Catastrophizing and Chronic Pain

It’s not uncommon to exclaim, at the beginning of a pain flare, “I’m not going to be able to stand it!” Another might express, “Now, I’m not going to be able to do anything today!” Yet, another takes it as a given that the increased pain is an indicator that the underlying health problem is getting worse. From this assumption, it’s easy to start thinking about how the future holds nothing but increasing disability, wheelchairs, and suffering.

These sentiments are examples of catastrophizing.

What is catastrophizing?

Catastrophizing is what we do when we see something through the lens of it being the worst-case scenario. We believe and feel that something is worse than it actually is.

We all do it. Everyone catastrophizes at least occasionally. Some of us do it a lot. Most of us are somewhere in between. The point, though, is
that we all do it.

The most common example of catastrophizing is simple worrying. When we worry, we don’t ponder good things happening to us. We don’t even tend to think about minimally bad things happening to us, such as inconveniences or hassles. We don’t tend to waste a lot of time worrying about those things. Rather, it’s the really bad stuff that we tend to worry about. It’s the worst-case scenarios that hold our attention and get us worked up.

Now, the thing about catastrophizing is that we tend to overestimate the likelihood that the worst-case scenarios will occur. Of course, worst-case scenarios are possible. Sometimes, they do in fact occur. If, however, we step back and take a real objective look at them, we might compare how often they occur with the countless number of times when they don’t occur. The comparison is stark. Worst-case scenarios are possible, but they are not likely. They tend to be once or twice in a lifetime events. When catastrophizing, though, we see the worst-case scenario as all-but-inevitable or, worse yet, already happening. There’s an assumption of certainty about it. That is to say, this sense of certainty comes about by overestimating the likelihood of the worst-case scenario.

Like anyone else, people with chronic pain can catastrophize. Take the common sentiments expressed in the above examples. When experiencing a pain flare, common automatic reactions are that you aren’t going to be able to stand it or that now you’ll never get anything done or that you think the increased pain is indicative of an inevitable worsening of the underlying health condition that initially started the pain. There is a sense of certainty that goes along with these automatic reactions. You just “know” that you won’t ever be able to stand it, or that you’ll never be able to get anything done, or that increasing disability is inevitable. However, if you can step out of the moment, and hold on your judgment of such certainty, you might begin to reflect on how true, really, these sentiments are.

What makes you so sure that you’ll ‘never be able to stand it’? How do you ‘know’ that this pain flare is going to be the whopper of all whoppers? Maybe it would be best to hold judgment, and see if it will be as bad as you anticipate. It might just turn out to be a run-of-the-mill flare. In fact, it is much more likely that it will be an average pain flare than the one that you'll 'never be able to stand.'

How warranted is your certainty that you’ll ‘never be able get anything done’? How likely is that scenario to occur? With a little creativity, there is almost always going to be something that you can do, even while experiencing a pain flare. Maybe you could sit and pay bills. Maybe you could call someone who you have been meaning to call but haven’t gotten around to it. Maybe you are at work and you decide to use the afternoon to catch up on reports and emails. You sit for a while at the computer and then you stand for a while at the computer, putting a few books under the keyboard, so you can still work at the computer. You also might take breaks to walk the hallway or stretch or both. Now, it won’t be the most productive day you’ll ever have, but, with pacing and a little adaptability, it’s much more likely that you’ll be able to do something productive.

What about the certainty that your pain flare is a sign of your inevitable decline? How true is that worst-case scenario? Of course, it is possible, but it’s not very likely. The nature of chronic pain is that pain waxes and wanes – pain flares come and pain flares go. What’s the likelihood that this pain flare is the one that won't ever go away and from which you'll start the decline into becoming wheelchair-bound? Isn’t it much more likely that this pain flare, like the others that come before it, will come and go?

While always possible, worst-case scenarios are low probability events. When we catastrophize, though, we overestimate the likelihood that the worst-case scenario will occur and become certain that it will happen or is already happening. We lose perspective on the problem and become certain that it is worse than it actually is.

Catastrophizing influences our perceptions

The sense of certainty that goes along with catastrophizing colors our perceptions, making what we experience worse than it actually is. This fact is what leads psychologists to categorize catastrophizing as a form of cognitive distortion. Catastrophizing distorts what it is we perceive.

It’s not very mysterious. Rather, it’s super common. We can think of any number of examples. Suppose your boss makes a critical remark about you and later looks at you strange after you say something in a meeting. You associate these events with some problems you have been having at work and before you know it you are taking the boss’ remark and the look as confirmation that any day now you are going to be let go. If you don’t step out of the moment, and gain some perspective on how you are perceiving these events, your experience is that you simply and unquestionably are in the process of getting fired and it can’t get much worse. To take another example, suppose you are arguing with your spouse and he or she walks out of the room hurt and angry. Your first thought is that your last hurtful remark put your spouse over the edge and that he or she is now leaving you. Your immediate reaction is one of ‘Don’t leave me!’ For the moment, your thoughts are going a million miles an hour and you have all the accompanying feelings of fear, anger, and abandonment. If you don’t step out of the moment, get grounded, and reflect on what’s going on, your experience is that your marriage is unquestionably ending and it can’t get much worse. In both these cases, we see that catastrophizing distorts our experience of what is really happening.

Catastrophizing tends to happen when we are ungrounded, vulnerable, anxious, or upset already and then something bad happens. In such cases, it’s hard to see the problem clearly. We are too ungrounded or anxious or upset. As such, the overall experience of the problem is that it is worse than it actually is. Conversely, when a problem occurs during a time that we are grounded, focused, supported, and confident, we deal much better with it because, in part, we see the problem more accurately.

The two parts that make up experience

This last notion leads to an exceptionally important, yet often overlooked, fact about human experience. We tend to think that whatever it is that we experience is solely due to what is happening to us. That is to say, we often simply assume that the quality and intensity of our experiences are only due to the qualities and severity of the external things that occur to us. It’s as if we forget that there’s a perceiving subject, who has these experiences.

Now, of course, what we experience is determined in part by external events – what they are, whether they are bad or good, and how bad or good they are. But, our experience is also determined in part by where we are at when these events occur.

When we are grounded and present, we might notice the beautiful sunset and fully appreciate it. The sunset subsequently might have a big impact on us. If, however, we are lost in our thoughts, or fretting because we are stuck in rush hour traffic, we might hardly even notice the beautiful sunset, let alone appreciate it, and subsequently it has little to no impact on us. It's the same external event, but two very different experiences and the experience is determined by how we are at the time of the external event.

Human experience is made up from two parts: 1) the things that happen to us and 2) how we are when things happen to us. When we are grounded, supported, confident and well-rested, we tend to experience the same event differently than when we are anxious, upset, vulnerable, lonely, abandoned, or overly tired and fatigued.

Catastrophizing is one of the ways that we color our perceptions of events when we come to the event feeling anxious, upset, vulnerable, left alone, or fatigued.

Catastrophizing is all-too-human

Sometimes, people are reluctant to acknowledge that they catastrophize. You can sometimes feel judged when people tell you that you’re making a mountain out of a molehill. You might automatically want to respond with assertions that the problem really is that bad -- it really is catastrophic -- and then feel invalidated when they don't believe you.

It’s important to remember, though, that we all do it. It’s part of our all-too-human condition. Human beings are not perfect. We are not omnipotently objective observers of the things that happen to us. We have all sorts of beliefs, attitudes, and feelings that bias and distort our perceptions. And, yes, we also catastrophize. All of us sometimes perceive things as worse than they really are. Some people do it rarely while other people do it a lot. Most of us are somewhere in between, catastrophizing more than rarely and less than all the time.

A good healthcare provider tends to remind us of things that we already know, but tend to forget in our day-to-day routines. One of these reminders is that it is a mark of health to be able to admit our imperfections. The first step towards getting better with regard to a problem is always to admit that you have the problem. In the case of catastrophizing, it’s a mark of health when we can acknowledge that we catastrophize, especially at the time when we are actually doing it. Indeed, an important health skill is the ability to step out of any given moment, reflect on what’s going on, and come to see the problem more clearly. By gaining perspective on the problem, we reduce the distress that’s associated with the problem and the problem comes to no longer have such a big impact on our lives. The problem comes to be less problematic as we initially experienced it to be.

This process is one of the many ways that people come to cope better with problems in life, including chronic pain. That is to say, we come to cope better with a problem when we get better at catching ourselves catastrophizing it, acknowledge that we are doing it, and reality-checking it. We thereby come to see the problem more clearly and subsequently we cope with it better– the problem becomes less distressing and less impairing.

Author: Murray J. McAllister, PsyD

Date of oublication: 11-24-2013

Date of last modification: 9-16-2022

About the author: Dr. McAllister is a pain psychologist, and the founder & publisher of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families.