'I call it stinkin' thinkin": A qualitative analysis of metacognition in people with chronic low back pain and elevated catastrophizing

Objectives. Pain catastrophizing is widely studied in quantitative pain research because of its strong link with poor pain outcomes, although the exact nature of this construct remains unclear. Focusing on its ruminative dimension, the present qualitative study aimed to explore a nascent aspect of pain catastrophizing - metacognition - by documenting people's attitudes towards rumination and examining how these metacognitions might influence the course it takes. Design. Qualitative interview study. Methods. Semi-structured interviews were conducted in a tertiary care setting with 15 adults experiencing chronic (>= 6 months) low back pain who scored highly (>= 30) on the Pain Catastrophising Scale. Transcripts were analysed using interpretative phenomenological analysis. Results. The first aim of documenting pain metacognitions revealed both positive (e.g., 'thinking helps me to cope') and negative (e.g., 'rumination is uncontrollable') attitudes towards pain rumination. These were often held simultaneously, creating internal conflict. The second aim of exploring the influence of metacognition on rumination showed that both negative and positive metacognitions could fuel perseverative thinking. However, more nuanced negative metacognitions (e.g., 'worry is pointless') could help to end episodes of rumination by motivating the use of concrete problem-solving or active coping behaviours. Conclusions. While most participants described pain rumination as uncontrollable and harmful, dwelling on pain could be helpful when focused on tangible and solvable problems, thereby translating into adaptive coping behaviours that eventually interrupt rumination. Future treatments may be more effective if they are based on individualized formulations of pain catastrophizing that focus on its perseverative nature and implicit function.