Perseverative Thinking May Partially Mediate the Association Between Pain Intensity and Catastrophizing

Perseverative thinking may partially mediate the relationship between pain and catastrophizing.

Perseverative thinking may partially mediate the relationship between pain and catastrophizing, according to study results published in the European Journal of Pain.

Perseverative thinking refers to a cognitive process in which a person experiences repetitive and prolonged negative thoughts about themselves, their situation, or their symptoms. Pain catastrophizing has been strongly linked to negative pain outcomes and poorer treatment response. Although there is an array of interventions aimed at managing pain catastrophizing, the effect size of these modalities may be modest and not clinically important. According to metacognitive theory, perseverative thinking is maintained in great part by higher order beliefs, referred to as metacognitions. With this study, investigators sought to examine the role of perseverative thinking and metacognition in pain catastrophizing.

A total of 510 adults (mean age, 37.5 years; 60% women) with chronic pain (≥3 months’ duration) were recruited online through Amazon Mechanical Turk. The most common site of pain in this cohort was in the lower back (n=305; 59.8%). Most patients (54.9%) had clinically significant catastrophizing scores, as indicated by scores on the Pain Catastrophizing Scale ≥24.

Perseverative thinking was found to partially mediate the effect of pain intensity on pain catastrophizing, accounting for 20% of the total effect. However, these effects of perseverative thinking only occurred at high levels of negative metacognition, with statistically significant effects only for scores ≥21 (60th percentile) on the negative pain metacognition scale (Pain Metacognitions Questionnaire-N). The effect of positive metacognition was statistically significant for scores ≥11 (50th percentile) on the Pain Metacognitions Questionnaire-P scale.

Related Articles

Thus, in individuals with greater levels of negative vs positive metacognition, pain intensity may have an indirect effect on pain catastrophizing via perseverative thinking.

Study limitations include its cross-sectional design, possible indirect effects of variables not included in the model, and the reliance on self-reported measures.

“Screening for unhelpful metacognitions, using the Pain Metacognitions Questionnaire, and then replacing these with more helpful metacognitions and associated coping behaviours has the potential to improve the efficacy of treatments for [pain catastrophizing] and pain outcomes more generally,” concluded the researchers.

Follow @ClinicalPainAdv


Schütze R, Rees C, Smith A, Slater H, O’Sullivan P. Metacognition, perseverative thinking, and pain catastrophizing: a moderated-mediation analysis [published online September 8, 2019]. Eur J Pain. doi:10.1002/ejp.1479