Teen Rumination: Cognitive Behavioral Therapy for Adolescent Depression

Teen Rumination Can Lead to and Exacerbate Depression

Depression is a mental health disorder the Diagnostic and Statistical Manual of Mental Disorders V (5^th Edition) defines as a mood disorder, which is a class of disorder used to describe all the various subtypes of depression and bipolar disorders.

Among depressive disorders, the DSM-V identifies nine subtypes of depressive disorder.

DSM-V: Types of Depression

1. Major Depressive Disorder (MDD). This is the most commonly diagnosed and most widely known form of depression
2. Disruptive Mood Dysregulation Disorder (DMDD). This is a childhood depressive disorder characterized by extreme anger, irritability, and frequent intense tantrums/outbursts
3. Persistent Depressive Disorder (Dysthymia). This type of depressive disorder often lasts for years, with remission of symptoms rarely lasting longer than two months
4. Premenstrual Dysphoric Disorder (PMDD). This type of depressive disorder is associated with the female menstrual cycle and can cause extreme mood swings/shifts than can have a negative impact on daily function and impair relationships.
5. Substance/Medication-Induced Depressive Disorder. This is depression caused by either illegal or legal substance use.
6. Depressive Disorder Due to Another Medical Condition. This disorder is associated with chronic illnesses such as cancer, or major accidents result in serious, life-altering injury.
7. Other Specified Depressive Disorder
   1. Seasonal Affective Disorder (SAD). This is a depressive disorder relate to the seasons of the year. Most often associated with winter, SAD can happen in summer, too.
   2. Treatment-resistant depression. People with treatment-resistant depression show slow and minimal response to therapy
   3. Atypical depression. People with atypical depression show symptoms of depression, but the symptoms not persistent and do not meet the criteria for MDD, PDD, or the other types of depression listed above
8. Unspecified Depressive Disorder. People with an unspecified depressive disorder show symptoms of depression with an intensity and frequency that meet clinical criteria, but do not meet specific criteria for the types of depression listed above.

All types of depression are similar in that they involve low mood and unwanted, intrusive thoughts. That brings us to the subject of this article. There’s one symptom that’s common to almost all types of depression: rumination.

What is Rumination?

The American Psychological Association (APA) defines rumination as:

“Obsessional thinking involving excessive, repetitive thoughts or themes that interfere with other forms of mental activity.”

Rumination is not only connected to depressive disorders. Evidence associates rumination with:

• Anxiety disorders
• Obsessive compulsive disorder
• Posttraumatic stress disorder
• Substance use disorder (SUD)
• Bulimia nervosa

What we want parents of teens to take away from these definitions is that rumination is not reminiscing or thinking things over or something harmless like taking a walk down memory lane. Rumination refers to patterns of thought that interfere with daily thinking and daily activity. In essence, rumination happens when unwanted thoughts appear, an individual spends disproportionate time and energy on those thoughts, and those thoughts have a negative impact on both emotion and behavior.

Rumination as a Risk Factor for Depression

Although rumination is associated with several different mental health disorders among adults and adolescents, it’s most often associated with the development of depressive disorders. A study called The “Role of Rumination in Promoting and Preventing Depression in Adolescent Girls” indicates that rumination is a significant issue with adolescent girls. According to the study authors, “rumination appears to maintain and exacerbate depression through at least three mechanisms.”

Here are the three mechanisms they identify:

1. Patterns of Thought

Rumination leads to habitual, negative thought patterns about the past, the present, and the future. People who engage in rumination:

• Recall and focus on negative events from the past
• Make negative inferences about ongoing events
• Often feel hopeless about the future

In the words of the study authors:

“Thus, rumination exercises and enhances negative thinking, which in turn can exacerbate depression.”

2. Cognitive Processes

Rumination interferes with effective problem-solving. People with depression who engage in rumination:

• Have a hard time finding effective solutions to interpersonal problems, compared to people who do not ruminate
• Lack confidence in the solutions they do find, which decreases the likelihood they’ll try to apply those solutions

In the words of the study authors:

“Thus, the problems of depressed ruminators may persist and worsen, further exacerbating their depression.”

3. Impact on Others

For people with depression who engage in rumination, excess rumination often may create interpersonal problems and drive away friends or loved ones. Here’s how that happens. People who engage in rumination:

• Often assume responsibility for the well-being of others
• Become emotionally dependent on others
• Exhibit excessive neediness in relationships
• Show increased willingness or desire for revenge in response to perceived transgression

In the words of the study authors:

“Therefore, ruminators may have interpersonal styles that drive away social support, further exacerbating their tendency toward depression.”

In addition, after a review of the available data, the study authors indicate that:

“Rumination is more common in adult females than adult males, and more common in adolescent females than adolescent males.”

Now let’s talk about what we know about treatment for depressive disorders characterized by excessive rumination.

Current Approaches to Treating Rumination in Depressive Disorders

There are several evidence-based approached to addressing rumination in depression treatment. The most successful approaches are based in a therapeutic approach called cognitive behavioral therapy (CBT).

CBT assumes the following: if patterns of thought that make an individual feel and behave in ways they don’t want to feel and behave, then changing those feeling and behaviors requires changing patterns of thought. A CBT treatment program helps teens connect patterns of thought, feeling, and behavior so they can replace the patterns they don’t want with the patterns they do want.

Here are the three primary, CBT-based approaches to addressing rumination in depression identified in the study:

1. Basic CBT: Cognitive Restructuring:

• • Cognitive restructuring helps teen recognize negative thought and replace them with productive, adaptive thoughts

2. Specialized CBT: Rumination-Focused Cognitive-Behavioral Therapy:

• • In this type of CBT, therapists help teen to improve their ability to recognize maladaptive ruminative thoughts and behaviors
  • Therapists focus on triggers and warning-signs of impending rumination
  • Therapists use guided imagery to help teens recall when adaptive thinking helped resolve problems
    • Adaptive thinking that involved compassion for others is effective
    • Adaptive thinking that involves being totally immersed in something other than ruminative thought is also effective

3. Contextual Emotion Regulation Therapy (CERT):

• • • In this CBT sub-type, therapists work on replacing habitual maladaptive responses to challenging or stressful situations
    • The first thing therapists try to do is explore possible responses from a teen’s pre-existing repertoire of emotional responses that improve their mood
    • When a teen does not have emotional responses to improve their mood at the ready, a CBT therapist works with them to develop appropriate, productive responses.

In addition, research shows that Mindfulness-Based Cognitive Therapy (MBCBT) is an effective treatment for rumination.

MBCBT for Teens:

• • • Increases self-awareness, nonjudgment, nonreactivity, and the ability to recognize and describe emotions
    • Deceases symptoms of depression
    • Increases psychological, emotional, and social quality of life

It’s clear that effective treatment for rumination in depression focuses on thoughts. The type and quality – i.e. life-affirming or life-interrupting – of thought affects emotion, which in turn affects behavior. That’s why CBT helps: it teaches teens to manage the disruptive, ruminative patterns of thought, and transform them to patterns of thought that are neither disruptive nor ruminative, but rather, promote well-being, positive mood, and optimal daily functioning.

Next – since evidence shows rumination is more common in girls than boys – we’ll take a moment to explore how therapists can tailor treatment for the types of depression-related rumination to help female adolescents.

Treatment for Rumination During Depression: Focus on Girls

The authors of the study on rumination in adolescent girls discuss two phenomenon that are common in girls with depression characterized by excess rumination: co-rumination and body image concerns. We’ll start with co-rumination.

Co-Rumination

Here’s the official definition of co-rumination:

“Co-rumination is a variant of depressive rumination that occurs in dyadic relationships. Specifically, co-rumination involves extensive discussion and perseveration on problems, repeated speculation about problems, and focus on the negative feelings associated with problems in the context of conversations between friends or acquaintances.”

Here’s the available data on co-rumination:

• Co-rumination occurs more frequently in adolescent female friendships than any other demographic
• Co-rumination is associated with increased symptoms of depression
  • This effect is only observed in female friendship pairs

Therefore, the study authors propose that co-rumination among female friendship pairs should be an important focus for girls in depression treatment. It’s important to recognize that co-rumination can deepen friendships and improve relationships – that’s why addressing co-rumination can be trick. The study authors believe psychoeducation is the key. Psychoeducation can help teen girls:

• Learn about appropriate self-disclosure and ways to support one another that avoid “repetitive focus on problems and negative feelings.”
• Learn to engage in active problem solving. This make co-rumination a positive, adaptive process, rather than a negative, maladaptive process that increases depressive symptoms.

Next, we’ll talk about the relationship between body image, teen rumination, and depression.

Body Image

Pre-occupation with physical appearance is a significant contributor to personal dissatisfaction among almost all demographic groups. When an individual is not happy with the way their body looks, it’s called body dissatisfaction. It’s something everyone experiences at some point. However, evidence shows:

• Body dissatisfaction during adolescence is associated with the onset of depressive symptoms in females
• Body dissatisfaction-related rumination can trigger:
  • Negative mood
  • Negative behavior
  • Persistent negative thoughts about shape and weight
• Negative mood, behavior, and negative thought about personal shape and weight are associated with onset of and increase in depressive symptoms

Depression, Rumination, and Adolescent Females

There’s another aspect of this topic we should address: the role of social media in teen rumination. We’ve published several articles about the relationship between social media and teen mental health over the past several years. We encourage you to read these three:

Does Social Media Cause Depression in Teenagers?

The Risks of Social Media to Adolescent Mental Health

Social Media and Wellbeing: It’s Not That You Use It, It’s How You Use It

That last article speaks directly to our subject matter: it’s how teens use social media that matters. When a whistleblower from Facebook testified before Congress on internal data on the harm Instagram can cause teenage girls, many people misunderstood the content of the testimony.

The takeaway for most casual readers was “Facebook and Instagram are bad for teen girls’ mental health.”

That’s not wrong, but it’s not entirely accurate. The real story is that for girls with depression and girls prone to negative comparing, Facebook and Instagram can exacerbate the symptoms of depression. This aligns with what we know about rumination, co-rumination, and body dissatisfaction among girls: the three together can lead to depression. And when we add an image-centric app like Instagram, combine that with the ability to comment and message in real time, the risks compound and create recipe for exactly the kind of co-rumination that can increase depressive thoughts.

But that doesn’t mean social media causes depression in teenage girls. What it means is that for teenage girls with depression, certain types of social media behavior – particularly those that involve negative comparing and co-rumination – can increase risk of depression.

The answer?

Parents can teach teenage girls about healthy social media use. In combination with rumination-focused cognitive behavioral therapy, a teenage girl with depression characterized by excessive rumination can learn to manage ruminative thoughts. They can find adaptive, productive, life-affirming strategies for deepening ties with friends, thinking about their past, and imagining their future that don’t involve rumination, but instead revolve around a healthy vision of life in the present moment and a vibrant future in recovery.

Finding Help: Resources

If you’re seeking treatment for teen rumination, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.