HealthRumination Is A Risk Factor For Anxiety

Rumination Is A Risk Factor For Anxiety

Have you ever felt like your mind was “stuck” and that you kept thinking about the same negative things over and over?

That, try as you might, you couldn’t stop thinking about a recent mistake or embarrassment or failure, or worry about how things were going in your life?

This phenomenon of getting stuck thinking about the same negative things over and over is what psychology researchers call rumination.

Rumination comes from the word ruminate, describing how cows chew cud over and over

Rumination was brought to the attention of psychologists by the late Susan Nolen-Hoeksema as a potential explanatory factor for the significant difference in rates of depression between men and women after onset of puberty. Women are significantly more likely to develop depression compared to men1 and Nolen-Hoeksema proposed this difference was due to the greater frequency by which women engage in rumination as a coping strategy compared to men2. Rumination has since been found to be associated with more depressive episodes, greater severity depression, and longer depression episodes3.

Given the strong overlap between depression and anxiety4, rumination began receiving more attention as a factor potentially involved in the development of anxiety5. Further investigation has supported the role of rumination as a transdiagnostic risk factor; that is, rumination seems to increase risk both for depression and anxiety. One study found that rumination accounts for a significant portion of the overlap between in depression and anxiety, both in adolescents and adults6.

What Are The Likely Causes?

In light of its role as a risk factor spanning multiple diagnoses, a natural question to ask is why do people ruminate? What causes rumination? Nolen-Hoeksema and colleagues (1991; 1999) originally proposed that rumination was a maladaptive emotion regulation strategy born of negative, uncontrollable experiences, where individuals increased attention and focused on one’s symptoms and their implications.

Deficits in attentional control have been proposed as another explanation for why people ruminate. Attention control is thought of as the ability to direct attention toward or away from stimuli depending on current task demands or goals. Rudi De Raedt and Ernst Koster (2010; 2011) have suggested instead that individuals who have difficulty disengaging their attention from negative thoughts get stuck in loops of negative thinking, leading to the phenomenon of rumination. This rumination, in turn, leads to anxiety and depression.

There have been a handful of research studies that support a general association between attentional control and rumination7. However, these studies often didn’t examine their relationship in the context of anxiety or depression symptoms. Moreover, most studies in this general topic area rely on undergraduate samples. Our research team based out of McLean Hospital and Harvard Medical School sought to rectify these issues by examining the association between attention control, rumination, and anxiety and depression symptoms in a clinical sample presenting for treatment to a psychiatric hospital.

We also were interested in applying a statistical technique called mediation to test if the relationship between poor attentional control and these clinical symptoms might be explained by rumination (i.e., whether or not people with poorer attentional control had stronger rumination, which in turn was associated with more clinical symptoms).

Our McLean/Harvard Investigation

We had individuals presenting to our treatment program complete validated instruments examining their level of rumination, quality of attentional control, and anxiety and depression symptoms. Our patients were either stepping down from hospitalization to an inpatient unit (helping them to more gradually transition back to things) or stepping up from their current level of care (as a way of avoiding an inpatient hospitalization), meaning that they were a group experiencing a large amount of suffering but generally representative of people who are experiencing clinical levels of anxiety and depression.

Using this statistical approach of mediation analysis, we found support for De Raedt and Koster’s attentional control model of rumination. Specifically, individuals with poor attentional control showed stronger rumination than those with good attentional control. This rumination, in turn, was tied to more severe anxiety and depression symptoms.

What The Research Tells Us

Our findings suggest that interventions that target attentional control may lead to improved emotion regulation and reduced clinical symptomatology via decreased rumination. Preliminary studies in this domain have shown support for directly targeting attentional control in the alleviation of anxiety and depression symptoms, decrease of rumination, and improvement of emotion regulation8.

Interestingly enough, mindfulness-based interventions have also been found to improve attentional control and reduce clinical symptomatology. Moreover, mindfulness meditation has been found to reduce rumination in patients with a history of depression and anxiety disorders9. Testing to what extent these gains are made via reductions in rumination is the one of the next questions that deserves attention in this area. Other interventions that directly target rumination, such as Ed Watkins’ Rumination-Focused Cognitive Behavioural Therapy (RFCBT10), may also train attentional control through emphases on shifting thinking away from ruminative thought (e.g., to more adaptive thinking patterns).

Given our results though, further emphasis on and exploration of direct attentional control training interventions seems merited. To wit, researchers and organizations like the National Institute on Mental Health have suggested that identifying and targeting these “neurocognitive” factors represents an exciting and growing field of interest within the study of anxiety and depression. The potential ease of implementation and dissemination of attentional control training interventions make this area a potential “high value” area of investigation.


1 – Kessler, R. C. (2003). Epidemiology of women and depression. Journal of Affective Disorders, 74(1), 5-13.

2 – Nolen‐Hoeksema, S., & Jackson, B. (2001). Mediators of the gender difference in rumination. Psychology of Women Quarterly, 25(1), 37-47.

3 – Broderick, P. C., & Korteland, C. (2004). A prospective study of rumination and depression in early adolescence. Clinical Child Psychology and Psychiatry, 9(3), 383-394.; Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology,109(3), 504.; Nolen-Hoeksema, S., Stice, E., Wade, E., & Bohon, C. (2007). Reciprocal relations between rumination and bulimic, substance abuse, and depressive symptoms in female adolescents. Journal of Abnormal Psychology, 116(1), 198.; Spasojević, J., & Alloy, L. B. (2001). Rumination as a common mechanism relating depressive risk factors to depression. Emotion, 1(1), 25.

4 – Hasin, D. S., Goodwin, R. D., Stinson, F. S., & Grant, B. F. (2005). Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Archives of General Psychiatry, 62(10), 1097-1106; Hettema, J. M. (2008). The nosologic relationship between generalized anxiety disorder and major depression. Depression and Anxiety, 25(4), 300-316.; Kessler, R. C., Gruber, M., Hettema, J. M., Hwang, I., Sampson, N., & Yonkers, K. A. (2008). Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up. Psychological Medicine, 38(03), 365-374.

5 – Ehring, T., & Watkins, E. R. (2008). Repetitive negative thinking as a transdiagnostic process. International Journal of Cognitive Therapy, 1(3), 192-205.

6 – McLaughlin, K. A., & Nolen-Hoeksema, S. (2011). Rumination as a transdiagnostic factor in depression and anxiety. Behaviour Research and Therapy, 49(3), 186-193.

7 – Demeyer, I., De Lissnyder, E., Koster, E. H., & De Raedt, R. (2012). Rumination mediates the relationship between impaired cognitive control for emotional information and depressive symptoms: A prospective study in remitted depressed adults. Behaviour Research and Therapy, 50(5), 292-297.; Donaldson, C., Lam, D., & Mathews, A. (2007). Rumination and attention in major depression. Behaviour Research and Therapy, 45(11), 2664-2678.; Fergus, T. A., Bardeen, J. R., & Orcutt, H. K. (2012). Attentional control moderates the relationship between activation of the cognitive attentional syndrome and symptoms of psychopathology. Personality and Individual Differences, 53(3), 213-217.; Whitmer, A. J., & Banich, M. T. (2007). Inhibition versus switching deficits in different forms of rumination. Psychological Science, 18(6), 546-553.

8 – Bomyea, J., & Amir, N. (2011). The effect of an executive functioning training program on working memory capacity and intrusive thoughts.Cognitive Therapy and Research, 35(6), 529-535; Gyurak, A., Ayduk, O., & Gross, J. J. (2010, January). Training executive functions: Emotion regulation and affective consequences. Poster presentation presented at the Genetic and Experiental Influences on Executive Function Conference, Boulder, CO, USA.; Papageorgiou, C., & Wells, A. (2000). Treatment of recurrent major depression with attention training. Cognitive and Behavioral Practice, 7(4), 407-413.; Siegle, G. J., Ghinassi, F., & Thase, M. E. (2007). Neurobehavioral therapies in the 21st century: Summary of an emerging field and an extended example of cognitive control training for depression. Cognitive Therapy and Research, 31(2), 235-262. ; Siegle, G. J., Price, R. B., Jones, N. P., Ghinassi, F., Painter, T., & Thase, M. E. (2014). You gotta work at it pupillary indices of task focus are prognostic for response to a neurocognitive intervention for rumination in depression. Clinical Psychological Science, 2(4), 455-471

9 – Ramel, W., Goldin, P. R., Carmona, P. E., & McQuaid, J. R. (2004). The effects of mindfulness meditation on cognitive processes and affect in patients with past depression. Cognitive Therapy and Research, 28, 433-455.

10 – Watkins, E. R., Mullan, E., Wingrove, J., Rimes, K., Steiner, H., Bathurst, N., Eastman, R., & Scott, J. (2011). Rumination-focused cognitive-behavioural therapy for residual depression: phase II randomised controlled trial. The British Journal of Psychiatry, 199(4), 317-322.

Post-doctoral Researcher; Assistant Project Scientist at University of California, Los Angeles

Dr. Kean Hsu is a post-doctoral researcher at UCLA's Anxiety and Depression Research Center. He holds a doctorate from USC and completed internships at Pacific Clinics and a research fellowship at McLean Hospital, Harvard Medical School. His research focuses on the impact of attention and cognitive control on anxiety and depression, as well as exploring psychotherapeutic interventions and mental health awareness in under-served communities.


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