Running head: CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 1

Concept Analysis of Pain Catastrophizing

Melissa A. Makhoul

American University of Beirut

Author Note

Melissa A. Makhoul, PhD student, Hariri School of Nursing, American University of Beirut,

Lebanon

Word count: 2,960

CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 2

Abstract

Background. Pain catastrophizing has been shown to exacerbate the pain experience and

contribute to the development of chronic pain. Given the important role of nurses in the

management of pain, it is essential for nurses to have a clear understanding of this concept.

Aim. To clarify the characteristics of pain catastrophizing by using Walker and Avant’s (1995)

concept analysis.

Data sources. Bibliographical search of the Medline, CINAHL, ScienceDirect, PsycINFO and

PubMed yielded 50 articles containing the keyword “pain catastrophizing” between 1995 and

2019 time period.

Results. Based on the different conceptual avenues and the use of the concept in the literature, a

theoretical definition has been provided, as well as its characteristics and operational definition.

A model case and contrary case were provided and allowed for the distinction between similar

and contrary concepts of pain catastrophizing.

Conclusion. The current understanding of pain catastrophizing is important for nurses to

intervene in either a preventive or curative approach of chronic pain. A re-conceptualization of

the concept of pain catastrophizing is needed and further studies are needed to broaden the

understanding of the phenomenon.

Keywords: pain, pain catastrophizing, catastrophizing, chronic pain, nursing

CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 3

Concept Analysis of Pain Catastrophizing

Introduction

Chronic pain is one of the most frequent reasons for which individuals seek medical care

(Dahlhamer et al., 2018).Worldwide, chronic pain affects 20% of the population and has been

linked to distress, demoralization and functional impairment, making it the leading cause of

disability and economic burden (Dahlhamer et al., 2018; International Association for the Study

of Pain, 2019). Extensive research has included pain catastrophizing as a critical psychological

factor that plays a crucial role in the experience of pain (Flink, Boersma, & Linton, 2013;

Neblett, 2017; Zale & Ditre, 2015). Increasing awareness of this psychological factor has led to

the conceptualization of pain from the biopsychosocial model which holds that, pain is not only

the result of biologic factors but also of complex interactions of biological and psychosocial

factors (Asmundson, gómez, Richter, & Carleton, 2012; Zale & Ditre, 2015).

Pain catastrophizing has been extensively studied in the field of psychology but given the

important role of nurses in several aspects of pain, it is essential for nurses to be aware of this

construct when treating pain. Only one study defined the concept of pain catastrophizing using

the Caron and Bower’s (2000) dimensional analysis (Martorella, Cote, & Choiniere, 2008);

however some components of the concept were not clearly defined. Considering recent findings

about pain catastrophizing and its relationship with negative therapeutic and health outcomes

(Leung, 2012), a thorough analysis is needed. The aim of this paper is to expand the

understanding of the concept of pain catastrophizing by using the Walker and Avant’s (1995)

concept analysis as a guideline.

CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 4

Data Sources

Data collection was carried out using a bibliographical search of the following resources.

A total of two English-language dictionaries and one English-Arabic dictionary, nursing and

medical were used to define “pain” and “catastrophizing”. The bibliographic search yielded 50

articles containing the keyword “pain catastrophizing” and its related terms selected from

Medline, CINAHL, ScienceDirect, PyscINFO and PubMed centered around patients with acute

and chronic-non cancer pain. One handbook entitled “Pain: A textbook for health professionals”

about the psychology of pain was also found to be relevant to the study. The search range was

limited to studies from 1995 to 2019 with English-language literature and full text availability.

This time period was chosen because the popularity of pain catastrophizing came into view after

the publication of the Pain Catastrophizing Scale (PCS) by Sullivan, Bishop, & Pivik in 1995

(M. J. L. Sullivan, Bishop, & Pivik, 1995).

Uses of the Concept of Pain Catastrophizing

Definition of Pain Catastrophizing from Dictionaries

The common uses of the words “pain” and “catastrophizing” were explored by using

dictionary definitions and encyclopedic descriptions. Pain is defined as "a localized or

generalized unpleasant bodily sensation or complex of sensations that causes mild to severe

physical discomfort and emotional distress and typically results from bodily disorder (such as

injury or disease)" (Miller-Keane Encyclopedia & Dictionary of Medicine, 1997). In Arabic,

Pain is translated to “‫ ”ألَم‬defined as an unpleasant feeling in a part of the body when sick or
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 5

injured, and catastrophe to “‫”كارثة‬

ِ described as an extremely bad event resulting in misery or

damage ("English-Arabic Dictionary," 2019).

The Merriam-Webster dictionary was used to explore the general definition of

catastrophizing because it includes the history and etymology of the word. The word

“catastrophe” was borrowed by English speakers from the Greek word katastrophē and it first

entered our language in the 16th century (Merriam-Webster, 2019). It was originally a theatrical

term referring to the end of a play, and because it was consistently part of a tragedy, the word

became rapidly associated with any situation of unhappy ending. By the 18 th century, the

definition of “catastrophe” had come to signify truly devastating events such as volcanic

eruptions and earthquakes. Centuries later, the meaning of “catastrophe” evolved into “terrible

disaster”, and is until recently used to describe less terrible events (Merriam-Webster, 2019).

The Merriam-Webster dictionary defines the verb “catastrophize” as: “Imagining the

worst possible outcome of an action or event and thinking about a situation or event as being a

catastrophe or having a potentially catastrophic outcome”.

Use of Pain Catastrophizing in Art

In 1875, Guy de Maupassant wrote a book “Sur L’eau” (“Afloat”), in which he described

his migraine pain as misery and causing severe emotional distress and disability to his life (M. J.

Sullivan et al., 2001) (Appendix A). He felt overwhelmed and helpless and surrendered to his

pain by using chemical means to alleviate it (M. J. Sullivan et al., 2001). In the 1940s, Frida

Kahlo, a Mexican painter, portrayed her intolerable neuropathic pain and fibromyalgia centered

around hopelessness and brokenness in two paintings, “the broken column” (Figure A1) and

“Without hope” (Figure A2) as shown in Appendix A (Leung, 2012).

CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 6

Philosophical Perspectives of Pain Catastrophizing

The philosophical perspective of Albert Ellis most likely influenced the conceptualization

of catastrophizing in relation to pain. The Roman Stoic teacher Epictetus wrote “It is more

necessary for the soul to be cured than the body, for it is better to die than to live badly” (D.

Robertson & T. Codd, 2019). Inspired by the Stoic philosophers, Ellis holds that, it is not the

situation that directly produces behaviors and emotions, but rather; it is one’s beliefs about the

situation that causes behavioral and emotional reactivity (M. J. Turner, 2016). In summary, Ellis

described catastrophizing as a negative cognitive response which he referred to an “irrational

belief”, and that is the prime element for developing emotional disorders (Neblett, 2017). It is not

precisely known when catastrophizing entered the pain field, but the actual conceptual

description of the phenomena evolved in the field of psychology (Neblett, 2017).

Use of Pain Catastrophizing in Psychology

In 1952, Albert Ellis was the first to formally define catastrophizing in several ways such

as; (a) exaggerating the situation far worse than it is, (b) perceiving the worst possible outcomes,

and (c) exaggerating the threat of the unwanted situation (Neblett, 2017). Subsequently, health

psychologists examined the role of catastrophizing in pain patients in which they described it as;

(1) the inability to shift attention away from pain (Spanos, Radtke-Bodorik, Ferguson, & Jones,

1979), (2) feelings of pessimism and lack of control over the painful situation (Rosenstiel &

Keefe, 1983), and (3) the tendency to magnify and exaggerate the pain experience (Chaves &

Brown, 1987). While referring to previous work on the concept, Sullivan et.al (2001) defined
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 7

pain catastrophizing as “an exaggerated negative mental set brought to bear during actual or

anticipated painful experience” (M. J. Sullivan et al., 2001).

Theoretical Perspectives of Pain Catastrophizing

Several conceptual models of catastrophizing have been introduced in order to increase

our understanding in which catastrophic thinking might influence pain. Three models described

pain catastrophizing as a coping strategy, these include: (1) the communal coping model, where

pain catastrophizing is viewed as a social-behavioral aspect that is used to elicit social support

(M. Sullivan, 2012); (2) appraisal model, where pain catastrophizing is negatively reinforced and

is the result of two appraisals denoting that if a person believes that pain is a threat , and

estimates that he/she is unable to cope with it, this person will have catastrophic thoughts

(Severeijns, Vlaeyen, & van den Hout, 2004); (3) the misdirected problem-solving model in

which catastrophizing is negatively reinforced and functions as an ineffective problem-solving

strategy which involves constant futile efforts at finding a cure for pain (Flink et al., 2013).

Other authors hypothesized pain catastrophizing as a purely cognitive construct, in which

it acts as primary precursor for developing fear resulting in avoidance of behaviors and

hypervigilance (Vlaeyen & Linton, 2000). Lately, the concept has been conceptualized as a

functional behavior that involves repetitive negative thinking which functions to downregulate

the negative affect (such as fear, anxiety) associated with persistent pain (Flink et al., 2013).

Appendix A provides a detailed description of the different conceptual models of pain

catastrophizing.

As a result of the different conceptualizations of pain catastrophizing in the field of

psychology, the phenomenon may be best described as “A negative cognitive-affective-coping

CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 8

response in which the person appraises pain as a serious threat, is unable to shift his/her attention

away from pain, and experiences feelings of helplessness resulting in exacerbation of the pain

experience, and the need to communicate this experience to the environment”.

Pain Catastrophizing from Patients’ Perspectives

Patients shared their experiences with pain catastrophizing as; imagining the worst

possible scenarios, magnifying the pain and its impact, feeling helpless, and having

uncontrollable constant thinking about the pain, resulting in physical, psychologic and social

harms (Amtmann et al., 2018; Schutze, Rees, Slater, Smith, & O'Sullivan, 2017). Besides, some

held positive metacognitions towards rumination in a way that it helped them in problem-solving

and adaptive coping with pain (Schutze et al., 2017).

Quantitative word count analysis provided evidence that pain catastrophizing is also

displayed in patients’ natural word use; these include more use of the first-person singular

pronouns “I”, pronouns referencing other people “she/he, they”, and expressions of sadness “cry,

sad” and anger “annoyed” (Junghaenel, Schneider, & Broderick, 2017). Indeed, these findings

suggest that pain catastrophizing can be also translated into communicative behaviors.

Distinguishing the Concept of Pain Catastrophizing from Other Closely Related Concepts

Catastrophizing has been shown to be significantly correlated with depression, anxiety

and fear of pain (Asmundson et al., 2012; Galenkamp, Lazaridou, Franceschelli, Napadow, &

Edwards, 2018; M. J. Sullivan & D'Eon, 1990). These concepts could be highly interrelated;

however, they are not the concept of pain catastrophizing. Another important concept to

distinguish pain catastrophizing from is chronic pain.

CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 9

Depression. Depression is a medical disease that affects negatively how a person feels

and acts, and the way he or she thinks; it generates feelings of unhappiness and/or a loss of

interest in activities usually enjoyed (American Psychiatric Association, 2017). Despite initial

claims of redundancy (M. J. Sullivan & D'Eon, 1990), research suggests that pain catastrophizing

is distinct from depression. A prospective study showed that pain catastrophizing significantly

predicts later depression beyond the variance accounted for the initial depression (Keefe, Brown,

Wallston, & Caldwell, 1989), and cross-sectional studies showed that pain catastrophizing

predicts pain-related outcomes even when controlling for depression (M. J. Sullivan, Stanish,

Waite, Sullivan, & Tripp, 1998; Walsh, Smith, & McGrath, 1998). It is true that these two

concepts tend to overlap but it is not necessary that they always appear at the same time; people

may have depression irrespective of pain.

Anxiety and Fear of Pain. Anxiety is defined as an emotion characterized by feelings of

tension, worried recurrent thoughts and physiological changes such as increased heartrate and

blood pressure, and sweating (American Psychological Association, 2019). Fear of pain is

described as a negative emotional response to a pain stimulus (perceived as threat) that drives

avoidance or escape behaviors (Asmundson et al., 2012; Leeuw et al., 2007). Pain

catastrophizing, anxiety and fear of pain are all characterized with attention to threat, and both

anxiety and pain catastrophizing initiate rumination about the worst possible consequences.

However, these constructs differ in that, pain catastrophizing is a cognitive aspect while anxiety

and fear of pain are emotions. Hence, pain catastrophizing could lead to several emotions, two of

which are anxiety and fear of pain.

Chronic Pain. Chronic pain is defined as pain that persists or recurs for more than a

three months duration that is often associated with distress, demoralization and functional
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 10

impairment (International Association for the Study of Pain, 2019). Chronic pain and pain

catastrophizing are strongly interrelated, however, not every patient with chronic pain will have

catastrophic thoughts about pain.

Determining Defining Attributes

The critical attributes of the concept of pain catastrophizing in which it is negatively

reinforced include; a) the tendency to magnify the threat value of actual or anticipated pain, b)

focused attention on pain, c) feelings of helplessness in the context of pain, d) inability to inhibit

pain-related thoughts in anticipation of, during or following a painful stimulus. A model case and

contrary case are presented in Appendix B.

Identifying Antecedents and Consequences

Literature on the antecedent status of pain catastrophizing suggests that its origins could

be both dispositional (trait; stable person-based characteristic) and situational (state; situation-

based characteristic) (J. A. Turner & Aaron, 2001). Hence, antecedents of pain catastrophizing

were classified into personal and situational factors and they are interrelated.

On the personal level, women tend to catastrophize more than men, and this may be

explained by women having a lower diffuse noxious inhibitory control (DNIC) neural circuitry,

or their tendency to be more emotionally expressive to pain or distress than men (Leung, 2012;

M. J. Sullivan et al., 2001). Pain catastrophizing is associated with specific genotypes and with

increased functional magnetic resonance imaging (fMRI) activities in brain areas involved in

anticipation of pain and processing negative emotions including attentional, sensory and

affective aspects of pain (Leung, 2012).

CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 11

Seen as a trait, childhood experience of trauma particularly emotional abuse, acts as a

unique predictor of pain catastrophizing in adulthood, in addition to insecure adult attachment

style (Edwards et al., 2010; Sansone, Watts, & Wiederman, 2013). Some personality traits;

anxiety sensitivity, neuroticism, chronic worriers (Burri, Ogata, Rice, & Williams, 2018;

Ramirez-Maestre, Esteve, Ruiz-Parraga, Gomez-Perez, & Lopez-Martinez, 2017), psychiatric

disorders (somatization, hypochondriasis, depression), and insomnia (Park et al., 2016; J. A.

Turner & Aaron, 2001) are also associated with pain catastrophizing.

Personal beliefs, knowledge, and attitudes largely influence the tendency to catastrophize

pain. As such, negative appraisal about pain, holding negative beliefs about pain (pain is a sign

of physical harm, I have little control over pain, I am unable to cope with pain), and having low

pain-specific resilience (such as poor self-efficacy, low optimism, negative emotions) affects

how the person expects and accepts pain ultimately influencing how the person copes with the

pain (Gonzalez et al., 2019; La Touche, Grande-Alonso, Arnes-Prieto, & Paris-Alemany, 2019;

Ong, Zautra, & Reid, 2010; J. A. Turner & Aaron, 2001).

Situational factors are the environment, family, and race, culture and ethnicity. The

environment is mainly related to the event that triggered the pain in which the person’s mind and

body are affected by the event (Su-fen Cheng , Roxie L. Foster, & Huang, 2003). It is believed

that catastrophizers prefer to cope with the pain in a “communal” approach through the presence

of others in order to gain social support and minimize interpersonal conflicts (Michael JL

Sullivan, 1995-2009). The person communicates his pain to the environment by displaying pain

behaviors (M. Sullivan, 2012). A spouse reinforces and maintains the exaggerated pain

expression by being sympathetic, providing attention, and passively sanctioning avoidance of

unwanted behaviors (M. J. Sullivan et al., 2001).

CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 12

Ethnic groups with minority status were shown to be more likely to catastrophize their

pain (Fabian, McGuire, Goodin, & Edwards, 2011), such African-Americans as compared to

White-Americans (Leung, 2012). This is partly explained by their tendency to use passive coping

strategies, holding beliefs that their pain will not be controlled due to supposed clinical

discrimination, and their need to seek social support (Meints, Miller, & Hirsh, 2016).

Pain catastrophizing decreases severely the quality of life of individuals (Semeru &

Halim, 2019). The consequences of pain catastrophizing are strongly linked to feelings of fear of

movement/re-injury resulting in avoidance of daily activities and hypervigilance of bodily

sensations (Leeuw et al., 2007; Vlaeyen & Linton, 2000); thereby exacerbating the pain

experience. Short term consequences of pain catastrophizing include increased pain intensity,

decreased emotional and social role functioning and mental health functioning (stress, anxiety,

irritation, frustration), increased length of hospital stays, and increased healthcare utilization

(Bergbom, Boersma, Overmeer, & Linton, 2011; Bond et al., 2015; Habib, Kertai, Cooter,

Greenup, & Hwang, 2019). The sympathetic responses from the person’s social environment

also contribute to decreased patient participation in customary activities (M. Sullivan, 2012).

Over a long term, physical, social, occupational and mental (depression, risk for suicidal

attempts) disability and disuse syndrome can occur (Legarreta, Bueler, DiMuzio, McGlade, &

Yurgelun-Todd, 2018; Nasiri, Pakdaman, Dehghani, & Togha, 2017; Neblett, 2017; Vlaeyen &

Linton, 2000). The continuous demands for support would also result in depletion of one’s social

support resources (increased interpersonal conflict, social rejection, and relationships conflicts)

(M. Sullivan, 2012; M. J. Sullivan et al., 2001; J. A. Turner & Aaron, 2001). Lastly, pain

catastrophizing has been linked to poor outcomes of varied pain treatments such as dependence

on opioids, higher incidence of side effects related drugs, poor pain relief from a wide range of
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 13

pain medications, and greater likelihood of discontinuation of pain relief pharmacotherapy

(Grosen et al., 2017; Helmerhorst, Vranceanu, Vrahas, Smith, & Ring, 2014; Lazaridou et al.,

2017; Toth, Brady, & Hatfield, 2014; Valdes et al., 2015).

Defining Empirical Referents

Pain catastrophizing can be measured during or immediately after pain (situational), or

through a recall of cognitions and feelings associated with a painful experience (dispositional)

(Leung, 2012). One of the most accurate tools used to measure pain catastrophizing is the pain

catastrophizing scale (PCS) which characterizes pain catastrophizing through three different

domains: (1) Magnification, (2) Rumination, and (3) Helplessness (Appendix D) (Edwards,

2015; Neblett, 2017). The PCS-Arabic language version has been validated with results of

psychometric evaluation supporting its internal consistency (Cronbach’s alpha range 0.88-0.92;

range of interitem 0.57-0.65), construct validity and clinical feasibility (Huijer, Fares, & French,

2017).

Discussion and Conclusion

According to modern theories, the origin, mechanism and process of how catastrophizing

influences pain are still not fully understood, yet the evolvement of conceptual models in

psychology is thought to explain potential mechanisms. Initially, the concept’s definition

presents two types of phenomena “actual pain” or “anticipated pain”. This gives rise to

preventive measures in anticipation of a pain experience and involves a therapeutic approach to

pain catastrophizing. From a preventive approach, nurses would identify high catastrophizers

before anticipated pain and provide early nursing interventions in order to prevent exacerbation

of the pain experience. On the other hand, nurses would also identify catastrophizers with
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 14

chronic pain and direct their care towards enhancing pain coping and cognitive thinking, thereby

breaking the vicious cycle of catastrophizing. In fact, a systematic review and meta-analysis

revealed that cognitive-behavioral therapy, multimodal treatment, and acceptance and

commitment therapy as the best evidence (moderate to high quality) for reducing pain

catastrophizing in chronic non-cancer pain (Schutze et al., 2018).

The concept’s terminology has been reflected mainly from health psychologists’

perspective. A qualitative study indicated that patients agreed on the definition of the concept

and no new subdomains were identified (Amtmann et al., 2018). However, they reported that the

term “pain catastrophizing” is stigmatizing in a sense that it denotes that their pain was not

believed or be used to deny treatment. Besides the concept’s terminology, there is also

conflicting evidence about the uniqueness of the pain catastrophizing scale with regards to other

concepts such as depression, pain anxiety, fear of pain and others (Flaskerud, 2015). Another

concern about the scale is that it measures only the cognitive processes and does not assess the

pain catastrophizing behaviors which might have important implications for characterizing the

determinants and interpersonal consequences (Flaskerud, 2015).

Based on the results of this concept analysis, and in order to intervene effectively, a re-

conceptualization of pain catastrophizing is needed. Perhaps, the most heuristic model would be

integrating aspects of the coping and cognitive perspectives of pain catastrophizing, in which the

cognitive factors contribute to pain catastrophizing resulting in exacerbation of the pain

experience and the social factors would act as reinforcing stimuli of catastrophizing.

Nevertheless, the existing knowledge of the concept is particularly important for nurses to

consider given their crucial role in treating pain and the association of pain catastrophizing with

negative therapeutic and health outcomes.

CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 15

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CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 21

Appendices

Appendix A

Use of the Concept of Pain Catastrophizing in Art

In “Sur L’eau” (Afloat), the novelist Guy de Maupassant (1875) wrote (Michael JL Sullivan,

1995-2009):

“Migraine is atrocious torment, one of the worst in the

world, weakening the nerves, driving one mad,
scattering one’s thoughts to the winds and impairing
the memory. So terrible are these headaches that I can
do nothing but lie on the couch and try to dull the pain
by sniffing ether”
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 22

Figure A1. Frida Kahlo's painting, “The broken column" portraying her broken spine and several
nails into her naked bodya

Figure A2. Frida Kahlo's painting, "Without hope" portraying her unbearable pain and feelings
of hopelessness through her bedbound self-forcefully fed multiple carcassesa
Adapted from Leung, L. (2012). Pain catastrophizing: an updated review. Indian journal of psychological medicine,
34(3), 204-217.

a
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 23

Appendix B

Theoretical Perspectives of Pain Catastrophizing (PC)

Table B1: Conceptualizations of Pain Catastrophizing

Conceptual models Description

Coping aspect

Communal coping model of pain (M. Sullivan, PC reinforces displays of pain behaviors and is
2012) used instrumentally to communicate pain in
order to maximize social support and minimize
interpersonal conflicts.
Appraisal model (Severeijns et al., 2004) PC is the result of two appraisals: (1) primary
appraisal (evaluation of the of the situation:
Magnification and Rumination), and (2)
secondary appraisal (evaluation of the ability to
cope with the situation: Helplessness).
Misdirected problem-solving model Catastrophic worry functions as a motive to
(Eccleston & Crombez, 2007) (Figure A2) medically find a “cure” for pain. Because total
pain relief is not a viable option,
catastrophizing becomes a part of an
unsuccessful problem-solving strategy
involving repeated futile efforts at finding a
cure for pain.
Cognitive aspect
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 24

Fear-avoidance model of pain (Vlaeyen &
Linton, 2000) (Figure A1)
Functional aspect
Pain Catastrophizing as a repetitive negative
thinking (Flink et al., 2013)
People who appraise pain to be unpleasant but
not an indicative of serious threat to their
general health will be able to participate in
behavioral restriction and gradually increase
their activity (confrontation) through which
functional recovery is finally achieved. On the
contrary, people who perceive pain as a threat
and catastrophize, will develop fear which
leads to hypervigilance and avoidance
behaviors. The long-term avoidance of
activities will eventually result in disuse,
depression and disability.
PC is a behavior that can be positively
reinforced (through positive metacognitions
about the problem and constructive problem-
solving) or negatively reinforced (through
abstract and passive cognitive thinking about
the problem without constructive problem-
solving).

Figure B1: Graphical display of Vlaeyen and Linton’s (2000) Fear-Avoidance model of paina

Adapted from Vlaeyen, J. W., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic
musculoskeletal pain: a state of the art. Pain, 85(3), 317-332

a
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 25

Figure B2: Graphical display of the misdirected problem-solving model by Eccleston and
Crombez (2007) a

a
Adapted from Flink, I. L., Boersma, K., & Linton, S. J. (2013). Pain catastrophizing as repetitive negative thinking:
a development of the conceptualization. Cognitive behaviour therapy, 42(3), 215-223.
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 26

Appendix C

Constructing a Model case and Contrary case

Model case

Mike is a 40-year-old male patient admitted to the orthopedic unit for a knee fracture injury

following a car accident who was scheduled for a total replacement of the left knee. Mike

underwent the surgery and was placed on multimodal pain therapy of Ibuprofen (NSAIDs),

Paracetamol and Patient controlled analgesia (PCA) morphine. Nurse Ralph was the nurse taking

care of him post-operatively. When Ralph went into Mike’s room, he found him grimacing,

frowning and moaning. Mike vocalized his pain as follow:

“I’m feeling really down. I’m afraid that my pain will get worse and I will not be able to

walk again. The pain is terrible, and I can’t stand it anymore. I will ruin everyone’s lives. I’m

always in pain and always thinking about the pain severity that I’m experiencing and how I can

get rid of it, but unfortunately it seems like there is nothing I can do to reduce the pain, even the

medications are not helping me. I’m trying my best not to move in bed, and I don’t want to

participate in physical therapy because I’m sure that if I’ll do, my pain will get worse.”

This proposed model case illustrates all the attributes of pain catastrophizing. Mr. Mike

evaluated his pain as a threat for his general health and displayed pain behaviors. He kept

thinking about the pain and set expectations to reduce it which led to feelings of helplessness. He

also withdrew from activities because he feared that his pain will get worse. Therefore, Mr. Mike

does not seem to accept his pain and is emotionally frustrated. This may be influenced by

personal and situational factors.

CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 27

Contrary case. The concept of “pain and mindfulness” was described as the opposite extreme of

pain catastrophizing. Mindfulness is described as a “non-elaborative, non-judgmental, present-

centered awareness in which each thought, feeling, or sensation that arises in the attentional field

is acknowledged and accepted as it is” (Bishop et al., 2004).

John is 55-year-old male patient who for the past 5 years has been experiencing chronic

neuropathic pain secondary to a stroke. John shares his experience with chronic pain and how

he lives with it:

“I focus on my pain severity and look at it with curiosity. My goal is not to minimize the

pain as much as I’d want but instead, I try my best to engage with it just as it is. Instead of

constantly thinking, worrying and getting all stressed about it, I try to think my way through it

and ask myself: What can I do to make this situation better? What’s most important for me to

focus my attention to in the present moment? I sit comfortably with my back straight, breathe

through my nose saying to myself ‘In’ and exhale slowly through my mouth saying ‘Out’ and my

pain eases quicker. Other times, I start playing Cards or I go for a little walk and my pain eases

off slowly”

The defining attributes of pain catastrophizing from this example are absent. The case

clearly distinguishes the concept of chronic pain from pain catastrophizing. Despite suffering

from chronic pain, Mr. John was mindful about it; he did not focus on how badly she wanted his

pain to stop but instead he shifted his attention to his pain with curiosity and without being

judgmental. John did not set expectations to ease off his pain but instead he related his pain

differently and did his best to engage with it. Mr. John approached his pain rather than avoided

it, he acknowledged it and responded to it with acceptance and compassion; thereby detaching
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 28

himself from catastrophic thoughts (magnify the threat value of pain, ruminate about pain, feel

helpless about pain).

Appendix D

Operational definition of pain catastrophizing: The pain catastrophizing scale (PCS)a (M. J. L.

Sullivan et al., 1995)

Pain Catastrophizing Scale

Aspects of Aspects of Rumination Aspects of Helplessness

Magnification subscale subscale subscale
When I’m in pain: When I’m in pain: When I’m in pain:
“I become afraid that the “I anxiously want the “I worry all the time
pain will get worse” pain to go away” about whether the pain
will end”
“I kept thinking of other “I can’t seem to keep it
painful events” out of my mind” “I feel I can’t go on”
“I wonder whether “I keep thinking about “It’s terrible and I think
something serious may how much it hurts” it’s never going to get
happen” any better”
“I keep thinking about
how badly I want the “It’s awful and I feel that
pain to stop” it overwhelms me”
“I feel can’t stand it
anymore”
a
The PCS consists of 13 items that describe different thoughts and beliefs about the“There’s nothing ItI can
pain experience. assesses
three correlated factors of pain catastrophizing: (1) Four items for Rumination, (2) do to reduce
Three items forthe intensity
Magnification,
and (3) Six items for Helplessness. The PCS asks clients to reflect on past painful of
experiences
the pain”and to indicate the
degree to which they experienced each of the 13 thoughts or feelings when experiencing pain, on 5-point scales (0=
not at all, 1= to slight degree, 2= to moderate degree, 3= to great degree, 4= all the time). A total PCS score is
calculated by adding the scores on all the items with higher scores indicating higher pain catastrophizing. The PCS
has high internal consistency (Cronbach’s alpha= 0.87). A cutoff score of more than 30 is said to be clinically
relevant (M. J. L. Sullivan et al., 1995).
CONCEPT ANALYSIS OF PAIN CATASTROPHIZING 29