Catastrophising and Pain (ii)
What are some of the indications that someone tends to catastrophise about their pain? How do we know? Do we have to use a questionnaire? Is it really my job to know about this if I’m not a psychologist – and what do I do about it?

These are the kinds of questions that have been posed to me as I’ve explored the topic of catastrophising, and I propose to answer the last question in my next post (sorry to keep stringing you along like this – I think many may know my take on that already!).

I work in a wonderful interdisciplinary team setting, in a centre where everyone who attends the Centre gets to complete a set of psychometrically sound questionnaires that all of the team are encouraged to use and interpret, so any of the team can be confident about identifying and working with a patient who catastrophises. BUT I know that many clinicians work alone, or work in a team that functions in a multidisciplinary way, and where patients don’t routinely complete questionnaires.

So, what can solo, primary care clinicians do?

As I mentioned before, questionnaires are not X-rays of the mind – they simply organise how information is obtained, and allow us to compare the responses from one person with the responses from many others so we can decide how similar or different this one person is. In other words, using a questionnaire is just another strategy to help assess where a person is at.

It’s possible and sometimes really helpful to just ask
. With some proviso’s of course – asking the right questions and not just asking but also observing behaviour and putting this information together in some form of clinical reasoning about what is going on, and what this might mean for treatment.

Even if you decide to use a questionnaire (and maybe the Pain Catastrophising Scale is a useful choice), it’s important to decide who to give it to, when to give it, and most importantly, how to interpret it because numbers just don’t mean anything on their own – not even percentage change over time tells us very much if we don’t know the meaning of the domains they are representing.

Here’s another Healthskills Advice for NonPsychologists list on questionnaires and catastrophising!

  1. Some indications for considering the use of a measure of catastrophising are people who present as highly anxious or distressed about their pain, who describe their pain in dramatic metaphors or say things like “my back will snap” or “my bones and nerves are being ground away”, who say things like “I can’t stand it any more” or “it’s terrible and it can’t go on”, or who are fearful they will “end up in a wheelchair” for example.  Particularly people who believe that moving will “do damage”, and those who seem completely helpless when they have pain “there’s nothing I can do when I have pain”.
  2. It’s probably not so helpful to administer a questionnaire for catastrophising in someone who is seeing you with acute pain (first episode, within the first two or three weeks), but more useful to give it to someone who has had their pain for six weeks or more (sub-acute), who has had episodes of pain that have lasted more than six weeks before and had a slow recovery.
  3. In primary care settings most people won’t demonstrate catastrophising – but there is some research that suggests up to 25% of people with acute pain hold catastrophic beliefs (Ciccone, Chandler & Kline, 2010), and this finding was in young, fit military people!  Clearly not everyone who has catastrophic beliefs when they have acute pain go on to develop long-term disability, but the risks are higher, so a screening assessment like the Orebro Musculoskeletal Pain Questionnaire might be useful for routine administration in acute, primary care settings.
  4. It’s not very useful to use an English language questionnaire with someone who doesn’t speak English well – see if there is a questionnaire in that person’s language instead.  Be wary of using a translator to help someone answer a questionnaire, because this can lead to unintended errors and invalidate scoring.  The same applies if the person has limited comprehension.
  5. Make sure you read and understand the questionnaire, what it measures, how it’s interpreted, what the reference or normative group is, and how to score it.  If you don’t know these things, you’d be far better off not to use the questionnaire! Kthx.
  6. If you’re going to ask about catastrophising, you can ask things like
    • What goes through your mind when your pain gets bad?
    • What do you think is happening then?
    • What images go through your mind when you’re really sore?
    • What can you do to help yourself when your pain is really bad?
    • What do you think will happen in the future if your pain gets bad?
    • What do you think is going on in your body when you’re really sore?
    • What can you do to get by when your pain is bad?

Can you tell that this post is not the last in this series? But wait, there’s more!  Come on back for more, and don’t forget to comment (they’re always welcome).
Ciccone DS, Chandler HK, & Kline A (2010). Catastrophic appraisal of acute and chronic pain in a population sample of new jersey national guard troops. The Clinical journal of pain, 26 (8), 712-21 PMID: 20664336


  1. Oh, this is a great topic. I think it’s often very hard for health care professionals when they do all they can to treat the pain and they’re still left with … symptoms that aren’t diminishing. And equally frustrating when panic and catastrophizing and pain remains high. It’s hard to distinguish between the two and it’s very, very frustrating.

    I have seen this both as a professional and as a recipient of care.

  2. Thanks for this. It really helps to analyze pain barometers more accurately, and a questionnaire would surely help. Can’t wait to read the next update.

    1. I’m glad it’s not getting too tedious! Questionnaires can help, as well as integrating what the person says at interview, what they do in performance, and the relevant history.

  3. I couldn’t agree more about catastrophising and pain! I saw someone just the other day who does it all the time. He is convinced that his back is about to “go” any second and as a result he just wasn’t living his life for fear of what he was convinced was about to happen but never materialised. I will definitely be using the questionnaire idea too. Thanks for that

    1. You’re welcome! Johan Vlaeyen and others have often said “it’s not the pain but the fear of pain that is the greatest problem” – so if there are ways to reduce the fear of having pain by helping the person either become more aware of the realistic probability of the problem arising (eg very few people do land up in a wheelchair because of back pain!), or by helping them realise they can cope with the pain (eg it won’t kill them, but it may be unpleasant and they can get through it), then people will have better quality of life. More about this in my next post!

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