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“OBSESSIVE RUMINATION disorder” appeared as a possible diagnosis in a recent “Ask Amy” column — triggered by PTSD in a woman who couldn’t stop thinking about her husband’s affair that had occurred 20 years earlier when both were 19 years old.
Rumination—considered a “core” feature of OCD (obsessive-compulsive disorder, with obsessive thoughts and compulsive actions)—focuses on past events, viewing them with guilt, regret, anger and envy; and can cause feelings of sadness, hopelessness and anger. In contrast, worry concerns future anticipated events and creates anxiety.
“Obsessive thinking can be like a hamster wheel, as one hamster gets off, another takes its place and the wheel keeps spinning,” according to the Cognitive Health Group’s OCD website page.
“The thoughts and behaviors of a person with OCD are persistent and disruptive to daily functioning, according to verywellmind. And the OCD incidence of between 4 and 22% among those diagnosed with PTSD compares to around 1% for OCD in the general population.
Rumination disorder, along with other forms of OCD that occur with PTSD, can respond to mindfulness training “where you purposefully and consciously yank your mind back to the present,” writes Amy Dickinson.
Mindfulness exercises involving breath and body awareness focus on “being.” In contrast, rather than working with the body, cognitive behavior therapy (CBT) uses the mind to reframe obsessive thoughts with the goal of “doing,” or acting, differently.
Psychedelic drugs, in particular MDMA (also known as Ecstasy), have recently proved effective in countering OCD by reducing fear and defensiveness as well as by enhancing the therapeutic process. In Phase 2 trials, 107 participants diagnosed with chronic PTSD lasting an average of almost 18 years had three sessions of MDMA-assisted psychotherapy. At the 12-month follow-up, almost two thirds no longer fit the diagnosis.
Other psychedelic drugs—ketamine, LSD and psilocybin—have helped some patients but not all. While “psychedelic-assisted therapy” currently involves dozens of therapist-hours—making it costly, not yet covered by insurance—the effects of psychedelic drugs on interrupting or rearranging brain connectivity have provided new information on the brain circuits involved in PTSD-related OCD.
The neurological dysfunctions of OCD may begin with the insula, a small region near the front of the brain that seems to control salience—the selection among competing stimuli for which one commands the brain’s attention. The insula sorts emotional responses such as pain, love, craving, enjoyment of music and food —thereby determining the power of negative stimuli to evoke feelings of pain.
By sorting and weighing competing stimuli, the insula creates a “global emotional moment,” an image of ourselves at one point in time. The accumulation of such moments may form the basis of self-awareness, playing a role not just in cognition but in decision-making and motivation at any point in time.
In one study, fMRI (functional MRI) scans showing “resting-state brain connectivity” in veterans with PTSD found “aberrantly” greater positive connectivity between the insula and the amygdala—the brain’s center for emotions and emotional motivation—compared to connectivity between the amygdala and the hippocampus, the center for learning and memory. The conclusion: emotions like fear may have more direct and greater control over these individuals than learned experience.
The Mindfulness-Based Stress Reduction (MBSR) program, pioneered by Jon Kabat- Zinn more than 30 years ago at the University of Massachusetts, Amherst, involves intensive practice over eight weeks of classes, with daily guided meditations on a CD that offers various options—sitting, standing, laying down—and durations, from under four minutes to 45 minutes or longer.
Comparing treatments for PTSD, researchers in the 1990s concluded that, while CBT promotes cognitive awareness, the “being “ mode targeted by mindfulness training was the one that led to lasting emotional changes, according to London psychotherapist Sheri Jacobson, founder of London-based Harley Therapy.
“The greater and more consistent your awareness of the present moment, the more likely it is you will catch the negative thought spirals and choose to disengage from distressing moods or worries,” writes Jacobson.
Harley Therapy employs a combination of MBSR and CBT called MBCT: the CBT teaches recognizing and reframing negative thoughts, and mindfulness then helps you “be less caught up in mental loops in the first place,” Jacobson notes. Even after therapy, she warns, “the link in your brain between negative thoughts and negative moods still exists and is ready to be reactivated. So being able to monitor and contain reactivation, which mindfulness aids with, is invaluable.”
By the end of my MBSR course, I had gotten better at using 15-minute midday breaks to focus on breathing and relax my body, and then to let go of random thoughts swirling around my brain. But when the morning news sets off that rumination wheel, I appreciate the mental respites like Ask Amy.
—Mary Carpenter
Mary Carpenter regularly reports on topical issues in health and medicine.
This is one of the most helpful articles I’ve read in a very long time. As a person who struggles with run-away ruminations, I now have some direction in choosing an effective therapy for this problem. Once again, thank you Mary Carpenter! Your articles continue to inform and guide me.