Worry, Rumination and Repetitive Thinking: Special Interest GroupGiovanni Maria Ruggiero Colette HirschLusia Stopa

Repetitive negative thinking • Worry, rumination an other types of repetitive negative

thinking (RNT) are transdiagnostic processes found across diverse problems including affective disorders, anxiety disorders, insomnia or psychosis (Harvey and Colleagues, 2004)

Key questions for the SIG• What are the processes involved in worry, rumination and

repetitive thinking?• How do they contribute to clinical disorders?• How can they be reduced?

What are the cognitive processes that we need to target?

• Repetitive uncontrollable worry• Rumination• Depressive rumination• Post-event processing in social anxiety disorder• Recurrent intrusive thoughts e.g. OCD• Suicidal ideation in depression• Thoughts accompanying impulsive urges in addictions, eating

disorders, self-harm etc• Imagery

Processes that might drive or underpin RNT• Metacognitive processes• Intolerance of uncertainty• Perfectionism• Other possible targets?

How do these cognitive processes contribute to clinical disorders?

• Transdiagnostic processes• Does this mean they are all relevant to all disorders?

• How much do we need to focus on content?• How are the different levels of processing involved?• How do trans-diagnostic models of RNT sit alongside disorder-

specific models of psychopathology?

How can RNT be reduced?• What interventions are there?• How good are they?• What is the right balance between a focus on process and a

focus on content?• In developing more effective interventions, what is the right

balance between transdiagnostic approaches and disorder-specific approaches?

COGNITION AND METACOGNITION IN GAD

Cognition and metacognition • How should we conceptualise RNT?• The process itself, i.e. repetitive, intrusive ‘cognitions’• Should we include the content?• Should we include metacognitive appraisals regarding the nature

of the thinking• or cognitive beliefs focused on the content (beliefs about self,

others, the world)

AN example: Cognition and metacognition in worry and GAD• For example, in the case of generalized anxiety disorder (GAD) worry

may be increased by either (Thielsch, Andor e Ehring, 2015)• metacognitions about worry itself and/or • a cognitive belief: Intolerance of Uncertainty (IoU)

Cognition in worry• The Intolerance of Uncertainty model (Dugas, Gagnon,

Ladouceur, & Freeston, 1998) highlights intolerance of uncertainty (IoU) as a cognitive key construct involved in worry and GAD.

Cognition in worry and GAD: Intolerance of Uncertainty • Intolerance of Uncertainty is defined as “a cognitive bias that

affects how a person perceives, interprets, and responds to uncertain situations on a cognitive, emotional, and behavioral level” (Dugas et al., 2005).

Cognition in worry and GAD: Intolerance of Uncertainty • IoU is conceptualized as a cognitive vulnerability factor for

GAD (Gentes & Ruscio, 2011; Koerner & Dugas, 2008)• Research has consistently shown strong associations between

IoU and levels of worry (Behar et al., 2009; Dugas & Robichaud, 2007).

Metacognition in worry and GAD• A large number of studies has shown strong associations

between metacognitions regarding uncontrollability and danger of worrisome thinking (Behar, DiMarco, Hekler, Mohlman, & Staples, 2009; Wells, 2004).

Metacognition in worry and GAD• Negative metacognitions (i.e., “Worry is uncontrollable and

dangerous”) are thought to lead to the maintenance of excessive levels of worry by causing futile attempts to stop worrying and thereby exaggerating the problem.

Cognition and metacognition• Only a handful of studies to date have investigated the role of

metacognitions and IoU within the same study.

Cognition and metacognition• Research has shown both constructs were significant

predictors of worry• However negative metacognition emerged as the stronger

prognostic construct when both variables were considered together (Gerlach et al., 2008; Khawaja & McMahon, 2011; Thielsch et al., 2015).

• In addition, metacognitive focused therapy is found to be more efficacious for the reduction of worry than cognitive therapy targeting IoU (van der Heiden, Muris, & van der Molen, 2012).

Cognition and metacognition• Therefore, negative metacognitions appear to show a closer

association with worry than the core component of the IoU model

• On the other hand, there is some evidence that the combination of both cognitive variables may be related to increased explanatory power showing either additive effects (e.g., Thielsch et al., 2015) or even interactive effects (e.g.; Ruggiero et al., 2012).

Cognition and metacognition• A combined perspective whereby intolerance of uncertainty is

a vulnerability factor and negative metacognitive beliefs as a maintenance factor for worry by leading to vain attempts of thought control

Cognition and metacognition• Thielsch’s findings using Ecological Momentary Assessment

(EMA) confirm that negative evaluation of occurring worrisome thoughts rather that the mere existence or frequency of worries is the crucial variable leading to excessive worry.

• Carolin Thielsch, et al., Do Metacognitions and Intolerance of Uncertainty Predict Worry in Everyday Life? An Ecological Momentary Assessment Study, Behavior Therapy (2015), http://dx.doi.org/10.1016/j.beth.2015.05.001

Cognition and metacognition• IoU can be assumed to predominantly play a role in initiating

the worry process, while negative metacognitions are mainly conceptualized as a maintaining factor (Thielsch et al., 2015; Ruggiero et al., 2012).