophizing and active coping were entered into the regression equation.

Results Preliminary Analyses A 1-way, between-groups analysis of covariance was conducted to examine the association between the presence or absence of headache pain with pain-coping strategies and with depressive symptoms while controlling for the effects of sex and ethnicity. After adjusting for sex and ethnicity, the results showed that there were no significant differences between the problem headache group and the control group with regard to the use of catastrophizing or active coping (see Table 1 for means and standard deviations). However, the problem headache group reported significantly greater depressive symptoms (M ⫽ 10.47, SD ⫽ 8.80, and M ⫽ 4.78, SD ⫽ 5.59, respectively; F[1, 192] ⫽ 20.74, P ⬍ .001, eta squared ⫽ 0.10) than the control group.

The Interaction Between Pain Coping (ie, Catastrophizing And Active Coping) and Headache Diagnosis Predicting Depressive Symptoms The interaction between catastrophizing and headache diagnosis and between active coping and headache diagnosis was significant for depressive symp-

Multivariate Correlates of Depressive Symptoms

STEP VARIABLES

␤

SE

BETA

t

1. Sex Ethnicity Diagnosisa 2. Active Coping Catastrophizing 3. Diagnosis ⫻ Active Coping Diagnosis ⫻ Catastrophizing

1.37 0.05 9.12 0.21 0.91 ⫺2.92 1.75

1.08 1.03 2.86 0.58 0.53 0.94 0.81

0.08 0.00 0.59† 0.03 0.14 ⫺0.49† 0.25*

1.27 0.05 3.19† 0.36 1.72 ⫺3.10† 2.15*

*P ⬍ .05. †P ⬍ .01. a

Diagnosis refers to problem headache vs control.

R2

⌬R2

.15

.15†

.24

.10†

.31

.06†

CLINICAL REPORT/Buenaver et al

315 active coping) would be a significant predictor of headache pain-related interference. Sex, ethnicity, and headache duration were entered as covariates in the first step. Headache pain severity was treated as a covariate and entered in the second step along with depressive symptoms and headache-free days which were also entered in the second step as predictors. Catastrophizing and active coping were entered in the third and final step of the regression equation as predictors. The main effects of headache pain severity, depressive symptoms, and catastrophizing were significantly related to headache pain-related interference, whereas active coping was not (Table 4).

Discussion Figure 1. Predicted depressive symptom scores for individuals high and low on catastrophizing. HA, Headache; BDI, Beck Depression Inventory.

toms (Table 2). The simple slopes provided from post hoc probing are displayed in Fig 1 and Fig 2. Post hoc analyses revealed that pain catastrophizing was positively and significantly related to depressive symptoms only among the problem headache individuals (␤ ⫽ 3.13; SE ⫽ 0.62; Beta ⫽ 0.49; t ⫽ 5.08, P ⫽ .000), and not for individuals in the control group (␤ ⫽ 0.89; SE ⫽ 0.54; Beta ⫽ 0.14; t ⫽ 1.64, p ⫽ 0.10). Similarly, active coping was negatively and significantly related to depressive symptoms among the individuals with problem headache (␤ ⫽ ⫺3.37; SE ⫽ 0.77; Beta ⫽ ⫺0.46; t ⫽ ⫺4.37, P ⬍ .001); however, active coping was not significant in predicting depressive symptoms in the individuals without headache pain (␤ ⫽ 0.14; SE ⫽ 0.61; Beta ⫽ 0.02; t ⫽ 0.23, P ⫽ .82).

Hierarchical Regression Investigating the Associations Between Pain Coping (ie, Catastrophizing and Active Coping) and Headache Pain Severity in the Problem Headache Group Hierarchical multiple regression was conducted to test the hypothesis that pain-coping (ie, catastrophizing and active coping) would be a significant predictor of headache pain severity. Sex, ethnicity, and headache duration were entered as covariates in the first step. Depressive symptoms and headache-free days were entered as predictors in the second step and catastrophizing and active coping as predictors in the third and final step of the regression equation. The main effects of headache-free days, depressive symptoms, and catastrophizing were significantly related to headache pain severity, whereas active coping was not (Table 3).

Hierarchical Regression Investigating the Associations Between Pain Coping (ie, Catastrophizing and Active Coping) and Headache Pain-Related Interference in the Problem Headache Group Hierarchical multiple regression was conducted to test the hypothesis that pain-coping (ie, catastrophizing and

The present findings highlight the potentially deleterious impact of catastrophizing on the experience of pain (headache pain, in this case). Although these data are cross-sectional, it is important to note the absence of significant differences between the problem headache group and the control group regarding the use of catastrophizing or active coping. Due to the cross-sectional nature of the study, the possibility of changes in catastrophizing and active coping in the headache group over the course of their pain condition cannot be ruled out. This is not particularly surprising, as these were generally healthy, nondisabled, young adults, relatively early in the course of what (for some of them, at any rate) may become a long-term pain condition. However, the groups did differ in reported depressive symptoms, with the headache group reporting significantly greater symptomatology (by a factor of 2) compared with the control group. Most interestingly, catastrophizing about pain was related to symptoms of depression only among the headache group and not the control group. Similarly, the use of active pain-coping was inversely related to depressive symptoms only among the headache group. In addition to their strong associations with depressionrelated symptoms in the headache group, individual differences in catastrophizing showed significant relationships with headache pain severity (even after controlling

Figure 2. Predicted depressive symptom scores for individuals high and low on active coping. HA, Headache; BDI, Beck Depression Inventory.

316 Table 3.

Catastrophizing and Headache

Multivariate Correlates of Headache Severity Score (Problem Headache Group Only) STEP VARIABLES

␤

SE

BETA

T

1. Sex Ethnicity Headache Duration 2. Headache-Free Days Depressive symptoms 3. Active Coping Catastrophizing Final Model: F(7, 72) ⫽ 3.71, P ⫽ .002

0.89 ⫺0.59 ⫺0.12 ⫺0.06 0.06 ⫺0.19 0.38

0.50 0.42 0.49 0.03 0.02 0.19 0.16

0.20 ⫺0.16 ⫺0.03 ⫺0.24 0.30 ⫺0.11 0.27

1.80 ⫺1.43 ⫺0.25 ⫺2.25* 2.75† ⫺0.97 2.34*

R2

⌬R2

.06

.06

.19

.14†

.27

.07*

*P ⬍ .05. †P ⬍ .01.

for depression), and with perceived interference of pain with day-to-day functioning (beyond the effects of depression and headache pain severity). In these latter analyses, while higher levels of catastrophizing predicted more severe headache pain and greater pain-related interference, individual differences in the use of other coping strategies did not exert significant influence on these parameters, underlining the primacy of catastrophizing and other “negative” cognitive and emotional processes in shaping pain-related outcomes.21 In our view, these results, in concert with other recent research on pain-related catastrophizing,32 reveal a somewhat novel conceptualization of catastrophizing as an individual difference factor (or diathesis) which is largely dormant until activated by the presence of pain or pain-related phenomena. This theory however, could be better tested using a longitudinal design to directly evaluate whether catastrophizing changes as a consequence of the development of a painful condition. Indeed, it is interesting to note that catastrophizing may only be triggered by persistent pain of a high enough severity; future studies would likely benefit from assessing potential interactions between the degree of an individual’s catastrophizing and the severity of their pain. For example, clinical pain of only mild intensity may not be adequate to activate catastrophizing cognitions and emotions, while moderate-to-severe pain reliably produces such activation. Further, it is also possible that the

Table 4.

headache group might have been more accurate in reporting their pain-coping strategies (ie, catastrophizing and active coping) compared with the pain-free control subjects. However, it would be extremely difficult to test this hypothesis because other than self-report there is currently no “gold standard” against which to compare an individual’s catastrophizing score to determine the accuracy of their report. There are several studies of generally-healthy adults, without a pain condition, in which catastrophizing scores were found to be predictive of various pain-related responses.41,47 The fact that catastrophizing is assessed in pain-free subjects, yet still is correlated with subsequent pain responses, suggests that self-report of catastrophizing is not completely inaccurate in healthy subjects, although it may indeed become more accurate after the onset of a pain condition. For example, in some studies of healthy adults, “in vivo” assessments of pain catastrophizing about specific pain events show greater associations with pain outcomes relative to standard measures of usual catastrophizing.10,14 Thus, participants in the headache group potentially had access to more recent memories of specific pain events (ie, headache episode), when self-reporting about catastrophizing, than respondents in the control group, consequently giving self-reports that were more similar to an “in vivo” assessment. Conversely, pain-free control subjects’ responses about pain catastrophizing might have been more general. Thus, future studies should

Multivariate Correlates of BPI Pain Interference (Problem Headache Group Only) STEP VARIABLES

␤

SE

Beta

T

1. Sex Ethnicity Headache Duration 2. Headache-Free Days Depressive symptoms Headache Pain Severity 3. Active Coping Catastrophizing Final Model: F(8, 71) ⫽ 4.31, P ⫽ .000

0.38 0.08 0.21 ⫺0.03 0.09 0.29 0.02 0.38

0.59 0.49 0.57 0.03 0.02 0.13 0.22 0.18

0.07 0.02 0.04 ⫺0.11 0.39 0.25 0.01 0.24

0.64 0.16 0.36 ⫺1.03 3.69† 2.26* 0.11 2.10*

Abbreviation: BPI, Brief Pain Inventory. *P ⬍ .05. †P ⬍ .01.

R2

⌬R2

.01

.01

.29

.28†

.33

.04

CLINICAL REPORT/Buenaver et al consider using measures of “in vivo” catastrophizing because recent research suggests that information gathered using this assessment method may be more strongly associated with pain-related outcomes. Importantly, after its activation, catastrophizing may have enduring effects; in a previous study, we found that individuals reporting more frequent catastrophizing were less likely to show resolution of sensitization after the offset of an acute clinical pain condition.15 To some degree, this model of catastrophizing makes intuitive sense; although individuals may differ widely in how prone they are to catastrophize when in pain, such individual differences are unlikely to produce substantive consequences until individuals are exposed to significant pain experiences. In prior studies, catastrophizing has been cross-sectionally linked with enhanced report of affective distress in a variety of clinical samples.13 Moreover, in patients experiencing pain, catastrophizing shows consistent association with symptoms of emotional distress over both short and long time periods. For example, longitudinal studies have related catastrophizing at one time point with increases in depression or distress 1 or more years later, indicating that the influence of catastrophizing on the affective consequences of pain may unfold over relatively long time horizons.7,29 However, microlongitudinal studies reveal that catastrophizing also shows short-term effects, as in a recent study utilizing daily diaries, where increases in catastrophizing on a given day related to worsened mood that same day and the following day.30,50 Overall, the findings of the present study add to this growing body of literature by documenting the specificity and diathesis-like features of pain-related catastrophizing; its associations with distress are substantially stronger among individuals with significant pain conditions, and among those with clinical pain conditions, its associations with important pain-related outcomes (eg, pain severity and disability) are independent of those global indices of distress. The relationship between catastrophizing and affective distress, namely depressive symptoms in this case, is one that has often been reported throughout the literature. Others have published studies characterizing this association in samples of either pain patients or healthy, pain-free adults. The correlation between catastrophizing and depressive symptoms that has been reported in the literature generally appears to be substantially stronger in pain patients relative to individuals who are pain-free. For example, recent studies in pain populations have documented correlations ranging from 0.6 to 0.7,4,16 whereas in studies of healthy adults the magnitude of this association has been reported to range from 0.2 to 0.3.18,35 In the present study the correlation between catastrophizing and depressive symptoms was r(85) ⫽ 0.41, P ⬍ .001 and r(114) ⫽ 0.20, P ⬍ .05, for the headache and control groups, respectively. The present study offers a unique perspective in that it is the first to assess this relationship in both samples (ie, with and without pain) together and evaluate the interaction between catastrophizing and pain status in relation to depressive symptoms. Our findings are unlikely to be limited in their implication to headache pain alone. We previously reported

317 strong relationships between catastrophizing and a variety of day-to-day pain symptoms in college students.18 Individual differences in catastrophizing appear to emerge relatively early in development (eg, before or during adolescence3), and are likely shaped by myriad factors including sociocultural norms, as well as interpersonal and familial relationships,9,13,46,47 genetic factors which shape a variety of pain responses,12 and numerous other variables that contribute to the experience of pain. The present results are unable to illuminate the mechanisms by which catastrophizing influences outcomes such as affective distress, but a variety of other research has identified multiple pathways through which catastrophizing may operate. For example, some research has examined the hypothesis that catastrophizing enhances the experience of pain via its effects on attentional processes. That is, high levels of catastrophizing may lead individuals to attend selectively and intensely to pain-related stimuli. Catastrophizers experience more difficulty controlling or suppressing painrelated thoughts than do noncatastrophizers, they ruminate more about their pain, and their cognitive and physical performance is more disrupted by anticipation of pain.8,22,52,53 In patients with chronic pain, catastrophizing is strongly correlated with increased attention to pain,42 and greater vigilance to bodily sensations.34,40 In addition, recent studies have also noted that catastrophizing may directly affect the processing of pain in the central nervous system; 2 recent functional MRI studies reveal that high catastrophizers showed enhanced activity in cortical regions involved in the affective processing of pain during the experience of acute pain.23,44 Recent data from our laboratory also suggest that catastrophizing may be directly associated with CNS pain-facilitatory processes in the spinal cord.17 These mechanisms are not mutually incompatible and are consistent with the present data. Overall, our findings highlight several important attributes of catastrophizing: Its strong associations with distress in the context of an ongoing pain condition (contrasted with the nonsignificant associations in individuals without a significant pain problem), and its unique influence on pain-related outcomes even after controlling for global measures of distress. Despite the limitations of this study, including its cross-sectional design and use of a convenience sample of undergraduate students, we hope that these findings will help to buttress a conceptualization of catastrophizing as a diathesis-like, individual difference factor that is crucially important in understanding the experience of pain.

Acknowledgments The authors gratefully acknowledge the assistance of Grayson N. Holmbeck, PhD, for his consultation on matters related to data analysis. The authors would also like to express their gratitude to Marjorie Pace, Martha Milne, and Kim Ryan for their assistance with data collection and management during this study.

318

Catastrophizing and Headache

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