Pain Catastrophizing: What Clinicians Need to Know

Pain Catastrophizing: What Clinicians Need to Know – Apr 2017 – By Robert J. Gatchel, PhD, ABPP and Randy Neblett, MA, LPC, BCB

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

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.”  

Origins of Catastrophizing

Catastrophizing is a cognitive process characterized by

  • a lack of confidence and control, and
  • an expectation of negative outcomes

This is a natural response to pain. Any person feels like this when pain limits their activity, but it’s considered a problem only for chronic pain patients.

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.

Nothing is wrong with our thinking: pain is an unmitigated disaster in the modern anti-opioid environment.

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.

No matter what positive plans, ideas, and desires I have, they will be foiled by pain, not by internal negative thoughts.

It may not be what happens to you that causes you to become anxious or tense but what you tell yourself about what happens.

When my back muscles spasm, I tell myself:

“this is a muscle spasm and my pain experience tells me that it will generally keep getting more intense and spreading to a larger area unless I use a muscle-relaxant medication. In the meantime, I can use ice to ease the burning sensation.”

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”).

Cognitive restructuring techniques have been effective in treating depression, anxiety, and stress in general.

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.

If there were a specific injury, I would know that it will heal in time. The problem is when pain happens without a specific injury.

Besides the initial work by Ellis,5,6 Beck7 and Miechenbaum 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

So essentially, they are trying to talk or argue you out of having pain.

Pain Catastrophizing

Pain-related catastrophizing was recognized in the late 1970s and 1980s, as clinical researchers began to evaluate cognitive-behavioral treatment (CBT) interventions for pain.

Pain catastrophizing has been found to intensify the experience of pain and depression.

But it’s already been shown that pain itself leads to “the experience of pain and depression” – even without catastrophizing.

Pain Catastrophizing and Fear Avoidance

Pain catastrophizing is a major component of current theories of pain-related fear avoidance.

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.

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.

Since I do have a painful medical disorder (EDS), I do have “high levels of self-reported pain, disability” and I’ve taught myself to avoid activities that aggravate my chronic pain, but this is all very rational.

My EDS causes my chronic pain and also led to my disability (intensively documented and approved) and I’ve been told by numerous PTs and doctor’s that I must limit my activities (no more 100-miles-in-a-day bike rides).

Yet, this can still be construed as catastrophizing,

Negative beliefs about pain, and/or negative illness information, can lead one to imagine the worst outcomes, during actual or anticipated painful experiences.

My negative belief about pain is that it limits my activities, which is indisputably true, and I never imagined the “worst outcome”, which I’d eventually discover was a genetic disorder that condemns me to lifelong pain.

Because pain catastrophizing and fear avoidance can be related to negative therapeutic outcomes, clinicians need to be aware of these behaviors in clinical settings.

When a person is in serious pain, I’m not sure it’s possible to talk them into feeling better.

And after a patient has been in pain for years, there are certainly grounds for catastrophizing, and even more when opioids are being withdrawn as a pain control option.

Self-Report Measures

The Pain Catastrophizing Scale was introduced in 1995. 

It is a self-report measure, consisting of 13 items scored from 0 to 4, resulting in a total possible score of 52. 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)

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.

They are putting the cart before the horse here:

“Pain intensity, pain-related disability, fear avoidance, and psychosocial distress” are *caused* by pain, not the other way around.

A related measure is the Pain Anxiety Symptom Scale (PASS). The PASS was designed to measure fear and anxiety responses to pain, which are often related to exaggerated or persistent pain behaviors.

Associations have been found between PASS scores and self-reported measures of

  • pain,
  • anxiety,
  • depressive symptoms,
  • disability, and
  • catastrophizing. 

Reductions in PASS scores have been found to accompany reductions in

  • pain intensity,
  • affective distress,
  • depressive symptoms and
  • increases in general activity.

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).

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).

Treatment Options in Clinical Practice

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.

Because pain catastrophizing involves distorted cognitions, a CBT approach is an obvious therapeutic choice.

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.

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.

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

Comprehensive pain management is the “shotgun approach”: if you try dozens of pain management techniques, there’s a good chance that some of them will work at least a little bit.

But, if you can find 10 such techniques, each of which decreases your pain by 10%, the combining them could be a very successful method of pain management. 

(Though I have to warn that the effects may not be additive. Getting good counseling and seeing friends more might each reduce your pain by 10%, but since they both work on the psycho-social aspect of pain, they may only achieve 12% pain relief in combination, not 20%.)


Pain catastrophizng 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.

It might be obvious that I don’t have a high opinion of the whole catastrophizing concept. I’ve previously posted studies that find the flaws in this idea:

For other posts about this, you can use the “catastrophizing” tag from the tag cloud below the list of posts in the right side column.

5 thoughts on “Pain Catastrophizing: What Clinicians Need to Know

  1. canarensis

    Honestly, this type of assumption drives me insane. They assume that “negative thoughts” and “catastrophizing” are, ipso facto, the cause of imaginary pain rather than a result of real pain. That thoughts like “I try to avoid activities that make my pain worse” are proof of irrational phobias rather than a rational means of avoiding things that increase pain & decrease QOL. It’s as if the old joke about “It hurts when I do this/Then stop doing that” now has the opposite interpretation; if you’re avoiding doing something that hurts, it’s proof of mental pathology rather than rational thinking.

    The Oregon Loons have a paper in their bibliography about CBT, which is one of the things they’re determined to completely replace medications with. The really insane thing is, their own paper on CBT concludes that (though it probably won’t actively damage anyone) it’s basically worthless in any meaningful or long-term pain relief sense. Yet the fact that anyone just looked at CBT seems to satisfy the task farce; their conclusions are based solely on their own predetermined beliefs, not anything resembling actual evidence.

    It’s like arguing with people with strongly held, extreme religious beliefs: nothing can shake them, certainly not facts and evidence that contradict their beliefs. Reasoning & logic are no part of their processes, just what they choose to believe, based upon nothing other than what they choose to believe. “I believe it and that’s good enough for me” might as well be tattooed on their foreheads. Forget the fact that medical care went past the ‘belief’ & magical thinking stages a while back.

    Speaking of; I’ve been saying for a while now that these “medical” Luddites would no doubt bring back fleams & bleeding bowls, only partly sarcastically. I had a communication from a woman the other day whose docs yanked her pain meds completely & are now giving her massive doses of ibuprofen. Needless to say, she developed serious bleeding problems. The doctor’s way of dealing with these iatrogenic bleeding problems? Wait for it— she has to go in every week to get a pint or two of blood withdrawn. No fleams….yet. No doubt they’ll prescribe ground mummy powder or “water of a young boy” next.

    Liked by 2 people

      1. canarensis

        Yup. What happened to the separation of church & state? Never mind the separation of church & medicine…the y might as well force everyone to be Christian Scientists & forego all medical treatment. That’d sure help the budget.

        Liked by 1 person


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