Pain catastrophizing: a critical review

Pain catastrophizing: a critical review | Expert Rev Neurother. 2009 May | free full-text PMC article

This article points out that pain catastrophizing has not been sufficiently studied to make it a certain *cause* of increasing pain. I, and others, believe the catastrophizing could just as easliy be caused by pain.

It may be a completely realistic response to crippling, disabling, torturous unrelieved pain.

Pain catastrophizing is conceptualized as a negative cognitive–affective response to anticipated or actual pain and has been associated with a number of important pain-related outcomes.  

In the present review, we first focus our efforts on the conceptualization of pain catastrophizing, highlighting its conceptual history and potential problem areas.

We then focus our discussion on a number of theoretical mechanisms of action: appraisal theory, attention bias/information processing, communal coping, CNS pain processing mechanisms, psychophysiological pathways and neural pathways.  

We then offer evidence to suggest that pain catastrophizing represents an important process factor in pain treatment.

In this updated and comprehensive review of the pain catastrophizing research literature, we critically evaluate the pain catastrophizing construct, positioning catastrophizing in its historical context and detailing a number of unresolved, yet critical, conceptual and measurement issues

Subsequently, we explicate the dominant theories of pain catastrophizing and evaluate the current empirical status of each, then follow with a concise overview of the importance of pain catastrophizing in the context of pain treatment.

Pain catastrophizing: conceptual & measurement considerations

The term catastrophizing was formally introduced by Albert Ellis [3] and subsequently adapted by Aaron Beck [4] to describe a mal-adaptive cognitive style employed by patients with anxiety and depressive disorders

Other researchers focused on the development of psychometrically sound self-report instruments that could be readily and reliably used with a variety of populations.

The Coping strategies Questionnaire (CSQ), developed by Rosentiel and Keefe [7], included a six-item subscale tapping dimensions of helplessness and pessimism in the context of pain.

Sullivan et al. elaborated on the CSQ by developing the Pain Catastrophizing Scale (PCS) [8], which incorporates items explicitly designed to assess other elements of catastrophizing

Initial factor analytic work indicated that the PCS yielded three second-order factors (i.e., helplessness, rumination and magnification). 



An area of assessment that is currently underdeveloped is that considering the behavioral elements of pain catastrophizing.

Collectively, pain catastrophizing is characterized by the tendency to magnify the threat value of pain stimulus and to feel helpless in the context of pain, and by a relative inability to inhibit pain-related thoughts in anticipation of, during or following a painful encounter

Trait (dispositional) versus state (situational) assessment

Although pain catastrophizing has most typically been conceptualized and assessed as a trait-like or dispositional variable, a handful of recent investigations have assessed pain catastrophizing in a state-like, situation-specific manner.

However, a more recent study demonstrated that state pain catastrophizing was not related to pain threshold, pain tolerance or ratings of cold pain

There are a number of shortcomings associated with the state pain catastrophizing literature that are in desperate need of empirical attention

First, the validity and reliability of state pain catastrophizing measures has not been adequately established

Second, correlations between state and trait measures of pain catastrophizing have ranged from small to moderate in magnitude [Campbell CM et al., Manuscript Submitted; 19–22]

This pattern of relationships is somewhat troubling given that each measure is designed to assess the same underlying cognitive processes.

Third, because state pain catastrophizing is assessed following painful stimulation, it is difficult to determine whether the stronger magnitude of relationship for state versus trait pain catastrophizing is not attributable in large part to confounding with the pain experience itself.

This is a big unwieldy paragraph that questions whether pain catastrophizing might not be due to the severity of the pain itself.

Subsequent studies will need to carefully determine whether state pain catastrophizing is a construct apart from pain and its affective constituent.

Construct redundancy

Pain catastrophizing is but one of a number of variables that tap into a negative pain schema, including pain anxiety, fear of pain and pain helplessnes

Moreover, pain catastrophizing shares significant variance with broader negative affect constructs, such as depression, anxiety, anxiety sensitivity, worry and neuroticism. A handful of recent studies call into question the extent to which pain catastrophizing is conceptually distinct from these other measures.

Since we already know that depression and anxiety are *caused* by chronic pain, these components of catastrophizing might as well be *caused* by pain.

In summary, there are some conflicting evidence as to the uniqueness of the pain catastrophizing construct above and beyond negative affectivity in general, or with regard to other negative pain-related cognitive process variables, such as fear of pain.

Nonetheless, substantial empirical evidence highlights the importance of pain catastrophizing in shaping the experience of acute and chronic pain.

Association of pain catastrophizing with pain-related outcomes

Pain catastrophizing has been associated with a number of indices of pain sensitivity in the context of experimental pain testing paradigms, both among healthy, pain-free participants and individuals with various chronic pain conditions

The literature also points to consistent and generally robust associations observed between pain catastrophizing and an array of clinical pain-related outcomes, including measures of clinical pain severity, pain-related activity interference, disability, depression (and other negative mood indices) and alterations in social support networks

Moreover, catastrophizing has been linked to increased behavioral expressions of pain, as well as a variety of illness behaviors (e.g., more frequent visits to healthcare professionals). It is important to note that the magnitude of these relationships is variable, with catastrophizing accounting for minimal variance in pain severity in some studies, and up to 31% of the variance in pain severity in others

Importantly, pain catastrophizing is also related prospectively to adverse pain-related outcomes.

Indeed, pain catastrophizing-assessed presurgery has been shown to account for significant variance in postsurgical pain ratings, narcotic usage, depression, pain-related activity interference and disability levels

a study by Edwards et al. suggested that pain catastrophizing was related to increased suicidal ideation in a large sample of chronic pain patients

In summary, pain catastrophizing has emerged as a rather potent predictor of a variety of pain-related outcomes, both in pain-free and chronic pain patient samples. We next address some of the postulated mechanisms by which pain catastrophizing might be associated with adverse outcomes (Table 1).

Theoretical mechanisms of action & supporting evidence

Appraisal theory

Some have framed pain catastrophizing in the context of Lazaraus and Folkman’s transactional model of stress and coping [44], at the core of which are the notions of primary and secondary appraisals

Primary appraisal concerns judgments regarding whether a potential stressor is irrelevant, benign-positive or stressful-negative.

Secondary appraisals are beliefs about coping options and the extent to which they will be successful or not.

there are threads of evidence suggesting that catastrophizing is associated with other appraisal processes, such as self-efficacy concerning one’s ability to control their pain

Attention bias/information processing

Some researchers have proposed that pain catastrophizing might be characterized by attention and information processing biases analogous to those observed in individuals with anxiety and depressive disorders

Specifically, it has been argued that pain catastrophizing amplifies the experience of pain via exaggerated attention biases to sensory and affective pain information.

Indeed, pain catastrophizing is rooted in traditional cognitive–behavioral conceptualizations of anxiety and depression, and is characterized substantially by a relative inability to suppress or inhibit pain-related cognitions.

Even in noncatastrophizers, pain demands attention, interrupts ongoing activity and interferes with mental processes

If this is true of patients who are not catastrophizing, it seems such heightened focus on the pain is generated by the severity of the pain itself.

These attentional and behavioral consequences of pain are largely adaptive, given that pain signals threat.

However, in persons who tend to catastrophize, pain might demand attention to the point of cognitive and behavioral immobilization.

In summary, preliminary studies using diverse experimental methods have suggested that pain catastrophizing is associated with a heightened attentional bias to pain-relevant stimuli (perhaps its negative affective element in particular) and an inability to disengage from pain or pain cues.

Catastrophizing in a communal context

Sullivan and colleagues advanced a communal coping model, suggesting that catastrophizing represents an interpersonal style of coping with pain and suffering

The model hinges on the notion that catastrophizing represents a behavioral coping strategy employed by individuals experiencing pain to elicit emotional and/or tangible support from others, thereby positively reinforcing pain and illness behaviors and undermining successful adaptation to pain.

Pain catastrophizing has also been associated with exaggerated punishing and critical responses from spouses and partners

Specifically, Cano’s analysis suggested that pain catastrophizing is associated with supportive response among patients with short pain duration, but punishing/negative responses among those with longer pain duration.

The relation between interpersonal problems and pain catastrophizing remained significant even after statistically controlling for general symptomatic distress.

These data suggest that pain catastrophizing is related to an interpersonal style characterized by submissiveness and high levels of dependency and support seeking. It was more recently shown that pain catastrophizing is associated with an insecure adult attachment style

More specifically, pain catastrophizing was linked to beliefs that others will not provide support in times of distress.

Pain catastrophizing, as well as fear of pain and hypervigilance to pain, were associated with perceptions of the self as incapable of coping with distress.

This is not catastrophizing, this is simply the reality for pain sufferers.

CNS mechanisms

A handful of studies have examined whether pain catastrophizing is associated with alterations in endogenous pain modulation pathways

several studies of the nociceptive flexion reflex, a polysynaptic spinal reflex that subserves withdrawal from potentially noxious stimuli, suggest that pain catastrophizing is not associated with nociceptive flexion reflex threshold

By contrast, pain catastrophizing is associated with alterations in supraspinal endogenous pain-inhibitory and -facilitatory processes

Temporal summation is assessed by administering repetitive, identical, phasic noxious stimuli. 

Typically, pain ratings increase across successive stimuli, reflecting a ‘summation’ process.

Temporal summation is quantified as the difference between the highest-rated stimulus and the initial stimulus of a given sequence.

A handful of studies using repetitive thermal stimulation have revealed correlations between pain catastrophizing and the degree of temporal summation

This sounds very true. For me, the amount of pain is not as burdensome as its persistence. A headache of hours or a day feels much worse on it’s 5th consecutive day.

These findings suggest that pain catastrophizing might be associated with diminished endogenous inhibition of pain coupled with central sensitization, which may represent a CNS mechanism by which pain catastrophizing is associated with the development, maintenance and aggravation of persistent pain

Physiological pathways

Although investigation of the physiological consequences of catastrophizing is a relatively new area of study, some interesting data have surfaced that suggest that pain catastrophizing might be related to altered physiological responses to stress and pain.

Aberrant patterns of muscle tension have received some initial investigation as potential meditational pathways

The relationship between catastrophizing and lower paraspinal or symptom-specific muscle responses to pain was augmented by efforts to suppress thoughts of pain.

Some data also suggest that pain catastrophizing is associated with altered hypothalamic–pituitary–adrenal axis activity.

The arthritis literature has identified helplessness as a potentially important factor in shaping some measures of disease activity

suggesting the possibility that pain catastrophizing might be related to altered neuroimmunologic responses to pain.

The advent of noninvasive brain imaging techniques has made possible the identification of various top-down and bottom-up neural circuits involved in the experience of pain, and hundreds of functional MRI studies have examined the brain’s processing of pain-related information

Seminowicz and Davis found that during mild and intense pain, pain catastrophizing was not significantly associated with activation in primary or secondary somatosensory cortices

During mild pain, pain catastrophizing was associated with exaggerated activity in the PFC, insular cortex and caudal ACC, suggesting exaggerated processing of the affective dimension of pain in particular.  

While I do believe our mental attitude greatly affects the amount of suffering our pain causes us, I do not believe this response should be criticized since it’s a natural reaction to disabling pain.

Instead of being told that our catastrophizing is *causing* our pain, it should be clearly stated that psychological treatment is just another tool to prevent us from being utterly defeated by our pain.

10 thoughts on “Pain catastrophizing: a critical review

  1. Kurt W.G. Matthies

    Leave it to Ellis to give us an unspellable, unpronounceable syndrome like Catastrophizing.

    I’ve often wondered (aloud) why is no one looking at the PTSD issues among the pain commumity — not just in patients, but in the docs who treat us.

    Years of misery added to added threat of the misery of opioid withdrawal, plus the loss of 25 to 50% of my analgesia, with no help for pain flares is enough to make any mellow old soul like yours truly, catastrophize.

    Liked by 2 people

    1. Zyp Czyk Post author

      Ain’t it great when people tell you how you feel? That’s what we used to call a “mind-f**k”, it feels like a rape of my mind.

      We call it reality, they call it catastrophizing – and they get to decide which it is, not we.

      I was also not surprised to find Ellis involved. He was always defining the patients feelings as wrong.

      Liked by 2 people

  2. Kathy Cooper

    Thank you Zyp Czyk!
    Catastrophizing is just one more example of the Pseudo Science that has crept into the dialogue. No one is looking at the Science behind this, it is just one more part of the blame game. This one allegation should lead to a more objective view of things, but that won’t happen. I used to think that it couldn’t hurt to “Talk to someone” or seek Psychiatric help, now I am more skeptical than ever. Many of these Practitioners have set us up for more obfuscation, with no clear results. In many cases they could be dangerous. There is no objectivity or critical thinking allowed. This might just be about perpetuating their business, and adding another level of obfuscation to an already complicated issue. Everyone should get a copy of their “Treatment Notes” and see of they are even on the same page with their Psychiatrist, or any Therapist. Their strategy in many cases is to create confusion and undermine their Client to keep them coming back.
    Their manner in many cases leads to more explaining which can then be interpreted as “catastrophizing.” They have played “Head games” with us. In many cases amplifying our distress. Apparently when they do not believe that Physical Pain exists, or their patients can be “Talked out of it.” This should be a serious problem, one that should have made a decent human being question this. There is little real Science backing any of this, only a few so called “Studies” that get attention because they reinforce the Narrative. This becomes self referencing, when the Psychiatrist already believes the Client is Pathological when they have pain. Psychiatrists can even interpret the facial expression of pain as anger, which fits their narrative as if they are projecting more negativity on the client. The client is just not trying hard enough. The damage they have done is incalculable.
    These so called Professional have failed us, this is not a Science, and no Science has been used to quantify whether this improves people lives or not. The only indicator anyone relies on any more is Profit and sustaining that profit. That is not an indicator of effectiveness. There is no Agency, no Scientific Data counting the Mistakes, the damage, or even the number of Suicides, which could be an indicator of the effectiveness of a “treatment.”
    This is some kind of nightmare which can only be described as Kafakaesque or Orwellian. It is not getting better. Think about it, there has only been an Increase in suicides, and people with Mental Health issues. The Economy, and our Social Problems get most of the blame. There is no Empirical Evidence that “Psychiatry” has improved anything in the past 2 decades.

    There is no objective questioning of any of this anymore. No one raised much of an objection when they re worded the DSMV, the Psychiatrists Bible, and billing Code reference. No one seem skeptical of the Psychiatric Industry exploiting this “Epidemic.” There appears to be a pattern of dismissing pain, which ads to the distress of people experiencing it. They have also found that it is more economical to treat various Psychological and Pain conditions with Atypical Anti Psychotics, people should be concerned about this, instead there is another conspiracy of silence. There is no longer any expectation of improvement, only damping down the distress, whether it is situational distress from basic survival in the System or a so called Mental Health Issue.

    Sorry I don’t write so well anymore, and trying to describe this is really difficult, even pointing out the mistakes or questioning anything has become a mental health problem.

    Liked by 1 person

    1. Zyp Czyk Post author

      It’s sad that there’s much truth to what you say, but I must thank psychiatric meds for saving my life. In my long journey through various psychiatrists and psychologists, most have been useless, but the few that were good were excellent. I “naturally” have such severe depression and anxiety that I cannot live with it.

      My best psychiatrist allowed me to try all kinds of meds of different categories, let me adjust dosages within reason and, most of all, BELIEVED ME even when my reactions were supposedly “impossible”. What a wonderful man. I literally wouldn’t be here without his help because I was in a bottomless pit of anguish at the time. I’m still on the regimen we finally arrived at after months of horrible trials and devastating errors.

      As with all “helpers” and “healers”, the very personal connection is crucial, and it can’t be taught if the talent isn’t pre-existing. Too many psychiatrists think too highly of their supposed “knowledge” and simply cannot listen to a patient who is telling them something that goes against their beliefs. We must never give them authority over our “thinking”, but rather enlist them as helpers as we struggle together to get through our difficult lives.

      One of the worst crimes of Psychiatry is that awful DSM V, where addiction and dependence are equated. I was shocked to see such ignorance in this manual that rules our medical establishment.

      After all, millions of people are dependent upon their antidepressants, but I would never say someone is addicted to Cymbalta, even though the withdrawals are extreme. I don’t know how something so medically false got into the manual, but now I don’t trust any of it.


      1. Kathy Cooper

        Thanks Zyp!
        I know that some people get help from the Anti Depressants. I recently weaned off of Cymbalta, I took it only because a PC Doctor felt more comfortable, prescribing when I took it. I had tried others that In retrospect maybe were not a good idea. I did have one good experience with a Psychiatrist, he believed me and I still remember him telling me about another Client who was a Machinist and was able to go back to work while on Opiates. That was the first time a “Professional” had told me there was even life after taking them. I was one of those people who thought they were a death sentence. I only considered them after years of everything else. He retired shortly after our encounter. I wonder what my life would be like now if he had not.
        This is the first time in 20 Years that I am not on an anti Depressant. I was told the pain was actually depression as I was repeatedly misdiagnosed. The Anxiety is there though and I am trying to control it. I am not sure how to evaluate it, I no longer trust my own judgement. I made a fool out of myself trying to prove I was not crazy, I looked even crazier. I feel like we have fallen through a rabbit hole, up is down anymore.
        I remember in the 70s there was this idea that Psychology was a Meaningful pursuit. That this Science would propel us into the future and would be applied to so many issues. What we have now is some kind of scary dystopia. The ones who have retired left the field to this new batch. They have somehow failed all of us, in justifying so many things that are really intolerable. The only Psychological Science used anymore seems to be for Marketing, Public Perception and gas lighting. I think they even took control or manipulated the Social Media groups that deal with Pain and other Medical issues. The Internet was supposed to bring us into the future, it was supposed to open everything up, even that has gotten ugly.

        Have a beautiful day, I too have moved to the mountains, where it feels like a lot of this awful stuff is far away, and nature is timeless. The big excitement today was a flock of Mockingbirds pestering a cat. Anytime this cat gets the idea to stalk in one of the trees, the mockingbirds show up and taunt him. He tries to be stealthy, but the Mockingbirds seem to know he is looking for nests, or some kind of mischief. They try to lure him out on a thinner branch, while they hop around squawking just out of reach.

        Liked by 1 person

        1. Zyp Czyk Post author

          Ah nature – “The best show on earth!” It helps not to watch TV.

          There’s so much going on all around us all the time that we aren’t even paying attention to. I can lose myself in the critters at the feeder for a long time :-)


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