Catastrophizing Mediates Associations Between Pain Severity, Psychological Distress, and Functional Disability Among Persons With Spinal Cord Injury Phil Ullrich Veterans Affairs Puget Sound Healthcare System and University of Washington Mark Jensen and John Loeser University of Washington Diana Cardenas University of Miami Objective: To examine associations between pain severity, psychological distress, catastrophizing, and indices of functional disability in a sample of persons with spinal cord injury (SCI). Catastrophizing was examined as a potential mediator of associations between pain severity, psychological distress, and functional disability. Design and Participants: Questionnaires assessing pain severity, psychological distress, catastrophizing, pain interference, and community integration were completed by 237 persons with SCI. Results: Psychological distress and pain severity were associated significantly with greater functional disability. Moreover, the association between pain severity and functional disability was strongest among persons with high psychological distress. Catastrophizing appeared to mediate the associations between pain severity, psychological distress, and functional disability. Conclusions: Pain severity and psychological distress have the potential for both direct and interactive effects on functional disability, possibly through the mediating effects of catastrophizing. Keywords: pain, spinal cord injury, catastrophizing, distress, functioning Pain and psychological distress have long been recognized as frequently co-occurring conditions with significant influence on functioning among medical patients (Fordyce, 1976). In recent decades, extensive research and theoretical discourse have been devoted to characterizing and explaining associations between pain, psychological distress, and functional disability among per- sons with medical illnesses (Bair, Robinson, Katon, & Kroenke, 2003; Banks & Kerns, 1996; Romano & Turner, 1985). Prevailing cognitive-behavioral theories have emphasized the role of cogni- tive processes such as catastrophizing in the development and maintenance of functional disability related to pain and psycho- logical distress. Catastrophizing refers to exaggerated negative expectations or interpretations of an experience such as pain (Sul- livan et al., 2001). Robust associations between catastrophizing and functioning have been observed across diverse patient groups, with both subjective and objectives measures of functioning, while controlling for possibly confounding effects of pain severity, ill- ness severity, or personality (Sullivan et al., 2001). Catastrophizing has a role related to pain schemas within cog- nitive-behavioral models describing the complex associations be- tween pain, psychological distress, and functioning. Pain schemas are memory stores of knowledge related to pain that are activated in response to environmental stimuli (Pincus & Morley, 2001). In support of the pain schema concept, persons with chronic pain conditions show patterns of cognitive-processing biases when compared to persons without pain (see review by Pincus & Mor- ley, 2001). In addition, persons with pain and depression show memory bias for negative self-referent pain and illness information Phil Ullrich, Department of Veterans Affairs, Spinal Cord Injury Quality Enhancement Research Initiative, Spinal Cord Injury and Disorders Stra- tegic Healthcare Group, Veterans Affairs Puget Sound Healthcare System, Seattle, WA and Department of Rehabilitation Medicine, University of Washington; Mark Jensen, Department of Rehabilitation Medicine, Uni- versity of Washington; John Loeser, Department of Neurological Surgery, University of Washington; Diana Cardenas, Department of Rehabilitation Medicine, University of Miami. This article presents the views of the authors; it does not necessarily represent the views or policies of the Department of Veterans Affairs or the Health Services Research and Development Service. This research was supported by Grant P01 HD33988 from the National Institutes of Health, National Institute of Child Health and Human Development, National Center for Rehabilitation Research, and by Grant H133N00003 from the National Institute on Disability and Rehabilitation Research, Office of Special Education and Rehabilitative Services, U.S. Department of Edu- cation. This work was also supported by a grant from the Department of Veterans Affairs, Veterans Health Administration, Health Services Re- search and Development Service, Spinal Cord Injury Quality Enhancement Initiative (SCI QUERI, SCT 01-169). We gratefully acknowledge the contributions of Amy Hoffman, Lindsay Washington, Emily Phelps, Laura Nishimura, Kristin McArthur, Kevin Gertz, Noel Pereyra-Johnston, Silvia Amtmann, Joe Skala, and Kerry Madrone, University of Washington School of Medicine, Department of Rehabilitation Medicine, in data collection and database management. Correspondence concerning this article should be addressed to Phil Ullrich, PhD, Veterans Affairs Puget Sound Healthcare System, Health Services Research & Development, 1100 Olive Way, Suite 1400, Seattle, WA 98101. E-mail: philip.ullrich@va.gov Rehabilitation Psychology 2007, Vol. 52, No. 4, 390 –398 Copyright 2007 by the American Psychological Association 0090-5550/07/$12.00 DOI: 10.1037/0090-5550.52.4.390 390 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.