Original Article

Procedural Anxiety, Pain Catastrophizing, and Procedure-Related Pain during EGD and Colonoscopy

Authors: Marco Lauriola, PhD, Manuela Tomai, PhD, Rossella Palma, MD, Gaia La Spina, MA, Anastasia Foglia, MA, Cristina Panetta, MD, Marilena Raniolo, MD, Stefano Pontone, MD, PhD


Objectives: Although sedatives and analgesic drugs defuse anxiety and relieve pain, digestive endoscopy still is uncomfortable and painful for some patients. Identifying patients who tolerate digestive endoscopy less well remains difficult. The present study evaluated the relations between procedural anxiety, catastrophizing thoughts, and pain, using a prospective design and multimodal assessments of pain.

Methods: A total of 118 consecutive patients were assessed for procedural anxiety before endoscopy. During endoscopy, a doctor rated the patients’ pain behavior. Before discharge, the patients retrospectively rated endoscopy pain and related catastrophizing thoughts.

Results: Notwithstanding sedation, our study revealed large between-subject variability in pain. Catastrophizing thoughts mediated the relation between procedure-related pain observed by the doctor and pain intensity reported by the patient. Catastrophizing thoughts also mediated the effect of procedural anxiety. Our study showed that anxiety exacerbates endoscopy pain when the patient engages in ruminative thinking and feels unable to cope with unpleasant bodily sensations.

Conclusions: This study shows that catastrophizing thoughts account for between-subject differences in endoscopy pain. Rumination and helplessness but not magnification explain how procedural anxiety may evolve in a painful endoscopy experience. To the extent that one can address catastrophizing thoughts, endoscopy pain can be mitigated, especially for patients who are difficult to sedate.
Posted in: Gastroenterology52 Psychiatry5

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1. Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother 2009;9:745-758.
2. Edwards RR, Bingham CO 3rd Bathon J, et al. Catastrophizing and pain in arthritis, fibromyalgia, and other rheumatic diseases. Arthritis Care Res 2006;55:325-332.
3. Pinto PR, McIntyre T, Almeida A, et al. The mediating role of pain catastrophizing in the relationship between presurgical anxiety and acute postsurgical pain after hysterectomy. Pain 2012;153:218-226.
4. Weissman-Fogel I, Sprecher E, Pud D. Effects of catastrophizing on pain perception and pain modulation. Exp Brain Res 2008;186:79-85.
5. Sullivan MJL, Bishop SR, Pivik J. The Pain Catastrophizing Scale: development and validation. Psychol Assess 1995;7:524-532.
6. Börsbo B, Peolsson M, Gerdle B. Catastrophizing, depression, and pain: correlation with and influence on quality of life and health-a study of chronic whiplash-associated disorders. J Rehabil Med 2008;40:562-569.
7. Drahovzal DN, Stewart SH, Sullivan MJL. Tendency to catastrophize somatic sensations: pain catastrophizing and anxiety sensitivity in predicting headache. Cogn Behav Ther 2006;35:226-235.
8. Granot M, Ferber SG. The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity: a prospective study. Clin J Pain 2005;21:439-445.
9. Craner JR, Gilliam WP, Sperry JA. Rumination, magnification, and helplessness: how do different aspects of pain catastrophizing relate to pain severity and functioning? Clin J Pain 2016;32:1028-1035.
10. Gilliam WP, Craner JR, Morrison EJ, et al. The mediating effects of the different dimensions of pain catastrophizing on outcomes in an interdisciplinary pain rehabilitation program. Clin J Pain 2017;33:443-451.
11. Meints SM, Stout M, Abplanalp S, et al. Pain-related rumination, but not magnification or helplessness, mediates race and sex differences in experimental pain. J Pain 2017;18:332-339.
12. Trevisani L, Zelante A, Sartori S. Colonoscopy, pain and fears: is it an indissoluble trinomial? World J Gastrointest Endosc 2014;6:227-233.
13. Jones MP, Ebert CC, Sloan T, et al. Patient anxiety and elective gastrointestinal endoscopy. J Clin Gastroenterol 2004;38:35-40.
14. Sewitch MJ, Gong S, Dube C, et al. A literature review of quality in lower gastrointestinal endoscopy from the patient perspective. Can J Gastroenterol 2011;25:681-685.
15. Khan RS, Ahmed K, Blakeway E, et al. Catastrophizing: a predictive factor for postoperative pain. Am J Surg 2011;201:122-131.
16. Grosen K, Drewes AM, Pilegaard HK, et al. Situational but not dispositional pain catastrophizing correlates with early postoperative pain in pain-free patients before surgery. J Pain 2016;17:549-560.
17. Papaioannou M, Skapinakis P, Damigos D, et al. The role of catastrophizing in the prediction of postoperative pain. Pain Med 2009;10:1452-1459.
18. Iani L, Lauriola M, Costantini M. A confirmatory bifactor analysis of the hospital anxiety and depression scale in an Italian community sample. Health Qual Life Outcomes 2014;12:1-8.
19. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc 2003;4:9-15.
20. Dawson R, von Fintel N, Nairn S. Sedation assessment using the Ramsay scale. Emerg Nurse 2010;18:18-20.
21. Monticone M, Baiardi P, Ferrari S, et al. Development of the Italian version of the Pain Catastrophising Scale (PCS-I): cross-cultural adaptation, factor analysis, reliability, validity and sensitivity to change. Qual Life Res 2012;21:1045-1050.
22. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Mahwah, NJ:Lawrence Erlbaum Associates;1988.
23. Hayes A. Introduction to Mediation, Moderation, and Conditional Process Analysis. New York:Guilford Press;2013.
24. Fritz MS, Mackinnon DP. Required sample size to detect the mediated effect. Psychol Sci 2007;18:233-239.
25. Stern AF. The Hospital Anxiety and Depression Scale. Occup Med (London) 2014;64:393-394.
26. Hazeldine S, Fritschi L, Forbes G. Predicting patient tolerance of endoscopy with conscious sedation. Scand J Gastroenterol 2010;45:1248-1254.
27. Bal BS, Crowell MD, Kohli DR, et al. What factors are associated with the difficult-to-sedate endoscopy patient? Dig Dis Sci 2012;57:2527-2534.
28. Essink-Bot M-L, Kruijshaar ME, Bac DJ, et al. Different perceptions of the burden of upper GI endoscopy: an empirical study in three patient groups. Qual Life Res 2007;16:1309-1318.
29. Behrouzian F, Sadrizadeh N, Nematpour S, et al. The effect of psychological preparation on the level of anxiety before upper gastrointestinal endoscopy. J Clin Diagn Res 2017;11:VC01-VC04.
30. Pontone S, Tonda M, Brighi M, et al. Does anxiety or waiting time influence patients' tolerance of upper endoscopy? Saudi J Gastroenterol 2015;21:111-115.
31. Woo AKM. Depression and anxiety in pain. Rev Pain 2010;4:8-12.
32. Tang J, Gibson SJ. A psychophysical evaluation of the relationship between trait anxiety, pain perception, and induced state anxiety. J Pain 2005;6:612-619.
33. Thibodeau MA, Welch PG, Katz J, et al. Pain-related anxiety influences pain perception differently in men and women: a quantitative sensory test across thermal pain modalities. Pain 2013;154:419-426.
34. Pérez-Edgar K, Fox NA. Temperament and anxiety disorders. Child Adolesc Psychiatr Clin N Am 2005;14:681-706.
35. Rothbart MK. Temperament, development, and personality. Curr Dir Psychol Sci 2007;16:207-212.
36. Edwards RR, Haythornthwaite JA, Sullivan MJ, et al. Catastrophizing as a mediator of sex differences in pain: differential effects for daily pain versus laboratory-induced pain. Pain 2004;111:335-341.
37. Fillingim RB, King CD, Ribeiro-Dasilva MC, et al. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain 2009;10:447-485.
38. Brown S, Bevan R, Rubin G, et al. Patient-derived measures of GI endoscopy: a meta-narrative review of the literature. Gastrointest Endosc 2015;81:1130-40.e1-e9.
39. Bruehl S, Chung OY. Psychological interventions for acute pain. In: Hadjistavropoulos T, Craig KD, eds. Pain: Psychological Perspectives. Mahwah, NJ: Lawrence Erlbaum Associates; 2003:245-270.
40. Maguire D, Walsh JC, Little CL. The effect of information and behavioural training on endoscopy patients’ clinical outcomes. Patient Educ Couns 2004;54:61-65.