Procedural Anxiety, Pain Catastrophizing, and Procedure-Related Pain During EGD and Colonoscopy

Marco Lauriola, PhD; Manuela Tomai, PhD; Rossella Palma, MD; Gaia La Spina, MA; Anastasia Foglia, MA; Cristina Panetta, MD; Marilena Raniolo, MD; Stefano Pontone, MD, PhD


South Med J. 2020;113(1):8-15. 

In This Article

Abstract and Introduction


Objectives: Although sedatives and analgesic drugs defuse anxiety and relieve pain, digestive endoscopy still is uncomfortable and painful for some patients. Identifying patients who tolerate digestive endoscopy less well remains difficult. The present study evaluated the relations between procedural anxiety, catastrophizing thoughts, and pain, using a prospective design and multimodal assessments of pain.

Methods: A total of 118 consecutive patients were assessed for procedural anxiety before endoscopy. During endoscopy, a doctor rated the patients' pain behavior. Before discharge, the patients retrospectively rated endoscopy pain and related catastrophizing thoughts.

Results: Notwithstanding sedation, our study revealed large between-subject variability in pain. Catastrophizing thoughts mediated the relation between procedure-related pain observed by the doctor and pain intensity reported by the patient. Catastrophizing thoughts also mediated the effect of procedural anxiety. Our study showed that anxiety exacerbates endoscopy pain when the patient engages in ruminative thinking and feels unable to cope with unpleasant bodily sensations.

Conclusions: This study shows that catastrophizing thoughts account for between-subject differences in endoscopy pain. Rumination and helplessness but not magnification explain how procedural anxiety may evolve in a painful endoscopy experience. To the extent that one can address catastrophizing thoughts, endoscopy pain can be mitigated, especially for patients who are difficult to sedate.


Pain catastrophizing (PC) is one of the most important psychological factors associated with the experience of pain.[1–4] PC is a mindset of exaggerated negative, cognitive, and emotional schemas that describe people's beliefs, appraisals, and feelings related to actual or expected pain experience.[1] PC embodies ruminative thoughts and failure to defuse pain-related thoughts, inability to cope with painful situations, and amplification of pain and fear of the negative consequences of pain.[5]

PC is linked to both state and trait anxiety, fear of pain, and depression.[6–8] Recent studies have started looking at the differential impact of the specific facets of PC on pain severity and impairment. In samples of adults with chronic conditions, pain severity was more strongly associated with helplessness and rumination.[9–11] In summary, PC predicts chronic, experimentally induced, and clinical pain, whereas negative feelings such as anxiety and depression may either precede or follow it.[1,3,4]

Endoscopic procedures such as esophagogastroduodenoscopy (EGD) and colonoscopy can be extremely stressful for patients. On the one hand, the potential adverse effects and the concern for the clinical outcomes evoke fear and anxiety that trigger a vicious circle of amplification of bodily sensations and pain.[12,13] On the other hand, higher satisfaction with endoscopy increases patients' compliance with medical advice, adherence to screening, and maintenance of positive relationships with their healthcare providers, thus favoring a more careful examination.[14] Previous research has shown that PC may affect spontaneous pain after surgery.[3,15–17] EGD and colonoscopy are entirely unexplored regarding the relation of PC to procedure-related pain. Unlike surgery, endoscopy pain is expected but less predictable and unlikely to depend on damaged tissues.

The primary aim of the present study was to investigate how PC would be associated with endoscopy pain, using patient-reported and pain behavior. We also aimed to examine the relative contributions of the three facets of catastrophizing thoughts. We expect helplessness and rumination to be more strongly related to pain, whereas helplessness and magnification may be associated with procedural anxiety and depression.