Catastrophizing contributes to the association between posttraumatic stress symptoms and pain outcomes in individuals with chronic low back pain: Differential effects as a function of sex

Posttraumatic stress symptoms (PTSS) are prevalent among individuals with chronic low back pain (CLBP) and are associated with worse pain-related outcomes. Pain catastrophizing is a cognitive factor associated with both trauma symptoms and pain, though it remains unclear whether these associations differ by sex, particularly given evidence that males and females may differ in trauma-related cognitive and emotional responses to pain. This study examined the extent to which pain catastrophizing contributes to the association between PTSS and pain outcomes in patients with CLBP, and whether these associations vary by sex. Participants were 742 adults with opioid-treated CLBP enrolled in a multisite randomized trial. Self-report measures assessed presence of PTSS (i.e., positive screen), pain catastrophizing, severity, and interference, and CLBP-related disability. Moderated mediation analyses were conducted using PROCESS Macro, controlling for psychological well-being, age, opioid dose, and study site. Results indicated that a positive PTSS screen was associated with higher catastrophizing, which in turn was associated with worse pain outcomes (severity, interference, and disability). Sex moderated the association between PTSS and catastrophizing, with a stronger relationship in males than females. Consequently, the indirect associations of PTSS with all pain outcomes via catastrophizing were significantly stronger among males. Findings support catastrophizing as a cognitive factor influencing the association between PTSS and pain-related outcomes in CLBP, and this association appears more salient in males. These findings highlight the importance of screening for PTSS and pain-related cognitive processes. Trauma-responsive interventions, informed by sex-related differences in coping and socialization, may enhance precision care in CLBP. Perspective: This article identifies pain catastrophizing as a cognitive factor contributing to the relationship between posttraumatic stress symptoms and pain outcomes in patients with chronic low back pain, with stronger indirect associations observed in males. Findings underscore the importance of trauma- and sex-informed approaches to optimize treatment of low back pain.