Is Long Covid 'all in the mind'?

New figures from the Norwegian Institute of Public Health show that fewer than 2 per cent were on sick leave six months after Covid-19 (Himmels et al., 2025). For this small group, the burden is severe. Yet other estimates suggest far more are suffering (NTB, 2025), while many receive little help because the health system finds no disease in the body. 

Large population studies show that there is often little correspondence between what people report of symptoms and what can be objectively assessed or measured in the body (Ballering et al., 2025). Thoughts, emotions, and life circumstances often explain symptoms better than biological findings. 

This points to a deeper issue: the divide between body and mind. Are symptoms 'real,' or are they 'just in the mind'? 

The mind-body divide 

The belief that the mind and body are separate creates two major problems. First, it means we believe that symptoms are always a warning sign from the body; and second, we can seriously underestimate the brain’s role in the experience of symptoms.

All symptoms are 'in the mind' – not because they are imaginary, but because the brain continuously makes inferences based on bodily signals and expectations. The communication goes both ways: the body affects the brain, and the brain affects the body. This interaction happens automatically, all the time, in everyone.

Take nausea as an example. The first time, it may be triggered by unusual bodily signals, such as when the balance system is overwhelmed on a boat or in a car. The brain experiences a prediction error, it receives conflicting input, and responds with nausea as a protective reaction. 

Later, reactions are shaped by experience, such as car- or seasickness, and thereby unconscious expectations of sharp bends in the road, large swells at sea, or even a person's mood. The brain can both amplify and dampen these signals. Over time, symptoms may persist even when the original cause is gone (Van den Bergh et al., 2017).

One part of the brain that plays an essential role in this process is the insula. It is active both when we register signals in the body and when we experience emotions. This helps explain why feelings and symptoms are so closely connected. 

We see it in everyday life: pain feels stronger when we are in a bad mood, and people who are feeling down report more complaints. For some, simply feeling sad or afraid is enough for the body to respond with symptoms. 

Experimental studies show that inducing negative emotions can make the brain generate symptoms (Bogaerts et al., 2023), activating structures that can actually be observed in the brain (Eisenberger et al., 2003; Hougaard et al., 2015).

Research also shows that symptoms that begin with a physical injury can last long after the cause is gone (Van den Bergh et al., 1997). The brain's predictive models continue to generate the experience. How closely feelings, body, and symptoms are linked varies both from person to person and within the same person over time (Van Den Houte et al., 2017).

When expectations shape experience 

A study using virtual reality (VR) goggles shows how strongly expectations can shape what we feel in the body (Finnegan et al., 2023). 

Healthy participants cycled while researchers varied both the resistance on the pedals and how steep the slope appeared in the VR goggles. Breathlessness was just as influenced by the sight of a steep hill as by the actual effort of pedaling harder.

It is therefore not only about what the body does, but about what the brain believes is happening. A central question is: How much is driven by signals from the body, and how much by the brain?

From acute to chronic 

In acute illness, symptoms usually correspond closely with the body's condition. As they become long-lasting, this link weakens and other factors take over.

In a large study of patients with asthma and chronic obstructive pulmonary disease, psychological factors explained five times more of daily breathlessness than biological measures of lung function (Ballering et al., 2025). 

When patients received a psychological self-management programme, unplanned doctor visits dropped by 58 per cent and hospital admissions by 40 per cent, while quality of life improved – even though lung function itself had not changed (Bourbeau et al., 2003). 

The same is seen in Long Covid, where several robust studies show that cognitive behavioural therapy reduces symptoms (Janse et al., 2018; Kuut et al., 2023; Nerli et al., 2024) even though the biological mechanisms are not yet fully understood.

What does this mean for Long Covid? 

That the Institute of Public Health in Norway finds fewer than 2 per cent with long-term sick leave after Covid-19 does not mean that persistent symptoms are rare. It only shows that different ways of measuring give different answers.

General practitioners report that three out of four symptoms they encounter lack a clear biomedical cause. In specialist care, this applies to one in three consultations. A quarter of patients who have been acutely ill say they still have complaints one year later, even when tests are normal.

An 'either–or' view of symptoms fuels stigma, over-diagnosis, and unnecessary investigations, while effective interventions are overlooked.

A necessary course correction 

Symptoms rarely have a single cause. They are more like a network of interacting factors and must therefore be understood holistically. Knowledge about how symptoms arise and are maintained – 'symptom science' – should have more space in medical education.

The health system must be structured so that patients receive a genuinely biopsychosocial approach from the very first day. For patients, it makes little difference how many are affected. The consequences are substantial in either case, both for individuals and for society.

A holistic understanding can finally put the 'mind versus body' divide behind us and open the way for a more solution-focused dialogue.

Concrete steps in primary care 

General practitioners and other frontline providers should explore both physical and psychological factors from the first consultation, not only after all tests are 'normal.'

A combination of medical examinations and early information about how symptoms arise and can be managed may reduce the risk that acute complaints develop into long-term problems.

The article is written on behalf of the Oslo Chronic Fatigue Network

 References:

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