Catastrophizing

A brief introduction to cognitive distortions

Cognitive distortions, cognitive biases, or ‘unhelpful thinking styles’ are the characteristic ways our thoughts become biased (Beck, 1963). We are always interpreting the world around us, trying to make sense of what is happening. Sometimes our brains take ‘shortcuts’ and we think things that are not completely accurate. Different cognitive short cuts result in different kinds of bias or distortions in our thinking. Sometimes we might jump to the worst possible conclusion (“this rough patch of skin is cancer!”), at other times we might blame ourselves for things that are not our fault (“If I hadn’t made him mad he wouldn’t have hit me”), and at other times we might rely on intuition and jump to conclusions (“I know that they all hate me even though they’re being nice”). These biases are often maintained by characteristic unhelpful assumptions (Beck et al., 1979).

Different cognitive biases are associated with different clinical presentations. For example, catastrophizing is associated with anxiety disorders (e.g. Nöel et al, 2012), dichotomous thinking has been linked to emotional instability (Veen & Arntz, 2000), and thought-action fusion is associated with obsessive compulsive disorder (Shafran et al, 1996).

Catching automatic thoughts and (re)appraising cognitions is a core component of traditional cognitive therapy (Beck et al, 1979; Beck, 1995; Kennerley, Kirk, Westbrook, 2007). Identifying the presence and nature of cognitive biases is frequently a helpful way of introducing this concept – clients are often quick to appreciate and identify with the concept of ‘unhelpful thinking styles’, and can easily be trained to notice the presence of biases in their own automatic thoughts. Once biases have been identified, clients can be taught to appraise the accuracy of these automatic thoughts and draw new conclusions. 

Catastrophizing

Individuals who catastrophize jump to the worst possible conclusions, think about the most catastrophic outcomes, and assume these scenarios are likely to occur. 

Descriptions of ‘catastrophizing’ in the cognitive behavioral literature have changed over time:

• Ellis (1962) described ‘catastrophizing’ as the tendency to magnify the likelihood and awfulness of a potential threat: “Instead of defeating his own ends by being exaggeratedly fearful, a rational human being should… realize that most of his worries are caused not by external dangers that may occur but by his telling himself ‘Wouldn’t it be terrible if this danger occurred?’ or ‘It would be frightful if this event exists and I cannot cope adequately with it’. He should learn, instead, to examine his catastrophizing internalized sentences, and to change them for the saner and more realistic philosophy: ‘It would be an awful nuisance or a bad thing if this danger occurred; but it would not be terrible, and I could cope with this nuisance or bad thing’”.
• Beck (1963) refers to catastrophization within his definition for the cognitive distortion ‘magnification and minimization’: “It was frequently observed that patient’s initial reaction to an unpleasant event was to regard it as a catastrophe. It was generally found on further inquiry that the perceived disaster was often a relatively minor problem.”
• Burns (1981) describes catastrophizing in similar terms: “Magnification (catastrophizing) or minimization: You exaggerate the importance of things (such as a goof-up or someone else’s achievement), or you inappropriately shrink things until they appear tiny (your own desirable qualities or the other fellow’s imperfections). This is also called the ‘binocular trick’”.
• Clark (1986) suggested panic attacks result from catastrophic interpretations of bodily sensations. He proposes that sensations in normal anxiety responses are misinterpreted in a catastrophic fashion: “The catastrophic misinterpretations involve perceiving these sensations as much more dangerous than they really are. Examples of catastrophic misinterpretation would be a health individual perceiving palpitations as evidence of an impending heart attack; perceiving a slight feeling of breathlessness as evidence of impending cessation of breathing and consequent death; or perceiving a shaky feeling as evidence of impending loss of control and insanity.”
• Kendall and Ingram (1987) suggested that anxiety-related thoughts often take the form of questions (e.g. “What am I going to do if … ?”). They propose that a “what if …?” questioning style tends to produce and maintain uncertainty. Subsequent research has revealed that “what if … ?” questions often relate to catastrophic outcomes and are especially prevalent amongst people who worry (e.g. Vasey & Borkovec, 1992).
• Catastrophizing has subsequently been described as “the tendency of individuals to apply a ‘what if …?’ questioning style to potential problematic features of their life” (Davey, 2006). People who catastrophize “persistently iterate the problematic features of their worry topic” with the effect that process usually leads the worrier to perceive progressively worse and worse outcomes, and to experience greater levels of emotional discomfort (Startup & Davey, 2001).

Examples of catastrophizing include:

• Noticing a new freckle and immediately thinking “What if it’s skin cancer?”.
• Assuming a loved one has died when they don’t return home on time.
• Thinking “What if the meeting with my boss doesn’t go well?”, followed by spiraling thoughts like “I’ll be fired” and “I’ll end up destitute”.

People who habitually use a catastrophizing thinking style may have ‘blind spots’ for:

• Making accurate estimates about the probability of events. 
• Anticipating realistic or positive outcomes.
• Recognizing their ability to cope with unfortunate events.

As with many cognitive biases, there are evolutionary reasons why people might think in a catastrophic manner. Gilbert (1998) suggests many information processing biases are ‘built in’ because these errors are in some way adaptive. Gilbert notes that “in potentially dangerous situations speed may be more adaptive than rationality” and that “under certain conditions there is a tendency to assume the worst – and thus be prepared for (and take action to avoid) the most serious outcome”.

Catastrophizing is associated with a range of clinical problems, including:

• Chronic pain (Severijns et al, 2001)
• Health anxiety (Salkovskis & Warwick, 1986)
• Generalized anxiety disorder (Provencher et al, 2000; Startup & Davey, 2001)
• Insomnia (Hiller et al., 2014)
• Mild traumatic brain injury / postconcussive symptoms (Bryant, 2001)
• Obsessive compulsive disorder (Shafran, 2005)
• Panic disorder (Clark, 1986)
• Persecutory delusions (Startup et al., 2007)
• Post-traumatic stress disorder (PTSD: Seligman et al, 2019; Jenness et al, 2016)
• Social anxiety (Hinrichsen & Clark, 2003)

Many people struggle with catastrophic thinking, and it sounds like it is something you experience too. Would you be willing to explore it with me?

Clinicians might begin by providing psychoeducation about catastrophizing and automatic thoughts more generally. Consider sharing some of these important details:

• Automatic thoughts spring up spontaneously in your mind, usually in the form of words or images.
• They are often on the ‘sidelines’ of our awareness. With practice, we can become more aware of them. It’s a bit like a theatre – we can bring our automatic thoughts ‘centre stage’. 
• Automatic thoughts are not always accurate: just because you think something, doesn’t make it true.
• Automatic thoughts are often inaccurate in characteristic ways. One common type of bias is ‘catastrophizing’: you assume that the worst possible scenarios are likely to happen and you won’t be able to cope with them.
• Signs that you are catastrophizing include “what if … ?” thoughts and imaginary scenarios that seem likely to happen. 
• Our minds are evolved to catastrophize to an extent. When we are uncertain or encounter something new, it is sometimes helpful to think about ‘worst case scenarios’ so we can plan our responses and stay safe. 

Many treatment techniques are helpful for working with catastrophizing and its consequences. 

• Distraction, grounding techniques, and mindful awareness. Catastrophizing and ‘worry chains’ take the mind to a frightening imagined future. Distraction, grounding techniques, and mindful awareness can bring the mind back to the safety of the here-and-now.
• Calming and soothing strategies. Strategies such as diaphragmatic breathing or progressive muscle relaxation can calm fight or flight responses that have been triggered by catastrophic thinking.
• Decentering. Meta-cognitive awareness (or decentering) describes the ability to stand back and view cognitions as an internal events that aren’t always accurate – as opinions rather than facts (Flavell, 1979). Clients can practice labeling the process of thinking rather than engaging with the content. For instance, they might say to themselves, “I’m catastrophizing again”, whenever they notice a catastrophic thought.
• Worry postponement. Worry postponement is a popular treatment intervention for clients who experience chains of catastrophic worry (i.e., individuals with GAD). It involves recognizing catastrophic thoughts and deferring these until a scheduled time. This can help manage catastrophic thinking and demonstrate that the client has more control over their thinking than they believed. 
• Cognitive restructuring with thought records. People who catastrophize overestimate the probability of danger and underestimate their ability to cope. Moreover, they tend to attribute bad events to permanent and pervasive causes (Abramson et al., 1978). Thought records can be used to capture and re-evaluate catastrophic thoughts as they arise. Useful prompts include:
  • “What is most likely to happen?”
  • “Your catastrophic thought focuses on the worst-case scenario, but what are better and more realistic outcomes?”
  • “If the worst did happen, how would you cope with it? What resources could you use?”
• Using data logs to measure likelihood. If clients frequently make catastrophic predictions about future events, data logs can be used to record the frequency with which these catastrophic events actually occur. This information can help clients ‘recalibrate’ their predictions and expectations.
• Teaching the anxiety equation. Salkovskis’ anxiety equation proposes: Anxiety = (Likelihood x Awfulness) / (Coping + Rescue).  For people who catastrophize, the components of this equation can be explored separately. Likelihood is addressed by considering the most likely outcome rather than the worst. Awfulness is addressed by considering the details of the catastrophic event and its consequences. Coping is addressed by considering what the client could do if the worst happened. Finally, rescue is addressed by considering the resources the client could draw upon.
• Testing beliefs and assumptions. If a client habitually thinks in a catastrophic manner, it may be helpful to explore whether they hold beliefs or assumptions that drive this style of thinking. Examples include “Thinking the worst keeps me safe”, “People always hurt me”, “The world is dangerous”, or “Thinking the worst gives me a chance to prepare”. If such assumptions are identified, the client can assess the accuracy and helpfulness of these beliefs. Their attitude towards healthier assumptions such as “Thinking the worst contributes to my anxiety” and “Worst case scenarios are rare and can be managed” can also be explored. Reality-testing the assumptions associated with catastrophic thinking is accomplished via behavioral experiments (e.g., surveys regarding other people’s attitudes towards uncertainty and the future).
• Training in self-compassion. Some research suggests that higher levels of self-compassion are associated with lower levels of catastrophizing. Accordingly, training clients in self-compassion might be helpful.

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