CAS: a key driver of mental distress
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Have you ever found yourself stuck in a loop of negative thinking, where your negative thoughts seem to take over? This is a common experience that's a central concept in understanding psychological disorders. It all comes down to the Cognitive Attentional Syndrome (CAS), a key element in metacognitive therapy (MCT), and how it impacts mental health.
Understanding self-regulation
You're out of breath, your heart is racing, and you're sweating. Not surprising since you just broke your personal record on a three mile run. Over the next few minutes, your body works to recover, and soon enough, your respiration slows down, your heart rate normalizes, and your temperature drops. This is an example of the human brain and body's many self-regulating functions, to which we entrust the important task of keeping us alive. You're generally not aware that your brain is doing all of this. Your heartbeat, respiration, body temperature, and metabolism are being dealt with in the background as an autonomous and unconscious process. But that doesn't mean you can't become conscious of these processes. While reading this, you may become aware of your breathing. This sudden awareness is completely natural — it can even be beneficial, for example, when we focus on our breath to blow up a balloon. After the balloon is inflated, what will you do? You trust that your body will control your breathing again. But what if you stopped believing that your respiration can self-regulate, and that you can't trust it to automatically keep you alive? This belief would cause you to constantly focus on controlling your breath, preventing it from self-regulating naturally — it would feel like if you let go of control, you could die.
The mind is a self-regulating system
Interestingly, the way your brain handles your thoughts, feelings, and symptoms works similarly to your bodily systems. Your mind is inherently a self-regulating system, which primarily operates on an autonomous level. In other words, you're mostly unaware of its functions, and your mind regulates itself without your interference. In fact, your brain processes thousands of thoughts and emotions a day, most of which are being dealt with without you ever noticing them. But just like with your respiration, you can also become conscious of your thoughts, feelings and symptoms. Just asking yourself, 'What am I thinking about now?' is an example of how you can become conscious of your thoughts and thinking processes. Other times we might notice a negative (intrusive) thought such as:
- 'What if I burn out?'
- 'What if it's cancer?'
- 'What if something happens to my partner?' Because this is an uncomfortable thought, you might notice it and pay more attention to it than you would a thought about needing to buy tomatoes on your way home from work. You are now aware of the thought. And similarly to the respiration analogy, the question is: what will you do now? Should you treat the thought as important and significant? Should you worry about it in order to be prepared? Should you scan your body for symptoms that could be a sign of burnout or cancer, and continuously keep an eye on it? Or should you leave the thought alone and trust your mind to deal with it? Is it even within your control how you respond to the thought? These are examples of what you believe about thinking. In other words, your metacognitive beliefs. We all have them, and these beliefs influence how we respond to uncomfortable thoughts, symptoms, and emotions.
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Unhelpful metacognitive beliefs hinder self-regulation
Some people tend to handle negative thoughts and feelings in ways that make them spiral, while others generally allow their mind to self-regulate. Research has repeatedly shown that metacognitive beliefs influence how people respond to triggering thoughts and feelings: Unhelpful metacognitive beliefs can lead you to get stuck in cycles of overthinking, anxiety, and threat monitoring. This is called the Cognitive Attentional Syndrome (CAS), and it plays an essential role in maintaining and amplifying mental distress.
The Cognitive Attentional Syndrome (CAS)
The CAS is a common denominator across psychiatric disorders. It involves the coping strategies you use mentally and behaviorally in response to trigger thoughts. The problem with the CAS is that it keeps you focused on threats, activates more negative thoughts and feelings, and blocks you from discovering more flexible and helpful ways of responding to triggers. The CAS hinders self-regulation, which causes negative thoughts and feelings to persist when they would normally fade. Engaging in the CAS also prevents us from discovering that negative thoughts and feelings can't harm us, and that we don't need to engage with them.
The CAS keeps psychological distress going.
The CAS consists of three main categories of coping strategies: 1) thinking style, 2) threat monitoring or self-focused attention and 3) behavioral strategies that backfire. Here are some examples of the three categories:
1. Thinking style Worry, rumination, dwelling, doubting, regretting, and more: These are repetitive and negative thinking styles that deepen and maintain negative feelings, and activate even more negative thought content. For example, someone might constantly worry about their health or ruminate over a negative interaction with a colleague.
2. Threat Monitoring This involves a heightened focus on potential dangers or negative outcomes. For instance, after experiencing a traumatic event, you might constantly scan your environment for signs of danger, even when there is no immediate threat. Or you might scan for bodily symptoms that could signify a scary medical condition. Some will constantly monitor their mind to check if certain thoughts or feelings appear.
3. Behavioral Strategies that backfire These include behaviors like avoiding situations that could trigger anxiety, using alcohol or drugs to cope, or using coping strategies such as breathing exercises, overpreparation, checking, or asking for reassurance. Although these strategies might provide temporary relief, they often backfire and can maintain or even exacerbate the problem. It's important to note that these strategies are also common amongst people who don't struggle with their mental health, and only become a problem when applied too often and too rigidly, with the goal of 'fixing' one's mental health [3].
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Interrupting the CAS
One of the goals in Metacognitive Therapy is to reduce the CAS. This is done by helping you recognize your thinking patterns and coping strategies, and how they contribute to your mental distress. The next step is to help you discover that you have more control over these thinking and coping patterns than you might think, and that you can choose to interrupt or to not engage in the CAS. One reason why it's important to reduce the CAS early in treatment, is because the CAS drains your cognitive resources, stopping you from discovering more helpful ways to cope with negative inner experiences. Also, the energy spent on worrying about a problem leaves less mental capacity for actually addressing it. Successfully interrupting the CAS opens up the door to questioning fundamental beliefs that fuel the CAS to begin with, such as:
- Can overthinking be outside of my control if I can interrupt it?
- Is worry actually helpful?
- Does focusing on symptoms help me prevent a panic attack, or does it make me MORE anxious? In Metacognitive Therapy, a main way to interrupt the CAS is through Detached Mindfulness (DM). Detached mindfulness is the opposite of the CAS. It's an attitude and a technique where you see thoughts and feelings as passing events in your mind, rather than threats that need your immediate attention. It refers to being aware of what's going on inside of you without responding to it [1]. Responding with detached mindfulness to trigger thoughts reduces the activation of the CAS and helps modify the unhelpful metacognitive beliefs that maintain the CAS. A goal of Metacognitive therapy is to help you see that it's not the thoughts and feelings that are the problem, but your response to them. When you respond to negative thoughts without activating the CAS, you'll notice that these inner experiences, while still uncomfortable, are simply passing events in your mind and body. For more support in understanding and interrupting the CAS, you can book an appointment with a certified MCT therapist here.
References:
[1] Hjemdal, O., Hagen, R., Nordahl, H. M., & Wells, A. (2013). Metacognitive Therapy for Generalized Anxiety Disorder: Nature, Evidence and an Individual Case Illustration. Cognitive and Behavioral Practice, 20(3), 301-313. Advance online publication. https://doi.org/10.1016/j.cbpra.2013.01.002
[2] Capobianco, L., & Nordahl, H. (2023). A brief history of metacognitive therapy: From cognitive science to clinical practice. Cognitive and Behavioral Practice, 30(1), 45–54. https://doi.org/10.1016/j.cbpra.2021.11.002
[3] Nordahl, H., Hjemdal, O., Johnson, S. U., & Nordahl, H. M. (2023). Metakognitiv terapi. Tidsskrift for Norsk psykologforening, 60(12), 781-791. https://doi.org/10.52734/CHIQ3716
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