Vol 14, N◦1
Metacognitions on Pain, Functionality
and Intensity of Pain in Women with
Metacogniciones sobre el dolor, la funcionalidad y la intensidad del
dolor en mujeres con ﬁbromialgia
Misleydis Ortega-González1,⋆iD, Daniel-Camilo Aguirre-
Acevedo2iD, Mercedes Jiménez-Benítez3iD
1Grupo de Neuropsicología y Conducta, Facultad de Medicina, Universidad de An-
tioquia. Medellín, Colombia.
2Grupo Académico de Epidemiología Clínica, Instituto de Investigaciones Médicas,
Facultad de Medicina, Universidad de Antioquia. Medellín, Colombia.
3Grupo de Investigación en Psicología Cognitiva, Departamento de Psicología. Facul-
tad de Ciencias Sociales y Humanas. Universidad de Antioquia. Medellín, Colombia.
Manuscript received: 05-08-2020
Copyright: ©2021. International Journal
of Psychological Research provides open ac-
cess to all its contents under the terms
of the license creative commons Attribution-
NonCommercial-NoDerivatives 4.0 Interna-
tional (CC BY-NC-ND 4.0)
Declaration of data availability: All rele-
vant data are within the article, as well as the
information support ﬁles.
Conﬂict of interests: The authors have de-
clared that there is no conﬂict of interest.
How to Cite:
Ortega-González, M., Jiménez-Benítez, M.
& Aguirre-Acevedo, Daniel-Camilo (2021).
Metacognitions Regarding the Pain, Function-
ality and Intensity of Pain in Women with
Fibromyalgia Dwelling in Medellin and its
Metropolitan Area (Colombia) . International
Journal of Psychological Research,14 (1), 78–
To determine the explanatory capacity of pain metacognitions and beliefs
over the functionality, coping and pain intensity, following the Model of
Self-Regulatory Executive Functions (S-REF) in a sample of women with
ﬁbromyalgia from Medellín and its Metropolitan Area. Method: Metacog-
nitions Scale on Symptom Control, Pain Self-eﬃcacy Questionnaire,
Chronic Pain Catastrophizing Scale, Chronic Pain Coping Questionnaire,
WHODAS 2.0 Scale, and Pain Intensity Numerical Scale. The sample was
represented by 108 women between 24 and 60 years old with a diagnosis
of ﬁbromyalgia. A modeling process was carried out through an analysis
of structural equations. Results: The ﬁnal model fails to ﬁt. Despite this,
the analysis suggests that negative metacognitions and pain self-eﬃcacy
have an eﬀect over the tendency to catastrophizing. The latter and the
pain self-eﬃcacy are the main mediators in the eﬀects of functionality.
The intensity of pain is not determined by the metacognitions related to it.
Determinar la capacidad explicativa de las metacogniciones y las creencias
del dolor sobre la funcionalidad, el afrontamiento y la intensidad del
dolor, siguiendo el Modelo de Funciones Ejecutivas de Autorregulación
(FEAR) en una muestra de mujeres con ﬁbromialgia de Medellín y su Área
Metropolitana. Método: Se aplicaron: Escala de Metacogniciones acerca
del Control de Síntomas, Cuestionario de Autoeﬁcacia al Dolor, Escala de
Catastroﬁzación al Dolor Crónico, Cuestionario de Afrontamiento al Dolor
Crónico, Escala WHODAS 2.0 y Escala numérica de la intensidad del
dolor. La muestra estuvo representada por 108 mujeres entre 24 y 60 años
con diagnóstico de ﬁbromialgia. Se realizó un proceso de modilización
por medio de un análisis de ecuaciones estructurales. Resultados: El
modelo ﬁnal no logra ajustarse. A pesar de ello, el análisis sugiere que
las metacogniciones negativas y la autoeﬁcacia al dolor tienen un efecto
sobre la tendencia a la catastroﬁzación. Esta última y la autoeﬁcacia
al dolor son las principales mediadoras en los efectos de funcionalidad.
La intensidad del dolor no está determinada por las metacogniciones
relacionadas con este.
Fibromyalgia, Metacognition, Self-eﬃcacy, Functionality, Catastrophism,
Fibromialgia, Metacognición, Autoeﬁcacia, Funcionalidad, Catastroﬁsmo,
Análisis de senderos.
int.j.psychol.res |doi:10.21500/20112084.4897 78
Self-regulation of pain in Fibromyalgia
It is estimated that more than 1.9 billion people in the
world suﬀer from some type of chronic painful condition
(Mills et al., 2019), understood as that which recurs or
persists for more than three months, causing a signiﬁcant
emotional or functional aﬀectation (Treede et al., 2015).
The nature of chronic pain is complex and its under-
standing implies integrating dimensions of an organic
and psychological nature, the eﬀorts of multiple disci-
plines, such as psychology and neuroscience, which have
added their knowledge to that of neurophysiology and
branches of clinical application, to generate theoreti-
cal models with the objective of knowing the multidi-
mensional nature of pain. Among these theories, the
Multidimensional Model of Pain or Neuromatrix Theory
(Melzack, 1996), the Fear Avoidance Model (Vlaeyen &
Linton, 2000), the Neurocognitive Model of Attention to
pain (Legrain et al., 2009), and, recently, the Dynamic
Pain Connectome Model (Kucyi & Davis, 2015) have
Although these models have approached the aspects
of the emotional or cognitive experience associated with
pain, they cannot satisfactorily explain the patients re-
sponse to this experience, its chronicity, and the im-
pact of pharmacological and non-pharmacological ther-
apies on functionality for diﬀerent chronic painful con-
ditions. In this regard, the neurocognitive model of Self-
regulatory Executive Functions has attracted interest
(Wells & Matthews, 1996), which aims to associate the
results of the sensory experience and illness with the
cognitive processes and beliefs related to the experience
of pain and the evaluation that the subject makes of
them. This model integrates subjective elements the in-
dividual’s beliefs and their evaluations to the variables
of daily impact of the patients, such as the intensity of
pain and functional compromise.
The model considers that emotional processing is car-
ried out through a system of three levels, which con-
stantly interact with each other. The Processing Units
are located At the lower level, which comprise the body’s
sensory systems (both interoceptive and exteroceptive)
and cognitive systems. At this level, which is charac-
terized by being automatic and not very reﬂective, the
information is channeled and the stimuli to which the
attentional eﬀort is intended are selected.
On the other hand, atthe intermediate level, self-regula-
tionfunctions are carriedout through pre-establishedplans
that guide the monitoring of sensory systems. This level
receives information from the cognitive processing units
to analyze it, and is characterized by being reﬂective
and with limited attention span (Reyes, 2015).
Finally, self-beliefs are located at the higher level,
which can be declarative, corresponding to ideas, eval-
uations or judgments about oneself (Sierra, 2010); or
procedural, which guide the way the individual gives a
personal meaning to the stimuli and provides the gen-
eral plan of the coping responses through the metacog-
nitive processes. Both can be understood as “implicit
plans that guide processing and operate largely outside
of consciousness” (Wells, 2000, p. 19).
Recently, some authors have considered that this
theoretical proposal may be useful for understanding
the perceptual, cognitive-emotional, and behavioral re-
sponses in conditions of both acute and chronic pain
(Kollmann et al., 2016; Spada et al., 2016; Yoshida et al.,
2012). One of the main properties of this model is the
integration into a single theoretical structure of the sen-
sory elements of the painful experience and their links
with the cognitive and self-regulation processes through
beliefs. This is a characteristic that is absent in the other
theoretical models, which have restricted themselves to
mentioning these relationships without committing to a
Additionally, it has been proposed that its integra-
tive capacity is what allows articulating the multiple evi-
dences that relate the psychological aspects, physical de-
terioration, and intensity of pain with the cognitions as-
sociated with it in patients with ﬁbromyalgia (Martínez
et al., 2015; Peñacoba-Puente et al., 2015; Tirado et al.,
2014). This condition has been deﬁned as a syndrome
of unknown origin that is characterized by the develop-
ment of generalized pain, multiple tender points (points
sensitive to pressure in muscle examination), in addition
to other symptoms such as fatigue, muscle stiﬀness, and
cognitive dysfunction (Wolfe et al., 2010). Its uncertain
etiology raises multiple questions related to the diagno-
sis and treatment of this condition, but above all with
the progressive deterioration in functionality and quality
of life of approximately 2% of the world population that
suﬀers from it (with a proportion of 4:1 between women
and men), as well as in the strategies for reducing the
impact on health systems (Cabo-Meseguer et al., 2017).
For these reasons, ﬁbromyalgia could be considered
as one of the pain syndromes that best meets the condi-
tions for the study of chronic pain within the framework
of the S-REF model. In fact, research on ﬁbromyal-
gia suggests that psychological and cognitive variables
can have a great inﬂuence on its progression and on its
interference with daily activities (Luciano et al., 2014;
Mobini et al., 2017; Vanhaudenhuyse et al., 2015).
Among these psychological and cognitive elements,
the catastrophic evaluations oriented towards pain stand
out (Loggia et al., 2015), which seem to be closely re-
lated to the emotional impact and reduction of the func-
tionality of patients (Lami et al., 2018). Likewise, the
perception of pain self-eﬃcacy seems to mediate the im-
pact of pain in daily life, the perception of pain and
the anxiety manifested by patients with this syndrome
(De Rooij et al., 2013; Lee et al., 2017). Additionally,
the impact that beliefs about pain have on the coping
int.j.psychol.res |doi: 10.21500/20112084.4897 79
Self-regulation of pain in Fibromyalgia
processes, functionality, and emotional state of patients
with the syndrome has gradually taken on greater in-
terest (Kollmann et al., 2016; Kuppens et al., 2015),
although this topic is still under development.
Given these questions about the nature of this syn-
drome, and based on the approaches and research an-
tecedents on the role of cognitions related to pain, the
present investigation is proposed with the purpose of
determining the explanatory capacity of metacognitions
about the control of symptoms, self-eﬃcacy, and catas-
trophism towards pain, over the functionality, coping,
and pain intensity, following the Model of Self-Regulation
Executive Functions. Figure 1shows the initial theoret-
ical model that was proposed.
2.1 Type of study
Analytical empirical study with a cross-sectional explana-
tory design with observable variables according to Ato et
al. (2013), in which psychometric techniques were used
to collect the information.
Non-random sampling, for convenience. The sample of
participants consisted of 108 women, between 24 and 60
years old, residing in Medellín and its Metropolitan Area
(Northwest Colombia), with a diagnosis of ﬁbromyalgia
given by a specialist doctor. Women with severe phys-
ical disability for any reason other than ﬁbromyalgia,
or with cognitive impairment that limited the responses
to the instruments were excluded. The veriﬁcation of
these disabling conditions was carried out through the
analysis of the clinical history provided voluntarily by
The collection of the sample was carried out through
diﬀerent procedures: 1. Invitation to participate made
by some medical specialists in the ﬁeld of pain in the city
of Medellín and the metropolitan area; 2. Direct invi-
tation to patients who required emergency consultation
in a home health care institution in Medellín and the
metropolitan area for pain control between June 2017
and June 2018; 3. Invitation to participate through a
social assistance foundation in Medellín; 4. Invitation to
participate through the mediation of other participants;
and 5. Invitation on social networks and through a Face-
book group, made up mainly of ﬁbromyalgia patients
from Medellín and its Metropolitan Area. The patients
were summoned for a meeting that lasted around one
hour. During the meeting, after the completion of the in-
formed consent for the participation in the study, a review
of the patient’s medical history was performed to conﬁrm
the diagnosis made by a doctor or specialist doctors.
Metacognitions Scale about Symptom Control (MSC)
(Fernie et al., 2015), designed to evaluate positive and
negative metacognitions related to the control of the dis-
ease or its consequences. It consists of 17 items, which
are answered according to a Likert scale of ﬁve response
options and the degree is evaluated according to the sub-
ject. Regarding the internal consistency, a Cronbach’s
alpha of .89 was obtained for Positive Metacognitions
about Symptom Control (PMCS) and .88 for Negative
Metacognitions about Symptom Control (NMCS) (Fer-
nie et al., 2015).
Pain Self-eﬃcacy Questionnaire (PSEQ), originally
created by Nichollas in 1989 to assess the self-eﬃcacy
beliefs of patients with chronic pain conditions, consists
of 10 items that inquire about the perception of self-
eﬃcacy that the subjects present to face diﬀerent sit-
uations of personal, work, and social nature, as well
as of their illness, related to their experience of pain.
Each item is evaluated through a seven-point Likert
scale ranging from 0 to 6, with 6 being the highest level
of self-eﬃcacy. The factoring analyses of the question-
naire establish a one-dimensional construct, with high
levels of internal consistency, and a Cronbach’s alpha of
.9 (Nicholas, 2007).
Pain Catastrophizing Scale (PCS) (Sullivan et al.,
1995). Made up of 13 items that assess the degree to
which the person has experienced a series of thoughts or
feelings in past painful experiences, on a 5-point scale,
where 0 means “not at all” and 4 “all the time”. It
has shown a good level of internal consistency, with a
Cronbach’s alpha of .86 (Suso-ribera et al., 2017).
Questionnaire about Facing Chronic Pain (QFCP;
Soriano & Monsalve, 2005), which assesses the strate-
gies for coping with chronic pain and is made up of 24
items that represent two dimensions of coping with pain:
Passive Coping and Active Coping. The Passive Cop-
ing is made up of two factors: religious coping and the
search for emotional support; while the Active Coping is
made up of four factors: distraction, mental self-control,
self-assertion, and search for instrumental social support.
Each of the items assesses the degree of agreement on
a 5-point Likert scale. The rates of internal consistency
of each of the factors, measured through the Cronbach’s
alpha, are .94, .88, .82, .81, .79, and .77, respectively (So-
riano & Monsalve, 2005). This scale has been validated
for patients with ﬁbromyalgia with similar results of in-
ternal consistency (Soucase et al., 2004; Vázquez-Rivera
et al., 2009).
WHODAS 2.0 scale (WHO, 2015) is a generic tool for
evaluating health and disability in the general and clini-
cal population. For this study, the use of a 12-item scale,
which has already been used in patients with ﬁbromyal-
gia was selected. The items make up two dimensions
that assess social-cognitive functionality (ScCF), inte-
grating the domains of relationships, daily activities for
work, cognitionm and participation; and self-care func-
tionality (SCF), integrating the domains of mobility and
int.j.psychol.res |doi: 10.21500/20112084.4897 80
Self-regulation of pain in Fibromyalgia
Initial theorical model. MC=Metacognitions about symptom control, NMC=Negative metacognitions
about symptom control, PMC=Positive metacognitions about symptom control, SEP=Self-eﬃcacy to
pain, CAT=Catastrohizing to pain, CP=Coping with pain, AC=Active coping, PC=Passive coping,
RUM=Rumitation, HOP=Hopelessness, MAG=Magniﬁcation, FUN=Functionality, SCF=Sociocognitive func-
tionality, FSC=Functionality for self-care, INT=Intensity. Own elaboration.
Note. Slope/Shape factors are not included in the intercept model. A parameter value with a plus sign
indicates the parameter value is ﬁxed. *indicates that the factor loadings may be ﬁxed to 4 (linear trajectory
model) or freely estimated (unspeciﬁed model).
self-care. Good levels of internal consistency have been
reported for both subscales, with a Cronbach’s alpha of
.83 for social-cognitive functionality and .81 for self-care
functionality (Smedema et al., 2016).
Numeric Pain Rating Scale: In order to assess the
intensity of pain at the time of application of the instru-
ments, the patients had to record the pain they felt at
the time, scoring from 0 (absence of pain) to 10 (maxi-
mum pain level).
Individual survey. An individual survey on socio-
demographic data was applied.
Since these instruments have not been validated in
Colombia, a process of linguistic and conceptual equiva-
lences was carried out by means of a judgment of experts
for its subsequent application in the sample. To do this,
the following steps were taken: 1. Direct translation of
the scales; 2. Translation synthesis; 3. Back-translation;
and 4. Expert evaluation.
2.4 Procedures for data collection
Two trained evaluators applied the scales in person to
the sample of participants, after obtaining the informed
The study took into account the ethical considera-
tions established in Resolution 8430 (1993, October 4)
of the Ministry of Health of the Republic of Colombia
and those raised in Law 1090 (2006) of the Ministry of
Social Protection, which regulates the Deontological and
Bioethical Code of studies in Psychology.
2.5 Analysis of the information
Given that this research has as its main objective the
modeling of a theoretical structure, the data analysis
involved two moments. In the ﬁrst of them, a descrip-
tive analysis of the variables and a correlational analysis
between them were performed using the SPSS 20®pro-
gram. For this, the levels of reliability and adequacy to
the factorial analysis of the variables were determined.
In a second moment, a modeling process was carried
out by means of a trail analysis. The ﬁtting evaluation
of the model was carried out with the Mplus®7.31 pro-
gram and, for this, iterative procedures were used, with
the Maximum Likelihood method, and the adjustment
measures: Chi-square test, Root Mean Square Error
of Approximation (RMSEA), Standardized Root Mean
Squared Residual (SRMR), Tucker-Lewis index (TLI),
and comparative ﬁt index (CFI). A signiﬁcance level of
5% was used for all tests, and, a value of 0.50 was taken
into account to identify the strength of the correlations
among the variables.
3.1 Sample description
The sample consisted of 108 women with a mean age of
47.2 years, being the most frequent age range in the sam-
ple corresponding to the interval 49-60, with 53.7%. Ap-
proximately 60% had a stable relationship and 68.52% of
the sample had developed higher level studies, including
int.j.psychol.res |doi: 10.21500/20112084.4897 81
Self-regulation of pain in Fibromyalgia
technical or technological training and university educa-
tion at undergraduate and graduate levels. Only 1.85%
of the participants reported not having completed for-
mal studies, although they had an adequate level of
reading comprehension to allow the application of psy-
chometric instruments. The socio-demographic details
of the sample are summarized in Table 1.
Sociodemographic variables, mood and aﬀective bal-
ance. Correlation matrix
Variable Category N= 108
24-36 years 18 16.67
37-48 years 32 29.63
49-60 years 58 53.70
Married/ 66 61.11
Single 22 20.37
Separate/Divorced 17 15.74
Widowed 3 2.78
No studies 2 1.85
Elementary school 13 12.04
Secondary school 19 17.59
Technical/Technology 41 37.96
Undergraduate 18 16.67
Postgraduate 15 13.89
Note. N: Total sample; fi: absolute frequency; %:
percentage of frequency.
3.2 Descriptive and correlational analysis
To start the data analysis, an evaluation of its behavior
was performed by using three methods of normality eval-
uation. The ﬁrst, by means of the Kolmogorov-Smirnov
test, in which it was found that this assumption was
not fulﬁlled; however, given that the results of the scales
could be aﬀected by the size of the sample, an analysis
was also performed through the visual inspection of the
QQ graphs, and we valued the Asymmetry and Kurto-
sis coeﬃcients for each of the scales. As suggested for
the development of analysis of structural equation mod-
els (Kline, 2011; Kumar & Upadhaya, 2017), these were
found among parameters of normal distribution. Ad-
ditionally, the criterion of the Central Limit Theorem
(Kwak & Kim, 2017) was considered to assume that
due to the size of the sample the data could be analyzed
under the assumption of normal behavior.
The results of the descriptive analysis of the instru-
ments are summarized in Table 2. The negative and
positive metacognitions dimensions about the control of
symptoms obtained an acceptable level of reliability, with
scores in Cronbach’s alpha of .79 and .77, respectively.
The relationships between the analysis dimensions
are presented in Table 3, which shows the correlation
matrix among the variables of the study. The positive
metacognitions variable showed weak correlations with
the negative metacognitions variable, that is, Active cop-
ing with pain and Passive coping with pain. In con-
trast, the negative metacognitions variable presented a
greater number and strength of correlation with Catas-
trophizing towards pain and its dimensions, with Socio-
Cognitive Functionality, Functionality for Self-care, and
Passive Coping to pain; and a negative correlation with
Self-eﬃcacy to pain.
In addition, the variable of Self-eﬃcacy to pain pre-
sentedmoderate negative correlationswithnegativeMeta-
cognitions,Rumination, Magniﬁcation,Hopelessness, Ca-
tastrophizing to pain, Socio-Cognitive Functionality, and
Functionality for Self-care, just as Low positive corre-
lation with Active coping with pain, and negative cor-
relation with Pain intensity. On the other hand, the
Catastrophizing to pain showed moderate correlations
with the variables of Socio-Cognitive Functionality and
Functionality for Self-care, as well as weak correlations
with Passive Coping to pain and Pain intensity.
3.3 Structural Model Development
To carry out the multivariate analysis, it was subjected
to the determination under the structure of the trail
analysis, which was done step by step, according to the
results of the goodness of ﬁt indices found between the
relationships among variables. It is important to clarify
that the resulting model is the product of changes that
were made in the original model, following the values of
the indices, but these modiﬁcations were made following
the theoretical guidelines, which are described below:
Starting from the original model proposed in Figure 1,
the following modiﬁcations were made: The latent vari-
able of Metacognitions about the control of Symptoms
was excluded from the analysis and the variable of posi-
tive Metacognitions, negative Metacognitions, and Self-
eﬃcacy to pain were used as endogenous variables. The
dimensions of Rumination, Magniﬁcation, and Hopeless-
ness, which constitute the pain catastrophism variable,
were removed to use the global result of the instrument.
The reliability results of the Pain Catastrophizing Scale
allowed us to conclude that it was possible to use the
global result of the instrument, and thereby improve the
goodness of ﬁt indices. The variables of coping with pain
were removed from the model, because their presence re-
duced the validity of the goodness of ﬁt indices, although
they did not modify the coeﬃcients of determination.
In Figure 2, the re-speciﬁed model is shown, in which
latent variables of negative metacognitions and positive
metacognitions, and pain self-eﬃcacy can be seen. On
the other hand, Catastrophizing to pain acts as a medi-
ating variable on the intensity of pain, Socio-Cognitive
Functionality, and Functionality for Self-care. Table 4
shows the results of the goodness of ﬁt indices and the
regression coeﬃcients of the re-speciﬁed model that were
best adapted statistically.
int.j.psychol.res |doi: 10.21500/20112084.4897 82
Self-regulation of pain in Fibromyalgia
Summary of descriptive data of each dimension of the study
Scale Dimension Ítems Range x S α IC 95% P25 P50 P75
CMSC PMC 9 9 to 36 23.66 6.684 .774 .708–.835 18 24 29
NMC 8 8 to 32 22.16 5.988 .798 .735–.851 18 22 27
SEP SEP 10 0 to 60 34.29 14.213 .924 .901–.944 23 36 45
CAT CAT 13 0 to 52 25.56 13.112 .942 .892–.942 16 26 36
CAD AC 16 16 to 80 48.30 9.983 .794 .733–.833 41 48 57
PC 8 8 to 40 24.95 8.172 .824 .769–.870 18 25 32
WHODAS 2.0 SCF 7 7 to 35 15.86 4.892 .82 .773–.876 12.25 16 19.75
FSC 5 5 to 25 18.21 5.267 .83 .763–.867 15 18.5 22
INT INT 0 to 10 6.69 2.684 5 7 9
Note. CMSC = Metacognitions Questionnaire about Symptom Control, NMC=Negative Metacogni-
tions Dimension, PMC=Positive Metacognitions Dimension, SEP=Self-eﬃcacy to pain Questionnaire,
PCQ=Pain Catastrophism Questionnaire, RUM=Rumination Dimension, MAG = Magniﬁcation Dimen-
sion, HOP=Hopelessness Dimension, CAT=Catastrophizing to pain , CPQ=Pain Coping Questionnaire,
AC=Active Coping Dimension, PC=Passive Coping Dimension, SCF=Social-Cognitive Function Dimen-
sion, FSC=Functionality for Self-Care Dimension. x=Mean, S=Standard deviation, α=Cronbach’s alpha,
CI=Conﬁdence interval, P25=25th percentile, P=50th percentile, P=75th percentile.
Matrix of correlations among variables
PMC NMC SEP CAT FSC SCF INT
PMC r1.00 0.204* -.008 -.067 -.030 -.040 -.115
p.00 .034 .934 .494 .760 .677 .236
NMC r-.329** .535** .441** .385** .040
p.001 .000 .000 .000 .682
SEP r-.564** -.563** -.590** -.371**
p.000 .000 .000 .000
CAT r.572** .562** .244**
p.000 .000 .011
FSC r.720** .323**
Note. PMC=Positive metacognitions, NMC=Negative metacognitions, SEP=Self-eﬃcacy to pain,
CAT=Catastrophizing to pain, AC=Active coping, PC=Passive coping, SCF=Social-cognitive function,
FSC=Functionality for Self-care, I=Intensity, r=Pearson’s correlation coeﬃcient, p=Level of signiﬁcance. *
The correlation is signiﬁcant at the 0.05 level (bilateral). Outlined in bold. ** The correlation is signiﬁcant at
the 0.01 level (bilateral). Outlined in bold.
Starting from the ﬁnal model, we can conclude that
the latent variables Positive Metacognitions, Negative
Metacognitions, and Self-eﬃcacy to pain inﬂuence each
other, so under this inﬂuence the direct eﬀect of the vari-
able Positive Metacognitions on Socio-Cognitive Func-
tionality had a magnitude of -.055, a -.050 on Functional-
ity for Self-care, and -.089 on Pain intensity , which as ef-
fect magnitudes are not considerable. Therefore, it is as-
sumed that the impact of the exogenous variable of Pos-
itive Metacognitions is not representative over its exoge-
nous variables (Self-Care Functionality, Socio-Cognitive
Functionality, Pain intensity). In turn, negative Meta-
cognitions as an exogenous variable of Catastrophizing
to pain had a direct eﬀect β=.393, while the direct
eﬀect of Catastrophizing pain as an endogenous vari-
able of Self-eﬃcacy to pain was β=−.437. The eﬀects
of these two variables explain 45.5% of the variance of
Catastrophizing to pain in this model.
In relation to the endogenous variable of Socio-Cogni-
tive Functionality, it was observed that positive Metacog-
nitions had a direct eﬀect β=−.55, which is not represen-
tative; Negative metacognitions had a direct eﬀect β=
.196, which is still considerably lower; and Self-eﬃcacy to
pain had a direct eﬀect β=−.351, which can be consid-
ered important. Here it should be noted that the strength
of the magnitude of this relationship is negative, which
int.j.psychol.res |doi: 10.21500/20112084.4897 83
Self-regulation of pain in Fibromyalgia
Goodness of ﬁt indices and regression coeﬃcient of the ﬁnal model
Model description χ2(gl) (p) RSMEA (IC 90%) CFI TLI SRMR R2
NMC–PMC– 4.8 (1) (p=.029) 0.187 (.048–.036) .985 .711 .027 SEP=11.2%
SEP (L) CAT=45.5%
Note. NMC=Negative Metacognitions Dimension, PMC=Positive Metacognitions Dimension, SEP=Pain Self-
eﬃcacy to pain Questionnaire, CAT=Pain Catastrophizing to pain Questionnaire, SCF=Social-cognitive Func-
tion Dimension, FSC=Functionality for Self-Care Dimension. CI=Conﬁdence interval, L=Variable considered
as latent, χ2=Chi squared, gl=Degrees of freedom, p=Level of signiﬁcance, RMSEA=Root Mean square error
of approximation, CFI=Comparative ﬁt index, TLI=Tucker-Lewis Index, SRMR=Standardized mean square
residual, R2=Multiple squared correlation.
Re-speciﬁed model. In the resulting model, the exogenous variables are seen to inﬂuence each other. Notice
that SEP has a direct eﬀect on endogenous variables and CAT behaves as a moderating variable for endogenous
variables. MC=Metacognitions about symptom control, NMC=Negative metacognitions about symptom control,
PMC=Positive metacognitions about symptom control, SEP=Self-eﬃcacy to pain, CAT=Catastrohizing to
pain, CP=Coping with pain, AC=Active coping, PC=Passive coping, RUM=Rumitation, HOP=Hopelessness,
MAG=Magniﬁcation, FUN=Functionality, SCF=Sociocognitive functionality, FSC=Functionality for self-care,
INT=Intensity. Own elaboration.
means that for each point that increases self-eﬃcacy, the
score in the subjects’ social cognitive functionality will de-
crease by three points; while Catastrophizing to pain had
a direct eﬀect β=.269. These variables explain 43.5% of
the variance of Socio-Cognitive Functionality.
For the endogenous variable of Functionality for Self-
Care, we found that positive metacognitions had a direct
eﬀect β=−.50, which is not representative; the negative
metacognitionsvariablehad adirect eﬀect β=.120, which
is still considerably lower; Self-eﬃcacy to pain had a direct
eﬀect β=−.401, an even greater eﬀect than in the case of
Socio-Cognitive Functionality; while Catastrophizing to
pain had a direct eﬀect β=.271. These variables explain
43.3% of the variance of Functionality for Self-care. It
is important to mention that the resulting model states
the existence of a considerable eﬀect on the functionality
variables whose origin cannot be determined.
To ﬁnish with the endogenous variables, it should be
noted that in Pain intensity, the positive Metacognitions
had a direct eﬀect β=−.089, which is not representa-
tive; Negative metacognitions had a direct eﬀect β=
−.111; Self-eﬃcacy to pain had a direct eﬀect β=−.355;
and Catastrophizing to pain had a direct eﬀect β=.098.
These variables explain 15.9% of the variance of pain in-
tensity. In summary, the ﬁnal model had a barely accept-
able ﬁt (χ2= 4.8,p=.029, RMSEA=.187, CFI=.985,
TLI=.711 CFI=.985, SRMR=.027), which implies that
the model does not manage to validate itself.
The results of this study do not allow us to aﬃrm that
the S-REF Model can satisfactorily explain the variables
of coping, functionality, and pain intensity in the study
sample. The analysis does not support with statistical
evidence the causal relationships proposed in the theoret-
ical model, although some research has proposed that this
maybe useful forunderstanding the roleof metacognitions
in the psychological processes associated with the experi-
ence of pain and its physical and emotional impact on
ﬁbromyalgia (Kollmann et al., 2016; Spada et al., 2016).
int.j.psychol.res |doi: 10.21500/20112084.4897 84
Self-regulation of pain in Fibromyalgia
However, this general result does not diminish the
importance of the conclusions that can be drawn from
the ﬁnal model. In this sense, the results suggest that
the variables of Positive Metacognitions, Negative Meta-
cognitions, and Self-eﬃcacy to pain act as exogenous
variables and inﬂuence each other, despite the fact that
the positive Metacognitions did not have a direct im-
pact on the moderating variable (Catastrophizing to
pain) and the exogenous variables (Self-Care Function-
ality, Socio-Cognitive Functionality, and Pain intensity).
These results diﬀer with the study developed by Koll-
mann et al. (2016), in which it was found that positive
Metacognitions inﬂuenced the variables of physical and
work impact that they evaluated.
Given these results, two reﬂections can be raised: (1)
the few correlations established by positive Metacogni-
tions cast doubt on their relevance in pain self-regulation
processes, although diﬀerent theorists consider the role
of beliefs and especially metacognitive beliefs fundamen-
tal factors in self-regulation phenomena (Bandura, 1998;
Beer & Moneta, 2012; Vohs & Baumeister, 2011); or (2)
based on their experiences, the patients have not devel-
oped useful or beneﬁcial attributions to the content of
their thoughts and control processes.
Although the results have not found a direct eﬀect
of positive Metacognitions on functionality, coping or
pain intensity, it cannot be said that these types of cog-
nitions do not have ﬁnal eﬀects on the pain experience
process, since, as can be seen in the model, this vari-
able does generate an impact on the variables: Negative
metacognitions and Self-eﬃcacy to pain, that is, it can
be stated that in this study its eﬀect may be indirect
on them. In contrast to this directionality of the ef-
fect, in their recent publication, Schütze et al. (2020)
has suggested that pain intensity may have an inﬂuence
on positive Metacognitions, although this directionality
of eﬀect was not considered in this study.
On the other hand, the results suggest that the two
variables, both Negative Metacognitions and Self-eﬃcacy
to pain, inﬂuence each other and behave as latent on
Catastrophizing to pain. Thus, the greater the belief in
the absence of control over the symptoms of ﬁbromyal-
gia is, especially pain, the lower the belief in self-eﬃcacy
about this same symptom is expected. Theoretical links
between personal self-eﬃcacy and the sense of control
have already been raised in other areas (Ajzen, 2002;
Bandura, 1992) but not in the ﬁeld of pain, which is
novel because this relationship between variables has not
been included in other research.
Regarding the eﬀect of the negative metacognitions
variable on Catastrophizing to pain, it can be said that
when thought control strategies are linked to attempts
to reduce these negative cognitions, a paradoxical eﬀect
occurs, leading to an increase in the catastrophic content
of the cognitions (Wang et al., 2018; Wenzlaﬀ & Wegner,
2000; Yoshida et al., 2012), and in negative evaluations
in diﬀerent dimensions of the subject (Nolen-Hoeksema
et al., 2008).
The relationship between the variables of Self-eﬃcacy
to pain and Catastrophizing to pain has been docu-
mented in other studies in this population (Sánchez et
al., 2011; Tirado et al., 2014). Few authors have been in-
clined to present explanations about the nature of this
relationship: some consider them independent evalua-
tions, highlighting their function as beliefs (Quartana et
al., 2009; Sánchez et al., 2011); while others postulate
theories about their interdependence relationship within
the framework of theoretical models. Such is the case
of Woby et al. (2007), who related them in the frame-
work of the Fear-Avoidance Model, suggesting that the
catastrophic assessment of pain precedes the perception
of self-eﬃcacy for functioning in the subject and, in this
way, the resulting behavior to pain is triggered in the face
of pain, either as that of confrontation or avoidance.
In our model, we have interpreted that self-eﬃcacy
assessments exercise declarative content functions at the
higher level that will guide the perception of the individ-
ual’s ability to manage pain, including the tendency to
catastrophize, but no conclusions can be drawn about
the inﬂuence of Catastrophizing to pain in Self-eﬃcacy
to pain. That is, that Self-eﬃcacy to pain can aﬀect
the Catastrophizing to pain, with whom it competes
at the intermediate level, inducing a cascade of actions
destined for the execution and control of action plans,
whether they are a behavioral or a cognitive action.
At the second level of the model, we see the rela-
tionships that are established with the higher level. Ac-
cording to what was proposed by the original authors
of the S-REF, the higher level participates directly in
the selection of plans to be executed at the second level.
Similarly, this intermediate level can participate in the
creation of new beliefs (Wells, 2000). This process must
be considered dynamic and with a transforming capacity
of cognitions related to pain. This is one of the elements
that has been ignored in the analyses of the Neuroma-
trix Model when it is used in the understanding of the
cerebral phenomena involved in the processing of painful
stimuli (Melzack, 2001).
Now, we see that the variables of Self-eﬃcacy to pain
and negative Metacognitions can explain a high percent-
age of the variance of Catastrophizing to pain, mainly
due to the eﬀect of Self-eﬃcacy to pain. In this sense,
the idea of Catastrophizing to pain is also taken up as
a moderating variable between exogenous and endoge-
nous variables, given that in the initial model proposed,
the variables of Active Coping with Pain and Passive
Coping with Active Pain were also constituted in Mod-
erator variables directly inﬂuenced by Catastrophizing
int.j.psychol.res |doi: 10.21500/20112084.4897 85
Self-regulation of pain in Fibromyalgia
On the other hand, the determination coeﬃcients for
the variables of Active coping with pain and Passive cop-
ing with pain explained a low percentage of their vari-
ance in the proposed general model, and aﬀected the
goodness of ﬁt indices, resulting in the decision of ex-
cluding these two dimensions in the ﬁnal model. Coping
with pain is one of the variables that presents problems
when trying to analyze it associated with other psycho-
logical variables, and it has been suggested that there
is a great lack of knowledge of the strategies and styles
of coping in the face of the painful experience and the
evaluation domains for the Latin-American population
(Campbell et al., 2009).
In any case, the fact of having excluded these variables
cannot simply be translated as that coping with pain was
completely excluded from the model, since Catastrophiz-
ing to pain is actually a coping strategy. In fact, in its
origins, this construct was a dimension of coping styles
that later, due to the robustness of its results, evolved to
become an independent construct (Neblett, 2017).
Returning to the idea of Catastrophizing to pain as a
moderating variable between exogenous and endogenous
variables, the statistical model supported the presump-
tion of the theoretical model for the eﬀect of this, in the
deterioration of the levels of functionality in both dimen-
sions, with a predominance over Functionality for Self-
care, and also for the performance in the Socio-Cognitive
Functionality dimension. Other research has found an
association between higher levels of Catastrophizing to
pain with the deterioration of the physical functionality
(Besen et al., 2017; Craner et al., 2016; Vohs & Baumeis-
Another point to consider is that the statistical anal-
ysis conﬁrmed the initial assumption that Self-eﬃcacy to
pain exercises functions at the intermediate level of the
model, in such a way that it is able to directly inﬂuence
endogenous variables, besides the indirect eﬀect that ex-
erts through the Catastrophizing to pain. Thus, the
model proposes that Self-eﬃcacy to pain has a negative
eﬀect on the impact variables with a predominance on
Functionality for Self-care, that is, the higher the degree
of self-eﬃcacy, the lower the commitment in terms of
functionality. Several studies have provided similar con-
clusions (Alok et al., 2014; Peñacoba-Puente et al., 2015;
Sánchez et al., 2011; Van Liew et al., 2018), and the re-
markable thing about this ﬁnding is that Self-eﬃcacy to
pain generated a greater eﬀect on them than the Catas-
trophizing to pain. Other studies have found similar
results, even in the same impact proportions (Sánchez
et al., 2011; Tirado et al., 2014).
Additionally, the results should be mentioned in rela-
tion to the intensity of the pain. The model explains only
a small percentage of the variance of this variable; and the
only variable that had an impact on it was Self-eﬃcacy to
pain. This may be related to the conclusions that other au-
thors have made of this, as the variable with the greatest
impact in the daily life of those who suﬀer from ﬁbromyal-
gia, in the perceptions that they have of the painful experi-
ence(De Rooij et al., 2013; Lee et al., 2017), as well as the
level of emotional commitment they manifest. Other in-
vestigations have found this relationship, although they
have not considered techniques of explanatory analysis
(Mirõ et al., 2011; Sánchez et al., 2011; Van Liew et al.,
2018; Wells-Federman et al., 2003).
On the other hand, it should be noted that these vari-
ables of Self-Care Functionality, Socio-Cognitive Func-
tionality, and Pain Intensity indirectly represent the third
and last level, also called processing units, because it is
constituted by the interoceptive sensory processing sub-
circuits, processing exteroceptive sensory, and cognitive
processing, which are subject to the eﬀects of the inter-
mediate level or self-regulation.
That is to say that these cognitions and the action
plans that they induce intervene directly on the process-
ing units, especially through the induction of monitoring
or hyper vigilance, and with it an intensiﬁcation of the
activity of the intermediate level, with the consequent
increase in rumination processes, a frequent characteris-
tic in patients with ﬁbromyalgia syndrome (Coppieters
et al., 2015). Now, although the theoretical model also
predicts that the activity of the cognitive processing sub-
unit inﬂuences the level of self-regulation through intru-
sive thoughts, the design of this project does not allow
to reach this conclusion.
Finally, according to the results obtained, the beliefs
and metacognitions of people who suﬀer from chronic
pain, as in the case of ﬁbromyalgia, are not enough to
explain the pain, the way a person deals with pain, how
it aﬀects their performance in society, and its intensity,
that is, the thoughts are not the origin of this condi-
tion and would not increase it. This would have impor-
tant implications both for the conceptualization of the
ﬁbromyalgia condition itself and for the pharmacologi-
cal and psychological therapeutic approach. In this last
aspect, it should be understood that, in psychological
therapy, false expectations should not be created about
how the change in thoughts related to pain will mod-
ify pain levels, and in this way prevent ﬁbromyalgia pa-
tients from feeling, as with pharmacological treatments
and others, frustrated by the low response to the mod-
ulation of the pain experience.
With the statistical technique of pathway analysis used
in the study, it cannot be stated that the S-REF Model
can satisfactorily explain the variables of coping, func-
tionality, and pain intensity in the study sample. It is
possible that it be necessary to consider that other vari-
ables have an eﬀect of greater impact on the model, and
that they have not been included in the proposed model.
int.j.psychol.res |doi: 10.21500/20112084.4897 86
Self-regulation of pain in Fibromyalgia
However, this general result does not diminish the
importance of the conclusions that can be drawn be-
tween the dimensions that make up the model resulting
from the analysis.
In the model derived from the study, positive metacog-
nitions, negative metacognitions, and pain self-eﬃcacy
were considered as exogenous variables. They constitute
the content of self-beliefs capable of directing the action
plans that are put into operation in the processes of
cognitive self-regulation in the face of the painful expe-
rience, and they are capable of inﬂuencing one another.
It is possible that metacognitive variables take part
in determining the functionality in patients with ﬁbromyal-
gia, but they do not modulate pain intensity. Self-eﬃcacy
to pain is the variable that exerts the greatest inﬂuence
on the impact variables and, possibly, participates in the
targeting of cognitive self-regulation plans that decrease
the intensity of pain and improve functionality.
Additionally, catastrophic cognitions about the painful
experience are inﬂuenced by negative evaluations about
control strategies and by the perception of self-eﬃcacy
in the face of this experience. It also acts as a moderator
of the impact variables.
Finally, it can be concluded that psychological vari-
ables and cognitions cannot explain the level of intensity
of pain reported by patients with ﬁbromyalgia.
6. Limitations and recommendations
An important limitation of the study was the sample
size, due to its inﬂuence on the analysis of structural
equations. However, it should be mentioned that ac-
cess to this type of clinical samples is usually very lim-
ited. Other investigations that include larger sample
sizes should be considered.
Additionally, a limitation was that this study did not
have male participants, which can be expected due to
the higher prevalence of this condition in women. For
future studies, the inclusion of the male population is
On the other hand, it is convenient that theoretical
and applied research in psychology focus on the ade-
quacy of instruments or on the design of new psychome-
tric scales for the study of chronic pain in our population,
since some instruments used in this study only had Ex-
pert judgment of linguistic and conceptual equivalence
and not with scales at a population level.
It would also be advisable to study the relationship
of the variables studied here with other clinical and ther-
apeutic variables that can demonstrate their inﬂuence
on metacognitive processes. In the future, it is recom-
mended to explore the inﬂuence of other variables that
explain the alteration of the functionality and intensity
of pain, taking into account other dimensions that have
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