OCD

When Depression Meets OCD: Understanding Rumination

Persistent OCD can lead to despair; so can depressive thoughts produce anxiety.

Posted Dec 13, 2019

 "Rumination" by Ahovsoyan/Wikimedia Commons/GNU FreeDocumentation License
Source: "Rumination" by Ahovsoyan/Wikimedia Commons/GNU FreeDocumentation License

OCD generates repetitive, all-consuming, irrational thoughts of anxiety and dread. Depression frequently involves repetitive, all-consuming, irrational thoughts of futility and hopelessness. In general terms, these two conditions seem to have a lot in common, and they are indeed frequently comorbid

But the repetitive thoughts caused by OCD and depression are subtly different—and they interact in complex and sometimes surprising ways. Persistent OCD can lead to despair, just as depressive thoughts can produce anxiety. But just as often, these two different modes of thought can be mutually exclusive—and by seeking relief from one, sufferers may paradoxically embrace the other. In previous columns, I’ve explored the intricacies of OCD and the machinery of obsessive thoughts, but today we’ll be examining their depressed equivalent—a form of thinking psychologists call rumination.

Researchers Joormann and Gotlib identify rumination as “a style of thought rather than just negative content… defined by the process of recurring thoughts and ideas often described as a ‘recycling’ of thoughts” (“Emotion Regulation in Depression”). In their paper “Rethinking Rumination," Nolen-Hoeksema, Wisco, and Lyubomirsky define rumination as a “mode of responding to distress that involves repetitively and passively focusing on symptoms of distress and on the possible causes and consequences of these symptoms.” Like OCD, rumination demands continuous, exhausting cognitive effort that never produces actual solutions. “Rumination does not lead to active problem solving to change circumstances… people who are ruminating remain fixated on the problems and on their feelings about them without taking action.” 

Both obsession and rumination are exacerbated by the tendency “to attend to and remember negative information rather than positive information… ruminators show biases towards negative information in tests of basic attention and implicit memory and show difficulties in inhibiting negative information when it is irrelevant” (“Rethinking Rumination”). Ruminators are compelled to return to depressed thoughts even when they understand that these thoughts are irrational or incorrect, and even when they consciously try to resist them: “Dysphoric participants were less likely to use the positive distracters and more likely to use the negative distracters… despite the fact that dysphoric participants acknowledged that positive distracters are more useful than negative distracters in redirecting attention away from distressing material” (“Rethinking Rumination”). 

As depressive thoughts and behaviors repeat over time, the process of rumination becomes increasingly familiar, even comfortable: “The individual selectively retrieves and rehearses negative recent events that match the sense of loss and hopelessness and notes similarities across them” (“Rethinking Rumination”). And just as with OCD symptoms, “mental rehearsal” makes it easier and easier to slide into rumination: “Individuals with major depression displayed greater automaticity in making future-event predictions [and] were less likely to predict that positive events would occur” (Miranda, Regina et al.). Sometimes rumination can become a sort of psychological security blanket—a damp, itchy, grey blanket stained with puke and crawling with moths, but a source of security nonetheless.

The distinctions between obsession and rumination are subtle. Obsession and rumination both stem from similar “concerns about control and uncertainty” (“Rethinking Rumination”). The difference lies in the balance between uncertainty and defeat. Both “involve hypervigilance to threat, worry has been most robustly distinguished from rumination by its emphasis on the future, as opposed to the past… it does not involve predicting few positive events to occur. These patterns partially reflect affective disruptions in the two disorders… shared high negative affect, but blunted positive emotion only in depression” (Miranda, Regina et al.).

Obsession allows for the possibility of taking control of and perhaps improving one’s circumstances: “When people are worrying, they are uncertain about their ability to control important outcomes, but they have some belief that they could control those outcomes if they just try (or worry) hard enough” (“Rethinking Rumination”). Niklas Törneke, in Learning RFT, describes how obsessive cycling can provide temporary distraction from depression: “If asked whether going over things, again and again, seems to lead him anywhere, he will probably acknowledge that it does not. Still, he keeps doing it… Perhaps he avoids other thoughts by dwelling on the past. But negative reinforcement is not the only governing consequence. This person’s rumination probably belongs to a functional class of behavior that we would call problem-solving” (232). 

As bizarre as it sounds, when depressive thinking overwhelms us, the panicked problem-solving of OCD can seem like a welcome distraction, and even provide the occasional, fleeting sense of meaningful progress.

In the same way, when OCD is overwhelming, depressive rumination can serve to replace the anxiety of uncertainty with overwhelming, but strangely comforting, futility. “When people ruminate, they build a mountain of evidence that all is hopeless and that they might as well give up. This certainty that all their efforts are fruitless may actually be less aversive than the uncertainty about whether they can control situations… withdrawal and inactivity that is justified by ruminations are reinforced because it reduces exposure to an aversive environment” (“Rethinking Rumination”). If one is absolutely certain that the worst possible outcome will occur, then there is no reason to attempt to prevent it—and obsessive-compulsive thoughts and rituals may cease to have meaning. 

Both obsession and rumination involve repetitive, overwhelmingly negative thoughts related to uncertainty—but while these symptoms overlap and intertwine, it’s important to distinguish them in treatment. For example, OCD sufferers are instructed to use Exposure-Response Prevention therapy to reduce the distress caused by uncertainty through habituation—but this tactic may backfire spectacularly if used to address depressive or ruminative fears. If the recurring negative thought is, “I am a worthless person” or “I will be driven to suicide,” then exposure will not reduce anxiety but reinforce depressive certainty. Instead of acceptance and recovery, dwelling on ruminative consequences only expands and deepens their influence.

Out-of-control negative thoughts, whether depressed or anxious, are always painful to experience. But recognizing the subtle distinctions between rumination and obsession can be crucial to successful treatment. If you’ve been diagnosed with either or both, it may be worth sitting down with your treatment provider to sort through the differences—to determine if some of your thoughts are reducing anxiety by nurturing the certainty of hopelessness or trying to proactively solve problems at the cost of anxiety and obsession.

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References

Jutta Joormann and Ian H. Gotlib. “Emotion Regulation in Depression: Relation to Cognitive Inhibition.” Cognition and Emotion. 2010 February 1; 24(2): 281–298.

Regina Miranda, Alyssa Wheeler, Lillian Polanco-Roman, Brett Marroquín. “The Future-Oriented Repetitive Thought (FoRT) Scale: A Measure of Repetitive Thinking about the Future.” Journal of Affective Disorders 207 (2017): 336–345. PMC. Web. 28 Apr. 2018.

Susan Nolen-Hoeksema, Blair E. Wisco, and Sonja Lyubomirsky. “Rethinking Rumination.” Perspectives on Psychological Science. Vol 3, Issue 5, pp. 400 – 424.

Niklas Törneke, Learning RFT: An Introduction to Relational Frame Theory and Its Clinical Application. Context Press, CA, 2010. p. 227.