Excellent article on metacognition [“The Power of Reflection,” by Stephen M. Fleming]. In reflecting on it, considering that metacognition is probably formed in large part with the help of external feedback, it occurs to me that for the past several decades, vast swaths of Americans have most likely had their metacognition impaired by unconditional positive reinforcement (for instance, unearned positive feedback or grade inflation), lack of punishment and drug abuse.

I have noticed that in mainstream American society many people have undue levels of confidence, which perhaps can be explained by impaired metacognition. This phenomenon is important because in matters such as hiring and mating we depend in no small part on one another's metacognition. Overconfidence or underconfidence can have direct consequences in many contexts, such as the above, and indirect consequences in many others downstream, such as the economy, unemployment, social discord, health and evolution.

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Another very enjoyable issue. Fleming's article was very well done. In his discussion of dysfunction, I noticed that all of the research that was cited concerned problems of reduced metacognitive functioning. I wonder whether dysfunction might also result from overactive metacognitive functioning. Some research suggests that rumination is a central feature of depression, at least in a subpopulation of depressed individuals. Rumination tends to be self-focused, including thoughts about one's own depressive symptoms; as such, it could be characterized as overactive metacognition.

I have chronic depression. I tend to ruminate, and much of my rumination is metacognitive. In fact, I have often described it this way to therapists, complaining that I sometimes have two, or even three layers of metacognition running at the same time, making it extremely difficult to concentrate. I would be interested to find out whether any research has shown that people with depression exhibit hyperactivity of the regions involved in metacognition or hypoactivity in the regions that exert top-down executive control over metacognitive processes.

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FLEMING RESPONDS: Konopasky raises an intriguing link between metacognition and rumination, a key feature of depression. We currently do not understand how the neurobiology of depression relates to the work on metacognition outlined in the article. Early PET studies found that depressed individuals have reduced glucose metabolism in the lateral prefrontal cortex and increased metabolism in medial prefrontal regions, compared with controls. Functional MRI studies have shown abnormal increases in functional connectivity among the medial prefrontal cortex and other brain regions in depression, possibly consistent with an increased self-focus and rumination.

Further experiments such as those suggested by Konopasky—examining brain activation and connectivity while depressed people engage in metacognition—would be needed to understand whether these tantalizing findings are related to changes in metacognitive thought.


Thank you for Stephani Sutherland's interesting article on fibromyalgia, “An Unnerving Enigma.” Unfortunately, one fundamental view about the origin of the disorder was missing. Fibromyalgia is, like tension headaches and some other not so well defined pain disorders, only one symptom of central sensitization syndrome, also known as migraine syndrome. As mentioned in the article, patients do not have just pain but also fatigue, memory and mood problems, sleep disturbances, and a variety of symptoms of the dysregulation of the autonomic nervous system.

This symptomatology does not differ at all from that what we see in chronic migraine. The entire spectrum of symptoms does not always manifest at the same time, but over the years—if different epigenetic and stress factors generate more and more widespread neuronal dysfunction—we see one symptom after another rising and fading, typically in a rhythm of three to four months. As a neurologist, I've seen hundreds (if not thousands) of migraine patients also diagnosed with fibromyalgia. After recognizing more than 10 years ago that fibromyalgia is just one variation of the sensorineural dysfunctions seen in migraine syndrome, I have had many more treatment options to offer to my patients.

Jyväskylä, Finland

SUTHERLAND REPLIES: As Ilmavirta rightly points out, fibromyalgia involves many symptoms aside from bodily pain that are rooted in the brain. Many questions still surround this “central sensitization,” which has been called by various other names as well, such as somatization syndrome. Fibromyalgia seems to be only one trigger of this sensitization; other mysterious pain conditions can also culminate in the brain state. The changes in the nervous system that lead to central sensitization are still poorly understood. But the new findings discussed in the article suggest that—contrary to previous investigations of patients with fibromyalgia—ongoing peripheral nerve damage could be one such trigger. The hope is that if the nerve damage were to be halted or alleviated, the rest of the syndrome might also recede, but much work remains to be done to determine whether that will happen in people with fibromyalgia.


Allison Bressler's article about domestic violence, “Love and Death,” inspired many letters to the editor. Some were complimentary: “Kudos to your magazine for publishing this story on domestic violence,” writes Kathryn Warren via e-mail. “All people need to be aware of the behavior signs of abusive persons so they can make better judgment calls before they invest in any relationship.”

Yet a few readers felt we focused unfairly on male violence toward women. “I agree most abuse comes from men, but women can also be abusive,” writes DeWayne Watts via e-mail. Research bears out this fact. Bressler responds, “That's true. Studies show that one out of seven men are battered in their relationship. It is important to note that number includes men in same-sex relationships. Men tend to experience verbal, emotional and financial abuse from their female partners; there are no specific studies that show at what rate women physically assault their partners.”

Many of you were concerned about the effect of domestic violence on children. “Men who abuse their wives don't abuse only their wives,” writes Michèle Gyselinck of Montreal. “Those who counsel women in abusive relationships might want to address the problem of how this abuse affects the kids, even if they aren't actually beaten themselves.” Bressler agrees and reports that many agencies do provide much needed counseling for children.

A couple of readers wrote in to suggest advice or further resources for victims. Paul Carney of Towson, Md., cautions that the article's recommendation to program the number for a shelter into a victim's phone could backfire: “Many abusers will check the victim's phone on a regular basis,” he writes. “The consequence of finding an unknown phone number, or that of a shelter, could be catastrophic.” Safety plans should indeed be tailored to each victim's circumstance, Bressler concurs. For a deeper discussion of abusive relationships and solutions, Citizens Advice Bureau counselor Michael Egan of St. Helens, England, suggests the highly regarded Why Does He Do That? by Lundy Bancroft (Berkeley Books, 2003).

The big question on many of your minds is: How can we change our culture so that abuse happens less frequently? “As an educator and parent of a young child, I am wondering what we can do much earlier in life to foster the development of women who would reject a partner's complete control of her finances, behavior and physical appearance and, furthermore, would recognize it right away as abuse,” writes Liz Swan via e-mail. Bressler reports that many schools in the U.S. have programs for middle school and high school children in which they learn about healthy and nonhealthy relationship behaviors. “I would also suggest that any parent engage their children about what they believe is healthy and not healthy in a partnership,” Bressler says. “We must begin the conversation with young children, in an age-appropriate way, so that they understand they are equal in their intimate relationships.” —The Editors