Rumination is the focused attention on the symptoms of one's mental distress, and on its possible causes and consequences, as opposed to its solutions, according to the Response Styles Theory proposed by Nolen-Hoeksema (1998). [1] [2]
Because the Response Styles Theory has been empirically supported, this model of rumination is the most widely used conceptualization. Other theories, however, have proposed different definitions for rumination. For example, in the Goal Progress Theory, rumination is conceptualized not as a reaction to a mood state, but as a "response to failure to progress satisfactorily towards a goal". [3] As such, both rumination and worry are associated with anxiety and other negative emotional states; however, its measures have not been unified. [4] Multiple tools exist to measure ruminative thoughts. Treatments specifically addressing ruminative thought patterns are still in the early stages of development. [5]
Response styles theory (RST) initially defined rumination as passively and repetitively focusing on one's symptoms of depression and the possible causes and consequences of these symptoms. [6] As evidence for this definition, rumination has been implicated in the development, maintenance, and aggravation of both depressive symptoms, [7] [8] as well as episodes of major depression. [9] Recently, RST has expanded the definition of rumination beyond depression to include passive and repetitive focus on the causes, consequences, and symptoms of one's distress in general. This change was made because rumination has been implicated in a host of disorders, not just depression. [4] [1]
RST also contends that positive distraction is the healthy alternative to rumination, where focus is directed to positive stimuli instead of to distress. [10] However, the literature suggests that positive distraction may not be as potent a tool as once thought. [4] [1]
Specifically, the S-REF model defines rumination as "repetitive thoughts generated by attempts to cope with self-discrepancy that are directed primarily toward processing the content of self-referent information and not toward immediate goal-directed action." [11] Put more simply, when a person ruminates, they aim to answer questions such as:
However, in answering these questions, ruminators tend to focus on their emotions (i.e., "self-referent information") as opposed to problem solving (i.e., "goal-directed action"). [11]
Meta-cognition is also an important part of the S-REF model and helps to explain the link between rumination and depression. [6] Specifically, those who hold "positive meta-cognitive beliefs" about rumination (to make sense of negative thoughts and emotions or ensure the prevention of the same) [12] are perhaps initially motivated to engage in rumination with high perseverance. [13] However, individuals who have engaged themselves in positive acts of rumination were more likely to use rumination as a coping mechanism upon encountering negative emotions. This causes the individual to modify his/her perception of rumination as unpleasant, unmanageable and "socially damaging" in general. [13] [14] Rumination additionally has a tendency to magnify with an up-regulation of emotions in the body, thus beginning the downward-moving spiral of depression. [15] The individual's "negative meta-cognitive" beliefs then contribute to the development and maintenance of depression. [13]
Goal progress theory (GPT), sometimes referred to as Control Theory, seeks to explain rumination as a function of goal progress. Specifically, GPT views rumination as an example of the Zeigarnik Effect, which suggests that individuals are more likely to remember information from unfinished tasks than from finished tasks. [3] [4] From this understanding, GPT defines rumination as "the tendency to think recurrently about important, higher order goals that have not yet been attained" or towards which sufficient progress has not been made. [4] [16]
GPT predicts that individuals for whom goal-related information is highly accessible should be more likely to ruminate. Various studies have provided support for this prediction. [3] However, the rumination experienced is focused more towards problem solving than rumination described by RST. [17]
Extensive research on the effects of rumination, or the tendency to self-reflect, shows that the negative form of rumination (associated with dysphoria) interferes with people's ability to focus on problem-solving and results in dwelling on negative thoughts about past failures. [18] Evidence from studies suggests that the negative implications of rumination are due to cognitive biases, such as memory and attentional biases, which predispose ruminators to selectively devote attention to negative stimuli. [19]
The organic causes of rumination are not fully understood. Research has identified the activation of certain regions in the brain's default mode networks as neural substrates of rumination, but the number of brain-imaging studies on rumination is limited. [20]
The tendency to negatively ruminate is a stable constant over time and serves as a significant risk factor for clinical depression. Not only are habitual ruminators more likely to become depressed, but experimental studies have demonstrated that people who are induced to ruminate experience greater depressed mood. [7] There is also evidence that rumination is linked to general anxiety, post traumatic stress, binge drinking, eating disorders, and self-injurious behavior. [1] Research suggests that rumination is somewhat associated with a higher frequency of non-suicidal self-injury, and more heavily associated with a history of non-suicidal self injury. [21]
Rumination was originally believed to predict the duration of depressive symptoms. In other words, ruminating about problems was presumed to be a form of memory rehearsal which was believed to actually lengthen the experience of depression. The evidence now suggests that although rumination contributes to depression, it is not necessarily correlated with the duration of symptoms. [1]
Research on the relationships between executive functions and rumination has yielded mixed results. Some studies have observed a negative correlation with two executive functioning abilities, set-shifting and inhibition, but the magnitudes of those relationships are unclear. [22] [23] Another study observed only one relationship between rumination and one executive function, specifically the ability to discard past information from working memory. [24] Other studies, however, found no relationship between rumination and working memory. [22] [23]
Theories of rumination differ in their predictions regarding the content of ruminative thoughts based on their respective conceptualizations. Some models propose that rumination is focused on negative feeling states and/or the circumstances surrounding that emotion (RST, rumination on sadness, five-factor model, [25] negative cognitive style, [26] social phobia [27] models). Rumination in other models focuses on discrepancies between one's current and desired status (goal progress, conceptual evaluative model of rumination). Finally, other models propose that it is the negative themes of uncontrollability and harm in metacognitions that are most important. [1] Some common thoughts that are characteristic of ruminative responses are questioning the well-being of oneself and focusing on the possible causes and consequences of one's depressive symptoms (Nolen-Hoeksema, 1991). For example, some ruminative thoughts include "why am I such a loser", "I'm in such a bad mood" or "I just don't feel like doing anything". [10]
There exist several types of rumination.
There are multiple tools for measuring rumination. These include the following:
The tendency to ruminate can be assessed with the Ruminative Responses Scale of the Response Styles Questionnaire. [32] [33] On this measure, people are asked to indicate how often they engage in 22 ruminative thoughts or behaviors when they feel sad or blue.
The Rumination On Sadness Scale is a self-report tool consisting of 13 items that uses the Likert Scale to measure rumination of sadness. [34]
The 31-item Repetitive Thinking Questionnaire (RTQ) measures worry, rumination, and post-event processing with the purpose of controlling for effects associated with a psychological diagnosis or disorder. It includes two subscales, Repetitive Negative Thinking (RNT) and Absence of Repetitive Thinking (ART). RNT is associated with anxiety, depression, and other negative emotions as it influences metacognitive beliefs, cognitive avoidance strategies, and maladaptive thought control strategies. [35] The ART subscale reflects the absence of those negative emotions associated with the RNT subscale, essentially measuring their opposites. [36]
The Rumination-Reflection Scale involves 24 items. Half of the questions look for adaptive reflective thought while the other half note self-rumination focus. This scale incorporates the Likert Scale. [37]
Recently, researchers have started to developed validated measurement protocol to best assess rumination in a dynamic fashion using experience sampling methodology. [38]
According to Susan Nolen-Hoeksema, women tend to ruminate when they are depressed, whereas men tend to distract themselves. This difference in response style was proposed to explain the higher rates of depression in women compared to men. [39] Research has supported the theory that women have a greater likelihood to ruminate than men, but the magnitude of this difference seems to be small. [40] The prediction that men are more likely to distract themselves has not been consistently supported in research. [41]
A meta-analysis was performed on both the sex differences in rumination of adults and the rumination subtypes "brooding" and "reflection." Studies show that women's chances of experiencing depressive symptoms or depression was twice that of men. The response styles theory (RST) suggests this may be due, to some extent, to higher rates of rumination in women. Brooding can be operationalized as continuous, passive, negative internalized thoughts. It is highly connected to worsening depression. Reflection is neutral, rather than negative, more active observation of self. In the meta-analysis, women showed statistically significant increases in levels of both brooding and reflection, supporting RST. Interestingly, there was a much smaller sex difference in reflection than brooding. The meta-analyses found similar results across multiple study designs. [42]
Although rumination is generally unhealthy and associated with depression, thinking and talking about one's feelings can be beneficial under the right conditions. According to Pennebaker, healthy self-disclosure can reduce distress and rumination when it leads to greater insight and understanding about the source of one's problems. [43] Thus, when people share their feelings with others in the context of supportive relationships, they are likely to experience growth. In contrast, when people repetitively ruminate and dwell on the same problem without making progress, they are likely to experience depression. Co-rumination is a process defined as "excessively discussing personal problems within a dyadic relationship", [44] a construct that is relatively understudied in both its negative and positive trade-offs.
Some studies have begun developing a type of cognitive behavioral therapy that focuses on rumination, but further research is still needed. [45] Rumination-focused cognitive behavior therapy aims to teach patients to recognize when they begin to ruminate and ultimately re-frame the way they view themselves. [5]
Rumination has been confounded with other similar constructs that may overlap with it. Worry and negative automatic thoughts are two of them.
Rumination appears closely related to worry. Some models consider rumination to be a type of worry (S-REF). [4] Worry has been identified as "a chain of thoughts and images, negatively affect-laden and relatively uncontrollable; it represents an attempt to engage in mental problem solving on an issue whose outcome is uncertain, but contains the possibility of one or more negative outcomes." [4] [46]
Worry is often studied in the context of generalized anxiety disorder (GAD), whereas rumination is often studied in the context of major depressive disorder. Because of the high comorbidity of these two conditions, more recent research is exploring the overlap of worry and rumination. [4]
According to the Mental Health Foundation, rumination has been identified to be one of the main problems that leads to anxiety and depression. A study conducted by psychologists from the University of Liverpool, suggests that dwelling on negative events that have occurred in one's life is the biggest predictor of depression and anxiety. [47]
Measures of rumination and worry have also demonstrated high correlations, above and beyond that of symptom measures of anxiety and depression (r=.66; Beck & Perkins, 2001). [48] Rumination and worry overlap in their relationships to anxiety and depression, although some studies do indicate specificity of rumination to depression and worry to anxiety. Rumination has been found to predict changes in both depression and anxiety symptoms and individuals with major depression have been reported to engage in levels of worry similar to individuals with GAD. As a whole, these studies suggest that rumination and worry are related not only to each other, but also each is related to symptoms of both depression and anxiety.
Other studies have demonstrated that the content of worry and rumination are distinct; worry thoughts are often focused on problem-solving and have a future orientation, whereas ruminative thoughts concern themes of loss and are more focused on the past. Rumination, as compared to worry, has also been associated with less effort and less confidence in problem solving (Papageorgiou & Wells, 2004). It has also been suggested that rumination and worry serve different purposes, namely that rumination is associated with greater belief in the personal relevance of a situation and a larger need to understand it, whereas worry is associated with a desire to avoid worry thoughts (Watkins 2004b). Worry has also been hypothesized to contain more imagery than rumination; however, support for this has been mixed. [49] [50] [51]
Overall, these studies suggest that worry and rumination are related constructs that both lead to depression and anxiety. It is likely that rumination and worry, as with rumination and reflection, are related types of repetitive negative thinking that may be better captured as subtypes of some larger construct, such as avoidant coping strategies.
Rumination has been compared to automatic negative thoughts, defined as repetitive thoughts that contain themes of personal loss or failure. Nolen-Hoeksema (2004) contends that rumination (as defined in RST) is distinct from negative automatic thoughts in that while negative automatic thoughts are relatively shorthand appraisals of loss and depression in depression, rumination consists of longer chains of repetitive, recyclic, negative and self-focused thinking that may occur as a response to initial negative thoughts. [52] Nolen also suggests that rumination may, in addition to analysis of symptoms, causes, and consequences, contain negative themes like those in automatic thoughts. Similarly, Papageorgiou and Wells (2004) have provided supports to this conclusion when they found that rumination can predict depression even when negative cognitions are controlled, suggesting that these constructs do not wholly overlap and have different predictive value. [11] Despite Nolen-Hoeksema's (2004) argument that rumination and negative automatic thoughts are distinct phenomena, the Response Style Questionnaire has been criticized for its conceptual overlap with negative automatic thoughts.
Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different from fear in that fear is defined as the emotional response to a real threat, whereas anxiety is the anticipation of a future threat. It is often accompanied by nervous behavior such as pacing back and forth, somatic complaints, and rumination.
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.
Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introduced by a group of US clinicians in the mid-1970s, the term was adopted by the American Psychiatric Association for this symptom cluster under mood disorders in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and has become widely used since.
Worry refers to the thoughts, images, emotions, and actions of a negative nature in a repetitive, uncontrollable manner that results from a proactive cognitive risk analysis made to avoid or solve anticipated potential threats and their potential consequences.
An intrusive thought is an unwelcome, involuntary thought, image, or unpleasant idea that may become an obsession, is upsetting or distressing, and can feel difficult to manage or eliminate. When such thoughts are associated with obsessive-compulsive disorder (OCD), Tourette's syndrome (TS), depression, body dysmorphic disorder (BDD), and sometimes attention-deficit hyperactivity disorder (ADHD), the thoughts may become paralyzing, anxiety-provoking, or persistent. Intrusive thoughts may also be associated with episodic memory, unwanted worries or memories from OCD, post-traumatic stress disorder, other anxiety disorders, eating disorders, or psychosis. Intrusive thoughts, urges, and images are of inappropriate things at inappropriate times, and generally have aggressive, sexual, or blasphemous themes.
Mindfulness-based cognitive therapy (MBCT) is an approach to psychotherapy that uses cognitive behavioral therapy (CBT) methods in collaboration with mindfulness meditative practices and similar psychological strategies. The origins to its conception and creation can be traced back to the traditional approaches from East Asian formative and functional medicine, philosophy and spirituality, birthed from the basic underlying tenets from classical Taoist, Buddhist and Traditional Chinese medical texts, doctrine and teachings.
Evolutionary approaches to depression are attempts by evolutionary psychologists to use the theory of evolution to shed light on the problem of mood disorders within the perspective of evolutionary psychiatry. Depression is generally thought of as dysfunction or a mental disorder, but its prevalence does not increase with age the way dementia and other organic dysfunction commonly does. Some researchers have surmised that the disorder may have evolutionary roots, in the same way that others suggest evolutionary contributions to schizophrenia, sickle cell anemia, psychopathy and other disorders. Psychology and psychiatry have not generally embraced evolutionary explanations for behaviors, and the proposed explanations for the evolution of depression remain controversial.
Behavioral activation (BA) is a third generation behavior therapy for treating depression. Behavioral activation primarily emphasizes engaging in positive and enjoyable activities to enhance one's mood. It is one form of functional analytic psychotherapy, which is based on a Skinnerian psychological model of behavior change, generally referred to as applied behavior analysis. This area is also a part of what is called clinical behavior analysis (CBA) and makes up one of the most effective practices in the professional practice of behavior analysis. The technique can also be used from a cognitive-behavior therapy framework.
Emotional self-regulation or emotion regulation is the ability to respond to the ongoing demands of experience with the range of emotions in a manner that is socially tolerable and sufficiently flexible to permit spontaneous reactions as well as the ability to delay spontaneous reactions as needed. It can also be defined as extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions. Emotional self-regulation belongs to the broader set of emotion regulation processes, which includes both the regulation of one's own feelings and the regulation of other people's feelings.
The theory of co-rumination refers to extensively discussing and revisiting problems, speculating about problems, and focusing on negative feelings with peers. Although it is similar to self-disclosure in that it involves revealing and discussing a problem, it is more focused on the problems themselves and thus can be maladaptive. While self-disclosure is seen in this theory as a positive aspect found in close friendships, some types of self-disclosure can also be maladaptive. Co-rumination is a type of behavior that is positively correlated with both rumination and self-disclosure and has been linked to a history of anxiety because co-ruminating may exacerbate worries about whether problems will be resolved, about negative consequences of problems, and depressive diagnoses due to the consistent negative focus on troubling topics, instead of problem-solving. However, co-rumination is also closely associated with high-quality friendships and closeness.
Behavioral theories of depression explain the etiology of depression based on the behavioural sciences, and they form the basis for behavioral therapies for depression.
Depression is a mental disorder characterized by prolonged unhappiness or irritability. It is accompanied by a constellation of somatic and cognitive signs and symptoms such as fatigue, apathy, sleep problems, loss of appetite, loss of engagement, low self-regard/worthlessness, difficulty concentrating or indecisiveness, or recurrent thoughts of death or suicide.
A persecutory delusion is a type of delusional condition in which the affected person believes that harm is going to occur to oneself by a persecutor, despite a clear lack of evidence. The person may believe that they are being targeted by an individual or a group of people. Persecution delusions are very diverse in terms of content and vary from the possible, although improbable, to the completely bizarre. The delusion can be found in various disorders, being more usual in psychotic disorders.
A cognitive vulnerability in cognitive psychology is an erroneous belief, cognitive bias, or pattern of thought that predisposes an individual to psychological problems. The vulnerability exists before the symptoms of a psychological disorder appear. After the individual encounters a stressful experience, the cognitive vulnerability shapes a maladaptive response that increases the likelihood of a psychological disorder.
Occupational therapy is used to manage the issues caused by seasonal affective disorder (SAD). Occupational therapists assist with the management of SAD through the incorporation of a variety of healthcare disciplines into therapeutic practice. Potential patients with SAD are assessed, treated, and evaluated primarily using treatments such as drug therapies, light therapies, and psychological therapies. Therapists are often involved in designing an individualised treatment plan that most effectively meets the client's goals and needs around their responsiveness to a variety of treatments.
Thought stopping (TS) is a cognitive self-control skill that should be used to counter dysfunctional or distressing thoughts, in hopes of interrupting sequences or chains of problem responses. When used with Cognitive Behavioural Therapy (CBT), it can act as a distraction, preventing an individual from focusing on their negative thought. Patients can replace a problematic thought with a positive one in order to reduce anxiety and worry. The procedure uses learning principles, such as counterconditioning and punishment. TS can be prescribed to address depression, panic, anxiety and addiction, among other afflictions that involve obsessive thought.
Metacognitive therapy (MCT) is a psychotherapy focused on modifying metacognitive beliefs that perpetuate states of worry, rumination and attention fixation. It was created by Adrian Wells based on an information processing model by Wells and Gerald Matthews. It is supported by scientific evidence from a large number of studies.
Perseverative cognition is a collective term in psychology for continuous thinking about negative events in the past or in the future.
Concreteness training (CNT) is the repeated practice of cognitive skills to create habitual behaviors in order to help reduce anxiety and depressive symptoms for those suffering from the disorder of depression. People suffering from depression have a tendency towards unhelpful abstract thinking and negative thoughts, such as viewing a single mistake as evidence that they are useless at everything. As such, CNT involves switching cognitive focus from negative thoughts to positive thoughts so as to cut down on rumination—focused attention on the symptoms of one's distress—and self-criticism, which can cause feelings of inadequacy and raise anxiety.
Katie A. McLaughlin is an American clinical psychologist and expert on how stress, trauma, and other adverse events, such as natural disorders or pandemics, affect behavioral and brain development during childhood and adolescence. McLaughlin is a Professor of Psychology at Harvard University.