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ORIGINAL ARTICLE

Catastrophic Thinking: A Transdiagnostic Process Across Psychiatric Disorders

Resham Gellatly1 • Aaron T. Beck1

Published online: 11 February 2016

� Springer Science+Business Media New York 2016

Abstract Since the description of catastrophizing by Ellis

(Reason and emotion in psychotherapy. Lyle Stuart,

Oxford, 1962) as a general factor in psychopathology,

numerous studies have explored this construct and its

association with many common disorders. This paper

investigates the role of catastrophic thinking across psy-

chiatric disorders. We conducted a comprehensive review

of the literature on the role of catastrophic beliefs as a

predictor and correlate of psychopathological disorders

including panic, phobia, health anxiety, obsessive–com-

pulsive disorder, posttraumatic stress disorder, pain, and

traumatic brain injury. The literature suggests that catas-

trophic thinking has been demonstrated to play a role in a

wide variety of disorders and has been a focal point for

prevention and psychotherapeutic intervention. While the

process of catastrophic thinking is transdiagnostic, content

is unique for each disorder. We propose a model for the

catastrophic cycle and discuss the utility of including

catastrophic beliefs in an alternative diagnostic

scheme based on cognitive theory. We offer recommen-

dations for prevention and psychotherapeutic interventions

that have targeted catastrophic thinking and led to

improvement in each particular disorder. We conclude with

recommendations for further research on the role of

mediation, as well further investigation of disorders such as

psychosis and irritable bowel syndrome, which emerging

evidence suggests may be related to catastrophic beliefs.

Keywords Catastrophic belief � Risk prediction � Transdiagnostic � Mediation � Intervention

Introduction

Ellis (1962) described ‘‘catastrophizing’’ as the tendency to

magnify a perceived threat and overestimate the serious-

ness of its potential consequences. Clinicians have cited its

causal role in a wide variety of disorders, and it is recog-

nized as a common feature in otherwise healthy individu-

als’ overreactions to the usual and unusual stressors of life.

Given the currency of the concept of catastrophizing in

both clinical and non-clinical contexts, evaluating its sci-

entific basis and application is of obvious value. In this

paper, drawing from existing research, we propose a model

of the catastrophic cycle and offer recommendations for its

prevention and treatment. By expanding the theory of

catastrophic thinking, we suggest a framework for under-

standing catastrophic thinking as a transdiagnostic process

with unique catastrophic beliefs in each disorder and offer

ideas for intervention at different points throughout the

catastrophic cycle.

The complex interaction between cognition, affect, and

behavior has been well documented for a number of years.

In the 1950s, Ellis, trained in traditional psychoanalysis,

reported a new approach, which he called rational therapy

(later termed rational emotive behavior therapy, or REBT).

Ellis proposed that it is a person’s ‘‘irrational beliefs’’ that

lead to dysfunctional negative feelings and behavior (Ellis

and Harper 1975). He focused on catastrophic beliefs

within the framework of REBT and coined the term

‘‘catastrophizing,’’ the tendency to magnify a perceived

threat and overestimate the seriousness of its potential

consequences (Ellis 1962).

& Resham Gellatly

resham.gellatly@gmail.com

1 Aaron T. Beck Psychopathology Research Center, Perelman

School of Medicine, University of Pennsylvania, 3535

Market Street, Room 2032, Philadelphia, PA 19104, USA

123

Cogn Ther Res (2016) 40:441–452

DOI 10.1007/s10608-016-9763-3

Following Ellis’ conceptualization of REBT, Beck

developed a model of depression based on cognitive dis-

tortions. His early work in the context of cognitive theory

led him to propose a number of cognitive distortions, one

of which was magnification, a cognitive process in which

depressed patients’ exaggerated beliefs led to misinterpre-

tation (Beck 1963, 1964). Later, Beck applied the concept

of exaggerated fears to panic and anxiety disorders (Beck

et al. 1985). D. M. Clark continued this line of research

within the cognitive theory framework and expanded the

concept of exaggerated fears into a cognitive model of

panic. He proposed misinterpretation of bodily sensations

as a central feature of panic disorder and later refined the

concept by separating the construct into distinct catas-

trophic interpretations in panic (Clark 1986, 1988).

Ingram and Kendall (1987) proposed a cognitive

framework for anxiety that can be applied to the concept of

catastrophic thinking. This refined approach distinguishes

the dimensions of cognition. According to their model,

cognition consists of cognitive content, cognitive proposi-

tions, cognitive operations, and cognitive products. As

applied to catastrophic thinking, cognitive propositions are

the beliefs about the content; cognitive operations are the

thinking processes in which the association between the

situation and the belief is shaped; and the cognitive product

is the catastrophic interpretation of the activating event.

Since these early investigations into the catastrophizing

cluster, the concept of catastrophic beliefs has been

expanded to a host of other problems, which the authors

will discuss in a review of the empirical literature. Seven

disorders were chosen to be the focus of this review based

on their ubiquity in the literature along with the authors’

clinical experience. Peer-reviewed articles and book

chapters were identified through a systematic search using

Google Scholar and PubMed. Taken together, early models

and studies of maladaptive cognitive appraisals demon-

strate a strong relationship between catastrophic beliefs and

various disorders and have set the stage for additional

research on the topic. We examine the transdiagnostic

process of catastrophic thinking across disorders, as well as

the distinct content of the beliefs in each disorder.

Panic Disorder

A number of theories, both biological and psychological,

have been proposed to explain the etiology of panic dis-

order (McNally 1990). Beck described the tendency of

panic patients to exaggerate the significance of experiences

in his early work on anxiety disorders (Beck 1986; Beck

et al. 1985). Clark emphasized process and meaning in his

conception of catastrophic misinterpretation of events. His

catastrophic misinterpretation model of panic (1986, 1988)

had a major influence on the way panic disorder was

understood and has been the basis for numerous studies in

the decades since.

Beck’s notion of exaggerated fears was supported by

studies (Ottaviani and Beck 1987; Sokol-Kessler and Beck

1987) in which subjects’ somatic symptoms were inter-

preted as catastrophic and indicative of imminent danger,

leading to panic attacks. The individuals’ thoughts included

fear of physical, mental, and behavioral catastrophes. A

characteristic belief of this disorder is that chest pain is a

sign of an impending heart attack. Beck observed that

panic patients have fixed focus on the symptoms and

catastrophic beliefs, which renders them unable to stop

anxiety before it escalates into panic (Beck 1988).

Other investigations (Austin and Richards 2001; Harvey

et al. 1993; Richards et al. 2001) reported that individuals

with panic disorders were likely to misinterpret general,

external stimuli as catastrophic in addition to internal

stimuli, extending the types of beliefs common to indi-

viduals with panic disorders. Measures such as Greenberg’s

Panic Belief Questionnaire (1988) and Khawaja and Oei’s

Catastrophic Cognitions Questionnaire (1992) focus on

dysfunctional attitudes and beliefs in these individuals as

opposed to interpretations.

Phobias

Catastrophic cognitions also have been implicated in each

of the phobic disorders: social phobia, agoraphobia, and

specific phobia. However, the content of specific exag-

gerated fears that set off and maintain the cycle differs.

Individuals with social phobia believe that in social

situations, they will behave in ways that are negatively

judged by those around them, and that these judgments will

have catastrophic consequences on their lives (Clark and

Wells 1995). Because they hold these beliefs, these indi-

viduals are prone to interpreting ambiguous social events

negatively, and mildly negative social events catastrophi-

cally (Clark and Beck 1988). Research suggests that

information processing biases, including interpretive bias

and attentional bias, play a critical role in maintaining

social phobia (Amir et al. 1998; Clark and McManus 2002;

Clark and Wells 1995; Rapee and Heimberg 1997; Stopa

and Clark 2000). Individuals with social phobia may

employ safety behaviors meant to reduce the risk of neg-

ative evaluation but which end up provoking the very

reaction they fear from those around them (Clark and Wells

1995). These interactions reinforce the individuals’ beliefs

that they are socially inept, fueling the cycle. A perceived

lack of control over anxiety response may be considered a

catastrophic belief about one’s competency (Hofmann

2005; Hofmann and Barlow 2002).

Individuals with agoraphobia have the belief that they

lack the capacity to escape threats of perceived

442 Cogn Ther Res (2016) 40:441–452

123

environmental dangers, particularly those involving social

situations (Beck et al. 2005). For an individual with

agoraphobia, a characteristic catastrophic belief might be,

‘‘If I visit a crowded shopping mall, I will panic and be

unable to leave.’’ A central feature of agoraphobia shared

with panic disorder is fear of anxiety symptoms and their

perceived catastrophic implications. It has been suggested

that excessive focus on bodily sensations of anxiety,

along with catastrophic beliefs about the consequences of

such symptoms, work in concert to maintain agoraphobia

(Belfer and Glass 1992; Goldstein and Chambless 1978).

Distressing, recurrent imagery, which has been reported in

agoraphobia (Day et al. 2004) may also play a role in the

development and maintenance of the disorder. Individuals

with specific phobias report catastrophic beliefs about

both the feared object or situation and their anticipated

reaction to the object or situation (Merckelbach et al.

1996).

Health Anxiety Disorder

Catastrophic thinking has been reported to play a role in

health anxiety disorder (HAD). Salkovskis and Warwick

(1986) were first to propose that health anxiety results from

catastrophic interpretations of symptoms, and their early

work led to the concept of HAD. Salkovskis and War-

wick’s (1986) cognitive model of HAD draws from Clark’s

model of panic. For example, a simple skin lesion may

invoke the belief, ‘‘I have skin cancer and am going to die

from it.’’ The tendency to make catastrophic interpretations

of bodily symptoms has been demonstrated in multiple

studies (Hadjistavropoulos et al. 1998; Marcus et al. 2007;

Rief et al. 1998). Salkovskis and Warwick’s original model

has since been expanded into fear of mental illness and has

led to studies specific to HAD (Rachman 2012).

Individuals with HAD overestimate the likelihood that

they have a disease, the gravity of the imagined disease,

and any somatic or psychological indicators of possible

disease (Haenen et al. 2000; Marcus and Church 2003). A

number of factors, including bodily changes, pain, and

intrusive images, may induce the dysfunctional belief and

set off health anxiety.

The role of intrusive images has been studied in HAD in

recent years. Intrusive images may present as memories of

threatening experiences or as imagined future physical or

mental illness. Research shows that intrusive images may

maintain or trigger health anxiety (Muse et al. 2010;

Sherman et al. 1985; Wells and Hackmann 1993), sug-

gesting that they might precipitate catastrophic thinking.

Tang et al. (2007) found a correlation between catastrophic

thoughts and safety behaviors in patients with high health

anxiety, lending additional support to the cognitive theory

of HAD.

Obsessive Compulsive Disorder

Catastrophic interpretation of intrusive thoughts has been

proposed to be a key component of obsessive–compulsive

disorder (OCD). While all individuals experience intru-

sive, unwanted thoughts to some degree, when the

thoughts are exceedingly distressing, persistent, and long

lasting, their significance may be misinterpreted as

catastrophic, and they can turn into abnormal obsessions

(Rachman 1997, 1998; Salkovskis 1985). Thought the

content of the thoughts may be immoral or disturbing,

cognitive models about OCD posit that the interpretation

itself results in preoccupation and excessive worry

(Calkins et al. 2013). Attempting to avoid the thoughts or

neutralize the obsession through compulsive behaviors

may provide temporary relief but ultimately reinforces

the pattern of catastrophic misinterpretation (Rachman

1997).

More recent research has investigated the relationship

between the personal significance an individual attaches to

a thought and their level of distress. Berman et al. (2011,

2012) found that intrusive thoughts involving family

members or friends induced greater distress than thoughts

involving strangers, as did thoughts about harm befalling

vulnerable people such as the weak and elderly. These

empirical findings support Rachman’s (1998) theory that

intrusive thoughts about helpless people are interpreted as

particularly catastrophic.

Thought–action-fusion (TAF) is a cognitive distortion

that has been proposed to explain the relationship between

thoughts and actions in OCD. Both TAF moral, the belief

that immoral thoughts are equivalent to unacceptable ac-

tions, and TAF likelihood, the belief that thinking about a

catastrophic event can cause it to happen, have been

explored as integral components of catastrophic misinter-

pretation in individuals with OCD (Shafran et al. 1996;

Berle and Starcevic 2005). While more research is needed

on how TAF beliefs differ across circumstances, current

research points to this construct as an important target for

intervention in OCD and other anxiety disorders (Thomp-

son-Hollands et al. 2013).

Posttraumatic Stress Disorder

Research suggests that catastrophic beliefs contribute to

stress disorders. The catastrophic belief in PTSD centers on

danger of an experienced traumatic event reoccurring.

Someone who was previously exposed to a bombing might

hear a car backfire, and his catastrophic belief would be,

‘‘A bomb just went off and I am in danger.’’ Ehlers and

Clark’s model (2000) of traumatic response proposes that

individuals with a maladaptive, or catastrophic, appraisal

of a traumatic event are more likely to overestimate threats

Cogn Ther Res (2016) 40:441–452 443

123

of present and future harm. They posit that a number of

negative appraisals, including those about PTSD symp-

toms, one’s own behavior and emotions, and others’

reaction to the traumatic event, contribute to the mainte-

nance of PTSD. This conclusion has been supported by a

number of correlational studies (Clohessy and Ehlers 1999;

Dunmore et al. 1999; Steil and Ehlers 2000).

In the past 10 years, several studies examined the pre-

dictive nature of catastrophic thought (Dunmore et al.

1999; Ehlers et al. 1998). Bryant and Guthrie’s (2005)

study was one of the first to find that catastrophic thinking

prior to trauma exposure predicted posttraumatic stress.

The authors found that trainee firefighters, assessed prior to

beginning active duty and 6 months in, were more likely to

develop posttraumatic stress if they displayed catastrophic

thinking at initial assessment. In particular, maladaptive

self-appraisals strongly predicted firefighters’ posttrau-

matic stress (Bryant and Guthrie 2005), a finding supported

in a follow-up study on the same sample (Bryant and

Guthrie 2007).

Terrorist attacks provide sobering yet unique opportu-

nities to study the impact of trauma on populations that

have not been self-selected. Unlike firefighters or soldiers,

who may have similar personality traits or backgrounds

that lead them to their professions, the individuals affec-

ted by terrorist attacks or natural disasters are usually a

representative sample of the general population. The 2013

Boston Marathon bombing and subsequent lockdown

affected Boston residents from all backgrounds: Some

were at the finish line when the bombs went off; others

could not return home; yet others were those who wat-

ched the grisly events replayed on TV and on social

media for weeks after.

In a recent study stemming from the bombings

(McLaughlin et al. 2014), researchers re-contacted Boston-

area adolescents who had participated in an fMRI study

2 years prior to the attack and asked them to complete a

survey measuring PTSD symptoms. A strong association

was found between catastrophizing measured by the Cog-

nitive Emotion Regulation Questionnaire (CERQ)

(Garnefski et al. 2001) 2 years prior to the Boston Mara-

thon attack and onset of PTSD symptoms after the attack, a

relationship that was not attenuated after controlling for

age, gender, or pre-attack anxiety (K. McLaughlin, per-

sonal communication, July 23, 2014). These findings sug-

gest catastrophic thinking may represent a vulnerability to

developing PTSD symptoms. Additionally, results indicate

that the CERQ is a reliable and valid scale that can be used

to measure catastrophizing and identify individuals who, if

untreated, are likely to experience symptoms of emotional

problems when exposed to adverse events.

Pain

The relationship between pain and catastrophic beliefs has

been well documented in a number of studies. Catastrophic

thinking in the context of pain has been defined as ‘‘an

exaggerated negative orientation toward pain stimuli and

pain experience’’ (Spevak and Buckenmaier 2011) and can

lead to increased pain, considerable psychological distress,

and reduced functioning. Although consensus has yet to be

reached on a theoretical framework for the relationship

between catastrophizing and pain, several cognitive models

have been proposed. Vlaeyen et al. (1995) proposed a

cognitive-behavioral model of fear avoidance that has been

supported by a number of studies. In chronic pain patients,

a catastrophic belief might be, ‘‘This pain is so intense and

crippling that it is unsafe for me to move.’’ Catastrophic

thinking plays a key role in Vlaeyen et al.’s model as the

juncture at which patients either enter a cycle of catastro-

phizing, in which they avoid movement and subsequently

end up in greater pain, or do not catastrophize, confronting

the feared stimulus and eventually healing.

Buer and Linton (2002) found support for Vlaeyen and

Linton’s (2000) model in a study on back pain and activ-

ities of daily living in the general population. Results

indicated that catastrophizing and fear-avoidance were

present in the non-chronic population and that higher levels

of pain were related to higher levels of catastrophizing.

Other studies (McCracken and Gross 1993; Woby et al.

2004) also found associations between catastrophizing and

fear-avoidance beliefs, lending additional support to

Vlaeyen and Linton’s fear-avoidance model.

Winterowd et al. (2003) propose a cognitive model of

pain that implicates negative thoughts, images, and beliefs

as both exacerbating pain and resulting from pain. They

identify catastrophic thinking, or jumping to conclusions,

as one of nine cognitive distortions contributing to the

maintenance of pain. Sullivan et al. (2001) discuss a

number of other potential models of the relation between

catastrophic thought and pain, including schema-activation

model, appraisal model, attentional model, and coping

model, in their review of theoretical perspectives. While

these models find varying degrees of support in dozens of

studies on pain and catastrophizing, an overarching theory

of the role of catastrophic beliefs in multiple disorders

would help to clarify the nature of this relationship.

Traumatic Brain Injury

A number of studies have examined the relationship

between traumatic brain injury (TBI) and catastrophic

thinking. In particular, studies demonstrate an association

444 Cogn Ther Res (2016) 40:441–452

123

between TBI and PTSD, indicating that PTSD can develop

after mild traumatic brain injury (MTBI) (Bryant and

Harvey 1998; Greenspan et al. 2006; Harvey and Bryant

2000; Hoge et al. 2008). This relationship has gained

particular importance in recent years due to the number of

returned Iraq and Afghanistan war veterans. Studies of this

population have found that MTBI increases the risk for

psychiatric illness, including PTSD (Fann et al. 2004;

Bryant et al. 2009, 2010; Hoge et al. 2008; Schneiderman

et al. 2008). Several mechanisms to explain this association

have been proposed, including fear conditioning, memory

reconstruction, post-amnesia resolution, neural damage

resulting from TBI, and ongoing stressors (Bryant 2011).

Postconcussive symptoms, which include dizziness,

fatigue, and headaches, may present as a result of an

interaction between PTSD and MTBI (Bryant and Harvey

1999). Bryant (2001) proposed a cognitive model of post-

concussive symptoms, which posits that catastrophic mis-

interpretation of postconcussive symptoms leads to the

same type of cyclical anxiety experienced by patients with

panic disorder. The presence of PTSD may maintain this

cycle, as evidence shows that people with PTSD are likely

to have an attentional bias toward negative experiences,

magnify negative sensations, and have a memory bias that

impairs retrieval of positive experiences (Bryant 2001).

Individuals with MTBI may catastrophically interpret a

headache, believing that the symptom means that their

brain injury is worsening.

Educating troops and veterans about brain damage may

have potentially adverse consequences. Individuals who

are made aware of the symptoms of TBI may become

hypervigilant and catastrophically interpret benign sensa-

tions (Bryant 2011). A similar phenomenon has been

observed in Gulf War veterans, who report more frequent

and more severe symptoms than other war veterans.

However, a medically indicated etiology for the cluster of

symptoms known as Gulf War Syndrome has not been

ascertained. It was speculated that veterans’ exposure to

extensive media coverage about the health hazards unique

to the Gulf War might have caused them to focus on their

symptoms and interpret them catastrophically (Iversen

et al. 2007).

A Synthesis

Review of the current literature indicates that catastrophic

beliefs confer predisposition to pathological disorders and

are an essential ingredient of the development and main-

tenance of the catastrophic cycle, as they bias information

processing. Drawing on the various studies in which some

aspects of catastrophic biasing have been reported, we

propose the following components contributing to this

problem: catastrophic beliefs, interpretive bias, attentional

bias, attentional fixation, and anxiety. These components

interact bi-directionally to sustain the catastrophic cycle.

Our cognitive model of the catastrophic cycle is presented

in Fig. 1.

When catastrophic beliefs are activated by precipitating

events, they evoke a memory of a previous event. The

memory triggers a catastrophic interpretation of the pre-

cipitating event and shapes the behavioral and affective

response, producing a vicious cycle. As the cycle is bi-

directional and self-sustaining, a catastrophic belief is not

the only possible precipitant. A memory that evokes a

catastrophic belief may also set off the cycle, offering

another potential point of intervention. The cycle, while

essentially following the same progression in a number of

disorders, may manifest differently depending on the dis-

order, each of which involves a unique type of belief. In the

case of panic, the cycle could be activated by an event that

leads to physical sensations interpreted to be threatening to

the individual’s health. For example, the precipitating

event might be hearing that a friend has passed away. The

shock of this news may cause heart palpitations. For an

individual with panic disorder, a characteristic catastrophic

belief about this somatic sensation might be, ‘‘My heart is

beating fast because I am having a heart attack.’’ Thus, the

catastrophic belief translates the symptom of heart palpi-

tations into a severe catastrophic event believed to have

adverse consequences. Following this interpretation, the

individual focuses attention on the palpitations. At the

same time, the individual experiences anxiety about the

palpitations and focuses attention on that anxiety, as well

as the belief; in this case, ‘‘I could be dying.’’ Immediately,

the self-focus on the palpitations, anxiety, and belief

occupies all cognitive processing so that the individual is

unable to access any corrective information to reappraise

the situation. Very quickly, the whole cycle escalates with

the experience of anxiety becoming the prominent feature,

as catastrophic interpretation of escalating anxiety symp-

toms fuels the anxiety and makes the palpitations stronger.

In individuals with panic disorder, this progression of the

catastrophic cycle may culminate in a full-blown panic

attack.

Safety-seeking behaviors become a very salient feature

in maintenance of the cycle. The individual who fears he is

having a heart attack might lie down in an attempt to avoid

the feared catastrophe. When the heart attack fails to occur,

he attributes this outcome to the avoidance behavior of

lying down. Thus, safety-seeking and avoidance behaviors

maintain the catastrophic cycle by reinforcing individuals’

beliefs that their feared catastrophes would have occurred

but for their avoidance behaviors.

In various disorders, different events set off the cycle.

Physical sensations are common precipitants in several

Cogn Ther Res (2016) 40:441–452 445

123

disorders. In addition to heart palpitations, dizziness,

shortness of breath, chest pain, and feeling faint are

somatic sensations that may set the stage for a panic attack.

For individuals with health anxiety, unusual body sensa-

tions are events that initiate the cycle. People with MTBI

may experience postconcussive symptoms, including

dizziness, fatigue, and headaches, which invoke their

catastrophic beliefs and spark the cycle. For predisposed

individuals, the simple experience of chronic pain may set

off the cycle.

In PTSD, external events are major activators of the

cycle. Individuals who have experienced disasters in the

surrounding environment become hypervigilant to envi-

ronmental cues that may be threatening. The disasters

may be single highly traumatic events such as the Boston

Marathon terrorist attack, the Omagh, Northern Ireland

car bombing, or the Pipe Alpha oil platform disaster, or a

series of stressful, traumatic situations experienced over a

period of time, such as combat exposure in soldiers and

emergency response by firefighters. For these individuals,

external events that trigger the catastrophic cycle could be

returning to the scene of the trauma, seeing images, or

reading text that recalls the trauma, or encountering

sensations such as smells or sounds that are similar to

those experienced at the time of the trauma. Internal,

somatic sensations may also be triggers for individuals

with PTSD.

In any disorder, once catastrophic beliefs are activated

by the event, disturbances in cognitive processing may

occur at any phase of the cycle. Individuals may demon-

strate attentional bias to the precipitating event, the

symptom, the anxiety, or all of these components. Conse-

quently, attentional fixation can occur at each of these

points as well. Because each construct of the model

interacts with the others to perpetuate the catastrophic

cycle, intervention at any of the stages can be effective

depending the individual.

Discussion

Catastrophic cognition is characteristic of a wide variety of

disorders, including anxiety disorders, PTSD, pain, and

physical disability, among others. The current literature

and research on catastrophic thinking provides support for

its role as both a correlate and predictor of many disorders.

Taken together, the body of work supports catastrophic

thinking as a transdiagnostic phenomenon we propose be

recognized as a clinically and scientifically useful global

construct for understanding multiple disorders.

Given its ubiquity, catastrophizing is a valuable marker

for different disorders and has important implications for

diagnosis and treatment. We suggest that catastrophic

thinking shows commonality as a mechanism across many

disorders and recommend approaching treatment accord-

ingly. It is important, however, to recognize that the content

of the beliefs varies among the disorders. We suggest that

treatment approaches address the unique content of each

disorder as well as the process of catastrophic thinking.

Many of the conditions discussed here have been treated

with psychotherapy, and results by and large have been

positive with significant improvements. Since these inter-

ventions are based on the theoretical constructs of catas-

trophizing, the success of the interventions provides quasi-

experimental evidence for the validity of the construct.

Precipitating event

Catastrophic beliefs

Interpretive bias

Attentional bias

Attentional fixation

Anxiety/somatic symptoms

Fig. 1 A cognitive model of catastrophic beliefs. Precipitating event

We propose that the catastrophic cycle is initiated by a precipitating

event that can be either external, such as an accident or terrorist

attack, or internal, such as pain or shortness of breath. Catastrophic

beliefs The event activates catastrophic beliefs. Individuals with

catastrophic beliefs exaggerate the potential negative consequences of

an event and imagine the worst possible outcome (Clark 1986).

Individuals who hold catastrophic beliefs believe the event to be more

threatening than it actually is, setting off a cycle that reinforces these

exaggerated beliefs. Interpretive bias An interpretive bias results

from the catastrophic beliefs and causes the individuals to interpret

neutral situations and events in negative ways (Beck and Greenberg

1984; Beck and Clark 1997; Clark 1986). We propose that the

interpretive bias results from individuals’ catastrophic beliefs.

Attentional bias Because the precipitating event is interpreted

catastrophically, the individual displays an attentional bias, a

disturbance in processing characterized by excessive attention to

potentially threatening information (MacLeod et al. 1986). Atten-

tional fixation We hypothesize that attentional fixation, described by

Beck (1988) as a disturbance in processing that leads to an inability to

reappraise dysfunctional cognitions, maintains and fuels the cycle.

Anxiety/somatic symptoms Finally, anxiety and somatic symptoms

play a critical role in the cycle. Symptoms such as shortness of breath,

chest pain, dizziness, or feeling out of control of the situation are

interpreted catastrophically, setting off the cycle once again

446 Cogn Ther Res (2016) 40:441–452

123

Nomenclature

Hofmann (2014) has proposed a model using the principles

of the research diagnostic criteria (RDoC), which has been

suggested as an alternative diagnostic scheme to the DSM-

V. Hofmann’s cognitive behavioral framework for classi-

fication is based on cognitive theory and includes a variety

of cognitive structures such as maladaptive schemas and

attentional processes, among others. We suggest that

catastrophic beliefs could be included in such a diagnostic

scheme since they fit the criteria of dysfunctional belief

schemas.

Prediction

Identifying individuals who hold catastrophic beliefs is an

important first step in interrupting the catastrophic cycle.

This approach is especially relevant to individuals who

work in high-risk environments and are likely to be

exposed to traumatic situations, such as firefighters,

emergency responders, soldiers, and oil rig workers. Once

vulnerable individuals are identified through a screening

device for catastrophic beliefs, we suggest they receive

preventive care that helps them de-catastrophize prior to

trauma exposure.

Prevention

Receiving preventive care may be an important consider-

ation for individuals who have been identified as vulnera-

ble to catastrophizing by a screening device such as the

CERQ, particularly if they hold high-risk jobs with likely

exposure to stressors. Preventive approaches range from

large-scale psychoeducational campaigns about catas-

trophic cognitions to training programs created specifically

for people who are entering occupations with high risk of

exposure to traumatic events, such as soldiers. Results from

an evaluation of the U.S. Army Master Resilience Trainer

(MRT) course (Reivich et al. 2011), which teaches resi-

lience-building skills to soldiers, indicate that the training

had a small but significant effect on reducing catastro-

phizing (Harms et al. 2013). While more research needs to

be done in this area, preventive programs targeting catas-

trophic thinking for other populations or individuals

entering dangerous situations may be developed in a sim-

ilar vein.

Preventive programs for individuals coping with pain

may benefit multiple populations. A mounting body of

evidence indicates that catastrophic beliefs are a key pre-

dictor of pain experience (Geisser et al. 2000; Sullivan

et al. 2001). Catastrophic beliefs have been found to predict

low back pain (Picavet et al. 2002), depression (Martin and

Dahlen 2005), disability and increased likelihood of

unemployment (Geisser and Roth 1998; Sullivan et al.

1998), and postoperative pain (Granot and Ferber 2005;

Pavlin et al. 2005). These predictive studies have impli-

cations for prevention. Picavet et al. (2002) suggest that

education is key in reducing catastrophic cognitions, either

on a smaller, individual scale, or on a larger, public health

scale. A population-based Australian media campaign on

low back pain prevention (Buchbinder et al. 2001) yielded

positive results for patients and doctors, as well a number

of benefits for insurance companies. These results suggest

that education-based prevention programs reduce catas-

trophizing in back pain patients and may be effective for

catastrophic cognitions in other disorders as well.

Treatment

Identifying individuals who hold catastrophic beliefs and

providing preventive care before they get into situations

that activate their catastrophic beliefs is ideal. However,

many people who have mental disorders that have devel-

oped or worsened in part due to their catastrophic beliefs

identify these beliefs as problematic only once they seek

treatment. Fortunately, a number of therapeutic applica-

tions have been proposed to counter catastrophic attitudes,

and they may be considered for intervention at any stage of

the cycle.

Multiple psychotherapeutic treatments have been

described for individuals with disorders in which catas-

trophic beliefs are implicated. Though different psy-

chotherapies may be best suited to particular populations,

the therapeutic relationship plays a critical role in treatment

outcome regardless of the approach taken (Beck 1976).

Establishing a strong relationship at the outset of therapy

and fostering a safe environment is key for individuals with

catastrophic beliefs, as the beliefs often involve perceived

threat to one’s safety. Therapists must be cognizant of the

individuals’ beliefs systems from the beginning of therapy

and throughout, validating their thoughts while facilitating

change.

While therapeutic techniques to address catastrophic

thinking can differ depending on the disorder, the crux of

the modification rests on learning or unlearning beliefs and

behaviors that sustain the catastrophic cycle. The two

major approaches are implicit, or reflexive, learning; and

explicit, or reflective, learning. A number of techniques

have been developed to facilitate both types of learning.

Implicit learning is best engendered through experiential

methods, such as exposure therapy. Explicit learning relies

on more conscious techniques, such as cognitive restruc-

turing. As evidenced by the current literature, different

approaches work best for different disorders. Once a ther-

apist has ascertained that their client engages in catas-

trophic thinking, they can begin to work on the problem

Cogn Ther Res (2016) 40:441–452 447

123

using implicit or explicit approaches derived from the

evidence base. Behavioral experiments utilize both implicit

and explicit approaches by couching exposure therapy in

an explicit framework that leads to an awareness of

catastrophic interpretations, and ultimately, provides tools

to reduce symptoms.

‘‘Decatastrophizing,’’ developed specifically to target

catastrophic beliefs, has been widely described as an

effective therapeutic cognitive intervention (Beck et al.

2005; Clark and Beck 2011; Vasey and Borkovec 1992)

that targets catastrophic beliefs and falls into the combined

implicit and explicit learning category. This process, which

exposes clients to their feared outcomes and offers coping

strategies, can be used to intervene in the catastrophic cycle

at its outset, when an individual’s catastrophic beliefs

activate the cycle. Using the inhibitory learning model of

extinction may be especially effective, as it targets mech-

anisms involved with expectancy processing that evidence

shows are affected in individuals with anxiety and pain

disorders (Rief et al. 2015). By utilizing exposures that

maximally violate the client’s expectancies about aversive

outcomes, deeper inhibitory learning takes place, facili-

tating memory consolidation (Craske et al. 2014). Even-

tually, the client’s catastrophic belief about an event will be

changed through a combination of cognitive and inhibitory

learning that targets inflated expectancies about catas-

trophic events.

Previously described for use in patients with panic dis-

order (Clark and Beck 2011), symptom induction exercises

may also help individuals with other disorders reduce

catastrophic beliefs about somatic symptoms of anxiety.

With the therapist present, the client induces symptoms of

panic that are typically catastrophically misinterpreted, and

instead of engaging in avoidance or safety behaviors,

endures the symptoms and learns that the internal sensa-

tions do not lead to disaster. These exercises, which

facilitate implicit learning through not reacting to symp-

toms and explicit learning through discussion of the tech-

nique with the therapist, are repeated throughout therapy.

Eventually, this intervention lead to a weakening of the

client’s catastrophic misinterpretations of somatic sensa-

tions, interrupting the catastrophic cycle at the stage in

which anxiety symptoms fuel the cycle.

Reappraisal is another strategy that can be taught in

psychotherapy to halt the catastrophic cycle. Hofmann

et al. (2013) describe cognitive reappraisal as ‘‘an adaptive

antecedent-focused emotion-regulation strategy’’ that when

used prevents an emotional response from being fully

activated. For example, a patient may have experienced a

panic attack associated with cognitions such as, ‘‘I am

having a heart attack.’’ A behavioral experiment revealed

that whenever he bent over he experienced some chest pain

due to pressure on his ribcage. He thus was able to

reappraise the symptoms as the pain is due to a sensitivity

of the ribs rather than a heart attack. Results from

McLaughlin et al.’s (2014) study on PTSD symptom onset

following a terrorist attack suggest that that reappraisal

may confer protection against the development of PTSD.

We can extend this finding to other disorders and consider

reappraisal an important explicit strategy akin to cognitive

restructuring that can interrupt the catastrophic cycle at the

attentional fixation stage.

As discussed earlier, intrusive visual images have been

found to play a role in catastrophic cognitions. These

images are often so vivid that individuals may experience

them as if they were actually occurring. Beck (1970)

suggested that images have a profound impact on affect, an

idea substantiated by the literature on the association

between images and feelings in various disorders. When

treating individuals who hold catastrophic beliefs and

report intrusive images, we recommend psychotherapists

consider using imagery-related interventions to modify the

content of the anxiety-inducing images. The strategies that

could be used include both implicit and explicit approa-

ches, such as decatastrophizing the image; gradual shaping

and modification of specific elements of the image; sub-

stituting positive imagery, substituting contrasting imagery,

exaggerating images; or combining these techniques until

the best method for the individual is found (Beck et al.

2005).

Future Research

Evidence has suggested that catastrophic thinking plays a

role in other disorders as well. In psychotic patients,

catastrophic worry is associated with higher levels of

delusional distress (Startup et al. 2007). Studies of anger

have shown that catastrophic thinking is associated with

increased anger and violent outbursts (Beck 1999; Hogg

and Deffenbacher 1986; Zwemer and Deffenbacher 1984).

A randomized control trial by Ludwig and Shah (2014)

emphasized the role of catastrophic thinking in violent

behavior of urban youth. This is also the focus of much

publicized treatment for these individuals. Catastrophic

thinking is has also been reported to be correlated with

irritable bowel syndrome (Drossman 1999; Hunt et al.

2009, 2014). There may be value in exploration of catas-

trophic thinking in a number of other disorders and psy-

chological problems, including depression and suicide

ideation.

Given the extensive literature on the predictive and

correlational value of catastrophic thinking in many dis-

orders, there has been surprisingly little attention paid to

mediation. While individuals have investigated catas-

trophic thought as a mediator in pain (Spinhoven et al.

448 Cogn Ther Res (2016) 40:441–452

123

2004; Turner et al. 2007), further work on mediation fol-

lowing the standards set by Kraemer et al. (2001), which

suggest multiple points of intervention based on careful

analysis of the relationships between latent risk factors,

would be valuable to understanding the causal associations

between catastrophic cognitions and disorders.

Finally, emerging evidence (Swartz et al. 2015;

McLaughlin et al. 2014) that suggests amygdala reactivity

is related to development of internalizing symptoms pro-

vides an important avenue for research investigating the

relationship between physiological and psychological pre-

dictors of symptom onset. While the these studies used

fMRI alone to demonstrate the correlation between

amygdala hyperactivity and symptomatology, future

research may use catastrophizing measures to predict

symptom onset in concert with fMRI and other imaging

procedures in order to gain a more robust understanding of

the biological and cognitive underpinnings of related

disorders.

In summary, the literature reveals that catastrophic

thinking has been demonstrated across a wide variety of

disorders and has been a focal point for prevention and

psychotherapeutic intervention. We propose that catas-

trophic thinking is an essential element in many disorders;

while the content varies according to the nature of the

disorder or problem, the process of catastrophic thinking

is effectively the same for each diagnostic category. Our

cognitive model illustrates the self-perpetuating nature of

the catastrophic cycle and may be used to better under-

stand the factors and cognitive processes underlying

multiple disorders. We have offered recommendations for

prediction, prevention and treatment. Further research is

needed to elucidate the content of catastrophic thinking in

many disorders in order to create prevention and treat-

ment programs that target specific beliefs. This survey of

the literature offers a new lens through which to examine

catastrophic cognitions underlying many disorders.

Compliance with Ethical Standards

Conflict of Interest Resham Gellatly and Aaron T. Beck declare

that they have no conflict of interest.

Ethical Approval This article does not contain any studies with

human participants or animals performed by any of the authors.

References

Amir, N., Foa, E. B., & Coles, M. E. (1998). Automatic activation and

strategic avoidance of threat-relevant information in social

phobia. Journal of Abnormal Psychology, 107(2), 285.

Austin, D. W., & Richards, J. C. (2001). The catastrophic misinter-

pretation model of panic disorder. Behaviour Research and

Therapy, 39(11), 1277–1291.

Beck, A. T. (1963). Thinking and depression: I. Idiosyncratic content

and cognitive distortions. Archives of General Psychiatry, 9(4),

324–333.

Beck, A. T. (1964). Thinking and depression: II. Theory and therapy.

Archives of General Psychiatry, 10(6), 561–571.

Beck, A. T. (1970). Role of fantasies in psychotherapy and

psychopathology. The Journal of Nervous and Mental Disease,

150(1), 3–17.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders.

New York, NY: International Universities Press.

Beck, A. T. (1986). Cognitive approaches to anxiety disorders. In F.

Shaw, Z. V. Segal, T. M. Vallis, & F. E. Cashman (Eds.), Anxiety

disorders: Psychological and biological perspectives (pp.

115–136). New York: Plenum Press.

Beck, A. T. (1988). Cognitive approaches to panic disorder: Theory

and therapy. In S. Rachman & J. D. Maser (Eds.), Panic:

Psychological perspectives (pp. 91–109). Hillsdale, NJ:

Erlbaum.

Beck, A. T. (1999). Prisoners of hate: The cognitive basis of anger,

hostility, and violence. New York: HarperCollins.

Beck, A. T., & Clark, D. A. (1997). An information processing model

of anxiety: Automatic and strategic processes. Behaviour

Research and Therapy, 35(1), 49–58.

Beck, A. T., Emery, G., & Greenberg, R. L. (1985, 2005). Anxiety

disorders and phobias: A cognitive perspective. New York:

Basic Books.

Beck, A. T., & Greenberg, R. L. (1984). Cognitive therapy in the

treatment of depression. In N. Hoffman (Ed.), Foundations of

cognitive therapy (pp. 155–178). New York: Plenum Press.

Belfer, P. L., & Glass, C. R. (1992). Agoraphobic anxiety and fear of

fear: Test of a cognitive-attentional model. Journal of Anxiety

Disorders, 6(2), 133–146.

Berle, D., & Starcevic, V. (2005). Thought–action fusion: Review of

the literature and future directions. Clinical Psychology Review,

25(3), 263–284.

Berman, N. C., Wheaton, M. G., & Abramowitz, J. S. (2012). The

‘‘Arnold Schwarzenegger Effect’’: Is strength of the ‘‘victim’’

related to misinterpretations of harm intrusions? Behaviour

Research and Therapy, 50(12), 761–766.

Berman, N. C., Wheaton, M. G., Fabricant, L. E., Jacobson, S. R., &

Abramowitz, J. S. (2011). The effects of familiarity on thought–

action fusion. Behaviour Research and Therapy, 49(10),

695–699.

Bryant, R. A. (2001). Posttraumatic stress disorder and mild brain

injury: Controversies, causes and consequences. Journal of

Clinical and Experimental Neuropsychology, 23(6), 718–728.

Bryant, R. (2011). Post-traumatic stress disorder vs traumatic brain

injury. Dialogues in Clinical Neuroscience, 13(3), 251.

Bryant, R. A., Creamer, M., O’Donnell, M., Silove, D., Clark, C. R.,

& McFarlane, A. C. (2009). Post-traumatic amnesia and the

nature of post-traumatic stress disorder after mild traumatic brain

injury. Journal of the International Neuropsychological Society,

15(06), 862–867.

Bryant, R. A., & Guthrie, R. M. (2005). Maladaptive appraisals as a

risk factor for posttraumatic stress: A study of trainee firefight-

ers. Psychological Science, 16(10), 749–752.

Bryant, R. A., & Guthrie, R. M. (2007). Maladaptive self-appraisals

before trauma exposure predict posttraumatic stress disorder.

Journal of Consulting and Clinical Psychology, 75(5), 812.

Bryant, R. A., & Harvey, A. G. (1998). Relationship between acute

stress disorder and posttraumatic stress disorder following mild

traumatic brain injury. American Journal of Psychiatry, 155(5),

625–629.

Bryant, R. A., & Harvey, A. G. (1999). Postconcussive symptoms and

posttraumatic stress disorder after mild traumatic brain injury.

The Journal of Nervous and Mental Disease, 187(5), 302–305.

Cogn Ther Res (2016) 40:441–452 449

123

Bryant, R. A., O’Donnell, M. L., Creamer, M., McFarlane, A. C.,

Clark, C. R., & Silove, D. (2010). The psychiatric sequelae of

traumatic injury. American Journal of Psychiatry, 167(3),

312–320.

Buchbinder, R., Jolley, D., & Wyatt, M. (2001). Population based

intervention to change back pain beliefs and disability: Three

part evaluation. BMJ, 322(7301), 1516–1520.

Buer, N., & Linton, S. J. (2002). Fear-avoidance beliefs and

catastrophizing: Occurrence and risk factor in back pain and

ADL in the general population. Pain, 99(3), 485–491.

Calkins, A. W., Berman, N. C., & Wilhelm, S. (2013). Recent

advances in research on cognition and emotion in OCD: A

review. Current psychiatry reports, 15(5), 1–7.

Clark, D. M. (1986). A cognitive approach to panic. Behaviour

Research and Therapy, 24, 461–470.

Clark, D. M. (1988). A cognitive approach to panic. In S. Rachman &

J. D. Maser (Eds.), Panic: Psychological perspectives (pp.

71–89). Hillsdale, NJ: Erlbaum.

Clark, D. M., & Beck, A. T. (1988). Cognitive approaches. In C. Last

& M. Hersen (Eds.), Handbook of anxiety disorders (pp.

362–385). New York: Pergamon.

Clark, D. A., & Beck, A. T. (2011). Cognitive therapy of anxiety

disorders: Science and practice. New York: Guilford Press.

Clark, D. M., & McManus, F. (2002). Information processing in

social phobia. Biological Psychiatry, 51(1), 92–100.

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia.

In R. G. Heimberg (Ed.), Social phobia: Diagnosis, assessment,

and treatment (pp. 69–93). New York: Guilford Press.

Clohessy, S., & Ehlers, A. (1999). PTSD symptoms, response to

intrusive memories and coping in ambulance service workers.

British Journal of Clinical Psychology, 38(3), 251–265.

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet,

B. (2014). Maximizing exposure therapy: An inhibitory learning

approach. Behaviour Research and Therapy, 58, 10–23.

Day, S., Holmes, E., & Hackmann, A. (2004). Occurrence of imagery

and its link with early memories in agoraphobia. Memory, 12(4),

416–427.

Drossman, D. A. (1999). Do psychosocial factors define symptom

severity and patient status in irritable bowel syndrome? The

American Journal of Medicine, 107(5), 41–50.

Dunmore, E., Clark, D. M., & Ehlers, A. (1999). Cognitive factors

involved in the onset and maintenance of posttraumatic stress

disorder (PTSD) after physical or sexual assault. Behaviour

Research and Therapy, 37(9), 809–829.

Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttrau-

matic stress disorder. Behaviour Research and Therapy, 38(4),

319–345.

Ehlers, A., Clark, D. M., Dunmore, E., Jaycox, L., Meadows, E., &

Foa, E. B. (1998). Predicting response to exposure treatment in

PTSD: The role of mental defeat and alienation. Journal of

Traumatic Stress, 11(3), 457–471.

Ellis, A. (1962). Reason and emotion in psychotherapy. Oxford: Lyle

Stuart.

Ellis, A., & Harper, R. A. (1975). A new guide to rational living.

Englewood Cliffs, NJ: Prentice-Hall.

Fann, J. R., Burington, B., Leonetti, A., Jaffe, K., Katon, W. J.,

& Thompson, R. S. (2004). Psychiatric illness following

traumatic brain injury in an adult health maintenance

organization population. Archives of General Psychiatry,

61(1), 53–61.

Garnefski, N., Kraaij, V., & Spinhoven, P. (2001). Negative life

events, cognitive emotion regulation and emotional problems.

Personality and Individual Differences, 30(8), 1311–1327.

Geisser, M. E., Robinson, M. E., & Riley, J. L, I. I. I. (2000). Pain

beliefs, coping, and adjustment to chronic pain: Let’s focus more

on the negative. Pain Forum, 8(4), 161–168.

Geisser, M. E., & Roth, R. S. (1998). Knowledge of and agreement

with chronic pain diagnosis: Relation to affective distress, pain

beliefs and coping, pain intensity, and disability. Journal of

Occupational Rehabilitation, 8(1), 73–88.

Goldstein, A. J., & Chambless, D. L. (1978). A reanalysis of

agoraphobia. Behavior Therapy, 9(1), 47–59.

Granot, M., & Ferber, S. G. (2005). The roles of pain catastrophizing

and anxiety in the prediction of postoperative pain intensity: A

prospective study. The Clinical Journal of Pain, 21(5), 439–445.

Greenberg, R. L. (1988). Panic disorder and agoraphobia. In J. M. G.

Williams & A. T. Beck (Eds.), Cognitive therapy in clinical

practice: An illustrative casebook (pp. 25–49). London:

Routledge.

Greenspan, A. I., Stringer, A. Y., Phillips, V. L., Hammond, F. M., &

Goldstein, F. C. (2006). Symptoms of post-traumatic stress:

Intrusion and avoidance 6 and 12 months after TBI. Brain

Injury, 20(7), 733–742.

Hadjistavropoulos, H. D., Craig, K. D., & Hadjistavropoulos, T.

(1998). Cognitive and behavioral responses to illness informa-

tion: The role of health anxiety. Behaviour Research and

Therapy, 36(2), 149–164.

Haenen, M. A., de Jong, P. J., Schmidt, A. J., Stevens, S., & Visser, L.

(2000). Hypochondriacs’ estimation of negative outcomes:

Domain-specificity and responsiveness to reassuring and alarm-

ing information. Behaviour Research and Therapy, 38(8),

819–833.

Harms, P. D., Herian, M. N., Krasikova, D. V., Vanhove, A., &

Lester, P. B. (2013). The comprehensive soldier and family

fitness program evaluation report# 4: Evaluation of resilience

training and mental and behavioral health outcomes. United

States Army Comprehensive Soldier Fitness Program. Monter-

rey, CA: Office of the Deputy Under Secretary of the Army.

Harvey, A. G., & Bryant, R. A. (2000). Two-year prospective

evaluation of the relationship between acute stress disorder and

posttraumatic stress disorder following mild traumatic brain

injury. American Journal of Psychiatry, 157(4), 626–628.

Harvey, J. M., Richards, J. C., Dziadosz, T., & Swindell, A. (1993).

Misinterpretation of ambiguous stimuli in panic disorder.

Cognitive Therapy and Research, 17(3), 235–248.

Hofmann, S. G. (2005). Perception of control over anxiety mediates

the relation between catastrophic thinking and social anxiety in

social phobia. Behaviour Research and Therapy, 43(7),

885–895.

Hofmann, S. G. (2014). Toward a cognitive-behavioral classification

system for mental disorders. Behavior Therapy, 45(4), 576–587.

Hofmann, S. G., Asmundson, G. J., & Beck, A. T. (2013). The science

of cognitive therapy. Behavior Therapy, 44(2), 199–212.

Hofmann, S. G., & Barlow, D. H. (2002). Social phobia (social

anxiety disorder). In D. H. Barlow (Ed.), Anxiety and its

disorders: The nature and treatment of anxiety and panic (pp.

454–476). New York: Guilford Press.

Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., &

Castro, C. A. (2008). Mild traumatic brain injury in US soldiers

returning from Iraq. New England Journal of Medicine, 358(5),

453–463.

Hogg, J. A., & Deffenbacher, J. L. (1986). Irrational beliefs,

depression, and anger among college students. Journal of

College Student Personnel, 27(4), 349–353.

Hunt, M. G., Ertel, E., Coello, J. A., & Rodriguez, L. (2014).

Development and validation of the GI-Cognitions Questionnaire.

Cognitive Therapy and Research, 38(4), 472–482.

Hunt, M. G., Milonova, M., & Moshier, S. (2009). Catastrophizing

the consequences of gastrointestinal symptoms in irritable bowel

syndrome. Journal of Cognitive Psychotherapy, 23(2), 160–173.

Ingram, R. E., & Kendall, P. C. (1987). The cognitive side of anxiety.

Cognitive Therapy and Research, 11(5), 523–536.

450 Cogn Ther Res (2016) 40:441–452

123

Iversen, A., Chalder, T., & Wessely, S. (2007). Gulf War illness:

Lessons from medically unexplained symptoms. Clinical Psy-

chology Review, 27(7), 842–854.

Khawaja, N. G., & Oei, T. P. S. (1992). Development of a

catastrophic cognition questionnaire. Journal of Anxiety Disor-

ders, 6, 305–318.

Kraemer, H. C., Stice, E., Kazdin, A., Offord, D., & Kupfer, D.

(2001). How do risk factors work together? Mediators, moder-

ators, and independent, overlapping, and proxy risk factors.

American Journal of Psychiatry, 158(6), 848–856.

Ludwig, J., & Shah, A. (2014). Think before you act: A new approach

to preventing youth violence and dropout. The Hamilton Project.

MacLeod, C., Mathews, A., & Tata, P. (1986). Attentional bias in

emotional disorders. Journal of Abnormal Psychology, 95(1), 15.

Marcus, D. K., & Church, S. E. (2003). Are dysfunctional beliefs

about illness unique to hypochondriasis? Journal of Psychoso-

matic Research, 54(6), 543–547.

Marcus, D. K., Gurley, J. R., Marchi, M. M., & Bauer, C. (2007).

Cognitive and perceptual variables in hypochondriasis and health

anxiety: A systematic review. Clinical Psychology Review,

27(2), 127–139.

Martin, R. C., & Dahlen, E. R. (2005). Cognitive emotion regulation

in the prediction of depression, anxiety, stress, and anger.

Personality and Individual Differences, 39(7), 1249–1260.

McCracken, L. M., & Gross, R. T. (1993). Does anxiety affect coping

with chronic pain? The Clinical Journal of Pain, 9(4), 253–259.

McLaughlin, K. A., Busso, D. S., Duys, A., Green, J. G., Alves, S.,

Way, M., & Sheridan, M. A. (2014). Amygdala response to

negative stimuli predicts PTSD symptom onset following a

terrorist attack. Depression and Anxiety, 31(10), 834–842.

McNally, R. J. (1990). Psychological approaches to panic disorder: A

review. Psychological Bulletin, 108(3), 403–419.

Merckelbach, H., de Jong, P. J., Muris, P., & van Den Hout, M. A.

(1996). The etiology of specific phobias: A review. Clinical

Psychology Review, 16(4), 337–361.

Muse, K., McManus, F., Hackmann, A., Williams, M., & Williams,

M. (2010). Intrusive imagery in severe health anxiety: Preva-

lence, nature and links with memories and maintenance cycles.

Behaviour Research and Therapy, 48(8), 792–798.

Ottaviani, R., & Beck, A. T. (1987). Cognitive aspects of panic

disorders. Journal of Anxiety Disorders, 1(1), 15–28.

Pavlin, D. J., Sullivan, M. J., Freund, P. R., & Roesen, K. (2005).

Catastrophizing: A risk factor for postsurgical pain. The Clinical

Journal of Pain, 21(1), 83–90.

Picavet, H. S. J., Vlaeyen, J. W., & Schouten, J. S. (2002). Pain

catastrophizing and kinesiophobia: Predictors of chronic low

back pain. American Journal of Epidemiology, 156(11),

1028–1034.

Rachman, S. (1997). A cognitive theory of obsessions. Behaviour

Research and Therapy, 35(9), 793–802.

Rachman, S. (1998). A cognitive theory of obsessions: Elaborations.

Behaviour Research and Therapy, 36(4), 385–401.

Rachman, S. (2012). Health anxiety disorders: A cognitive construal.

Behaviour Research and Therapy, 50(7), 502–512.

Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral

model of anxiety in social phobia. Behaviour Research and

Therapy, 35(8), 741–756.

Reivich, K. J., Seligman, M. E., & McBride, S. (2011). Master

resilience training in the US Army. American Psychologist,

66(1), 25–34.

Richards, J. C., Austin, D. A., & Alvarenga, M. E. (2001).

Interpretation of ambiguous interoceptive stimuli in panic

disorder and non-clinical panic. Cognitive Research and Ther-

apy, 25(3), 235–246.

Rief, W., Glombiewski, J. A., Gollwitzer, M., Schubo, A., Schwart-

ing, R., & Thorwart, A. (2015). Expectancies as core features of

mental disorders. Current Opinion in Psychiatry, 28(5),

378–385.

Rief, W., Hiller, W., & Margraf, J. (1998). Cognitive aspects of

hypochondriasis and the somatization syndrome. Journal of

Abnormal Psychology, 107(4), 587.

Salkovskis, P. M. (1985). Obsessional-compulsive problems: A

cognitive-behavioural analysis. Behaviour Research and Ther-

apy, 23(5), 571–583.

Salkovskis, P. M., & Warwick, H. (1986). Morbid preoccupations,

health anxiety and reassurance: A cognitive-behavioural

approach to hypochondriasis. Behaviour Research and Therapy,

24(5), 597–602.

Schneiderman, A. I., Braver, E. R., & Kang, H. K. (2008).

Understanding sequelae of injury mechanisms and mild trau-

matic brain injury incurred during the conflicts in Iraq and

Afghanistan: Persistent postconcussive symptoms and posttrau-

matic stress disorder. American Journal of Epidemiology,

167(12), 1446–1452.

Shafran, R., Thordarson, D. S., & Rachman, S. (1996). Thought–

action fusion in obsessive compulsive disorder. Journal of

Anxiety Disorders, 10(5), 379–391.

Sherman, S. J., Cialdini, R. B., Schwartzman, D. F., & Reynolds, K. D.

(1985). Imagining can heighten or lower the perceived likelihood

of contracting a disease the mediating effect of ease of imagery.

Personality and Social Psychology Bulletin, 11(1), 118–127.

Sokol-Kessler, L., & Beck, A. T. (1987). Cognitive treatment of panic

disorder. Paper presented at American Psychiatric Association,

Chicago, IL.

Spevak, C., & Buckenmaier, C, I. I. I. (2011). Catastrophizing and

pain in military personnel. Current Pain and Headache Reports,

15(2), 124–128.

Spinhoven, P., Kuile, M., Kole-Snijders, A. M., Mansfeld, M. H.,

Ouden, D. J., & Vlaeyen, J. W. (2004). Catastrophizing and

internal pain control as mediators of outcome in the multidis-

ciplinary treatment of chronic low back pain. European Journal

of Pain, 8(3), 211–219.

Startup, H., Freeman, D., & Garety, P. A. (2007). Persecutory

delusions and catastrophic worry in psychosis: Developing the

understanding of delusion distress and persistence. Behaviour

Research and Therapy, 45(3), 523–537.

Steil, R., & Ehlers, A. (2000). Dysfunctional meaning of posttrau-

matic intrusions in chronic PTSD. Behaviour Research and

Therapy, 38(6), 537–558.

Stopa, L., & Clark, D. M. (2000). Social phobia and interpretation of

social events. Behaviour Research and Therapy, 38(3), 273–283.

Sullivan, M. J., Stanish, W., Waite, H., Sullivan, M., & Tripp, D. A.

(1998). Catastrophizing, pain, and disability in patients with soft-

tissue injuries. Pain, 77(3), 253–260.

Sullivan, M. J., Thorn, B., Haythornthwaite, J. A., Keefe, F., Martin,

M., Bradley, L. A., & Lefebvre, J. C. (2001). Theoretical

perspectives on the relation between catastrophizing and pain.

The Clinical Journal of Pain, 17(1), 52–64.

Swartz, J. R., Knodt, A. R., Radtke, S. R., & Hariri, A. R. (2015). A

neural biomarker of psychological vulnerability to future life

stress. Neuron, 85(3), 505–511.

Tang, N. K., Salkovskis, P. M., Poplavskaya, E., Wright, K. J., Hanna,

M., & Hester, J. (2007). Increased use of safety-seeking

behaviors in chronic back pain patients with high health anxiety.

Behaviour Research and Therapy, 45(12), 2821–2835.

Thompson-Hollands, J., Farchione, T. J., & Barlow, D. H. (2013).

Thought–action fusion across anxiety disorder diagnoses: Speci-

ficity and treatment effects. The Journal of Nervous and Mental

Disease, 201(5), 407.

Turner, J. A., Holtzman, S., & Mancl, L. (2007). Mediators,

moderators, and predictors of therapeutic change in cognitive–

behavioral therapy for chronic pain. Pain, 127(3), 276–286.

Cogn Ther Res (2016) 40:441–452 451

123

Vasey, M. W., & Borkovec, T. D. (1992). A catastrophizing

assessment of worrisome thoughts. Cognitive Therapy and

Research, 16(5), 505–520.

Vlaeyen, J. W., Kole-Snijders, A. M., Boeren, R. G., & Van Eek, H.

(1995). Fear of movement/(re) injury in chronic low back pain

and its relation to behavioral performance. Pain, 62(3), 363–372.

Vlaeyen, J. W., & Linton, S. J. (2000). Fear-avoidance and its

consequences in chronic musculoskeletal pain: A state of the art.

Pain, 85(3), 317–332.

Wells, A., & Hackmann, A. (1993). Imagery and core beliefs in health

anxiety: Content and origins. Behavioural and Cognitive

Psychotherapy, 21(03), 265–273.

Winterowd, C., Beck, A. T., & Gruener, D. (2003). Cognitive therapy

with chronic pain patients. New York: Springer.

Woby, S. R., Watson, P. J., Roach, N. K., & Urmston, M. (2004).

Adjustment to chronic low back pain—The relative influence of

fear-avoidance beliefs, catastrophizing, and appraisals of control.

Behaviour Research and Therapy, 42(7), 761–774.

Zwemer, W. A., & Deffenbacher, J. L. (1984). Irrational beliefs,

anger, and anxiety. Journal of Counseling Psychology, 31(3),

391.

452 Cogn Ther Res (2016) 40:441–452

123