by David Gavel, PhD

Consider this situation: A 51-year-old pipe-welder and father of 3 was in your office this morning to hear the results of an MRI related to complaints of progressively worsening back pain. He sits down and anxiously awaits your feedback as he writhes in pain. You inform him that imaging showed the presence of degenerative disc disease and briefly explain that his condition is present in some form with more than 90% of men over the age of 50 [1], many of whom are asymptomatic [2]. Before he even asks, you explain a variety of non-invasive treatment options for managing the pain and recommend that he consider limiting or altering activities that may speed up the “wear and tear” of his back. He expresses his understanding and heads home to inform his wife that “the doc said my back is disintegrating and I’ll never be able to work again. I don’t know how we’ll survive if I can’t work.”

Notice how the news received by the wife seems to be drastically different than the words you expressed in the office. In this scenario, during your conversation with him there was no conversation about employment, specific worsening of symptoms, or any direct orders to cease and desist all meaningful activity. So, what happened? How did your objective diagnosis and empirically supported recommendations turn into a convoluted message to the wife as if it was a game of telephone at a 7-year-old slumber party? The answer is catastrophizing, and it is explained by the cognitive model.

The cognitive model [3] is a widely accepted and well published framework for understanding the crucial role that internal thoughts and attitudes play in the daily experience of emotion and behavior. More specifically, the model proposes that over the course of our lifetime, we all develop patterns of thought that influence our understanding of the world around us and the meaning we place on events in our lives. Unfortunately, these thought patterns do not always work in our favor and certain dysfunctional thinking patterns tend to underline many of our most undesirable experiences. Among these dysfunctional patterns is the aforementioned catastrophizing. In a nut shell, catastrophizing is the tendency to draw erroneous and often irrational conclusions about the severity of a current situation or to believe that a future situation will end in the worst possible way. For example, after a seven-week romantic relationship ends, a 15-year-old screams “I’ll be alone forever in a house full of cats for the rest of my life!”. Or a middle-aged employee recklessly speeds through rush hour traffic with the thought “If I’m late, I’ll be fired, and we’ll be out on the street for sure.” In both examples, the individual expresses emotions and behaviors that seem unreasonable given the reality of the situation. But that reality is distorted by the worst-case scenario (i.e., belief) that keeps running through their mind (i.e., thought). And the result is a series of undesirable emotions and behaviors.

In the management of chronic pain, catastrophizing is linked to a host of negative physical [4] and psychological outcomes [5] and is a common reason why patients sit in my office and describe how their depression began after a medical provider said “Your back is the worst I’ve ever seen,” “You’ll just have to learn to live with the pain,” or “You will never be able to…(work, play, walk, run, function)…again.” Now to be clear, I have no way of knowing whether quotes like these are the exact words used by the treating medical provider or not. In fact, it is quite likely they are not, and I would like to go on believing that way. But when a patient sits in my office for a psychological evaluation after 8 years of chronic pain that nearly ended with a recent suicide attempt, it is almost irrelevant whether these exact words were ever spoken or not. What matters most is that the patient carrying these burdensome thoughts interpreted that meaning from the situation: “life as I know it, is over.” And like a church bell clanging through the empty halls of a cathedral, this sentiment rings loud and clear inside the mind of the patient and influences every aspect of life for the worse.

Fortunately, there are a number of very effective forms of mental health treatment of chronic pain (e.g. cognitive behavioral therapy for pain) but one does not have to be a psychologist or other mental health provider to help offset some of this influence with patients. In a brief informational blog post entitled “What’s in a Word? The Power of Language in Chronic Pain Treatment,” [6] physiotherapist Carol Miller discusses the influence of language in the assessment and treatment of pain. Ms. Miller encourages providers to use language to explore and understand the patients’ subjective beliefs about pain, expectations for their treatment, and goals for the future. Asking open ended questions or using norm-referenced pain screeners (e.g., Pain Catastrophizing Scale) are two effective and brief methods for eliciting thoughtful information about the patient experience. Furthermore, she offers the idea that understanding our own beliefs about chronic pain and how those beliefs are reflected in our language can lead to more effective patient encounters. Regarding catastrophizing, Ms. Miller’s recommendations for intentional focus on language can lead to invaluable opportunities for providers to clarify any erroneous conclusions a patient may have drawn about the implications of their condition. George Orwell once remarked that “if thought corrupts language, language can also corrupt thought.” If we accept that our spoken words are the outward expression of internal thought, then we must also accept that our words carry weight that bears meaning for the thoughts and lives of our patients.

[1] Teraguchi M, Yoshimura N, Hashizume H, et al. Prevalence and distribution of intervertebral disc degeneration over the entire spine in a population-based cohort: the Wakayama Spine Study. Osteoarthritis And Cartilage. 2014;22(1):104-110. doi:10.1016/j.joca.2013.10.019.

[2] Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR American journal of neuroradiology. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.

[3] Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York, NY, US: Guilford Press.

[4] Talaei KM, Fischerauer SF, Lee S, Ring D, Vranceanu A. Pain Catastrophizing Mediates the Effect of Psychological Inflexibility on Pain Intensity and Upper Extremity Physical Function in Patients with Upper Extremity Illness. Pain Practice. 2017;17(1):129-140. doi:10.1111/papr.12494.

[5] Shim E, Song Y, Park S-H, Lee K-M, Go D, Hahm B-J. Examining the Relationship Between Pain Catastrophizing and Suicide Risk in Patients with Rheumatic Disease: the Mediating Role of Depression, Perceived Social Support, and Perceived Burdensomeness. International Journal of Behavioral Medicine. 2017;24(4):501-512. direct=true&db=s3h&AN=124131574&site=ehost-live. Accessed October 10, 2018.