Defusing Catastrophe

Here’s how to help patients—and ourselves—recognize cognitive distortions.

Everyone has experienced moments when one bad outcome convinces us we are doomed to a life of failure. These catastrophic thoughts are akin to making a proverbial mountain out of a mole hill. It is why after a breakup, we think no one will ever love us. It is that seizing fear when waiting on a doctor’s report. It is that gnawing feeling when someone vaguely texts “we need to talk.”

This exaggerated expectation that only the worst possible outcome will occur can exert a powerful and debilitating influence over our lives. Left unchecked, these catastrophic thoughts can set dangerous patterns that prohibit us from taking reasonable chances, following inspiration, or recognizing life’s silver linings.

As psychiatrists, we often encounter catastrophic thinking in our patients. We understand how difficult it can be to change these patterns, even with professional help. And while it is often easier to see this in others, the demands of our profession make us susceptible to falling into these very same traps. Tasked with supporting our patients’ well-being, psychiatrists—and physicians in general—feel enormous pressure to produce positive changes in their lives. When our patients suffer setbacks, it is hard to not take it personally. And it can cast a strong and deeply personal shadow of doubt on our abilities.

Then there are the traps of burnout that can lead to catastrophic thinking: regulatory hoops, the ever-increasing bureaucracy and paperwork, clinician shortages, training mandates, the threat of malpractice lawsuits, and the COVID-19 pandemic. Like a hamster on a treadmill, it is easy to feel that there is never enough time and no end in sight.

Getting out of a catastrophic funk requires following the same treatment and advice we might give our patients. This means asking for help when we need it—something many physicians find difficult to do. Our jobs require us to be stalwart and seemingly infallible, but without balance and mindfulness, we continue to walk a dangerous razor’s edge of catastrophic thinking.

What is Catastrophic Thinking?

Catastrophic thinking, also known as magnifying, is a kind of cognitive distortion—a thought pattern that is irrational or exaggerated. Psychologist Albert Ellis, PhD, first coined the phrase in 1957 as he was developing his rational-emotive behavior therapy, a precursor to modern-day cognitive behavioral therapy. His ABC model involved an activating event, beliefs that were irrational, and the consequences of those beliefs. His theory was that our emotions and perceptions are not formed by an event—rather, how we think about the event directs how we feel.1

Catastrophic thinking can be triggered by one’s perception of what is happening at present or what they anticipate will happen in the future. Situations that trigger magnifying usually fall into 3 categories: how we interpret vague or ambiguous information, how we cope with the loss of someone or something valuable, and fear—especially irrational fear.

Catastrophic thinking shares some similarities with anxiety. The difference is that anxiety may serve a purpose, such as justified fear, while catastrophizing involves irrational magnification. It is also linked to depression, where feelings of unhappiness and helplessness can trigger an avalanche of catastrophic thoughts. Catastrophizing is common among those who have experienced traumatic events, or anything that threatens their safety and security or shatters their sense of control. It is common among those suffering from posttraumatic stress disorder (PTSD), depression, and anxiety. Among combat military troops, those with high levels of catastrophic thinking were 29% more likely to develop PTSD. Additionally, those who experienced high levels of catastrophic thinking coupled with higher combat intensity were 274% more likely to develop PTSD.2

Ironically, catastrophic thinking can serve as a dysfunctional coping mechanism. After all, if you are always expecting the worst, you will rarely be disappointed. But this comfort can come at a steep price—one that can increase debilitating feelings of anxiety, avoidance, and isolation.3

Magnifying can also affect and intensify how we experience pain. This is especially true with those suffering from chronic pain. Pain catastrophizing can feed on the memory and trauma of past events, which can influence how patients perceive future pain. Additionally, it can cause patients to ruminate on it and ultimately feel helpless against the idea of it. Pain symptoms account for 80% of physician visits and $100 billion a year in health care expenditures and lost productivity.4 Because of this, it is essential for physicians to gauge patterns of catastrophic thinking in their patients—not just to recognize the exaggerations, but to notice symptoms of other potential problems. Patients suffering from painful medical disorders in particular report high levels of catastrophic thoughts, along with self-reported pain, disability, and fear-avoidance behaviors.5 In a worst-case situation, catastrophic pain is a risk factor for suicidal ideation in those suffering from chronic pain.4

Catastrophizing and Physician Burnout

Among physicians, burnout is a leading cause of catastrophic thinking. Defined as emotional and physical exhaustion brought on by prolonged stress, burnout has been noted in 50% of physicians-in-training and practicing physicians.6 It is generally attributed to work environments rooted in excessive workloads, inefficient work processes, clerical burdens, work-home conflicts, and a lack of input or control, leadership culture, or organizational support. Female and younger physicians are more likely to report higher rates of burnout.6

In addition to feelings of cynicism, burnout can reduce one’s sense of effectiveness and personal accomplishment, leaving a person feeling emotionally drained. At worst, depersonalization associated with burnout can lead some to regard patients as objects rather than human beings.6 Physical symptoms include fatigue, body aches, headaches, gastrointestinal effects, increased susceptibility to common infections, and disrupted sleep patterns.7

Physician burnout is a common problem that has far-reaching effects. For patients, it can result in lower-quality care, medical errors, longer recovery times, and lower patient satisfaction. Physicians are more likely to experience substance abuse problems, depressive and suicidal ideation, and motor vehicle crashes. The health care industry suffers at large due to reduced physician productivity, turnover, and less access for patients. All of this has resulted in $4.6 billion a year in costs.8

The pandemic has created its own unique breeding ground for burnout, with 53% of health care workers reporting high levels. Heading into its third year, the rebounding pandemic and its relentless pressure on the health care system creates an environment ripe for catastrophic thinking. Rather than succumb to its pitfalls, awareness is the first step in fortifying our mental defenses.

Psychiatrists are particularly susceptible to burnout, more so than surgeons and other physicians. In some ways, the stakes are higher, as our patients are more prone to violence and suicide. Because we use ourselves as tools to treat patients, we are vulnerable to a powerful range of emotions. These include feeling powerless against illness, fear of becoming ill, and the obsessive need to rescue patients.9

Decatastrophizing Catastrophe

Ellis did more than identify catastrophic thinking. He highlighted a way out of it by expanding the original ABC model to include ABCDE. The “D” refers to the disputation of beliefs, which calls for irrational thoughts to be converted into rational ones. And the “E” represents the effects these new and healthier thoughts might have on a person’s well-being. One of the best ways to counteract catastrophic thinking is by challenging it. Ellis’ method of decatastrophizing involves posing rational questions,3 such as:

-What exactly am I worried about?

-How likely is this event to occur?

-What is the worst thing that can happen?

-If this happened, what would I do?

-What might I say to reassure myself?

Sometimes, saying “stop” out loud can help disrupt the pattern of repetitive negative thoughts. In the heat of the moment, it can be difficult to recognize catastrophic thinking as it is happening. The help of a clinician can clearly define these patterns and use a cognitive-behavioral approach to decatastrophizing. In some situations, clinicians may prescribe antidepressants or other medications to address the root causes of catastrophic thinking.

Over time, this hard work of observing patterns and reframing our reaction pays off in the form of hard-earned resilience. Resilience is measured by our ability to quickly recover from stress. It is a way of building mental fortitude despite—and because of—life’s hardships. Another benefit is that it can drown out catastrophic thoughts by interpreting failures as opportunities to learn and grow. Techniques to build resilience include taking on challenges where the risks are reasonable, discovering one’s personal meaning of life, and being surrounded by people who believe in you. Other methods to build resilience include:

Transcendental meditation (TM):TM is a meditation technique that involves silently repeated mantras to help reduce stress and promote a relaxed state of awareness. In one of the author’s studies, health care workers during the pandemic who practiced TM for 3 months showed significantly improved symptoms of emotional exhaustion, anxiety, and insomnia over time when compared to a control group.10 In another pandemic study, emergency clinicians who practiced TM experienced significant reductions in burnout, along with fewer symptoms of depression, anxiety, stress, and sleep disturbances.11

Mindfulness: This practice turns down the volume of mental chatter by engaging full attention on our daily and mundane tasks. By focusing on the here and now, mindfulness can help practitioners gain broader awareness of cognitive patterns and better control over irrational thoughts. One study found mindfulness was predictive of lower levels of disability, anxiety, depression, and catastrophizing in patients suffering from chronic back pain.12

Sudarshan Kriya yoga (SKY):Through structured body postures, breathing exercises, and cognitive-behavioral processes, practitioners learn relaxation and stress-management techniques. Studies indicate that SKY offers a therapeutic option capable of reducing symptoms of depression and anxiety.13

Self-care: Exercise, healthy eating, and getting enough sleep all help shore up our defenses against catastrophic thinking. Being kind and tending to one’s needs can have a calming effect on our tendency to dwell on the negative.

Clickable technology: Web- and phone-based apps provide quick, anonymous options to those hesitant about seeking mental health treatment. This technology helps users track moods, learn mindfulness techniques and exercises, and keep catastrophic moods in check. One study found that online tools helped reluctant health care workers reduce stress, burnout, depression, and suicidal ideation.14

Examples of apps include:

-Happify: Provides daily games tasked with increasing happiness, reducing stress, and overcoming negative thought patterns.

-Headspace: Provides mindfulness and meditative tools designed to reduce stress and improve focus and sleep.

-Worry Watch: Helps users track moods with guided journaling, coping techniques, check-ins, and positive affirmations.

Concluding Thoughts

They say physicians make the worst patients. Our need to display strength and dependability can prevent us from seeking help when we need it. As a result, many of us would prefer to cope alone rather than admit weakness and face the silent judgement of our peers. But this thinking runs counter to what motivated us to pursue a career in mental health in the first place. We often preach that our overall health is deeply grounded in mental health. Physicians can improve overall patient care by identifying situations that lead to catastrophizing and burnout and taking measures to correct it.

Catastrophizing can be catastrophic, but it can be managed by building resilience. As physicians, we need to apply this to ourselves just as we do our patients. As the saying goes, “Physician, heal thyself.” Never has this been more apt than in the current pandemic.

Dr Vaishnavi is a neuropsychiatrist, cognitive neuroscientist, adjunct associate in the department of medicine at Duke University, and a psychiatrist with Mindpath Health.

References

1. Selva J. Albert Ellis’ ABC model in the cognitive behavioral therapy spotlight. Positive Psychology. December 13, 2021. Accessed February 2, 2022. https://positivepsychology.com/albert-ellis-abc-model-rebt-cbt/

2. Seligman MEP, Allen AR, Vie LL, et al. PTSD: catastrophizing in combat as risk and protection. Clinical Psychological Science. 2019;7(3):516-529.

3. Lonczak HS. Catastrophizing and decatastrophizing: a PositivePsychology.com guide. Positive Psychology. December 7, 2021. Accessed February 2, 2022. https://positivepsychology.com/catastrophizing/

4. Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9(5):745-758.

5. Gatchel RJ, Neblett R. Pain catastrophizing: what clinicians need to know. Practical Pain Management. Accessed February 2, 2022. https://www.practicalpainmanagement.com/pain/other/co-morbidities/pain-catastrophizing-what-clinicians-need-know

6. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018;283(6):516-529.

7. Queen D, Harding K. Societal pandemic burnout: a COVID legacy. Int Wound J. 2020;17(4):873-874.

8. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. Journal Intern Med. 2018;283(6):516-529.

9. Kumar S. Burnout in psychiatrists. World Psychiatry. 2007;6(3):186-189.

10. Joshi S, Vaishnavi S, Brucker A, et al. Targeting healthcare provider burnout during the COVID-19 pandemic. 2022 ATS (American Thoracic Society) International Conference, May 13-18, 2022.

11. Azizoddin DR, Kvaternik N, Beck M, et al. Heal the healers: a pilot study evaluating the feasibility, acceptability, and exploratory efficacy of a transcendental meditation intervention for emergency clinicians during the coronavirus disease 2019 pandemic. J Am Coll Emerg Physicians Open. 2021;2(6):e12619.

12. Cassidy EL, Atherton RJ, Robertson N, et al. Mindfulness, functioning and catastrophizing after multidisciplinary pain management for chronic low back pain. Pain. 2012;153(3):644-650.

13. Hamilton-West K, Pellatt-Higgins T, Sharief F. Evaluation of a Sudarshan Kriya yoga (SKY) based breath intervention for patients with mild-to-moderate depression and anxiety disorders. Prim Health Care Res Dev. 2019;20:e73.

14. Pospos S, Young IT, Downs N, et al. Web-based tools and mobile applications to mitigate burnout, depression, and suicidality among healthcare students and professionals: a systematic review. Acad Psychiatry. 2018;42(1):109-120.