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Two people have the same serious injury. Both get surgery and start rehab. One person reports manageable pain and gets back to work within a series of weeks. The other person reports unmanageable pain and stays on long-term disability. How can similar injuries and diseases cause such dramatically different outcomes?

Well, variables like pre-injury health, genetics and rehab compliance play an influential role, but surprisingly, research shows that the way you think about pain is one of the most significant predictors of negative pain and disability outcomes. In fact, pain catastrophizing is a better predictor of future pain and disability than current pain, disease, anxiety, depression and neuroticism.1

It’s not what you’d expect, but a lengthy body of research demonstrates that when you get preoccupied with pain and feel helpless in your ability to control it – it feels much worse.

Fortunately, this means that by learning a few relatively simple techniques, you can change the way you look at pain and dramatically reduce discomfort and disability.

Read on to learn more about:

  • Pain catastrophizing; what is it?
  • How do you think about pain? – Take a self test to find out
  • How and why does our thinking affect pain perception?
  • Most importantly, if you have a pain catastrophizing problem, what can you do to correct it?

What Is Pain Catastrophizing?

Although you might think that you have little control over your pain experience, the way you think about pain can substantially change your pain perception – both for the good and for the bad.

Some people develop extremely negative beliefs and thinking patterns about pain. This is called pain catastrophization and research shows that catastrophizing worsens pain. People who catastrophize:2

  1. Focus excessively on their pain and on anticipation of future pain (rumination).
  2. Magnify the threat that pain poses to everyday functioning (this limits activity and increases disability).
  3. Feel helpless to manage their pain.

Test Yourself

This self test is based on the pain catastrophizing scale.

Would changing your thinking and beliefs on pain help to reduce your pain and improve your quality of life?

As a starting point to answering this difficult life-question, give yourself a score for each of the following statements about how you think and feel while experiencing pain. For each statement, choose the score that best represents your experience:

  • 0 = Not at all
  • 1 = Occasionally
  • 2 = Sometimes
  • 3 = Usually
  • 4 = Always

 Pain Catastrophizing Self Test

  1. When I am in pain I feel worried about it and I want the pain to disappear.
  2. When I’m in pain I can’t get the pain out of my mind.
  3. When I’m in pain I feel worried that the pain will never get better.
  4. When I am in pain I feel like I can’t take it any longer.
  5. When I am in pain I am scared that the pain is going to intensify.
  6. When I am in pain I can’t do anything to ease my discomfort.
  7. When I am in pain I worry that something bad might happen.
  8. When I am in pain I focus a lot on how much it hurts.
  9. When I am in pain I think a lot about other experiences that hurt.
  10. When I am in pain it is so horrible that I feel overwhelmed.
  11. When I am in pain I often think about how much I wish the pain would go away or get better.
  12. When I am in pain I feel bad and I think the pain is never going to get better.
  13. When I am in pain I feel anxious and really want it to disappear.


The maximum possible score is 52. Scores higher than 30 indicate significant catastrophizing.

Why Should You Care?

If you earned a high score on the self test above, do you really need to take any action? Can changing your thinking really have any significant impact on your pain and quality of life?

Well, people who score highly on measures of pain catastrophizing tend to experience greater pain-related problems, such as:3

  • Increased healthcare needs/use (more frequent doctor’s visits, etc.).
  • Greater acute and chronic pain perception.
  • Reduced natural pain suppression and inhibition ability (CNS alterations).
  • Increased disability.
  • Worsened post surgical outcomes.
  • Greater pain related disruption to daily life activities.
  • Increased likelihood of intentional medication overdoses and other suicide attempts.4

Basically, people who have overly negative pain related thinking styles feel more pain and experience more disability – and reducing pain and disability are two pretty solid reasons to care about how you think about pain.

How and Why Does Pain Catastrophizing Worsen Pain?

Researchers know that pain catastrophizing increases your pain perception but they’re not totally sure why this happens. It likely increases your perception of pain in a couple of ways:5

  1. It leads to a hyper-focus on pain and on the anticipation of pain. This increases the sensation of pain.
  2. It causes an exaggerated emotional response to pain (worry, anxiety, hopelessness, etc.) which also increases the perception of pain.

Using MRI scans, we can see that during a painful experience (blunt pressure pain) people with higher pain catastrophizing scores have increased activation in a number of areas of the brain, such as:

  • The medial frontal cortex and the cerebellum – Elevated activity in these areas corresponds to increased anticipation/worry in before pain.
  • The dorsolateral prefrontal cortex – Related to increased attention to pain.
  • The claustrum and amygdala – Related to the emotional consequences of pain.

There is some research evidence to suggests that pain catastrophizing also disrupts endogenous (natural) pain control systems – something that could diminish the effectiveness of analgesic medications like opioids.6

Overcoming Catastrophizing with CBT

  1. So catastrophizing can cause you pain and disability; if you tallied a high score on the test above, this is probably not something you’d feel very happy about.
  2. But if you look at it another way, you might decide that being a current pain catastrophizer isn’t so unlucky after all – since research shows that with a brief period of treatment, you can change your negative thinking habits and substantially decrease pain and disability!

To reduce pain catastrophizing you need to change your thinking from fear-based vigilance to acceptance and broadened thinking – and to reduce hopelessness and helplessness you need to learn effective techniques for pain management and coping.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is the most commonly recommended intervention for pain catastrophizing.1 Pain can distort your core beliefs, assumptions and automatic thoughts, and these distortions can cause increased disability and pain. By learning to challenge and correct distorted thinking, you can improve function and reduce pain. As you gain coping and pain management skills that actually work you retake a sense of control over your life and reduce helplessness and hopelessness with action and self directed competence.7

Here are some examples of the kinds of knowledge, tools and skills you might gain from a CBT for pain catastrophizing therapy program.

  • Learning how stress and mood affect pain and learning that you can control your pain to some degree by learning strategies to control stress and mood.
  • Learning to identify, challenge and replace unhealthy automatic thoughts – for example, to replace, “This pain will never get better.” With, “The pain is bad right now but I can ease it a bit with heat therapy.”
  • Learning to challenge unhealthy core beliefs – for example, to replace “I can’t exercise because of my back pain.” With, “I can’t do certain activities but actually some low impact exercises ease my discomfort.” Or, “Since I can’t sit for more than an hour I’ll never be able to go back to work again.” Could become, “I’ll probably have to modify my work routine, but with adjustments I’ll be able to contribute at work again soon.”

Why Get CBT?

CBT is a structured and time-limited form of therapy – so you can expect to see benefits quickly and finish with therapy within a period of weeks or months. Much of the work is done outside of therapy sessions as homework and you’ll gain transferable skills that last a lifetime. Research proves that CBT is a very effective psychological pain treatment, whether you have catastrophizing issues or not.

There are no worrisome side effects associated with CBT (unlike that seen with opioid medications, for example.)

Other Common Treatments

 Some other common interventions for pain catastrophizing include:

  • Group therapy – Therapy groups can provide support and information on how to cope and thrive while living with pain. Group therapy can help people solve specific problems, learn new approaches, learn healthier ways to respond to and manage pain and much more.
  • Mindfulness and acceptance therapy.
  • Physical therapy – By increasing stamina and strength and by decreasing your fear of certain movements and activities you can reduce inactivity and disability.
  • Occupational therapy – For many people, pain controls activities – pain is in charge. By learning new techniques for everyday activities you can retake control and increase independence and functioning.
  • Biofeedback – Biofeedback gets you in tune with your body and increases your ability to self-soothe and manage pain.
  • Stress management and relaxation training  – Pain causes stress, pain reduces your stress tolerance and stress worsens pain. By learning effective stress management techniques you can reduce pain.
  • Learning activity moderation – Both insufficient and excessive activity worsen pain. The key is to learn pacing and moderation techniques that maximize your activity potential.

Quick Improvements

One very exciting aspect of cognitive behavioral and multimodal pain treatments to reduce catastrophizing is that you can see big gains in a short time period. For example, the Mayo Clinic runs a 3 week outpatient multimodal pain program. After 3 weeks of treatment, 75% of participants score a reduction in pain catastrophizing and improved overall health – and 85% reported improved physical functioning.8

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Page last updated Apr 22, 2014

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