Measuring Racing Thoughts in Healthy Individuals: the Racing and Crowded Thoughts Questionnaire (RCTQ)

Comprehensive Psychiatry 82 (2018) 37–44

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Comprehensive Psychiatry

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Measuring racing thoughts in healthy individuals: The Racing and Crowded Thoughts Questionnaire (RCTQ)

Luisa Weiner a,b,⁎, Sébastien Weibel a,b,WagnerdeSousaGurgelc, Ineke Keizer d,MarianneGex-Fabryd, Anne Giersch a, Gilles Bertschy a,b,e a INSERM U1114, Strasbourg, France b Psychiatry Department, University Hospital of Strasbourg, France c Institute of Psychiatry (IPq), University of São Paulo (USP), São Paulo, SP, Brazil d Department of Mental Health and Psychiatry, University Hospitals of Geneva, Switzerland e Translational Medicine Federation, University of Strasbourg, France article info abstract

Available online xxxx Racing thoughts refer to an acceleration and overproduction of thoughts, which have been associated with manic Keywords: and mixed episodes. Phenomenology distinguishes ‘crowded’ from ‘racing’ thoughts, associated with mixed Racing thoughts depression and mania, respectively. Recent data suggest racing thoughts might also be present in healthy individ- Crowded thoughts uals with sub-affective traits and symptoms. We investigated this assumption, with a 34-item self-rating scale, Affective temperament the Racing and Crowded Thoughts Questionnaire (RCTQ), and evaluated its reliability, factor structure, and Cyclothymia concurrent validity. 197 healthy individuals completed the RCTQ, the Temperament Evaluation of Memphis, Thought overactivation – Distractibility Pisa, Paris, and San Diego autoquestionnaire (TEMPS-A), the Beck Depression Inventory (BDI), the Altman Self-Rating Mania scale (ASRM), and the Ruminative Response Scale (RRS). Exploratory factor analysis yielded a three-factor solution, labeled ‘thought overactivation’, ‘burden of thought overactivation’,and‘thought overexcitability’. Internal consistency of each of the three subscales of the RCTQ was excellent. The TEMPS-A cyclothymia score was associated with the three factors, suggesting good concurrent validity. The ‘thought activation’ subscale was selectively associated with current elated mood and included items conveying both the notion of increased amount and velocity of thoughts, whereas the ‘burden of thought overactivation’ subscale was associated with current low mood. The ‘thought overexcitability’ subscale included items conveying the notion of distractibility, and was associated with both elated and low mood. Rumination was not a signiﬁcant predictor of RCTQ subscores. These results suggest that the RCTQ has good psychometric properties. Racing and crowded thoughts, as measured by the RCTQ, are a multi-faceted phenomenon, distinct from rumination, and particularly associated with mood instability even in its milder forms. © 2018 Elsevier Inc. All rights reserved.

1. Introduction populations, e.g., [5,6], suggesting that mood, and possibly thought ac- tivity, might be conceptualized as a continuum. In addition, Dodd et al. Racing thoughts refer to a subjective acceleration and overproduc- [7] reported that the ‘cognitive and behavioral activation’ subscore of tion of thoughts. They are mainly associated with manic/hypomanic ep- the Internal States Scale (ISS) [8], which measures experience of racing isodes in bipolar disorder (BD) and also belong to the “with mixed thoughts and elevated energy [7], was particularly associated with dys- features” speciﬁer criteria of major depression [1]. On a phenomenolog- functional hypomanic attitudes in a sample of healthy students. It seems ical level, recent models have conceptualized racing thoughts as related thus plausible that healthy individuals experience racing thoughts. to depressive and manic mood [2], and also to creativity [3]. However, To the best of our knowledge, racing thoughts have not been de- these models only concern individuals with full-blown mood disorders, scribed in healthy volunteers, and only two studies have investigated and do not take into account the broad kraepelinian notion of mood dis- racing thoughts in patients with mood disorders [9,10]. orders including subclinical temperamental forms [4]. Yet cyclothymic Although in the DSM-5 the unitary term ‘racing thoughts’ alone is and hyperthymic traits have been widely described in healthy used [1], at least two types of racing thoughts have been identiﬁed in phenomenological studies in patients with mood disorders, i.e., ‘crowded’ and ‘racing’, associated with low and elated mood, respec- ⁎ Corresponding author at: INSERM1114, Department of Psychiatry, University Hospital of Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France. tively [2,11]. Moreover, the phenomenology of crowded and racing E-mail address: [email protected] (L. Weiner). thoughts seems to differ: crowded thoughts are usually associated

https://doi.org/10.1016/j.comppsych.2018.01.006 0010-440X/© 2018 Elsevier Inc. All rights reserved. 38 L. Weiner et al. / Comprehensive Psychiatry 82 (2018) 37–44 with a very unpleasant and tense feeling related to thoughts of all kind 2. Methods accumulating in one's mind [2,11,12]. In contrast, racing thoughts are characterized by a rapid flow of thoughts usually associated with posi- 2.1. Participants tive emotions, that may be accompanied by increased creativity and productivity [3,13]. For this cross-sectional study, 215 individuals were recruited among To our knowledge, only one qualitative study [9] investigated the the staff and students of the University Hospital of Strasbourg. Eighteen phenomenology of racing thoughts in patients with mood disorders. participants were excluded because they had a personal history of Thirty-four categories that were clustered in six main themes emerged psychiatric or neurological disorders or were taking psychotropic from the reports of 45 patients, suggesting that numerous mechanisms medication. The study sample thus included 197 healthy individuals may be at stake in the overall concept of racing thoughts. In the same aged 19–56 (M = 26, SD = 7.3). Women constituted 65% of the sample. study, based on the expertise of clinicians, the authors subsequently de- Participants had on average 16.3 years of education (cf. Table 1 for veloped a self-report questionnaire composed of 16 items that included detailed demographic information). The majority of participants were racing, crowded, and ruminative thoughts [9]. A principal component university students, mostly in psychology and medical schools analysis of the initial 16-item scale indicated that a single component (74.1%). This study was part of a larger protocol involving time explained 55.9% of the variance, with major and exclusive contributions perception; results obtained on the time perception tasks were from 9 items. Rumination items were not part of this component. The published elsewhere [21]. Participants provided written informed final 9-item self-rating scale was called Subjective Thought consent prior to inclusion in the study, in accordance with the Overactivation Questionnaire (STOQ) [9]. Given its single-factor struc- Declaration of Helsinki. ture, ‘Thought Overactivation’ was chosen as an overarching term including racing and crowded thoughts. Scores correlated with both 2.2. Materials and procedures activation and depression indices of the ISS [8] in patients with mood disorders, suggesting that they assessed a thought pattern associated Participants filled-out five self-report questionnaires assessing with both depressive and manic mood. However, this scale did not ad- mood and thought patterns. Questionnaires were administered in a dress the numerous facets found in the qualitative analysis of patient re- fixed order. All measures were completed in a quiet room as part of a ports. Thus, in order to determine whether or not thought wider testing session. overactivation is a multi-faceted concept, as qualitative and phenomenological data suggest [2,9], it is necessary to develop new scales 2.2.1. Racing and Crowded Thoughts Questionnaire (RCTQ) scale allowing a fine-grained analysis of the phenomenology of thought development overactivation in patients with mood disorders, but also, from the per- The RCTQ is a 34-item self-report questionnaire that assesses spective of a continuum spanning from mood disorders to subclinical thought overactivity during the past 24 h (Fig. 1). Nine items of the temperament traits, in healthy individuals. RCTQ belong to the STOQ [9], of which 4 underwent very minor wording In healthy volunteers, data regarding the phenomenology of thought adaptations, whereas the remaining 25 items were developed by three overactivation are still lacking. It is thus unknown whether racing and crowded thoughts are found in healthy individuals, and how they relate Table 1 to mild mood variations. Distribution of scores on the 34 items of the RCTQ. An interesting issue is the comparison of thought overactivation RCTQ item Mean (SD) % floor % ceiling and rumination. Rumination could be easily confused with racing or crowded thoughts, inasmuch as it has been defined as a repetitive, 1 1.56 (1.26) 26.9 9.1 2 1.29 (1.21) 35.1 5.6 and analytical pattern of thinking associated with the onset and the 3 0.98 (1.15) 44.2 5.6 maintenance of depression [14]. According to the Response Styles 4 1.49 (1.26) 29.4 6.6 Theory (RST) [15], rumination includes both self-reflection, considered 5 1.13 (1.09) 35.5 3.5 to be an adaptive form of rumination, and brooding, i.e., a repetitive 6 1.41 (1.41) 38.1 11.2 focus on one's negative emotions, considered to be maladaptive [16]. 7 0.97 (1.09) 43.7 3.1 8 1.49 (1.23) 26.9 6.6 Brooding and crowded thoughts are therefore both accompanied by 9 1.36 (1.21) 32.5 4.1 low mood, but, unlike crowded thoughts, brooding is repetitive in 10 0.45 (0.84) 71.1 1.5 nature and is associated with a decreased amount of thoughts [3,17]. 11 1.02 (1.12) 41.6 3.5 Whereas there is a large amount of evidence suggesting that 12 1.15 (1.10) 34.0 4.6 13 0.48 (0.87) 69.5 1.5 õrumination is a trait of unipolar depression, e.g., [18], data on 14 0.64 (0.92) 60.4 0.5 rumination in euthymic individuals with BD and in healthy populations 15 0.92 (1.15) 49.7 3.1 with sub-affective presentations are scarce [19]. In at-risk populations, 16 1.10 (1.12) 41.6 1.5 Pavlickova et al. [20] found increased levels of rumination in 17 1.44 (1.24) 29.9 5.6 offspring of bipolar parents compared to offspring of healthy controls, 18 0.54 (0.85) 62.4 0.5 19 1.35 (1.33) 37.6 9.1 but they did not control for the presence of racing and crowded 20 0.86 (1.00) 48.2 0.5 thoughts. 21 1.12 (1.06) 35.5 2.0 The aim of the present study is to evaluate the factor structure, 22 0.60 (0.82) 57.4 0.5 validity and reliability, in a sample of healthy subjects, of a new 23 0.62 (0.95) 60.9 1.5 24 0.77 (0.97) 51.8 1.0 34-item self-report questionnaire – the Racing and Crowded Thoughts 25 1.17 (1.20) 41.1 3.5 Questionnaire (RCTQ). To evaluate its concurrent validity in healthy 26 0.89 (1.06) 47.7 2.0 individuals, measures evaluating affective temperaments and current 27 0.48 (0.77) 66.0 0.5 mood were administered in addition to the RCTQ. If the RCTQ is 28 0.94 (1.08) 46.7 1.5 able to capture a phenomenon specifically associated with mood 29 0.47 (0.77) 72.1 2.0 fi fi 30 0.76 (1.02) 53.8 2.5 instability, then we should nd signi cant correlations between the 31 1.32 (1.18) 32.5 3.1 RCTQ and measures of cyclothymia, as well as current elated and low 32 1.27 (1.25) 36.5 6.6 mood. Moreover, racing and crowded thoughts, measured with 33 0.89 (1.07) 49.2 2.5 the RCTQ, were expected to be distinct and independent from 34 0.61 (0.89) 59.9 1.5 rumination. Legend: SD = standard deviation; RCTQ = Racing and Crowded Thoughts Questionnaire.