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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.
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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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