Interactive effects of pain catastrophizing and mindfulness on pain intensity in women with fibromyalgia

Abstract

The objective of this study was to examine the association between facets of trait mindfulness, pain catastrophizing, and pain severity in a sample of patients with fibromyalgia. Patients with fibromyalgia completed validated baseline and diary assessments of clinical pain, mindfulness, and pain catastrophizing. Multilevel modeling analyses indicated that the daily association between catastrophizing and pain intensity was moderated by certain mindfulness facets. Our findings suggest that various aspects of mindfulness may interact differently with pain and catastrophizing, which may have implications for the design and testing of interventions targeting mindfulness and catastrophizing in fibromyalgia patients.

Keywords

catastrophizing chronic pain fibromyalgia mindfulness pain severity

Introduction

Fibromyalgia (FM) is a complex chronic pain disorder characterized by widespread pain and tenderness. The hallmark symptom of FM is persistent disabling pain in numerous body regions, but FM patients experience other symptoms such as sleep disturbances, fatigue, difficulty thinking clearly (“fibro fog”), stress, anxiety, and depression (Dean et al., 2017). The prevalence of FM in the United States is approximately 6.4 percent and the condition is more common in women than men (Marques et al., 2017). Despite this high prevalence, the etiology of the disorder is still unknown, and the diverse nature of FM symptoms suggests a complex biopsychosocial basis.

Negative pain-related cognitions, also known as catastrophizing, are prominent in individuals with FM (Loggia et al., 2015). Catastrophizing is conceptualized as an negative pattern of pain-related thoughts (Lefebvre, 1981; Turk and Rudy, 1996), including cognitions of helplessness, pessimism, rumination about pain, and magnification of pain complaints (Flor et al., 1993; Geisser et al., 1994; Keefe et al., 1989). In patients with FM, catastrophizing is associated with enhanced nociceptive sensitivity and increased severity of FM symptoms (Edwards et al., 2006; Loggia et al., 2015).

Several psychological and biological mechanisms have been proposed to underlie the impact of catastrophizing on FM symptoms. It has been suggested that catastrophizing interferes with beneficial health behaviors, such as exercise, ultimately leading to a worsening of FM symptoms (Edwards et al., 2006; Taylor et al., 2017). The magnifying aspect of catastrophizing about pain may increase a patient’s attention to pain symptoms, leading to increased pain perception and unpleasant bodily sensations (Edwards et al., 2006). Furthermore, high catastrophizing in FM patients is associated with greater activation in brain regions associated with emotional and motivational modulation of pain (Gracely et al., 2004; Kim et al., 2015; Loggia et al., 2015). Positive or “resilience” factors may counterbalance or mitigate the deleterious effects of negative cognitive/emotional processes such as catastrophizing. For instance, previous research has demonstrated an inverse link between mindfulness and pain intensity in various chronic pain conditions (Ball et al., 2017; Bohlmeijer et al., 2011). Mindfulness has been incorporated into many types of psychological therapy. For example, Mindfulness-Based Stress Reduction (MBSR) therapy incorporates the practices of mindful meditation and has been used to treat patients with chronic pain (Kabat-Zinn, 1982). MBSR integrates different formal mindfulness practices such as meditation, body scan, and yoga exercises (Lauche et al., 2013). Mindfulness-based interventions have been shown to be beneficial for patients with chronic pain and for patients who catastrophize (Hilton et al., 2017; Mun et al., 2014; Schutze et al., 2010; Zeidan et al., 2010, 2012). Although there is some evidence for the efficacy of mindfulness-based practices, a systematic review deemed the evidence insufficient to definitively recommend mindfulness intervention for treating FM symptoms (Lauche et al., 2013).

Mindfulness does not try to reduce negative thoughts but aims at developing awareness and refocusing every time the mind wanders (Cash et al., 2015). Mindfulness is a way of paying attention to the present with non-judgmental awareness (Kabat-Zinn, 1982). It comprises various tenets including attention to external experiences, conversion of internal experiences into words, attending to the present moment, not recognizing thoughts and feelings as negative or positive, and allowing thoughts and feelings to enter and leave the mind (Bohlmeijer et al., 2011). As a result, by adopting alternative, balanced cognitions, the patient’s distress and pain are likely to be reduced (Jensen et al., 2018). FM’s variety of symptoms and comorbid catastrophizing make its interactions with mindfulness more complicated, in that catastrophizing is a dysfunctional way of being overly aware of pain. Because of this, an exploration of the relationship between different facets of mindfulness and catastrophizing is merited, in order to understand which aspects of mindfulness training may be most useful to individuals with high catastrophizing.

While some evidence has identified cross-sectional inverse associations between catastrophizing and mindfulness (Day et al., 2015; Elvery et al., 2017; Mun et al., 2014), we know very little about how catastrophizing and mindfulness interact to influence FM pain symptoms over time. Evidence in the literature of the relationship between mindfulness and catastrophizing has been mixed. Some studies have demonstrated negative associations between measures of mindfulness and pain catastrophizing (Ball et al., 2017; Bohlmeijer et al., 2011; Cassidy et al., 2012; Day et al., 2015; Schutze et al., 2010). However, some studies have indicated no significant relationship between mindfulness and catastrophizing or have even found inverse relationships between catastrophizing and some mindfulness subscales (De Boer et al., 2014). The relationship between mindfulness and pain catastrophizing in the literature remains inconclusive most likely due to the fact that mindfulness is a multifaceted construct that can be measured in a variety of ways (Turner et al., 2016). It has been posited that these inconclusive findings are a result of a two-component model of mindfulness tenets consisting of awareness and acceptance (Bishop et al., 2004). Research suggests that catastrophizing interacts with awareness and acceptance differently, therefore causing a possibly contrary body of research on mindfulness and catastrophizing interactions (Turner et al., 2016). The aim of the present microlongitudinal study was to examine the associations among mindfulness (and its various aspects), catastrophizing, and pain in patients with FM. We hypothesize that trait mindfulness will moderate catastrophizing effects on average daily pain in patients with FM.

Materials and methods

In total, we invited 120 FM patients for screening. Patients were diagnosed as having FM (as confirmed by physician and medical records) and met the recently proposed American College of Rheumatology criteria, which require the presence of widespread pain as well as a number of somatic and cognitive symptoms (Wolfe, 2010). After screening the 120 FM patients, 88 women met the inclusion and exclusion criteria described below. This study was approved by the Partners Human Research Committee, and written informed consent was obtained from all participants.

Participants were screened for the following criteria. The inclusion criteria were as follows: (1) 18–75 years old, (2) female, (3) Wolfe et al.’s (2011) research criteria for FM diagnosis for at least 1 year, (4) baseline pain intensity of at least 4/10 on average and pain report for at least 50 percent of days, and (5) fluent in English and able to provide written informed consent. The exclusion criteria included (1) comorbid acute pain condition or comorbid chronic pain condition that is rated by the subject as more painful than FM, (2) current use of stimulant medications or the fatigue associated with sleep apnea or shift work (e.g. modafinil), (3) pregnant or nursing, (4) any psychiatric disorder involving a history of psychosis (e.g. schizophrenia, severe personality disorders), (5) psychiatric hospitalization in the past 6 months, (6) current or recent use of recreational drugs, (7) current participation in mindfulness therapy, (8) active suicidal ideation, and (9) lower limb vascular surgery or current lower limb vascular dysfunction.

Procedures

The baseline visit included the informed consent, completion of questionnaires, and confirmation of eligibility (described below). In addition, participants were asked to complete daily diaries for 7 days assessing daily pain and negative cognitions on pain (e.g. catastrophizing). Four surveys were used to assess key study variables: (1) Revised Fibromyalgia Impact Questionnaire (FIQR), (2) Brief Pain Inventory (BPI), (3) Pain Catastrophizing Scale (PCS), and (4) Five-Facet Mindfulness Questionnaire (FFMQ).

Clinical measures

Sociodemographic data

Sociodemographic information included date of birth, marital status, educational, current occupational status, duration of pain symptoms, and medical comorbidities (Table 1).

Table 1.

Sociodemographic variables.

	N = 88
Age (mean ± SD)	46.24 ± 12.96
% Married	36
% Caucasian	79.1
% Employed (full-time/part-time)	29.1/30.2
% Education levels (college degree)	70.9

SD: standard deviation.

Catastrophizing

The PCS (Osman et al., 1997) is a well-validated, widely used, self-report measure of catastrophic thinking associated with pain. The PCS has good psychometric properties in pain patients and controls. PCS includes three subscales: rumination, magnification, and helplessness.

FM symptoms

A validated short-form PCS was used to measure daily pain catastrophizing using two questions from each subscale and calculating their sum (Lee et al., 2018). In order to measure FM symptomatology, we used the FIQR and the BPI. The FIQR is 21-question measure with an 11-point numeric rating scale (NRS) of 0 to 10, with 10 being “worst.” The FIQR is divided into three subscales for scoring: (1) “function,” (2) “overall impact,” and (3) “symptoms,” as well as a total overall score to assess the total impact of FM symptoms on a patient’s life. The BPI is a 15-item measure, which includes two multi-item subscales that measure (1) pain intensity and (2) pain interference with daily activities (Cleeland and Ryan, 1994); the BPI is well-validated in chronic pain and is frequently recommended as an outcome measure of pain severity and pain interference.

Mindfulness

A validated 24-item version of the Five-Facet Mindfulness Questionnaire-Short Form (FFMQ-SF) was used (Bohlmeijer et al., 2011) to measure mindfulness. The FFMQ examines five aspects of mindfulness: (1) observing (Observe), (2) describing (Describe), (3) acting with awareness (Act with awareness), (4) detachment (Detach) to inner experience, and (5) non-judging (Non-judging) of inner experience and uses a five-point Likert-type scale with answer choices ranging from 1 (never or very rarely true) to 5 (very often or always true) (Baer et al., 2008). Total scores for each subgroup were calculated by summing the items, with reverse scoring for 12 items that were worded in the opposite direction. Internal consistency coefficients have been reported as adequate to high, and intercorrelations between the five facets have been reported to range from .32 to .56, p < .01 (Bohlmeijer et al., 2011).

Pain intensity

Patients were asked to report their daily average level of pain intensity (0 “no pain” to 100 “pain as bad as it could be”) once a day for a period of 7 days using NRS via the Research Electronic Data Capture (REDCap) system.

Pain catastrophizing

Patients were asked to report their levels of catastrophizing (0 “not at all” to 4 “all the time”) once a day for a period of 7 days using a Likert scale via the Research Electronic Data Capture (REDCap)

Data analysis

All analyses were conducted using IBM-SPSS v.24. Descriptive data for continuous variables were presented as means and standard deviations (SDs), and data for categorical variables were presented as percentages (see Table 1). All analyses were conducted using multilevel modeling (MLM) and the MIXED command in SPSS-IBM. MLM is well-suited to handle the hierarchical nested data structure of the proposed study, in which repeated daily assessments (Level 1 units) were nested within participants. MLM is also well-suited to handle the unequal number of data points across participants due to random missing data (Peugh, 2010; Singer et al., 2003), which is typical of longitudinal study designs.

Data cleaning included correction of out-of-range values and checking for potential outliers. In terms of outlier analysis, we first inspected the potential presence of multivariate outlier cases involving main independent variables (IVs: PCS and FFMQ) and the study outcome (i.e. pain intensity). No multivariate outlier cases were detected. We first conducted preliminary analyses examining the potential confounding influence of participants’ demographic (i.e. age, ethnicity) characteristics on average pain ratings.

In order to select the covariance structure for multilevel models, we compared different types of covariance structures (i.e. AR1, compound symmetry, Toeplitz) by examining model fit information. Comparison of model fit was based on the Akaike information criterion (AIC) and the Schwarz’s Bayesian information criterion (BIC), as recommended (Cheng et al., 2010). Across all models, the best model fit was achieved using the first-order autoregressive (AR1) structure. In addition to providing the best model fit, the AR1 structure permits to account for the autocorrelations between repeated outcome assessments (i.e. pain intensity). For all these reasons, the first-order autoregressive (AR1) structure was selected for our multilevel models.

All multilevel models were built using daily pain ratings as the dependent (i.e. outcome) variable. Level 1 PCS (daily pain catastrophizing) and Level 2 FFMQ (mindfulness subscales) were then simultaneously added to the model, which permitted examination of the effects of catastrophizing and mindfulness facets on daily ratings of FM pain severity. As recommended, all Level 1 scores were centered within participants, and Level 2 scores were centered at the grand mean (Enders and Tofighi, 2007; Nezlek, 2001). Model building followed a sequential procedure (Kopala-Sibley et al., 2012; Russell et al., 2011; Wallace and Chen, 2006), which first involved specifying a random intercept and fixed effects for IVs. When significant fixed effects emerged, slopes were then treated as random effects, and model fit was re-evaluated using the likelihood ratio test. Random parameters were dropped if they resulted in a significantly worse model fit (Schwartz and Stone, 1998; Singer, 1998; Singer et al., 2003). All models were carried out using maximum likelihood estimation and included a first-order autoregressive variance covariance matrix (AR1) in order to account for autocorrelations between repeated assessments.

Results

Descriptive statistics

Descriptive statistics for study measures are presented in Table 1. The average age of patients was 46.24 years (SD = 12.96) and all participants were female. Missing data percentages were low with baseline questionnaires missing only 1.7 percent and diary data missing only 17.6 percent. Table 2 shows Pearson correlations among study measures and Table 4 shows the means and standard deviations of the variables measured.

Table 2.

Pearson correlations between mindfulness traits, daily pain intensity, and catastrophizing.

	FFMQ-Observe	FFMQ-Describe	FFMQ-Detach	FFMQ-Acting with awareness	FFMQ-Non-judging	Daily average pain intensity	Daily catastrophizing	PCS
FFMQ-Observe	–
FFMQ-Describe	.266**	–
FFMQ-Detach	.016	.179**	–
FFMQ-Acting with awareness	.107*	.350**	.232**	–
FFMQ-Non-judging	−.071	.198**	.134**	.369**	–
Daily average pain intensity	.020	−.148**	−.062	−.063	−.122*	–
Daily catastrophizing	−.044	−.315**	−.121*	−.267**	−.390**	.583**	–
PCS	−.071	−.293**	−.336**	−.358**	−.487**	.419**	.746**	–

PCS: Pain Catastrophizing Scale; FFMQ: Five-Facet Mindfulness Questionnaire.

p < .01; **p < .001.

Multilevel models were built to examine the effects of daily catastrophizing scores and mindfulness subscales (FFMQ) on daily pain ratings (see Table 3 and Figures 1 to 3). Multilevel models reveal that there was no significant change in daily pain catastrophizing (B = −0.23, standard error (SE) = 0.32, p > .05) and daily pain intensity (B = −0.06, SE = 0.08, p > .05) over the 7 days measured. A separate model was created for each FFMQ subscale where the Level 2 FFMQ subscale scores were added as IVs to the previous model (Table 3).

Table 3.

Multilevel model examining the influence of trait mindfulness and catastrophizing on the average pain ratings of fibromyalgia patients.

Fixed effects	β	SE	T	p value
Intercept	53.1	1.85	28.67	<.001
FFMQ-Observe	0.026	0.62	0.043	ns
Daily pain catastrophizing	1.96	0.17	11.22	⩽.001
FFMQ-Observe × PCS	−0.12	0.06	−2.1	<.05
Intercept	52.9	1.82	28.93	<.001
FFMQ-Acting with awareness	−0.38	0.56	−0.688	ns
Daily pain catastrophizing	2.02	0.17	11.5	⩽.001
FFMQ-Acting with awareness × PCS	0.13	0.05	2.3	<.05
Intercept	52.9	1.8	29.1	<.001
FFMQ-Non-judging	−0.54	0.38	−1.41	ns
Daily pain catastrophizing	2.05	0.17	11.8	⩽.001
FFMQ-Non-judging × PCS	0.13	0.04	3.4	⩽.001
Intercept	52.89	1.8	29.3	<.001
FFMQ-Describe	−0.71	0.45	−1.59	ns
Daily pain catastrophizing	1.96	0.17	11.2	⩽.001
FFMQ-Describe × PCS	0.01	0.04	0.25	ns
Intercept	52.9	1.8	28.9	<.001
FFMQ-Detach	−0.22	0.42	−0.52	ns
Daily pain catastrophizing	1.96	0.17	11.2	⩽.001
FFMQ-Detach × PCS	0.01	0.04	0.3	ns

β: unstandardized regression coefficient; SE: standard error; FFMQ: Five-Facet Mindfulness Questionnaire; PCS: Pain Catastrophizing Scale.

Daily pain catastrophizing is a Level 1 variable centered within persons. FFMQ-Observe, FFMQ-Acting with Awareness, FFMQ-Non-judging, FFMQ-Describe, and FFMQ-Detach are Level 2 variables centered at the grand mean.

Figure 1.

The significant effects of the interaction between FFMQ-Observe and daily catastrophizing on pain intensity.

Figure 2.

The significant effects of the interaction between FFMQ-Acting with awareness and daily catastrophizing on pain intensity.

Figure 3.

The significant effects of the interaction between FFMQ-Non-judging and daily catastrophizing on pain intensity.

Table 4.

Clinical variables (data presented as mean ± SD).

	Patients
BPI (Severity)	5.13 ± 2
BPI (Interference)	5.47 ± 2.3
Daily PCS (total score)	13.54 ± 6.2
Average pain intensity	52.43 ± 18.9
FIQR Function	15.61 ± 6.5
FIQR Overall	11.14 ± 5.7
FIQR Symptoms	29.35 ± 8.2
FIQR Total	56.11 ± 18.8
FFMQ-Observe	15.45 ± 3
FFMQ-Describe	17.13 ± 4
FFMQ-Detach	14.41 ± 4.5
FFMQ-Acting with awareness	16.12 ± 3.4
FFMQ-Non-judging	16.21 ± 4.7

BPI: Brief Pain Inventory; PCS: Pain Catastrophizing Scale; FIQR: Fibromyalgia Impact Questionnaire-Revised; FFMQ: Five-Facet Mindfulness Questionnaire; SD: standard deviation.

The main effect of the FFMQ-Observe subscale was not significant (B = 0.03, SE = 0.62, p > .05) indicating that the pain intensity was not significantly influenced by FFMQ-Observe. The main effect of daily pain catastrophizing on pain intensity was significant (B = 1.96, SE = 0.17, p < .001) suggesting that pain intensity was significantly influenced by daily pain catastrophizing. There was a significant two-way (catastrophizing*FFMQ-Observe) interaction (B = −0.12, SE = 0.06, p < .05) indicating an influence of pain catastrophizing and FFMQ-Observe on average pain intensity experienced. As can be seen in the figure, high scores on the Observe subscale appear to act as a buffer against the harmful effects of catastrophizing.

The main effect of the FFMQ-Acting with awareness subscale was not significant (B = −0.38, SE = 0.56, ns) indicating that pain intensity was not significantly influenced by FFMQ-Acting with awareness. The main effect of daily pain catastrophizing on pain intensity was significant (B = 2.02, SE = 0.17, p < .001) suggesting that pain intensity was significantly influenced by daily pain catastrophizing. There was a significant two-way (catastrophizing*FFMQ-Acting with awareness) interaction effect (B = 0.13, SE = 0.05, p < .05) indicating that there is an influence of pain catastrophizing and FFMQ-Acting with awareness on pain intensity. The positive interaction term suggests that high-catastrophizing patients with higher scores on the Acting with awareness subscale tend to report the highest pain ratings.

The main effect of the FFMQ-Non-judging self-subscale was not significant (B = −0.54, SE = 0.38, ns) indicating that pain intensity was not significantly influenced by FFMQ-Non-judging. The main effect of daily pain catastrophizing on pain intensity was significant (B = 2.05, SE = 0.17, p < .001) suggesting that pain intensity was significantly influenced by daily pain catastrophizing. There was again a significant two-way (catastrophizing*FFMQ-Non-judging) interaction effect (B = 0.13, SE = 0.04, p < .001) indicating that there is an influence of pain catastrophizing and mindful non-judging on average pain intensity experienced. The nature of this interaction is similar to that for the Acting with awareness subscale; patients who are both high in catastrophizing and who have high non-judgment scores tend to report the highest daily pain ratings.

In addition, separate models were run using the FFMQ-Describe and the FFMQ-Detach subscales. Neither the FFMQ-Describe nor FFMQ-Detach yielded significant results for their main effects (B = −0.71, SE = 0.45, p > .05; B = −0.22, SE = 0.42, p > .05). FFMQ-Describe and FFMQ-Detach also did not have significant interactions with PCS scores (B = 0.01, SE = 0.04, p > .05; B = 0.01, SE = 0.044, p > .05).

Discussion

In this study, we examined the relationship between mindfulness, catastrophizing, and clinical pain. Results of multilevel analyses indicated that the association between catastrophizing and pain intensity was moderated by certain mindfulness facets (Observe, Acting with awareness, and Non-judging), but not others (Describe, Detach). These findings are congruent with previous reports on the association between catastrophizing, pain, and mindfulness (Jensen et al., 2018). The main finding that emerged from our study was that different facets of mindfulness differentially moderated the impact of catastrophizing on daily pain. Multilevel analyses indicated that higher “Observe” scores were associated with a reduced impact of high catastrophizing on FM pain. This moderating effect of FFMQ-Observe is congruent with prior research (Bohlmeijer et al., 2011). Among the mindfulness facets, Observe is the only one assessing external experiences, as opposed to internal feelings and experiences (Day et al., 2017; Lilja et al., 2013). For patients with chronic pain, particularly high catastrophizers, this external focus may be of benefit, potentially helping them distract their focus away from their painful internal experiences (Johnson, 2005). In fact, a prior study showed that chronic pain patients with high catastrophizing derived more analgesic benefit from a distracting stimulus (Schreiber et al., 2014).

In contrast, it seems that the other facets of mindfulness impact the association between catastrophizing and pain in a different way. Specifically, our results indicated that non-judgment and awareness may tend to amplify the negative effects of catastrophizing. This may occur because patients with high levels of these mindfulness characteristics may be more likely to accept negative, catastrophic thoughts and feelings which can lead to increased pain. The thought process associated with the Non-judging facet of mindfulness involves not recognizing thoughts as negative or positive. For patients with pain and high catastrophizing, adopting a non-judging attitude toward these negative thoughts about pain may allow them to have more impact and thus worsen pain (Geisser et al., 2003). Likewise, patients with higher awareness tend to be more aware of their symptoms and experience heightened pain (Picavet et al., 2002). In other words, patients with high levels of catastrophizing and awareness might be more attentive to their daily pain. In light of this, it is not surprising that patients with high catastrophizing and high awareness reported higher pain intensity than patients with low awareness and low catastrophizing.

Because mindfulness is a multidimensional set of skills and facets, and each facet may interact differently with other constructs (Lilja et al., 2013), including catastrophizing (in both positive and negative ways), it is important to distinguish which practices are applied to chronic pain patients, especially FM patients who have high catastrophizing. Previous research has suggested that teaching patients how to mindfully respond to pain-related cognitive content could increase their level of functioning (Day et al., 2017; Jensen, 2011). These results support the efficacy of therapeutic techniques that encourage mindful approaches to pain-related cognitions and emotions (Thorn, 2017; Vowles et al., 2007). Although some of our present results are contrary to existing evidence demonstrating that mindfulness acts as a buffer between negative emotions and pain, the present findings open new avenues in understanding the unique role that mindfulness plays among high pain catastrophizers. The influence of catastrophizing on pain responses is consistent with the findings of several studies (Edwards et al., 2006; Severeijns et al., 2001); however, the unique role of mindfulness makes these findings interesting. Previous research has suggested that cognitive processes in pain models can be divided into two parts: cognitive content and cognitive process (Jensen, 2011; McCracken and Vowles, 2014). Cognitive content refers to what a patient thinks about pain, and cognitive process is the how they think about pain (Day and Thorn, 2014; Jensen, 2011). On one hand, pain catastrophizing scales assess the actual content of thoughts (i.e. “I feel I can’t go on”). On the other hand, the mindfulness scales assess the process by which thoughts are understood (i.e., “In difficult situations, I can pause without immediately reacting”) (Day et al., 2017; Jensen et al., 2018). Prior research has demonstrated that pain catastrophizing is associated with a dysfunctional thinking and evaluation in the appraisal stage (Thorn et al., 2002). Therefore, patients who usually catastrophize may have difficulty assessing and appraising internal states such as thoughts and emotions. The Non-judging and Awareness aspects of mindfulness require a thoughtful appraisal that patients with high scores in catastrophizing might not be able to perform effectively. The opposite direction moderational relationships between catastrophizing and different FFMQ subscales highlight the nuanced nature of the interactions between these constructs. While an accepting, mindful focus on external stimuli may be beneficial in tempering the effects of catastrophizing, a similar focus on internal states and thoughts may tend to aggravate some aspects of chronic pain for patients who experience high levels of catastrophizing (Picavet et al., 2002).

Collectively, mindfulness-based interventions for chronic pain seem to be effective via reductions in catastrophizing and increases in mindfulness. Although a number of issues remain in need of clarification, including the processes by which mindfulness works, the role of cognitive changes needs to be addressed in future clinical trials. This study has a number of limitations that should be highlighted when interpreting these results. One of the main limitations was the restricted time frame of the study (i.e. 1 week), which prevents us from drawing causal conclusions about long-term associations between these factors. In addition, while the strength of the study consists of daily assessment of pain and catastrophizing, we did not collect daily mindfulness ratings, which limits out ability to evaluate fluctuations in mindfulness over time. Another important limitation is the possibility that the mental skill required to meaningfully differentiate between cognitive content and process may require some practice from the patients’ perspective. Thus, as the participants in this study were not treated, asking a naïve patient to “watch” their thoughts or not judge them may be more meaningful after some instruction or practice. As a result, it would be useful to examine the extent to which significant interactions that emerge with baseline data replicate in the same sample of patients after mindfulness interventions. Despite these limitations, the results of this study provide some insight into the possible associations between catastrophizing and mindfulness in chronic pain populations as well as implications for future clinical interventions. Therefore, strategies designed to reduce pain catastrophizing and increase mindfulness, in a way that is meaningful, in this population can also have a beneficial effect at reducing clinical pain.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Baer

Smith

Lykins

et al . (2008) Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment 15: 329–342.

Ball

Nur Shafina Muhammad Sharizan

Franklin

et al . (2017) Does mindfulness meditation improve chronic pain? A systematic review. Current Opinion in Obstetrics and Gynecology 29: 359–366.

Bishop

Lau

Shapiro

et al . (2004) Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice 11: 230–241.

Bohlmeijer

ten Klooster

Fledderus

et al . (2011) Psychometric properties of the five facet mindfulness questionnaire in depressed adults and development of a short form. Assessment 18: 308–320.

Cash

Salmon

Weissbecker

et al . (2015) Mindfulness meditation alleviates fibromyalgia symptoms in women: Results of a randomized clinical trial. Annals of Behavioral Medicine 49: 319–330.

Cassidy

Atherton

Robertson

et al . (2012) Mindfulness, functioning and catastrophizing after multidisciplinary pain management for chronic low back pain. Pain 153: 644–650.

Cheng

Edwards

Maldonado-Molina

et al . (2010) Real longitudinal data analysis for real people: Building a good enough mixed model. Statistics in Medicine 29: 504–520.

Cleeland

Ryan

(1994) Pain assessment: Global use of the Brief Pain Inventory. Annals Academy of Medicine Singapore 23: 129–138.

Day

Lang

Newton-John

et al . (2017) A content review of cognitive process measures used in pain research within adult populations. European Journal of Pain 21: 45–60.

10.

Day

Thorn

(2014) Using theoretical models to clarify shared and unique mechanisms in psychosocial pain treatments: A commentary on McCracken and Morley’s theoretical paper. The Journal of Pain 15: 237–238.

11.

Day

Smitherman

Ward

et al . (2015) An investigation of the associations between measures of mindfulness and pain catastrophizing. The Clinical Journal of Pain 31: 222–228.

12.

De Boer

Steinhagen

Versteegen

et al . (2014) Mindfulness, acceptance and catastrophizing in chronic pain. PLoS ONE 9: e87445.

13.

Dean

Arnold

Crofford

et al . (2017) Impact of moving from a widespread to multisite pain definition on other fibromyalgia symptoms. Arthritis Care & Research 69: 1878–1886.

14.

Edwards

Bingham

3rd Bathon

et al . (2006) Catastrophizing and pain in arthritis, fibromyalgia, and other rheumatic diseases. Arthritis and Rheumatism 55: 325–332.

15.

Elvery

Jensen

Ehde

et al . (2017) Pain catastrophizing, mindfulness, and pain acceptance: What’s the difference? The Clinical Journal of Pain 33: 485–495.

16.

Enders

Tofighi

(2007) Centering predictor variables in cross-sectional multilevel models: A new look at an old issue. Psychological Methods 12: 121–138.

17.

Flor

Behle

Birbaumer

(1993) Assessment of pain-related cognitions in chronic pain patients. Behaviour Research and Therapy 31: 63–73.

18.

Geisser

Casey

Brucksch

et al . (2003) Perception of noxious and innocuous heat stimulation among healthy women and women with fibromyalgia: Association with mood, somatic focus, and catastrophizing. Pain 102: 243–250.

19.

Geisser

Robinson

Keefe

et al . (1994) Catastrophizing, depression and the sensory, affective and evaluative aspects of chronic pain. Pain 59: 79–83.

20.

Gracely

Geisser

Giesecke

et al . (2004) Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain 127: 835–843.

21.

Hilton

Hempel

Ewing

et al . (2017) Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Annals of Behavioral Medicine 51: 199–213.

22.

Jensen

(2011) Psychosocial approaches to pain management: An organizational framework. Pain 152: 717–725.

23.

Jensen

Thorn

Carmody

et al . (2018) The role of cognitive content and cognitive processes in chronic pain: An important distinction? The Clinical Journal of Pain 34: 391–401.

24.

Johnson

(2005) How does distraction work in the management of pain? Current Pain and Headache Reports 9: 90–95.

25.

Kabat-Zinn

(1982) An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry 4: 33–47.

26.

Keefe

Brown

Wallston

et al . (1989) Coping with rheumatoid arthritis pain: Catastrophizing as a maladaptive strategy. Pain 37: 51–56.

27.

Kim

Loggia

Cahalan

et al . (2015) The somatosensory link in fibromyalgia: Functional connectivity of the primary somatosensory cortex is altered by sustained pain and is associated with clinical/autonomic dysfunction. Arthritis & Rheumatology 67: 1395–1405.

28.

Kopala-Sibley

Zuroff

Russell

et al . (2012) Understanding heterogeneity in borderline personality disorder: Differences in affective reactivity explained by the traits of dependency and self-criticism. Journal of Abnormal Psychology 121: 680–691.

29.

Lauche

Cramer

Dobos

et al . (2013) A systematic review and meta-analysis of mindfulness-based stress reduction for the fibromyalgia syndrome. Journal of Psychosomatic Research 75: 500–510.

30.

Lee

Protsenko

Lazaridou

et al . (2018) Encoding of self-referential pain catastrophizing in the posterior cingulate cortex in fibromyalgia. Arthritis & Rheumatology 70: 1308–1318.

31.

Lefebvre

(1981) Cognitive distortion and cognitive errors in depressed psychiatric and low back pain patients. Journal of Consulting and Clinical Psychology 49: 517–525.

32.

Lilja

Lundh

L-G

Josefsson

et al . (2013) Observing as an essential facet of mindfulness: A comparison of FFMQ patterns in meditating and non-meditating individuals. Mindfulness 4: 203–212.

33.

Loggia

Berna

Kim

et al . (2015) The lateral prefrontal cortex mediates the hyperalgesic effects of negative cognitions in chronic pain patients. The Journal of Pain 16: 692–699.

34.

McCracken

Vowles

(2014) Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist 69: 178–187.

35.

Marques

Santo

Berssaneti

et al . (2017) Prevalence of fibromyalgia: Literature review update. Revista Brasileira de Reumatologia 57: 356–363.

36.

Mun

Okun

Karoly

(2014) Trait mindfulness and catastrophizing as mediators of the association between pain severity and pain-related impairment. Personality and Individual Differences 66: 68–73.

37.

Nezlek

(2001) Multilevel random coefficient analyses of event- and interval-contingent data in social and personality psychology research. Personality and Social Psychology Bulletin 27: 771–785.

38.

Osman

Barrios

Kopper

et al . (1997) Factor structure, reliability, and validity of the Pain Catastrophizing Scale. Journal of Behavioral Medicine 20: 589–605.

39.

Peugh

(2010) A practical guide to multilevel modeling. Journal of School Psychology 48: 85–112.

40.

Picavet

HSJ

Vlaeyen

Schouten

(2002) Pain catastrophizing and kinesiophobia: Predictors of chronic low back pain. American Journal of Epidemiology 156: 1028–1034.

41.

Russell

Moskowitz

Zuroff

et al . (2011) Anxiety, emotional security and the interpersonal behavior of individuals with social anxiety disorder. Psychological Medicine 41: 545–554.

42.

Schreiber

Campbell

Martel

et al . (2014) Distraction analgesia in chronic pain patients: The impact of catastrophizing. Anesthesiology 121: 1292–1301.

43.

Schutze

Rees

Preece

et al . (2010) Low mindfulness predicts pain catastrophizing in a fear-avoidance model of chronic pain. Pain 148: 120–127.

44.

Schwartz

Stone

(1998) Strategies for analyzing ecological momentary assessment data. Health Psychology 17: 6–16.

45.

Severeijns

Vlaeyen

van den Hout

et al . (2001) Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. The Clinical Journal of Pain 17: 165–172.

46.

Singer

Willett

Singer

et al . (2003) Doing data analysis with the multilevel model for change. In: Singer

Willett

(eds) Applied Longitudinal Data Analysis: Modeling Change and Event Occurrence. New York: Oxford University Press, pp. 96–97.

47.

Singer

(1998) Using SAS PROC MIXED to fit multilevel models, hierarchical models, and individual growth models. Journal of Educational and Behavioral Statistics 23: 323–355.

48.

Taylor

Davis

Yeung

et al . (2017) Relations between adaptive and maladaptive pain cognitions and within-day pain exacerbations in individuals with fibromyalgia. Journal of Behavioral Medicine 40: 458–467.

49.

Thorn

(2017) Cognitive Therapy for Chronic Pain: A Step-by-Step Guide (2nd edn). New York: Guilford Press.

50.

Thorn

Boothby

Sullivan

(2002) Targeted treatment of catastrophizing for the management of chronic pain. Cognitive and Behavioral Practice 9: 127–138.

51.

Turk

Rudy

(1996) Cognitive factors in chronic pain and disability. In: Dobson

Craig

(eds) Advances in Cognitive-Behavioral Therapy, vol. 2. Thousand Oaks, CA: SAGE, pp. 83–115.

52.

Turner

Anderson

Balderson

et al . (2016) Mindfulness-based stress reduction and cognitive behavioral therapy for chronic low back pain: Similar effects on mindfulness, catastrophizing, self-efficacy, and acceptance in a randomized controlled trial. Pain 157: 2434–2444.

53.

Vowles

McCracken

Eccleston

(2007) Processes of change in treatment for chronic pain: The contributions of pain, acceptance, and catastrophizing. European Journal of Pain 11: 779–787.

54.

Wallace

Chen

(2006) A multilevel integration of personality, climate, self-regulation, and performance. Personnel Psychology 59: 529–557.

55.

Wolfe

Clauw

Fitzcharles

et al . (2011) Fibromyalgia criteria and severity scales for clinical and epidemiological studies: A modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. The Journal of Rheumatology 38: 1113–1122.

56.

Wolfe

(2010) New American College of Rheumatology criteria for fibromyalgia: A twenty-year journey. Arthritis Care & Research 62: 583–584.

57.

Zeidan

Gordon

Merchant

et al . (2010) The effects of brief mindfulness meditation training on experimentally induced pain. The Journal of Pain 11: 199–209.

58.

Zeidan

Grant

Brown

et al . (2012) Mindfulness meditation-related pain relief: Evidence for unique brain mechanisms in the regulation of pain. Neuroscience Letters 520: 165–173.