The Catastrophe of Pain Catastrophizing

Our brains are totally amazing. We have a few innate “rules” about the world built into our brains, and then they are shaped through interactions with our environment to develop complex cognitive schemas, or sets of beliefs, about the world and how we interact with it. We come by these rules honestly; in some circumstances in our lives, they were helpful. And once they are developed, we rely on them to navigate our world.

Many of us have some type of belief deep down that the world can be dangerous (it can be) and that we need to be on the alert for potential problems and anticipate worst-case scenarios so that we can identify methods for avoiding them. These cognitive patterns serve a purpose. If we are unaware of potential problems or do not understand the magnitude with which a small screw-up could lead to a larger consequence, then we do not have the feedback we need to correct while there is still time to salvage the situation. But, as many people who have participated in talk therapy can attest, overreliance on these types of patterns can also contribute to uncomfortable and undesirable consequences, like anxiety, worry, and fear.

We call this style of thinking “catastrophizing,” the idea being that we are focused on the worst-case scenario, a “catastrophe,” rather than on the present moment and more positive versions of the future. Psychologists who work with all sorts of people identify catastrophizing as a cognitive style that may not be serving their patients and help them reframe these thoughts to something often more accurate. The problem comes when you are working with patients where the “catastrophe” is often the reality and where thoughts about the worst-case scenario often seem prescient.

People living with chronic pain get the shortest end of the stick in Western medicine. Patients with chronic pain may be dismissed as complainers or malingerers or have their symptoms minimized as having a “low pain tolerance.” The treatments we developed turned out to be addictive, and now we have an entire country on high alert for any possible signs of opioid addiction while ignoring the epidemic of untreated and undertreated chronic pain. Even the National Institutes of Health initiative meant to fund pain research is written with a focus on reducing opioid addiction rather than treating pain (HEAL: Helping to End Addiction Long-Term). We are desperate for any treatment that is nonaddictive and can help people with chronic pain live fuller lives.

It turns out that the way we think about pain matters. People in pain who pay more attention to the pain, spend more of their time thinking about their pain, and in particular, imagine the worst-case scenarios about their pain tend to recover more poorly from pain-causing incidents like accidents and surgical procedures and have a harder time doing things they enjoy while living with pain. And research shows that treatments that reduce pain catastrophizing do seem to help people with a variety of chronic pain conditions (including my own research with migraine) experience less pain and get back to living life.

The problem is that the “catastrophe” many of our patients worry about is their reality. They worried they would not recover fully—and they didn’t. They worried that their pain would last forever and so far that seems true. Our patients rightfully feel patronized when we call their lived experience a “catastrophe,” as though it is so outlandish it will never happen. For many, they are already living it. This is the challenge therapists tackle when working with chronic pain. It requires a more flexible, broader set of skills to help patients find alternative thinking patterns that still feel true to their experiences, while opening up the possibility for a more functional future.

When doctors call patients “catastrophizers,” we are intimating that this is an unchangeable trait of the patient: they are a catastrophizer. That is absolutely not the case. We work with pain catastrophizing because it is so amenable to change. And when it improves, people feel better and find it more tolerable to engage in activities they enjoy.

There is no easy answer for how to deal with the fact that changing thinking patterns can help people with chronic pain, while also recognizing that this fact leads some to dismiss people living with chronic pain. Perhaps a broader cultural shift in the stigma associated with chronic pain is what is truly needed. Because no matter what we call it, reducing “pain catastrophizing” helps many people living with chronic pain, and is an important tool in our all-too-slim toolbox for chronic pain treatment.