Rumination in bipolar disorder: a systematic review

Silveira Jr., Érico de M.; Kauer-Sant'Anna, Marcia

doi:10.1590/1516-4446-2014-1556

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Review Article • Rev. Bras. Psiquiatr. 37 (3) • Jul-Sep 2015 • https://doi.org/10.1590/1516-4446-2014-1556 linkcopy

Rumination in bipolar disorder: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective: To conduct a systematic review of the literature about the symptom of rumination in bipolar disorder (BD).

Methods: We searched the MEDLINE (PubMed), ISI Web of Knowledge, PsycINFO, and SciELO databases using the descriptors “rumination” and “bipolar disorder” and no time limits. This strategy yielded 105 references, of which 74 were selected. Inclusion criteria were studies involving patients with BD and the use of at least one validated scale for the assessment of rumination. Review articles were excluded. Seventeen articles were ultimately analyzed and included in the review.

Results: Rumination is present in all BD phases, is a stable interepisodic symptom, is associated with symptoms of depression, anxiety, and hypomania, and may occur in response to both positive and negative affect. There is no research on rumination and neurobiological findings in patients with BD.

Conclusions: Rumination seems to be independent of mood state, but shows close relationship with it. It is possible that rumination has a negative impact on cognitive and executive functions, particularly inhibitory control. Finally, rumination is an important symptom in both phases of BD, and, therefore, may be a useful target for further exploration as a dimensional domain and a transdiagnostic phenomenon in Research Domain Criteria (RDoC) projects.

Bipolar disorder; rumination; executive function; cognitive emotion regulation; Research Domain Criteria; transdiagnostic approach

Study	Design	N	M/F	Age(mean ± SD)	Age at onset(mean ± SD)	Rumination assessment	Diagnostic assessment	Psychological assessments	Results
Wolkenstein⁹	Cross-sectional	42 BD Rem43 MD39 HC	16/2612/3116/23	40.9±12.836.9±13.342.2±13.3	28.4±11.528.4±12.4	CERQ	SCID ISCID II	QIDS-SRHAM-DSRMIYMRS	- BD and MD reported more frequent use of self-blame, rumination, and catastrophizing than HC, and less frequent use of putting into perspective and positive reappraisal. - BD and MD did not differ in any CERQ subscale.
Gilbert¹⁰	Prospective	31 BD Rem31 MD	11/2010/21	30.9±9.7631.71±11.15	12.9±10.6^†15.1±10.5^†	RPA	SCID-IVBRMSIDS-C	PANASHR^‡ECG^‡	- Rumination and emotional inertia were different between BD and MD. - The use of maladaptive emotional strategies was differently associated with manic and depressive states. - 6-month follow-up: induced rumination was not associated with depressive or manic symptoms.
Fletcher¹¹	Cross-sectional	86 BD I107 BD II96 MD90 HC	155/224	39.7±11.4	18.4±7.019.4±10.220.8±11.3	RSQRPACERQ	MINI	CIPMBrief COPE	- HC used more adaptive coping strategies than patients. - In BD, rumination was more focused on emotion and on the self than in MD when faced with positive affect; conversely, when faced with negative affect, BD engaged more in risk-taking than MD. - BD I and BD II used similar coping strategies. - The importance of psychological intervention in the treatment of BD II is reinforced.
Pavlickova¹²	Prospective	28 BD Rem12 BD Dep8 BD Hypo	14/34	45.4±10.8	27.2±9.7	RSQ	PANASHRSDBRMS	ESMMomentary self-esteemSelf-esteem fluctuations	- Rumination predicted lower positive affect; positive affect predicted decreases in rumination, whereas negative affect increased rumination. - Adaptive coping increases self-esteem and positive affect.
Rowland¹³	Cross-sectional	126 SZ97 BD I81 HC	73/5336/6137/44	45.5±11.051.3±12.144.6±12.9	N/A	CERQ	OPCRITBEDDIGSFIGSDASSHPS	None	- SZ and BD I showed more rumination, catastrophizing, and self-blame than HC, and less frequently used adaptive strategies (e.g., putting into perspective) in stressful situations. - In BD, rumination predicted depressive symptoms, anxiety symptoms, and hypomania. - These findings may reflect cognitive deficits in frontal executive functions in SZ and BD when faced with negative affect, with the use cognitive of repair [reappraisal?] strategies; both SZ and BD may present deficits in the ability to interpret emotional stimuli.
Rowland¹⁴	Cross-sectional	56 SZ33 BD I58 HC	32/2418/1529/29	44.6±10.440.7±11.333.9±12.2	N/A	CERQ	ISSPANSS	FEESTTASIT	- SZ ruminated more than BD and used more projection. - BD were more likely to blame themselves and less likely to engage in positive reappraisal than SZ. - Compared to HC, SZ showed impaired perception of positive and negative emotion; BD did not differ from HC.
Contreras¹⁵	Cross-sectional	164 BD I8 BD II18 BD NOS13 SZA DB2 SZ7 SMD	97/115	45.3±12.2	N/A	STAI	DIGSFIGS	None	- Rumination and worry may explain subsyndromal anxiety symptoms in Costa Rican patients with a history of mania or hypomania. - Methodological limitation: factor analytic study.
Kim¹⁶	Cross-sectional	227 MD68 BD I52 BD II37 BD NOS65 PD16 GAD11 OCD	177/299	16 to 88 years (range)	N/A	RSQ	SCIDHRSDHRSA	None	- Rumination was found among individuals with MD, BD, GAD, and OCD, possibly indicating ineffective thought control. - Methodology: this study assessed the psychometric properties of RSQ to validate the Korean version of the scale.
Green¹⁷	Cross-sectional	105 BD I124 UR63 HC	33/7247/7731/32	52.4±14.152.3±15.658.3±16.8	N/A	CERQ	DASSHPS	None	- BD more frequently presented maladaptive cognitive strategies such as rumination, catastrophizing, and self-blame in response to negative events than UR and HC. - BD I and UR reported more frequent use of maladaptive regulatory strategies than HC.
Gruber¹⁸	Cross-sectional	39 BD I34 HC	11/2812/22	42.5±13.838.2±11.1	19.5±12.1	RSQRPAEmotion response to rumination induction	SCIDYMRSDS-CPANAS	HR^‡ECG^‡RSA	- BD reported greater trait rumination about positive and negative emotion when compared with HC. - Rumination induction did not reveal differences between the groups. - Rumination about positive and negative affect in BD, as well as increased cardiovascular arousal, were associated with a greater frequency of lifetime depression and mania. - Methodology: illness course assessed retrospectively.
Liu¹⁹	Cohort	223 COMD112 HC	N/A	N/A	N/A	RSQ	Suicide attempts	None	- COMD scored higher on maladaptive response styles and lower on adaptive styles. - Compared to COMD, probands with a history of suicide attempt were less likely to report the use of distracting activities to manage their depressed mood. - COMD who engaged in dangerous activities in response to depressed mood were more likely to attempt suicide (HR = 1.8, 95%CI 1.2-2.8).
Perlis²⁰	Cohort	386 BD I197 BD II	218/365	40.6±12.1	16.6±8.2	RSQRPACERQ	SCIDADEMINICGI-S	None	- Great variation of symptoms in between depressive episodes in BD. - Rumination was a stable symptom during depressive episodes.
Van der Gucht⁸	Prospective	34 BD Man/Hypo/Mix30 BD Dep43 BD Eut41 HC	13/218/2218/2520/21	45.5±41-50^‡46.2±42-49^‡47.5±43-51^‡47.9±43-52^‡	23.9±21-27^§21.0±17-25^§24.0±22-26^§	RSQ	SCIDCSMSHRSDBRMSPANAS	Self-esteem diary Autobiographical memoryCARROTPSIBIS/BASPITRSE	- BD in all phases showed high levels of sociotropy and autonomy, low self-esteem, self-esteem instability, rumination, and, less clearly, an impaired ability to recall specific autobiographical memories. - Vulnerability to depression was evident even in euthymic patients.
Gruber²¹	Cross-sectional	21 BD I19 INS20 HC	6/1510/9	39.0±2.548.8±2.6	15.5±4.922.9±14.3^\|\|	GRS	SCIDIDS-CYMRSIDIDSISDBDIBAI	PSWQCCL	- Rumination and worry were transdiagnostic processes between insomnia and BD. - BD showed more negative automatic thoughts than HC; INS did not differ from HC .
Johnson²²	Cross-sectional	28 BD35 MD44 HC	39/68	19.1±1.5	N/A	RSQRPA	SCIDHPSIDD-L	None	- BD and MD ruminated more than HC in response to negative affect. - Patients in hypomania ruminated after negative affect but focused their thoughts on their own qualities and positive affect.
Simon²³	Cross-sectional, ancillary to cohort	60 BD I27 BD II11 BD NOS	42/56	44.8±13.9	27.5±13.2^†	RSQ	MINISBQASIFQPDSS-SR	PSWQEACSFNE	- Higher RSQ scores were associated with greater suicidal ideation, and higher coping scores with lower suicidal ideation, in BD, during both depressive and manic episodes, in both males and females. - Rumination may mediate the relationship between anxiety and suicidal ideation.
Thomas²⁴	Cross-sectional	14 BD Dep40 BD Man29 BD Rem44 HC	11/310/2011/1814/30	38.3±12.245.9±12.445.8±11.237.4±12.7	N/A	RSQ	HRSDBRMSNART	None	- Rumination was greater in BD Rem and BD Dep when compared with BD Man and HC. - There was no correlation between rumination, sex, and IQ. - Risk-taking and active coping were associated with manic symptoms. - Methodological limitation: multiple groups with small sizes.

^*
Age at first treatment; ^† duration of illness (years); ^‡ physiological measures; ^§ 95% confidence interval; ^|| average length of sleep disturbance.

ADE = Affective Disorders Evaluation; ASI = Reiss-Epstein-Gursky Anxiety Sensitivity Index; BD I = bipolar disorder type 1; BD II = bipolar disorder type 2; BD Dep = bipolar disorder in depressive episode; BD Eut = bipolar disorder in euthymic state; BD Hypo = bipolar disorder currently hypomanic; BD Man = bipolar disorder in manic episode; BD Man/Hypo/Mix = bipolar disorder in manic or hypomanic or mixed episode; BD NOS = bipolar disorder not otherwise specified; BD Rem = bipolar disorder in remission; BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory; BED = best estimate diagnosis; BAS = Behavioral Activation System Scale; BIS = Behavioral Inhibition System scale; BRMS = Bech-Rafaelsen Mania Scale; CARROT = Card Arranging Reward Responsivity Objective Test; CCL = Cognition Checklist; CERQ = Cognitive Emotion Regulation Questionnaire; CGI-S = Clinical Global Impression Scale for Current Severity; CIPM = Coping Inventory for Prodromes of Mania; COMD = childhood-onset mood disorder; CSMS = Cassidy Scale for Manic States; DASS = Depression and Anxiety Stress Scale; DIGS = Diagnostic Interview for Genetic Studies; DSISD = Duke Structured Interview for Sleep Disorders; EACS = Emotional Approach Coping Scale; ECG = electrocardiogram; ESM = Experience Sampling Method; F = female; FEEST = Ekman 60-Faces Task from the Facial Expressions of Emotion: Stimuli and Test; FIGS = Family Interview for Genetic Studies; FNE = Fear of Negative Evaluation scale; FQ = Fear Questionnaire; GAD = generalized anxiety disorder; GRS = Global Rumination Scale; HAM-D = Hamilton Depression Rating Scale; HC = healthy controls; HPS = Hypomanic Personality Scale; HR = heart rate; HRSA = Hamilton Rating Scale for Anxiety; HRSD = Hamilton Rating Scale for Depression; IDD-L = Inventory to Diagnose Depression - Lifetime; IDI = Insomnia Diagnostic Interview; IDS-C = Inventory of Depressive Symptomatology; INS = primary insomnia; IQ = intelligence quotient; ISS = Internal States Scale; M = male; MD = unipolar depression; MINI = Mini International Neuropsychiatric Interview; NART = National Adult Reading Test for IQ; OCD = obsessive compulsive disorder; OPCRIT = diagnostic interview for psychosis; PANAS = Positive and Negative Affect Scale; PANSS = Positive and Negative Syndrome Scale; PD = panic disorder; PDSS-SR = Self-Rated Panic Disorder Severity Scale; PIT = pragmatic inference task; PSI = Personality Style Inventory; PSWQ = Penn State Worry Questionnaire; QIDS-SR = Quick Inventory for Depressive Symptomatology - Self-Report; RPA = Responses to Positive Affect Questionnaire; RSA = respiratory sinus arrhythmia; RSE = Rosenberg Self-Esteem Scale; RSQ = Response Styles Questionnaire; SBQ = Suicide Behaviors Questionnaire; SCID = Structured Clinical Interview for DSM-IV; SD = standard deviation; SMD = substance-induced mood disorder; SRMI = Self-Report Manic Inventory; STAI = State-Trait Anxiety Inventory; SZA B = schizoaffective disorder, bipolar type; SZ = schizophrenia; TASIT = Awareness of Social Inference Test; UR = unaffected biological relatives of BD probands; YMRS = Young Mania Rating Scale.

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