Question drawn from
the topic:
The role of rumination and worry in the maintenance of anxiety
disorders
An original piece of
work by:
Word count: 4391
(Excluding title
page, table of contents, abstract and references)
Table of Contents
Abstract 3
Introduction 5
Definition of terms 5
Context 5
Choice of Papers 6
Sources 6
Inclusion Criteria 7
Exclusion Criteria 7
Papers 8
Wells and Sembi (2004) 8
Critique 9
Segue 10
Michael et al. (2007) 10
Critique 11
Segue 12
Ehring et al. (2008) 12
Critique 14
Segue 14
Ehring et al. (2009) 14
Critique 15
Segue 16
Laposa and Rector (2012) 16
Critique 17
All Papers 17
Critique 17
Synthesis 19
Implications 21
Limitations of this review 22
Conclusions 22
References 24
Abstract
This essay reviews five papers that
further the work done by (Ehlers & Mayou, 2002) whose study correlates
rumination with Post-traumatic stress disorder (PTSD).
These five papers take rumination
as a maintaining factor for PTSD and:
1. See
its clinical effectiveness.
2. Improve
its predictive ability.
3. Establish
what rumination’s active ingredients are.
The tentative findings from this paper
are as follows:
Firstly there can be a clinical
rationale for treating rumination first for trauma victims who haven’t
developed PTSD.
Secondly the predictive aspect of
rumination post trauma is strengthened when you take into account the following
factors:
1. Negative
feelings before and after ruminating.
2. Occurrence
of “what if” and “why” questions.
3. Compulsion
levels to ruminate.
Thirdly there are two types of
rumination, trauma rumination and depressive rumination (about causes and
consequences of depression). The former is a cognitive avoidance strategy that
prevents processing of the trauma memory. The latter prevents restructuring of
the dysfunctional thoughts about the trauma. This leads to clinical utility of treating
different types of rumination differently.
Due to the small number of papers
reviewed, the small numbers of participants in the studies, and the weaknesses
in these papers, the findings of this paper should be viewed as tentative and
suggesting areas for further research.
Introduction
Definition of terms
1. Rumination
Defined in the dictionary as “to meditate or ponder
(upon)” (Hanks, 1988, p. 1334), it has become a technical psychological term
and open to debate (Stöber, 1998), Watkins (2004). The definition used in this
paper is rumination is perseverative, abstract, evaluative thought about the
past (Nolen-Hoeksema et al. 2008, p.406).
2. PTSD
a.
Diagnosable in the DSM-IV-TR (American
Psychiatric Association, 2000) when “following a traumatic event an individual needs to have
one re-experiencing symptom, three avoidance or numbing symptoms, and at least
two hyperarousal symptoms” (Grey 2009, p.2).
3. Maintenance
a.
“the psychological processes which keep a
problem going” (Westbrook,
2007, p.45).
Context
Ehlers and Steil (1995) suggested
that rumination was a maintaining factor for PTSD. The specific reasons for this are that it:
1. Prevents
disconfirmation of the negative appraisals of the trauma and its sequelae (Ehlers
& Steil 1995).
2. Increases
intrusions (Steil, Ehlers, 2000) and prevents a change in intrusive images (Wells
1997, p.268).
3. Increases
threat monitoring and therefore hyperarousal (Wells & Sembi, 2004).
Later papers have supported the
idea that rumination was a maintaining factor. For example, the prospective
study of Clohessy and Ehlers (1999) shows how rumination levels predict PTSD
severity with people in motor vehicle accidents (MVA). Their findings are
supported by Murray, Ehlers, and Mayou (2002) who show the same relation with
ambulance service workers.
However, these studies have two
weaknesses. Firstly they take rumination as a single entity and secondly they
are all prospective studies. These studies can be improved by examining the
clinical utility of rumination maintaining PTSD. Likewise if we can understand
rumination in more detail, this again will enable further clinical utility.
A more precise definition of
rumination will also enable:
1. Improved
empirical data quality.
a.
If participants are unclear about what constitutes
rumination how can they accurately report on it?
2. Higher
clinical efficacy.
a.
If there is a functional and dysfunctional
aspect of rumination then we will more easily be able to target the latter.
This essay reviews papers that improve
our understanding of rumination’s maintenance aspect and whether treating rumination
has a positive impact on PTSD.
Choice of Papers
Sources
Derived from the following
databases\search engines: Google scholar, Medline, Psychinfo and Ebsco.
Search terms: PTSD, rumination,
maintenance, Post traumatic stress disorder.
Inclusion Criteria
1. Recent
papers, i.e. published post 2000.
2. Either
looks at the active ingredient of rumination or looks at the efficacy of
treating rumination in PTSD.
Exclusion Criteria
1. Children
as participants as the aim of this paper targets adults.
Papers
Wells and Sembi (2004)
This paper aims to show that using three
core treatments (discontinuing rumination, threat monitoring and increased
mindfulness) will enable the natural process of recovery from PTSD, i.e., “Reflexive
Adaptation Process (RAP)” (Wells & Sembi, 2004, p.307).
The authors used an AB design.
Phase A incorporated four sessions and was a “no intervention” phase which
provided a baseline. Phase B, meanwhile, incorporated eight sessions during
which intervention was made.
The study examined six participants
with the following shared characteristics:
·
All diagnosed with PTSD via the DSM-IV-TR (American
Psychiatric Association, 2000) criteria.
·
All had suffered either a violent or sexual
assault.
·
All had referred themselves to UK mental health
services.
·
All diagnosed with Major Depressive Disorder
(MDD) via the DSM-IV-TR (American Psychiatric Association, 2000) criteria.
Participants were excluded if they had prior experience of CBT, major
head injuries or current substance misuse problems. There were follow up
assessments at 3, 6, and 18–41 months. Treatment commenced 3–10 months
post-trauma.
There was an intrinsic link to
rumination between the three treatments they proposed. If you are more mindful,
then you ruminate less (Borders et al., 2010). If you decrease threat
monitoring, you decrease rumination (Harvey et al., 2007). Consequently, whilst
three interventions were proposed their relatedness to rumination was seen as
strong and the effect of each core treatment was to decrease rumination,
directly or indirectly.
Whilst the participants started
with moderate to severe PTSD, they all improved with treatment. As Wells and
Sembi note: “None of the patients met criteria for PTSD assessed by the PDS[1] at 3, 6
and longer term follow-up.” (Wells & Sembi, 2004, p.316).
Critique
The paper explores the possibility
of having a reduced treatment for PTSD, by focussing on reducing rumination with
encouraging results.
The participants made progress even
though they had MDD which is impressive as if there is comorbid depression this
“dominates the clinical picture to the extent that it makes some forms of PTSD
treatment impossible (for example, owing to extreme lack of energy, social
withdrawal and inactivity)” (National Institute for Clinical Excellence, 2005,
p.13).
However there are certain aspects
about this paper that are a cause for concern and therefore bring into question
the reliability and validity of the results:
1. There
is no control group, meaning we can’t rule out time being the active ingredient
to recovery.
2. The
paper claims that multiple base lines from these 6 people and the period
between trauma and treatment can obviate the need for a control group. However
in the Davidson trauma scale figures (Davidson, 1996) which contained the most
dramatic decreases, the Phase B gains in 5/6 clients were congruent with the Phase
A gradient, which would indicate their natural recovery rate.
3. Researcher
bias. One of the authors of the paper is Adrian Wells; the results of the paper
prove that his metacognitive theory is effective for PTSD. It is therefore
difficult not to question the results due to the author testing his own theory.
You would need corroborating evidence by more independent parties to verify his
results.
4. Generalizability
is weak due to a sample size of 6, meaning the sample is unrepresentative of
the general clinical population we would like to generalise these results to.
5. He
doesn’t measure rumination before and after treatment, nor does he measure
threat monitoring or mindfulness which was his treatment package. To have
certainty that these 3 treatments were the reason for the PDS scores, you need
to see these scores dropping too. So we can’t rule out that it was another
factor that accounted for the PDS scores decreasing.
Segue
The next paper looks to test an
aspect of the meta-cognitive theory that Wells and Sembi (2004) use. It also
looks to refine our understanding of the active ingredient of rumination.
Michael et al. (2007)
Michael’s paper sets out to examine
the following questions:
1. Do
metacognitive positive\negative assumptions about rumination correlate with PTSD
severity?
2. How
do the following aspects of rumination correlate with PTSD?
a.
Compulsion to continue ruminating.
b.
Occurrence of unproductive thinking.
c.
Occurrence of "what if” and “why"
questions.
d.
Negative feelings before and after rumination.
3. Does
rumination correlate with the frequency of intrusive memories?
4. How
do trauma victims rumination levels who have and don’t have PTSD, compare?
The research examined the
experiences of 81 participants in a cross sectional study (study 1) and 73 in a
longitudinal study (study 2). Participants were recruited via flyers to members
of Victim Support[2]
in south England and Wales. They included both participants who had and did not
have PTSD. All participants had been either physically or sexually assaulted
and 26% in study 1 and 32% in study 2 had experienced prior assault.
The results showed that in the PTSD
group, rumination was more common and people ruminated for longer than the non
PTSD group. Rumination levels by
themselves didn’t correlate with PTSD severity. However when you added in
negative feelings before and after ruminating, as well as occurrences of “what
if” and “why” questions and compulsion to ruminate, then a correlation was
found. Also, it was discovered that positive
beliefs about rumination were not correlated with the amount of time spent
ruminating.
Critique
It was a strength of this study to
show that people who have had trauma but not PTSD ruminate too and that
rumination per se is not a sufficient
condition to predict PTSD severity. Rather, what we need is to understand
characteristics and consequences of rumination as detailed in the section
above.
However, mentioning people who had
previous accidents but not revealing whether or not they were traumatised raises
questions as to whether these findings are generalizable to PTSD from type 1 or
type 2 trauma.
The cohort came from people who
presented to Victim Support suggesting a motivation to self-care. What is not
clear, however, is whether the lack of such motivation would yield the same
results. The rumination data was collected via a rumination questionnaire which
used a Likert Scale. However as Ogden and Lo (2001) show, Likert scales provide
contradictory results when compared to free text accounts. Consequently, if the
questions posed to the participants didn’t reflect their answers on a topic, inaccurate
data could be collected.
Furthermore, the rumination
questionnaire didn’t distinguish different types of rumination which, as we
shall see in the following paper, have different relations to PTSD. This omission would lead us to question what
type of rumination (plus the various factors mentioned above) correlate to PTSD
severity.
Segue
This paper moves us towards the
position that rumination, the type of ruminating and its antecedents and consequences,
predict PTSD severity. The next paper meanwhile, aims to investigate whether reduced
concreteness is an active ingredient of rumination and can predict severity.
Ehring et al. (2008)
This paper aimed to show that rumination
predicts the maintenance of PTSD and that an active ingredient of rumination is
the reduced concreteness of its thought content. (Ehring et al., 2008, p.488).
The method was both a
cross-sectional and longitudinal study on patients from Accident and Emergency
(A&E) at Kings Cross hospital who had been involved in a road traffic
accident (RTA). There were 101 participants in the cross-sectional study and
147 in the longitudinal. Most injuries (65% and 60%) were minor, few were life
threatening (6% and 4%) and the remainder urgent (29% and 36%). Over 80% were
discharged within 24 hours. The cross-sectional study interviewed them once,
whereas the longitudinal study interviewed them four times over a six months
period. They measured two aspects of rumination:
1. Rumination
in relation to intrusions about the trauma and its consequences, via the
Responses to Intrusions questionnaire (Clossy & Ehlers, 1999).
2. Rumination
about depressive symptoms via the Response Style questionnaire (Nolen-Hoeksema
& Morrow, 1991).
What they found was that rumination
about the trauma was “significantly and substantially correlated with the
severity of PTSD symptoms from 2 weeks after the trauma. Rumination was not
only related to concurrent PTSD symptoms, but also predicted subsequent
symptoms at 6 months” (Ehring et al., 2008, p.500). They also discovered that
the reduced concreteness of rumination by itself couldn’t predict PTSD severity
but when you added in frequency of rumination, then it could (Ehring et al.,
2008, p.502). The study also showed that “depressive rumination assessed prior
to the traumatic experience significantly predicted post-trauma symptoms of
depression” (Ehring et al., 2008, p.501).
It has been argued that depression is a maintaining factor of PTSD as it
prevents modification of the negative appraisals of the trauma and its sequelae
(Ehlers and Steil, 1995). This paper adds a further dimension by suggesting that
depressive rumination leads to depression which maintains PTSD.
Critique
The sample size of this study was
large with 248 people which enables us to generalise these findings more easily
to the wider clinical population. The results were found consistent over the
different measurement points in the longitudinal study, so we can use these
findings more comfortably at different times after the trauma. Consequently, if
a client presents with high levels of rumination at a time after trauma we can
predict PTSD severity levels.
A potential weakness however is that
the paper correlated rumination with symptom severity and not persistence which
would indicate maintenance. However Shalev et al. (1997) show that severity of
PTSD symptoms does predict persistence.
The generalizability of the results
should be questioned in terms of severity of PTSD. The PDS values of participants
are not revealed but rather only its relation to rumination. Only 5%-6% had
life threatening injuries which could indicate low PDS values. Of course
witnessing a traumatic incident which in itself is not life threatening can
produce severe PTSD (Marmar 2006). However, without
the figures about PTSD severity, caution must be shown when drawing on the
conclusions of the study.
Segue
From this paper then we are left
seeing a relationship between rumination and severity of PTSD and an
inconclusive position relating abstractness of rumination to severity. To look
further at this position I turn to the following paper.
Ehring et al. (2009)
This paper seeks to “test the
hypothesis that the abstractness of thinking is responsible for the
dysfunctional effects of trauma-related rumination” (Ehring et al., 2009,
p.285). All 83 participants were university students, 67% of them female. The
study split the participants into three groups to test: distraction, abstract
rumination and concrete rumination. The researchers played participants a video
of a real life RTA with commentary and then had them complete a computer task.
The task for the abstract group was
to ruminate on an abstract thought displayed on a computer screen which related
to the video, before pressing a button revealing additional abstract thoughts. The concrete group did the same as the
abstract group but with concrete thoughts. The distraction group had an easy
computer task unrelated to their video.
The results showed that the video
produced a fear response and then PTSD symptoms. The abstract group produced
longer negative mood and arousal in comparison to the concrete group. The
distraction group showed the highest number of intrusive recollections in
response to reminders, whereas there was no significant difference between the abstract
and concrete groups.
Critique
The study excluded type 2 traumas thereby
enabling us to generalise for PTSD from type 1 trauma. Rumination was also examined
in both its abstract and concrete aspects giving us a clearer understanding of
the relationship between rumination and PTSD.
This was an analogue test of an RTA
so questions can be raised as to its generalizability to actual trauma both of
similar and different type. Holmes and Bourne (2008), have argued that you can generalise
from analogue to actual trauma, but, in this particular study, the trauma that
has been induced is of low severity, so it remains to be seen whether the
results can be generalised to more severe trauma.
Also, the high number of female
participants in this study reduces the generalizability of its results to men
in light of Kessler et al.’s (1995), finding that women are more likely to
develop PTSD in response to trauma.
Segue
What the previous papers have
looked at is the relationship between post trauma rumination to PTSD. However, what
they haven’t done is to look at rumination levels before trauma (i.e. trait
levels) and this is something that is addressed in the next paper.
Laposa and Rector (2012)
This paper examines three
areas:
1.
Whether trait rumination correlates with
intrusion severity.
2.
Whether peritraumatic processes, and rumination
in response to traumatic intrusions correlate to intrusion development.
3.
Whether post-state anxiety in intrusions, and
anxiety may be related to both peritraumatic processing and rumination.
Improving on previous papers, Lapsoa and Rector refine the notion of
rumination distinguishing between anxious rumination and rumination in response
to intrusions. Anxious rumination is where individuals focus on ruminative content
themes pertaining to gaining control and coping “with future uncertainty”
(Laposa & Rector, 2012, p.878). Rumination in response to intrusions is ruminating
about the content of the intrusion, triggered by the intrusion.
The study used the distressing film paradigm which provides an analogue
trauma. It tested 91 female university students with a mean age of 20, excluding
anyone who had had a car accident in the last 6 months. Participants were shown
a film of invasive surgery of a person who subsequently died as a result of an
RTA. Their intrusions were then measured over the following week via self-report
and an intrusions diary.
The results the study found were
that:
·
“Anxious rumination was not significantly
correlated with intrusions” (Laposa & Rector, 2012, p.881).
·
“Rumination in response to intrusion was
correlated with intrusion frequency” (Laposa & Rector, 2012, p.880).
·
“Trait rumination was not a vulnerability factor
in the development of intrusions” (Laposa & Rector, 2012, p.882).
Critique
There was a large sample size of 91
in this study, which helps us generalise to the wider clinical population. The
researchers broke rumination down into both its state and trait aspects as well
as distinguishing different types of rumination, (i.e. anxious rumination and
rumination in relation to intrusions), which was not something done in the
previous papers.
The difficulty with the work,
however, is firstly the ability to generalise the findings given that the study
only examined female university students. As with Ehring et al.’s (2009) study
discussed above, this weakens our ability to generalise to men in light of Kessler’s
findings that females are more likely than men to develop PTSD (Kessler et al.,
1995).
Also, the higher than average
levels of intelligence of university students again weakens the ability to generalise
the results to people of lower than average intelligence levels.
All Papers
Critique
A problem that spans all papers is
the ability to measure rumination. There is one method, self-report, and that is
done currently or retrospectively. As Gorin
and Stone (2001) demonstrate retrospective reports are prone to inaccuracy. Also,
as we have seen in Wells and Sembi (2004), increasing your meta-cognitions has
an impact on your rumination and thus reporting on your current ruminations may
have an impact on those ruminations. Thus the act of measuring changes what is
measured.
The difficulty in accuracy in
measuring rumination thus weakens the findings of all papers presented and it
will only be through studies with large participant sizes and cross referencing
with different types of studies that the findings above would be corroborated
and gain increased validity.
In all studies bar Laposa and
Rector (2012), there is no mention of the client’s trait rumination levels.
Having this knowledge of pre trauma levels of rumination would allow a more
accurate correlation to PTSD severity. If,
for example, a client generally ruminated at a level of 10 ruminations pre
trauma and then 15 ruminations post trauma, it would seem reasonable to relate
the rise of 5 ruminations to the PTSD severity. However, none of the papers
examined in this essay were able to gain such specific and measurable data. Whilst Laposa and Rector (2012) showed there
was no relation between trait rumination levels and PTSD severity, it would
seem helpful to rule this out in the other papers.
Synthesis
There are two related strands to
this paper: 1) what is it about rumination that can predict PTSD severity\persistence
and 2) does treating rumination move PTSD sufferers to recovery? If rumination
maintains PTSD then if we treat rumination we should improve PTSD symptoms and
also be able to correlate rumination levels with PTSD severity.
The clinical application of
rumination as a maintenance factor of PTSD is shown in Wells and Sembi (2004).
Here we see impressive results for treating rumination and moving PTSD clients
with MDD to recovery. However, the validity
of the results are weakened both by the aforementioned criticisms including its lack of generalizability, and by Michael et al.’s
(2007) paper which showed that metacognitive beliefs about rumination are not
correlated with PTSD severity which is part of the theory Wells used to
underpin his work.
The predictive aspect of rumination
as a maintenance factor of PTSD is firstly looked at in Michael et al. (2007). What
was important from this paper is that it showed that people who have trauma but
not PTSD ruminate as well. This led to him arguing that it is not rumination per se that predicts PTSD severity, (something
which earlier papers had claimed) but rather rumination plus a range of
additional factors (negative feelings before and after ruminating, occurrence
of “what if” and “why” questions and compulsion to ruminate). However as he
treated rumination as a single entity rather than classifying it by its types
(depressive, trauma and anxious) this would suggest further research is
required before these results can be deemed reliable.
Ehring et al. (2008) refined the predictive
ability of rumination by distinguishing between different types of rumination (e.g.
trauma rumination and depressive rumination). This highlighted different
maintaining factors of rumination. Firstly trauma rumination is a maintaining
factor due to not enabling the processing of the intrusions of PTSD due to
cognitive avoidance (Borkovec et al., 2004). Secondly depressive rumination is
a maintaining factor as it maintains the negative appraisal of the trauma and
its sequelae Ehlers and Steil (1995).
Whilst Michael et al. (2007) made
yet further refinements by looking at different types of rumination and meta aspects of them, what they didn’t do was to refine the definition
of rumination and its types. The question they asked to ascertain rumination
levels was about “dwelling on the assault” (Michael et al., 2007, p.315). This leaves us not knowing what occasioned
the rumination, nor what aspect of the assault was of concern. In future, it
could be within a more precise approach that we could start to understand what
specific type of rumination maintains PTSD.
We see further developments within
Laposa and Rector’s (2012) study, which looked at anxious ruminations and intrusion
rumination. Their findings that anxious ruminations doesn’t predict severity
but intrusion ruminations does, further improves our knowledge base, notwithstanding
the critiques of the paper mentioned above.
The sense of abstraction of
rumination was looked at as an active ingredient of rumination. The importance of this is the underlying
theory that because rumination is abstract it reduces imaginal engagement and distressing
affect (Stöber & Borkovec, 2002) which prevents the processing of
situational accessible memories (SAM) into verbally accessible memories (VAM)
(Brewin et al., 1996). Moving memories from SAM to VAM, reduces the “nowness”
of memory and reduces memory retrieval triggered by sense data, which are two
key aspects of intrusions.
Ehring et al. (2008) looked to
correlate reduced concreteness to PTSD severity. Their results show
abstractness plus frequency can correlate with PTSD severity. Ehring et al. (2009) then showed that
abstractness didn’t correlate with intrusion frequency but did correlate with
longer negative mood. What they appear to be pointing towards is a weakening of
the theory that it is the abstraction of rumination per se that maintains PTSD
(Stöber & Borkovec, 2002). If this theory were unequivocally true then
abstraction should correlate with PTSD severity without mediation.
Implications
Clinical
Whilst each paper had its
weaknesses and we can’t draw strong conclusions from any, there nevertheless seem
to be some potentially useful clinical implications.
The refinement of our understanding
of rumination as a maintaining factor in PTSD provided by these papers, enables
better indicators of treatment types as follows:
1. Intrusion
rumination: prevents processing of trauma memory into autobiographical memory
(Ehlers & Clark 200) and is predictive of PTSD severity. Treating this
could be a precursor to reliving.
2. Depressive
rumination: maintains negative
appraisals of the trauma and its sequelae and is predictive of PTSD. Treating
this could be a precursor to cognitive restructuring.
The scope of these ideas both
extends to someone with PTSD and someone who has had trauma for more than 2 weeks
but hasn’t developed PTSD. The combined weight of the papers reviewed and
referenced here suggest a strong correlation between rumination levels and
PTSD, although further work is needed to be clear on the type of rumination and
its meta properties to increase validity.
The financial implications of this are
encouraging, namely that we could treat people in fewer sessions as time
consuming reliving and rescripting would be needed less. Likewise we can see
when PTSD is likely to develop, treat it earlier and thereby prevent the loss
of functionality and additional treatment costs that would ensue should PTSD
develop.
Further Study
The implications of the papers
reviewed call, I believe, for more empirical support to two topics.
1. What
are the active ingredients of rumination that maintains PTSD?
2. The
clinical efficacy of treating rumination first with PTSD.
The recommendations for future
papers would be to:
1. Use
a strict definition of rumination, its types and meta-properties.
2. Use
a variety of design types and large cohorts to address the difficulty in
measuring rumination.
3. Use
a mixed sex cohort of mixed educational ability to increase generalizability.
Limitations of this review
It must be highlighted that this
paper only specifically reviewed 5 papers, so the emerging recommendations are tentative
and should be subject to further empirical testing.
Conclusions
The above papers add weight to the
clinical utility of treating rumination first in PTSD and prospectively adds
weight to the position that it is not rumination levels per se that predicts PTSD but type of rumination plus other
factors. There is inherent weakness
however of measuring rumination and any cognitive activity that doesn’t have a
behavioural correlate as mentioned above. The difficulty of accurate
measurement cannot deter research in this field as this would prevent empirical
support to cognitive factors. Whilst absolute accuracy is unattainable,
existing studies offer some encouraging,
albeit not yet entirely validated clinical outcomes (e.g. Wells and Sembi (2004)). Consequently, whilst measuring rumination for
predictive studies is not entirely accurate, the fact that treating rumination eliminates
the symptoms of PTSD suggests there is
still some value in undertaking such research.
This paper posed the question of “Does
rumination maintain PTSD and what are its active ingredients?” The tentative
answer to this would be: yes it can maintain PTSD but there must be other
factors involved for this to be the case. We need to be clear on the type of
rumination and what aspect of PTSD it maintains so we can be clear on
treatment. This is also crucial in terms of determining the active ingredients
of rumination. This review suggests that abstractness is not an active
ingredient per se but added to “what
if questions”, compulsion to ruminate and negative mood before then it is.
However, as these weren’t studied in relation to type of rumination we must be
cautious in our application of these findings.
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[1]
PDS=Posttraumatic stress diagnostic scale (Foa, 1995)
[2]
Victim Support is a charitable organisation that offers support to victims of
crime who have reported the incident to the police.
