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Rumination in Generalized Anxiety and Social Phobia: A Qualitative Systematic Review

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Rumination has often been investigated in relation to the etiology and maintenance of major depression. Evidence now suggests that rumination is also associated with anxiety disorders. However, there are relatively few studies that examine ruminative response in clinical samples such as generalized anxiety disorder (GAD) or social phobia (SP). The goal of this article is to provide a comprehensive review of the studies analyzing the relations between rumination, generalized anxiety disorder and social phobia. A comprehensive search of the literature identified 37 studies that were included in this review. We searched the PsycArticles, PubMed, Sciencedirect and Web of Science databases, beginning with January 2000.We conclude that investigating the potential role of rumination in social phobia and generalized anxiety has implications for current cognitive models as well as in clinical practice.
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Rumination in Generalized Anxiety and Social
Phobia: A Qualitative Systematic Review
SERGIU P. VĂLENAŞ 1
AURORA T. SZENTAGOTAI 2
Abstract
Rumination has often been investigated in relation to the etiology and
maintenance of major depression. Evidence now suggests that rumination is
also associated with anxiety disorders. However, there are relatively few
studies that examine ruminative response in clinical samples such as gen-
eralized anxiety disorder (GAD) or social phobia (SP). The goal of this article
is to provide a comprehensive review of the studies analyzing the relations
between rumination, generalized anxiety disorder and social phobia. A com-
prehensive search of the literature identified 37 studies that were included
in this review. We searched the PsycArticles, PubMed, Sciencedirect and
Web of Science databases, beginning with January 2000.We conclude that
investigating the potential role of rumination in social phobia and general-
ized anxiety has implications for current cognitive models as well as in clini-
cal practice.
Keywords
rumination, generalized anxiety disorder, social phobia, systematic review
Theoretical Perspectives on Rumination
Rumination is defined as ‘‘behavior and thoughts that focus one’s attention
on one’s depressive symptoms and on the implications of these symptoms’’
(Nolen-Hoeksema, 1991). According to Response Style Theory (Nolen-
Hoeksema, 1991) rumination is a cognitive process hallmarked by repetitive
thinking and negative automatic thoughts. Theories of rumination
The Response style theory (Nolen-Hoeksema, 1991) denes rumination as
repetitive and passive thinking about one’s symptoms of distress and the
1. Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, No. 37,
Republicii Street 400015, Cluj-Napoca, Cluj, Romania. E-mail: sergiu.valenas@ubbcluj.ro;
2. Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University
62 | SERGIU P. VĂLENAŞ; AURORA T. SZENTAGOTAI
possible causes and consequences of these symptoms. Usually, people who
are involved in this process repeatedly ask themselves why they can’t get go-
ing or what’s wrong with them. Ruminators frequently feel that they cannot
ever get over some situations. They do not actively solve the problem, but in-
stead remain fixed on their problems and feelings, without taking any action.
Usually they are caught in a vicious circle. The response style theory (Nolen-
Hoeksema, 1991) maintains that rumination exacerbates and prolongs dis-
tress, specifically depression, through particular mechanisms. The first
mechanism refers to the enhancement of the effects of depressed mood on
thinking. The second one refers to rumination interfering with effective prob-
lem solving, which makes people think in a more pessimistic and fatalistic
ways. The third mechanism is related to rumination interfering with instru-
mental behavior.
In their model of social phobia, Clark and Wells (1995) conceptualize ru-
mination as a post-event process that follows a social or performance event
such as public speaking or social interactions. According to Clark and Wells
(1995) post-event rumination is included in their cognitive model of social
phobia. They conceptualize rumination as a process involved in maintaining
social anxiety, along with self-focused attention, in-situation safety behav-
iors, assumptions, and self-schemata. The authors suggest that individuals
engaged in post-event rumination are influenced by features of anxiety feel-
ings and negative cognitions related to their self-perception. Clark and Wells
(1995) underline the importance of a social or performance event and
thoughts and feelings processed during it. They also suggest that past recol-
lections of perceived social failures may be important in maintaining nega-
tive cognitions and feelings related to social phobia.
Martin, Tesser and McIntosh (1993) discuss rumination in the Goal Pro-
gress theory. They argue that rumination is the recurrent tendency to think
about some important goals that have not yet been met. They define rumina-
tion as “thoughts that are conscious, recurrent, instrumentally oriented, and
not demanded by the immediate environment” (p. 20). However, rumina-
tion occurs when people do not make any progress toward their important
goals. This theory could have implications in anxiety, regarding both cogni-
tions and action tendencies.
Conway, Csank, Holm, and Blake (2000) present rumination as repetitive
thinking about sadness and all events or circumstances related to sadness.
From this perspective we can appreciate that ruminative thoughts are related
Rumination in Generalized Anxiety and Social Phobia... | 63
to features of negative mood, are not goal directed and are not shared with
others. On the other hand, Alloy and colleagues (2000) define rumination as
negative inferences that follow stressful situations. This model is a very useful
adjunct to the response style theory (Nolen-Hoeksema, 1991) because rumi-
nation can be captured before the presence of negative affect. This theory is
grounded in the hopelessness theory of depression (Abramson, Metalsky, &
Alloy, 1989) and Beck’s (1967) cognitive theory of depression.
The Self-Regulatory Executive Function (S-REF) Theory of rumination
(Wells & Matthews, 1994; 1996) integrates metacognitive beliefs in the con-
ceptualization of rumination. This could have an important role in making
rumination a durable response style. This theory is a broader view of emo-
tional disorders, which involves attention, cognition regulation, beliefs re-
garding emotion regulation strategies, and interactions at the cognitive level
(Wells & Matthews, 1994; 1996). Wells and Matthews state that, being a multi-
faced construct, it is necessary to make multiple measurements to capture
the ruminative phenomenon.
The theories mentioned above are predominantly focused on the role of
rumination in depression, therefore most previous studies have focused on
the association between rumination and depressive symptoms. However, ev-
idences suggest that rumination is a process that may be involved in other
forms of psychopathology, such as anxiety disorders. Some researchers have
demonstrated the role of rumination in anxiety (Garnefski & Kraaij, 2006;
Schwartz & Koenig, 1996), while others found that rumination predicts both
anxiety and depression (Nolen- Hoeksema, 2000).
Nolen-Hoeksema (2000) suggested that rumination can be studied in re-
lation to anxiety disorders. She argued that individuals who ruminate tend
to be more uncertain when trying to solve complex problems, that content
analysis of ruminators reflect uncertainty regarding the controllability and
management of important situations, and that, due to uncertainty, these per-
sons analyze in a ruminative manner everything that happens or that
others say. Even though worry is most often researched in connection with
generalized anxiety disorder (GAD),some authors began to investigate rumi-
nation in this area too.The most investigated form of repetitive thought in
GAD patients is worry (McEvoy, Mahoney, & Moulds, 2010). A core diagnostic
feature in GAD, worry is often significantly correlated with rumination
(Segerstrom, Tsao, Alden, & Craske, 2000; Watkins, 2004) and they have some
common characteristics (McLaughlin, Sibrava, Behar, & Borkovec, 2006).
64 | SERGIU P. VĂLENAŞ; AURORA T. SZENTAGOTAI
Both processes are repetitive and are self-focused (Segerstrom et al., 2000)
and both are reported by individuals in clinical samples (Gruber, Eidelman, &
Harvey, 2008). Either rumination or worry is significantly related to anxiety
and depression (Fresco, Frankel, Mennin, Turk, &Heimberg, 2002). Re-
searchers suggest that a difference between worry and rumination is that
worry is future-oriented, while rumination is past-oriented (Papageorgiu &
Wells, 1999).
In social anxiety provoking situations, researchers often study rumination
as a post-event process. Social phobic persons tend to experience anxiety
when anticipating a social event (Clark, 2005). In these situations they men-
tally review in detail what they think might happen. This increases their anx-
ious mood and focuses them on past failures, negative images of themselves,
and other predictions of poor performance and rejection. If these processes
occur, social phobic persons avoid the event completely (Clark, 2005). On the
other hand, if socially phobic individuals participate in events, they are most-
ly in a self-focused processing mode, they expect failure and will unaccepted
by others.
Given the implications of rumination in anxiety, the goal of this article is
to provide a comprehensive review of studies analyzing the relations between
rumination, generalized anxiety disorder and social phobia.
Material and methods
Literature search and inclusion criteria
We searched the PsycArticles, PubMed,Sciencedirect and Web of Science da-
tabases, beginning with January 2000, using combinations of the search
terms (1)rumination AND generalized anxiety disorder,(2)rumination AND
GAD, (3)rumination AND anxiety, (4)rumination ANDsocial phobia.
Inclusion criteria for studies considered for our analysis were: (a) the
useof anassessment measure for rumination (b) participants diagnosed with
GAD or SP, (c) studies published in English, in a peer-reviewed journal, (d)
the use of an experimental/longitudinal design, (e) the inclusion of adult
samples only and (f) studies published after 2000.
We limited our search to studies published between 2000 and 2014 to in-
crease the likelihood of finding the necessary data, on the assumption that,
Rumination in Generalized Anxiety and Social Phobia... | 65
compared to the authors of older papers, the authors of more recent papers
would be more likely to have the raw data required for examining anxiety and
rumination in their study.
After screening abstracts and titles of articles against the inclusion criteria we
found64 studies, but 28 articles were excluded because they did not meet the
inclusion criteria. Therefore, 8 studies focused on GAD and rumination and
28 studies on SP and rumination were analyzed. Figure 1 presents a summary
of the study selection and exclusion.
Rumination and Generalized anxiety disorder
We found 9studies analyzing the relationships between rumination and GAD.
In the study conducted by Decker, Turk, Hess, and Murray (2008) the authors
asked participants to complete a daily diary and questionnairesassessing
emotion regulation strategies. They had two groups, one with participants
meeting GAD criteria and a control group. Results indicated that rumination
was more frequent in the GAD group than in the control group.Kim, Yu, Lee,
and Kim (2012) assessed ruminative response in clinical patients. They com-
pared patients with major depressivedisorder (MDD) with patients suffering
Figure 1. Flow chart of study selection
66 | SERGIU P. VĂLENAŞ; AURORA T. SZENTAGOTAI
from bipolar disorder (BPD), panic disorder with/without agoraphobia (PD),
and generalized anxiety disorder or obsessive–compulsive disorder
(GAD/OCD) using the Ruminative Response Scale (RRS) that includes the
subscales of “brooding” and “reflective pondering”. Results showed no sig-
nificant differences between groups on the “brooding” subscale. The MDD
and GAD groups did not show significant differences in rumination levels.
The MDD, BPD, and GAD/OCD groups did not differ in their ruminative re-
sponses; only the PD group had significantly lower scores than the other
groups. These results could lead to the conclusion that rumination is a trans-
diagnostic trait.
Another important conclusion is that rumination has general effects in
the maintenance of negative mood, whichis sustained by the fact that the
GAD/OCD, MDD and BPD groups reported the same level of rumination.
Aldao, Mennin, and McLaughlin (2013) examined the relationship be-
tween spontaneous state-level worry and rumination and heart rate variabil-
ity (HRV) in GAD patients. They observed different associations between
worry and rumination in relation to HRV. Worry was more consistently asso-
ciated with HRV across emotional contexts than rumination.
In line with the idea that rumination along with worry, could be a transdi-
agnostic construct, McEvoy, Watson, Watkins, and Nathan (2013) found that
patients with and without comorbid diagnoses did not generally differ across
the principal diagnosis groups (MDD, GAD, SAD or PD) on worry or rumina-
tion.Another important aspect is that comorbidity was associated with higher
level of repetitive negative thinking in the form of both rumination and wor-
ry. Along the same line, Watkins (2009) investigated whether rumination is a
transdiagnostic process that is related to comorbid Axis I and II symptoms.
He found that rumination may be a transdiagnostic process with implica-
tions for disorders comorbid with depression. He showed that the brooding
component was significantly related to GAD status after controlling for de-
pression and even after controlling for worry. Reflection instead was not sig-
nificantly related to any diagnosis. The conclusion of the study is that rumi-
nation is independently related to both depression and anxiety.
In a study conducted by Starr and Davila (2012a), the authors investigate
the role of cognitive factors and interpersonal functioning in anxious and de-
pressed patients. Results show that anxious and depressed moods were
strongest associated on days when people ruminated about their anxiety
symptoms and made negative attributions about their anxiety symptoms. Al-
Rumination in Generalized Anxiety and Social Phobia... | 67
so, these constructs are strongly associated on days in which people make
negative attributions about their anxiety.
Yook, Kim, Suh, and Lee (2010) investigated intolerance of uncertainty,
worry, and rumination in major depressive disorder and generalized anxiety
disorder. They discovered that rumination did not mediate the relationship
between intolerance of uncertainty and anxiety.
Stein, et al., (2012) investigated if worry and rumination in mothers with
GAD and MDD, diagnosed in the postnatal 6 months, interfered with mater-
nal responsiveness to their 10-month old infants. Mothers and infants were
allocated to a worry/rumination prime or to a neutral prime. For GAD wor-
ry/rumination, priming had a negative impact on maternal responsiveness to
infant vocalization and decreased maternal vocalization. Other effects were
that mothers with GAD used stronger control after the neutral prime than the
worry/rumination prime. Ruscio, Seitchik, Gentes, Jones, and Hallion et al.,
(2011) investigated if repetitive thinking may be a risk factor for depression
and generalized anxiety disorder. Results revealed that participants with a
higher level of perseverative thought displayed higher levels of later behav-
ioral avoidance, negative affect and traits that have been related to anxiety
and depression symptoms. Table 2 presentsa summary of studies which in-
vestigated rumination in GAD patients.
68 | SERGIU P. VĂLENAŞ; AURORA T. SZENTAGOTAI
Table 1. Rumination in GAD
Authors Partici-
pants
Rumination
measure
GAD
measure Outcomes
Aldao et
al. 2013 N = 68 - Ru visual ana-
logue scale - SCID
- Worry, rumination, and HRV were
largely insensitive to contextual varia-
tions;
- Levels of rumination higher during
the sadness than the fear film clip;
Decker et
al. 2008 N=138 -ERSQ - GAD-
Q-IV
-High level of Ru in the GAD group
compared to controls.
Kim et al.,
2012 N=476 - K-RRS - SCID
-The PD group had significantly lower
scores than the MDD, BPD, and
GAD/OCD groups.
McEvoy et
al., 2013 N=513 -RRS -MINI
PLUS
- Ru did not generally differ across pa-
tients with vs. without comorbid diag-
noses.
Ruscio et
al., 2011 N=154
- Brooding sub-
scale (from RRS)
-Rumination sub-
scale (from RRQ)
-ADIS-
IV-L
- PT related to behavioral avoidance,
negative affect and some traits relevant
to anxiety and depression symptoms.
Starr &
Davila
2012a
N=55
- Answer in a daily
diary “how much
did you think or
ruminate about
feeling anxious to-
day?”
- SCID
- Ratings of anxious mood were more-
closely associated on days when partic-
ipants ruminated about their anxiety or
viewed anxietysymptoms more nega-
tively;
Stein et
al., 2012 N=253
Activation of ru-
mination through
worry/rumination
prime (WRP)
-SCID
- WRP led to decreased maternal vocal-
ization for GAD;
Watkins,
2009 N=116 - RSQ -SCID
-Evidence that Ru may be a transdiag-
nostic process involved in psychologi-
cal disorders other than depression;
-Ru was positively associated with both
depression and anxiety;
-Brooding was related to comorbid
OCD and GAD;
-Ru was associated with traitsassociat-
ed with BPD.
- Social anxiety was not associated with
Ru;
Rumination in Generalized Anxiety and Social Phobia... | 69
Y
ook et al.,
2010 N=71 - RSQ
- MINI –
INI
- In GAD, MDD, and comorbid
GAD/MDD patients IU was correlated
with worry, anxiety symptoms, depres-
sive symptoms and Ru;
- Ru did not mediate the relationship
between IU and anxiety;
- Ru completely mediate the relation-
ship between IU and depression;
Note. Ru= Rumination; ADIS-IV-L = Anxiety Disorders Interview Schedule for
DSM-IV–Lifetime Version (Brown, DiNardo, & Barlow, 1994); BPD = Bipolar
disorder; ERSQ = Emotion Regulation Strategies Questionnaire (Feldman-
Barrett et al., 2001); GAD = Generalized anxiety disorder; GAD-Q-IV = The
Generalized Anxiety Disorder Questionnaire-IV (Newman et al., 2002); IU =
Intolerance of uncertainty; K-RRS = Korean-Ruminative Response Scale (Kim
et al., 2009); MDD = Major depressive disorder; MINI – INI = MINI -
International Neuropsychiatric Interview (Sheehan, Lecrubier, & Sheehan,
1998); MINI PLUS = Mini international neuropsychiatric interview (Version
5.0, Sheehan etal.,2001); OCD = Obsessive–compulsive disorder; PD = Panic
disorder with/without agoraphobia; PT = perseverative thoughts; RRQ = Ru-
mination-Reflection Questionnaire (Trapnell & Campbell, 1999); RRS = Ru-
minative response scale (Nolen-Hoeksema and Morrow,1991);RSQ = Re-
sponse Styles Questionnaire—Ruminative Responses Scale (Nolen-Hoeksema
and Morrow 1991); SCID = Structured Clinical Interview for the DSM-IV
(Spitzer et al., 1992; Williams et al., 1992); WRP = Worry/Rumination Prime.
Rumination and Social Phobia
Mellings and Alden (2000) investigated three cognitive processes (self-
focused attention, post-event rumination, and anticipatory processing)
which they considered that can induce bias in thoughts and memory of social
events. The outcomes supported the idea that biases in social judgments
might be determined by selective attention to negative self-related infor-
mation. An important role in negative self-related information is played by
post-event rumination.
Abbott and Rapee (2004)explored the role of self-appraisals and post-
event rumination in social phobia. They investigated the link between self-
appraisals of performance, symptom severity and post event rumination in
socially phobic individuals. They also explored the effects of cognitive behav-
ioral therapy on socially phobic individuals. Compared to the control group,
70 | SERGIU P. VĂLENAŞ; AURORA T. SZENTAGOTAI
the socially phobic group maintained a higher level of negative appraisal of
their speech and got involved in more negative rumination. Results showed
that theCBT intervention reduced both negative self-appraisals and negative
rumination.
Rapee and Abbott (2007) tested two models for providing general support
to the relationships between social anxiety levels, anxiety in response to a so-
cial-evaluative threat and negative rumination. They found that negative ru-
mination was a mediator between trait social anxiety and negative bias of
past performance. In the same line, Kokovski and Rector (2008) examined
post-event processing in relation to anxiety-provoking tasks. Results showed
that post-event processing was relatively stable across tasks and was related
to social failure. Authors also showed that post-event processing is specific to
social anxiety as depressive rumination was not a significant predictor of
PEP.
Dannahy and Stopa, (2007) investigated differences in metacognitive pro-
cesses between high and low anxious individuals. High socially anxious per-
sons reported more negative post-event processing than low anxious people,
while there were no significant differences in positive post-event pro-
cessing.Also, negative appraisals of performance and social anxiety level were
linked to the degree of negative post-event processing. Using a clinical sam-
ple, Laposa and Rector (2011) examined potential predictors of post-event
processing. Results showed state social anxiety during the exposure and anx-
ious coping-focused ruminationwere predictors of post-event processing.
The authors also investigated the stability of PEP in the context of videotaped
exposure. Results revealed that PEP was stable over a four-week period.
Moreover, state social anxiety was a unique predictor of PEP over and above
pre-treatment social anxiety.Chen, Rapee, and Abbott, (2013) reportedthat
trait social anxiety directly predicted rumination in response to a social anxi-
ety task. They also showed that some cognitive factors, such as perceived in-
appropriate focus of attention, state anxiety, self-evaluation ofperformance
and perceived probability and consequences of negative evaluation were as-
sociated with post-event rumination. These results are consistent with previ-
ous findings (Abbott & Rapee, 2004; Kocovski & Rector, 2008) that showed
that after anxiety-provoking situation, persons with high levels of trait social
anxiety will ruminate. Along the same line, Fehm, Schneider, and Hoyer
(2007) investigated if post-event processing is specific to social anxiety or to
social situations.They found that social situations elicit higher levels of PEP
Rumination in Generalized Anxiety and Social Phobia... | 71
and are more often followed by negative cognitive processing. These results
should be carefully viewed, because the effect sizes of differences were medi-
um. An interesting finding of Fehm et al. (2007) was that social anxiety or fear
of negative evaluation was a significant predictor of the level of rumination
after social situations, but not after a phobic situation. Gaydukevych and
Kocovski (2012) tested the causal link between self-focused attention and
post-event processingin social anxiety. Results showed that individuals with
high self-focused attention had a higher frequency of negative post-event
processing than the group with low self-focused attention. No significant dif-
ferences between groupswere observed in terms of positive post-event pro-
cessing.The influence of trait social anxiety in stressor anticipation was
measured at the level of subjective and physiological responses (Gramer,
Schild, & Lurz, 2012). Participants with trait social anxiety had greater heart
rate reactivity. They also reported increases in perceived arousal. Even if par-
ticipants had the possibility to prepare for task, this did not influence their
subjective experience, indicating emotion regulation problems in socially
anxious individuals. This results is in line with the findings of reported Perini,
Abbott, and Rapee (2006) who investigated performance perception as a me-
diator of the relationship between social anxiety and negative post-event ru-
mination. They found that performanceperception is a mediator between so-
cial anxiety and post-event rumination in a social phobic group asked to de-
liver an impromptu speech and to self-evaluate the speech.
Kocovski, MacKenzie, and Rector (2011) investigated social anxiety and
the effects of rumination and distraction after delivering a speech task. So-
cially phobic individuals were randomly assigned to a rumination (guided
negative rumination) or to a distraction condition. Results showed that one
week later, participants from rumination condition reported more negative
thoughts about the event than participants from distraction condition. Wong
and Moulds (2009) obtained similar results, showing that rumination, com-
pared to distraction, maintained rumination in both low and high socially
anxious individuals. The rumination group reported a higher level of mala-
daptive self-beliefs compared to the distraction group.Makkar and Grisham
(2012) investigated deliberate engagement in post-event processing in high
and low socially anxious persons and its effects on emotion, cognition and
behavior after a speech task. They compared deliberate engagement in post-
event processing with distraction. The authors found that there were some
constructive outcomes of engagement in post-event processing. Self-
72 | SERGIU P. VĂLENAŞ; AURORA T. SZENTAGOTAI
perceived speech quality and reduction of negative performance appraisals
of high socially anxious individuals were the outcomes after the manipula-
tion. Regarding otheroutcomes, cognitive and behavioral, there were not sig-
nificant differences. In an attempt to examine if reflective pondering can be
an adaptive emotion regulation strategy in negative emotions, Cristea, Matu,
Szentagotai Tatar, and David (2013) found that reflective pondering along
with acceptance and reappraisal are efficient for the cognitive component of
anxiety. Battista and Kocovski (2010) investigated the relationships between
social anxiety, post-event processing, and alcohol use. Results showed that
the amount of alcohol consumed predicted increased levels of post-event
rumination, especially among socially phobic persons. For individuals who
are socially anxious and struggle with anger, Trew and Alden (2009) demon-
strated that rumination is an important factor linking social anxiety and trait
anger. The brooding component fully mediated the relation between these
constructs, while reflective pondering partially mediated the relationship be-
tween social anxiety and anger suppression.
Edwards, Rapee, and Franklin (2003) investigated if people with high lev-
els of social anxiety wouldruminate more after receiving negative or positive
feedback after an impromptu speech. The authors also investigated wheth-
erparticipants would show a bias toward remembering the negative aspects
of the event. Results were mixed showing that there were significant differ-
ences between high and low socially anxious individuals regarding the
brooding component. Social anxiety and depression were each independent-
ly related to negative rumination, but after controlling for depression levels,
the interaction between positive and negative rumination groups was weak-
er. Regarding the bias, there were no significant differences between negative
recall bias and negative rumination. In two experiments, Morgan and
Banerjee (2008) investigated if the content of feedback and the style of post-
event processing are associated with a bias in the retrieval of autobiograph-
ical memories. In the first experiment, participants were instructed to focus
on positive or negative feedback, after they recalled autobiographical memo-
ries. Results showed that a focus on negative feedback in high socially anx-
ious individualsleadsto the recall of memories rated as higher in anxiety. In
the second experiment, participants engaged in either a ruminative or reflec-
tive response style after the social task. Results revealed that high anxious
people in the ruminative response style condition reported a recall of memo-
ries rated with a higher average anxiety. Investigating the relations among
Rumination in Generalized Anxiety and Social Phobia... | 73
perfectionism, negative social feedback, interpersonal rumination, depres-
sive symptoms and social anxiety, Nepon, Flett, Hewitt, and Molnar (2011)
demonstrated that all these constructs were significantly associated with de-
pressive symptoms and social anxiety. An important aspect of the study is
that it revealed that negative social feedback and interpersonal rumination
mediated the relationship between perfectionism and distress. Zou and
Abott (2012) examined the link between perceptions of performance and
post-event processing after an impromptu speech. Participants received false
feedback and they had to self-evaluate their performance, mood and rumina-
tion (post-event processing) levels. Findings suggest that false feedback in-
fluenced personal self-evaluation and negative rumination, especially in the
social anxiety group. Makkar and Grisham (2013) showed that effects of phys-
iological feedback, as increasing or decreasing heart rate, are not specific to
participants with social phobia. They compared low and high socially anx-
ious participants who received false psychological feedback during in an im-
promptu speech. Results revealed that participants, who believed that physi-
ological responses arose during the speech, reported morefrequent negative
ruminative thoughts about the speech, higher levels of negative affect and a
bad performance. Self-focused attention mediated all these constructs.
Vassilopoulos (2008) investigated the effects of two self-focused attention
(analytical and experiential) and rumination in the maintaining of social anx-
iety symptoms. He instructed high and low anxious participants to think
about their symptoms in an analytical way that determined less positive
thoughts than thinking in a non-analytical way. The results were similar re-
garding experiential self-focus condition in which participants reported re-
duced ratings of anxious mood. In analytical self-focus condition there were
no significant changes in anxious mood.Wong and Moulds (2012a) investi-
gatedthe effects of analytical and experiential processing during anticipatory
processing and post-event rumination on self-reported anxiety. Results indi-
cated that there were no significant effects on self-reported anxiety during
anticipatory processing or post-event rumination in socially anxious individ-
uals. However, experiential processing generated high standard and condi-
tional beliefs in anticipatory processing, and it led to stronger unconditional
beliefs during post-event rumination.In an attempt to examine global and lo-
cal evaluations of public speaking performance, Cody and Teachman (2011)
conducted a study in socially anxious and non-anxious individuals. The au-
thors demonstrated that socially anxious individuals evaluated their perfor-
74 | SERGIU P. VĂLENAŞ; AURORA T. SZENTAGOTAI
mance as low, right after a speech task. High socially anxious individuals
evaluated global aspects of their performance more negatively over time than
low socially anxious individuals. The relation between global performance
evaluations and social anxiety was mediated by post-event rumination.
Wong and Moulds (2012a) examined the relationship between ruminative
processing and specific maladaptive self-beliefs. These types of beliefs in-
clude high standards for social performance, conditional beliefs concerning
social evaluation and unconditional beliefs about the self (Clark & Wells,
1995).Results suggested that trait rumination was uniquely related to at least
two types of the maladaptive self-beliefs (stronger conditional and uncondi-
tional beliefs). These are important characteristics of social anxiety.Wong
and Moulds (2010) predicted that positive metacognitive beliefs about rumi-
nation would be associated with higher levels of social anxiety. They con-
ducted two studies demonstrating that, when controlling for gender and de-
pression levels, social anxiety correlated with positive metacognitive beliefs
about rumination. Table 3 summarizes studies investigating rumination in
SP patients.
Rumination in Generalized Anxiety and Social Phobia... | 75
Table 3. Rumination in Social Phobia
Authors Partici-
pants
Rumination
measure
SP
measure Outcomes
Abbott &
Rapee,
2004
N = 86 -TQ - ADIS-IV
-Socially phobic people engaged in more neg-
ative rumination about the speech task rela-
tive to nonclinical controls;
- CBT treatment reduced negative self-
appraisals and negative rumination;
Battista &
Kocovski,
2010
N = 208 -PEP - SPS
-The amount of alcohol consumed predicted
increased levels of PEP, above and beyond
levels of trait social anxietyand depression;
Chen et al.,
2013 N = 121 -TQ -SPS
- Correlation between negative PEP and trait
social anxiety;
- Association between PEP and perceived in-
appropriate focus of attention, state anxiety,
self-evaluation of performance and perceived
probability and consequences of negative
evaluation;
Cody &
Teachman,
2011
N = 90 -PEPQ - SIAS
- SPS
- PEP mediatedbetween global performance
evaluations and social anxiety levels;
Cristea et
al., 2013 N = 103
- Induction task
adapted from
(Treynor et al.,
2003);
-EMAS -T
-SA levels influenced the comparative effi-
ciency of reappraisal and acceptance as con-
trasted to reflective pondering for negative
emotions and anxiety;
Dannahy &
Stopa, 2007 N = 50 -TQ
- SPRS
- High socially anxious participants reported
more negative PEP, no differences were found
between the groups in terms of positivePEP;
Edwards et
al., 2003 N = 53 -TQ - APPQ-S
-Differences in post event brooding after so-
cial
performance;
- SA and depression were each independently
related to negative Ru for the social event;
- No significant differences between negative
recall bias and negative Ru;
Fehm et al.,
2007 N = 217 -PEPQ - HADS
- Social situations elicit higher levels of PEP
and are more often followed by negative cog-
nitive processing;
- Social anxiety is a signicant predictor for
the amount of PEP after social but not after
phobic situations;
Gaydukevy
ch &
Kocovski,
2012
N = 82 -PEPQ -SIAS
- The self-focused attention group reported a
similar amount of positive PEP but more fre-
quent negative PEP over 24hours;
Gramer et
al., 2012 N = 70 -TQ -SAP - Self evaluations are an essential determinant
of post-task rumination;
Kocovski &
Rector,
2008
N = 76 -RSQ - SPS
- SIAS
- SA predicted PEP;
- Rurelated to depressive symptoms was not a
significant predictor of PEP;
- PEP is stable over time;
76 | SERGIU P. VĂLENAŞ; AURORA T. SZENTAGOTAI
Kocovski et
al., 2005 N = 112
-CHIP
- RSQ
-EMAS
-The SA group was more likely to use rumina-
tive
coping strategies;
- The High SA group was less likely to use dis-
traction coping strategies;
Kocovski et
al., 2011 N = 114
- TQ
- PEP
- SPS
- SA in the distraction condition led to more
positive thoughts compared with the guided
negative Ru condition;
-SA and depression predicted greater post-
event rumination and negative thoughts after
a week;
Laposa &
Rector,
2011
N = 75
- PEPQ
- ARQ
-SCID
- Baseline SA symptoms and state anxiety dur-
ing the videotaping were predictive of PEP;
- PEP was stable over a four-week period;
- State SA was a unique predictor of PEP over
and above pre-treatment SA;
Makkar &
Grisham,
2012
N = 81
-PEP manipulation
instructed partici-
pants to focus on
the anxious
thoughts, images,
feelings, and so-
matic sensations
relating to the first
speech
- SPS
-STAI
-Engaging in PEP, as opposed to distraction,
led to increased willingness to give the second
speech,reduction in negative performance
appraisals,underestimation of performance
better self-perceived speech quality;
Makkar &
Grisham,
2013
N = 80 -TQ
-BFNES
- SPS
- Believing heart rate increase participants re-
ported higher levels of negative affect, nega-
tive appraisals of performance, greater under-
estimation of performance relative to the as-
sessor, and more frequent negative rumina-
tive thoughts about the speech;
Mellings &
Alden,
2000
N = 116 -RQ - SAD - PEP contributed to the recall of negative self-
related information;
Morgan &
Banerjee,
2008
N = 158
-Rumination and
reflection items
adapted after items
used by McFarland
and Buehler (1998).
-SPAI
-The high SA group engaged in a ruminative
response style recalled memories with the
highest average anxiety rating;
Nepon et
al., 2011 N = 155 -RIO -LSAS
-Socially prescribed perfectionism and perfec-
tionistic self-presentation were significantly
associated with negative social feedback and
Ru following interpersonal events;
- negative social feedback and interpersonal
rumination mediated the relation between
components of perfectionism and distress;
Perini et
al., 2006 N = 60
-RRS
-Post-event Rumi-
nation Question-
naire adapted from
the measure used
in Abbott and
Rapee (2004)
-ADIS-IV
- SPS
- Perception of performance mediated the re-
lationship between SA and PEP;
Rapee &
Abbott,
2007
N = 201
-Post-event rumi-
nation (Abbott &
Rapee, 2004);
- SPS
- SIAS
- Negative Ru mediated between SA and nega-
tive bias in the recollection of performance;
Rumination in Generalized Anxiety and Social Phobia... | 77
Trew &
A
lden, 2009 N = 363 -RRS -SIAS
- Brooding fully mediated the relationship be-
tween SA and trait anger and partially mediat-
ed the relationship between SA and anger ex-
pression;
Vass-
ilopoulos,
2008
N = 117
-Rumination task
adapted from
Hoeksema and
Morrow’s (1993);
-FNE
- Experience of symptoms in a non-analytical
way led to more positive thoughts;
- Experiential self-focus significantly reduced
ratings of anxious mood;
- Analytical self-focus resulted in no signifi-
cant change in anxious mood;
Wong &
Moulds,
2009
N = 93
-
V
isual
A
nalogue
Scales (VAS) for
mood and rumina-
tion (Watkins &
Moulds, 2005);
- Induction task for
rumination
adapted from No-
len-Hoeksema and
Morrow’s (1993);
-FNE
- DASS
-Ru maintained anxiety in high and low so-
cially anxious individuals, and maintained
unconditional beliefs in high socially anxious
individuals;
Wong &
Moulds,
2010
N = 250
(Study1)
N =
124(Stud
y2)
- PBRSSA
- RTQ
-SPS
-SIAS
- Higher levels of SA were associated with
stronger endorsement of positive beliefs
about Ru;
- Positive beliefs about Ru partially mediated
the association between SA and trait Ru;
Wong &
Moulds,
2012a
N = 94
(Experi-
ment 1)
N = 74
(Experi-
ment 2)
-Induction task
adapted from Wat-
kins and Moulds
(2005);
-FNE
- No significant effects were found on self-
reported anxiety during anticipatory pro-
cessing and post-event rumination in social-
lyanxious individuals;
- The experiential mode led to stronger high
standard and conditional beliefs during antic-
ipatoryprocessing, and stronger uncondition-
al beliefs during PEP;
Wong &
Moulds,
2012b
N = 180 - RTQ -FNE
-SPS
- Trait Ru did not predict maladaptive beliefs
at different times;
- Trait Ru at Time 1 uniquely predicted
stronger conditional and unconditional be-
liefs;
Zou & Ab-
bott, 2012 N = 80
-Post-event rumi-
nation adapted
from the TQ
-SIAS
-ADIS
- Perceptions of own performance and levels
of positive affect significantly predicted the
degree of engagement innegative Ru about
the task;
Notes.ADIS = Anxiety Disorders Interview Schedule for DSMIV- TR (DiNardo,
Brown, & Barlow, 1994); ADIS-IV = Anxiety Disorders Interview Schedule for
DSM–IV; APPQ-S = Social Anxiety Scale of the Albany Panic and Phobia
Questionnaire (Rapee, Craske, & Barlow,1994); ARQ = Anxious Rumination
Questionnaire (Rector et al., 2008); BFNES = Brief Fear of Negative Evaluation
Scale (Leary, 1983); CHIP = Coping with Health Injuries and Problems scale
78 | SERGIU P. VĂLENAŞ; AURORA T. SZENTAGOTAI
(Endler & Parker, 2000); DASS = Depression Anxiety Stress Scales (Lovibond &
Lovibond, 1995); EMAS – T = Endler Multidimensional Anxiety Scales-Trait
(Endler, Edwards, & Vitelli, 1991); EMAS = Endler Multidimensional Anxiety
Scales (Endler, Edwards, & Vitelli, 1991); FNE = Fear of Negative Evaluation
scale (Watson & Friend, 1969); HADS = Hospital Anxiety and Depression Scale
(German: Herrmann, Buss, & Snaith, 1995; Zigmond & Snaith, 1983); LSAS =
Liebowitz Social Anxiety Scale (Liebowitz, 1987); PBRS-SA = Positive Beliefs
About Rumination Scale — Adapted for Social Anxiety (Watkins & Moulds,
2005); PEP = Post-Event Processing Questionnaire (Rachman et al., 2000);
PEPQ = Post-Event Processing Questionnaire (Rachman, Grüter-Andrew, &
Shafran, 2000); RIO = Rumination About an Interpersonal Offense (Wade et
al., 2008); RQ = Rumination Questionnaire (Mellings & Alden, 2000); RRS =
Ruminative Response Scale of the Response Style Questionnaire (RSQ) (No-
len- Hoeksema & Morrow, 1991); RSQ = Response Styles Questionnaire (No-
len-Hoeksema & Morrow, 1991); RTQ = Repetitive Thinking Questionnaire
(McEvoy, Mahoney, & Moulds, 2010); Ru = Rumination; SA = Social Anxiety;
SAD = Social Avoidance and Distress scale (Watson & Friend, 1969); SAP = So-
cial Anxiety Scale (Lück, 1971); SCID = Structured Clinical Interview for Axis I
Disorders (First, Spitzer, Gibbon, & Williams, 1996, 2002); SIAS = Social In-
teraction Anxiety Scale (Mattick & Clarke, 1998); SPAI = Social Phobia and
Anxiety Inventory (Turner, Beidel, & Dancu, 1996); SPRS = Social perfor-
mance rating scale, (Fydrich et al., 1998); SPS = Social Phobia Scale (Mattick
& Clarke, 1998); STAI = StateTrait Anxiety Inventory (Spielberger, Gorsuch, &
Lushene, 1970); TQ = Thoughts Questionnaire (Edwards, Rapee, & Franklin,
2003).
Rumination in Generalized Anxiety and Social Phobia... | 79
Discussion
This study assesses the current status of research concerning rumination in
social phobia and generalized anxiety disorder.
Relatively few studies examined rumination or repetitive thoughts in in-
dividuals with GAD. Results indicate that GAD patients are more ruminative
than healthy controls (Decker et al., 2008; Yook et al., 2010). Similarly, socially
phobic people have the tendency to engage in more negative rumination
(Abbott & Rapee, 2004).
In both correlational and experimental studies, there are differences in
the way rumination is measured by the type of outcome involved. While in
studies involving GAD patients a trait measure of rumination is preferred,
more precisely the RSQ, in studies investigating SAD patients a state measure
is predominantly employed, namely the PEPQ.
Usually, in experimental studies, GAD was investigated in comparison
with other disorders, such as OCD, MDD, BPD, PD (Kim et al., 2012). Only 3
studies manipulated rumination in GAD patients. Results of these studies re-
vealed that levels of rumination were higher during exposure to a sad film
clip (Aldao et al., 2013), that activation of worry and rumination was associat-
ed to decreased maternal vocalization during mother-child interaction (Stein
et al., 2012), and that a higher level of rumination was related to a higher level
of later behavioral avoidance, negative affect and some traits which are close
to anxiety and depression symptoms (e.g.,repetitive negative thinking, self-
evaluation of performance) (Ruscio et al., 2012). Ruscio et al. (2012)underline
that an important issue to address in future work is investigating if persevera-
tive thoughts are etiological factors, maintaining factors, or severity markers
for GAD and MDD.
Correlational designs investigating rumination in GAD patients have
found that these individuals report higher levels of rumination (Decker et al.,
2008), that rumination does not differ across patients with and without
comorbid diagnoses (McEvoy et al., 2013), and that they tended to report be-
ing anxious on days when they ruminate (Starr & Davilla, 2012a). Some au-
thors discuss rumination as a transdiagnostic factor, but results are not yet
conclusive (Kim et al., 2012; Watkins, 2009). Watkins et al., (2009) found that
rumination may be a transdiagnostic factor which is independently associat-
ed with anxiety and depression. He showed that the brooding component
was significantly related to GAD status after controlling for depression. Fu-
80 | SERGIU P. VĂLENAŞ; AURORA T. SZENTAGOTAI
ture research is needed to explain relations between repetitive negative
thoughts and distal risk factors. Also, future research should examine vulner-
ability and maintaining factors for repetitive negative thought, that are com-
mon and distinct across disorders. McEvoy et al., (2013) suggests that this can
have implications in identifying mechanisms responsible for the develop-
ment of multiple specific disorders.
The effects of social anxiety on post-event processing have mostly been
investigated in experimental studies (Abott & Rapee, 2004; Chen et al., 2013;
Edwards et al., 2003). The majority of these studies used impromptu speech
for inducing anxiety (Abbott & Rapee, 2004; Chen et al., 2013; Cody & Teach-
man, 2011) and measured PEP at various time intervals after the speech later
(Dannahy & Stopa, 2007; Gramer et al., 2012; Kocovski et al., 2011; Perini et
al., 2006). Many studies brought evidence supporting that social anxiety pre-
dicted PEP (Dannahy & Stopa, 2007; Kokovski & Rector, 2008). They also
demonstrated a positive correlation between PEP and perceived inappropri-
ate focus of attention, state anxiety, self-evaluation of performance and per-
ceived probability and consequences of negative evaluation (Chen et al.,
2013).
The main findings of studies manipulating ruminationhave shown that
socially phobic people engage in more negative rumination (Abbott & Rapee,
2004), report high levels of global performance evaluations (Cody & Teach-
man, 2011), recall more anxious memories (Morgan & Banerjee, 2008), main-
tain anxiety-related and unconditional beliefs (Wong & Moulds, 2009), lead
to increased willingness to give the second speech (Makkar &Grisham) and
influenced perceptions of own performance and levels of positive affect (Zou
& Abott). Future research on these aspects would benefit from the inclusion
of physiological measures to complement self-report measures. Wong et al.
(2010) suggests that future studies should design and validate treatments for
social anxiety that are specifically focused on rumination and metacognitive
beliefs specific to this disorder.
Some studies assessed rumination during therapy sessions. Abbott and
Rapee, (2004) showed that CBT reduced negative self-appraisal and negative
rumination. Kokovski and Rector, (2008) assessed rumination in relation with
two tasks in Cognitive Behavioural Group Therapy (attending the first group
therapy session and in-session exposure task). Results revealed significant
PEP occurred after both events. Laposa and Rector, (2011) examined poten-
tial predictors of PEP in group cognitive behavioural treatment. They showed
Rumination in Generalized Anxiety and Social Phobia... | 81
that severity of social anxiety as assessed prior to treatment was associated
with more PEP.
There are correlational studies that demonstrate that social anxiety is a
significant predictor for the level of PEP (Fehm et al., 2007), is associated with
stronger endorsement of positive beliefs (which partially mediate the asso-
ciation between social anxiety and rumination) about rumination (Wong &
Moulds, 2010), is significantly associated with socially prescribed perfection-
ism and perfectionistic self-presentation (Nepon et al., 2011), and is linked
with using ruminative coping strategies (Kocovsky et al., 2005). On the other
hand, trait rumination does not predict maladaptive beliefs at different times
(Wong & Moulds, 2010). Future research is needed to identify additional fac-
tors that are relevant in terms of predicting rumination among socially anx-
ious individuals following a social stressor (Chen et al., 2013).
Studies reviewed here have a number of limitations. Among these are the
relatively small sample sizes (Decker et al., 2008; Kim et al., 2012; Starr &
Davila, 2012a; Yook et al., 2010), and the use of cross-sectional designs, which
do not warrant causal conclusions (McEvoy et al., 2013; Starr & Davila, 2012a;
Watkins, 2008).Another limitation is related to the fact that socially anxious
people may report higher levels of negative rumination just because they are
aware that they are indeed socially anxious (Abott & Rapee, 2004; Perini et al.,
2006; Rapee, & Abbott, 2007). Some studies use predominantly female sam-
ples, making it difficult to generalize findings (Dannahy & Stopa, 2007; Vass-
ilopoulos, 2008). Generalization to clinical samples is also restrictedconsider-
ing that, in most studies, were students with elevated social anxiety (Kocovski
et al., 2005; Vassilopoulos, 2008; Gaydukevych & Kocovski, 2012).
To conclude, although existing studies offer interesting material regarding
the connection between rumination and anxiety problems, more research is
needed in this area. More experimental studies are necessary, particularly in
the case of patients suffering from GAD. We believe these studies would have
important clinical implications.
82 | SERGIU P. VĂLENAŞ; AURORA T. SZENTAGOTAI
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... A possible interpretation of this result is the practice (or expertise) in the processing of such information. Psychological disorders are strongly associated with ruminations (see e.g., Ehlers & Clark, 2000;Vălenas & Szentagotai, 2014;Wilkinson et al., 2013); patients tend to frequently think about objects and situations related to their problem, which could increase the familiarity (or the idiosyncratic frequency of usage) of such information (Williams et al. 1998). Stroop interference was shown to rise with the familiarity of words (Dalgleish, 1995;Klein, 1964; but see Burt, 2002;Kahan & Hely, 2008). ...
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... One such process is the ruminative thought style. The basis for including rumination in the MMSA-based social anxiety model is the empirical body of research that documents the relationship between rumination and social anxiety (for comprehensive review of these research see Valenas & Szentagotai, 2014). Most of these studies indicate that socially anxious and socially phobic individuals engage in more negative rumination. ...
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... Rumination is defined as a repetitive cognitive pattern that focuses on the causes and consequences of emotional states, and also on past problems and events (Nolen-Hoeksema, 1991). Numerous studies have investigated rumination in relation with depressive symptoms (Nolen-Hoeksema, 1991;Nolen-Hoeksema, 2000;Nolen-Hoeksema, Morrow, & Fredrickson, 1993), but evidence now suggests that rumination is also associated with anxiety (Abela & Hankin, 2011;Brozovich & Heimberg, 2008;Fresco, Frankel, Mennin, Turk, & Heimberg, 2002;Susan Nolen-Hoeksema, 2000;Vălenaș & Szentagotai, 2014). Social anxiety is one of the anxiety disorders most often studied in relation with rumination; however, some ambiguous aspects still need to be clarified. ...
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