Ruminations

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Definition[edit]

According to Sansone et al., rumination is a “perseverative cognition” that is focused on “negative content, generally past and present, and results in emotional distress.” (Rumination. Relationships with Physical Health, Randy A. Sansone, M and Lori A. Sansone, MD, Innov Clin Neurosci. 2012 Feb; 9(2): 29–34 available in full online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312901/.) According to Wikipedia “Perseverative cognition[1][2] is a collective term in psychology for continuous thinking about negative events[3] in the past or in the future (e.g. worry, rumination and brooding, but also mind wandering about negative topics[4][5]).”

Psychological aspects of rumination in general[edit]

Psychologists distinguish between what is known as “positive rumination” and “negative rumination”; and between “brooding vs. self-reflection”. They have also studied the relationship to catastrophic thinking, and the “role of impaired disengagement” as well as “state vs. trait features”.

Presence of rumination in psychiatric conditions[edit]

Rumination has been found in many psychiatric syndromes including depression, alcohol abuse, generalized anxiety disorder, social anxiety disorder, obsessive compulsive disorder, post-traumatic stress disorder and bulimia nervosa.

Studies of rumination in the somatic literature[edit]

Rumination has been studied in chronic pain where it has been “associated with symptom magnification as well as poorer clinical outcomes.”

Ruminations about pain[edit]

Flood of worries about each pain[edit]

In the experience of the author, there are certainly cases of fibromyalgia whereby the patient is flooded with worries that each pain or paresthesia (an often painful pins and needles feeling) may be related to serious illness. For example, I had one patient whose pain in the left breast area contributed to an excessive fear of cancer (cancerphobia) and even thorough investigation and negative mammography did little to reassure her. Pain related fears, thus, giving rise to frequent visits to the emergency department (e.g. out of fear that say the latest “fibropain” in the chest wall might be from a heart attack). Some patients are virtually unreassurable, and each successive pain brings with it voiced fears that the latest pain may be due to cancer or another serious underlying disease. These frequently results in ongoing patient initiated demands for laboratory testing and x-rays. It can occupy a good portion of the doctor patient relationship.

Rumination in fibromyalgia[edit]

A study was done by Malin et al. to examine the thinking style of rumination in women with fibromyalgia to assess the effect of rumination on their stress levels and several other psychological variables. (Rumination modulates stress and other psychological processes in fibromyalgia. Katrina Malin 1, Geoffrey Owen Littlejohn 1 Eur J Rheumatol 2015 Dec;2(4):143-148. doi: 10.5152/eurjrheum.2015.0005. Epub 2015 Aug 21. DOI: 10.5152/eurjrheum.2015.0005, available in full online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047227/.)

Results showed “that those with higher levels of rumination had increased the use of negative coping techniques (p<0.001), higher anxiety (p<0.001), depression (p<0.001), and poor sleep levels (p<0.05).”

A correlation was found between rumination “and lower optimism (p<0.001) and control (Mastery) (p<0.001). High rumination correlated strongest with stress (p<0.001). Rumination predicted 26% of variance for perceived stress.” The authors concluded that: “Rumination influenced several psychological processes deemed important in FM and was an important contributor to stress in FM.” They made the reasonable prediction that treating rumination is a worthy treatment strategy going forward.

For further information about rumination in fibromyalgia see:

A confirmatory factor analysis of the Pain Catastrophizing Scale: invariant factor structure across clinical and non-clinical populations, Stefaan Van Damme 1, Geert Crombez, Patricia Bijttebier, Liesbet Goubert, Boudewijn Van Houdenhove. Pain. 2002 Apr;96(3):319-24, DOI: 10.1016/s0304-3959(01)00463-8

Pain-focused thoughts and behaviors in fibromyalgia[edit]

One fibromyalgia patient came to the realization that she was using up too much mental energy thinking about her pains.

Treatment[edit]

According to Sansone et al., as of 2012, treatment of rumination in primary care settings has started to unfold.

One approach is psychotherapy for the conflicts giving rise to the rumination. Rumination may subside if a life problem gets resolved such as a legal or financial problem.

A large percentage of fibromyalgia patients have insomnia. Current guidelines are that for most people the recommended first line treatment is CBT-I. One of the five key elements is relaxation training which is focused on being done to get to sleep or get back to sleep (i.e. when the patient is rumination worrying). What all this means is that as of 2020, forward looking fibromyalgia treatments are already providing this in forms such as “4-7-8” breathing, cognitive shuffle, progressive muscle relaxation training on closing the lights and various other techniques such as imagery and guided imagery.