Interactions between autonomic symptoms, interoception, illness perceptions and distress in Long COVID fatigue: An integrative model

BackgroundLong COVID is characterised by persistent symptoms, especially fatigue. We investigated the severity and impact of cognitive and physical fatigue in Long COVID, exploring associations with autonomic symptoms, interoceptive sensibility, illness perceptions and distress, underpinned by a novel framework integrating active inference and the Common Sense Model of Self-Regulation.MethodOnline cross-sectional survey between November 2024 and September 2025. Adults with self-reported COVID-19 and ≥12 weeks of fatigue symptoms were recruited via convenience sampling and completed validated questionnaires assessing fatigue, autonomic symptoms, interoceptive sensibility, illness perceptions and distress. Correlations and regression analyses examined associations between variables. Results183 participants completed the survey. Fatigue severity and impact were high, with physical fatigue rated more severe (Z = −2.96, p = .003) and impactful (Z = -8.714, p < .001) than cognitive fatigue. Correlational analyses showed moderate-to-strong associations between fatigue and autonomic symptoms, interoception, illness perceptions and distress. In regression models, these variables explained 21–54% of variance in fatigue. Autonomic symptoms were positively associated with cognitive and physical fatigue. Depression was associated with cognitive fatigue. Illness perceptions were associated with physical, but not cognitive fatigue. Interoceptive sensibility showed both positive and negative associations with fatigue.ConclusionsLong COVID fatigue is severe and multifaceted. It involves a dynamic interplay between dysfunction in physiological systems, illness perceptions, and distress, with interactions varying across dimensions of fatigue. We propose a framework of interacting physiological and psychological factors that shape the prediction and processing of bodily signals, ultimately giving rise to fatigue.