“Catastrophizing” – why we feel sicker than we actually are

by Carolyn Thomas

It’s distressingly common in cardiac circles to run into people who don’t have heart disease, but who are very certain that they do. When I first heard some of their stories, I suspected that these people are being misdiagnosed, but the reality may instead be that there’s no heart disease here at all.

This scenario came up recently with a woman with few if any cardiac symptoms, no definitive test results, and very little reason for believing she might have a heart condition. Yet she was so utterly convinced a heart attack was imminent that she described feeling like a “ticking time bomb”. A fellow heart attack survivor, far braver than I, suggested to this woman that she might be experiencing a phenomenon called catastrophizing.  

Trauma therapist John Flanagan of Oregon helps to define this:

“Catastrophizing can take many forms. It can be reading too much into what or how a doctor tells us about an illness. Essentially, catastrophizing is making assumptions about what’s going on based on very limited or circumstantial evidence. It is assuming a more dire conclusion than we have adequate evidence to support. And it is having an emotional reaction proportional to that dire conclusion.”

With catastrophic thinking, these women are not in real danger, even though the fight or flight response is activating as their minds scan for all possible dangers or events that might be threatening.

In his essay, Anxiety Disorders and Catastrophic Thinking, Jim Lowrance writes:

“Even though the catastrophic thinker can often recognize these thoughts as irrational, she might find it very difficult to keep them from occurring repeatedly. This kind of phobic thinking can mean that the anxious person inadvertently trains her mind to develop fears of perceived dangers.”

Mental health professionals sometimes compare this phenomenon to attention-seeking behaviour. Experts at the UK Workplace Bullying project, for example, explain it in this way:

“A person who has low levels of self-esteem and self-confidence may consequently feel insecure; to counter these feelings of insecurity, they might spend a large proportion of their lives creating crisis situations in which they become the centre of attention.”

Another possible explanation for cardiophobia/cardiac anxiety syndrome comes from the psychological theory of the crisis-prone personality. According to the academic textbook Cognitive-Behavioral Strategies in Crisis Intervention, psychologists Gina Fusco and Arthur Freeman write that the crisis-prone person finds simply “waking in the morning and having to cope with life’s daily events is fraught with potential crises and the resulting angst.”  These people tend to seek if not revel in drama, become worked up over small problems, and tend to see themselves as the center of their all-too-frenetic universes.

John Flanagan draws this distinction between a crisis and a catastrophe:

  • crisis is when something bad happens that needs to be dealt with in an expeditious manner.
  • catastrophe is when something extremely bad happens and there is very little one can do about it. Catastrophizing is essentially turning a crisis into a catastrophe.

John tells his own story of the day that he went to his doctor complaining of an unusual rash.  His doctor was unable to immediately diagnose the cause of the rash, but John was ultimately told that test results suggested a rare but mild auto-immune disorder. He explains:

“The rash was a concern. The doctor’s inability to diagnose it was a crisis. But my own sense that I was going to actually die from it was catastrophizing. In this example, there was no actual catastrophe.”

Another 39 year-old woman from San Francisco is also catastrophizing when she describes her own cardiophobia or cardiac anxiety syndrome.

“I suffer from not only severe cardiophobia myself, but I also have what I call projected cardiophobia.

“Not only do I have severe panic attacks worrying over my own heart health, but I also worry for my boyfriend. I project my anxiety onto him, and am always afraid that he is going to have a heart attack, too.”

Living like this can feel truly miserable. Yet years of NOT dying, or of NOT having a heart attack as feared do not necessarily reassure the person who is catastrophizing. No amount of reassurance or normal diagnostic tests or simply continuing to be alive are enough to be convinced.

Cardiophobia, according to Dr. Georg Eifert, is defined as an anxiety disorder characterized by repeated complaints of chest pain, heart palpitations, and other somatic sensations accompanied by fears of having a heart attack and of dying. He explained in the journal Behavioral Research Therapy that those with cardiophobia tend to:

  • focus attention on their heart when experiencing stress and arousal
  • perceive the heart’s function in a phobic manner
  • continue to believe that they suffer from an organic heart problem despite repeated negative medical tests

He adds that in order to reduce anxiety, they “seek continuous reassurance, make excessive use of medical facilities, and avoid activities believed to elicit symptoms”.

Heart sisters, this is just about the point at which my own miserably unsympathetic Smaller Self kicks in, wanting to quote my dear friend Marlline, who likes to say things like: “Suck it up, Buttercup!”

Those who insist on wasting limited medical resources in search of a high-drama diagnosis that will never come make it so much harder for those of us who actually are ill to be taken seriously by the medical profession.

Instead, we are then lumped in with the cardiophobes of the world, dismissed and sent home in mid-heart attack, as I and many other female heart attack survivors have experienced.  

This is an extremely serious issue.

We do know that female heart patients are typically under-diagnosed and then under-treated even when appropriately diagnosed compared to men. Women under the age of 55, in fact, are seven times more likely than men to be misdiagnosed.

Many of these women in mid-heart attack are regularly and tragically misdiagnosed with anxiety or panic attacks, whose symptoms can mimic actual heart attack symptoms. See also: When Your Doctor Mislabels You as an “Anxious Female”

One wonders how many catastrophizing cardiophobes my exhausted and burned out E.R. doctor ran into before I arrived at his door – and before he sent me home with an acid reflux misdiagnosis, just another over-reacting middle aged woman with heartburn making a big fuss over nothing?

Ironically, people under the age of 50 who have been diagnosed with panic attacks, a type of anxiety disorder, can develop a greater risk of subsequently developing heart disease or suffering a heart attack than the normal population, according to 2010 research published in the European Heart Journal. This is not surprising, given what we now know about the damaging effect of stress hormones like cortisol and adrenaline on the delicate endothelial cells lining our coronary arteries. Catastrophizing cardiophobes may be actually able to create the very cardiac crisis they fear – unless they seek mental health treatment well in advance. They could wait until that heart attack happens, or they could seek help instead to mange their anxiety.

So why are we human beings tempted to cripple ourselves emotionally by catastrophizing? John Flanagan’s theory is that we catastrophize for a variety of different reasons at various times:

  • because our society teaches us to do it
  • because it is what we are used to, especially if we grew up in a dysfunctional family
  • because our childhood was a catastrophe
  • because we fear that our ability to control our own lives, like a house of cards, is about to collapse
  • because we have been waiting our whole lives for a “real” catastrophe to happen to us so that we can feel justified
  • because even though we may have suffered in the past, we have not felt entirely sure that we had any reason to suffer
  • because we are finally feeling vindicated, exonerated and validated in our suffering
  • because having a serious illness or other disaster befall us makes us feel like others will finally recognize our suffering
  • because a catastrophe seems to legitimize our eccentric or inappropriate behaviours
  • because our past experience has taught us that it was only when we were ill that attention was paid to us
  • because we may have felt shamed for being ill, and thus believe that only a very serious diagnosis is legitimate

Sometimes, adds John Flanagan,  our tendency to catastrophize about certain things can be a useful tool to teach us about ourselves:

“Just like any other symptom, its character may stem from our original trauma and therefore may shed light on what that trauma was and how it impacted us.”

South Carolina psychologist Dr. Lisa Holland recommends an approach called Cognitive Behavioural Therapy to help manage the anxiety that leads to catastrophizing. Here’s a simple CBT tool she suggests to get started:

1. Stop and acknowledge what you feel: I’m scared, annoyed, lonely…

2. Question your thinking: ask yourself, is this really the worst thing?

3. Prioritize your thinking: ask yourself, is it worse than the time ___ or when I ___?

If you still struggle, please seek a therapist trained in Cognitive Behavioral Therapy to help you.


   See also: Are You a ‘Disease Seeker’ or a ‘Health Seeker’?


NOTE: Comments are now closed.


19 thoughts on ““Catastrophizing” – why we feel sicker than we actually are

  1. Pingback: Go for it!
  2. I understand what your getting at but we’ll have to agree to disagree. I went into my (prior) doctor and told her I was having chest pains, heatburn and pvc’c. I was told to take prilosec. I asked if she could refer me to a cardiologist. I was told I woulds have to have more symptoms. So for another couple of years I told myself that it was only anxiety, heartburn, allergies,until, my now physician insisted I saw a cardiologist. Guess what? It was a heart attack. Isn’t it better to err on the side of caution, especially for women where this is the number one cause of death and totally treatable if gotten to early? Do you wait to get a mammogram until after you find a lump? Women are more misdiagnosed and under treated then men by large margins. My cardiologist isn’t doing an angio because my arteries look fine and so does my heart. I don’t have so called “Heart Disease” He claims that women often have heart attacks that the cause just dissapears. Upon doing further research this isn’t necessarily the case, so do I not deserve the time to look further to make sure there is no micro blockage? How do they know they don’t have heart disease if they don’t go to him in the first place? With all the information on the internet and tv telling women that Heart attacks for them don’t act “Normal” why shouldn’t they panic? It can appear like indigestion, the flu, Muscle spasms on the wrong side? My nephew, who is only 32, called his wife to take him home because he had the flu, she didn’t like his paleness and took him to the hospital instead, He was having a heart attack, and now sports a pace maker. The symptoms can be too easily confused with something else. I say, Let them go and have the tests to make sure they are safe. There life is in no way of less value than mine, and if early intervention can help them then great.


  3. Mayo was very smart to put you on the payroll, you validate the industry’s sexism & distract from its incompetence. “Those who insist [*insist*!] on wasting limited medical resources in search of a high-drama diagnosis that will never come make it so much harder for those of us who actually are ill to be taken seriously by the medical profession.” You speak for yourself.

    In the US, people don’t get good preventive care. And mental healthcare is more limited. The US medical profession has fought health reform tooth an nail. They are very afraid of the Canadian system.


    1. Dear Disappointed – I am not on Mayo’s payroll (or anybody’s payroll – I’m merely a heart patient volunteering at what I do here). And you are absolutely right: I DO speak for myself, and only myself. Readers have the right to read or not to read, to comment or not to comment, to agree or to disagree with my opinions. I live in Canada (aka “commy pinko land of socialized medicine”) where the vast majority of citizens love and appreciate our healthcare system. It’s certainly not perfect, but it’s far better in so many ways than what you have in the U.S.


  4. Whilst I agree with what you’re trying to say I do find the article confusing due to the fact that it can be taken in a contradicting way.

    My personal opinion is when it comes to anxiety, there is a deep seeded doubt within that person’s brain thinking of worst case scenarios. It is a doctor’s duty of care to see if there is legitimate concern. Once determined, or if determined there is no reason for concern, then the patient needs to be explained this properly in a caring manner. There needs to be a discussion into preventing the anxiety and/or help, understanding that it can also be confusing for the patient in this situation.

    I do however understand that it can be more than frustrating for someone who has heart problems and them having to wait due to people who are congesting the health system. Hopefully one day things can improve.

    Liked by 1 person

  5. While your article convinced me I’m probably dealing with a panic attack currently instead of a heart attack, the overall tone is displeasing. Suffering from anxiety and panic attacks is truly the most miserable way to live. Mine was brought on by a terrible childhood and every type of abuse. I’ve been through so much counseling, see a Psychiatrist every other month, have done breathing exercises, meditation, hypnosis and am in recovery for 4 years from alcoholism. I have really done the work to cure my anxiety.

    While it is better, here I sit once again googling to convince myself I’m NOT having a heart attack. It’s a very difficult thing to describe. I know this is likely anxiety, but the panic takes over.

    I can only speak for myself, but I really think most people who go to the ER for heart issues genuinely believe they are having them. So what is one to really do?
    -sidenote: I’ve never even been to the ER… So some of us stick it out in the dark of the night fearing we may die.

    Liked by 1 person

    1. I feel the same way. But I have been to the ER a few times. I hate waking up thinking, and waiting for a panic attack. I check my blood pressure all day, look at my arms, feel them, check my pulse. Worse of all I have Hypertension! And my medications don’t even seem to work due to my ANXIETY!


  6. This article reads as if I want to live my life as someone who cannot stop thinking about these things. If I could just turn my brain off that would be great but I can’t. And matter of fact it hurts my feelings to think that there are other women who would not be so supportive and think I was doing it to get attention. If I wanted attention this is certainly not the way I would want it.

    Liked by 1 person

    1. I couldn’t agree more. My paternal grandmother dropped dead of a heart attack when she was only 44. My father had his first heart attack at 32. I am now 30 and have been crippled with cardiophobia since I was 19. While I logically know that my fear is a phobia resulting from being an impressionable child seeing my father in ICU after his first heart attack, my emotional “flight or fight” response is constantly nagging me to believe otherwise. In the early days of my phobia, I would go to the ER several times a year with what felt like a heart attack but always proved to be panic. I wore a 24-hour holter monitor that showed frequent (but benign) palpitations; all EKGS have been normal (aside from ectopic beats). No one on my maternal side has ever had a single cardiac event, but on my father’s side they have occurred at unusually early ages for two generations. It’s hard to have a realistic outlook.

      I was also conflicted about this article. On one hand, the author is telling people not to worry if they have cardiophobia, but on the other recognizing that cardiophobia can cause cardiac conditions or even be misdiagnosed as anxiety in women under 50. So should we worry or not? Also, as Toni pointed out, it is NOT as simple as turning off a switch.

      After over a decade of this life-altering anxiety, I no longer run to the ER when I think I’m having a heart attack. I assume it’s a panic attack and that it will pass as it always does. But what happens the one time it really IS a life-threatening cardiac event and I have trained myself to ignore the symptoms (which can identically mirror legitimate symptoms)?

      It is not as cut and dry as “Suck it up, buttercup” (and that’s coming from someone who is usually a fan of that mentality in general).

      Liked by 2 people

  7. Could it be just as or more appropriate to call for more medical services to be available to the public from hospitals and health providers, than to blame individual patients for not being able to tell the difference between panic attacks or anxiety disorders and heart issues?

    Liked by 2 people

  8. While I understand what you are saying and why, this page relays several conflicting messages, both within itself and with tradition heart attack advice. You state that people with panic attacks are at greater risk for heart attacks, but that people with panic attacks are clogging up the medical system, by getting checked for what they believe are early or current heart attack symptoms. On this same website it is stated that many women who believe they are having early or current heart problems are misdiagnosed with panic attacks and sent home. How does one truly know if they are having panic attacks or being misdiagnosed by overworked exhausted doctors, that tend to misdiagnose young women with heart problems frequently? Also, most websites indicate that if a women even suspects a heart attack, that she should call 911, and not wait. Do you not worth that by chiding those who have panic attacks for “abusing the medical system,” that you also could be discouraging them from seeking help for real heart issues? Further, what if this page actually convinces women who are having real heart issues that they are “catastrophizing,” or just have anxiety, causing them to stay home when they should have sought help? This page, in part, portrays women with panic attacks or anxiety disorders as people who are knowingly taking resources from real heart attack victims by suggesting they should know better than to mis-use the medical system, while at the same time acknowledging that there are many causes for their anxiety disorder or panic attacks that go beyond their control or outside of their knowledge. Many doctors give patients with other health issues, including mental health or anxiety EKG’s to exclude other more serious issues. Just as you are upset about being misdiagnosed and sent home, wouldn’t you be upset if a doctor diagnosed you correctly with anxiety, but also failed to check for serious health issues that it turns out you also have? Lastly, this page, while addressing a real problem, minimizes the seriousness of severe anxiety disorders, which can effect an individuals ability to function and be healthy, and through many avenues cause many other more serious problems. I understand the frustration, but do you really need to berate those who think they have symptoms, and feel the need to be seen for them?

    Liked by 2 people

    1. Agreed! And if you have dealt with anxiety for a long time, and start to get new symptoms, how are you to know if they are a progression of your anxiety or symptoms of an actual heart attack (which may have occurred because of your prolonged anxiety) that require a trip to the ER or cardiac tests?
      While this article was helpful in proving to me that I’m not alone, I did find that it was conflicting with the information on the rest of the page.

      Liked by 1 person

  9. I agree Stephen, training in HOW to reduce anxiety should be given to all heart patients.

    And, if I could teach the heart sisters one Cognitive Behavioral skill, it would be how to regulate catastrophe thinking.

    Two reasons for learning this skill, (1) chronic catastrophizing signals your sympathetic nervous system to ramp up your heart rate, and (2) more women tend to engage in catastrophe thinking than men.

    (So here’s a simple CBT tool to get started)

    1. Stop and acknowledge what you feel: I’m scared, annoyed, lonely…

    2. Question your thinking: ask yourself, is this really the worst thing?

    3. Prioritize your thinking: ask yourself, is it worse than the time___ or when I ___?

    If you still struggle, please seek a therapist trained in Cognitive Behavioral Therapy to help you.

    Thank you Carolyn for starting a discussion about this important topic!

    Liked by 1 person

  10. “…Those who insist on wasting limited medical resources in search of a high-drama diagnosis that will never come make it so much harder for those of us who actually are ill to be taken seriously by the medical profession..”

    I too have suspected this for a long time, as a nurse and bypass survivor. With our health care debate still raging over how to keep escalating costs under control, we have to somehow compute the difference between patients like you and I who actually need those scarce medical resources, and those ‘high drama diagnosis-seekers” who are “catastrophizing” for whatever reason.

    They may need other kinds of medical care to address mental health issues; but not expensive and unnecessary cardiac procedures while other real heart patients are forced to wait in the queue.

    Love your website. You do good work here.

    Liked by 1 person

    1. Carolyn’s Note: This comment has been removed because I don’t allow name-calling on my site.


    2. Given how often women are told that heart attacks in women present oddly, how, exactly, is a woman or a doctor to know someone isn’t having cardiac problems without doing tests? In fact, medical professionals saying “I know it’s just anxiety” and sending ppl home without doing any proper testing seems a great way to have more women die of treatable cardiac issues than already do.

      Further, cardiac testing may be a legitimate part of treatment even for someone who does not have a cardiac issue, as it establishes that the symptoms being reported are ‘safe’ to ignore. As someone who developed anxiety following an incident with several days of significant tachycardia triggered by a virus (including a few days stay in the hospital for monitoring due to the tachycardia) having some additional testing done helped me gain trust that the problem had in fact resolved with no lasting issues, so I had a counter for the thoughts that come with anxiety, which has allowed me to greatly improve my anxiety-related issues.


  11. Five years after a heart attack and after thirty years of clinical work, I am more and more convinced that training anxiety reduction needs to be a major focus of attention and treatment in most medical situations.

    This would apply both to those folks who are experiencing the kind of catastrophic thinking you write about in this article, and folks who have been through heart problems with “real” anxiety.

    It is very difficult to stop free-floating anxiety, whatever the source — whether one comes from a dysfunctional family, has PTSD, or fears another heart attack. Anxiety is an automatic, unconscious response; telling yourself not to be anxious is like telling yourself to relax. (I still get anxious with any kind of chest pain — my mind knows better, my body is remembering what happened once and goes into red alert if I am not mindful.)

    There are, of course, strategies to learn anxiety reduction, something I hope to see soon in your wonderful blog.

    Liked by 1 person

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