Original Article
The perseverative cognition hypothesis: A review of worry, prolonged stress-related physiological activation, and health

https://doi.org/10.1016/j.jpsychores.2005.06.074Get rights and content

Abstract

Perseverative cognition, as manifested in worry and rumination, is a common response to stress, but biopsychological models of stress and health have largely ignored it. These models have generally focused on physiological activation that occurs during stress and have insufficiently addressed effects that occur in anticipation of, or following, stressful events. We argue that perseverative cognition moderates the health consequences of stressors because it can prolong stress-related affective and physiological activation, both in advance of and following stressors. We review evidence that worry, rumination, and anticipatory stress are associated with enhanced cardiovascular, endocrinological, immunological, and neurovisceral activity. The findings yield preliminary support for our hypothesis, suggesting that perseverative cognition might act directly on somatic disease via enhance activation via the cardiovascular, immune, endocrine, and neurovisceral systems.

Introduction

Worrisome thinking is a common response to stressful events, but for the most part, this construct has been mainly studied within the context of test anxiety in students and anxiety disorders. Worry plays a role in nearly all anxiety disorders and it is a basic feature of generalized anxiety disorder (GAD). Even in the area of anxiety, it was not until the 1980s that the potential etiological importance of the concept became recognized and systematically investigated (see Ref. [1]). In the case of rumination, extensive scholarly recognition of its role in psychopathology (mainly depression) is of an even more recent date [2]. In this paper, we will argue that worry, rumination, and related phenomena may play a much broader role; that is, they may be crucial factors in somatic health as well. We will present evidence that such cognitions have physiological sequelae that can lead to long-term health consequences, including cardiovascular disease (CVD) and other organic diseases. Furthermore, we will outline the diverse processes and mechanisms underlying these long-term health consequences, including currently known physiological and neurovisceral concomitants of worry. The article will begin with the definition and nature of worry, rumination, and related concepts and the crucial mechanism that these phenomena share, called perseverative cognition. Next, we will discuss the etiological role that perseverative cognition may play in somatic disease.

Section snippets

Worry, rumination, and perseverative cognition

Several definitions of worry have been given. Borkovec et al. [3], [4] introduced a working definition of worry that appears to be most often used: Worry is a chain of thoughts and images, negatively affect-laden, and relatively uncontrollable. It represents an attempt to engage in mental problem solving on an issue whose future outcome is uncertain but contains the possibility of one or more negative outcomes; consequently, worry is related closely to fear process.

Thus, the definition

Why perseverate?

The most concrete function attributed to worry is an attempt at constructive mental problem solving, although it may represent an unproductive and, perhaps, even a counterproductive attempt [5]. Davey [5] and coworkers found positive correlations between worry and problem-focused coping, but only after controlling for the effect of trait anxiety. Thus, worry appeared to be associated with a habitual tendency for attempted active problem solving combined with low confidence of success.

Tallis and

Perseverative cognition, somatic illness, and physiology

Studies of stress, coping, and disease have largely ignored worry, rumination, and other perseverative cognitive phenomena. The bulk of research in this area has involved either discrete stressors, such as life events or daily hassles, or discrete coping strategies, or both. When chronic stress has been studied, such as marital or social–economic stress, the emphasis has been mostly on the stimulus characteristics or the individual's perception of them and seldom on enduring cognitive processes

The role of perseverative cognition in stress-coping disease

Traditionally, coping strategies are usually regarded as moderators of stressor effects on health. That is, coping strategies are regarded as a means by which the effect of stressors is ameliorated by eliminating or avoiding the stressor, or by changing its meaning. Perseverative cognition, in contrast, can be thought of as a mediator, or a final pathway by which the stressor exercises its effects on the body's systems. It does this by virtue of its propensity to prolong the stressor itself, in

Perseverative cognition and perceived control

A core cognition of this perseverative state is the perception that control over a stressor, i.e., one's ability to actively cope, is threatened. Perceived uncontrollability over threat or challenge and related concepts like hopelessness have been documented as critical determinants of pathogenic physiological states and final health problems (e.g., Refs. [18], [19], [20]). Theoretically, perseverative cognition is caused by perceived uncontrollability of a stressor: If a stressor is

Somatic disease and physiological activation

We will now focus on the available evidence concerning the potential pathogenic effects of perseverative cognition. There is recent evidence of the link between perseverative cognition and disease outcomes, as well as with physiological functioning that is relevant for the development of somatic disease. We will give an overview of the findings with worry and rumination, as well as those with anticipatory stress. With respect to the latter, we discussed above that a large part of perseverative

The influence of type of operationalization of perseverative cognition and other moderators

As is shown in Table 1, a variety of operationalizations have been used for state as well as trait worry and rumination. The state instruments or manipulations are difficult to compare because of a lack of details in the reviewed articles. Still, the effects of states of perseverative cognition on symptoms and physiological activity appear to be very consistent across the seven studies that measured or manipulated them [30], [38], [45], [46], [56], [66], [67], [69]. This is less the case for

Perseverative cognition: neurovisceral concomitants

Thayer and Lane [76] have recently outlined the neurophysiological concomitants of perseverative cognition. These concomitants directly involve the regulation of the autonomic nervous system and, therefore, are important in understanding how perseverative cognition can mediate the influence of stressors on a broad range of diseases. For this reason, we will go into some detail discussing the neurovisceral pathways involved and some of the evidence linking them to perseverative cognition. The

Conclusions

In this article, we provided the groundwork for a theoretical approach to the relationship between worry, rumination, anticipatory stress, physiological concomitants of these states, and health. We have introduced the term perseverative cognition to describe the core cognitive–emotional process involved in worry and rumination, thus allowing this concept to be applied to a wider range of emotional states and dispositions than has previously been done, including anticipatory stress. We have

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