A few recent accounts of suicide in the families of some of my patients along with headlines of fashion icon Kate Spade and celebrity chef Anthony Bourdain taking their own lives led me to write this post. The root causes of mental health issues are incredibly complex, so during lectures and weekend workshops I try my best to simplify them by focusing on a common thought pattern called rumination.
I'm not a mental health expert, but in my clinic where I focus on reversing/preventing cardiometabolic disorders like obesity, diabetes, and cholesterol disorders, I often find we cannot reach our full health potential (optimal body composition, labs and energy levels) until we optimize mental health.
This post will explain how rumination is linked to common mental health conditions like anxiety and depression, and how we are consciously and unconsciously triggering rumination in our children and loved ones, and some simple steps to identify and curb rumination.
Before we talk about rumination as a thought process, I wanted to point out that ruminants are actually animals like giraffe, sheep, cows and goats who chew on food that is partially digested in a special compartment of their stomach called the rumen, that is then regurgitated back up into their mouth so they can re-chew it.
When we ruminate or dwell on thoughts, we also in essence keep regurgitating thoughts about the past or future which we continue “chewing on” for days, weeks, months or even years.
Short, limited periods of rumination, like stress, won't have long term effects on your health. However, when you continue ruminating on specific events for longer periods of time it can cause serious damage to your mental and physical health.
Linking Rumination to Depression and Anxiety
Rumination is an early thought pattern that can lead to common mental health disorders like depression and anxiety. Just like prediabetes is a precursor to diabetes, rumination may be thought of as a form of “pre-depression” or “pre-anxiety.”
How is rumination linked to depression or anxiety? Individuals who ruminate persistently on past traumas and events tend to fall on the depression side of the spectrum, while a persistent rumination about future events dictates a greater tendency towards anxiety.
In other words, regrets about the past fuel depression while ongoing worry about the future triggers anxiety.
Many patients that we see in the clinic have some combination of depression and anxiety.
I may be oversimplifying the roots of mental health disorders a bit, but I think shining the spotlight on rumination is a significant first step towards understanding how and why we may end up with a mental state that seems difficult to control.
Science of Rumination Effects
I mentioned how the origin of the word rumination refers to how certain animals digest food. Interestingly, this study shows how taking probiotics reduced ruminating thoughts, suggesting a possible link between an imbalance in the bacteria in our digestive tract and an imbalance in our thoughts.
Now I wouldn't oversimplify mental health down to something that can be fixed by taking a supplement, but the probiotic study does suggest a link between the bacteria in our gut and our thoughts. Ideally, this would motivate you to change your diet first, instead of just adding a probiotic to an unhealthy diet.
In our clinic we clearly see in nearly all cases that mood improves as food improves.
Speaking of immunity, this study finds that rumination's impact on immune system activation and inflammation is more pronounced as we age. Inflammation is linked to nearly every chronic health condition (heart disease, cancer, Alzheimer's disease, autoimmune conditions, etc.).
Rumination, in other words, is a deeper, often more subtle form of chronic stress which is not as obvious as the panic and overwhelming stress we typically think of. Many of my patients who stress silently or think they have stress under control, appearing visibly calm on the outside, are persistent ruminators. It's a habit I personally am constantly working to overcome.
The key point is as follows:
Regardless of how calm you appear on the outside, your body still recognizes rumination as a threat, and mounts a physiological response, which on a chronic basis can lead to mental and physical disease.
When Are Rumination Roots Planted?
Most of you parents reading this blog may have the best intentions as you raise your children, but often we say things and do things that are causing significant damage and are planting the seeds for our children becoming ruminators in the future.
Every respected mental health expert I've come across has told me that the foundation for adult mental health disorders is laid somewhere in the first decade of life or even earlier. The field of behavioral epigenetics shows that intergenerational stress experienced by say your grandmother may have shaped your genes and influenced how you respond to stress.
In certain cultures, rumination roots are planted deep by certain parenting behaviors and extremely high expectations. This is a common occurrence in the Bay Area where many of my patients are of East Asian and South Asian ancestry.
This article discusses how Asian American teenage girls have the highest rate of depression out of any racial, ethnic or gender group.
The “Asian” type of parenting can be extended to any culture where parents are constantly driving kids to overreach and overextend towards excellence while compromising their mental wellbeing, their physical health and in many ways robbing them of the normal childhood every kid deserves. Unfortunately in hard-driving Silicon Valley and other Type A parts of the world, this type of parenting is ubiquitous.
Children and teens who silently comply to all the demands you are putting on their plate are often ruminators. Many develop chronic stress, depression and anxiety in college or later in life. As a parent, you need to be periodically checking in on their emotions and help them express and verbalize their thoughts.
Parents of Asian or “Asian-type” teenage suicide victims who tend to be ruminators commonly report that their child was quiet, shy and didn't cause any trouble. In other words, “the perfect child.” Everything I Never Told You by Celeste Ng is a powerful and moving piece of fiction that really captures the dysfunction and grief internalized by many of today's youth.
Driving kids and teens to compete athletically and academically, to build their own apps, start their own charitable organizations or even start-up companies, give TED talk-like presentations and focusing on changing the world while getting straight As, instead of riding around the neighborhood aimlessly on their bicycles is not a recipe for future fulfillment. If it was, then my high achieving patients would all be in bliss, and that is clearly not the case as is outlined in a Fortune magazine cover story highlighting my work in Silicon Valley, titled “Is Silicon Valley Bad for Your Health?”
Common Rumination Thought Processes or “Movies”
The simple process of labeling your thoughts and externalizing so you are watching your thoughts like an outsider is an important step towards regaining control. In my workshops I often tell participants the minute they start ruminating, to say something like “there I go ruminating again.” If you can't stop the thoughts, then take out the popcorn and start watching them like you are watching a movie or TV show on Netflix.
When you become the watcher of your own rumination movie, you remove the strong negative charge associated with the content and this subtle shift dissipates the impact it has on your mind and body.
If you want to counteract the content even more effectively, try categorizing your rumination movie. Below I've listed the top three “Rumination Movie Themes” that people here in Silicon Valley are constantly playing out in their heads and which I'm sure readers living outside Silicon Valley can relate to.
The goal of me listing them out is so you not only understand your damaging thought patterns better and realize that you are not alone, but to also try to avoid instilling these same thought patterns in your own children and loved ones.
Movie theme #1: If-then
If I had only done that, then this would or wouldn't have happened. A list of some specifics:
- “If I hadn't gone into engineering or high-tech and instead went into medicine, where I get to interact more with humans, then my life would have been better.” (Physicians currently face 50 percent burnout rates. For high-tech parents pushing kids into medicine, make sure they're in it because they truly love it or they may resent you later.)
- “If I hadn't gone into medicine and instead worked at a high-tech company that showers their employees with all kinds of benefits or became a tech entrepreneur, then I'd be so much happier.” (As referenced earlier, mental and physical health problems and burnout are very common in high stress, high-tech workers)
- “If I hadn't left my home country to immigrate here, then I wouldn't be so lonely. I would have been surrounded by my family, my community and my culture. People just don't understand me here.” (Unfortunately modern day families even in other parts of the world are suffering. Living closer to your family in your home country is by no means a path to happiness. Family relations are complex and I've had some close friends, relatives and patients living in India tell me they wish they had emigrated to a different country to build their own life.)
- If I had married someone else or didn't get married…then my life might have been so much better.
- If we had moved to a different city, then we'd have close friends and neighbors and be so much happier.
- If I had taken that other job, then I'd have less stress, make more money, etc.
The fundamental flaw with “if-then thinking” is focusing on external changes to achieve inner fulfillment.
It's a completely irrational belief system where one thinks a hypothetical change would have assured a more fulfilling outcome. The examples I give follow the typical “grass is greener on the other side” mentality.
Doctors think they'd be happier if they were engineers, engineers think they'd be happier if they were doctors, immigrants think they'd be happier back in their home country, while those stuck in their home country often wish they could escape the stressors and responsibilities of being near family.
Movie Theme #2: Great Expectations
If you are raised in an environment where good enough is never good enough, you learn to lead life in a partially dissatisfied state at all times. No meal, no trip, no job, no vacation, no friend, etc. is ever quite good enough. The sum total of multiple experiences that don't meet expectations over a period of many years may lead to a general sense of dissatisfaction about life. Studies show that levels of the pleasure-producing chemical dopamine come crashing down when expectations are unmet and this article provides further insights into how our expectations are intimately tied to our mental well-being.
A related concept is that of the hedonic treadmill. The hedonic treadmill (or hamster wheel) is a preset thermostat for your own intrinsic level of happiness. So let's say someone was wired to be generally unhappy from childhood. If that person wins the lottery and becomes instantly rich, there would be a momentary rush of happiness or a thrill, which over time would return back to your preset thermostat level of happiness. Studies of lottery winners show that they don't respond to ordinary situations or everyday events with an inflated level of bliss.
The treadmill refers to how individuals are constantly spinning on a wheel where they seek outside pleasures, hoping that will some how reset their thermostat to a higher level of happiness. “Maybe if I leave this job and join a start-up, run my own business, make more money, get a nicer car, or push my kids harder so I can live through their success, then I'll be happier…”
Angry, dissatisfied, unhappy, selfish people don't all of a sudden become peaceful, happy, selfless individuals as a result of positive changes in their financial or personal situation. The converse is also true. If you are wired to be happy and more resilient, then sudden adverse changes in your health or your finances may temporarily move your happiness levels lower, but then you snap back closer to your pre-programmed levels.
Again, in my neck of the woods, there is a tremendous focus on constantly driving towards external goals to hopefully reset the thermostat. This rarely ever works. As a matter of fact, it just creates sequentially greater and greater expectations that result in temporary highs, but then you're back to your preset level of dissatisfaction. “All these years of hard work and sacrifice, yet I still feel like this.” Sound familiar?
I'm by no means encouraging you to demotivate yourself or your kids, but for every moment you set a high goal, take time to appreciate all the surrounding moments, achievements, and gifts you take for granted.
If you are pushing yourself or your loved ones towards external goals and setting higher and higher expectations while consistently sacrificing nutrition, exercise, sleep, social connection, nature connection and mindfulness, then you are chaining yourself to the hedonic treadmill and not making progress towards a more fulfilling life.
I deliberately have learned to set really low expectations for most events and personal interactions in my life and it really has made a huge difference for me. If expectations are not met, no worries and if they're met or exceeded, then I feel joy and gratitude.
Movie Theme #3: Me vs You
If you are constantly comparing yourself, your spouse, your parents, your job, your friends, your house, your dog, etc. to anyone or anything else on a regular basis, then you are setting yourself up for a life of unhappiness.
Comparative thinking often fuels rumination. Everyone has it better than you…right? You got dealt the short stick in the game of life.
The real fallacy of comparative thinking is painting a rosy picture about the lives of those around you or believing the rosy picture they paint about themselves at social gatherings or on social media is true.
I have worked in Silicon Valley now for over a decade. I have patients who grace the covers of Fortune magazine, who are worshipped like deities and are often set as a “role model” for their kids to follow. “If you work hard, you too can someday be like Frank Moneybags.” However, are these individuals put on pedestals truly role model individuals, spouses, parents, bosses, etc.?
Many of us viewed Anthony Bourdain as leading an ideal life. A real life culinary Indiana Jones setting out on cultural immersion adventures to distant corners of the planet. I'd often say to myself, now he's living an incredible life.
Anthony is tragically an example of someone we thought we understood based on his TV persona, which exuded confidence, adventure, excitement, and fame. Clearly none of us on the outside knew the real Anthony Bourdain.
Unfortunately it's also common in many cultures to avoid discussing daily pains and sorrows. Conversations are highly curated with filtered content including how well work is going, how outstanding one's kids are doing, with an occasional blanket statement referring to “high stress” or life being “crazy busy.”
Then all of a sudden you hear a piece of shocking news about someone you thought was leading a near perfect life, succumbing to a massive heart attack, being diagnosed with cancer or going through a divorce. Friends and community may reach out for support, but often they are also trying to get inside information to fuel gossip.
Comparative thinking has fueled unhappiness for a long time, but in our modern generation this effect has been amplified dramatically through social networking. In fact, it is specifically the social comparison component of platforms like Facebook that are a key trigger to depression as shown in this study.
The next time you are on Facebook, Instagram, etc., just pay attention to the specific emotions you experience. How much of it is pure joy and how much of it is “oh there he/she goes again showing off their vacation photos, family photos, selfies, etc.” Comparison envy is a common emotion experienced from social networking platforms and this can cause periods of rumination even after you are off your device. If this describes your own experience, I strongly suggest you severely curtail your use of these platforms or stop them altogether.
Daydreaming vs Rumination
At one of my stress workshops a parent told me that her 9-year-old son spends lots of time daydreaming about books he has read or movies he has seen. She was worried this might lead to rumination, so she decided to try to keep him busy with a multitude of activities.
I explained that daydreaming is different than rumination and can spark creativity, consolidate previously learned information, and just provide the brain with much needed rest. Dr.Jerome Singer is an authority on this topic and explains daydreaming in detail here, during an interview with Scientific American.
A common proverb that gives daydreaming a bad reputation is “An idle mind is the devil's workshop,” but it really depends on the content of that idle mind. If most of it is past regrets and future worries, then we would call that rumination.
If on the other hand it's mostly creative content, fantasy, or perhaps planning out a new business idea, then it can be considered daydreaming or brainstorming, which is the space where I find my own ideas for blog topics, presentations, innovations at work, or answers to tough clinical cases.
Become the Wise Elder Now
I often take care of multiple generations of families. I recently met an elderly man in clinic, whose son, also my patient, experienced a heart attack at the age of 46. He shared with me the frustration of how much today's parents are pressuring their kids. He was not only worried about his own son, but also his grandkids who he felt were being pressured into too many academic enrichment activities with the goal of making sure they would some day be wealthy entrepreneurs.
Upon further questioning though, he admitted that he parented his kids the same way. Only now in retirement is he able to have a completely different view on how high pressure parenting has affected his kids, who he admitted are leading highly stressful lives, and now his grandkids who he feels are experiencing both physical and mental health effects from overwhelming pressure.
Every now and then we need to become the wise elder by pausing and reflecting on whether we are moving ourselves and our loved ones in a direction of inner fulfillment which helps elevate the setting on our happiness thermostat, or are we simply hopping back on the never ending hedonic treadmill.
Key Tips Summarized
Understanding the concept of rumination gives you a valuable window into your own mind and an opportunity to interrupt this detrimental thought process, tied to common mental health disorders. Some key points are below:
- Identify. Label rumination when it happens…”there I go ruminating again.”
- Categorize. Be familiar with the common rumination movie themes you replay in your head like if-then, great expectations, and social comparisons.
- Externalize. Grab some popcorn (handful of nuts would be healthier!) and watch ruminating thoughts like a movie.
- Detach and Distract. Rumination is sticky and it will pin you to your office chair, your couch or your bed, so you feel helpless and paralyzed. You literally become a victim or prisoner of your own thoughts. Immediately detach yourself from your rumination environment and then positively distract yourself with exercise, reach out to a friend, read a book you enjoy, do something creative, get out into nature, etc. Mondays are days I'm most susceptible to rumination and the simple act of working in a public place like a coffee house rather than in my solitary office makes a huge difference.
- Be Present. Recall I said that ruminating about the past is linked to depression while ruminations about the future are tied to anxiety. The space in between is the present and mindfulness practices like meditation help bring you back to your center.
- Pause and Reflect. Become the wise elder every now and then. Ask yourself if you're constantly running on the hedonic treadmill and forcing your family down a similar path. Prioritize your mind and body and encourage those you love to do the same. Remember, you cannot reset your thermostat through incessant material pursuits and external goal achievements.
- Get Help. For many, the rumination movies continue to dominate their lives despite using some of the above techniques. There are past experiences and traumas that have become strongly embedded into our psyche and need to be addressed by a mental health professional. Unfortunately seeking help is often considered taboo to the very individuals and cultures that need it the most.
I hope this post helps you better understand the inner workings of your mind and how a nearly imperceptible, automatic thought process like rumination can lead to so much suffering. I also hope it helps open up deeper conversations among your own family, loved ones, and community so more individuals feel empowered to open up and share, rather than internalize and suffer.
For my comprehensive toolkit of stress reduction resources including short videos on using my favorite Apps, go to this page.