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Objectives: Due to a number of conceptual and methodological limitations, existing research has provided only equivocal evidence that deficits/biases in attentional control (AC) are causally implicated in depressive rumination and/or that Cognitive Control Training (CCT) can be used to remediate such vulnerabilities. By using a well-validated training task and ensuring adequate training exposure, the current study aimed to examine the hypothesis that daily CCT would reduce rumination and improve mood among participants with elevated ruminative disposition. Method: Using a multiple baseline design (MBD), eight high-ruminating university participants rated their daily levels of rumination and mood before and after the randomly-determined introduction of daily CCT, designed to enhance their level of AC. Daily ratings were compared before and after the introduction of CCT, using systematic visual analysis and randomisation tests for significance at the group level. Results: No evidence was found to support the hypothesis that daily CCT reduces rumination and/or improve mood. While participants improved in their performance within the CCT across the training period, there was no evidence of near- or far-transfer, visual analysis revealed no impact of the introduction of daily training, and all group-level analyses were non-significant (p ≥ .05). Conclusion: Despite addressing a number of conceptual/methodological concerns, the current study provides no further support for AC theories of rumination or the use of CCT-based treatments for depression. Such conclusions must be interpreted in light of other methodological limitations, however, including the use of a non-clinical sample and the use of MBD to detect delayed treatment effects.

Objective: Anxiety and depression have been conceptualised as being associated with “an abundance of habit and a dearth of control” (Hertel, 2015, p. 1). There has been a recent and burgeoning interest toward understanding the role of habits in health psychology and in the psychological disorders of obsessive-compulsive disorder and addiction in particular. To the author’s knowledge, there has been no previous systematic review that aimed to summarise the research investigating the involvement of mental habits in anxiety and depression in clinical and non-clinical populations. Method: The term habit was operationalized and inclusion criteria were specified in the domains of habit measurement, research paradigms, and manipulation tasks. A search across four databases was conducted: Web of Science, EBSCOhost, PubMed and OVID (PsycARTICLES and Journals@OVID). A progressive screening procedure yielded 8 relevant studies related to mental habits in anxiety (n = 1), depression (n = 4) and both anxiety and depression (n = 3). Results: Self-report habit measures correlate with the presence of symptoms. Computational modelling reinforcement learning and goal-devaluation paradigms demonstrate that anxiety and depression are associated with deficits in goal-directed learning and decision-making in favour of habitual learning strategies. Cognitive bias modification meets the criteria for enabling habit change and can strengthen or weaken interpretative habits in response to training. Conclusions: Despite considerable variability and limitations in the design of the studies appraised in this review, overall findings indicate support for habitual thought processes being implicated in anxiety and depression. Treating problematic thought processes in anxiety and depression as habitual – cued automatically by contextual cues, not goal-dependent and resistant to change – may be beneficial for future research and clinical applications. Abstract (Experimental Study) This study investigated predictions from the habit-goal framework for depressive rumination (Watkins & Nolen-Hoeksema, 2014) using a simultaneous replication single case experimental design in a multiple baseline case series. Seven high ruminators were recruited from community and university settings (with one participant’s data later excluded due to insufficient baseline rumination). Following a baseline monitoring period, participants received an intervention that included (i) spotting personal triggers for rumination and (ii) the practice of a scripted concrete thinking exercise (CTE) in response to these triggers, utilising an implementation intention (If-Then plan). It was predicted that practice of the IF-THEN CTE, linked to warning signs, would result in a significant reduction in both frequency and automaticity of rumination in the intervention phase compared to baseline. At the group level, using randomization tests (Onghena & Edgington, 2005), reductions in automaticity of rumination were trending toward statistical significance whilst the impact of the intervention on rumination frequency was not statistically significant. Effect size calculations, using nonoverlap of all pairs, demonstrated a medium effect of the intervention on automaticity (NAP = .76) and weak to medium effect on frequency of rumination (NAP = .66). Visual and statistical analysis of individual data demonstrated that two participants experienced statistically significant benefits (p < .05) for a reduction in automaticity of rumination and one participant’s frequency of rumination was significantly reduced. These two participants also showed the greatest levels of automaticity for the IF-THEN-CTE intervention during the intervention phase. Five participants demonstrated a strong or medium effect of the intervention on automaticity and two participants demonstrated a medium effect on frequency. Taken together, the data is broadly consistent with the predictions made by the habit-goal framework. Pre and post measures indicate reductions for all participants in rumination as habit using the self-report habit index (SRHI) and overall rumination levels rated on the ruminative responses scale (RRS). At post intervention three participants no longer met criteria for inclusion to the study on the RRS. Despite mixed results, feedback at debrief indicated that the intervention was acceptable to participants who reported that they would carry on using it after the study ended.

Objective: Childhood abuse (CA) is commonly associated with increased frequency of high-risk behaviours (HRB) in adolescence. Similarly, research has highlighted links between CA and blunted responses to reward. To date, little attention has been devoted to examine if altered reward processes may also be linked to increased engagement in HRB. To explore this hypothesis, this systematic review collated research that investigated the relationship among CA, reward processes and HRB. Specifically, the review addressed the question: Are HRB associated with altered reward processes in children and adults with a history of CA? Method: Behavioural and neurobiological studies on CA, reward processing and HRB in children and adults were selected from multidisciplinary and subject-specific databases published prior to the 1st of March 2016. The systematic literature search yielded 271 records with 198 non-duplicated results. Screening of 14 full-text publications led to five eligible studies synthesized in this review. Results: Results confirmed impaired reward learning and increased HRB in those with a history of CA. Associations of blunted anticipatory or consummatory reward processing and HRB in individuals with CA remained inconclusive. Conclusions: Reward learning appears to be associated with CA. Further research is required to explore the relationship between reward processes and HRB. Understanding CA from a neurodevelopment perspective is a critical step to developing effective intervention strategies to reduce HRB. Empirical Paper: Abstract Objective: Following childhood abuse (CA), adolescence often sees the onset of depression and high-risk behaviour (HRB). Despite the prevalence, little is known about underlying neurobiological factors linking CA and HRB. To address this gap, I examined if anticipatory and consummatory reward processing in adolescents with CA predict frequency of HRB, irrespective of depressive symptoms. Methods: Thirty-seven adolescents (M=17.08 years; SD = 1.86) participated in the study: 13 females with CA and current major depressive disorder (MDD), eight females with MDD and no CA, and 16 individuals with no CA and no MDD for comparison (control group). Adolescents completed the Card-Guessing paradigm to assess reward processing, while undergoing a magnetic resonance imaging scan. Neural region-of-interest responses in the striatum and pallidum were assessed during anticipatory and consummatory reward phases. Hierarchical regression models investigated if neural responses to reward were altered based on exposure to CA and if altered neural responses predicted higher use of HRB. Results: Data showed that (1) depressed adolescents engaged more frequently in HRB irrespective of history of CA, (2) anticipatory and consummatory reward processes were not altered based on a history of CA, and (3) blunted activation in right pallidum in anticipation of rewards predicted HRB irrespective of depressive symptoms. Conclusion: Although the current study did not confirm changes in reward processing following CA, blunted reward ‘wanting’ was linked to more frequent HRB. Findings are relevant to theories highlighting the critical role of the pallidum in perceiving cues as rewarding and in initiating goal-directed actions to obtain rewards.

Attributional style is hypothesised to causally contribute to depression vulnerability through influencing both emotional response and rumination following life events. Consistent with this hypothesis, Peters et al. (2011) found that training individuals towards a pessimistic attributional style, characterised by internal-stable attributions for negative events and external-unstable attributions for positive events, resulted in greater negative mood and emotional reactivity to perceived failure, relative to training a resilient attributional style characterized by the reverse pattern of attributions. To date, however, the relative contribution of the internal-external and stable-unstable dimensions, their interaction, and their application to positive or negative events upon influencing emotional response and, by theoretical extension, risk for depression, remains unresolved. To resolve this question, 80 participants received training manipulating attributional style along four dimensions (i.e., internal versus external attributions for negative events; internal versus external attributions for positive events; stable versus unstable attributions for negative events; stable versus unstable attributions for positive events) in a 24 orthogonal factorial design. Participants then completed a perceived failure induction task. Measures of emotion and state rumination were completed pre-manipulation, post- manipulation, and post-induction. The internality dimension for positive and, separately, negative events influenced both immediate emotional response and emotional reactivity. Stable attributions for negative events increased negative emotional response and moderated the effect of internal attributions for negative events: internal attributions to negative resulted in greater emotional reactivity relative to external attributions, but only in the context of stable attributions for negative events. Both internal and stable dimensions also had independent effects. These findings identifying the active components driving the effect of attributional style upon emotional reactivity suggest slight revisions and refinements to attribution models of depression vulnerability. Furthermore, it provides further evidence that attributional style can be modified and furthers understanding of how CBM-attribution training could be developed as a potential intervention for the treatment of depression.

Background: One-in-three carers of stroke survivors experience depression with no psychological treatments tailored to meet their needs, such as barriers to attending traditional face-to-face psychological services. A cognitive behavioural therapy (CBT) self-help approach may represent an effective, acceptable solution. Methods: Informed by the MRC framework (2008) for complex interventions, six studies informed development, feasibility and piloting of a CBT self-help intervention for depressed carers of stroke survivors: Study One: Systematic review and meta-analysis of psychological interventions targeting depression and anxiety in carers of people with chronic health conditions; Study Two: Interviews to understand difficulties experienced by depressed and anxious carers; Study Three: Interviews to understand positive coping strategies used by non-depressed and non-anxious carers; Study Four: Drawing on results of Studies One to Three, iterative modelling to develop the CBT self-help intervention; Study Five: Feasibility randomised controlled trial to examine methodological and procedural uncertainties for a Phase III definitive trial; Study Six: Updated systematic review and meta-analysis. Results: Study One: 16 studies identified for inclusion yielding small and medium effect sizes for depression and anxiety respectively, with trends for individually delivered treatments over shorter session durations to be more effective for depression. Six additional studies were included in Study Six, replicating Study One results; Study Two: Depressed and anxious carers experience difficulties adapting to the caring role, managing uncertainty, lack of support and social isolation; Study Three: Non-depressed and non-anxious carers utilise problem-focused coping strategies to gain balance and adapt to caring role, use assertiveness, seek social support and positive reinterpretation; Study Four: Developed a theory-driven CBT self-help intervention; Study Five: Recruited 20 informal carers in 10-months, representing 0.08% of invited carers randomised with high attrition in the intervention arm. Lack of GP recognition, gatekeeping and barriers to accessing psychological support identified as reasons for poor recruitment. Conclusions: A greater appreciation is required concerning barriers experienced by informal carers of stroke survivors to accessing support for depression and type of acceptable psychological support.

Objective: Theoretical and empirical evidence suggests a relationship between Repetitive Thought (RT, e.g. rumination), and depression in patients with Coronary Heart Disease (CHD). To date, cross-sectional studies indicate that rumination is associated with depression in CHD, but additional prospective longitudinal research is required to determine if rumination predicts subsequent depression. This research therefore aimed to test the hypothesis that RT, specifically rumination, is a vulnerability factor for depression over time in a CHD population. It was predicted that RT at baseline would predict depression rates at three month follow-up after controlling for baseline depression and potential confounding factors. Methods: Inpatients and outpatients with a diagnosis of CHD completed self-report questionnaires at baseline (N = 101) and at three month follow-up (N = 85). The data was analysed using a hierarchical multiple regression. Results: Baseline rumination significantly predicted depression at the three month follow-up after controlling for baseline depression and potential confounding factors. Rumination accounted for 8.3% of the variance (p< .001). Subscales of brooding and reflection were also found to be individually predictive of follow-up depression explaining 4% of the variance (p< .005) and 7% of the variance (p< .001) respectively. Conclusion: Findings are consistent with previous prospective and cross-sectional research that indicates that rumination plays a unique role in the maintenance of depression in CHD patients and is an identifiable vulnerability factor.

The overarching aim of this research was to understand factors implicated in the maintenance of rumination and worry, conceptualised as a transdiagnostic process of repetitive negative thought (RNT), through the use of cross-sectional, prospective, and experimental research designs. Rumination and worry have been repeatedly implicated in the development and maintenance of various forms of psychopathology, in particular, depression and anxiety disorders. Given the negative outcomes for mood and psychopathology, there is a need for a better understanding of vulnerability factors that maintain this unconstructive thinking. Based on a review of the literature, an integrative theoretical model was developed and tested using structural equation modelling. Using cross-sectional data, the model was tested in a large sample of adults (n = 506). Of the broad range of proximal and distal vulnerability factors examined, only neuroticism and beliefs about the function of repetitive thought remained significantly associated with RNT once current symptoms were statistically controlled. Emotional abuse and abstract processing were indirectly associated with RNT. Following on from this, a prospective study examined which of these vulnerability factors prospectively predicted change in RNT over six to eight weeks. Only neuroticism and the specific belief that repetitive thought aids instrumental understanding predicted change in RNT, after controlling for depression and anxiety symptoms. Next, two experimental studies were conducted to explore the causal relationship between RNT and the belief that RNT aids insight and understanding, by experimentally manipulating this appraisal and measuring the impact on state RNT. Whilst methodological issues with the first experimental study precluded clear conclusions being drawn about the nature of the relationship, the second experimental study demonstrated that participants manipulated to believe that RNT is helpful for increasing insight and understanding had greater levels of state RNT after exposure to a stressor, relative to participants manipulated to believe that RNT is unhelpful. Finally, in order to see whether rumination has any consequences that may potentially reinforce its further use, an experimental study was conducted to manipulate processing mode (abstract rumination versus concrete thinking) and examine the effect on a range of outcomes relating to insightfulness and avoidance. Whilst rumination did not lead to increased insight, it did afford more justification for avoidance, relative to concrete thinking. The clinical and theoretical implications of these findings are discussed with respect to existing theories of repetitive negative thought.

The focus of the thesis is the investigation of the causal nature of the established association between rumination and that ability to resolve interference from task-irrelevant information, and prepotent responses. Rumination is a term used to refer to both unhelpful dwelling on negative moods and depressive symptoms (e.g., Nolen-Hoeksema, 1991), and repetitive intrusive thoughts around the theme of unresolved personal goals (Martin & Tesser, 1996). It has been proposed that rumination occupies working memory resources, thereby depleting cognitive control capabilities necessary for the performance of concurrent effortful tasks (Hartlage, Alloy, Vasquez, & Dykman, 1993; Hertel, 2004; Watkins & Brown, 2002). This model constitutes one possible account of the considerable data demonstrating an association between depressive rumination and deficits on tasks invoking inhibitory processes (Joormann, Yoon, & Gotlib, 2007). An inhibition construct is invoked to account for the empirical observation of interference; however there are few instances where inhibition is unambiguously driving interference (MacLeod, 2007). Moreover, there is evidence that inhibition is not a unitary construct (Friedman & Miyake, 2004). Five experiments manipulated rumination on depressive symptoms and on personal goals in dysphoric and unselected samples in order to test Watkins and Brown’s (2002) hypothesis that state rumination impairs interference control capabilities. The causal impact of state rumination was examined on interference control tasks that implicate different inhibitory sub-types: resistance to proactive interference from positive and negative material (Studies One, Two, and Five), and prepotent response inhibition on a go/no-go paradigm (Studies Three and Four). No evidence was found to support the prediction that state rumination about depressed mood (Studies One and Two) or on-going personal goal discrepancies (Study Five) causes difficulties resolving interference from irrelevant emotional material relative to non-ruminative control conditions in both dysphoric (Studies One and Two) and unselected (Study Five) samples. No evidence was found to support the prediction that state rumination about personal goal discrepancies impairs prepotent response inhibition relative to non-ruminative control conditions (Studies Three and Four). There was some tentative evidence to suggest that ruminating on personal goal discrepancies increased efficiency in holding a single goal active in working memory without reinforcement (Study Four). The implications of these findings for existing models of the causal nature of the relationship between rumination and interference control processes is discussed (Chapter Nine). It is concluded that models proposing a causal impact of state rumination on available working memory capacity are insufficient to fully account for the established association between the trait tendency to ruminate and increased susceptibility to interference from irrelevant material.

As a GWR research project joint funded by Hospiscare, the main objective of this research was to examine the nature of psychological distress in palliative care, with the specific purpose of developing and evaluating accessible psychological interventions suitable for Hospiscare staff to use with clients. There is evidence that palliative care patients and their caregivers experience psychological difficulties including (a) studies of depression and anxiety in palliative care; (b) the concerns expressed by palliative care patients and their caregivers. However, the studies are generally qualitative in nature based on interviews of small samples of participants. Therefore, Study 1 and Study 2 adopted a cross-sectional design to examine psychological distress and rumination in samples of palliative care patients, their caregivers and an age-matched control group. The results from Study 1 and Study 2 indicated that psychological distress and rumination on existential concerns were elevated in palliative care patients and their caregivers. Furthermore, findings suggested an association between psychological distress and abstract rumination. Study 3 reported a case series piloting an intervention developed from concreteness training (CT) designed to address abstract rumination in palliative care. The case series indicated that with some modification to the identification and screening of patients, the treatment could be acceptable and feasible for palliative care patients. Study 4 examined the effectiveness of the CT guided self-help intervention in a randomized controlled trial. Findings indicated that the intervention could be effective for reducing anxiety, but not depression in palliative care patients. Moreover, Study 5’s findings also raised the possibility that abstractness was a partial mediator of the effects of the intervention on self-reported symptoms of anxiety in palliative care patients. Study 5 utilised a cluster randomized controlled design to evaluate a training programme designed to teach hospice staff how to deliver the CT guided self-help intervention. Results indicated that there was a more positive impact of routine care on patient distress for nurses attending training, when compared to nurses not attending the training. However, the training did not impact on nurses’ self-reported confidence or behaviour in addressing patients’ distress.

The thesis aim was to increase understanding of interpersonal antecedents and consequences of rumination, defined as ‘repetitive and passive thinking about one’s symptoms of depression and the possible causes and consequences of those symptoms’ (Nolen-Hoeksema, 2004, p.107). As a proof-of-principle study, rumination predicted diminished relationship satisfaction, three months later, in a sample of remitted depressed adults (N = 57). In the next study, rumination was associated with a maladaptive submissive interpersonal style and rejection sensitivity, controlling for depressive symptoms, other interpersonal styles and gender, in a different sample (N = 103 currently depressed, previously depressed and never depressed adults). Subsequent chapters incorporated a second assessment point of data from this same sample. Longitudinal analyses were undertaken to investigate; a) do rumination and depressogenic interpersonal factors predict future depression?; b) does rumination prospectively predict increased rejection sensitivity and submissive interpersonal behaviours, and, vice-versa, do these interpersonal factors predict increased rumination?; c) does rumination prospectively predict poor social adjustment and interpersonal stress? Consistent with previous findings, Time 1 rumination predicted increased depression six months later. Unexpectedly, the effect of rumination on future depression was mediated by its relationship with the submissive interpersonal style. Partially consistent with the stated predictions, Time 1 rejection sensitivity (but not the submissive interpersonal style) prospectively predicted increased rumination, but rumination did not predict rejection sensitivity or the submissive interpersonal style. As predicted, rumination prospectively predicted increased chronic interpersonal stress and poor social adjustment (but not acute interpersonal stress). In a final study, rumination was manipulated via an applied intervention (concreteness training, CT), within the context of a randomized controlled trial (N = 79 clinically depressed adults). Analyses compared the change in social adjustment and submissive interpersonal behaviour reported in the CT condition compared to a treatment as usual (TAU) condition. There was a significantly greater reduction in rumination in the CT compared to TAU condition, p < .05. Moreover, the reduction in submissive interpersonal behaviours was significantly greater in the CT compared to TAU condition, p < .05. The change in social adjustment was not greater in the CT compared to TAU condition. Thus, a psychological intervention which reduces rumination decreased maladaptive submissive interpersonal behaviour. The implications of the findings are discussed in relation to theory of rumination and interpersonal theories of depression.