Why Overthinkers Make No Progress (Rumination) – Transcript

00:00Today, we're going to talk about rumination. When I was a third-year psychiatry resident, I had a group of patients that came into my office with a couple of different diagnoses. One person had a mood disorder, one person had an anxiety disorder, and one person had PTSD. And so as I started working with them, I started doing psychotherapy because that's what a third year resident is supposed to do. I had a wonderful supervisor, so I started therapizing them, right? So we worked a lot on their emotions, emotional processing, things like journaling, doing things like thought logs that look at the relationship between their thoughts,

00:29their actions, and their behaviors. But despite doing all of this emotional work, they didn't seem to be getting better. And when I was sitting in the room with them, it just sort of felt to me like their minds were out of their control. No matter how much we talk about how hurt they feel, their mind would start spiraling in some kind of direction.

00:49So I started doing something a little bit unorthodox. I sort of looked at this and I sort of said, okay, like this mind is going way off track. They get stuck in these cycles of repetitive thinking. Let's just learn how to shut off the mind. So I started teaching them more stuff from like yoga and meditative traditions, and then something kind of funny happened. So then I got called into my program director's office one day and she asked me like, so how are things going with this set of patients? How are things going with the supervisor? And I said, honestly, like things seem a little bit hard, you know, I'm trying to do psychotherapy with them. It doesn't seem very effective.

01:18I'm teaching them some like yoga and meditation techniques. Those seem to be working like, okay, I'm not quite sure. And that's when she informs me that the supervisor that I'm working with is essentially firing me. She says that the supervisor that you're working with feels like she can't work with you anymore. And I was like really shocked and I was like, did I do something wrong? Like, you know, why? Like I was a bit confused.

01:38And she said, well, like, you know, the supervisor says that you're sitting with these patients and you're doing something, but it's not psychotherapy and she's a psychotherapy supervisor. So she can't like guide you in something unless you're willing to like do that thing. So thankfully it turned out to be totally fine. I don't think the supervisor made a mistake or anything. In fact, I think it was a really, really pro move on her part. She recognized that I was doing something that has value and that I probably needed a different kind of guidance to learn psychotherapy and sort of blend these two things. And that was awesome. It worked

02:08out great. A lot of the stuff that I ended up doing with my patients was actually pretty effective. And a lot of that stuff is like when we think about something like rumination or depression or anxiety, we don't really think about how can I control the mind itself? Or how can I put my mind in a fizz or how can I put my brain in a physiologic state where we are less likely to ruminate? So if you guys want info like that, check out Dr. K's guide. We have a ton of great techniques in there about sort of shaping your brain,

02:35shaping your body and shaping your mind. And what I didn't realize at the time is that these were patients who were ruminators. These are patients who repetitively think about something over and over and over again. It's almost as if their mind is turned against them. And the really shocking thing about rumination is we may think, okay, like if your mind gets caught in thought loops or spirals, like you should go see a therapist.

02:58But actually it turns out that if you are someone who ruminates, therapy is less likely to be effective for you. So this was first demonstrated in a large-scale longitudinal studies in which rumination prospectively predicted the onset of major depressive episodes and depressive symptoms in non-depressed and currently depressed individuals across follow-up periods ranging from six weeks to five years. So what this means is that if you were ruminator, the degree of

03:26rumination predicts the onset of depression. But it's not just depression. Large-scale prospective longitudinal studies, that means that studying things prospectively, right? So we're not doing like a retrospective data analysis, found that rumination predicted subsequent substance use, eating disorders, alcohol abuse, and PTSD symptoms following trauma, even after controlling for initial symptoms.

03:51So this is kind of shocking because what these studies show is that if you have a traumatic event, if you are someone who ruminates, the likelihood for that traumatic event to turn into PTSD is correlated with your rumination. So not only does rumination increase your risk for all kinds of mental disorders, but it actually interferes with treatment. So it turns out that as a PGY3, what I didn't realize is it's not that I was doing psychotherapy incorrectly, it's that if you're someone

04:19who ruminates, there's a good chance that psychotherapy won't be as effective for you. Indeed, there is growing evidence that elevated rumination at the start of treatment predicts poorer outcomes to cognitive behavioral therapy for depression, such as increased time to remission and reduced likelihood of achieving remission.

04:38Rumination at the end of mindfulness CBT treatment predicts a depressive relapse. So that means that when you complete a course of treatment, if you are a ruminator, if you're a ruminator, that increases the risk that your depression will actually relapse and you'll get depressed again.

04:53For patients receiving brief CBT in a partial hospitalization program, so these are people who have intensive care, right, they're receiving intensive care, baseline rumination predicted subsequent anxiety and depression and the examination of symptom trajectories indicated that when rumination did not improve, symptoms of depression and anxiety did not improve and were likely to worsen over time. So this is crazy, right? This means that if you are someone who

05:20ruminates and you go to treatment and you do not target the rumination specifically, this will reduce the efficacy of treatment and in some studies may even predict worsening depression and anxiety despite the fact that you did the treatment.

05:37So how is it that rumination interferes with treatment of psychotherapy and why is it that rumination predicts the the propensity for depressive relapse symptoms of anxiety for a trauma to turn into PTSD? How does this actually happen? So the first problem with rumination is that it is an emotional magnifier. The first negative effect of rumination found in experimental studies is that it exacerbates and prolongs existing emotional states such as sadness, anger, anxiety and depression.

06:05Okay? And in parallel it it elaborates and further polarizes any thought content focused on during the rumination. So these are two really important things to understand, okay? The first thing that it does is it magnifies and prolongs whatever we think about and usually negative states, so sadness, anger, whatever. So here's practically what happens. So if I do something stupid today, generally speaking tomorrow is a new day and I don't have to linger with the effects of my stupidity. If you are someone who ruminates,

06:35the problem is that if you make a mistake today it causes you hurt for the next year or the next two years, maybe even a lifetime. I've worked with ruminators that had problems in high school, like they got dumped by their significant other and they just like feel trapped by that particular injury and this is like 20 years later.

06:55You may have seen sort of examples of this, right? People who get like sort of frozen in time and can't move past something, that is literally what rumination does. So rumination takes a single instance of damage and turns it into dot damage until you are done ruminating with it, which oftentimes is sort of never, right? Because you can keep on replaying these thoughts over and over and over again.

07:18So not only does it increase the duration of emotional injury, it also increases the intensity. Now, how does this happen? This is something that's really important to understand and it kind of leads to black and white thinking. So this is something that's really wild. Have you all ever been like at the grocery store and tried to figure out what to buy? So you're sitting there at a grocery store, there's lots of different options and then you're like, I don't know what to buy and you sit there and you

07:47think about it for a little bit and as you think about it for a little bit you make a decision. So I want you all to understand this is really wild, but the more that your mind thinks about something, the more polarized you become. This is just a feature of the mind, okay? If that sounds kind of crazy, just hear me out. So when I'm like, if I don't know if I should take this job or not take this job, what do I do? I think about it.

08:11So at the beginning I may be like, let's say here is take job and here is pass on job and at the beginning of my thinking process I'm somewhere in this middle area, right? But despite the fact that I'm in the middle area, as I think about it more and more and more, I start to drift this way and drift this way and drift this way and this and then eventually I make up my mind. So I want you all to think about how crazy it is to make up your mind. I want you all to think about how

08:37impossible it is for a computer. If a computer makes a calculation and ends up with a question mark, I don't know about generative AI because they just hallucinate all kinds of crap, right? Once you have a certain amount of inputs, like if I have a mathematical equation and I don't have enough information to solve the equation and I put it into a computer, the computer is going to say, at the first iteration or the tenth iteration, we don't have enough info to solve the problem. That is not how the human mind works.

09:02The more that we chew over things in our mind, the more polarized we become naturally. I wasn't sure if I was going to break up with you. I thought about it a lot and now I know I'm going to break up with you. What new information do I have? None. So the more that we turn things over in our mind, the more abstract we become, right? So as I think about things, more and more and more, I will start to deduce abstract principles. So like let's take

09:28the example of someone who is ruminating, let's say here's high school and I never had a girlfriend. Let's say the reason I never had a girlfriend is because my parents were poor, right? So like I couldn't hang out with people. Everyone wanted to have the fancy shoes and I didn't have the fancy shoes so I considered myself unattractive and that's why I don't have a girlfriend. Then I go to uni and then what happens is I struggled to adjust to uni. I ended up getting depression in my freshman year. Really, really common

09:55occurrence and since I got depression in my freshman year, I didn't form what everybody was making friends. I didn't make friends so I kind of got left out of all of the forming friend circles so now I got kind of left behind and then that's the reason that I don't have a girlfriend. And then now I started my job but since I didn't have a girlfriend in high school or college, I don't know how to talk to girls and since I am behind now, I have no girlfriend. So if we look at this situation, there are strong

10:24contextual reasons why I've been single my whole life. This problem happened over here, this problem happened over here, but then what happens with the mind as I chew on this over and over and over again, I start to come up with an abstract conclusion, which is that I am a loser. So the brain, what the brain does, what the mind does is it looks at this problem and it collects all of this data and then it tries to draw an abstract conclusion. Now here's the problem with an

10:53abstract conclusion. The more intelligent you are by the way, the more likely this is to happen. This is not actionable. So what we find with rumination is actually shocking. Even though ruminators report that it increases perceived insight into problems, experimental studies demonstrate that rumination interferes with effective problem solving both by making individuals more pessimistic and also more abstract and less able to access specific details of how to resolve a difficulty.

11:22And this includes dysphoric mothers with infants under 12 months. So this is wild. So what this means is like this is something that is in your brain and like forget about all these like complicated you know histories and know high school this happened and college this happened. Like we can study the effects of rumination and how much it causes problems with like mothers and infants who are like 12 months. So this effect can be observed over there. So it's really like a neurological effect. It happens in the brain. And

11:50so what happens when we ruminate a lot is we develop this abstract thing and if I ask someone who feels like a loser, how well do you understand your problem? They will say I understand it incredibly well. The reason that I'm in incel is because of XYZ. I'm not trying to bash on incels because of this and this and this and this and this and this and this. I understand everything. The black pill is real. I've read so much research. It's so true of so many people's experiences. My understanding is great. My understanding level is 100. What are you going to do about it? Nothing can be done.

12:18I don't know what to do about it. I can't think of any solution because I am a loser. This is the problem with rumination because when we make an abstract conclusion from these highly specific actionable scenarios, we end up with a conclusion that is not actionable. So it keeps us stuck. It also makes us pessimistic, which is a big problem because not only does it enhance our negative emotional circuitry, but here in my nucleus accumbens, in my frontal lobes, any