International Journal of Behavioral Medicine

, Volume 24, Issue 4, pp 542–551 | Cite as

Unique Contributions of Acceptance and Catastrophizing on Chronic Pain Adaptation

  • Julia R. Craner
  • Jeannie A. Sperry
  • Afton M. Koball
  • Eleshia J. Morrison
  • Wesley P. Gilliam
Article

Abstract

Purpose

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.

Method

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.

Results

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.

Conclusion

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.

Keywords

Catastrophization Chronic pain/psychology Psychological adaptation 

Introduction

Several decades of research have established that psychological factors, particularly cognitive appraisal variables, are strongly related to adaptation to chronic pain [1]. 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 [3]. 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 [4]. 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 [5]. 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 [6]. 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 [9]. 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) [9]. 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 [11]. 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 [12].

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 [13] 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 [13]. Similarly, pain catastrophizing has been conceptualized from a pain-fear-avoidance perspective with more negative outcomes [14]. 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 [7], or as the underlying context in which catastrophic thoughts occur [9]. 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 [18]. 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 [18]. 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 [9].

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 [19], while others have demonstrated that both pain catastrophizing and acceptance uniquely predict functional disability [10]. Similarly, acceptance has been found to significantly moderate the relationship between pain severity and negative affect [20], while another study found that catastrophizing, but not acceptance, significantly mediated the relationship between pain intensity and emotional dysfunction [19], and another found that both catastrophizing and acceptance were associated with depressed mood [10].

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 [18]. 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 [21]. 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.

Methods

Participants

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.

The final sample included 161 women (64.7%) and 88 men (35.3%) who were on average 50.12 years of age (SD = 13.5) and with 15.12 years of education (SD = 3.25). The majority of participants reported that they were married (63.1%) or single (21.7%) and identified as Caucasian/White (93.2%). Approximately half of participants reported that they were currently using opioid pain medications at the time of admission (45.4%). Patients endorsed an average pain duration of 10.54 years (SD = 10.51). Participant characteristics are described in Table 1.
Table 1

Participant characteristics (N = 249)

Variable

M (SD) or frequency (%)

Age (years)

50.12 (13.50)

Education (years)

15.12 (3.25)

Gender

 Men

88 (35.3%)

 Women

161 (64.7%)

Race

 White/Caucasian

232 (93.2%)

 Black/African American

6 (2.4%)

 Native American/Alaska Native

3 (1.2%)

 Asian/Pacific Islander

1 (.4%)

 Other/undisclosed

7 (2.8%)

Marital status

 Married

157 (63.1%)

 Single

54 (21.7%)

 Divorced

23 (9.2%)

 Widowed

10 (4.0%)

 Other/undisclosed

5 (2.0%)

Ethnicity

 Hispanic/Latino/Latina

7 (.4%)

Pain duration (years)

10.54 (10.51)

Current opioid use

113 (45.4%)

Measures

Canadian Occupational Therapy Performance Measure [24]

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 [5]

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 [5]. 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 [27]

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 [28]. Cronbach’s alpha for the current sample was .94, indicating high internal consistency.

Patient Health Questionnaire-9 [29]

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 [30]. Internal consistency in the current sample was .83.

West Haven-Yale Multidimensional Pain Inventory (WHYMPI) [31]

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.

Results

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

Pain catastrophizing and acceptance were significantly correlated in the opposite direction (r = −.55), which is consistent with the theoretical assumption that higher catastrophizing is associated with low pain acceptance and vice versa. Further, the moderate correlation between the two measures supports the assertion that these are distinct, but related, constructs. Pain catastrophizing was significantly (ps < .01) and positively correlated with perceived pain intensity, pain interference, affective distress due to pain, and depression and negatively correlated with occupational therapist-rated functioning. Conversely, pain acceptance was significantly correlated in the negative direction with pain severity, pain interference, affective distress, and depressive symptoms and positively correlated with occupational therapist-rated patient self-report of performance. Means, standard deviations, and correlations between measures are included in Table 2.
Table 2

Means, standard deviations, and correlations between measures (N = 249)

Measure

M (SD)

Theoretical range

Actual range

1.

2.

3.

4.

5.

6.

7.

1. Catastrophizing (PCS)

25.11 (11.61)

0–52

1–52

 

2. Acceptance (CPAQ)

52.77 (15.64)

0–120

13–99

−.55**

3. Pain severity (WHYMPI)

4.19 (1.02)

0–6

1.33–6

.37**

−.29**

4. Pain interference (WHYMPI)

4.57 (1.02)

0–6

1–6

.36**

−.51**

.45**

5. Pain-related negative affect (WHYMPI)

3.38 (1.15)

0–6

0–6

.47**

−.44**

.35**

.43**

6. Depressive symptoms (PHQ-9)

11.62 (5.84)

0–27

0–27

.49**

−.49**

.32**

.50**

.60**

7. Occupational performance (COPM)a

2.80 (1.03)

1–10

1–7

−.29**

.30**

−.29**

−.31**

−.23**

−.25**

an = 200

**p < .001

Pain Severity (WHYMPI)

Results of a multiple hierarchical regression suggested that the demographic variables entered in the first step (age, gender, opioid use, pain duration) accounted for a non-significant 2.5% of the variance in pain severity (F(4,244) = 1.56, p = .19). Next, pain catastrophizing and acceptance were entered in the second step, which accounted for an additional 14.2% of the variance in pain severity (FΔ(2,242) = 20.69, p < .001). Finally, the interaction between catastrophizing and acceptance was entered in the third step; however, this did not contribute additional significant variance (R2Δ = .001, FΔ(1,241) = .43, p = .51), suggesting no moderation effect. Results indicated that only pain catastrophizing was significantly associated with pain severity (β = .29, p < .001). Pain acceptance was not a unique predictor of this relationship (β = −.13, p = .07). See Table 3.
Table 3

Hierarchical regression of pain acceptance and pain catastrophizing on pain severity

Variable

B

SE (B)

β

R2Δ

Step 1

.025

 Age

.003

.005

.040

 

 Sex

−.175

.136

−.082

 

 Pain duration

.006

.006

.059

 

 Opioid use

−.231

.133

−.113

 

Step 2

.142***

 Catastrophizing

.026

.006

.291***

 

 Acceptance

−.008

.005

−.130

 

Step 3

.001

 Catastrophizing × acceptance

<.001

<.001

−.039

 

Total F(7,241) for step 3 = 6.99***. Adjusted R2 = .145

***p < .001

Pain-Related Negative Affect (WHYMPI)

Results of a multiple hierarchical regression on negative affect associated with pain indicated that age, gender, opioid use, and pain duration accounted for 1.5% of the variance in affect, which was non-significant (F(4,244) = .92, p = .45). The addition of pain severity on step 2 added an additional 11.9% of explained variance (FΔ(1,243) = 33.45, p < .001). On step 3, pain catastrophizing and acceptance were added, and results revealed that these variables accounted for an additional 17.1% of the variance in negative affect (FΔ(2,241) = 29.67, p < .001). Finally, the interaction term entered on the fourth step was not significant, accounting for .6% of explained variance (FΔ(1,240) = 2.00, p = .16). Both catastrophizing (β = .27, p < .001) and acceptance (β = −.24, p < .001) were significant predictors in this model. See Table 4.
Table 4

Hierarchical regression of pain acceptance and pain catastrophizing on pain-related negative affect

Variable

B

SE (B)

β

R2Δ

Step 1

.015

 Age

−.006

.006

−.065

 

 Sex

−.157

.155

−.065

 

 Pain duration

.011

.007

.096

 

 Opioid use

−.030

.151

−.013

 

Step 2

.119***

 Pain severity

.396

.068

.350***

 

Step 3

.171***

 Catastrophizing

.027

.007

.268***

 

 Acceptance

−.018

.005

−.241***

 

Step 4

.006

 Catastrophizing × acceptance

<.001

<.001

.077

 

Total F(8,240) for step 4 = 13.54***. Adjusted R2 = .29

***p < .001

Depressive Symptoms (PHQ-9)

Results of a multiple hierarchical regression on depressive symptoms indicated that the demographic variables were not significant predictors in the model, accounting for 3.3% of the variance in depressive symptoms (F(4,244) = 2.09, p = .08). Next, pain severity was significant, contributing an additional 9.8% in explained variance (FΔ(1,243) = 27.37, p < .001). In the third step, the addition of pain catastrophizing and acceptance explained an additional 22.4% of the variance in depression (FΔ(2,241) = 41.78, p < .001). The interaction between catastrophizing and acceptance was not significant in the fourth step (R2Δ = .004, FΔ(1,240) = 1.43, p = .23), suggesting no moderation effect. Both pain catastrophizing (β = .27, p < .001) and pain acceptance (β = −.30, p < .001) were unique predictors of depressive symptoms. See Table 5.
Table 5

Hierarchical regression of pain acceptance and pain catastrophizing on depressed mood

Variable

B

SE (B)

β

R2Δ

Step 1

.033

 Age

−.042

.029

−.097

 

 Sex

−1.041

.777

−.085

 

 Pain duration

.084

.036

.151*

 

 Opioid use

−.124

.757

−.011

 

Step 2

.098***

 Pain severity

1.813

.346

.317***

 

Step 3

.224***

 Catastrophizing

.139

.032

.277***

 

 Acceptance

−.113

.023

−.303***

 

Step 4

.004

 Catastrophizing × acceptance

−.002

.002

−.063

 

Total F(8,240) for step 4 = 16.77***. Adjusted R2 = 34

*p < .05; ***p < .001

Pain Interference (WHYMPI)

Next, a multiple hierarchical regression was conducted using pain interference as the dependent variable. Age, gender, current opioid use, and pain duration were not significant predictors and accounted for 1.5% of the variance in pain interference (F(4,244) = .92, p = .45). In the second step, pain severity contributed an additional 20.2% in explained variance in pain interference (FΔ(1,243) = 63.83, p < .001). The addition of pain catastrophizing and pain acceptance in the third step explained an additional 16.2% of the variance in pain interference (FΔ(2,241) = 31.50, p < .001). On the fourth step, the interaction between catastrophizing and acceptance was entered and contributed an additional non-significant .4% of explained variance (FΔ(1,240) = 1.60, p < .21). As hypothesized, chronic pain acceptance was a significant predictor of pain interference (β = −.41, p < .001). Contrary to expectations, pain catastrophizing was not significant in this model beyond the effects of pain acceptance (β = .03, p = .64). See Table 6.
Table 6

Hierarchical regression of pain acceptance and pain catastrophizing on pain interference

Variable

B

SE (B)

β

R2Δ

Step 1

.015

 Age

−.006

.005

−.081

 

 Sex

−.176

.137

−.083

 

 Pain duration

.001

.006

.014

 

 Opioid use

−.105

.134

−.051

 

Step 2

.202***

 Pain severity

.456

.058

.456***

 

Step 3

.361***

 Catastrophizing

.003

.006

.030

 

 Acceptance

−.027

.004

−.407***

 

Step 4

.004

 Catastrophizing × acceptance

<.001

<.001

.065

 

Total F(8,240) for step 4 = 18.67***. Adjusted R2 = 36

***p < .001

Performance in Everyday Living Activities (COPM)

Finally, a multiple hierarchical regression was conducted using occupational therapist-rated performance in everyday activities, as an additional self-report measure of pain-related interference. The first step, including demographic variables, was not significant (F(4,195) = 1.77, p = .14) and explained 3.5% of the variance in occupational performance. Pain severity, entered in the second step, was significant (FΔ(1,194) = 16.82, p < .001), contributing an additional 7.7% to explained variance. Next, the third step, which included pain catastrophizing and pain acceptance, was significant (FΔ(2,192) = 5.55, p = .005) and explained an additional 4.9% of the variance in performance. As before, the interaction between pain catastrophizing and acceptance was not significant (R2Δ < .001, FΔ(1,191) = .005, p = .94). Only pain acceptance was a significant predictor (β = .24, p = .003), whereas pain catastrophizing was not (β = .02, p = .82). See Table 7.
Table 7

Hierarchical regression of pain acceptance and pain catastrophizing on occupational performance

Variable

B

SE (B)

β

R2Δ

Step 1

.035

 Age

−.014

.006

−.180*

 

 Sex

.070

.154

.033

 

 Pain duration

−.003

.007

−.027

 

 Opioid use

.003

.150

.001

 

Step 2

.077***

 Pain severity

−.288

.070

−.279***

 

Step 3

.049**

 Catastrophizing

.002

.007

.019

 

 Acceptance

.016

.005

.242**

 

Step 4

<.001

 Catastrophizing × acceptance

<.001

<.001

−.072

 

Total F(8,191) for step 4 = 4.57***. Adjusted R2 = .125

*p < .05; **p < .01; ***p < .001

Discussion

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 [18]. Similarly, research involving individuals without chronic pain found that higher levels of catastrophizing significantly increased pain perception following experimental pain induction procedures [35]. 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 [10]. However, results of another study suggested that neither acceptance nor catastrophizing was associated with negative affect related to experimentally induced pain [18] and yet another study found significant associations between catastrophizing and emotional distress, but not acceptance [19]. Our study supports the position [18] 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 [2]. 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 [21]. A study by Baranoff and colleagues [10] 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 [10].

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 [37]. 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 [40]. Similarly, Baranoff and colleagues [10] 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 [41]. 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.

Notes

Compliance with Ethical Standards

Funding

No funding was received for this study.

Conflict of Interest

The authors declare that they have no conflicts of interest.

Ethical Approval

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

Informed consent was obtained from all individual participants included in the study.

Disclosures

No financial disclosures.

References

  1. 1.
    Roth RS, Geisser ME, Williams DA. Interventional pain medicine: retreat from the biopsychosocial model of pain. Transl Behav Med. 2012;2:106–16.CrossRefPubMedGoogle Scholar
  2. 2.
    Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9:745–58.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Jensen MP, Turner JA, Romano JM. Changes in beliefs, catastrophizing, and coping are associated with improvement in multidisciplinary pain treatment. J Consult Clin Psychol. 2001;69:655–62.CrossRefPubMedGoogle Scholar
  4. 4.
    Keefe FJ, Brown GK, Wallston KA, Caldwell DS. Coping with rheumatoid arthritis pain: catastrophizing as a maladaptive strategy. Pain. 1989;37:51–6.CrossRefPubMedGoogle Scholar
  5. 5.
    McCracken LM, Vowles KE, Eccleston C. Acceptance of chronic pain: component analysis and a revised assessment method. Pain. 2004;107(1–2):159–66.CrossRefPubMedGoogle Scholar
  6. 6.
    McCracken LM. Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain. 1998;74:21–7.CrossRefPubMedGoogle Scholar
  7. 7.
    McCracken LM, Eccleston C. Coping or acceptance: what to do about chronic pain? Pain. 2003;105:197–204.CrossRefPubMedGoogle Scholar
  8. 8.
    McCracken LM, Eccleston C, Bell L. Clinical assessment of behavioral coping responses: preliminary results for a brief inventory. Eur J Pain. 2005;9(1):69–78.CrossRefPubMedGoogle Scholar
  9. 9.
    Vowles KE, McCracken LM, Eccleston C. Patient functioning and catastrophizing in chronic pain: the mediating effects of acceptance. Health Psychol. 2008;27(2 Suppl):S136–43.CrossRefPubMedGoogle Scholar
  10. 10.
    Baranoff J, Hanrahan SJ, Kapur D, Conoor JP. Acceptance as a process variable in relation to catastrophizing in multidisciplinary pain treatment. Eur J Pain. 2013;17(1):101–10.CrossRefPubMedGoogle Scholar
  11. 11.
    de Vries HJ, Reneman MF, Groothoff JW, Geertzen JHB, Brouwer S. Workers who stay at work despite chronic nonspecific musculoskeletal pain: do they differ from workers with sick leave? J Occup Rehabil. 2012;22(4):489–502.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Chiros C, O’Brien WH. Acceptance, appraisals, and coping in relation to migraine headache: an evaluation of interrelationships using daily diary methods. J Behav Med. 2011;34(4):307–20.CrossRefPubMedGoogle Scholar
  13. 13.
    Sturgeon JA, Zautra AJ. Psychological resilience, pain catastrophizing, and positive emotions: perspectives on comprehensive modeling of individual pain adaptation topical collection on psychiatric management of pain. Curr Pain Headache Rep. 2013;17(3):317.CrossRefPubMedGoogle Scholar
  14. 14.
    Ramírez-Maestre C, Esteve R, López-Martínez AE. Fear-avoidance, pain acceptance and adjustment to chronic pain: a cross-sectional study on a sample of 686 patients with chronic spinal pain. Ann Behav Med. 2014;48(3):402–10.CrossRefPubMedGoogle Scholar
  15. 15.
    Esteve R, Ramírez-Maestre C, López-Martínez AE. Adjustment to chronic pain: the role of pain acceptance, coping strategies, and pain-related cognitions. Ann Behav Med. 2007;33(2):179–88.CrossRefPubMedGoogle Scholar
  16. 16.
    de Boer MJ, Steinhagen HE, Versteegen GJ, Struys MMRF, Sanderman R. Mindfulness, acceptance and catastrophizing in chronic pain. PLoS One. 2014;9(1):e87445.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Poppe C, Crombez G, Devulder J, Hanoulle I, Vogelaers D, Petrovic M. Personality traits in chronic pain patients are associated with low acceptance and catastrophizing about pain. Acta Clin Belg. 2011;66(3):209–15.PubMedGoogle Scholar
  18. 18.
    Richardson EJ, Ness TJ, Doleys DM, Baños JH, Cianfrini L, Richards JS. Depressive symptoms and pain evaluations among persons with chronic pain: catastrophizing, but not pain acceptance, shows significant effects. Pain. 2009;147(1–3):147–52.CrossRefPubMedGoogle Scholar
  19. 19.
    Gillanders DT, Ferriera NB, Bose S, Esrich T. The relationship between acceptance, catastrophizing and illness representations in chronic pain. Eur J Pain. 2013;17(6):893–902.CrossRefPubMedGoogle Scholar
  20. 20.
    Kratz AL, Davis MC, Zautra AJ. Pain acceptance moderates the relation between pain and negative affect in female osteoarthritis and fibromyalgia patients. Ann Behav Med. 2007;33(3):291–301.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Richardson EJ, Ness TJ, Doleys DM, Baños JH, Cianfrini L, Scott RJ. Catastrophizing, acceptance, and interference: laboratory findings, subjective report, and pain willingness as a moderator. Health Psychol. 2010;29(3):299–306.CrossRefPubMedGoogle Scholar
  22. 22.
    Crombez G, Eccleston C, Baeyens F, Eelen P. When somatic information threatens, catastrophic thinking enhances attentional interference. Pain. 1998;75(2–3):187–98.CrossRefPubMedGoogle Scholar
  23. 23.
    Crombez G, Eccleston C, Van den Broeck A, Van Houdenhove B, Boubert L. The effects of catastrophic thinking about pain on attentional interference by pain: no mediation of negative affectivity in healthy volunteers and in patients with low back pain. Pain Res Manag. 2002;7(1):31–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N. The Canadian Occupational Performance Measure: an outcome measure for occupational therapy. Can J Occup Ther. 1990;57(2):82–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Carpenter L, Baker GA, Tyldesley B. The use of the Canadian Occupational Performance Measure as an outcome of a pain management program. Can J Occup Ther. 2001;68(1):16–22.CrossRefPubMedGoogle Scholar
  26. 26.
    Eyssen ICJM, Steultjens MPM, Oud TAM, Bolt EM, Maasdam A, Dekker J. Responsiveness of the Canadian Occupational Performance Measure. J Rehabil Res Dev. 2011;48(5):517–28.CrossRefPubMedGoogle Scholar
  27. 27.
    Sullivan MLJ, Bishop SR, Pivik J. The Pain Catastrophizing Scale: development and validation. Psychol Assessment. 1995;7:524–32.CrossRefGoogle Scholar
  28. 28.
    Osman A, Barrios FX, Kopper BA, et al. Factor structure, reliability, and validity of the Pain Catastrophizing Scale. J BehavMed. 1997;20:589–605.Google Scholar
  29. 29.
    Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Blackwell TL, McDermott A. Test review: Patient Health Questionnaire – 9 (PHQ-9). Rehabil Couns Bull. 2014;57:246–8.CrossRefGoogle Scholar
  31. 31.
    Kerns IV RD, Turk DC, Rudy TE. West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain. 1985;23:345–56.CrossRefPubMedGoogle Scholar
  32. 32.
    Verra ML, Angst F, Staal JB, Brioschi R, Lehmann S, Aeschlimann A, de Bie RA. Reliability of the Multidimensional Pain Inventory and stability of the MPI classification system in chronic back pain. BMC Musculoskelet Disord. 2012;13:155–63.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Craner J, Gilliam W, Sperry J. Rumination, magnification, and helplessness: how do different aspects of pain catastrophizing impact pain-related outcomes? Clin J Pain. 2015; doi:10.1097/AJP.0000000000000355.Google Scholar
  34. 34.
    Sullivan MJ, Lynch ME, Clark AJ. Dimensions of catastrophic thinking associated with pain experience and disability in patients with neuropathic pain conditions. Pain. 2005;113:310–5.CrossRefPubMedGoogle Scholar
  35. 35.
    Kristiansen FL, Olesen AE, Brock C, Parisa G, Petrini L, Mogil JS, Drewes AM. The role of pain catastrophizing in experimental pain perception. Pain Pract. 2014;14:E136–45.CrossRefPubMedGoogle Scholar
  36. 36.
    McCormick ZL, Gagnon CM, Caldwell M, Patel J, Kornfeld S, Atchison J, et al. Short-term functional, emotional, and pain outcomes of patients with complex regional pain syndrome treated in a comprehensive interdisciplinary pain management program. Pain Med. 2015;16:2357–67.CrossRefPubMedGoogle Scholar
  37. 37.
    Townsend CO, Kerkvliet JL, Bruce BK, Rome JD, Hooten WM, Luedtke CA, Hodgson JE. A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: comparison of treatment outcomes based on opioid use status at admission. Pain. 2008;140:177–89.CrossRefPubMedGoogle Scholar
  38. 38.
    Craner J, Sperry J, Evans M. Pain catastrophizing and outcomes of a 3-week comprehensive pain rehabilitation program: treatment mechanisms and maintenance of gains. Pain Med. 2016; doi:10.1093/pm/pnw070.PubMedGoogle Scholar
  39. 39.
    Vowles KE, McCracken LM, Eccleston C. Processes of change in treatment for chronic pain: the contributions of pain, acceptance, and catastrophizing. Eur J Pain. 2007;11:779–87.CrossRefPubMedGoogle Scholar
  40. 40.
    Turner J, Sherman K, Anderson M, Balderson B, Cook A, Cherkin D. Catastrophizing, pain self-efficacy, mindfulness, and acceptance: relationships and changes among individuals receiving CBT, MBSR, or usual care for chronic back pain. Pain. 2015;16(4):S96.CrossRefGoogle Scholar
  41. 41.
    Gagnon CM, Matsuura JT, Smith CC, Stanos SP. Ethnicity and interdisciplinary pain treatment. Pain Practice. 2014;14(6):532–40.CrossRefPubMedGoogle Scholar
  42. 42.
    Thorne BE, Day ME, Burns J, Kuhajda MC, Gaskins SW, Sweeney K, McConley R, Ward LC, Cabbil C. Randomized trial of group cognitive behavioral therapy compared with a pain education control for low-literacy rural people with chronic pain. Pain. 2011;152:2710–20.CrossRefGoogle Scholar

Copyright information

© International Society of Behavioral Medicine 2017

Authors and Affiliations

  • Julia R. Craner
    • 1
    • 2
    • 3
  • Jeannie A. Sperry
    • 1
  • Afton M. Koball
    • 4
  • Eleshia J. Morrison
    • 1
  • Wesley P. Gilliam
    • 1
  1. 1.Department of Psychiatry and PsychologyMayo ClinicRochesterUSA
  2. 2.Department of Psychiatry and Behavioral MedicineSpectrum Health SystemGrand RapidsUSA
  3. 3.College of Human MedicineMichigan State UniversityGrand RapidsUSA
  4. 4.Department of Behavioral HealthGundersen Health SystemLa CrosseUSA

Personalised recommendations