RESEARCH ARTICLE For reprint orders, please contact: [email protected]
Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain
Practice Points
Melanie J Edwards1, Nicole KY Tang†1,2, Anwen M Wright1, Paul M Salkovskis3 & Carolyne M Timberlake4 Rumination was prominent in chronic pain patients and was triggered by the experience of pain. The focus of the rumination spanned across the past, present and future, with contents concerning not
only pain, but also related issues such as work, family, relationships, finance and health in general. For some patients, pain rumination appears to maintain or increase pain perception via an elevated focus
on pain. A reciprocal relationship between rumination and negative emotions was suggested with negative
emotion both triggering and resulting from rumination. Sleep difficulties were reported to be both a trigger and effect of rumination. Chronic pain patients who often ruminate held a number of positive beliefs about rumination
(e.g., problem-solving, avoiding repeating mistakes) and negative beliefs about self in overcoming rumination (e.g., rumination as uncontrollable, lack of alternatives to rumination). A quarter of the participants we interviewed were identified as infrequent ruminators; they held few
positive beliefs about rumination. Distinguished from frequent ruminators, infrequent ruminators were able to disengage from the
repetitive thinking process by engaging in meaningful activities or taking action to solve the immediate problem, rather than being ‘stuck’ in rumination.
SUMMARY
Aims: A thinking process central to the etiology of emotional disorders, rumination is commonly observed in chronic pain. However, very little is understood about the characteristics of pain-related rumination and the mechanisms through which rumination impacts on pain perception and disability. This study began investigating this cognitive phenomenon by qualitatively examining chronic pain patients’ experience of rumination. Methods: Semistructured interviews were conducted with 20 chronic pain patients. Themes were extracted from interview transcripts using thematic analysis. Department of Psychology, Institute of Psychiatry, King’s College London, UK Arthritis Research UK Primary Care Centre, Keele University, UK 3 Department of Psychology, University of Bath, UK 4 Princess Royal University Hospital, South London Healthcare NHS Trust, UK † Author for correspondence: Tel.: +44 178 273 4875; [email protected] 1 2
10.2217/PMT.11.29 © 2011 Future Medicine Ltd
Pain Manage. (2011) 1(4), 311–323
ISSN 1758-1869
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research article Edwards, Tang, Wright, Salkovskis & Timberlake Results: Six themes were extracted from interviews with frequent ruminators. These elucidated the pattern of rumination and suggested a reciprocal relationship of rumination with not only pain, but also negative emotions and sleeplessness. Frequent ruminators appeared to hold positive beliefs about rumination and negative beliefs about self in overcoming pain. Two themes were extracted from interviews with infrequent ruminators: implicating negative beliefs about rumination and the flexible use of disengagement strategies in these individuals. Conclusion: Rumination occurs frequently and can be easily triggered by pain, negative emotions and sleeplessness in patients who lack alternative coping strategies and believe rumination is a way to problem-solve. A tentative model of pain-related rumination has been proposed, outlining interesting hypotheses for rigorous empirical investigations.
Rumination is broadly defined as a repetitive process whereby individuals go over and over the same thoughts in their mind. It has been implicated as one of the key cognitive pheno mena precipitating and maintaining a range of emotional disorders. Notably, in depression, rumination has been found to predict the onset and duration of a depressive episode [1,2] , and to be associated with depressive symptoms [3] , overgeneral memory [4,5] and impaired problemsolving [3,4] . Rumination has also been linked to social phobia [6] , post-traumatic stress disorder [7] , health anxiety [8] , poorer self-reported physi cal health in older adults [9] and increased con current physical complaints in otherwise healthy individuals [10] . However, rumination is not exclusive to emotional disorders. Clinical observations sug gest that patients with chronic pain do spend a considerable amount of time ruminating about their pain, its causes and consequences. Such ruminative thinking could be either a cause or an effect of the experience of persistent pain. It may also be a process by which negative emo tions associated with the experience of pain are amplified. There is evidence for a reciprocal relationship between rumination and symptoms of anxiety and depression. Feeling anxious/sad increases the likelihood of negative thinking, which further increases the experience of fear and sadness, making it yet more likely that the person will think negatively about other things in a self-maintaining vicious circle [11] . We hypothesize that the experience of rumination is linked to the experience of pain and negative emotions, but the existence and reciprocality of the r elationships remain to be elucidated. Several previous studies have identified a possible association between rumination, pain and disability in chronic pain patients [12,13] . In a cross-sectional study that aimed to examine correlates of bodily pain in female patients with
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chronic fatigue syndrome, Nijs and colleagues [14] found the level of bodily pain strongly cor related with rumination and helplessness, but not magnification as measured with the Pain Catastrophizing Scale (PCS) [15] . In another cross-sectional study, Osman and colleagues val idated the use of the PCS in samples of commu nity volunteers and pain outpatients [16] . These investigators found that the PCS total score correctly differentiated the two criterion groups in 77% of the cases. However, when the three PCS subscales (magnification, rumination and helplessness) were examined independently, only the rumination subscale was found to be clini cally useful in differentiating pain patients from community volunteers, with an overall classifica tion accuracy of 76.7%. In examining the role of catastrophizing in determining levels of pain and disability in people who had sustained soft tissue injuries following accidents, Sullivan and colleagues [12] found that scores on the PCS [15,17] significantly predicted self-reported disability as measured with the Pain Disability Index (PDI) [17] . Catastrophizing as a whole explained 4% of the variance in disability score, even when the effects of age, pain duration and pain intensity were accounted for. Interestingly, however, only the rumination subscale contributed unique variance to the prediction of disability. In a further study by the same group, Sullivan and his associates investigated whether the three subscales of the PCS interacted with duration of chronicity in predicting severity of painrelated disability (as measured with the PDI) [13] . A total of 150 patients with low back pain as their primary complaint were classified into one of three groups according to their reported pain duration (6 months to 2 years; 2–4 years; >4 years). Regression analyses were performed to examine the extent to which catastrophizing pre dicts disability separately in each of the groups. Rumination, but not other components of
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Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain catastrophizing, accounted for 18% of the vari ance in disability for patients who had been off work for 2–4 years. Rumination also uniquely contributed to the prediction of disability in patients who had been off work for more than 4 years (variance = 4%), beyond the effects of age, sex, pain intensity and helplessness. Despite its possible etiological role in chronic pain and disability, rumination as a psychologi cal construct has received relatively little research and clinical attention. There are at least two plau sible barriers. First, historically, rumination has been introduced to the study of pain as a subcom ponent of pain catastrophizing and assessed using the four-item subscale of the PCS (items are: “I anxiously want the pain to go away”, “I can’t seem to keep it out of my mind”, “I keep thinking about how much it hurts”, “I keep thinking about how badly I want the pain to stop”) [15] . The lack of conceptual clarity may have discouraged the study of rumination as an independent cognitive process, even though rumination and catastro phizing can be viewed as distinct but interacting phenomena, with the latter being concerned with the catastrophic content of the thoughts and the former being concerned with the reiterative proc ess of thinking. Specifically, catastrophic apprais als involve the attribution of meaning to an inter nal or external event. Once an appraisal has been made, this may trigger a more detailed rumina tive train of thought, which may help explain the attentional disruption, disengagement from meaningful activities and low mood [18,19] com monly observed in chronic pain patients. Second, very little is known about the pattern and charac teristics of pain rumination, resulting in few ideas for testing the factors that promote or diminish rumination. Whilst the rumination subscale of the PCS measures the occurrence of rumination, it does not provide information about the pheno menology (e.g., focus, content and triggers) of rumination, as well as the context in which a person is motivated to ruminate. This void calls for a better qualitative account of rumination in chronic pain that outlines a clearer roadmap for future research and treatment development work. The present study aimed to examine in detail the phenomenology of rumination in chronic pain using a qualitative approach [20] and to generate specific hypotheses for future empirical investigation. Previously, a related con cept – worry – has been investigated under the theoretical framework of misdirected problemsolving [21,22] . In this particular model, worry is
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posited as a response to the awareness of pain and its associated impact and functions to pro mote problem-solving. If such problem-solving leads to success, worry would decrease. However, if one fails to identify a solution to the problem, worry would increase. Applied to the context of chronic pain, it is proposed that repeated failure to resolve chronic pain would create a ‘persever ance loop’ that amplifies worry, which in turn motivates hypervigilance and further efforts to resolve the pain using the same ‘solutions’ [22] . The model did not make a distinction between worry and rumination, but defined worry as a predominantly negative experience characterized by a chain of thoughts and images. The model did not specify the characteristics of worry in chronic pain, but in a related observational study, Eccleston and colleagues noted chronic pain patients experienced both pain and non pain-related worries [23] . Compared with non pain-related worry, worry concerning chronic pain was viewed as more difficult to dismiss, distracting, attention grabbing and distressing. Patients also reported more pain during painrelated worries than during nonpain-related worries. Extending these findings, rumination in chronic pain is evaluated in this study using a qualitative approach, with a particular empha sis on understanding pain patients’ experience of rumination in terms of its pattern, perceived functions and effects, and factors preceding and motivating rumination. To facilitate the identifi cation of strategies for successful disengagement from rumination, we also separately examined themes extracted from interviews with a subset of patients who reported infrequent rumination despite pain. The qualitative approach is con sidered to be particularly suited for the purpose of identifying the features of rumination as a private cognitive process and for exploring the beliefs and pathways through which the act of ruminating is moderated. Method Overview
A semistructured interview focused on patients’ experience of rumination was conducted as part of a larger program of research that sys tematically investigated the role of rumination in chronic pain. The idea was to gather infor mation to both inform the development of a theoretical model and to enrich the mechanis tic understanding of rumination gained from experimental studies that follow.
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research article Edwards, Tang, Wright, Salkovskis & Timberlake The study protocol received full ethical approval. The first twenty participants recruited into the research completed the interview and a questionnaire package that included the ShortForm McGill Pain Questionnaire (SF-MPQ) [24] , the Pain Disability Questionnaire (PDQ) [25] , the Hospital Anxiety and Depression Scale (HADS) [26] and the Catastrophizing in Pain Scale (CIPS) [27] . Scores on these questionnaires were used to characterize the sample.
participants were white (85%), employed (70%), and married or cohabiting (65%). Participants reported a moderately high level of disability and distress, as indicated by a mean PDQ score of 73, a HADS anxiety score of 7 and a HADS depression score of 8. The mean catastrophiz ing score was 22 (scale range = 0–80). Overall, the current sample have demographic and pain characteristics comparable to those of samples reported in other clinical studies conducted in the UK [28] .
Participants
Participants were chronic pain patients recruited from two pain relief units in London, UK. Inclusion criteria were: chronic pain of at least 6 months duration; English as first language; age between 18 and 65 years. Exclusion criteria included: presence of a condition that would prevent the participant completing the ques tionnaire/interview or giving informed consent (e.g., learning difficulties, severe psychopatho logy, dementia); presence of a condition likely to cause impairment on the neuropsychological tasks that formed part of the linked experimental study (e.g., stroke, brain injury, epilepsy); termi nal illness; pain of a malignant nature; epidural, cortisone injection, operation or nerve block within the last month; current severe depression or signs of acute distress; severe psychopathology (e.g., schizophrenia, bipolar disorder). Of the first 85 patients approached, 22 agreed to take part in the experimental study and interview, 58 patients declined to take part (work/family commitments = 14; pain too severe to complete study tasks = 5; distance to research site = 11; not interested = 26; other reasons = 2) and five patients met exclusion criteria (pain due to cancer = 1; severe depres sion = 4). One patient who agreed to take part reported no pain rumination so the interview was not conducted. We were unable to include one patient in the analysis because of technical problems with the interview recording. The final sample comprised five men (25%) and 15 women (75%), with the mean age of the participants being 45 years (range: 26–61). Participants reported a variety of pain com plaints and 75% reported pain in more than one site. The most commonly reported sites of pain were back (75%), followed by neck (35%), shoulder (30%), head (25%) and knee (25%). Mean pain duration was 8.6 years (range: 1–40; median = 6.9 years), and mean pain intensity rating (as measured by the SF‑MPQ visual analogue scale) was 4.6. The majority of
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Interview
Semistructured interviews were conducted indi vidually. The typical duration of the interview was 1 h. Each interview was audiotaped for later transcription. The interview began with a definition of rumination, given below: “What rumination means is chewing over, so it’s thoughts that you chew over or turn over in your mind, which might worry or trouble you, which seem to stick in your head or keep coming back to you, either in the same form or in a slightly different form. These thoughts can be related to the past, present or future.” The interview was in two sections. The first section explored the participant’s general expe rience of rumination and contained questions about the topics and triggers of their rumination, what ends their rumination, and how easy/diffi cult it is for them to stop ruminating. Participants were asked to rate the frequency of their rumina tion, in the previous 2 weeks, as “almost never”, “sometimes”, “often”, “very often” or “almost always”. Other questions explored the partici pant’s beliefs about rumination and whether there might be more helpful alternatives to rumi nation. Participants were asked to estimate what percentages of their ruminations were focused on the past, present or future. The second section of the interview required the participant to recall a recent specific episode of pain-related rumination. After identifying an episode and priming their memory of what hap pened at that time, they were asked questions about that specific episode of rumination in rela tion to the content, trigger, process and effects of the rumination. Other questions attempted to investigate whether participants were using rumination to problem-solve, whether rumi nation led them to take action and whether
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Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain ruminating gave them any sense of confidence or control. Participants were asked whether there might have been an alternative to rumination that would have been more helpful. Core questions asked during the interview are provided in Box 1. Participants were encour aged to digress and add any thoughts they had about other phenomena related to pain and rumination.
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Analysis
Interviews were transcribed verbatim by two researchers (MJE and AW). Transcripts were analyzed using thematic analysis in accordance with the principles and procedures set out by Braun and Clarke [29] . Thematic analysis pro vides a transparent, systematic method for iden tifying, analyzing and reporting themes from qualitative data. The data analysis process is
Box 1. Core interview questions. Section A: Exploring the general experience of rumination 1. Topics of rumination: -- Typically people ruminate about a great number of things. I wonder if you could tell me about some of the main things that you tend to ruminate about? 2. Frequency of rumination: -- Thinking back over the past few weeks, how often have you noticed that you were ruminating? 3. Triggers of rumination: -- Have you noticed that there are things that tend to start you ruminating? 4. What ends the rumination: -- Is there anything that tends to end the rumination? 5. Ease of ending rumination: -- For some people rumination is just something that happens to them briefly and it’s easy enough for them to move onto something else. Other people find that they become very stuck in it. What’s your experience of rumination? 6. Positive beliefs about rumination: -- Can you tell me about any benefits that you can see in ruminating? 7. Negative beliefs about rumination: -- What about any disadvantages of ruminating? 8. Alternatives to rumination: -- Do you think there are other things you could do instead of ruminating that would be more helpful? 9. Focus of rumination: -- Thinking about rumination in general, thinking back over the last few weeks, do you think you have thought more about the past or future? Section B: Investigating a recent episode of pain rumination 1. Topic of rumination: -- Could you now tell me what were you ruminating about? 2. Trigger of rumination: -- Can you remember what started you ruminating? 3. What ends the rumination: -- Can you remember what ended the rumination? 4. Effects of rumination on mood and pain: -- Did you notice any change in your mood (pain) whilst ruminating? 5. Problem-solving: -- Did you get a sense that you were addressing or trying to sort out a problem? -- Did ruminating about the problem lead you to take any action? 6. Control: -- Did ruminating give you a sense of control over the problem? 7. Alternatives to rumination: -- I wonder with the benefit of hindsight, if you could go back to that situation, would you do the same thing and ruminate about the problem or would you do something else?
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research article Edwards, Tang, Wright, Salkovskis & Timberlake largely data-driven, although it is understood that the researcher also plays an active role in identifying patterns of meaning and interpret ing the extracted themes. Thematic analysis is a widely accepted qualitative analytic method within the field of psychology and has been applied to fruitfully explore unknown pheno mena and highlight avenues for future research in chronic pain [30–32] . Initial analysis of the data was conducted by the interviewer (MJE) and a member of the research team (AW) who were familiar with the flow and context of the interviews. It has been suggested that previous exposure to visual and/or paralinguistic cues can enhance accuracy in the analysis of the interviews [33] . The analysis followed the steps below: Familiarization with the data: each transcript
was read and re-read, interesting features were noted. Coding the data: an initial list of codes were
produced. The transcripts were re-read and the codes generated were applied systemati cally across all transcripts by MJE and AW, independently. Each transcript was then reviewed to compare application of the coding system. Any discrepancies were then discussed and resolved. Extracting themes: coded data were grouped
into potential themes and data were organized into a table. The relationships between the themes were considered. Reviewing extracted themes: initial themes
were discussed with a further researcher (NT) and the relationships between themes and the levels of themes were considered. Refining and reporting themes: further ana
lysis of the transcripts was conducted. Themes were refined and scrutinized by two further researchers (NT and PS), who brought to bear their research/clinical experience working with patients suffering from chronic pain and anxiety problems. Reporting of the findings is divided into three sections. First, we describe the general pattern of rumination amongst chronic pain patients as revealed by the frequency and content ratings. Second, we report the themes extracted from the interview transcripts and provide direct quotes from the participants for each theme reported. Quantitative observations are also reported with a view to allowing the reader to judge to what extent
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the qualitative interpretation we offer can be gen eralized to other people with chronic pain. Finally, we separately describe the themes extracted from interviews given by chronic pain patients who were identified as “infrequent ruminators”. The term “infrequent ruminators” in this study refers to those individuals who reported “sometimes” or “almost never” as their general rumination fre quency and also reported infrequent pain rumina tion during the interview. From the full sample of 20, five infrequent ruminators were identified and their interview transcripts were examined in special contrast to those of frequent rumina tors, in order to elucidate strategies for effective disengagement from rumination. Results Frequency & patterns of rumination
60% of participants reported ruminating “very often” or “almost always” – in general during the previous 2 weeks. The remaining participants reported the frequency of their general rumina tion to be often (5%), sometimes (30%) or almost never (5%). All participants reported ruminat ing about their pain. Besides pain, participants reported ruminating about a variety of topics including work (60%), family (60%), finances (50%), relationships (40%) and health (30%). On average participants reported 33% of their rumi nations to be past-focused, 38% future-focused and 28% focused on present events. Themes of rumination
“I ruminate when the pain is bad”
All participants – including the infrequent ruminators – reported that pain-related rumi nation was triggered by experiencing pain. Paintriggered rumination was mostly concerned with thinking about how to relieve the pain, what had triggered the episode of pain, how much longer the episode would last, how the pain was stop ping them from doing certain activities and how the pain will affect them in the future. “…when I do get like the pain in my back and stuff like that, I know that makes me down and then I start dwelling on like the pain and what it’s stopping me from doing so I find that can set it [rumination] off as well, like when the pain gets really bad.” (Female, 26, back and head pain) Pain-related rumination often led onto rumi nation about other concerns, expanding the breadth and duration of rumination.
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Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain “…in my case it [pain-related rumination] very clearly becomes the catalyst for it to start unraveling to other things. I started to think yeah my back’s really bad, work’s really crap and it really is a trigger. I mean, as far as I’m concerned it’s sort of taking your finger out of the dyke and watching floodwater start to pour through … that it sort of unleashes you on other areas, it triggers other fretting.” (Male, 43, head, neck, shoulder and back pain) Just over one third of participants (35%) reported that rumination made their pain worse. For some participants this seemed to be a result of rumination maintaining their focus on the sensation of pain or negative experiences: “Sometimes they [ruminations] can increase the physical pain because they create stresses and tensions in the muscles and the neck and the head and that kind of stuff … so thinking about things that I can’t change or uh have happened in the past can actually make the pain worse … I think bad things and it makes it [the pain] worse.” (Male, 43, back pain) “I ruminate when I’m feeling down”
Low mood and stress were commonly cited emotional factors that preceded episodes of rumination, reported by 40% of participants. Rumination appeared to be mood dependent to some extent, as exemplified by the following quote: “I think it [rumination] is dependent on my mood. If I’m feeling down, if I’m feeling sort of pressurized, stressed, those sorts of things, I think I probably find it harder to switch off. If I feel low then I think I tend to dwell on those thoughts more.” (Female, 38, back pain) Conversely, many participants (85%) reported that rumination had a negative effect on their mood. Low mood was a commonly reported consequence of rumination with par ticipants reporting that rumination led to them feeling even unhappier. Half of the participants reported that rumination increased feelings of frustration, leaving them feeling irritable, fed up and short-tempered. This is perhaps not too surprising considering that many participants reported ruminating over their frustration at the pain stopping them from doing certain activi ties. Thus, rumination appears to maintain or
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even increase this feeling of frustration at the disabling effects of the pain: “I think it [rumination] can sometimes make the experience worse. Like I find sometimes, like say if I’m in pain, I’ ll sort of think about the pain and it’ ll upset me and I’ ll get annoyed that I’m in pain …I get annoyed that, you know, I’m still young and I’ve got this pain and, you know, you sort of feel a bit pathetic really.” (Female, 26, back and leg pain) “I get stuck in rumination”
Half of all participants reported feeling that rumination was uncontrollable. Reports included believing that they had no control over whether they ruminated or the duration of rumination once it had begun. Some partici pants reported that they found it difficult to stop ruminating, saying that they found it hard to “switch off ” or that they got “stuck” in their ruminative thinking. “When I get in that state [rumination], I just sort of shut out. And I’m just stuck and I feel like I can’t get out of it … I get like this little devil in my head that just don’t want me to snap out of it and makes me think about it over and over until I feel like I want to scream … I can’t seem to snap out of it.” (Female, 37, back and abdomen pain) “I don’t know what else to do”
Half of all participants reported a belief that there were no alternatives to rumination avail able to them. Some participants were unable to generate alternative ways of responding to pain and other problems. Others acknowledged that there were other things that they could do but reported not having tried them, not believing that they were capable of doing them, or that the alternatives would not work for them. “I am positive that there must be other ways of dealing with it [rumination] because I see lots of other people who don’t live their lives like I do but I haven’t investigated any of them. I suspect that there are things that I could do. I haven’t done any of them.” (Male, 43, back pain) “Rumination helps me solve my problems”
Interestingly, three quarters of the participants reported at least one benefit of rumination. The most common perceived benefit was that engag ing in rumination is problem-solving. The focus
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research article Edwards, Tang, Wright, Salkovskis & Timberlake of such ‘problem-solving’ ruminations tended to be on how to make the pain go away, stop it from getting worse, or how to rearrange the plans/activities that the pain had prevented them from undertaking. “Sometimes I like to ruminate over things to try and work out a solution to the problem. I like to be able to put my feelings into words because then I can understand them … sorting out your problems is the advantage of it.” (Female, 47, shoulder, neck and arm pain) The belief that engaging in rumination is ‘problem-solving’ was not specific to pain-related concerns but was also held for other concerns. However, when asked about a specific episode of pain-related rumination, only 30% of these participants reported finding a solution to the problem in the episode of rumination discussed. One quarter of participants reported that engaging in rumination helped them to find something positive in what would otherwise be a negative situation. This commonly consisted of either using the experience to make themselves mentally stronger, trying to change the situa tion into a more positive one, or focusing on the things that they could still do. “I have to look for something that says ‘ok well this is going to happen and it’s not good but there’s got to be some benefit coming out of it’. So, I think it’s trying to sort of try in your mind and your body to think that you can get something positive out of anything that happens … most of these thoughts are what I can do to make it better so I try and come out of it in a better ideal.” (Male, 43, shoulder, neck and back pain) Some participants (30%) reported that engag ing in rumination helped them to avoid repeat ing past mistakes. This belief was held for both pain and nonpain-related rumination. In the context of pain-related rumination, this included trying to identify what had triggered the pain so that they could avoid repeating that activ ity or movement in the future and reduce the likelihood of experiencing pain. “I would tend to think ‘well what’s triggered off that pain? Why am I in pain? What did I do wrong? Um, oh yes, I did this. Oh I shouldn’t do that. And must try not to do that again’.” (Female, 53, head, neck, back, arm and leg pain)
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“I ruminate when I can’t sleep”
Even though sleep was not a topic we set out to investigate, more than a quarter of participants interviewed reported experiencing episodes of rumination during the night. Some participants reported that their ruminations often occurred at night when they were attempting to get to sleep but were unable to “switch off”. For oth ers, concerns about not being able to sleep even became the focus of the rumination. “[I ruminate] occasionally when I’m having trouble sleeping. Actually, most often when I’m having trouble sleeping. Trying to get to sleep at night and your brain’s whizzing round. Or waking up early in the morning and trying to get back to sleep and your brain’s whizzing round.” (Female, 47, neck, shoulder and back pain) Some participants (30%) reported that rumination had a negative effect on their sleep. Mainly the effects appeared to relate to a delayed sleep onset during the night. “I sleep really badly because I wake up in the middle of the night and all I’ ll be doing is ruminating about work … it’s constant and I know that I ruminate because it wakes me up three, four, five times a night.” (Male, 43, back pain) Infrequent ruminators
As described in the method section, five out of the 20 participants (25%) were identified as infrequent ruminators. A number of differences were identified between these participants and the rest of the sample. “I don’t see any point in ruminating”
It was noted that in comparison to the rest of the sample, these participants held few posi tive beliefs about rumination. For example, the infrequent ruminators appeared to be less likely to hold the belief that rumination is problemsolving. In fact, to these infrequent ruminators, there appeared to be a clear distinction between rumination and problem-solving: “…only if you ruminate about a particular problem but then that comes down to problemsolving doesn’t it, rather than ruminating … I don’t see any sense in keep actually looking at a particular negative idea and trying to solve it by ruminating about it. It doesn’t actually do anything or achieve anything.” (Male, 59, back pain)
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Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain “I do something to take my mind off the pain”
Infrequent ruminators were able to generate alternatives to rumination and reported being able to engage in these alternatives in contrast to frequent ruminators who commonly had difficulty generating alternatives or, if they were able to, doubted their ability to engage in them. Additionally, the alternatives gener ated by the infrequent ruminators tended to be more action-orientated involving engaging in a distracting task or taking action to solve the immediate problem. “I will actively try to eradicate negative thoughts … if I do find myself thinking negatively I will tend to do something active that will take my mind off it. Anything from, you know, doing a crossword puzzle to some sort of mental activity.” (Male, 59, back pain) Not surprisingly, infrequent ruminators reported that episodes of pain-related rumina tion tended to be brief and that they found it easy to move on from the rumination. This is in stark contrast with the frequent ruminators who commonly reported beliefs about rumina tion being uncontrollable and difficult to move on from. Conclusion Data from the interviews revealed that, while rumination is common in chronic pain, it occurs in varying patterns and is experienced differ ently by different individuals. If generalization was to be made, the themes extracted suggest that ruminative process is typically triggered by pain, negative emotion, and for some, difficul ties sleeping. Consistent with previous charac terization of rumination in the depression litera ture [34] , the general focus of rumination tended to be evenly distributed across concerns from the past, present and future, touching on not only pain, but also related issues such as work, fam ily, finance, relationships and health in general. Many patients interviewed found it difficult to end rumination, citing the feeling of having no control over ruminating or getting “stuck” in the ruminative thinking. Although not an enjoyable experience, positive beliefs about rumination as problem-solving were reported by frequent ruminators, especially when no alter native solution to rumination was identified. Infrequent ruminators, on the other hand, hold negative beliefs about rumination and manage
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to disengage from rumination effectively by actively engaging in alternative mental activi ties or taking actions to problem-solve. For these people, rumination was reportedly brief and easy to move on from. Whilst the patients interviewed did not explic itly link their experience of rumination with disability – as highlighted in several previous studies [12–16] , reciprocal relationships of rumi nation with pain and negative emotions were mentioned. On the relationship between rumi nation and pain, findings of the present study are consistent with the hypothesis that rumination can occur as a response to pain. In over one third of the participants, pain rumination appears to also maintain or increase pain perception, via an elevated attentional focus on pain as described by these patients. On the relationship between rumination and mood in chronic pain, 40% of participants reported low mood to be a trigger for their rumination and 85% reported experienc ing low mood after rumination. This suggests a mutually interacting relationship between rumi nation and negative mood similar to that found in the depression literature [1–3] . Considering that up to one third of chronic pain sufferers are thought to have comorbid depression [19] , the current study raises the possibility that rumina tion may play a role in maintaining depressive symptoms in chronic pain. Sleep was not a topic that we set out to inves tigate, and yet the data drew our attention to the trend that rumination was particularly promi nent when patients were experiencing difficul ties sleeping. Almost one third of participants associated rumination with delayed sleep onset and waking up during the night. It is not clear whether rumination is a cause or an effect of sleeplessness, but it is plausible that if rumina tion is not successfully resolved before bedtime then sleep disruption commonly occurs. Presleep rumination has previously been found to predict poorer self-reported sleep [35] . Our group is now conducting a more focused experimental investigation evaluating the effects of night-time rumination on sleep. While previous research has investigated positive and negative beliefs about rumination in anxious and depressed samples, this is the first study to have investigated these beliefs in a chronic pain sample. The positive beliefs about rumination held by chronic pain patients – for example, rumination is problem-solving, helps to avoid repeating past mistakes – are similar
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research article Edwards, Tang, Wright, Salkovskis & Timberlake to those reported by depressed individuals and nondepressed students about depressive rumination [36,37] . Many chronic pain patients we interviewed engaged in rumination in an attempt to problem-solve but usually failed to find solutions. This observation is in line with the proposal described in the misdirected problem-solving model in which individuals are motivated to worry in an attempt to prob lem-solve, but failure to resolve the problem of pain fuels further worry [22] . The patients we interviewed also reported a number of negative beliefs about self including that they felt that they had no control over rumination and that they were not capable of engaging in alterna tives to rumination about pain. These negative beliefs may indicate the experience of mental defeat. Mental defeat has been used to describe the impact of chronic pain on a person’s self concept. It described a state of mind marked by a loss of autonomy, and can be understood as “a disabling type of self-processing where repeated episodes of persistent and debilitating pain trig ger negative beliefs about the self in relation to pain” [38,39] . It is plausible that chronic pain patients with high levels of mental defeat may believe that they have no solution to the situation other than engaging in rumination and/or that they have no control over their rumination once it has started, although this suggestion awaits empirical confirmation. Nolen-Hoeksema and Morrow suggest that rumination is distinct from problem-solving as individuals engag ing in rumination merely focus on analyzing their symptoms without making specific plans or attempting to take action [40] . Interestingly, such a distinction is shared by infrequent but not frequent ruminators in the present study. Further research should investigate whether the strength of these positive and negative beliefs is related to frequency of rumination in chronic pain patients. Synthesizing the themes extracted with our understanding of rumination in the emotional disorders literature and our own work on a cognitive-behavioral understanding of pain, we propose��������������������������������� ���������������������������������������� a tentative account of how rumi nation may be ��������������������������������� triggered,����������������������� facilitated and termi nated in patients with chronic pain (illustrated in Figure 1). The partial model proposed here is intended to clarify the specific role of negative rumination to form a more coherent view of rumination-related processes and generate test able hypotheses for future research on this topic.
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The proposed model should be equally relevant to frequent and infrequent ruminators with chronic pain, as the principle of rumination generation and maintenance are hypothesized to be the same. However, one would imagine that negative beliefs about rumination and the use of distraction tasks would have the effect of inhibiting or even terminating rumination. Both pain and negative emotions appear to have the capacity to trigger catastrophizing and rumination and thus serve as starting points for the model. Consistent with previous literature [41–43] , pain and negative emotions are not only reciprocally linked (arrow A, Figure 1), but can, through the initiation of negative appraisals (e.g., catastrophizing), trigger a chain of ruminative thoughts, either individually or in combination (arrow B, Figure 1). Positive beliefs about rumination have been found to predict rumination in depressed individuals and nondepressed students [44,45] . Repeated engagement in rumination about pain is potentially facilitated by the person’s positive beliefs about rumination (arrow C, Figure 1). Engagement in rumination and the extent of negative appraisals may also be exacerbated by negative beliefs about self in overcoming pain and rumination, including the psycho logical phenomenon of mental defeat (arrow D, Figure 1). Higher levels of mental defeat has been linked to greater levels of anxiety and depres sion in chronic pain patients [39] . Based on these findings and the cognitive theories of anxiety and depression [46,47] , it is hypothesized that the association between negative emotion and negative beliefs about self is likely to run in both directions (arrow E, Figure 1). From the patients’ reports, we learned that rumination also occurs at night, thus, the model predicts that unresolved daytime rumi nation may continue into or reoccur during the evening (arrow F, Figure 1) and disrupt sleep (arrow G, Figure 1). Obviously, awakenings at night provided extra opportunities for rumina tion (arrow H, Figure 1). From the reports of the infrequent ruminators, we learned that cogni tive-behavioral strategies were used to terminate rumination. These include negative beliefs about rumination (e.g., rumination is unhelpful) and the use of action-orientated problem-solving and engaging in a distracting task (arrow I, Figure 1). The model predicts that rumination may result in an increased attentional focus on pain, thus maintaining or increasing pain
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Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain
Negative beliefs about self (including mental defeat)
Positive beliefs about rumination
Rumination termination
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Rumination termination and sleep onset
I
I
Negative emotions Negative appraisals/ catastrophizing Daytime rumination
Pain
Night-time rumination
J
K Increased attentional focus
Sleep disruption Causal factor
M
Facilitating factor
L
Figure 1. Proposed partial model of rumination in chronic pain. For a description of the arrow letters, please see text.
(arrows J & K, Figure 1). Finally, rumination may result in increased mood disturbance by a direct effect of rumination on mood (arrow L, Figure 1) and/or indirectly as a consequence of increased pain (arrow M, Figure 1). Rigorous experimen tal research will be required to examine the proposed relationships outlined in the model. In conclusion, the present study provides an in-depth exploration of the phenomenology of rumination in chronic pain. Pain-related rumination is frequent and accompanied by increased negative emotion and – for some patients – increased pain and sleep difficul ties. The study highlights the importance of positive beliefs about rumination and negative beliefs about self as possible factors maintain ing pain-related rumination. The model pro posed provides a starting point for experimental work investigating the role of rumination in chronic pain, in particular the nature of the relationship between pain, mood and rumina tion, and between rumination and its possible maintaining factors. The relationship between pain, sleep and rumination clearly also needs further investigation.
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Disclosure Preliminary data of this study have been presented at the British Pain Society Annual Scientif ic Meeting, London, UK, 31 March–3 April 2009 and at the British A ssociation for Behavioura l a nd Cognitive Psychotherapies Annual Conference, Manchester, UK, 20–23 July 2010.
Financial & competing interests disclosure Part of the research on rumination in chronic pain was supported by a project grant from BackCare. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
Ethical conduct of research The authors state that they have obtained appropriate insti tutional review board approval or have followed the princi ples outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.
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Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain
Practice Points
Melanie J Edwards1, Nicole KY Tang†1,2, Anwen M Wright1, Paul M Salkovskis3 & Carolyne M Timberlake4 Rumination was prominent in chronic pain patients and was triggered by the experience of pain. The focus of the rumination spanned across the past, present and future, with contents concerning not
only pain, but also related issues such as work, family, relationships, finance and health in general. For some patients, pain rumination appears to maintain or increase pain perception via an elevated focus
on pain. A reciprocal relationship between rumination and negative emotions was suggested with negative
emotion both triggering and resulting from rumination. Sleep difficulties were reported to be both a trigger and effect of rumination. Chronic pain patients who often ruminate held a number of positive beliefs about rumination
(e.g., problem-solving, avoiding repeating mistakes) and negative beliefs about self in overcoming rumination (e.g., rumination as uncontrollable, lack of alternatives to rumination). A quarter of the participants we interviewed were identified as infrequent ruminators; they held few
positive beliefs about rumination. Distinguished from frequent ruminators, infrequent ruminators were able to disengage from the
repetitive thinking process by engaging in meaningful activities or taking action to solve the immediate problem, rather than being ‘stuck’ in rumination.
SUMMARY
Aims: A thinking process central to the etiology of emotional disorders, rumination is commonly observed in chronic pain. However, very little is understood about the characteristics of pain-related rumination and the mechanisms through which rumination impacts on pain perception and disability. This study began investigating this cognitive phenomenon by qualitatively examining chronic pain patients’ experience of rumination. Methods: Semistructured interviews were conducted with 20 chronic pain patients. Themes were extracted from interview transcripts using thematic analysis. Department of Psychology, Institute of Psychiatry, King’s College London, UK Arthritis Research UK Primary Care Centre, Keele University, UK 3 Department of Psychology, University of Bath, UK 4 Princess Royal University Hospital, South London Healthcare NHS Trust, UK † Author for correspondence: Tel.: +44 178 273 4875; [email protected] 1 2
10.2217/PMT.11.29 © 2011 Future Medicine Ltd
Pain Manage. (2011) 1(4), 311–323
ISSN 1758-1869
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research article Edwards, Tang, Wright, Salkovskis & Timberlake Results: Six themes were extracted from interviews with frequent ruminators. These elucidated the pattern of rumination and suggested a reciprocal relationship of rumination with not only pain, but also negative emotions and sleeplessness. Frequent ruminators appeared to hold positive beliefs about rumination and negative beliefs about self in overcoming pain. Two themes were extracted from interviews with infrequent ruminators: implicating negative beliefs about rumination and the flexible use of disengagement strategies in these individuals. Conclusion: Rumination occurs frequently and can be easily triggered by pain, negative emotions and sleeplessness in patients who lack alternative coping strategies and believe rumination is a way to problem-solve. A tentative model of pain-related rumination has been proposed, outlining interesting hypotheses for rigorous empirical investigations.
Rumination is broadly defined as a repetitive process whereby individuals go over and over the same thoughts in their mind. It has been implicated as one of the key cognitive pheno mena precipitating and maintaining a range of emotional disorders. Notably, in depression, rumination has been found to predict the onset and duration of a depressive episode [1,2] , and to be associated with depressive symptoms [3] , overgeneral memory [4,5] and impaired problemsolving [3,4] . Rumination has also been linked to social phobia [6] , post-traumatic stress disorder [7] , health anxiety [8] , poorer self-reported physi cal health in older adults [9] and increased con current physical complaints in otherwise healthy individuals [10] . However, rumination is not exclusive to emotional disorders. Clinical observations sug gest that patients with chronic pain do spend a considerable amount of time ruminating about their pain, its causes and consequences. Such ruminative thinking could be either a cause or an effect of the experience of persistent pain. It may also be a process by which negative emo tions associated with the experience of pain are amplified. There is evidence for a reciprocal relationship between rumination and symptoms of anxiety and depression. Feeling anxious/sad increases the likelihood of negative thinking, which further increases the experience of fear and sadness, making it yet more likely that the person will think negatively about other things in a self-maintaining vicious circle [11] . We hypothesize that the experience of rumination is linked to the experience of pain and negative emotions, but the existence and reciprocality of the r elationships remain to be elucidated. Several previous studies have identified a possible association between rumination, pain and disability in chronic pain patients [12,13] . In a cross-sectional study that aimed to examine correlates of bodily pain in female patients with
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chronic fatigue syndrome, Nijs and colleagues [14] found the level of bodily pain strongly cor related with rumination and helplessness, but not magnification as measured with the Pain Catastrophizing Scale (PCS) [15] . In another cross-sectional study, Osman and colleagues val idated the use of the PCS in samples of commu nity volunteers and pain outpatients [16] . These investigators found that the PCS total score correctly differentiated the two criterion groups in 77% of the cases. However, when the three PCS subscales (magnification, rumination and helplessness) were examined independently, only the rumination subscale was found to be clini cally useful in differentiating pain patients from community volunteers, with an overall classifica tion accuracy of 76.7%. In examining the role of catastrophizing in determining levels of pain and disability in people who had sustained soft tissue injuries following accidents, Sullivan and colleagues [12] found that scores on the PCS [15,17] significantly predicted self-reported disability as measured with the Pain Disability Index (PDI) [17] . Catastrophizing as a whole explained 4% of the variance in disability score, even when the effects of age, pain duration and pain intensity were accounted for. Interestingly, however, only the rumination subscale contributed unique variance to the prediction of disability. In a further study by the same group, Sullivan and his associates investigated whether the three subscales of the PCS interacted with duration of chronicity in predicting severity of painrelated disability (as measured with the PDI) [13] . A total of 150 patients with low back pain as their primary complaint were classified into one of three groups according to their reported pain duration (6 months to 2 years; 2–4 years; >4 years). Regression analyses were performed to examine the extent to which catastrophizing pre dicts disability separately in each of the groups. Rumination, but not other components of
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Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain catastrophizing, accounted for 18% of the vari ance in disability for patients who had been off work for 2–4 years. Rumination also uniquely contributed to the prediction of disability in patients who had been off work for more than 4 years (variance = 4%), beyond the effects of age, sex, pain intensity and helplessness. Despite its possible etiological role in chronic pain and disability, rumination as a psychologi cal construct has received relatively little research and clinical attention. There are at least two plau sible barriers. First, historically, rumination has been introduced to the study of pain as a subcom ponent of pain catastrophizing and assessed using the four-item subscale of the PCS (items are: “I anxiously want the pain to go away”, “I can’t seem to keep it out of my mind”, “I keep thinking about how much it hurts”, “I keep thinking about how badly I want the pain to stop”) [15] . The lack of conceptual clarity may have discouraged the study of rumination as an independent cognitive process, even though rumination and catastro phizing can be viewed as distinct but interacting phenomena, with the latter being concerned with the catastrophic content of the thoughts and the former being concerned with the reiterative proc ess of thinking. Specifically, catastrophic apprais als involve the attribution of meaning to an inter nal or external event. Once an appraisal has been made, this may trigger a more detailed rumina tive train of thought, which may help explain the attentional disruption, disengagement from meaningful activities and low mood [18,19] com monly observed in chronic pain patients. Second, very little is known about the pattern and charac teristics of pain rumination, resulting in few ideas for testing the factors that promote or diminish rumination. Whilst the rumination subscale of the PCS measures the occurrence of rumination, it does not provide information about the pheno menology (e.g., focus, content and triggers) of rumination, as well as the context in which a person is motivated to ruminate. This void calls for a better qualitative account of rumination in chronic pain that outlines a clearer roadmap for future research and treatment development work. The present study aimed to examine in detail the phenomenology of rumination in chronic pain using a qualitative approach [20] and to generate specific hypotheses for future empirical investigation. Previously, a related con cept – worry – has been investigated under the theoretical framework of misdirected problemsolving [21,22] . In this particular model, worry is
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posited as a response to the awareness of pain and its associated impact and functions to pro mote problem-solving. If such problem-solving leads to success, worry would decrease. However, if one fails to identify a solution to the problem, worry would increase. Applied to the context of chronic pain, it is proposed that repeated failure to resolve chronic pain would create a ‘persever ance loop’ that amplifies worry, which in turn motivates hypervigilance and further efforts to resolve the pain using the same ‘solutions’ [22] . The model did not make a distinction between worry and rumination, but defined worry as a predominantly negative experience characterized by a chain of thoughts and images. The model did not specify the characteristics of worry in chronic pain, but in a related observational study, Eccleston and colleagues noted chronic pain patients experienced both pain and non pain-related worries [23] . Compared with non pain-related worry, worry concerning chronic pain was viewed as more difficult to dismiss, distracting, attention grabbing and distressing. Patients also reported more pain during painrelated worries than during nonpain-related worries. Extending these findings, rumination in chronic pain is evaluated in this study using a qualitative approach, with a particular empha sis on understanding pain patients’ experience of rumination in terms of its pattern, perceived functions and effects, and factors preceding and motivating rumination. To facilitate the identifi cation of strategies for successful disengagement from rumination, we also separately examined themes extracted from interviews with a subset of patients who reported infrequent rumination despite pain. The qualitative approach is con sidered to be particularly suited for the purpose of identifying the features of rumination as a private cognitive process and for exploring the beliefs and pathways through which the act of ruminating is moderated. Method Overview
A semistructured interview focused on patients’ experience of rumination was conducted as part of a larger program of research that sys tematically investigated the role of rumination in chronic pain. The idea was to gather infor mation to both inform the development of a theoretical model and to enrich the mechanis tic understanding of rumination gained from experimental studies that follow.
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research article Edwards, Tang, Wright, Salkovskis & Timberlake The study protocol received full ethical approval. The first twenty participants recruited into the research completed the interview and a questionnaire package that included the ShortForm McGill Pain Questionnaire (SF-MPQ) [24] , the Pain Disability Questionnaire (PDQ) [25] , the Hospital Anxiety and Depression Scale (HADS) [26] and the Catastrophizing in Pain Scale (CIPS) [27] . Scores on these questionnaires were used to characterize the sample.
participants were white (85%), employed (70%), and married or cohabiting (65%). Participants reported a moderately high level of disability and distress, as indicated by a mean PDQ score of 73, a HADS anxiety score of 7 and a HADS depression score of 8. The mean catastrophiz ing score was 22 (scale range = 0–80). Overall, the current sample have demographic and pain characteristics comparable to those of samples reported in other clinical studies conducted in the UK [28] .
Participants
Participants were chronic pain patients recruited from two pain relief units in London, UK. Inclusion criteria were: chronic pain of at least 6 months duration; English as first language; age between 18 and 65 years. Exclusion criteria included: presence of a condition that would prevent the participant completing the ques tionnaire/interview or giving informed consent (e.g., learning difficulties, severe psychopatho logy, dementia); presence of a condition likely to cause impairment on the neuropsychological tasks that formed part of the linked experimental study (e.g., stroke, brain injury, epilepsy); termi nal illness; pain of a malignant nature; epidural, cortisone injection, operation or nerve block within the last month; current severe depression or signs of acute distress; severe psychopathology (e.g., schizophrenia, bipolar disorder). Of the first 85 patients approached, 22 agreed to take part in the experimental study and interview, 58 patients declined to take part (work/family commitments = 14; pain too severe to complete study tasks = 5; distance to research site = 11; not interested = 26; other reasons = 2) and five patients met exclusion criteria (pain due to cancer = 1; severe depres sion = 4). One patient who agreed to take part reported no pain rumination so the interview was not conducted. We were unable to include one patient in the analysis because of technical problems with the interview recording. The final sample comprised five men (25%) and 15 women (75%), with the mean age of the participants being 45 years (range: 26–61). Participants reported a variety of pain com plaints and 75% reported pain in more than one site. The most commonly reported sites of pain were back (75%), followed by neck (35%), shoulder (30%), head (25%) and knee (25%). Mean pain duration was 8.6 years (range: 1–40; median = 6.9 years), and mean pain intensity rating (as measured by the SF‑MPQ visual analogue scale) was 4.6. The majority of
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Interview
Semistructured interviews were conducted indi vidually. The typical duration of the interview was 1 h. Each interview was audiotaped for later transcription. The interview began with a definition of rumination, given below: “What rumination means is chewing over, so it’s thoughts that you chew over or turn over in your mind, which might worry or trouble you, which seem to stick in your head or keep coming back to you, either in the same form or in a slightly different form. These thoughts can be related to the past, present or future.” The interview was in two sections. The first section explored the participant’s general expe rience of rumination and contained questions about the topics and triggers of their rumination, what ends their rumination, and how easy/diffi cult it is for them to stop ruminating. Participants were asked to rate the frequency of their rumina tion, in the previous 2 weeks, as “almost never”, “sometimes”, “often”, “very often” or “almost always”. Other questions explored the partici pant’s beliefs about rumination and whether there might be more helpful alternatives to rumi nation. Participants were asked to estimate what percentages of their ruminations were focused on the past, present or future. The second section of the interview required the participant to recall a recent specific episode of pain-related rumination. After identifying an episode and priming their memory of what hap pened at that time, they were asked questions about that specific episode of rumination in rela tion to the content, trigger, process and effects of the rumination. Other questions attempted to investigate whether participants were using rumination to problem-solve, whether rumi nation led them to take action and whether
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Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain ruminating gave them any sense of confidence or control. Participants were asked whether there might have been an alternative to rumination that would have been more helpful. Core questions asked during the interview are provided in Box 1. Participants were encour aged to digress and add any thoughts they had about other phenomena related to pain and rumination.
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Analysis
Interviews were transcribed verbatim by two researchers (MJE and AW). Transcripts were analyzed using thematic analysis in accordance with the principles and procedures set out by Braun and Clarke [29] . Thematic analysis pro vides a transparent, systematic method for iden tifying, analyzing and reporting themes from qualitative data. The data analysis process is
Box 1. Core interview questions. Section A: Exploring the general experience of rumination 1. Topics of rumination: -- Typically people ruminate about a great number of things. I wonder if you could tell me about some of the main things that you tend to ruminate about? 2. Frequency of rumination: -- Thinking back over the past few weeks, how often have you noticed that you were ruminating? 3. Triggers of rumination: -- Have you noticed that there are things that tend to start you ruminating? 4. What ends the rumination: -- Is there anything that tends to end the rumination? 5. Ease of ending rumination: -- For some people rumination is just something that happens to them briefly and it’s easy enough for them to move onto something else. Other people find that they become very stuck in it. What’s your experience of rumination? 6. Positive beliefs about rumination: -- Can you tell me about any benefits that you can see in ruminating? 7. Negative beliefs about rumination: -- What about any disadvantages of ruminating? 8. Alternatives to rumination: -- Do you think there are other things you could do instead of ruminating that would be more helpful? 9. Focus of rumination: -- Thinking about rumination in general, thinking back over the last few weeks, do you think you have thought more about the past or future? Section B: Investigating a recent episode of pain rumination 1. Topic of rumination: -- Could you now tell me what were you ruminating about? 2. Trigger of rumination: -- Can you remember what started you ruminating? 3. What ends the rumination: -- Can you remember what ended the rumination? 4. Effects of rumination on mood and pain: -- Did you notice any change in your mood (pain) whilst ruminating? 5. Problem-solving: -- Did you get a sense that you were addressing or trying to sort out a problem? -- Did ruminating about the problem lead you to take any action? 6. Control: -- Did ruminating give you a sense of control over the problem? 7. Alternatives to rumination: -- I wonder with the benefit of hindsight, if you could go back to that situation, would you do the same thing and ruminate about the problem or would you do something else?
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research article Edwards, Tang, Wright, Salkovskis & Timberlake largely data-driven, although it is understood that the researcher also plays an active role in identifying patterns of meaning and interpret ing the extracted themes. Thematic analysis is a widely accepted qualitative analytic method within the field of psychology and has been applied to fruitfully explore unknown pheno mena and highlight avenues for future research in chronic pain [30–32] . Initial analysis of the data was conducted by the interviewer (MJE) and a member of the research team (AW) who were familiar with the flow and context of the interviews. It has been suggested that previous exposure to visual and/or paralinguistic cues can enhance accuracy in the analysis of the interviews [33] . The analysis followed the steps below: Familiarization with the data: each transcript
was read and re-read, interesting features were noted. Coding the data: an initial list of codes were
produced. The transcripts were re-read and the codes generated were applied systemati cally across all transcripts by MJE and AW, independently. Each transcript was then reviewed to compare application of the coding system. Any discrepancies were then discussed and resolved. Extracting themes: coded data were grouped
into potential themes and data were organized into a table. The relationships between the themes were considered. Reviewing extracted themes: initial themes
were discussed with a further researcher (NT) and the relationships between themes and the levels of themes were considered. Refining and reporting themes: further ana
lysis of the transcripts was conducted. Themes were refined and scrutinized by two further researchers (NT and PS), who brought to bear their research/clinical experience working with patients suffering from chronic pain and anxiety problems. Reporting of the findings is divided into three sections. First, we describe the general pattern of rumination amongst chronic pain patients as revealed by the frequency and content ratings. Second, we report the themes extracted from the interview transcripts and provide direct quotes from the participants for each theme reported. Quantitative observations are also reported with a view to allowing the reader to judge to what extent
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the qualitative interpretation we offer can be gen eralized to other people with chronic pain. Finally, we separately describe the themes extracted from interviews given by chronic pain patients who were identified as “infrequent ruminators”. The term “infrequent ruminators” in this study refers to those individuals who reported “sometimes” or “almost never” as their general rumination fre quency and also reported infrequent pain rumina tion during the interview. From the full sample of 20, five infrequent ruminators were identified and their interview transcripts were examined in special contrast to those of frequent rumina tors, in order to elucidate strategies for effective disengagement from rumination. Results Frequency & patterns of rumination
60% of participants reported ruminating “very often” or “almost always” – in general during the previous 2 weeks. The remaining participants reported the frequency of their general rumina tion to be often (5%), sometimes (30%) or almost never (5%). All participants reported ruminat ing about their pain. Besides pain, participants reported ruminating about a variety of topics including work (60%), family (60%), finances (50%), relationships (40%) and health (30%). On average participants reported 33% of their rumi nations to be past-focused, 38% future-focused and 28% focused on present events. Themes of rumination
“I ruminate when the pain is bad”
All participants – including the infrequent ruminators – reported that pain-related rumi nation was triggered by experiencing pain. Paintriggered rumination was mostly concerned with thinking about how to relieve the pain, what had triggered the episode of pain, how much longer the episode would last, how the pain was stop ping them from doing certain activities and how the pain will affect them in the future. “…when I do get like the pain in my back and stuff like that, I know that makes me down and then I start dwelling on like the pain and what it’s stopping me from doing so I find that can set it [rumination] off as well, like when the pain gets really bad.” (Female, 26, back and head pain) Pain-related rumination often led onto rumi nation about other concerns, expanding the breadth and duration of rumination.
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Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain “…in my case it [pain-related rumination] very clearly becomes the catalyst for it to start unraveling to other things. I started to think yeah my back’s really bad, work’s really crap and it really is a trigger. I mean, as far as I’m concerned it’s sort of taking your finger out of the dyke and watching floodwater start to pour through … that it sort of unleashes you on other areas, it triggers other fretting.” (Male, 43, head, neck, shoulder and back pain) Just over one third of participants (35%) reported that rumination made their pain worse. For some participants this seemed to be a result of rumination maintaining their focus on the sensation of pain or negative experiences: “Sometimes they [ruminations] can increase the physical pain because they create stresses and tensions in the muscles and the neck and the head and that kind of stuff … so thinking about things that I can’t change or uh have happened in the past can actually make the pain worse … I think bad things and it makes it [the pain] worse.” (Male, 43, back pain) “I ruminate when I’m feeling down”
Low mood and stress were commonly cited emotional factors that preceded episodes of rumination, reported by 40% of participants. Rumination appeared to be mood dependent to some extent, as exemplified by the following quote: “I think it [rumination] is dependent on my mood. If I’m feeling down, if I’m feeling sort of pressurized, stressed, those sorts of things, I think I probably find it harder to switch off. If I feel low then I think I tend to dwell on those thoughts more.” (Female, 38, back pain) Conversely, many participants (85%) reported that rumination had a negative effect on their mood. Low mood was a commonly reported consequence of rumination with par ticipants reporting that rumination led to them feeling even unhappier. Half of the participants reported that rumination increased feelings of frustration, leaving them feeling irritable, fed up and short-tempered. This is perhaps not too surprising considering that many participants reported ruminating over their frustration at the pain stopping them from doing certain activi ties. Thus, rumination appears to maintain or
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even increase this feeling of frustration at the disabling effects of the pain: “I think it [rumination] can sometimes make the experience worse. Like I find sometimes, like say if I’m in pain, I’ ll sort of think about the pain and it’ ll upset me and I’ ll get annoyed that I’m in pain …I get annoyed that, you know, I’m still young and I’ve got this pain and, you know, you sort of feel a bit pathetic really.” (Female, 26, back and leg pain) “I get stuck in rumination”
Half of all participants reported feeling that rumination was uncontrollable. Reports included believing that they had no control over whether they ruminated or the duration of rumination once it had begun. Some partici pants reported that they found it difficult to stop ruminating, saying that they found it hard to “switch off ” or that they got “stuck” in their ruminative thinking. “When I get in that state [rumination], I just sort of shut out. And I’m just stuck and I feel like I can’t get out of it … I get like this little devil in my head that just don’t want me to snap out of it and makes me think about it over and over until I feel like I want to scream … I can’t seem to snap out of it.” (Female, 37, back and abdomen pain) “I don’t know what else to do”
Half of all participants reported a belief that there were no alternatives to rumination avail able to them. Some participants were unable to generate alternative ways of responding to pain and other problems. Others acknowledged that there were other things that they could do but reported not having tried them, not believing that they were capable of doing them, or that the alternatives would not work for them. “I am positive that there must be other ways of dealing with it [rumination] because I see lots of other people who don’t live their lives like I do but I haven’t investigated any of them. I suspect that there are things that I could do. I haven’t done any of them.” (Male, 43, back pain) “Rumination helps me solve my problems”
Interestingly, three quarters of the participants reported at least one benefit of rumination. The most common perceived benefit was that engag ing in rumination is problem-solving. The focus
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research article Edwards, Tang, Wright, Salkovskis & Timberlake of such ‘problem-solving’ ruminations tended to be on how to make the pain go away, stop it from getting worse, or how to rearrange the plans/activities that the pain had prevented them from undertaking. “Sometimes I like to ruminate over things to try and work out a solution to the problem. I like to be able to put my feelings into words because then I can understand them … sorting out your problems is the advantage of it.” (Female, 47, shoulder, neck and arm pain) The belief that engaging in rumination is ‘problem-solving’ was not specific to pain-related concerns but was also held for other concerns. However, when asked about a specific episode of pain-related rumination, only 30% of these participants reported finding a solution to the problem in the episode of rumination discussed. One quarter of participants reported that engaging in rumination helped them to find something positive in what would otherwise be a negative situation. This commonly consisted of either using the experience to make themselves mentally stronger, trying to change the situa tion into a more positive one, or focusing on the things that they could still do. “I have to look for something that says ‘ok well this is going to happen and it’s not good but there’s got to be some benefit coming out of it’. So, I think it’s trying to sort of try in your mind and your body to think that you can get something positive out of anything that happens … most of these thoughts are what I can do to make it better so I try and come out of it in a better ideal.” (Male, 43, shoulder, neck and back pain) Some participants (30%) reported that engag ing in rumination helped them to avoid repeat ing past mistakes. This belief was held for both pain and nonpain-related rumination. In the context of pain-related rumination, this included trying to identify what had triggered the pain so that they could avoid repeating that activ ity or movement in the future and reduce the likelihood of experiencing pain. “I would tend to think ‘well what’s triggered off that pain? Why am I in pain? What did I do wrong? Um, oh yes, I did this. Oh I shouldn’t do that. And must try not to do that again’.” (Female, 53, head, neck, back, arm and leg pain)
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“I ruminate when I can’t sleep”
Even though sleep was not a topic we set out to investigate, more than a quarter of participants interviewed reported experiencing episodes of rumination during the night. Some participants reported that their ruminations often occurred at night when they were attempting to get to sleep but were unable to “switch off”. For oth ers, concerns about not being able to sleep even became the focus of the rumination. “[I ruminate] occasionally when I’m having trouble sleeping. Actually, most often when I’m having trouble sleeping. Trying to get to sleep at night and your brain’s whizzing round. Or waking up early in the morning and trying to get back to sleep and your brain’s whizzing round.” (Female, 47, neck, shoulder and back pain) Some participants (30%) reported that rumination had a negative effect on their sleep. Mainly the effects appeared to relate to a delayed sleep onset during the night. “I sleep really badly because I wake up in the middle of the night and all I’ ll be doing is ruminating about work … it’s constant and I know that I ruminate because it wakes me up three, four, five times a night.” (Male, 43, back pain) Infrequent ruminators
As described in the method section, five out of the 20 participants (25%) were identified as infrequent ruminators. A number of differences were identified between these participants and the rest of the sample. “I don’t see any point in ruminating”
It was noted that in comparison to the rest of the sample, these participants held few posi tive beliefs about rumination. For example, the infrequent ruminators appeared to be less likely to hold the belief that rumination is problemsolving. In fact, to these infrequent ruminators, there appeared to be a clear distinction between rumination and problem-solving: “…only if you ruminate about a particular problem but then that comes down to problemsolving doesn’t it, rather than ruminating … I don’t see any sense in keep actually looking at a particular negative idea and trying to solve it by ruminating about it. It doesn’t actually do anything or achieve anything.” (Male, 59, back pain)
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Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain “I do something to take my mind off the pain”
Infrequent ruminators were able to generate alternatives to rumination and reported being able to engage in these alternatives in contrast to frequent ruminators who commonly had difficulty generating alternatives or, if they were able to, doubted their ability to engage in them. Additionally, the alternatives gener ated by the infrequent ruminators tended to be more action-orientated involving engaging in a distracting task or taking action to solve the immediate problem. “I will actively try to eradicate negative thoughts … if I do find myself thinking negatively I will tend to do something active that will take my mind off it. Anything from, you know, doing a crossword puzzle to some sort of mental activity.” (Male, 59, back pain) Not surprisingly, infrequent ruminators reported that episodes of pain-related rumina tion tended to be brief and that they found it easy to move on from the rumination. This is in stark contrast with the frequent ruminators who commonly reported beliefs about rumina tion being uncontrollable and difficult to move on from. Conclusion Data from the interviews revealed that, while rumination is common in chronic pain, it occurs in varying patterns and is experienced differ ently by different individuals. If generalization was to be made, the themes extracted suggest that ruminative process is typically triggered by pain, negative emotion, and for some, difficul ties sleeping. Consistent with previous charac terization of rumination in the depression litera ture [34] , the general focus of rumination tended to be evenly distributed across concerns from the past, present and future, touching on not only pain, but also related issues such as work, fam ily, finance, relationships and health in general. Many patients interviewed found it difficult to end rumination, citing the feeling of having no control over ruminating or getting “stuck” in the ruminative thinking. Although not an enjoyable experience, positive beliefs about rumination as problem-solving were reported by frequent ruminators, especially when no alter native solution to rumination was identified. Infrequent ruminators, on the other hand, hold negative beliefs about rumination and manage
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to disengage from rumination effectively by actively engaging in alternative mental activi ties or taking actions to problem-solve. For these people, rumination was reportedly brief and easy to move on from. Whilst the patients interviewed did not explic itly link their experience of rumination with disability – as highlighted in several previous studies [12–16] , reciprocal relationships of rumi nation with pain and negative emotions were mentioned. On the relationship between rumi nation and pain, findings of the present study are consistent with the hypothesis that rumination can occur as a response to pain. In over one third of the participants, pain rumination appears to also maintain or increase pain perception, via an elevated attentional focus on pain as described by these patients. On the relationship between rumination and mood in chronic pain, 40% of participants reported low mood to be a trigger for their rumination and 85% reported experienc ing low mood after rumination. This suggests a mutually interacting relationship between rumi nation and negative mood similar to that found in the depression literature [1–3] . Considering that up to one third of chronic pain sufferers are thought to have comorbid depression [19] , the current study raises the possibility that rumina tion may play a role in maintaining depressive symptoms in chronic pain. Sleep was not a topic that we set out to inves tigate, and yet the data drew our attention to the trend that rumination was particularly promi nent when patients were experiencing difficul ties sleeping. Almost one third of participants associated rumination with delayed sleep onset and waking up during the night. It is not clear whether rumination is a cause or an effect of sleeplessness, but it is plausible that if rumina tion is not successfully resolved before bedtime then sleep disruption commonly occurs. Presleep rumination has previously been found to predict poorer self-reported sleep [35] . Our group is now conducting a more focused experimental investigation evaluating the effects of night-time rumination on sleep. While previous research has investigated positive and negative beliefs about rumination in anxious and depressed samples, this is the first study to have investigated these beliefs in a chronic pain sample. The positive beliefs about rumination held by chronic pain patients – for example, rumination is problem-solving, helps to avoid repeating past mistakes – are similar
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research article Edwards, Tang, Wright, Salkovskis & Timberlake to those reported by depressed individuals and nondepressed students about depressive rumination [36,37] . Many chronic pain patients we interviewed engaged in rumination in an attempt to problem-solve but usually failed to find solutions. This observation is in line with the proposal described in the misdirected problem-solving model in which individuals are motivated to worry in an attempt to prob lem-solve, but failure to resolve the problem of pain fuels further worry [22] . The patients we interviewed also reported a number of negative beliefs about self including that they felt that they had no control over rumination and that they were not capable of engaging in alterna tives to rumination about pain. These negative beliefs may indicate the experience of mental defeat. Mental defeat has been used to describe the impact of chronic pain on a person’s self concept. It described a state of mind marked by a loss of autonomy, and can be understood as “a disabling type of self-processing where repeated episodes of persistent and debilitating pain trig ger negative beliefs about the self in relation to pain” [38,39] . It is plausible that chronic pain patients with high levels of mental defeat may believe that they have no solution to the situation other than engaging in rumination and/or that they have no control over their rumination once it has started, although this suggestion awaits empirical confirmation. Nolen-Hoeksema and Morrow suggest that rumination is distinct from problem-solving as individuals engag ing in rumination merely focus on analyzing their symptoms without making specific plans or attempting to take action [40] . Interestingly, such a distinction is shared by infrequent but not frequent ruminators in the present study. Further research should investigate whether the strength of these positive and negative beliefs is related to frequency of rumination in chronic pain patients. Synthesizing the themes extracted with our understanding of rumination in the emotional disorders literature and our own work on a cognitive-behavioral understanding of pain, we propose��������������������������������� ���������������������������������������� a tentative account of how rumi nation may be ��������������������������������� triggered,����������������������� facilitated and termi nated in patients with chronic pain (illustrated in Figure 1). The partial model proposed here is intended to clarify the specific role of negative rumination to form a more coherent view of rumination-related processes and generate test able hypotheses for future research on this topic.
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The proposed model should be equally relevant to frequent and infrequent ruminators with chronic pain, as the principle of rumination generation and maintenance are hypothesized to be the same. However, one would imagine that negative beliefs about rumination and the use of distraction tasks would have the effect of inhibiting or even terminating rumination. Both pain and negative emotions appear to have the capacity to trigger catastrophizing and rumination and thus serve as starting points for the model. Consistent with previous literature [41–43] , pain and negative emotions are not only reciprocally linked (arrow A, Figure 1), but can, through the initiation of negative appraisals (e.g., catastrophizing), trigger a chain of ruminative thoughts, either individually or in combination (arrow B, Figure 1). Positive beliefs about rumination have been found to predict rumination in depressed individuals and nondepressed students [44,45] . Repeated engagement in rumination about pain is potentially facilitated by the person’s positive beliefs about rumination (arrow C, Figure 1). Engagement in rumination and the extent of negative appraisals may also be exacerbated by negative beliefs about self in overcoming pain and rumination, including the psycho logical phenomenon of mental defeat (arrow D, Figure 1). Higher levels of mental defeat has been linked to greater levels of anxiety and depres sion in chronic pain patients [39] . Based on these findings and the cognitive theories of anxiety and depression [46,47] , it is hypothesized that the association between negative emotion and negative beliefs about self is likely to run in both directions (arrow E, Figure 1). From the patients’ reports, we learned that rumination also occurs at night, thus, the model predicts that unresolved daytime rumi nation may continue into or reoccur during the evening (arrow F, Figure 1) and disrupt sleep (arrow G, Figure 1). Obviously, awakenings at night provided extra opportunities for rumina tion (arrow H, Figure 1). From the reports of the infrequent ruminators, we learned that cogni tive-behavioral strategies were used to terminate rumination. These include negative beliefs about rumination (e.g., rumination is unhelpful) and the use of action-orientated problem-solving and engaging in a distracting task (arrow I, Figure 1). The model predicts that rumination may result in an increased attentional focus on pain, thus maintaining or increasing pain
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Thinking about thinking about pain: a qualitative investigation of rumination in chronic pain
Negative beliefs about self (including mental defeat)
Positive beliefs about rumination
Rumination termination
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Rumination termination and sleep onset
I
I
Negative emotions Negative appraisals/ catastrophizing Daytime rumination
Pain
Night-time rumination
J
K Increased attentional focus
Sleep disruption Causal factor
M
Facilitating factor
L
Figure 1. Proposed partial model of rumination in chronic pain. For a description of the arrow letters, please see text.
(arrows J & K, Figure 1). Finally, rumination may result in increased mood disturbance by a direct effect of rumination on mood (arrow L, Figure 1) and/or indirectly as a consequence of increased pain (arrow M, Figure 1). Rigorous experimen tal research will be required to examine the proposed relationships outlined in the model. In conclusion, the present study provides an in-depth exploration of the phenomenology of rumination in chronic pain. Pain-related rumination is frequent and accompanied by increased negative emotion and – for some patients – increased pain and sleep difficul ties. The study highlights the importance of positive beliefs about rumination and negative beliefs about self as possible factors maintain ing pain-related rumination. The model pro posed provides a starting point for experimental work investigating the role of rumination in chronic pain, in particular the nature of the relationship between pain, mood and rumina tion, and between rumination and its possible maintaining factors. The relationship between pain, sleep and rumination clearly also needs further investigation.
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Disclosure Preliminary data of this study have been presented at the British Pain Society Annual Scientif ic Meeting, London, UK, 31 March–3 April 2009 and at the British A ssociation for Behavioura l a nd Cognitive Psychotherapies Annual Conference, Manchester, UK, 20–23 July 2010.
Financial & competing interests disclosure Part of the research on rumination in chronic pain was supported by a project grant from BackCare. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
Ethical conduct of research The authors state that they have obtained appropriate insti tutional review board approval or have followed the princi ples outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.
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