Dispositional mindfulness appears to exert beneficial effects in the experience of chronic pain and related symptoms. However, there is currently no widely accepted theoretical model that explains the mechanisms underlying this relationship. Furthermore, existing studies often lack sufficient theoretical justification, adequate sample sizes to ensure statistical power, and precise analytical methods to identify the specific mechanisms involved.
Method
The present study analyzed the adequacy of the recent model proposed by Wilson et al. (2023), according to which dispositional mindfulness (assessed via Five Facet Mindfulness Questionnaire) predicts reduced pain perception (assessed via Abbreviated McGill Pain Questionnaire) through decreased pain catastrophizing (Pain Catastrophizing Scale). The study aimed to replicate the original findings in a large sample of the general population (n = 1075) and examine the model in a chronic pain population (n = 467), in which it has not been previously analyzed. Our methodological approach employs structural equation modeling, allowing us to clarify the specific facets of mindfulness that most significantly contribute to this relationship.
Results
Dispositional mindfulness, particularly its facet of non-judgment of inner experience, significantly predicted lower pain scores through decreased pain catastrophizing, specifically in its helplessness dimension, both in the healthy subgroup and in those with chronic pain. These findings replicate those of Wilson et al. (2023) in the general sample and, notably, extend to the chronic pain sample as well.
Conclusions
Our results provide robust evidence supporting the model proposed by Wilson et al. (2023) and extend it by showing that within mindfulness a non-judgment attitude plays a crucial role in reducing helplessness when facing pain. These findings offer valuable insights for developing evidence-based interventions aimed at promoting health and managing chronic pain for which there is still no effective treatments options.
Chronic pain, defined as pain lasting longer than three months, is a widespread public health issue and represents a leading cause of morbidity globally (Chambers et al., 2024; Yong et al., 2022). In the United States, approximately 50.2 million adults (20.5%) reported experiencing pain most days or every day in 2022, and the prevalence of chronic pain conditions ranges from 20 to 36% (Stubhaug et al., 2024). Chronic pain is closely linked to a diminished quality of life, affecting physical, emotional, social, and occupational aspects (Bucourt et al., 2021; Edwards et al., 2018), and imposes a significant economic burden on society through disability allowances and medical expenses (Cabo-Meseguer et al., 2017; Stubhaug et al., 2024). Moreover, this condition increases the risk of opioid prescription and misuse following medical discharge (Shah et al., 2020).
The experience of pain is a complex phenomenon involving interactions among sensory, cognitive-affective, and dispositional factors (Zeidan et al., 2018). One of the most prominent models describing pain is the fear-avoidance model of pain (Vlaeyen & Linton, 2000; Vlaeyen et al., 2016), which explains how cognitive responses to acute pain can influence long-term pain perception, potentially leading to functional limitations or chronic pain. According to this model, catastrophizing interpretations of pain (e.g., "I feel like I can't go on") can generate fear of pain (an anticipatory affective response to actual pain) and hypervigilance to pain (heightened attention to threatening stimuli). Such fear becomes a conditioned response linked to situations or activities perceived as potentially painful (e.g., exercise, lifting heavy objects). As a result, the person may avoid these activities, leading to reduced use of affected body parts and subsequent functional limitations, which can lead to deterioration of the musculoskeletal and cardiovascular systems. Furthermore, avoidance behaviors reduce opportunities for positive reinforcement from daily life, potentially leading to negative emotional states and depression. Finally, disability, physical deconditioning, and depression increase the risk of re-injury or prolonged pain experiences (Vlaeyen & Linton, 2000).
Several studies have demonstrated the protective role of mindfulness attitude to various factors associated with pain experience, both through mindfulness training (see the meta-analysis by Best et al., 2024; Hilton et al., 2017; Ng et al., 2024; Nicolardi et al., 2024), and dispositional or trait mindfulness (e.g., Harrison et al., 2019; McCracken & Thompson, 2009; McCracken et al., 2007; Mischkowski et al., 2021; Mu & Lee, 2024; Wilson et al., 2022; Zeidan et al., 2018). Specifically, dispositional mindfulness has been shown to mitigate pain perception in the general population. For instance, Zeidan et al. (2018) found that higher levels of mindfulness, as measured by the Freiburg Mindfulness Inventory (FMI; Walach et al., 2006), predicted reduced pain intensity and pain aversion in a sample of 76 healthy people. Furthermore, Harrison et al. (2019) demonstrated that higher mindfulness levels, assessed through the Five Facet Mindfulness Questionnaire (FFMQ), were related to greater pain thresholds (measured via thermal stimulation) and lower pain catastrophizing in 40 healthy volunteers. Additionally, Mischkowski et al. (2021) found that higher mindfulness scores, measured using the Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003), predicted lower subjective ratings on sensory and affective dimensions of pain in 131 participants from the general population, although this association was not observed for experimental pain measures involving thermal stimulation.
In addition, dispositional mindfulness has been associated with beneficial effects on pain experience against the experience of pain in people with chronic pain. McCracken et al. (2007) demonstrated that mindfulness levels, assessed using the MAAS (Brown & Ryan, 2003), predicted lower pain-related anxiety in a sample of 105 patients with various types of chronic pain, mainly low back pain. McCracken and Thompson (2009) conducted a comprehensive assessment of mindfulness components in 150 patients with chronic pain, identifying the facet "acting with awareness" as the strongest predictor of physical functioning within this population. However, other studies have reported that while mindfulness (as measured by MAAS) is associated with perceived health, it does not necessarily correlate with symptom severity in a sample of 250 people with osteoarthritis (Chu et al., 2024).
Although overall the evidence suggests that mindfulness has a protective role in the experience of pain both in the general population and in people with chronic pain, there is still no widely accepted model that clearly elucidates the mechanisms by which mindfulness influences pain perception. Schütze et al. (2010) were the first to propose the integration of mindfulness attitude within the fear-avoidance model of pain. In their study, they assessed all variables of the model alongside dispositional mindfulness (measured through MAAS and FFMQ) in a sample of 104 patients with various chronic pain conditions, predominantly low back pain, to determine whether dispositional mindfulness plays a distinct and meaningful role within the model. Their findings indicated that dispositional mindfulness indeed plays an independent role in the fear-avoidance model, explaining between 17–41% of the variance, with the most substantial association being with pain catastrophizing and moderating the relationship between pain catastrophizing and pain intensity. Several investigations have shown a relationship between dispositional mindfulness and pain catastrophizing (Conti et al., 2020; Curtin and Norris, 2017; Day et al., 2015; Dorado et al., 2018; Mun et al., 2014). For example, Day et al. (2015) showed in a sample of 214 healthy people that there was a relationship between mindfulness (FFMQ), particularly the facets of non-reactivity, non-judgment and acting with awareness, and pain catastrophizing, although these relationships were no longer significant when the contribution of worry was controlled. Additionally, Mun et al. (2014) examined the roles of dispositional mindfulness and pain catastrophizing as potential mediators in the relationship between chronic pain severity and pain-related disability among 177 students with low pain levels and 157 students with high pain severity. Although their initial mediation model was not statistically significant, they found that higher mindfulness was related to lower pain catastrophizing, even beyond the influence of pain acceptance. However, pain catastrophizing did not predict pain-related impairment when mindfulness was controlled. Curtin and Norris (2017) proposed a revised pain fear-avoidance model incorporating rumination and mindfulness (measured with the FFMQ) as relevant variables. Their study, involving 201 participants with chronic pain, demonstrated that mindfulness, particularly the facets of non-reactivity, non-judgment, and acting with awareness, was related to all model components except for pain intensity. Nonetheless, mindfulness did not significantly mediate the relationship between rumination and pain components. Dorado et al. (2018) explored the interaction between dispositional mindfulness and pain catastrophizing in predicting pain among 88 patients with fibromyalgia. Their findings suggested that the facets most involved in this relationship were non-judgment and acting with awareness. Finally, Conti et al. (2020) investigated the role of pain catastrophizing as a potential mechanism explaining the relationship between mindfulness and depression and anxiety in a chronic pain population, obtaining significant results in the chronic pain subsample (17 of 48 participants).
Wilson et al. (2023) conducted the only study, to our knowledge, that systematically tested the hypothesis proposed by Schütze et al. (2010), which suggested incorporating dispositional mindfulness into the fear-avoidance model of pain. They performed two studies involving 362 and 580 participants from the general population, respectively, examining the fear-avoidance model of pain by introducing mindfulness (measured using the MAAS) before pain catastrophizing. Through structural equation modeling, they found that the proposed model did not adequately fit the data. Surprisingly, a simplified model in which mindfulness predicted reduced pain intensity and sensitivity through pain catastrophizing alone provided the best fit for the data, even surpassing the original model that excluded mindfulness.
The present study aimed to replicate and extend the recent results of Wilson et al. (2023) to provide evidence in support of the mindfulness model of pain. Following their simplified model on the mindfulness, catastrophizing, and pain relationship, which provided the best fit in their studies, we collected a sufficiently large sample of both the general population and participants with chronic pain to draw robust conclusions. Additionally, to go a step further and enhance specificity in identifying the dimensions of mindfulness most protective against pain, we employed the FFMQ measure of mindfulness, allowing us to conduct structural equation modeling analyses at the facet level. Hypothesis 1 was that greater dispositional mindfulness would be associated with reduced pain perception through the mediation of less pain catastrophizing, thereby replicating the findings of Wilson et al. (2023). Hypothesis 2 was that this relationship would be similarly observed in the chronic pain subsample, where this model has not yet been evaluated (Conti et al., 2020; Curtin and Norris, 2017; Dorado et al., 2018; Mun et al., 2014). Finally, Hypothesis 3, based on the reviewed literature (Curtin and Norris, 2017; Day et al., 2015; Dorado et al., 2018; McCracken & Thompson, 2009; Schütze et al., 2010), posited that the non-judgment, non-reactivity, and acting with awareness facets of mindfulness would exhibit the strongest predictive power in the mindfulness, catastrophizing and pain relationship.
Method
Participants
The total sample of this study comprised 1542 Spanish participants (Mage = 31.79, SDage = 15.15, Range = 18–84, 69.2% women), of which 1075 belonged to the general population without pain (Mage = 30.3, SDage = 14.72, Range = 18–77, 65% women), and 467 were people with chronic pain (Mage = 35.26, SDage = 15.57, Range = 18–84, 78% women). Participants were classified into the chronic pain group based on their scores on the Central Sensitization Inventory (CSI; Mayer et al., 2012). Informed consent was obtained from all participants before commencing the survey, which was completed anonymously and voluntarily. The only inclusion criterion was being within the age range of 18 to 90 years.
Procedure
The study was conducted online using LimeSurvey platform provided by the University of Granada, which was similar to systems like SONA, and was advertised through the university’s social networks. In addition, pain-related support groups were invited to participate in the survey. Participants were asked to complete an online survey of approximately one hour in duration, which included different questionnaires and questions. To reduce the likelihood of random responses, typing-based answers were incorporated throughout the survey, allowing researchers to assess whether participants were providing elaborated responses. The study strictly adhered to data protection regulations, complied with the ethical standards outlined in the Declaration of Helsinki (World Medical Association, 2013), and received approval from the ethics committee of the University of Granada.
Measures
This study is part of a broader project that included additional variables. For the present work, the three instruments detailed below were utilized, along with demographic measures employed as control variables (age, sex, level of education and health status). The CSI (Central Sensitization Inventory; Mayer et al., 2012; see Cuesta-Vargas et al., 2016 for its Spanish adaptation to) was also administered. It includes items identifying the presence of central sensitization-related diagnoses (restless legs syndrome, chronic fatigue syndrome, fibromyalgia, temporomandibular joint disorder, migraine or tension headaches, irritable bowel syndrome, multiple chemical sensitivity, and neck injury). The CSI was used to establish the chronic pain subgroup.
FFMQ (Five Facet Mindfulness Questionnaire; Baer et al., 2006; see Cebolla et al., 2012 for its Spanish version). This self-administered instrument comprises 39 items rated on a Likert scale ranging from 1 (never or very rarely true) to 5 (very often or always true). It measures the five components of dispositional mindfulness: observing (e.g., "I notice the smells and aromas of things"), describing (e.g., "I’m good at finding the words to describe my feelings"), acting with awareness (e.g., "I am easily distracted", reversed item), non-judgment of inner experience (e.g., "I disapprove myself when I have irrational ideas", reversed item), and non-reactivity to inner experience (e.g., "I can observe my feelings without getting lost in them"). The instrument has demonstrated satisfactory reliability and validity in previous work (α = from 0.80 to 0.91; Cebolla et al., 2012) and in our sample (McDonald's Omega for the total score was 0.89; observing ω = 0.81; describing ω = 0.52; acting with awareness ω = 0.89; non-judgment of inner experience ω = 0.91; non-reactivity to inner experience ω = 0.78).
MPQ-SF (McGill Pain Questionnaire-short form; Melzack, 1987; Masedo and Esteve, 2000 for its Spanish version). This measure consists of 15 items with verbal descriptors of pain rated on a Likert scale ranging from 0 (no) to 3 (severe pain). The items are categorized into a sensory scale (11 descriptors, e.g., throbbing, jolting) and an affective scale (4 descriptors, e.g., terrible, tormenting). Additionally, it includes two items: one assessing current pain intensity and another measuring pain intensity over the last week, both rated on a range from 0 to 10. The Spanish version of this instrument has demonstrated satisfactory validity and reliability in previous work (α = 0.74; Masedo and Esteve, 2000) and in our sample (total score ω = 0.91; sensory scale ω = 0.86; affective scale ω = 0.84).
PCS (Pain Catastrophizing Scale; Sullivan et al., 1995; see García-Campayo et al., 2008 for its Spanish adaptation). This instrument consists of 13 items rated on a Likert scale ranging from 0 (not at all) to 4 (all the time), designed to assess the three dimensions of pain catastrophizing: rumination (e.g., "I keep thinking about how much it hurts"), magnification (e.g., "It's terrible and I think it will never get better"), and helplessness (e.g., "I feel like I can't go on") associated with pain. The Spanish adaptation of this scale has demonstrated adequate reliability and validity in previous work (α = 0.79; García-Campayo et al., 2008) and in our sample (total score ω = 0.95; rumination ω = 0.93; magnification ω = 0.8; helplessness ω = 0.89).
Data Analyses
The recruited sample (n = 1542) and the identified chronic pain subgroup (n = 467) surpassed the minimum required sample size (n = 289) calculated based on the effect size reported by Wilson et al. (2023) of 0.21, a desired statistical power of 0.95, and a significance level of 0.05. All analyses were conducted using the JASP software (JASP Team, 2023) and its SEM (Structural Equation Modeling) toolbox powered by the Lavaan package. Descriptive statistics were presented as means (M), standard deviations (SD), and percentages (%). Statistical significance was established at p < 0.05, with 95% confidence intervals applied. Pearson correlation analyses were performed among the three primary measures to provide an initial exploration of the data. Mediation analyses were subsequently conducted with pain catastrophizing (PCS) as a mediator between dispositional mindfulness (FFMQ) and pain (MPQ-SF), in line with the simplified model proposed by Wilson et al. (2023). This analysis was first performed on the general population sample, followed by the chronic pain subgroup. To enhance specificity, a structural equation model was developed incorporating the facets of each questionnaire as predictors: observing, describing, acting with awareness, non-judgment of inner experience, and non-reactivity to inner experience. The mediators included: rumination, helplessness, and magnification, while the outcome variables were pain intensity, and both the sensory and affective dimensions of pain. Finally, the model was repeated at the facet level in the chronic pain subsample.
Results
Sociodemographic Characteristics, Descriptive and Correlational Analysis
Table 1 shows the sociodemographic characteristics of the total sample, as well as those of the general and chronic pain groups. Among the total sample, 69.5% of participants were single, 23.4% were married, and 5.5%, 0.9%, and 0.6% were divorced, separated, or widowed, respectively. Regarding education, 56.7% of participants had completed university studies, 18.2% finished high school, 16% had vocational training, and 6%, 2.9%, and 0.2% had completed secondary, elementary, or no formal education, respectively. Concerning employment status, the 53.3% of participants were students, 36.4% were employed, and 5.2%, 3.2%, and 1.9% were unemployed, retired, or on sick leave, respectively. In terms of self-reported health status, 13.6% described their health as excellent, 51.1% as good, 31.2% as fair, and 4.1% as poor.
Table 1
Sociodemographic characteristics
Total sample
n = 1542
General sample
n = 1075
Chronic pain sample
n = 467
Age, M (SD), range
31.80 (15.15)
30.30 (14.72)
35.26 (15.57)
Gender, n (%)
men
471 (30.5%)
373 (34.7%)
98 (21%)
women
1058 (68.6%)
694 (64.6%)
364 (77.9%)
non binary
13 (0.8%)
8 (0.7%)
5 (1.1%)
Education level, n (%)
Without formal education
3 (0.2%)
3 (0.3%)
0 (0%)
Primary school
45 (2.9%)
23 (2.1%)
22 (4.7%)
Secondary school
92 (6%)
59 (5.5%)
33 (7.1%)
High school graduate
280 (18.2%)
210 (19.5%)
70 (15%)
Professional instruction
247 (16%)
153 (14.2%)
94 (20.1%)
University studies
875 (56.7%)
627 (58.3%)
248 (53.1%)
Marital status, n (%)
Single
1072 (69.5%)
791 (73.6%)
281 (60.2%)
Married
361 (23.4%)
227 (21.1%)
134 (28.7%)
Widowed
10 (0.6%)
4 (0.4%)
6 (1.3%)
Separated
14 (0.9%)
9 (0.8%)
5 (1.1%)
Divorced
85 (5.5%)
44 (4.1%)
41 (8.8%)
Employment status, n (%)
Student
822 (53.3%)
622 (57.9%)
200 (42.8%)
Active
561 (36.4%)
370 (34.4%)
191 (40.9%)
Retired
49 (3.2%)
31 (2.9%)
18 (3.9%)
Unemployed
80 (5.2%)
43 (4%)
37 (7.9%)
Temporary disability leave
16 (1%)
4 (0.4%)
12 (2.6%)
Permanent disability leave
14 (0.9%)
5 (0.5%)
9 (1.9%)
Current health perceived, n (%)
Excellent
210 (13.6%)
172 (16%)
38 (8.1%)
Good
788 (51.1%)
594 (55.3%)
194 (41.5%)
Acceptable
481 (31.2%)
289 (26.9%)
192 (41.1%)
Poor
63 (4.1%)
20 (1.9%)
43 (9.2%)
The descriptive analyses of the variables of interest are presented in Table 2, being consistent with previous findings (Wilson et al., 2023). Significant differences were observed between the general population and the chronic pain group across all subscales of the FFMQ, except for describing and non-reactivity, as well as for the MPQ-SF, PCS and CSI (values between t = 1.99, p < 0.05 and t = −14.02, p < 0.001). Pearson correlation analyses for the total sample (Table 3) revealed significant negative correlations between the FFMQ and both MPQ-SF and PCS. Notably, the facets of non-judgment, acting with awareness, and describing are significantly correlated with lower scores on MPQ-SF and PCS. This pattern of correlations was consistently observed in both the general population and chronic pain groups when analyzed separately.
Table 2
Descriptive statistics of the main variables
Total sample
n = 1542
M (SD)
General sample
n = 1075
M (SD)
Chronic pain sample
n = 467
M (SD)
t1540 /U
Minimum and maximun
score
Mindfulness (FFMQ)
FFMQ Total
123.46 (17.97)
124.06
(17.86)
122.08 (18.18)
1.99*
39–195
Observing
22.91 (6.6)
22.62 (6.65)
23.58 (6.44)
−2.61**
8–40
Describing
26.52 (6.98)
26.62 (6.53)
26.28 (6.86)
0.92
8–40
Acting with awareness
27.33 (6.98)
27.65 (6.89)
26.58 (7.13)
2.79**
8–40
Non-judgment
27.22 (7.82)
27.66 (7.84)
26.21 (7.69)
3.36***
8–40
Non-reactivity
19.48 (5.16)
19.50 (5.29)
19.43 (4.85)
0.23
7–35
Pain (MPQ-SF)
MPQ-SF Total
4.92 (6.74)
3.53 (5.02)
8.11 (8.81)
−12.89***
0–45
Current intensity
0.68 (0.93)
0.51 (0. 79)
1.07 (1.10)
−177,908.50***
0–5
Intensity last week
3.05 (2.18)
2.59 (1.89)
4.10 (2.43)
−13.22***
0–10
Sensory
3.82 (4.92)
2.81 (3.78)
6.15 (6.27)
−12.86***
0–33
Affective
1.1 (2.18)
0.72 (1.60)
1.97 (2.97)
−10.66***
0–12
Pain Catastrophizing (PCS)
PCS Total
13.36 (11.37)
12.07 (10.65)
16.31 (12.39)
−6.83***
0–52
Rumination
5.21 (4.55)
4.83 (4.44)
6.10 (4.67)
−5.09***
0–16
Helplessness
5.09 (4.99)
4.48 (4.49)
6.51 (5.73)
−7.45***
0–24
Magnification
3.05 (2.81)
2.77 (2.64)
3.71 (3.08)
−6.11***
0–12
Central Sensitization (CSI)
CSI Total
33.36 (15.18)
30.00 (13.64)
41.11 (15.72)
−14.02***
0–100
* p < 0.05,** p < 0.01, *** p < 0.001
Table 3
Pearson correlation matrix between Mindfulness (FFMQ), and its facets, and Pain (MPQ-SF), and Pain Catastrophizing (PCS)
Total sample
General sample
Chronic pain sample
MPQ-SF
PCS
MPQ-SF
PCS
MPQ-SF
PCS
FFMQ Total
−0.22**
−0.29**
−0.25**
−0.26**
−0.20**
−0.32**
Observing
0.21**
0.23**
0.14**
0.21**
0.31**
0.25**
Describing
−0.12**
−0.13**
−0.14**
−0.12**
−0.10*
−0.13**
Acting with awareness
−0.32**
−0.34**
−0.29**
−0.30**
−0.37**
−0.41**
Non-judgment
−0.30**
−0.42**
−0.30**
−0.40**
−0.31**
−0.44**
Non-reactivity
−0.01
−0.03
−0.01
−0.02
−0.01
−0.06
PCS
0.46**
–
0.37**
–
0.52**
–
*p < 0.05,** p < 0.01
Simplified Model in General Population
To test our first hypothesis concerning the mechanism by which mindfulness may be protective against pain, we constructed the simplified model proposed by Wilson et al. (2023). In this model, the FFMQ served as the predictor, MPQ-SF as the dependent variable, and PCS as the mediator in the general population (n = 1075) (Table 4 and Fig. 1). The direct effect of FFMQ on MPQ-SF was significant (z = −5.49, p < 0.001). The total effect of FFMQ on MPQ-SF (sum of the direct effect and indirect effects) was also significant (z = −8.309, p < 0.001). As anticipated, the mediation effect of PCS was significant (z = −7.031, p < 0.001).
Table 4
Simplified model: mediation of Pain Catastrophizing (PCS) in the relationship between Mindfulness (FFMQ) and Pain (MPQ-SF) in the general sample
Standardized Estimate
SE
z
p
Lower CI
Upper CI
Direct Effect
FFMQ MPQ-SF
−0.045
0.008
−5.491
< 0.001
−0.061
−0.029
Indirect Effect
FFMQ PCS MPQ
−0.024
0.003
−7.031
< 0.001
−0.031
−0.018
Total Effect
FFMQ MPQ-SF
−0.069
0.008
−8.309
< 0.001
−0.085
−0.053
Fig. 1
Simplified model graph for the general sample: Mindfulness (FFMQ) predicts Pain (MPQ-SF) mediated by Pain Catastrophizing (PCS)
To explore our third hypothesis regarding which FFMQ components are most relevant to the relationship between mindfulness and pain in the general population, we performed the model at the dimension level (Table 5 and Fig. 2). The model was statistically significant (χ2 = 1843.451, p < 0.001). All facets of the FFMQ, except describing, are related to some factor of the PCS. Among all FFMQ facets, non-judgment emerged as the strongest predictor of all PCS factors (rumination z = −7.64, p < 0.001; magnification z = −8.27, p < 0.001; and helplessness z = −8, p < 0.001). Notably, of these, the helplessness dimension was the most strongly related to the MPQ-SF subscales (intensity z = 14.43, p < 0.001; sensory z = 15.88, p < 0.001; and affective z = 16.84, p < 0.001).
Table 5
Pain Catastrophizing (PCS) facet model mediating the Mindfulness (FFMQ) and Pain (MPQ-SF) relationship in the general sample
Model
χ2
Df
p
1843.451
18
< 0.001
Predictor
Outcome
Estimate
SE
z
p
Lower CI
Upper CI
Magnification
Helplessness
Rumination
Magnification
Helplessness
Rumination
Magnification
Helplessness
Rumination
Observing Describing
Act aware.. Non-judgment
Non-reactivity Observing Describing
Act aware.. Non-judgment
Non-reactivity
Observing Describing
Act aware.. Non-judgment
Non-reactivity
Intensity
Intensity
Intensity
Sensory
Sensory
Sensory
Affective
Affective
Affective
Rumination
Rumination
Rumination
Rumination
Rumination
Helplessness
Helplessness
Helplessness
Helplessness
Helplessness
Magnification
Magnification
Magnification
Magnification
Magnification
0.012
0.176
−0.035
0.085
0.383
−0.122
0.046
0.171
−0.065
0.117
−0.018
−0.036
−0.153
−0.115
0.072
−0.010
−0.089
−0.160
−0.134
0.054
−0.018
−0.038
−0.097
−0.048
0.021
0.012
0.012
0.041
0.024
0.024
0.017
0.010
0.010
0.024
0.022
0.023
0.020
0.029
0.024
0.022
0.023
0.020
0.029
0.014
0.013
0.013
0.012
0.017
0.578
14.435
−2.816
2.072
15.879
−5.004
2.639
16.844
−6.335
4.825
−0.825
−1.574
−7.641
−3.987
2.994
−0.441
−3.891
−8.009
−4.668
3.821
−1.371
−2.860
−8.270
−2.863
0.563
< 0.001
0.005
0.038
< 0.001
< 0.001
0.008
< 0.001
< 0.001
< 0.001
0.409
0.115
< 0.001
< 0.001
0.003
0.659
< 0.001
< 0.001
< 0.001
< 0.001
0.171
0.004
< 0.001
0.004
−0.029
0.152
−0.059
0.005
0.336
−0.170
0.012
0.151
−0.085
0.069
−0.062
−0.081
−0.192
−0.171
0.025
−0.054
−0.133
−0.199
−0.190
0.026
−0.044
−0.064
−0.120
−0.081
0.053
0.200
−0.011
0.166
0.431
−0.074
0.080
0.191
−0.045
0.164
0.025
0.009
−0.114
−0.058
0.120
0.034
−0.044
−0.121
−0.078
0.082
0.008
−0.012
−0.074
−0.015
Fig. 2
Facet model graph in the general sample: Mindfulness (FFMQ) predicts Pain (MPQ-SF) mediated by Pain Catastrophizing (PCS)
To evaluate our second hypothesis regarding the mediation of catastrophizing in the relationship between mindfulness and pain in the chronic pain subgroup, we applied the simplified model proposed by Wilson et al. (2023) to the chronic pain subsample (n = 467), (Table 6 and Fig. 3). While the direct effect was not statistically significant (z = −0.97, p = 0.329), the total effect was significant (z = −4.44, p < 0.001), and PCS demonstrated a significant mediation effect in the relationship between FFMQ and MPQ-SF (z = −6.234, p < 0.001).
Table 6
Simplified model:Pain Catastrophizing (PCS) mediation in the Mindfulness (FFMQ) and Pain (MPQ-SF) relationship in the chronic pain sample
Standardized Estimate
SE
z
p
Lower CI
Upper CI
Direct Effect
FFMQ MPQ-SF
−0.020
0.020
−0.976
0.329
−0.059
0.020
Indirect Effect
FFMQ PCS MPQ
−0.078
0.012
−6.234
< 0.001
−0.102
−0.053
Total Effect
FFMQ MPQ-SF
−0.098
0.022
−4.444
< 0.001
−0.141
−0.055
Fig. 3
Simplified model graph for chronic pain sample: Mindfulness (FFMQ) predicts Pain (MPQ-SF) mediated by Pain Catastrophizing (PCS)
As in the previous section and with the aim of analyzing our third hypothesis, the structural equation model was further refined to incorporate specific FFMQ and PCS facets relevant in the relationship between FFMQ and MPQ-SF within the chronic pain subsample (Table 7 and Fig. 4). The model was statistically significant (χ2 = 749.376, p = < 0.001). The facets of non-judgment, acting with awareness, and non-reactivity demonstrated the strongest associations with PCS dimensions. Notably, non-judgment most robustly predicted all three PCS factors (rumination z = −4.99, p < 0.001; magnification z = −5.96, p < 0.001; and helplessness z = −4.24, p < 0.001). Similarly, helplessness remained the most predictive factor of MPQ-SF subscales (intensity z = 13.17, p < 0.001; sensory z = 14.76, p < 0.001; and affective z = 16.08, p < 0.001).
Table 7
Pain Catastrophizing (PCS) facet model mediating the Mindfulness (FFMQ) and Pain (MPQ-SF) relationship in chronic pain sample
Model
X2
df
p
749.376
18
< 0.001
Predictor
Outcome
Estimate
SE
Z
p
Lower CI
Upper CI
Magnification
Intensity
2.71E-01
0.033
0.008
0.994
-0.065
0.066
Helplessness
Intensity
0.236
0.018
13.173
< 0.001
0.201
0.271
Rumination
Intensity
-0.051
0.022
-2.349
0.019
-0.094
-0.008
Magnification
Sensory
0.305
0.082
3.729
< 0.001
0.145
0.465
Helplessness
Sensory
0.647
0.044
14.764
< 0.001
0.561
0.733
Rumination
Sensory
-0.291
0.054
-5.437
< 0.001
-0.396
-0.186
Magnification
Affective
0.075
0.039
1.931
0.053
-0.001
0.150
Helplessness
Affective
0.333
0.021
16.085
< 0.001
0.293
0.374
Rumination
Affective
-0.130
0.025
-5.116
< 0.001
-0.179
-0.080
Observing
Rumination
0.083
0.036
2.305
0.021
0.012
0.153
Describing
Rumination
0.062
0.033
1.867
0.062
-0.003
0.127
Act aware.
Rumination
-0.130
0.035
-3.678
< 0.001
-0.199
-0.061
Non-judgment
Rumination
-0.158
0.032
-4.991
< 0.001
-0.220
-0.096
Non-reactivity
Rumination
-0.117
0.045
-2.566
0.010
-0.206
-0.028
Observing
Helplessness
0.127
0.043
2.942
0.003
0.042
0.211
Describing
Helplessness
0.023
0.040
0.566
0.571
-0.055
0.101
Act aware.
Helplessness
-0.209
0.042
-4.937
< 0.001
-0.292
-0.126
Non-judgment
Helplessness
-0.161
0.038
-4.244
< 0.001
-0.236
-0.087
Non-reactivity
Helplessness
-0.183
0.054
-3.353
< 0.001
-0.289
-0.076
Observing
Magnification
0.067
0.023
2.955
0.003
0.023
0.112
Describing
Magnification
-0.010
0.021
-0.469
0.639
-0.051
0.031
Act aware.
Magnification
-0.073
0.022
-3.228
0.001
-0.117
-0.028
Non-judgment
Magnification
-0.120
0.020
-5.956
< 0.001
-0.159
-0.080
Non-reactivity
Magnification
-0.116
0.029
-4.010
< 0.001
-0.172
-0.059
Fig. 4
Facet model graph in the chronic pain sample: Mindfulness (FFMQ) predicts Pain (MPQ-SF) mediated by Pain Catastrophizing (PCS)
This study aimed to replicate the results of Wilson et al. (2023) model, which proposes that pain catastrophizing mediates the relationship between mindfulness and pain in the general population (Hypothesis 1), and to evaluate its applicability to people with chronic pain (Hypothesis 2). In addition, we sought to identify the most relevant facets of mindfulness in this effect, hypothesizing according to previous research, that non-judgment, non-reactivity, and acting with awareness would be particularly relevant (Hypothesis 3). Our results confirm all three hypotheses. The simplified model of Wilson et al. (2023) was found to be significant in both the general and the chronic pain samples. Furthermore, structural equation analysis highlights the predominant role of the non-judgment facet of mindfulness and the helplessness facet of pain catastrophizing as pivotal components of the model.
Dispositional mindfulness has been consistently linked to enhanced well-being (e.g., Brown & Ryan, 2003; Prieto-Fidalgo et al., 2022) and our findings suggest it also provides resilience against pain perception. Higher levels of dispositional mindfulness were associated with reduced pain catastrophizing and lower pain in the general population, aligning with the model of Wilson et al. (2023). Equanimity, that is, accepting experiences without judgment, appears to enhance one's ability to endure discomfort (reduced helplessness) without amplifying its intensity (reduced catastrophizing). Over time, adopting a non-judgmental approach may promote exposure to sensations and foster a sense of efficacy in coping with them. Prior research has linked non-judgment with higher self-efficacy and self-esteem (Moniz-Lewis et al., 2022; Soysa & Wilcomb, 2015). In the short term, non-judgment may be associated with improved cognitive control by limiting mind-wandering about the positive or negative nature of experiences. Indeed, dispositional mindfulness has been shown to reduce mind-wandering (Aguerre et al., 2023; Cásedas et al., 2022), and enhance cognitive control efficiency within non-affective situations (Aguerre et al., 2021). In contexts where experiences are highly affective, such as pain, equanimity may be particularly essential for remaining present without engaging in mind-wandering. This notion aligns with the recent capacity–efficiency mindfulness theory, suggesting that mindfulness may increase cognitive efficiency by reducing vulnerability to mind-wandering and negative affect (Cásedas et al., 2024). A reduced tendency toward mind-wandering probably leads to reduced presence of maladaptive or biased cognitions about pain (Ford et al., 2023), which ultimately contributes to pain improvement (Vlaeyen & Linton, 2000). To our knowledge, this is the first study to replicate their findings with theoretically grounded hypotheses and in a substantial sample (n = 1075).
As a novel contribution, this study demonstrates that the simplified model of Wilson et al. (2023) also applies to people with chronic pain. Our results indicate that, among people with chronic pain (n = 467), dispositional mindfulness exerts a protective effect against the experience of pain via reduced pain catastrophizing. While the direct effect of mindfulness was not significant, the mediation was, suggesting that the reduction of pain catastrophizing is the principal mechanism underlying reduced pain perception (Ford et al., 2023; Vlaeyen & Linton, 2000). It is to be noted that in the chronic pain sample, the effect of mindfulness on perceived pain is very nearly completely mediated by catastrophizing, whereas there is only partial mediation in the general sample. When examining both samples, it is also informative to see the large differences in the percentage of women, which is higher in the chronic pain sample, and the differences in pain catastrophizing and pain intensity, while the level of mindfulness is similar in both groups. Altogether these findings align with previous studies highlighting the inverse relationship between mindfulness and pain catastrophizing in chronic pain populations (Curtin & Norris, 2017; Dorado et al., 2018; Mun et al., 2014), providing empirical support for similar mechanisms operating in the relationship between mindfulness and pain in people with and without chronic pain.
The reduction of catastrophizing thoughts due to mindfulness emerges as a crucial mechanism in reducing pain perception. However, our findings highlight the need for further refinement of these mechanisms, as previously suggested by studies investigating the role of acceptance or rumination in this relationship (Curtin & Norris, 2017; Mun et al., 2014). Our results indicate, concerning dispositional mindfulness, that the non-judgment of inner experience is the facet that most strongly predicts all three components of pain catastrophizing across both general and chronic pain samples. This finding is consistent with previous research (Curtin & Norris, 2017; Day et al., 2015; Dorado et al., 2018; McCracken & Thompson, 2009; Schütze et al., 2010), emphasizing the protective role of the facets of non-judgment, non-reactivity and acting with awareness against pain. Thus, it is more the attitude (of non-judgment), than the attention on the present itself, which is protective against catastrophic thoughts and pain. On the other hand, within pain catastrophizing, the helplessness factor is most strongly associated with pain perception, exceeding the impact of rumination and magnification. This suggests that the feeling of being unable to tolerate pain, rather than excessive attention or magnifying and amplifying the painful situation, most significantly affects pain perception. Perhaps non-judgment (allowing experiences to unfold without evaluative judgment) may attenuate emotional processing and enhance resilience in coping with pain.
Limitations and Future Directions
Our study is subject to several limitations. The survey was administered online and distributed via university students, acquaintances, and pain-related support groups to achieve a sufficiently large sample. This recruitment strategy may have resulted in an overrepresentation of university students, potentially introducing sampling bias. Additionally, the survey's length (approximately one hour) could have influenced the quality of responses. Furthermore, the study was not preregistered, as it was part of a larger project and informed by insights from preliminary analyses. Future validation of the model would benefit from preregistration to enhance methodological transparency and reproducibility. Moreover, some concerns have been raised regarding the sensitivity and validity of the FFMQ, for example, beginner meditators may score higher on the FFMQ than experienced monastics (see different arguments on the debate in Baer et al., 2022; Goldberg et al., 2016; Lecuona et al., 2021). Although this concern is mostly unrelated to our sample of non-meditators, we conducted analyses at the facet level (following the recommendations for using the FFMQ by Lecuona et al., 2021), and note that the model has been previously tested with a different mindfulness scale (MAAS in Wilson et al., 2023). Additionally, the proposed model would benefit from future testing incorporating diverse mindfulness measures, including alternative questionnaires and objective assessments such as the breath counting task (Lim et al., 2018) to further validate the model. A main limitation of our study is its cross-sectional nature, which precludes causal inferences. Future research should conduct longitudinal studies to provide deeper insights into these relationships and support the development of evidence-based interventions. An additional avenue for future research involves examining individuals who have recovered from chronic pain. While this proportion is likely relatively small (approximately 10–30%), understanding how dispositional mindfulness relates to their current pain status could offer valuable insights into potential protective or adaptive mechanisms. It would also be of interest to include objective measures of pain, such as EEG biomarkers or measures of thermal stimulation, to determine whether pain improvement is both subjective and objective.
In conclusion, our investigation, grounded in Wilson et al.'s (2023) model, successfully replicates their findings within a large general population sample (n = 1075), extends them to individuals with chronic pain (n = 467), and identifies the dimensions acting as mechanisms of the observed effects. The results of the present study show that both in the general population and people with chronic pain, the mechanism by which mindfulness (especially its non-judgment facet) improves the experience of pain is through less pain catastrophizing (specifically, less helplessness in the face of pain). These results underscore the importance of examining mindfulness at the facet level to better understand its protective mechanisms. Rigorous and systematic research of these relationships may be key to the development of tailored evidence-based interventions for chronic pain conditions, for which there is still not enough effective treatment, and for health promotion in healthy people. Ultimately, the cultivation of mindfulness remains a promising approach to enhancing integrative health and improving quality of life.
Declarations
Artificial Intelligence Statement
AI was not used.
Ethical Approval
The study was approved and carried out following the recommendations of the Research Ethics Committee of the University of Granada, approved by CEIM/CEI Provincial de Granada (Consejería de Salud y Familias, Junta de Andalucía), and in accordance with the Declaration of Helsinki (World Medical Association, 2013), project PID2019-109612 GB-I00, MCIN/AEI/https://doi.org/10.13039/501100011033.
Conflict of Interest
The authors declare that they have no conflict of interest.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
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