The lived experience of severe pain, understandably, can lead to a process of catastrophizing, which is a cognitive distortion where patients assume the worst possible outcome in any situation where it is unlikely, not just spine surgery. Catastrophizing can manifest in two ways:
- Magnification: Making a current situation seem like a catastrophe
- Future catastrophizing: Imagining the worst possible outcome of a future event
In such cases, how can a caregiver know when to refer a spine patient to a psychologist?
Researchers from The University of Iowa Hospitals and Clinics Department of Orthopedics and Rehabilitation, who use the Pain Catastrophizing Scale to assess a patient’s response to pain and identify any catastrophic thinking, designed a study which could, possibly, serve as the basis for a psychological referral protocol.
Their study, “Evaluation of Pain Catastrophizing Scale for surgical referral to pain psychology in patients undergoing spinal surgery,” was published in the September 2024 edition of NASSJ.
Co-author Valerie J. Keffala, Ph.D., clinical associate professor at University of Iowa Health Care, a Board-Certified Clinical Health Psychologist specializing in pain management (and is the only person in the state of Iowa with these credentials), told OTW, “I work with patients who experience persistent pain, though I also work with patients presenting a variety of medical health concerns across the medical spectrum. I have clinical expertise in using Acceptance and Commitment Therapy, which is my primary therapeutic intervention. I have been part of the Department of Orthopedics and Rehabilitation (we are not just a surgical department) for nearly 30 years.”
“This study came about when a medical student at University of Iowa Hospitals and Clinics—Shray Kumar (first author)—was interested in completing a study in the department of Orthopedics and Rehabilitation. He approached Dr. Catherine Olinger, clinical assistant professor in that department, who then brought the idea to me.”
What Is the Pain Catastrophizing Scale?
The Pain Catastrophizing Scale is a validated patient-reported outcome measure which quantifies experienced pain and maps underlying thought processes. Patients rate 13 statements describing pain with a score from 0–4 for each question, 0 being seen as “not at all” and 4 being “all the time. Additionally, the scale poses questions which cover rumination, magnification, and helplessness, indicators of intrusive thoughts, inability to cope with pain, and exacerbation of pain symptoms.
Once each patient finished filling out the scale, researchers sum the scores. The maximum score is 52, minimum 0.
As Dr. Keffala explained to OTW, “I have been interested in using Pain Catastrophizing Scale as a marker for referring patients to pre- or post-surgical psychological interventions. Spine surgeons are not trained to make decisions about the need for psychological intervention or, usually, to consider psychological factors in pre-surgical screening (see The Psychology of Spine Surgery by Andrew R. Block for a good review of this topic).”
“Therefore, we wanted to see if the Pain Catastrophizing Scale might be a helpful screening tool for psychological evaluation and intervention in this setting and compare that to surgeons’ judgments about the need of referral for psychological evaluation and intervention.”
Study Conclusions
According to Keffala, “This study showed that the Pain Catastrophizing Scale was a useful tool for helping identify psychological distress (rumination, magnification, and hopelessness) in patients experiencing pain.
“Though it is only one tool, it can bring the patient’s experience of distress to the attention of clinicians, whereupon a referral to a pain psychologist can be made,” explained Keffala.
Furthermore, “We looked at three orthopedic surgeons’ decision-making process in referring patients to me, the department clinical health/pain psychologist, comparing their responses to each other and to Pain Catastrophizing Scale standardized scores.”
Keffala noted that spine surgeons are typically not trained to detect patients with significant psychological distress symptoms which may affect their patients pain levels. “Using standardized assessment, such as the Pain Catastrophizing Scale, and clear operationally determined criteria in pre-surgical screening can help identify patients who would benefit from evaluation and intervention by a clinical health psychologist who specializes in pain management prior to surgery.”
Treating Pain Triggered Catastrophizing
Dr. Keffala explained to OTW that some interventions, notably Acceptance and Commitment Therapy, have shown promise for patients for whom pain has led to catastrophizing. “Acceptance and Commitment Therapy uses six core processes (acceptance/willingness, cognitive diffusion, being in the present moment, self as context/perspective taking, values, and committed action) to help build psychological flexibility and live in ways that reflect what matters to patient (their values).”
“Acceptance and Commitment Therapy can help individuals change their relationship with their health concerns, including persistent pain, so that it no longer becomes the focus of their lives, improving quality of life and mental health.”
“My work in Acceptance and Commitment Therapy stresses that pain is part of the patient’s experience, it’s not who they are. Though experience of pain may be present, the experience is always changing. I focus with patients on how they are responding to their experience of pain. We explore the actions patients can take to live in a manner that reflects the things and people who matter to them.”
The Key? Psychological Flexibility
“While living with persistent pain will likely be different than life prior to the presence of pain, one can continue to live a life rich with meaning and purpose. Our minds set rigid rules and expectations about how things ‘must’ be, but reality shows us that when we live with psychological flexibility, rather than rigidity, there are many ways to engage in our lives with meaning and purpose. Following Acceptance and Commitment Therapy interventions patients typically demonstrate improvement in function and quality of life, and reduction of anxiety and depression. There are hundreds of randomized controlled trials using Acceptance and Commitment Therapy across a wide number of persistent pain and health concerns demonstrating this.”
