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14 Articles in Volume 15, Issue #6
Antihistamine for G-CSF–Induced Bone Pain
Book Review: Advanced Headache Therapy
Brain Drain: Lymphatic Drainage System Discovered in the Brain
Case History of Chronic Migraine: Update 2015 Part 2
Disturbed Sleep: Causes and Treatments
Is Topical Ketamine Ready For Prime Time?
Letters to the Editor: Central Sensitization, Microglia Modulators, Supplements
New App Helps Interpret Urine Drug Test Results
Osteoarthritis Update: 2015
Pain Catastrophizing: What Clinicians Need to Know
PPM Editorial Board: Tips for Treating Osteoarthritis
Practical Overview of Osteoarthritis
Status Report on Role of Stimulants in Chronic Pain Management
Treatment of Osteoarthritis

Pain Catastrophizing: What Clinicians Need to Know

Most clinicians are unfamiliar with the term pain catastrophizing. Without treatment, patients who catastrophize about their pain are at higher risk for developing chronic pain and disability.

A recent survey of Practical Pain Management readers revealed that 66% of the respondents were unfamiliar with the construct of pain catastrophizing. The purpose of this article is to explain what it is, how to identify it, and how to treat it.

As will become apparent, it is extremely important to understand this construct to prevent and treat chronic pain. Indeed, during the past 2 decades, chronic pain clinical researchers began to emphasize the important role that certain specific sets of negative beliefs (such as catastrophizing and fear avoidance) play in the maintenance and exacerbation of chronic pain.1

Gatchel et al define pain catastrophizing as “an exaggerated negative orientation toward actual or anticipated pain experiences…current conceptualizations most often describe it in terms of appraisal or as a set of maladaptive beliefs.”1 Moreover, there is a great deal of evidence for the role it plays in chronic pain.1-3

Origins of Catastrophizing

Catastrophizing is a cognitive process characterized by a lack of confidence and control, and an expectation of negative outcomes.4 The origins of this construct can be traced to early work in cognitive psychology. Albert Ellis originally developed what came to be known as Rational-Emotive Therapy (RET), based on the assumption that psychosocial disorders, such as anxiety, were caused by irrational or faulty patterns of thinking.5,6 Basically, Ellis asserted that the focus of treatment should be directed at changing the internal negative thoughts/sentences that people say to themselves that produce negative emotional responses.

Indeed, there usually is a strong connection between how you think and how you feel. It may not be what happens to you that causes you to become anxious or tense but what you tell yourself about what happens. We all have thoughts constantly going through our minds as we take in and evaluate events around us. These are called “automatic thoughts” because we often do not notice them consciously.

Based on Ellis’ RET technique, an A-B-C Model for constructive thinking was developed. When a stressful situation (an Activating event) results in anxiety (a Consequence), there often are distorted thoughts (Beliefs) that mediate the anxiety. Distorted belief systems often involve catastrophic thoughts (exaggeration/magnification of the noxious properties of an activating event, or “blowing one’s concerns out of proportion”).

Effective cognitive behavioral therapy approaches have been developed by Ellis and others7,8 to change non-constructive thinking and replace it with more constructive, positive self-talk that will reduce negative emotional components.9 Cognitive restructuring techniques have been effective in treating depression, anxiety, and stress in general.10 They also may be effective in allowing patients to deal more successfully with stressors that are closely associated with the precipitation or exacerbation of physical symptoms.

Subsequently, health psychologists recognized catastrophizing as a general pattern of emotional thoughts/beliefs in which chronic pain patients overestimate the degree of emotional distress and discomfort that may be caused by a stressful experience, such as being injured, and then overly focus on the negative aspects of pain caused by the injury.11

Besides the initial work by Ellis,5,6 Beck7 and Miechenbaum8 also reported success using cognitive restructuring techniques to treat anxiety and depression. In this approach, the therapist determines the specific thoughts or negative self-statements that are assumed to produce an increase in anxiety or depression and helps the patient modify these negative self-thoughts or self-statements and replace them with positive self-statements.9

Pain Catastrophizing

A key component of catastrophizing is the role that one’s imagination can play in anticipating negative outcomes. Pain catastrophizing is a negative cascade of cognitive and emotional responses to actual or anticipated pain—magnification, rumination, and feelings of hopelessness.12

Pain-related catastrophizing was recognized in the late 1970s and 1980s, as clinical researchers began to evaluate cognitive-behavioral treatment (CBT) interventions for pain. Several components of pain catastrophizing have been delineated, such as excessive worry, rumination, and the inability to shift attention away from pain-related thoughts; negative expectations based on previous memories of pain; negative self-statements; feelings of helplessness; and the inability to cope effectively with pain.13-15 Pain catastrophizing has been found to intensify the experience of pain and depression.4,16 A recent meta-analysis concluded that higher pain catastrophizing often is associated with higher self-reported pain and disability, and may lead to delayed recovery in patients with low back pain.17 A separate meta-analysis determined that decreased catastrophizing during treatment for low back pain was associated with better outcomes.18

It is essential for successful chronic pain management to understand that patients with painful medical disorders commonly have high levels of self-reported pain, disability, catastrophizing, and fear-avoidance behaviors. Because pain catastrophizing and fear avoidance can be related to negative therapeutic outcomes, clinicians need to be aware of these behaviors in clinical settings.

Pain Catastrophizing and Fear Avoidance

Pain catastrophizing is a major component of current theories of pain-related fear avoidance.19-21 In the basic fear-avoidance model, if one interprets pain as especially threatening and begins to catastrophize, this can lead to feelings of pain-related fear, avoidance of daily activities, and hypervigilance or overmonitoring of bodily sensations.22 Negative beliefs about pain, and/or negative illness information, can lead one to imagine the worst outcomes, during actual or anticipated painful experiences.18 This type of pain catastrophizing is believed to be a precursor for fear-avoidance behaviors, which can result in physical deconditioning, depression, as well as disability from work, recreation, and/or family activities. Indeed, as highlighted by Gatchel et al, there is clear evidence that fear avoidance is closely related to increased pain, physical disability, and long-term sick leave in chronic pain patients.1

Self-Report Measures

The Pain Catastrophizing Scale was introduced in 1995.23 It is a self-report measure, consisting of 13 items scored from 0 to 4, resulting in a total possible score of 52.24 The higher the score, the more catastrophizing thoughts are present. Previous studies have shown a cutoff of more than 30 points to be associated with clinical relevance. This measure has been found to have good psychometric properties, including high test-retest reliability and high internal consistency (Chronbach’s alpha = 0.87-0.95).25-27

Scores on the Pain Catastrophizing Scale have been found to correlate with other health measures, including pain intensity, pain-related disability, fear avoidance, and psychosocial distress.28,29 Some examples of the items include: “I keep thinking about how badly I want the pain to stop; I worry all the time about whether the pain will end; and I become afraid that the pain may get worse.”

A related measure is the Pain Anxiety Symptom Scale (PASS).30 The PASS was designed to measure fear and anxiety responses to pain, which are often related to exaggerated or persistent pain behaviors. Although several versions of the Scale have been reported, the most common consists of 20 items, each rated on a 5-point scale from 0 (never) to 5 (always). Higher scores indicate higher levels of pain-related anxiety. The following pain anxiety severity levels have been recommended for clinical interpretation: mild = 0 to 34; moderate = 35 to 67; and severe = 68 to 100.31

Associations have been found between PASS scores and self-reported measures of pain, anxiety, depressive symptoms, disability, and catastrophizing.30 Reductions in PASS scores have been found to accompany reductions in pain intensity, affective distress, depressive symptoms and increases in general activity.32 It has demonstrated good psychometric properties, including construct validity, criterion-related validity, and internal consistency (Chronbach’s alpha = 0.94).30 Some examples of PASS items are: “Pain sensations are terrifying” and “When pain comes on strong, I think that I might become paralyzed or more disabled.”

Finally, Neblett et al have developed a new and psychometrically-sound measure of pain-related fear avoidance, with a specific pain catastrophizing component, the Fear Avoidance Components Scale (FACS).22 The FACS consists of 20 items scored from 0 (completely disagree) to 5 (completely agree), with a total possible score of 100. The following fear-avoidance severity levels have been recommended for clinical interpretation: subclinical (0-20), mild (21-40), moderate (41-60), severe (61-80), and extreme (81-100). The FACS has demonstrated good reliability and high internal consistency (Chronbach’s alpha = 0.92). Examples of some catastrophizing-related items on the FACS include: “I believe that my pain will keep getting worse until I won’t be able to function at all” and “I am overwhelmed by fear when I think about my painful medical condition.”

Treatment Options in Clinical Practice

Employing an interdisciplinary pain management approach (medical, interventional, behavioral, social, etc) has been found to be both efficacious and cost-effective in managing chronic pain conditions.33,34 This interdisciplinary pain management approach is based upon the biopsychosocial model of pain.35 The biopsychosocial model views pain as the result of a dynamic interaction of biological, psychological, and social factors that perpetuate and may even worsen the clinical presentation. Thus, besides simultaneously dealing with the biological aspects of pain, psychosocial components also need to be simultaneously taken into account.

Pain catastrophizing is one of these important psychosocial components. Indeed, just as one would not overlook the assessment/treatment of depression and potential medication misuse often found in chronic pain patients, constructs such as pain catastrophizing and other fear-avoidance beliefs also should not be overlooked.

Because pain catastrophizing involves distorted cognitions, a CBT approach is an obvious therapeutic choice. It also should be pointed out that the use of the term CBT will vary widely and may include techniques such as self-instruction (eg, imagery, distraction, etc.), relaxation and biofeedback, adaptive coping strategies (such as increasing assertiveness and minimizing negative self-defeating thoughts), and changing maladaptive beliefs about pain.1,35 Patients may be exposed to various selections of these CBT strategies.

Catastrophizing often is related to misinterpretations of illness information, so reality-based education about a patient’s diagnosis and prognosis can help prevent a distorted and catastrophic view of one’s health outcomes. A trained therapist can help by challenging specific catastrophic pain-
related beliefs with a CBT approach, such as by “examining the evidence” to support the beliefs. When certain activities are anticipated to have “horrible” consequences (such as increased pain or worsening of one’s medical condition), graded exposure to the activities sometimes can help patients overcome their pain-related fears and negative fear-avoidance beliefs.36

Finally, because chronic pain is a biopsychosocial issue, these CBT techniques are most effective when embedded into a more comprehensive pain management program that also includes general medical management, physical reconditioning, focus on functional improvements, follow-up therapy, and post-treatment follow-up. Evidence-based scientific data have documented the efficacy and cost-effectiveness of such comprehensive interdisciplinary pain management programs.33,34


Pain catastrophing plays an important role in chronic pain. It was found to be associated with intensified experiences of pain and depression, and often is associated with higher self-reported pain and disability. This type of pain catastrophizing is believed to be a precursor for fear-avoidance behaviors, which can result in a number of negative biopsychosocial consequences such as physical deconditioning, depression, as well as disability. Recognition of this has led to the development of CBT methods as a means of effectively managing those cognitive components.

Last updated on: April 12, 2017
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