Pretreatment levels of rumination predict cognitive-behavioral therapy outcomes in a transdiagnostic sample of adults with anxiety-related disorders

Increasing research has implicated rumination in the development and maintenance of many types of psychopathology, including anxiety-related disorders. A few studies have explored the impact of rumination during cognitive-behavioral therapy (CBT) for anxiety-related disorders (which relies heavily on exposure-based interventions), with mixed results. The present study assessed levels of (trait) rumination before starting treatment for predicting outcomes in 147 adults seeking CBT for anxiety-related disorders in an open treatment clinic. Results revealed that pretreatment levels of rumination significantly predicted (lower) quality of life at the end of treatment, after accounting for baseline variance in quality of life. This finding remained robust when also accounting for demographics, depression, general anxiety, and diagnosis. This result was not observed for self-reflection (a construct related to, but distinguishable from, rumination). Nevertheless, a follow-up (receiver-operator characteristic) analysis showed that pretreatment rumination did not reliably distinguish participants who showed clinically meaningful gains in quality of life during treatment from those who did not. Theoretical and clinical implications of these findings are discussed. We propose that rumination may impede emotional processing during CBT for anxiety, and warrants further attention and treatment. However, more advanced methods (e.g., multivariate modeling) are needed to improve the prognostic utility of rumination.     

Patient progress during two time-limited psychotherapies as measured by the Rutgers psychotherapy progress scale

Abstract

The maintenance of residual symptoms following acute treatment is common and is associated with poor long-term prognosis. This study investigates whether a cognitive-behavioral group treatment is effective in reducing residual depression by targeting depressive rumination. Participants (N=60) were randomly assigned to either the group treatment or a wait-list control condition. Treatment significantly improved depressed mood, rumination, perceived control over rumination and dysfunctional metacognitive beliefs compared with the wait condition. Treatment gains were maintained over the follow-up period of 1 year. Attrition was low and treatment satisfaction was high. Eight individuals suffered from a depressive relapse/recurrence in the year following treatment. The results indicate that cognitive-behavioral group therapy for depressive rumination is effective and well accepted by patients suffering from residual depression.     

Rumination and vomiting in the developmentally disabled: A critical review of the behavioral, medical, and psychiatric treatment research

Medical and psychiatric research regarding the treatment of vomiting and rumination among developmentally disabled individuals was selectively reviewed. Because of serious methodological flaws which pervade the psychiatric literature, claims for the effectiveness of psychiatric interventions for vomiting and rumination cannot be justified. Medical interventions (e.g., pharmacological and surgical interventions) were found to be effective when rumination was attributable to a specific organic pathology. In the absence of identified organic pathology for rumination, medical interventions are of questionable efficacy and because of the risks and side effects associated with these procedures, are seldom the intervention of first choice for functional rumination. Behavioral procedures for the treatment of vomiting and rumination are described and critically reviewed for their efficacy, side effects, and the generalization and maintenance of their effects. Although methodological weaknesses limit conclusions regarding the efficacy of some behavioral interventions, several procedures have sound experimental support including oral hygiene, differential reinforcement of incompatible behaviors, and food satiation procedures. These behavioral interventions are the treatments of choice when organic causes of rumination cannot be identified. Suggestions for future research and applications are discussed.     

Explicating the role of amygdala substructure alterations in the link between hypoleptinemia and rumination in anorexia nervosa

Objective

The amygdaloid complex plays a pivotal role in emotion processing and has been associated with rumination transdiagnostically. In anorexia nervosa (AN), we previously observed differential reductions of amygdala nuclei volumes (rostral-medial cluster substantially affected) and, in another study, elevated food−/weight-related rumination. Both amygdala volumes and rumination frequency correlated with characteristically suppressed leptin levels in AN. Thus, we hypothesized that amygdala nuclei alterations might be associated with AN-related rumination and potentially mediate the leptin-rumination relationship in AN.

Methods

Rumination (food−/weight-related) was assessed using ecological momentary assessment for a 14-day period. We employed frequentist and Bayesian linear mixed effects models in females with AN (n = 51, 12–29 years, majority admitted to inpatient treatment) and age-matched healthy females (n = 51) to investigate associations between rostral-medial amygdala nuclei volume alterations (accessory basal, cortical, medial nuclei, corticoamygdaloid transitions) and rumination. We analyzed mediation effects using multi-level structural equation models.

Results

Reduced right accessory basal and cortical nuclei volumes predicted more frequent weight-related rumination in AN; both nuclei fully mediated the effect of leptin on weight-related rumination. In contrast, we found robust evidence for the absence of amygdala nuclei volume effects on rumination in healthy females.

Conclusion

This study provides first evidence for the relevance of specific amygdala substructure reductions regarding cognitive symptom severity in AN and points toward novel mechanistic insight into the relationship between hypoleptinemia and rumination, which might involve the amygdaloid complex. Our findings in AN may have important clinical value with respect to understanding the beneficial neuropsychiatric effects of leptin (treatment) in AN and potentially other psychiatric conditions such as depression.     

Functional connectivity of the amygdala and subgenual cingulate during cognitive reappraisal of emotions in children with MDD history is associated with rumination

Major Depressive Disorder (MDD) is characterized by poor emotion regulation. Rumination, a maladaptive strategy for dealing with negative emotions, is common in MDD, and is associated with impaired inhibition and cognitive inflexibility that may contribute to impaired emotion regulation abilities. However, it is unclear whether rumination is differently associated with emotion regulation in individuals with MDD history (MDD-ever) and healthy individuals. In this study, children (8–15 years old) performed a cognitive reappraisal task in which they attempted to decrease their emotional response to sad images during fMRI scanning. Functional connectivity (FC) between both the amygdala and subgenual anterior cingulate (sACC) increased with cortical control regions during reappraisal as rumination increased in MDD-ever, while connectivity between those regions decreased during reappraisal as rumination increased in healthy controls. As the role of cortical control regions is to down-regulate activity of emotion processing regions during reappraisal, this suggests that rumination in MDD-ever, but not controls, is associated with inefficient regulation. This finding suggests that rumination may be particularly associated with poor emotion regulation in MDD-ever, and may also indicate qualitative group differences in whether rumination is maladaptive. These differences in rumination may provide important insight into depressive risk and potential avenues for treatment.     

Measuring state pre-event and post-event rumination in Social Anxiety Disorder: Psychometric properties of the Socially Anxious Rumination Questionnaire (SARQ)

Cognitive models have consistently recognised pre-event and post-event rumination as maintaining factors in Social Anxiety Disorder (SAD). This study aimed to investigate the psychometric properties of a state-based measure of pre-event and post-event rumination in SAD: The Socially Anxious Rumination Questionnaire (SARQ), which was formerly known as the Thoughts Questionnaire. In particular, we examined the factor structure, internal consistency, test-retest reliability, construct validity, sensitivity to treatment response, clinical cut-off scores (relative to non-clinical participants), and associated test performance indicators of the SARQ. The sample comprised 505 adults with a principal diagnosis of SAD and 130 non-clinical controls. Pre-event and post-event rumination were assessed in relation to a three-minute impromptu speech. Results indicated single factors for the SARQ: Pre-event and SARQ: Post-event scales, along with excellent internal consistency, good test-retest reliability, sound sensitivity to cognitive-behavioural treatment response, and a clear ability to discriminate between individuals with a principal diagnosis of SAD and non-clinical controls. The findings justify the SARQ’s use as a robust and reliable measure of state rumination for individuals with SAD that can be used both before and after encountering a social threat.     

Shooting the Messenger: Authors' Response

We aimed to investigate the effect of sleep problems, depression, and cognitive processes on suicidal risk among 460 young adults. They completed self-report questionnaires assessing suicidal behavior, sleep quality, depressive symptoms, emotion regulation, rumination, and impulsivity. Suicidal participants exhibited higher rates of depressive symptoms, sleep problems, expressive suppression, rumination, and impulsivity. A confirmatory factor analysis model revealed pathways to suicidal risk that showed no direct pathways between sleep problems and suicidal risk. Instead, sleep was related to suicidal risk via depression and rumination, which in turn increased suicidal risk. These results suggest that addressing sleep problems will be useful in either the treatment or prevention of depressive and rumination symptoms and reduction in suicidal risk.     

Rumination: The Eating disorder of infancy

Rumination is a relatively rare, potentially fatal syndrome in infants. This article reviews the historical and current treatment of rumination. Two cases are presented: a six-month-old who narrowly escaped surgery when the disorder was not recognized, and a complicated case from the neonatology intensive care unit. Environmental changes and enhanced mothering are described as being critical to correction of rumination and appropriate weight gain.     

Induced rumination dampens executive processes in dysphoric young adults

Self-focused, analytical mental rumination constitutes a central process in depression. It has been hypothesized that such rumination depletes executive resources that are necessary for an efficient cognitive regulation of emotion and behavior. However, most of the research supporting this hypothesis is of correlational nature. The present study examined the effects of induced rumination versus distraction on executive capacities in dysphoric and nondsyphoric college students. Executive functioning was measured with the Stroop task. Results indicate that induced rumination decreases inhibition capacities in dysphoric individuals only. The flexibility facet of executive functioning was not affected by induced rumination. However, dysphoric individuals demonstrated a fundamental impairment in this latter capacity, independent of rumination induction. The implications for the facets of executive functioning affected by depression and by rumination are discussed.     

Varied citrus treatment of ruminant gagging in a teenager with Batten's disease

Chronic ruminant gagging was substantially reduced in a severely retarded 13-year-old girl with Batten's disease through the use of contingent citrus juice in an ABAB design. Previous literature suggests that citrus juice may not be effective for treatment of rumination in older and/or handicapped children due to habituation. In this study, habituation may have been prevented by alternating lime juice and lemon juice when ruminative gagging reached a predetermined rate. The lemon/lime variation offers an effective, practical, and acceptable alternative to other response suppression procedures for rumination.