What doctors wish patients knew about stopping catastrophic thoughts

For many people, stress and anxiety escalated significantly at the onset of the COVID-19 pandemic. Yet for others, additional fears, worries and thoughts of doom and gloom predominated their daily lives throughout the pandemic. While the anxiety may be unavoidable, the endless fears, thinking of the worst-case scenario and that things won’t get better can be consuming.

This is catastrophic thinking—or catastrophizing. And when catastrophic thinking sets in, you might feel that everything will start to unravel, and your life will be ruined, which can impede your happiness and can be a major risk factor for post-traumatic stress disorder. But there are ways to stop these destructive thoughts.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

For this installment, AMA member Tom Zaubler, MD, MPH, a psychiatrist in Morristown, New Jersey, took time to discuss how patients can stop catastrophic thinking. He is the chief medical officer of NeuroFlow, which makes digital health tools for patient self-care.

“Catastrophic thinking is a cognitive distortion that occurs when people have a hard time weighing the likelihood of certain outcomes and believe that terrible or catastrophic outcomes—which are highly unlikely—become, in one’s mind, salient and extremely likely,” Dr. Zaubler explained, noting “it can lead to a lot of suffering.”

But “it is not an uncommon problem. On some level, we all do that,” he said. “We’ve all had these experiences where we say something to a loved one or in a meeting and suddenly, we think: Is that the end of my job, my relationship, whatever it may be. And that’s just part of the human condition.

“It is, however, important to recognize when this type of thinking becomes persistent and interferes with one’s life,” Dr. Zaubler added, noting that “catastrophic thinking can be a symptom of an underlying problem with anxiety which can be effectively treated with psychotherapy and, in some cases, medication.”

“The basic message here is that it’s important to identify because sometimes people are not aware that they’re engaging in this catastrophic thinking,” Dr. Zaubler said. “People can go through life often feeling like it’s a pretty dangerous place out there and at any moment something awful can happen.”

“There are defenses in place that make it very difficult for us to recognize catastrophizing, but it starts with identifying it,” he said, noting that “holding out hope is an important step in this because if you are so locked into the catastrophic thinking that it can never get better, it’s hard to take the steps to actually get better.”

“We all may experience momentary angst, but some of us struggle to reality-test around the likelihood of the negative outcomes actually happening,” Dr. Zaubler said, noting “there are people who engage in this sort of catastrophic thinking so that it becomes a perpetual state of anxiety about all sorts of horrific outcomes.”

“Catastrophic thinking occurs not only in the context of social interactions, but also with regard to concerns about our health and well-being,” he said. “We see it with people who are hypochondrial where there’s catastrophic thinking about this small little growth that could be a pimple, but I’m concerned it is melanoma, and I’m going to die.”

“One of the challenges in treating people with pain—which is another example of this—is that people who catastrophize can struggle with pain symptoms,” Dr. Zaubler said. “And a critical component of treating people with pain is managing anxiety and the associated catastrophic thinking.

“There are shared neural pathways  that mediate pain, depression and anxiety,” he added. “And our experience of pain is much more pronounced when we’re anxious, so the catastrophizing of somatic symptoms, including pain, is something that is important to address not just with injections and pain medications, but through appropriate cognitive behavioral interventions that can really make a profound difference.”

“To varying degrees, we have all been impacted by COVID. The trauma of a loved one dying or living with the fear of contracting COVID when there were so many unknowns early in the pandemic can lead to persistent feelings of helplessness, anxiety and catastrophic thinking,” Dr. Zaubler said. “COVID-19—for large swaths of our young population—was an adverse child event that will have a lingering psychological impact including a heightened sense of vulnerability and fear of negative outcomes.

“And, unfortunately, marginalized communities have been hit the hardest by COVID,” he added. “We are just beginning to understand the psychological, socioeconomic and political fallout from COVID, which may well impact us for generations. I’m still seeing people who are deeply impacted by 9/11.” 

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“We can’t control our feelings. We can’t turn them on and off like a light switch, but we can attempt to modulate our feelings by working through our thinking,” Dr. Zaubler said. For example, “if I get on a plane and I am convinced that the plane is going to crash, I can attempt to figuratively or literally take a deep breath.”

Then test “reality around the statistical probability of the plane actually crashing and compare that against risks that we take all the time with our activities of daily living,” he said.

“While we can attempt to reality-test our fears and participate in resilience-enhancing activities like mindfulness-based stress reduction, it can be very difficult—especially when we are consumed with anxiety—to do this on our own,” Dr. Zaubler said.

“We’re not especially good at probabilistic thinking,” he said, noting “we have all sorts of cognitive biases and heuristics that take us down the wrong path.”

To address catastrophic thinking, “cognitive behavioral psychotherapy focuses on automatic and reflexive thoughts and ways to challenge them, including reality testing,” Dr. Zaubler said. “There is a strong evidence base supporting the effectiveness of psychotherapy for anxiety and catastrophic thinking.

“It is also important to assess whether someone with catastrophic thinking has an underlying anxiety disorder and would benefit from medication which can be immensely helpful,” he said.

“We live in a world where self-care and prioritizing one’s own health and needs often can get lost. So, pause and take a moment for yourself,” Dr. Zaubler said. “If you’re a parent who is taking care of kids, it’s important to put the proverbial oxygen mask on oneself because you’re not going to be able to help others if you’re not taking care of yourself.”

“Getting adequate sleep, exercise and time to be meditative are restorative,” he said. “We also know the importance for our psychological health of engaging regularly in pleasurable activities such as social interactions with loved ones and friends, listening to music, reading a book, or taking a walk outside.”

“There’s this misconception that if someone is struggling with a problem with their thinking or behavior that it feels awkward, it feels uncomfortable, so how do you bring it up? Is it OK to bring it up? Is it going to make matters worse?” Dr. Zaubler said. “While we should avoid judging someone with catastrophic thinking or labeling them as irrational, it is important to convey concern and ask if they are feeling anxious.

“Empathically supporting someone to talk about their anxiety and—when appropriate—seek help can be unburdening and immensely helpful,” he added. “Sometimes just making a gentle observation—I noticed that you seemed concerned about something and wondered if you would like to talk—can open the door and help that person feel less isolated with their anxiety.”