Insistence on sameness, repetitive negative thinking and mental health in autistic and non-autistic adults

“…and recurring intrusive thoughts, images or impulses which cause distress (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM -5), American Psychiatric Association, 2013), ruminative thinking is common in OCD and distinct from obsessional rumination (Wahl et al., 2011).”

“Autism, a neurodevelopmental condition characterised by difference in social communication and a restricted, repetitive pattern of behaviours, interests and activities is pre-sent in approximately 1% of people (Zeidan et al., 2022).”

“Obsessing subscale of the Obsessive-Compulsive Inventory (OCI-R; Foa et al., 2002).”

“Autistic people are at significant risk of experiencing mental health problems, with a lifetime prevalence of 42% for anxiety conditions and 37% for depression (Hollocks et al., 2019) and high rates of obsessive-compulsive disorder (OCD; e.g. Lai et al., 2019).”

“The measure has good psychometric properties, including good construct validity and internal consistency (Trapnell & Campbell, 1999).”

“Worry, described as ‘a chain of thoughts and images, negatively affect-laden and relatively uncontrollable’ (Borkovec et al., 1983, p. 9) is a prominent feature of GAD.”

“RNT describes a thinking process that is repetitive, negative in content and difficult to disengage from (Ehring & Watkins, 2008).”

“In respect of functional analysis, the approach is based on the principles outlined in Behavioural Activation for depression (Jacobson et al., 2001).”

“Autistic people are at significant risk of experiencing mental health problems, with a lifetime prevalence of 42% for anxiety conditions and 37% for depression (Hollocks et al., 2019) and high rates of obsessive-compulsive disorder (OCD; e.g. Lai et al., 2019).”

“For example, rumination or RNT about the self which is past-orientated (Trapnell & Campbell, 1999) has links with depression in typically developing populations (Smith & Alloy, 2009).”

“CBT has been shown to be effective in reducing anxiety for autistic young people if adapted to meet their needs (Wood et al., 2009).”

“Rumination is known to predict the number and duration of episodes of major depression (Robinson & Alloy, 2003).”

“Depression and anxiety (Patient Health Questionnaire Anxiety-Depression Scale; PHQ-ADS; Kroenke et al., 2016).”

“Anxiety and depression are highly co-morbid conditions (Kessler et al., 2007) and a single intervention targeting both has many potential benefits.”

“Studies have found relationships between insistence on sameness, repetitive sensory motor behaviours and anxiety in autistic children (Wigham et al., 2015), suggesting that insistence on sameness plays a significant role in anxiety for autistic populations.”

“Earlier studies indicate that increased awareness of and negative perceptions about autism may have a negative impact on mental health likely through social comparison processes (Cooper et al., 2017; Gotham et al., 2014; Hedley & Young, 2006).”

“A subcategory of the restricted repetitive behaviours (RRBI) domain of autism is insistence on sameness (Bishop et al., 2013), which refers to a preference for routine, difficulties with change and compulsive or ritualistic behaviour.”

“There is evidence that rumination reduces following treatment for depression in autistic people from a randomised control trial of mindfulness-based stress reduction (MBSR; Spek et al., 2013).”

“Multiple genetic and psychosocial factors contribute to the elevated rates of anxiety and depression in this group (Han et al., 2022; Nord & Garfinkel, 2022; Rydzewska et al., 2019).”

“As executive functioning (EF) impairments are frequently reported in autistic people across the lifespan, CCT interventions such as attention control training (Papageorgiou & Wells, 2000) may be highly relevant.”

“Multiple genetic and psychosocial factors contribute to the elevated rates of anxiety and depression in this group (Han et al., 2022; Nord & Garfinkel, 2022; Rydzewska et al., 2019).”

“Such rumination may in turn exacerbate OCD symptoms by strengthening negative internal appraisals of obsessional thoughts (Freeston & Ladouceur, 1997; Raines et al., 2017).”

“The OCI-R has been used with autistic populations (e.g. Russell et al., 2013), is valid and reliable (Foa et al., 2002), with good discriminant validity (Cad-man et al., 2015).”

“In autistic adolescents, rumination has been found to correlate with depression scores, as well as insistence on sameness (Gotham et al., 2014).”

“Earlier studies indicate that increased awareness of and negative perceptions about autism may have a negative impact on mental health likely through social comparison processes (Cooper et al., 2017; Gotham et al., 2014; Hedley & Young, 2006).”

“As a transdiagnostic factor, there are similarities in the process of RNT across different conditions, but some disorder-specific differences in the content or form of RNT (e.g. Wahl et al., 2019).”

“Insistence on sameness (Adult Repetitive Behaviours Questionnaire; RBQ-2A subscale; Barrett et al., 2015).”

“Autistic adults indeed report engaging in more rumination than non-autistic adults, and rumination has been found to significantly correlate with depression scores in autistic people (Crane et al., 2013).”

“Indeed, cognitive inflexibility is noted as significantly associated with internalising symptoms in young autistic people in a recent review and meta-analysis on this topic (Lei et al., 2022 (Watkins, 2015).”

“Multiple genetic and psychosocial factors contribute to the elevated rates of anxiety and depression in this group (Han et al., 2022; Nord & Garfinkel, 2022; Rydzewska et al., 2019).”

“In a study of parent ratings of 72 autistic children and young people, high rates of ritualistic and sameness behaviours were significantly associated with severity of anxiety, depressive and oppositional defiant disorder symptoms (Stratis & Lecavalier, 2013).”

“Such rumination may in turn exacerbate OCD symptoms by strengthening negative internal appraisals of obsessional thoughts (Freeston & Ladouceur, 1997; Raines et al., 2017).”

“In terms of psychological factors, high rates of repetitive cognitive processes such as worry and rumination have been found to be associated with anxiety and depression in autistic people (DeLong, 2004; Gotham et al., 2014; van Heijst et al., 2020).”

“In terms of psychological factors, high rates of repetitive cognitive processes such as worry and rumination have been found to be associated with anxiety and depression in autistic people (DeLong, 2004; Gotham et al., 2014; van Heijst et al., 2020).”

“…and recurring intrusive thoughts, images or impulses which cause distress (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM -5), American Psychiatric Association, 2013), ruminative thinking is common in OCD and distinct from obsessional rumination (Wahl et al., 2011).”

“Participants completed additional measures which were reported by Cooper et al. (2022) and then completed additional procedures linked to the ADEPT study(Russell et al., 2020) , which are reported elsewhere.”

“Social cognition and executive function have been the targets of cognitive remediation interventions for autistic people to date (see Dandil et al., 2020 for a review) with some evidence for effectiveness, suggesting that attentional control training could be feasibly adapted for autism.”

“Indeed, cognitive inflexibility is noted as significantly associated with internalising symptoms in young autistic people in a recent review and meta-analysis on this topic (Lei et al., 2022 (Watkins, 2015).”

“In a study of these phenomena in a sample of 200 non-autistic people but capturing the broader autism phenotype using the AQ, Keenan et al. (2018) found that perseverative thinking was associated with rumination and depression.”

“Our findings highlight the role of RNT in depression-anxiety, consistent with previous research (e.g. Gotham et al., 2014; Williams et al., 2021).”

“A recent longitudinal study identified that trait-like RNT at baseline was significantly associated with both depression and anxiety symptoms (measured separately) over the course of 12 weeks in autistic and non-autistic college students (McKenney et al., 2023).”

“Behavioural Activation has been adapted for autistic adults experiencing depression and found to be feasible and acceptable (Horwood et al., 2021; Russell et al., 2020).”

“In an earlier study, we used descriptive experience sampling methods (DESM; Cooper et al., 2022) to investigate cognitive repetition.”

“However, findings from a large study in autistic adults found that personality factors also mediate the relationship between insistence on sameness and depression in autistic adults (Schwartzman et al., 2022).”

“This measure has been designed for use in both autistic and non-autistic adults, with a similar factor structure across groups, indicating that this can be a useful transdiagnostic measure (Brett et al., 2024).”

“…showed that a tendency toward behavioral repetition could contribute to repetitive negative thinking, which was linked to mental health problems (Cooper & Russell, 2024), we think that more research is needed to fully understand the links between repetitive behaviors, ER, and mental health…”

“It is possible that the association between autistic traits and MD traits becomes more pronounced at higher, clinically signi fi - cant levels of autistic traits, where sensory sensitivities and cognitive styles like rumination are more marked (Cooper & Russell, 2024; Normansell-Mossa et al., 2021).”

“The fixed mindset, and more specifically, the insistence on sameness, may increase the vulnerability of repetitive negative thinking, which is an important transdiagnostic factor in depression and anxiety (17).”

“Compared to non-autistic peers, autistic adults report increased RNT, especially in relation to depression, as captured by questionnaire (Cooper & Russell, 2025) and diary methods (Cooper et al., 2022).”

“Research shows that higher rates of RRBIs contribute to increased rumination, resulting in greater mental health challenges, such as higher rates of anxiety and depression [7].”