The Pain Self-Efficacy Questionnaire (PSEQ) is a 10-item questionnaire developed to assess the confidence people aged 18+ with ongoing pain have in performing activities while in pain (Nicholas, 2007). The PSEQ is applicable to all persisting pain presentations. It enquires into the level of self-efficacy regarding a range of functions, including household chores, socialising, work, as well as coping with pain without medication and is helpful in assessing the impact that pain is having on a respondent’s life.
For clinicians, the PSEQ offers several practical advantages. It assists in screening and case formulation by highlighting the psychological factors that shape how patients respond to injury or unpleasant physical sensations, rather than relying on pain intensity ratings alone. The PSEQ can guide intervention selection and treatment planning, identifying patients who may benefit from targeted psychological support, pain education, or specific self-efficacy–building strategies. Additionally, the scale shows strong correlations with functional measures and is strongly associated with disability levels, demonstrating sensitivity to change following pain management interventions and programs (Nicholas, 2007; Williams et al., 1993). This is valuable for identifying patients at risk of poor outcomes or treatment dropout, and for gauging readiness for activity-based programs. As an outcome measure, the scale’s sensitivity to change makes it valuable for monitoring progress over time and evaluating treatment effectiveness.
Example PSEQ item:
In essence, the PSEQ represents a brief yet comprehensive measure that captures patients’ confidence in their ability to function despite pain—providing clinicians with essential information to guide treatment decisions, optimise intervention timing, and ultimately improve outcomes for individuals living with chronic pain conditions.
In the Pain Self-Efficacy Questionnaire (PSEQ), self-efficacy is measured by a total score that can range from 0 (no self-efficacy) to 60 (complete self-efficacy).
Higher scores on the PSEQ are indicative of more self-efficacy. Outcome can also be presented as percentiles to help contextualise scores in comparison to the typical range of experience of others experiencing pain. For example, a percentile of 50 represents average self-efficacy among chronic pain patients, corresponding to a raw score of approximately 19:
Among injured workers, research suggests that scores around the scores around 40 are associated with return to work and maintenance of functional gains, whilst lower scores tend to predict less sustainable gains (Adams and Williams, 2003) and are non-indicative of the individual returning to work (Coughlan et al., 1995). Recent research has established that PSEQ scores below 22 are associated with twice the likelihood of daily opioid use in chronic pain patients, making this threshold (approximately 55th percentile) useful for identifying individuals who may benefit from targeted self-efficacy interventions before or alongside pharmacological treatments (Mo et al., 2023). The relation between the PSEQ and pharmacological reliance can also be supported with the response to item 7 (Ralph et al., 1994), where lower scores on this item correlate with higher doses of pain medication.
With multiple administrations, a line chart will be produced to observe progress of the client over time. The graph includes percentile-based threshold lines marking the boundaries between interpretive categories (very low, low, moderate, high, and very high self-efficacy) to provide visual context for score changes. These visual markers enhance interpretation by showing not only the magnitude of change but also the clinical significance of movement between functional categories over the course of treatment.
The PSEQ has undergone extensive international validation across 28 studies involving 9,853 participants in 14+ languages (Dubé et al., 2021). Psychometric properties are consistently robust across cultural adaptations, with excellent internal consistency (Cronbach’s α = 0.92-0.93) and test-retest reliability (ICC = 0.86, range: 0.75-0.93) (Nicholas, 2007; Dubé et al., 2021). Factor analysis confirms a stable unidimensional structure accounting for 60.9% of variance across all translations and pain conditions (Nicholas, 2007; Asghari et al., 2001; Van Der Maas et al., 2012).
Strong construct validity is demonstrated through expected correlations with clinical measures: negative associations with disability (r = -0.71 to -0.29), depression (r = -0.68 to -0.32), anxiety (r = -0.63 to -0.32), and catastrophizing (r = -0.74 to -0.36), and positive correlations with quality of life measures (r = 0.38-0.57) (Dubé et al., 2021). The instrument shows good responsiveness to change with effect sizes of 0.53-0.73 and minimal clinically important differences of 5.5-8.5 points for chronic low back pain patients (Dubé et al., 2021).
Advanced psychometric analysis using Item Response Theory with 1,511 patients confirmed appropriate use of the 7-point response scale and identified Items 6, 8, and 9 as having the highest discrimination parameters (Costa et al., 2017). Item 7 (“coping without medication”) consistently showed weaker performance but was retained for clinical utility. The PSEQ-10 has been validated across diverse chronic pain conditions including low back pain, mixed musculoskeletal disorders, neck pain, fibromyalgia, and osteoarthritis (Dubé et al., 2021).
Percentiles are derived from a comprehensive normative sample of 13,343 chronic pain patients from 36 pain clinics across Australia and New Zealand, representing the largest and most geographically diverse sample available for the PSEQ, with a mean score of 20.7 (SD = 13.3) (Nicholas et al., 2019).
The PSEQ measures pain self-efficacy – a patient’s confidence in performing activities despite ongoing pain – rather than pain intensity or disability levels. This distinction is crucial because self-efficacy beliefs strongly predict functional outcomes, treatment engagement, and long-term recovery independent of pain severity. The PSEQ provides unique clinical value by identifying patients who may benefit from psychological interventions, predicting treatment dropout risk, and guiding intervention timing. With excellent psychometric properties (Cronbach’s α = 0.92-0.93) and validation across 14+ languages, it offers a brief 2-3 minute assessment that complements rather than replaces pain intensity measures, providing essential information for comprehensive pain management planning.
PSEQ scores range from 0-60, with higher scores indicating greater self-efficacy. Using normative data from 13,343 chronic pain patients: scores ≥40 (90th percentile) indicate high self-efficacy associated with successful return to work; scores 18-29 (48th-75th percentile) represent moderate self-efficacy; scores 5-17 (12th-45th percentile) suggest low self-efficacy requiring targeted intervention; and scores 0-4 (<10th percentile) indicate very low self-efficacy needing intensive support. Critically, scores below 22 (55th percentile) are associated with twice the likelihood of daily opioid use, making this a key threshold for identifying patients who may benefit from self-efficacy interventions before or alongside pharmacological treatments.
A change of 6.65 points represents the minimal clinically important difference (0.5 standard deviation) for detecting meaningful improvement or decline in pain self-efficacy. This threshold provides a standardized approach for interpreting change scores across treatment episodes. For chronic low back pain specifically, established minimal clinically important differences range from 5.5-8.5 points. Changes below this threshold likely represent normal fluctuation rather than true clinical change. The PSEQ demonstrates good sensitivity to change (effect sizes 0.53-0.73) and should be administered at treatment initiation, completion, and 3-6 month follow-up to capture meaningful clinical improvements.
The PSEQ is strongly validated across multiple chronic musculoskeletal conditions including low back pain, neck pain, fibromyalgia, osteoarthritis, and upper limb disorders. It’s appropriate for adults 18+ with chronic pain and has robust validation in 14 languages. However, important limitations include: no validation in pediatric populations (<18 years), insufficient evidence for neuropathic pain and cancer pain, contraindication in moderate-severe dementia or cognitive impairment, and limited data in post-surgical pain contexts. The instrument is designed for ongoing/chronic pain rather than acute episodes, so use with first-time pain experiences requires clinical judgment.
The PSEQ should never be used as a standalone measure but as part of a multidimensional assessment. The optimal core battery combines PSEQ with Depression Anxiety Stress Scales (DASS-21) for mood and stress assessment, Fatigue Assessment Scale (FAS) for chronic fatigue evaluation, and Short Health Anxiety Inventory (SHAI) for health anxiety screening, providing non-redundant information across key pain-related domains. Administer at four key timepoints: initial assessment, treatment start, treatment completion, and 3-6 month follow-up. The excellent test-retest reliability (ICC = 0.86) and minimal practice effects support this schedule, allowing sufficient time for meaningful clinical change while maintaining practical feasibility in busy clinical settings.
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