When a patient catastrophizes their chronic pain, symptoms could begin to interfere with their daily life, and teenagers may be the most vulnerable to this problem.
By Thomas G. Ciccone
Interview with Amanda B. Feinstein, PhD
Adolescence is a difficult time for most children—but with chronic pain involved, it could be especially hard. In a study about pain behaviors, researchers from Stanford University found that for adolescents (13-17 years), pain catastrophizing was a strong predictor of pain intereference, compared with younger children (8-12 years) and adults (18-23 years; 24-29 years).1
Pain catastrophizing is recognized as a negative cognitive pattern often seen in patients with chronic pain and is characterized as ruminating on symptoms, over-exaggerating the severity of symptoms, and expressing a sense of dread and helplessness related to perceived or anticipated symptoms.2,3
The link between the emotional impact of pain and pain interference is especially strong in adolescents.
“Pain catastrophizing is a common construct measured in pediatric pain. We know from the adult literature that catastrophizing tends to be one of the strongest predictors of poor outcomes,” lead author Amanda B. Feinstein, PhD, a licensed clinical psychologist and postdoctoral fellow at the Stanford University School of Medicine and Stanford Children’s Health, told Practical Pain Management. “Therefore, researchers have been turning their attention to this construct in youth to learn more about how it predicts pain and function in younger patients.”
However, Dr. Feinstein and her colleagues did not find that younger children and adolescent patients had clinically elevated levels of catastrophizing. The study also found no signficant difference in the mean levels of catastrophizing between younger children and adolescents, something that contradicts some past research.4-6 Instead, catastrophizing appeared to be a strong predictor of pain intereference in adolescent patients.
As for children, emotional distress (anxiety, depression, etc.) seemed to be the strongest predictor of pain interference, not catastrophizing. In fact, some research now suggests pain catastrophizing behaviors are not so similar to the kind of “maladaptive cognitive coping attempts” seen in adult patients.7-8“Instead, it could be a more normative reaction by children, who at their young age, may lack the kinds of coping resources that tend to develop in later adolescence and adulthood,” Dr. Feinstein explained.
Pain Catastrophizing: How Does It Affect Different Age Groups?
In the study, which was published in The Journal of Pain,1 Dr. Feinstein and her colleagues used data from a cross-sectional cohort of 1,028 individuals living with chronic pain conditions. This cohort featured both adult and pediatric patients, with data collected from data the Collaborative Health Outcomes Information Registry (CHOIR), which serves as the platform for Stanford’s pain management clinics. The pediatric version of this platform (Peds-CHOIR) is led by Dr. Rashmi Bhandari, PhD, director of pain psychology services in the Pediatric Pain Management Clinic.
The registry, which was created in partnership with the National Institutes of Health (NIH), serves as an open-source foundation for collecting information about patients living with chronic pain across the country. It provided Dr. Feinstein and her colleagues with clinical measures of pain catastrophizing, pain intensity, pain interference, and emotional distress scores from an array of patients living with chronic pain conditions.
“A unique aspect of this registry that speaks directly to this work is the tracking of both pediatric and adult patients on comparable physical and psychosocial constructs, thereby enhancing our potential to track our pediatric patients over time into adult care,” said Dr. Feinstein.
While pain catastrophizing appeared to have a significant effect on pain intereference scores for adolescents, the same could not be said for younger children and adults. Indeed, previous research has found pain catastrophizing tends to decline with age2 as people develop more adaptive responses to pain and stress naturally.9 According to the authors, these kinds of insights could offer a valuable “developmental context” about pain interference. The age of a patient could have a signifcant effect on what cognitive aspects are affecting their functional outcomes, something that may be better addressed through targeted care.
Using Clinical Psychology to Help Treat Chronic Pain
“These findings may point to the importance of involving a mental health provider, such as a pediatric psychologist, to assist the child or adolescent to enhance their coping with chronic pain. Cognitive behavioral approaches may address all of the above components, and involving the child’s caregivers is often a critical part of this process,” Dr. Feinstein said.
For younger patients, aspects like pain catastrophizing, emotional distress, and pain intensity all could be relevant factors that could go unaddressed. According to Dr. Feinstein, The Pediatric Pain Management Clinic at Stanford Children’s Health integrates psychologists as part of its interdisciplinary pediatric pain clinics, and patients and their caregivers typically are recommended for follow-up care with a psychologist to address how the patient can use better coping methods for managing their chronic pain.
Obviously, for some families there may be stigma is associated with handing a parent a referral to a psychologist, insinuating the child’s pain is “all in their head,” which is why clinicians should be mindful of the language they use when describing the kind of mind-body connection that is so critical to understanding chronic pain, said Dr. Feinstein. Most patients simply may not understand chronic pain is biopsychosocial.
“Explaining the IASP’s [International Association for the Study of Pain] definition of pain as both a ‘sensory and an emotional experience’ can help reduce patients’ perceived stigma of having emotional reactions concomitant with their pain conditions,” and it could make it more understandable that a psychologist would be an integral part of their pain management team, said Dr. Feinstein.
“In both children and adults, we believe it is important for the physician to provide validation of the patient’s pain experience. Because patient’s caregivers are often quite anxious about their child’s pain, providing the family with a concrete plan of action steps to take, including reassurance, may be helpful,” Dr. Feinstein told Practical Pain Management.
Dr. Feinstein and her colleagues intend to identify characteristics that predict treatment response, pain severity, and course, as well as to track outcomes, determine treatment effectiveness, and better understand chronic pain conditions in children.
- Feinstein AB, Sturgeon AB, Darnall BD, et al. The effect of pain catastrophizing on outcomes: A developmental perspective across children, adolescents, and young adults with chronic pain.J Pain. 2017;18(2):144-154.
- Crombez G, Bijttebier P, Eccleston C, et al. The child version of the pain catastrophizing scale (PCS-C): a preliminary validation.Pain. 2003;104:639-646.
- Sullivan MJ, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation.Psychol Assess. 1995;7:524-532.
- Keefe FJ, Williams DA. A comparison of coping strategies in chronic pain patients in different age groups.J Gerontol. 1990;45:P161-P165.
- Molton I, Jensen MP, Ehde DM, et al. Coping with chronic pain among younger, middle-aged, and older adults living with neurological injury and disease.J Aging Health. 2008;20:972-996.
- Tran ST, Jastrowski Mano KE, et al. Distinct influences of anxiety and pain catastrophizing on functional outcomes in children and adolescents with chronic pain.J Pediatr Psychol. 2015;40:744-755.
- Rosenstiel AK, Keefe FJ. The use of coping strategies in chronic low back pain patients: Relationship to patient characteristics and current adjustment.Pain. 1983;17:33-44.
- Sturgeon JA, Zautra AJ. State and trait pain catastrophizing and emotional health in rheumatoid arthritis.Ann Behav Med. 2013;45:69-77.
- Brown JM, O’Keeffe J, Sanders SH, et al. Developmental changes in children’s cognition to stressful and painful situations.J Pediatr Psychol. 1986;11:343-357.