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Despite considerable past interest in distinguishing the patterns of attentional bias that characterise vulnerability to anxiety and to depression, little research has yet sought to delineate the attentional correlates of two affective dimensions that differentially contribute to these alternative forms of emotional vulnerability—negative and positive affectivity. In the present study, we employ a novel variant of the attentional probe task to examine selective attentional engagement with, and disengagement from, negative words, in participants whose heightened emotional vulnerability reflects either elevated negative affectivity, or attenuated positive affectivity. Elevated negative affectivity was found to be associated with both increased attentional engagement with, and impaired attentional disengagement from, negative information, especially when this was anxiety relevant. In contrast, attenuated positive affectivity was associated with facilitated attentional disengagement from negative information,...

BackgroundThe development of widely accessible, effective psychological interventions for depression is a priority. This randomized trial provides the first controlled data on an innovative cognitive bias modification (CBM) training guided self-help intervention for depression.MethodOne hundred and twenty-one consecutively recruited participants meeting criteria for current major depression were randomly allocated to treatment as usual (TAU) or to TAU plus concreteness training (CNT) guided self-help or to TAU plus relaxation training (RT) guided self-help. CNT involved repeated practice at mental exercises designed to switch patients from an unhelpful abstract thinking habit to a helpful concrete thinking habit, thereby targeting depressogenic cognitive processes (rumination, overgeneralization).ResultsThe addition of CNT to TAU significantly improved depressive symptoms at post-treatment [mean difference on the Hamilton Rating Scale for Depression (HAMD) 4.28, 95% confidence interval (CI) 1.29–7.26], 3- and 6-month follow-ups, and for rumination and overgeneralization post-treatment. There was no difference in the reduction of symptoms between CNT and RT (mean difference on the HAMD 1.98, 95% CI −1.14 to 5.11), although CNT significantly reduced rumination and overgeneralization relative to RT post-treatment, suggesting a specific benefit on these cognitive processes.ConclusionsThis study provides preliminary evidence that CNT guided self-help may be a useful addition to TAU in treating major depression in primary care, although the effect was not significantly different from an existing active treatment (RT) matched for structural and common factors. Because of its relative brevity and distinct format, it may have value as an additional innovative approach to increase the accessibility of treatment choices for depression.

Converging research findings indicate that rumination is correlated with a specific maladaptive interpersonal style encapsulating submissive (overly-accommodating, non-assertive and self-sacrificing) behaviours, and an attachment orientation characterised by rejection sensitivity. This study examined the prospective longitudinal relationship between rumination, the submissive interpersonal style, and rejection sensitivity by comparing two alternative hypotheses: (a) the submissive interpersonal style and rejection sensitivity prospectively predict increased rumination; (b) rumination prospectively predicts the submissive interpersonal style and rejection sensitivity. Currently depressed (n = 22), previously depressed (n = 42) and never depressed (n = 28) individuals completed self-report measures assessing depressive rumination and key psychosocial measures of interpersonal style and behaviours, at baseline and again six months later. Baseline rejection sensitivity prospectively predicted increased rumination six months later, after statistically controlling for baseline rumination, gender and depression. Baseline rumination did not predict the submissive interpersonal style or rejection sensitivity. The results provide a first step towards delineating a potential casual relationship between rejection sensitivity and rumination, and suggest the potential value of clinical assessment and intervention for both rejection sensitivity and rumination in individuals who present with either difficulty.

BackgroundAbout 20% of major depressive episodes become chronic and medication-refractory and also appear to be less responsive to standard cognitive–behavioural therapy (CBT).AimsTo test whether CBT developed from behavioural activation principles that explicitly and exclusively targets depressive rumination enhances treatment as usual (TAU) in reducing residual depression.MethodForty-two consecutively recruited participants meeting criteria for medication-refractory residual depression were randomly allocated to TAU v. TAU plus up to 12 sessions of individual rumination-focused CBT. The trial has been registered (ISRCTN22782150).ResultsAdding rumination-focused CBT to TAU significantly improved residual symptoms and remission rates. Treatment effects were mediated by change in rumination.ConclusionsThis is the first randomised controlled trial providing evidence of benefits of rumination-focused CBT in persistent depression. Although suggesting the internal validity of rumination-focused CBT for residual depression, the trial lacked an attentional control group so cannot test whether the effects were as a result of the specific content of rumination-focused CBT v. non-specific therapy effects.

Background: Previous findings implicated rumination (recurrent dwelling on abstract concerns) in elevated psychological distress in palliative patients. We hypothesised that reducing rumination may be important in addressing psychological distress in palliative care. Aim: This study tested the prediction that a brief guided self-help technique targeting abstract rumination would reduce psychological distress in palliative patients. Design: A randomised controlled trial evaluated 4 weeks of guided self-help that involved patients practising thinking more concretely by recalling specific and vivid memories of when they were completely absorbed in an activity or scene. Participants completed a combination of standardised questionnaires to assess anxiety, depression, and quality of life. Setting/participants: Palliative care patients who were reporting clinically significant psychological distress, whilst also physically well enough to take part in the trial were recruited from hospices in Devon and Somerset and randomised to either a treatment condition ( n = 19) receiving 4 weeks of guided self-help, or a waiting-list control condition ( n = 15) receiving treatment as usual. Results: As predicted, the palliative patients receiving the intervention reported significantly greater reductions in anxiety than the waiting-list controls ( F(1,23) = 20.55, p 2 = 0.47). However, no significant effect was found on depression or quality of life. Conclusion: The findings suggest that a brief guided self-help intervention based on concreteness training can be effective in addressing anxiety in palliative care.

Background Patients with a life-limiting illness, such as cancer, and their carers experience elevated psychological distress. However, the psychological mechanisms underpinning distress in palliative care have been little studied. Recent theories predict that individuals who experience increased uncertainty in the context of ongoing difficulties, such as palliative patients and their carers, will (a) think more abstractly; (b) ruminate more; and (c) be more distressed. Methods Palliative patients (n = 36, 90% with cancer), their carers (n = 29), and age-matched controls (n = 30) completed standardized questionnaires to assess anxiety, depression, and rumination, and open-ended interviews to identify their concerns and idiosyncratic levels of rumination. Concerns were analyzed linguistically for level of abstraction. Results As predicted, (i) palliative patients and carers reported significantly more uncertainty, rumination, and abstract thinking than controls; (ii) uncertainty, abstractness, and rumination were associated with psychological distress. Conclusions Abstraction and rumination are psychological mechanism potentially involved in increased psychological distress in palliative care. Copyright © 2011 John Wiley & Sons, Ltd.

Research in healthy controls has found that mood influences cognitive processing via level of action identification: happy moods are associated with global and abstract processing; sad moods are associated with local and concrete processing. However, this pattern seems inconsistent with the high level of abstract processing observed in depressed patients, leading Watkins (2008, 2010) to hypothesise that the association between mood and level of goal/action identification is impaired in depression. We tested this hypothesis by measuring level of identification on the Behavioural Identification Form after happy and sad mood inductions in never-depressed controls and currently depressed patients. Participants used increasingly concrete action identifications as they became sadder and less happy, but this effect was moderated by depression status. Consistent with Watkins' (2008) hypothesis, increases in sad mood and decreases in happiness were associated with shifts towards the use of more concrete action identifications in never-depressed individuals, but not in depressed patients. These findings suggest that the putatively adaptive association between mood and level of identification is impaired in major depression.

Goals, events, and actions can be mentally represented within a hierarchical framework that ranges from more abstract to more concrete levels of identification. A more abstract level of identification involves general, superordinate, and decontextualized mental representations that convey the meaning of goals, events, and actions, “why” an action is performed, and its purpose, ends, and consequences. A more concrete level of identification involves specific and subordinate mental representations that include contextual details of goals, events, and actions, and the specific “how” details of an action. This review considers three lines of evidence for considering that dysregulation of level of goal/action identification may be a transdiagnostic process. First, there is evidence that different levels of identification have distinct functional consequences and that in non-clinical samples level of goal/action identification appears to be regulated in a flexible and adaptive way to match the level of goal/action identification to circumstances. Second, there is evidence that level of goal/action identification causally influences symptoms and processes involved in psychological disorders, including emotional response, repetitive thought, impulsivity, problem solving and procrastination. Third, there is evidence that the level of goal/action identification is biased and/or dysregulated in certain psychological disorders, with a bias towards more abstract identification for negative events in depression, GAD, PTSD, and social anxiety.

Theoretical models and empirical evidence suggest that brooding, the maladaptive sub-component of depressive rumination, is associated with a sub-set of depressogenic interpersonal difficulties characterised by submissive interpersonal behaviours and rejection sensitivity. This study tested whether these cognitive and interpersonal vulnerability factors independently predicted future depression and investigated their interdependence in predicting depression. A heterogeneous adult sample completed self-report measures assessing depressive symptoms, brooding, reflection, rejection sensitivity and maladaptive interpersonal behaviours, at baseline and six months later. When examined separately, brooding and an interpersonal component reflecting submissive, (overly-accommodating, non-assertive, and self-sacrificing) interpersonal behaviours each prospectively predicted increased depressive symptoms six months later, after controlling for baseline depressive symptoms and gender. When examined together, the submissive interpersonal style but not brooding predicted depression, indicating that this maladaptive interpersonal style may mediate the effect of brooding on future depression. Thus, the effects of brooding on depression may in part depend on its association with an interpersonal style characterised by submissiveness.

The study examined the relationship between brooding, the maladaptive sub-component of depressive rumination, an important cognitive mechanism implicated in the aetiology of depression, and a range of depressogenic psychosocial factors, including insecure attachment styles and maladaptive interpersonal behaviours. It was hypothesised that brooding (but not the more adaptive reflection component) is associated with an attachment pattern characterised by fear of rejection, and an interpersonal style characterised by submissiveness. Currently depressed (n = 29), previously depressed (n = 42) and never-depressed (n = 32) adults completed self-report measures assessing depressive symptoms, rumination (brooding and reflection), attachment orientation and maladaptive interpersonal behaviours. The study hypotheses were partially supported: After controlling for gender and depressive symptoms, brooding was significantly associated with one indicator of underlying rejection concerns (rejection sensitivity, p = .05), but was not associated with another indicator of underlying rejection concerns (anxious attachment style) or with avoidant attachment style. After controlling for depressive symptoms, brooding was uniquely associated with the submissive interpersonal style (p < .01). Brooding was not correlated with needy or cold interpersonal styles after controlling for depressive symptoms.

Objective. To test the hypothesis that rumination contributes to poor social functioning by examining whether ruminative brooding predicts subsequent relationship satisfaction in individuals with a history of major depression. Method. Participants (N=57) were interviewed to assess depressive symptoms and completed self-report measures of brooding and relationship satisfaction, at intake into the study (Time 1) and 3 months later (Time 2). Results. Brooding was related concurrently to relationship satisfaction at Time 2 (p

In this reply to the comment of McVay and Kane (2010), I consider their argument concerning how Watkins's (2008) elaborated control theory informs their perspective on the role of executive control in mind wandering. I argue that although in a number of places the elaborated control theory is consistent with the perspective of McVay and Kane that mind wandering represents a failure of executive control, their account makes a number of claims that are not articulated in the elaborated control theory-most notably, the hypothesis that level of construal moderates entry of thoughts into awareness. Moreover, the relevant literature suggests that the relationship between level of construal and executive control may be more complex, and may be determined by multiple factors beyond those proposed in this executive-control failure account of mind wandering. Finally, the implications of this model of mind wandering for understanding repetitive thought in general are considered, and it is proposed that examining level of executive control as a further moderating variable within elaborated control theory may be of value.

Rumination has been identified as a core process in the development and maintenance of depression. Treatments targeting ruminative processes may, therefore, be particularly helpful for treating chronic and recurrent depression. The development of such treatments requires translational research that marries clinical trials, process-outcome research, and basic experimental research that investigates the mechanisms underpinning pathological rumination. For example, a program of experimental research has demonstrated that there are distinct processing modes during rumination that have distinct functional effects for the consequences of rumination on a range of clinically relevant cognitive and emotional processes: an adaptive style characterized by more concrete, specific processing and a maladaptive style characterized by abstract, overgeneral processing. Based on this experimental work, two new treatments for depression have been developed and evaluated: (a) rumination-focused cognitive therapy, an individual-based face-to-face therapy, which has encouraging results in the treatment of residual depression in an extended case series and a pilot randomized controlled trial; and (b) concreteness training, a facilitated self-help intervention intended to increase specificity of processing in patients with depression, which has beneficial findings in a proof-of-principle study in a dysphoric population. These findings indicate the potential value of process-outcome research (a) explicitly targeting identified vulnerability processes and (b) developing interventions informed by research into basic mechanisms.

This study investigated the interrelationship of thought control strategies, thought suppression, and rumination in depression. Participants with current (n = 52) and remitted (n = 36) major depression, and never-depressed control participants (n = 49) completed measures that indexed symptoms of depression and a range of thought control techniques including rumination, worry, and thought suppression. Following recent commentaries on the White Bear Suppression Inventory, we differentiated between those items that indexed thought intrusions and those that indexed thought suppression. After controlling for current depression severity, we found: (a) a significant positive association between worry, thought intrusions and rumination, consistent with recent proposals of a common construct of repetitive thought; (b) that thought suppression positively correlated with rumination and the thought control strategies of distraction and punishment; and (c) a lack of any relationship between other thought control strat...

A tendency toward abstract and overgeneral processing is a cognitive bias hypothesized to causally contribute to symptoms of depression. This hypothesis predicts that training dysphoric individuals to become more concrete and specific in their thinking would reduce depressive symptoms. To test this prediction, 60 participants with dysphoria were randomly allocated either to (a) concreteness training; (b) bogus concreteness training, matched with concreteness training for treatment rationale, experimenter contact, and treatment duration but without active engagement in concrete thinking; (c) a waiting-list, no training control. Concreteness training resulted in significantly greater decreases in depressive symptoms and significantly greater increases in concrete thinking than the waiting-list and the bogus training control, and significantly greater decreases in rumination than the waiting-list control. These findings suggest that concreteness training has potential as a guided self-help intervention for mild-to-moderate depressive symptoms.

This article defines and explains the transdiagnostic approach to cognitive-behavioral therapy (CBT) and elaborates on its conceptual foundations and implications for research and practice. We argue that the approach has good philosophical, historical, pragmatic, and empirical foundations. We distinguish between transdiagnostic approaches based on multiple processes that are universally applied (e.g., Harvey, Watkins, Mansell, & Shafran, 2004), multiple processes limited in the range of disorders covered (e.g., Fairburn, Cooper, & Shafran, 2003), symptom-based accounts (e.g., Persons, 1986), and universal single process accounts (e.g., experiential avoidance, self-absorption). We summarize existing evidence and identify key issues relating to the methodology of future research on the transdiagnostic approach. The article concludes by highlighting the great potential benefits of the approach and highlights significant practical, political, and scientific obstacles to putting it into practice on a large scale. © 2009 Springer Publishing Company.

Models of self-regulation propose that negative affect is generated when progress towards goals is perceived to be inadequate. Similarly, ruminative thinking is hypothesised to be triggered by unattained goals (Martin & Tesser, 1996). We conducted an experience-sampling study in which participants recorded their negative affect, ruminative self-focus, and goal appraisals eight times daily for one week. Negative affect and ruminative self-focus were each associated with low levels of goal success and (with the exception of sadness) high levels of goal importance. As predicted, the combination of low goal success and high goal importance was associated with the highest levels of negative affect, and this interaction was marginally significant for ruminative self-focus. Decomposition of the ruminative self-focus measure revealed that the success by importance interaction was significantly associated with focus on problems but not focus on feelings. Findings did not differ for individuals reporting high versus low levels of depressive symptoms or trait rumination. These results suggest that self-regulatory models of goal pursuit provide a useful explanatory framework for the study of affect and ruminative thinking in everyday life.

In a replication and extension of Watkins, Teasdale, and Williams (2003), a scrambled sentences paradigm was used to test whether prompting contextual processing of negative cognitive primes would limit the activation of dysphoric mood. Participants were divided into two groups and, after a dysphoric mood induction procedure, were asked to unscramble sentences that either did or did not emphasise the contextual aspects of moods. Consistent with Watkins et al., participants' despondency decreased significantly more in the contextual group than in the neutral group. This effect could not be accounted for by variations in the way sentences were unscrambled.

Three studies are reported showing that emotional responses to stress can be modified by systematic prior practice in adopting particular processing modes. Participants were induced to think about positive and negative scenarios in a mode either characteristic of or inconsistent with the abstract-evaluative mind-set observed in depressive rumination, via explicit instructions (Experiments 1 and 2) and via implicit induction of interpretative biases (Experiment 3), before being exposed to a failure experience. In all three studies, participants trained into the mode antithetical to depressive rumination demonstrated less emotional reactivity following failure than participants trained into the mode consistent with depressive rumination. These findings provide evidence consistent with the hypothesis that processing mode modifies emotional reactivity and support the processing-mode theory of rumination.

The author reviews research showing that repetitive thought (RT) can have constructive or unconstructive consequences. The main unconstructive consequences of RT are (a) depression, (b) anxiety, and (c) difficulties in physical health. The main constructive consequences of RT are (a) recovery from upsetting and traumatic events, (b) adaptive preparation and anticipatory planning, (c) recovery from depression, and (d) uptake of health-promoting behaviors. Several potential principles accounting for these distinct consequences of RT are identified within this review: (a) the valence of thought content, (b) the intrapersonal and situational context in which RT occurs, and (c) the level of construal (abstract vs. concrete processing) adopted during RT. Of the existing models of RT, it is proposed that an elaborated version of the control theory account provides the best theoretical framework to account for its distinct

We hypothesized that the reduced concreteness theory of worry (Stober & Borkovec, 2002) would be applicable to negative recurrent thinking in general, including depressive rumination. To test this prediction, the current study compared the concreteness of problem descriptions of currently depressed (n = 30), recovered depressed (n = 29) and never-depressed (n = 30) individuals. Participants provided open-ended descriptions of two current major problems about which they repeatedly dwell. Blind ratings demonstrated reduced concreteness of the problem descriptions and associated perceived consequences reported by the depressed group relative to the recovered depressed and control groups, which did not differ from each other. These findings are consistent with the hypothesis that recurrent thinking in depression involves reduced concreteness, paralleling the findings in GAD.

The treatment of chronic and recurrent depression is a priority for the development of new interventions. The maintenance of residual symptoms following acute treatment for depression is a risk factor for both chronic depression and further relapse/recurrence. This open case series provides the first data on a cognitive-behavioural treatment for residual depression that explicitly targets depressive rumination. Rumination has been identified as a key factor in the onset and maintenance of depression, which is found to remain elevated following remission from depression. Fourteen consecutively recruited participants meeting criteria for medication--refractory residual depression [Paykel, E.S., Scott, J., Teasdale, J.D., Johnson, A.L., Garland, A., Moore, R. et al., 1999. Prevention of relapse in residual depression by cognitive therapy--a controlled trial. Archives of General Psychiatry 56, 829-835] were treated individually for up to 12 weekly 60-min sessions. Treatment specifically focused on switching patients from less helpful to more helpful styles of thinking through the use of functional analysis, experiential/imagery exercises and behavioural experiments. Treatment produced significant improvements in depressive symptoms, rumination and co-morbid disorders: 71% responded (50% reduction on Hamilton Depression Rating Scale) and 50% achieved full remission. Treating depressive rumination appears to yield generalised improvement in depression and co-morbidity. This study provides preliminary evidence that rumination-focused CBT may be an efficacious treatment for medication--refractory residual depression.

It has been widely established that depressed mood states and clinical depression, as well as a range of other psychiatric disorders, are associated with a relative difficulty in accessing specific autobiographical information in response to emotion-related cue words on an Autobiographical Memory Test (AMT; J. M. G. Williams and K. Broadbent, 1986). In 8 studies the authors examined the extent to which this relationship is a function of impaired executive control associated with these mood states and clinical disorders. Studies 1-4 demonstrated that performance on the AMT is associated with performance on measures of executive control, independent of depressed mood. Furthermore, Study 1 showed that executive control (as measured by verbal fluency) mediated the relationship between both depressed mood and a clinical diagnosis of eating disorder and AMT performance. Using a stratified sample in Study 5, the authors confirmed the positive association between depressed mood and impaired performance on the AMT. Studies 6-8 involved experimental manipulations of the parameters of the AMT designed to further indicate that reduced executive control is to a significant extent driving the relationship between depressed mood and AMT performance. The potential role of executive control in accounting for other aspects of the AMT literature is discussed.

BackgroundIndividuals with a history of recurrent depression have a high risk of repeated depressive relapse/recurrence. Maintenance antidepressant medication (m-ADM) for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to m-ADM. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce the risk of relapse/recurrence compared with usual care but has not yet been compared with m-ADM in a definitive trial.ObjectivesTo establish whether MBCT with support to taper and/or discontinue antidepressant medication (MBCT-TS) is superior to and more cost-effective than an approach of m-ADM in a primary care setting for patients with a history of recurrent depression followed up over a 2-year period in terms of preventing depressive relapse/recurrence. Secondary aims examined MBCT’s acceptability and mechanism of action.DesignSingle-blind, parallel, individual randomised controlled trial.SettingUK general practices.ParticipantsAdult patients with a diagnosis of recurrent depression and who were taking m-ADM.InterventionsParticipants were randomised to MBCT-TS or m-ADM with stratification by centre and symptomatic status. Outcome data were collected blind to treatment allocation and the primary analysis was based on the principle of intention to treat. Process studies using quantitative and qualitative methods examined MBCT’s acceptability and mechanism of action.Main outcomes measuresThe primary outcome measure was time to relapse/recurrence of depression. At each follow-up the following secondary outcomes were recorded: number of depression-free days, residual depressive symptoms, quality of life, health-related quality of life and psychiatric and medical comorbidities.ResultsIn total, 212 patients were randomised to MBCT-TS and 212 to m-ADM. The primary analysis did not find any evidence that MBCT-TS was superior to m-ADM in terms of the primary outcome of time to depressive relapse/recurrence over 24 months [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.67 to 1.18] or for any of the secondary outcomes. Cost-effectiveness analysis did not support the hypothesis that MBCT-TS is more cost-effective than m-ADM in terms of either relapse/recurrence or quality-adjusted life-years. In planned subgroup analyses, a significant interaction was found between treatment group and reported childhood abuse (HR 1.89, 95% CI 1.06 to 3.38), with delayed time to relapse/recurrence for MBCT-TS participants with a more abusive childhood compared with those with a less abusive history. Although changes in mindfulness were specific to MBCT (and not m-ADM), they did not predict outcome in terms of relapse/recurrence at 24 months. In terms of acceptability, the qualitative analyses suggest that many people have views about (dis)/continuing their ADM, which can serve as a facilitator or a barrier to taking part in a trial that requires either continuation for 2 years or discontinuation.ConclusionsThere is no support for the hypothesis that MBCT-TS is superior to m-ADM in preventing depressive relapse/recurrence among individuals at risk for depressive relapse/recurrence. Both treatments appear to confer protection against relapse/recurrence. There is an indication that MBCT may be most indicated for individuals at greatest risk of relapse/recurrence. It is important to characterise those most at risk and carefully establish if and why MBCT may be most indicated for this group.Trial registrationCurrent Controlled Trials ISRCTN26666654.FundingThis project was funded by the NIHR Health Technology Assessment programme and the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula and will be published in full inHealth Technology Assessment; Vol. 19, No. 73. See the NIHR Journals Library website for further project information.

Previous research has demonstrated that heightened ruminative disposition is characterized by an attentional bias to depressogenic information at 1,000-ms exposure durations. However, it is unknown whether this attentional bias reflects facilitated attentional engagement with depressogenic information, or impaired attentional disengagement from such information. The present study was designed to address this question. In keeping with recent theoretical proposals, our findings demonstrate that heightened ruminative disposition is associated only with impaired attentional disengagement from depressogenic information, and does not involve facilitated attentional engagement with such information. In addition to resolving this key issue, the present study provided converging support for the previous claim that rumination-linked attentional bias is specific to depressogenic information, and also lends weight to the contention that rumination-linked attentional bias may be evident only when controlled attentional processing is readily permitted by using stimulus exposure durations of 1,000 ms. We discuss the theoretical implications of these findings and highlight key issues for future research.

Transdiagnostic models of psychopathology are increasingly prominent because they focus on fundamental processes underlying multiple disorders, help to explain comorbidity among disorders, and may lead to more effective assessment and treatment of disorders. Current transdiagnostic models, however, have difficulty simultaneously explaining the mechanisms by which a transdiagnostic risk factor leads to multiple disorders (i.e., multifinality) and why one individual with a particular transdiagnostic risk factor develops one set of symptoms while another with the same transdiagnostic risk factor develops another set of symptoms (i.e., divergent trajectories). In this article, we propose a heuristic for developing transdiagnostic models that can guide theorists in explicating how a transdiagnostic risk factor results in both multifinality and divergent trajectories. We also (a) describe different levels of transdiagnostic factors and their relative theoretical and clinical usefulness, (b) suggest the types of mechanisms by which factors at 1 level may be related to factors at other levels, and (c) suggest the types of moderating factors that may determine whether a transdiagnostic factor leads to certain specific disorders or symptoms and not others. We illustrate this heuristic using research on rumination, a process for which there is evidence it is a transdiagnostic risk factor.

BACKGROUND: Cognitive behavioural therapy is an effective treatment for depression. However, one third of the patients do not respond satisfactorily, and relapse rates of around 30 % within the first post-treatment year were reported in a recent meta-analysis. In total, 30-50 % of remitted patients present with residual symptoms by the end of treatment. A common residual symptom is rumination, a process of recurrent negative thinking and dwelling on negative affect. Rumination has been demonstrated as a major factor in vulnerability to depression, predicting the onset, severity, and duration of future depression. Rumination-focused cognitive behavioural therapy is a psychotherapeutic treatment targeting rumination. Because rumination plays a major role in the initiation and maintenance of depression, targeting rumination with rumination-focused cognitive behavioural therapy may be more effective in treating depression and reducing relapse than standard cognitive behavioural therapy.METHOD/DESIGN: This study is a two-arm pragmatic randomised controlled superiority trial comparing the effectiveness of group-based rumination-focused cognitive behaviour therapy with the effectiveness of group-based cognitive behavioural therapy for treatment of depression. One hundred twenty-eight patients with depression will be recruited from and given treatment in an outpatient service at a psychiatric hospital in Denmark. Our primary outcome will be severity of depressive symptoms (Hamilton Rating Scale for Depression) at completion of treatment. Secondary outcomes will be level of rumination, worry, anxiety, quality of life, behavioural activation, experimental measures of cognitive flexibility, and emotional attentional bias. A 6-month follow-up is planned and will include the primary outcome measure and assessment of relapse.DISCUSSION: The clinical outcome of this trial may guide clinicians to decide on the merits of including rumination-focused cognitive behavioural therapy in the treatment of depression in outpatient services.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02278224 , registered 28 Oct. 2014.

Repetitive thinking about negative experience, such as worry and rumination, is increasingly recognized as a transdiagnostic process underlying various forms of psychopathology including anxiety and depression. Recent theoretical models have emphasized the role of impaired attentional control and the habitual nature of negative biases in the development and maintenance of pathological repetitive thought. In this introduction, we provide a brief overview of these theories and of how the articles in the special series provide experimental evidence concerning these basic mechanisms underlying rumination and worry, and their relation to clinical dysfunction. Together the research summarized in these articles instantiates these theoretical frameworks and provides convergent evidence confirming the value of adopting a transdiagnostic approach that focuses directly on fundamental mechanisms of psychopathology, instead of on diagnostic criteria.

Two experiments are reported in which nondysphoric participants, not prone to excessive levels of rumination in everyday life, were asked to retrieve autobiographical memories using the Williams and Broadbent ( 1986 ) procedure (AMT). In the first experiment, two variants of a self-related category fluency task were interleaved among sets of autobiographical memory cues. In one variant (blocked) a normal model of analytic rumination was induced by grouping prompts on a single superordinate theme together. In the other (intermixed) prompts from several different themes were grouped together. It was predicted that the blocked variant would reduce the number of specific memories recollected and increase the number of categoric memories relative to the intermixed variant. This prediction was confirmed and provides the first demonstration of a bidirectional causal influence of analytic rumination on the balance between specific and categoric retrievals. A second experiment showed no alteration in this balance when the same fluency manipulation involved animal-related categories rather than self-related ones. The results support a two component model of autobiographical retrieval being driven in part by the extent to which an analytic mode of processing is adopted in the short term and in part by the level of differentiation in self-related schematic models.

Major depression is characterised by ruminative thinking whilst worry is considered central in generalised anxiety disorder (GAD). However, not only do these two forms of repetitive negative thinking regularly co-occur in the same individual but similarities between worry and rumination are apparent. Adapting a methodology developed by Langlois et al. (Behav. Res. Therapy 38 (2000) 157-173), this study directly compared worry and rumination in a non-clinical population across a series of variables drawn from current models (appraisal, general descriptors and emotional reactions). Each of 149 female volunteers, with a wide range of age and backgrounds, identified a ruminative thought and a different worry and subsequently evaluated them using the Cognitive Intrusion Questionnaire. Significant within-subject differences were revealed on seven variables: chronicity, unpleasantness, reality of problem, future orientation, past orientation, feelings of worry and insecurity. There were no differences found between worry and rumination on appraisals and strategies, consistent with accounts that propose that worry and rumination share the same processes but involve different content (Cognitive Ther. Res. 24 (2000) 671-688).

Papageorgiou and Wells (2001) reported that positive beliefs about rumination were elevated in depressed patients, using the Positive Beliefs about Rumination Scale (PBRS). However, this study had a relatively small sample and there is a possibility that there were confounds within this measure between the severity of depressed mood and endorsement of beliefs. This study attempted to replicate these findings within a larger sample, and to extend these findings to recovered depressed patients, who are known to demonstrate elevated rumination. Furthermore, a version of the PBRS adapted to reduce confounds with mood state and valence was also used. Consistent with predictions, both currently depressed and recovered depressed patients had elevated scores on both the original and adapted PBRS compared to never-depressed controls. The present findings confirm that positive beliefs about rumination are genuinely associated with elevated levels of rumination in depression-prone groups and indicated that previous similar positive findings (Papageorgiou & Wells, 2001) were not the result of methodological confounds such as criteria contamination in the PBRS or small sample size.

In a previous randomized controlled study, the authors reported significant beneficial effects of cognitive therapy for relapse prevention in bipolar disorder patients up to 1 year. This study reports additional 18-month follow-up data and presents an overview of the effect of therapy over 30 months.Patients with DSM-IV bipolar I disorder (N=103) suffering from frequent relapses were randomly assigned into a cognitive therapy plus medication group or a control condition of medication only. Independent raters, who were blind to patient group status, assessed patients at 6-month intervals.Over 30 months, the cognitive therapy group had significantly better outcome in terms of time to relapse. However, the effect of relapse prevention was mainly in the first year. The cognitive therapy group also spent 110 fewer days (95% CI=32 to 189) in bipolar episodes out of a total of 900 for the whole 30 months and 54 fewer days (95% CI=3 to 105) in bipolar episodes out of a total of 450 for the last 18 months. Multivariate analyses of variance showed that over the last 18 months, the cognitive therapy group exhibited significantly better mood ratings, social functioning, coping with bipolar prodromes, and dysfunctional goal attainment cognition.Patients in the cognitive therapy group had significantly fewer days in bipolar episodes after the effect of medication compliance was controlled. However, the results showed that cognitive therapy had no significant effect in relapse reduction over the last 18 months of the study period. Further studies should explore the effect of booster sessions or maintenance therapy.

Rumination (Nolen-Hoeksema, 1991) and worry (Borkovec, Ray, & Stober, 1998) are forms of recurrent negative thinking that are implicated in the maintenance of, respectively, depression and generalized anxiety disorder. However, despite their clinical significance, the mechanisms underlying rumination and worry are not well understood. This study aimed to test recent suggestions that particular appraisals and strategies in response to intrusive thoughts may be associated with increased tendency to ruminate and worry. 148 volunteers reported appraisals and strategies to worry and rumination-related intrusions (as measured with the Cognitive Intrusion Questionnaire) and the tendency to ruminate and tendency to worry, as measured by the Response Styles Questionnaire and the Penn State Worry Questionnaire, respectively. Increased tendency to ruminate was associated with a greater need to understand a situation, increased personal importance of the situation and the strategies of analysing a situation and dwelling on the causes and meanings of situations. Increased tendency to worry was associated with greater disapproval of worry-related intrusions, and with the strategy of replacing a worrisome intrusion with another unpleasant thought. These correlational findings are consistent with meta-cognitive (Watkins & Baracaia, 2001) and goal-discrepancy accounts (Martin & Tesser, 1996) of rumination, and with a cognitive avoidance account of worry (Borkovec et al., 1998).

Objectives. Future thinking is an important domain of cognitive functioning, with reduced ability to imagine positive future events associated with hopelessness in depression and parasuicide. Rumination has been shown to exacerbate negative cognitive biases in depression, and to reduce likelihood estimations for positive future events. We examine the hypothesis that, in depressed patients, rumination would reduce the ability to imagine positive future events, whilst increasing the ability to imagine negative future events. Method. The ability to imagine positive and negative future events was assessed using the future thinking paradigm (MacLeod, Rose, & Williams, 1993). Depressed and nondepressed participants completed the future thinking task after being randomly allocated to either a rumination or distraction manipulation (Nolen-Hoeksema & Morrow, 1993). Mood was measured before and after the manipulation. Participants also completed a standard verbal fluency task. Results. In the depressed group, compared to distraction, rumination increased both negative and positive future thinking, although the effect was only significant for negative future thinking once baseline levels of hopelessness were controlled for. These findings are consistent with the prediction that rumination would increase negative future thinking, but inconsistent with the prediction that rumination would reduce positive future thinking. Previous findings that, compared to controls, depressed patients generated fewer positive future events were replicated. Conclusion. Ruminative self-focus leads to greater negative future thinking in depressed patients, further confirming that rumination exacerbates negative cognitive biases in depression. The relationship between rumination and positive future thinking was unexpected, but might potentially reflect a general priming of self-related information by rumination.

This paper describes the development and beta-test of an eight-session computer therapy program for anxiety and depression, ‘ Beating the Blues ’. Developed by a multi-functional team, the program uniquely combines multi-media interactive computer technology with empirically-validated cognitive-behavioral therapy (CBT) techniques and crucial non-specific aspects of therapy. The paper describes how the project proceeded through its development phase, the unexpected hurdles that occurred and the lessons learnt. As an integral part of the development, the program was beta-tested with 20 patients. Despite the small numbers and the fact that the eight sessions were completed at an accelerated rate, feedback was positive. Patients reported it was helpful, easy to use, and of those who had had previous treatment for their problems, the majority indicated it compared at least as well as other forms of therapy. The beta-test also highlighted where changes were needed to the program. These were implemented prior to release of the program for the next phase of testing. Lastly, the beta-test indicated that the program had sufficient promise for it to be evaluated formally by randomized controlled trial.

We tested the hypothesis that impaired social problem solving in depression is a consequence of state-oriented rumination, which can be ameliorated by improving awareness of mental processes. 32 currently depressed, 26 recovered depressed, and 26 never depressed participants completed the Means Ends Problem Solving Test while randomly allocated to no questions, state-oriented ruminative questions, (e.g. focusing on why you have a problem) or process-focused questions (e.g. focusing on how you decide to solve a problem). In the no question condition, the currently depressed group was significantly impaired at problem solving compared to the never depressed and recovered depressed groups, which did not differ from each other. As predicted, the process-focused questions significantly improved social problem solving in depressed patients, compared to no questions and state-oriented questions, which did not differ from each other. As predicted, compared to the process-focused questions, the state-oriented questions significantly impaired social problem solving in the recovered depressed group. These results are consistent with recent theories and treatment developments which suggest that increased awareness of mental processes can shift people away from ruminative thinking, thereby, reducing depressive relapse.

Rumination has been recognised as an important maintaining factor in depression. Adapting the mood-as-input theory to rumination, we hypothesised that high ruminators have a default “as many as can” stop rule for determining when to stop analysing the causes and consequences of any problem, such that negative mood signals insufficient problem solving, leading to recurrent analysis and self-focus (i.e. rumination). To explore this hypothesis, 60 participants were randomly instructed to continue generating reasons for a recent depressed mood under three conditions: an “as many as you can” stop-rule, an “as long as you feel like continuing” stop-rule, and a “no stop-rule” condition. Participants were split into high and low ruminators on a median split on Ruminative Response Scale scores. As predicted, the high ruminators in the “as many as you can” and “no stop rule” conditions produced significantly more reasons for their depressed mood (without significantly differing from each other), than either the high ruminators in the “feel like continuing” condition or the low ruminators in all conditions. These results suggest that high ruminators adopt a default “as many as can” stop rule and that teaching high ruminators to use a “feel like continuing” rule may reduce rumination.

FROM: Hetrick SE, Cox GR, Witt KG, et al . Cognitive–behavioural therapy (CBT), third-wave CBT and interpersonal therapy (IPT) based interventions for preventing depression in children and adolescents. Cochrane Database Syst Rev 2016;(8):CD003380. Major depressive disorder is a leading global cause of lifelong disability, with the greatest increase in incidence occurring in mid-to-late adolescence into young adulthood. Onset in childhood predicts poor long-term educational, social and health outcomes. Therefore, interventions to prevent depression in children and adolescents have considerable potential to reduce the global burden of depression. Prior research has suggested that selective and indicated prevention interventions targeted, respectively, at high risk or subsyndromal children and young people may outperform universal interventions that deliver to all individuals in the population.1–3 The specialised register of the Cochrane Common Mental …

Background Increased life expectancy has resulted in a greater provision of informal care within the community for patients with chronic physical health conditions. Informal carers are at greater risk of poor mental health, with one in three informal carers of stroke survivors experiencing depression. However, currently no psychological treatments tailored to the unique needs of depressed informal carers of stroke survivors exist. Furthermore, informal carers of stroke survivors experience a number of barriers to attending traditional face-to-face psychological services, such as lack of time and the demands of the caring role. The increased flexibility associated with supported cognitive behavioral therapy self-help (CBTsh), such as the ability for support to be provided by telephone, email, or face-to-face, alongside shorter support sessions, may help overcome such barriers to access. CBTsh, tailored to depressed informal carers of stroke survivors may represent an effective and acceptable solution. Methods/Design This study is a Phase II (feasibility) randomized controlled trial (RCT) following guidance in the MRC Complex Interventions Research Methods Framework. We will randomize a sample of depressed informal carers of stroke survivors to receive CBT self-help supported by mental health paraprofessionals, or treatment-as-usual. Consistent with the objectives of assessing the feasibility of trial design and procedures for a potential larger scale trial we will measure the following outcomes: a) feasibility of patient recruitment (recruitment and refusal rates); (b) feasibility and acceptability of data collection procedures; (c) levels of attrition; (d) likely intervention effect size; (e) variability in number, length and frequency of support sessions estimated to bring about recovery; and (f) acceptability of the intervention. Additionally, we will collect data on the diagnosis of depression, symptoms of depression and anxiety, functional impairment, carer burden, quality of life, and stroke survivor mobility skill, self-care and functional ability, measured at four and six months post-randomization. Discussion This study will provide important information for the feasibility and design of a Phase III (effectiveness) trial in the future. If the intervention is identified to be feasible, effective, and acceptable, a written CBTsh intervention for informal carers of stroke survivors, supported by mental health paraprofessionals, could represent a cost-effective model of care. Trial registration Current Controlled Trials ISRCTN63590486.

Depression is a common and distressing mental health problem that is responsible for significant individual disability and cost to society. Medication and psychological therapies are effective for treating depression and maintenance anti-depressants (m-ADM) can prevent relapse. However, individuals with depression often express a wish for psychological help that can help them recover from depression in the long-term. A recently developed treatment, mindfulness-based cognitive therapy (MBCT), shows potential as a brief group program for people with recurring depression. This trial asks the policy research question; is MBCT with support to taper/discontinue antidepressant medication (MBCT-TS) superior to m-ADM in terms of: a primary outcome of preventing depressive relapse/recurrence over 24 months; and secondary outcomes of (a) depression free days, (b) residual depressive symptoms, (c) antidepressant medication (ADM) usage, (d) psychiatric and medical co-morbidity, (e) quality of life, and (f) cost effectiveness? An explanatory research question also asks whether an increase in mindfulness skills is the key mechanism of change. The design is a single-blind, parallel randomized controlled trial examining MBCT-TS versus m-ADM with an embedded process study. To answer the main policy research question the proposed trial compares MBCT-TS with m-ADM for patients with recurrent depression. Four hundred and twenty patients with recurrent major depressive disorder in full or partial remission will be recruited through primary care. Depressive relapse/recurrence over two years is the primary outcome variable. Analyses will be conducted following CONSORT standards and overseen by the trial’s Data Monitoring and Safety Committee. Initial analyses will be conducted on an intention-to-treat basis, with subsequent analyses being per protocol. The explanatory question will be addressed in two mutually informative ways: quantitative measurement of potential mediating variables pre- and post-treatment and a qualitative study of service users’ views and experiences. If the results of our exploratory trial are extended to this definitive trial, MBCT-TS will be established as an alternative approach to maintenance antidepressants for people with a history of recurrent depression. The process studies will provide evidence about the effective components which can be used to improve MBCT and inform theory as well as other therapeutic approaches. Trial registered 7 May 2009; ISRCTN26666654 .