Perseverative Cognition, Psychopathology, and Somatic Health

  • Bart Verkuil
  • Jos F. Brosschot
  • Winifred A. Gebhardt
  • Julian F. Thayer


Perseverative cognition (PC), such as worry and rumination, is a common reaction to stressful events in everyday life. According to the PC hypothesis, prolonged cognitive representations of stressful events will increase the total amount of time that these events have a “wear and tear” effect on the human body. In this chapter, we provide an overview of the role that PC plays in the onset and maintenance of stress related mental and somatic health problems. Furthermore, we propose that unconscious PC, traditionally studied within the context of psychopathology, might have substantial somatic health relevant effects as well. Finally, we present a self-regulation perspective on PC and propose that it forms part of the default response to threat, novelty and ambiguity. This default response is enhanced in chronic worriers who show excessive commitment to their goals, use PC as a strategy to cope with possible threats to goal attainment and have difficulties to recognize signals of safety. In conclusion, research on the PC hypothesis has provided valuable insight into the link between stressful events, psychopathology, and somatic health.


Stressful Event Neutral Word Emotion Regulation Strategy Health Complaint Somatic Disease 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This writing of this chapter was financially supported by grants from The Ohio State University, Department of Psychology.


  1. Abbott, M. J., & Rapee, R. M. (2004) Post-event rumination and negative self-appraisal in social phobia before and after treatment.Journal of Abnormal Psychology,113, 136–144.CrossRefPubMedGoogle Scholar
  2. Amat, J., Baratta, M. V., Paul, E., Bland, S. T., Watkins, L. R., & Maier, S. F. (2005) Medial prefrontal cortex determines how stressor controllability affects behavior and dorsal raphe nucleus.Nature Neuroscience,8, 365–371.CrossRefPubMedGoogle Scholar
  3. Bargh, J. A., & Ferguson, M. J. (2000) Beyond behaviorism: On the automaticity of higher mental processes.Psychological Bulletin,126, 925–945.CrossRefPubMedGoogle Scholar
  4. Boldero, J., & Francis, J. (2002) Goals, standards, and the self: Reference values serving different functions.Personality and Social Psychology Review,6, 232.CrossRefGoogle Scholar
  5. Borkovec, T. (1982) Insomnia.Journal of Consulting and Clinical Psychology,50, 880–896.CrossRefPubMedGoogle Scholar
  6. Borkovec, T. D., & Hu, S. (1990) The effect of worry on cardiovascular response to phobic imagery.Behaviour Research and Therapy,28, 69–73.CrossRefPubMedGoogle Scholar
  7. Borkovec, T. D., Lyonfields, J. D., Wiser, S. L., & Deihl, L. (1993) The role of worrisome thinking in the suppression of cardiovascular response to phobic imagery.Behaviour Research and Therapy,31, 321–324.CrossRefPubMedGoogle Scholar
  8. Borkovec, T. D., Ray, W. J., & Stöber, J. (1998) Worry: A cognitive phenomenon intimately linked to affective, physiological, and interpersonal behavioral processes.Cognitive Therapy and Research,22, 561–576.CrossRefGoogle Scholar
  9. Borkovec, T. D., & Roemer, L. (1995) Perceived functions of worry among generalized anxiety disorder subjects: Distraction from more emotionally distressing topics?Journal of Behavior Therapy and Experimental Psychiatry,26, 25–30.CrossRefPubMedGoogle Scholar
  10. Broadbent, E., Petrie, K. J., Alley, P. G., & Booth, R. J. (2003) Psychological stress impairs early wound repair following surgery.Psychosomatic Medicine,65, 865–869.CrossRefPubMedGoogle Scholar
  11. Brosschot, J. F. (2002) Cognitive-emotional sensitization and somatic health complaints.Scandinavian Journal of Psychology,43, 113–121.CrossRefPubMedGoogle Scholar
  12. Brosschot, J. F., Gerin, W., & Thayer, J. F. (2006) The perseverative cognition hypothesis: A review of worry, prolonged stress-related physiological activation, and health.Journal of Psychosomatic Research,60, 113–124.CrossRefPubMedGoogle Scholar
  13. Brosschot, J. F., Pieper, S., & Thayer, J. F. (2005) Expanding stress theory: prolonged activation and PC.Psychoneuroendocrinology,30, 1043–1049.CrossRefPubMedGoogle Scholar
  14. Brosschot, J. F., & Van Der Doef, M. (2006) Daily worrying and somatic health complaints: Testing the effectiveness of a simple worry reduction intervention.Psychology and Health,21, 19–31.CrossRefGoogle Scholar
  15. Brosschot, J. F., Van Dijk, E., & Thayer, J. F. (2007) Daily worry is related to low heart rate variability during waking and the subsequent nocturnal sleep period.International Journal of Psychophysiology,63, 39–47.CrossRefPubMedGoogle Scholar
  16. Brown, R. J. (2004) Psychological mechanisms of medically unexplained symptoms: An integrative conceptual model.Psychological Bulletin,130, 793–812.CrossRefPubMedGoogle Scholar
  17. Cohen, S., & Williamson, G. M. (1991) Stress and infectious disease in humans.Psychological Bulletin,109, 5–24.CrossRefPubMedGoogle Scholar
  18. Davey, G. C. L. (1994) Worrying, social problem-solving abilities, and social problem-solving confidence.Behaviour Research and Therapy,32, 327–330.CrossRefPubMedGoogle Scholar
  19. Davey, G. C. L. (2006) A mood-as-input account of perseverative worrying. In G. C. L. Davey & A. Wells (Eds.),Worry and its psychological disorders: Theory, assessment and treatment (pp. 217–237). Chicester: Wiley.CrossRefGoogle Scholar
  20. Devoulyte, K. B. A., & Sullivan, M. J. L. P. (2003) Pain catastrophizing and symptom severity during upper respiratory tract illness.Clinical Journal of Pain,19, 125–133.CrossRefPubMedGoogle Scholar
  21. Eccleston, C., Crombez, G., Aldrich, S., & Stannard, C. (2001) Worry and chronic pain patients: A description and analysis of individual differences.European Journal of Pain,5, 309–318.CrossRefPubMedGoogle Scholar
  22. Emmons, R. A., & King, L. A. (1988) Conflict among personal strivings: Immediate and long-term implications for psychological and physical well-being.Journal of Personality and Social Psychology,54, 1040–1048.CrossRefPubMedGoogle Scholar
  23. Feather, N. T. (1963) Mowrer’s revised two-factor theory and the motive-expectancy-value model.Psychological Review,70, 500.CrossRefPubMedGoogle Scholar
  24. Foa, E. B., & Kozak, M. J. (1986) Emotional processing of fear: Exposure to corrective information.Psychological Bulletin,99, 20–35.CrossRefPubMedGoogle Scholar
  25. Fortune, D. G., Richards, H. L., Kirby, B., McElhone, K., Markham, T., Rogers, S., et al. (2003) Psychological distress impairs clearance of psoriasis in patients treated with photochemotherapy.Archives of Dermatology,139, 752–756.CrossRefPubMedGoogle Scholar
  26. Gebhardt, W. A., Van Der Doef, M., Massey, E. K., Verhoeven, C., & Verkuil, B. (2010) Goal commitment to finding a partner and satisfaction with life among female singles: The mediating role of rumination.Journal of Health Psychology,15, 122–130.CrossRefPubMedGoogle Scholar
  27. Goschke, T., & Kuhl, J. (1993) Representation of intentions: Persisting activation in memory.Journal of Experimental Psychology: Learning, Memory, & Cognition,19, 1211–1226.CrossRefGoogle Scholar
  28. Hammen, C. (2005) Stress and depression.Annual Review of Clinical Psychology,1, 293.CrossRefPubMedGoogle Scholar
  29. Hay, J. L., Buckley, T. R., & Ostroff, J. S. (2005) The role of cancer worry in cancer screening: A theoretical and empirical review of the literature.Psycho-Oncology,14, 517–534.CrossRefPubMedGoogle Scholar
  30. Hazen, R. A., Vasey, M. W., & Schmidt, N. B. (2009) Attentional retraining: A randomized clinical trial for pathological worry.Journal of Psychiatric Research,43, 627–633.CrossRefPubMedGoogle Scholar
  31. Hoehn-Saric, R., Schlund, M. W., & Wong, S. H. Y. (2004) Effects of citalopram on worry and brain activation in patients with generalized anxiety disorder.Psychiatry Research: Neuroimaging,131, 11–21.CrossRefPubMedGoogle Scholar
  32. Holeva, V., Tarrier, N., & Wells, A. (2001) Prevalence and predictors of acute stress disorder and PTSD following road traffic accidents: Thought control strategies and social support.Behavior Therapy,32, 65–83.CrossRefGoogle Scholar
  33. Holman, E. A., Silver, R. C., Poulin, M., Andersen, J., Gil-Rivas, V., & McIntosh, D. N. (2008) Terrorism, acute stress, and cardiovascular health: A 3-year national study following the September 11th attacks.Archives of General Psychiatry,65, 73.CrossRefPubMedGoogle Scholar
  34. Holmes, E. A., Brewin, C. R., & Hennessy, R. G. (2004) Trauma films, information processing, and intrusive memory development.Journal of Experimental Psychology: General,133, 3–22.CrossRefGoogle Scholar
  35. Johnson, R. E., Chang, C. H., & Lord, R. G. (2006) Moving from cognition to behavior: What the research says.Psychological Bulletin,132, 381–415.CrossRefPubMedGoogle Scholar
  36. Jones, N. P., Papadakis, A. A., Hogan, C. M., & Strauman, T. J. (2009) Over and over again: Rumination, reflection, and promotion goal failure and their interactive effects on depressive symptoms.Behaviour Research and Therapy,47, 254–259.CrossRefPubMedGoogle Scholar
  37. Kaptein, A. A., Helder, D. I., Kleijn, W. C., Rief, W., Moss-Morris, R., & Petrie, K. J. (2005) Modern health worries in medical students.Journal of Psychosomatic Research,58, 453–457.CrossRefPubMedGoogle Scholar
  38. Kindt, M., Brosschot, J. F., & Boiten, F. (1999) High-level cognition in phobics: Abstract anticipatory memory is associated with the attenuation of physiological reactivity to threat.Journal of Anxiety Disorders,10, 473–489.CrossRefGoogle Scholar
  39. Kivimaki, M., Leino-Arjas, P., Kaila-Kangas, L., Luukkonen, R., Vahtera, J., Elovainio, M., et al. (2006) Is incomplete recovery from work a risk marker of cardiovascular death? Prospective evidence from industrial employees.Psychosomatic Medicine,68, 402–407.CrossRefPubMedGoogle Scholar
  40. Klinger, E. (1975) Consequences of commitment to and disengagement from incentives.Psychological Review,82, 1–25.CrossRefGoogle Scholar
  41. Koole, S. L., Smeets, K., Van Knippenberg, A., & Dijksterhuis, A. (1999) The cessation of rumination through self-affirmation.Journal of Personality and Social Psychology,77, 111–125.CrossRefGoogle Scholar
  42. Kubzansky, L. D., Kawachi, I., Spiro, A., III, Weiss, S. T., Vokonas, P. S., & Sparrow, D. (1997) Is worrying bad for your heart?: A prospective study of worry and coronary heart disease in the normative aging study.Circulation,95, 818–824.CrossRefPubMedGoogle Scholar
  43. Lang, P. J. (1995) The emotion probe: Studies of motivation and attention.American Psychologist,50, 372–385.CrossRefPubMedGoogle Scholar
  44. Lazarus, R. S. (1991) Progress on a cognitive-motivational-relational theory of emotion.American Psychologist,46, 819–834.CrossRefPubMedGoogle Scholar
  45. LeDoux, J. E. (2000) Emotion circuits in the brain.Annual Review of Neuroscience,23, 155–184.CrossRefPubMedGoogle Scholar
  46. Linden, W., Earle, T. L., Gerin, W., & Christenfeld, N. (1997) Physiological stress reactivity and recovery: Conceptual siblings separated at birth?Journal of Psychosomatic Research,42, 117–135.CrossRefPubMedGoogle Scholar
  47. Looper, K. J., & Kirmayer, L. J. (2001) Hypochondriacal concerns in a community population.Psychological Medicine,31, 577–584.CrossRefPubMedGoogle Scholar
  48. Lyonfields, J. D., Borkovec, T. D., & Thayer, J. F. (1995) Vagal tone in generalized anxiety disorder and the effects of aversive imagery and worrisome thinking.Behavior Therapy,26, 457–466.CrossRefGoogle Scholar
  49. MacLeod, C., Rutherford, E., Campbell, L., Ebsworthy, G., & Holker, L. (2002) Selective attention and emotional vulnerability: Assessing the causal basis of their association through the experimental manipulation of attentional bias.Journal of Abnormal Psychology,111, 107–123.CrossRefPubMedGoogle Scholar
  50. Magee, P. L., MacLeod, A. K., Tata, P., & Regan, L. (2003) Psychological distress in recurrent ­miscarriage: The role of prospective thinking and role and goal investment.Journal of Reproductive and Infant Psychology,21, 35–47.CrossRefGoogle Scholar
  51. Marsh, R. L., Hicks, J. L., & Bink, M. L. (1998) Activation of completed, uncompleted, and partially completed intentions.Journal of Experimental Psychology: Learning, Memory, & Cognition,24, 350–361.CrossRefGoogle Scholar
  52. Martin, L. L., & Tesser, A. (1996) Some ruminative thoughts. In R. S. Wyer (Ed.),Ruminative thoughts: Advances in social cognition, Volume IX (pp. 1–47). Hillsdale, NJ: Lawrence Erlbaum Associates.Google Scholar
  53. McCullough, M. E., Orsulak, P., Brandon, A., & Akers, L. (2007) Rumination, fear, and cortisol: An in vivo study of interpersonal transgressions.Health Psychology,26, 126–132.CrossRefPubMedGoogle Scholar
  54. McEwen, B. S. (2003) Mood disorders and allostatic load.Biological Psychiatry,54, 200–207.CrossRefPubMedGoogle Scholar
  55. Mcintosh, W. D., Harlow, T. F., & Martin, L. L. (1995) Linkers and nonlinkers – Goal beliefs as a moderator of the effects of everyday hassles on rumination, depression, and physical complaints.Journal of Applied Social Psychology,25, 1231–1244.CrossRefGoogle Scholar
  56. Mineka, S. (1992) Cognitive biases and the emotional disorders.Psychological Science,3, 65.CrossRefGoogle Scholar
  57. Morris, J. S., Öhman, A., & Dolan, R. J. (1999) A subcortical pathway to the right amygdala mediating “unseen” fear.Proceedings of the National Academy of Sciences of the United States of America,96, 1680–1685.CrossRefPubMedGoogle Scholar
  58. Nitschke, J. B., Sarinopoulos, I., Oathes, D. J., Johnstone, T., Whalen, P. J., Davidson, R. J., et al. (2009) Anticipatory activation in the amygdala and anterior cingulate in generalized anxiety disorder and prediction of treatment response.American Journal of Psychiatry,166, 302–310.CrossRefPubMedGoogle Scholar
  59. Nolen-Hoeksema, S. (1991) Responses to depression and their effects on the duration of depressive episodes.Journal of Abnormal Psychology,100, 569–582.CrossRefPubMedGoogle Scholar
  60. Öhman, A., & Mineka, S. (2001) Fears, phobias, and preparedness: toward an evolved module of fear and fear learning.Psychological Review,108, 483–522.CrossRefPubMedGoogle Scholar
  61. Papageorgiou, C., & Wells, A. (2001) Positive beliefs about depressive rumination: Development and preliminary validation of a self-report scale.Behavior Therapy,32, 13–26.CrossRefGoogle Scholar
  62. Petrie, K. J., Broadbent, E. A., Kley, N., Moss-Morris, R., Horne, R., & Rief, W. (2005) Worries about modernity predict symptom complaints after environmental pesticide spraying.Psychosomatic Medicine,67, 778–782.CrossRefPubMedGoogle Scholar
  63. Pieper, S., Brosschot, J. F., Van der Leeden, R., & Thayer, J. F. (2007) Cardiac effects of momentary assessed worry episodes and stressful events.Psychosomatic Medicine,69, 901–909.CrossRefPubMedGoogle Scholar
  64. Robichaud, M., & Dugas, M. J. (2005) Negative problem orientation (Part II): construct validity and specificity to worry.Behaviour Research and Therapy,43, 403–412.CrossRefPubMedGoogle Scholar
  65. Roelofs, J., Papageorgiou, C., Gerber, R. D., Huibers, M., Peeters, F., & Arntz, A. (2007) On the links between self-discrepancies, rumination, metacognitions, and symptoms of depression in ­undergraduates.Behaviour Research and Therapy,45, 1295–1305.CrossRefPubMedGoogle Scholar
  66. Rothermund, K. (2003) Automatic vigilance for task-related information: Perseverance after ­failure and inhibition after success.Memory & Cognition,31, 343–352.CrossRefGoogle Scholar
  67. Rozanski, A., Blumenthal, J. A., & Kaplan, J. (1999) Impact of psychological factors on the ­pathogenesis of cardiovascular disease and implications for therapy.Circulation,99, 2192–2217.CrossRefPubMedGoogle Scholar
  68. Ruiz-Padial, E., & Vila, J. (2007) Fearful and sexual pictures not consciously seen modulate the startle reflex in human beings.Biological Psychiatry,61, 996–1001.CrossRefPubMedGoogle Scholar
  69. Schooler, J. W., & Engstler-School, T. Y. (1990) Verbal overshadowing of visual memories: Some things are better left unsaid.Cognitive Psychology,22, 36–71.CrossRefPubMedGoogle Scholar
  70. Segerstrom, S. C., Schipper, L. J., & Greenberg, R. N. (2008) Caregiving, repetitive thought, and immune response to vaccination in older adults.Brain, Behavior, and Immunity,22, 744–752.CrossRefPubMedGoogle Scholar
  71. Selye, H. (1951) The general-adaptation-syndrome.Annual Review of Medicine,2, 327–342.CrossRefPubMedGoogle Scholar
  72. Shah, J., & Higgins, E. T. (1997) Expectancy x value effects: Regulatory focus as determinant of magnitude and direction.Journal of Personality & Social Psychology,73, 447–458.CrossRefGoogle Scholar
  73. Skaggs, W. E., & McNaughton, B. L. (1996) Replay of neuronal firing sequences in rat hippocampus during sleep following spatial experience.Science,271, 1870–1873.CrossRefPubMedGoogle Scholar
  74. Startup, H. M., & Davey, G. C. L. (2003) Inflated responsibility and the use of stop rules for catastrophic worrying.Behaviour Research and Therapy,41, 495–503.CrossRefPubMedGoogle Scholar
  75. Stickgold, R., Malia, A., Maguire, D., Roddenberry, D., & O’Connor, M. (2000) Replaying the game: Hypnagogic images in normals and amnesics.Science,290, 350–353.CrossRefPubMedGoogle Scholar
  76. Szábo, M., & Lovibond, P. F. (2002) The cognitive content of naturally occurring worry episodes.Cognitive Therapy and Research,26, 167–177.CrossRefGoogle Scholar
  77. Tallis, F., Eysenck, M., & Mathews, A. (1991) Elevated evidence requirements and worry.Personality and Individual Differences,12, 21–27.CrossRefGoogle Scholar
  78. Thayer, J. F., & Brosschot, J. F. (2005) Psychosomatics and psychopathology: looking up and down from the brain.Psychoneuroendocrinology,30, 1050–1058.CrossRefPubMedGoogle Scholar
  79. Thayer, J. F., Friedman, B. H., & Borkovec, T. D. (1996) Autonomic characteristics of generalized anxiety disorder and worry.Biological Psychiatry,39, 255–266.CrossRefPubMedGoogle Scholar
  80. Thayer, J. F., Friedman, B. H., Borkovec, T. D., Johnsen, B. H., & Molina, S. (2000) Phasic heart period reactions to cued threat and nonthreat stimuli in generalized anxiety disorder.Psychophysiology,37, 361.CrossRefPubMedGoogle Scholar
  81. Thayer, J. F., & Lane, R. D. (2000) A model of neurovisceral integration in emotion regulation and dysregulation.Journal of Affective Disorders,61, 201–216.CrossRefPubMedGoogle Scholar
  82. Thayer, J. F., & Lane, R. D. (2007) The role of vagal function in the risk for cardiovascular disease and mortality.Biological Psychology,74, 224–242.CrossRefPubMedGoogle Scholar
  83. Turner, J. A., Mancl, L., & Aaron, L. A. (2004) Pain-related catastrophizing: a daily process study.Pain,110, 103–111.CrossRefPubMedGoogle Scholar
  84. Ursin, H., & Eriksen, H. R. (2004) The cognitive activation theory of stress.Psychoneuroendocrinology,29, 567–592.CrossRefPubMedGoogle Scholar
  85. Van Amelsvoort, L. G. P. M., Kant, I. J., Bultmann, U., & Swaen, G. M. H. (2003) Need for recovery after work and the subsequent risk of cardiovascular disease in a working population.Occupational and Environmental Medicine,60, 83–87.CrossRefGoogle Scholar
  86. Verkuil, B., Brosschot, J. F., Borkovec, T. D., & Thayer, J. F. (2009) Acute autonomic effects of experimental worry and cognitive problem solving: Why worry about worry?International Journal of Clinical and Health Psychology,9, 439–453.Google Scholar
  87. Verkuil, B., Brosschot, J. F., & Thayer, J. F. (2007) A sensitive body or a sensitive mind? Associations among somatic sensitization, cognitive sensitization, health worry, and subjective health complaints.Journal of Psychosomatic Research,63, 673–681.CrossRefPubMedGoogle Scholar
  88. Vrana, S. R., Cuthbert, B. N., & Lang, P. J. (1986) Fear imagery and text processing.Psychophysiology,23, 247–253.CrossRefPubMedGoogle Scholar
  89. Walker, M. P., & Stickgold, R. (2004) Sleep-dependent learning and memory consolidation.Neuron,44, 121.CrossRefPubMedGoogle Scholar
  90. Watkins, E. R. (2008) Constructive and unconstructive repetitive thought.Psychological Bulletin,134, 163–206.CrossRefPubMedGoogle Scholar
  91. Watkins, E. R., & Baracaia, S. (2002) Rumination and social problem-solving in depression.Behaviour Research and Therapy,40, 1179–1189.CrossRefPubMedGoogle Scholar
  92. Wells, A., & Matthews, G. (1996) Modelling cognition in emotional disorder: The S-REF model.Behaviour Research and Therapy,34, 881–888.CrossRefPubMedGoogle Scholar
  93. Williams, J. M., Watts, F. N., MacLeod, C., & Mathews, A. (1997)Cognitive psychology and emotional disorders. New York: Wiley.Google Scholar
  94. Wilson, E. J., MacLeod, C., Mathews, A., & Rutherford, E. M. (2006) The causal role of interpretive bias in anxiety reactivity.Journal of Abnormal Psychology,115, 103–111.CrossRefPubMedGoogle Scholar
  95. Wood, J. V., & Dodgson, P. G. (1996) When is self-focused attention an adaptive coping response? Rumination and overgeneralization versus compensation. In I. G. Sarason, G. R. Pierce, & B. R. Sarason (Eds.),Cognitive interference: theories, methods, and findings (pp. 231–259). Hillsdale, NJ: Erlbaum.Google Scholar
  96. Woody, S., & Rachman, S. (1994) Generalized anxiety disorder (GAD) as an unsuccessful search for safety.Clinical Psychology Review,14, 743–753.CrossRefGoogle Scholar
  97. Wulsin, L. R., Vaillant, G. E., & Wells, V. E. (1999) A systematic review of the mortality of depression.Psychosomatic Medicine,61, 6–17.PubMedGoogle Scholar
  98. Zeigarnik, B. (1927) Das Behalten erledigter und unerledigter Handlungen [The memory of completed and uncompleted actions].Psychologische Forschung,9, 1–85.CrossRefGoogle Scholar
  99. Zoccola, P. M., Dickerson, S. S., & Zaldivar, F. P. (2008) Rumination and cortisol responses to laboratory stressors.Psychosomatic Medicine,70, 661–667.CrossRefPubMedGoogle Scholar

Copyright information

© Springer New York 2011

Authors and Affiliations

  • Bart Verkuil
    • 1
  • Jos F. Brosschot
  • Winifred A. Gebhardt
  • Julian F. Thayer
  1. 1.Clinical, Health and Neuropsychology UnitLeiden University, Institute of PsychologyLeidenNetherlands

Personalised recommendations