Distress Intolerance in Patients with Depression and Pain Catastrophizing: Implications for Pain Care and the Social Work Profession

Background: Pain is a complex construct that contributes to significant impairment in both physical and psychological domains and particularly in trauma and orthopedic surgery settings where social work is first line of intervention treating psychosocial factors in patient care. There are both protective and exacerbating psychosocial factors involved in the adaptation to pain, such as depression and pain catastrophizing, which is described as to ruminate, magnify and feel helpless about pain. Distress intolerance is defined as the inability to effectively manage somatic or emotional states and may help explain cognitive and functional impairments of pain. However, additional research is needed to better understand the relationships among these psychosocial variables to better equip social workers to provide evidenced based practices.

Methods: We administered a health survey and medical record review among outpatient trauma and orthopedic surgery clinic patients. Eligibility included: patients ages 18-64, admitted into acute care for injury or trauma-related orthopedic surgery and had a scheduled follow up appointment at an outpatient clinic≤6 months and currently taking an opioid medication. Data collected included demographics, substance use, mental health, and health characteristics. Descriptive and univariate statistics were calculated to characterize the population. A multi-level mediation model with latent variables (MSEM) was conducted using structural modeling to further identify the mechanisms through which depression is associated with pain catastrophizing. The MSEM model included the observed variables of distress intolerance as the mediator, depression as primary predictor, and a latent pain catastrophizing variable as the outcome, comprised of three manifest variables: pain helplessness, pain magnification, and pain rumination. 

Results: This was an exploratory analysis in which 72 participants in total completed the survey,        (94% response) with just over half of the participants screening positive for depression (51.4%). The mean score of distress tolerance was 20.10 (SD=11.16) and the range is 10 to 50. The mean score for pain catastrophizing was 12.38 (SD=13.08), the range is 0 to 52 with higher scores indicating worse condition. The MSEM model indicates an overall good fit, (CFI =.99, RMSEA = .11(90%CI:.000, .232), SRMR=.035), in which both measurement model and the regression path coefficients were all significant. Specifically, a significant direct effect emerged from depression to pain catastrophizing (b=.24, z =2.83, p <.01) as well as a significant indirect effect as mediated by distress intolerance (Db=.20, z=2.63, p<.001) from depression to pain catastrophizing, suggesting that distress intolerance partially mediated the path from depression to pain catastrophizing.

Conclusions: Distress intolerance may serve a critical role in understanding catastrophic appraisals on long-term adjustment to pain in trauma and orthopedic surgery clinic patients with depression. These data help to better inform the social work profession of psychosocial factors to help develop more robust and holistic pain management protocols. In order to better establish these findings, future research should employ longitudinal designs to examine these relationships in national samples.