Cognitive Behavioral Processes Across Psychological Disorders: A Review of the Utility and Validity of the Transdiagnostic Approach

Abstract

The transdiagnostic approach states that there are key cognitive and behavioral processes responsible for maintaining symptoms and these are shared across psychological disorders (Harvey, Watkins, Mansell, & Shafran, 2004). The first goal of this article is to justify the potential utility of a transdiagnostic perspective for theory, research and treatment using empirical evidence and clinical vignettes. We then take as an example one set of cognitive processes-attentional processes-to illustrate the approach. Evidence for three attentional processes is provided: vigilance to external concern-related stimuli; vigilance to internal concern-related stimuli (self-focused attention) and attentional avoidance. It is concluded that each of these attentional processes are transdiagnostic. We then discuss three possible resolutions to the question: How can a transdiagnostic perspective be valid when the different psychological disorders present so differently? The three proposals are: (1) variations in idiosyncratic current concerns; (2) variations in the degree of shared processes and (3) distinct processes for specific disorders or groups of disorders. The role of a transdiagnostic approach in supporting the development and testing of theories of psychopathology is highlighted and the need for future studies that incorporate multiple patient groups is discussed.

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Psychological
treatment
of
depressive
rumination
Ed
Watkins
1,2
Depressive
rumination
is
the
tendency
to
repeatedly
dwell
on
the
causes
and
meanings
of
negative
symptoms,
feelings,
and
problems.
It
has
been
robustly
implicated
as
an
important
mechanism
in
the
onset
and
maintenance
of
depression,
and
has
recently
been
proposed
as
a
potential
therapy
target
to
improve
treatment
efficacy.
I
describe
emerging
trial
research
on
psychological
therapies
that
target
rumination,
which
provides
encouraging
preliminary
evidence
that
rumination-
focused
interventions
may
enhance
treatment
outcome,
although
key
limitations
are
noted,
including
the
lack
of
a
definitive
comparison
to
existing
therapies.
Recent
advances
in
cognitive
bias
modification
that
implicate
cognitive
biases
in
the
maintenance
of
rumination
are
highlighted
as
indicating
that
this
approach
has
potential
to
treat
rumination.
Addresses
1
Study
of
Maladaptive
to
Adaptive
Repetitive
Thought
(SMART)
Lab,
University
of
Exeter,
United
Kingdom
2
School
of
Psychology,
University
of
Western
Australia,
Australia
Corresponding
author:
Watkins,
Ed
(e.r.watkins@exeter.ac.uk)
Current
Opinion
in
Psychology
2015,
4:32–36
This
review
comes
from
a
themed
issue
on
Depression
Edited
by
Christopher
G
Beevers
http://dx.doi.10.1016/j.copsyc.2015.01.020
2352-250X/#
2015
Elsevier
Ltd.
All
rights
reserved.
Introduction
Depressive
rumination
is
defined
as
a
response
style
characterized
by
repetitive
thinking
about
the
symp-
toms,
causes,
meanings,
and
consequences
of
depres-
sion,
for
example,
repeated
dwelling
on
questions
like
‘Why
did
this
happen
to
me?
Why
do
I
feel
like
this?
Why
do
I
always
react
this
way?’
[1,2].
Recent
theoreti-
cal
work
has
proposed
that
unresolved
goals
produce
rumination
but
also
that
pathological
rumination
is
a
mental
habit
—
an
automatic
cognitive
response
condi-
tioned
to
triggering
stimuli
such
as
low
mood
[3

].
Rumination
has
been
identified
as
a
major
psychological
risk
factor
for
depression,
and,
hence,
as
a
treatment
target.
In
this
review,
I
consider
the
background,
evi-
dence,
and
future
directions
for
the
psychological
treat-
ment
of
rumination.
Why
is
rumination
an
important
treatment
target?
Although
there
are
effective
psychotherapies
for
depres-
sion,
less
than
a
third
of
patients
show
sustained
remission
and
rates
of
relapse
are
high
after
recovery,
indicating
a
pressing
need
for
better
treatments.
Targeting
mecha-
nisms
identified
in
the
maintenance
of
depression
is
one
approach
mooted
to
improve
treatment
efficacy
and
du-
rability.
Rumination
is
a
strong
candidate
mechanism
because
it
has
been
robustly
implicated
in
the
onset
and
maintenance
of
depression.
In
large-scale
longitudi-
nal
studies,
rumination
prospectively
predicts
the
onset
of
major
depressive
episodes
and
depressive
symptoms
in
non-depressed
and
currently
depressed
individuals,
and
mediates
the
effects
of
other
major
risk
factors
on
de-
pression
[4,5,6

,7

].
In
experimental
studies,
manipulat-
ing
rumination
causally
exacerbates
existing
negative
affect
and
negative
cognition
[2,8].
Elevated
rumination
is
a
common
residual
symptom
after
both
partial
and
full
remission
from
depression
[9,10].
It
is
associated
with
slower
treatment
response
and
poorer
rates
of
recovery
to
antidepressant
medication
and
cognitive
therapy,
sug-
gesting
that
it
may
interfere
with
therapeutic
response
[11–13].
Rumination
has
also
been
identified
as
a
transdiagnostic
process,
defined
as
a
mechanism
that
causally
contributes
to
the
onset,
maintenance,
or
recurrence
of
multiple
disorders
[14].
Rumination
is
common
to
depression,
generalized
anxiety
disorder,
social
anxiety,
post-traumat-
ic
stress
disorder,
and
eating
disorders
[15,16].
In
large-
scale
prospective
longitudinal
studies,
rumination
pre-
dicted
substance
abuse,
eating
disorders
[17],
and
alcohol
abuse
[18],
after
controlling
for
initial
symptoms,
and
explained
the
concurrent
and
prospective
associations
between
symptoms
of
anxiety
and
depression
[19].
Co-
occurrence
of
depression
and
anxiety
is
the
modal
clinical
presentation,
with
this
co-morbidity
associated
with
poorer
outcomes.
Thus,
targeting
rumination
may
enhance
treatment
out-
comes
by
directly
addressing
an
underlying
maintaining
mechanism
and
by
better
treating
co-morbidity
between
depression
and
anxiety
[20–22].
Because
rumination
involves
repetitive
negative
thought,
cognitive
beha-
vioural
therapy
(CBT),
which
challenges
negative
thoughts
and
increases
rewarding
behaviours,
is
indicated
to
reduce
rumination.
However,
to
date,
most
trials
of
CBT
have
not
assessed
rumination,
leaving
unresolved
whether
standard
CBT
effectively
reduces
rumination
(see
[11–13]
for
negative
evidence).
Rumination
needs
to
be
included
as
an
outcome
measure
within
treatment
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Current
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2015,
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trials
to
establish
whether
existing
interventions
reduce
rumination.
Nonetheless,
several
CBT
treatments
have
specifically
targeted
rumination,
with
encouraging
pre-
liminary
evidence.
Metacognitive
therapy
Metacognitive
therapy
is
based
on
the
hypothesis
that
rumination
is
initiated
by
positive
metacognitive
beliefs
about
the
usefulness
of
rumination
and
then
exacerbated
by
negative
metacognitive
beliefs
about
the
negative
consequences
of
rumination
[23].
Metacognitive
therapy
focuses
on
challenging
these
metacognitive
beliefs
and
trains
patients
to
disengage
their
attention
from
self-focus
to
external
stimuli.
To
date,
metacognitive
therapy
has
only
been
examined
in
a
small
open
case
series
for
patients
with
treatment-resistant
depression,
with
posi-
tive
within-subject
change
but
without
any
randomiza-
tion
or
control
condition
[24].
Rumination-focused
CBT
(RFCBT)
RFCBT
[21,25

,26]
is
theoretically
informed
by
experi-
mental
research
indicating
that
there
are
distinct
modes
of
processing
during
repetitive
thinking
with
distinct
consequences
[8]:
an
abstract,
decontextualized,
and
global
style,
characteristic
of
depressive
rumination,
which
causally
contributes
to
its
maladaptive
conse-
quences
including
poor
problem-solving
and
increased
emotional
reactivity,
relative
to
a
concrete,
specific,
and
contextualized
style
[27–29].
Whilst
still
grounded
within
the
core
principles
and
techniques
of
standard
CBT
for
depression,
RFCBT
includes
several
novel
elements
that
build
on
this
research.
First,
it
incorporates
the
functional–analytic
and
contex-
tual
approach
developed
in
Behavioural
Activation
[30,31].
Within
this
approach,
rumination
is
conceptual-
ized
as
a
learned
habitual
behaviour
that
acts
as
a
form
of
avoidance
and
that
develops
through
negative
reinforce-
ment.
Functional
analysis
examines
how,
when
and
where
rumination
does
and
does
not
occur,
and
its
ante-
cedents
and
consequences,
to
formulate
its
possible
func-
tions
and
to
make
plans
that
systematically
reduce
or
replace
it.
This
approach
explicitly
targets
rumination-as-
a-habit
[3

]
by
identifying
antecedent
cues
to
rumina-
tion,
controlling
exposure
to
these
cues,
and
by
practising
alternative
helpful
responses
to
these
cues.
Second,
RFCBT
uses
functional
analysis,
imagery,
beha-
vioural
experiments,
and
experiential
approaches
to
shift
a
patient
from
the
unconstructive
processing
style
to
the
constructive
style.
Functional
analysis
is
used
to
discrim-
inate
between
helpful
versus
unhelpful
thinking
about
difficulties
and
to
coach
patients
towards
more
helpful
thinking.
Patients
use
directed
imagery
to
recreate
previ-
ous
mental
states
when
a
thinking
style
directly
counter
to
rumination
was
active,
including
concrete
thinking,
memories
of
being
completely
absorbed
in
an
activity
(e.g.,
‘flow’
experiences),
and
experiences
of
increased
compassion
to
self
or
others.
A
randomized
controlled
trial
(RCT)
allocated
forty-two
patients
with
medication-refractory
residual
depression
to
treatment-as-usual
(TAU)
alone
or
to
TAU
plus
indi-
vidualized
RFCBT
[25

].
TAU
consisted
of
ongoing
antidepressant
medication
and
out-patient
clinical
man-
agement.
TAU
plus
RFCBT
significantly
reduced
rumi-
nation
and
depression
relative
to
TAU
alone
(remission
rates:
TAU
21%;
TAU
+
RFCBT
62%),
comparing
favourably
to
remission
rates
(25%)
found
for
TAU
plus
standard
CBT
in
another
trial
for
residual
depression
[32].
Change
in
rumination
mediated
the
effect
of
treat-
ment
condition
on
depression,
although
this
was
only
measured
concurrently,
preventing
conclusions
about
causal
direction.
A
separate
trial
confirmed
that
group-
delivered
RFCBT
improved
depressed
mood
and
re-
duced
rumination
relative
to
a
waiting
list
condition
in
patients
with
residual
depression,
with
treatment
gains
maintained
over
one
year
follow-up
[33

].
These
results
provide
preliminary
evidence
consistent
with
the
hypothesis
that
explicitly
targeting
rumination
enhances
outcomes
for
hard-to-treat
depression.
Howev-
er,
no
definitive
conclusion
is
possible
until
a
large-scale
RCT
compares
RFCBT
versus
standard
CBT
with
a
longer
follow-up.
Because
rumination
has
been
implicated
as
a
risk
factor
for
depression
onset,
RFCBT
was
recently
tested
as
a
preventative
intervention
for
depression
and
anxiety
(Topper
et
al.,
unpublished
data).
Group
and
Internet
RFCBT
were
compared
to
a
waiting
list
control
group
in
251
adolescents
and
young
adults
with
elevated
rumina-
tion
but
without
current
major
depression
or
anxiety
disorder
in
a
high-risk
prevention
design.
Relative
to
the
waiting
list
control,
both
RFCBT
interventions
sig-
nificantly
reduced
worry,
rumination,
anxiety,
and
de-
pression
at
post-intervention
and
one-year
follow-up,
and
halved
one-year
rates
of
major
depression
and
generalized
anxiety
disorder.
Because
diagnostic
rates
were
derived
from
standard
cut-offs
on
self-report
measures,
replication
is
required
using
structured
diagnostic
interviews.
None-
theless,
these
results
provide
proof-of-principle
that
ru-
mination
increases
risk
for
the
onset
of
major
depression
and
generalized
anxiety
disorder,
and
that
targeting
ru-
mination
has
transdiagnostic
benefit.
Mindfulness-based
CBT
Another
treatment
hypothesized
to
reduce
rumination
is
Mindfulness-based
CBT
(MBCT).
MBCT
is
a
psychoso-
cial
group-based
relapse
prevention
programme
that
incorporates
meditational
practice
within
the
framework
of
CBT
principles
as
a
means
to
increase
resilience
against
depression
[34].
A
key
element
is
mindfulness
practice
in
which
participants
learn
experientially
to
Psychological
treatment
of
depressive
rumination
Watkins
33
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Current
Opinion
in
Psychology
2015,
4:32–36

Author's personal copy
maintain
their
attention
to
their
breath,
thoughts,
and
feelings,
and
to
hold
such
experiences
in
awareness,
in
a
non-judgmental
and
accepting
way.
These
mindfulness
skills
are
hypothesized
to
enable
individuals
to
develop
alternative
responses
to
negative
thoughts
and
feelings,
and,
thereby,
to
step
out
of
habitual
patterns
of
rumina-
tion.
MBCT
has
been
demonstrated
to
be
an
effective
relapse
prevention
treatment
for
individuals
with
three
or
more
episodes
of
depression
[35].
Mindfulness
approaches
reduce
rumination
in
experi-
mental
analogue
studies
[36]
and
in
trials
of
MBCT
for
patients
with
a
history
of
recurrent
major
depression,
relative
to
waiting
list
control
[37]
and
treatment-as-usual
[38

],
with
the
reduction
of
depressive
symptoms
medi-
ated
by
decreased
levels
of
rumination
[38

].
However,
in
another
trial,
MBCT
did
not
reduce
rumination
more
than
continuation
antidepressants
[39].
Cognitive
bias
modification
Cognitive
bias
modification
(CBM)
uses
systematic
prac-
tice
that
introduces
training
contingencies
to
modify
automatic
patterns
of
processing
selectivity,
for
example,
by
selectively
reinforcing
attention
towards
positive
rela-
tive
to
negative
words
[40].
It
has
provided
evidence
that
cognitive
biases
causally
contribute
to
anxiety
and
de-
pression
symptoms
and
is
being
developed
as
a
stand-
alone
or
adjunct
treatment,
with
encouraging
albeit
mixed
results
[41].
Because
CBM
can
be
automated
through
Internet
and
app
programmes,
it
could
increase
treatment
access
and
coverage,
whilst
reducing
costs.
Looking
ahead,
CBM
has
potential
to
treat
rumination.
First,
emergent
evidence
suggests
that
single
session
CBM
training,
whether
training
cognitive
control
or
al-
tering
interpretative
bias,
influences
state
rumination
[42

,43

],
consistent
with
the
hypothesis
that
rumina-
tion
arises
from
impairments
in
disengaging
from
nega-
tive
self-referent
information
[44].
Second,
if
rumination
is
a
mental
habit
[3

],
then
to
achieve
sustained
improve-
ments,
interventions
need
to
train
a
new
habit
where
the
triggering
cue
for
rumination
is
associated
with
an
alter-
native
incompatible
response.
If
a
habit
is
left
in
place,
although
it
may
temporarily
not
be
expressed
when
its
triggering
stimuli
are
absent
(e.g.,
when
treatment
improves
low
mood),
it
will
re-emerge
once
those
stimuli
reoccur
(e.g.,
when
faced
with
stress).
CBM
is
a
good
candidate
to
change
habits,
because
it
involves
the
same
associative
and
instrumental
learning
processes
as
habit
formation
[40,45

].
However,
to
be
considered
as
a
potential
treatment,
CBM
training
needs
to
successfully
generalize
to
changes
in
trait
rumination
and
to
clinical
populations,
following
extended
training.
To
date,
there
is
preliminary
evidence
for
atten-
tional
bias
modification
and
concreteness
training
CBM.
A
double-blind
study
of
attentional
bias
modification
extended
to
eight
sessions
over
two
weeks
in
77
undergrad-
uate
students
with
elevated
depressive
symptoms,
success-
fully
reduced
depression
and
rumination
relative
to
placebo
training
and
no-training
[46].
Rumination
mediat-
ed
the
effect
of
attention
bias
change
on
subsequent
depressive
symptoms,
although
this
was
not
a
clinical
sample.
Concreteness
training
CBM
is
derived
from
the
proces-
sing
mode
research
and
involves
repeated
practice
at
focusing
on
the
specific
details,
context,
and
sequence
of
difficult
events
using
audio-recorded
mental
exercises
in
response
to
identified
warning
signs
for
rumination.
Providing
proof-of-principle,
concreteness
training
for
one
week
in
individuals
with
stable
dysphoria
reduced
depression,
anxiety,
and
rumination
relative
to
a
no-
treatment
control
and
a
credible
attention
placebo
control
[47].
A
further
trial
randomized
121
patients
with
major
depression
recruited
in
primary
care
to
TAU
as
provided
by
general
practitioners
including
antidepressants,
TAU
plus
concreteness
training,
or
TAU
plus
relaxation
train-
ing.
The
training
conditions
were
matched
for
rationale,
therapist
contact,
identification
of
warning
signs
and
daily
practice
over
six
weeks,
and
delivered
via
one
face-to-face
session
and
three
30-min
telephone
sessions
[48

].
Both
training
conditions
significantly
and
equivalently
reduced
depression
and
anxiety
relative
to
TAU,
with
benefits
maintained
over
six
months.
The
parsimonious
interpre-
tation
is
that
non-specific
treatment
effects
or
practising
alternative
behaviours
to
warning
signs
reduced
depres-
sion.
However,
concreteness
training
reduced
rumination
more
than
relaxation
training
and
TAU,
and
reduced
depression
more
than
relaxation
training
when
it
became
habitual,
suggesting
that
repeated
training
of
alternative
cognitive
responses
may
have
specific
benefit.
Conclusion
In
this
review,
we
saw
that
there
are
good
theoretical
and
empirical
reasons
to
hypothesize
that
targeting
rumina-
tion
may
enhance
treatments
for
depression.
Recent
trials
of
CBT
that
explicitly
targeted
rumination
support
this
hypothesis,
with
large
between-treatment
group
effect
sizes
that
compare
favourably
to
existing
treatments
and
with
changes
in
rumination
repeatedly
mediating
symp-
tom
improvement.
RFCBT
and
MBCT
look
most
prom-
ising
as
their
benefits
have
been
replicated
in
multiple
RCTs
from
independent
groups.
However,
caution
is
still
required
in
interpreting
these
findings
because
of
the
relatively
small
sample
sizes,
lack
of
direct
comparisons
to
active
treatments,
especially
to
standard
CBT,
and
the
need
for
further
replication.
A
common
thread
across
the
potentially
effective
treat-
ments
is
a
focus
on
tackling
rumination-as-a-habit,
in
which
new
responses
are
made
contingent
on
the
trigger-
ing
cues
for
rumination
[3

].
More
explicit
application
of
the
habit
change
literature
to
psychotherapy
may
enhance
34
Depression
Current
Opinion
in
Psychology
2015,
4:32–36
www.sciencedirect.com

Author's personal copy
therapy
outcomes.
CBM,
although
in
its
infancy,
provides
one
such
potential
avenue.
Acknowledgements
This
article
describes
work
supported
by
a
NARSAD
Young
Investigator
Award
and
an
UK
Medical
Research
Council
Experimental
Medicine
grant
to
the
author.
References
and
recommended
reading
Papers
of
particular
interest,
published
within
the
period
of
review,
have
been
highlighted
as:

of
special
interest

of
outstanding
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large
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0.94
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Current
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2015,
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worry
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vating
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
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negative
resolutions
of
ambiguous
situations
increased
state
rumination
following
recall
of
a
negative
personal
experience,
relative
to
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to
make
benign
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it
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for
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automatic
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esis
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with
major
depression.
Concreteness
training
CBM
outper-
formed
treatment-as-usual
in
reducing
depression
(effect
size
d
=
0.89
SD
units,
95%
CI
0.42–1.36)
and
rumination,
providing
evidence
that
CBM
can
successfully
target
both.
A
matched
treatment
control
(relaxation)
reduced
depression
but
not
rumination,
implicating
non-specific
treat-
ment
effects
in
changing
depression
but
more
specific
effects
in
reducing
rumination.
36
Depression
Current
Opinion
in
Psychology
2015,
4:32–36
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