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Pain, catastrophizing, and depression in the rheumatic diseases

A Correction to this article was published on 03 June 2011

This article has been updated


Persistent and disabling pain is the hallmark of osteoarthritis, rheumatoid arthritis, fibromyalgia, and various other rheumatologic conditions. However, disease severity (as measured by 'objective' indices such as those that employ radiography or serology) is only marginally related to patients' reports of pain severity, and pain-related presentation can differ widely between individuals with ostensibly similar conditions (for example, grade 4 osteoarthritis of the knee). Increasing evidence in support of the biopsychosocial model of pain suggests that cognitive and emotional processes are crucial contributors to inter-individual differences in the perception and impact of pain. This Review describes the growing body of literature relating depression and catastrophizing to the experience of pain and pain-related sequelae across a number of rheumatic diseases. Depression and catastrophizing are consistently associated with the reported severity of pain, sensitivity to pain, physical disability, poor treatment outcomes, and inflammatory disease activity, and potentially with early mortality. A variety of pathways, from cognitive to behavioral to neurophysiological, seem to mediate these deleterious effects. Collectively, depression and catastrophizing are critically important variables in understanding the experience of pain in patients with rheumatologic disorders. Pain, depression, and catastrophizing might all be uniquely important therapeutic targets in the multimodal management of a range of such conditions.

Key Points

  • Catastrophizing, the tendency to ruminate about and magnify pain, and depression, a more general mood disorder, are common in patients with chronically painful rheumatic conditions

  • Catastrophizing and depression are risk factors for a number of adverse long-term pain-related outcomes such as physical disability, increased severity of pain, enhanced pain sensitivity and others

  • Catastrophizing and depression are complex biopsychosocial constructs that act through a variety of pathways, including behavioral, cognitive, and neurophysiological pathways

  • Catastrophizing and depression represent important targets of pain treatment, and could be instrumental in helping to tailor pain-management strategies to individual patients

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Figure 1: Depression and catastrophizing: influence on pain-related outcomes.

Change history

  • 28 April 2011

    In the version of this article initially published online, the name of author Christine Cahalan was misspelled. The error has been corrected for the HTML and PDF versions of the article.


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This work was supported by NIH grants AR 051315 (R. R. Edwards), AT 004641 (M. T. Smith and J. A. Haythornthwaite) and AG 034982 (R. R. Edwards), and by awards from the American College of Rheumatology (R. R. Edwards) and Arthritis Foundation (R. R. Edwards).

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R. R. Edwards, C. Cahalan and G. Mensing researched the data for the article. M. Smith, J. Haythornthwaite and R. R. Edwards provided a substantial contribution to discussions of the content. All authors contributed significantly to writing sections of the article, and to reviewing and editing the manuscript before submission.

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Correspondence to Robert R. Edwards.

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Edwards, R., Cahalan, C., Mensing, G. et al. Pain, catastrophizing, and depression in the rheumatic diseases. Nat Rev Rheumatol 7, 216–224 (2011).

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