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Rumination in OCD

Typically when we think about the key features of OCD, we tend to think about it in terms of the distress that is caused by Intrusive thoughts (Obsessions) and the things that we do to reduce this distress (compulsions).  Often, we will think about these compulsions in terms of the things that we can see people do – whether that be checking, counting, reassurance seeking, avoidance or hoarding.

What people tend to think less about are the things that we can’t see.  The things that happen in our heads – the mental argument, the worry, the prayers or the mental neutralising that all lie under the surface but are equally as problematic for the OCD sufferer.  In this article, we are going to look at another mental process in OCD, that of Rumination.  We are going to understand a little more about what Rumination in OCD looks like, why it keeps OCD going and, most importantly, what we can do to stop and reduce it.

Rumination – A definition

Rumination in OCD is different to a typical intrusive thought.  Where an intrusive thought is a thought in an of itself, rumination is a process – a cycle of repetitive thoughts, often with an emphasis on trying to work out why we are having a particular intrusion or to establish whether a particular event happened in the way that we think it did.

Let’s look at an example.  “Colin” was driving home from work and travels over a bump in the road.  He hears the jolt and as he pulls further away, he has the intrusive thought, “What if I just ran over someone?”  In fact, the thought is so real to him that he stops the car and takes a look down the road to see if anyone is laying injured.  He doesn’t see anything so he gets back in the car and continues his journey.  As he is driving he begins to work through his memory of the event.

“I didn’t see anyone laying on the floor so no one must be injured,” he thinks, before having a second thought, “but it was dark so I might have missed them.”

“There was a streetlight in the corner of the road – I think it was bright enough to see if someone was hurt.”  This is then quickly followed by another thought, “but it could have been a small child or someone wearing dark clothes – I could have hit them.

This pattern of cyclical thinking is what characterises rumination in OCD.  We try to make sense of the intrusion by thinking through past events to establish certainty around what actually happened.   We remember a piece of evidence that refutes the intrusion, but then this is quickly followed by something which creates more uncertainty and as such more distress.  Rumination in OCD can have the sufferer caught up for long periods of time.

Why does rumination in OCD not help?

Let’s think about why anyone would ruminate anyway – What is the function of rumination, what does it actually do?  Typically, we find that people think about the past because it updates our understanding of why or how something has happened.  So, in OCD, if I have an intrusive thought, part of me believes that thinking about the past (ruminating) will help me to work out what has or hasn’t happened so that I can alleviate my distress and move forward.  But sadly, this is not always so.

Let’s think about memory.  When we remember things we are not necessarily remembering an accurate picture of what actually happened.  Instead we are creating a representation of what happened from fragments of information that our mind sees as relevant at the time of remembering.  This means that our memories can be prone to distortions, biases and other tricks that stop us from finding the narrative of events that we want, which can then lead to further distress.  Memory is reconstructive not reproductive.

So when we ruminate, with the implicit belief that the answer to understanding our intrusions and distress lies in understanding the context in which the intrusion occurred, we will never be able to remember every little detail and this leaves us with doubt and uncertainty.  This lack of certainty can fuel the fire of OCD, leading to further intrusions, compulsions, rumination and ultimately distress.

Treatment for Rumination in OCD.

To treat rumination in OCD, it is first necessary to understand that, just like checking, ordering and other OCD compulsions, Rumination is also a “Behaviour”.  Rumination is what we call a higher order, covert behaviour.  This means that, just like with other OCD compulsions we can train ourselves to interrupt the behaviour with such techniques as exposure and response prevention (ERP)  and behavioural experiments.

      • Exposure and Response Prevention (ERP) – ERP is the technique that has the greatest evidence as an effective OCD treatment.  It involves deliberately exposing the OCD sufferer to their feared thoughts or triggers and preventing them from using their compulsions.  This is done in a graded way so that with each ERP task, they are exposing themselves to more and more fear-provoking situations.  So how do we do this with Rumination in OCD?

Like we mentioned earlier, Rumination is a behaviour just like any other OCD behaviour.  It is a process that is engaged in as a response to an intrusive thought.  So we need to create opportunities to be exposed to the intrusions (or their over-all theme) and then disrupt and/or ruin the effect of the rumination.  Taking our example from earlier, where “Colin” had the intrusion that he ran someone over, we can see that Colin’s OCD theme is around causing Harm.  We would therefore create situations in which he would be exposed to the fear and deliberately inhibit him from using rumination.

As he has the fear of causing Harm, we might want to use an imaginal exposure.  We would get him to write out in great detail a script about actually running over someone in his car.  By generating as much detail as we can about his fear, including the sights, sounds, sensations and anything else that really provokes this fear, he will start to feel distress and want to use his rumination as a way of reducing it.  However, rather than him engaging in rumination to reduce fear, we want to render it useless because given enough time, Colin’s distress will reduce anyway, without him using any problematic compulsions.

When reading the narrative of hitting someone with his car, we want to reduce the effectiveness of rumination in dealing with his distress.  One way we can do this is by encouraging him to repeat the intrusion, “yes, I have hit someone with my car” whenever he finds himself ruminating or we could get him to re-read the most distressing parts of the script.  Both of these strategies help to re-distress Colin making his rumination ineffective.

Over time, because he has been re-reading his script (or listening back to it if recorded to audio) Colin learns that the distress reduces, the intrusions are simply thoughts and that he doesn’t need to use rumination as a way of achieving this.

Other interventions for Rumination in OCD

For many, rumination can feel like an automatic process, something that we just do.  But there are things that we can do to reduce it.  As it is a behaviour, by noticing that we are doing it we can make a conscious decision to detach from it and refocus upon another behaviour.  The following is a step by step guide to interrupting rumination:

        1. Use a diary or notepad to monitor and record your rumination.  This makes it more of a conscious process and will also allow you to notice patterns in your rumination (e.g., where and when it is more likely to happen.)
        2. Write out a cost/benefit analysis of rumination.  Write out two columns – one titled “Costs”, the other titled “Benefits.”  Now take some time to write out all of the benefits of rumination and then the costs.  Afterwards take some time to reflect upon what you’ve written.  Is rumination really something that helps us?
        3. Detach from the process.  I recommend using a sensory grounding exercise to guide your attention from being caught up in rumination in your head and to bring it back to the present moment.
        4. Practice Mindfulness.  Mindfulness training helps us to remain focused upon the present moment in the the here and now and to be able to observe and detach from mental process such as rumination or worry.

Conclusions

We have covered just a little bit about Rumination in OCD and how it can be treated using CBT and ERP.  If you’d like to find out more or give us any feedback then you can drop us a line at enquiries@accesscbt.co.uk or call on 07887 701 176