Lecture3: Catastrophizing

Though this session focuses on fear and anxiety, I think I need an additional comment on another relevant issue, catastrophizing. It is not uncommon to hear about the stories of a ‘catastrophized patient’, who screams or cries during dental treatment. But here catastrophizing is defined from the sense of cognitive neuroscience. It is a mental set or a way of interpreting things. In terms of pain, catastrophizing is an exaggerated negative mental set brought to bear during actual or anticipated pain experiences.

You can see from this definition: what matters is not really how loudly patients are crying. What matters is the thought – the catastrophic thoughts they form about a threat, such as pain. Therefore, catastrophizing should be described from not just emotional but also cognitive and behavioural aspects. The behavioural aspect is especially important. When patients are overwhelmed by catastrophic thoughts, they may avoid further encounters of the potential threat. For example, if patients excessively worry about pain during dental treatment, they may simply cancel their appointment with dentists, which lead to a worse outcome for their oral health.

Based on the concepts, researchers have developed the pain catastrophizing scale to assess the individual difference in the tendency and frequency to have a catastrophic thought about pain.

These ‘thoughts’ can be generally associated with three psychological constructs: rumination, magnification, and helplessness. When patients feel catastrophic about pain, they may ‘ruminate’ or chew the ideas again and again. In other words, their mind is occupied by these thoughts. Especially, the thoughts are usually about an excessive worry or negative anticipation of what will happen. For example, they may think the outcome of treatment is getting worse, even if the treatment has not yet started. The tendency to magnify the negative expectation is associated with helplessness, i.e., patients feel they are unable to cope with the threat. Again, catastrophizing is not just an emotional experience but a cognitive process by which negative thoughts are amplified.

Just like dental anxiety, evaluating patients’ catastrophic thoughts should also be a critical step in patient management in dental practice. I have been studying the issue of pain catastrophizing for many years and I have to say this concept is highly underestimated by dental professionals. One of the reasons is that we tend to label our patients with a specific emotional type, as I mentioned earlier, and we tend to focus on the ‘quantity’ of the emotional experience. For example, we will judge if patients become less anxious after treatment. The concept of catastrophizing highlights the importance of the ‘quality’ of emotional experiences. Patients may become less anxious, but still trapped within their catastrophic thoughts.

Unfortunately, how they are engaged with these thoughts are not explicit to dentists. A good practice to manage patients fear and anxiety should include the assessment of patients’ catastrophic thoughts. A very simple method is to ask them to explain what factors aggravate their fear and anxiety. Catastrophic thoughts can be spotted only by listening to patients’ own words.