Pain catastrophizing is a negative cognitive-affective response to pain, associated with various pain-related outcomes. This review critically evaluates the concept, highlighting conceptual and measurement issues, and discusses theoretical mechanisms such as appraisal theory, attention bias, communal coping, CNS mechanisms, psychophysiological pathways, and neural pathways. Evidence suggests that pain catastrophizing is an important process factor in pain treatment. An integrated heuristic model is proposed for future research. Pain catastrophizing is linked to pain sensitivity, clinical outcomes, and adverse effects like depression and suicide risk. It is associated with attentional bias, exaggerated negative affect, and interpersonal consequences. Research indicates that pain catastrophizing may be related to altered physiological responses, hypothalamic-pituitary-adrenal axis activity, and neuroimmunologic responses. Neural correlates include activation in brain regions involved in affective processing and pain regulation. Pain catastrophizing is a key process variable in pain treatment outcomes, with reductions in catastrophizing associated with improvements in pain, disability, and depression. Future research should focus on understanding the unique role of catastrophizing, its mechanisms, and its integration with other cognitive and emotional processes. The review emphasizes the need for further studies to clarify the role of catastrophizing in pain management and its potential as a target for intervention.Pain catastrophizing is a negative cognitive-affective response to pain, associated with various pain-related outcomes. This review critically evaluates the concept, highlighting conceptual and measurement issues, and discusses theoretical mechanisms such as appraisal theory, attention bias, communal coping, CNS mechanisms, psychophysiological pathways, and neural pathways. Evidence suggests that pain catastrophizing is an important process factor in pain treatment. An integrated heuristic model is proposed for future research. Pain catastrophizing is linked to pain sensitivity, clinical outcomes, and adverse effects like depression and suicide risk. It is associated with attentional bias, exaggerated negative affect, and interpersonal consequences. Research indicates that pain catastrophizing may be related to altered physiological responses, hypothalamic-pituitary-adrenal axis activity, and neuroimmunologic responses. Neural correlates include activation in brain regions involved in affective processing and pain regulation. Pain catastrophizing is a key process variable in pain treatment outcomes, with reductions in catastrophizing associated with improvements in pain, disability, and depression. Future research should focus on understanding the unique role of catastrophizing, its mechanisms, and its integration with other cognitive and emotional processes. The review emphasizes the need for further studies to clarify the role of catastrophizing in pain management and its potential as a target for intervention.