Catastrophizing or Rational Alarm?

Catastrophizing or Rational Alarm?

Cynthia Toussaint

Cynthia Toussaint

By Cynthia Toussaint

In March I was honored to be invited to be the person with pain’s voice for a Stanford University Twitter chat that focused on pain psychology.

I’m very excited about pain psychology as an emerging therapy due to the mind-body connection as I believe our emotional state generally effects our pain levels and visa versa.

Several years ago, I benefited from numerous visits with a pain psychologist at the USC Pain Center. It was eye-opening to partner with a psychologist who chose to exclusively treat people with pain. This doctor helped me tremendously with my daily mindfulness meditation by using biofeedback where I got to watch myself amp or lessen my stress level. It was fascinating to feel my pain follow accordingly.

I was onboard with everything regarding the Twitter chat until a doctor asked what part “catastrophizing” plays in our pain experience. Upon seeing that word, my gut clinched. I immediately wanted to defend, not only me, but all women in pain. In my 14 years of pain advocacy, I’ve never heard a woman speak positively about this word. In fact, it’s quite the opposite.

As it’s been explained to me, catastrophizing is when we with pain assume the deepest, darkest, most negative outcome after a pain-spiking event. Psychologists theorize that when our mind goes to that black place, our bodies respond in step leading to a self-fulfilling prophesy.

While I believe the theory has merit, I can’t tell you how often we women in pain talk bitterly about this word because it makes us feel misunderstood. When we’re told we’re catastrophizing, we feel dismissed as if (yet again!) our doctors are blaming us for our pain.

Not only does the word damn us, I know first-hand catastrophizing can serve a valuable, self-preserving purpose. Here’s one example…

Five years ago a physical therapist wanted to try to straighten my severe, 20-year CRPS arm contracture. Everything in my gut told me not to do this. My fear was that the outcome of this treatment could lead to losing some or all of my right arm use… again! Hey, I was in my first in 27-year partial remission, swimming a mile, enjoying unlimited typing, writing and piano playing. Even throwing a football. What was so special about a straight arm anyway?

I finally agreed to let Brianna work on just my head and back as she said this would help unfold my arm. When she cheated and pulled on my contracted limb, I screamed bloody murder – and my life went back to uninterrupted torture.

I phoned Brianna two days later sobbing and desperate. She told me I had a muscle spasm and to meditate. When I saw her at my next appointment – even more desperate – Brianna released me from PT stating I had a “resolving elbow injury” and was catastrophizing.

The sad truth is Brianna had broken my arm. But because the doctors read her records about my catastrophizing, I went through hell without an accurate diagnosis for a year. At that point, my arm had healed incorrectly and it was too late for non-surgical treatment.

If my physical therapist and subsequent doctors believed my report of pain rather than thinking I was making a mountain out of a molehill, I wouldn’t be dictating this post.

On the Twitter chat, I answered the question with “People with pain respond very adversely to the word ‘catastrophizing.’ It makes them feel misunderstood.” I thought the clinicians would be all over me because none of them were questioning the term.

But they listened. One psychologist even asked what term we’d be more comfortable with. That deep care warmed my heart – and I told her I’d think on it. Perhaps “rational alarm”?

There’s no question we women in pain are impacted by our mind/body connection – and sometimes we get in the way of our wellness. But the term catastrophizing sounds condescending, alluding to us having no rational basis for our very rational fear. To quote Jon Kabat-Zinn, high-impact pain is 24/7 full catastrophe living. Sometimes it makes every damn bit of sense to think the worst.

Chronic pain, especially the high-impact variety, is complicated stuff. I embrace the compassionate psychologists who are earnest in making a better day for those of us challenged with this life-altering disease.

Women (and men) in pain, let’s work together with our pain psychologists to find middle ground. I believe without a doubt that unlocking the mind/body mystery is a huge piece of our better wellness puzzle. But we must feel respected in the process.

 Editor’s Note- Cynthia Toussaint is a frequent contributor to the National Pain Report. She founded the non-profit For Grace which is devoted to raising awareness for women in pain.

Subscribe to our blog via email

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

There are 12 comments for this article
  1. Toni Snark at 12:07 pm

    I noticed something about your story; something that – as a chronic pain patient and disabled person – disturbs me to no end. The existence of what I call “the self-righteously abled.” Your PT, Brianna, would firmly be classified as one. Younwere fine with having a function, albeit not exactly straight, arm. But Brianna couldn’t stand this “otherness” in you, even though you stated you were fine with it, and went out of her way to deceive you, and in the process, hurt you. Then, because you were not readily appreciative of her efforts to “fix” you, she dismissed you from her practice. This kind of blatant ableist condescension and discrimination sends me into a rage. This attitude makes me want to hurl obsceneties at the self-righteously abled who think they know better than us, merely by way of them being “normal” by society’s standards. Screw normal. And screw them.

  2. Angel at 6:04 pm

    Your post made me cry. Yes yes yes this is exactly why that word bothers me. Trust is broken almost completely by the time female pain patients are finally listened to and taken seriously. I almost died from leukemia after being told I was a hypochondriac for years. Turns out chronic leukemia dating back 7 years prior with CRPS (erythramyalgia) had eaten away my body until my organs shut down. How can you rebuild trust in doctors after that? You try but it’s a long long road. Until people in pain are treated respectfully adding labels only creates a harmful environment not a healing one.

  3. Elisa Friedlander at 4:12 pm

    Hi Cynthia, Thank you for this and your other writing! I’ve read your book and cringed about your PT story… clearly the last thing you do is catastrophize! As a psychotherapist w/ CRPS (currently not working because of the pain) – I would like to respectfully remind those in pain who need mental health support to look for a licensed mental health professional –skilled and experienced in treating patients with pain. The term “Pain psychologists” has proven to be misleading to so many in pain, those who look specifically for this buzzword phrase. Look for psychotherapists, social workers, etc. as well as psychologists to expand your likelihood of finding a qualified therapist who is a good match for you. LMFT (Licensed Marriage and Family Therapist) LPCC (Licensed Professional Clinical Counselor), LCSW (Licensed Clinical Social Worker), etc. Call and ask about their qualifications, approach, experience etc. working w/ patients in pain. A day with lower pain to all!! https://www.ElisaFriedlander.com/blog

  4. Dave at 9:21 am

    Its morally outrageous for a very small group of “experts” to define the meaning and import of peoples painful experience- that violates the sanctity of being human. Calling people in pain catastrophizers is a blatant attempt to control and denigrate people and it clearly suggests the labeler feel overwhelmed by the normal experience of suffering of people in pain. So instead of recognizing their ego is overwhelmed- a small group of pain specialists wish to project their inadequacies onto people in pain by claiming their suffering is abnormal. need I mention that Leon Kass- a bioethicist indicated in a book that medicine doesnt deal well with suffering? Need I mention that studies have shown parts of doctors brain shut off when dealing with peoples suffering. Need I mention that in the book Social Intelligence- that Daniel Goleman- points out that doctors lose compassion as a result of their medical school training?
    I understand that medical and professional narcissism don’t recognize the civility of common boundaries of human experience. Professionals like to label people- without regard to the effects of those labels-and in the most undemocratic and dehumanizing manner. Once upon a time homosexuality was labeled as deviant in the DSM. Catastrophizing doesn’t exist- its an inhumane attempt to degrade people in pain and diminish their suffering. Its unfortunate that so called experts are so unreflexive and careless as to claim people in pain have no right to assert the meaning of their experience and they are reckless to claim that only scientists have a right to tell people the meaning of their experience when it comes to suffering. Shame on those careless people who claim their is any morality in labeling people “catastrophizers”

  5. Maria Molaro at 12:00 am

    And what do we do with the rest of us an able to get our medications prescribed and then fille the talk i good but some of us are dying out here in the meantime. Im all for advocacy on the behalf of pain management, but what do the the rest of us do, month to month, trying to just barely survive?No. POST THIS! THIS IS WHY PEOPLE COME TO YOUR WEBSITE!!! It is a forum, not just for a couple of “expertise writers views…it is for ALL of us!!! Not just the people who attend conferences, but for all the people who can no longer get around, because of pain!!!

  6. Maria Molaro at 11:55 pm

    And what do we do with the rest of us an able to get our medications prescribed and then fille the talk i good but some of us are dying out here in the meantime. Im all for advocacy on the behalf of pain management, but what do the the rest of us do, month to month, trying to just barely survive?

  7. Teri Marks at 9:27 pm

    Thank you! Thank you! Thank you!
    As a chronic pain patient and a trained professional in the field of psychology I have felt this term undermined every gut feeling I had when my body was screaming to protect itself and medical and psychological professionals threw it in my face so casually. I worked really hard to not “catastrophize” my “situation” and my pain. But, as you gave in your example with “Brittany”, most things serve a purpose and should really be thoroughly looked at through the eyes of the patient before a term like that is thrown around. I, too, do not like the term at all. I like your alternative term “Rational Alarm”. I do understand that chronic pain patients can get overwhelmed and “normal” things can seem bigger and tougher than they are for them than regular people. But here’s a news flash, it is! Everything is bigger and tougher than it is for normal people. That is where the medical and counseling help comes in to assist in “coping skills”. Ways of living with the “new you”. I had to go to counseling for years with a psychologist that specialized with adjustment disorders for people living with chronic pain. We need help knowing its normal to have to “adjust” to incredible changes with our bodies and that its okay. We do not need condescendence. We need help and understanding. Thank you for helping and understanding Cynthia Toussaint!

  8. Jean Price at 5:15 pm

    Cynthia…I think the word holds different meanings for different people….but they all do seem negative in that they don’t take into account the actual limits of a person’s ability to be emotionally balanced while in pain! There was even an earlier article on this site that stated catastrophizing was the CAUSE of chronic pain! (Funny how that’s not even a word recognized by my spell check!). Any episode of pain….whether acute or chronic exacerbations….impacts more than our physical state by the very nature of pain itself and the nature of our being three part organisms…of body, mind, and spirit. You can say this of all illness, in fact. A person with the flu trying to keep up normal activities of daily care or a person with appendicitis trying to find some quality of life and maintain function! So chronic pain is really no different, EXCEPT it’s a protracted, daily struggle with our bodies, minds and spirits…and in reality we can expect more the next day, not because we obsess…but because that’s what chronic pain is about! In my opinion, to label this and treat it as pathological is a mistake, and the word seems to denote that we are doing something wrong and hurting ourselves. Not true. Yet, we do need to recognize our makeup and we can work to help our minds and spirits with the same tenacity we use for our physical bodies. A more appropriate word might just be “complicated grief” or ” complex grief”, since grief issues and the emotions of grief come to play a role in all chronic pain. Based on the change equals loss equals grief concept, we all have had major and ripple changes that culminated in chronic pain. And pain itself creates changes. The losses mount over time. Few people have had the benefit of looking at how grief impacts our lives and few also have been able to adequately process their grief and the feelings that come with it. I think grief counseling is an important part of pain care, and we need qualified family psychologist specialized in grief to go to…and so do our family members! Their losses are staggering too! And I thinks that’s part of why families can seem unsupportive or worse…abandon…those in pain, because they are faced with their own changes and losses and feelings from the pain they can’t seem to help us with! I’ve said this before, but I so believe this is the single best experience I had pre-pain that helped me when pain became my way of life. I am more resilient and generally happier (when I’m not looking at CDC guidelines!) now and I feel more able to face each day and the days struggles. Sometimes our pain may seem worse, but it may be our coping is just shot! And other days our pain may be less restricting yet it’s really because our coping is running at 150%!! So yes, our minds have a great deal to do with how we live with pain and how we perceive the severity at times. As for spiritual health, mine was strengthen before I started having pain and I find much comfort in my beliefs and prayers and the prayers of others. I think when we face the black hole, God is there with us. I have some books I go to daily for uplifting thoughts and I have learned the important things in life for me are still so very easy…to love, to enjoy nature, to be kind, to laugh, to smile, and to reach out to my friends. With pain, maybe these times are less often but they are still easy…and enough. And when they are not, I often realize my pain level is up, and I need to just wallow and be generous to myself. I don’t think I’m unusual, I think I’m pretty average…but I had an unusual experience with learning about grief to help others and learning a model based on the tasks of grieving. Then when pain became part of my days, I got to practice what I had preached! It’s not without effort, but it’s worth that extra effort of helping out our whole selves, not just the physical side. And to do it NOT from the standpoint we are broken…because we are so NOT! And any psychologist who approaches us as broken probably isn’t the right one! Rather we are normal beings trying to live life with purpose and joy and we’ve been given an extra load to carry, an often invisible load that can’t be laid down or left at the side of the road. And we can be the better for it, if we lighten others loads, know we are not alone, find a little help where we can, and walk slowly! We’ll still get there!

  9. Dave at 3:27 pm

    Good for you Cynthia for standing up to the nonsense about catastrophizing that so called caring doctors have promulgated. These “caring” doctors suffer from a mind projection fallacy in claiming there is such a thing as “catastrophizing”. It reflects their lackof emotional literacy and sensitivty and a cheap way to insult people in pain.
    Its time for critical pain studies where the discursive imperialism of government and the health industry when it comes to pain care is deconstructed and laid bare for all to see. Lets not let them get away with their thinly veiled efforts to demean and degrade people in pain. They already treat people in pain as serfs without rights- now they seek to add insult onto injury for the sake of their one upmanship

  10. JoDawn at 1:20 pm

    “They listened”
    Two of the most beautiful words in medicine.
    Thank you!!

  11. Richard A. Lawhern, Ph.D. at 12:40 pm

    You say that “the term catastrophizing sounds condescending”. I have news for you, Cynthia: it actually IS condescending. This term has much in common with others used frequently to marginalize or dismiss medical symptoms in women. Women are told that they are depressed when they present with pain in ER settings. A woman presenting with chest pain has a significantly higher risk than a man of dying of the heart attack that the ER doctor hasn’t properly evaluated for, perceiving her as “somatic” or “overly dramatic.” These realities are quite well documented.

    A lot of the medical mistreatment of women doubtless stems from the work of Sigmund Freud and his predecessors in mainstream neurology. These learned idiots invented the term “conversion hysteria” out of thin air and surmise. The more modern version may be “somatic symptom disorder” as proposed in the DSM-5. You or I can have an SSD “diagnosis” hung on us for the offense of “over-magnifying” our experience of pain and becoming “obsessed” or “preoccupied with” our pain at the expense of other areas of our lives.

    What is really going on, however, is that we are discomfiting doctors by demanding that they actually evaluate us to determine why we hurt and what is going on. Once this diagnostic code goes into a patient’s medical records, they can reliably anticipate not being taken seriously when they continue to request medical evaluation and differential diagnosis for their real problems. They get written off as head cases — and in more than a few instances are told that they will not be medically treated until they have been evaluated for mental health issues.

    I commend for your consideration, my researched article on “Psychogenic Pain and Iatrogenic Suicide”, published by the Association for Humanistic Psychology on its website, the “Global Summit for Diagnostic Alternatives”.

    I do not doubt that there is “some” mind-body connection. Supportive counseling has a constructive role to play for some people, some of the time. I see that connection often enough in chronic neurological face pain patients with whom I interact in Internet forums. But I am convinced by wide reading and patient interactions that we are a long way from either understanding how this mechanism works, or reliably employing it to improve patient quality of life. A very large number of outright quacks employ the term in ways that are rather frequently dangerous to patient health and welfare.

    If it were up to me, the entire field of psychosomatic medicine would be abolished as an urban myth.

    Regards

  12. Candy Asman, RN at 12:12 pm

    As a person living with pain, my appreciation of Cynthia Toussaint’s courageous voice of advocacy in publicly sharing her journey leaves me despite bilateral shoulder pain with both hands clapping! I, too, embrace new paradigms that utilize the mind body connection to palliate or manage pain with greater efficacy.
    Today, pain management is considered by many to be an oxymoron.
    The late Dr.Wayne Dyer was known for saying, “When we change the way we look at things, the things we look at change.” Whether you subscribe to this belief or not, it interfaces with cognitive therapy where each feeling is preceded by a thought. I have accessed what allopathic medicine, complementary integrative medicine including mindfulness meditation, modified body work, acupuncture, biofeedback and prayer or some type of spiritual healing offers. I empathize with Ms. Toussaint and all in pain whether severity at 1/10 or 9/10. Personally, different modalities have worked for periods of time and different pain symptoms. The critical constant and weapion fighting dissapointment bordering on demoralization has been ongoing scrupulous re evaluation and alteration in plan..
    The light that cannot be extinguished despite the ongoing opioid/controlled substance struggles are utilizing current practices while aggressively exploring non exogenous chemical coping modalities.
    The greater number of tools in the therapeutic armamentarium, the greater potential for pain management to no longer be an oxymoron.
    I have been a health care professional for three decades. In my clinical experience, “catastrophizing” or catastrophic thinking has been used in the domain of anxiety disorders; from generalized to panic disorder.In this arena reactions to catastrophizing and “learned helplessness” a sibling term — but one that warrants another show — mirror those seen in the pain domain.
    I must disagree with Ms. Toussaint’s personal anecdotal reference as illustrative of “catastrophizing.” It was not catastrophic thinking illustrated in her traumatic experience. Simply stated, “It was not what a reasonably prudent practitioner may have done,” a medico-legal term utilized in discerning negligence and/or malpractice.
    Catastrophic thinking might have manifested as, “I instantly visualuzed permanent loss of limb function, global somatic decline, suffering with intractable pain and need for an alternative level of care, maybe even a Nursing home.” That inner dialogue would define catastrophic thinking to my understanding. May I suggest the term “irrational level of alarm” by consumers of care if universal criteria are developed and employed in an interdisciplinary manner. Akin to the DSM IV-R or ICD 10. Less value laden terms, like “compliant” that can connote “good patient” and “non compliant” as “too needy.”
    A universal investment in evidence based practice is far more therapeutic. I thank Ms Toussaint for her remarkable voice for change in the treatment of underserved warriors. “Once felt, never forgotten.”