2. Journal Of Musculoskeletal Pain, Vol. 22(2): 145–151, 2014
! 2014 Informa Healthcare USA, Inc.
ISSN: 1058-2452 print / 1540-7012 online
DOI: 10.3109/10582452.2014.883020
RESEARCH ARTICLE
Creation of the Abbreviated Measures of the Pain Catastrophizing
Scale and the Short Health Anxiety Inventory: The PCS-4 and
SHAI-5
Arjan G. J. Bot, MD
1,2
, Ste´phanie J. E. Becker, MD
1,2
, Hanneke Bruijnzeel, BS
1
,
Marjolein A. M. Mulders, MD
1
, David Ring, MD, PhD
1,2
, and Ana-Maria Vranceanu, PhD
2,3
1
Deparatment of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA, 2
Harvard Medical School, Boston,
MA, USA, and 3
Department of Behavioral Medicine, Benson Henry Mind Body Institute, Massachusetts General Hospital,
Boston, MA, USA
ABSTRACT
Objective: In patients with arm and upper extremity illness, pain catastrophizing and health anxiety are important
factors in disability, pain and patient satisfaction. The aim of this study was to develop a shorter version of the 13-item
Pain Catastrophizing Scale [PCS] and 18-item Short Health Anxiety Inventory [SHAI].
Methods: One hundred and sixty-four patients [54% women, mean age of 51 years] with a variety of upper extremity
diagnoses enrolled in this study. Patients completed the PCS, the SHAI, the Disabilities of Arm Shoulder and Hand
questionnaire [DASH] for disability, the Patient Health Questionnaire-9 [PHQ-9] for depressive symptoms and a scale
to measure pain. Inter-correlation analyses were conducted on each of the subscales of the PCS and the SHAI and
questions were selected based on the magnitude of their inter-item correlation.
Results: Questions 3, 6, 8 and 11 remained in the PCS-4 and showed good internal consistency [a ¼ 0.86] and
correlated highly with the original PCS [r ¼ 0.96]. Questions 2, 3, 12, 15 and 17 were chosen for the SHAI-5. The SHAI-
5 had a ¼ 0.67 and had a correlation or r ¼ 0.87 with the SHAI-18. Both the SHAI-5 and PCS-4 had equal correlations
with DASH, PHQ and pain as the original questionnaires.
Conclusions: We found that the PCS-4 and SHAI-5 were comparable to the original questionnaires, but further studies
should be conducted in order to confirm our findings. This study provides preliminary evidence that the PCS-4 and
SHAI-5 could be used to screen for health anxiety and pain catastrophizing in busy orthopedic settings.
Level of Evidence: Diagnostic Level II
KEYWORDS: Health anxiety, pain catastrophizing, short form questionnaires
INTRODUCTION
Pain catastrophizing [the tendency to ruminate on
the pain experience, feel hopeless and helpless when
in pain] and health anxiety [the tendency to be overly
concerned about health] are important factors
associated with pain and disability across many
acute and chronic pain conditions (1–30). In patients
with arm and upper extremity illness, pain catastro-
phizing and health anxiety are significant predictors
of disability, pain intensity, and satisfaction in
patients with both discrete and nonspecific condi-
tions (14,17,31–33).
The Pain Catastrophizing Scale [PCS] is a reliable
and valid measure with three interrelated factors:
rumination, magnification and helplessness (23).
The PCS has good internal consistency, Crohnbach’s
¼ 0.87 for the entire scale, ¼ 0.87 for the
rumination scale, ¼ 0.60 for the magnification
Correspondence: David Ring, MD, PhD, Department of Orthopedic Surgery, Massachusetts General Hospital, Yawkey 2100, 55
Fruit St, Boston 02114, USA. E-mail: dring@partners.org
Submitted: 11 November 2012; Revisions Accepted 6 August 2013; published online 16 April 2014
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3. scale and ¼ 0.79 for the helplessness scale (23).
The PCS significantly correlates with depression
[r ¼ 0.26], trait anxiety [r ¼ 0.32], negative affectivity
[r ¼ 0.32], fear of pain [r ¼ 0.80] (23), disability
(31–33) and pain intensity (4,14,16,25).
The Health Anxiety Inventory [HAI] is a
reliable and valid measure of preoccupation
and worry about health (19). Health anxiety is
encountered frequently in medical clinics. A study
found that 19.8% of the studied patients in five
different specialties had health anxiety; the highest
percentage [24.7%] was found in the neurology
clinic (27). Health anxiety is a significant predictor
of pain and disability in patients with chronic
pain (9,34). In patients with hand and upper
extremity illness, health anxiety is a mediator
for development of non-specific arm pain
(28,33,35–37).
The HAI has excellent internal consistency
[Crohnbach’s ¼ 0.95] and sensitivity to detect
clinical improvement (19). The Short Health
Anxiety Inventory [SHAI; the short version of the
HAI] (19), which has 14 general items and 4
negative consequence items from the original HAI,
also showed good internal consistency
[Crohnbach’s ¼ 0.89] (19). Patients with high
scores on the SHAI [hypochondriac and anxious
patients] also have high scores on depression, the
Avoidance scale, the Reassurance scale, the Beck
Anxiety Inventory, the Spielberger State-Anxiety
Inventory and the Spielberger Trait-Anxiety
Inventory (19). The short version of the HAI was
designed specifically for the screening of patients in
a medical setting (19).
Given the aforementioned evidence, it becomes
pivotal to assess health anxiety and pain catastro-
phizing in patients with arm and upper extremity
illness presenting to a hand surgical practice. By
addressing these factors via efficacious cognitive
behavioral therapy we can improve disability and
pain as well as the efficacy of medical procedures
(28,33,38–41). However, the PCS and SHAI are
fairly long and cumbersome to use in a busy
surgical practice. Hence, the purpose of this study
is to develop shorter, reliable and valid versions for
both questionnaires. Our null-hypothesis is that
there will be no difference in the magnitude of the
correlation of the shorter version of the SHAI and
PCS with disability as measured with the DASH-
questionnaire when compared to the long version.
Secondary hypotheses are that there will be no
differences in the magnitude of the correlation of
the shorter version of the SHAI and PCS with
depression and pain.
METHODS
Study design
One hundred and seventy adult patients [18 years
and older] visiting one of fore hand surgeons
for a new or return visit were invited to enroll
in this Institutional Review Board approved
study and provided informed consent. Patients
were enrolled between December 2009 and
June 2011.
Evaluation
At enrollment, patients completed demographics
and questionnaires. The Disabilities of Arm Should
and Hand [DASH] questionnaire (42) was com-
pleted to measure arm specific disability, the Patient
Health Questionnaire-9 [PHQ-9] (43) to measure
symptoms of depression, the PCS (23) to assess
catastrophic thinking, the SHAI to test for health
anxiety (19) and an 11-point ordinal pain scale to
measure pain intensity.
The 13-item PCS was used to measure miscon-
ceptions of nociception and a higher score on this
scale indicates more catastrophic thinking (23).
There are three subscales in this questionnaire:
rumination [questions 1, 7, 9 and 11], magnification
[questions 3, 6 and 13], and helplessness [questions
2, 4, 5, 8, 10 and 12] (23).
The SHAI contains 18 questions which are
answered on a scale from 0 to 3 and total scores
range between 0 and 54; higher scores correspond
to more health anxiety (19). The scale consists of
a two subscales: four negative consequence items
[question 15, 16, 17 and 18] and the other
14 questions (19).
For missing individual questions in the SHAI and
PCS, we imputed the mean of the patient’s other
questions.
Statistical analysis
For this study we used a convenience sample of
164 patients. Crohnbach’s alpha coefficient was
calculated for the SHAI, the PCS and each of the
subscales of the questionnaires to measure internal
consistency of the questionnaires.
Five sets of inter-correlation analysis were con-
ducted on subscales of the SHAI and PCS in order to
create shorter questionnaires of the PCS and SHAI.
The items for the short scales were selected based on
their corrected inter-item correlation value [highest
magnitude]. When the selected item contributed to
reduced scale variability, we selected the next
question based on the magnitude of the inter-item
correlation (44).
146 A. G. J. Bot et al.
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4. Correlation analysis between subscales of the
proposed short version of the PCS [rumination,
magnification and helplessness] and the SHAI [the
first items and the negative consequence items] with
the matched subscales of the longer questionnaires
was conducted. We also did correlation analysis
for the non-matching subscales of both the SHAI
and the PCS, and investigated the correlation of the
short and long questionnaires with each other.
Shortening questionnaires may lead to a
decreased validity of the questionnaires; therefore
we investigated the correlation of both the proposed
short questionnaires and the original questionnaires
with the DASH, PHQ-9 and pain [with Pearson
correlation]. The obtained correlation coefficients
were compared using Fisher’s Z-transformation.
RESULTS
A total of six patients were excluded; one patient did
not feel comfortable completing the questionnaires
and withdrew from the study, and five patients did
not have a valid DASH questionnaire, which was
used to compare short and long questionnaires,
which left a cohort of 164 patients.
Patient characteristics
There were 89 women [54%] and 75 men [46%],
with a mean age of 51 years [range, 18 to 89 years]
and 41% of the patients were new patients. Sixty-six
percent did not have previous surgery and symptoms
were present for an average of 18 months. There
were multiple diagnoses: a fracture in 56 patients,
carpal tunnel syndrome in 19 patients, osteoarthritis
in 17 patients, trigger finger in 10 patients, non-
specific arm pain in seven patients and other
diagnoses in 55 patients.
Twelve percent of the patients smoked, 30% of
the patients were single, 3% were living with a
partner, 45% were married, 16% divorced and 6%
were widowed. The working status was as follows:
full-time 49%, part-time 14%, homemaker 3.7%,
retired 18%, unemployed 14% and workers com-
pensation 1.8%. The patients had a mean of 15 years
of schooling [Table 1].
Outcomes
The mean DASH score was 29 ± 19, mean PHQ-9
score was 3.6 ± 4.4 points, mean PCS was 5.3 ± 6.9
and the SHAI was 11 ± 6.6 in this cohort.
Inter-item correlations
We did inter-correlation analysis on the three
subscales of PCS and the two subscales of the
SHAI. For the PCS in the rumination subscale,
question 11 [‘‘I keep thinking about how badly
I want the pain to stop’’] was selected; in the
magnification subscale question 3 [‘‘It’s terrible and
I think it’s never going to get any better’’] and
question 6 [‘‘I become afraid that the pain may get
worse’’] and in the helplessness subscale question 8
[‘‘I anxiously want the pain to go away’’]. Question 8
did not have the highest value of inter-item correl-
ation of all questions in the subscale, but the
questions with higher correlations would lead to a
reduced variance of the subscale and were therefore
not selected for the short form of the PCS [Table 2].
For the SHAI questions 15 [‘‘If I had a serious
illness I would . . . ’’] and 17 [‘‘A serious illness
would ruin . . . aspects of my life’’] were selected
from the negative consequence items subscale;
from the other subscale questions 2 [‘‘I notice
aches and pains . . . ’’], 3 [‘‘ . . . aware of bodily
sensation or changes’’] and 12[‘‘I . . . think I have a
serious illness’’] were retained in the subscale of the
short questionnaire. Questions 2 and 3 did not have
TABLE 1. Demographics of patients.
n ¼ 164
Parameter Mean ± SD Range
Age in years 51 ± 15 18–89
Presence of symptoms in months 18 ± 39 0–240
Years of schooling 15 ± 2.6 5–20
Number Percentage
Gender
Male 75 46
Female 89 54
Visit type
New 67 41
Follow–up 97 59
Previous Surgery
Yes 54 33
No 110 67
Smoking
Yes 19 12
No 145 88
Marital status
Single 49 30
Living with partner 5 3.0
Married 74 45
Separated/Divorced 26 16
Widowed 10 6.1
Working status
Full–time 80 49
Part–time 23 14
Homemaker 6 3.7
Retired 29 18
Unemployed 23 14
Workers compensation 3 1.8
SD ¼ standard deviation.
Creation of PCS-4 and SHAI-5 147
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5. the highest corrected inter-item correction, but were
chosen because the other questions would lead to
reduced scale variability (44) [Table 2].
Correlation with the subscales of the long
questionnaires
The short subscales correlated highly with the
matching subscales on the longer questionnaires
[correlation coefficient ranged from 0.86 to 0.94
for the subscales of PCS, and 0.82 to 0.89 for the
subscales of the SHAI]. Each of the subscales in
the short questionnaire correlated significantly with
the other non-matching subscales in the original
subscales of the PCS, with a correlation coefficient
ranging from 0.60 to 0.82 [Table 3]. There was a
moderate correlation between the non-matching
subscales in the short and long questionnaires of
the SHAI [the correlation coefficient was 0.30 and
0.44] [Table 4]. The correlation of the PCS-4 and
PCS-13 was r ¼ 0.96, and the correlation of the
SHAI-5 and the SHAI-18 was r ¼ 0.87.
Internal consistency and correlation statistics for the
new questionnaires
Statistical evaluation revealed a Crohnbach’s alpha
of 0.67 for the five-question version of the SHAI and
0.86 for the four-question version of the PCS.
The Crohnbach’s alpha coefficient was 0.93 for the
full PCS and 0.88 for the SHAI-18 [Table 5].
Both the short PCS-4 and PCS-13 correlated
significantly with pain, disability as measured with
the DASH, and depression as assessed with PHQ
[correlation ranged between r ¼ 0.46 to r ¼ 0.64]
[Table 6]. Both the short and long version of the
SHAI correlated significantly with the DASH, the
PHQ-9 and pain [correlation ranged between
r ¼ 0.20 and r ¼ 0.48] [Table 6]. There were no
statistical differences in the correlation coefficients of
TABLE 2 Inter-item correlations of PCS-4 and SHAI-5.
n ¼ 164
Question PCS-4 Corrected inter-item
Rumination Correlation
11 I keep thinking about how badly I want the pain to stop
Magnification
3 It’s terrible and I think it’s never going to get any better 0.66
6 I become afraid that the pain may get worse 0.66
Helplessness
8 I anxiously want the pain to go away
SHAI-5
SHAI first 14 questions
Q2 I notice aches and pain less/as much/more than other people/I am aware of aches or
pains in my body all the time
0.51
Q3 As a rule I am not/Sometimes I am, I am often/I am constantly aware of bodily
sensation or changes
0.46
Q12 I never/sometimes/often/usually think I have a serious illness 0.44
Negative consequence items
Q15 If I had a serious illness I would still be able to enjoy my life quite a lot/a little/unable/
completely unable
0.53
Q17 A serious illness would ruin some/many/almost every/every aspect(s) of my life 0.53
PCS ¼ Pain Catastrophizing Scale, SHAI ¼ Short Health Anxiety Inventory
TABLE 3. Correlation of subscales PCS-4 with subscales of PCS-13.
n ¼ 164
Pearson’s correlation
yPCS-13
Rumination Magnification Helplessness
r p r p r p
yPCS-4
Rumination 0.88 p50.001 0.72 p50.001 0.82 p50.001
Magnification 0.76 p50.001 0.94 p50.001 0.75 p50.001
Helplessness 0.67 p50.001 0.60 p50.001 0.86 p50.001
yPCS ¼ Pain Catastrophizing Scale
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6. the short and long questionnaires with the DASH,
the PHQ-9 and pain.
DISCUSSION
This study described the development of a four-item
version of the PCS and a five-item version of
the SHAI. Both abbreviated questionnaires showed
good or acceptable internal consistency [PCS-4:
Crohnbach’s ¼ 0.86; SHAI-5 Crohnbach’s
¼ 0.67], which were slightly lower than the original
scales due to reduction in number of scale items.
The short questionnaires correlated highly with the
original questionnaire, PCS r ¼ 0.96 and SHAI
r ¼ 0.87. The matching subscales in the short and
long questionnaires correlated highly in both SHAI
and PCS, and both the short and long questionnaires
had comparable correlation coefficients with meas-
ures of depression, disability and pain.
The purpose of this study was to develop shorter
questionnaires that could be easily used in a [hand
and upper extremity] clinic to screen for cata-
strophic thinking and health anxiety. The questions
were reduced in both questionnaires to one third of
the original number of questions, which would make
screening for these conditions less time consuming
and cumbersome for the patients.
There are several shortcomings in this study which
should be considered. This study only described the
development of the shorter version of the PCS-4 and
SHAI-5, but was not intended to validate the short
questionnaires. Validation studies should be con-
ducted to confirm the findings in this study.
Although we used a validated methodology (44),
there are always points of discussion in the method
of shortening a questionnaire and selecting ques-
tions. We used the corrected inter-item correlations
as a tool to select the questions and chose the next
question when the selected item would yield
reduced scale variability (44). Based on this
method we did not select one question in the
PCS and two alternative questions in the SHAI
with the highest corrected inter-item correlation.
A suggestion for having selected the right questions
is to compare the correlations of the original and
the shortened version of the questionnaire with
disability, depression and pain. The correlations
with the outcome variables did not significantly
differ between the short and long versions in this
study, which is an indication that the selected
questions measure the same as the original ques-
tionnaire, although other studies should confirm
these findings.
In the final version of the SHAI, we selected three
questions from the first 14 items, and two from the
negative consequence items, but for the PCS we
TABLE 6. Correlation of the pain catastrophizing scale and the short health anxiety index with the
disabilities of the arm, should and hand questionnaire, patient health questionnaire and pain.
n ¼ 164
Bivariate analysis
*DASH ^PHQ-9 Pain
Pearson’s correlation r p r p r p
yPCS 0.50 p50.001 0.64 p50.001 0.47 p50.001
yPCS-4 0.46 p50.001 0.57 p50.001 0.48 p50.001
SHAI-18 0.26 0.001 0.48 p50.001 0.20 0.012
SHAI-5 0.23 0.004 0.43 p50.001 0.20 0.009
*DASH ¼ Disabities of the Arm, Shoulder and Hand
^PHQ ¼ Patient Health Questionnaire
yPCS ¼ Pain Catastrophizing Scale
SHAI ¼ Short Health Anxiety Index
TABLE 4. Correlation of subscales short healthy anxiety
inventory-5 with subscales of short health anxiety
inventory-18.
Pearson’s correlation
SHAI-18
First 14 items
Negative
consequence items
r p r p
SHAI-5
First items 0.82 p50.001 0.30 p50.001
Negative items 0.44 p50.001 0.89 p50.001
SHAI ¼ Short Health Anxiety Index
TABLE 5. Outcomes short and long forms of Pain
Catastrophizing Scale and Short Healthy Anxiety Inventory
n ¼ 164.
Questionnaires Score SD Range g a
yPCS 13 5.3 6.9 0–32 0.93
yPCS-4 2.0 2.7 0–12 0.86
SHAI-18 11 6.8 1–33 0.88
SHAI-5 4.0 2.4 0–12 0.67
yPCS ¼ Pain Catastrophizing Scale
SHAI ¼ Short Health Anxiety Index
gCrohnbach’s a: internal consistency coefficient
SD ¼ standard deviation
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7. selected two questions of the magnification subscale
and only one in the two other subscales. The
decision to select two questions from the magnifi-
cation subscale and two from the rumination and
helplessness subscale makes it impossible to compare
the internal consistency of the two subscales with
the original subscale. However, the correlation of the
short subscale compared to the longer subscale of
the PCS was high [correlation coefficient ranged
from 0.86 to 0.94].
These shortcomings stress the importance of
validating results of this study with a different
sample. Confirmation of these results would increase
confidence that the abbreviated versions of the PCS
and SHAI are reliable and valid, and would foster
incorporation of these questionnaires as part of
screening for all new patients presenting to hand
surgical practices. Both catastrophic thinking and
heightened illness concern can be treated with
cognitive behavior therapy and the shortened
forms of the questionnaires can be used in the
setting of screening for these conditions.
DECLARATION OF INTEREST
The authors declare that there are no conflicts of interest
with regards to this study
Arjan G.J. Bot has received grants from ‘‘VSB fonds’’,
‘‘Prins Bernhard CultuurFonds/Banning de Jong Fonds’’,
both non-medical grants and the orthopaedic: ‘‘Anna
Fonds travel grant’’
Ste´phanie J.E. Becker has received grants from ‘‘Anna
Fonds’’, ‘‘Genootschap Noorthey’’ and ‘‘Vreedefonds’’.
Hanneke Bruijnzeel has received a grant from
‘‘Anna Fonds’’.
Marjolein A.M. Mulders has received a grant from
‘‘Anna Fonds’’.
David Ring receives royalties from Wright Medical
Technology Inc.; is consultant for Wright Medical,
Skeletal Dynamics, Biomet; received honoraria from AO
North America, AO International; has royalties contracted
with Biomet, Skeletal Dynamics; has stock Options in
Illuminos; received study specific grants from Skeletal
Dynamics (Pending); received funding for Hand Surgery
Fellowship from AO North America and is Deputy Editor
for Review Articles, Journal of Hand Surgery Am., Deputy
Editor for Hand and Wrist, Journal of Orthopaedic
Trauma, Assistant Editor, Journal of Shoulder and
Elbow Surgery.
Ana-Maria Vranceanu received a grant from the
Orthopedic Association of Trauma (OTA).
REFERENCES
1. Abramowitz JS, Olatunji BO, Deacon BJ: Health anxiety,
hypochondriasis and the anxiety disorders. Behav Ther 38:
86–94, 2007.
2. Asrani S, Samuels B, Thakur M, Santiago C, Kuchibhatla M:
Clinical profiles of primary open angle glaucoma versus normal
tension glaucoma patients: A pilot study. Curr Eye Res 36:
429–435, 2011.
3. Chmielewski TL, Zeppieri Jr G, Lentz TA, Tillman SM, Moser
MW, Indelicato PA, George SZ: Longitudinal changes in
psychosocial factors and their association with knee pain and
function after anterior cruciate ligament reconstruction.
Phys Ther 91: 1355–1366, 2011.
4. Darnall BD, Sazie E: Pain characteristics and pain catastrophiz-
ing in incarcerated women with chronic pain. J Health Care
Poor Underserved 23: 543–556, 2012.
5. DeMarinis V, Barsky AJ, Antin JH, Chang G: Health psych-
ology and distress after haematopoietic stem cell transplant-
ation. Eur J Cancer Care (Engl) 18: 57–63, 2009.
6. Fernandes L, Storheim K, Lochting I, Grotle M: Cross-cultural
adaptation and validation of the Norwegian pain catastrophiz-
ing scale in patients with low back pain. BMC Musculoskelet
Disord 13: 111, 2012.
7. Gandhi R, Tsvetkov D, Dhottar H, Davey JR, Mahomed NN:
Quantifying the pain experience in hip and knee osteoarthritis.
Pain Res Manag 15: 224–228, 2010.
8. Geisser ME, Robinson ME, Keefe FJ, Weiner ML:
Catastrophizing, depression and the sensory, affective and
evaluative aspects of chronic pain. Pain 59: 79–83, 1994.
9. Hadjistavropoulos HD, Hadjistavropoulos T: The relevance of
health anxiety to chronic pain: research findings and recom-
mendations for assessment and treatment. Curr Pain Headache
Rep 7: 98–104, 2003.
10. Katz L, Tripp DA, Nickel JC, Mayer R, Reimann M, van
Ophoven A: Disability in women suffering from interstitial
cystitis/bladder pain syndrome. BJU Int. 2013 Jan;111(1):
114–21. doi: 10.1111/j.1464-410X.2012.11238.x. Epub 2012
May 11. PMID: 22578191.
11. Kehler MD, Hadjistavropoulos HD: Is health anxiety a
significant problem for individuals with multiple sclerosis?
J Behav Med 32: 150–161, 2009.
12. Khan RS, Skapinakis P, Ahmed K, Stefanou DC, Ashrafian H,
Darzi A, Athanasziou T: The association between preoperative
pain catastrophizing and postoperative pain intensity in cardiac
surgery patients. Pain Med 13: 820–827, 2012.
13. Martinez MP, Sanchez AI, Miro E, Medina A, Lami MJ: The
relationship between the fear-avoidance model of pain and
personality traits in fibromyalgia patients. J Clin Psychol Med
Settings 18: 380–391, 2011.
14. Nunez F, Vranceanu AM, Ring D: Determinants of pain in
patients with carpal tunnel syndrome. Clin Orthop Relat Res
468: 3328–3332, 2010.
15. Olsson CB, Grooten WJ, Nilsson-Wikmar L, Harms-Ringdahl
K, Lundberg M: Catastrophizing during and after pregnancy:
Associations with lumbopelvic pain and postpartum physical
ability. Phys Ther 92: 49–57, 2012.
16. Papaioannou M, Skapinakis P, Damigos D, Mavreas V,
Broumas G, Palgimesi A: The role of catastrophizing in the
prediction of postoperative pain. Pain Med 10: 1452–1459,
2009.
17. Ring D, Kadzielski J, Malhotra L, Lee SG, Jupiter JB:
Psychological factors associated with idiopathic arm pain.
J Bone Joint Surg Am 87: 374–380, 2005.
18. Saeden B, Tornkvist H, Ponzer S, Hoglund M: Fracture of the
carpal scaphoid: A prospective, randomised 12-year follow-up
comparing operative and conservative treatment. J Bone Joint
Surg Br 83: 230–234, 2001.
19. Salkovskis PM, Rimes KA, Warwick HM, Clark DM: The
Health Anxiety Inventory: Development and validation of
scales for the measurement of health anxiety and hypochon-
driasis. Psychol Med 32: 843–853, 2002.
20. Seivewright H, Salkovskis P, Green J, Mullan N, Behr G, Carlin
E, Young S, et al: Prevalence and service implications of health
150 A. G. J. Bot et al.
JMuscoskeletalPainDownloadedfrominformahealthcare.combyUVAUniversiteitsbibliotheekSZon01/22/15
Forpersonaluseonly.
8. anxiety in genitourinary medicine clinics. Int J STD AIDS 15:
519–522, 2004.
21. Severeijns R, Vlaeyen JW, van den Hout MA, Picavet HS: Pain
catastrophizing and consequences of musculoskeletal pain:
A prospective study in the Dutch community. J Pain 6:
125–132, 2005.
22. Souer JS, Buijze G, Ring D: A prospective randomized controlled
trial comparing occupational therapy with independent exer-
cises after volar plate fixation of a fracture of the distal part of the
radius. J Bone Joint Surg Am 93: 1761–1766, 2011.
23. Sullivan M, Bishop SR, Pivik J: The Pain Catastrophizing Scale:
Development and validation. Psychol Assessment 7: 525–532,
1995.
24. Tang NK, Salkovskis PM, Poplavskaya E, Wright KJ, Hanna M,
Hester J: Increased use of safety-seeking behaviors in chronic
back pain patients with high health anxiety. Behav Res Ther 45:
2821–2835, 2007.
25. Theunissen M, Peters ML, Bruce J, Gramke HF, Marcus MA:
Preoperative anxiety and catastrophizing: A systematic review
and meta-analysis of the association with chronic postsurgical
pain. Clin J Pain. 2012 Nov-Dec;28(9):819–41. doi: 10.1097/
AJP.0b013e31824549d6.
26. Tripp DA, Nickel JC, Katz L: A feasibility trial of a cognitive-
behavioural symptom management program for chronic pelvic
pain for men with refractory chronic prostatitis/chronic pelvic
pain syndrome. Can Urol Assoc J 5: 328–332, 2011.
27. Tyrer P, Cooper S, Crawford M, Dupont S, Green J, Murphy D,
Salkovskis P, et al.: Prevalence of health anxiety problems in
medical clinics. J Psychosom Res 71: 392–394, 2011.
28. Vranceanu AM, Safren SA, Cowan J, Ring DC: Health concerns
and somatic symptoms explain perceived disability and idio-
pathic hand and arm pain in an orthopedics surgical practice:
a path-analysis model. Psychosomatics 51: 330–337, 2010.
29. Witvrouw E, Pattyn E, Almqvist KF, Crombez G, Accoe C,
Cambier D, Verdonk R: Catastrophic thinking about pain as a
predictor of length of hospital stay after total knee arthroplasty:
A prospective study. Knee Surg Sports Traumatol Arthrosc 17:
1189–1194, 2009.
30. Kowalyk KM, Hadjistavropoulos HD, Jones SL: What impact
does pregnancy have on anxiety about health? J Psychosom
Obstet Gynaecol 30: 223–230, 2009.
31. Lozano Calderon SA, Paiva A, Ring D: Patient satisfaction after
open carpal tunnel release correlates with depression. J Hand
Surg Am 33: 303–307, 2008.
32. Niekel MC, Lindenhovius AL, Watson JB, Vranceanu AM,
Ring D: Correlation of DASH and QuickDASH with meas-
ures of psychological distress. J Hand Surg Am 34: 1499–1505,
2009.
33. Vranceanu AM, Barsky A, Ring D: Psychosocial aspects of
disabling musculoskeletal pain. J Bone Joint Surg Am 91:
2014–2018, 2009.
34. Hadjistavropoulos HD, Owens KMB, Hadjistavropoulos T,
Asmundson GJG: Hypochondriasis and health anxiety among
pain patients: Health anxiety: Clinical and research perspectives
on hypochondriasis and related disorders, Wiley, London,
2001, pp. 298–324.
35. Vranceanu AM, Safren S, Zhao M, Cowan J, Ring D:
Disability and psychologic distress in patients with nonspecific
and specific arm pain. Clin Orthop Relat Res 466: 2820–2826,
2008.
36. Vranceanu AM, Barsky A, Ring D. Less specific arm illnesses.
J Hand Ther 24: 118–122; quiz 123, 2011.
37. Vranceanu AM, Ring D: Value of psychological evaluation
of the hand surgical patient. J Hand Surg Am 33: 985–987,
2008.
38. Barsky AJ, Ahern DK: Cognitive behavior therapy for hypo-
chondriasis: A randomized controlled trial. JAMA 291:
1464–1470, 2004.
39. Vranceanu AM, Safren S: Cognitive-behavioral therapy for
hand and arm pain. J Hand Ther 24: 124–130 (quiz 131), 2011.
40. Warwick HM, Clark DM, Cobb AM, Salkovskis PM:
A controlled trial of cognitive-behavioural treatment of hypo-
chondriasis. Br J Psychiatry 169: 189–195, 1996.
41. Looper KJ, Kirmayer LJ: Behavioral medicine approaches to
somatoform disorders. J Consult Clin Psychol 70: 810–827,
2002.
42. Hudak PL, Amadio PC, Bombardier C: Development of an
upper extremity outcome measure: The DASH (disabilities of
the arm, shoulder and hand) [corrected]: The Upper Extremity
Collaborative Group (UECG). Am J Ind Med 29: 602–608,
1996.
43. Kroenke K, Spitzer RL, Williams JB: The PHQ-9: Validity of
a brief depression severity measure. J Gen Intern Med 16:
606–613, 2001.
44. McCracken LM, Dhingra L: A short version of the Pain Anxiety
Symptoms Scale (PASS-20): Preliminary development and
validity. Pain Res Manag 7: 45–50, 2002.
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![Journal Of Musculoskeletal Pain, Vol. 22(2): 145–151, 2014
! 2014 Informa Healthcare USA, Inc.
ISSN: 1058-2452 print / 1540-7012 online
DOI: 10.3109/10582452.2014.883020
RESEARCH ARTICLE
Creation of the Abbreviated Measures of the Pain Catastrophizing
Scale and the Short Health Anxiety Inventory: The PCS-4 and
SHAI-5
Arjan G. J. Bot, MD
1,2
, Ste´phanie J. E. Becker, MD
1,2
, Hanneke Bruijnzeel, BS
1
,
Marjolein A. M. Mulders, MD
1
, David Ring, MD, PhD
1,2
, and Ana-Maria Vranceanu, PhD
2,3
1
Deparatment of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA, 2
Harvard Medical School, Boston,
MA, USA, and 3
Department of Behavioral Medicine, Benson Henry Mind Body Institute, Massachusetts General Hospital,
Boston, MA, USA
ABSTRACT
Objective: In patients with arm and upper extremity illness, pain catastrophizing and health anxiety are important
factors in disability, pain and patient satisfaction. The aim of this study was to develop a shorter version of the 13-item
Pain Catastrophizing Scale [PCS] and 18-item Short Health Anxiety Inventory [SHAI].
Methods: One hundred and sixty-four patients [54% women, mean age of 51 years] with a variety of upper extremity
diagnoses enrolled in this study. Patients completed the PCS, the SHAI, the Disabilities of Arm Shoulder and Hand
questionnaire [DASH] for disability, the Patient Health Questionnaire-9 [PHQ-9] for depressive symptoms and a scale
to measure pain. Inter-correlation analyses were conducted on each of the subscales of the PCS and the SHAI and
questions were selected based on the magnitude of their inter-item correlation.
Results: Questions 3, 6, 8 and 11 remained in the PCS-4 and showed good internal consistency [a ¼ 0.86] and
correlated highly with the original PCS [r ¼ 0.96]. Questions 2, 3, 12, 15 and 17 were chosen for the SHAI-5. The SHAI-
5 had a ¼ 0.67 and had a correlation or r ¼ 0.87 with the SHAI-18. Both the SHAI-5 and PCS-4 had equal correlations
with DASH, PHQ and pain as the original questionnaires.
Conclusions: We found that the PCS-4 and SHAI-5 were comparable to the original questionnaires, but further studies
should be conducted in order to confirm our findings. This study provides preliminary evidence that the PCS-4 and
SHAI-5 could be used to screen for health anxiety and pain catastrophizing in busy orthopedic settings.
Level of Evidence: Diagnostic Level II
KEYWORDS: Health anxiety, pain catastrophizing, short form questionnaires
INTRODUCTION
Pain catastrophizing [the tendency to ruminate on
the pain experience, feel hopeless and helpless when
in pain] and health anxiety [the tendency to be overly
concerned about health] are important factors
associated with pain and disability across many
acute and chronic pain conditions (1–30). In patients
with arm and upper extremity illness, pain catastro-
phizing and health anxiety are significant predictors
of disability, pain intensity, and satisfaction in
patients with both discrete and nonspecific condi-
tions (14,17,31–33).
The Pain Catastrophizing Scale [PCS] is a reliable
and valid measure with three interrelated factors:
rumination, magnification and helplessness (23).
The PCS has good internal consistency, Crohnbach’s
¼ 0.87 for the entire scale, ¼ 0.87 for the
rumination scale, ¼ 0.60 for the magnification
Correspondence: David Ring, MD, PhD, Department of Orthopedic Surgery, Massachusetts General Hospital, Yawkey 2100, 55
Fruit St, Boston 02114, USA. E-mail: dring@partners.org
Submitted: 11 November 2012; Revisions Accepted 6 August 2013; published online 16 April 2014
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