ARE YOU A CATASTROPHIZER OR MINIMIZER?
The Spectrum of How We Manage Chronic Conditions.
I do a lot of research on hypermobility and work with hypermobile clients. In some cases the cause of hypermobility is an inherited collagen disorder that is a chronic condition. Like many chronic conditions such as fibromyalgia, or chronic fatigue it can be a challenge managing the many symptoms. I am intrigued by the many ways that people react and manage diagnoses of health conditions. If we look at people’s background, psychology, and physiology it starts to become more clear how and why people respond the way they do.
As we all know everyone reacts to challenge differently. For example you’re driving to work and, BAM! you get a flat tire. Ugh! Some throw their arms up in the air and go straight to catastrophe and think, ‘How am I going to get through my day now!’ Whereas there are other folks who are indeed annoyed by their present predicament, but immediately are looking for solutions figuring out ways to make their day still work.
When you are working with clients who are dealing with any sort of health condition it is helpful to know which type of person you have in front of you. How they would react to challenges like the flat tire example above can give you insight as to how they might internalize and perceive a challenging chronic health condition. This knowledge can better enable you to figure out more effective tactics to cater to that person.
In the flat tire example the first person would be considered a catastrophizer which is defined as, “a person who sees adversity or illness as more serious than it actually is.” They might be known as your glass half empty folks. These clients will have comments like; ‘Are you sure that’s not going to hurt?’, ‘Do you think I might have torn it?’, ‘I can’t do that! My neck will flare again!’, or ‘I’ll never run again!’ Instead of asking for alternatives or finding possible routes to getting stronger and better they are immobilized by their diagnosis. I have x condition so I can’t do y. This is one side of the spectrum of how people react when diagnosed with a chronic condition.
On the other end are those that are more in the minimizing category. They tend to ignore their symptoms to a fault. These clients may sound a bit more like this, ‘Well I went on a five mile run, my knee was kind of killing me, but whatever it’s ok.’, as they hobble into the gym. This reaction can be as problematic as your catastrophizers due to the fact that by ignoring their symptoms they often end up injured. So that lovely run or hike that evened out their mood can no longer be done, and it can tailspin them into more symptom flare ups.
Neither of these reactions are ideal so we want to figure out how to steer clients to the middle. Ideally you want to get them to react to that flat tire as a challenge but manageable, in which they can tolerate it and find solutions. It is good to get to a place where the person will recognize and honor their condition, but is always looking for any and all management solutions.
ORIGINS
These different reactions to challenge can often be seeded in an individuals’ background. The catastrophizers can sometimes have pre-existing anxiety and depression. A study was done where researchers were looking at pain, and how the brain processes pain. They had preliminary evidence showing that some people can have an initial painful injury and some of these individuals may have a predisposition to becoming a chronic pain patient from that initial incident based on how their brain works and reacts to pain.(1) One could posit that analogously people may have a predisposition to turn an initial diagnosis into a constant state of complaint and catastrophe. They may be predisposed to view their condition through a depressed and anxious lens. It’s hard to see solutions when someone’s lens is telling them there are no solutions, so why would they even try to find them.
Catastrophizers tend to also have a high ACE number(2). ACE stands for adverse childhood experiences. These experiences are trauma events such as divorce, abuse, neglect, and or death during childhood. Growing up with abusive parents and uncertainty in the home children tend to grow up to be adults with an engrained and habitual tendency to be in an overprotective state. It can be hard for these individuals to focus on opportunity when they have been primed their whole lives to be in a state of hyper vigilance and search for threat instead of safety and solution.
On the other end your minimizers may also have an origin of ACE’s. In this case one of the more predominant childhood experiences might be a history of extreme neglect. These individuals have a tendency to overlook their own care because they were minimally cared for as children. This early childhood neglect can turn into minimizing any and all of their ailments or basic needs as adults. They will be your clients who don’t seem to go to the doctor after a month long ailment, rarely go to regular check-ups, the dentist, and also tend to have poor diet habits. Minimizers won’t be looking for solutions or help because most often they are ignoring the condition all together.
Minimizing can also originate unfortunately from experience with poor medical care. Maya Dusenbery describes this phenomena in her book “Doing Harm”.(3) She specifically talks about women in her book with patient stories in which they go to the doctor with pain and complaints only to be prescribed anti-depressants, and other psychological medication. In these examples these patients actually needed gall bladder surgery, appendectomies, and cancer treatment. Many of the women ended up with near death experiences because of medical disregard. Being ignored so often and disregarded by the medical community can be one of the reasons that people acquiesce, downplay, and minimize their conditions.
Another reason for minimizing can originate from the impact of culture and how, more often with men, there is a pressure to not appear broken or weak and so the habit of minimizing becomes second nature. Many athletes deal with underlying health conditions but will minimize them due to the need to stay on a team to gain a scholarship, or a career might be on the line.
SOLUTIONS: WHAT TO DO
Whether your client is a minimizer or catastrophizer it is best to first address the preexisting conditions of high ACE’s, depression, or anxiety. These issues along with the essentials, or low hanging fruit that everyone needs, such as proper nutrition, quality sleep, and stress management are first priority. Not addressing these essential elements can be the equivalent of people showing up to a race starving with no shoes, or water. They will be ill prepared to properly manage life, much less life with a chronic condition. So finding the right care, medications, and or therapy is important in being prepared at the start line of their daily life. Once these are addressed then they can start moving on to tackling the maintenance strategy of their condition.
To manage these conditions for the catastrophizer you initially want them to redirect their focus in a more positive direction. Obviously different approaches will work with different people. One adage I use sometimes is often taught in skiing or mountain biking. An instructor will advise you to focus and steer towards the clear path you want to take. They will emphasize DO NOT focus on the huge boulder because that is exactly where you will end up if you stare down the big bad boulder. I personally learned this lesson all too well flying through the air and donating some blood to the trail due to the fact I couldn’t stop focusing on all those boulders and bulbous roots. I finally learned the lesson at about the last mile of riding and started to find the clear path.
At the end of this rather painful expedition the lesson started to sink in. I realized that it was a brilliant metaphor for dealing with life’s obstacles and challenges. You need to stop staring at the boulder or condition you have and start focusing in on alternative options, clear paths, and solutions. Eventually you will start to move through life without slamming into several hundred adversities along the way and a clearer less pain ridden path starts to emerge.
For example I had a client that could only focus on her inability to run and the hip that was keeping her from running. Her hip and running were her proverbial boulder in the road. I needed to get her eyeballs off of those and get her to focus on something else that could give her joy and well-being. This may take a bit of probing and asking lots of questions but eventually you will find that other activity that gave them a spark at some point in their life. It might be surfing, hiking, I don’t know maybe line-dancing. For her it was hip-hop dancing. So we looked for classes and found ones that worked with her schedule, and she could also do it at home. While she was taking classes we worked on getting her body and hip stronger. The dancing was giving her variable movement at the hip and any moves that annoyed it she steered clear of. Slowly as she got stronger her outlook looked a bit less gloom and doom and she started to see opportunity.
Once she stopped focusing on all the obstacles or things she couldn’t do she started seeing other options. She took other classes and enjoyed being able to lift more and more weight with her increased strength. Increasingly you will find clients start to be more receptive to alternative solutions that you offer instead of instinctively hitting your ideas out of the park with line drive force. They will start to work with you to figure out how to get more sleep, slowly increase tolerance, and accept alternative exercises. This increase in receptivity will open up their proverbial box and all sorts of options and solutions will drop in. As they find more success being receptive and open instead of always looking for threat it becomes more of a grooved habit that is easier and easier to tap into.
For your minimizers, we again have to deal with low hanging fruit. For them, some of that low hanging fruit will be focusing on their general health check-ups and basic nutrition. Next it is teaching them to pay attention a bit more to their bodies. I have had clients who have walked for 3 months on broken bones, and torn ligaments. In these cases I inform them that their perception of a 5 out of 10 on a pain scale may be more like an 8 or 9 in the average person. I describe to them that their warning lights aren’t calibrated accurately so I encourage them to speak up when they feel a 3 to 5.
For a minimizer I ask them every day and many times within a session how they are feeling. I watch for any sign of wincing. For these guys wincing might be a flicker. They won’t show anything demonstrable, they are really good at hiding their pain or discomfort. Another tell tale sign can be holding their breath which can sometimes just be that it is a hard skill, but it can also mean that they are in pain. Just have them be aware of it and ask them to take note of how they are feeling. Ask them, ‘Can they breath normal?’ and they may have not even noticed, and can continue breathing fine. In general, always be checking in.
WOE IS ME DAYS
Now with both of these types there will be days that I call ‘pity me’ days. They might lament that unlike their friends they can’t stay out late, have drinks, get crap sleep, and still function the next day. So take the days to bitch and moan, but eventually get back on the horse and continue the regimen. The author Laura Zera who contends with her own health issues described her daily regimen, “I must persevere to move through the world without falling down, and my toolbox has grown into a pantry that includes medication, three flavors of therapy, exercise, a careful diet, supplements, blue lights, neurofeedback, acupuncture, and meditation.”
I find this to be a common recipe for folks who have to deal with chronic health conditions. It takes time and patience to habituate to finding that measured and positive response to the hardships that life throws at people. It takes time for people to see clear solutions in front of them instead of brick walls.
With chronic conditions it’s ideal to come to a place of acceptance, trying to learn and appreciate the lessons they can get from the adversity that they deal with everyday. Finding a routine that works helps people cultivate capacity in their body rather than chip away from it. The hope is that with perspective comes strength, and movement becomes a joyful endeavor. It is by no means an easy process, but heading in the right direction starts with the right mindset.
- Mansour, A.R., Farmer, M., Baliki M., Apkarian,(2014) A., Chronic Pain: The Role of Learning and Brain Plasticity. Restor. Neurol. Neuroscience. 32(1):129-139.
- Felitti, V., Anda, R, Nordenberg, D., Willmiamson, D. Spitz, A., Edwards, V., Koss, M., Marks, J., (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. The Adverse Childhood Experiences(ACE) Study. Am. J. Prev. Med. 14(4)”245-258.
- Dusenbery, M. “Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick.”