Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment
Harvey, A., G., Watkins, E., Mansell, W., Shafran, R. (2004) 
Chapter 5
Thought

Introduction

Metacognitive processes and beliefs: those concerned with the appraisal, monitoring or control of thinking itself

Intrusions

Intrusions are spontaneous, unwanted, unbidden, uncontrollable and discrete thoughts, images, or urges that are attributed to internal origins.
Many intrusive thoughts involve memories.

Normal and abnormal intrusions

Intrusions are normal and universal.
What distinguishes normal form abnormal intrusions is that clinical intrusions tend to be experienced as more intense, more uncomfortable, and less controllable.

Patients differ in their appraisals and responses to intrusions compared to controls.
They tend to view them as more meaningful and important, and are more likely to act in response to them.
Two particular responses to intrusions are unhelpful

• Recurrently dwelling on them
• Thought suppression

Forms of intrusions

Intrusions can occur in the form of

• Verbal thought
• Image
• Urge

Images

Images are contents of consciousness that possess sensory qualities. They usually provide a perceptual-like analogue of some or all of the sensory aspects of a real-world experience.

Images are particularly potent at evoking emotional and physiological responses and at influencing the development of coping plans and the implementation of behaviour.
Verbal thoughts and images each influence and lead onto the other.

Urges

An urge is the internal experience of a desire to perform a particular act.
They can be induced by exposure to the object of the desire, contextual cues associated with the behaviour, emotional triggers and imagining performing an action or imagining a desired outcome.

Current concerns

The majority of psychological disorders are characterized by disorder-specific intrusive thoughts.

Intrusive thoughts are triggered by conditioned associations at either a sensory or a meaning level.
Stimulus or response cues associated with the content of the intrusion can trigger the intrusion.

Recurrent negative thinking: worry and rumination

One response to an intrusive thought is to further dwell on the subject matter of the intrusion, trying to work through or resolve it.
This is likely if the intrusion is considered to be personally important.
The recurrent thinking, in response to a negative intrusion, could result in worry or rumination.

Worry: a chain of thoughts and images, negatively affect-laden and relatively uncontrollable.
Rumination: dysfunctional, redundant, repetitive, and stereotypical thinking

Worry and rumination often involve self-focused attention.

Discussion

Definite transdiagnostic processes

Evidence suggests that recurrent negative thinking is an important process that is common across all of the psychological disorders.
As such, recurrent negative thinking meets the criteria for a definitive transdiagnostic process.

Different types of recurrent thinking

•  Worry
• Rumination
• Obsessions

There is an debate to whether worry and rumination only differ in the content of the recurrent thinking or whether they involve related but distinct processes.

Obsessions are more likely to be visual images, are less realistic, more involuntary, easier to dismiss, and less distracting.
An egosyntonic thought is consistent with the individual’s beliefs and values.
An egodystonic thought is not acceptable within the person’s beliefs.
The egodystonic quality of the intrusions is the hallmark of obsessions and appears to discriminate obsessive intrusions from worrisome or ruminative intrusions.

There are enough similarities between obsessions and worry to consider them as lying on the same continuum and sharing many of the same appraisals and strategies.

Causal role of recurrent thinking

Prospecitive studies

Rumination predicts future symptoms.

Experimental studies

Studies suggest that recurrent thinking may play a causal role in the maintenance of psychological disorders.

Theoretical issues

The content of recurrent thinking may differ between the disorders to reflect the particular current concerns of each disorder (and each individual patient).

Recurrent thinking has been conceptualized as an attempt at problem solving and as a self-regulatory attempt to try resolve unfulfilled goals.
Recurrent thinking, whether it is useful problem solving or unhelpful rumination, will persists until the goal is attained or the goal is discarded.

• Worry has been conceptualized as an attempt to avoid negative events, prepare for the words and to problem solve
• Rumination has been proposed to be an ineffective attempt at problem solving, as well as an attempt to make sense of depressed mood

Functional recurring thinking

Recurrent thinking can be helpful in resolving goals and solving problems.
It is useful for problem solving if it is appropriate, focused on real, objective concerns and relatively brief.
Whether recurrent thinking about a problem becomes functional or not may depend on the manner in which a person approaches the problem.
Positive orientation, encompassing confidence in one’s ability to solve the problem, is associated with better outcomes.

Recurrent thinking may be functional in emotional processing.
Emotional processing: a process whereby emotional disturbances are absorbed and decline to the extent that other experiences and behaviour can proceed without disruption.
Elaboration and focus on an upsetting event is a critical aspect of emotional processing.

What determines functional versus dysfunctional recurrent thinking?

One factor that seems important in the use of worry and rumination seems to be the beliefs that people hold about the utility of this strategy in response to intrusive thoughts or problems.
Another factor is how easy it is to solve the problem and the ode of the recurrent thinking, as well as the learning (conditioning) associated with the recurrent thinking.

Insoluble problems
The problem that people are attempting to resolve may be an important determinant of the duration and helpfulness of recurrent thinking.
Problem solving may become stuck in rumination if the problem chosen is not easily soluble or amenable to intervention.

Mode of processing
The mode of thinking used during attempts at working through or solving problems.
Both worry and rumination involve more verbal thinking and less visual imagery.
Cognitive avoidance theory: verbal worrying reduces the amount of aversive imagery associated with emotional concerns, thus minimizing the physiological and emotional responses to such concerns. This inhibits emotional processing.
By minimizing the physiological and emotional response to difficulties, verbal worrying will prevent emotional processing, which requires sufficient activation of an emotional response to upsetting memories or events to be successful.

Worry and rumination are associated with a more abstract and less concrete style of thinking.
Problem descriptions are less concrete for worry-related problems.
An abstract-conceptual style of thinking is characteristic of the spontaneously occurring phenomenology of rumination.
The reduced concreteness theory of worry: the increased abstract thinking found in worry reduces visual imagery and hence reduced physiological and emotional response because abstract thoughts evoke imagery with less vividness, speed and ease.
This reduced concreteness also explains impaired problem solving within worry and rumination.

Conditioning
The tendency to worry or ruminate could be further maintained by higher-order conditioning.

Clinical implications

Recurrent thinking

Three interventions may be particularly effective for reducing negative recurrent thinking

• Replacing cognitive avoidance with approach towards thoughts and feelings, providing an opportunity for habituation
• Shifting processing to a more concrete, less abstract level
• Identifying and challenging the positive and negative metacognitive beliefs hypothesized to contribute to recurrent thinking

Several potential approaches for achieving the first two

• Repeated exposure whilst developing alternative responses
• Use of detailed and vivid imagery to reduce avoidance
• Use of planned worry periods to establish a sense of control
• Expressive writing and talking
• Establish an action-oriented mode of thinking by providing a more process-focused way of thinking