The Role of Social Constraints and Catastrophizing in Pelvic and Urogenital Pain. Tomakowsky, et al. Int Urogynecol J. 2016 Jun 10.

Michelle Spicka, DPT
August 3, 2016
Pelvic Physical Therapy Distance Journal Club

Description: This study tested the hypothesis that social constraints (the perception that those close to a patient can inhibit, discourage or dissuade a person from disclosing one’s feelings or talking about one’s problems) would be associated with distress, pain and problems with functioning, beyond the influence of the widely recognized risk factor of pain catastrophizing.

Pain catastrophizing is the tendency to magnify pain, feel helpless and ruminate on one’s pain and it has been established as a reliable correlate of chronic pain in a variety of patient populations per previous research.  In women with IC and bladder pain syndrome, pain catastrophizing has been linked to greater depression, poorer general mental health, poorer quality of life and more severe pain.

No previous studies have examined how social constraints are associated with pain and adjustment in patients with pelvic and urogenital pain. 

Method: 122 consecutive women were selected from an urban, multidisciplinary urology specialty center and all reported pelvic and/or urogenital pain age range 17-88.

This study used the 13-item Pain Catastrophizing Scale (PCS) which captures magnification, helplessness, and rumination about pain, and the 15-item General Social Constraints scale (GCS).  The patients also filled out the Patient Health Questionnaire-8 (PHQ-8) and the Generalized Anxiety Disorder-7 questionnaire (GAD-7).  Two separate pain measures were used.

Results:

1)      Pain catastrophizing and social constraints were significantly associated with all pain measures and distress.

2)      In regressions, both pain catastrophizing and social constraints were simultaneously independent predictors of general distress, general pain severity and pain interference with functioning and together explained a moderate portion of the variance in outcome variables.

3)      Pain catastrophizing (but not social constraints) also significantly predicted urogenital pain.

4)      Regarding demographics, higher education was significantly related to lower general distress and being married/partnered was marginally related to lower social constraints.

Both pain catastrophizing and social constraints are important to the experience of pelvic and urogenital pain and effective pain treatment should include attention to these psychological and social factors.  The findings of this study suggests that both catastrophizing and social constraints might merit identification in patients and interventions designed accordingly to help them process painful feelings and problems may benefit both pain and functioning. 

Limitations: Assumptions regarding causal relationships in this study are inherently limited because of its cross-sectional and correlational design.

Discussion:

1)      Numerous studies have shown that depression and anxiety are elevated in women with pelvic and urogenital pain.  Nickel, et al. identified other psychosocial variables related to bladder pain syndromes and concomitants such as quality of life and disability which might play a role in the experience of pain in both men and women.

2)      Perceived social constraints may be especially important in patients with pelvic or urogenital pain as they often self-stigmatize and feel embarrassment or shame about diagnoses associated with elimination, sexuality and pain.  If a woman believes that she lacks supportive social relationships in working through her painful feelings and problems, she may have difficulty resolving those concerns satisfactorily.  Symptoms may be exacerbated and there is interference in cognitive processing of painful experiences. 

3)      Pain catastrophizing and perceived social constraints should be identified in patients in light of their impactful relationship with pain and referrals made to mental health professionals.  We can not underestimate, however, OUR role as a “family” for patients, helping to fill needs for processing reactions to difficult problems, and helping patients to de-catastrophize their reactions to the challenges of coping with pain and associated problems.

Other research:

1)      Pain catastrophizing in pregnancy seems to be associated with lumbopelvic pain and postpartum physical ability (Olsson et al. Phys Ther 2012).

2)      Depression and catastrophizing are consistently associated with the reported severity of pain, sensitivity to pain, physical disability, poor treatment outcomes and inflammatory disease activity in patients with chronic prostatitis/chronic pelvic pain syndrome. (Kwon et al. Int Neurourol J 2013).

3)      Younger age and catastrophization are correlated with persistent pain following surgery for endometriosis and the severity of endometriosis does not predict persistent pain. (Carey et al. Int J Gynaecol Obstet 2014).