Catastrophic thinking may amplify cancer pain, comparative study in Oman and Lebanon finds

Cancer pain has long been treated as a problem of biology: tumors pressing on nerves, chemotherapy scarring tissue, opioids titrated against a number on a scale. A new comparative study from Oman and Lebanon adds a striking psychological dimension to that picture, suggesting that the way patients think about their pain may shape how intensely they feel it, and may even help explain why pain differs between countries. The research, published in Supportive Care in Cancer, followed 200 adults with cancer, half recruited at Sultan Qaboos University Hospital in Oman and half at Tripoli Governmental Hospital in Lebanon, and measured pain intensity alongside two opposing psychological responses: pain catastrophizing, the tendency to ruminate on and magnify pain, and pain acceptance, the willingness to experience pain while continuing to engage in valued activities.

The headline finding is that catastrophizing stood out as the strongest psychological predictor of pain intensity, even after the researchers statistically accounted for sex, cancer stage, cancer type, smoking, physical activity, analgesic use, and country. In the pooled sample of 200 patients, pain intensity correlated positively with catastrophizing with a Pearson coefficient of 0.53, a moderate-to-strong association in this field, while acceptance showed a negative correlation of −0.35. Intriguingly, acceptance and catastrophizing were themselves strongly inversely correlated at −0.59, suggesting these two constructs capture overlapping, largely opposite ways of appraising persistent pain.

The cross-national comparison added an unexpected layer. Lebanese participants reported significantly higher average pain intensity, 5.77 on an 11-point numeric scale versus 2.69 among Omani participants, along with markedly higher catastrophizing scores of 28.30 versus 14.55. Omani participants, meanwhile, reported substantially higher pain acceptance, at 61.79 versus 47.43. All of these differences were statistically significant, and the study’s explanatory regression model, which combined psychological, clinical, and demographic variables, accounted for roughly 44 percent of the variance in pain intensity, a substantial share for a construct as subjective and multidimensional as cancer pain.

Perhaps the most conceptually provocative result came from the exploratory mediation analysis. When the researchers used the PROCESS macro with 5,000 bootstrap samples to decompose the association between country and pain intensity, they found that catastrophizing statistically accounted for part of the gap. The total association between country and pain intensity was 3.08 points; adding catastrophizing to the model reduced the direct association to 1.85, leaving a significant indirect effect of 1.23 points flowing through the psychological variable. In plain terms, some of the difference in reported pain between the two countries traveled through differences in catastrophic thinking, although the authors are careful to stress that this is a statistical decomposition of group differences in cross-sectional data, not proof of a causal mechanism.

The theoretical scaffolding for these findings comes from the fear-avoidance model and the biopsychosocial model of pain. Catastrophizing, operationally measured by the 13-item Pain Catastrophizing Scale across three components of rumination, magnification, and helplessness, is thought to amplify perceived threat, bias attention toward pain signals, and fuel hypervigilance and avoidance, which in turn reinforce the chronic pain experience. Acceptance, grounded in psychological flexibility models and measured here by the Chronic Pain Acceptance Questionnaire with its activity engagement and pain willingness subscales, represents the opposite pole: acknowledging pain without futile control efforts while maintaining a functional life. The study’s instruments all showed strong psychometric properties in their validated Arabic versions, with internal consistency values ranging from roughly 0.83 to 0.94 in this sample.

Why, then, did acceptance fail to independently predict pain intensity in the adjusted regression despite its clear bivariate association? The authors point to conceptual overlap: because acceptance and catastrophizing are so strongly negatively correlated, the model cannot cleanly separate their contributions, and catastrophizing appears to be the more proximal cognitive amplifier of the raw sensory experience of pain. Acceptance, they argue, may exert its benefits primarily on broader outcomes such as psychological adjustment, physical functioning, and quality of life, rather than on pain intensity itself. That distinction carries real clinical weight, because it implies that interventions targeting catastrophic thinking might yield more direct reductions in perceived pain, while acceptance-based approaches like acceptance and commitment therapy may better improve how patients live with the pain they have.

The clinical profiles of the two samples differed in ways that complicate simple interpretation. Most Omani participants had hematological malignancies, 88 percent, often at unspecified stages, whereas 84 percent of Lebanese participants had solid tumors at more clearly documented stages. The Lebanese sample was older on average, 58.20 versus 43.58 years, more heavily represented by women, more likely to smoke, and more likely to report comorbidities and a family history of cancer. Notably, analgesic use emerged as a strong independent predictor of higher pain intensity, a relationship the authors attribute largely to reverse causation: patients in more pain are prescribed more medication. Yet even among analgesic users, pain remained clinically significant, echoing prior evidence that combined pharmacological strategies provide adequate relief in only about 70 percent of patients and can carry sedation, cognitive impairment, and dependence risks.

The country variable itself remained significant even after adjustment, pointing to contextual factors the study could not directly measure: differences in healthcare infrastructure, treatment access, disease burden at diagnosis, and sociocultural norms around expressing pain. Prior research in Oman has documented barriers to optimal cancer pain management, including fear of addiction, concerns about tolerance, and reluctance to report pain because of stigma. In Arab societies more broadly, sociocultural expectations may shape both how pain is communicated and which coping strategies, catastrophizing or acceptance, patients adopt. The authors argue that numeric pain scores should therefore be read within their sociocultural context rather than as pure biomedical indicators, and that cultural or systemic influences may shape cognitive appraisals that in turn color perceived intensity.

The practical implications are concrete. Because catastrophizing independently predicted pain severity, the authors recommend that oncology assessments look beyond intensity ratings to evaluate pain-related cognitions, and that structured psychological interventions, particularly cognitive-behavioral therapy, be integrated with pharmacological treatment. Meta-analytic evidence cited in the paper supports the value of cognitive-behavioral therapy for mental health and quality of life in cancer populations, and acceptance and commitment therapy has shown benefits for psychological flexibility, fatigue, sleep, and quality of life. A multidisciplinary model combining medical management with culturally sensitive, psychologically informed supportive care, the authors conclude, offers the best route to better pain control and less overreliance on medication.

The study’s limitations are worth keeping in view. The cross-sectional design precludes causal inference, self-reported measures are vulnerable to reporting biases shaped by cultural norms, and variables such as depression, anxiety, socioeconomic status, and healthcare access were not directly measured. The mediation finding is explicitly framed as exploratory. Still, as one of the first studies to simultaneously examine catastrophizing and acceptance in a cross-national Arab oncology sample, the work makes a compelling case that the mind’s appraisal of pain is not a footnote to cancer care but a modifiable target in its own right. The authors call for longitudinal and interventional studies to test whether reducing catastrophic thinking actually lowers perceived pain intensity, a question that, if answered affirmatively, could reshape supportive cancer care across diverse cultural settings.

Subject of Research: Psychological predictors of cancer pain intensity, including pain catastrophizing and pain acceptance, among patients in Oman and Lebanon

Article Title: Pain catastrophizing, pain acceptance, and pain intensity among patients with cancer in Oman and Lebanon: a comparative cross-sectional study

Article References: Hassan, J., Dankar, M., Al Azri, Z., Al Maskari, S., Al Senaidi, T., Al Maqbali, A., & Al Abri, B. (2026). Pain catastrophizing, pain acceptance, and pain intensity among patients with cancer in Oman and Lebanon: a comparative cross-sectional study. Supportive Care in Cancer, 34(10), Article 944. https://doi.org/10.1007/s00520-026-11191-y

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11191-y

Keywords: cancer pain, pain catastrophizing, pain acceptance, Oman, Lebanon, psycho-oncology, cross-sectional study, pain intensity, cognitive-behavioral therapy, biopsychosocial model, supportive care, Arab region