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SP0004 The Impact of Catastrophizing in Obtaining Remission in RA
  1. H.B. Hammer
  1. Dept. of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway

Abstract

Pain catastrophizing is conceptualized as a negative cognitive–affective response to anticipated or actual pain and has been associated with a number of important pain-related outcomes. Catastrophizing is defined as a tendency to magnify or exaggerate the threat value or seriousness of pain sensations, and tendency to pain-related worry and fear, coupled with an inability to divert attention away from pain.

A Coping Strategies Questionnaire (CSQ) was developed and later a Pain Catastrophizing Scale (PCS). Factor analytic work indicated that the PCS yielded the three second-order factors helplessness, rumination and magnification. Thus pain catastrophizing evaluated by the questionnaires is characterized by the tendency to magnify the threat value of pain stimulus and to feel helpless in the context of pain, and by a relative inability to inhibit pain-related thoughts in anticipation of, during or following a painful encounter [1].

Pain catastrophizing has most typically been conceptualized and assessed as a dispositional variable. However, maladaptive thoughts are latent and in need of a cue to become manifest. Enough evidence has accumulated to suggest that high levels of catastrophizing about pain should be considered a “risk marker” for adverse immediate and long-term pain-related outcomes. Moreover, the apparent role of catastrophizing in contributing to the effectiveness of a variety of pain treatments suggests that it may become a key target of many chronic pain management programs.

Pain is the most common and disabling symptom of rheumatoid arthritis (RA). Although physicians often assume that inflammation is the stimulus for pain, many RA patients continue to have pain despite adequately suppressed inflammation. A review on pain catastrophizing [2] found that it is positively related, in both cross-sectional and prospective studies across different musculoskeletal conditions, to the reported severity of pain, affective distress, muscle and joint tenderness, pain-related disability, poor outcomes of pain treatment, and, potentially, to inflammatory disease activity. Moreover, these associations generally persist after controlling for symptoms of depression. There appear to be multiple mechanisms by which catastrophizing exerts its harmful effects, from maladaptive influences on the social environment to direct amplification of the central nervous system's processing of pain.

Several prospective studies have illustrated the longitudinal association of catastrophizing with pain in RA. In daily diary studies, patients with RA who exhibited greater catastrophizing reported more day-to-day pain and attention to pain than low catastrophizers. Findings from another prospective study suggested that baseline catastrophizing scores predicted enhanced pain and depression in patients with RA at 1-year follow-up. Catastrophizing may also influence the success of pain-related treatments in patients with musculoskeletal disease.

Our group found the level of pain catastrophizing to be highly associated to all patient's reported outcomes (joint pain VAS, patient's global VAS, MHAQ, tender joints) as well as composite scores (DAS28, SDAI, CDAI) in contrast to no associations with the more objective assessments (swollen joints, laboratory and ultrasound assessments) in established RA patients starting bDMARD [3]. This may have important consequences regarding the evaluation of disease activity of patients with established.

We also found that the level of pain catastrophizing decreased during the one- year study, indicating that pain catastrophizing may be influenced by the clinical treatment including both psychosocial and medical factors. In addition, patients shifting from being pain catastrophizers to not being pain catastrophizers after one year, showed significantly lower levels of patient's reported outcomes than patients staying pain catastrophizers, in spite of no differences in objective measures of disease activity.

Thus, pain catastrophizing is a critically important variable in understanding the experience of pain in rheumatologic disorders as well as other chronic pain conditions. It is important to be aware of the level of pain catastrophizing in the evaluation of medical treatment of patients with different inflammatory rheumatic diseases.

1. Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother 2009; 9(5): 745–758

2. Edwards RR, Bingham CO, Bathon J, Haythornthwaite JA. Catastrophizing and Pain in Arthritis, Fibromyalgia, and Other Rheumatic Diseases. Arthritis & Rheumatism (Arthritis Care & Research) 2006; 55(2): 325–332.

3. Hammer HB, Uhlig T, Lampa J. Pain catastrophizing has a major impact on both subjective and composite outcomes in patients with rheumatoid arthritis; results from a longitudinal study of patients starting bDMARDs. To be submitted.

Disclosure of Interest None declared

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