When Tolerating Pain Is a Warning Sign, Not a Strength

For decades, pain clinics have asked patients a deceptively simple question: how much pain would be acceptable to you? The intuition behind the question seems obvious. A patient who says they could tolerate a pain level of 50 on a 100-point scale sounds tough, resilient, someone whose internal resources outstrip their suffering. But a new study from Hannover Medical School in Germany turns that intuition on its head. Among more than 800 people with chronic pain, those who reported higher acceptable pain levels were not coping better. They were carrying a heavier psychological burden, one that remained hidden after researchers statistically stripped away the influence of how much pain the patients were actually in.

The study, published in BMC Psychology, is a secondary analysis of 822 consecutive patients treated at the university pain clinic’s outpatient department between February 2019 and July 2020. All patients completed their assessments through a validated digital tool called SymptomMapper, which requires sequential completion of every item before submission, a design feature that explains the near-perfect data completeness in the sample. The participants, roughly two-thirds of them women with an average age of 53.7 years, reported a mean pain intensity of 59.2 on the visual analogue scale. Their mean acceptable pain was 25.5, but the distribution was strikingly skewed: about 7 percent said no pain at all was acceptable, while 8 percent reported values of 50 or higher.

The researchers, led by Yannick Bruns, examined how the single acceptable-pain item related to six psychosocial outcomes: somatization measured with the PHQ-15, anxiety with the GAD-7, sleep impairment on a visual analogue scale, perceived stress with the PHQ stress module, depression with the PHQ-9, and pain-related disability with the Pain Disability Index. Crucially, the statistical models adjusted not just for one measure of pain severity but for three, the mean, maximum, and current pain intensity over the previous four weeks, along with trauma category, age, and sex. A Bonferroni correction set the significance threshold at 0.008 to guard against false positives across the six tests.

The results were consistent and, in one sense, counterintuitive. Each 10-point increase on the acceptable pain scale was associated with significantly greater somatization, anxiety, sleep impairment, and perceived stress. The association with depression fell just short of significance, and there was no association at all with functional disability. The incremental variance explained by acceptable pain was modest, between 0.8 and 1.4 percent for the four significant outcomes, but the direction of every significant association pointed the same way: higher tolerance, more psychological distress. Three prespecified sensitivity analyses, including one that excluded extreme values and another that dummy-coded trauma, left the pattern intact.

Why would a higher tolerance for pain signal worse rather than better mental health? The authors offer several non-exclusive explanations. The first is that the acceptable-pain question functions, in disguise, as an expectation item. A patient who answers that a pain level of 60 would be acceptable may be saying less about stoicism and more about hopelessness: they do not expect meaningful improvement, so they have lowered the bar for what they would settle for. Low treatment expectations are well documented predictors of poorer outcomes in chronic pain, which would make a high acceptable-pain score a marker of demoralization rather than resilience.

A second interpretation draws on response shift theory from quality-of-life research. People who live with relentless pain and psychosocial distress may recalibrate their internal standards upward, coming to accept higher pain levels not because they cope well but because they have adapted to suffering. Supporting this reading, trauma category was independently associated with higher acceptable pain in the dataset, and an exploratory post-hoc interaction test found that the acceptable-pain association with depression grew progressively stronger across trauma categories. In patients with no trauma history, the coefficient was essentially zero; in those with PTSD-level trauma, it rose to 0.67 per 10 scale points. The pattern was Bonferroni-significant, though the authors stress it was post hoc and requires replication.

The subgroup comparisons sharpen the picture. Patients who reported acceptable pain values of 50 or higher, just 66 people, had the highest proportion of PTSD-level trauma at 22.7 percent, the highest mean pain intensity at 77.2, and elevated scores on every psychosocial measure, including a mean PHQ-15 somatization score of 15.8, which crosses from the moderate into the severe range. At the opposite pole, the 58 patients who said no pain was acceptable were younger and had the lowest somatization, anxiety, and stress scores. These differences persisted after adjustment for all three pain intensity measures, meaning they cannot be explained away by the simple fact that the high-tolerance group hurt more.

The authors are careful to flag a methodological alternative that could partly account for the findings. Negative affectivity, the dispositional tendency to experience negative emotions, is known to inflate correlations between self-report measures. The specificity pattern in the data, significant associations with mood and symptom questionnaires but none with the disability index, is consistent with such shared reporting bias, since functional limitations may be less susceptible to it. The researchers also note that a single visual analogue item has no established psychometric properties and is semantically ambiguous: responses may reflect treatment expectations, resignation, normative beliefs about pain endurance, or strategic communication in a clinical encounter, and the cross-sectional design cannot disentangle these meanings.

What the study does establish, within its limits, is a sharp conceptual distinction between tolerance and acceptance. Established measures of pain acceptance, such as the Chronic Pain Acceptance Questionnaire, are consistently associated with lower distress; patients who accept pain while pursuing valued activities fare better psychologically. The acceptable-pain item behaved in exactly the opposite direction, and without the specificity that genuine acceptance shows. The authors hypothesize that acceptable pain reflects a tolerance threshold rather than a coping quality, and that the two may even be inversely related. They also connect the finding to earlier work showing that low pain tolerance on the Heidelberg screening predicts chronification of acute back pain, suggesting the present result may be a complementary observation in patients whose pain has already become chronic.

The clinical message is cautious but clear. Because acceptable pain is already collected in some pain clinics as part of intake procedures, the temptation to read a high value as a favorable sign is real. This study suggests that temptation should be resisted. A high acceptable-pain score, particularly in a patient with a trauma history, may instead prompt clinicians to look more closely at somatic symptoms, anxiety, sleep, and stress. The authors emphasize that the small effect sizes mean the item is not yet a validated screening tool, and prospective studies are needed to test whether baseline acceptable pain predicts psychosocial deterioration over time. But as a hypothesis-generating finding, it lands with force: the patients who claim they can bear the most may, in fact, be bearing the heaviest loads of all.

Subject of Research: The association between self-reported acceptable pain intensity and psychosocial symptom burden in chronic pain patients

Article Title: Self-reported acceptable pain intensity is associated with psychosocial burden beyond pain severity in chronic pain patients: a cross-sectional study

Article References: Bruns, Y., Manuel, J., Neumann, A., Eberhardt, M., & Karst, M. (2026). Self-reported acceptable pain intensity is associated with psychosocial burden beyond pain severity in chronic pain patients: a cross-sectional study. BMC Psychology, 14(1), Article 1473. https://doi.org/10.1186/s40359-026-05731-8

Image Credits: AI Generated

DOI: 10.1186/s40359-026-05731-8

Keywords: chronic pain, acceptable pain, psychosocial burden, somatization, anxiety, sleep impairment, perceived stress, trauma, PTSD, pain assessment, pain clinics, response shift