In patients with endometriosis, pain catastrophizing and pain disability influence each other, new research suggested.
An analysis of data from almost 700 patients with self-reported endometriosis who were participating in a larger international longitudinal study showed that the average Pain Catastrophizing Scale (PCS) score was significantly higher among patients with higher Pain Disability Index (PDI) scores and those with higher pain intensity scores.
The investigators conducted the study "so that we could potentially recommend treatments beyond the biomedical, which, although helpful overall, are limited in terms of their scope, as they do not directly target psychosocial factors such as pain catastrophizing," study author Caroline F. Pukall, PhD, professor of psychology at Queens University in Kingston, Ontario, told Medscape Medical News. "Psychological treatment of chronic pain conditions that includes a focus on decatastrophizing has been shown to positively impact outcomes."
The findings were published online on January 1, 2024, in the Journal of Obstetrics and Gynaecology Canada.
Clinically Relevant Catastrophizing
Pukall and Samantha Levang, a graduate student in psychology at Queen's University, analyzed data from 686 patients with a self-reported diagnosis of endometriosis. Participants' average age was 31.5 years. About 87% of participants were White, and most (92.6%) were cisgender women.
Symptoms appeared at an average age of 17 years, but the first endometriosis diagnosis was not made until an average of 9.5 years later: Age 26 years.
Pain intensity was measured using a Numeric Rating Scale (NRS) ranging from 0 (no pain) to 10 (worst pain ever felt) to rate the average (experienced in a typical month) intensity of the pain. A score of ≥ 5 was used to indicate moderate to high levels of pain intensity.
The investigators defined pain catastrophizing as "amplified negative appraisals marked by helplessness regarding current and/or anticipated pain." Pain catastrophizing has been associated with physical disability greater than that associated with the chronic pain itself, as well as overprediction of pain, increased healthcare and medication use, and longer hospital visits.
For the PCS, participants rated statements on a 5-point scale from 0 (not at all) to 4 (all the time). Scores ranged from 0 to 52, with scores of ≥ 30 indicating clinically relevant pain catastrophizing.
For the PDI, participants rated the degree to which pain interferes with functioning in family or home responsibilities, recreation, social activity, occupation, sexual behavior, self-care, and life-support activity on a scale ranging from 0 (no disability) to 10 (total disability). The total score ranged from 0 to 70, with scores ≥ 35 indicating a moderate level of pain-related disability.
The researchers analyzed between-group differences in pain disability among participants below and above the clinically relevant pain catastrophizing level. They also examined between-group differences in pain catastrophizing among patients below and above the clinically relevant moderate pain disability level.
A Biopsychosocial Framework
Experiencing moderate or greater levels of pain intensity was associated with increased levels of pain disability and pain catastrophizing.
There was a significant difference in the level of pain catastrophizing, such that the average PCS total score for participants whose PDI total scores were ≥ 35 was 9.8 points greater than those with PDI total scores of < 35.
Among participants whose PDI total scores were ≥ 35, the average PCS pain rumination score was 3.0 points higher than for those with PDI total scores < 35. This difference was significant. Likewise, there were significant differences in the level of pain magnification and pain helplessness for participants whose PDI total scores were < 35 vs ≥ 35.
Participants whose pain intensity NRS scores were ≥ 5 had PDI scores that were 13.8 points greater than those with pain intensity NRS scores < 5. Also, the average PCS total score was 11.7 points higher for those whose pain intensity NRS scores were ≥ 5.
In addition, strong associations were found at the total and domain levels of pain catastrophizing and increased levels of pain disability.
"Pain catastrophizing significantly impacts pain disability, and vice versa," the authors concluded. "Healthcare providers are strongly encouraged to evaluate the effects of endometriosis on patients using a biopsychosocial framework."
"Misinformation and misinformed biases" may play a role in the 9.5-year gap between the appearance of symptoms and an endometriosis diagnosis, said Pukall. "Research has indicated that many clinicians dismiss and normalize cisgender women's pelvic pain as typical menstrual discomfort, and in their treatment plans, prioritize fertility over pain alleviation. One can see how difficult it can be for many to receive a legitimate diagnosis, and this difficulty can directly impact patients' routes to medical treatment and disability-related assistance."
One limitation of the study was its recruitment of participants through social media, support organizations, and physicians because those participants tend to have more severe impacts on quality of life. Also, diagnoses were self-reported rather than documented by a healthcare professional. Finally, the analyses were based on cross-sectional data that cannot prove cause and effect.
Holistic Multidisciplinary Teams
Commenting on the study for Medscape Medical News, James Robinson, MD, director of minimally invasive gynecologic surgery at MedStar Washington Hospital Center in Washington, DC, said, "Recognition and treatment of the psychosocial aspects of chronic pain is at least as important as addressing the better understood domains of pelvic floor tension myalgia and central sensitization. There is emerging evidence that by aggressively addressing the psychosocial aspects of pain, objective physical measures of pain may also improve." Robinson was not involved in the current study.
"The best patient outcomes come from holistic multidisciplinary teams that can reliably identify unique components of pain generation and rapidly make appropriate referrals to complementary providers," he said.
"In a perfect treatment plan, patients who score high on the PCS will have access to pain psychologists [who can help] with recommendations to redirect catastrophizing thoughts and associated avoidance actions," Robinson continued. "Treatment of depression and anxiety through therapeutic counseling or medical management is equally important and is likely as important as utilizing pelvic floor physical therapy to address associated pelvic floor tension myalgia and vestibulodynia."
"Less traditional alternative approaches to psychosocial impacts such as meditation, yoga, and acupuncture also offer significant benefits in many patients," he added.
The study was funded by the Canadian Institutes of Health Research and the International Society for the Study of Women's Sexual Health. Pukall is a research consultant for Initiator Pharma and a clinical consultant for Pelva Health. She also received royalties from Oxford University Press for a textbook she edited. She received research funding from the Canadian Institutes of Health Research and the International Society for the Study of Women's Sexual Health. Robinson reported no conflicts of interest.