Transcript

Episode Transcript

Bart Van Buchem (00:00.00) Hello and welcome to another episode of the Pain Podcast presented by Le Pub Scientifique. My name is Bart van Buchem and with me Tim Beames, in the midst of the summer, another episode. So without further ado, we're going to talk about pain catastrophizing, which is a big theme in both, let's say, from a clinical perspective but also literature is quite a little bit of debate going on. And I find it a really dirty term to be honest. I kind of don't like it. I feel really uncomfortable in using it literally.

But yeah, we're just going to have a bit of discussion. So it's just for the outlines for this session, you can expect that we dive and dig a bit into what is really from the literature, from the definition, how we can let's say operationalize it for the clinical work, going to a little bit of a dive in the neuroscience of catastrophic thinking and catastrophizing in general. And let's see if we can squeeze and give you some ideas how to communicate, let's say, moving beyond "don't think like that" - that phrase is trying to avoid.

And as last, probably we can give you some advice on how building a clinical toolkit for with a notion of catastrophizing. So Tim, catastrophizing or catastrophizing, what would your take on that in terms of the clinical and both scientific terminology?

Tim Beames (01:45.22) Yeah, well, you've already said it. It's an awful word, isn't it? It's sort of wrapped so much. Do you know what? As you were saying it, I just remembering a patient of mine. She said, "I know that people measure like catastrophization or something, but I prefer to call it awfulizing." And I always remember that and just think it was a really lovely sort of switch round.

But I think it does a good job of really saying a lot about what catastrophization is measuring. Here is that we are looking at both the magnification of the experience wrapped up in the emotional expression of what's going on, the rumination, which is a common thing, you know, the thinking about, dwelling on, repeating, etc., and the sense of helplessness that someone is in as well.

So yeah, I think coming back to my patient flipping it around and saying she was awfulizing or an awfulizer, I think that's kind of quite a nice way of reframing it, or it certainly was for me. So that's my understanding of it. And yeah, I have in the past, I used to measure the PCS, the pain catastrophization scale with people as a fairly common measure, and obviously you get distinct sort of categories coming from that as well. And you know, depending on where someone scores, that in essence steers you in a direction, doesn't it? Gives you a sense of where you might work.

If you don't measure those discretely, then certainly within someone's narrative you get a sense of this as well, don't you? So when you start hearing a story and repetition within a theme, etc., comes out. And I think I stole this from Dave at some point, Dave Butler, but whoever it was, I thank because they said imagine they've said this and they've repeated this theme two or three times to you in the session - imagine how many times they've said it to themselves, you know, just internally.

And I always think about that. And the other thing I think about is the influence of catastrophization on things like attention. And you can immediately see how bringing awareness to something can alter your attentional processing, and through those changes there could be a fairly understandable link with some of what we see in pain. So the increase in pain perception, the altered endogenous inhibitory mechanisms. So yeah, so you can sort of see where some of this could play out from a scientific perspective as well.

Bart Van Buchem (04:22.31) Yeah, so you're already sort of defining it not as a solely cognitive feature, right? And so this is already starting to be a rumination of all the data comes in and that somehow got catastrophized or magnified in some way without even within consciousness, if you like. Although if you and then I think, sorry I'm jumping in there, but I think that a big flip for me is instead of, you know, the blame that can go into this - "Oh look at you, you know, you keep thinking about it or you keep repeating it or you're giving it too much bandwidth or whatever."

But there's some merit there to someone having the analytical brain or that they are the type of person or in this particular situation that they're able to come up with multiple alternative possibilities of the problems that could arise or the difficulties or the helplessness. And instead of seeing the, you know, blaming someone for that, sort of flipping that around and going, "Wow, look at your ability to be able to problem solve."

So perhaps that gives us a sense of where we might position ourselves from a therapeutic sense. You know, you've coming up with the problems, what's behind that? So that sense of understanding of uncertainty, of frustration, of your expectations relating to what's going on, I think could all feed those processes in a totally understandable way as well.

Tim Beames (05:41.18) Yeah, so there are a few cases I want to sort of just present here. So when you take an interview or using questionnaires that are designed to locate catastrophizing or pain related fear, like the fear avoidance questionnaire. And I think the roots of these questionnaires are sitting quite close to Geert Crombez and Johan Vlaeyen's work from Belgium, which amazing work in this area and still lots going on. I think I can refer to sessions we've had with Ann Meulders. Is that correct?

Bart Van Buchem (06:11.45) Yes, that's correct.

Tim Beames (06:12.88) So there's still a lot in it and we can see that the research is also pointing out like this is still an important thing. If people do have this pain related fear or catastrophizing, it does help. But what my point would be here - so my patient would generally say, "Well, I'm not afraid of the pain, I'm not afraid," but when they are in pain, they do behave or they do have signs and symptoms that you would consider to be like anxiety.

So they do get stressed, they get these pins and needles or numbness in both hands, and then they feel heart palpitations and they start to have all these issues you would consider to be part of an anxiety response. So you have this patients depending on the moment whether they are in fear or not.

So any thoughts on that? Because I find it always very hard to grasp because it's such a - you're not always in fear or catastrophizing because it depends on when and what's going on at that stage. Is it still helpful then to measure it rather than give it like this label? Because I think that's probably someone's get a label like "you are catastrophizing."

Bart Van Buchem (07:18.76) Yeah, yeah, yeah. Well, it's a good question actually. Yeah, I mean, what's the value in labeling anything? But from a scientific point of view, it means that you can measure it. But whether you're measuring something that - I mean, coming back like if you're - I'm thinking about Johan Vlaeyen and Crombez's original fear avoidance model because it was a sort of stimulus driven model, wasn't it? So the fear came after the pain and you know, that's that sort of distinctly tells you the way that you're then going to interpret what that is.

And I don't know, I'd have to go back and see Michael Sullivan's original ideas, but I imagine it might have been a bit like that where we're coming out and we're starting to use other models to rationalize and understand what might be going on inside someone. So you're sort of describing to me what I would consider an emotive and embodied response and someone at an unconscious level is - they just experience something happening in their body when they interpret it.

The best approximation of the interpretation is that "I must be anxious or I must be worried or whatever." So yeah, it's but it is difficult, isn't it? Because then you're trying to rationalize something that is incredibly challenging to be able to communicate.

Tim Beames (08:35.42) Yeah, so what will be the neuroscience? I think we can bridge then and then come back to the communication. So how could fear induce, let's say, central sensitization or peripheral sensitization like a true process in the body that is going to lower the thresholds of the nociceptors? Is there a how could it do that?

Bart Van Buchem (08:55.91) I mean, I've got a couple of sort of potential ways of doing that, haven't we? We've got from a brain network perspective that flip towards an altered saliency and the effect that that has on the descending modulatory pathways all the way down to the level of the peripheral neuron. If we have, you know, a predictive or anticipatory shift based on my expectation that when I do this I'm going to experience pain, will shift you into a place where your body is going to receive what it's expecting. So from a sensory point of view.

So yeah, that might be one way of rationalizing what's going on. And that's done at a completely unconscious level, isn't it? You know, hierarchically that's done so quickly, so rapidly, and so far beyond...

Tim Beames (09:41.23) Yeah, you can't say it's the thought, right? So it's the thought is only one of the symptoms, I would say, or is it one of the causes?

Bart Van Buchem (09:48.77) Well, I guess that then depends on - I don't know. We're going into areas where I don't feel confident enough in my current understanding of them, but the whole sort of system one, system two... But you can see the field is moving as well. Psychology like Ann Meulders, so they do embrace the whole predictive processing and understanding of how awareness and consciousness is sort of evolving over the last decade.

But they also have these very, let's say, conditioning models which implies that this is a, like, let's say a grounded psychology theory based on solely, let's say, thinking models. But it's also connected to neuroscience models nowadays, but it's hard to really understand and prove what's going on in the brain.

And what the science says is quite interesting - how does a thought can reduce endogenous pain inhibition, for example, which is a hard thing to say because you can't measure it. It's just a suggestion or which is grounded in theory and not quite fully understood, but at least it's a framework that probably leads to different type of treatments.

And that's why you probably start thinking about discussing this with patients. But just one of my patient would say, "Well, I'm not making this up. So I am - so even people who are totally involved with the whole idea - so I'm a catastrophizer, but can I catastrophize therefore having more pain? I said can I'm thinking and then therefore I have pain or more pain?"

I found that a really interesting and challenging thought which would be hard to say a fully yes because I don't think we know that we can think our pain. So I'm just thinking this up literally, which an interesting thought, isn't it, Tim? But we have to be very cautious with these because I think when even people like - we're getting if you the deeper you dive into this neuroscience, the more you think it's like a thing, it's like a machine thing, it's not like - and you can reprogram it or by not thinking about it, is it better?

I found it challenging to be honest.

Bart Van Buchem (11:48.33) You're sort of skirting on - well, I feel like you're skirting on whether or not behaviorist perspectives are the way forward or whether it's something alternative. And I think that's possibly where it is, but it's very helpful because it makes sense, right? It's an easy way. So it's just basically labeling and therefore you're going to do exposure therapy.

I think O'Sullivan does a great job in doing that and sometimes it works great on behavior and but if it does change pain, not always, but sometimes it does for sure. But the mechanisms are poorly understood as far as I know and it's hard to predict. And that's probably brings us to the second thing where if you're going to link it to, let's say, more modern science like uncertainty and predictive processing.

How would that sound like? How would be the accurate way of putting catastrophizing in a modern contemporary scientific view on pain?

Tim Beames (12:42.55) Oh god. What from a predictive processing point of view? You're dropping me in here, aren't you? So yeah, I mean I don't think - put you on the spot, but you're the expert, Tim. Thank you very much.

I at a very basic level that there is enough credibility in the prediction that there is confidence given to that. So it's heavily weighted towards that being an accurate prediction and therefore less likely that alternative predictions can play out. So you know, expecting the worst, for instance, so you know, essentially it's a bit like the elephant in the room, isn't it? You're expecting the worst, that's what you see, that's what you think about, and that's more likely to happen as well.

Thinking about the reverse or thinking about the way through that from a predictive processing is that it is helpful to notice that that's the way that you're sort of, if you want, programmed. And not to dismiss or discount and to sort of suppress it, but to offer up alternatives. So the alternatives might be you expected the worst, what really happened?

Oh, so you know, let's give some evidence. Let's give some credible evidence that something alternative could or did happen. And you can see where things like journaling techniques could actually be quite helpful in those instances or we've obviously talked a lot about experiential so embodied practices.

So you know, asking someone to engage in an activity and reflect on that activity. So the ability to sort of update in real time someone's predictions about what's going to happen again could be really powerful. It's not going to suddenly just, you know, change things overnight, but at least it gives alternative evidence.

So you know, the weighting is less heavily towards the worst possible scenario. And I would like - and I'm keep coming back because I've got a patient in mind actually. We're working together at the moment and he's an amazing analytical thinker. You know, that's his superpower and we keep talking about his super as his superpower because he has the ability to come up with an endless number of potential problems.

Which I believe talking to him is really helpful for his job. The challenge that we have - and this is the challenge I think often with persistent pain - is because there is a lot of complexity and uncertainty relating to it, that a number of his potential problems are credible. Like that's a credible thing to think about. You know, could it be that we find this? Yes, it could be. But there's also a number of other alternatives.

And a big part of why I'm bringing him up is that he's heavily weighted towards, you know, the next possible problem. And what we're actually trying to work on is build the ability to understand alternative possibilities and be okay with a bit of uncertainty as well. Sort of sit with - we don't quite know what's going to happen and can you be okay with that? But doing it in a sort of fairly gentle way to begin with.

Bart Van Buchem (15:41.88) Yeah, so just communication wise, and so typical case of when pain catastrophizing lies on the, let's say, it's very clear and obvious that I think on my patient would be not even thinking about bending forward and making sure he or she is not even trying because and then the fears that comes out would be typically like very vocal.

So, "I'm not going to do that. That's going to break my back. It's a bad idea. I heard that before." So I think that's the obvious. Then there's the patient that will do it, but you can see they're sweating and they're grunting and trying to and actually say, "Well, after the second time, they are say, well, I don't think it's a good idea to move on, right? I don't think I should. I've tried it again." Then it didn't work out.

And then there's the person - I describe two people. You've got the awfulizer and then you've got the avoider.

Tim Beames (16:32.44) Yeah, exactly. Yeah.

Bart Van Buchem (16:34.21) And then probably the third one would be someone who's not really vocally just doing what you're saying and it's basically trying to get through and then the day after or the week after, "Since I've done that, I couldn't do anything." Which is a tricky one because does it - is the last one, is that still catastrophizing? Is that possibly a mechanism that relates to catastrophizing, especially when there's the delay of the onset magnification?

Tim Beames (17:01.18) It would do for sure, wouldn't it? Yeah, there's something in it, right? Does it as a from a physical therapy point of view or let's say osteo or chiro, do you think that's something that will be a main thing for main target for therapy?

Well, you could if you're looking at problem-based approaches, you know, looking at the thinking behind the awfulizer, the saboteur, the endurer, etc. And you know, it can help, can't it? Like naming those parts of that person. And but that's one approach. You know, an alternative that we've obviously talked about in detail is about the fact that it's helpful to have a solution-focused approach as well or to have that as your focus.

So then they might have an awfulizer, but they might also have the positive thinker and the happy-go-lucky and so there will be other parts of them that need a bit more bandwidth. And often, often it's, you know, those people, those parts of them aren't given the bandwidth. And sometimes they're not given the bandwidth because again, that credible evidence of danger is still present.

You know, there is still, you know, some perceived threat there in some way, shape or form. And whether that's uncertainty about what's going on and whether things will change over time or or a loss of identity or a shift in agency or whatever it is, it can be quite understandable that that there is that sort of perception of threat still in the background.

Bart Van Buchem (18:22.67) Yeah, of course. Sometimes just from clinical experience, it's sometimes just easier to when these worries can be addressed and people learn how to cope with this worry and they can basically reframe the, let's say, the fear or the worry about "something goes wrong in the back and this is going to be disaster" towards something "All right, so I know this is a feeling I can cope with. It's not going to be terribly wrong there even if it's hurting me a lot."

And I see sometimes that that can be very helpful because it takes away the stress of the, let's say, the cognitive circle of thoughts that's helpful and get people to moving. It doesn't necessarily means that people get less pain, right? And I think the research has been quite consistent there when you see like big meta-analysis and systematic reviews that done over these type of treatment when they're focusing on on worry and anxiety, then you can see they do well on worry and anxiety, but they still report same amounts or levels of pain, but they are more active in life, which is very helpful to understand.

What is your how do can you predict the outcome of your therapy if you focus on on these types of issues that people have? Although they may come in with a pain problem, but they end up like "I can cope much better," which is reflected in many, many, many randomized clinical trials as well. So it's quite interesting.

So getting from there, you mentioned something like journaling. I heard you - I'm not sure you said scaling, but techniques to sort of get the conversation on and about the fear or the anxiety that comes with or even previous own pain. What are your - where do you feel like easy takeaways for the listeners to address catastrophizing without labeling it as such?

Tim Beames (20:12.43) Yeah, yeah. Well, look, I mean the first place is somewhere we always go is validation, isn't it? And so, you know, if it sounds challenging, why not communicate that back to that person? "This sounds really tough, hard, challenging." And I usually also acknowledge and congratulate them for being able to, you know, problem solve and come up with the worst possible scenarios.

Because what would the alternative be? The alternative would be that you just brazenly go through life, you know, without care or worry, and there is a risk then as well. So I tend to go there first. And then you can - I mean, depending on the person, people that you're working with - notice and point out, you know, bring it to their attention about what what might be a part of that and you can rationalize it in a way and you can make sense of that over time.

Some people like journaling. And some people notice things like the effect that this has on their body. Sorry, that's the building work in the background. And then, let's hope that they stop a little bit. And then, yeah, so journaling isn't for everybody, but there are different ways of journaling as well.

And we talked about problem-based and solution-based as well. And if we're trying to bring a part of them out like the, you know, the happy-go-lucky, the joyful, the calm, the lover, the whatever it is part that's being suppressed. And, you know, there are journaling techniques that you can use to to bring that out as well. Noticing the gifts.

We talked about sim hunting with Explain Pain, but I like thinking about gifts and glimmers and hope and calm and joy and happiness and I spend time working with people there. And yeah, we can do a lot about the sort of internal reframe as well, the narrative. I spend - I mean, this is my work, but I'm sure everybody has different ways of doing it - but we talk a lot about visualizing and even writing down and spending some time picturing that person who they want to embody and be and but maybe that's strong, robust character that they want to be.

And although we've sort of scooted over a little bit, it can be really valuable to understand the potential threats and threat stressors and the effect that that has on our body. So, you know, if someone has a whole bunch of really challenging stuff going on in their life, that can have and will have an effect on their biology.

And there are little things that we can do to recognize those and then there are little things that we can do to support us through those processes. So the lifestyle type advice. So again, things we've talked about in lots of detail, but hygiene, diet, etc., actually have value here.

Bart Van Buchem (22:35.81) Yeah, I think related to the work of the Leuven and Sullivan and many authors we haven't mentioned here, but what you can see this combination of both like education plus experiential learning. And you can fill in yourself how that could work out nicely. And even in I think even in a like an exercise, in an exercise type of context, you could stress the idea of "I'm weak" that people learning "Well, I'm not that weak." You could handle more than you thought, which also consists how to deal with flare-ups, for example, that and reframing that.

You put it really nicely how validation in the first place, but also secondly is trying to kind of, I would say, how you say that from validation doesn't mean that you say "Well, this is very bad, you should be very worried about this and I understand," but I think also having the contrary, trying to flip the charge and basically giving information that they're not they're wrong, but giving this information or this experience that they have to reprogram, in that sense, the prediction.

And then we come back to - we're closing the loop with predictive processing - trying to find proof of less threat and therefore more possibilities, perhaps, and curiosity in the thinking. I love that point when people are starting to to sort of bring up things that "I want to do" and instead of sticking with the uncomfortableness, the helplessness, starting to be more creative again, which is a great place to be in your treatment. It makes me happy, at least.

Tim Beames (23:59.72) It's going to give them, you know, that bandwidth when there wasn't something else to potentially compete with the catastrophic thinking, the awfulizing, as, you know, bringing things that give joy into their life are great.

Bart Van Buchem (24:12.43) Yeah, yeah, yeah. We mentioned a few metaphors. Something I've been spending quite a long time with people recently over is you can both have, you know, your worries and they can be understandable worries, but at the same time you can also have joy in your life as well. They're not like one or the other. You can have both. And yeah, understanding and making sense of those fears and those worries can alleviate it totally.

Tim Beames (24:37.18) Yeah, yeah. Well, that's a nice final word. So let me summarize. Can I tell you one last story because I keep - Oh yeah, go for it.

Yeah, just before I can finish - like anybody got some stories about, you know, their work with catastrophization or awfulizing, etc., we'd love to hear from you. But I had to speak at a conference after Michael Sullivan. And it was the year that Prince William got married. So whenever that was, it was a while back in South Africa. It was in Stellenbosch. And I was doing the talk immediately after him and someone's question in the audience was like, "What do you think about Explain Pain as a treatment?"

And he basically rubbished it. And then my talk was pain education for the - and it was basically a talk about Explain Pain. And I just remember coming up on stage onto the stage thinking, "Thanks, Michael Sullivan." You like completely belittled what I was just about to talk about. So yeah, whenever I think of the pain catastrophization scale or catastrophization as just a word, I always also come back to that one memory. It's such a crazy thing, isn't it?

Bart Van Buchem (25:37.91) Yeah, yeah. Well, everyone has this if you're presenting. Yeah, there's always a the person you don't want to follow up on. Even when they've just said that as well.

Tim Beames (25:46.22) Yeah, well, absolutely. Absolutely. Yeah, yeah, yeah. That's our own catastrophization.

Bart Van Buchem (25:51.43) Well, there are ways of what we can see from our clinical work. If you have a colleague, people been referred from or referred to, you might have your thinking of "Oh god, how we going to start up and where where we going to start?" Don't mention the C word, right? The catastrophization word.

Well, as we know now, just in summary, right? Catastrophizing is not a flaw. It needs an accurate understanding by definition and how it's been communicated. I think that's very important. I think catastrophizing should be, let's say, the scientific term and that's where it belongs. And the operational work, the day-to-day clinical work probably needs something very different that you don't have to mention the word at least, but we know what it can mean because it can mean different things.

It's a great - it's a threat signal that makes sense in chronic pain for sure. And I just say our job is probably not - we shouldn't shut it down, but we should listen, validate, and slowly help shift the story by using all kind of techniques available.

And I want you just just a reflection question - what's one change you could make in your language or strategy this week? So this is a little bit of a challenge. If you're seeing patients this week, just try it. Let's see if you can can make that little language change so you can at least address it and therefore challenging it. That will be a nice way of starting to get more comfortable with your own catastrophization.

And I'm urgently asking you or telling you you should go to our platform, have a look. There's some talks with Ann Meulders. We did had some previous talks in podcasts about the same topic on problem solving and solution-based working, which be highly relevant, especially within our premium membership.

You can find all kinds of challenges addressed as well as in the clinical discussions. You will see the our experts and residents do use these techniques all the time. So it's great to learn from others just by watching them telling about it or their stories. And yeah, we're sticking with curiosity and looking forward to the next episode.

Tim Beames (27:47.84) Lovely. Right. Thank you for listening and see you soon, Timmy. Bye.