Beth Darnall, PhD, on the need to address patterns of negative pain appraisal in patients.

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with Beth Darnall, PhD

While pain is typically considered in biomedical terms, cognitive and emotional factors also figure significantly into how an individual experiences pain. Pain is often challenging and distressing and triggers a host of responses in the body and mind. Applying tools to regulate mental and physical responses to pain may help reduce the negative impacts of pain. Pain patients can learn skills that help to cultivate pain relief while also improving treatment outcomes.

Research shows that when individuals focus on pain and feelings of helplessness – often known as “pain catastrophizing" – their pain intensity worsens and the efficacy of medical interventions becomes limited.1,2 While everyone has difficult moments, the persistent pattern of rumination on pain can be detrimental as it heightens distress, amplifies pain processing in the nervous system, and undermines treatment outcomes. While acquiring the tools to self-soothe will not cure chronic pain, this process may improve a patient’s ability to control their experience and reduce their pain and its impacts. Self-regulation of pain may be optimized and integrated into any treatment regimen to create a more comprehensive and effective pain care plan.

A Better Term for Catastrophizing

“Even though we study pain catastrophizing, I prefer talking about ‘negative regulation of pain’ or ‘negative pain appraisal’ because it is more acceptable to patients,” said Beth Darnall, PhD, a clinical professor in the department of anesthesiology, perioperative, and pain medicine at Stanford University. Dr. Darnall has led multiple clinical trials on pain catastrophizing and approaches to minimize its effects; she has also written several pain management books, including the recently published Psychological Treatments for Patients with Chronic Pain. “Pain catastrophizing is a term that has been used for decades, and unfortunately it is often perceived as pejorative,” she told PPM. While pain catastrophizing has been the enduring term, newer scales are using “pain appraisal.” (Join the conversation about the term "catastrophizing" on Twitter @PracticalPain @BethDarnall)

“Pain catastrophizing or negative pain appraisal is a persistent pattern of having difficulty shifting the focus away from the worst aspects of pain,” explained Dr. Darnall. In these cases, people will often ruminate on their pain (eg, “I can’t stop thinking about how much it hurts”); magnify their pain (eg, “I’m afraid that something serious might happen”); and feel helpless to manage their pain (eg, “There is nothing I can do to reduce the intensity of my pain”).3

The Overlapping Process of Pain

At its core, negative pain appraisal represents poor mental and emotional regulation in the face of pain. Research suggests that this process shapes the central nervous system, including neural functioning during pain; even the brain “at rest” is on higher alert for possible pain. These ongoing patterns actually worsen pain and distress, and prospectively contribute to poorer treatment outcomes, including surgical recovery.4-6 “The way I like to explain it is that the nervous system is doing a good job of trying to protect you. While this could be viewed as a positive thing in some regards, in other ways it can work against you,” said Dr. Darnall.

It is important to remember that pain is an individual experience that is influenced by a host of factors, including a patient’s history, prior pain experience, and how reactive their physiology is to a perceived threat – including pain. “I say this over and over again: Your pain is real, there’s a medical basis for it,” said Dr. Darnall of communicating with her patients. “And we can still find opportunities to help each person be best equipped to help themselves.”

The right set of skills, learned through non-pharmacological treatments, may help patients better regulate their pain experience. This is not to say that chronic pain conditions can be cured, or that medical treatments will not be needed, she noted, “but they can favorably alter the trajectory of the pain experience. Over time, that will start to reshape some of these neurological patterns in the nervous system. This allows people to feel and have greater control because they can focus on self-soothing – and therefore are better soothed.”

The Role of Self-Regulation

The ultimate goal in optimizing self-regulation of pain is to help patients feel that they have more control. Not only does more control make pain more tolerable for patients, it also helps them have a better response to the medical treatment.

Research is underway to better understand how cognitive and emotional regulation of pain can help patients suffer less. Dr. Darnall and others have worked to develop and validate scales to assess mental/emotional patterns in chronic pain,7,8 and to learn how treatments can be applied to shape adaptive neural networks that help steer neurophysiology toward a sense of safety – even in the face of pain.

Her team at Stanford is applying this science to the surgical setting by teaching patients about pain and how they experience it before they enter the operating room. Specifically, Dr. Darnall developed a treatment called “My Surgical Success,” a digital perioperative psychoeducational program aimed at providing information and skills to help patients during the recovery period. Surgical patients learn skills to regulate stress and pain responses, thereby decreasing stress and improving recovery. Results from a randomized controlled pilot study of 68 women undergoing surgery for breast cancer have been encouraging.9

Clinicians may also use these methods to help patients with acute or chronic pain. First, identify patients who may be struggling, advised Dr. Darnall. This may mean a need for additional medical treatment, and often signals a need for self-soothing techniques. While working with a pain or health psychologist may be beneficial, particularly within the context of mental health comorbidities, virtually all patients may also benefit from some basic education on pain and what they can do to help themselves.

There is a range of non-medication therapies that may help patients acquire self-regulation skills and positive action plans for pain management. These include: Cognitive Behavioral Therapy for chronic pain (pain-CBT), Acceptance and Commitment Therapy for chronic pain (a variation of CBT), mindfulness-based stress reduction/meditation, biofeedback, and hypnosis.

“There are a lot of ways for people to cultivate skills to calm their nervous system. There’s no single right way to do it,” said Dr. Darnall. Often, patients will integrate different techniques and approaches into their self-care plans. “It’s inspiring to see people with challenging medical conditions report that they are living better with pain. It’s not uncommon to us to hear people say, ‘I still have chronic pain, but I now have my life back.’"

Last updated on: April 12, 2019

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Three Approaches Found Effective for Pain Catastrophizing