Editor’s note: The second North American Pain School (NAPS) took place June 25-29, 2017, in Montebello, Quebec, Canada. An educational initiative of the International Association for the Study of Pain (IASP) and Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), and presented by the Quebec Pain Research Network (QPRN), NAPS brings together leading experts in pain research and management to provide 30 trainees with scientific education, professional development, and networking experiences. This year’s theme was “Where Does It Hurt and Why: Peripheral and Central Contributions to Pain Throughout the Body.” Six of the trainees were also selected to serve as PRF-NAPS Correspondents, who provided firsthand reporting from the event, including interviews with NAPS’ six visiting faculty members and summaries of scientific sessions, along with coverage on social media. This is the second installment of interviews from the Correspondents, whose work is featured on PRF and RELIEF, PRF’s sister site for the general public. See the first, third, fourth, and fifth installments of NAPS interviews.
Jennifer Haythornthwaite, PhD, is a professor in the Department of Psychiatry and Behavioral Sciences, and director of the Center for Mind-Body Research, at Johns Hopkins University, Baltimore, US. Her main research interests are the psychosocial aspects of pain, especially the impact of negative emotions on pain and pain-related disability. Haythornthwaite sat down with PRF-NAPS Correspondent Lincoln Tracy, a research fellow at Monash University, Australia, to discuss her path to clinical psychology, her perspective on the role of catastrophizing in pain, and her advice to young researchers. Below is an edited transcript of their conversation.
What first made you interested in science?
I grew up in an academic household, so science was always held in high esteem. In fact, working in science goes back multiple generations in my family. The real question was which area of science I would go into, as opposed to whether or not I would pursue a career in science. I feel very fortunate that I had a very advantaged family background, including a high education level, a very intellectual environment, and lots of discussions about all sorts of different issues.
Given your upbringing in science, how did you move into pain research?
I meandered because I was really good at math and was going to be a mathematician, but I didn’t like my math program in college. My father was an engineer, so I tried physics, but then I got a D in that. I eventually met with a career counselor and ended up in general psychology, and from there I went on to specialize in clinical psychology.
When I was in graduate school it was the early days of behavioral medicine. There were two major areas that you could work in as a psychologist: one was cardiac rehabilitation, and the other was pain. This was about a decade after Ronald Melzack and Patrick Wall’s gate control theory of pain was first published, and so behavioral medicine had a number of pain-related research opportunities.
When I did my internship, which is part of the training to become a clinical psychologist, I went to a veterans affairs (VA) hospital affiliated with Yale that had a really great pain clinic. During my internship I had the opportunity to meet Dennis Turk, who was famous at the time, and then other key people in the field like Bob Kerns. That’s really when I became a pain researcher.
How did your work at the VA hospital spark your interest in catastrophizing?
When I started there I was learning about modern pain thinking. Wilbert Fordyce was writing about behavioral and operant approaches at the University of Washington, and Bob and Dennis were developing cognitive behavioral approaches for pain. As a clinical psychologist, I became really interested in understanding both approaches and how to do these interventions in patients.
At the time, we were also looking at depression, and I had a chance to interview probably 150 people with chronic pain about depression. Those interviews allowed me to develop a database of symptom profiles in my head, which got me interested in the impact of pain on people’s lives and how depression is clearly one part of it.
Then I developed an interest in why some people get depressed and others don’t. We know that coping is really important for cognitive behavioral interventions, so I started to study coping. Any time I put catastrophizing in the statistical model, everything else washed out. Catastrophizing was a powerful factor that predicted all sorts of other things, and most other aspects of how patients coped didn’t, so I started paying more and more attention to it.
In terms of my approach to research, I’m very much a data-based scientist: numbers matter, and I think about the world in that way. I’ve always found data very compelling. I used to analyze my own data, but while I don’t do it anymore—other people in the group do—I wish I did because I’ve lost a very important skill set. For me, the data have always told the story, and it’s your job to understand the story and figure it all out.
What projects are you currently working on?
Right now we’re running a couple of different studies looking at whether catastrophizing can be changed. We are curious to see if doing so leads to alterations in underlying pain mechanisms such as central sensitization or the inflammatory response to pain. It’s an important piece of the puzzle to understand, given how important catastrophizing is to pain. It may or may not be true, but we think it is.
How important is it to take a multidisciplinary approach to pain research and treatment?
It’s critical for both. Although we’ve had multidisciplinary treatment historically, it’s been slowly eroding with tight healthcare dollars. The US is a mess because of our capitalistic drive to make money.
Pain is so complicated—no single discipline is going to solve the problem or increase our knowledge to the degree we need. We have to work with each other from our various areas of expertise and skill sets to synergize new ideas and methodologies, and hopefully a better understanding and better outcomes will emerge. I can’t see it being any other way at this point.
What are the biggest challenges the pain research field faces at the moment?
One of the big societal problems is the misunderstanding of pain, and we see this both with patients and their families, as well as providers, who aren’t necessarily pain specialists. One of the challenges is to help all of them understand the complexity of pain. Just because pain is complex doesn’t mean that patients are malingering.
One of the other frustrations I have is the extent to which, at least in the US, pain management has been virtually equated with opioid management. We have so many alternative ways to manage pain that are non-opioid focused, but this hasn’t gotten out to patients, families, and their providers.
Sorting out the issue of central sensitization is another big challenge for researchers as a community. It’s shifted the playing field over the last two decades, but you can tell from the talks at NAPS that we all have our own way of thinking about it. The question is, Do we think about central sensitization narrowly or broadly? If we’re going to think about it broadly, then what do we include and what do we exclude? How do we go about refining the concept so that it helps us move forward both in terms of our understanding of pain and of treatment?
Looking back over your career in pain research, is there anything that you’ve really changed your mind about in terms of the science?
I experienced a paradigm shift around quantitative sensory testing (QST) in laboratory studies of pain. For so long I thought these tests wouldn’t have value. That was because I was so clinically focused. I had come from the VA hospital, where we talked to people with amputations who would talk about missing a limb. I wondered how we could possibly learn something in the laboratory that would generalize to a situation like that. I just couldn’t appreciate it for years, and so that was a real turnaround for me. But, like everything, laboratory testing has its strengths and weaknesses. It’s not perfect, but it helps us understand, and that’s what we’re all looking for.
What key lessons do you try to convey to the trainees who work in your lab?
I really strive to impart that they do something they’re passionate about. I’ve had so much fun in my career and want everybody to have as much fun as I’ve had. I could never have told you back when I did my clinical internship at the VA hospital that I would be doing what I’m doing now. That’s another thing that’s so great about research careers, but that’s why it’s important to do something that you really enjoy. As long as you’re enjoying your work, you’re going to infuse it with energy and curiosity, and you’ll make good decisions as you meander along the path you’ve created.
It’s also important that trainees understand that no one follows a straight and smooth path. Everybody has papers that are rejected and grants that are not funded. While career trajectories aren’t portrayed that way, I absolutely believe it because I know it happens. So you need to be very resilient to disappointment in this line of work, hang in there, and feel joy from the work and the process, because it’s delayed gratification—sometimes it’s massively delayed gratification. But some of my toughest reviews have created my best papers.
Earlier you spoke about how you tried math and physics before you went into psychology. If you hadn’t pursued psychology, what would you have done?
I probably would have stuck with math and pursued statistics. it’s a way of being a scientist—a different way than a lot of people think—but for me it’s very satisfying.
I also tinkered with becoming an anthropologist. During my senior year in college I took an anthropology course and loved it. Studying ancient cultures was fascinating—it was a different kind of science. But then I realized I didn’t want to change gears as a senior.
But I was never interested in medicine or biology, so what I know about pain has really come from pain research per se, and not from anything else. I learn as I go. When my basic science colleagues tell me I should be interested in something, I try to become as knowledgeable as I can.
Finishing on a lighter note: If you could have a dinner party with anyone from history, dead or alive, who would be at the table with you?
I already know a lot of people from the pain world, so I’m going to go outside of it here. I have an interest in international politics, so Madeleine Albright, the former US Secretary of State, would definitely be one of them. She is an amazing woman who’s accomplished a great deal. I would also love to have dinner with Margaret Mead or Jane Goodall, because they have done such interesting and important work as scientists.
Finally, I would invite Diana Nyad or Anne Morrow Lindbergh. Diana Nyad is an amazing swimmer who has swum the English Channel; Lindbergh was an aviator and the first American woman to earn a glider pilot’s license. Their careers were all about persevering to achieve very difficult goals, usually doing so alone. It would be fascinating to hear what led them to do what they did, and what got them through dark nights in the middle of a panic and a horrible rainstorm with thunder and lightning. How did they cope?
Additional Reading
Psychological interventions that target sleep reduce pain catastrophizing in knee osteoarthritis.
Lerman SF, Finan PH, Smith MT, Haythornthwaite JA
Pain. 2017 Jul 31
Pain catastrophizing may moderate the association between pain and secondary hyperalgesia.
Pressman AJ, Peterlin, BL, Tompkins DA, Salas RE, Buenaver LF, Haythornthwaite JA, Campbell CM
J Appl Behav Res 2017 Mar;22(1):e12096.
Mathur VA, Kiley KB, Carroll PC, Edwards RR, Lanzkron S, Haythornthwaite JA, Campbell CM
J Pain. 2016 Nov;17(11):1227-36.
Pain, catastrophizing, and depression in the rheumatic diseases.
Edwards RR, Calahan C, Mensing G, Smith M, Haythornthwaite JA
Nat Rev Rheum. 2011 April;7(4):216-24.
Depression and the chronic pain experience.
Haythornthwaite JA, Sieber WJ, Kerns RD
Pain 1991 Aug;46(2):177-184
Kerns RD, Haythornthwaite JA
J Consult Clin Psychol 1988 Dec;56(6):870-6.
