Letter to the Editor: The Demographics of Pain Catastrophizing in a Primary Care Sample

Randy A. Sansone, MD; Daron A. Watts, MD; and Michael W. Wiederman, PhD
Dr. Sansone is a Professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio. Dr. Watts is a resident in the Department of Psychiatry at Wright State University School of Medicine in Dayton, Ohio. Dr. Wiederman is a Professor in Psychology at Columbia College in Columbia, South Carolina.

Innov Clin Neurosci. 2013;10(9–10):10–14

Funding/financial disclosures: No funding was received for the preparation of this article. The authors have no conflicts relevant to the content of this article.

Dear Editor:

The Pain Catastrophizing Scale (PCS),[1] which assesses catastrophic thoughts and feelings about pain, is well represented in the empirical literature. For example, the PCS has been studied in relationship to cross-cultural validation;[2–4] various medical conditions, such as low-back pain,[5] whiplash,[6] chronic pain in incarcerated women,[7] vaginismus,[8] cancer,[9] and postoperative pain;[10] and various psychological investigations including family relationships,[11] positive personal attributes,[12] attachment dynamics,[13] anxiety,[14] and major depressive disorder.[15] In addition, the PCS has been used to explore demographic differences in specific types of patient samples (e.g., samples defined by a singular pain syndrome). In these studies, gender,[16–18] age,[19] and ethnicity[20,21] have tended to demonstrate demographic variations (i.e., higher in women in 2 of 3 studies; no age differences; higher in African-Americans). However, we were unable to locate a single study using the PCS to determine the demographic profile of pain catastrophizing in a primary care sample—the focus of the present study.

Potential participants were men and women, ages 18 years or older, who were being seen at an outpatient internal medicine clinic for nonemergent medical care. The clinic is staffed predominantly by residents in the department of internal medicine, and is located in a mid-sized mid-western United States city. We excluded individuals with compromising medical (e.g., debilitating pain), intellectual (e.g., mental retardation), cognitive (e.g., dementia), or psychiatric symptoms (e.g., psychotic) of a severity to preclude the candidate’s ability to successfully complete a survey (n=13). This exclusion process was informal and undertaken by the recruiter as patients registered for clinical service.

Whereas 349 individuals were approached, 244 agreed to participate, for a participation rate of 70 percent. As for the 105 individuals who did not participate, 68 refused outright, 13 appeared too distressed, 21 appeared too burdened (e.g., struggling with children), and 21 reported not wanting to commit the time. Of the 244 individuals who agreed to participate, 239 completed the Pain Catastrophizing Scale. Of these 239 respondents, 62.3 percent were women and 37.7 percent were men, ranging in age from 21 to 80 years (mean [M]= 45.74, standard deviation [SD] = 15.12). Most participants were White (76.2%); however, 20.5 percent of participants were African-American, 0.8 percent Asian, 1.7 percent Hispanic, and 0.8 percent “Other.” With regard to educational attainment, all but 2.1 percent had at least graduated high school, whereas 24.3 percent had earned at least a bachelors degree.

During clinic hours, one of the authors (D.A.W.) positioned himself in the lobby of the clinic, approached consecutive incoming patients following registration, and informally assessed exclusion criteria. With potential candidates, the recruiter reviewed the focus of the project (i.e., a study examining pain) and then invited each to participate. Each participant was asked to complete a six-page anonymous survey, which took about 10 minutes. Surveys were completed onsite in the lobby, before appointments with providers. Participants were asked to place completed surveys into sealed envelopes and then into a collection box in the lobby of the clinic. Completion of the survey was considered implied consent, which was explained to participants on the cover page to the survey.

In addition to demographic variables, we assessed the catastrophizing of pain using the PCS.[1] The PCS is a 13-item self-report measure that assesses catastrophic thoughts and feelings about pain. This measure has a 5-point Likert-style response scale (0=not at all to 4=all the time) and the scoring range is 0 to 52, with higher scores indicating higher levels of catastrophic thoughts and feelings about pain. The PCS has three underlying factors or dimensions of pain catastrophizing: rumination (items 8, 9, 10 and 11), magnification (items 6, 7 and 13) and helplessness (items 1, 2, 3, 4, 5 and 12). With regard to validity, the PCS has been validated in both clinical and nonclinical populations.[1,22–24] In the current study, Cronbach’s alpha was 0.98 for the 13-item measure, 0.97 for the rumination subscale, 0.88 for the magnification subscale, and 0.96 for the helplessness subscale. In the current study, each of the three subscales of the PCS were very highly correlated with each other (all three correlations were 0.93) and with the total score (correlations ranged from 0.97–0.98), so only the total PCS score was considered further.

As for the demographic patterns associated with pain catastrophizing, scores on the PCS were statistically significantly correlated with both age (r= -0.30, p<0.001) and level of education (r= -0.22, p<0.98), yet age and education were not statistically significantly correlated (r= 0.003, p<0.98). Mean scores on the PCS did not differ significantly between men (M=11.73, SD=12.83) and women (M=14.11, SD=13.27), F(1,237)=1.83, p<0.19. With regard to race/ethnicity, the only two groups large enough for comparison were White and African-American. Mean scores on the PCS did not differ significantly between White (M=13.73, SD=13.05) and African-American (M=11.67, SD=14.06) respondents, F(1,229)=0.98, p<0.35.

In contrast to most previous studies using the PCS, we did not find any gender or racial/ethnic differences with regard to pain catastrophizing. However, also in contrast to previous studies, we found that age and education were related to PCS scores. To place findings into a general perspective, it appears that demographic findings with the PCS may be sample-dependent. However, additional research is needed to confirm that primary care samples demonstrate the preceding patterns.

This study has a number of potential limitations. These include the self-report nature of all data; small sample size; and indigent nature of the clinic, which may affect the ability to generalize findings to other types of clinics. However, this is one of the few studies, if only study, to examine pain catastrophizing with the PCS in a general primary care sample, and demographic findings demonstrate some contrasting results in comparison with other studies.

References
1. Sullivan MJL, Bishop SC, Pivik J. The Pain Catastrophizing Scale: development and validation. Psychol Assess. 1995;7:524–532.
2. Cho S, Kim HY, Lee JH. Validation of the Korean version of the Pain Catastrophizing Scale in patients with chronic non-cancer pain. Qual Life Res. 2012. Epub ahead of print. PMID:23180163.
3. Morris LC, Grimmer-Somers KA, Louw QA, Sullivan MJ. Cross-cultural adaptation and validation of the South African Pain Catastrophizing Scale (SA-PCS) among patients with fibromyalgia. Health Qual Life Outcomes. 2012;10:137.
4. Sehn F, Chachamovich E, Vidor LP, et al. Cross-cultural adaptation and validation of the Brazilian Portuguese version of the Pain Catastrophizing Scale. Pain Med. 2012;13:1425–1435.
5. Beneciuk JM, Bishop MD, Fritz JM, et al. The STarT back Screening Tool and individual psychological measures: evaluation of prognostic capabilities for low back pain clinical outcomes in outpatient physical therapy settings. Phys Ther. 2013;93:321–333.
6. Bostick GP, Carroll LJ, Brown CA, et al. Predictive capacity of pain beliefs and catastrophizing in whiplash associated disorder. Injury. 2012. Epub ahead of print. DOI: 10.1016/j.injury.2012.10.007.
7. Darnall BD, Sazie E. Pain characteristics and pain catastrophizing in incarcerated women with chronic pain. J Health Care Poor Underserved. 2012;23:543–556.
8. Borg C, Peters ML, Schultz WW, de Jong PJ. Vaginismus: heightened harm avoidance and pain catastrophizing cognitions. J Sex Med. 2012;9:558–567.
9. Carroll EM, Kamboj SK, Conroy L, et al. Facial affect processing in patients receiving opioid treatment in palliative care: preferential processing of threat in pain catastrophizers. J Pain Symptom Manag. 2011;41:975–985.
10. Papaioannou M, Skapinakis P, Damigos D, et al. The role of catastrophizing in the prediction of postoperative pain. Pain Med. 2009;10:1452–1459.
11. Gauthier N, Thibault P, Sullivan MJ. Catastrophizers with chronic pain display more pain behaviour when in a relationship with a low catastrophizing spouse. Pain Res Manag. 2011;16:293–299.
12. Hood A, Pulvers K, Carrillo J, et al. Positive traits linked to less pain through lower pain catastrophizing. Pers Individ Dif. 2012;52:401–405.
13. McWilliams LA, Asmundson GJ. The relationship of adult attachment dimensions to pain-related fear, hypervigilance, and catastrophizing. Pain. 2007;127:27–34.
14. Granot M, Ferber SG. The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity: a prospective study. Clin J Pain. 2005;21:439–445.
15. Chung KF, Tso KC, Yeung WF, Li WH. Quality of life in major depressive disorder: the role of pain and pain catastrophizing cognition. Compr Psychiatry. 2012;53:387–395.
16. Rivest K, Cote JN, Dumas JP, et al. Relationships between pain thresholds, catastrophizing and gender in acute whiplash injury. Man Ther. 2010;15:154–159.
17. Thom BE, Clements KL, Ward LC, et al. Personality factors in the explanation of sex differences in pain catastrophizing and response to experimental pain. Clin J Pain. 2004;20:275–282.
18. Sullivan MJL, Tripp DA, Santor D. Gender differences in pain and pain behavior: the role of catastrophizing. Cognit Ther Res. 2000;24:121–134.
19. Ruscheweyh R, Nees F, Marziniak M, et al. Pain catastrophizing and pain-related emotions: influence of age and type of pain. Clin J Pain. 2011;27:578–586.
20. Fabian LA, McGuire L, Goodin BR, Edwards RR. Ethnicity, catastrophizing, and qualities of the pain experience. Pain Med. 2011;12:314–321.
21. Goodin BR, Fillingim RB, Machala S, et al. Subjective sleep quality and ethnicity are interactively related to standard and situation-specific measures of pain catastrophizing. Pain Med. 2011;12:913–922.
22. D’Eon JL, Harris CA, Ellis JA. Testing factorial validity and gender invariance of the Pain Catastrophizing Scale. J Behav Med. 2004;27:361–372.
23. Osman A, Barrios FX, Gutierrez PM, Kopper BA, Merrifield T, Grittmann L. The Pain Catastrophizing Scale: further psychometric evaluation with adult samples. J Behav Med. 2000;23:351–365.
24. Rainville P, Feine JS, Bushnell MC, Duncan DH. A psychophysical comparison of sensory and affective responses to four modalities of experimental pain. Somatosens Mot Res. 1992;9:265–277.