Catastrophizing and depression are the main predictors for pain in patients with CFS

It is known that chronic fatigue syndrome (CFS) patients often present unhelpful pain beliefs / behaviors, such as catastrophic thinking, depressive thoughts, passive coping strategies and fear of movement or kinesiophobia.  Several of these beliefs and personality traits could potentially enhance pain perception, a process known as cognitive emotional sensitization.

Therefore we studied the role of several psychosocial determinants of chronic pain in CFS patients.[1] Pain catastrophizing, depression, kinesiophobia and several passive coping styles were related to pain, but catastrophizing and depression were the main predictors for pain measured at the same time and measured 6 to 12 months later in patients with CFS with chronic widespread musculoskeletal pain. Depression and catastrophizing were able to predict 23% of the pain variance 6 to 12 months later.

Since these factors may be at the basis of chronic pain and act as important therapy barriers in CFS it is important to consider these psychosocial factors in the approach of CFS patients experiencing chronic widespread pain. The therapeutic approach of these patients is indeed a real challenge, because there is not a clear source of nociception and complaints are widespread and general. Furthermore, CFS patients often present with low tolerance or fear to certain physical therapy modalities (e.g. exercise, painful manual techniques, etc.) and those typical unhelpful pain cognitions / behaviors. Therefore, besides or before addressing the physical components, the treatment approach of these patients should account for these cognitive and emotional aspects.

The latter may in fact be the first point of interest in the therapeutic approach, since these factors are related to the pain and may be important therapy barriers. A possible tool to influence these psychological factors and in consequence eventually pain is providing pain education, which has already been shown to be efficacious in reducing pain catastrophizing in CFS patients.[2]

About Mira Meeus

Dr Mira MeeusMira Meeus obtained her PhD degree in Rehabilitation Sciences and Physiotherapy in 2008 at the Vrije Universiteit Brussel (Belgium) on central sensitization in chronic fatigue syndrome. Presently, she is assistant professor at Ghent University and at the Artesis University College Antwerp (Belgium). Her main research topics of interest are chronic pain, central sensitization, exercise pathophysiology and rehabilitation in chronic pain populations like those suffering from chronic fatigue syndrome, fibromyalgia, and chronic whiplash associated disorders. She is (co-)author of +/- 40 publications in international peer-reviewed journals and is 2012 awardee of the IASP early research career grant.


[1] Meeus M, Nijs J, Van Mol E, Truijen S, & De Meirleir K (2012). Role of psychological aspects in both chronic pain and in daily functioning in chronic fatigue syndrome: a prospective longitudinal study. Clinical rheumatology, 31 (6), 921-9 PMID: 22349876

[2] Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, & Truijen S (2010). Pain physiology education improves pain beliefs in patients with chronic fatigue syndrome compared with pacing and self-management education: a double-blind randomized controlled trial. Arch Phys Med Rehab, 91 (8), 1153-9 PMID: 20684894


  1. Ass Pro Meeus may have confused several aspects of the poorly named condition Chronic Fatigue Syndrome (CFS/ME). I know scores of sufferers of the condition & hardly one of them could be said to have fear of exercise. They do have a rational fear of a consequence known as Post Exertional Malaise (PEM). It’s described as a feeling of being utterly ill – much like having influenza – following exercise, & appears hours or days following activities exceeding the individual’s capacity. The fear is not of the exercise, but a learned respect for the consequences of certain activities or levels of activity. Many sufferers have gone from being fit & healthy one day to being fully incapacitated the next – in one example a 30 year old female who was worked as a full time dance instructor developed the condition & within a fortnight developed severe PEM following a fire alarm in her building where she had to descend 16 flights of steps – something she was neither afraid of nor something that would have affected her a fortnight earlier. She certainly wasn’t expecting the consequence so “fear” is not attributable. This is of course one example among many.

    The second point I would like to address is the confusion of cause & effect of pain in CFS. CFS itself I would suggest is a diagnosis made by lazy doctors. I don’t believe the condition exists – though I believe sufferers with the diagnosis are very ill. In many cases pain is the cause of the CFS & not a symptom or effect. With proper examination the cause of pain may be able to be discovered & diagnosed. Fatigue is a symptom of almost every single diagnosis of illness, including pain conditions. It is negligent in doctors to diagnose CFS in cases where pain exists. A pain condition could cause every symptom attributable to CFS, so I feel Ass Pro Meeus is oversimplifying in this instance. Depression is a cause of nociception in any otherwise healthy individual. Attributing this finding to CFS patients is not unique nor helpful.

    My third point is that depression is an effect & not a cause of chronic illness. It would be crazy for a patient sick for years & whose condition is addressed in a similar manner described above by many doctors not to be depressed. This depression is reactive, not clinical. It is not the cause of the illness but the consequence & exists only for short periods in most patients. It is a natural reaction facing the loss of the lives they anticipated living & the uncertain future. In fact in criteria for diagnosis of CFS (e.g. Fukuda) a diagnosis of clinical depression would exclude a diagnosis of CFS.

    CFS patients with anxiety who are treated with Cognitive Behavioural Therapy do show a decrease in anxiety, however this does not affect their condition – i.e. improvement in anxiety (catatrophising) does not improve CFS, nor pain in CFS.

    The abstract described here shows a study that is full of confusions. I would question the selection of “CFS” patients, and would recommend that patients diagnosed with CFS presenting with pain ought to be fully assessed for pain conditions which would explain their other symptoms. The end result in most cases of pain will not improve their symptoms significantly but will result in a better understanding of the condition by the patient & their doctors.

    I’m afraid this short address is another instance of misunderstanding & negligence in the medical profession routinely experienced by sufferers of the condition ridiculously labelled “CFS”. A discussion on central sensitisation would have been more interesting & possibly more enlightening.

    I do believe that pain education will improve coping in patients with pain – this is not exclusive to patients with “CFS”. That is why we run successful pain education programmes. Again, this is no breakthrough.

    What would be interesting would be to discover what pain condition these patients have that is causing “fatigue” & other symptoms. This does not apply to all patients with a “CFS” diagnosis, but should be considered in the diagnosis.

  2. I am very interested in this topic as a particular case I am treating is exactly as you explain plus a fear of exercise due to orthostatic intolerance and the suggestion that these patients get worse with the smallest amount of exercise. i would love to have additional info on this topic

    KAL Reply:

    Whether the conclusions above apply to your patient depends on the definition used for diagnosis (there are multiple definitions used which define substantially different cohorts making extrapolation of conclusions difficult at best) and co-occurring pain conditions such as fibromylagia. Physiologists at the Fatigue Lab at the University of the Pacific have a standardized protocol used to objectively measure the abnormalities relating to post exertional malaise lasting 24 hours or longer unrelieved by rest. Exercise is recommended up to the point where the patient’s symptoms are exacerbated in patients with PEM. Pushing beyond this point may cause relapse according to these researchers. And Cook et al 2012 notes the importance of accounting for comorbid conditions when conducting CFS research, particularly when examining psychophysiological responses to exercise.