Transdiagnostic emotion regulation processes in bipolar disorder and insomnia

Research and treatment have traditionally adopted a 'disorder-focused' approach by targeting one specific disorder, aiming to understanding its cause, maintenance and treatment. The aim of the present study was to contribute to the burgeoning interest in examining common, or 'transdiagnostic,' processes across disorders. Three candidate transdiagnostic processes involved in emotion regulation - rumination, worry, and automatic negative thoughts - were examined in euthymic bipolar I disorder (n=21) and insomnia (n=19), and a non-clinical control group (n=20). Rumination and worry were endorsed to a larger degree by the bipolar and insomnia groups compared to the control group. However, while the bipolar group had more negative automatic thoughts than the control group, there were no significant differences in negative automatic thoughts between the bipolar and insomnia groups or the insomnia and control groups. These results suggested that rumination and worry, but not negative automatic thoughts, might be common across bipolar disorder and insomnia. However, these findings no longer remained significant when current symptoms of anxiety and depression were controlled for. Prospective and experimental studies are needed to test the extent to which these processes contribute to the etiology or maintenance of insomnia and bipolar disorder.     

An experiential avoidance conceptualization of depressive rumination: Three tests of the model

This study examined an experiential avoidance conceptualization of depressive rumination in 3 ways: 1) associations among questionnaire measures of rumination, experiential avoidance, and fear of emotions; 2) performance on a dichotic listening task that highlights preferences for non-depressive material; and 3) psychophysiological reactivity in an avoidance paradigm modeled after the one used by Borkovec, Lyonfields, Wiser, and Deihl (1993) in their examination of worry. One hundred and thirty-eight undergraduates completed questionnaire measures and participated in a clinical interview to diagnose current and past episodes of depression. Of those, 100 were randomly assigned to a rumination or relaxation induction condition and participated in a dichotic listening task, rumination/relaxation induction, and depression induction. Questionnaire measures confirmed a relationship between rumination status and avoidance; however, no significant effects were found in the dichotic listening task. Psychophysiological measures indicated no difference in physiological response to a depression induction among high ruminators (HR). However, low ruminators (LR) in the relaxation condition exhibited a larger IBI response than LR in the rumination condition. Overall, these results provide partial support for an avoidance conceptualization of depressive rumination. Implications of these findings are discussed.     

Mood-as-input and depressive rumination

This article describes a test of mood-as-input theory predictions as applied to a rumination task in a nonclinical population. An experimenter-controlled interview was used to allow participants to reflect on a personal period of depression while in an experimentally-induced mood state (either negative or positive) or while deploying a specific stop rule for the task (either an “as many as can” or “feel like continuing” stop rule). As predicted by mood-as-input theory, persistence at the rumination task was greatest in the group experiencing negative mood while deploying an “as many as can” stop rule, and this suggests a mechanism that may contribute to perseverative depressive rumination. It is argued that the variables that contributed to perseveration in this study are already known to be characteristic of ruminative thinkers (e.g. negative mood and positive metacognitive beliefs about rumination that will command the deployment of “as many as can” stop rules for rumination). It is also argued that mood-as-input processes may provide a common mechanism for perseverative rumination and perseverative worry, and this common mechanism may account for many of the similarities between these two functionally-distinct activities.     

An experimental analogue study into the role of abstract thinking in trauma-related rumination

Trauma-related rumination has been shown to predict the maintenance of posttraumatic stress disorder (PTSD). However, it is still unclear how rumination can be distinguished from functional forms of thinking about traumatic events. The current study used an analogue design to experimentally test the hypothesis that the abstractness of thinking is responsible for the dysfunctional effects of trauma-related rumination. Eighty-three healthy university students first watched a distressing video and were then randomly assigned to abstract ruminative thinking, concrete thinking or distraction. Abstract thinking was found to lead to a significantly longer maintenance of negative mood and arousal than both concrete thinking and distraction. These results are in line with earlier findings in the context of excessive worry and depressive rumination and support the view that abstractness is a critical factor for the dysfunctional effects of trauma-related rumination. However, results regarding intrusive memories were not supportive of the hypotheses. Unexpectedly, the distraction group showed the highest number of intrusions, whereas the abstract and concrete conditions did not significantly differ. Implications for theoretical models of trauma-related rumination and possible clinical implications are discussed.     

Worry and rumination: differential associations with anxious and depressive symptoms and coping behavior

Worry and rumination are closely allied cognitive processes that impact on the experience of anxious and depressive symptoms. Using a prospective design, this study examined overlapping and distinct features of worry and rumination in relation to symptoms and coping behavior in a nonclinical sample of Singaporean college students. Worry and rumination were highly correlated, but they retained distinct components that predicted anxious and depressive symptoms differentially within and across time. Specifically, worry was uniquely associated with anxious and depressive symptoms whereas rumination was uniquely related to depression. In comparison to rumination, worry emerged as the dominant cognitive vulnerability factor that predicted increments in symptoms over time. With regards to coping behavior, low perceived coping effectiveness partially mediated the relation between worry and increases in anxiety and depression. Conversely, rumination uniquely predicted higher disengagement from problems, which resulted in further exacerbation of depressive mood. These results demonstrated not only the distinct features of worry and rumination on coping behavior, but also the different coping pathways by which they differentially impact on subsequent symptoms.     

Training the removal of negative information from working memory: A preliminary investigation of a working memory bias modification task

Rumination in depressed adults is associated with a bias toward retaining negative information in working memory. We developed a task designed to modify this cognitive bias by having subjects repeatedly practice removing negative words from working memory, thereby enabling them to retain positive and neutral words. To assess the efficacy of this task, we recruited 60 adults who reported elevated repetitive negative thought (RNT) and randomly assigned them to receive a single administration of either the working memory bias modification (WMBM) task or a control task. Subjects in the WMBM condition exhibited greater reduction in proactive interference for negative information than did those in the control condition. These results suggest that the WMBM task reduces biased retention of negative information in working memory and, thus, may be useful in investigating the possible causal role of this cognitive bias in RNT or depression.     

The everyday dynamics of rumination and worry: precipitant events and affective consequences

ABSTRACT

Rumination and worry are two perseverative, negatively valenced thought processes that characterise depressive and anxiety disorders. Despite significant research interest, little is known about the everyday precipitants and consequences of rumination and worry. Using an experience sampling methodology, we examined and compared rumination and worry with respect to their relations to daily events and affective experience. Participants diagnosed with Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), co-occurring MDD–GAD, or no diagnosis carried an electronic device for one week and reported on rumination, worry, significant events, positive affect (PA), and negative affect (NA). Across the clinical groups, occurrences of everyday events predicted subsequent increases in rumination, but not worry. Further, higher momentary levels of rumination, but not worry, predicted subsequent decreases in PA and increases in NA. Thus, in these clinical groups, rumination was more susceptible to daily events and produced stronger affective changes over time. We discuss implications for theory and clinical intervention.     

The effects of modifying interpretation bias on worry in generalized anxiety disorder

This study investigated whether facilitating a benign interpretive bias decreases negative thought intrusions in generalized anxiety disorder (GAD). Clients were randomly allocated to an interpretation modification condition in which they repeatedly accessed benign meanings of emotionally ambiguous homographs and scenarios, or to a control condition in which they accessed threat and benign meanings with equal frequency. Worry frequency was assessed using a breathing focus task that involved categorising the valence of thought intrusions before and after an instructed worry period. Interpretation bias was assessed during the modification tasks, and on a different measure of interpretation bias (sentence completion) following a period of worry. The experimental procedure modified interpretations made during training, and in the later sentence completion task. Furthermore, compared to the control group, the benign group showed fewer negative thought intrusions during breathing focus (as rated by both participants and an assessor). These findings show that it is possible to induce a more benign interpretive bias in GAD clients and that this reduces negative thought intrusions.     

The effect of attention modification with explicit vs. minimal instructions on worry

In this experiment we investigated the effect of different instructions on the modification of attentional biases, and subsequently on worry persistence. Participants without excessive worry completed a modified dot-probe task, designed to train attention either to threat or neutral words. Half of each group was given explicit instructions regarding the relationship between word valence and target location, and half were given the more usual minimal instructions. Impact on worry persistence was assessed by categorizing the valence of thought intrusions before and after a period of instructed worry. Response latencies to test items on the dot-probe task showed that attention had been successfully manipulated in the expected direction, and explicit instructions led to more effective attention modification. Moreover, participants in the attend-threat group who received explicit instructions reported significantly more negative thought intrusions following instructed worry, as rated by an assessor, whereas participants in the attend-neutral group did not. These findings suggest that an attentional bias towards threatening information plays a role in worry persistence, and that explicit instructions may be helpful in modifying this bias.     

Depressive symptoms and cognitive control in a mixed antisaccade task: Specific effects of depressive rumination

Growing empirical evidence suggests that cognitive and affective problems in depression may be a reflection of cognitive control impairments. However, to date, the nature of such impairments is still poorly understood and further investigation of this topic is required to advance current knowledge on the underlying vulnerability factors for depression. Using a mixed antisaccade paradigm, the present study examined if depressive symptoms in general, and more specifically rumination, are related to impairments in cognitive control functions such as inhibition and switching. The results on antisaccade latency and error rates indicated that depressive symptoms in general were not related to impairments in inhibition and switching. However, rumination was associated with impaired inhibition such that high, compared to low, ruminators had slower antisaccade latencies. No group differences were observed on antisaccade error rates. Implications for understanding the underlying vulnerability factors for the development of depressive symptoms are discussed.     

An open trial of cognitive therapy for chronic insomnia

We describe the development of a cognitive therapy intervention for chronic insomnia. The therapy is based on a cognitive model which suggests that the processes that maintain insomnia include: (1) worry and rumination, (2) attentional bias and monitoring for sleep-related threat, (3) unhelpful beliefs about sleep, (4) misperception of sleep and daytime deficits and (5) the use of safety behaviors that maintain unhelpful beliefs. The aim of cognitive therapy for insomnia is to reverse all five maintaining processes during both the night and the day. In an open trial 19 patients meeting diagnostic criteria for primary insomnia were treated with cognitive therapy for insomnia. Assessments were completed pretreatment, posttreatment and at 3-, 6- and 12-month followup. The significant improvement in both nighttime and daytime impairment evident at the posttreatment assessment was retained up to the 12 month followup.     

Intrusive thoughts mediate the association between neuroticism and cognitive function

Although research has established a negative association between trait neuroticism and cognition, little is known about the mechanisms that underlie this relationship. We examined the tendency to experience intrusive thoughts and negative affect as potential mediators of the relationship between neuroticism and cognitive performance. We hypothesized that the tendency to experience intrusive thoughts reflects ineffective attentional control and would account for the relationship between neuroticism and cognitive performance over and above the mediating effect of negative affect. Three hundred seventeen adults (M_age = 49.43) completed a series of attention-demanding cognitive tasks as well as self-report measures of intrusive thoughts, negative affect, and neuroticism. Intrusive thoughts mediated the association between trait neuroticism and cognitive performance beyond negative affect. These findings are consistent with the hypothesis that the tendency to experience intrusive thoughts is a mechanism through which trait neuroticism influences cognitive performance.     

Flexibility is not always adaptive: Affective flexibility and inflexibility predict rumination use in everyday life

The present study examined whether cognitive flexibility in the processing of emotional material (i.e., affective flexibility) predicts the use of rumination in response to negative events in daily life. One hundred fifty-seven undergraduate participants completed daily diaries for six consecutive days. Affective flexibility was measured with a novel task-switching paradigm using emotional pictures. Results show that affective inflexibility when switching away from processing the emotional meaning of negative material was associated with increased use of rumination in daily life. In contrast, affective inflexibility when switching away from processing the emotional meaning of positive material was related to decreased use of rumination. Importantly, affective flexibility predicted use of rumination beyond non-affective measures of executive functioning. This is the first study to show that inflexibility is not uniformly associated with increased rumination but that inflexibility in the processing of positive material can predict lower levels of rumination.     

Cognitive-behavioral therapy of insomnia: A clinical case series study of patients with co-morbid disorders and using hypnotic medications

Cognitive-behavioral therapy for insomnia (CBTi) has demonstrated considerable efficacy within randomized clinical trials and case-series designs. This case-series study in a community sleep medicine clinic assessed the effectiveness of an eight-session CBTi protocol chronic insomnia patients who were allowed to continue their use of hypnotics (intent-to-treat n = 48), administered by a clinical psychology doctoral student receiving training and supervision in CBTi by a behavioral sleep medicine certified clinician. Outcome measures included daily sleep diaries, self-report measures on insomnia severity, dysfunctional beliefs and attitudes about sleep, daytime sleepiness, as well as medication usage. Patients showed significant improvements in sleep onset latency, wake time after sleep onset, sleep efficiency, insomnia severity, and dysfunctional sleep beliefs from pre- to post-treatment. No changes were seen in daytime sleepiness - patients were not excessively sleepy either before or after treatment. Use of sleep medication declined significantly from 87.5% pre-treatment to 54% post-treatment, despite no active efforts to encourage patients to withdraw. Results demonstrate that a CBTi conducted in a community sleep medicine clinic with patients not required to discontinue sleep-related medications can have similar effects as therapy delivered among those not on medication.     

Distinguishing between level and impact of rumination as predictors of depressive symptoms: An experience sampling study

Rumination—repetitively thinking about one's emotional state, its causes and consequences—exacerbates negative mood and plays an important role in the aetiology and maintenance of depression. Yet, it is unclear whether increased vulnerability to depression is associated with simply how much a person ruminates, or the short-term impact rumination has on a person's negative mood. In the current study, we distinguish between the level versus the impact of rumination, and we examine how each uniquely predicts changes in depressive symptoms over time in an undergraduate sample. Using experience sampling, we assessed students’ (N = 101) subjective experiences of positive and negative affect and their use of rumination and distraction in daily life for seven days. Participants also reported their depressive symptoms before and after the experience sampling. Increases in depressive symptoms over the week were predicted by how much people ruminated, but not by its impact on negative mood.     

Psychological treatment of hypnotic-dependent insomnia in a primarily older adult sample

Objective

This study tested cognitive behavior therapy (CBT) in hypnotic-dependent, late middle-age and older adults with insomnia.

Method

Seventy volunteers age 50 and older were randomized to CBT plus drug withdrawal, placebo biofeedback (PL) plus drug withdrawal, or drug withdrawal (MED) only. The CBT and PL groups received eight, 45 min weekly treatment sessions. The drug withdrawal protocol comprised slow tapering monitored with about six biweekly, 30 min sessions. Assessment including polysomnography (PSG), sleep diaries, hypnotic consumption, daytime functioning questionnaires, and drug screens collected at baseline, posttreatment, and 1-year follow-up.

Results

Only the CBT group showed significant sleep diary improvement, sleep onset latency significantly decreased at posttreatment. For all sleep diary measures for all groups, including MED, sleep trended to improvement from baseline to follow-up. Most PSG sleep variables did not significantly change. There were no significant between group differences in medication reduction. Compared to baseline, the three groups decreased hypnotic use at posttreatment, down 84%, and follow-up, down 66%. There was no evidence of withdrawal side-effects. Daytime functioning, including anxiety and depression, improved by posttreatment. Rigorous methodological features, including documentation of strong treatment implementation and the presence of a credible placebo, elevated the confidence due these findings.

Conclusions

Gradual drug withdrawal was associated with substantial hypnotic reduction at posttreatment and follow-up, and withdrawal side-effects were absent. When supplemented with CBT, participants accrued incremental self-reported, but not PSG, sleep benefits.     

Distinguishing voluntary from involuntary attention to emotion

This study explored whether voluntary attention to emotion is distinguishable from involuntary attention to emotion. University students (N = 166) completed self-report questionnaires, designed for this study, intended to measure voluntary and involuntary attention to one’s own emotions. Moreover, participants completed questionnaires measuring other emotional constructs and distress. Finally, participants completed a dot probe task intended to obtain a behavioral measure of voluntary attention to emotion. Affect intensity was positively correlated with both voluntary and involuntary attention to emotion. As expected, dot probe emotional bias scores were associated with self-reported voluntary attention to emotion, but not with involuntary attention to emotion. Voluntary and involuntary attention to emotion were also differentially associated with clarity of emotion, anhedonic depression, and worry. The results of this study suggest it is important to distinguish between voluntary and involuntary attention to one’s own emotions.     

Domain-specificity and individual differences in worry

Worrying is generally perceived to be an undesirable mental state. An evolutionary approach suggests, however, despite the potential distress, worry may function to focus individuals’ attention on evolutionarily-relevant tasks. In the current study (N = 193), we demonstrated that participants’ primary worries were focused within domains central to reproductive success and mate-value. Furthermore, mating strategy predicted worries in the domains of social status and mating. Neuroticism, as an individual difference reflecting vigilance to threats, was correlated with worry about fitness-relevant but not fitness-irrelevant domains. The current study documents the first domain-specific assessment of worries and complements this analysis with intriguing individual difference predictors of worry.     

The interplay of trait worry and trait anxiety in determining episodic retrieval: The role of cognitive control

Worrying is a key concept in describing the complex relationship between anxiety and cognitive control. On the one hand, cognitive control processes might underlie the specific tendency to engage in worrying (i.e., trait worry), conceptualized as a future-oriented mental problem-solving activity. On the other hand, the general tendency to experience the signs and symptoms of anxiety (i.e., trait anxiety) is suggested to impair cognitive control because worrisome thoughts interfere with task-relevant processing. Based on these opposing tendencies, we predicted that the effect of the two related constructs, trait anxiety and trait worry, might cancel out one another. In statistics, such instances have been termed suppressor situations. In four experiments, we found evidence for such a suppressor situation: When their shared variance was controlled, trait worry was positively whereas trait anxiety was negatively related to performance in a memory task requiring strategic, effortful retrieval. We also showed that these opposing effects are related to temporal context reinstatement. Our results suggest that trait worry and trait anxiety possess unique sources of variance, which differently relate to performance in memory tasks requiring cognitive control.