Chapter 27
Pain catastrophizing and fear of movement: detection and intervention

Catherine Paré & Michael J.L. Sullivan

Department of Psychology, McGill University, Montréal, Québec, Canada

Over the past two decades, considerable research has accumulated indicating that medical status variables cannot fully account for presenting symptoms of pain and disability in individuals with chronic pain conditions [1]. Biopsychosocial models have been put forward suggesting that a complete understanding of pain experience and pain‐related outcomes will require consideration of physical, psychological and social factors [2]. Catastrophic thinking and fear of movement are two psychological variables that have been shown to be significant determinants of pain and disability associated with persistent pain conditions. This chapter will briefly review what is currently known about the impact of pain catastrophizing and fear of movement on pain outcomes. The chapter will describe assessment techniques and intervention approaches for individuals who present with high levels of pain catastrophizing and fear of movement.

Pain catastrophizing

Pain catastrophizing has emerged as one of the most robust and powerful predictors of pain‐related outcomes [3, 4]. Pain catastrophizing has been defined as “an exaggerated negative mental set brought to bear during actual or anticipated pain” [5]. The term pain catastrophizing is used to describe a particular response to pain symptoms that includes elements of rumination (i.e. excessive focus on pain sensations), magnification (i.e. exaggerating the threat value of pain sensations) and helplessness (i.e. perceiving oneself as unable to cope with pain symptoms). To date, several hundred studies have been published showing a relation between pain catastrophizing and adverse pain outcomes [3, 6].

Investigations have revealed a relation between pain catastrophizing and adverse pain outcomes in patients with a wide range of acute and persistent pain conditions [4]. High levels of pain catastrophizing have been associated with increased pain and pain behavior, increased use of healthcare services, poor surgical outcomes, longer hospital stays, increased use of analgesic medication, opioid misuse and higher rates of occupational disability [7, 8]. In samples of patients with chronic pain, pain catastrophizing has been associated with heightened disability, predicting the risk of chronicity and the severity of disability better than illness‐related variables or pain itself [9]. Numerous investigations have revealed that pain catastrophizing is associated with a number of markers of pathological pain processing, including temporal summation of pain [10], sensitivity to movement‐evoked pain [11], neuroendocrine responses [12], conditioned pain modulation [13] and widespread pain [14].

Pain catastrophizing has been shown to be associated with poor response to numerous pain management interventions. For example, high scores on pain catastrophizing have been associated with less pain reduction following joint injection [15], radiofrequency neurotomy [16] and multidisciplinary rehabilitation [17]. Pain catastrophizing has been shown to predict poor response to physical therapy [18], analgesic medication [19, 20], opioids [21] and surgical interventions [22, 23]. Our group has recently shown that high post‐treatment scores on a measure of pain catastrophizing predict failure to maintain gains made in the rehabilitation of whiplash injury [24].

In the past decade, an increasing amount of research has been dedicated to understanding the relationship between pain catastrophizing and mental health and the consequent impact on pain‐related outcomes. Pain catastrophizing has been associated with increased symptoms of depression, anxiety and PTSD [25, 26, 27]. One recent study revealed that clinically significant mental health difficulties mediated the relationship between pain catastrophizing levels and occupational disability [26]. Recently, pain catastrophizing has been proposed to play a role in the underlying mechanisms of problematic recovery from pain or mental health difficulties [28, 29].

Fear of movement associated with pain

Fear of pain, or kinesiophobia, has been defined as a “highly specific negative emotional reaction to pain eliciting stimuli involving a high degree of mobilization for escape/avoidance behavior” [30]. It can also be aroused by impending pain and encompasses present‐ and future‐directed cognitions about pain [31, 32]. Fear of movement is a type of pain‐related fear characterized by avoidance of activity associated with pain or premature termination (i.e., escape) of activity causing pain [33]. Escape refers to behaviors that are enacted with the goal of terminating pain experience. Avoidance behavior refers to behavior that postpones or prevents pain experience. Once learned, avoidance behaviors can be self‐perpetuating. Self‐perpetuation of avoidance behavior occurs when individuals develop the expectation that future activities will be associated with pain. Extreme avoidance of movement can contribute to significant disability. Although the role of fear of movement has been extensively studied in individuals with low back pain, only recently have investigators examined pain‐related fears in patients with other types of pain conditions such as arthritis and whiplash injury [34].

The combined negative impact of pain catastrophizing and fear of movement has primarily been interpreted using the Fear‐Avoidance Model of Pain [33]. According to the Fear‐Avoidance Model, individuals will differ in the degree to which they interpret their pain symptoms in a ‘catastrophic’ or ‘alarmist’ manner. The model predicts that catastrophic thinking following the onset of pain will contribute to heightened fears of movement. In turn, fear is expected to lead to avoidance of activity that might be associated with pain [33]. Prolonged inactivity is expected to contribute to depression and disability. The model is recursive such that increased pain symptoms, distress and disability become the input for further catastrophic or alarmist thinking [33]. Since its inception in 2000, the same authors have provided an updated version of the model [35] (Figure 27.1). This updated version has moved away from detailing specific processes that arise following pain, such as pain catastrophizing, and shifted towards a conditioning‐based explanation of an individual’s response to pain [35]. Research findings have been consistent in showing that high levels of fear‐avoidance beliefs are associated with more pronounced pain‐related disability [34].

It has been suggested that assessment of catastrophizing and fear of movement should be part of the routine evaluation of patients with pain conditions. There has also been a call for the development of interventions that are designed to specifically target catastrophizing and fear of movement [9].

Assessment of catastrophizing

Several instruments have been developed to assess pain catastrophizing. Considerable research on catastrophizing has used the Coping Strategies Questionnaire (CSQ) [36]. The CSQ is a 48‐item self‐report measure consisting of seven coping subscales, including a 6‐item catastrophizing subscale. Respondents are asked to rate the frequency with which they use the different strategies described by scale items. The catastrophizing subscale of the CSQ contains items reflecting pessimism and helplessness in relation to coping with pain. Two shortened versions of the CSQ have been developed to improve upon the clinical utility of the questionnaire [37, 38].

Schematic illustration of diagnostic and therapeutic approach in patients with non-cardiac chest pain. — **Figure 27.1** The fear‐avoidance model of pain.

*Source:* Vlaeyen et al. 2016. Reproduced with permission of Wolters Kluwer Health, Inc.

The Pain Catastrophizing Scale (PCS) is currently the most widely used measure of pain catastrophizing [4, 39]. The PCS is a self‐report questionnaire that assesses three dimensions of catastrophizing: rumination (“I can’t stop thinking about how much it hurts”), magnification (“I worry that something serious may happen”) and helplessness (“It’s awful and I feel that it overwhelms me”). The PCS consists of 13 items describing different thoughts and feelings that individuals may experience when they are in pain [39]. On this measure, respondents are asked to rate the frequency with which they experience different catastrophic thoughts and feelings when they are in pain on a 5‐point scale with the endpoints (0) not at all and (4) all the time. The reliability and validity of the PCS has been well established [40]. The PCS yields a total score and subscale scores for rumination, magnification and helplessness. Individuals who obtain scores above 20 are considered to fall within the risk range [41].

The PCS has been translated into over 27 languages. Adaptations of the PCS have been developed for different populations such as the PCS‐child [42], PCS‐significant other [43] and PCS‐parent [44]. Recently, the PCS was adapted for daily use [45]. Shorter versions of the PCS have recently been developed and can be useful under conditions where assessment burden might need to be taken into consideration [46].

Treatments aimed at reducing catastrophizing

Findings linking pain catastrophizing to problematic recovery outcomes over the past two decades have provided the impetus for the development of interventions designed to reduce pain catastrophizing [47, 48, 49, 50, 51]. The content and structure of these interventions has varied widely, ranging from information‐based web applications to psychosocial interventions delivered by trained professionals [47, 48, 52, 53, 54, 55]. Interventions targeting pain catastrophizing have generally ranged in duration from 4‐10 weeks [49, 50, 54]. Techniques used to target catastrophizing include a host of cognitive behavioral techniques, such as education, thought monitoring, reappraisal, guided disclosure, validation, goal setting, emotional problem solving and activity scheduling [50, 56, 57]. Research has been consistent in showing that reductions in pain catastrophizing predict improvements in pain‐related outcomes, suggesting that the success of pain or disability management interventions are at least partially dependent on reducing pain catastrophizing [47, 58, 59, 60].

A recent review by Schutze et al. (2018) highlighted that most interventions used to reduce pain catastrophizing have yielded only modest outcomes [61]. Mental health comorbidity might be a factor relevant to the modest impact of treatments aimed at reducing pain catastrophizing [52, 61, 62, 63, 64 ]. If high scores on measures of pain catastrophizing reflect a high probability of mental health comorbidity, it is likely that many psychoeducational or web‐based interventions targeting pain catastrophizing might not be sufficient to yield meaningful improvement in clinical outcomes.

Assessment of fear of movement

Several scales have been developed to assess pain‐related fears including the Tampa Scale for Kinesiophobia (TSK) [65], the Fear‐Avoidance Beliefs Questionnaire (FAB‐Q) [66], the Fear of Pain Questionnaire III (FPQ‐III) [32] and the Pain and Anxiety Symptom Scale (PASS) [67]. The FAB‐Q is most relevant for individuals who might have specific fears of work‐related activities. The FPQ‐III assesses the degree to which individuals are fearful of different pain‐inducing situations (e.g. dental pain, surgery) but is not specific to activity or movement. The item‐content of the PASS addresses anxiety‐related symptoms (e.g, sweating, agitation, dread, fear) that might be associated with pain.

The TSK [65] is the most widely used measure of fear of movement. Respondents are asked to make ratings of their degree of agreement with each of the 17 statements. Four items of the TSK (items 4, 8, 12 and 16) are reversed such that higher scores represent less, as opposed to more, fear of movement. Respondents’ ratings are summed to yield a total score where higher values reflect greater fear of movement. The item content of the TSK is most relevant for individuals who are suffering from pain due to musculoskeletal injury or from pain that is exacerbated by activity (e.g. arthritis). The TSK has been shown to have satisfactory validity and reliability for evaluating fear of movement and to be associated with various indices of disability [68]. The TSK has been shortened by some researchers to produce 11‐, 13‐ and 14‐item versions [69]. Although widely used, reviews of the literature have called into question the construct validity and responsiveness of most measures of fear of pain [70].