In Chronic Pain, Catastrophizing Tied to Disrupted Circuitry

By Oakes, Kari | Clinical Psychiatry News, May 2019 | Go to article overview

In Chronic Pain, Catastrophizing Tied to Disrupted Circuitry


Oakes, Kari, Clinical Psychiatry News


REPORTING FROM APS 2019

MILWAUKEE -- When a patient with acute pain tumbles into a chronic pain state, many factors are at play, according to the widely accepted biopsychosocial theory of pain. Emotional, cognitive, and environmental components all contribute to the persistent and recalcitrant symptoms chronic pain patients experience.

Now, modern neuroimaging techniques show how, for some, pain signals hijack the brain's regulatory networks, allowing rumination and catastrophizing to intrude on the exteroception that's critical to how humans interact with one another and the world. Interrupting catastrophizing with nonpharmacologic techniques yields measurable improvements --and there's promise that a single treatment session can make a lasting difference.

"Psychosocial phenotypes, such as catastrophizing, are part of a complex biopsychosocial web of contributors to chronic pain. Catastrophizing almost certainly acts via a variety of pathways, and it seems to be a really important factor to measure, both for pharmacologic and nonpharmacologic treatment," said Robert R. Edwards, PhD, a psychologist at Brigham and Women's Hospital/Harvard Medical School (Boston) Pain Management Center. Dr. Edwards moderated a session focused on catastrophizing at the scientific meeting of the American Pain Society.

MRI shows brain connectivity

Through magnetic resonance imaging techniques that measure functional connectivity, researchers can now see how nodes in the brain form connected networks that are differentially activated.

For example, the brain's salience network (SLN) responds to stimuli that merit attention, such as evoked or clinical pain, Vitaly Napadow, PhD, said during his presentation. Key nodes in the SLN include the anterior cingulate cortex, the anterior insula, and the anterior temporoparietal junction. One function of the salience network, he said, is to regulate switching between the default mode network (DMN)--an interoceptive network --and the central executive network, usually active in exteroceptive tasks.

"The default mode network has been found to play an important role in pain processing," Dr. Napadow said. These brain regions are more active in self-referential cognition thinking about oneself--than when performing external tasks, he said. Consistently, studies have found decreased DMN deactivation in patients with chronic pain; essentially, the constant low hum of pain-focused DMN activity never turns off in a chronic pain state.

For patients with chronic pain, high levels of catastrophizing mean greater impact on functional brain connectivity, said Dr. Napadow, director of the Center for Integrative Pain Neuroimaging at the Martino Center for Biomedical Imaging at Massachusetts General Hospital and Harvard Medical School, Boston.

Looking at patients with chronic low back pain, he and his research team looked for connections between the DMN and the insula, which has a central role in pain processing. This connectivity was increased only in patients with high catastrophizing scores, said Dr. Napadow, with increased DMN-insula connectivity associated with increased pain scores only for this subgroup (Pain. 2019 Mar 4. doi: 10.1097/j.pain.0000000000001541).

"The model that we're moving toward is that chronic pain leads to a blurring in the canonical network" of brain connectivity, Dr. Napadow said. "The speculation here is that the DMN-SLN linkage could be a sort of neural substrate for a common perception that chronic pain patients have--that their pain becomes part of who they are. Their interoceptive state becomes linked to the pain they are feeling: They are their pain."

Where to turn with this information, which has large clinical implications? "Catastrophizing is a consistent risk factor for poor pain treatment outcomes, especially when we're talking about pharmacologic treatments," Dr. Edwards said. …

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