Catastrophizing: A Weaponised Construct
The Pain Catastrophizing Scale (PCS) is a questionnaire frequently given to ME/CFS patients to measure supposedly “catastrophic” thinking about symptoms—the idea that patients make their condition worse by dwelling on it in an exaggerated, worst-case-scenario way. The questionnaire has been used to justify referring patients to psychological treatments (CBT, graded exercise) instead of biomedical investigation. But the evidence says it doesn’t measure what its users claim.
The questionnaire measures how much pain you have, not how you think about it. When researchers look at what the PCS actually correlates with, the answer is pain severity—not dysfunctional thinking. Patients with more severe illness score higher because they have more symptoms, not because their thinking is distorted (ME/CFS Science 2024).
ME/CFS patients score normally once you account for how sick they are. When PCS scores are adjusted for objective disease severity, ME/CFS patients look the same as healthy people. Their scores are proportionate to their actual symptom burden.
The label has been used to deny care. Patients labeled as “catastrophizers” have been refused specialist referrals, had disability claims rejected, and been sent to psychological treatment instead of biomedical investigation. The word functions as a mechanism for dismissing patient-reported symptoms as psychologically amplified.
The evidence against catastrophizing as a meaningful construct goes further. Poort et al. (2021, n=134) ran a formal clinical trial testing whether changes in catastrophizing explained why anyone got better from CBT or graded exercise for severe fatigue—and found they didn’t (Poort et al. 2021). People improved (when they did) because they got fitter or became more active, not because their thinking changed. If catastrophizing doesn’t explain treatment outcomes even in the therapies designed to target it, it’s not a valid treatment target. Sohl and Friedberg (2008, n=43 CFS) found that catastrophizing affects how people remember their fatigue—they recall it as worse than it was—but does not predict how they experience it in the moment or how active they actually are (Sohl and Friedberg 2008). Catastrophizing is about memory for symptoms, not the symptoms themselves.
The accumulating evidence—that the questionnaire measures symptom severity rather than thinking style, that catastrophizing doesn’t predict treatment outcomes, that it affects memory more than experience, and that the label has been used to deny people medical care—supports abandoning the term in ME/CFS clinical and research contexts.