The way we interact with physical symptoms seems to be linked to how intense they feel, and add to emotional distress and disability. Metacognitive therapy (MCT) has researched how thinking about physical symptoms affects people with chronic pain and chronic fatigue. It seems that
Worrying and ruminating about fatigue and pain are connected to how severe these symptoms feel, according to MCT. Worrying and analyzing are cyclic thinking patterns activated by beliefs about our thinking and our perceived lack of control over attention.
Reducing worry and rumination is an important part of MCT treatment for reducing emotional distress. Research indicates, that this can also have a positive impact on reducing chronic physical distress like chronic pain and fatigue (2).
Somatic complaints like pain and fatigue are also called ‘medically unexplained syndromes’ (MUS). People with MUS experience distress and impairment due to their physical symptoms. They also often suffer from anxiety, depression, and stress.
Why would overthinking worsen pain and fatigue?
It is currently unclear whether overthinking directly impacts physical symptoms of chronic pain and fatigue. However, research has documented how overthinking in this population leads to a poorer prognosis, adverse health behaviors, poorer self-care, less productivity, and a decreased quality of life (4).
But according to Professor Adrian Wells, the founder of MCT, specific thinking styles contribute to the worsening of pain and fatigue symptoms(3). Wells developed together with his colleague a model of how psychological illness is caused and maintained by this thinking style called the Cognitive Attentional Syndrome (CAS).
The CAS consists of:
- worrying and ruminating (which are ongoing cyclic thinking patterns)
- monitoring for threatening information ( for example, dangerous thoughts, emotions, or symptoms)
- ineffective attempts to regulate emotions (for example, thought suppression and avoidance)
The reason why the CAS causes both psychological and physical distress is because it causes negative thoughts and emotions to persist. Worrying about a thought like, What if I will never feel better? will maintain the thought and the feelings of hopelessness and frustration. Similarly, paying too much attention to physical symptoms of pain and fatigue increases access to noticing these symptoms, causing us to only pay attention to negative information.
The CAS also causes cognitive overload because too much worrying and ruminating takes a lot of mental energy, leading to feeling exhausted.
Another consequence of the CAS is that it prevents us from learning new information about our thinking, making us believe, for example, that we can’t stop worrying about how we feel.
People with chronic pain have experienced pain for more than 12 weeks, whereas people with chronic fatigue syndrome experience symptoms like poor concentration, extreme fatigue, problems with memory, and sleep disturbance for a minimum of 6 months.
Why does thinking about thinking worsen pain and fatigue?
Our thinking is influenced by what we think about it. For example, most people believe to some extent, that worrying about future problems can help us prepare for it, or that analyzing problems is a way to find solutions. But what we think about our thinking can be false and biased.
For example, people who suffer from anxiety falsely believe that they can’t stop worrying or that their worrying can cause a heart attack or mental breakdown. Likewise, people who suffer from chronic fatigue or pain also have false beliefs about their thinking and their attention.
For instance, people who suffer from chronic fatigue syndrome have little confidence in how much control they have over their attention. They don’t believe that they can move their attention around and pay attention to other meaningful activities when feeling tired or in pain. Instead, they feel that they have no choice but to pay attention to their symptoms of pain, fatigue, or nausea, which only makes them notice them more. On top of that, they won’t make an effort to engage in activities that prove that they can function despite fatigue and pain and that way creating a vicious cycle that maintains their symptoms.
How much time we spend thinking about physical symptoms and what we think about our thinking is linked to pain and symptom severity in chronic pain and chronic fatigue syndrome.
How can MCT treat chronic pain and chronic fatigue?
Since the majority of patients with chronic pain and fatigue worry, ruminate, and disengage from meaningful activities, Metacognitive therapy focuses on reducing these unhelpful thinking patterns and encourages patients to resume daily activities.
Creating awareness of worry and rumination
The first step in therapy is to create awareness of how much time patients spend worrying/ruminating about their condition as well as the thoughts that trigger their overthinking. This is an important step since many mistake their worrying with dealing with their situation.
An important goal in therapy is for patients to understand how overthinking leads to negative emotional consequences like anxiety and depression. And that overthinking together with disengaging from meaningful activities create a vicious cycle that can exacerbate their physical condition.
Helping reduce rumination and worry
Rumination and worry are repetitive thinking that we have full control over. However, due to false beliefs, most patients don’t believe that they can stop worrying about the future or dwelling on the consequences of their condition.
Therefore, treatment focuses on changing these false beliefs that keep worrying and ruminating going through practicing specific strategies to leave negative thoughts alone instead of worrying about them.
Through consistent MCT practice, patients with chronic pain and chronic fatigue can feel more in control over their thinking and empowered to resume daily activities, assured that their symptoms are no longer a hindrance to living a meaningful and worry-free life.
Metacognitive Therapy (MCT) focuses on regulating too much time spent overthinking (worrying and ruminating) and unhelpful attention strategies. This is instead of challenging the content of the patient’s concerns like, “What if I never feel better?“. Reducing overthinking helps patients become more flexible in dealing with their concerns: “I don’t need to worry about the future because it’s not helpful“.
Research about MCT for Chronic pain and chronic fatigue
| Type of Research | Findings |
| (3) Do beliefs about the way we think influence emotional consequences and physical symptoms of chronic fatigue syndrome? | Beliefs about how we think independently affect psychological and physical symptoms in people with chronic fatigue syndrome and these beliefs should be changed in psychotherapy treatment |
| (5) Does changing thinking about thinking (metacognitive beliefs) with CBT or Graded exercise therapy lead to less fatigue in people with chronic fatigue syndrome? | Changing beliefs about thinking reduces fatigue severity, but it is unclear whether this is due to directly changing beliefs about thinking or because the patients spent less time thinking about and paying attention to their fatigue symptoms |
| (6) Are people with chronic pain more affected psychologically because of their thinking about their thinking instead of their pain? | Beliefs about thinking seem to impact how people with chronic pain adjust psychologically to their condition |
Why is thinking about thinking important? Research in the past two decades clearly shows how beliefs about thinking (also called metacognitive beliefs in Metacognitive therapy) play a more important role in causing mental disorders than difficult situations or negative thoughts and emotions. It is therefore important to change metacognitive beliefs in therapy to achieve recovery from mental disorders.
How can MCT help you if you suffer from chronic fatigue and chronic pain?
Although the research doesn’t agree on whether therapy can directly reduce your symptoms of chronic pain and fatigue, it does have a large impact on helping you adjust psychologically to your condition.
Many people who suffer from chronic physical conditions also suffer from anxiety and depression and due to this develop unhelpful coping behaviors that could make their condition worse. For example, if you withdraw from your usual activities or social interactions, it can leave more time for overthinking and noticing how you feel.
Therapy will help you take back control over worrying about your condition and help you discover that you can still live a meaningful life despite your physical symptoms. This could lead to noticing them less and maybe even experiencing relief along the way.
Reducing unhelpful thinking will help them pay less attention to physical symptoms and learn to live a meaningful life despite a chronic condition.
Summary
- People with chronic pain and chronic fatigue syndrome usually also struggle with mental health issues like anxiety and depression
- Overthinking in the form of prolonged worry and rumination contribute to maintaining anxiety and depression in these patients
- How these patients think about their thinking (metacognitive beliefs) may also contribute to worsening their physical symptoms.
- Metacognitive therapy (MCT) can effectively reduce rumination and worry in people who suffer from chronic pain and chronic fatigue syndrome and help them cope with their condition in a better way.
References
- Lenzo V, Sardella A, Martino G, Quattropani MC. A Systematic Review of Metacognitive Beliefs in Chronic Medical Conditions. Front Psychol. 2020 Jan 10;10:2875. doi: 10.3389/fpsyg.2019.02875. PMID: 31998178; PMCID: PMC6965316.
- Keen, E., Kangas, M., & Gilchrist, P. T. (2022). A systematic review evaluating metacognitive beliefs in health anxiety and somatic distress. British Journal of Health Psychology, 27(4), 1398-1422.
- Maher-Edwards, L., Fernie, B.A., Murphy, G., Wells, A. & Spada, M.M. (2011). Metacognitions and negative emotions as predictors of symptom severity in chronic fatigue syndrome. Journal of Psychosomatic Research, 70, 311-317.
- Capobianco L, Faija C, Husain Z, Wells A. Metacognitive beliefs and their relationship with anxiety and depression in physical illnesses: A systematic review. PLoS One. 2020 Sep 10;15(9):e0238457. doi: 10.1371/journal.pone.0238457. PMID: 32911486; PMCID: PMC7500039.
- Fernie, B. A., Murphy, G., Wells, A., Nikcevic, A. V., and Spada, M. M. (2015). Treatment outcome and metacognitive change in CBT and GET for chronic fatigue syndrome. Behav. Cogn. Psychother. 44, 397–409. doi: 10.1017/S135246581500017X
- Ziadni, M. S., Sturgeon, J. A., and Darnall, B. D. (2018). The relationship between negative metacognitive thoughts, pain catastrophizing and adjustment to chronic pain. Eur. J. Pain. 22, 756–762. doi: 10.1002/ejp.1160.
- Jacobsen HB, Glette M, Hara KW and Stiles TC (2020) Metacognitive Beliefs as Predictors of Return to Work After Intensive Return-to-Work Rehabilitation in Patients With Chronic Pain, Chronic Fatigue and Common Psychological Disorders: Results From a Prospective Trial. Front. Psychol. 11:70. doi: 10.3389/fpsyg.2020.00070