HELPING MAKE YOUR CHRONIC PAIN JOURNEY EASIER
The pain cHronic•les
LATEST BLOG ARTICLES
Chronic pain is a complex and often misunderstood condition that affects millions of people around the world. It's important to note that every individual's experience with chronic pain can be unique, and what works for one person may not necessarily work for another. I’ll will be providing some insights into the causes, mechanisms, and challenges of chronic pain based on my personal experience in the hopes that it will help make your chronic pain journey easier.
Michelle Marikos, Founder & CEO
Moving Through Chronic Pain
Pain is Pain
HELPING MAKE YOUR CHRONIC PAIN JOURNEY EASIER
PAIN PERCEPTION REVOLUTION:
Unveiling the Power of Thoughts in Chronic Pain Management
Removing the stigma surrounding pain catastrophizing
I had never heard of ‘pain catastrophizing’ until I attended the Mayo Pain Rehabilitation Center almost 20 years ago. During my six-week rehabilitation program, various types of treatment and therapies were presented to help each attendee achieve individualized goals in returning to an active and fulfilling life.
The program essentially focuses on helping people learn aspects of their pain
and life they can control when a cure for the pain is not possible. The subject of pain catastrophizing came up in a class called ‘Cognitive Coping Skills – Changing Your Thoughts about Your Chronic Pain and Illness’. We looked at the effects of positive and negative thought patterns, how thought patterns form and how these can lead to catastrophic thinking (a common negative thought pattern that may arise from painful or unfair situations – often our human tendency is to view events much worse than they actually are), for example you may have said to yourself, “ I can't take this anymore” or “The pain has ruined my life”. We talked through lots of negative or inaccurate thinking examples, and how our perception or interpretation of a situation may not always reflect facts; thus the belief that the continued pain can only arise from a serious illness. This creates a cycle of belief that greatly increases stress, makes symptoms worse and limits the ability to use effective coping skills.
I remember how I felt defined by my pain; my thoughts and long-held beliefs around my pain, its limitations on my life and the way I viewed the world had become ingrained into my very being, and I didn’t even know that I was ‘catastrophizing’.
I truly believed I would never get married, have children or have any semblance of a ‘normal life’ because of my pain. Twenty years on, I still find it enormously triggering to reflect upon how those thought patterns had consumed me.
During the early days of the Mayo Clinic program, we were encouraged to do positive affirmations, and I remember thinking how stupid they were. How could that possibly fix my pain? What was the point of saying stuff out loud that simply made no sense to me? Looking back, I started the program with a deeply troubled and negative view of pain management. But once we started talking about cognitive coping skills and pain catastrophizing, a light bulb went on, the positive affirmations and the positive thought processes started to make more sense to me.
One of our homework assignments was to write out a list of positive affirmations that had meaning and resonated with us. Even though the affirmations were now in my own voice, I could still hear the monkey chatter saying how dumb this activity was. Only when talking more about the cognitive coping skills and the pain catastrophizing was I able to use my positive affirmations to good effect. They were simple: “I'm okay”, “I'm not harmed”, “I can do this”, but they helped. I used them throughout my pain medication tapering and also when I caught myself having negative thoughts.
To this day, I use positive affirmations, albeit slightly altered versions, such as “You can do hard things.” When I tell my toddler son that he can do hard things, I also tell myself that I can do hard things – one of which is living with chronic pain.
What’s in a name?
The term ‘catastrophizing’ was coined in 1962 by psychologist Albert Ellis, and refined later by psychiatrist Aaron Beck. It was defined as a relatively common ‘cognitive distortion’ associated with anxiety and depression. Catastrophizing impairs self-efficacy, social functioning, and is linked to physical disability in both acute injury and chronic pain.
In recent years, reports have pointed to problems with the term ‘pain catastrophizing’. Critiques of the term have come from several sources, including individuals with chronic pain, advocates for individuals with chronic pain, and pain scholars. Reports indicate that the term has been used to dismiss the medical basis of pain complaints, to question the authenticity of pain complaints, and to blame individuals with pain for their pain condition. The term ‘can come across to some as judgmental. It stands in direct contradiction to the concept of chronic pain as a biopsychosocial disease, implying a degree of blame on the part of the person with chronic pain.
This has prompted calls to rename or delete the term ‘pain catastrophizing’; however, I believe that changing the term will do little to solve these problems. Continued calls for changing the terminology (alternatives such as pain-related distress, pain-related worry, pain-related fear and hypervigilance have all been suggested) will only divert attention away from the function of the term. Yes, I do consider ‘catastrophizing’ as a negative response or behavior, but I also recognize first-hand from my own lived experience that this is something that I do, and many others living with chronic pain do it.
Not only are there formidable obstacles to removing the word ‘catastrophizing’, any replacement may well come to have similar negative connotations for patients. Over time, the new term would carry the same semantic elements of dysfunction, deficiency, and pathology that we associate with the term ‘catastrophizing’. After all, any word in a language eventually acquires the characteristics of its referent.
There are two important things to understand when it comes to negative thought patterns around pain, the first is that this isn’t your fault; worrying in response to pain is a logical response. The second is that you can learn to change it.
We should be having open conversations about pain catastrophizing because it is real. We should not be nitpicking over how to label it, but focusing our efforts on addressing it and coping with it. At the end of the day, the name doesn’t really matter here; it’s what we do with it and how we go about changing our thought patterns.
What is pain catastrophizing?
A little bit of concern about your pain is natural and doesn’t present a problem. But if you find yourself constantly worrying about the pain, and thinking the worst, you’re ‘catastrophizing’. Every time you do this it signals more danger to the brain (which creates all pain) and as a result, you’ll feel more pain more often.
This study defines pain catastrophizing as, “a persistent pattern of distressing cognitive and emotional responses to current or anticipated pain.“
Pain catastrophizing has been proven to worsen pain, to increase disability, decrease functioning, and worsen mental health, as explained in this study here. The study also found that, “pain catastrophizing accounted for up to 31% of the variance in pain severity”. How and why does catastrophizing affect chronic pain in such a severe way?
Three pain catastrophizing components
There are three parts to catastrophizing about your pain: not everyone will experience them all and they will vary in severity. You may experience different aspects on different days, depending on what is happening in your life and how you are experiencing your symptoms.
Rumination: this simply means that you cannot get the pain off your mind. You may be constantly thinking about how much it hurts, feel unable to distract yourself or focus on anything else.
Magnification: this means you may be focused on events that haven’t even happened yet, thinking about how much worse they could potentially make your pain, or be worrying about how your chronic pain condition is going to worsen over time. For example, you may think, “this pain is only going to get worse, then I won’t be able to work, then I won’t be able to support my family” and so on, even if these beliefs are not based on facts.
Helplessness: this involves feeling as though you are not in control of your pain, that it is running your life. You may feel that there is nothing you can do to improve your life or your symptoms, essentially that there is no hope.
Understanding the Journey
How does catastrophizing affect chronic pain?
Increased stress
Being in a constant state of worry can result in stress levels rising. As all know, that’s detrimental to the body which is not designed to cope with the effects of stress for prolonged periods. Stress makes the body fatigued as it’s over worked, constantly stuck in a state of ‘fight or flight’. Stress keeps muscles tense, suppresses your immune system, and increases inflammation as well as pain; this becomes a cycle of stress causing pain and pain causing stress.
Fear avoidance
Anticipating pain getting worse with activity can lead to fear of movement, also called kinesiophobia; you may begin to avoid situations which you feel could worsen your pain as a result of this fear. As you avoid activity, your body becomes deconditioned meaning your muscles weaken. This makes further activity harder as your body is not prepared for it, which reinforces to your brain that your worries were ‘right’ because the activity did cause pain.
The brain learns pain
Our brains are neuroplastic which means they learn from what is happening in our environment and what our bodies experience. Chronic pain changes our nerve pathways, meaning that our brain learns that it ‘should’ produce pain in certain situations, when in fact it isn’t needed. Our nervous system becomes overactive.
By anticipating and worrying that certain actions are going to worsen your pain, you are reinforcing to your brain that these situations ‘should’ cause pain. So the way your nervous system and brain is working is changed – the brain has learnt that it should create pain messages for the activities you are worried about and doesn’t inhibit pain.
Less or more likely to seek help
Those who catastrophize about their pain tend to be at one of two extremes when it comes to seeking help for their pain. Due to the fear of movement and the fear of what doctors may ‘find’ during appointments, those who catastrophize about pain may be less likely to seek help. However, some people who catastrophize frequently visit their doctor in excess.
Mental health
Feeling constantly worried about your pain and being unable to engage in regular day to day activities can take a real toll on your mental health. Anxiety can develop or be worsened; often the feelings of helplessness, being unable to focus on things that you enjoy and the pain being all-consuming can lead to depression.
The Pain Catastrophizing Scale
While no single scale can meet all needs, I think it's really important for providers to use the Pain Catastrophizing Scale as a way to start a conversation with their patients about their thought processes around their pain. Furthermore, it gives the provider a different view/context and insight about what their patients are going through.
How it works
In order to establish how severe your level of pain catastrophizing is and how much it’s affecting your pain levels and daily functioning, a scale is typically used based around the three concepts mentioned earlier: rumination, magnification and helplessness. Patients are asked to score 13 negative thoughts about pain on a sliding scale of 0 (not at all) to 5 (all the time) for example, indicating how often you experience those thoughts and how they affect you.
The doctor will also discuss other symptoms, your lifestyle and clinical history; from there, the appropriate treatment can be recommended.
The power of the ‘a-ha’ moment
When I look back to my first encounter with pain catastrophizing at the Mayo Clinic all those years ago, I can now see how powerful that moment was when I realized that my fear of pain was exacerbating my suffering; when you start to see how the pattern works, you will experience a breakthrough on your journey with chronic pain. When you notice that you are in a heightened state of fear and anxiety, and you start to believe that every twinge or discomfort can feel like a dire threat, amplifying your pain experience and triggering a vicious cycle of distress, when you start to recognize these patterns within yourself, you can make a pivotal shift in perspective, one that empowers you to take control of your pain management. It’s not easy. It takes a lot of discipline. It won’t always work.
Acknowledging pain catastrophizing doesn't mean dismissing or trivializing the reality of your pain. Instead, it's about reclaiming agency over your thoughts and emotions, and recognizing that you have the power to influence how you perceive and respond to pain.
Armed with this insight, you can explore various strategies to address your pain catastrophizing and fear.
Mindfulness techniques – deep breathing, meditation, and progressive muscle relaxation can help calm the nervous system and cultivate a more grounded awareness of the present moment.
Cognitive-behavioral therapy (CBT) – another valuable tool for challenging negative thought patterns and developing healthier coping strategies. By working with a therapist trained in CBT, you can learn to reframe catastrophic thoughts, challenge irrational beliefs about pain, and build resilience in the face of adversity.
Talking therapies – counseling to deal with anxiety and depression can help to reduce the feelings of helplessness that come with pain catastrophizing, and put you in a better mental state to begin other therapies directed towards your catastrophizing.
Interdisciplinary rehabilitation programs – one of the most successful treatments for pain catastrophizing is a combination of CBT techniques and physical therapy to build up the body’s fitness and range of motion. CBT techniques, when combined with a physical aspect to teach the patient how to move their body in a safe way, not only can build confidence but can really tackle fear and worry from both angles.
For many of us living with chronic pain, catastrophizing can become almost second nature. However, when we start to challenge and change these negative thought patterns, we can develop healthier coping strategies and improve our overall well-being.
For medical providers specializing in chronic pain, understanding pain catastrophizing is not just about prescribing medications or treatments; it's about recognizing the holistic impact of pain on a person's life. Underneath this pain is a person who may have been just like them at one point; able to work a 40-hour week, have a family, get out of bed without pain, take a shower every day, enjoy hobbies, play sports, travel, and idly complain that they stubbed their toe. The symptoms and severity may vary, but we all go through the same psychosocial changes in our lives. We each deserve an individual and flexible treatment plan. Pain is complex; it changes from moment to moment. One day we can go out to the store and maybe for the next week we will be flat on our backs.
Ultimately, the goal is to shift the narrative surrounding chronic pain from one of hopelessness and despair to one of resilience and empowerment. By fostering a deeper understanding of pain catastrophizing and its effects, we can work towards changing the way we think about our pain and, in turn, improve our ability to manage it effectively.
#chronicpain #understandingpain #chronicpaincauses #painawareness #peersforpain
Michelle Marikos’ fall from a balcony in her early twenties, and her subsequent decades long debilitating chronic pain, inspired her to launch Moving Through Chronic Pain and her PEER™ Method programs to facilitate deeper connections between those living with chronic pain and their community of providers, employers, and family members.
Michelle Marikos, Founder & CEO
Moving Through Chronic Pain
Pain is Pain
HELPING MAKE YOUR CHRONIC PAIN JOURNEY EASIER
PAIN PERCEPTION REVOLUTION:
Unveiling the Power of Thoughts in Chronic Pain Management
Removing the stigma surrounding pain catastrophizing
I had never heard of ‘pain catastrophizing’ until I attended the Mayo Pain Rehabilitation Center almost 20 years ago. During my six-week rehabilitation program, various types of treatment and therapies were presented to help each attendee achieve individualized goals in returning to an active and fulfilling life.
The program essentially focuses on helping people learn aspects of their pain
and life they can control when a cure for the pain is not possible. The subject of pain catastrophizing came up in a class called ‘Cognitive Coping Skills – Changing Your Thoughts about Your Chronic Pain and Illness’. We looked at the effects of positive and negative thought patterns, how thought patterns form and how these can lead to catastrophic thinking (a common negative thought pattern that may arise from painful or unfair situations – often our human tendency is to view events much worse than they actually are), for example you may have said to yourself, “ I can't take this anymore” or “The pain has ruined my life”. We talked through lots of negative or inaccurate thinking examples, and how our perception or interpretation of a situation may not always reflect facts; thus the belief that the continued pain can only arise from a serious illness. This creates a cycle of belief that greatly increases stress, makes symptoms worse and limits the ability to use effective coping skills.
I remember how I felt defined by my pain; my thoughts and long-held beliefs around my pain, its limitations on my life and the way I viewed the world had become ingrained into my very being, and I didn’t even know that I was ‘catastrophizing’.
I truly believed I would never get married, have children or have any semblance of a ‘normal life’ because of my pain. Twenty years on, I still find it enormously triggering to reflect upon how those thought patterns had consumed me.
During the early days of the Mayo Clinic program, we were encouraged to do positive affirmations, and I remember thinking how stupid they were. How could that possibly fix my pain? What was the point of saying stuff out loud that simply made no sense to me? Looking back, I started the program with a deeply troubled and negative view of pain management. But once we started talking about cognitive coping skills and pain catastrophizing, a light bulb went on, the positive affirmations and the positive thought processes started to make more sense to me.
One of our homework assignments was to write out a list of positive affirmations that had meaning and resonated with us. Even though the affirmations were now in my own voice, I could still hear the monkey chatter saying how dumb this activity was. Only when talking more about the cognitive coping skills and the pain catastrophizing was I able to use my positive affirmations to good effect. They were simple: “I'm okay”, “I'm not harmed”, “I can do this”, but they helped. I used them throughout my pain medication tapering and also when I caught myself having negative thoughts.
To this day, I use positive affirmations, albeit slightly altered versions, such as “You can do hard things.” When I tell my toddler son that he can do hard things, I also tell myself that I can do hard things – one of which is living with chronic pain.
What’s in a name?
The term ‘catastrophizing’ was coined in 1962 by psychologist Albert Ellis, and refined later by psychiatrist Aaron Beck. It was defined as a relatively common ‘cognitive distortion’ associated with anxiety and depression. Catastrophizing impairs self-efficacy, social functioning, and is linked to physical disability in both acute injury and chronic pain.
In recent years, reports have pointed to problems with the term ‘pain catastrophizing’. Critiques of the term have come from several sources, including individuals with chronic pain, advocates for individuals with chronic pain, and pain scholars. Reports indicate that the term has been used to dismiss the medical basis of pain complaints, to question the authenticity of pain complaints, and to blame individuals with pain for their pain condition. The term ‘can come across to some as judgmental. It stands in direct contradiction to the concept of chronic pain as a biopsychosocial disease, implying a degree of blame on the part of the person with chronic pain.
This has prompted calls to rename or delete the term ‘pain catastrophizing’; however, I believe that changing the term will do little to solve these problems. Continued calls for changing the terminology (alternatives such as pain-related distress, pain-related worry, pain-related fear and hypervigilance have all been suggested) will only divert attention away from the function of the term. Yes, I do consider ‘catastrophizing’ as a negative response or behavior, but I also recognize first-hand from my own lived experience that this is something that I do, and many others living with chronic pain do it.
Not only are there formidable obstacles to removing the word ‘catastrophizing’, any replacement may well come to have similar negative connotations for patients. Over time, the new term would carry the same semantic elements of dysfunction, deficiency, and pathology that we associate with the term ‘catastrophizing’. After all, any word in a language eventually acquires the characteristics of its referent.
There are two important things to understand when it comes to negative thought patterns around pain, the first is that this isn’t your fault; worrying in response to pain is a logical response. The second is that you can learn to change it.
We should be having open conversations about pain catastrophizing because it is real. We should not be nitpicking over how to label it, but focusing our efforts on addressing it and coping with it. At the end of the day, the name doesn’t really matter here; it’s what we do with it and how we go about changing our thought patterns.
What is pain catastrophizing?
A little bit of concern about your pain is natural and doesn’t present a problem. But if you find yourself constantly worrying about the pain, and thinking the worst, you’re ‘catastrophizing’. Every time you do this it signals more danger to the brain (which creates all pain) and as a result, you’ll feel more pain more often.
This study defines pain catastrophizing as, “a persistent pattern of distressing cognitive and emotional responses to current or anticipated pain.“
Pain catastrophizing has been proven to worsen pain, to increase disability, decrease functioning, and worsen mental health, as explained in this study here. The study also found that, “pain catastrophizing accounted for up to 31% of the variance in pain severity”. How and why does catastrophizing affect chronic pain in such a severe way?
Three pain catastrophizing components
There are three parts to catastrophizing about your pain: not everyone will experience them all and they will vary in severity. You may experience different aspects on different days, depending on what is happening in your life and how you are experiencing your symptoms.
Rumination: this simply means that you cannot get the pain off your mind. You may be constantly thinking about how much it hurts, feel unable to distract yourself or focus on anything else.
Magnification: this means you may be focused on events that haven’t even happened yet, thinking about how much worse they could potentially make your pain, or be worrying about how your chronic pain condition is going to worsen over time. For example, you may think, “this pain is only going to get worse, then I won’t be able to work, then I won’t be able to support my family” and so on, even if these beliefs are not based on facts.
Helplessness: this involves feeling as though you are not in control of your pain, that it is running your life. You may feel that there is nothing you can do to improve your life or your symptoms, essentially that there is no hope.
Understanding the Journey
How does catastrophizing affect chronic pain?
Increased stress
Being in a constant state of worry can result in stress levels rising. As all know, that’s detrimental to the body which is not designed to cope with the effects of stress for prolonged periods. Stress makes the body fatigued as it’s over worked, constantly stuck in a state of ‘fight or flight’. Stress keeps muscles tense, suppresses your immune system, and increases inflammation as well as pain; this becomes a cycle of stress causing pain and pain causing stress.
Fear avoidance
Anticipating pain getting worse with activity can lead to fear of movement, also called kinesiophobia; you may begin to avoid situations which you feel could worsen your pain as a result of this fear. As you avoid activity, your body becomes deconditioned meaning your muscles weaken. This makes further activity harder as your body is not prepared for it, which reinforces to your brain that your worries were ‘right’ because the activity did cause pain.
The brain learns pain
Our brains are neuroplastic which means they learn from what is happening in our environment and what our bodies experience. Chronic pain changes our nerve pathways, meaning that our brain learns that it ‘should’ produce pain in certain situations, when in fact it isn’t needed. Our nervous system becomes overactive.
By anticipating and worrying that certain actions are going to worsen your pain, you are reinforcing to your brain that these situations ‘should’ cause pain. So the way your nervous system and brain is working is changed – the brain has learnt that it should create pain messages for the activities you are worried about and doesn’t inhibit pain.
Less or more likely to seek help
Those who catastrophize about their pain tend to be at one of two extremes when it comes to seeking help for their pain. Due to the fear of movement and the fear of what doctors may ‘find’ during appointments, those who catastrophize about pain may be less likely to seek help. However, some people who catastrophize frequently visit their doctor in excess.
Mental health
Feeling constantly worried about your pain and being unable to engage in regular day to day activities can take a real toll on your mental health. Anxiety can develop or be worsened; often the feelings of helplessness, being unable to focus on things that you enjoy and the pain being all-consuming can lead to depression.
The Pain Catastrophizing Scale
While no single scale can meet all needs, I think it's really important for providers to use the Pain Catastrophizing Scale as a way to start a conversation with their patients about their thought processes around their pain. Furthermore, it gives the provider a different view/context and insight about what their patients are going through.
How it works
In order to establish how severe your level of pain catastrophizing is and how much it’s affecting your pain levels and daily functioning, a scale is typically used based around the three concepts mentioned earlier: rumination, magnification and helplessness. Patients are asked to score 13 negative thoughts about pain on a sliding scale of 0 (not at all) to 5 (all the time) for example, indicating how often you experience those thoughts and how they affect you.
The doctor will also discuss other symptoms, your lifestyle and clinical history; from there, the appropriate treatment can be recommended.
The power of the ‘a-ha’ moment
When I look back to my first encounter with pain catastrophizing at the Mayo Clinic all those years ago, I can now see how powerful that moment was when I realized that my fear of pain was exacerbating my suffering; when you start to see how the pattern works, you will experience a breakthrough on your journey with chronic pain. When you notice that you are in a heightened state of fear and anxiety, and you start to believe that every twinge or discomfort can feel like a dire threat, amplifying your pain experience and triggering a vicious cycle of distress, when you start to recognize these patterns within yourself, you can make a pivotal shift in perspective, one that empowers you to take control of your pain management. It’s not easy. It takes a lot of discipline. It won’t always work.
Acknowledging pain catastrophizing doesn't mean dismissing or trivializing the reality of your pain. Instead, it's about reclaiming agency over your thoughts and emotions, and recognizing that you have the power to influence how you perceive and respond to pain.
Armed with this insight, you can explore various strategies to address your pain catastrophizing and fear.
Mindfulness techniques – deep breathing, meditation, and progressive muscle relaxation can help calm the nervous system and cultivate a more grounded awareness of the present moment.
Cognitive-behavioral therapy (CBT) – another valuable tool for challenging negative thought patterns and developing healthier coping strategies. By working with a therapist trained in CBT, you can learn to reframe catastrophic thoughts, challenge irrational beliefs about pain, and build resilience in the face of adversity.
Talking therapies – counseling to deal with anxiety and depression can help to reduce the feelings of helplessness that come with pain catastrophizing, and put you in a better mental state to begin other therapies directed towards your catastrophizing.
Interdisciplinary rehabilitation programs – one of the most successful treatments for pain catastrophizing is a combination of CBT techniques and physical therapy to build up the body’s fitness and range of motion. CBT techniques, when combined with a physical aspect to teach the patient how to move their body in a safe way, not only can build confidence but can really tackle fear and worry from both angles.
For many of us living with chronic pain, catastrophizing can become almost second nature. However, when we start to challenge and change these negative thought patterns, we can develop healthier coping strategies and improve our overall well-being.
For medical providers specializing in chronic pain, understanding pain catastrophizing is not just about prescribing medications or treatments; it's about recognizing the holistic impact of pain on a person's life. Underneath this pain is a person who may have been just like them at one point; able to work a 40-hour week, have a family, get out of bed without pain, take a shower every day, enjoy hobbies, play sports, travel, and idly complain that they stubbed their toe. The symptoms and severity may vary, but we all go through the same psychosocial changes in our lives. We each deserve an individual and flexible treatment plan. Pain is complex; it changes from moment to moment. One day we can go out to the store and maybe for the next week we will be flat on our backs.
Ultimately, the goal is to shift the narrative surrounding chronic pain from one of hopelessness and despair to one of resilience and empowerment. By fostering a deeper understanding of pain catastrophizing and its effects, we can work towards changing the way we think about our pain and, in turn, improve our ability to manage it effectively.
#chronicpain #understandingpain #chronicpaincauses #painawareness #peersforpain
Michelle Marikos’ fall from a balcony in her early twenties, and her subsequent decades long debilitating chronic pain, inspired her to launch Moving Through Chronic Pain and her PEER™ Method programs to facilitate deeper connections between those living with chronic pain and their community of providers, employers, and family members.
Michelle Marikos, Founder & CEO
Moving Through Chronic Pain
