Are worry, rumination, and post-event processing one and the same?

Are worry, rumination, and post-event processing one and the same?
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   Journal of Anxiety Disorders 24 (2010) 509–519 Contents lists available at ScienceDirect  JournalofAnxietyDisorders Are worry, rumination, and post-event processing one and the same?Development of the repetitive thinking questionnaire Peter M. McEvoy a , b , ∗ , Alison E.J. Mahoney c , Michelle L. Moulds d a Centre for Clinical Interventions, Perth, Australia b School of Psychology, University of Western Australia, Perth, Australia c Clinical Research Unit for Anxiety and Depression, Sydney, Australia d School of Psychology, University of New South Wales, Sydney, Australia a r t i c l e i n f o  Article history: Received 7 December 2009Received in revised form 26 February 2010Accepted 19 March 2010 Keywords: RuminationWorryPost-event processingRepetitive thinkingTransdiagnostic a b s t r a c t Accumulating evidence suggests that repetitive negative thinking (RNT) is a transdiagnostic phe-nomenon. However, various forms of RNT such as worry, rumination, and post-event processing havebeen assessed using separate measures and have almost exclusively been examined within the anxiety,depression, and social phobia literatures, respectively. A single transdiagnostic measure of RNT wouldfacilitate the identification of transdiagnostic maintaining factors of RNT, and would be more efficientthanadministeringseparatemeasuresforeachdisorder.ItemsfromthreeexistingmeasuresofRNTweremodified to remove diagnosis-specific content and administered to a sample of undergraduate students( N  =284).Exploratoryfactoranalysisyieldedtwofactorslabeled RepetitiveNegativeThinking  and  AbsenceofRepetitiveThinking(ART) .TheRNTscaledemonstratedhighinternalreliabilityandwasassociatedwithanxiety, depression, anger, shame, and general distress. Moreover, the RNT scale was associated withconstructsthataretheoreticallyrelatedtoengagementinRNT,includingpositiveandnegativemetacog-nitions,cognitiveavoidance,thoughtsuppression,andthoughtcontrolstrategies.TheARTscalehadlittlepredictive utility. Theoretical and clinical implications are discussed. © 2010 Elsevier Ltd. All rights reserved. 1. Introduction The seminal work of Fairburn and colleagues in the context of eating disorders prompted what has become known as a transdi-agnostic approach to the maintenance of psychological disorders.Fairburn, Cooper, and Shafran (2003) developed a transdiagnos-tic model of eating disorders by highlighting the mechanismsthat maintain eating pathology  across  the DSM-IV eating dis-order categories, and thus departed from the more traditionaldisorder-focusedapproach.Harvey,Watkins,Mansell,andShafran(2004)adoptedandbroadenedthistransdiagnosticperspectiveandsought to identify shared cognitive and behavioral processes thatare linked to the persistence of a range of clinical conditions. Theirsystematicreviewoftheempiricalliteraturehighlightedrepetitivenegative thought as one such transdiagnostic process that is char-acteristic of the cognitive profile of a range of psychopathologies(Harvey et al., 2004). In a more recent review, Ehring and Watkins (2008)concludedthatelevatedrepetitivenegativethoughtisafea- ∗ Corresponding author at: Centre for Clinical Interventions, 223 James Street,Northbridge, Perth, Western Australia 6003, Australia. Tel.: +61 8 9227 4399;fax: +61 8 9328 5911. E-mail address: (P.M. McEvoy). ture of most Axis I disorders, and cited depression, social phobiaandposttraumaticstressdisorder(PTSD)amongtheirexamples.Inanother recent review, Watkins (2008) identified key factors that determinewhetherrepetitivethoughthasadaptiveormaladaptiveconsequences; namely, (i) thought valence, (ii) the context of therepetitivethought,and(iii)themodeofprocessingadoptedduringrepetitive thought.Depressive rumination (Nolen-Hoeksema, 1991, 2004) is arguablythemoststudiedformofrepetitivethoughtintheclinicalliterature. Depressive rumination refers to a pattern of repetitivethinking in response to sad mood in which an individual analy-sesthecauses,meaningsandimplicationsoftheirmood,problemsand events from the past. Rumination is a core cognitive feature of clinicallyandresiduallydepressedindividuals,andhasbeenlinkedto the duration, severity and maintenance of depressive episodes(see Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008). Longitudinal evidencehasdemonstratedthatindividualswhoengageindepres-sive rumination have an elevated likelihood of depression onset(Nolen-Hoeksema,Morrow,&Fredrickson,1993)andmaintenance (Nolen-Hoeksema,2000).Experimentalstudiesconfirmthatrumi- nation exacerbates depressed mood (Nolen-Hoeksema & Morrow,1993), and causally implicate rumination in poor problem solv-ing (Watkins & Moulds, 2005a), preferential encoding of negative self-referent material (Moulds, Kandris, Starr, & Wong, 2007), the 0887-6185/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2010.03.008  510  P.M. McEvoy et al. / Journal of Anxiety Disorders  24 (2010) 509–519 retrievalofovergeneralmemories(Watkins&Teasdale,2001),and poor emotional processing of negative events (Watkins, 2004) in depressed and dysphoric samples.As the hallmark diagnostic feature of generalized anxiety dis-order, worry is a form of repetitive thought that has been mostinvestigated in the context of anxiety. Worry and ruminationhave primarily been distinguished in terms of their temporalfocus (i.e., worry is future-oriented, rumination is past-oriented;Papageorgiou & Wells, 1999). Nonetheless, there is evidence thatthese two types of repetitive thought share common processes(e.g., Watkins, Moulds, & Mackintosh, 2005) and that both are reportedbyindividualsacrossdifferentclinicalgroups(e.g.,Gruber,Eidelman, & Harvey, 2008). In addition, some researchers haveexaminedtherelationshipbetweenworryandruminationbycom-paring participants’ responses on self-report measures that tapboth types of repetitive thought. Segerstrom, Tsao, Alden, andCraske (2000) reported that worry and rumination were signifi-cantly associated with a measure of repetitive thinking, and thatboth types of repetitive thought were, in turn, associated withanxiety and depression (see also Fresco, Frankel, Mennin, Turk, &Heimberg, 2002). However, in other studies, worry and rumina-tionhaveloadedondistinctfactors(e.g.,Fresco,Heimberg,Mennin,& Turk, 2002; Goring & Papageorgiou, 2008). Thus, the degree towhich worry and rumination may be associated with a commonunderlying construct of repetitive thinking requires further inves-tigation.Accordingtotheoreticalaccountsofsocialphobia(Clark&Wells,1995; Rapee & Heimberg, 1997), repetitive thinking about socialevents is a core maintaining process. Post-event processing (PEP)has been documented in high socially anxious and socially phobicsamples, following real-life social events as well as laboratory-based social-evaluative tasks, such as giving a speech (e.g., Abbott& Rapee, 2004; Kocovski, Endler, Rector, & Flett, 2005; Lundh &Sperling, 2002; Mellings & Alden, 2000; Perini, Abbott, & Rapee,2006;Rachman,Grüter-Andrews,&Shafran,2000).Inlinewiththesuggestion that rumination and worry may be captured by a com-mon construct of repetitive thought, it is plausible that post-eventprocessingmightsimilarlyreflectthisconstruct.Toourknowledge,the interrelationship of post-event processing and other types of repetitivethought(i.e.,worry,rumination)hasnotbeenexamined.Lundh and Sperling (2002) recruited an undergraduate sam-ple to record their experience of PEP following a distressingsocial situation. These researchers found that while PEP follow-ing negative-evaluative events (i.e., those involving a degree of negative evaluation or the respondent as the focus of attention)was associated with a measure of social anxiety (i.e., Social Pho-bia Scale), PEP following other socially evaluative situations (i.e.,those involving guilt, anger, or no explicit evaluative component)was not. Interestingly, however, PEP was rated as similarly preva-lent (How much did you think about the event afterwards?) anddistressing (How distressing was it to think about the event?)regardless of whether all socially distressing situations or onlynegative-evaluative situations were considered. This finding sug-gests that respondents experienced distressing PEP to the samedegree regardless of whether or not there was an evaluative com-ponent to the social experience. Thus, PEP appears to be commonregardless of whether the core feature of social phobia is present(i.e.fearofnegativeevaluation),furthersupportingthenotionthatrepetitivenegativethinkingisacommonexperiencefollowingdis-tressing events.Fehm, Schneider, and Hoyer (2007) examined the specificityof PEP for social anxiety by comparing social situations to non-evaluative phobic situations. These researchers found that whilerespondents reported engaging in PEP following both phobic andsocial situations, PEP was more intense in social situations. How-ever, in a multiple regression analysis, PEP following a socialsituation significantly predicted PEP following a phobic situationafter controlling for fear of negative evaluation, phobic anxiety,general anxiety, and depression. The reverse was also true. Thatis, PEP following a phobic situation significantly predicted PEP fol-lowing social situations. The authors suggested that these findingspoint to a general predisposition to ruminative thinking. Interest-ingly, the Fear of Negative Evaluation scale was only associatedwith PEP following social situations, rather than phobic situations.Although the authors argued that this is evidence of the speci-ficity of PEP for social fears, an alternative possibility is that fearof negative evaluation is simply a moderator of repetitive negativethinking. It may also be that the version of the Post-Event Process-ingQuestionnaireusedinthisstudywasmorevalidforsocialfearscompared to phobic situations. A transdiagnostic measure couldshed light on this issue.Kocovski and Rector (2008) attempted to examine the diag-nostic specificity of PEP in relation to depressive rumination.Measures of social anxiety, depression and depressive ruminationwereadministeredtoasampleofpatientswithsocialanxietydisor-der attending group CBT. Measures of PEP were then administeredduring the second treatment session (with reference to the firsttreatment session) and again in session four (with reference toan exposure task completed in session 3). Interestingly, PEP wasassociated with social anxiety but not with depressive rumination(rumination in response to depressive symptoms). Moreover, thepartial correlation between PEP and social anxiety controlling fordepression was greater in magnitude than the partial correlationbetween PEP and depression when controlling for social anxiety.However, this finding is perhaps not surprising given that (a) theinstructions on the RRS ask respondents to complete the itemswith respect to times when they feel down, depressed or bluerather than socially anxious, (b) some Ruminative Response Scale(RRS, Nolen-Hoeksema & Morrow, 1991) items include depres- sivesymptoms,and(c)depressiveruminationwasmeasuredsome(unspecified) weeks before PEP. The significant partial correlationbetween depression and PEP when controlling for social anxietyis also consistent with a general tendency to ruminate, irrespec-tive of content. The lack of a measure not tied to diagnosis-specificcontent has limited researchers’ ability to test this possibility, andthen to examine the notion that common maintaining factors areatplayacrossdisordersregardlessofthecontentoftherumination.The alternative hypothesis would of course be that the diagnosis-specific content has important implications for our understandingand treatment of various emotional disorders.Some researchers who have investigated the associationbetween different types of repetitive thought have administeredstandardself-reportinstrumentsthatindextheconstructsofinter-est,andexaminedthedegreetowhichresponsesonthesemeasuresare associated. Several researchers have conducted factor analy-ses of common measures of worry (typically the Penn State WorryQuestionnaire, PSWQ, Meyer, Miller, Metzger, & Borkovec, 1990)and rumination (typically the RRS, Nolen-Hoeksema & Morrow,1991) to determine whether items from these scales load on acommon repetitive thinking factor or separate factors. Some stud-ies have found that the PSWQ and RRS scale items exclusively oralmost exclusively load on separate factors (e.g., Fresco, Frankel,et al., 2002; Fresco, Heimberg, et al., 2002; Goring & Papageorgiou,2008;Muris,Roelofs,Meesters,&Boomsma,2004).However,thereis at least one potentially important source of method varianceacross the scales that could explain this finding. Specifically, allitems within the PSWQ include the word “worry”, whereas noneof the RRS items do. At present, a validated measure of repetitivethinkingthatcontainsitemsnotanchoredtodisorder-specificcon-tent remains absent from the literature. As highlighted by Ehringand Watkins (2008), an ongoing challenge for investigators in thefield is the absence of such a generic measure that is independent  P.M. McEvoy et al. / Journal of Anxiety Disorders  24 (2010) 509–519 511 of disorder-specific concerns and symptoms. The development of such an instrument will be critical for advancements in theoryand clinical practice. The administration of a generic measure of repetitivethinkingtoavarietyofclinicalgroupswillpermitconfir-mationofrepetitivethoughtasatransdiagnosticcognitiveprocess,andclarifyitsroleinpredictingthepersistenceofvariouspatholo-gies.Intermsofclinicalpractice,itwillprovideaninstrumentthatcan be administered to all patients, irrespective of diagnosis or thepresence and nature of comorbidity.With this absence in the extant literature in mind, our pri-mary goal in this study was to draw on existing measures thatindex types of repetitive thought (namely, depressive rumina-tion, worry, post-event processing) by using items of the RRS,PSWQ and Post-Event Processing Questionnaire-Revised (PEPQ-R,McEvoy & Kingsep, 2006) to develop a general measure of repet-itive negative thinking. Critically, the strategy used by Watkins etal.(2005),thatinvolvedreplacingtheterm“worry”with“thoughtsorimages”,wasusedpriortosubjectingitemstofactoranalysis.Toour knowledge, this study was the first to attempt to remove thisconfound. Moreover, this study was the first to include the PEPQ-R as an additional measure of repetitive thinking, which has morerecentlybeendevelopedfromthePost-EventProcessingQuestion-naire (Rachman et al., 2000) to index rumination in social phobia. The srcinal PEPQ and the PEPQ-R have demonstrated good inter-nal reliability and have been found to be associated with measuresof social anxiety (PEPQ, Rachman et al.) and anxiety in social situa-tions for a sample with social phobia (PEPQ-R, McEvoy & Kingsep,2006).Ourdevelopmentofanew,genericmeasurethatmergedtheitems of the RRS, PSWQ and PEPQ-R positioned us to determine:(i) if these measures in fact tap the same underlying construct of repetitive thinking, alternatively (ii) whether they index differentconstructs as they apply to different disorders, or (iii) whether acombination of these applies (i.e., that one construct is common toall emotions and others are particular to each disorder). Accord-ingly,weinstructedparticipantstothinkaboutanindexevent(i.e.,‘thelasttimeyoufeltespeciallydistressedorupset’),andtorespondto modified items from the RSS, PSWQ and PEPQ-R with respect totheir experience of the event  after   it occurred.In addition, we explored the interrelationship of repetitivethinkingandanumberoftheory-drivenconstructsthatarethoughtto promote engagement in repetitive thinking and have alsobeen previously linked to rumination and worry; namely, positiveand negative metacognitive beliefs (Papageorgiou & Wells, 1999;Watkins & Moulds, 2005b), thought control strategies (Watkins & Moulds, 2009) and avoidance strategies (Moulds, Kandris, et al., 2007; Moulds, Kandris, & Williams, 2007). Wells and colleagues’(Wells, 1995, 2000; Wells & Carter, 2001; Wells & Matthews,1996)Self-RegulatoryExecutiveFunction(S-REF)modelpositsthatmetacognitive beliefs about the utility of recurrent thinking arekeyvariablesthatdriveitspersistence.Specifically,thismodelsug-gests that positive metacognitions (e.g.,  worrying helps me to avoid problems in the future ) motivate engagement with worry, whilenegative metacognitions (e.g.,  when I start worrying I cannot stop )maintain the ruminative cycle and result in maladaptive attemptsto control thoughts. Indeed, previous research has found empiri-cal evidence that metacognitions contribute to the developmentand maintenance of a number of disorders characterized by recur-rent and distressing thinking, such as generalized anxiety disorder(GAD, Ruscio & Borkovec, 2004; Wells & Carter, 2001), obsessive compulsivedisorder(OCD,Wells&Papageorgiou,1998),posttrau- matic stress disorder (Holeva, Tarrier, & Wells, 2001), depression (Papageorgiou & Wells, 2003), and psychosis (Morrison & Wells, 2003).Borkovecandcolleagues’(e.g.,Borkovec,Alcaine,&Behar,2004)avoidancetheoryofworrysuggeststhatworry’sfunctionistoavoidthe occurrence of future catastrophes, and that it is negativelyreinforced by suppression of sympathetic reactions to anxiety-provoking stimuli and the non-occurrence of the catastrophe.Moreover, worry is more superficial and abstract and thus lessdistressing than thoughts and images that may naturally occur,which also negatively reinforces engagement in this type of repet-itive thought. On the grounds that worry is verbal rather thanvisual/image-based,thistheorypositsthatworryimpedestheacti-vation of somatic/physiological arousal (Vrana, Cuthbert, & Lang,1986).Stöber(1998)andBorkovec,Ray,andStöber(1998)hypoth- esized that the abstractness, or reduced concreteness, of worryis the cognitive mechanism that limits activation of imagery. Inthis way, worry functions as an avoidance strategy by preventingemotional processing of the content of worries. In support of thisaccount Sexton and Dugas (2008) f ound that cognitive avoidance strategies were significantly correlated with measures of worry,including the PSWQ ( r  =.57). Moreover, Wells and Davies (1994)reportedcorrelationsbetweenthePSWQandvariousthoughtcon-trolstrategies( r  =.39–.50).Thereisalsoevidencefortheassociationbetween thought control strategies and various clinical disordersthat involve repetitive thinking; for example acute stress disor-der (Warda & Bryant, 1998), PTSD with co-morbid depression (Reynolds&Wells,1999),andgeneralizedanxietydisorder(Coles& Heimberg,2005).Therefore,ameasureofrepetitivenegativethink-ingshouldbeassociatedwithattemptstocontroloravoidnegativethoughts or emotions.Ourhypotheseswereasfollows.First,wepredictedthatafactoranalysis would yield one main repetitive thinking factor. Alterna-tively,itwasplausiblethatthatseparatefactorsmightemergethatwererelatedtodistinctemotions(e.g.,depressionvsanxiety).Sec-ond,wehypothesizedthatrepetitivethinkingwouldbeassociatedwith symptoms of depression and anxiety, as well as with specificemotionsassociatedwiththereferencesituation(namely,anxiety,anger,shame,andgeneraldistress).Third,wepredictedthatrepet-itive thinking would be associated with metacognitions, thoughtcontrol, and cognitive avoidance strategies. 2. Method  2.1. Participants Participants ( N  =284) were first year undergraduate psychol-ogy students (70.4% women). Mean age was 19.91 years ( SD =4.36, Range =17–56).  2.2. Measures 2.2.1. Repetitive Thinking Questionnaire The 1 RTQ is a measure of repetitive negative thinking (RNT)developed from an initial pool of 44 items drawn exclusivelyfrom the PSWQ (Meyer et al., 1990), the PEPQ-R (McEvoy & Kingsep,2006)andtheRRSfromtheResponseStylesQuestionnaire(RSQ; Nolen-Hoeksema & Morrow, 1991). Consistent with previ- ous research (e.g., Treynor, Gonzalez, & Nolen-Hoeksema, 2003)we removed items that likely measured depression symptoms.Althoughrepetitivenegativethinkingcouldconceivablybefocusedonphysicalsymptoms,weexcludedallitemsthatindexedphysicalsymptoms because they were not cognitive in nature and becausewedeemedthedegreetowhicheachphysicalsymptomwastrans-diagnostic indeterminable. Finally, we excluded two items of thePSWQ (‘I have been a worrier all my life’ and ‘I never worry aboutanything’)becausetheycouldnotbemeaningfullyrelatedtoaspe-cific situation, as required for this study. A pool of 33 potential 1 The RTQ is available from the authors.  512  P.M. McEvoy et al. / Journal of Anxiety Disorders  24 (2010) 509–519 RNT questionnaire items remained 2 , 13 each from the PSWQ andthe RRS, with 7 from the PEPQ-R. The order of these items wasrandomized.Wemodifiedtheitemsfromeachscaleinthefollowingwaysforthe purposes of the current study. First, we instructed participantsto answer the items in relation to a specific situation. Participantswere asked to describe the last time that they felt particularly dis-tressed,andthenratedthe33itemsastohowtrueeachstatementwasoftheirexperienceafterthedistressingsituation.Ratingsweremade across a 5-point response scale:  Not true at all (1), Somewhat true (3),  or  Very true (5). Second, we employed the item adaptation method utilized byWatkins et al. (2005) and used the phrase ‘thoughts or images’ toprecedetheRRSandPEPQ-Ritems.Forexample:‘Youhadthoughtsor images asking ‘ why do I always react this way ?’. Thirdly, ref-erences to worry in the PSWQ were replaced with references tothoughts or thinking (e.g., ‘I know I shouldn’t worry about things,butIcannothelpit’became‘IknewIshouldn’thavethoughtaboutthe situation, but I couldn’t help it’).  2.2.2. Positive and Negative Affect Scale (PANAS; Watson, Clark,& Tellegen, 1988) We used the 10-item Negative Affect subscale of the PANAS tomeasure the range and degree of negative emotions experiencedby participants at the time of their reference distressing situation.Thenegativeemotionsinclude: distressed , upset  ,  guilty , scared , hos-tile ,  irritable ,  ashamed ,  nervous ,  jittery , and  afraid,  and are rated ona 5-point response scale;  Very slightly or not at all (1), A little (2),Moderately (3), Quite a bit (4)  or  Extremely (5) .  2.2.3. Meta-Cognitions Questionnaire—30 (MCQ-30; Wells & Cartwright-Hatton, 2004) The MCQ-30 measures five domains of positive and negativemetacognitive beliefs, metacognitive monitoring, and judgmentsof cognitive confidence. The five subscales are: (1) positive beliefsabout worry, (2) negative beliefs about uncontrollability and dan-ger,(3)cognitiveconfidence(assessingconfidenceinattentionandmemory), (4) negative beliefs concerning the consequences of notcontrollingthoughts,and(5)cognitiveself-consciousness(theten-dency to focus attention on thought processes). The subscales andtotal score have good internal consistencies, ranging from .72 to.93. The 4-point response scale is:  Do not agree (1), Agree slightly(2), Agree moderately (3),  or  Agree very much (4).  As in the RTQ,references to worry were replaced by references to thoughts andthinking(e.g.,‘Worryingaboutmyproblemshelpsmecope’became‘Thinking about my problems helps me cope’). Internal consisten-cies in the current study ranged from .71 to .86.  2.2.4. Positive Beliefs about Rumination Scale-Adapted (PSRS-A;Watkins & Moulds, 2005b) This 9-item scale was adapted from the Positive Beliefs aboutRuminationScaledevelopedbyPapageoriouandWells(2001).The PBRS-Aassessesthedegreetowhichrespondentsholdbeliefsaboutwhether repetitive thinking is helpful. The PBRS-A replaces refer-encestodepressionandrumination(intheoriginalPBRS)withthegeneric descriptors of feeling and thinking. For example, ‘I needto ruminate about my problems to find answers to my depres-sion’ became ‘I need to think about things to find answers to how Ifeel’.The4-pointresponsescaleisidenticaltotheMCQ-30.Internalconsistency in the current study was .85. 2 Alistoftheitemsalongwiththerationaleforexclusionandinclusionisavailablefrom the authors.  2.2.5. Thought Control Questionnaire (TCQ; Wells & Davies, 1994) This30-itemmeasureassessesvariousstrategiesusedtocontrolunpleasant or unwanted thoughts. Five subscales describe the dif-ferentstrategies:(1)distraction,(2)socialcontrol,(3)punishment,(4) worry, and (5) reappraisal. Reported internal consistencies of subscales range from .64 to .83. Each item is endorsed on a four-point rating scale as follows;  Never (1), Sometimes (2), Often (3),  or  AlmostAlways(4) .Internalconsistenciesinthecurrentstudyrangedfrom .70 to .81.  2.2.6. Cognitive Avoidance Questionnaire (CAQ; Gosselin et al., 2002; Sexton & Dugas, 2008) The CAQ is a 25-item measure that assesses an individual’suse of five cognitive avoidance strategies in response to threat-ening thoughts. Subscales measure the strategies of: (1) thoughtsubstitution, (2) transformation of images into verbal thoughts,(3) distraction, (4) avoidance of stimuli that trigger unpleasantthoughts,and(5)thoughtsuppression.Participantsrespondalonga5-pointscalerangingfrom Notatalltypical(1) to Completelytypical(5). TheEnglishversionoftheCAQdemonstratesgoodinternalcon-sistency ( ˛ =.73–.95) and test–retest reliability ( r  =.70–.85; Sexton& Dugas, 2008). Internal consistencies in the current study rangedfrom .68 to .88.  2.2.7. White Bear Suppression Inventory (WBSI, Wegner &  Zanakos, 1994) WBSI consists of 15 items that assess participants’ chronic ten-dency to deliberately avoid thinking about or suppress unpleasantthoughts. Internal consistency ( ˛ =.87) and test–retest reliability( r  =.69–.92) are adequate. The 5-point response scale ranges from Strongly Disagree (1)  to  Strongly Agree (5).  In the current study,the Total, Intrusion, and Suppression scale scores were calculated.Internal consistencies were .91, .87, and .83, respectively.  2.2.8. Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer,1988) The BAI consists of 21 items and measures the severity of anxi-ety symptoms over the previous week. Reliability and validity areestablished;internalconsistencyreliabilitycoefficientsrangefrom.85 and .94, with a test–retest reliability coefficient of .75.  2.2.9. Beck Depression Inventory (BDI-II; Beck, Steer, & Brown,1996) The BDI-II (henceforth referred to as BDI) is a widely used 21-item measure of severity of depression symptoms experiencedduringthepreviousfortnight.ThereliabilityandvalidityoftheBDIhas been well established, with a test–retest reliability coefficientof .93 and internal reliability of .86.  2.3. Procedure ParticipantswerefirstyearundergraduatepsychologystudentsatTheUniversityofNewSouthWaleswhoreceivedcredittowardstheir course requirements for their involvement. The RTQ, MCQ-30, BDI, BAI, TCQ, CAQ, and WBSI were administered as part of alarger questionnaire battery. Before completing the RTQ, partici-pants were asked to write a brief description about a recent eventduringwhichtheyfeltdistressedorupset.Theywerethenaskedtocomplete the negative items from the PANAS with respect to howthey felt during the target situation. Finally, they were asked tocompletetheRTQwithrespecttotheirexperiencesafterthetargetsituation,alongwiththeothertheoreticallyrelatedmeasures.Thisstudy received approval from the School of Psychology’s HumanResearch Ethics Panel (HREAP, Behavioural) at The University of New South Wales.  P.M. McEvoy et al. / Journal of Anxiety Disorders  24 (2010) 509–519 513  Table 1 RotatedfactorloadingsforPrincipalAxisFactorAnalysisoftheModifiedPennStateWorryQuestionnaire(PSWQ),RuminativeResponseScale(RRS),andPost-EventProcessingQuestionnaire-Revised.Repetitive Thinking Questionnaire (RTQ) item Original scale Factor 1 Factor 2 Factor 1: Repetitive Negative Thinking (RNT) I knew I shouldn’t have thought about the situation, but I couldn’t help it PSWQ5 .69  − .18I noticed that I had been thinking about the situation. PSWQ13 .68  − .30You had thoughts or images of the situation that were difficult to forget. PEPQ-R6 .68  − .20Once I started thinking about the situation, I couldn’t stop. PSWQ14 .66  − .39You had thoughts or images of the situation that you tried to resist thinking about. PEPQ-R7 .66  − .09You had thoughts or images that “ I won’t be able to do my job/work because I feel sobadly.”  RRS2 .66  − .12I thought about the situation all the time. PSWQ15 .65  − .36You had thoughts or images about all your shortcomings, failings, faults, mistakes. RRS15 .65  − .06You had thoughts or images about a past event that came into your head even whenyou did not wish to think about it again.PEPQ-R3 .64  − .12You had thoughts or images about the situation and wishing it had gone better. RRS12 .63  − .11You had a lot of thoughts or images of the situation after it was over. PEPQ-R2 .61  − .31Your thoughts overwhelmed you PSWQ2 .60  − .18You had thoughts or images about how alone you felt. RRS1 .60  − .12You went some place alone to think about your feelings. RRS18 .59  − .02You had thoughts or images about how angry you were with yourself. RRS19 .59  − .02You had thoughts or images asking “ Why do I always react this way? ” RRS9 .58  − .09The situation really made you think PSWQ4 .57  − .22You had thoughts or images about the situation that occurred over and over again,that resulted in your feelings getting worse and worse.PEPQ-R8 .57  − .25You had thoughts or images about the situation that resulted in you avoiding similarsituations and that reinforced a decision to avoid similar situations.PEPQ-R13 .56 .17You went away by yourself and thought about why you felt this way RRS10 .55  − .05You had thoughts or images like “ Why can’t I get going  ?” RRS8 .53 .04I was always thinking about something. PSWQ7 .51  − .21You had thoughts or images about turning the clock back to do something again, butdo it better.PEPQ-R12 .48  − .10You had thoughts or images like “ Why do I have problems other people don’t have?”   RRS13 .47  − .02You listened to sad music RRS20 .46  − .03When you were under pressure, you thought a lot about the situation PSWQ6 .44  − .21I thought about the situation until it was all done PSWQ16 .41  − .12 Factor 2: Absence of Repetitive Thinking (ART) I didn’t tend to think about it (the situation) PSWQ3  − .19 .70I didn’t have enough time to do everything, so I didn’t think about it PSWQ1  − .03 .62There was nothing more I could do about the situation, so I didn’t think about itanymore.PSWQ11  − .15 .58I found it easy to dismiss distressing thoughts about the situation PSWQ8  − .25 .56 Note.  RRS=Ruminative Response Scale, PSWQ=Penn State Worry Questionnaire, PEPQ-R=Post-Event Processing Questionnaire-Revised. 3. Results  3.1. Principal Axis Factor Analysis Common factor analysis (i.e., principal axis factor analysis) wasused to analyze the 33 candidate items derived from the PSWQ,RRS, and PEPQ-R. Oblique rotation was used because if multiplefactors were derived it would was expected that they would becorrelated with one another. Common factor analysis was usedfor consistency with previous research (e.g., Fresco, Frankel, et al.,2002). Moreover, estimates from common factor analysis tend toreplicate better with confirmatory factor analysis and our inten-tion was to examine relationships among manifest variables tolatentvariables(Floyd&Widaman,1995).Nobivariatecorrelations betweenitemsexceeded.71,suggestingthatitemredundancywasnot a significant problem. Several methods of estimating the mostappropriatenumberoffactorswereused.First,Velicer’sminimumaveragepartial(MAP)andHorn’sparallelanalysis(O’Connor,2000)were used because they have demonstrated robust estimations inthedevelopmentofhealthmeasuresofbetween20and50variablesin samples of 100–300 subjects (Coste, Fermanian, & Venot, 1995).In addition, the Eigenvalues and Scree Test were examined. TheMAP test, parallel analysis, and Scree plot indicated the presenceof two factors. Seven Eigenvalues were greater than 1 (10.25, 2.40,1.55,1.42,1.38,1.09,1.01).Consistentwithpreviousresearch(e.g.,Fresco, Frankel, et al., 2002; Goring & Papageorgiou, 2008), itemswere removed if no factor loadings exceeded .4, or if the highestloading was not at least .1 higher than their second highest load-ing. Two items were removed based on these criteria. The testswere run again and the MAP test, parallel analysis, and Scree plotsagain suggested two factors. Six factors had Eigenvalues greaterthan 1 (10.11, 2.37, 1.48, 1.37, 1.23, 1.05). The two-factor modelwas easily interpretable with all positively worded items loadingon the first factor, and all negatively worded items loading on thesecond factor. Table 1 provides the rotated factor loadings for allitems.Factor 1, labeled  Repetitive Negative Thinking,  contained themajority of items ( n =27) and reflected various aspects of repeti-tive negative thinking. This factor explained 30.6% of the variance.Factor 2 contained the negatively worded PSWQ items ( n =4)and was labeled  Absence of Repetitive Thinking (ART) . This factorexplained 5.7% of the variance. Factor scores were computed fromthis two-factor solution. Cronbach’s alpha suggested that inter-nal consistency was excellent for the RNT scale ( ˛ =.93, averageinter-itemcorrelation=.34)andwasgoodfortheARTscale( ˛ =.72,average inter-item correlation=.40). The scales were weakly butsignificantly negatively correlated ( r  = − .20,  p <.01).Themeantotalscores(standarddeviation)fortheRNTandARTscales were 71.97 (22.02) and 8.41 (3.37). When average ratingswere calculated for each scale the corresponding means (standarddeviations)were2.67(0.82)and2.10(0.84),respectively.Indepen-dent samples  t  -tests were conducted to compare scores for males
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