# When Pain Catastrophizing Is Not Catastrophizing: Identifying Normative From Exaggerated Responses Relative to Referent Pain Intensity

## TL;DR

The study shows that pain catastrophizing scores depend on the context of referent pain intensity, suggesting that scores should be interpreted with consideration of the pain context.

## Contribution

The study introduces a method to distinguish normative from exaggerated pain catastrophizing by using referent pain intensity as a contextual anchor.

## Key findings

- PCS scores varied significantly with referent pain intensity, explaining 40% of variability.
- High catastrophizing scores were context-dependent, with no significant sex differences observed.

## Abstract

Although pain catastrophizing has been studied widely, there is no consensus on what constitutes an exaggerated response, that is, true catastrophizing, from what might be proportional unpleasant or negative responses to pain. Most available catastrophizing assessments ask respondents to consider when “in pain,” with no assessment of these referent pain anchors. Thus, the influence of referent pain on catastrophic thinking remains unclear. We aimed to assess consistency across referent pain scenarios and to characterize “high” catastrophizing—representing exaggerated responses relative to referent pain intensity.

A total of 228 adults (152F) completed this observational study. The Pain Catastrophizing Scale (PCS) was completed 4 times interspersed with other assessments. First, with standard instructions, then with specific referent scenarios in a blocked order to minimize order effects. Anticipated scenario pain intensities were rated using a 0–10-cm scale. PCS cross-situational consistency was assessed with intraclass correlations. Mixed linear models evaluated the PCS—referent pain relationship, with and without covariate adjustment.

PCS cross-situational consistency was high, with ICCs = 0.79–0.84. However, total scores varied significantly across referent scenarios, where catastrophizing generally increased with referent pain intensity (R = 0.74, p < 0.0001), and pain explained 40% of PCS variability. The best fit model of “high” catastrophizing, using the 75th percentile, varied with referent pain intensity, underscoring the importance of contextual anchors, without notable sex differences.

Trait PCS scores should not be interpreted as context-free indices of catastrophizing. The wide range of published PCS cut points may in part reflect differences in referent pain, highlighting the need to contextualize catastrophizing scores for appropriate interpretation.