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Preoperative Anxiety and Catastrophizing: A Systematic Review and Meta-analysis of the Association With Chronic Postsurgical Pain

Theunissen, Maurice MSc*; Peters, Madelon L. PhD; Bruce, Julie PhD; Gramke, Hans-Fritz MD, PhD*; Marcus, Marco A. MD, PhD*

doi: 10.1097/AJP.0b013e31824549d6
Review Article

Objectives: Anxiety and pain catastrophizing predict acute postoperative pain. However, it is not well established whether they also predict chronic postsurgical pain (CPSP). The aim of this systematic review and meta-analysis was to investigate whether high levels of preoperative anxiety or pain catastrophizing are associated with an increased risk of CPSP.

Methods: Electronic search databases included PubMed and PsychINFO. Additional literature was obtained by reference tracking and expert consultation. Studies from 1958 until October 2010, investigating the association between preoperative anxiety or pain catastrophizing and CPSP in adult surgery patients, were assessed. The primary outcome was the presence of pain at least 3 months postoperatively.

Results: Twenty-nine studies were included; 14 instruments were used to assess anxiety or pain catastrophizing. Sixteen studies (55%) reported a statistically significant association between anxiety or pain catastrophizing and CPSP. The proportion of studies reporting a statistically significant association was 67% for studies of musculoskeletal surgery and 36% for other types of surgery. There was no association with study quality, but larger studies were more likely to report a statistically significant relationship. The overall pooled odds ratio, on the basis of 15 studies, ranged from 1.55 (95% confidence interval, 1.10-2.20) to 2.10 (95% confidence interval, 1.49-2.95). Pain catastrophizing might be of higher predictive utility compared with general anxiety or more specific pain-related anxiety.

Discussion: There is evidence that anxiety and catastrophizing play a role in the development of CPSP. We recommend that anxiety measures should be incorporated in future studies investigating the prediction and transition from acute to chronic postoperative pain.

*Department of Anesthesiology and Pain Treatment, Maastricht University Medical Center

Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands

Warwick Clinical Trials Unit, University of Warwick, Coventry, UK

M.L.P. received an Innovative Research Grant (VICI) from the Netherlands Organization of Scientific Research (grant #453-07-005); the institution received money from Grünenthal company for consultancy of M.A.M. The remaining authors declare no conflict of interest.

Reprints: Maurice Theunissen, MSc, Department of Anesthesiology and Pain Treatment, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands (e-mail:

Received June 28, 2011

Accepted December 6, 2011

© 2012 Lippincott Williams & Wilkins, Inc.