Patient Functioning and Catastrophizing in Chronic Pain: The Mediating Effects of Acceptance

Abstract

Catastrophic thinking is associated with disability and distress for many with chronic pain. The effects of catastrophic thinking likely rely not only on the content or frequency of the thoughts, but also on other cognitive, behavioral, and environmental influences that are present. One possible influence is acceptance, which involves experiencing thoughts, moods, or sensations without some of their supplemental psychological effects on behavior, especially when these effects can contribute to less freedom in daily functioning.
The present study sought to explore how acceptance influenced the relations between catastrophizing and patient functioning in 344 individuals with chronic pain.
Chronic Pain Acceptance Questionnaire, Pain Catastrophizing Scale.
Analyses indicated that acceptance mediated the effects of catastrophic thinking on depression, anxiety and avoidance, and physical and psychosocial functioning with indirect effect tests suggesting that the variance in functioning predicted by catastrophizing was significantly reduced with the inclusion of acceptance.
These results suggest that research and clinical work in the area may benefit from a broadened perspective where the occurrence of catastrophic thinking is considered within the wider context of the behavioral processes that give this thinking its impact.

Full text

Patient Functioning and Catastrophizing in Chronic Pain:
The Mediating Effects of Acceptance
Kevin E. Vowles, Lance M. McCracken, and Christopher Eccleston
Royal National Hospital for Rheumatic Diseases and University of Bath
Objective: Catastrophic thinking is associated with disability and distress for many with chronic pain.
The effects of catastrophic thinking likely rely not only on the content or frequency of the thoughts, but
also on other cognitive, behavioral, and environmental influences that are present. One possible influence
is acceptance, which involves experiencing thoughts, moods, or sensations without some of their
supplemental psychological effects on behavior, especially when these effects can contribute to less
freedom in daily functioning. Design: The present study sought to explore how acceptance influenced the
relations between catastrophizing and patient functioning in 344 individuals with chronic pain. Main
Outcome Measures: Chronic Pain Acceptance Questionnaire, Pain Catastrophizing Scale. Results:
Analyses indicated that acceptance mediated the effects of catastrophic thinking on depression, anxiety
and avoidance, and physical and psychosocial functioning with indirect effect tests suggesting that the
variance in functioning predicted by catastrophizing was significantly reduced with the inclusion of
acceptance. Conclusion: These results suggest that research and clinical work in the area may benefit
from a broadened perspective where the occurrence of catastrophic thinking is considered within the
wider context of the behavioral processes that give this thinking its impact.
Keywords: acceptance, catastrophizing, acceptance and commitment therapy, chronic pain, mediation
Catastrophic thinking, a process of exaggerated worrying, help-
less, and distress-amplifying thoughts in response to pain, occurs
with some degree of regularity among patients with chronic pain
(Keogh & Asmundson, 2004; Sullivan et al., 2001). A large
evidence base demonstrates strong links between the experience of
catastrophic thinking and distress, disability, and pain intensity
(e.g., Burns, Kubilus, Bruehl, Harden, & Lofland, 2003; Cook,
Brawer, & Vowles, 2006; Sullivan et al., 2001). Such findings
have influenced the development of conceptual models, such as the
fear-avoidance model of chronic pain, and related treatment ap-
proaches (Vlaeyen & Linton, 2000).
The effects of catastrophic thoughts on patient functioning pre-
sumably rely not only on their content or frequency, but also on the
experiences and current circumstances of the person having them.
For example, behavior disruptions and suffering from catastrophic
thoughts are more likely to occur when they overwhelm other
potential influences on behavior and limit response choices, such
as when they lead to exaggerated emotional responses and unnec-
essary avoidance. On the other hand, every person, including those
who suffer with chronic pain, has likely had the experience of
having a catastrophic thought but dismissing it as unimportant or
of no particular concern. Therefore, there is a need for analyses of
the processes by which catastrophic thinking exerts its behavioral
and emotional impact.
Emerging psychological theories discuss acceptance in relation
to effects of the experience of aversive thoughts, moods, or sen-
sations (Hayes, Strosahl, & Wilson, 1999). Acceptance entails
having contact with painful or discouraging experiences without
some of their added influences on behaviors, particularly influ-
ences that lead to unnecessary avoidance, limit participation in life,
or impede the pursuit of important goals (Hayes et al., 1999;
McCracken, 1998, 2005). With regard to chronic pain, this line of
reasoning suggests that sensations of pain, even when intense,
need not inhibit success at living a meaningful life, nor do they
need to be fought against, ignored, suppressed, or conquered
before success can occur. Although the notion that it is possible to
live with these difficult and distressing aspects of chronic pain is
somewhat counterintuitive, there is increasing supportive evidence
for acceptance of chronic pain, with a general finding that greater
acceptance is associated with less disability, distress, and utiliza-
tion of healthcare resources (Dahl, Wilson, & Nilsson, 2004;
Kratz, Davis, & Zautra, 2007; McCracken, Carson, Eccleston, &
Keefe, 2004; McCracken, Vowles, & Eccleston, 2005; Wicksell,
Melin, & Olsson, 2007), better future functioning (McCracken &
Eccleston, 2005), and greater success at living according to per-
sonal values (McCracken & Yang, 2006).
If the process of acceptance offers real clinical utility, however,
it needs to apply to the experience of chronic pain in a broad sense.
It is not intended to include sensations of pain alone, but the entire
conglomeration of aversive sensations, thoughts, and emotions that
are a natural part of the chronic pain experience—in effect, all of
these contribute to the “pain” of chronic pain. If the process of
acceptance is to offer a true conceptual advance and real clinical
utility, its role in chronic pain will need to be demonstrated in
relation to the wider array of elements in the pain experience.
Kevin E. Vowles, Lance M. McCracken, and Christopher Eccleston, the
Department of Psychology, Pain Management Unit, Royal National Hos-
pital for Rheumatic Diseases and University of Bath.
Correspondence concerning this article should be addressed to Kevin E.
Vowles. Pain Management Unit, Royal National Hospital for Rheumatic
Diseases, Upper Borough Walls, Bath BA1 1RL, United Kingdom. E-mail:
K.Vowles@Bath.ac.uk
Health Psychology Copyright 2008 by the American Psychological Association
2008, Vol. 27, No. 2(Suppl.), S136–S143 0278-6133/08/$12.00 DOI: 10.1037/0278-6133.27.2(Suppl.).S136
S136
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