Motivation and emotion/Book/2013/Rumination

= Rumination: How to Battle the Invasion of Negative Thoughts =



Overview
Rumination: Battling the Invasion of Negative Thoughts aims to offer a comprehensive guide to the Response Styles Theory of Rumination (RST), the Self-Regulation Executive Function (S-REF) model and alternative psychological theories that have shaped our understanding of rumination. Furthermore, it will examine psychological and self-help treatments with the intention of presenting a practical way in which to "improve your life". This chapter aims to explore the groups of people affected by rumination, the antecedents and the consequences. Moreover, it will uncover the processes by which rumination occurs and the implication this has for different treatments. This chapter will present alternative explanations and similar constructs to rumination. However, rumination will consistently be understood as a maladaptive cognitive process implicated in ineffective everyday coping and the maintenance or progression of depression. In other words, rumination as a symptom of major depression is the focus of this chapter. Thus, in line with a self-help theme, this book aims to offer an understanding of the psychology theories of rumination, the psychological treatments used to address individuals presenting with a ruminative response style, and to offer practical and generalized self-help methods.

Introduction
Rumination is an emotional cognitive response to depressed moods or feelings of sadness often described as an ongoing, stubborn cycle of repetitive, passive and often negative thoughts, mainly implicated in major depression. Moreover, ruminative content usually involves thinking about one's symptoms of depression and it's causes and consequences (Nolen-Hoeksema, 2004). Two theories have dominated research on rumination, the RST and the and S-REF model. The RST understands rumination to be a ineffective response, characteristic of the individual, to negative affect. On the other hand, the S-REF model proposes that individuals ruminate because of metacognitive beliefs concerning the function and consequences of rumination. Alternative theories have suggested it is a function of self-regulation or goal-progress. Research has demonstrated how certain developmental antecedents may explain why certain individual's have a propensity to ruminate. Furthermore, research has presented deleterious consequences, such as the maintaining and exacerbating of depression related symptoms. A number of psychological treatments have been developed to treat depression as whole, with the hope of modifying rumination. However, certain psychological treatments and self-help strategies have been implemented to directly address the process of rumination.

Models of Rumination
The S-REF model of rumination and the RST are the two prominent theories in the study of rumination and have subsequently influenced understandings of depression and psychological treatments. Alternative explanations include Goal-Progress Theory, maladaptive and adaptive self-focus and Impaired Disengement Theory. Moreover, there are similar, but distinguishable, cognitive constructs to rumination.

The Response Styles Theory (RST)
RST defines rumination as a cognitive response style which involves repetitively and passively thinking about one’s symptoms of depression and its causes and consequences (Nolen-Hoeksema, 2004). Rumination is said to arise in response to feelings of sadness or depression and this response is what determines whether that negative mood is maintained or exacerbated (Whitmer & Gotlib, 2013). Several studies (Conway, Csank, Holm, & Blake, 2000; Nolen-Hoeksema, 2004; Ciesla, Dickson, Anderson, & Neal, 2011) have revealed individual differences in the tendency to engage in rumination. In other words, certain people have a certain response style to negative affect. According to RST, rumination is comprised of three factors, brooding, reflecting and depression-related thoughts, with brooding being a particularly maladaptive component of rumination (Treynor, Gonzalez & Nolen-Hoeksema, 2003). Nolen-Hoeksema (2004) proposed rumination exacerbates and prolongs depressive symptoms through four mechanisms; 1) rumination make a person more likely to use negative thoughts and memories, triggered by depressed mood, to understand the current situation; 2)interferes with effective problem solving; 3) interferes with behaviors that will contribute to solutions for a depressed state; and 4) chronically ruminating has negative social outcomes, as it often causes a loss of social supports. Moreover, rumination predicts an increase in depressive symptoms, with distraction, the alternative, leading to effective problems solving and a decrease in depressive symptoms (Nolen-Hoeksema, 2004). Several studies have demonstrated that higher levels of depressive symptoms are associated with a propensity to ruminate (Nolen-Hoeksema & Morrow, 1991; Nolen-Hoeksema, 1999; Crane, Barnhofer, & Williams, 2007). The Ruminative Responses Scale (RRS) from the Response Scale Questionnaire (RSQ) was developed by Nolen-Hoeksema (1991) and is most commonly used to assess rumination defined by RST. The RRS Contains 22 items asking participants to describe how often they engage in ruminative thoughts and behaviors when feeling sad or depressed. Additionally, they are asked to describe self-focused depressed mood, symptom focused depressed mood, and focus on the possible consequences or causes of their mood (e.g. “I won’t be able to concentrate if I keep feeling this way”) (Nolen-Hoesksema, 2004).

The Self-Regulatory Executive Function (S-REF) Model
According to the S-REF model of emotional disorders individuals ruminate because of metacognitive beliefs concerning the function and outcomes of rumination. Thus, depressed individuals may have positive metacognitive beliefs about rumination, that it is a helpful coping strategy. However, when rumination fails to offer an effective solution negative metacognitive beliefs arise related to instability and harm in rumination (Roelofs, Huiber, Peeters, Arntz & van Os, 2009). The Self-Regulatory Executive Function (S-REF) model of rumination comprises three levels of processing: 1) lower level processing networks; 2) supervisory executive system; and 3) self-knowledge level comprised of self-beliefs and standard plans for coping (Matthews & Wells, 2004). At the lower level information is processed routinely and Negative Automatic Thoughts (NATs) are experienced at this level which is typical of depression. Significant external stimuli is processed at the supervisory executive level, negative events are also appraised at this level and a coping strategy is sought after (Matthew & Wells). Both lower level and supervisory executive levels of processing depend upon the third level of processing, self-relevant knowledge as it provides a frame of references for responses and generic procedures for coping (Matthews & Wells, 2004). Thus, the S-REF model posits that emotional disorders are maintained by a number of factors which include the inability to monitor dysfunctional beliefs and ineffective use of the supervisory executive level to formulate an appropriate coping strategy(Roelofs, Huiber, Peeters, Arntz & van Os, 2009). Meta-cognitive beliefs about rumination can be assessed on the Negative and Positive Beliefs about Rumination Scales (Wells & Papageorgiou, 2004).

Alternative Explanations for Rumination
Researchers have explored the functional purpose of rumination and have suggested it can be seen as a function of goal progress, self-regulation, emotional regulation or a direct response to stressful events (Papageorgiou & Wells, 2004). Rumination may be conceptualized as a specific response to stress where negative, event-related rumination occurs after a stressful event occurs(Smith & Alloy, 2009). Befittingly, it is known as the Stress-Reactive model and has many similarities to the RST. However, it proposes rumination consist only of thoughts about the stressful events rather than other cognitive processes such as memories (Smith & Alloy, 2009). According to Goal-Progress Theory rumination is the tendency to repetitively think about goals that have not yet been achieved(Martin, Shrira & Startup, 2004). Thus, a failure to attain or progress towards a goal causes rumination. Moreover, a goal has the tendency to remain prominent in memory making it more likely to be detected and acted upon. Consequently, rumination is seen in this model as a self-regulation process which helps to instigate a solution to the problem impeding goal attainment (Martin, Shrira & Startup, 2004). Rumination has also been described in terms of adaptive and maladaptive self-focus. Self-focus models distinguish Conceptual Evaluative Self-focus rumination which is a maladaptive form of rumination, perpetuating or amplifying depressive symptoms. Alternatively, Experiential Self-focus is an adaptive form which is important for effective emotional processing, self-regulation, greater self-awareness and self-knowledge (Smith & Alloy, 2009). Similarly, rumination has been described as a function of regulation of emotions where rumination is seen to be an important function of cognitive emotional processes like attention and appraisal(Smith & Alloy, 2009). This Cognitive Emotional Regulatory Process theory of rumination allows for the possibility that rumination may also carry with it negative themes such as self-blame which affect cognitive emotional processes (Smith & Alloy, 2009). The Impaired Disengagement Hypothesis understands depressive rumination from a cognitive perspective. It assumes that ruminative thoughts are cued by internal stressors, such as negative affect or memories, or external stressors that impede upon goal progress (Koster, De Lissnyder, Derakshan, & De Raedt, 2011). This hypothesis identifies cognitive conflict signalling (negative thoughts are identified as being inconsistent with positive self views) as being a normal cognitive process to disengage from negative thoughts. However, individuals who ruminate lack attentional control when cognitive signalling conflict arises and sustain attention on self-referring negative information (Koster, De Lissnyder, Derakshan, & De Raedt, 2011).

Similar Cognitive Constructs
There are a number of cognitive processes similar to rumination that occur in depression or as a negative response to external events. For example, worry is similar in that it is thought to exacerbate anxious or depressed moods, impede problem solving and cause withdrawal (Ciesla, Dickson, Andersn & Neal, 2011). However, it is characterized by negative expectations about a future event whereas rumination involves dwelling on things from the past or perpetuating a current negative thought. Negative automatic thoughts are short-lived evaluations of failure and loss whereas rumination is better characterized as a longer lived, repetitive and cyclic thinking process (Papageorgiou & Wells, 2004). Newby & Moulds (2012) investigated features of rumination and intrusive memories and found a number of similarities between the constructs. Both rumination and intrusive memories had similar thought components and were associated with the same negative emotions. Thus, they were only found to be distinguishable in duration (Newby & Moulds, 2012). There are also cognitive processes that have similar properties to rumination but without any deleterious outcomes, such as private self-reflection or self-analysis. However, Nolen-Hoeksema & Morrow (1993) demonstrate that private self-consciousness is a propensity to self-analyze regardless of the mood and is not a predictor of depression after controlling for rumination. Rumination is often self-focused and involves negative appraisals of self rather than being a productive motif in reducing discrepancy between real and ideal states, characterized by self-reflection (Papageorgiou & Wells, 2004).

Consequences of Rumination
Rumination is consistently found to be related to worsening and prolonging of depressive symptoms and implicated in the development of major depressive disorders (Nolen-Hoeksema, 2000; Newby & Moulds, 2012). Ruminating has a number of deleterious consequences such as loss of social support, poor problem-solving capabilities, withdrawal or avoidance and lack of motivation for meaningful tasks. A number of maladaptive processes arise from rumination including dysfunctional attitudes, poor problem solving, helplessness, pessimism, self-criticism and neuroticism. Moreover, it has been implicated in self-harm, suicide and excessive alcohol consumption (Crane, Barnhofer & Williams, 2007;Hilt, Nolen-Hoeksema & Cha, 2008; Ciesla, Dickson, Anderson & Neal, 2011).

Antecedents/Causes of Rumination
Certain developmental antecedents have been proposed to contribute individual’s tendency to ruminate rather than avoiding negative thoughts, finding active solutions and seeking out social support (Nolen-Hoeksema, 2004). Nolen-Hoeksema (2004) suggests that for children, parental modelling of depressive rumination and passive responses to challenging situations is precursory to exhibiting the same responses. Moreover, children who were not encouraged to problem solve were more prone to becoming helpless to sources of upset. Nolen-Hoeksema, Grayson & Larson (1999) found that women are significantly more likely than men to ruminate and that the gender difference found in depression becomes non-significant after controlling for rumination. It is thought that males are encouraged more while growing up to develop an active solution to their depressed mood in comparison to females which may account for the existing gender differences in rumination (Nolen-Hoeksema, 2004).

Negative Outcomes of Rumination
Rumination leads people to think more negatively about past, present and future. Dysphoric ruminators are more likely to attribute current problems to their own failures. Moreover, they have a propensity to minimize their successes and overgeneralize failures (Nolen-Hoeksema, Wisco & Lyubomirsky, 2008). In regards to the future they tend to be pessimistic and hold low expectations for upcoming events. Rumination interferes with interpersonal problem solving by eliciting beliefs that problems are unsolvable or too great. Furthermore, when an individual can construct a solution rumination has been shown to inhibit the motivation to implement it (Lybomirsky & Nolen-Hoeksema, 1995). Lyubomirsky and Tkach (2004) indicated this lack of motivation is maintained by the focus on depressive symptoms. In turn, this negative focus influences beliefs about one's ability to do something about their situation (Lyubomirsky & Tkach, 2004). Lybomirsky and Nolen-Hoeksema (1995) found throughout three experiments that dysphoric participants induced to ruminate were more pessimistic and negative in their thinking, rumination predicted the perpetuation of dysphoric mood, and participants generated less effective solutions to interpersonal problems.

Rumination also endorses a tendency to withdraw from constructive behaviors. A study found that women prone to ruminate were delayed in seeking diagnoses for breast cancer upon initial discovery of a breast lump (Lyubomirsky, Kasri, Chang & Chung, 2006).

Rumination has led to a loss of social support with rumination associated with a number of socially undesirable personality traits such as aggression and dependence (Nolen-Hoeksema, Wisco & Lyubomirsy, 2008).

Crane, Barnhofer and Williams (2007) demonstrated that deficits in problem-solving, caused by rumination, are associated with suicide. Thus, rather than suicide being related to the excessive thoughts surrounding symptoms and causes of one's depression it is the inability to think of a solution other than suicide (Crane, Barnhofer & Williams, 2007). Hilt, Nolen-Hoeksema and Cha (2008) found that rumination is implicated in the process involved with non-suicidal self-harm (NSSI). Ciesla, Dickson, Anderson and Neal (2011) examined the deleterious effects of depressive and angry rumination on drinking among college students, proposing to find a relationship between rumination and alcohol use or binge drinking behaviors and as a means of escaping ruminative thoughts. The results indicated that higher levels of angry rumination in both men and women were related to significantly greater alcohol consumption (Ciesla, Dickson, Anderson & Neal, 2011).

Managing Rumination
Various cycles of negative thought are found in many psychological disorders such as Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), Post Traumatic Stress Disorder (PTSD), and Obsessive Compulsive Disorder (OCD) (Purdon, 2004). For sufferers of depression thoughts are often invaded by perceived flaws in character, past mistakes and wrongdoings and many OCD sufferers ruminate about why they feel compelled to perform ritual behaviors and have obsessive thoughts (Matthews & Wells, 2004). Moreover, re-occurring images or thoughts about a traumatic event, re-living the event (consciously recounting what happened) and getting revenge are symptomatic of PTSD (Matthews & Wells, 2004). However, rumination can also be found within the general population in response to social situations, generally negative moods or “down days” and memories of negative past events or circumstances. The literature implies a distinction between normal forms of rumination that occur outside of the clinical setting where an individual may engage in self-focused information processing (Matthews & Wells, 2004). In other words, after dwelling on a particular issue many people will find an action based solution or totally divert their attention. Thus, rumination becomes a problem in everyday life when it does not lead to a solution, prolongs or maintains negative affect and impedes effective coping and everyday function. Consequently, self-help methods may be an effective solution for battling the invasion of negative thoughts within the general and clinical population along with a number of psychological approaches.

Psychological Treatment
Psychological treatments include thought stopping, relaxation, desensitization and meditation. Moreover, various forms of these methods are found in specific therapies like, Cognitive Behavioral Therapy (CBT), Meta-cognitive Therapy and Mindfulness Based Cognitive Therapy (MBCT).

Thought Suppression
Thought suppression or stopping is introducing an aversive stimulus when rumination is beginning to occur. Thought suppression can be practiced in a therapeutic setting but is better taught and practiced by patients. The procedure a patient would be encouraged to practice is to introduce the aversive stimuli (e.g. say “stop” to themselves, pinch or snap an elastic band on themselves) at the occurrence of negative thoughts. Research has indicated that suppression of negative thoughts appears to be a successful short-term strategy (Purdon, 2004).

Relaxation Training
Relaxation serves to benefit suffers of both anxiety and depressive symptoms by alleviating bodily tensions induced by stress and encouraging flexibility in physiological responses (Purdon, 2004).

Attention Training
Attention Training Treatment (ATT) trains individuals in selective attention, attention switching, and divided attention. Wells (2000) developed the technique in response to the belief that all emotional disorder is due to a cognitive attention “syndrome” which is responsible for maintaining dysfunction. ATT works by getting patients to focus on different auditory stimuli and switching attention to more than one stimulus at once. Patients are asked to practice this twice a day and if negative thoughts enter their mind during a practice they are told to treat it as “noise” and it needs to be ignored (Purdon, 2004).

Cognitive Behavioral Therapy (CBT) and Meta-cognitive Therapy
CBT is based upon Beck's Cognitive Model of emotional disorders (1967) which places an emphasis on the negative patterns of thought in depression. CBT aims to modify three domains of negative thinking: 1) NATs; 2) thinking errors; and 3) depressogenic schemas (McMillan & Fisher, 2004). The content of NATs may be likened to depressive rumination, thus, the techniques used to challenge NATs may also be effective in modifying depressive rumination (McMillan & Fisher, 2004). CBT involves identifying the specific content of NATs, the person's beliefs about them, the emotions that occur with the thoughts and the intensity of these emotions. A therapist would help the person to challenge these thoughts and feelings using strategies such as re-phrasing NATs, questioning the evidence the person has about NATs and evaluating counter evidence or coming up with alternative explanations. Moreover, people with depression tend to make thinking errors (e.g. catastrophising and over-generalisation), attribute failures internally and have negative self-schemas. Hence, CBT employs methods to identify and label thinking errors, to re-attribute failures and to identify and challenge core beliefs (McMillan & Fisher, 2004).
 * Meta cognitive therapy is based upon the S-REF model in that it focuses on rumination and metacognitions. Metacognitions of rumination are the underlying and core beliefs about negative thoughts which are amplified by mood disturbances

associated with the negative appraisals of life events (Wells & Papageorgiou, 2004). The metacognitive model proposes that that people often believe that rumination is uncontrollable or that it is advantageous which make them either reluctant to challenge or abandon it (Wells & Papageorgiou, 2004). Thus the goals of metacognitive therapy are to introduce the patient to the idea that rumination is actually a source of the problem, facilitate abandonment of rumination, promote flexibility in cognitive control of rumination, challenge core beliefs and modify the negative beliefs about the emotions contributing to self-focus (Wells & Papageorgiou, 2004).

Mindfulness Based Cognitive Therapy (MBCT)
MBCT trains people to develop non-judgmental awareness of bodily sensations, thoughts and feelings, including difficult or discomforting ones, with goal of developing a "decentred" perspective such that the thoughts are seen as passing events in the mind(Purdon, 2004). Rather than challenging the negative thoughts the patient is encouraged to be aware of them and then disengage from them (Purdon, 2004). A central part of mindfulness is structured meditation where the patient allows for such thoughts to enter the mind and practices disengaging from them. Individuals who have experienced depressive episodes have a strong association between negative affect and repetitive negative thinking (Purdon, 2004). Rumination then becomes an almost habitual way of thinking in response to any stimulus that decreases a mood state. Thus, the attentional control skills taught in mindfulness meditation may be an effective method for breaking this habit or preventing relapse into major depression (Baer, 2003).

Self-help
Effective self-help strategies are cost-effective ways to reduce symptoms of depression or prevent the risk of depressive symptoms, such as rumination, progressing into a depressive disorder (Morgan & Jorm, 2008). Morgan and Jorm (2008) reviewed a large number of self-help strategies that belonged to the categories: herbal medicines or dietary supplements; substances; dietary methods; psychological methods; lifestyle changes; and physical and sensory methods. Upon reviewing the literature, the self-help strategies found to be the most effective for treatment of depressive symptoms included;S-adenosylmethione (SAMe); St John's Wort; bibliotheraphy; computerised interventions; distraction; relaxation training; exercise; pleasant activities; sleep deprivation; and light therapy (Morgan & Jorm, 2008).

Seeking help
http://www.beyondblue.org.au/

http://www.blackdoginstitute.org.au/

http://www.sane.org/information/factsheets-podcasts/178-depression

http://www.psychology.org.au/medicareprovider/Results.aspx?source=map&div_no=222

Conclusion
Rumination is an emotional cognitive response to depressed moods or feelings of sadness often described as an ongoing, stubborn cycle of repetitive, passive and often negative thoughts, mainly implicated in major depression. Moreover, the content usually involves thinking about one's symptoms of depression and it's causes and consequences (Nolen-Hoeksema, 2004). A number of maladaptive processes arise from rumination including dysfunctional attitudes, poor problem solving, helplessness, pessimism, self-criticism and neuroticism. Moreover, it has been implicated in self-harm, suicide and excessive alcohol consumption (Crane, Barnhofer & Williams, 2007;Hilt, Nolen-Hoeksema & Cha, 2008; Ciesla, Dickson, Anderson & Neal, 2011). The S-REF model of rumination and the RST are the two prominent theories in the study of rumination and have subsequently influenced understandings of depression and psychological treatments. Alternative explanations include Goal-Progress Theory, maladaptive and adaptive self-focus and Impaired Disengagement Theory. Moreover, there are similar, but distinguishable, cognitive constructs to rumination such as worry. Research has demonstrated how certain developmental antecedents may explain why certain individual's have a propensity to ruminate. Furthermore, research has presented deleterious consequences, such as the maintaining and exacerbating of depression related symptoms.Rumination becomes a problem in everyday life when it does not lead to a solution, prolongs or maintains negative affect and impedes effective coping and everyday function. Consequently, self-help methods may be an effective solution for battling the invasion of negative thoughts within the general and clinical population along with a number of psychological approaches. Moreover, there are a number of websites that offer strategies, seek services and provide information about depression and its symptoms such as, the Black Dog Institute and Beyond Blue.

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