Are Pain Catastrophizing, Mindfulness, and Pain Acceptance Related or Unique Constructs?

Chronic pain is by definition a bodily sensation, but its perceived magnitude depends on both physical and psychological processes. It has been suggested that attention to pain sensations might actually increase sensory flow of pain signals to the brain, accentuating pain perceptions (1). The attention paid to pain, and the importance we attribute it in daily life, molds expectations about its impact on physical and psychosocial function. This can determine the failure or success of pain management strategies, and even whether actual pain reduction is achieved. 

Therefore, a range of psychological approaches aimed to improve pain management and to alleviate the impact of chronic pain on physical and psychosocial function are being increasingly adopted in Physical Therapy practice to address chronic pain. Among the most widely used at present are Acceptance and Commitment Therapy (ACT), Mindfulness-Based Interventions (MBIs), and Cognitive-Behavioral Therapy (CBT) (2, 3). 

Pain Catastrophizing, Mindfulness, and Pain Acceptance

For these and many other treatment modalities, self-report surveys are the standard way to profile attitudes and beliefs about pain before treatment, and measure its efficacy afterwards. However, there is uncertainty about what theoretical elements within these approaches are responsible for outcomes. Moreover, since these strategies often target similar or related aspects of the pain experience, it is unclear which surveys, or individual items therein, can better represent treatment processes, predict with higher confidence treatment outcomes, and orient treatment strategies. 

Hence, research in this field is increasingly focusing on both factor analysis (intra-survey data analysis) and comparative analysis of self-reported questionnaires that address pain attitudes and beliefs. The goal here is to identify the survey’s ability to uniquely assess cognitive or behavioral patterns predictive of important pain-related outcomes, in comparison with other measurement tools. 

The goal here is to identify the survey’s ability to uniquely assess cognitive or behavioral patterns predictive of important pain-related outcomes, in comparison with other measurement tools.  Share on X

Pain Surveys: Which Measures What? 

An interesting example of this kind of research is a 2017  study published in the Clinical Journal of Pain that compared three widely used questionnaires, the PCS, FFMQ-SF, and the CPAQ-8, to determine their unique contributions to the prediction of pain intensity, pain interference, and depression (4).

Pain Catastrophizing, Mindfulness, and Pain Acceptance

Pain Catastrophizing Scale (PCS). Pain catastrophizing represents the tendency to magnify or exaggerate the magnitude or threat of pain (5), and is commonly linked to experiential avoidance (the attempt to avoid uncomfortable thoughts, feelings, memories, images and physical sensations—even when doing so creates harm). According to Sullivan et al. (1995) people who catastrophize tend to do three things, all of which are measured by this questionnaire (6).

  1. They ruminate about their pain (e.g. “I can’t stop thinking about how much it hurts”)
  2. They magnify their pain (e.g. “I’m afraid that something serious might happen”)
  3. They feel helpless to manage their pain (e.g. “There is nothing I can do to reduce the intensity of my pain”)

The PCS items ask respondents to rate, from 0 (not at all) to 4 (all the time), the frequency of 13 different negative pain-related thoughts and feelings like the ones above. Higher scores indicate a greater frequency of catastrophic thoughts about one’s pain.

The Five-Facet Mindfulness Questionnaire (FFMQ-SF) is a 24-item short-form version of the original FFMQ 39-item scale that measures the five facets of mindfulness (7): 

  1. Observing (“I pay attention to physical experiences, such as the wind in my hair or sun on my face”)
  2. Describing (“I’m good at finding the words to describe my feelings”)
  3. Awareness (“I find myself doing things without paying attention”)
  4. Non-judging (“I tell myself that I shouldn’t be feeling the way I’m feeling)” 
  5. Non-reactivity (“When I have distressing thoughts or images, I don’t let myself be carried away by them”)  

The Chronic Pain Acceptance Questionnaire (CPAQ-8) is a shortened version of the original 20-item CPAQ questionnaire and measures pain acceptance through 2 subscales (8): 

  1. Activity Engagement assesses willingness to engage in daily life activity despite pain (“I lead a full life even though I have chronic pain”; “When my pain increases, I can still take care of my responsibilities”)
  2. Pain Willingness assesses a perceived need for pain control (“Keeping my pain level under control takes first priority whenever I am doing something”; “Before I can make any serious plans, I have to get some control over my pain”).

Items are ranked on a scale ranging from 0 (never true) to 6 (always true), and higher scores indicate more pain acceptance.

Pain Catastrophizing, Mindfulness, and Pain Acceptance

Study methods. The study recruited 260 undergraduate students enrolled in first year psychology courses at the University of Queensland, Australia, who reported either: (1) recurrent pain (at least 4 days of pain that significantly interfered with daily activities within the 30 days prior to the study initiation), or (2) chronic pain (pain experienced most days within the last 90 days). 

The 4-item pain intensity scale (items 3 to 6) within the Brief Pain Inventory (BPI) was completed by participants to indicate the intensity of least, average, and worst pain over the past week, as well as the intensity of their current pain, on a scale ranging from 0 (no pain) to 10 (pain as bad as you can imagine). The total score was the average of the 4 ratings.

The goal of the study was to examine to what extent the PCS, FFMQ-SF, and CPAQ-8 account for unique variance in pain-related variables (proportion of the outcome that is solely attributable to an individual survey). Following the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations, criterion measures of Pain Intensity, Pain Interference, and Depression were selected and assessed using three brief measures from the larger Patient Reported Outcomes Measurement Information System (PROMIS) item banks.

Regression analyses were then applied to correlate the scores of the PCS, FFMQ-SF, and CPAQ-8 with those obtained in the BPI and PROMIS tools. 

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A Strong Predictive Role for Pain Catastrophizing 

The study results suggested that reducing pain catastrophizing is the most critical aspect to target in psychological interventions for chronic pain (4). 

Pain Intensity. The PCS score was found to be a significant unique predictor of pain intensity; a greater amount of pain catastrophizing predicted higher pain intensity, even while controlling for the significant PROMIS Anxiety covariate. Two FFMQ-SF scales were also significant predictors in the model after controlling for age, sex, and anxiety. As hypothesized, the FFMQ-SF Describing scale was a significant negative predictor, such that a higher level of this mindfulness domain predicted less intense pain. Unexpectedly, the FFMQ-SF Observing scale was a significant positive predictor in the model, with a higher observing score associated with greater pain intensity.

Pain Interference. As expected, the PCS score was found to be a significant predictor, such that higher pain catastrophizing predicted more pain interference. The FFMQ-SF Non-reactivity scale was also found to be a significant predictor in the model, although in the opposite direction to what was expected, as a higher level of non-reactivity predicted a greater amount of pain interference.

Depression. The PCS score was a significant positive predictor of depression, such that more catastrophic pain thoughts predicted higher depression scores. The FFMQ-SF Non-judging scale was significantly negatively associated with the criterion variable, with higher levels of non-judging predicting less depressive symptoms.

Meanwhile, on further analysis of treatment mediators:

  • Both pain catastrophizing and a non-judgmental approach were found to be unique mediators of the association between pain intensity and depression.
  • The PCS partially mediated the association between pain intensity and pain interference, contributing comparatively significantly more than the FFMQ-SF Non-reactivity scale.
The study results suggested that reducing pain catastrophizing is the most critical aspect to target in psychological interventions for chronic pain. Share on X

In summary, the study highlights specific and shared mechanisms of commonly implemented psychosocial pain treatments. It concludes that pain catastrophizing, mindfulness, and pain acceptance are related, but unique constructs, while unique associations with the pain criterion measures were revealed for the PCS and select FFMQ-SF scales. Interestingly, the finding that higher scores on the FFMQ-SF Observing and Non-reactivity scales, respectively, predicted worse pain intensity and pain interference was counterintuitive, and suggested that these mindfulness responses not be adaptive in the context of pain in the studied population. 

In line with previous research, pain catastrophizing was negatively correlated with pain acceptance and mindfulness facets of acting with awareness, a non-judging attitude, and non-reactivity (9, 10). This agrees also with past findings suggesting that mindfulness is a mediator of the relationship between pain severity, and both catastrophizing and pain-related impairment (11). 

As the authors point out, “PCS emerged as the most robust process, highlighting the importance of targeting this cognitive domain in streamlining pain treatments to optimize outcome”.

Time to ACT!  Our new course ACT in Motion (A Pain Exposure Protocol) is open now!


1- Eccleston, C., & Crombez, G. (1999). Pain demands attention: A cognitive–affective model of the interruptive function of pain. Psychological bulletin, 125(3), 356.

2- Day, M. A., Thorn, B. E., & Burns, J. W. (2012). The continuing evolution of biopsychosocial interventions for chronic pain. Journal of Cognitive Psychotherapy, 26(2), 114-129.

3- Sturgeon J. A. (2014). Psychological therapies for the management of chronic pain. Psychology research and behavior management, 7, 115–124. doi:10.2147/PRBM.S44762

4- Elvery, N., Jensen, M. P., Ehde, D. M., & Day, M. A. (2017). Pain catastrophizing, mindfulness, and pain acceptance. The Clinical journal of pain, 33(6), 485-495.

5- Quartana, P. J., Campbell, C. M., & Edwards, R. R. (2009). Pain catastrophizing: a critical review. Expert review of neurotherapeutics, 9(5), 745-758.

6- Sullivan, M. J., Bishop, S. R., & Pivik, J. (1995). The pain catastrophizing scale: development and validation. Psychological assessment, 7(4), 524.

7- Bohlmeijer, E., Ten Klooster, P. M., Fledderus, M., Veehof, M., & Baer, R. (2011). Psychometric properties of the five facet mindfulness questionnaire in depressed adults and development of a short form. Assessment, 18(3), 308-320.

8- Fish, R. A., McGuire, B., Hogan, M., Morrison, T. G., & Stewart, I. (2010). Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in an Internet sample and development and preliminary validation of the CPAQ-8. Pain, 149(3), 435-443.

9- Day, M. A., Smitherman, A., Ward, L. C., & Thorn, B. E. (2015). An investigation of the associations between measures of mindfulness and pain catastrophizing. The Clinical journal of pain, 31(3), 222-228.

10- Vowles, K. E., McCracken, L. M., & Eccleston, C. (2008). Patient functioning and catastrophizing in chronic pain: The mediating effects of acceptance. Health psychology, 27(2S), S136.

11- Mun, C. J., Okun, M. A., & Karoly, P. (2014). Trait mindfulness and catastrophizing as mediators of the association between pain severity and pain-related impairment. Personality and Individual Differences, 66, 68-73.

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