Nipping negative repetitive thinking in the bud has the potential to stave off numerous mental health disorders.
Think Eeyore and Piglet. Cheerful Piglet is a chronic worrier, coping with anxiety; glum Eeyore mulls over everything that might go wrong, sinking into depression. But both struggle with repetitive negative thoughts.
People who think this way often have trouble with maintaining their own well-being and relationships with others, says Thomas Ehring, a psychologist at Ludwig Maximilian University of Munich. “They repeatedly keep thinking about [something] without it being constructive.”
Clinicians typically address negative thoughts, such as worry and rumination, as part of a treatment plan for many diagnosed disorders, including depression, anxiety, obsessive-compulsive disorder, insomnia, suicidal ideation and other ailments. But formal diagnoses are not necessary to help people overcome this distressing way of thinking, experts argue.
The specifics of the stressor matter less than people’s tendency to get stuck in endless doom loops, says psychologist Michelle Moulds of the University of New South Wales in Sydney. In fact, given its prevalence across disorders, clinicians should consider targeting negative thinking directly, write Moulds and Peter McEvoy, a psychologist at Curtin University in Perth, Australia, in February in Nature Reviews Psychology.
“We can look beyond diagnoses,” Moulds says, and ask “what is it for this particular person that is keeping them stuck?”
Getting a diagnosis
Formal diagnoses for mental health disorders were rare up until about half a century ago. But in 1980, the third edition of the Diagnostic and Statistical Manuel, or DSM-III, established thorough diagnostic criteria for a wide range of mental health disorders. The latest iteration is over 900 pages long and covers over 500 diagnostic categories.
“This has become the mainstream way of dealing with poor mental health. Look at disorders as our main unit of analysis,” Ehring says.
The current system is premised on the idea that most patients will present with a single disorder. That diagnosis should then guide treatment. In reality, most people struggling with mental health problems meet the diagnostic criteria for multiple disorders. And even when two people receive the same diagnosis, they may experience strikingly different symptoms.
Shared symptoms
Those shortcomings have prompted many researchers to turn their attention to what are called transdiagnostic factors, or symptoms that seem to transcend diagnostic boundaries. Those factors can include avoidance tendencies, interpersonal challenges, attentional biases and repetitive negative thinking.
Researchers in this emerging field remain divided: Should they combine conventional and transdiagnostic approaches? Or to do away with conventional diagnoses altogether and simply treat those overarching transdiagnostic symptoms?
Regardless of where one lands in that debate, recent advances in understanding and measuring repetitive negative thinking make the factor an ideal case study into what a transdiagnostic treatment approach could look like in the future, say Moulds and others.
Identifying repetitive negative thinking
To identify individuals prone to repetitive negative thinking, some experts are starting to utilize scales that focus not on the content of persistent thoughts but their underlying patterns. The Perseverative Thinking Questionnaire, for example, asks people to rate statements, such as, “The same thoughts keep going through my mind again and again” or “I keep asking myself questions without finding an answer,” on a scale from 0 for never to 4 for almost always.
In tandem with those efforts, several therapies have emerged in recent years that target repetitive negative thinking directly. Such therapies shift the trajectory of a talk session, says psychologist Edward Watkins of the University of Exeter in England. Watkins helped develop one such therapy, known as Rumination-Focused Cognitive Behavioral Therapy, or RFCBT.
For instance, imagine two patients. One has been diagnosed with depression and is fixated on how hopeless they feel. The other has been diagnosed with obsessive compulsive disorder and cannot stop worrying about how the germs on their hands can make them sick. A clinician trained in traditional cognitive behavioral therapy will often help patients understand their specific mental health diagnosis by working through the unique content of their thoughts.
A clinician trained in the RFCBT, meanwhile, does not need a formal diagnosis to deliver care. Rather than exploring why something might have happened, or the deeper significance of the event, therapies that target negative thinking help patients shift to more actionable questions, such as how they can do something about it, Watkins says. In other words, transdiagnostic approaches seek to modify how people think, regardless of what they are thinking about.
Warding off mental health issues
The long-term hope is that identifying and treating those prone to repetitive negative thinking could protect such individuals from developing more serious mental health challenges in the future, Moulds and McEvoy write. This research is nascent but promising. For instance, in one study of roughly 250 teens and young adults who scored high on screenings for repetitive negative thinking, half the group received training to restructure such thought patterns while the other half did not. Those receiving the training showed lower levels of self-reported anxiety and depression symptoms a year after the intervention, researchers reported in March 2017 in Behaviour Research and Therapy.
Transdiagnostic approaches to care recognize that people do not fit into discrete diagnostic categories for mental health, Watkins says. Nor must such approaches be limited to mental health disorders. With mounting research showing how stress impacts the body, such as by increasing inflammation or blood pressure, clinicians could consider common physical and mental health factors in tandem. “It’s emerging … that [long-term health] is not just transdiagnostic between mental health disorders but transdiagnostic between mental and physical health,” he says.
If you or someone you know is facing a suicidal crisis or emotional distress, call or text the 988 Suicide & Crisis Lifeline at 988.