Rumination’s Role in Obsessive Compulsive Disorder

While rumination may be a key feature in the obsessive compulsive cycle, it doesn’t get as much attention as the potent obsessions and the typically visible compulsions. Yet it’s omnipresent, a war going on inside the sufferer’s head.

Intrusive Thoughts versus Ruminations versus Compulsions

For example, someone who suffers from Contamination OCD may fear that they were exposed to HIV because they touched a rail on an escalator at the local mall. This fear is an intrusive thought, one that’s given validity because they have a mental illness. The intrusive thought is considered the “obsession” component of the disorder.

After the thought appears, the sufferer may attempt to gauge the likelihood of their fear by thinking about the occurrence over and over again. They may try to remember whether or not they saw blood on the escalator’s rail, they may think about the people who were in front of them and try to determine whether or not they “looked” like they had HIV (Were they skinny or sickly looking, for instance?), they may consider how long any potential blood would have been in the open air (rendering the virus noninfectious), or they may try to remember whether or not they felt any type of liquid or wetness on their hands. All of this is rumination.

Of course, they may also engage in other compulsions too, either physical actions or mental ones. They might wash their hands repeatedly or use things like bleach just in case. They may study their hands for cracks or cuts where foreign blood could have entered. They may check their clothes for red marks that indicate the presence of bodily fluids. They may go back to the escalator and look for blood stains. They may take an HIV test weeks later to make sure they don’t test positive. They may also engage in less visible compulsions, such as silently praying, counting to a good number, trying to reverse their intrusive thought, or thinking positive thoughts that cancel out the bad ones.

Rumination: A Trap

What’s more, OCD even has a way of making sufferers ruminate from things that happened years prior. For example, someone with Harm OCD may certainly ruminate over their recent drive to Walgreens, mentally retracing their steps from the day before to make sure they didn’t run over an elderly lady as she walked through the parking lot or a child riding his tricycle through a crosswalk. But OCD will also encourage the sufferer to ruminate about the long ago past, inviting them to visually recall their drive into the mountains three years before. Can they remember whether or not they felt any “bumps” as they neared the summit? Do they know if they were speeding or distracted by their children? Do they recall hearing police sirens in the distance?

OCD is never satisfied, which means it can make you ruminate over just about anything.

Signs of Rumination

• Thoughts that appear as though they’re solution-focused in the context of an obsession (e.g., you want to use your thoughts to “prove” to yourself that you could not have possibly gotten syphilis from using a restaurant bathroom)
• Thoughts that are engaged in as a way to gain insight or seek clarification in the context of an obsession
• Thoughts that are focused on a specific fear or your “flavor” of OCD
• Thoughts that feel important, as though you can’t go do other things until you finish with the thoughts at hand
• Thoughts that, when looked at logically, appear to make a mountain out of a molehill (e.g., you overhead someone from a distance clearing their throat at the dog park and now you’re concerned they gave you COVID)
• Thoughts that keep you awake at night or make it so that you can’t fully relax
• Thoughts that offer you reassurance (although it’s temporary)

Rumination Outside of OCD

For example, someone who is a bit of a perfectionist or has a type-A personality may obsessively ruminate over a failure (or a perceived failure) in hopes of doing better next time. Someone who is highly competitive may obsessively ruminate over the best way to defeat their competition. Someone who is having issues in their marriage, may obsessively ruminate about whether or not their spouse is unfaithful. The latter is different from Relationship OCD where sufferers ruminate over their relationship without the existence of a threat. In other words, someone with Relationship OCD may worry about infidelity on their husband or wife’s part (or on their own part) even when their marriage is happy and stable.

Rumination can happen in anyone but it’s more common in women. Women tend to want to think things through when they perceive a problem whereas men tend to distract themselves and/or ignore that a problem even exists. Doctors hypothesize that this is one of the reasons depression is significantly more common in females.

Rumination in OCD is a negative when it’s done as a compulsion. But, on its own, rumination isn’t always a bad thing. For instance, healthy rumination can lead to solutions for those who are trying to problem-solve. Rumination among friends can also solidify bonds because it acts as self-disclosure and allows relationships to grow.

But it walks a fine line between good and bad. Beneficial rumination leads to progress and is done occasionally. Unhealthy rumination leaves the person stuck and feeling worse. In that way, it can be akin to venting about your struggles. Getting things off your chest from time to time is a wonderful way to unburden yourself and relieve stress. Complaining about how your life isn’t going anywhere day after day to everyone you know is a great way to get uninvited from the neighborhood holiday party. Like they say, “Everything in moderation!”

How to Stop Ruminating

Those with OCD who ruminate can benefit from the above, but they generally need more direct help as well. As a rule, rumination is treated similarly to any other compulsion and therapy may involve the following:

Medication: There are several medications that treat OCD, though not everyone responds to them all equally (some people may not respond to any). An individual’s genetic makeup largely influences what medications they’ll react to and which ones they should avoid due to adverse effects. Anyone who is beginning OCD treatment may benefit from taking a genetic test to learn what kind of metabolizer they are (such as ultra-rapid, extensive, intermediate, or poor). This knowledge allows them to choose medications more likely to help.

From a general standpoint, the most common OCD medications used are SSRIs and SNRIs. SSRIs are Serotonin Specific Reuptake Inhibitors, a class of antidepressants that increase serotonin in the brain. They include Lexapro, Prozac, Celexa, Luvox, Zoloft, and Paxil. SNRIs are Serotonin-Norepinephrine Reuptake Inhibitors. They are similar to SSRIs but they enhance both serotonin and norepinephrine in the brain. They include Pristiq, Cymbalta, Effexor, Savella, and Fetzima.

Anafranil, a tricyclic antidepressant, is commonly prescribed as well. It tends to be highly useful in OCD but it comes with more potent side effects too, which deters some from taking it.

OCD is sometimes treated with off-label medications as well, including Risperdal, Haldol, Zyprexa, Seroquel, Abilify, Valium, Xanax, Buspar, NAC, Namenda, Tramadol, or Ketamine. However, most prescribers start with more traditional medications first.

Therapy: Therapy is typically required for anyone with OCD and stopping the ruminations are part of treatment. The gold standard is Exposure Response Prevention (ERP), which is a type of Cognitive Behavioral Therapy (CBT). During ERP treatment, sufferers are asked to expose themselves to their distressing thoughts (or allow those thoughts to appear organically) and then refrain from reacting to the thoughts in a compulsive manner.

For instance, someone who has Checking OCD and fears that they didn’t lock the front door before bedtime will be asked to refrain from any checking compulsions (such as physically checking to see if the front door is locked) but they will also be asked to refrain from ruminating too. They will be asked not to mentally retrace their steps to make sure turning the deadbolt was part of their nightly routine, they’ll be asked not to search their memory for proof that they did in fact lock the door, they’ll be asked not to think about alternative forms of security (such as reassuring themselves that they did lock the screen door even if they didn’t lock the main one), and they’ll be asked not to ruminate over the local crime statistics in their neighborhood.

Refusing to give into the compulsion (whether it’s checking or ruminating) causes anxiety on the part of the sufferer, which is why ERPs are so hard to perform. But the more people are able to persist, the easier they become. Medication is often used with the purpose of making ERPs easier.

While ERP is consistently believed to be the most effective form of treatment, it’s sometimes combined with other modalities such as Acceptance Commitment Therapy (ACT) and mindfulness.

For rumination compulsions specifically, sufferers may also be instructed to document these ruminations (at least initially) through journal writing or audio recording. This allows them to look for patterns and recognize ruminations more readily.

Some sufferers may be asked to assess their ruminations as well, listing out a “pro” and “con” list that helps them distinguish OCD ruminations from non-OCD ruminations that, in moderation, may be helpful (such as ruminations that involve looking for a way to reprogram computer software at work or how to fix a leaky bathroom faucet).

Lifestyle changes: On their own, lifestyle changes won’t cure OCD but they can help minimize everyday stress, which helps control symptoms to some degree. Because of this, ruminators may be encouraged to eat a diet rich in whole grains, fruits, and vegetables; cut out or eliminate caffeine, alcohol, and tobacco; engage in regular exercise; and surround themselves with high value activities. The latter provides motivation for the OCD sufferer to stop ruminating and, instead, move onto activities more important to them.

When it comes down to it, rumination is not a type of OCD but a symptom. If it’s done in the context of an obsession, it will always make the disorder worse in the long run (even if it provides temporary relief). That’s why stopping the rumination – fumigating the ruminating – is so important to healing.