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. Author manuscript; available in PMC: 2025 Dec 1.
Published in final edited form as: J Affect Disord. 2024 Aug 12;366:74–82. doi: 10.1016/j.jad.2024.08.054

Predictors of Psychosocial Impairment in a Transdiagnostic Sample: Unique Effects of Repetitive Negative Thinking

Alexandra M Adamis a, Julia G Lebovitz a, Lauren Oberlin b, Serena Chen b, Dustin Phan b, Katharine C Burns c, Faith M Gunning b, Katherine E Burdick c,d,*
PMCID: PMC11894607  NIHMSID: NIHMS2020135  PMID: 39142590

Abstract

Background:

Repetitive negative thinking (RNT) is a transdiagnostic process involving perseverative, unproductive, and uncontrollable thoughts. Although RNT may impede adaptive psychosocial functioning by prolonging negative mood states, strengthening cognitive biases, and preventing effective problem-solving, the extent to which RNT is associated with risk for poor psychosocial outcomes is unclear. Given that this has clear transdiagnostic treatment implications, the present study aimed to isolate the unique relationship of RNT with social functioning and life satisfaction in a mixed clinical and non-clinical sample.

Methods:

In 201 mid-to-later life adult participants (27 with primary diagnoses of bipolar disorder, 84 with major depressive disorder, and 90 healthy volunteers), we measured RNT, social functioning, life satisfaction, trait rumination, DSM-5 diagnoses, depressive symptoms, manic symptoms, cognitive control performance, and global cognitive functioning.

Results:

Linear regression models revealed that RNT, but not rumination, was significantly associated with poorer social functioning (β = .42 p < .001) and reduced life satisfaction (β = −.42, p < .001) after controlling for clinical and cognitive covariates.

Limitations:

Limited demographic diversity, cross-sectional design, self-reporting of outcomes.

Conclusions:

Results suggest that RNT may confer risk for key psychosocial outcomes during middle to later adulthood, over and above the effects of clinical and cognitive variables and independent of diagnostic status. Findings lend support to the notion of RNT as a transdiagnostic process and suggest that RNT may be an important therapeutic target for adults with poor social functioning and/or reduced life satisfaction.

Keywords: Cognition, Disability, Bipolar disorder, Major depressive disorder, Repetitive negative thinking, Rumination

Introduction

Social functioning and life satisfaction are fundamental aspects of psychosocial well-being that reflect individuals’ ability to engage in positive relationships, successfully enact social roles, and appraise their lives as fulfilling and meaningful (Pavot & Diener, 2008; Weissman & Bothwell, 1976). Both social functioning and life satisfaction are significantly reduced in diverse forms of psychopathology, and these impairments often persist even after symptom reduction or disorder remission (Busseri & Peck, 2015; Coryell et al., 1993; Hansson, 2002; Hirschfeld et al., 2000; Pyne et al., 1997). Accordingly, there is a clear need to elucidate specific mechanisms that are associated with poor psychosocial outcomes across diagnostic categories to inform best approaches for targeting and improving treatment.

Repetitive negative thinking (RNT) may be one such mechanism that underlies psychosocial maladjustment across clinical presentations. RNT is a transdiagnostic process of repetitive, unproductive, and uncontrollable perseveration on negative thought content (Ehring & Watkins, 2008; Kaplan et al., 2018; Wahl et al., 2019). Elevated RNT has been shown to engender negative affect (McLaughlin et al., 2007), impede adaptive behavior and problem-solving (Ehring & Watkins, 2008), and increase risk for somatic disease (Brosschot et al., 2006), all of which may contribute to poorer social functioning and life satisfaction. RNT is considered a higher-order factor pertaining to the process of cognitive perseveration (Arditte et al., 2016; Wahl et al., 2019), and it includes various forms that differ in their characteristic content and temporal orientation, such as depressive rumination (i.e., distress-focused and past-oriented; E. R. Watkins & Roberts, 2020) and anxious worry (i.e., threat-focused and future-oriented; Borkovec, 1994). Taxometric analyses suggest that RNT is dimensional and, at high levels, is associated with the onset and maintenance of varied forms of psychopathology including mood and anxiety disorders (Arditte et al., 2016; Ehring & Watkins, 2008; Olatunji et al., 2010; Ruscio et al., 2001; Wahl et al., 2019). As such, it is possible that RNT may be a mechanism that has direct effects on the reduced social functioning and life satisfaction commonly observed across different clinical populations (Busseri & Peck, 2015; Hansson, 2002; Hirschfeld et al., 2000; Pyne et al., 1997). However, prior research on the specific relationship among RNT, social functioning, and life satisfaction is limited.

Much of the existing literature on the psychosocial impact of RNT has focused on rumination in the context of depression. Rumination is a form of RNT that is specifically focused on one’s distress or problems, as well as their causes, meanings, and consequences (E. R. Watkins & Roberts, 2020). Excessive rumination is thought to be maladaptive by negatively biasing thinking and impeding effective problem-solving and instrumental behavior (Nolen-Hoeksema, 1991). Indeed, prior research has shown that rumination strengthens negative processing biases, interferes with effective problem-solving, and depletes cognitive resources (Lyubomirsky & Nolen-Hoeksema, 1995; Nolen-Hoeksema et al., 2008; E. Watkins & Brown, 2002). Notably, these effects extend beyond immediate cognitive and behavioral outcomes, as rumination has also been linked to diminished social functioning and reduced life satisfaction in both clinical and nonclinical samples (Eldeleklioglu, 2015; Harrington & Loffredo, 2010; Lam et al., 2003; Newman & Nezlek, 2019; Nolen-Hoeksema et al., 2008; Zheng et al., 2019). However, rumination is a relatively disorder- and content-specific process that does not represent the full spectrum of RNT (Kaplan et al., 2018). It is unknown if it is depressive rumination specifically that contributes to poor psychosocial outcomes, or rather if it is the transdiagnostic process of perseveration that is pathogenic. Further investigation is warranted to determine whether transdiagnostic RNT represents a robust predictor of psychosocial functioning, independent of the disorder- and content-specific process of rumination.

To gain a more comprehensive understanding of RNT as a putative risk factor for poor psychosocial functioning, it is also important to rule out some potential “confounds” that may explain its effects. For example, the impaired disengagement hypothesis posits that deficits in cognitive control (i.e., inhibition, shifting, and updating abilities; Miyake & Friedman, 2012) underlie perseverative tendencies by increasing the difficulty of inhibiting negative thoughts and shifting the contents of one’s working memory towards more adaptive responses (Koster et al., 2011). Numerous studies have found empirical support for the link between RNT and deficits in cognitive control functions (e.g., Davis & Nolen-Hoeksema, 2000; De Lissnyder et al., 2012; Joormann & Gotlib, 2008; Levens et al., 2009; Nolen-Hoeksema et al., 2008; Roberts et al., 2021; Zetsche et al., 2018) and such cognitive deficits, in turn, are robustly predictive of poor psychosocial outcomes including reduced work and impaired social functioning (McIntyre et al., 2013; Millan et al., 2012). Consequently, it is possible that deficits in cognitive control could account for the hypothesized link between RNT and psychosocial maladjustment. Similarly, RNT has been shown to positively correlate with the severity of mood disorder symptoms including depression and mania (Arditte et al., 2016; Favaretto et al., 2020; Wahl et al., 2019), which are strongly predictive of psychosocial impairment (Coryell et al., 1993; Hirschfeld et al., 2000; Michalak et al., 2005; Pyne et al., 1997). Thus, the relation between RNT and psychosocial outcomes may be attributable to the effects of mood disorder diagnosis or level of active symptom severity. However, it is also possible that RNT constitutes a unique mechanism driving psychosocial impairment that is not merely an artifact of cognitive deficits or mood disorder symptomatology. Consistent with this view, RNT has been conceptualized as a maladaptive emotion regulation strategy, or an attempt to modulate negative affective states that is ultimately ineffective (McRae & Gross, 2020). Overreliance on RNT as a strategy for responding to negative emotions could lead to increased stress, emotional instability, and interpersonal difficulties (Gross, 2014). However, it remains unknown if RNT uniquely predicts psychosocial functioning even after accounting for variability in cognitive functions and clinical severity.

The present manuscript aimed to address these gaps in the literature by isolating the specific effects of RNT on social functioning and life satisfaction in a mixed sample of individuals with mood disorders and healthy volunteers with no psychiatric history. Identifying mechanisms that underlie psychosocial maladjustment across diagnostic categories has important implications for informing optimal treatment targets and interventions for adults with poor social functioning and life satisfaction. Consistent with the notion that the transdiagnostic process of perseveration is maladaptive more so than the specific content/form of one’s negative thoughts (Ehring & Watkins, 2008; Kaplan et al., 2018; Wahl et al., 2019), we predicted that RNT would be associated with poorer social functioning and life satisfaction even after accounting for rumination. Further, given prior research on the harmful effects of RNT on cognition, behavior, and affect (Brosschot et al., 2006; Ehring & Watkins, 2008; McLaughlin et al., 2007), we hypothesized that the relationship of RNT with psychosocial outcomes would remain significant even after controlling for cognitive and clinical variables.

Methods

Participants

Participants (n = 201) included 111 individuals with a primary mood disorder diagnosis and 90 healthy volunteers aged 45–70 years (M = 57.60, SD = 6.98). Amongst those with a primary mood disorder diagnosis, 84 had recurrent major depressive disorder (MDD), 22 had bipolar disorder I (BDI), and 5 had bipolar disorder II (BDII). All participants were affectively stable when assessed, defined as < 10 on the Young Mania Rating Scale (YMRS; Young et al., 1978), < 12 on the Hamilton Depression Rating Scale (HAM-D; Hamilton, 1960), and no psychiatric hospitalizations during the past month. Participants were excluded if they had mild cognitive impairment (Montreal Cognitive Assessment [MoCA] ≤ 19; Nasreddine et al., 2005), a history of central nervous system trauma, current active unstable medical problems, substance use disorder within the past three months, more than four standing psychotropic medications, electroconvulsive therapy in the past year, a known neurological disorder, contraindications to MRI scanning, an inability to speak English, visual impairment (i.e., corrected visual acuity < 20/70), or color blindness.

Procedure

Participants were enrolled at the Brigham and Women’s Hospital (BWH) in Boston, Massachusetts, and Weill Cornell Medicine (WCM) in New York, New York as part of a larger study investigating brain-based mechanisms of emotion regulation in aging and mood disorders. Participants were recruited through the Mass General Brigham Clinical Trials Website, the Mass General Brigham Research Patient Data Registry, study referrals, and online and print advertisements in the local community. All procedures were approved by the BWH and WCM institutional review boards. Participants provided informed consent before the initiation of study procedures.

Participation was split into two separate study visits. During the first visit, participants were administered clinical measures including the Structured Clinical Interview for Diagnostic and Statistical Manual-5 (DSM-5) Disorders (SCID-5), HAMD, and YMRS; cognitive measures including the MOCA, the MATRICS Consensus Cognitive Battery (MCCB), and the Wisconsin Card Sorting Test (WCST); and self-report measures including the Social Adjustment Scale- Self Report (SAS). During the second study visit, participants completed additional self-report measures which included the Perseverative Thinking Questionnaire (PTQ), the Ruminative Response Scale (RRS), and the Satisfaction with Life Scale (SWLS), as well as resting-state functional magnetic resonance imaging (data not included in this manuscript). All clinical measures were administered by trained and supervised masters- and doctoral-level study staff, and cognitive measures were administered by trained and supervised bachelor-level study staff. Study visits were typically within 2 weeks of each other, and data were analyzed as cross-sectional. In the case that the participant could not complete their second visit within two weeks of the first visit, the HAMD and YMRS were repeated during the second visit to provide an updated measure of mood disorder symptoms and the updated scores were used. The HAMD and YMRS were re-administered for this purpose for only 10.7% of participants. Participants were compensated up to $320 for their participation in the study.

Clinical Measures

Structured Clinical Interview for DSM-5 Disorders (SCID-5; First, 2015).

The SCID-5 is semi-structured diagnostic interview for major DSM-5 diagnoses. The SCID-5 was administered to confirm diagnostic history of MDD, BD, or no psychiatric disorders, as well as to assess for comorbid diagnoses.

Hamilton Rating Scale for Depression (HAMD; Hamilton, 1960).

The HAMD is a 24-item structured interview assessing the severity of depressive symptoms in the past several days. The HAMD was administered to measure participants’ current level of depressive symptoms. Scores range from 0 to 76, with higher scores reflecting more severe depressive symptoms.

Young Mania Rating Scale (YMRS; Young et al., 1978).

The YMRS is an 11-item structured interview assessing the severity of manic symptoms in the past week. The YMRS was administered to measure participants’ current level of manic symptoms. Scores range from 0 to 60, with higher scores reflecting more severe mania.

Repetitive Negative Thinking Measures

Perseverative Thinking Questionnaire (PTQ; Ehring et al., 2011).

The PTQ is a 15-item self-report measure of RNT. Individuals rate on a 5-point Likert scale the extent to which they tend to engage in RNT when thinking about negative experiences or problems (e.g., “I get stuck on certain issues and can’t move on”). The PTQ is comprised of three lower-order factors: core characteristics of RNT, unproductiveness of RNT, and RNT capturing mental capacity (Ehring et al., 2001). Total PTQ scores range from 0 to 60, with higher scores reflecting more habitual RNT. The PTQ is considered a gold-standard measure of RNT, and it has been shown to demonstrate strong reliability (Cronbach’s alpha = .95) and convergent validity (Ehring et al., 2011). Internal consistency of the PTQ in the present sample was excellent (Cronbach’s alpha = .98). Internal consistencies of the core characteristics of RNT, unproductiveness of RNT, and RNT capturing mental capacity subscales were good to excellent (Cronbach’s alphas = .97, .87, and .91, respectively).

Ruminative Response Scale (RRS; Treynor et al., 2003).

The RRS is a self-report measure of habitual rumination. Participants rate 22 items about the extent to which they engage in a ruminative response style when feeling down, sad, or depressed (e.g., “Think about how alone you feel”) on a scale from 1 (almost never) to 4 (almost always), with higher scores indicating more frequent rumination. The RRS has two subscales with five items each, Brooding and Reflection. The Brooding subscale reflects “a passive comparison of one’s current situation with some unachieved standard,” whereas the Reflection subscale reflects “a purposeful turning inwards to engage in cognitive problem-solving to alleviate one’s depressive symptoms” (Treynor et al., 2003). The RRS is a widely used measure of rumination that has been shown to have strong convergent and predictive validity (Nolen-Hoeksema, 1991). Internal consistency of the RRS in the present sample was excellent (Cronbach’s alpha = .96). Internal consistencies of the Brooding and Reflection subscales were good (Cronbach’s alphas = .89 and .81, respectively).

Psychosocial Functioning Measures

Social Adjustment Scale- Self Report (SAS; Weissman & Bothwell, 1976).

The SAS is a 54-item self-report measure of social functioning across six domains (work, social and leisure activities, relationships with extended family, marital role, parental role, and family unit role) rated over the past 2 weeks. Participants respond to different subsets of items depending on the social roles that they hold. The overall adjustment score is obtained by averaging scores across all completed items, with higher scores reflecting more impairment in social functioning. In addition to providing an assessment of one’s social functioning across several core life domains, the SAS-SR has demonstrated strong convergent validity: it has been shown to strongly correlate with clinical assessments of social functioning (r = .72) and ratings from close associates of respondents (r = .74) within clinical populations (Weissman & Bothwell, 1976).

Satisfaction with Life Scale (SWLS; Diener et al., 1985).

The SWLS is a 5-item self-report measure of global cognitive judgments on life satisfaction. Participants indicate how much they agree with items (e.g., “In most ways my life is close to my ideal”) using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Scores range from 5 to 35, with higher scores reflecting more life satisfaction. Per the instrument’s scoring instructions, scores below 20 represent dissatisfaction with one’s life and scores above 20 indicate life satisfaction. The SWLS strong internal consistency, temporal reliability, and convergent validity, as it has been shown to correlate with interviewer estimates of participant life satisfaction (r = .43) and other subjective well-being scales, such as the Life Satisfaction Index (r = .46; Diener et al., 1985). Internal consistency of the SWLS in the present sample was excellent (Cronbach’s alpha = .93).

Cognitive Measures

MATRICS Consensus Cognitive Battery (MCCB; Nuechterlein et al., 2008).

The MCCB is a battery of assessments measuring global cognitive functioning across seven domains: speed of processing, attention and vigilance, working memory, verbal learning, visual learning, reasoning and problem-solving, and social cognition. For the verbal learning subtest, the more complex California Verbal Learning Test- 2nd edition (Elwood, 1995) was used in place of the Hopkins Verbal Learning Test to provide a more sensitive measure of verbal learning abilities, consistent with prior work (Burdick et al., 2014). The MCCB composite T-score is reflective of participants’ abilities across all seven cognitive domains (i.e., global cognition), and it is normed based on individuals’ age and sex, with a mean of 50 and standard deviation of 10.

Wisconsin Card Sorting Task (WCST; Heaton, 1981).

The computerized WCST was used as a measure of cognitive control. Participants view four reference cards and are asked to match a stimulus card to one of the reference cards. Participants are not told how to match the cards but are given feedback on whether they are “correct” or “incorrect” on each trial based on the predetermined match category (i.e., color, shape, or number). After a certain number of correct matches, the match category changes; thus, participants are tasked with inhibiting their prepotent sorting response, shifting their matching strategy, and updating their sorting rule. The perseverative errors (PE) T-score, which accounts for age and years of education, captures cognitive control abilities as it documents the extent to which participants responded using an incorrect match strategy after receiving feedback that this response is incorrect (Millan et al., 2012). Higher T-scores indicate fewer perseverative errors and accordingly better cognitive control.

Statistical Analysis

Sample characteristics were assessed continuously and categorically by diagnostic status (i.e., MDD vs. BD vs. Healthy Volunteer) using one way Analysis of Variance (ANOVAs) and chi-squared tests as applicable. Bivariate correlations were used to examine associations among study variables in the full sample. Two multivariate linear regression models were used to evaluate the relations between RNT (PTQ), social adjustment (SAS), and life satisfaction (SWLS), while covarying for sex (male = 0, female =1), age, race1 (nonwhite = 0, white =1), MDD (no MDD diagnosis = 0, MDD diagnosis = 1), BD (no BD diagnosis = 0, BD diagnosis = 1), current symptom levels (YMRS, HAMD), global cognitive functioning (MCCB composite t score), cognitive control (WCST preservative errors t score), and rumination (RRS Reflection and Brooding subscales). All analyses were conducted with SPSS Statistics for Windows Version 24.

Results

Sample Demographics and Group Differences in Clinical and Cognitive Variables

Descriptive statistics for demographic variables are presented in Table 1. The sample was predominantly female (63.7%; n = 128), and the racial/ethnic composition was as follows: 72.1% (n = 145) White, 14.9% Black (n = 30), 7.5% (n = 15) Hispanic, 6.0% (n = 12) Asian, 4.0% (n = 8) more than one race, and 3.0% (n = 6) other. There were no significant demographic differences between diagnostic groups except sex, such that there was a greater proportion of males in the healthy volunteer group than the mood disorder groups. Accordingly, sex was included as a covariate in subsequent analyses. Descriptive statistics for clinical, cognitive, and psychosocial variables by group are presented in Table 1, and correlations among study variables across the full sample are presented in Table 2. The MDD and BD groups had significantly higher levels of depression, mania, RNT, and rumination, and significantly lower levels of social functioning and life satisfaction than the healthy volunteer group. RNT (as assessed by the PTQ) and the brooding type of rumination (as assessed by the RRS) were significantly inversely associated with cognitive control abilities (as assessed by the WCST; rs = −.22 and −.16, respectively, ps < .05), indicating a potential cognitive deficit linked to perseverative thinking. RNT was also significantly associated with increased symptoms of depression and mania (rs = .36-.52, ps < .001), increased rumination (both brooding and reflection; rs = .59-.75, ps < .001) and decreased social functioning and life satisfaction (rs = .59-.64, ps < .001). Further, the sample presented with a wide range of comorbid conditions as assessed by the SCID-5. Namely, 31.0% (n = 63) of the sample had a comorbid anxiety disorder and 13.2% (n = 27) had a comorbid substance use disorder in their lifetime.

Table 1.

Group Differences in Demographic, Clinical, Cognitive, and Functional Variables

MDD (n = 84) BD (n = 27) Healthy Volunteer (n = 90) F or Chi Square
Age 57.70 (6.81) 57.11 (7.66) 57.56 (7.01) 0.08
Sex 13.49*
 Female 64 (76,19) 19 (70.37) 45 (50.00)
 Male 20 (23.91) 8 (29.63) 45 (50.00)
Race 4.55 10.02
 White 65 (77.38) 20 (74.07) 60 (66.67)
 Black 10 (11.90) 4 (14.81) 16 (17.78)
 Asian 5 (5.95) 0 (0.00) 7 (7.78)
 More than 1 race 1 (1.19) 1 (3.70) 6 (6.67)
 Other 3 (3.57) 2 (7.41) 1 (1.11)
Ethnicity 0.93 0.83
 Hispanic 6 (8.33)) 1 (3.70) 8 (8.89)
 Non-Hispanic 78 (92.86) 26 (96.30) 82 (91.11)
HAMD 6.04 (3.82) 5.00 (4.61) 1.02 (2.05) 53.27*
YMRS 0.81 (1.42) 1.44 (2.36) 0.18 (0.66) 10.10*
PTQ 26.90 (12.35) 31.33 (14.83) 9.70 (10.30) 60.53*
WCST 46.07 (0.30) 44.04 (13.80) 48.73 (15.16) 1.61
MCCB 46.46 (24.06) 45.35 (7.04) 50.26 (7.01) 1.53
RRS Reflection 10.10 (3.27) 10.33 (3.16) 6.58 (2.07) 41.26*
RRS Brooding 10.31 (3.67) 12.00 (4.67) 6.46 (1.82) 48.12*
SAS 2.27 (0.54) 2.40 (0.65) 1.64 (0.34) 46.50*
SWLS 18.58 (8.01) 16.11 (7.53) 25.20 (6.76) 24.72*
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Note: Data represented as Mean (SD) or N (%);

*

p<.001; HAMD = Hamilton Depression Rating Scale; YMRS = Young Mania Rating Scale; PTQ = Perseverative Thinking Questionnaire; WCST = Wisconsin Card Sorting Task Perseverative Errors T-Score; MCCB = Matrics Consensus Cognitive Battery Composite T-Score; RRS Reflective = Rumination Response Scale- Reflection subscale; RRS Brooding = Rumination Response Scale- Brooding subscale; SAS = Social Adjustment Scale- Self Report; SWLS = Satisfaction With Life Scale.

Table 2.

Correlations Among Study Variables

1 2 3 4 5 6 7 8 9
1. HAMD -
2. YMRS .46** -
3. PTQ .52** .36** -
4. WCST .03 -.11 -.22* -
5. MCCB -.10 .08 -.06 .21** -
6. RRS Ref. .36** .34** .59** -.11 .09 -
7. RRS Brood. .48** .38** .75** -.17* .04 .73** -
8. SAS .57** .39** .64** -.06 -.17* .39** .55** -
9. SWLS -.48** -.31** -.59** .13 .09 -.38** -.51** -.63** -
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Note:

*

p<.05,

**

p<.001; HAMD = Hamilton Depression Rating Scale; YMRS = Young Mania Rating Scale; PTQ = Perseverative Thinking Questionnaire; WCST = Wisconsin Card Sorting Task Perseverative Errors T-Score; MCCB = Matrics Consensus Cognitive Battery Composite T-Score; RRS Ref. = Rumination Response Scale- Reflection subscale; RRS Brood. = Rumination Response Scale- Brooding subscale; SAS = Social Adjustment Scale- Self Report; SWLS = Satisfaction With Life Scale.

Model 1: Effects of RNT on Social Functioning

To assess the effects of RNT on social functioning, we examined a multiple regression model testing the relation between PTQ and SAS scores while covarying for sex, age, race, mood disorder diagnoses, current symptom levels, global cognitive functioning, cognitive control, and rumination. Results are displayed in Table 32, and the predicted SAS scores at varying levels of PTQ are displayed in Figure 1. The model explained 54.6% of the variance in SAS scores. The PTQ significantly predicted higher SAS scores (reflecting worse social functioning; β = 0.42, p <.001). MDD (β = 0.16, p <.05), BD (β = 0.16, p <.05), and current depressive symptoms (β = 0.19, p <.01) also predicted significantly poorer social functioning. After accounting for PTQ scores, the Brooding subscale of the RRS (i.e., maladaptive rumination about one’s symptoms) was not significantly linked to social functioning (p > .05). Contrastingly, the Reflection subscale of the RRS (i.e., rumination applied towards intentional problem-solving) significantly predicted less social dysfunction (β = −0.17, p <.05). Age, sex, race, cognitive performance, and manic symptoms were not significantly associated with social functioning (ps > .05). When the interval in days between visit one and visit two was included as a predictor in the model, primary results remained unchanged. Supplementary analyses examined the three sub-factors of RNT (i.e., core characteristics of RNT, unproductiveness of RNT, and RNT capturing mental capacity) as independent variables in Model 1. Results revealed that “unproductiveness of RNT” (β = 0.25, p < .01) and “RNT capturing mental capacity” (β = 0.23, p < .05) significantly predicted poorer social functioning (see Supplementary Table 1).

Table 3.

Regression coefficients predicting (1) social functioning and (2) life satisfaction from repetitive negative thinking, controlling for clinical severity and cognitive functioning

1. Social Functioning (SAS)
 2. Life Satisfaction (SWLS)
B SE β t p B SE β t p
Age 0.00 0.00 0.03 0.63 .53 0.08 0.07 0.07 1.11 .27
Sex 0.03 0.06 0.03 0.47 .64 1.39 1.00 0.08 1.40 .16
Race -0.13 0.07 -0.10 -1.82 .07 1.84 1.13 0.10 1.62 .11
MDD 0.18 0.09 0.16 2.02 <.05 -0.31 1.44 -0.02 -0.21 .83
BD 0.28 0.11 0.16 2.50 .01 -1.79 1.80 -0.07 -0.99 .32
HAMD 0.03 0.01 0.19 2.70 .01 -0.46 0.16 -0.23 -2.86 <.01
YMRS 0.04 0.02 0.10 1.78 .08 0.07 0.39 0.01 0.17 .87
PTQ 0.02 0.00 0.42 5.18 <.001 -0.22 0.05 -0.42 -4.56 <.001
WCST 0.00 0.00 0.09 1.61 .11 -0.01 0.04 -0.01 -0.14 .89
MCCB -0.00 0.00 -0.02 -0.34 .73 0.06 0.07 0.05 0.80 .43
RRS Ref -0.03 0.01 -0.17 -2.24 .03 0.05 0.21 0.02 0.24 .82
RRS Brood 0.02 0.01 0.15 1.66 .10 -0.14 0.22 -.06 -0.63 .53
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Note: SAS = Social Adjustment Scale- Self Report; MDD = major depressive disorder diagnosis (0 = no, 1 = yes); BD = bipolar disorder diagnosis (0 = no; 1 = yes); HAMD = Hamilton Depression Rating Scale; YMRS = Young Mania Rating Scale; PTQ = Perseverative Thinking Questionnaire; WCST = Wisconsin Card Sorting Task Perseverative Errors T-Score; MCCB = Matrics Consensus Cognitive Battery Composite T-Score; RRS Ref = Rumination Response Scale- Reflection subscale; RRS Brood = Rumination Response Scale- Brooding subscale

Figure 1.

Figure 1.

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Unstandardized predicted values of SAS scores as a function of PTQ scores in Model 1. SAS = Social Adjustment Scale- Self Report; PTQ = Perseverative Thinking Questionnaire.

Model 2: Effects of RNT on Life Satisfaction

Next, to assess the effects of RNT on life satisfaction, we tested the same model with SWLS as the outcome variable. Results are displayed in Table 33, and the predicted SWLS scores at varying levels of PTQ are displayed in Figure 2. The model explained 41.9% of the variance in SWLS scores. The PTQ predicted significantly lower SWLS scores (reflecting worse life satisfaction; β = −0.42, p <.001). HAMD scores (β = −0.23, p <.01) were also a significant predictor of SWLS scores, such that endorsing more severe symptoms of depression were associated with poorer life satisfaction. Age, sex, race, manic symptoms, mood disorder diagnoses, cognitive performance, and rumination were not significantly associated with social functioning (ps > .05). When the interval in days between visit one and visit two was included as a predictor in the model, primary results remained unchanged. Supplementary analyses examined the three sub-factors of RNT (i.e., core characteristics of RNT, unproductiveness of RNT, and RNT capturing mental capacity) as independent variables in Model 2. Results revealed that “unproductiveness of RNT” trended towards a significant negative association with life satisfaction (β = −0.21, p = .06; see Supplementary Table 1).

Figure 2.

Figure 2.

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Unstandardized predicted values of SWLS scores as a function of PTQ scores in Model 2. SWLS = Satisfaction with Life Scale; PTQ = Perseverative Thinking Questionnaire.

Discussion

The present study aimed to isolate the unique effects of habitual RNT on social functioning and life satisfaction in a transdiagnostic sample. We found that RNT significantly predicted both reduced social functioning and life satisfaction after controlling for demographics (i.e., age, sex, race), rumination, mood disorder diagnoses, mood disorder symptom severity, global cognitive functioning, and cognitive control performance. In contrast, maladaptive rumination (i.e., brooding) did not remain a robust predictor of psychosocial outcomes after accounting for habitual levels of RNT. This pattern of results is consistent with prior literature suggesting that RNT represents a higher-order construct that largely subsumes rumination and cuts across diagnostic categories (Arditte et al., 2016; Wahl et al., 2019). These findings also suggest that it is the process of negative cognitive perseveration that is most maladaptive, more so than the specific content or temporal orientation of one’s negative thoughts. While the content of one’s perseverated-on-thoughts is likely still important and predictive of more idiosyncratic emotional responses, cognitive schemas, and patterns of behavior (McLaughlin et al., 2007), the observed results suggest that negative perseveration in general is associated with reduced psychosocial well-being. Specifically, negative thought that consumes cognitive resources and is repetitive, intrusive, unproductive, and uncontrollable was found to be maladaptive (Ehring & Watkins, 2008; Wahl et al., 2019). Indeed, supplementary analyses indicated that it is specifically the unproductiveness factor of RNT that is most strongly tied to psychosocial outcomes. Considered alongside the finding that reflection, or ruminative thinking that is intended to problem-solve around one’s depressive symptoms, was associated with improved social functioning, these result point to the (un)productiveness of RNT as a key determinant of whether engaging in perseverative thinking helps or hurts one’s psychosocial functioning. Further, the relationships between RNT and psychosocial outcomes remained significant even after controlling for clinical status and severity, suggesting that associations with RNT were non-specific to diagnostic group and were not attributable to mood disorder symptomatology. Indeed, the sample was largely euthymic when assessed, assisting in our ability to probe these relationships without the interference of active symptomatology. These results expand upon prior research showing that elevated RNT may be involved in the onset and maintenance of a broad range of psychiatric disorders (Ehring & Watkins, 2008) by showing that RNT may have unique relations with key psychosocial outcomes that are core to adults’ quality of life.

We found that the relations between RNT and psychosocial outcomes were significant over and above the effects of both global cognitive functioning and cognitive control performance. This finding is noteworthy given the large body of evidence demonstrating that cognitive control deficits are associated with both RNT (Davis & Nolen-Hoeksema, 2000; De Lissnyder et al., 2012; Joormann & Gotlib, 2008; Koster et al., 2011; Levens et al., 2009; Nolen-Hoeksema et al., 2008; Roberts et al., 2021; Zetsche et al., 2018) and psychosocial dysfunction (McIntyre et al., 2013; Millan et al., 2012). Accordingly, RNT may not solely be an artifact of cognitive inflexibility or mood disorder symptoms, but rather may constitute, at least in part, a unique process that independently confers risk for poor psychosocial outcomes. Consistent with this view, prior research suggests that RNT may be initiated either implicitly or explicitly as an attempt to modulate negative emotions, that, once initiated, is ineffective and difficult to terminate (Gross, 2014; Joormann & Stanton, 2016). Individuals who engage in excessive RNT commonly endorse positive beliefs about its utility, such as improving one’s sense of insight, control, or problem-solving abilities (Borkovec, 1994; Lyubomirsky & Nolen-Hoeksema, 1993; Papageorgiou & Wells, 2001), which may positively reinforce the habitual use of RNT in the short-term despite its long-term negative consequences.

Excessive RNT may contribute to psychosocial impairments in a number of ways. For instance, elevated rumination has been shown to engender negative information processing biases, interfere with productive problem-solving, and impede adaptive behavior by facilitating pessimistic fixation on one’s problems or distress (Eldeleklioglu, 2015; Harrington & Loffredo, 2010; Lam et al., 2003; Newman & Nezlek, 2019; Nolen-Hoeksema et al., 2008; Zheng et al., 2019). Similarly, excessive worry has been shown to predict elevated perceptions of threat, physiological arousal, reduced cognitive performance, and impaired decision-making and problem solving (Berenbaum et al., 2007; Llera & Newman, 2020; Metzger et al., 1990; Tallis & Eysenck, 1994). RNT, as a common process underlying both rumination and worry (Arditte et al., 2016), may confer risk for reduced social functioning and life satisfaction via such intermediary mechanisms, however such hypotheses need to be tested in future research. Alternatively, it is also possible that psychosocial impairments could have detrimental effects on thinking processes (i.e., that the reverse pathway is significant). Lower social functioning and life satisfaction may contribute to increased interpersonal stress and/or negative mood states (Herzberg et al., 1998), which could increase one’s propensity to engage in maladaptive RNT (McEvoy et al., 2013). Future longitudinal and experimental research is needed to disentangle the directionality, including the potential bidirectionality, of the relation between RNT and psychosocial outcomes.

In addition, we also found that neither global cognitive functioning (as assessed by the MCCB) nor cognitive control performance (as assessed by perseverative errors on the WCST) was significantly linked to social functioning or life satisfaction in the regression models after accounting for the effects of clinical and cognitive covariates. This finding contrasts with prior literature showing strong associations between cognitive deficits and psychosocial impairment (McIntyre et al., 2013; Millan et al., 2012). However, the observed null effects of cognition could be attributable to the inclusion of clinical variables (i.e., mood disorder diagnoses, depression symptoms, and mania symptoms) as covariates in the regression models, as well as the recruitment of a currently euthymic sample and the inclusion of healthy participants in dimensional analyses. Given that mood disorders are typically associated with cognitive deficits, particularly related to cognitive control functions (McIntyre et al., 2013; Millan et al., 2012; Snyder, 2013), multicollinearity and the eligibility criteria may have obscured relations between cognitive functioning and psychosocial outcomes.

The results of the present study may have important clinical implications. Our findings suggest that RNT may be a tractable treatment target for individuals with poor social functioning and/or life satisfaction across clinical presentations. Clinicians may consider assessing for RNT amongst adults with low psychosocial well-being to inform their treatment plans. There are several evidence-based treatments available that have been shown to attenuate RNT and accordingly may be beneficial for adults with low social functioning and/or reduced life satisfaction. Rumination-focused cognitive-behavioral therapy (rf-CBT) employs psychoeducation to frame rumination as a learned, habit-driven behavior, and uses behavior modification techniques (e.g., functional analysis, behavioral experiments) to reduce clients’ overreliance on rumination (E. R. Watkins et al., 2011). While originally designed to target rumination, meta-analytic evidence supports the efficacy of rf-CBT in reducing RNT generally, and this effect was found to significantly correlate with reductions in depression severity (Spinhoven et al., 2018). Further, mindfulness- and acceptance-based therapies offer treatment components such as mindfulness (i.e., nonjudgmental present-moment awareness) and decentering (i.e., de-fusing from thoughts) that may be useful in curbing RNT by helping patients learn how to passively observe negative thoughts and emotions without responding to them in the form of perseveration (Kaplan et al., 2018). Evidence suggests that such mindfulness- and acceptance-based interventions have significant effects on reducing maladaptive RNT (Feldman et al., 2010; MacKenzie et al., 2018; Snippe et al., 2015). Finally, metacognitive therapy combines strategies such as mindfulness, attention training, rumination postponement, and metacognitive restructuring to target RNT, and it has demonstrated promising effects in reducing both RNT and psychiatric symptoms in samples with anxiety and depressive disorders (Wells et al., 2009, 2012; Wells & King, 2006).

Despite noteworthy methodological strengths including the use of a mixed sample and collecting data at multiple levels of analysis, the present study is not without limitations. The study was cross-sectional; thus, inferences of temporal precedence and causality cannot be made. Future longitudinal research that accounts for preexisting differences in psychosocial functioning to examine residual change in outcomes as a function of RNT is needed to examine the directionality of effects. Further, experimental research that tests the effects of RNT inductions on psychosocial outcomes, as well as on putative mediators of the observed effects (e.g., negative information processing biases, impaired problem solving), is necessary to inform whether and how these relations are causal. The sample was relatively small, highly educated, predominantly White, and only included mid- to later-life adults with a primary mood disorder diagnosis (primarily MDD) or no psychiatric history. This restricted demographic and clinical diversity may limit the generalizability of findings to broader populations, thus replication and expansion of the present study in a larger and more diverse sample is warranted. Further, the main predictor and outcome variables (i.e., RNT, rumination, social functioning, life satisfaction) were assessed via self-reports which are subject to response biases. Future studies could supplement these findings by assessing study variables at more objective levels of analysis, such as by incorporating behavioral measures of RNT (e.g., Wade et al., 2022) and clinical interview-based assessments of psychosocial functioning (e.g., Weissman, 1975).

Nevertheless, the present study found support for RNT as a transdiagnostic predictor of psychosocial well-being, above and beyond the effects of rumination and clinical and cognitive variables. Future research can expand upon these findings by examining the longitudinal effects of RNT on psychosocial outcomes, testing these relationships in more diverse clinical samples, and exploring potential mediators of the observed link between RNT and psychosocial adjustment.

Supplementary Material

1

Highlights.

  • Dysregulated emotion impedes social functioning and life satisfaction in mid- to late-life

  • Specific behavioral mechanisms driving poorer psychosocial functioning are unclear

  • The study enrolled a mixed clinical and non-clinical sample of 156 adults

  • Repetitive negative thinking (RNT) was associated with lower psychosocial functioning

  • RNT had effects above and beyond cognitive abilities and clinical symptom severity

Acknowledgements:

We thank all study participants for their time and effort, without whom this research would not have been possible.

Role of the Funding Source:

This study was funded by the National Institute of Mental Health via R01MH124381 (to KEB and FMG).

Funding:

This work was funded by the National Institute of Mental Health (R01MH124381).

KEB receives honorarium from the Breakthrough Discoveries for thriving with Bipolar Disorder for her role as Scientific Director of the Integrated Network and as an advisory board member for Merck & Co. FMD receives financial support from the American Medical Association that is unrelated to the work presented in this manuscript. All other authors declare that they have no known competing financial interests or personal relationships that could appear to influence the work reported in this paper.

Footnotes

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Declaration of Interests: KEB receives honoraria as the Scientific Director for the non-profit Breakthrough Discoveries for thriving with Bipolar Disorder and for service on a scientific advisory board for Merck. AMA, JGL, LO, SC, DP, KCB, and FMG have nothing to disclose.

1

Due to small sample sizes of individual racial/ethnic groups, we lacked sufficient power to probe the effects of individual racial/ethnic identities; thus, race was coded as a binary variable.

2

Given the relatively small number of BD patients, secondary analyses tested the same models while excluding BD patients from the sample and removing BD diagnosis as an independent variable. Results remained unchanged.

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