Pain catastrophizing: a Veteran guide to pain-related worry

Before your appointment

The term can sound judgmental. A useful conversation should begin with what you are experiencing and what support you need. Your pain deserves assessment and care, whether or not worry is part of it.

What is pain catastrophizing?

Pain catastrophizing describes a pattern of recurring distressing thoughts and feelings about current or expected pain. Researchers commonly describe three parts: rumination, magnification, and helplessness. In everyday language, that can mean struggling to stop thinking about pain, expecting a devastating outcome, or feeling that you have no useful options.

Pain psychologist Beth Darnall explains these patterns in her 2017 talk on reducing pain catastrophizing. Her practical point is that coping skills can be learned. In the Q&A, she describes noticing distressing thoughts, developing more balanced responses, and practicing relaxation.

For example, imagine that a familiar flare arrives before a family gathering. The thought “I will never be able to enjoy anything again” reaches far beyond the immediate problem. A care plan can address both the flare and that frightening prediction. This is an illustrative example, not a diagnosis or a patient story.

Does this mean my pain is psychological?

Pain involves interacting biological, psychological, and social influences. The International Association for the Study of Pain emphasizes that a person's account of pain should be respected. Psychological support can belong in the same plan as medical treatment and rehabilitation. IASP's explanation of pain provides that broader context.

For a Veteran who has already had to explain symptoms repeatedly, being told to change your thoughts may feel dismissive. You can ask your clinician to be specific: “What concern are we working on, and how will you continue to assess the physical symptoms?”

A questionnaire about pain-related thoughts cannot determine whether an injury is present or whether new symptoms are safe to ignore. If symptoms are new, substantially different, or worsening unexpectedly, ask your medical team about assessment rather than treating them only as a worry problem.

How CBT for chronic pain can help

Cognitive behavioral therapy for chronic pain, often called CBT-CP, combines practical skills such as pacing activities, relaxation, sleep strategies, and examining pain-related thoughts. The work is collaborative: you and a clinician identify difficulties, practice responses, and review what changes in daily life.

The VA therapist manual describes looking for realistic, balanced interpretations rather than forcing cheerful ones. The aim might be to participate in a manageable part of a family visit, recover a routine, or feel better prepared for a flare. Those goals can matter even when pain remains.

A small exercise to discuss with your clinician

Choose one recent situation and write down the thought that came with it. Keep it specific: “If I attend the gathering, the whole evening will be ruined.” Then consider what you know, what you are predicting, and what your care team has advised.

A balanced response might be: “The evening may be difficult. I can discuss a shorter visit, arrange breaks, and follow my flare plan.” The replacement thought should feel credible to you. It does not have to promise a good outcome.

This example adapts the VA manual's approach to recognizing and reviewing automatic thoughts. Bring it to an appointment if you are unsure how to apply it. Your clinician can help distinguish an untested prediction from a concern that calls for medical attention or a change in activity.

For a familiar flare, the Valor flare-plan guide can help organize that conversation.

What has research found since the talk?

The talk describes early work on a brief skills class. A later randomized trial, published in 2021, compared a two-hour Empowered Relief class with eight sessions of CBT and a health education class in 263 adults with chronic low back pain. At three months, Empowered Relief met the study's noninferiority criteria compared with CBT for catastrophizing, pain intensity, and pain interference. That means the differences stayed within the study's predefined limits. CBT performed better on physical function. Read the trial.

These findings support a shorter option for some patients. They do not establish that every brief class replaces individualized treatment, or that this webinar provides the same intervention.

Veteran-specific evidence is also available. A 2026 randomized trial enrolled 184 patients with chronic musculoskeletal pain at a VA medical center. Six individual, 30-minute CBT sessions added to usual pain care improved pain interference more than usual care alone, with benefits present three months after treatment. Pain interference means how much pain disrupts life. The study involved one medical center and a predominantly male sample, which limits how broadly its findings can be applied. Read the Veteran trial.

Neither trial guarantees an individual result. Agree on what progress would look like for you and when to reassess the plan.

How can Veterans ask for this care?

VA offers CBT-CP across its health care system, including a brief version typically accessed through primary care. Ask your VA team about the options at your facility and whether remote visits are available. VA's CBT-CP information explains the service.

Useful questions include:

• Can you refer me to someone trained in CBT for chronic pain?
• Would a brief program or a longer course fit the problems I want help with?
• How will this fit with rehabilitation, medications, and any other treatment I receive?
• What can we adjust if concentration, fatigue, scheduling, or travel makes participation difficult?
• What will we try next if the first approach does not help?

If you also receive treatment for PTSD or another condition, ask the teams to coordinate their plans. A pain-focused service has a specific purpose; it should be clear how it fits your other care.

Prepare one concern and one goal

You do not need to arrive with a perfect explanation. Bring a recurring worry and something you would like help doing. For example: “I keep expecting a flare whenever I make plans. I want help preparing for a short visit with my family.”

Use the Valor chronic pain care guide to organize the appointment. If you are exploring Valor's home-based support, ask what the program includes and how it would fit your current care. Pain education or coaching should not be assumed to provide the same service as psychotherapy, and the studies above do not establish outcomes for Valor.

About this article

Adapted from Beth Darnall's “Reducing Catastrophizing to Prevent and Treat Chronic Pain,” published by Work Wellness Institute on May 25, 2017. Review covered the complete available automatic transcript, including Q&A, and a selected treatment slide. The examples and referral questions are an editorial adaptation for Veterans; later clinical sources are linked separately. This is an educational article without recorded clinician sign-off.