Thursday, December 11, 2014

Depression And Stress/Mood Disorders: Causes Of Repetitive Negative Thinking And Ruminations

This is an article I've been working on for a long time, and have just managed to find the right encouragement to finish it due to recent research in the subject. Unlike most of my research articles, this one is specifically for someone who is very important to me, and by extension everyone who suffers from repetitive negative thinking but aren't sure why. I'm hoping it will improve their understanding, or just help them in some way, in figuring out the potential causes or cures for their symptoms.

Not always in snippets like this, but just as cluttering.
If I were to pinpoint the one general topic that brought me into psychology, it would be mood disorders. Mood disorders, such as depression or mania, have always been of great interest to me, primarily because many people I have known have suffered from them, including myself. The people who read this who have shared such experiences know that these types of things are not something a person just cures or recovers from: one learns to cope with them, and adaptation is often spontaneous or a result of ad hoc motivations and encouragements. Still, even during these more constructive times, symptoms will still persist. One of these, which is quite familiar to me and many others, would be repetitive negative thinking, or RNT.

While most people would just describe this as a general descriptor of how they feel or what they're going through, it's actually a clinically significant term that lends a lot of research in the field of psychology. RNT is defined as abstract, perseverative, negative focus on one's problems and experiences that is difficult to control. RNT has been found to prolong negative affect, or the character trait of having negative emotions, and impair cognitive, behavioural and interpersonal performance. Individuals who suffer from RNT usually develop it during adolescence, after which it becomes difficult to stop. This is very important for clinical purposes, as it informs the priorities in intervention and prevention of RNT.

RNT has been associated with numerous stress and mood disorders, including generalized anxiety disorder (GAD), major depressive disorder (MDD), post-traumatic stress disorder (PTSD) and social anxiety disorder. While repetitive thought (RT) is generalized and can have either positive or negative consequences, RNT can be reliably distinguished from other RTs such as obsession or functional repetitious thoughts, thus many have supported it as a transdiagnostic process. This implies that it is of clinical and theoretical significance and interest, and has led many researchers to consider causes or risk factors for RNT, but the research is still open, one reason being that researchers do not always approach RNT from the same perspective or measurement. In this post, I would like to address primarily the risk factors for RNT and its similar descriptor, ruminations, and possible preventative measures or cures. The reason for this is while RNT is symptomatic of individuals with mood or stress disorders, it is also in itself a risk factor for those disorders, and so treating it as early as possible can be crucial for childhood development and adolescence.

One risk factor for RNT and ruminations is early family context and child temperament. Early family contexts which are characterized by over-controlling parenting or negative-submissive expression predict high levels of RNT -- or as its characterized in the study, adolescent ruminations. Further, child temperament moderates this association. Children with negative affect and low levels of effortful control, the ability to suppress a dominant response to perform a subdominant response, show an additional influence on adolescent rumination. This means that children who are prone to think negatively, but are less likely to suppress domineering behaviour from their parents, will be at even greater risk of adolescent rumination than children who only have the early family context. To counter this, some researchers have suggested that intervention models are preferable, and that intervention should occur as soon as possible to prevent the development of ruminations.

Another risk factor is being the child of a depressed mother. Children of mothers who have a history of major depression are at higher risk for ruminations than children with mothers who have no such history. This also coincides with prior research which shows that children of mothers with depression are 3-4 times more likely to be diagnosed with depression as well. In addition, children who have past histories of depressive episodes and ruminations are more likely to exhibit such behaviours currently than those who have no such history. The nature of these relationships has been suggested as environmental in nature, as the study at the beginning of this paragraph suggests, or genetic. The most popular explanation for the latter association is responsive, meaning that how you respond to your own depressive behaviours can have prolonging effects.

The genetic explanation is not without evidence, though, in a general sense. Research has examined the relationship between the serotonin transporter polymorphism 5-HTTLPR, the brain-deprived neurotropic factor polymorphism BDNF Val66Met, and ruminations. Individuals with two short alleles of the 5-HTTLPR polymorphism or two Met alleles of the BDNF Val66Met polymorphism have been shown to ruminate more under conditions of life stress than those with other genotypes. Furthermore, accumulation of these risk alleles across genes is associated with higher levels of rumination. This suggests that these two polymorphisms moderate the relationship between life stress and ruminations.

One final risk factor for RNT is gender. Women are much more likely to ruminate than men, specifically during depression. While it has been suggested that men are more likely to attempt to distract themselves during depression, this has not been substantially supported by the data, and would still be consistent with the maintenance theory; that is, ruminations may serve as a distraction from depressive symptoms. In addition to its particular applicability here, the higher risk for RNT in women may also explain the higher prevalence of depression in women than in men.

The reasons for expressing RNT are numerous, but this doesn't get to how to prevent it. As mentioned earlier, some researchers have suggested that intervention methods at an early age would be most effective, since RNT is persistent and can start to develop as early as preschool. This seems to be the most favoured approach, however what of individuals who suffer from RNT but are too old for intervention methods, or individuals who received intervention but still exhibit RNT? What can be done for them?

Working off the maintenance theory, cognitive avoidance strategies may have a paradoxical effect on RNT. Individuals who try to place emphasis on suppressing RNT and ruminations unintentionally place greater focus on the thoughts themselves, and make it harder to get rid of them. In addition, by increasing their likelihood of reoccurring or persisting, avoidance strategies have negative long-term consequences by decreasing the individuals experience in coping or dealing with RNT. This suggests that the best way to deal with RNT is not to suppress the thoughts, but reflect on them; and as ruminations are characterized by focusing on the consequences of certain events and actions, to try to "think positive," which is, of course, easier said than done.

Or, you could just look at this...
Recent research suggests that sleep may be able to moderate RNT, and that RNT is associated with both timing of sleep and sleep duration. Individuals who go to bed later, or individuals who sleep less, are at higher risk for ruminations than individuals who go to bed earlier, or sleep longer. This association exists in both individuals with disorder-specific ruminations or from a transdiagnostic approach. While this may only suggest that individuals who suffer from RNT get less sleep or take longer to fall asleep, the opposite is just as likely to be true. This gives a lot of agency to all individuals who suffer from RNT, and is thus, in my view, a good approach to take to moderate ruminations.

Finally, it may be good to just talk about things; thinking and talking about persistent negative thoughts, in the right circumstances, can result in healthier individuals. Healthy self-disclosure can be beneficial to individuals suffering from RNT if their experiences sharing their feelings result in an increased understanding about the source of one's problems; in which case, I hope this article helps in itself. Individuals who disclose their feelings in the context of supportive relationships can experience growth and benefit in dealing with RNT and ruminations, and so confession can be a viable option for individuals suffering from them.

More research needs to be conducted concerning the causes of RNT; however, multiple associations have been made, and some of the ones discussed in this article are quite rigorous in nature. Multifaceted approaches in examining the causes of RNT may help reconcile for the differences between disorder-specific research and transdiagnostic approaches. This can help us better understand the nature of this affliction and improve our resources in knowing how to deal with or prevent them, so as to develop the onset of depression and other mood/stress disorders as well as promote healthier, happier individuals.

Thank you all very much for reading.



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ResearchBlogging.orgSources:

Clasen, P., Wells, T., Knopik, V., McGeary, J., & Beevers, C. (2011). 5-HTTLPR and BDNF Val66Met polymorphisms moderate effects of stress on rumination. Genes, Brain and Behavior, 10 (7), 740-746 DOI: 10.1111/j.1601-183X.2011.00715.x

Cox, S., Mezulis, A., & Hyde, J. (2010). The influence of child gender role and maternal feedback to child stress on the emergence of the gender difference in depressive rumination in adolescence. Developmental Psychology, 46 (4), 842-852 DOI: 10.1037/a0019813

Ehring, T., & Watkins, E. (2008). Repetitive Negative Thinking as a Transdiagnostic Process. International Journal of Cognitive Therapy, 1 (3), 192-205 DOI: 10.1680/ijct.2008.1.3.192

Freeston, M., Ladouceur, R., Provencher, M., & Blais, F. (1995). Strategies used with intrusive thoughts: Context, appraisal, mood, and efficacy. Journal of Anxiety Disorders, 9 (3), 201-215 DOI: 10.1016/0887-6185(95)00002-6

Gibb, B., Grassia, M., Stone, L., Uhrlass, D., & McGeary, J. (2011). Brooding Rumination and Risk for Depressive Disorders in Children of Depressed Mothers. Journal of Abnormal Child Psychology, 40 (2), 317-326 DOI: 10.1007/s10802-011-9554-y

Hilt, L., Armstrong, J., & Essex, M. (2012). Early family context and development of adolescent ruminative style: Moderation by temperament. Cognition & Emotion, 26 (5), 916-926 DOI: 10.1080/02699931.2011.621932

KOVACS, M., SHERRILL, J., GEORGE, C., POLLOCK, M., TUMULURU, R., & HO, V. (2006). Contextual Emotion-Regulation Therapy for Childhood Depression: Description and Pilot Testing of a New Intervention. Journal of the American Academy of Child & Adolescent Psychiatry, 45 (8), 892-903 DOI: 10.1097/01.chi.0000222878.74162.5a

McEvoy, P., Watson, H., Watkins, E., & Nathan, P. (2013). The relationship between worry, rumination, and comorbidity: Evidence for repetitive negative thinking as a transdiagnostic construct. Journal of Affective Disorders, 151 (1), 313-320 DOI: 10.1016/j.jad.2013.06.014

Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100 (4), 569-582 DOI: 10.1037//0021-843X.100.4.569

Nolen-Hoeksema, S., Stice, E., Wade, E., & Bohon, C. (2007). Reciprocal relations between rumination and bulimic, substance abuse, and depressive symptoms in female adolescents. Journal of Abnormal Psychology, 116 (1), 198-207 DOI: 10.1037/0021-843X.116.1.198

Nota, J., & Coles, M. (2014). Duration and Timing of Sleep are Associated with Repetitive Negative Thinking. Cognitive Therapy and Research DOI: 10.1007/s10608-014-9651-7

Strauss, J., Muday, T., McNall, K., & Wong, M. (1997). Response Style Theory Revisited: Gender Differences and Stereotypes in Rumination and Distraction. Sex Roles, 36 (11/12), 771-792 DOI: 10.1023/A:1025679223514

Watkins, E. (2008). Constructive and unconstructive repetitive thought. Psychological Bulletin, 134 (2), 163-206 DOI: 10.1037/0033-2909.134.2.163

22 comments:

  1. I've been trying to figure out what to say for the past several minutes in order to truly articulate myself after reading this post; I never knew that repetitive negative thinking was an actual term, or something that is even researched in psychology. I always thought it was a kind of insignificant side effect of some of the disorders you mentioned above, people with low self-esteem, etc., and that was it. I just had no idea that there was research into this and that it is something studied. I guess I'm trying to say is that it's comforting knowing there is exploration into this topic, and not just a "Well stop thinking about it" kind of thing.

    I'm curious about your thoughts on the part on childhood and early intervention to prevent RNT and ruminations in adolescence. When I read that, I couldn't help but think that early intervention would be extremely unlikely or even impossible in early childhood because honestly, how many children understand what's going on in their heads enough to make it apparent there's a problem? And, from my own thoughts, I also think it'd be unlikely that a child in the examples you gave would be willing to share their thoughts with their parents, especially if they are the cause of such thoughts, making early intervention unlikely again. Basically: I think that early childhood intervention to prevent adolescent RNT is unlikely to occur due to the situations that will cause the RNT and ruminations to begin with. So, what are your thoughts on that? Since you're better versed on the subject (obviously), there might be things I don't know when it comes to intervention in childhood, so maybe you can explain that to me. (I hope I made sense, sorry!)

    You know me, so you'll know that I'm grateful that you've made a post about this because it gives me some kind of validity and understanding of this subject. It also gives me hope that psychologists and researchers will continue to get a better understanding of RNT, more preventive methods, and more effective ways to cope with it.

    Thank you for including something like this on your blog, Lex. It _is_ helpful, and I'm sure many other people are thankful as well. (Looks at the "Share" bar).

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    1. I had seldom heard it either; at the very least, I never knew it was a term for clinical consideration. I had heard of ruminations before, though. It is comforting, and by no means should you "just forget about it" -- that just makes things worse.

      Concerning your questions about early intervention, unfortunately I think you're right. The model suggested by Kovacs et al. (2006) was contextual emotion-regulation therapy (CERT), which of course would require parental consent. I would seldom expect the child to self-disclose to their parents or talk to them about their behaviour, but to friends instead, and that usually happens once they've built a strong social network (i.e. starting in adolescence). The problem is, the typicality of parents who use the types of parenting methods mentioned in the article to being narcissistic is very high, and thus would likely reject intervention programs. I think the wording is crucial: intervention in childhood depression is much easier to accept among parents than intervention in RNT explicitly due to their upbringing, as an expressed possibility. That would likely get a kick in the ass out the door; parents are cynical enough of psychologists, let alone relevant clinicians. It's an unfortunate and complicated situation, which is why I wanted to place strong emphasis on the solutions for individuals after any possibility for intervention has been lost, or if intervention didn't work when they were a child, because I see that as being the most likely scenario.

      I'm glad this post helped you especially, but others as well. I've already received feedback from people who personally appreciated this article, and that makes me feel good. The Shares astonished me... It's actually record-breaking for how quickly it came. I'm very hopeful now, as well as grateful, given that the past few weeks have not been the most successful or pleasant concerning blog matters.

      Thank you for sharing your input. I hope I answered your question sufficiently!

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    2. You've answered me more than well enough, so thank you. It confirms what I was thinking and helps me better understand the reality of this.

      I'm glad you've gotten so much feedback and attention from this post. Of course you deserve it for all your posts for the hard work you put into each one; for one that might be personally significant to a lot of your viewers though, I'm especially glad for the response you've gotten already. :)

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  2. Very high quality post. I'm glad that that a lot of people have taken notice to this. Childhood depression must be a terrible thing to deal with, especially given the things you mentioned in your other comment.

    What do you think the reason is for the gender differential in coping with depressive episodes? I heard that men are more likely to drink, but why do you think women are more likely to ruminate than men, specifically?

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    1. Thanks Nick, I'm glad too! I feel for children who don't have the voice, the means or the words to get themselves help, and I resent parents who are too proud to admit that there's something wrong with their child, either by their own doing or otherwise.

      I can't offer a solid answer to that. Some pretty confident reasons would be explainable via PMDD and PPD, but they can't explain the whole. Hormones may play a role, since the depression gap starts at puberty but ends after menopause, but that's too much of a generalized response and quite frankly I'm tired of the "hormones bind us" crap anyway.

      Consider this possibility: it's socially normative for men to want to suppress their feelings and deal with them, i.e "be strong," while it's okay for women to have feelings, but expressing them too often and to others can be seen as being needy. It would follow then that men would want to suppress their feelings, or not acknowledge them, while women would linger on them. It obviously depends on the individual, and their support group, but I see that as a possible idea. You have experience dealing with this: what do you think?

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    2. I honestly hadn't considered gendered depressive disorders, and I feel stupid for that. As for your suggestion, I can see what you're saying, but you would still have to answer the question of why the woman needs to ruminate and the man needs to forget. If they're both responding to societal expectations, then why is it that the woman still needs to think on her emotions but the man needs to forget them. Why wouldn't they both just try to forget them, or why wouldn't they both just think about them, but just avoid the expression of those feelings externally?

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    3. Societal expectations can be internalized, surely, and fear of having undesired disclosure of internal feelings and emotions can also be a great stressor which might push genders to respond differently to RNT. A woman is simply afraid of being too needy, so she just doesn't say anything but addresses her feelings anyway. A man is afraid of having emotions at all, and so tries to get rid of them or distract them.

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    4. Alright, I can see that. Thanks for your thoughts.

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  3. Ruminations are of particular interest due to their paradoxical causality/association with depression. To give more information to Mykala's question earlier, intervention preadolescence, specifically CERT, is concerned with a child's adaptive self-regulation of distress and dysphoria, as these precede the onset of depressive disorders. Problems in this adaptive function will result in the inability to cope or facilitate the onset of depression, thus the intervention framework needs to take into account, identify and remediate dysfunctional regulatory responses. This directly involves the normative social context which precedes developmental regulatory response, which speaks problematically to the use of CERT in the case of RNT onsets which are a result of early family context. The child's inability to properly regulate or response to distress and dysphoria cannot be altered, and agency for CERT incorporation is ultimately given to the parent(s) or guardian(s). This could lead to even worse developmental issues for the child if the parent is instructed how to help prevent depression but not alter their own behavior; it will result in a child with unconventional and harmful ideas of what is socially normative. In these cases, even if the child does not already exhibit dysfunctional regulatory responses to distress/dysphoria, the intervention should be focused on the parents, not the child. That is, proper parenting would be the key in such a scenario. In short, CERT is not always the best solution.

    Very informative, Lex. I'm glad to see you looking into these topics, but of course I enjoy your musings in anthropology and religion as well.

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    1. For those of us who can't understand Brutal's reading-out-of-a-psychology-dictionary bullshit, here's a translation:

      "Responses to distress and dysphoria are a developmental process which comes about within a given context of what's socially normative, while intervention techniques are given to parents for utilization to help prevent depression in their children with negative affectivity. If parents are teaching their children how to respond to stressors, but those parents ARE the stressors, then those children are going to have a fucked up view of what's socially normative, and that could just make the problems worse down the line; therefore, other intervention methods besides CERT should be considered."

      Jesus fucking Christ Brutal, you could have said what I just did without making all of our brains prolapse.

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    2. Sure, but first I'll shove the dictionary up your ass.

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    3. If you two are done, I'd like to respond to Brutal's concerns.

      I used Kovacs et al. as an illustration of how researchers are looking into clinical intervention frameworks to address pretenses for depressive disorders in adolescence. Of course, CERT is founded on the premises that (1) the child has dysfunctional regulatory responses to distress, and (2) the parents are competent and capable of raising their child properly; but CERT is but one of many intervention frameworks, which are all context- and case-specific. Having said that, the primary focus of this article was not on intervention, but on how to help the majority population (i.e. those in adolescence or post-adolescence) alleviate RNT, since intervention is too late. I merely used the study to address what can be done before adolescence. I would have used a meta-analysis, but I couldn't find one.

      Thank you for your input, Brutal. It's especially nice to have you inform the discussion, since you're far more qualified than I am.

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  4. Although it is research you have done a good thing Lex. This was helpful for me and many other, I am sure. Thank you for your hard work. If you had option, I would donate to support you. :)

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  5. Here is the problem, as I see it, with the way depression is treated today:

    Scientists and healthcare professionals seem to all assume that the answer to every illness is a drug. Every day, we are bombarded with news articles that drugs are the
    way to fix any and all physical or mental problems.

    "Overweight? Take this pill. Got depression? Take Prozac, or Ketamine, or as I have seen in news reports today - Laughing gas! Can't sleep? Take that pill, and oh by the way, these pills have side effects, so you will have to take a bunch of other pills to combat them!"

    I used to suffer with depression terribly and antidepressants, as is the case with most people who take them, did not work. The doc used to start writing out a prescription for them before I even sat down!
    In my search for a cure, I stumbled upon the http://destroydepression.com, which is a
    system written by a former depression sufferer. What it teaches is a 7 step natural process that anyone can do. Diet, exercise, CBT, talk therapy and mindfulness are all part of the course to name but a few of the sections, and for me it was a godsend and my depression has almost vanished within a few short months.

    The problem with all these pills and injections is a: they don't work for enough people, and b: they don't tackle the root cause of depression.

    Depression is becoming such a massive problem because of how much the human race has changed in the last 30 years. We as a race have not changed much since stone age times, however since we entered the technological age our way of life has changed dramatically - this is the cause of depressionin my view.

    The reason I have come to this conclusion is, that is exactly what the destroy depression system is based on - and by changing just a few things we can revert back to our previous way of life. For me it worked, and for many others it has too.

    I doubt systems like that will get much press though, after all, how will big Pharma companies make money from them?

    Come to think of it - when was the last time a big Pharma company cured anything? Polio maybe? It is not in their best interests to cure something - if they do that they will not make as much money. Much better they just mask the problems so we have to go back for more of their drugs. That way, they keep getting paid!

    ReplyDelete
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    1. "Scientists and healthcare professionals seem to all assume that the answer to every illness is a drug. Every day, we are bombarded with news articles that drugs are the
      way to fix any and all physical or mental problems."

      As discussed in this article, clinicians and psychologists consider much more than drugs. It's a myth that psychologists/psychiatrists only prescribe pills to handle these illnesses. They are always voluntary, and you are always free to read the list of side effects before taking them. Some individuals choose to take them because therapeutic methods may not work, and just because some individuals have bad experiences with these pills does not mean that everyone should be prevented from having access. It comes down to the individual, and just because these methods do not work for some individuals does not mean it shouldn't be permitted for any.

      "I used to suffer with depression terribly and antidepressants, as is the case with most people who take them, did not work. The doc used to start writing out a prescription for them before I even sat down!"

      Well then I would suggest finding another psychiatrist, or finding a psychologist instead, assuming what you said is true and you're not advertising.

      "In my search for a cure, I stumbled upon the [link], which is a system written by a former depression sufferer. What it teaches is a 7 step natural process that anyone can do. Diet, exercise, CBT, talk therapy and mindfulness are all part of the course to name but a few of the sections, and for me it was a godsend and my depression has almost vanished within a few short months."

      I'm happy for you, but that method may not necessarily work for all of us. I know it certainly didn't work for me. For some individuals, therapy is enough. For others, it isn't. Don't project your own experiences onto all depression sufferers.

      "The problem with all these pills and injections is a: they don't work for enough people, and b: they don't tackle the root cause of depression."

      If they treat a statistically significant number of people and are clinically shown to work in those cases, then they're a valid option. Also, they're not meant to tackle the root cause. They're meant to remediate the symptoms until other methods help you cope with depression.

      "Depression is becoming such a massive problem because of how much the human race has changed in the last 30 years. We as a race have not changed much since stone age times, however since we entered the technological age our way of life has changed dramatically - this is the cause of depression in my view."

      I'm as cynical as recent technological developments as the next person, but there's no way to link it to depression. I would attribute it partially to diets, improvements within the psychology community in diagnosing depression, and changes in what is considered socially normative in terms of sadness and depressive episodes.

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    2. "The reason I have come to this conclusion is, that is exactly what the destroy depression system is based on - and by changing just a few things we can revert back to our previous way of life. For me it worked, and for many others it has too."

      It could also be seen as being based on the premise that interaction with live animals is the cause of depression as well. Really, I don't think using a cell phone while going to therapy is going to make your depression persist any more than it already would. Correlation =/= causation.

      "I doubt systems like that will get much press though, after all, how will big Pharma companies make money from them? Come to think of it - when was the last time a big Pharma company cured anything? Polio maybe? It is not in their best interests to cure something - if they do that they will not make as much money. Much better they just mask the problems so we have to go back for more of their drugs. That way, they keep getting paid!"

      The pharmaceutical companies don't come up with the pills. Scientists do by testing their efficacy in a lab setting. Pharmaceutical companies only produce them in mass quantities for distribution. So, they haven't cured anything because that's not their job.

      Not being in their best interest is irrelevant. I had a similar discussion with someone who claimed that dental hygienists would not want to support water fluoridation because healthier teeth means less clients. I countered with the point that by the same logic, firefighters would never want to participate in events to educate people on fire prevention. But wait, they do! Do you know why? Because people are not as selfish as you think. Veterinarians do not try to complicate matters just to bring their clients' pets back into the office. Dentists do not break your teeth so you have to come back in. Tech specialists do not set your laptop to break in a week so you have to come back. None of these happen. This is a seldom-recognized fallacy called "asserting the consequent."

      You would benefit from reading the APA's take on this matter:

      http://www.apa.org/monitor/2012/06/prescribing.aspx

      It's not an unrecognized issue. People in the psychology community condemn this type of practice. This does not invalidate the use of pills, however. It invalidates medical health professionals who do not examine their clients before offering a prescription for these pills. This is most likely in the case of psychiatrists, as their qualifications are in such matters. They aren't required to be trained in psychology, so they don't know how to use some other, possibly more preferable (for some individuals) evidence-based treatments.

      There are problems, yes, but it doesn't warrant conspiracy theories about the pharmaceutical companies. That's just ridiculous.

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    3. This is such a wonderfully informed and balanced reply to Anonymous's comment. And your whole post is fantastic, by the way.

      Delete
    4. I try to be stern but truthful when addressing claims such as these. I put a lot of work into this post since it's such an important topic, so I'm glad that paid off.

      Thank you very much for commenting Neurocritic! I'm a big fan of your work.

      Delete
  6. Is there any research available for those who suffer from RNT but have no early family context?

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    1. I know, I'm sorry that I didn't include anything like that in the article, but unfortunately none such literature exists to my knowledge. I can confidently say, however, that RNT and ruminations would be much more likely to occur in children who were raised without healthy parents than their counterparts. As Brutal discussed, proper responsiveness to distress and dysphoria is a developmental process with socially normative context. Without the proper context to assist in the developmental process of coping with stressors, the child will likely be susceptible to depressive episodes later in the future, including experiences of RNT. I hope that answers your question.

      Delete

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