Fear, Catastrophizing, and Training

Austin Baraki
June 23, 2018
Reading Time: 10 minutes
Table of Contents


    Regular followers are likely familiar with our interest in a “biopsychosocial” approach to both training and injury, particularly the modifiable psychological factors that can have significant effects on performance, recovery, and subsequent adaptation. One important phenomenon we discuss frequently in the context of acute injury and persistent pain is catastrophizing.

    Catastrophizing is a complex psychological process (sometimes described as a cognitive distortion) in which an individual appraises a situation in a maladaptive, excessively negative way — for example, immediately thinking of the “worst-case scenario“.

    It consists of three fundamental components:

    1) Rumination, e.g.:
    “I can’t stop thinking about how much pain I’m in, and how badly I want it to stop<.”

    2) Magnification, e.g.:
    “I am worried that something bad is going to happen to me, or that my pain will get worse.”

    3) Helplessness, e.g.:
    “This pain is overwhelming, and there is nothing I can do to about it.”

    In the setting of pain, a clinical tool known as the Pain Catastrophizing Scale (PCS) can help assess these primary factors (see here). Higher catastrophizing scores predict greater severity and duration of pain, as well as greater utilization of analgesics and healthcare services. It is may be associated with certain personality traits as well.

    Catastrophizing and fear are therefore targets of psychological therapies for persistent pain, such as Cognitive Behavioral Therapy (CBT), Cognitive Functional Therapy (CFT), and general Pain Neuroscience Education (PNE).

    It is also why I always ask questions like “What do you think is going on?” and “What are you most worried about?” to get an idea of how they’re interpreting their own symptoms — and the answers to these questions are often very telling.

    But how do we develop these ideas in the first place? Where do they come from?

    Social Learning

    There is a substantial evidence base showing how we can acquire some of these beliefs socially. In the face of uncertainty, we take cues from our environment and learn how to identify, interpret, and respond to unfamiliar experiences. This starts in early childhood and is a continuous process of observation and interaction with others – and you’ve probably never paid much attention to this yourself.

    For example, observing your parents’ pain-related beliefs, behaviors, and coping styles (including fear-avoidance and catastrophizing) as a child tends to result in you exhibiting similar coping styles and responses as an adult [1,2]. In other words, the more your parents freaked out about their own pain, the more likely you are to later exhibit similar responses as an adult. You learned how to respond to pain from them.

    Similarly, among children with persistent pain, frequent attention/attending to pain from parents, granting permission to avoid activity due to pain, and less autonomy in self-managing symptoms all predict greater long-term disability [3]. In other words, if you had a painful condition as a child (e.g., cancer, sickle cell disease, or some other pain syndrome), the more your parents freaked out about your pain, were hypervigilant and constantly attentive to it, and/or took control of managing your symptoms, the more disabled you’re likely to become from pain over the long term.

    Additionally, actively observing others in pain also commands your attention and triggers spontaneous neurological and psychological reactions, including reflexive distress, appraisal, and empathy [4,5]. These processes modify your future response to noxious stimuli when placed in a similar context.

    For example, witnessing a training partner writhe in agony during an exacerbation of acute back pain, or years of watching a family member complain about “bad knees” throughout their lives produces changes in your own brain that can later influence your own experience of back or knee pain. Similarly, your own response to pain — whether “positive” or “negative” — can impact those around you by priming them to have similar experiences in the future.

    We also readily learn and internalize these ideas from those in a position of authority — like doctors, therapists, or coaches. One survey of 130 individuals with persistent back pain found that they believed persistent low back pain is

    1) due to the body being like a ‘broken machine’,

    2) permanent/immutable,

    3) complex, and

    4) very negative.

    However, the most important finding of this study was that 89% of the participants in this study reported learning these deeply negative beliefs from their health care professionals [6]. This represents an enormous problem in the healthcare field that must be rectified if we ever hope to reduce the burden of persistent pain in society.

    Training & Pain

    So far we’ve discussed how catastrophizing involves “worst-case scenario” thinking resulting from rumination, magnification, and helplessness in the face of pain. It is commonly accompanied by fear-avoidance beliefs and behaviors, and how all these ideas can be learned through social observation and interaction — particularly from contact with those in a position of authority.

    However, this phenomenon doesn’t just occur in the setting of pain — just about every symptom or complaint can be associated with or exacerbated by catastrophizing. And we’ve observed many people doing this in daily life or in training without even realizing it. So, how do these concepts relate to what we do in the gym?

    Let’s start by looking at “pain” in the gym — particularly, delayed-onset muscle soreness.

    In one group of healthy participants who underwent an experimental protocol to induce delayed-onset muscle soreness (DOMS) in the low back, their baseline fear of pain predicted reductions in maximal force production (i.e., strength) and increased interference of pain in daily activities [7]. In other words, pre-training psychological factors were predictive of how much their post-training strength performance was affected, and how much they were affected by muscle pain. Similarly, in another trial where shoulder DOMS was induced in healthy participants, baseline fear of pain was also predictive of post-training disability and fear of movement [8].

    These findings suggest that your thoughts and beliefs about pain (and probably about soreness itself) influence the severity of soreness and performance hit you experience from a training stress. And although this has not been formally studied in the same way as persistent back pain, based on the previously discussed data it seems likely that these beliefs are also learned socially, by observing and interacting with those around us and our coaches.

    Similarly, when we work with aging patients or trainees, there is often a large focus on general aches and “creaky joints” as evidence of the aging process inevitably “wearing the body out,” reflecting a limited capacity to train and/or adapt.

    In fact, patellofemoral crepitus (“crunchy knees”) has never been definitively linked with joint pathology; research has actually shown that subjects are typically most fearful of the meaning of crepitus, believing it represents joint damage, premature aging, or degeneration — proof of having “bad knees” [9]. This makes individuals feel “old”, anxious, and fearful, and therefore reluctant to participate in physical activities that provoke crepitus (like squatting, for example).

    At this point, it should not be surprising that these incorrect beliefs are often similarly learned from healthcare providers and coaches. Even in the setting of clinical osteoarthritis, there is ample evidence showing that fear-avoidance behavior and catastrophizing is associated with more severe symptoms and greater functional impairment, whereas the “objective” X-ray appearance of joint degeneration typically provides little predictive value for these things.

    The historical observation of someone who experienced knee problems or reported having “bad knees” — whether a friend, relative, coach, or healthcare provider — results in an assumption of the same process taking place, confirming fears and leading to reduction or avoidance of activity. For example, regularly hearing a lifter in their 60s describe the inevitable degeneration and pain of aging joints likely primes the younger trainee to fear, experience, and report more of these symptoms as they get older. This is especially common when interacting with experienced lifters and coaches — everyone has heard the retired powerlifter telling the younger lifter “Your body will pay for lifting those heavy weights when you’re older!

    This phenomenon reflects the innumerable daily influences we experience as a social species, which prime us to draw conclusions and create narratives about our own symptoms and experience that are often incorrect and/or harmful.


    As previously discussed, the relevance of these psychosocial processes is not just limited to pain. Let’s consider the phenomenon of fatigue, which has been defined as:

    “A disabling symptom in which physical and cognitive function is limited by interactions between performance fatigability and perceived fatigability.” [10]

    This is a fancy way of saying that fatigue is a disabling symptom due to both:

    1) The decline in an objective measure of performance over time during activity (performance fatigability), AND

    2) Changes in sensations that regulate the integrity of the performer, due to changes in homeostasis and psychological factors (perceived fatigability, see fig 2 for details).

    This suggests that there is both a physiologic and a psychological component to fatigue. Most readers are well acquainted with the experience of fatigue from a physiologic component after trying a set of tempo squats. But given what we have learned about psychosocial factors and their influence on pain, it may be interesting to see whether similar concepts apply to fatigue as well.

    Fortunately, we have evidence!

    Catastrophizing & Fatigue

    A 2013 systematic review of 14 studies looked at the association of catastrophizing and fatigue in the setting of chronic illness [11]. The review included 14 studies, of which 7 looked at early stage breast cancer patients, 3 studied chronic fatigue syndrome, 2 multiple sclerosis, 1 fibromyalgia, and 1 healthy volunteers. Eight of the 14 studies were longitudinal in design (i.e., they followed the patients over time), whereas the rest were cross-sectional (i.e., they took a “snapshot” of subjects at one point in time). The studies used several assessment methods, including a tool known as the Fatigue Catastrophizing Scale (FCS, see here) analogous to the PCS described above.

    Nearly all of the studies showed strong, significant associations between catastrophizing and fatigue severity, and also showed that catastrophizing was a predictor of fatigue’s disruptiveness in daily physical performance. They also point out that “the unnecessary increase of attention to the symptom in catastrophizers may influence the person’s motivation” … which has clear implications for daily function and performance.

    When considered outside the context of clinical medicine, the findings in this study seem to match our coaching experience in that trainees who are perpetually hyper-focused (ruminating) on various symptoms of fatigue, aches, and/or their general recovery status tend to underperform and may exhibit poorer motivation to train.

    Many of these trainees have an excessively negative perception of their recovery abilities (magnification), viewing themselves as less resilient or uniquely hyper-sensitive to certain training or life stressors. They are often heard complaining that “Doing [X] absolutely WRECKS me!”

    This perception may be related to:

    • undertaking a novel training approach that they are unfamiliar with, unadapted to, mistrusting and/or apprehensive of
    • general beliefs related to the physiology of recovery
    • general beliefs related to aging, or sex differences between men and women.
    • having certain medical conditions or taking certain medications

    And these problems are also often seen as relatively fixed or permanent conditions (helplessness) that are unlikely to ever improve.

    Practical Implications

    We have observed similar negative beliefs about fatigue as reflecting the body’s fragility, especially with age, needing extreme caution and exquisitely precise dosing of training stress in order to avoid the dreaded overtraining syndrome – a phenomenon which essentially does not occur in the context of general population trainees undertaking resistance training a few times per week.

    These beliefs likely come from social interactions with fellow lifters and/or those in a position of authority — whether more experienced lifters, coaches, or medical professionals.

    For example, when a more experienced lifter tells their less experienced counterpart catastrophic details about how horribly their knees ache in response to a high intensity squat session, how “DESTROYED” they felt after a high volume deadlift session, or how they “CAN BARELY WALK” after their last week of training, there is little recognition of the cumulative social effects these statements have. They prime the other person to perceive & experience the same things when placed under similar conditions in the future.

    Our trainees quickly learn to avoid using phrases like “that workout SUCKED / was AWFUL / HELL / TRASH“, or reporting “I feel WRECKED / DESTROYED / HIT BY A TRUCK / LIKE DEATH / LIKE GARBAGE“. These are all extremely common descriptors you’ll hear in a regular gym setting, on the internet, or elsewhere – you have probably said them yourself at some point. People say these sorts of things with a bizarre pride, without realizing the underlying thought processes and appraisals they reflect, even if used in jest.

    Instead, if a trainee is experiencing more symptoms fatigue than usual, we actively reframe their perception in the same way we help trainees reframe their appraisals of pain and injury. We’ll take a step back and review their training to make sure the “dose” of stress was reasonable, or to see whether a lower stress period is indicated. But we’ll also point out that being “wrecked” doing ten pull-ups, for example, more likely reflects that you are simply unadapted to doing pull-ups (perhaps even undertrained), rather than being inherently sensitive to a particular movement pattern, exercise intensity, or volume dose.

    We provide reassurance that it will improve, that they will tolerate it better and better the more trained they become, and that this is part of the process of building the cumulative adaptations necessary to optimize future performance. In this light, avoiding the feared activity becomes the lifter’s problem to solve, and they learn to see it as a challenge that is fully within their capacity to overcome. This method of reframing facilitates more productive training from a physical and mental standpoint, generally improves motivation to train, and may help avoid unnecessary alterations to training or excessive deloading.


    So, in the same way we encourage healthcare providers to be mindful of the language and narratives used when interacting with patients, we push for the same mindfulness and care in a coaching context to avoid inducing these negative beliefs in our trainees.

    When it comes to fatigue and recovery, we emphasize the trainability of recovery capacity, in that the more training you perform at reasonable “doses”, the better you get at tolerating and recovering from training, regardless of age, sex, health, or disease. Of course, the specific dose will ultimately prove different for everyone, but the key is that everyone can improve from where they are now, and should not be afraid to do so.

    Given the general dose-response effects seen in training, if the goal is to optimize training outcomes (rather than to achieve some minimum acceptable level of adaptation), we typically need the trainee to tolerate more training from a physiologic and a psychological standpoint.

    As usual, in anticipation of readers reactions I must point out that we are obviously not denying the physiologic reality of fatigue, its effects on performance, or suggesting that fatigue is “all in your head”, as we can all observe objective performance decreases under fatigue.

    However, there is a very significant, non-negligible subjective / perceptual component to fatigue that we can take control of and modify as coaches and lifters if we know how to identify and reframe it — and with this skill, you may ultimately surprise yourself with how well you can adapt and perform under fatigue.

    So, pay attention to your thought processes, behavioral responses, and your interactions with others when it comes to training, fatigue, and injury. Feeding into histrionics is unnecessary and harmful, while stoicism is likely beneficial here. In short: there is no need to make the perception of fatigue or pain worse than it needs to be for yourself or for your trainees.


    1. Stone et al. Adolescents’ Observations of Parent Pain Behaviors: Preliminary Measure Validation and Test of Social Learning Theory in Pediatric Chronic Pain. J Ped Psych Jan 2017.
    2. Kraljevic et al. Parents’ pain catastrophizing is related to pain catastrophizing of their adult children. Int. J. Behav. Med. 2012 March
    3. Palermo et al. Family and Parent Influences on Pediatric Chronic Pain: A Developmental Perspective. Am Psychol. 2014 Feb-Mar.
    4. Fan et al. The Neural Mechanisms of Social Learning from Fleeting Experience with Pain. Front Behav Neurosci. 2016 Feb
    5. Kenneth C. Social Communication Model of Pain.  PAIN July 2015.
    6. Setchell J. Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC Musculoskelet Disord. 2017 Nov 17;18(1):466.
    7. Bishop, Mark D, Maggie E Horn, and Steven Z George. “Exercise-Induced Pain Intensity Predicted by Pre-Exercise Fear of Pain and Pain Sensitivity.” The Clinical journal of pain 27.5 (2011): 398–404. PMC. Web. 8 June 2018.
    8. George SZ1, Dover GC, Fillingim RB. Fear of pain influences outcomes after exercise-induced delayed onset muscle soreness at the shoulder. Clin J Pain. 2007 Jan;23(1):76-84.
    9. Robertson CJ, Hurley M, Jones F. People’s beliefs about the meaning of crepitus in patellofemoral pain and the impact of these beliefs on their behaviour: A qualitative study. Musculoskelet Sci Pract. 2017 Apr;28:59-64.
    10. Enoka RM, Duchateau J. Translating Fatigue to Human Performance. Medicine and science in sports and exercise. 2016;48(11):2228-2238. doi:10.1249/MSS.0000000000000929.
    11. Lukkahatai N, Saligan LN. Association of Catastrophizing and Fatigue: A Systematic Review. Journal of psychosomatic research. 2013;74(2):100-109. doi:10.1016/j.jpsychores.2012.11.006.
    Austin Baraki
    Austin Baraki
    Dr. Austin Baraki is a practicing Internal Medicine Physician, competitive lifter, and strength coach located in San Antonio, Texas. Originally from Virginia Beach, Virginia, he completed his undergraduate degree in Chemistry at the College of William & Mary, his doctorate in medicine at Eastern Virginia Medical School, and Internal Medicine Residency at the University of Texas Health Science Center in San Antonio.

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