Catastrophizing, depression, and pain: Correlation with and influence on quality of life and health – A study of chronic whiplash-associated disorders
From: J Rehabil Med. 2008 Jul;40(7):562-9
The aims of this study were: (1) to classify subgroups according to the degree of pain intensity, depression, and catastrophizing, and investigate distribution in a group of patients with chronic whiplash associated disorders; and (2) to investigate how these subgroups were distributed and inter-related multivariately with respect to consequences such as health and quality of life outcome measures. DESIGN: Descriptive cross-sectional study. A total of 275 consecutive chronic pain patients with whiplash associated disorders who were referred to a university hospital. The following data were obtained by means of self-report questionnaires: pain intensity in neck and shoulders, background history, Beck Depression Inventory, the catastrophizing scale of Coping Strategy Questionnaire, Life Satisfaction Checklist, the SF-36 Health Survey, and the EuroQol.
Principal component analysis was used to recognize subgroups according to the degree of pain intensity, depression, and catastrophizing. These subgroups have specific characteristics according to perceived health and quality of life, and the degree of depression appears to be the most important influencing factor. From a clinical point of view, these findings indicate that it is important to assess patients for intensity of pain, depression, and catastrophizing when planning a rehabilitation programme. Such an evaluation will help individualize therapy and intervention techniques so as to optimize the efficiency of the programme.
Chronic pain, including chronic whiplash associated disorder, has a negative impact on quality of life and negative consequences for perceived health. The bio-psychosocial framework of chronic pain proposes an interaction between several factors that influence the development and maintenance of chronic pain and its consequences.
Pain intensity is an important factor that contributes to various forms of disability, which in turn is related to the chronicity dimension of pain. Acute pain levels can predict functional outcome following whiplash injury. However, in terms of the impact on perceived quality of life, pain intensity has not been found to be the most prominent contributor.
Catastrophizing has been broadly defined as an exaggerated negative orientation toward pain stimuli and pain experience. Studies identify connections between catastrophizing and psychological distress, physical functioning and disability, ratings of pain intensity, interference with life activities, psychosocial dysfunction and quality of life. Knowledge about whether catastrophizing is a cause or a consequence of chronic pain is still lacking; there are studies that can be interpreted either way.
Depression is not simply a co-morbid condition, but interacts with chronic pain to increase morbidity and mortality. High
frequencies of depressive symptoms have been found in patients with chronic pain as well in the chronic whiplash associated disorder subgroup. Depressed patients with chronic pain report greater pain intensity, greater interference from pain, more pain behaviours, less life control, and greater use of passive/avoidance coping strategies than non-depressed patients with chronic pain. The temporal relationship between chronic pain and depression is under debate. Fishbain et al. found strong support for the
consequence hypothesis: depression is a consequence that follows the development of pain. To describe the relationship between
chronic pain and depression, Banks & Kerns developed a diathesis-stress-model where the diathesis is conceptualized as pre-existing, semi-dormant characteristics of the individual before the onset of chronic pain. These characteristics are activated
by the stress of the chronic condition and may lead to depression. Qualitative differences between depression as a result of chronic pain and depression as a primary psychiatric disorder have been reported.
Pincus & Morley in Cognitive-processing bias in chronic pain: a review and integration. Review. Psychol Bull 2001, suggest that “affective distress”, which incorporates wider emotions such as anger, frustration, fear, and sadness, is a better term than “depression”.
The framework of the bio-psycho-social model emphasizes an integrated relationship between depression, pain intensity and catastrophizing. Fear and avoidance beliefs and strategies are influenced by catastrophizing and depression in patients with chronic pain. Distinct profiles of psychological functioning could be identified and meaningfully related to future disability. For chronic whiplash associated disorder patients, a combination of symptoms (pain and depression) and catastrophizing may
explain their health-related quality of life issues.
Based on the above literature it is reasonable to expect that patients with high pain intensity, depression and catastrophizing will perceive their health and quality of life as considerably worse than those patients who rate their situations better with respect to these 3 factors. Using, for example, certain regression techniques, the mean influences of these 3 factors on health and quality of life can theoretically be determined separately at group level for each outcome variable. However, the clinical question might be more complex; for example, are the effects of high catastrophizing with respect to health and quality of life similar when pain intensity is high and low? Or, from a treatment or rehabilitation perspective, is it important to intervene against high catastrophizing regardless of pain intensity in patients with whiplash associated disorders? These questions are complex and require a large number of subjects in order to achieve valid regression models for the whole range of the 3 symptoms (i.e. pain intensity, depression and catastrophizing). An alternative approach is to divide into subgroups based on dichotomizing of the 3 symptoms separately and then investigate how the different combinations of dichotomized symptoms will differ with respect to health and quality of life. In a second step based on these results, but also requiring a substantial sample size, cluster analysis can be performed in order to confirm the results obtained.
Based on dichotomizing of 3 factors: the degree of pain intensity, depression, and catastrophizing, this study identified subgroups with specific characteristics according to perceived health and quality of life. The degree of depression appears to be the most important influencing factor. From a clinical point of view, our findings indicate the importance of assessing each individual in detail with respect to intensities of pain, depression, and catastrophizing when planning treatment and rehabilitation.
