Catastrophising, or thinking the worst, is one of those psychological factors that we know influences distress and disability in people with chronic pain. It’s quite a common phenomenon, and sometimes can stand us in good stead – after all, if we can think of the worst things that can happen, then plan to avert those possible disasters, then life will be sweet, yes? ermmmm – no, as a matter of fact. Catastrophising can actually function to narrow our thinking down, reducing the range of options we can come up with to manage situations, and it can also function to focus us on things that haven’t worked out while at the same time minimising our appreciation of things that are working well.
In chronic pain, catastrophising is often an outcome to measure – the thought is that if people learn to think more positively about what might happen when their pain is bad, they’ll be in a better position to cope with their pain. This is thought to reduce the level of distress by being more realistic about the potential for negative things to happen. People who can face difficult times with a greater sense of the real level of threat can harness resources more effectively and often avert negative situations before they happen.
There are a number of interesting theories about resilience and how people cope more positively with life’s situations. One of these theories is the ‘broaden and build’ theory first developed by Fredrickson, (2001). In the ‘broaden’ part of this theory, it’s thought that positive emotions serve to broaden what we attend to and think about, and in doing so, widen the range of things we consider and think about so that we can think of more options than we consider when we’re under stress. This is thought to help us cope better with stress because we can think of a greater range of things that might work to help us out of that particular difficulty.
Some of the other relevant discussions about resilience and positive emotions suggests that while resilience can be thought of as a trait, or a fairly stable ‘way of viewing the world’, one aspect of reslience that is important is the ability to generate and have positive emotions. Maybe having positive emotions is just a by-produce of resilience, or maybe it’s that if we can remain positive despite stressors being present, then we will be able to be resilient – but it’s certainly evident that when people are able to find something positive in a difficult situation, or if they can find something funny in their situation or even find something to comfort and therefore increase positive mood, they seem to cope better than people who ‘think the worst’ and then remain focused on these negative aspects of their situation.
How does this fit with catastrophising and chronic pain?
Well, in an interesting ‘daily process study’ by Ong, Zautra and Reid, people who were being seen for their chronic pain were asked to keep a daily diary and record catastrophising, pain intensity, and both positive and negative emotions over a period of 14 days. At the beginning of the study they were asked to complete a set of questionnaires including a measure of resilience, neuroticism, and the usual range of demographic details.
The aim of the study was to see how resilience characteristics related to catastrophising, positive and negative emotions, and pain. There were four main questions: (1) Is there a gender difference in catastrophising? (2) Is there a relationship between the level of resilience and the changes experienced in pain catastrophising? (3) Do positive emotions reduce pain catastrophising? and (4) Is the relationship between resilience and pain catastrophising influenced by positive emotion?
What did they discover?
Well, the first question about whether there is a relationship between gender and catastrophising found that yes, women in this study of 95 people, were more likely to catastrophise. Why this is, we don’t know. More research please!
The second question about resilience and catastrophising found that people who were identified as more resilient (using the scales in this study, anyway) were less likely to score as highly on the measure of catastrophising as people who were found to be less resilient. So it seems that if you have that tendency to bounce back, you’re also less likely to think the worst in a stressful situation. Which one comes first, we are not quite as certain.
The third question about whether positive emotions could influence catastrophising about pain also found that yes, if these participants felt positive on one day, they’d tend to score less on catastrophising the following day. (I guess you can see that maybe the reverse also applied – so it could easily become a downward spiral of feeling low in mood, then the next day, tending to think the worst – which is probably only going to increase the likelihood of feeling even lower that subsequent day!).
And lucky last, the question about whether positive emotions influenced the relationship between resilience and catastrophising (ie mediated that relationship) was also tested. In this rather complex set of calculations, it was found that the relationship between being generally resilient and the degree of catastrophising experienced on a daily basis was mediated by positive emotions. So if you’re generally resilient, but have a bad day, this can influence your catastrophising, but not to the same extent as if you’re generally less resilient, when it can lead to a really big increase in catastrophising.
What does this mean for us as clinicians?
The first thing that strikes me when I look at this is that if we can help people identify and pursue things that make them feel more positive, and they do this on a daily basis, it might help them be more able to think more realistically about their situation. So rather than freaking out about their pain, and being really concerned that their pain is going to overwhelm them, people who have had a couple of positive experiences through the day might be more likely to think that their pain is bothering them, but they can deal with it.
This leads me to consider the many ways in which we can help people generate positive events in their lives. Not everything we suggest to people needs to involve ‘hard work’! It’s actually OK to throw a ball for the dog and laugh at her antics. It’s fine to get out an old comedy movie and watch it for laughs. There could be merit in ‘laughing meditation’ where people are encouraged just to start laughing – it’s almost impossible to resist laughing when you see someone else chuckling away! Maybe even get people to look at my Friday Funnies? – oh, maybe not.
The next thing that comes to mind is that while women tend to be more likely to catastrophise, it was also found that positive emotions had a greater effect on catastrophising in women. The authors of this paper suggest that maybe women have more trouble regulating emotions (don’t talk to our menfolk will you? They’d only agree…sigh…), but add that perhaps a greater emphasis on using ways to increase positive emotions will pay dividends for women.
We have a long way to go to really understand what helps people look on the bright side or have bounce back when they experience life’s challenges. At least one thing we can draw from this study is that by increasing positive emotions there is a reasonable chance we can help people reduce their degree of catastrophising about their pain. I’ll post more about how to increase positive emotions shortly – but this is one area that is an especially important one for clinicians working in chronic pain, and especially for occupational therapists who are ‘expert’ in occupations that people enjoy. Having positive emotions seems to generate more options for coping, and increases the sense that life can go on – and this has got to be good for the people we work with.
Ong, A., Zautra, A., & Reid, M. (2010). Psychological resilience predicts decreases in pain catastrophizing through positive emotions. Psychology and Aging, 25 (3), 516-523 DOI: 10.1037/a0019384
Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56, 218–226. doi:10.1037/0003-066X.56.3.218