What is Emotional Self-Regulation?

Introduction

Emotional self-regulation or emotion regulation is the ability to respond to the ongoing demands of experience with the range of emotions in a manner that is socially tolerable and sufficiently flexible to permit spontaneous reactions as well as the ability to delay spontaneous reactions as needed.

Refer to Emotional Dysregulation.

It can also be defined as extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions. Emotional self-regulation belongs to the broader set of emotion regulation processes, which includes both the regulation of one’s own feelings and the regulation of other people’s feelings.

Emotion regulation is a complex process that involves initiating, inhibiting, or modulating one’s state or behaviour in a given situation – for example, the subjective experience (feelings), cognitive responses (thoughts), emotion-related physiological responses (for example heart rate or hormonal activity), and emotion-related behaviour (bodily actions or expressions). Functionally, emotion regulation can also refer to processes such as the tendency to focus one’s attention to a task and the ability to suppress inappropriate behaviour under instruction. Emotion regulation is a highly significant function in human life.

Every day, people are continually exposed to a wide variety of potentially arousing stimuli. Inappropriate, extreme or unchecked emotional reactions to such stimuli could impede functional fit within society; therefore, people must engage in some form of emotion regulation almost all of the time. Generally speaking, emotion dysregulation has been defined as difficulties in controlling the influence of emotional arousal on the organisation and quality of thoughts, actions, and interactions. Individuals who are emotionally dysregulated exhibit patterns of responding in which there is a mismatch between their goals, responses, and/or modes of expression, and the demands of the social environment. For example, there is a significant association between emotion dysregulation and symptoms of depression, anxiety, eating pathology, and substance abuse. Higher levels of emotion regulation are likely to be related to both high levels of social competence and the expression of socially appropriate emotions.

Theory

Process Model

The process model of emotion regulation is based upon the modal model of emotion. The modal model of emotion suggests that the emotion generation process occurs in a particular sequence over time. This sequence occurs as follows:

  1. Situation: the sequence begins with a situation (real or imagined) that is emotionally relevant.
  2. Attention: attention is directed towards the emotional situation.
  3. Appraisal: the emotional situation is evaluated and interpreted.
  4. Response: an emotional response is generated, giving rise to loosely coordinated changes in experiential, behavioural, and physiological response systems.

Because an emotional response (4.) can cause changes to a situation (1.), this model involves a feedback loop from (4.) Response to (1.) Situation. This feedback loop suggests that the emotion generation process can occur recursively, is ongoing, and dynamic.

The process model contends that each of these four points in the emotion generation process can be subjected to regulation. From this conceptualisation, the process model posits five different families of emotion regulation that correspond to the regulation of a particular point in the emotion generation process. They occur in the following order:

  1. Situation selection.
  2. Situation modification.
  3. Attentional deployment.
  4. Cognitive change.
  5. Response modulation.

The process model also divides these emotion regulation strategies into two categories:

  • Antecedent-focused strategies (i.e. situation selection, situation modification, attentional deployment, and cognitive change) occur before an emotional response is fully generated.
  • Response-focused strategies (i.e. response modulation) occur after an emotional response is fully generated.

Strategies

Situation Selection

Situation selection involves choosing to avoid or approach an emotionally relevant situation. If a person selects to avoid or disengage from an emotionally relevant situation, he or she is decreasing the likelihood of experiencing an emotion. Alternatively, if a person selects to approach or engage with an emotionally relevant situation, he or she is increasing the likelihood of experiencing an emotion.

Typical examples of situation selection may be seen interpersonally, such as when a parent removes his or her child from an emotionally unpleasant situation. Use of situation selection may also be seen in psychopathology. For example, avoidance of social situations to regulate emotions is particularly pronounced for those with social anxiety disorder and avoidant personality disorder.

Effective situation selection is not always an easy task. For instance, humans display difficulties predicting their emotional responses to future events. Therefore, they may have trouble making accurate and appropriate decisions about which emotionally relevant situations to approach or to avoid.

Situation Modification

Situation modification involves efforts to modify a situation so as to change its emotional impact. Situation modification refers specifically to altering one’s external, physical environment. Altering one’s “internal” environment to regulate emotion is called cognitive change.

Examples of situation modification may include injecting humour into a speech to elicit laughter or extending the physical distance between oneself and another person.

Attentional Deployment

Attentional deployment involves directing one’s attention towards or away from an emotional situation.

Distraction

Distraction, an example of attentional deployment, is an early selection strategy, which involves diverting one’s attention away from an emotional stimulus and towards other content. Distraction has been shown to reduce the intensity of painful and emotional experiences, to decrease facial responding and neural activation in the amygdala associated with emotion, as well as to alleviate emotional distress. As opposed to reappraisal, individuals show a relative preference to engage in distraction when facing stimuli of high negative emotional intensity. This is because distraction easily filters out high-intensity emotional content, which would otherwise be relatively difficult to appraise and process.

Rumination

Rumination, an example of attentional deployment, is defined as the passive and repetitive focusing of one’s attention on one’s symptoms of distress and the causes and consequences of these symptoms. Rumination is generally considered a maladaptive emotion regulation strategy, as it tends to exacerbate emotional distress. It has also been implicated in a host of disorders including major depression.

Worry

Worry, an example of attentional deployment, involves directing attention to thoughts and images concerned with potentially negative events in the future. By focusing on these events, worrying serves to aid in the down-regulation of intense negative emotion and physiological activity. While worry may sometimes involve problem solving, incessant worry is generally considered maladaptive, being a common feature of anxiety disorders, particularly generalised anxiety disorder.

Thought Suppression

Thought suppression, an example of attentional deployment, involves efforts to redirect one’s attention from specific thoughts and mental images to other content so as to modify one’s emotional state. Although thought suppression may provide temporary relief from undesirable thoughts, it may ironically end up spurring the production of even more unwanted thoughts. This strategy is generally considered maladaptive, being most associated with obsessive-compulsive disorder.

Cognitive Change

Cognitive change involves changing how one appraises a situation so as to alter its emotional meaning.

Reappraisal

Reappraisal, an example of cognitive change, is a late selection strategy, which involves a change of the meaning of an event that alters its emotional impact. It encompasses different substrategies, such as positive reappraisal (creating and focusing on a positive aspect of the stimulus), decentring (reinterpreting an event by broadening one’s perspective to see “the bigger picture”), or fictional reappraisal (adopting or emphasizing the belief that event is not real, that it is for instance “just a movie” or “just my imagination”). Reappraisal has been shown to effectively reduce physiological, subjective, and neural emotional responding. As opposed to distraction, individuals show a relative preference to engage in reappraisal when facing stimuli of low negative emotional intensity because these stimuli are relatively easy to appraise and process.

Reappraisal is generally considered to be an adaptive emotion regulation strategy. Compared to suppression (including both thought suppression and expressive suppression), which is positively correlated with many psychological disorders, reappraisal can be associated with better interpersonal outcomes, and can be positively related to well-being. However, some researchers argue that context is important when evaluating the adaptiveness of a strategy, suggesting that in some contexts reappraisal may be maladaptive. Furthermore, some research has shown reappraisal does not influence affect or physiological responses to recurrent stress.

Distancing

Distancing, an example of cognitive change, involves taking on an independent, third-person perspective when evaluating an emotional event. Distancing has been shown to be an adaptive form of self-reflection, facilitating the emotional processing of negatively valenced stimuli, reducing emotional and cardiovascular reactivity to negative stimuli, and increasing problem-solving behaviour.

Humour

Humour, an example of cognitive change, has been shown to be an effective emotion regulation strategy. Specifically, positive, good-natured humour has been shown to effectively up-regulate positive emotion and down-regulate negative emotion. On the other hand, negative, mean-spirited humour is less effective in this regard.

Response Modulation

Response modulation involves attempts to directly influence experiential, behavioural, and physiological response systems.

Expressive Suppression

Expressive suppression, an example of response modulation, involves inhibiting emotional expressions. It has been shown to effectively reduce facial expressivity, subjective feelings of positive emotion, heart rate, and sympathetic activation. However, the research findings are mixed regarding whether this strategy is effective for down-regulating negative emotion. Research has also shown that expressive suppression may have negative social consequences, correlating with reduced personal connections and greater difficulties forming relationships.

Expressive suppression is generally considered to be a maladaptive emotion regulation strategy. Compared to reappraisal, it is positively correlated with many psychological disorders, associated with worse interpersonal outcomes, is negatively related to well-being, and requires the mobilization of a relatively substantial amount of cognitive resources. However, some researchers argue that context is important when evaluating the adaptiveness of a strategy, suggesting that in some contexts suppression may be adaptive.

Drug Use

Drug use, an example of response modulation, can be used to alter emotion-associated physiological responses. For example, alcohol can produce sedative and anxiolytic effects and beta blockers can affect sympathetic activation.

Exercise

Exercise, an example of response modulation, can be used to down-regulate the physiological and experiential effects of negative emotions. Regular physical activity has also been shown to reduce emotional distress and improve emotional control.

Sleep

Sleep plays a role in emotion regulation, although stress and worry can also interfere with sleep. Studies have shown that sleep, specifically REM (rapid eye movement) sleep, down-regulates reactivity of the amygdala, a brain structure known to be involved in the processing of emotions, in response to previous emotional experiences. On the flip side, sleep deprivation is associated with greater emotional reactivity or overreaction to negative and stressful stimuli. This is a result of both increased amygdala activity and a disconnect between the amygdala and the prefrontal cortex, which regulates the amygdala through inhibition, together resulting in an overactive emotional brain. Due to the subsequent lack of emotional control, sleep deprivation may be associated with depression, impulsivity, and mood swings. Additionally, there is some evidence that sleep deprivation may reduce emotional reactivity to positive stimuli and events and impair emotion recognition in others.

In Psychotherapy

Emotion regulation strategies are taught, and emotion regulation problems are treated, in a variety of counselling and psychotherapy approaches, including Cognitive Behavioural Therapy (CBT), Dialectical Behaviour Therapy (DBT), Emotion-Focused Therapy (EFT), and Mindfulness-Based Cognitive Therapy (MBCT).

For example, a relevant mnemonic formulated in DBT is “ABC PLEASE”:

  • Accumulate positive experiences.
  • Build mastery by being active in activities that make one feel competent and effective to combat helplessness.
  • Cope ahead, preparing an action plan, researching, and rehearsing (with a skilled helper if necessary).
  • Physical illness treatment and prevention through checkups.
  • Low vulnerability to diseases, managed with health care professionals.
  • Eating healthy.
  • Avoiding (non-prescribed) mood-altering drugs.
  • Sleep healthy.
  • Exercise regularly.

Developmental Process

Infancy

Intrinsic emotion regulation efforts during infancy are believed to be guided primarily by innate physiological response systems. These systems usually manifest as an approach towards and an avoidance of pleasant or unpleasant stimuli. At three months, infants can engage in self-soothing behaviours like sucking and can reflexively respond to and signal feelings of distress. For instance, infants have been observed attempting to suppress anger or sadness by knitting their brow or compressing their lips. Between three and six months, basic motor functioning and attentional mechanisms begin to play a role in emotion regulation, allowing infants to more effectively approach or avoid emotionally relevant situations. Infants may also engage in self-distraction and help-seeking behaviours for regulatory purposes. At one year, infants are able to navigate their surroundings more actively and respond to emotional stimuli with greater flexibility due to improved motor skills. They also begin to appreciate their caregivers’ abilities to provide them regulatory support. For instance, infants generally have difficulties regulating fear. As a result, they often find ways to express fear in ways that attract the comfort and attention of caregivers.

Extrinsic emotion regulation efforts by caregivers, including situation selection, modification, and distraction, are particularly important for infants. The emotion regulation strategies employed by caregivers to attenuate distress or to up-regulate positive affect in infants can impact the infants’ emotional and behavioural development, teaching them particular strategies and methods of regulation. The type of attachment style between caregiver and infant can therefore play a meaningful role in the regulatory strategies infants may learn to use.

Recent evidence supports the idea that maternal singing has a positive effect on affect regulation in infants. Singing play-songs, such as “The Wheels on the Bus” or “She’ll Be Comin’ Round the Mountain” have a visible affect-regulatory consequence of prolonged positive affect and even alleviation of distress. In addition to proven facilitation of social bonding, when combined with movement and/or rhythmic touch, maternal singing for affect regulation has possible applications for infants in the NICU (neo-natal intensive care unit) and for adult caregivers with serious personality or adjustment difficulties.

Toddler-Hood

By the end of the first year, toddlers begin to adopt new strategies to decrease negative arousal. These strategies can include rocking themselves, chewing on objects, or moving away from things that upset them. At two years, toddlers become more capable of actively employing emotion regulation strategies. They can apply certain emotion regulation tactics to influence various emotional states. Additionally, maturation of brain functioning and language and motor skills permits toddlers to manage their emotional responses and levels of arousal more effectively.

Extrinsic emotion regulation remains important to emotional development in toddlerhood. Toddlers can learn ways from their caregivers to control their emotions and behaviours. For example, caregivers help teach self-regulation methods by distracting children from unpleasant events (like a vaccination shot) or helping them understand frightening events.

Childhood

Emotion regulation knowledge becomes more substantial during childhood. For example, children aged six to ten begin to understand display rules. They come to appreciate the contexts in which certain emotional expressions are socially most appropriate and therefore ought to be regulated. For example, children may understand that upon receiving a gift they should display a smile, irrespective of their actual feelings about the gift. During childhood, there is also a trend towards the use of more cognitive emotion regulation strategies, taking the place of more basic distraction, approach, and avoidance tactics.

Regarding the development of emotion dysregulation in children, one robust finding suggests that children who are frequently exposed to negative emotion at home will be more likely to display, and have difficulties regulating, high levels of negative emotion.

Adolescence

Adolescents show a marked increase in their capacities to regulate their emotions, and emotion regulation decision making becomes more complex, depending on multiple factors. In particular, the significance of interpersonal outcomes increases for adolescents. When regulating their emotions, adolescents are therefore likely to take into account their social context. For instance, adolescents show a tendency to display more emotion if they expect a sympathetic response from their peers.

Additionally, spontaneous use of cognitive emotion regulation strategies increases during adolescence, which is evidenced both by self-report data and neural markers.

Adulthood

Social losses increase and health tends to decrease as people age. As people get older their motivation to seek emotional meaning in life through social ties tends to increase. Autonomic responsiveness decreases with age, and emotion regulation skill tends to increase.

Emotional regulation in adulthood can also be examined in terms of positive and negative affectivity. Positive and negative affectivity refers to the types of emotions felt by an individual as well as the way those emotions are expressed. With adulthood comes an increased ability to maintain both high positive affectivity and low negative affectivity “more rapidly than adolescents.” This response to life’s challenges seems to become “automatised” as people progress throughout adulthood. Thus, as individuals age, their capability of self-regulating emotions and responding to their emotions in healthy ways improves.

Additionally, emotional regulation may vary between young adults and older adults. Younger adults have been found to be more successful than older adults in practicing “cognitive reappraisal” to decrease negative internal emotions. On the other hand, older adults have been found to be more successful in the following emotional regulation areas:

  • Predicting the level of “emotional arousal” in possible situations.
  • Having a higher focus on positive information rather than negative.
  • Maintaining healthy levels of “hedonic well-being” (subjective well-being based on increased pleasure and decreased pain).

Overview of Perspectives

Neuropsychological Perspective

Affective

As people age, their affect – the way they react to emotions – changes, either positively or negatively. Studies show that positive affect increases as a person grows from adolescence to their mid 70s. Negative affect, on the other hand, decreases until the mid 70s. Studies also show that emotions differ in adulthood, particularly affect (positive or negative). Although some studies found that individuals experience less affect as they grow older, other studies have concluded that adults in their middle age experience more positive affect and less negative affect than younger adults. Positive affect was also higher for men than women while the negative affect was higher for women than it was for men and also for single people. A reason that older people – middle adulthood – might have less negative affect is because they have overcome, “the trials and vicissitudes of youth, they may increasingly experience a more pleasant balance of affect, at least up until their mid-70s”. Positive affect might rise during middle age but towards the later years of life – the 70s – it begins to decline while negative affect also does the same. This might be due to failing health, reaching the end of their lives and the death of friends and relatives.

In addition to baseline levels of positive and negative affect, studies have found individual differences in the time-course of emotional responses to stimuli. The temporal dynamics of emotion regulation, also known as affective chronometry, include two key variables in the emotional response process: rise time to peak emotional response, and recovery time to baseline levels of emotion. Studies of affective chronometry typically separate positive and negative affect into distinct categories, as previous research has shown (despite some correlation) the ability of humans to experience changes in these categories independently of one another. Affective chronometry research has been conducted on clinical populations with anxiety, mood, and personality disorders, but is also utilised as a measurement to test the effectiveness of different therapeutic techniques (including mindfulness training) on emotional dysregulation.

Neurological

The development of functional magnetic resonance imaging has allowed for the study of emotion regulation on a biological level. Specifically, research over the last decade strongly suggests that there is a neural basis. Sufficient evidence has correlated emotion regulation to particular patterns of prefrontal activation. These regions include the orbital prefrontal cortex, the ventromedial prefrontal cortex, and the dorsolateral prefrontal cortex. Two additional brain structures that have been found to contribute are the amygdala and the anterior cingulate cortex. Each of these structures are involved in various facets of emotion regulation and irregularities in one or more regions and/or interconnections among them are affiliated with failures of emotion regulation. An implication to these findings is that individual differences in prefrontal activation predict the ability to perform various tasks in aspects of emotion regulation.

Sociological

People intuitively mimic facial expressions; it is a fundamental part of healthy functioning. Similarities across cultures in regards to nonverbal communication has prompted the debate that it is in fact a universal language. It can be argued that emotion regulation plays a key role in the ability to generate the correct responses in social situations. Humans have control over facial expressions both consciously and unconsciously: an intrinsic emotion programme is generated as the result of a transaction with the world, which immediately results in an emotional response and usually a facial reaction. It is a well documented phenomenon that emotions have an effect on facial expression, but recent research has provided evidence that the opposite may also be true.

This notion would give rise to the belief that a person may not only control his emotion but in fact influence them as well. Emotion regulation focuses on providing the appropriate emotion in the appropriate circumstances. Some theories allude to the thought that each emotion serves a specific purpose in coordinating organismic needs with environmental demands. This skill, although apparent throughout all nationalities, has been shown to vary in successful application at different age groups. In experiments done comparing younger and older adults to the same unpleasant stimuli, older adults were able to regulate their emotional reactions in a way that seemed to avoid negative confrontation. These findings support the theory that with time people develop a better ability to regulate their emotions. This ability found in adults seems to better allow individuals to react in what would be considered a more appropriate manner in some social situations, permitting them to avoid adverse situations that could be seen as detrimental.

Expressive Regulation (In Solitary Conditions)

In solitary conditions, emotion regulation can include a minimisation-miniaturisation effect, in which common outward expressive patterns are replaced with toned down versions of expression. Unlike other situations, in which physical expression (and its regulation) serve a social purpose (i.e. conforming to display rules or revealing emotion to outsiders), solitary conditions require no reason for emotions to be outwardly expressed (although intense levels of emotion can bring out noticeable expression anyway). The idea behind this is that as people get older, they learn that the purpose of outward expression (to appeal to other people), is not necessary in situations in which there is no one to appeal to. As a result, the level of emotional expression can be lower in these solitary situations.

Stress

The way an individual reacts to stress can directly overlap with their ability to regulate emotion. Although the two concepts differ in a multitude of ways, “both coping [with stress] and emotion regulation involve affect modulation and appraisal processes” that are necessary for healthy relationships and self-identity.

According to Yu. V. Shcherbatykh, emotional stress in situations like school examinations can be reduced by engaging in self-regulating activities prior to the task being performed. To study the influence of self-regulation on mental and physiological processes under exam stress, Shcherbatykh conducted a test with an experimental group of 28 students (of both sexes) and a control group of 102 students (also of both sexes).

In the moments before the examination, situational stress levels were raised in both groups from what they were in quiet states. In the experimental group, participants engaged in three self-regulating techniques (concentration on respiration, general body relaxation, and the creation of a mental image of successfully passing the examination). During the examination, the anxiety levels of the experimental group were lower than that of the control group. Also, the percent of unsatisfactory marks in the experimental group was 1.7 times less than in the control group. From this data, Shcherbatykh concluded that the application of self-regulating actions before examinations helps to significantly reduce levels of emotional strain, which can help lead to better performance results.

Decision Making

Identification of our emotional self-regulating process can facilitate in the decision making process. Current literature on emotion regulation identifies that humans characteristically make efforts in controlling emotion experiences. There is then a possibility that our present state emotions can be altered by emotion regulation strategies resulting in the possibility that different regulation strategies could have different decision implications.

Effects of Low Self-Regulation

With a failure in emotion regulation, there is a rise in psychosocial and emotional dysfunctions caused by traumatic experiences due to an inability to regulate emotions. These traumatic experiences typically happen in grade school and are sometimes associated with bullying. Children who can not properly self-regulate express their volatile emotions in a variety of ways, including screaming if they don’t have their way, lashing out with their fists, throwing objects (such as chairs), or bullying other children. Such behaviours often elicit negative reactions from the social environment, which, in turn, can exacerbate or maintain the original regulation problems over time, a process termed cumulative continuity.

These children are more likely to have conflict-based relationships with their teachers and other children. This can lead to more severe problems such as an impaired ability to adjust to school and predicts school dropout many years later. Children who fail to properly self-regulate grow as teenagers with more emerging problems. Their peers begin to notice this “immaturity”, and these children are often excluded from social groups and teased and harassed by their peers. This “immaturity” certainly causes some teenagers to become social outcasts in their respective social groups, causing them to lash out in angry and potentially violent ways. Being teased or being an outcast in childhood is especially damaging because it could lead to psychological symptoms such as depression and anxiety (in which dysregulated emotions play a central role), which, in turn, could lead to more peer victimisation. This is why it is recommended to foster emotional self-regulation in children as early as possible.

What is Reduced Affect Display?

Introduction

Reduced affect display, sometimes referred to as emotional blunting, is a condition of reduced emotional reactivity in an individual.

It manifests as a failure to express feelings (affect display) either verbally or nonverbally, especially when talking about issues that would normally be expected to engage the emotions. Expressive gestures are rare and there is little animation in facial expression or vocal inflection. Reduced affect can be symptomatic of autism, schizophrenia, depression, posttraumatic stress disorder, depersonalisation disorder, schizoid personality disorder or brain damage. It may also be a side effect of certain medications (e.g. antipsychotics and antidepressants).

Reduced affect should be distinguished from apathy and anhedonia, which explicitly refer to a lack of emotion, whereas reduced affect is a lack of emotional expression (affect display) regardless of whether emotion (underlying affect) is actually reduced or not.

Types

Constricted Affect

A restricted or constricted affect is a reduction in an individual’s expressive range and the intensity of emotional responses.

Blunted and Flat Affect

Blunted affect is a lack of affect more severe than restricted or constricted affect, but less severe than flat or flattened affect. “The difference between flat and blunted affect is in degree. A person with flat affect has no or nearly no emotional expression. He or she may not react at all to circumstances that usually evoke strong emotions in others. A person with blunted affect, on the other hand, has a significantly reduced intensity in emotional expression”.

Shallow Affect

Shallow affect has equivalent meaning to blunted affect. Factor 1 of the Psychopathy Checklist identifies shallow affect as a common attribute of psychopathy.

Brain Structures

Individuals with schizophrenia with blunted affect show different regional brain activity in fMRI scans when presented with emotional stimuli compared to individuals with schizophrenia without blunted affect. Individuals with schizophrenia without blunted affect show activation in the following brain areas when shown emotionally negative pictures: midbrain, pons, anterior cingulate cortex, insula, ventrolateral orbitofrontal cortex, anterior temporal pole, amygdala, medial prefrontal cortex, and extrastriate visual cortex. Individuals with schizophrenia with blunted affect show activation in the following brain regions when shown emotionally negative pictures: midbrain, pons, anterior temporal pole, and extrastriate visual cortex.

Limbic Structures

Individuals with schizophrenia with flat affect show decreased activation in the limbic system when viewing emotional stimuli. In individuals with schizophrenia with blunted affect neural processes begin in the occipitotemporal region of the brain and go through the ventral visual pathway and the limbic structures until they reach the inferior frontal areas. Damage to the amygdala of adult rhesus macaques early in life can permanently alter affective processing. Lesioning the amygdala causes blunted affect responses to both positive and negative stimuli. This effect is irreversible in the rhesus macaques; neonatal damage produces the same effect as damage that occurs later in life. The macaques’ brain cannot compensate for early amygdala damage even though significant neuronal growth may occur. There is some evidence that blunted affect symptoms in schizophrenia patients are not a result of just amygdala responsiveness, but a result of the amygdala not being integrated with other areas of the brain associated with emotional processing, particularly in amygdala-prefrontal cortex coupling. Damage in the limbic region prevents the amygdala from correctly interpreting emotional stimuli in individuals with schizophrenia by compromising the link between the amygdala and other brain regions associated with emotion.

Brainstem

Parts of the brainstem are responsible for passive emotional coping strategies that are characterized by disengagement or withdrawal from the external environment (quiescence, immobility, hyporeactivity), similar to what is seen in blunted affect. Individuals with schizophrenia with blunted affect show activation of the brainstem during fMRI scans, particularly the right medulla and the left pons, when shown “sad” film excerpts. The bilateral midbrain is also activated in individuals with schizophrenia diagnosed with blunted affect. Activation of the midbrain is thought to be related to autonomic responses associated with perceptual processing of emotional stimuli. This region usually becomes activated in diverse emotional states. When the connectivity between the midbrain and the medial prefrontal cortex is compromised in individuals with schizophrenia with blunted affect an absence of emotional reaction to external stimuli results.

Prefrontal Cortex

Individuals with schizophrenia, as well as patients being successfully reconditioned with quetiapine for blunted affect, show activation of the prefrontal cortex (PFC). Failure to activate the PFC is possibly involved in impaired emotional processing in individuals with schizophrenia with blunted affect. The mesial PFC is activated in aver individuals in response to external emotional stimuli. This structure possibly receives information from the limbic structures to regulate emotional experiences and behaviour. Individuals being reconditioned with quetiapine, who show reduced symptoms, show activation in other areas of the PFC as well, including the right medial prefrontal gyrus and the left orbitofrontal gyrus.

Anterior Cingulate Cortex

A positive correlation has been found between activation of the anterior cingulate cortex and the reported magnitude of sad feelings evoked by viewing sad film excerpts. The rostral subdivision of this region is possibly involved in detecting emotional signals. This region is different in individuals with schizophrenia with blunted affect.

Diagnoses

Schizophrenia

Patients with schizophrenia have long been recognized as showing “flat or inappropriate affect, with splitting of feelings from events … feelings seem flat instead of being in contact with what is going on”. One study of flat affect in schizophrenia found that “flat affect was more common in men, and was associated with worse current quality of life” as well as having “an adverse effect on course of illness”.

The study also reported a “dissociation between reported experience of emotion and its display” – supporting the suggestion made elsewhere that “blunted affect, including flattened facial expressiveness and lack of vocal inflection … often disguises an individual’s true feelings.” Thus, feelings may merely be unexpressed, rather than totally lacking. On the other hand, “a lack of emotions which is due not to mere repression but to a real loss of contact with the objective world gives the observer a specific impression of ‘queerness’ … the remainders of emotions or the substitutes for emotions usually refer to rage and aggressiveness”. In the most extreme cases, there is a complete “dissociation from affective states”.

Another study found that when speaking, individuals with schizophrenia with flat affect demonstrate less inflection than normal controls and appear to be less fluent. Normal subjects appear to express themselves using more complex syntax, whereas flat affect subjects speak with fewer words, and fewer words per sentence. Flat affect individuals’ use of context-appropriate words in both sad and happy narratives are similar to that of controls. It is very likely that flat affect is a result of deficits in motor expression as opposed to emotional processing. The moods of display are compromised, but subjective, autonomic, and contextual aspects of emotion are left intact.

Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) was previously known to cause negative feelings, such as depressed mood, re-experiencing and hyperarousal. However, recently, psychologists have started to focus their attention on the blunted affects and also the decrease in feeling and expressing positive emotions in PTSD patients. Blunted affect, or emotional numbness, is considered one of the consequences of PTSD because it causes a diminished interest in activities that produce pleasure (anhedonia) and produces feelings of detachment from others, restricted emotional expression and a reduced tendency to express emotions behaviourally. Blunted affect is often seen in veterans as a consequence of the psychological stressful experiences that caused PTSD. Blunted affect is a response to PTSD, it is considered one of the central symptoms in post-traumatic stress disorders and it is often seen in veterans who served in combat zones. In PTSD, blunted affect can be considered a psychological response to PTSD as a way to combat overwhelming anxiety that the patients feel. In blunted affect, there are abnormalities in circuits that also include the prefrontal cortex.

Assessment

In making assessments of mood and affect the clinician is cautioned that “it is important to keep in mind that demonstrative expression can be influenced by cultural differences, medication, or situational factors”; while the layperson is warned to beware of applying the criterion lightly to “friends, otherwise [he or she] is likely to make false judgments, in view of the prevalence of schizoid and cyclothymic personalities in our ‘normal’ population, and our [US] tendency to psychological hypochondriasis”.

R.D. Laing in particular stressed that “such ‘clinical’ categories as schizoid, autistic, ‘impoverished’ affect … all presuppose that there are reliable, valid impersonal criteria for making attributions about the other person’s relation to [his or her] actions. There are no such reliable or valid criteria”.

Differential Diagnosis

Blunted affect is very similar to anhedonia, which is the decrease or cessation of all feelings of pleasure (which thus affects enjoyment, happiness, fun, interest, and satisfaction). In the case of anhedonia, emotions relating to pleasure will not be expressed as much or at all because they are literally not experienced or are decreased. Both blunted affect and anhedonia are considered negative symptoms of schizophrenia, meaning that they are indicative of a lack of something. There are some other negative symptoms of schizophrenia which include avolition, alogia and catatonic behaviour.

Closely related is alexithymia – a condition describing people who “lack words for their feelings. They seem to lack feelings altogether, although this may actually be because of their inability to express emotion rather than from an absence of emotion altogether”. Alexithymic patients however can provide clues via assessment presentation which may be indicative of emotional arousal.

“If the amygdala is severed from the rest of the brain, the result is a striking inability to gauge the emotional significance of events; this condition is sometimes called ‘affective blindness'”. In some cases, blunted affect can fade, but there is no conclusive evidence of why this can occur.

What is Emotionality?

Introduction

Emotionality is the observable behavioural and physiological component of emotion. It is a measure of a person’s emotional reactivity to a stimulus.

Most of these responses can be observed by other people, while some emotional responses can only be observed by the person experiencing them. Observable responses to emotion (i.e. smiling) do not have a single meaning. A smile can be used to express happiness or anxiety, while a frown can communicate sadness or anger. Emotionality is often used by experimental psychology researchers to operationalise emotion in research studies.

Early Theories

By the late 1800s, many high-quality contributions became interested in analysing emotion because of the works of psychologists and scientists such as Wilhelm Wundt, George Stout, William McDougall, William James, and George Herbert Mead. William James preferred to focus on the physiological aspects of emotional response, although he did not disregard the perceptual or cognitive components. William McDougall thought of emotion as the articulation of a natural response built on instinct. Other psychologists reasoned that although gestures express emotion, this is not the entirety of their function. Wundt analysed that emotion portrays both expression and communication.

As Irrational

One of the oldest views of emotion is that emotion indicates inferiority. In early psychology, it was believed that passion (emotion) was a part of the soul inherited from the animals and that it must be controlled. Solomon identified that in the Romantic movement of the eighteenth and nineteenth centuries, reason and emotion were discovered to be opposites.

As Physiological

Physiological responses to emotion originate in the central nervous system, the autonomic nervous system, and the endocrine system. Some of the responses include: heart rate, sweating, rate and depth of respiration, and electrical activity in the brain. Many researchers have attempted to find a connection between specific emotions and a corresponding pattern of physiological responses, but the results have been inconclusive.

Later Theories

The significant theories of emotion can be divided into three primary categories: physiological, neurological, and cognitive. Physiological theories imply that activity within the body can be accountable for emotions. Neurological theories suggest that activity within the brain leads to emotional responses. Lastly, cognitive theories reason that thoughts and other mental activity have a vital role in the stimulation of emotions. Common sense suggests that people first become consciously aware of their emotions and that the physiological responses follow shortly after. Theories by James-Lange, Cannon-Bard, and Schachter-Singer contradict the common-sense theory.

James-Lange

The James-Lange theory of emotion was proposed by psychologist William James and physiologist Carl Lange. This theory suggests that emotions occur as a result of physiological responses to outside stimuli or events. For example, this theory suggests that if someone is driving down the road and sees the headlights of another car heading toward them in their lane, their heart begins to race (a physiological response) and then they become afraid (fear being the emotion).

Cannon-Bard

The Cannon-Bard theory, which was conceptualized by Walter Cannon and Phillip Bard, suggests that emotions and their corresponding physiological responses are experienced simultaneously. Using the previous example, when someone sees the car coming toward them in their lane, their heart starts to race and they feel afraid at the same time.

Schachter-Singer

Stanley Schachter and Jerome Singer proposed a theory also known as the two-factor theory of emotion, which implies emotion have two factors: physical arousal and cognitive label. This suggests that if the physiological activity occurs first, then it must cognitively be distinguished as the cause of the arousal and labelled as an emotion. Using the example of someone seeing a car coming towards them in their lane, their heart would start to race and they would identify that they must be afraid if their heart is racing, and from there they would begin to feel fear.

Gender Differences

The opposition of rational thought and emotion is believed to be paralleled by the similar opposition between male and female. A traditional view is that “men are seen as rational and women as emotional, lacking rationality.” However, in spite of these ideas, and in spite of gender differences in the prevalence of mood disorders, the empirical evidence on gender differences in emotional responding is mixed.

When engaging in social interaction, studies show that women smile significantly more than men do. It is difficult to determine the exact difference between males and females to explain this disparity. It is possible that this difference in expression of emotions is due to societal influences and conformity to gender roles. However, this may not fully explain why men smile less than women do.

The male gender role involves characteristics such as strength, expert knowledge, and a competitive nature. Smiling may be stereotypically associated with weakness. Men may feel that if they engage in this perceived weakness, it may contradict their attempts to show strength and other traits of the male gender role. Another broad explanation for the contrast in male and female gender expression is that women have reported to experience greater levels of emotional intensity than men, in both positive and negative aspects, which could naturally lead to greater emotional response. It has also been reported that men are more likely to confide in female companions, revealing their emotions and intimacy, while females are typically comfortable confiding in both genders. This suggests that men are more particular about how they express the emotions they feel, potentially relating back to gender roles.

Across Cultures

There are six universal emotions which expand across all cultures. These emotions are happiness, sadness, anger, fear, surprise, and disgust. Debate exists about whether contempt should be combined with disgust. According to Ekman (1992), each of these emotions have universally corresponding facial expressions as well.

In addition to the facial expressions that are said to accompany each emotion, there is also evidence to suggest that certain autonomic nervous system (ANS) activity is associated with the three emotions of fear, anger, and disgust. Ekman theorizes that these specific emotions are associated with the universal physiological responses due to evolution. It would not be expected to observe the same physiological responses for emotions not specifically linked to survival, such as happiness or sadness.

Ekman’s theories were early challenged by James A. Russell, and have since been tested by a variety of researchers, with ambiguous results. This seems to reflect methodological problems relating to both display rules and to the components of emotion. Current thinking favours a mix of underlying universality combined with significant cultural differences in the articulation and expression of emotion. Emotions serve different functions in different cultures.

Positive

Positive emotionality is the ability to control positive mood and emotions, people with positive emotions seek for social reward. Positive emotionality can be a preventive factor in blocking out certain types of mental illness. In a study of a sample of 1,655 youth (54% girls; 7-16 years), it found that the higher their positive emotionality was, the lower their depression would be. Depression was considered by its definition of the inability to receive positive emotions or pleasure. The youth’s temperament, adaptive emotion regulation (ER) strategies, and depressive symptoms were determined through a questionnaire. The study also reported that depressive symptoms could be reduced through emotion regulation of positive mood. A study by Charles T. Taylor et al. linked being exposed to positive emotions before a surgery to less anxiety and a decrease in having symptoms after treatment.

Negative

Negative emotionality is the opposite of positive emotionality. People are unable to control their positive mood and emotions. Everyone experiences negative emotionality in different levels, there are different factors that effect each individual in a different way. Negative emotionality effects many aspects of our lives in terms of coping and the relationship that people share with one another. Neuroticism is one of the biggest factors found in negative emotionality. Someone on the higher spectrum of neuroticism is often more anxious and enjoy the feelings of their negative emotion. Some research suggests that obese children compared to children who are not obese have higher levels of negative emotionality and the ability to control emotions.

What is Emotional Dysregulation?

Introduction

Emotional dysregulation is a term used in the mental health community that refers to emotional responses that are poorly modulated and do not lie within the accepted range of emotive response.

Refer to Emotional Self-Regulation.

Emotional dysregulation can be associated with an experience of early psychological trauma, brain injury, or chronic maltreatment (such as child abuse, child neglect, or institutional neglect/abuse), and associated disorders such as reactive attachment disorder. Emotional dysregulation may be present in people with psychiatric disorders such as attention deficit hyperactivity disorder, autism spectrum disorders, bipolar disorder, borderline personality disorder, complex post-traumatic stress disorder, and foetal alcohol spectrum disorders. In such cases as borderline personality disorder and complex post-traumatic stress disorder, hypersensitivity to emotional stimuli causes a slower return to a normal emotional state. This is manifested biologically by deficits in the frontal cortices of the brain.

Possible manifestations of emotional dysregulation include extreme tearfulness, angry outbursts or behavioural outbursts such as destroying or throwing objects, aggression towards self or others, and threats to kill oneself. Emotional dysregulation can lead to behavioural problems and can interfere with a person’s social interactions and relationships at home, in school, or at place of employment.

Etymology

The word “dysregulation” is a neologism created by combining the prefix “dys-” to “regulation”. According to Webster’s Dictionary, dys- has various roots and is of Greek origin. With Latin and Greek roots, it is akin to Old English tō-, te- “apart” and in Sanskrit dus- “bad, difficult.” It is frequently confused with the spelling “disregulation” with the prefix “dis” meaning “the opposite of” or “absence of”.

Child psychopathology

There are links between child emotional dysregulation and later psychopathology. For instance, ADHD symptoms are associated with problems with emotional regulation, motivation, and arousal. One study found a connection between emotional dysregulation at 5 and 10 months, and parent-reported problems with anger and distress at 18 months. Low levels of emotional regulation behaviours at 5 months were also related to non-compliant behaviours at 30 months. While links have been found between emotional dysregulation and child psychopathology, the mechanisms behind how early emotional dysregulation and later psychopathology are related are not yet clear.

Symptoms

Smoking, self-harm, eating disorders, and addiction have all been associated with emotional dysregulation. Somatoform disorders may be caused by a decreased ability to regulate and experience emotions or an inability to express emotions in a positive way. Individuals who have difficulty regulating emotions are at risk for eating disorders and substance abuse as they use food or substances as a way to regulate their emotions. Emotional dysregulation is also found in people who have an increased risk of developing a mental disorder, in particularly an affective disorder such as depression or bipolar disorder.

Early Childhood

Research has shown that failures in emotional regulation may be related to the display of acting out, externalizing disorders, or behaviour problems. When presented with challenging tasks, children who were found to have defects in emotional regulation (high-risk) spent less time attending to tasks and more time throwing tantrums or fretting than children without emotional regulation problems (low-risk). These high-risk children had difficulty with self-regulation and had difficulty complying with requests from caregivers and were more defiant. Emotional dysregulation has also been associated with childhood social withdrawal. Common signs of emotional dysregulation in early childhood include isolation, throwing things, screaming, lack of eye contact, refusing to speak, rocking, running away, crying, dissociating, high levels of anxiety, or inability to be flexible.

Internalising Behaviours

Emotional dysregulation in children can be associated with internalizing behaviours including:

  • Exhibiting emotions too intense for a situation.
  • Difficulty calming down when upset.
  • Difficulty decreasing negative emotions.
  • Being less able to calm themselves.
  • Difficulty understanding emotional experiences.
  • Becoming avoidant or aggressive when dealing with negative emotions.
  • Experiencing more negative emotions.

Externalising Behaviours

Emotional dysregulation in children can be associated with externalizing behaviours including:

  • Exhibiting more extreme emotions.
  • Difficulty identifying emotional cues.
  • Difficulty recognizing their own emotions.
  • Focusing on the negative.
  • Difficulty controlling their attention.
  • Being impulsive.
  • Difficulty decreasing their negative emotions.
  • Difficulty calming down when upset.

Protective Factors

Early experiences with caregivers can lead to differences in emotional regulation. The responsiveness of a caregiver to an infant’s signals can help an infant regulate their emotional systems. Caregiver interaction styles that overwhelm a child or that are unpredictable may undermine emotional regulation development. Effective strategies involve working with a child to support developing self-control such as modelling a desired behaviour rather than demanding it.

The richness of an environment that a child is exposed to helps the development of emotional regulation. An environment must provide appropriate levels of freedom and constraint. The environment must allow opportunities for a child to practice self-regulation. An environment with opportunities to practice social skills without over-stimulation or excessive frustration helps a child develop self-regulation skills.

Emotional Dysregulation and Substance Use

Several variables have been explored to explain the connection between emotional dysregulation and substance use in young adults, such as child maltreatment, cortisol levels, family environment, and symptoms of depression and anxiety. Vilhena-Churchill and Goldstein (2014) explored the association between childhood maltreatment and emotional dysregulation. More severe childhood maltreatment was found to be associated with an increase in difficulty regulating emotion, which in turn was associated with a greater likelihood of coping by using marijuana. Kliewer et al. (2016) performed a study on the relationship between negative family emotional climate, emotional dysregulation, blunted anticipatory cortisol, and substance use in adolescents. Increased negative family emotional climate was found to be associated with high levels of emotional dysregulation, which was then associated with increased substance use. Girls were seen to have blunted anticipatory cortisol levels, which was also associated with an increase in substance use. Childhood events and family climate with emotional dysregulation are both factors seemingly linked to substance use. Prosek, Giordano, Woehler, Price, and McCullough (2018) explored the relationship between mental health and emotional regulation in collegiate illicit substance users. Illicit drug users reported higher levels of depression and anxiety symptoms. Emotional dysregulation was more prominent in illicit drug users in the sense that they had less clarity and were less aware of their emotions when the emotions were occurring.

Treatment

While cognitive behavioural therapy is the most widely prescribed treatment for such psychiatric disorders, a commonly prescribed psychotherapeutic treatment for emotional dysregulation is dialectical behavioural therapy, a psychotherapy which promotes the use of mindfulness, a concept called dialectics, and emphasizes the importance of validation and maintaining healthy behavioural habits.

When diagnosed as being part of ADHD, norepinephrine and dopamine reuptake inhibitors such as methylphenidate (Ritalin) and atomoxetine are often used.

References

Kliewer, W., Riley, T., Zaharakis, N., Borre, A., Drazdowski, T.K. & Jäggi, L. (2016) Emotion Dysregulation, Anticipatory Cortisol, and Substance Use in Urban Adolescents. Personality and Individual Differences. 99, pp.200-205. doi:10.1016/j.paid.2016.05.011. PMC 5082236. PMID 27795602.

Prosek, E.A., Giordano, A.L., Woehler, E.S., Price, E. & McCullough, R. (2018) Differences in Emotion Dysregulation and Symptoms of Depression and Anxiety among Illicit Substance Users and Nonusers. Substance Use & Misuse. 53(11), pp.1915-1918. doi:10.1080/10826084.2018.1436563. PMID 29465278. S2CID 3411848.

Vilhena-Churchill, N. & Goldstein, A.L. (2014) Child Maltreatment and Marijuana Problems in Young Adults: Examining the Role of Motives and Emotion Dysregulation. Child Abuse & Neglect. 38(5), pp.962-972. doi:10.1016/j.chiabu.2013.10.009. PMID 24268374.

What is Affect (Psychology)?

Introduction

Affect, in psychology, refers to the underlying experience of feeling, emotion or mood.

Dimensions of Affect

Affective states are psycho-physiological constructs – meaning, largely, concepts that connect mental and physical processes. According to most current views, they vary along three principal dimensions: valence, arousal, and motivational intensity.

  • Valence is the subjective spectrum of positive-to-negative evaluation of an experience an individual may have had.
    • Emotional valence refers to the emotion’s consequences, emotion-eliciting circumstances, or subjective feelings or attitudes.
  • Arousal is objectively measurable as activation of the sympathetic nervous system, but can also be assessed subjectively via self-report.
  • Motivational intensity refers to the impulsion to act; the strength of an urge to move toward or away from a stimulus and whether or not to interact with said stimulus.
    • Simply moving is not considered approach (or avoidance) motivation.

It is important to note that arousal is different from motivational intensity. While arousal is a construct that is closely related to motivational intensity, they differ in that motivation necessarily implies action while arousal does not.

Affect Display

Affect is sometimes used to mean affect display, which is a facial, vocal, or gestural behaviour that serves as an indicator of affect.

Effects

In psychology, affect brings about an organism’s interaction with stimuli.

Affect can influence cognitive scope (the breadth of cognitive processes). Initially, it was thought that positive affects broadened whereas negative affects narrowed cognitive scope. However, evidence now suggests that affects high in motivational intensity narrow cognitive scope whereas affects low in motivational intensity broaden it. The construct of cognitive scope has proven valuable in cognitive psychology.

Affect Tolerance

According to a research article about affect tolerance written by psychiatrist Jerome Sashin (1985), “Affect tolerance can be defined as the ability to respond to a stimulus which would ordinarily be expected to evoke affects by the subjective experiencing of feelings.” Essentially it refers to one’s ability to react to emotions and feelings. One who is low in affect tolerance would show little to no reaction to emotion and feeling of any kind. This is closely related to alexithymia.

“Alexithymia is a subclinical phenomenon involving a lack of emotional awareness or, more specifically, difficulty in identifying and describing feelings and in distinguishing feelings from the bodily sensations of emotional arousal” (Glimcher & Fehr, 2014). At its core, alexithymia is an inability for an individual to recognise what emotions they are feeling – as well as an inability to describe them. According to Dalya Samur and colleagues (2013) people with alexithymia have been shown to have correlations with increased suicide rates, mental discomfort, and deaths.

Affect tolerance factors, including anxiety sensitivity, intolerance of uncertainty, and emotional distress tolerance, may be helped by mindfulness. Mindfulness refers to the practice of being hyper aware of one’s own feelings, thoughts, sensations, and the stimulus of the environment around you – not in an anxiety-inducing way, but in a gentle and pleasant way. Mindfulness has been shown to produce increased subjective well-being, reduced psychological symptoms and emotional reactivity, and improved behavioural regulation.

Relationship to Behaviour and Cognition

The affective domain represents one of the three divisions described in modern psychology: the other two being the behavioural, and the cognitive. Classically, these divisions have also been referred to as the “ABC’s of psychology”. However, in certain views, the cognitive may be considered as a part of the affective, or the affective as a part of the cognitive; it is important to note that “cognitive and affective states … [are] merely analytic categories.”

Instinctive and Cognitive Factors in Causation of Affect

Affect can mean an instinctual reaction to stimulation that occurs before the typical cognitive processes considered necessary for the formation of a more complex emotion. Robert B. Zajonc (1980) asserts this reaction to stimuli is primary for human beings and that it is the dominant reaction for non-human organisms. Zajonc suggests that affective reactions can occur without extensive perceptual and cognitive encoding and be made sooner and with greater confidence than cognitive judgments.

Many theorists, such as Lazarus (1982) consider affect to be post-cognitive: elicited only after a certain amount of cognitive processing of information has been accomplished. In this view, such affective reactions as liking, disliking, evaluation, or the experience of pleasure or displeasure each result from a different prior cognitive process that makes a variety of content discriminations and identifies features, examines them to find value, and weighs them according to their contributions (Brewin, 1989). Some scholars, such as Lerner and Keltner (2000) argue that affect can be both pre- and post-cognitive: initial emotional responses produce thoughts, which produce affect. In a further iteration, some scholars argue that affect is necessary for enabling more rational modes of cognition (Damasio, 2006).

A divergence from a narrow reinforcement model of emotion allows other perspectives about how affect influences emotional development. Thus, temperament, cognitive development, socialisation patterns, and the idiosyncrasies of one’s family or subculture might interact in nonlinear ways. For example, the temperament of a highly reactive/low self-soothing infant may “disproportionately” affect the process of emotion regulation in the early months of life (Griffiths, 1997).

Some other social sciences, such as geography or anthropology, have adopted the concept of affect during the last decade. In French psychoanalysis a major contribution to the field of affect comes from André Green (1973). The focus on affect has largely derived from the work of Deleuze and brought emotional and visceral concerns into such conventional discourses as those on geopolitics, urban life and material culture. Affect has also challenged methodologies of the social sciences by emphasizing somatic power over the idea of a removed objectivity and therefore has strong ties with the contemporary non-representational theory.

Brief History

A number of experiments have been conducted in the study of social and psychological affective preferences (i.e., what people like or dislike). Specific research has been done on preferences, attitudes, impression formation, and decision making. This research contrasts findings with recognition memory (old-new judgements), allowing researchers to demonstrate reliable distinctions between the two. Affect-based judgements and cognitive processes have been examined with noted differences indicated, and some argue affect and cognition are under the control of separate and partially independent systems that can influence each other in a variety of ways (Zajonc, 1980). Both affect and cognition may constitute independent sources of effects within systems of information processing. Others suggest emotion is a result of an anticipated, experienced, or imagined outcome of an adaptational transaction between organism and environment, therefore cognitive appraisal processes are keys to the development and expression of an emotion (Lazarus, 1982).

Psychometric Measurement

Affect has been found across cultures to comprise both positive and negative dimensions. The most commonly used measure in scholarly research is the Positive and Negative Affect Schedule (PANAS) (Watson, Clark & Tellegen, 1988). The PANAS is a lexical measure developed in a North American setting and consisting of 20 single-word items, for instance excited, alert, determined for positive affect, and upset, guilty, and jittery for negative affect. However, some of the PANAS items have been found either to be redundant or to have ambiguous meanings to English speakers from non-North American cultures. As a result, an internationally reliable short-form, the I-PANAS-SF, has been developed and validated comprising two 5-item scales with internal reliability, cross-sample and cross-cultural factorial invariance, temporal stability, convergent and criterion-related validities.

Mroczek and Kolarz (1998) have also developed another set of scales to measure positive and negative affect. Each of the scales has 6 items. The scales have shown evidence of acceptable validity and reliability across cultures.

Non-Conscious Affect and Perception

In relation to perception, a type of non-conscious affect may be separate from the cognitive processing of environmental stimuli. A monohierarchy of perception, affect and cognition considers the roles of arousal, attention tendencies, affective primacy (Zajonc, 1980), evolutionary constraints (Shepard, 1984; 1994), and covert perception (Weiskrantz, 1997) within the sensing and processing of preferences and discriminations. Emotions are complex chains of events triggered by certain stimuli. There is no way to completely describe an emotion by knowing only some of its components. Verbal reports of feelings are often inaccurate because people may not know exactly what they feel, or they may feel several different emotions at the same time. There are also situations that arise in which individuals attempt to hide their feelings, and there are some who believe that public and private events seldom coincide exactly, and that words for feelings are generally more ambiguous than are words for objects or events. Therefore, non-conscious emotions need to be measured by measures circumventing self-report such as the Implicit Positive and Negative Affect Test (IPANAT; Quirin, Kazén & Kuhl, 2009).

Affective responses, on the other hand, are more basic and may be less problematic in terms of assessment. Brewin has proposed two experiential processes that frame non-cognitive relations between various affective experiences: those that are prewired dispositions (i.e. non-conscious processes), able to “select from the total stimulus array those stimuli that are causally relevant, using such criteria as perceptual salience, spatiotemporal cues, and predictive value in relation to data stored in memory” (Brewin, 1989, p.381), and those that are automatic (i.e. subconscious processes), characterised as “rapid, relatively inflexible and difficult to modify… (requiring) minimal attention to occur and… (capable of being) activated without intention or awareness” (Brewin1989 p.381). But a note should be considered on the differences between affect and emotion.

Arousal

Arousal is a basic physiological response to the presentation of stimuli. When this occurs, a non-conscious affective process takes the form of two control mechanisms: one mobilising and the other immobilising. Within the human brain, the amygdala regulates an instinctual reaction initiating this arousal process, either freezing the individual or accelerating mobilisation.

The arousal response is illustrated in studies focused on reward systems that control food-seeking behaviour (Balleine, 2005). Researchers have focused on learning processes and modulatory processes that are present while encoding and retrieving goal values. When an organism seeks food, the anticipation of reward based on environmental events becomes another influence on food seeking that is separate from the reward of food itself. Therefore, earning the reward and anticipating the reward are separate processes and both create an excitatory influence of reward-related cues. Both processes are dissociated at the level of the amygdala, and are functionally integrated within larger neural systems.

Motivational intensity and Cognitive Scope

Measuring Cognitive Scope

Cognitive scope can be measured by tasks involving attention, perception, categorisation and memory. Some studies use a flanker attention task to figure out whether cognitive scope is broadened or narrowed. For example:

  • Using the letters “H” and “N” participants need to identify as quickly as possible the middle letter of 5 when all the letters are the same (e.g. “HHHHH”); and
  • When the middle letter is different from the flanking letters (e.g. “HHNHH”).

Broadened cognitive scope would be indicated if reaction times differed greatly from when all the letters were the same compared to when the middle letter is different. Other studies use a Navon attention task to measure difference in cognitive scope. A large letter is composed of smaller letters, in most cases smaller “L”‘s or “F”‘s that make up the shape of the letter “T” or “H” or vice versa. Broadened cognitive scope would be suggested by a faster reaction to name the larger letter, whereas narrowed cognitive scope would be suggested by a faster reaction to name the smaller letters within the larger letter. A source-monitoring paradigm can also be used to measure how much contextual information is perceived: for instance, participants are tasked to watch a screen which serially displays words to be memorised for 3 seconds each, and also have to remember whether the word appeared on the left or the right half of the screen. The words were also encased in a coloured box, but the participants did not know that they would eventually be asked what colour box the word appeared in.

Main Research Findings

Motivation intensity refers to the strength of urge to move toward or away from a particular stimulus.

Anger and fear affective states, induced via film clips, conferred more selective attention on a flanker task compared to controls as indicated by reaction times that were not very different, even when the flanking letters were different from the middle target letter. Both anger and fear have high motivational intensity because propulsion to act would be high in the face of an angry or fearful stimulus, like a screaming person or coiled snake. Affects high in motivational intensity, thus, narrow cognitive scope making people able to focus more on target information. After seeing a sad picture, participants were faster to identify the larger letter in a Navon attention task, suggesting more global or broadened cognitive scope. The sad emotion is thought to sometimes have low motivational intensity. But, after seeing a disgusting picture, participants were faster to identify the component letters, indicative of a localised more narrow cognitive scope. Disgust has high motivational intensity. Affects high in motivational intensity, thus, narrow cognitive scope making people able to focus more on central information. whereas affects low in motivational intensity broadened cognitive scope allowing for faster global interpretation. The changes in cognitive scope associated with different affective states is evolutionarily adaptive because high motivational intensity affects elicited by stimuli that require movement and action should be focused on, in a phenomenon known as goal-directed behaviour. For example, in early times seeing a lion (fearful stimulus) probably elicited a negative but high motivational affective state (fear) in which the human being was propelled to run away. In this case the goal would be to avoid getting killed.

Moving beyond just negative affective states, researchers wanted to test whether or not the negative or positive affective states varied between high and low motivational intensity. To evaluate this theory, Harmon-Jones and Gable (2009) created an experiment using appetitive picture priming and the Navon task, which would allow them to measure the attentional scope with the detection of the Navon letters. The Navon task included a neutral affect comparison condition. Typically, neutral states cause broadened attention with a neutral stimulus. They predicted that a broad attentional scope could cause a faster detection of global (large) letters, whereas a narrow attentional scope could cause a faster detection of local (small) letters. The evidence proved that the appetitive stimuli produced a narrowed attentional scope. The experimenters further increased the narrowed attentional scope in appetitive stimuli by telling participants they would be allowed to consume the desserts shown in the pictures. The results revealed that their hypothesis was correct in that the broad attentional scope led to quicker detection of global letters and the narrowed attentional scope led to quicker detection of local letters.

Bradley and colleagues (2001) wanted to further examine the emotional reactions in picture priming. Instead of using an appetitive stimulus they used stimulus sets from the International Affective Picture System (IAPS). The image set includes various unpleasant pictures such as snakes, insects, attack scenes, accidents, illness, and loss. They predicted that the unpleasant picture would stimulate a defensive motivational intensity response, which would produce strong emotional arousal such as skin gland responses and cardiac deceleration. Participants rated the pictures based on valence, arousal and dominance on the Self-Assessment Manikin (SAM) rating scale. The findings were consistent with the hypothesis and proved that emotion is organised motivationally by the intensity of activation in appetitive or defensive systems.

Prior to research in 2013, Harmon-Jones and Gable (2009) performed an experiment to examine whether neural activation related with approach-motivation intensity (left frontal-central activity) would trigger the effect of appetitive stimuli on narrowed attention. They also tested whether individual dissimilarities in approach motivation are associated with attentional narrowing. In order to test the hypothesis, the researchers used the same Navon task with appetitive and neutral pictures in addition to having the participants indicate how long since they had last eaten in minutes. To examine the neural activation, the researchers used an electroencephalography and recorded eye movements in order to detect what regions of the brain were being used during approach motivation. The results supported the hypothesis suggesting that the left frontal-central hemisphere is relative for approach-motivational processes and narrowed attentional scope. Some psychologists were concerned that the individuals who were hungry had an increase in the left frontal-central due to frustration. This statement was proved false because the research shows that the dessert pictures increase positive affect even in the hungry individuals. The findings revealed that narrowed cognitive scope has the ability to assist us in goal accomplishment.

Clinical Applications

Later on, researchers connected motivational intensity to clinical applications and found that alcohol-related pictures caused narrowed attention for persons who had a strong motivation to consume alcohol. The researchers tested the participants by exposing them to alcohol and neutral pictures. After the picture was displayed on a screen, the participants finished a test evaluating attentional focus. The findings proved that exposure to alcohol-related pictures led to a narrowing of attentional focus to individuals who were motivated to use alcohol. However, exposure to neutral pictures did not correlate with alcohol-related motivation to manipulate attentional focus. The Alcohol Myopia Theory (AMT) states that alcohol consumption reduces the amount of information available in memory, which also narrows attention so only the most proximal items or striking sources are encompassed in attentional scope. This narrowed attention leads intoxicated persons to make more extreme decisions than they would when sober. Researchers provided evidence that substance-related stimuli capture the attention of individuals when they have high and intense motivation to consume the substance. Motivational intensity and cue-induced narrowing of attention has a unique role in shaping people’s initial decision to consume alcohol. In 2013, psychologists from the University of Missouri investigated the connection between sport achievement orientation and alcohol outcomes. They asked varsity athletes to complete a Sport Orientation Questionnaire which measured their sport-related achievement orientation on three scales – competitiveness, win orientation, and goal orientation (Weaver et al., 2013). The participants also completed assessments of alcohol use and alcohol-related problems. The results revealed that the goal orientation of the athletes were significantly associated with alcohol use but not alcohol-related problems.

In terms of psychopathological implications and applications, college students showing depressive symptoms were better at retrieving seemingly “nonrelevant” contextual information from a source monitoring paradigm task. Namely, the students with depressive symptoms were better at identifying the colour of the box the word was in compared to non-depressed students. Sadness (low motivational intensity) is usually associated with depression, so the more broad focus on contextual information of sadder students supports that affects high in motivational intensity narrow cognitive scope whereas affects low in motivational intensity broaden cognitive scope.

The motivational intensity theory states that the difficulty of a task combined with the importance of success determine the energy invested by an individual. The theory has three main layers.

  • The innermost layer says human behaviour is guided by the desire to conserve as much energy as possible. Individuals aim to avoid wasting energy so they invest only the energy that is required to complete the task.
  • The middle layer focuses on the difficulty of tasks combined with the importance of success and how this affects energy conservation. It focuses on energy investment in situations of clear and unclear task difficulty.
  • The last layer looks at predictions for energy invested by a person when they have several possible options to choose at different task difficulties.

The person is free to choose among several possible options of task difficulty. The motivational intensity theory offers a logical and consistent framework for research. Researchers can predict a person’s actions by assuming effort refers to the energy investment. The motivational intensity theory is used to show how changes in goal attractiveness and energy investment correlate.

Mood

Refer to Mood (Psychology).

Mood, like emotion, is an affective state. However, an emotion tends to have a clear focus (i.e. its cause is self-evident), while mood tends to be more unfocused and diffuse. Mood, according to Batson, Shaw and Oleson (1992), involves tone and intensity and a structured set of beliefs about general expectations of a future experience of pleasure or pain, or of positive or negative affect in the future. Unlike instant reactions that produce affect or emotion, and that change with expectations of future pleasure or pain, moods, being diffuse and unfocused and thus harder to cope with, can last for days, weeks, months or even years (Schucman & Thetford, 1975). Moods are hypothetical constructs depicting an individual’s emotional state. Researchers typically infer the existence of moods from a variety of behavioural referents (Blechman, 1990). Habitual negative affect and negative mood is characteristic of high neuroticism.

Positive affect and negative affect (PANAS) represent independent domains of emotion in the general population, and positive affect is strongly linked to social interaction. Positive and negative daily events show independent relationships to subjective well-being, and positive affect is strongly linked to social activity. Recent research suggests that high functional support is related to higher levels of positive affect. In his work on negative affect arousal and white noise, Seidner (1991) found support for the existence of a negative affect arousal mechanism regarding the devaluation of speakers from other ethnic origins. The exact process through which social support is linked to positive affect remains unclear. The process could derive from predictable, regularised social interaction, from leisure activities where the focus is on relaxation and positive mood, or from the enjoyment of shared activities. The techniques used to shift a negative mood to a positive one are called mood repair strategies.

Social Interaction

Affect display is a critical facet of interpersonal communication. Evolutionary psychologists have advanced the hypothesis that hominids have evolved with sophisticated capability of reading affect displays.

Emotions are portrayed as dynamic processes that mediate the individual’s relation to a continually changing social environment. In other words, emotions are considered to be processes of establishing, maintaining, or disrupting the relation between the organism and the environment on matters of significance to the person.

Most social and psychological phenomena occur as the result of repeated interactions between multiple individuals over time. These interactions should be seen as a multi-agent system – a system that contains multiple agents interacting with each other and/or with their environments over time. The outcomes of individual agents’ behaviours are interdependent: Each agent’s ability to achieve its goals depends on not only what it does but also what other agents do.

Emotions are one of the main sources for the interaction. Emotions of an individual influence the emotions, thoughts and behaviours of others; others’ reactions can then influence their future interactions with the individual expressing the original emotion, as well as that individual’s future emotions and behaviours. Emotion operates in cycles that can involve multiple people in a process of reciprocal influence.

Affect, emotion, or feeling is displayed to others through facial expressions, hand gestures, posture, voice characteristics, and other physical manifestation. These affect displays vary between and within cultures and are displayed in various forms ranging from the most discrete of facial expressions to the most dramatic and prolific gestures.

Observers are sensitive to agents’ emotions, and are capable of recognising the messages these emotions convey. They react to and draw inferences from an agent’s emotions. The emotion an agent displays may not be an authentic reflection of his or her actual state (refer to Emotional Labour).

Agents’ emotions can have effects on four broad sets of factors:

  • Emotions of other persons.
  • Inferences of other persons.
  • Behaviours of other persons.
  • Interactions and relationships between the agent and other persons.

Emotion may affect not only the person at whom it was directed, but also third parties who observe an agent’s emotion. Moreover, emotions can affect larger social entities such as a group or a team. Emotions are a kind of message and therefore can influence the emotions, attributions and ensuing behaviours of others, potentially evoking a feedback process to the original agent.

Agents’ feelings evoke feelings in others by two suggested distinct mechanisms:

  • Emotion contagion:
    • People tend to automatically and unconsciously mimic non-verbal expressions.
    • Mimicking occurs also in interactions involving textual exchanges alone.
  • Emotion interpretation:
    • An individual may perceive an agent as feeling a particular emotion and react with complementary or situationally appropriate emotions of their own.
    • The feelings of the others diverge from and in some way complement the feelings of the original agent.

People may not only react emotionally, but may also draw inferences about emotive agents such as the social status or power of an emotive agent, his competence and his credibility. For example, an agent presumed to be angry may also be presumed to have high power.

References

Balliene, B.W. (2005) Dietary Influences on Obesity: Environment, Behavior and Biology. Physiology & Behaviour. 86(5), pp.717-730.

Batson, C.D., Shaw, L.L. & Oleson, K.C. (1992). Differentiating Affect, Mood and Emotion: Toward Functionally based Conceptual Distinctions. Emotion. Newbury Park, CA: Sage.

Blechman, E.A. (1990). Moods, Affect, and Emotions. Hillsdale, New Jersey: Lawrence Erlbaum Associates: Hillsdale.

Bradley, M.M., Codispoti, M., Cuthbert, B.N. & Lang, P.J. (2001) Emotion and motivation I: Defensive and appetitive reactions in picture processing. Emotion. 1(3), pp.276-298. doi:10.1037/1528-3542.1.3.276.

Brewin, C.R. (1989) Cognitive Change Processes in Psychotherapy. Psychological Review. 96(45), pp.379-394. doi:10.1037/0033-295x.96.3.379.

Damasio, A. (2006) Descartes’ Error: Emotion, Reason, and the Human Brain. London: Vintage (Part of the Random House Group).

Glimcher, P.W. & Fehr, E (Eds.) (2014) Chapter 27 – Understanding Others: Brain Mechanisms of Theory of Mind and Empathy. Neuroeconomics (Second Edition). Academic Press. pp.513-532. https://doi.org/10.1016/B978-0-12-416008-8.00027-9.

Green, A. (Author), Sheridan, A. (Trans) & Spillius, E.B. (General Editor) (1999) The Fabric of Affect in the Psychoanalytic Discourse. The New Library of Psychoanalysis 37. London: Routledge.

Griffiths, P.E. (1997) What Emotions Really Are: The Problem of Psychological Categories. Chicago: The University of Chicago Press.

Harmon-Jones, E. & Gable, P.A. (2009) Neural Activity Underlying the Effect of Approach-Motivated Positive Affect on Narrowed Attention. Psychological Science. 20(4), pp.406-409. doi:10.1111/j.1467-9280.2009.02302.x.

Lazarus, R.S. (1982) Thoughts on the Relations between Emotions and Cognition. American Physiologist. 37 (10), pp.1019-1024.

Lerner, J.S. & Keltner, D. (2000) Beyond valence: Toward a model of emotion-specific influences on judgement and choice. Cognition and Emotion. 14(4), pp.473-493. doi:10.1080/026999300402763.

Mroczek, D.K. & Kolarz, C.M. (1998) The effect of age on positive and negative affect: A developmental perspective on happiness. Journal of Personality and Social Psychology. 75(5), pp.1333-1349. doi:10.1037/0022-3514.75.5.1333.

Quirin, M., Kazén, M. & Kuhl, J. (2009) When nonsense sounds happy or helpless: The Implicit Positive and Negative Affect Test (IPANAT). Journal of Personality and Social Psychology. 97(3), pp.500-516. doi:10.1037/a001606

Samur, D., Tops, M., Schlinkert, C., Quirin, M., Cuijpers, P. & Koole, S.L. (2013) Four decades of research on alexithymia: moving toward clinical applications. Frontiers in Psychology. 4, pp.861. https://dx.doi.org/10.3389%2Ffpsyg.2013.00861.

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Book: Emotion Efficacy Therapy

Book Title:

Emotion Efficacy Therapy: A Brief, Exposure-Based Treatment for Emotion Regulation Integrating ACT and DBT.

Author(s): Matthew McKay (PhD) and Aprilia West (PSyD, MT).

Year: 2016.

Edition: First (1st).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

If you treat clients with emotion regulation disorders – including depression, anxiety, post-traumatic stress disorder (PTSD), bipolar disorder, and borderline personality disorder (BPD) – you know how important it is for these clients to take control of their emotions and choose their actions in accordance with their values. To help, emotion efficacy therapy (EET) provides a new, theoretically-driven, contextually-based treatment that integrates components from acceptance and commitment therapy (ACT) and dialectical behaviour therapy (DBT) into an exposure-based protocol. In doing so, EET targets the transdiagnostic drivers of experiential avoidance and distress intolerance to increase emotional efficacy.

This step-by-step manual will show you how to help your clients confront and accept their pain, and learn to apply new adaptive responses to emotional triggers. Using a brief treatment that lasts as little as eight weeks, you will be able to help your clients understand and develop a new relationship with their emotions, learn how to have mastery over their emotional experience, practice values-based action in the midst of being emotionally triggered, and stop intense emotions from getting in the way of creating the life they want.

Using the transdiagnostic, exposure-based approach in this book, you can help your clients manage difficult emotions, curb negative reactions, and start living a better life. This book is a game changer for emotion exposure treatment!

Book: Holistic Wellness In The NewAge

Book Title:

Holistic Wellness In The NewAge – A Comprehensive Guide To NewAge Healing Practices: Volume 01.

Author(s): Swatika Jain (Editor).

Year: 2015.

Edition: First (1st).

Publisher: CreateSpace Independent Publishing Platform.

Type(s): Paperback and Kindle.

Synopsis:

A Comprehensive Guide To NewAge Healing Practices Tools, Techniques & Real Life Stories By Over 45 Accomplished Master Facilitators In the book “Holistic Wellness In The NewAge” we showcase various therapies in the Mind, Body & Soul domain…

This book covers the various topics of Holistic approach to wellness and the subject of energy medicine.

The publishers invited articles from accomplished healers who have been practicing various NewAge Therapies to contribute with articles supported by testimonials and personal experiences in whatever therapy they excel in..

Book: The History of Emotions

Book Title:

The History of Emotions (Historical Approaches).

Author(s): Rob Boddice.

Year: 2017.

Edition: First (1st).

Publisher: Manchester Unviersity Press.

Type(s): Hardcover, Paperback, and Kindle.

Synopsis:

This book introduces students and professional historians to the main areas of concern in the history of emotions.

It discusses how the emotions intersect with other lines of historical research relating to power, practice, society and morality.

Addressing criticism from within and without the discipline of history, the book offers a rigorous defence of this new approach, demonstrating its potential centrality to historiographical practice, as well as the importance of this kind of historical work for our general understanding of the human brain and the meaning of human experience.

What is the Intergenerational Transmission of Risk for PTSD Symptoms & the Roles of Maternal and Child Emotion Dysregulation?

Research Paper Title

Intergenerational transmission of risk for PTSD symptoms in African American children: The roles of maternal and child emotion dysregulation.

Background

Emotion dysregulation is a transdiagnostic risk factor for many mental health disorders and develops in the context of early trauma exposure.

Research suggests inter-generational risk associated with trauma exposure and post-traumatic stress disorder (PTSD), such that maternal trauma experiences and related symptoms can negatively impact child outcomes across development.

The goals of the present study were to examine child and mother correlates of child PTSD symptoms and the unique roles of child and maternal emotion dysregulation in understanding child PTSD symptoms.

Methods

Subjects included 105 African American mother-child dyads from an urban hospital serving primarily low-income minority individuals.

Results

Correlational results showed that child trauma exposure, child emotion dysregulation, maternal depressive symptoms, maternal emotion dysregulation, and potential for maternal child abuse all were significantly associated with child PTSD symptoms (ps < 0.05).

Hierarchical linear regression models revealed that child trauma exposure, maternal depression, and maternal abuse potential accounted for 29% of the variance in child PTSD symptoms (p < 0.001).

Both child emotion dysregulation (Rchange² = 0.14, p < .001) and maternal emotion dysregulation (Rchange² = 0.04, p < .05) were significantly associated with child PTSD symptoms independent of other risk factors and potential for maternal abuse was no longer a significant predictor.

Conclusions

These results suggest that maternal emotion dysregulation may be an important factor in influencing their child’s PTSD symptoms above and beyond child-specific variables.

Both maternal and child emotion dysregulation could be valuable treatment targets for improving maternal mental health and parenting behaviours and bolstering child health outcomes, thus reducing inter-generational transmission of risk associated with trauma.

Reference

Powers, A., Stevens, J.S., O’Banion, D., Stenson, A.F., Kaslow, N., Jovanovic, T. & Bradley, B. (2020) Intergenerational transmission of risk for PTSD symptoms in African American children: The roles of maternal and child emotion dysregulation. Psychological Trauma: Theory, Research, Practice and Policy. doi: 10.1037/tra0000543. [Epub ahead of print].

Is There a link between Cosmetic Facial Injection & Emotional Disorder Syndrome?

Research Paper Title

Emotional disorder syndrome after cosmetic facial injection.

Background

There are a number of patients who develop severe anxiety or depression after receiving facial cosmetic injections.

The researchers presented a 32-year-old woman who developed frequent panic, tension headache, tachycardia, shortness of breath, and sleep disorder for a year after the injection of hyaluronic acid on her forehead and glabella.

Brain magnetic resonance imaging (MRI) showed multiple flaky and slightly longer T1, slightly longer T2 signals on the anterior frontal white matter. However, the patient’s brain MRI scan 5 months before the injection showed no such performance.

The patient was asked to consult the psychiatrist and was diagnosed with anxiety disorder.

The researchers name such phenomenon by Emotional disorder syndrome after cosmetic facial injection and assume that there are three major reasons for the emergence of this syndrome:

  • One reason may be that emotional disorder is caused by the mental state of the patient.
  • The second reason to explain the emotional disorder might be the frontal lobe syndrome caused by the frontal embolism during the filler injection.
  • Another reason may be leukoaraiosis, a brain white matter change which may cause depression and anxiety.

Reference

Wang, C., Sun, T., Zhu, L., Zhang, Y. & Wang, X. (2020) Emotional disorder syndrome after cosmetic facial injection.