Unique Contributions of Acceptance and Catastrophizing on Chronic Pain Adaptation
Pain catastrophizing and acceptance represent distinct but interrelated constructs that influence adaptation to chronic pain. Clinical and laboratory research suggest that higher levels of catastrophizing and lower levels of acceptance predict worse functioning; however, findings have been mixed regarding which specific outcomes are associated with each construct. The current study evaluates these constructs in relation to pain, affect, and functioning in a treatment-seeking clinical sample.
Participants included 249 adult patients who were admitted to an interdisciplinary chronic pain rehabilitation program and completed measures of pain and related psychological and physical functioning.
Hierarchical multiple regression analyses indicated that pain catastrophizing and acceptance both significantly, but differentially, predicted depressive symptoms and pain-related negative affect. Only pain catastrophizing was a unique predictor of perceived pain severity, whereas acceptance uniquely predicted pain interference and performance in everyday living activities. There were no significant interactions between acceptance and catastrophizing, suggesting no moderation effects.
Findings from the current study indicate a pattern of results similar to prior studies in which greater levels of catastrophic thinking is associated with higher perceived pain intensity whereas greater levels of acceptance relate to better functioning in activities despite chronic pain. However, in the current study, both acceptance and catastrophizing were associated with negative affect. These relationships were significant beyond the effects of clinical and demographic variables. These results support the role of pain acceptance as an important contribution to chronic pain-related outcomes alongside the well-established role of pain catastrophizing. Results are limited by reliance on self-report data, cross-sectional design, and low racial/ethnic diversity.
KeywordsCatastrophization Chronic pain/psychology Psychological adaptation
Several decades of research have established that psychological factors, particularly cognitive appraisal variables, are strongly related to adaptation to chronic pain . Among these, pain catastrophizing has consistently emerged as a robust predictor of perceived pain and disability [1, 2]. Pain catastrophizing involves the tendency to respond to pain with more negative interpretations and anticipated outcomes . Studies have shown that greater levels of catastrophic thinking in response to pain are associated with a variety of negative outcomes, including greater perceived pain intensity, disability, and distress . Pain catastrophizing, therefore, represents a psychological construct with a strong potential impact on adjustment to chronic pain. However, other unique variables that impact pain, distress, or impairment have been suggested, including those that may interact with pain catastrophizing to influence outcomes. Recently, the construct of pain acceptance has gained attention as a psychosocial variable that contributes to pain-related adjustment over and above that of pain catastrophizing . Yet, the precise nature of the relationship between acceptance and catastrophizing, and how each of these constructs impacts pain-related outcomes, remains unclear due to mixed research findings.
Pain acceptance can be described as a willingness to experience painful sensations, without attempting to avoid them, and to persist with important activities despite pain . Acceptance is thought to promote better adaptation to chronic pain because attempts to avoid or control unwanted internal sensations are believed to lead to increased distress and disability [7, 8, 9]. Furthermore, greater acceptance of pain promotes persistence in pursuing a meaningful life despite pain-related difficulties . This can be described as turning one’s focus away from the struggle to control pain and towards functional goals that promote participation in important life activities (e.g., attending a child’s sporting event despite chronic pain) . Importantly, this general framework is consistent with psychosocial and rehabilitation approaches to pain management. The beneficial effects of pain acceptance have been described in several studies, which indicate that greater levels of acceptance are associated with decreased depressive symptoms, pain-related interference in activities, and perceived disability [9, 10]. Further, one study investigating employment status among individuals with chronic musculoskeletal pain found that those who continued working despite chronic pain endorsed lower pain catastrophizing and higher levels of pain acceptance compared to those who took extended sick leave due to pain . Extending these findings, researchers have also found that higher levels of acceptance were associated with lower levels of pain interference and catastrophic thinking in participants’ daily lives .
Pain acceptance and catastrophizing can be understood as distinct but related constructs that may interact to impact pain and related functioning. A conceptual framework outlined by Sturgeon and Zautra  suggests that pain acceptance and catastrophizing can be described as dispositional resilience and vulnerability factors, respectively. In the context of a pain episode, these factors have important implications for cognitive, affective, and behavioral responses to pain . Similarly, pain catastrophizing has been conceptualized from a pain-fear-avoidance perspective with more negative outcomes . In contrast, pain acceptance represents a more positive pathway for coping with pain and is associated with better adjustment to chronic pain [14, 15]. Not surprisingly, higher pain acceptance is associated with lower levels of pain catastrophizing across several research studies [12, 16, 17].
Although acceptance and catastrophizing may appear as conceptual opposites, research supports that they can co-occur and interact to influence distress and well-being. However, the specific cognitive processes involved in each construct may differ. Researchers have posited that whereas catastrophizing may represent an automatic negative evaluation of pain, acceptance may represent a more deliberate and flexible response to pain , or as the underlying context in which catastrophic thoughts occur . Accordingly, an individual’s level of acceptance of chronic pain may impact the extent to which catastrophic thinking has a negative effect on pain and functioning. Catastrophizing and acceptance may be viewed as different responses to pain that mitigate adjustment . For example, the extent to which an individual experiences negative emotions in the context of pain may be influenced by greater levels of pain catastrophizing, whereas the extent to which individuals are able to accept these internal experiences and pursue meaningful life goals may relate to more positive emotional functioning . Accordingly, these constructs may interact to influence pain-related adaptation. Supporting this framework, researchers found that pain acceptance significantly mediated the relationship between pain catastrophizing and several outcome variables, including depression, pain-related anxiety, and physical and psychosocial disability. Interestingly, acceptance was not significantly associated with pain intensity in their study .
Empirical investigations examining the relationship between catastrophizing and acceptance on outcomes have produced somewhat mixed results. Although both catastrophizing and acceptance have demonstrated an association to pain severity, interference, and quality of life among those with chronic pain, the unique contributions of each construct are not currently well understood. In some studies, results support that pain acceptance, but not catastrophizing, is associated with physical dysfunction , while others have demonstrated that both pain catastrophizing and acceptance uniquely predict functional disability . Similarly, acceptance has been found to significantly moderate the relationship between pain severity and negative affect , while another study found that catastrophizing, but not acceptance, significantly mediated the relationship between pain intensity and emotional dysfunction , and another found that both catastrophizing and acceptance were associated with depressed mood .
In order to evaluate the unique contributions of acceptance and catastrophizing on pain, depressive symptoms, and functional interference in a controlled setting, Richardson and colleagues [18, 21] conducted a series of laboratory experiments using a standardized ischemic pain induction procedure administered to participants with a history of low back pain. Results indicated that pain catastrophizing was uniquely associated with baseline depressed mood, while neither acceptance nor catastrophizing was associated with the negative affect produced by the pain procedure . Furthermore, only pain catastrophizing was associated with perceived pain. However, only pain willingness, a domain of pain acceptance, predicted task performance after the pain induction and moderated the relationship between catastrophizing and pain-related task interference . Of note, prior studies have demonstrated that higher levels of pain catastrophizing are associated with task interference in the context of laboratory-induced pain [22, 23]; however, these studies did not take into account the influence of pain acceptance. As a whole, the literature points to differential relationships between each variable and outcomes, but given mixed findings and the use of different methodologies across studies, additional research is needed to clarify these relationships.
The primary aim of the current study was to clarify the unique contributions of acceptance and catastrophizing in relation to measures of pain intensity, negative affect, and pain-related interference among a relatively large sample (N = 249) of treatment-seeking individuals with long-duration, chronic pain. In particular, we aim to evaluate whether findings from laboratory research using a standardized pain induction procedure translate to this clinical sample. Based on the prior literature and study findings [10, 18, 21], we hypothesized that catastrophizing, but not acceptance, would uniquely associate with greater pain intensity ratings, whereas both acceptance and catastrophizing would be associated with increased pain interference and depressive symptoms. A secondary aim of this study was to explore the interactions between acceptance and catastrophizing in predicting these outcome variables. Consistent with prior research, we hypothesized that acceptance would moderate the relationship between pain catastrophizing and depressive symptoms and between pain catastrophizing and pain interference.
Participants included 249 adults who enrolled in a 3-week intensive interdisciplinary pain rehabilitation program in the northern Midwest region of the USA between April and December 2015. Eligibility criteria for this program were evaluated based on clinical interview and included (1) chronic non-cancer pain in one or more anatomical sites that is severe enough to warrant clinical attention; (2) pain that caused significant distress or impairment in one or more areas of functioning; (3) psychological factors that were judged to have a role in the onset, severity, exacerbation, or maintenance of pain; (4) symptoms that did not appear to be intentionally produced or feigned; and (5) patient that did not require a higher level of care for active substance abuse, medical, or psychiatric problems (e.g., psychosis, active suicidality). Program data indicates that the majority of patients admitted in 2015 had diagnoses of generalized joint/muscle myofascial pain (32.6%), back/spine pain (25.3%), fibromyalgia (17.4%), or headache/migraine pain (7.3%). This study was approved by the institutional review board (IRB) of the treatment study site. The initial sample included 258 participants; however, nine participants were excluded from analyses due to excessive missing data, resulting in a final sample of 249 with complete data.
Participant characteristics (N = 249)
M (SD) or frequency (%)
Native American/Alaska Native
Pain duration (years)
Current opioid use
Canadian Occupational Therapy Performance Measure 
The Canadian Occupational Therapy Performance Measure (COPM) is a semi-structured interview assessing self-reported performance across various activities of daily living (e.g., functional mobility, household management, socialization). Two subscales are generated: performance and satisfaction. Only the performance subscale was used in the current study. The COPM has been psychometrically evaluated among groups of individuals with various conditions (e.g., brain injury, arthritis, pain) with good reliability and validity [25, 26]. This interview was administered specifically by occupational therapists on our interdisciplinary team.
Chronic Pain Acceptance Questionnaire 
The Chronic Pain Acceptance Questionnaire (CPAQ) assesses patients’ acceptance of their pain condition. This 20-item scale has two subscales: willingness to experience pain and engagement in activities despite pain. Each item is rated on a scale from 0 (never true) to 6 (always true), with higher total scores indicating greater pain acceptance. The revised (20-item) scale was used in this study . This measure has good psychometric properties, including adequate internal consistency and validity in chronic pain samples [5, 9]. In the current sample, internal consistency (Cronbach’s alpha) was .82.
Pain Catastrophizing Scale 
The Pain Catastrophizing Scale (PCS) assesses catastrophic thinking in response to pain. This measure contains 13 items and includes three subscale domains: rumination, helplessness, and magnification. Items are rated on a scale from 0 (not at all) to 4 (all the time). Higher scores indicate greater pain catastrophizing, and a score of 30 is indicative of clinical significance. Psychometric investigations suggest good reliability, with high test-retest reliability and adequate internal consistency. Further, research supports the construct validity of the measure, given high correlations with pain and negative affect . Cronbach’s alpha for the current sample was .94, indicating high internal consistency.
Patient Health Questionnaire-9 
The Patient Health Questionnaire-9 (PHQ-9) is a brief self-report measure of depressive symptoms containing nine items rated on a scale from 0 (not at all) to 3 (nearly every day) for the previous 2 weeks. Items are based on diagnostic criteria for depression. Cutoff points of 5, 10, 15, and 20 represent mild, moderate, moderate-severe, and severe levels of depressive symptoms, respectively. This measure has been used extensively in research and has demonstrated good psychometric properties, including high internal consistency and test-retest reliability . Internal consistency in the current sample was .83.
West Haven-Yale Multidimensional Pain Inventory (WHYMPI) 
The West Haven-Yale Multidimensional Pain Inventory (WHYMPI) is a 52-item measure that assesses several dimensions of pain and pain-related functioning. This measure contains three separate sections, the first of which includes the following subscales: pain severity, pain interference, perception of control over life, affective distress, and social support. For the current study, only the pain severity (three items), pain interference (nine items), and affective distress (three items) subscales were used. Items are rated on a scale from 0 (e.g., not at all severe) to 6 (e.g., extremely severe), and subscale scores are generated by averaging the items in a given scale. The WHYMPI has been used extensively in chronic pain research, and psychometric evaluations suggest good reliability and validity for the measure, including internal consistencies ranging from adequate to high across subscales [31, 32]. In the current study, Cronbach’s alpha was .69 for pain-related negative affect, .77 for pain severity, and .90 for pain interference.
Data Analytic Approach
Statistical analyses were conducted using a series of hierarchical multiple regression analyses. For each analysis, age, gender, current self-reported opioid use, and pain duration were entered on the first step, in order to control for the potential influence of these variables on outcome measures. Perceived pain severity was entered on the second step, except in the analysis where pain severity is the primary dependent variable. This approach is consistent with prior research [28, 29, 33, 34]. Pain catastrophizing and acceptance were entered simultaneously on the next step. The interaction between catastrophizing and acceptance was calculated and entered on the final step. A significant interaction indicates the presence of a moderation effect. Where significant interactions exist, the moderation effect is interpreted by conducting follow-up tests of simple slopes. Given that measures of pain acceptance and catastrophizing correlate in the opposite direction (i.e., higher levels of catastrophizing and lower levels of acceptance are associated with worse functioning), analyses were also conducted by re-scoring the interaction measure and including this as a predictor in the calculation of the interaction term; however, this did not change the interpretation or significance of the results for moderation analyses and so was not included in order to maintain consistency in the interpretation of directionality of the factors. All continuous variables were centered on their respective means prior to conducting analyses in order to facilitate interpretation of the regression coefficients. For the analysis in which occupational therapist-rated performance is the outcome variable, data was available for a subset of participants due to a change in data collection (n = 200); accordingly, variables were re-centered for this analysis using the available subset. Statistical assumptions were evaluated before analyses were conducted and revealed no concerns with multicollinearity based on the tolerance and variance inflation factors for each analysis. Power analyses indicated that the sample size was adequate to detect a significant effect. Significance was evaluated using a criterion of p < .05. Data were analyzed using IBM SPSS 22.0 software.
Correlations Between Pain Catastrophizing, Pain Acceptance, and Measures of Pain and Functioning
Means, standard deviations, and correlations between measures (N = 249)
1. Catastrophizing (PCS)
2. Acceptance (CPAQ)
3. Pain severity (WHYMPI)
4. Pain interference (WHYMPI)
5. Pain-related negative affect (WHYMPI)
6. Depressive symptoms (PHQ-9)
7. Occupational performance (COPM)a
Pain Severity (WHYMPI)
Hierarchical regression of pain acceptance and pain catastrophizing on pain severity
Catastrophizing × acceptance
Pain-Related Negative Affect (WHYMPI)
Hierarchical regression of pain acceptance and pain catastrophizing on pain-related negative affect
Catastrophizing × acceptance
Depressive Symptoms (PHQ-9)
Hierarchical regression of pain acceptance and pain catastrophizing on depressed mood
Catastrophizing × acceptance
Pain Interference (WHYMPI)
Hierarchical regression of pain acceptance and pain catastrophizing on pain interference
Catastrophizing × acceptance
Performance in Everyday Living Activities (COPM)
Hierarchical regression of pain acceptance and pain catastrophizing on occupational performance
Catastrophizing × acceptance
Although pain catastrophizing is a robust predictor of adaptation to chronic pain, there are other important psychosocial constructs that may impact distress and disability among individuals with chronic pain. A growing body of research indicates that pain acceptance is a particularly promising predictor of pain interference, mood, and disability [10, 19, 20]. The primary finding of the current study was that pain acceptance is uniquely associated with pain-related interference, pain-related negative affect, and depression, beyond the effects of pain catastrophizing, perceived pain severity, and demographic variables including pain duration and current opioid use. Conversely, only pain catastrophizing was uniquely associated with pain severity but was not a significant predictor of pain interference after accounting for the influence of pain acceptance. These results support the assertion that pain catastrophizing and acceptance are distinct constructs that have different relationships to various outcome variables. Moreover, these results may have implications in clinical interventions for improved pain management.
In the present study, we hypothesized that pain catastrophizing would be a unique predictor of pain intensity. This was supported by our findings and is consistent with prior research. For example, laboratory research with individuals with low back pain suggested that catastrophizing was uniquely associated with perceived pain after a standardized pain induction procedure, but acceptance was not . Similarly, research involving individuals without chronic pain found that higher levels of catastrophizing significantly increased pain perception following experimental pain induction procedures . We also hypothesized that both acceptance and catastrophizing would be associated with pain interference and depressive symptoms. This was partially supported by the findings of this study. Participants in the current study completed a measure of affective distress associated with pain and a measure of depressive symptoms during the past 2 weeks. Results indicated that for each measure of negative affect, both pain acceptance and catastrophizing were unique predictors. This is consistent with previous studies, which have found that both acceptance and catastrophizing are significant predictors of emotional dysfunction . However, results of another study suggested that neither acceptance nor catastrophizing was associated with negative affect related to experimentally induced pain  and yet another study found significant associations between catastrophizing and emotional distress, but not acceptance . Our study supports the position  that acceptance of pain, which includes involvement in important life activities despite pain, is associated with more positive emotional functioning. However, consistent with both the theoretical and empirical literature on pain catastrophizing, having negative evaluations of pain may negatively impact emotional functioning . Accordingly, both constructs may be important in our understanding of negative affect among individuals with chronic pain.
Contrary to expectations, only pain acceptance was uniquely associated with pain-related interference on a self-report measure of pain interference and a semi-structured interview assessing interference in various activities of daily living. This was significant beyond the effects of pain severity or duration. Pain catastrophizing was not a significant predictor in this model, nor was there a significant interaction between acceptance and catastrophizing. Again, prior research has yielded mixed findings on the relationship between catastrophizing, acceptance, and interference in activities. For example, in a laboratory study, both acceptance and catastrophizing were associated with self-reported overall pain interference, whereas only acceptance predicted objectively measured interference on a standardized task . A study by Baranoff and colleagues  found that pain acceptance predicted physical therapy performance, but both acceptance and catastrophizing predicted self-reported functional disability. The current findings suggest that pain acceptance may be uniquely associated with one’s ability to continue to perform life tasks in the context of chronic pain (i.e., lower pain interference). This is consistent with the theoretical basis for chronic pain acceptance, given that persistence with goals and activities despite pain is a central component of this construct .
Unlike several prior studies, we did not find that chronic pain acceptance moderated the relationship between pain catastrophizing and outcome variables. Indeed, there were no statistically significant interactions between acceptance and catastrophizing in moderation analyses in our study. This supports the assertion that these are distinct constructs; however, additional research should be conducted to further understand how they are inter-related.
The results of the current study have theoretical implications for the understanding of different psychological constructs that contribute to pain and related functioning among chronic pain patients. In addition, these findings have important clinical implications. The results of several studies suggest that both catastrophizing and acceptance can be modified in treatment [36, 37] and that these may serve as treatment mechanisms that partially account for treatment improvement [38, 39]. Further, longitudinal research indicates that treatment improvements can be maintained several months following treatment . Interestingly, it does not appear to be necessary to directly target pain acceptance in treatment (e.g., mindfulness-based treatments, acceptance, and commitment therapy) to produce significant increases in this construct. For example, one study comparing mindfulness-based stress reduction (MBSR), cognitive behavioral therapy (CBT), and usual care for chronic pain found no significant differences in pre- to post-treatment changes in acceptance across groups . Similarly, Baranoff and colleagues  found significantly increased acceptance following a CBT treatment program and acceptance was a significant treatment mechanism predicting improvement beyond the effects of decreased pain and catastrophizing. These findings may be related to the overlap between different biopsychosocial treatment approaches to chronic pain, which promote functional restoration versus pain reduction, a process which may require an increase in pain-related acceptance regardless of whether this construct is overtly targeted. More research is needed to understand how to optimize treatment gains in acceptance. Importantly, the results of this study demonstrate relationships between pain acceptance and catastrophizing and outcome variables beyond that which can be explained by the influence of perceived pain intensity, opioid use status, pain duration, age, or gender.
Among the strengths of the current study are the use of a relatively large treatment-seeking population of patients with chronic pain and the use of multiple measures assessing negative affect and pain-related interference. However, findings should be interpreted in the context of several limitations. Importantly, this study is cross-sectional in nature. Accordingly, the assumption of directionality between predictor and outcome variables is based on theoretical assumptions and prior research, and not longitudinal data collection. Further, all data collected in this study relied on patients’ self-report of pain and related functioning and did not include any objective measures (e.g., physical therapy performance). Additionally, there was a substantial lack of racial/ethnic diversity in our sample, which primarily involved individuals who identified as Caucasian. This is particularly important in light of research suggesting that there may be treatment-related differences among individuals identifying with different racial or ethnic groups [41, 42]. However, a recent study indicated that there were no differences between Caucasian, African American, and Latino/Latina groups in pain catastrophizing or pain acceptance improvements following participation in an interdisciplinary pain treatment program . In addition, the use of a heterogeneous sample of patients with various chronic pain conditions may strengthen the representativeness of the data, but this also limits the extent to which these findings potentially apply to specific groups of patients with chronic pain (e.g., chronic low back pain vs. fibromyalgia). It is also important to note that participants in the current study were those presenting for intensive treatment with long duration of illness and significant functional impairment, which limits generalizability to the population of patients with chronic pain experiencing varying degrees of distress and disability. Future research should be conducted to compare catastrophizing and acceptance among different patient populations and assessing potential differences in their relations to outcome variables.
Overall, the findings of the current study support the assertion that chronic pain acceptance is a potentially important psychological construct that influences distress and functioning among individuals with chronic pain. Greater levels of pain acceptance can be conceptualized as a resiliency, or protective, factor for those with chronic pain, which, studies suggest, can be improved with treatment. The current results also suggest that pain catastrophizing is a key vulnerability factor for worse perceived pain and functioning among those with chronic pain, consistent with prior research. Although these constructs overlap, they appear to be distinct factors that have different relationships with outcome variables. Future research aimed at understanding the specific ways in which these constructs may interact and relate to longitudinal treatment outcomes would be a valuable addition to the literature.
Compliance with Ethical Standards
No funding was received for this study.
Conflict of Interest
The authors declare that they have no conflicts of interest.
All procedures performed involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
No financial disclosures.
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