Tools Refined to Assess Catastrophizing in Chronic Pain

Nancy A. Melville

May 27, 2016

AUSTIN, Texas — With evidence on the detrimental effects of catastrophizing on chronic pain well documented and ever increasing, researchers are making headway in refining the tools needed to measure the highly subjective symptom.

The current gold standard in measuring catastrophizing, the Pain Catastrophizing Scale (PCS), a validated 13-item instrument, considers factors including rumination, helplessness, and magnification, but a need for a more efficient daily tool exists, Beth Darnall, PhD, a clinical associate professor in the Division of Pain Medicine at Stanford University, California, told Medscape Medical News.

"The lack of a validated daily measure stands as a barrier for studies that aim to characterize mechanisms of pain treatment and how pain catastrophizing adaptation [and] change occurs," she said.

In developing the daily instrument, Dr Darnell and her colleagues conducted rounds of interviews with patients in chronic pain, ultimately validating two versions of a daily PCS: a three-item and a five-item version that are considered suitable for daily use.

Among the five items are three questions evaluating symptoms of rumination and one question each assessing measures of magnification of pain symptoms and feelings of helplessness.

A three-item version of the scale, involving only questions of rumination, was also found to be an appropriate construct of daily pain catastrophizing, with efficacy similar to that of the five-item version.

"At the daily level, catastrophizing appears to have a single dimension that is best represented by rumination," Dr Darnell said.

"Ultimately, these daily PCS measures equip researchers with the tools to better characterize the impact of psychological factors on the experience of pain and medical symptoms and will inform the development of targeted, personalized therapies."

Dr Darnell and colleagues presented their findings at the American Pain Society (APS) 35th Annual Scientific Meeting.

The validation of the daily PCS was conducted as part of a large grant from the National Institute of Health's National Center for Complementary and Integrative Health, and a clinical trial is set to begin in the fall to investigate the mechanisms and efficacy of catastrophizing treatment.

"Catastrophizing is one of the most impactful factors for acute and chronic pain outcomes — it actually predicts recovery from surgery and the development of chronic pain, and can increase need for pain treatment and medications, such as opioids," Dr Darnell explained.

"Having a daily PCS measure will help researchers study how catastrophizing treatment works, and how catastrophizing changes."

"It will inform research that seeks to understand mechanisms of catastrophizing and its impact on pain and related symptoms, such as mood, anxiety, sleep."

Alternative Instrument

Researchers with the University of Alabama are meanwhile working on an alternative instrument to the PCS, called the Composite Catastrophizing Measure-Short Form (CCM-SF), in an effort to address some shortcomings of the PCS.

"The PCS is a great measure, but other researchers have commented that it may not cover all of the constructs associated with catastrophizing, especially what one might call 'worst-case scenario' cognitions," senior author Beverly Thorn, PhD, director of the University of Alabama Pain Management Team and professor and chair of Psychology at the University of Alabama, Birmingham, told Medscape Medical News.

The PCS covers only rumination, helplessness, and magnification, and some items are worded in such a way that the item asks two questions or taps two constructs, she explained.

"For example: 'It's terrible and I think it's never going to get any better' from Sullivan's Helplessness factor, actually says 'It's terrible' (pain severity) and 'it's never going to get any better' (pessimism)," Dr Thorn said. "We tried to clean that up a little bit."

In addition, the PCS also presents items, such as rumination, sequentially, rather than randomly distributed, which could present a method variance problem, and reliability of the measures of patient magnification of pain symptoms is less than ideal on the PCS, with only three items, Dr Thorn said.

First author Benjamin P. Van Dyke, MA, added that the CCM-SF was designed to also address areas of the PCS considered to be overly conflated with items on depression symptoms.

"The construction of the CCM-SF removed items that were not specifically testing catastrophizing and that were too closely linked to depression in order to address that issue," he said.

In their presentation at the APS meeting, the researchers sought to validate the CCM-SF in a clinical sample of 300 patients with chronic pain who are participating in a clinical trial of two psychosocial self-management approaches.

They found the instrument provided good consistency among the clinical sample that was similar to a nonclinical sample. The CCM-SF correlated strongly with the PCS and significantly predicted Brief Pain Inventory Intensity and Interference scores among patients at baseline.

"We are trying to broaden the construct of catastrophizing to include domains that have previously been unexamined," Dr Thorn noted.

"At the same time, we are wanting to keep any measure developed to a reasonable, clinically useful length."

Dr Darnell, Dr Thorn, and Dr Van Dyke have disclosed no relevant financial relationships. Dr Darnell's research received support from the National Institutes of Health's National Center for Complementary and Integrative Health. Dr Van Dyke's study was partially funded through a Patient-Centered Outcomes Research Institute Award.

American Pain Society (APS) 35th Annual Scientific Meeting. Presented May 13, 2016.

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