Reflecting on rumination: Consequences, causes, mechanisms and treatment of rumination
Section snippets
Rumination exacerbates psychopathology
A key finding across experimental and prospective studies is that rumination can exacerbate psychopathology in at least four ways: (a) it magnifies and prolongs existing negative mood states and associated negative thinking; (b) it interferes with effective problem-solving; (c) it interferes with active instrumental behaviour; (d) it reduces sensitivity to changing contingencies and context. Each of these effects is briefly reviewed in turn.
Rumination as an emotional magnifier
Experimental studies manipulating rumination have
Developmental antecedents and mechanisms underlying rumination
In considering the potential developmental antecedents and mechanisms of rumination, we first review what environmental and biological factors are associated with increased risk for depression. We then briefly review the most detailed accounts of rumination to date - Response Styles Theory (Nolen-Hoeksema, 1991) and Control Theory (Martin & Tesser, 1996), and their implications for mechanisms underlying rumination. We then describe a new model (H-EX-A-GO-N) that emerges from and elaborates on
Environmental context associated with vulnerability to rumination
The major environmental context factors associated with increased trait tendency to ruminate can be broadly categorized into (a) early adversity including childhood sexual and emotional abuse; (b) interpersonal stress and difficult circumstances; (c) unhelpful parenting styles and (d) socio-cultural expectancies and socialisation.
Biological characteristics associated with rumination
There is emergent evidence that particular patterns of brain activation and genetic polymorphisms are associated with rumination, raising the possibility that these biological substrates contribute to the vulnerability for rumination. However, caution is needed here, as the direction of causality is not yet established: biological changes could because or consequence of rumination, or associated with a common third factor.
Proximal mechanisms underlying rumination
In considering the mechanisms underpinning rumination, we start by considering the two predominant theories of rumination – Response Styles Theory (Nolen-Hoeksema, 1991) and Control Theory (Martin & Tesser, 1996), which respectively contribute two key mechanisms: the formation of a pathological habit through repeated learning and activation of rumination via unsatisfactory goal progress.
The integrative H-EX-A-GO-N model
The H-EX-A-GO-N model hypothesizes that each of the five mechanisms outlined contributes to the onset and maintenance of rumination in an additive and synergistic way: with each additional mechanism present, the greater the likelihood that an individual develops a propensity towards trait rumination. It proposes that a combination of multiple elements is necessary for pathological rumination to develop, as each factor on its own is not necessarily sufficient to produce an increase in trait
Treatment of rumination
All of the consequences of rumination reviewed earlier highlight the potential value of successfully targeting rumination. Successfully targeting rumination could enhance the efficacy and potency of psychological treatments and improve patient outcomes, especially for patients with co-morbid anxiety and mood disorders, and for those who are more chronic, complex, and less responsive to treatments. Indeed, patients with co-morbid anxiety and depression often have the poorest response to
Further research and new directions
In addition to the specific hypotheses arising from the H-EX-A-GO-N model that require testing, there are several further areas of merit for further exploration in rumination research. First, whilst self-report will necessarily always be critical to the study of rumination because it is essentially an experience of internal subjective consciousness, the development of well-validated implicit behavioural and psychophysiological incidences of rumination would be advantageous to the field. Such
Conclusion
The current review confirmed that depressive rumination has multiple negative consequences: (a) it exacerbates psychopathology across a range of mental health diagnoses including anxiety and depression, psychosis, insomnia and impulsive behaviours by magnifying and prolonging existing negative mood states and associated negative thinking, interfering with problem-solving and instrumental behaviour, and reducing sensitivity to changing contingencies and context; (b) it acts as a
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
One author (EW) has developed a variant of cognitive-behavioural therapy designed to target rumination (rumination-focused CBT), and receives royalties from Guilford Press for a published treatment manual for this intervention and receives remuneration for providing training workshops in this intervention. There are no other conflicts of interest.
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