Emotion Regulation in Substance Use Disorders 431 ment, and maintenance of these severe dis- may predate the development of SUDs and orders. Of course, because SUDs are com- could therefore be conceptualized as a risk plex disorders, they are likely caused and factor predicting illness onset. maintained by an intricate combination of factors, including genetic, cognitive, behav- In the years since this work was published, ioral, individual-difference, and environ- additional data has accumulated to further mental variables, that likely interact across suggest that poor self-c ontrol2 in childhood multiple levels of analysis. At this time, emo- is indeed a risk factor for drug use and the tion regulation abilities are already emerging development of SUDs. For example, Mof- as one important contributor in the etiology fitt and colleagues (2011) followed 1,000 and maintenance of SUDs, although in the children from birth to age 32. In childhood, next decade it is likely that larger longitu- participants were assessed on various self- dinal studies will allow us to identify addi- control measures related to emotion regula- tional factors. tion, including emotional lability, frustra- tion tolerance, and persistence. The authors Emotion (dys)Regulation as an Early report that individual differences in self- Risk Factor control were significantly predictive of adult As reviewed below, SUDs are frequently health outcomes, including substance use associated with emotion regulation deficits. and dependence, as much as 30 years later. The specific question here is: Do these defi- Importantly, the contribution of self-c ontrol cits precede the development of the disorder factors was distinct from the contribution of so that they may be considered a risk fac- intelligence, social class, and other family- tor? The answer appears to be yes. Begin- life variables. Strikingly, the highest and ning with the classic “marshmallow test” lowest one-fifth of the sample on measured experiments in the 1960s by Mischel and self-control were associated with a preva- colleagues, it has been proposed that the lence of 3 and 10%, respectively, of polysub- ability to delay gratification, and regulate stance dependence in adulthood. emotions like desire, is crucial to children’s developmental trajectories (for review, see In addition, in childhood, the related Mischel, Ayduk, Berman, Casey, Gotlib, et construct of trait impulsivity—the ten- al., 2011 and Luerssen & Ayduk, this vol- dency to act without thought or regard for ume). In these studies, preschool children consequences—has been repeatedly asso- were typically presented with a tasty treat ciated with the development of SUDs in and told that they could have it now, or later adolescence and adulthood (see Iva- alternatively, wait to receive two treats at a nov, Newcorn, Morton, & Tricamo, 2011; later time—if they could delay gratification. Verdejo-García, Lawrence, & Clark, 2008, In his seminal work, Mischel reported that for reviews). Furthermore, longitudinal children vary in their ability to delay gratifi- studies suggest that children who suffer cation, ranging from not being able to wait from childhood disorders such as attention- at all to waiting as long as the experimenter deficit/hyperactivity disorder and conduct allowed (and using a variety of spontaneous disorder, which are associated with poor strategies to facilitate delay). In his follow- emotional/behavioral regulation and impul- u p work, Mischel (2011) reported that those sivity, are far more likely to use drugs and preschool children who were able to delay to receive an SUD diagnosis by late adoles- gratification the longest (by waiting for a cence or young adulthood (e.g., August et larger treat rather than indulging immedi- al., 2006). It has also been suggested that ately in a smaller treat) later achieved higher the association between childhood disrup- Standard Achievement Test (SAT) scores, tive behavior and adolescent-onset sub- had better social-cognitive and emotional stance use may be mediated by early defi- coping in adolescence, and importantly, cits in emotion regulation and inhibitory were least likely to use crack cocaine in control (Ivanov et al., 2011). A similar con- adulthood. This body of work highlights struct used by Tarter and colleagues (2003), how individual differences in emotion regu- termed neurobehavioral disinhibition, is lation (which manifest as early as preschool) indexed by measures of emotion regulation, executive cognitive functioning, and behav- ior control. This construct distinguishes between 10- to 12-year-old boys who are at
432 PSYCHOPATHOLOGY low vs. high risk for development of SUDs (Steinberg, 2005), both of which expose ado- (determined by parental SUD diagnosis). In lescents to drugs. Thus, increased exposure addition, this construct was found to predict to drugs, coupled with increased emotional substance use at age 16, as well as SUDs in reactivity and decreased regulatory capaci- early adulthood. ties (rooted in ongoing brain development), make adolescence a particularly vulnerable The mechanisms by which early emotion period for substance use. dysregulation leads to later SUDs are a tar- get of current investigation. One prevailing Indeed, drug use is most often initiated hypothesis is that emotion regulation abili- in adolescence. For example, 82.4% of first ties (and cognitive control more generally) uses of alcohol occur in individuals under depend on the function of PFC regions (see the age of 21 (the legal drinking age), and Ochsner & Gross, this volume; Johnstone 58.8% of smokers had their first cigarette & Walter, this volume) that are not yet fully under the age of 18 (SAMHSA, 2011). These developed in children and adolescents (see early use statistics are especially important, Riediger & Klipker, this volume). Indeed, because earlier age of onset is associated with adolescence represents a period of both higher rates of SUDs and worse outcomes. reduced emotion regulation abilities (Silvers For example, those who initiated alcohol et al., 2012) as well as substantial neural use prior to age 14 are more than four times development (Giedd et al., 1999). Specifi- more likely to receive an SUD diagnosis in cally, regions of lateral PFC have been found adulthood (16.2 vs. 3.8%; similar rates are to be relatively hypoactive during emotion-Â
Emotion Regulation in Substance Use Disorders 433 with more drug use (e.g., Berking et al., exhibit relative deficits in nonaffective forms 2011) possibly as a means of emotion regu- of self-regulation and executive function, lation (Bonn-Miller, Vujanovic, & Zvolen- including working memory and response sky, 2008). Second, less effective styles of inhibition, which may also relate to PFC emotion regulation (e.g., suppression vs. function (Goldstein & Volkow, 2011). reappraisal) are related to increased drug use (Fucito, Juliano, & Toll, 2010). Third, Emotion (dys)Regulation in Current individual differences in negative affect have SUDs: Regulation of Craving been repeatedly associated with drug use In the previous section, I reviewed evidence and relapse in clinical (e.g., Gamble et al., suggesting that those with SUDs have dif- 2010), as well as laboratory studies (e.g., ficulties regulating emotions. Notably, the Sinha & Li, 2007). Fourth, as reviewed ear- evidence overwhelmingly centers on regula- lier, SUDs are highly comorbid with affective tion of negative emotions. However, in the disorders, such as depression, which feature context of SUDs, it is critical to consider impaired regulation of negative affect as a not only regulation of negative emotion but key diagnostic feature (American Psychiatric also an additional and very specific form of Association, 2013). Furthermore, those with emotion regulation, namely, the regulation co-o ccurring symptoms of SUDs and affec- of craving. tive disorders show significantly higher rates of relapse to drug use after treatment (e.g., Craving, defined here as “intense desire Bradizza, Stasiewicz, & Paas, 2006) offer- for drugs,” has long been considered a key ing additional support for the link between contributor to drug use (e.g., O’Brien, Chil- emotion regulation deficits and SUDs. dress, Ehrman, & Robbins, 1998). Although this view has been challenged (Perkins, 2009) Additional evidence links constructs substantial evidence links drug craving to related to emotion regulation and SUDs. For drug-taking behavior, and it has been sug- example, emotional intelligence—defined as gested that loss of control over cue-induced the ability to be aware of emotions, identify craving is at the root of compulsive drug tak- emotions correctly, interpret them appro- ing (e.g., Goldstein & Volkow, 2011). For priately, and regulate them effectively—is example, levels of reported craving predict inversely associated with alcohol and drug- drug use as well as relapse to drug taking related problems (Riley & Schutte, 2003). following abstinence (e.g., Crits-C hristoph Moreover, emotional intelligence moderated et al., 2007; Epstein, Marrone, Heishman, the association between negative emotion Schmittner, & Preston, 2010; Galloway, Sin- and alcohol craving in alcohol-dependent gleton, & the Methamphetamine Treatment individuals (Cordovil de Sousa Uva et al., Project Corporate Authors, 2008). Con- 2010). Furthermore, a recent meta-analysis versely, the ability to use various strategies of this construct suggests that not only is it to regulate craving is associated with lower inversely related to smoking, alcohol, and craving (Kober, Kross, Mischel, Hart, & drug use, but also that individual differences Ochsner, 2010; Kober, Mende-S iedlecki, et in particular components, namely, “iden- al., 2010; Westbrook et al., 2013) and lower tification of emotion” and “regulation of drug use (O’Connell, Hosein, Schwartz, & emotion,” are particularly related to SUDs Leibowitz, 2007). Further, the acquisition (Kun & Demetrovics, 2010). Similarly, of strategies during cognitive-behavioral distress tolerance—the ability to persist in therapy (as discussed below) is associated goal-directed activity when experiencing with better long-term outcomes (Carroll, psychological distress—is related to emo- Nich, Frankforter, & Bisighini, 1999). Fur- tion regulation and is inversely associated thermore, the use of cognitive strategies to with substance use frequency and SUDs regulate craving both during and after treat- (Marshall-Berenz, Vujanovic, & MacPher- ment is associated with reduced craving and son, 2011), as well as SUD treatment drop- reduced relapse over time (O’Connell et al., out and eventual relapse (e.g., Daughters et 2007; Shiffman et al., 1996). These findings al., 2005). In addition, impulsivity is report- suggest that craving is a key motivator of edly higher in those with SUDs (see Verdejo- substance use, and that effective regulation García et al., 2008, for review). Finally, it of craving is associated with lower drug use has been suggested that those with SUDs
434 PSYCHOPATHOLOGY and better outcomes for those with SUDs. thought to instantiate the experience of crav- This in turn suggests that regulation of crav- ing. Preliminarily, it further appears that the ing is a specific form of regulation that is use of cognitive strategies to regulate crav- particularly important in the maintenance ing may depend on increased activity in PFC of drug use behavior in SUDs. but that mindfulness-based strategies may not, although additional data are required The neural mechanism by which regula- to confirm this pattern of results. tion of craving operates to reduce drug use is a topic of current research. It has been To summarize, this section has reviewed shown previously that exposure to drug evidence suggesting that emotion regula- cues (e.g., drug-related images, movies, or tion is implicated in SUDs, both as an early paraphernalia) increases craving, as well as risk factor and as an ongoing motivator of drug use (e.g., Shiffman et al., 2013). Fur- drug use. For example, individual differ- thermore, several meta-analyses have shown ences in emotion regulation and impulsivity that such cue-induced craving is consistently during development are predictive of drug associated with neural activity in a network use initiation and SUDs. Furthermore, indi- of regions including the ventral striatum, viduals with ongoing SUDs exhibit deficits the subgenual anterior cingulate, and the in emotion regulation compared to healthy amygdala (e.g., Chase, Eickhoff, Laird, & controls, and negative affect in such indi- Hogarth, 2011). These regions, which are viduals is associated with instances of drug thought to relate to learning, salience, and use. Importantly, most of the available evi- value encoding, previously have been associ- dence centers around regulation of negative ated with the acute effects of drugs. We have emotion. However, regulation of craving is recently shown that when cigarette smokers emerging as another form of regulation that use cognitive strategies in instances of crav- is important in the etiology and mainte- ing (e.g., when they think about the long- nance of these disorders, and may constitute term negative consequences of smoking), one key route by which targeted treatments they report lower craving (Kober, Kross, can ameliorate SUDs, as discussed further et al., 2010), and exhibit lowered activity below. in the neural systems that underlie craving, such as the ventral striatum (Kober, Mende- PFC in SUDs: Mechanism Siedlecki, et al., 2010). Importantly, the reg- for Emotion (dys)Regulation? ulation of craving with cognitive strategies In the prior sections I have reviewed evi- is associated with concurrently increased dence suggesting that PFC development may activity in PFC regions including the dor- underlie the role of emotion dysregulation solateral (dlPFC) and ventral PFC—regions as a distal causal factor for development of previously associated with regulation of SUDs in adolescence. But is this the neural negative emotion (see Ochsner & Gross, this mechanism that underlies general deficits in volume). These findings have since been rep- emotion regulation present in SUDs? Indeed, licated with positron emission tomography many current models of SUDs propose that in cocaine users (Volkow et al., 2010) and the loss of control over craving and drug electrophysiological measurements in ciga- taking (as evident in the diagnostic criteria rette smokers (Littel & Franken, 2011). for the disorder) is a result of reduced or compromised PFC function (e.g., Everitt & Interestingly, we’ve recently shown that Robbins, 2005; Goldstein & Volkow, 2011; use of mindfulness-based strategies to regu- Potenza, Sofuoglu, Carroll, & Rounsaville, late cue-induced craving is also associated 2011; Volkow, Wang, Fowler, & Tomasi, with reductions in reported craving, and 2011). And this “PFC hypothesis” is con- with reduced neural activity in “craving sistent with the already-established link regions,” including the subgenual cingulate. between cognitive control generally—and However, the use of such mindfulness-based emotion regulation specifically—and the strategies was not associated with concur- function of PFC in healthy adults (see Och- rent increase in PFC activity (Westbrook et sner & Gross, this volume). However, neu- al., 2013). Taken together, these findings are consistent with the hypothesis that, across strategies, regulation of craving operates by reducing neural activity in regions that are
Emotion Regulation in Substance Use Disorders 435 roimaging studies directly testing emotion Daumann et al., 2011) and in right ven- regulation abilities in SUDs are scarce. Nev- trolateral PFC (vlPFC) specifically, where ertheless, in the following sections, I review thickness was inversely correlated with drug findings that individuals with SUDs exhibit craving (Tabibnia et al., 2011). In alcohol- structural abnormalities in various PFC dependent subjects compared to controls, regions, as well as functional differences lower gray matter volume was reported in studies of nonaffective forms of cogni- across the PFC (Fein, Di Sclafani, & Mey- tive control (for a brief review of neuroim- erhoff, 2002) and more specifically in the aging methodologies used in such studies, lateral and superior PFC and OFC (Durazzo see Kober & DeLeone, 2011). Importantly, et al., 2011) and medial and lateral PFC although some of these PFC abnormalities (Rando et al., 2011). In these latter studies, may precede the development of SUDs, I lower medial PFC volume was associated review evidence suggesting that chronic with more drinking posttreatment or shorter drug use is associated with both structural time to relapse. In addition, in some studies and functional changes in PFC. Such drug- (but not all) PFC volume was inversely asso- induced changes, in turn, suggest that SUDs ciated with cognitive control measures. For may also lead to decrements in PFC that may example, PFC gray matter volume correlated underlie further emotion dysregulation (Fig- inversely with executive function measures ure 26.1B). in cocaine-dependent individuals (Fein et al., 2002). In reviewing this evidence, it is important to note that the PFC is a very large struc- Consistent with these gray matter find- tural division in the brain, and that different ings in PFC, diffusion tensor imaging (DTI) subregions within the PFC perform very dif- measures of PFC white matter integrity dis- ferent computations and subserve different tinguish between individuals with alcohol functions—even within the general “cogni- use disorders and controls (e.g., Pfeffer- tive control” framework (Miller & Cohen, baum, Rosenbloom, Rohlfing, & Sullivan, 2001). However, at this stage, there are not 2009) and further differ between individu- yet sufficient data to make finer distinctions als who relapsed and those who sustained about the functional role of PFC subdivisions abstinence following treatment (Sorg et al., in SUDs, or to begin to speculate about the 2012). In cocaine-dependent participants, role each subregion might have in the neu- lower measurements of white matter integ- ropathology of these disorders. I hope that rity are consistently found in various PFC data collected in the next decade will allow regions (e.g., Romero, Asensio, Palau, San- us to answer such questions with far greater chez, & Romero, 2010). Similar findings specificity than we can today. were reported in methamphetamine (Ali- cata, Chang, Cloak, Abe, & Ernst, 2009) Structural Differences in the PFC and in opiate users (Bora et al., 2012; Liu et Differences in brain structure have been al., 2008). reported between those with SUDs and healthy controls, using several different Taken together, this body of structural neu- methodologies, especially in various subre- roimaging work suggests that there are con- gions of PFC. For example, using voxel-based sistent anatomical differences between those morphometry, cigarette smokers exhibited with SUDs and healthy controls. A caution- reduced PFC gray matter density compared ary note here is that it is not yet clear what to healthy controls, and PFC thickness was these differences mean. While it is tempting negatively correlated to reported smoking to interpret these differences as indicating (measured in packs-per-year; Brody et al., impairment in individuals with SUDs, this 2004). In cocaine-dependent individuals, link has not yet been consistently demon- relatively reduced gray matter density in strated. For instance, although reportedly orbitofrontal cortex (OFC) and anterior cin- lower than that in controls, cortical thick- gulate cortex (ACC) was reported (Franklin ness and cognitive function are often within et al., 2002). Similarly, lower thickness and normal range in SUDs (see Hart, Marvin, volume were reported for other stimulant Silver, & Smith, 2011, for extended discus- users in various prefrontal regions (e.g., sion). Nevertheless, these differences are consistently reported across PFC and across types of SUDs. Furthermore, although indi-
436 PSYCHOPATHOLOGY vidual studies differ with respect to the local- letters except X with a button press, and ization of these differences (possibly due to to withhold responding to X. Using this sample characteristics, drug pharmacology, task, a series of studies reported relatively drug use patterns, and methodological and worse performance in cocaine- and heroin- statistical differences), and only some stud- dependent individuals compared to healthy ies find association with clinical outcomes, controls, along with reduced activity in the PFC is repeatedly implicated, especially several PFC regions, including the dorsal lateral portions. Reported differences are ACC (dACC), dlPFC, and vlPFC (e.g., Fu et especially salient given the known role for al., 2008; Hester & Garavan, 2004). Such PFC in emotion regulation and cognitive findings suggest at least some functional control in healthy adults. Taken together, alterations in PFC circuits in SUDs, even in these structural findings are consistent with the absence of emotion regulation demand. the hypothesized mechanism by which PFC Similarly, Li, Luo, Yan, Bergquist, and abnormalities may contribute to or underlie Sinha (2009) used the stop-signal response deficient emotion regulation in SUDs. How- inhibition task, and reported lower activ- ever, future work could more directly link ity in dlPFC in alcohol dependence, which structural findings in PFC with emotion further related to higher alcohol craving regulation in SUDs. self-r eports. In cocaine-d ependent individu- als, dACC activity was lower than that in Functional Differences in PFC controls and negatively correlated with self- Differences in measures of PFC function reported difficulties in emotion regulation between individuals with SUDs and healthy (Li et al., 2008). controls have been consistently reported since the early days of functional neuroim- The Stroop color–word task has also been aging. For example, using various forms of used to probe inhibitory control in SUDs by positron emission tomography (PET), it has comparing neural activity during incongru- been established that those with SUDs often ent (BLUE written in red ink) and congruent exhibit relative reductions in “D2” type (BLUE written in blue ink) trials. Using PET, receptors of the neurotransmitter dopamine both marijuana- and cocaine-dependent in striatum and PFC, with some evidence that participants showed reduced “Stroop effect” these reductions persist even after months activity in dACC and dlPFC (Bolla et al., of abstinence (see Volkow et al., 2011, for 2004; Eldreth, Matochik, Cadet, & Bolla, review). PET measures of glucose metabo- 2004). In the cocaine-dependent sample lism have repeatedly shown decreased activ- only, dlPFC activity negatively correlated ity in OFC, ACC, and dlPFC. In stimulant with cocaine use (least “Stroop effect” activ- users decreased activity is further related to ity for the heaviest users; Bolla et al., 2004). relatively decreased D2 receptor availability Similarly, DeVito, Kober, Carroll, and in striatum (Volkow et al., 2011). Notably, Potenza (in preparation) recently used the in alcohol-dependent individuals, striatal Stroop task and fMRI in cocaine-d ependent D2 availability is linked to not only to PFC participants, and found reduced Stroop- activity but also to self-reported alcohol related PFC activity compared to controls. craving, suggesting that all three processes Similar findings have been reported with may be functionally related (i.e., OFC func- methamphetamine users (Nestor, Ghahre- tion, D2 receptor availability, and craving; mani, Monterosso, & London, 2011). In Heinz et al., 2005). marijuana-dependent individuals who were about to begin treatment, Kober, DeVito, More recently, several studies have spe- DeLeone, Carroll, and Potenza (under cifically investigated brain function dur- review) found reduced “Stroop effect” activ- ing performance of non-affective cognitive ity in dlPFC compared to healthy controls, control tasks comparing individuals with and positive correlations between PFC activ- SUDs and healthy controls, typically with ity and treatment success. Similarly, Berk- functional magnetic resonance imaging man, Falk, and Lieberman (2011) related (fMRI). One frequently used task is the go/ neural activity during go/no-go task perfor- no-go response inhibition task, in which mance to treatment outcome and reported participants are asked to respond to all that increased PFC activity during the task was related to a weaker association between
Emotion Regulation in Substance Use Disorders 437 craving and cigarette smoking during subse- outside of the scope of this chapter to discuss quent abstinence. the unique mechanism of action or pharma- cological effects of individual drugs, one Taken together, these studies suggest that now-classic finding is that all drugs that are those with SUDs exhibit poorer performance abused by humans share one common effect. in cognitive control tasks, as well as lower That is, all drugs of abuse—either directly activity in PFC regions typically associated or indirectly—increase concentrations of the with emotion regulation and executive func- neurotransmitter dopamine in the “meso- tion more generally, including dlPFC and corticolimbic” pathway, which includes the dACC. Some studies reported direct asso- ventral tegmental area, the ventral striatum, ciation between lower PFC function and and the PFC (e.g., Dichiara & Imperato, less cognitive control or emotion regulation, 1988; Volkow et al., 2011).3 In turn, this while others link greater PFC activity to bet- drug-induced increase in dopamine is asso- ter treatment outcomes (e.g., Berkman et ciated with long-term changes or adapta- al., 2011; Kober et al., under review). These tions to neurons in this pathway, including findings are therefore consistent with the in PFC (Lüscher & Malenka, 2011). These hypothesis that PFC abnormalities in struc- changes are thought to facilitate associa- ture or function underlie emotion dysregula- tions between drugs and drug-related cues tion in SUDs. (e.g., alcohol and the bar where one drinks; cigarettes and the lighter one uses for smok- Effects of Drug Use on PFC ing), lead to future cue-induced drug crav- Data reviewed thus far suggests that those ing, and reduce cognitive control (Volkow et with SUDs exhibit deficits in emotion regu- al., 2011). lation, and both structural and functional differences in PFC compared to healthy con- Furthermore, it is thought that some of trols. Notably, most of the reviewed data the effects of acute as well as chronic drug were generated in the context of case–c ontrol use are neurotoxic—damaging to neural studies—m easured at a single point in time, tissue (Weiss & Koob, 2001). Such claims in individuals with active SUDs. Therefore, emerge primarily from an animal literature it is not clear whether some of these reported experimentally documenting various forms abnormalities precede the development of of neuronal damage following heavy drug SUDs (and may serve as a risk factor, as administration (e.g., Gouzoulis-M ayfrank discussed previously), whether they are the & Daumann, 2009). Although it is not result of chronic drug use (and reflect the clear that such findings translate to human effects of drug exposure) or an interaction drug users (Hart et al., 2011), some studies of both. Evidence for PFC abnormalities as in humans have linked length of drug use a preexisting risk factor includes a recent with measures of structural or functional study of individuals with SUDs (cocaine or integrity, which is consistent with animal amphetamine dependence) and their unaf- findings. For example, in opiate users, PFC fected siblings compared to healthy adults. white matter integrity correlated negatively Both individuals with SUDs and their unaf- with length of opiate use (Bora et al., 2012; fected siblings shared a neurological pheno- Liu et al., 2008). Similarly, some human type of reduced structural connectivity in studies have shown that various functional the right vlPFC, which was further related and structural abnormalities normalize fol- to performance on the stop-signal response lowing drug abstinence, implicating drug inhibition task (Ersche et al., 2012). These use itself in the originally observed differ- findings suggest that potential abnormalities ences in PFC (e.g., Gouzoulis-Mayfrank & in lateral PFC may underlie regulatory defi- Daumann, 2009). Taken together, the evi- cits that in fact predate the onset of SUDs. dence suggests that even if some PFC abnor- malities precede the development of SUDs, On the other hand, there is ample evi- drug use itself is associated with long-term dence, mostly from animal studies, that changes to many brain circuits, including chronic/regular drug use alters both func- PFC. Furthermore, these changes may cre- tion and structure of PFC and other brain ate or exacerbate deficits in emotion regula- circuits (for an excellent recent review, see tion in SUDs. In essence, this suggests that Lüscher & Malenka, 2011). Although it is chronic drug use may lead to a vicious cycle,
438 PSYCHOPATHOLOGY in which impaired emotion regulation leads that difficulties regulating both negative to drug use, and drug use may further lead (stress, anxiety, or depression) and appeti- to impaired emotion regulation. tive (drug craving) states are associated with drug use and with relapse to drug use fol- Treatment for€SUDs: lowing abstinence. Therefore, it is no sur- The Role of€Emotion€Regulation prise that at this recovery phase, many of the Treatments for SUDs are varied and com- leading treatments include training of emo- plex, as is appropriate given the hetero- tion regulation skills in general, and regula- geneous and complex nature of the disor- tion of craving in particular (e.g., Potenza et ders that they treat. At this time, despite al., 2011; see Figure 26.1B). Indeed, learning repeated scientific efforts, there are few to tolerate or regulate cravings and not to FDA-approved pharmacological treatments act on them is the cornerstone of many of for SUDs. Therefore, nonpharmacological the available treatments, as discussed below. (e.g., psychological) treatments are most Finally, the last phase of treatment, relapse common. While the goal of treatment may prevention, focuses on implementing long- be conceptualized as reductions in drug use term strategies for maintaining abstinence, and in drug-rÂ
Emotion Regulation in Substance Use Disorders 439 drugs, and managing situations related to with (2) an attitude of acceptance toward drug-use opportunities (e.g., refusing offers the present moment (Bishop et al., 2004). As of drugs). such, mindfulness is often practiced through mindfulness meditation, which consists of Subsequent treatment sessions (modules) focusing attention on one’s immediate expe- focus on problem solving, tolerating and rience (e.g., sensations, breathing, thoughts, regulating negative affect, and improv- emotion), and regarding it nonjudgmen- ing social skills more generally. Ultimately, tally. This is thought to cultivate the abil- individuals who undergo CBT (compared to ity to observe—rather than be caught up other treatments) are more likely to decrease in—one’s own experience, and to further drug use and/or achieve abstinence during facilitate more skillful or mindful respond- and even after treatment has ended (i.e., ing (as opposed to automatic reaction; “the sleeper effect”; Potenza et al., 2011). Zgierska et al., 2009). Importantly, medita- Although the treatment includes many mod- tion and MBTs have been associated with ules and stages, one important mechanism beneficial effects on stress, anxiety, pain, of action is thought to be via enhancing cog- cardiac health, immune functions, psycho- nitive control over negative affect that may logical well-being, cognitive functioning, lead to drug craving, and over drug crav- and several psychiatric disorders (including ing and drug taking behavior (e.g., Kiluk, mood and anxiety disorders; see Hölzel et Nich, Babuscio, & Carroll, 2010; Potenza et al., 2011, for review). Therefore, it is not al., 2011). This hypothesis is supported by difficult to extrapolate how MBTs could be the finding that the number and quality of beneficial for fostering better emotion regu- strategies for regulation of craving increase lation in SUDs. from pre- to post-CBT treatment, and pre- dict relapse (e.g., Carroll et al., 1999), and Indeed, several mindfulness-based treat- formally mediate the relationship between ments have recently been adapted for SUDs. treatment and duration of abstinence (Kiluk Unlike the well-established CBTs, these et al., 2010). In turn, this increase in regula- treatments have just shown preliminary effi- tion skills is hypothesized to be mediated by cacy and are now the focus of rigorous ran- improved PFC function from pre- to post- domized controlled trials. MBTs for SUDs treatment (Potenza et al., 2011; see Figure typically include training in mindfulness 26.1B for a schematic illustration). Consis- meditation, and a focus on attention to and tent with this hypothesis, Kober, Kross, et al. acceptance of present-m oment experience (2010) have shown that use of CBT-like cog- (including negative emotion and drug crav- nitive strategies during cue-induced craving ing). The modal instruction is to regard inter- is associated with decreases in self-reported nal experiences (e.g., drug craving) as tran- craving, as well as increased activity in sient, and to observe and accept them as-is, dlPFC and vlPFC (Kober, Mende-Siedlecki, without reacting (e.g., without engaging in et al., 2010). In addition, DeVito et al. (2011) drug use). For example, both mindfulness- recently reported that those who underwent based relapse prevention (MBRP; Bowen, CBT exhibited increased efficiency in vlPFC Chawla, & Marlatt, 2010) and mindfulness and dlPFC during the Stroop task from pre- training for smoking (MTS; Brewer et al., to post-CBT treatment, which is consistent 2011) make use of the concept of “urge surf- with improvements in cognitive control and ing,” the practice of regarding craving like a emotion regulation. However, future studies wave that rises, reaches a peak, and subsides should test that hypothesis more directly. naturally. Patients are instructed to attend to and accept the sensations as they rise, fall, Mindfulness‑Based Treatments and finally disappear—and this technique Mindfulness-based treatments (MBTs) for is likened to tolerating cravings rather than a variety of psychiatric conditions have actively regulating them, as in CBT (Brewer emerged in recent years, beginning with et al., 2011). Consistently, Westbrook et al. mindfulness-based stress reduction (MBSR). (2013) have shown that mindful attention to Mindfulness has been defined as a two- smoking cues is associated with lower self- component construct: (1) self-regulation of reported craving and lower neural activity in attention to the present moment, coupled regions previously associated with craving, without concomitant increases in PFC activ-
440 PSYCHOPATHOLOGY ity. As such, mindful attention and accep- tance may be regulatory, by preventing the these disorders. In this chapter, I reviewed amplification of craving rather than damp- data suggesting that emotion regulation is ening them down. one such crucial factor. Indeed, difficulties in emotion regulation in childhood and ado- Clinically, MBRP, typically administered lescence serve as predictive factors for future as a follow-up to inpatient treatment, is drug use and the development of SUDs. Sub- reportedly efficacious in reducing drug use sequently, those with SUDs report greater and relapse across several different popu- difficulty regulating negative emotions than lations with SUDs, including alcohol and do healthy controls, which contributes to polysubstance users (e.g., Witkiewitz & ongoing drug use. Furthermore, I reviewed Bowen, 2010). In addition, Brewer et al. evidence suggesting that craving for drugs is (2011) have recently shown in a pilot ran- one of the key predictors of drug use, and domized controlled trial that MTS admin- that the ability to regulate craving effec- istered as a stand-alone treatment was effec- tively is directly related to reduced drug use tive in achieving smoking cessation. Finally, in SUDs. similar elements of mindful attention and acceptance are parts of dialectical behav- Consistent with these observations, psy- ior therapy and acceptance and commit- chosocial treatments for SUDs often focus ment therapy, both of which have shown on emotion regulation and on the regula- preliminary efficacy for SUDs (Hernández- tion of craving as means for reducing drug López, Luciano, Bricker, Roales-Nieto, & use. Indeed, improvement in those skills fol- Montesinos, 2009; Linehan et al., 2002). lowing treatments such as CBT and MBTs Taken together, these data show substantial is associated with improved abstinence. promise for MBTs in the treatment of SUDs, Finally, I reviewed data suggesting that dif- although the research is still in its infancy. ferences in PFC structure, as well as function, Nevertheless, one prominent hypothesis sug- may underlie impaired emotion regulation in gests that these treatments work by enhanc- those with SUDs, and that ongoing drug use ing emotion regulation, as patients learn to leads to adaptations in PFC that may further practice mindfulness in the face of craving impair emotion regulation. However, it will as well as negative emotion. This is sup- be critical to focus future research on more ported by several findings, including consis- precisely characterizing the neural mecha- tent reductions in craving post-MBRP (e.g., nisms behind observed PFC deficits in SUDs Witkiewitz & Bowen, 2010), and a negative and behind treatment-related improvements. correlation after MTS between amount of Indeed, it is my sincere hope that in the com- meditation practice and smoking (Brewer et ing years, additional data will allow us to al., 2011). establish these links more firmly. This could lead to the development of better treatments Concluding Remarks that improve emotion regulation in individ- Casual drug use is quite prevalent, and a uals suffering from these devastating disor- percentage of drug users develop SUDs, ders. which are severe psychiatric conditions with staggering social, economic, and personal Acknowledgments costs. This underscores the need to identify risk factors that render specific individu- I would like to thank Danielle Bolling, Cameron als more vulnerable to the development of DeLeone, and Maggie Mae Mell for their invalu- SUDs. Furthermore, once established, SUDs able help preparing this chapter. Thanks also go are chronic, relapsing, and very difficult to to Alan Anticevic, Rebecca Boswell, Kathleen treat psychiatric conditions; this underscores Carroll, Ralph DiLeone, James Gross, and one the need to better characterize the proximal anonymous reviewer, for very helpful comments. causal factors that lead to continued drug And finally, thanks to all those who investigate use, and to better understand the mecha- emotion regulation in substance use disorders. nisms that underlie effective treatments for Your work inspired this chapter and will con- tinue to inspire research in this area for years to come.
Emotion Regulation in Substance Use Disorders 441 Notes (2011). Deficits in emotion-regulation skills predict alcohol use during and after cognitive- 1. Psychoactive drugs are those that primarily behavioral therapy for alcohol dependence. act on the brain and change thinking, mood, and behavior. These include legal drugs (e.g., Journal of Consulting and Clinical Psychol- alcohol, nicotine, caffeine, and opioid pain ogy, 79(3), 307–318. medications), as well as illicit drugs (e.g., her- Berkman, E. T., Falk, E. B., & Lieberman, M. oin, cocaine, amphetamines, and marijuana). D. (2011). In the trenches of real-world self- control: Neural correlates of breaking the link 2. Self-control is often defined as the process of between craving and smoking. Psychological inhibition of an otherwise imminent thought, Science, 22(4), 498–506. emotion, or action—and as such, it includes Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., emotion regulation. Related to this is the Anderson, N. D., Carmody, J., et al. (2004). construct of cognitive control, which more Mindfulness: A proposed operational defini- broadly includes goal maintenance, selective tion. Clinical Psychology: Science and Prac- attention, conflict monitoring and resolution, tice, 11(3), 230–241. response inhibition, and emotion regulation. Bolla, K., Ernst, M., Kiehl, K., Mouratidis, M., See Gross (this volume) for discussion. Eldreth, D., Contoreggi, C., et al. (2004). Prefrontal cortical dysfunction in abstinent 3. It is now known that many other neurotrans- cocaine abusers. Journal of Neuropsychiatry mitter systems are involved in drug taking and Clinical Neurosciences, 16(4), 456–464. and in the development of SUDs, and the next Bonn-Miller, M. O., Vujanovic, A. A., & Zvo- decade will likely bring additional investiga- lensky, M. J. (2008). Emotional dysregulation: tions into other neurotransmitter systems and Association with coping-oriented marijuana their relation to SUDs. use motives among current marijuana users. Substance Use and Misuse, 43(11), 1656–1668. References Bora, E., Yücel, M., Fornito, A., Pantelis, C., Harrison, B. J., Cocchi, L., et al. (2012). American Psychiatric Association. (2013). Diag- White matter microstructure in opiate addic- nostic and statistical manual of mental disor- tion. Addiction Biology, 17(1), 141–148. ders (5th ed.). Arlington, VA: Author. Bowen, S., Chawla, N., & Marlatt, G. A. (2010). Alicata, D., Chang, L., Cloak, C., Abe, K., & Mindfulness-based relapse prevention for Ernst, T. (2009). Higher diffusion in striatum addictive behaviors: A clinician’s guide. New and lower fractional anisotropy in white mat- York: Guilford Press. ter of methamphetamine users. Psychiatry Bradizza, C. M., Stasiewicz, P. R., & Paas, N. D. Research: Neuroimaging, 174(1), 1–8. (2006). Relapse to alcohol and drug use among individuals diagnosed with co-occurring men- August, G. J., Winters, K. C., Realmuto, G. M., tal health and substance use disorders: A Fahnhorst, T., Botzet, A., & Lee, S. (2006). review. Clinical Psychology Review, 26(2), Prospective study of adolescent drug use 162–178. among community samples of ADHD and Brewer, J. A., Mallik, S., Babuscio, T. A., Nich, non-ADHD participants. Journal of Ameri- C., Johnson, H. E., Deleone, C. M., et al. can Academy of Child and Adolescent Psy- (2011). Mindfulness training for smoking ces- chiatry, 45(7), 824–832. sation: Results from a randomized controlled trial. Drug and Alcohol Dependence, 119(1– Badiani, A., Belin, D., Epstein, D., Calu, D., 2), 72–80. & Shaham, Y. (2011). Opiate versus psycho- Brody, A. L., Olmstead, R. E., London, E. D., stimulant addiction: The differences do mat- Farahi, J., Meyer, J. H., Grossman, P., et al. ter. Nature Reviews Neuroscience, 12(11), (2004). Smoking-induced ventral striatum 685–700. dopamine release. American Journal of Psy- chiatry, 161(7), 1211–1218. Baker, T. B., Piper, M. E., McCarthy, D. E., Carroll, K. M. (1998). Therapy manuals for drug Majeskie, M. R., & Fiore, M. C. (2004). Addiction motivation reformulated: An affec- addiction: A cognitive-behavioral approach: tive processing model of negative reinforce- Treating cocaine addiction. Bethesda, MD: ment. Psychological Review, 111(1), 33–51. National Institute of Drug Abuse. Berking, M., Margraf, M., Ebert, D., Wupper- man, P., Hofmann, S. G., & Junghanns, K.
442 PSYCHOPATHOLOGY Carroll, K. M., Nich, C., Frankforter, T. L., & abused by humans preferentially increase syn- Bisighini, R. M. (1999). Do patients change aptic dopamine concentrations in the meso- in the way we intend?: Treatment-specific limbic system of freely moving rats. Proceed- skill acquisition in cocaine-d ependent patients ings of the National Academy of Sciences using the Cocaine Risk Response Test. Psy- USA, 85(14), 5274–5278. chological Assessment, 11, 77–85. Durazzo, T. C., Tosun, D., Buckley, S., Gazdz- inski, S., Mon, A., Fryer, S. L., & Meyerhoff, Chase, H. W., Eickhoff, S. B., Laird, A. R., & D. J. (2011). Cortical thickness, surface area, Hogarth, L. (2011). The neural basis of drug and volume of the brain reward system in alco- stimulus processing and craving: An activation hol dependence: Relationships to relapse and likelihood estimation meta-analysis. Biologi- extended abstinence. Alcoholism: Clinical and cal Psychiatry, 70(8), 785–793. Experimental Research, 35, 1187–1200. Dutra, L., Stathopoulou, G., Basden, S. L., Childress, A. R., Hole, A. V., Ehrman, R. N., Leyro, T. M., Powers, M. B., & Otto, M. W. Robbins, S. J., McLellan, A. T., & O’Brien, (2008). A meta-analytic review of psychoso- C. P. (1993). Cue reactivity and cue reactiv- cial interventions for substance use disorders. ity interventions in drug dependence. NIDA American Journal of Psychiatry, 165(2), 179– Research Monograph, 137, 73–73. 187. Eldreth, D. A., Matochik, J. A., Cadet, J. L., & Cordovil de Sousa Uva, M., Timary, P., Cortesi, Bolla, K. I. (2004). Abnormal brain activity M., Mikolajczak, M., Blicquy, P. R., & Lumi- in prefrontal brain regions in abstinent mari- net, O. (2010). Moderating effect of emotional juana users. NeuroImage, 23(3), 914–920. intelligence on the role of negative affect in Epstein, D. H., Marrone, G. F., Heishman, S. the motivation to drink in alcohol-d ependent J., Schmittner, J., & Preston, K. L. (2010). subjects undergoing protracted withdrawal. Tobacco, cocaine, and heroin: Craving and use Personality and Individual Differences, 48(1), during daily life. Addictive Behaviors, 35(4), 16–21. 318–324. Ersche, K. D., Jones, P. S., Williams, G. B., Tur- Crits-C hristoph, P., Gibbons, M. B. C., Barber, J. ton, A. J., Robbins, T. W., & Bullmore, E. P., Hu, B., Hearon, B., Worley, M., & Gallop, T. (2012). Abnormal brain structure impli- R. (2007). Predictors of sustained abstinence cated in stimulant drug addiction. Science, during psychosocial treatments for cocaine 335(6068), 601–604. dependence. Psychotherapy Research, 17(2), Everitt, B. J., & Robbins, T. W. (2005). Neural 240 –252 . systems of reinforcement for drug addiction: From actions to habits to compulsion. Nature Daughters, S. B., Lejuez, C., Bornovalova, M. Neuroscience, 8(11), 1481–1489. A., Kahler, C. W., Strong, D. R., & Brown, Fein, G., Di Sclafani, V., Cardenas, V., Gold- R. A. (2005). Distress tolerance as a predic- mann, H., Tolou-Shams, M., & Meyerhoff, tor of early treatment dropout in a residential D. J. (2002). Cortical gray matter loss in substance abuse treatment facility. Journal of treatment-naive alcohol dependent individu- Abnormal Psychology, 114(4), 729–734. als. Alcoholism: Clinical and Experimental Research, 26(4), 558–564. Daumann, J., Koester, P., Becker, B., Wagner, Fein, G., Di Sclafani, V., & Meyerhoff, D. J. D., Imperati, D., Gouzoulis-M ayfrank, E., (2002). Prefrontal cortical volume reduction & Tittgemeyer, M. (2011). Medial prefron- associated with frontal cortex function deficit tal gray matter volume reductions in users in 6-week abstinent crack-cocaine dependent of amphetamine-type stimulants revealed by men. Drug and Alcohol Dependence, 68(1), combined tract-based spatial statistics and 87–93. voxel-based morphometry. NeuroImage, Fox, H. C., Hong, K. A., & Sinha, R. (2008). 54(2), 794–801. Difficulties in emotion regulation and impulse control in recently abstinent alcoholics com- DeVito, E. E., Kober, H., Carroll, K. M., & pared with social drinkers. Addictive Behav- Potenza, M. N. (in preparation). Sex differ- iors, 33(2), 388–394. ences in the neural correlates of cognitive con- Franklin, T. R., Acton, P. D., Maldjian, J. A., trol in cocaine dependence. Gray, J. D., Croft, J. R., Dackis, C. A., et al. DeVito, E. E., Worhunsky, P. D., Carroll, K. M., Rounsaville, B. J., Kober, H., & Potenza, M. N. (2011). A preliminary study of the neural effects of behavioral therapy for substance use disorders. Drug and Alcohol Dependence, 122(3), 228–235. Dichiara, G., & Imperato, A. (1988). Drugs
Emotion Regulation in Substance Use Disorders 443 (2002). Decreased gray matter concentration H., & Vincenzo Piazza, P. (1995). Social in the insular, orbitofrontal, cingulate, and stress increases the acquisition of cocaine self- temporal cortices of cocaine patients. Biologi- administration in male and female rats. Brain cal Psychiatry, 51(2), 134–142. Research, 698(1–2), 46–52. Fu, L., Bi, G., Zou, Z., Wang, Y., Ye, E., Ma, Hart, C. L., Marvin, C. B., Silver, R., & Smith, L., et al. (2008). Impaired response inhibition E. E. (2011). Is cognitive functioning impaired function in abstinent heroin dependents: An in methamphetamine users?: A critical review. fMRI study. Neuroscience Letters, 438(3), Neuropsychopharmacology, 37(3), 586–608. 322–326. Hart, C. L., Ward, A. S., Haney, M., Foltin, R. Fucito, L. M., Juliano, L. M., & Toll, B. A. W., & Fischman, M. W. (2001). Methamphet- (2010). Cognitive reappraisal and expressive amine self-a dministration by humans. Psycho- suppression emotion regulation strategies pharmacology, 157(1), 75–81. in cigarette smokers. Nicotine and Tobacco Heinz, A., Siessmeier, T., Wrase, J., Buchholz, H. Research, 12(11), 1156–1161. G., Gründer, G., Kumakura, Y., et al. (2005). Galloway, G. P., Singleton, E. G., & the Meth- Correlation of alcohol craving with striatal amphetamine Treatment Project Corporate dopamine synthesis capacity and D2/3 recep- Authors. (2008). How long does craving pre- tor availability: A combined [18F]DOPA and dict use of methamphetamine?: Assessment of [18F]DMFP PET study in detoxified alcoholic use one to seven weeks after the assessment patients. American Journal of Psychiatry, of craving. Substance Abuse: Research and 162(8), 1515–1520. Treatment, 1, 63–79. Hernández-López, M., Luciano, M. C., Bricker, Gamble, S. A., Conner, K. R., Talbot, N. L., Yu, J. B., Roales-Nieto, J. G., & Montesinos, F. Q., Tu, X. M., & Connors, G. J. (2010). Effects (2009). Acceptance and commitment therapy of pretreatment and posttreatment depressive for smoking cessation: A preliminary study of symptoms on alcohol consumption following its effectiveness in comparison with cognitive treatment in project MATCH. Journal of Stud- behavioral therapy. Psychology of Addictive ies on Alcohol and Drugs, 71(1), 71–77. Behaviors, 23(4), 723–730. Giedd, J. N., Blumenthal, J., Jeffries, N. O., Cas- Hester, R., & Garavan, H. (2004). Executive tellanos, F. X., Liu, H., Zijdenbos, A., et al. dysfunction in cocaine addiction: Evidence (1999). Brain development during childhood for discordant frontal, cingulate, and cerebel- and adolescence: A longitudinal MRI study. lar activity. Journal of Neuroscience, 24(49), Nature Neuroscience, 2, 861–862. 11017–11022. Gilbert, D. G., Crauthers, D. M., Mooney, D. Hölzel, B. K., Lazar, S. W., Gard, T., Schuman- K., McClernon, F. J., & Jensen, R. A. (1999). Olivier, Z., Vago, D. R., & Ott, U. (2011). Effects of monetary contingencies on smoking How does mindfulness meditation work?: relapse: Influences of trait depression, person- Proposing mechanisms of action from a con- ality, and habitual nicotine intake. Experi- ceptual and neural perspective. Perspectives on Psychological Science, 6(6), 537–559. mental and Clinical Psychopharmacology, Ivanov, I., Newcorn, J., Morton, K., & Tri- 7(2), 174–181. camo, M. (2011). Inhibitory control deficits Goldstein, R. Z., & Volkow, N. D. (2011). Dys- in childhood: Definition, measurement, and function of the prefrontal cortex in addiction: clinical risk for substance use disorders. In M. Neuroimaging findings and clinical implica- T. Bardo (Ed.), Inhibitory control and drug tions. Nature Reviews Neuroscience, 12(11), 652 – 669. abuse prevention: From research to trans- Gouzoulis-M ayfrank, E., & Daumann, J. (2009). lation (pp. 125–144). New York: Springer Neurotoxicity of drugs of abuse—the case of Science+Business Media. methylenedioxy amphetamines (MDMA, Jaffe, J. H., & Jaffe, F. K. (1989). Historical per- ecstasy), and amphetamines. Dialogues in spectives on the use of subjective effects mea- Clinical Neuroscience, 11(3), 305–317. sures in assessing the abuse potential of drugs. Gross, J. J. (this volume, 2014). Emotion regula- NIDA Research Monographs, 92, 43–72. tion: Conceptual and empirical foundations. Johnstone, T., & Walter, H. (this volume, 2014). In J. J. Gross (Ed.), Handbook of emotion The neural basis of emotion dysregulation. In regulation (2nd ed., pp. 3–20). New York: J. J. Gross (Ed.), Handbook of emotion regu- Guilford Press. lation (2nd ed., pp. 58–75). New York: Guil- Haney, M., Maccari, S., Le Moal, M., Simon, ford Press.
444 PSYCHOPATHOLOGY Jones, B. T., Corbin, W., & Fromme, K. (2001). Li, C. S. R., Huang, C., Yan, P., Bhagwagar, Z., A review of expectancy theory and alcohol Milivojevic, V., & Sinha, R. (2008). Neural consumption. Addiction, 96, 57–72. correlates of impulse control during stop sig- nal inhibition in cocaine-dependent men. Neu- Kessler, R. C., Berglund, P., Demler, O., Jin, R., ropsychopharmacology, 33(8), 1798–1806. Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distri- Li, C. S. R., Luo, X., Yan, P., Bergquist, K., & butions of DSM-IV disorders in the National Sinha, R. (2009). Altered impulse control in Comorbidity Survey Replication. Archives of alcohol dependence: Neural measures of stop General Psychiatry, 62(6), 593–602. signal performance. Alcoholism: Clinical and Experimental Research, 33(4), 740–750. Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: focus on Linehan, M. M., Dimeff, L. A., Reynolds, S. K., heroin and cocaine dependence. American Comtois, K. A., Welch, S. S., Heagerty, P., et Journal of Psychiatry, 142(11), 1259–1264. al. (2002). Dialectical behavior therapy versus comprehensive validation therapy plus 12-step Kiluk, B. D., Nich, C., Babuscio, T., & Carroll, for the treatment of opioid dependent women K. M. (2010). Quality versus quantity: Acqui- meeting criteria for borderline personality dis- sition of coping skills following computerized order. Drug and Alcohol Dependence, 67(1), cognitive behavioral therapy for substance use 13–26. disorders. Addiction, 105(12), 2120–2127. Litt, M. D., Cooney, N. L., & Morse, P. (2000). Kober, H., & DeLeone, C. M. (2011). Smoking Reactivity to alcohol-related stimuli in the and neuroimaging: A review. Current Cardio- laboratory and in the field: Predictors of crav- vascular Risk Reports, 5(6), 484–491. ing in treated alcoholics. Addiction, 95(6), 889–900. Kober, H., DeVito, E. E., DeLeone, C. M., Car- roll, K. M., & Potenza, M. N. (under review). Littel, M., & Franken, I. H. A. (2011). Inten- Pre-treatment neural activity in cannabis tional modulation of the late positive potential users differs from controls and relates to long in response to smoking cues by cognitive strat- term treatment outcome. egies in smokers. PloS ONE, 6(11), e27519. Kober, H., Kross, E. F., Mischel, W., Hart, C. L., Liu, H., Li, L., Hao, Y., Cao, D., Xu, L., & Ochsner, K. N. (2010). Regulation of crav- Rohrbaugh, R., et al. (2008). Disrupted white ing by cognitive strategies in cigarette smok- matter integrity in heroin dependence: A con- ers. Drug and Alcohol Dependence, 106(1), trolled study utilizing diffusion tensor imag- 52–55. ing. American Journal of Drug and Alcohol Abuse, 34(5), 562–575. Kober, H., Mende-Siedlecki, P., Kross, E. F., Weber, J., Mischel, W., Hart, C. L., et al. Luerssen, A., & Ayduk, O. (this volume, 2014). (2010). Prefrontal–striatal pathway underlies The role of emotion and emotion regulation in cognitive regulation of craving. Proceedings of the ability to delay gratification. In J. J. Gross the National Academy of Sciences, 107(33), (Ed.), Handbook of emotion regulation (2nd 14811–14816. ed., 111–125). New York: Guilford Press. Kober, H., Turza, A. C., & Hart, C. L. (2009). Lüscher, C., & Malenka, R. C. (2011). Drug- Risk factors for substance use, abuse, and evoked synaptic plasticity in addiction: From dependence: Learning. In H. Kranzler & P. molecular changes to circuit remodeling. Neu- Korsmeyer (Eds.), Encyclopedia of drugs, ron, 69(4), 650–663. alcohol, and addictive behavior (3rd ed.). Macmillan Reference USA. Marlatt, G. A., & Witkiewitz, K. (2005). Relapse prevention for alcohol and drug problems. In Koob, G. F., & Le Moal, M. (2008). Neurobio- G. Marlatt & D. Donovan (Eds.), Relapse logical mechanisms for opponent motivational prevention: Maintenance strategies in the processes in addiction. Philosophical Transac- treatment of addictive behaviors (2nd ed., tions of the Royal Society B: Biological Sci- pp. 1–44). New York: Guilford Press. ences, 363(1507), 3113–3123. Marshall-Berenz, E. C., Vujanovic, A. A., & Kun, B., & Demetrovics, Z. (2010). Emotional MacPherson, L. (2011). Impulsivity and alco- intelligence and addictions: A systematic hol use coping motives in a trauma-exposed review. Substance Use and Misuse, 45(7–8), sample: The mediating role of distress toler- 1131–1160. ance. Personality and Individual Differences, 50(5), 588–592. Le Moal, M. (2009). Drug abuse: Vulnerability and transition to addiction. Pharmacopsychi- McRae, K., Gross, J. J., Weber, J., Robertson, E. atry, 42(S1), 542–555.
Emotion Regulation in Substance Use Disorders 445 R., Sokol-H essner, P., Ray, R. D., et al. (2012). Perkins, K. A. (2009). Does smoking cue-induced The development of emotion regulation: An craving tell us anything important about nico- fMRI study of cognitive reappraisal in chil- tine dependence? Addiction, 104(10), 1610– dren, adolescents and young adults. Social 1616. Cognitive and Affective Neuroscience, 7(1), 11–22. Pfefferbaum, A., Rosenbloom, M., Rohlfing, Miller, E. K., & Cohen, J. D. (2001). An inte- T., & Sullivan, E. V. (2009). Degradation of grative theory of prefrontal cortex function. association and projection white matter sys- Annual Review of Neuroscience, 24(1), 167– tems in alcoholism detected with quantitative 202. fiber tracking. Biological Psychiatry, 65(8), Mischel, W., Ayduk, O., Berman, M. G., Casey, 680 – 690. B., Gotlib, I. H., Jonides, J., et al. (2011). ‘Willpower’ over the life span: Decomposing Pfeifer, J. H., Lieberman, M. D., & Dapretto, M. self-regulation. Social Cognitive and Affective (2007). “I know you are but what am I?”: Neu- Neuroscience, 6(2), 252–256. ral bases of self-and social knowledge retrieval Moffitt, T. E., Arseneault, L., Belsky, D., Dick- in children and adults. Journal of Cognitive son, N., Hancox, R. J., Harrington, H. L., et Neuroscience, 19(8), 1323–1337. al. (2011). A gradient of childhood self-control predicts health, wealth, and public safety. Potenza, M. N., Sofuoglu, M., Carroll, K. M., & Rounsaville, B. J. (2011). Neuroscience of Proceedings of the National Academy of Sci- behavioral and pharmacological treatments ences, 108(7), 2693–2698. for addictions. Neuron, 69(4), 695–712. Morasco, B. J., Gritzner, S., Lewis, L., Oldham, R., Turk, D. C., & Dobscha, S. K. (2011). Sys- Rando, K., Hong, K. I., Bhagwagar, Z., Li, C. S. tematic review of prevalence, correlates, and R., Bergquist, K., Guarnaccia, J., et al. (2011). treatment outcomes for chronic non-cancer Association of frontal and posterior corti- pain in patients with comorbid substance use cal gray matter volume with time to alcohol disorder. Pain, 152(3), 488–497. relapse: A prospective study. American Jour- National Institute of Mental Health (NIMH). nal of Psychiatry, 168(2), 183–192. (2007). National Comorbidity Survey: Life- time prevalence estimates. Available from Riediger, M., & Klipker, K. (this volume, 2014). www.hcp.med.harvard.edu/ncs. Emotion regulation in adolescence. In J. J. Nestor, L. J., Ghahremani, D. G., Monterosso, Gross (Ed.), Handbook of emotion regulation J., & London, E. D. (2011). Prefrontal hypoac- (2nd ed., 187–202). New York: Guilford Press. tivation during cognitive control in early absti- nent methamphetamine-dependent subjects. Riley, H., & Schutte, N. S. (2003). Low emo- Psychiatry Research: Neuroimaging, 194(3), tional intelligence as a predictor of substance- 287–295. use problems. Journal of Drug Education, Nunes, E. V., & Levin, F. R. (2004). Treatment 33(4), 391–398. of depression in patients with alcohol or other drug dependence. Journal of the American Romero, M. J., Asensio, S., Palau, C., Sanchez, Medical Association, 291(15), 1887–1896. A., & Romero, F. J. (2010). Cocaine addiction: O’Brien, C. P., Childress, A. R., Ehrman, R., Diffusion tensor imaging study of the inferior & Robbins, S. J. (1998). Conditioning fac- frontal and anterior cingulate white matter. tors in drug abuse: Can they explain compul- Psychiatry Research: Neuroimaging, 181(1), sion? Journal of Psychopharmacology, 12(1), 57– 63. 15–22. Ochsner, K. N., & Gross, J. J. (this volume, 2014). Shiffman, S., Dunbar, M., Kirchner, T., Li, X., The neural bases of emotion and emotion regu- Tindle, H., Anderson, S., et al. (2013). Smoker lation: A valuation perspective. In J. J. Gross reactivity to cues: Effects on craving and on (Ed.), Handbook of emotion regulation (2nd smoking behavior. Journal of Abnormal Psy- ed., pp. 23–42). New York: Guilford Press. chology, 122(1), 264–280. O’Connell, K. A., Hosein, V. L., Schwartz, J. E., & Leibowitz, R. Q. (2007). How does coping Shiffman, S., Paty, J. A., Gnys, M., Kassel, J. A., help people resist lapses during smoking cessa- & Hickcox, M. (1996). First lapses to smok- tion? Health Psychology, 26(1), 77–84. ing: Within-subjects analysis of real-time reports. Journal of Consulting and Clinical Psychology, 64(2), 366–379. Silvers, J. A., McRae, K., Gabrieli, J. D. E., Gross, J. J., Remy, K. A., & Ochsner, K. N. (2012). Age-related differences in emotional reactivity, regulation, and rejection sensitiv- ity in adolescence. Emotion, 12(6), 1235– 1247.
446 PSYCHOPATHOLOGY Sinha, R., & Li, C. S. R. (2007). Imaging stress- (2008). Impulsivity as a vulnerability marker and cue-induced drug and alcohol craving: for substance-use disorders: Review of find- Association with relapse and clinical impli- ings from high-risk research, problem gam- cations. Drug and Alcohol Review, 26(1), blers and genetic association studies. Neuro- 25–31. science and Biobehavioral Reviews, 32(4), 777–810. Sorg, S. F., Taylor, M. J., Alhassoon, O. M., Volkow, N. D., Fowler, J., Wang, G., Telang, F., Gongvatana, A., Theilmann, R. J., et al. Logan, J., Jayne, M., et al. (2010). Cognitive (2012). Frontal white matter integrity predic- control of drug craving inhibits brain reward tors of adult alcohol treatment outcome. Bio- regions in cocaine abusers. NeuroImage, 49, logical Psychiatry, 71, 262–268. 2536–2543. Volkow, N. D., Wang, G. J., Fowler, J. S., & Steinberg, L. (2005). Cognitive and affective Tomasi, D. (2011). Addiction Circuitry in the development in adolescence. Trends in Cogni- Human Brain. Annual review of pharmacol- tive Sciences, 9(2), 69–74. ogy and toxicology, 52(1), 321–336. Weiss, F., & Koob, G. F. (2001). Drug addiction: Substance Abuse and Mental Health Services Functional neurotoxicity of the brain reward Administration (SAMHSA). (2011). Results systems. Neurotoxicity Research, 3(1), 145– 156. from the 2010 National Survey on Drug Use Westbrook, C., Creswell, J. D., Tabibnia, G., Jul- son, E., Kober, H., & Tindle, H. A. (2013). and Health (NSDUH): Summary of national Mindful attention reduces neural and self- findings (NSDUH Series H-41). Rockville, reported cue-induced craving in smokers. MD: Author. Tabibnia, G., Monterosso, J. R., Baicy, K., Aron, Social Cognitive and Affective Neuroscience, A. R., Poldrack, R. A., Chakrapani, S., et al. 8(1), 73–84. (2011). Different forms of self-c ontrol share a Witkiewitz, K., & Bowen, S. (2010). Depres- neurocognitive substrate. Journal of Neurosci- sion, craving, and substance use following a ence, 31(13), 4805–4810. randomized trial of mindfulness-based relapse Taioli, E., & Wynder, E. L. (1991). Effect of the prevention. Journal of Consulting and Clini- age at which smoking begins on frequency of cal Psychology, 78(3), 362–374. smoking in adulthood. New England Journal Zgierska, A., Rabago, D., Chawla, N., Kushner, of Medicine, 325(13), 968–969. K., Koehler, R., & Marlatt, A. (2009). Mind- Tarter, R. E., Kirisci, L., Mezzich, A., Cornelius, fulness meditation for substance use disorders: J. R., Pajer, K., Vanyukov, M., et al. (2003). A systematic review. Substance Abuse, 30(4), Neurobehavioral disinhibition in childhood 266–294. predicts early age at onset of substance use disorder. American Journal of Psychiatry, 160(6), 1078–1085. Verdejo-G arcía, A., Lawrence, A. J., & Clark, L.
Chapter 27 A Psychological Construction Account of Emotion Regulation and Dysregulation: The Role of Situated Conceptualizations Lisa Feldman Barrett Christine D. Wilson‑Mendenhall Lawrence W. Barsalou For the last several centuries, philosophers, fuzzy bee buzzing around your head triggers and later, psychologists have assumed that a state of fear, which you then regulate by the mind works like a machine—a printing suppressing the urge to run and by distract- press, a switchboard, a computer. According ing yourself with a close examination of the to the machine metaphor, the mind consists local scenery, such as an interestingly shaped of a number of functionally distinct pro- rock or tree). Regulation might also occur cesses (mental “modules” or “faculties”) that before the response occurs, preempting the interact with one another; if separated, these processes would still retain their identity and FIGURE 27.1. A depiction of the machine meta- function. The machine metaphor dictates a phor of brain function. particular view of mental causation: “Psy- chological process A” localized in one swath of brain tissue (a region or a network) causes a change in a separate and distinct “psycho- logical process B” localized in another swath of tissue (see Figure 27.1). A good example of the machine metaphor at work can be found in the science of emotion regulation. It is largely assumed, for example, that an emotion, like fear, is created by one process computed in one part of the brain (usually in subcortical limbic or paralimbic cortex) that is regulated by executive or other cogni- tive processes located elsewhere in the brain (typically somewhere in prefrontal cortex). In the process model of emotion regulation (Gross, this volume), an emotion can be trig- gered first, then subsequently is regulated (e.g., you are walking in the woods, and a 447
448 PSYCHOPATHOLOGY emotion from ever taking place (e.g., before selves be characterized at both the psycho- you start your walk, you might remind your- logical level (e.g., Barrett, 2006, 2012) and self that bees are a part of nature; they pol- the level of brain networks (e.g., Barrett & linate beautiful flowers and make delicious Satpute, 2013; Lindquist & Barrett, 2012). honey). Regardless of which comes first, the These core systems are like the “mental state emotion is separate from its regulation. variables” (see Salzman & Fusi, 2010), fac- ets or core systems that describe the brain In the last several years, scientists have state. As basic “ingredients” of the mind, come to question whether the mind and they are necessary for but not specific to brain work like a machine with separate, emotion generation, or to emotion regula- interacting bits and pieces (e.g., Barrett, tion per se, just as flour and salt are nec- 2009), and assumptions about modularity, essary for but not specific to bread. As the even in sensory cortices, are strongly in ques- brain transitions from one state to another, tion. As a consequence, other working meta- mental states ebb and flow, and people give phors for the mind and the brain are more special names to these different states. We apt—say, molecules that are constructed of refer to this as a psychological construction- atoms, chamber music emerging from the ist, or merely a constructionist, approach to interplay of instruments, or recipes from the mind and brain. From this construction- a well-stocked pantry full of ingredients. ist point of view, emotions are not unique These metaphors begin with a deceptively mental states that are caused by dedicated simple observation: During every moment mechanisms, to be modified by another set of of waking life, the brain takes in sensory dedicated regulatory mechanisms. Instead, input captured from the world outside the emotions emerge, and regulation occurs, as skin (light, vibrations, odors, etc.) and sen- the consequence of an ongoing, continually sations captured from within the body that modified constructive process that makes holds the brain (the internal “milieu”), and sensory inputs meaningful. Every mental uses knowledge from prior experience (also state, including an emotion both before and variously called concepts, memories, associ- after regulation is said to have occurred, is ations, beliefs, predictions, etc.)—stored in a situated conceptualization, constructed association cortex, and in sensory neurons from assemblies of neurons that perform and subcortical regions—and makes those sensory, conceptual, attentional, and action sensory inputs meaningful. This occurs by functions. creating situated conceptualizations (Bar- rett, 2006, 2012; Barsalou, 2003, 2009; In this chapter, we examine in more detail Barsalou, Niedenthal, Barbey, & Ruppert, the concept of emotion regulation as result- 2003; Wilson-Mendenhall, Barrett, Sim- ing from the never ending sequence of situ- mons, & Barsalou, 2011). A situated con- ated conceptualizations that occur as the ceptualization initially is like a prediction brain transitions from one state to another. of what sensory input stands for in the First, we introduce the general idea that world (i.e., object or event identification), knowledge (as reactivation and recombina- which properties are salient (i.e., deserving tion of prior experience) gives meaning to of attention), what to do about that sensory incoming sensory input and is itself enac- input (i.e., a predicted action), and what the tive (i.e., adds novel features via perceptual homeostatic and metabolic consequences inference). Next, we link these notions to the will be (i.e., affective changes). From our idea of situated conceptualizations from the perspective, the brain’s architecture can be literature on concepts and categories, and thought of as a situated conceptualization discuss how we have broadened it into a gen- generator producing the individual brain eral proposal of constructed mental states states that correspond to each individual that involve making meaning of sensory mental state, such as an individual instance input and even modifying sensations during of fear or an instance of regulation. the process. We then discuss how emotions might be understood as situated conceptual- Building on the kitchen metaphor (in Bar- izations, and how emotion regulation might rett, 2009), we have proposed that each be reconceptualized as shifting from one sit- brain state, each situated conceptualization, uated conceptualization to another. Finally, can be understood in terms of more core sys- we use this framework to consider how emo- tems (i.e., the ingredients), which can them-
Emotion Regulation as Situated Conceptualizations 449 tional dysregulation might be understood in and-white image. A second lesson is that no terms of the situated conceptualizations that matter how hard you try, you cannot gain are constructed. introspective access to the processes in your brain that underlie using stored knowledge Making Meaning of Sensory Input to make incoming sensations meaningful. Take a look at the image in Figure 27.2. As Experimental methods are necessary to you look at this image, your brain is try- unmask its workings. The third lesson from ing to make sense of the visual input it is this example is that your brain infers ele- receiving. If you are having difficulty mak- ments of the experience that are not imme- ing sense of the visual input from the image diately present (e.g., the lines that link the (e.g., you cannot recognize an object in it), black and gray blobs together into the shape then you are in a state of experiential blind- of a bee). Although you cannot gain intro- ness (e.g., Fine, Wade, Brewer, May, Good- spective access to these inferred features, you man, et al., 2003). This is because, usually, can get a sense that this inference process in the blink of an eye, quite automatically works by conjuring some additional percep- and with no effort whatsoever, your brain tual detail—t he soft drone of buzzing, or the is able to integrate impinging sensory stim- delicate flutter of wings. In your mind’s eye, ulation seamlessly with its vast amount of you might see the object nose around as it stored knowledge (from prior experience), searches for pollen. You might even be able allowing you to construct a visual represen- to smell the sweet fragrance of the flower. tation of the object. Such knowledge is not Inference is considered one of the primary merely helpful—it is necessary to normal purposes of memory and is how experiences perception. Without prior experience, the of the past help to inform situated action sensations are meaningless, and if this were in the present. You could not survive in the an object before you, in three-d imensional world without this capacity. Some scientists space, you would not know how to act on refer to this inference process as simulation it. The definition of adaptive behavior is the (e.g., Barsalou, 1999, 2009), where you can use of past experience to guide future action. connect immediate sensory input with a vast body of sensory, motor, affective, and other, Now look at the image at the end of the related information stored in memory; we chapter (on page 465). Then return to look also refer to it as categorization (Barrett, again at Figure 27.2. 2006). We hope you can now see the object, The fourth lesson is that these inferences because you have had an experience to help prepare you for situated action. For some you make sense of the visual input. The first people, perhaps, who have experienced lesson here is that it very difficult to “unsee” bees as part of a beautiful garden and/or the object in the original “blobby” black- as producing a sweet, tasty delight (honey), the image of a bee is calming and bucolic. FIGURE 27.2. An illustration of experiential blindness.
450 PSYCHOPATHOLOGY For them, seeing a bee might mean moving of your attentional focus. When sensations in to get a closer look, with an associated from the visual world are foregrounded (and reduction in heart rate, blood pressure, and sensations from the body are in the back- skin conductance. For other people, perhaps ground), you experience the bee as friendly who have been stung, resulting in pain and or wicked because you are focused on the swelling, the image of a bee is terrifying. For bee, and not on how your body is respond- these people, seeing a bee might mean freez- ing to the bee (e.g., Anderson, Siegel, White, ing, with an associated increase in heart & Barrett, 2012). When sensations from rate, blood pressure, and skin conductance. the body are foregrounded, either because Or, it might mean waving their arms or run- they are particularly intense, because such ning away, with an increase in heart rate and focus has been useful and reinforced in a skin conductance but a decrease in blood prior situation like this one, or because you pressure. These are the sorts of physiologi- focus explicitly on them, you will experience cal changes that we scientists record when either tranquility or distress. we show study participants images from the International Affective Picture System The sixth lesson from this example is (IAPS; Lang, Bradley, & Curthbert, 2008) that prior experiences seed the construction stimulus set (e.g., Bradley, Codispoti, Cuth- of present and future experiences by shap- bert, & Lang, 2001). They arise during a ing the meaning of momentary, incoming prediction of how the body should respond sensory input. Why might you automati- in a specific situation (what we have previ- cally experience the calm of a bee buzzing ously referred to as an “affective predic- in a bucolic garden, whereas another person tion”; Barrett & Bar, 2009). might automatically experience the terror of a bee attacking and stinging the body? The The fifth lesson from this example is that answer lies in the nature of prior experience. the process of making meaning of external Actual experiences with bees, movie scenes sensations will always produce some kind of that involve bees, stories, or simply instruc- automatic change in your physical state. It tion about bees constitute the knowledge is these internal sensations that likely form that is used to make sensations meaning- the basis of your pleasant or unpleasant core ful. Your learning history predisposes you affective tone that accompanies any men- to experience sensations from the world and tal states of which it is a part (Barrett & from your own body in particular modal Bliss-Moreau, 2009; Russell, 2003; Wundt, ways. All things being equal, you have 1897); the actual visceral changes are not developed experiential “habits”—what you necessary for feeling, of course, although have experienced in the past is very likely some representation of them in the brain is what you will experience in the present, required. In the same way that your brain because stored representations of the past used prior experience to make meaning of help to constitute the present (hence, the the visual sensations in Figure 27.2, it will phrase “the remembered present”; Edelman, also use such knowledge to make mean- 1998). It is now well known that the same ing of these bodily sensations. These two brain network (termed the default mode or meaning-m aking achievements are not hap- mentalizing network) involved in long-term pening in quick succession—they are occur- memory is also important for imagining the ring simultaneously, as a function of how future (Andrews-Hanna, Reidler, Sepul- the brain understands the current sensory cre, Poulin, & Buckner, 2010), and recent array to create a unified conscious moment evidence suggests that these networks are (cf. Barrett, 2009). They are not occurring also important for constructing emotions in in a single instant, but they are evolving over the present (Kober et al., 2008). It is very time. This meaning making rarely happens likely that when faced with the visual input deliberately, but more often occurs as instan- in Figure 27.2 your brain reconstituted a taneously, continuously, and effortlessly for number of different associations that were internal sensations as it does for external in competition with one another, and that sensations. These insights form the basis of via a variety of selection processes (Barrett, our conceptual act theory of emotion (Bar- Tugade, & Engle, 2004; Sporns, Tononi, & rett, 2006). You experience a perception of Edelman, 2000a, 2000b), only one was fully the situation versus an emotion as a function realized (perhaps according to the logic of
Emotion Regulation as Situated Conceptualizations 451 constraint satisfaction) (e.g., Barrett, Och- while viewing the bee a few paragraphs ear- sner, & Gross, 2007; Barsalou et al., 2003). lier, for example, perhaps you experienced The same logic might hold for making mean- the moment as an emotion; when the focus ing of internal sensations. When is a high was on the visual sensations, perhaps you arousal state fear, or anger, or excitement? It experienced it merely as a perception of the might depend on your prior experience with bee. In each case, the visual input was the these sensations in different contexts, and in same—what differed was the situated con- particular, how those various instances were ceptualization. paired with emotion words such as “fear,” “anger,” or “excitement” (cf. Barrett, 2006; In the past, we have referred to the cre- Barrett, Lindquist, & Gendron, 2007). With ation of situated conceptualizations as an additional learning or training, it should be act of categorization, because situated con- possible to change your experiential habits. ceptualizations are enactments that develop By deliberately cultivating certain types of for categories of experience (a variety of experiences, it should be possible to modify situated conceptualizations develop for the the population of representations that are categories fear, anger, etc.; Barrett, 2006). available for use in the present. To understand how situated conceptualiza- tions work, then, it is important to under- Situated Conceptualizations stand how concepts and categories work. In our prior writing, we have focused on Categorization is not a narrow, limited the process of meaning making as a psy- process—it does not happen only when you chological construction of emotion that explicitly attempt to assign an object to one involves creating situated conceptualiza- grouping or another. Categorization plays a tions of internal bodily sensations that are central role in all cognitive activity, includ- highly context-dependent and coordinated ing the sorts of high-level perceptions that with the immediate situation (cf. Barrett, are involved in emotion and emotion regula- 2006; Wilson-Mendenhall et al., 2011). In tion. Categorizing is a fundamental cogni- fact, however, the notion of a situated con- tive activity. To categorize sensory input is ceptualization implies that people are mak- to determine what it is, why it is, and what ing meaning of both internal and external to do with it. sensations at the same time, to create a uni- fied conscious field (cf. Barrett, 2009). Con- A central property of human knowledge ceptual knowledge is distributed throughout is that it is organized categorically. Unlike the brain’s modal systems for perception and a recording device that simply stores each action in the form of simulators that reenact individual, holistic, bitmapped image of sensory, action, affect, and other elements the world, the human brain is constantly of situations captured through experience interpreting aspects of experience, using (e.g., Barsalou, 1999; Simmons & Barsalou, concepts in memory to make sensations 2003). From this perspective, knowledge is meaningful. A concept can be viewed as central to not only the cognition involved in aggregated memories that accumulate thinking and imagining offline (reenacting for a category across experiences with its or simulating a situation that is not present) instances. By focusing attention on some but also to perceiving external sensations aspect of experience repeatedly, a concept from the world and internal sensations from develops over time from instances of the the body (in which case knowledge fuses respective category experienced across situ- with impinging sensory input—this fusion ations (Barsalou, 1999; Barsalou & Hale, occurs seamlessly because knowledge is 1993; Murphy, 2002). The concept of bee, stored and represented in the same format for example, aggregates diverse information or “language” as the sensations), both of about the category of bees across a variety which are involved in predicting and guid- of situations into a loosely organized repre- ing one’s actions. In this sense, conceptual sentation that includes properties (e.g., yel- knowledge is enactive. When your brain low and black, with wings), relations (e.g., was foregrounding your bodily sensations flowers), rules (for something to be a bee, it must have black and yellow stripes, it must fly, etc.), and exemplars (e.g., instances of honey bees, carpenter bees, a queen bee, etc.).1 Concepts develop for all aspects of
452 PSYCHOPATHOLOGY human experience related to bee, including that is available to represent new instances objects, settings, and actions (e.g., flowers, of the category “bee.”2 Later, when your honey, gardens, freezing, running, swatting, brain requires conceptual knowledge to pro- flying, buzzing, stinging). From simpler con- cess some incoming sensory input, it samples cepts, more complex concepts emerge for from the populations of situated conceptual- events (e.g., strolling in a garden, fear of the izations, associated with relevant concepts, bee). Concepts also develop for a wide vari- to create a novel situated conceptualiza- ety of internal states (e.g., aroused, quiet), as tion, integrating current sensory input and well as for the properties and relations that retrieved (modal) conceptual knowledge describe instances of concepts (e.g., yellow, (Barsalou, 2009). From this perspective, fast, sweet, above, after, cause). Although conceptual processing is actually more like concepts reflect experience to a considerable scene perception, because the brain pro- extent, they undoubtedly have biological duces a conceptual state using multimodal bases that scaffold learning (Barsalou, 1999, information about entire situations. In this 2008; Carey, 2009; Rips, 2010; Simmons & way, a situated conceptualization allows an Barsalou, 2003). experiencer to interpret incoming informa- tion and draw inferences that go beyond the Extensive evidence now exists that an information given. instance of conceptual knowledge (an instance of a concept, or a conceptualiza- It is impossible to have conscious access tion) emerges from different multimodal sys- to the processes that create situated concep- tems in the brain (e.g., McClelland, 2010). tualizations, because they are initiated in Depending on the modalities relevant for the first milliseconds of perception (or per- processing a concept’s instances, particu- haps even before sensory input is actually lar modal areas of the brain store informa- encountered), and evolve over time, but it is tion about the category and can later rep- possible to demonstrate the brain’s computa- resent the category in the absence of actual tional power in creating them by engaging in instances. Martin (2001, 2007) reviews a little imagination. For example, close your evidence, for example, that different multi- eyes and create an image of a yellow and modal profiles represent living versus non- black bee in your mind (i.e., simulate a bee). living things. Other research has similarly In doing this, your brain is creating a rep- established the multimodal profiles that resentation that includes the sights, sounds, represent the self and others (cf. Legrand smells, and so forth, of the bee, along with & Ruby, 2009; Northoff et al., 2006; Van a situation in which the bee occurred, all of Overwalle, 2009), people, buildings, and which would prepare you for a certain type tools (e.g., Simmons, Reddish, Bellgowan, of action (to run, to peer closer, to swat, to & Martin, 2010), the external world versus freeze). This representation involves the acti- internal states (Golland, Golland, Bentin, & vation of neurons throughout your brain, Malach, 2008), and so forth. including sensory and motor neurons, as well as neurons that regulate and represent Category instances (e.g., a bee) are never an internal body (somatovisceral) state. All encoded alone into conceptual knowledge, these elements (activation of sensory and even though their context may not explic- motor neurons, changes in the physical itly be the focus of attention. Initially, when state of the body, preparations for action) encoding a category instance of a bee, for are examples of what it means to say that example, from actual prior experience with a representation is “embodied” (Barrett & bees, observational learning about bees, Lindquist, 2008). This is also what it means hearing stories about bees, or being told to say that the brain is making a predic- rules about bees, the brain captures the ele- tion about an object and how to act on it ments of the setting in which the bee occurs (Lindquist, Wager, Kober, Bliss-M oreau, & (i.e., other agents and objects), internal Barrett, 2012) or, as we noted before, to say sensory (i.e., somatovisceral) cues from the that the brain is simulating a bee. This sort body, as well as actions, instructions from of simulation would occur if you were pre- others (in the form of rules) and words (e.g., sented with an image of a bee and asked to the phonological form for “bee”). Over time, recognize it (as in the prior section of this these situated conceptualizations create a chapter), to categorize it explicitly (assign it heterogeneous population of information
Emotion Regulation as Situated Conceptualizations 453 to one stimulus grouping over another), to ceptual instances of the concept, it also con- judge it in some way, or to perform any kind trols interactions and predicts the resultant of cognitive task with it. It would occur if events. you were being asked to remember a bee, talk about a bee, think about a bee, or when Emotions and Emotion Regulation perceiving bees during an outdoor walk. as Situated Conceptualizations Initial work on situated conceptualizations Once concepts become established in focused on how this theory of concepts can memory, they play central roles throughout be applied to perceiving or interacting with cognition and perception (e.g., Barsalou, concrete objects in relevant situations (for a 2003; Murphy, 2002), and, as we suggest, review, see Barsalou, 2009), with concep- emotion. As people experience incoming tual knowledge represented using the brain’s sensory input from the world and the body, modal systems for perception, action, and they use prior experience to categorize the internal bodily states. We further developed agents, objects, setting, behaviors, events, these ideas into a theory of emotion (Barrett, properties, relations, and bodily states 2006) and a broader theory of mental states that are present. As described in Wilson- more generally (Barrett, 2009), although in Mendenhall et al. (2011), a situated concep- the present discussion we focus on emotion. tualization is the conceptualization of the We hypothesize that situated conceptual- current situation across parallel streams of izations have relevance for not only under- conceptual processing for all of these ele- standing the nature of emotion but also ments. As information from the current situ- presenting a computational framework for ation registers simultaneously in these pro- understanding emotion regulation. cessing streams, conceptual systems on each of them categorize the respective informa- Emotions as tion and draw inferences. At a more global Situated Conceptualizations level, abstract relational concepts integrate In our view, an emotion concept typically conceptualizations on the individual pro- forms when a given emotion word (e.g., cessing streams into coherent interpretations “fear”) is explicitly uttered (e.g., by a care- of larger events taking place across the situ- giver or teacher) during many different ation as a whole. Categorical inferences (i.e., instances involving a variety of changes in predictions) follow, including inferences feelings, physiology, and actions, becoming about how an object, or entity, is likely to the statistical regularity that holds the con- behave, how one can best interact with it, cept together across instances involving dif- the likely value to be obtained from inter- ferent sensory input and actions (cf. Barrett, acting with it, and so forth, and on a larger Lindquist, et al., 2007). Selectively attend- scale, about how situations may unfold ing with some consistency to components during an event. From the perspective of of experience results in category knowledge grounded cognition, situated conceptual- that is captured in memory (Schyns, Gold- izations are responsible for producing the stone, & Thibaut, 1998). Because emotions action, internal states, and perceptual con- are abstract, language appears to guide struals that underlie goal-related activity in selective attention to the changes in inter- the current situation. Because modalities for nal states that characterize an emotion in action, internals states, and perceptual con- a given situation. For example, each time a struals are typically active when a concept is parent (or some other person) labels a child’s learned, situated conceptualizations gener- internal state or behavior with an emotion ate activity in these systems as they become term, or a child observes the emotion term active on later occasions. On activating the being used to label someone else’s behavior, concept for bee, a situated conceptualization the child extracts information about that might activate representations of situation- instance (including the phonological form of specific approach–avoid actions (e.g., swat- the word) and integrates it with past infor- ting the bee), representations of internal mation associated with the same term that states such as pleasure or displeasure, and perceptual construals that direct the body toward a particular instance of pleasure or displeasure. Not only does bee represent per-
454 PSYCHOPATHOLOGY is stored in memory. In this way, the pho- nological form for “fear” could become a tions in the self as the experience of emo- perceptual regularity that occurs repeatedly tion, or sensory input (from facial actions, across situations, and a concept fear forms voice, etc.) coming from others as emotional (it is certainly the case that young infants expressions. The meaning acquired by the can use abstract words to make conceptual sensations is not based solely on the physical inferences about objects that differ in their properties of sensations alone (as body states sensory properties; Dewar & Xu, 2009). or actions, as represented in the physiol- The consequence is that accumulating con- ogy of the body and/or in neural activations ceptual knowledge for fear, for example, within the brain). Conceptual knowledge is will vary within a person over instances as required to give it additional functionality context and situated action demand. No sin- and meaning. For example, an increase in gle situated conceptualization for fear need heart craatteeg(oXr1y) counts as feeling afraid a(cYt1i-) give a complete account of the category fear. when knowledge about fear is There is not one script for fear or one abstract vated as a specific, embodied representation representation for fear.3 For example, fear of fear, such as when a bee is attempting to might occur when excitedly declaring a risky isntinhgeayrotura(tCe1t).akInesthonis example, the increase bet, when lethargically sensing the first signs a meaning and allows of flu, when frantically fleeing a blazing fire, a predicted behavior that it would not oth- or when casually flirting with an attractive erwise have alone. Emotion regulation stranger. On any given occasion, the content might be characterized in the same way. A of a situated conceptualization for fear will dsoifetcurraeeataipospenr-iasnipsheaeclaif(rYitc2r)aretwephr(eXesn2e)nactnoaotutionhntesr as evidence be constructed to contain mainly those prop- embodied, erties of fear that are contextually relevant, of a bee is and it therefore contains only a small sub- activated, such as when it is floating above set of the knowledge available in long-term a brightly colored flower petal (C 2b).e In these memory about the category fear. 4 In a given examples, the concept fear might applied instance, then, the situated conceptualiza- to internal sensations from the body, because tion for fear has the potential to change the they are in the focus of attention, or because internal state of the perceiver, because when fear is part of a situated conceptualization retrieving information about fear, sensory, that is part of the concept bee. It is a mis- motor, and interoceptive states are partially nomer to refer to conceptual knowledge as reinstated in the relevant aspects of cortex, merely psychological or social. For physical simulating an instance. actions and body states (X) to count as an emotion (Y), some kind of physical change We have hypothesized that concepts and has to take place somewhere in the brain of categories for emotion work in essentially a perceiver to complete a situated conceptu- the same way as other kinds of abstract con- alization in that perceiver at that moment cepts in the conceptual system, where each in time (C). So a psychological construc- individual situated conceptualization for a tion approach makes predictions about the specific emotion (e.g., fear) refers to an entire brain basis of emotion (and emotion regula- situation, including both the internal and tion), but one that is different from the typi- external sensations (Wilson-Mendenhall cal machine metaphor illustrated in Figure et al., 2011). In this way, emotions can be 27.1 and found in most natural kind mod- thought of as affective changes that are els of emotion (also see Jones, Kirkland, & linked to the situation in some way (cf. Bar- Cunningham, this volume). An instance of rett, 2006; Clore & Ortony, 2008) and emo- emotion is hypothesized to correspond to an tions can be said to reflect the structure of entire brain state—or a series of states chang- situations. The key hypothesis can be stated ing over time—including representations of as follows: A momentary array of sensations the body and/or actions and the additional from the world (light, sound, smell, touch, information that is necessary to create the and taste) combined with sensations from the new meanings that make emotions real, that body (X) counts as perception of emotion (Y) is, the parts that are crucial for creating the during a situated conceptualization (C) (Bar- situated conceptualizations. rett, 2012). Here, a “perception” is meant In our view, then, changes in heart rate to indicate perceiving an instance of sensa- or blood pressure, facial actions such as
Emotion Regulation as Situated Conceptualizations 455 smiles or frowns, and behaviors such as cry- cortical and subcortical contributions), or ing or freezing, are not evidence of emotions even a series of brain state transitions across in and of themselves. Instead, they become time, then mental causation is not mechanis- part of an emotional episode when they take tic per se, but probabilistic, such that Brain on a certain meaning in a certain situation State A at Time T (bee in the forest) increases (Barrett, 2012). Via situated conceptualiza- the probability of Brain State B at Time T tions, physical changes acquire the ability to + 1 (fear of the bee expressed as a racing perform functions that they do not have on heart and sweaty hands and the perception their own (creating social meaning, prescrib- of a stick as a weapon), making swatting ing actions, allowing communication, aid- more likely (but perhaps also a bee sting ing social influence). In this view, category more likely) (Figure 27.3). Alternatively, the knowledge about emotions does not cause encounter with the bee might be followed emotions per se—it constitutes emotions by by situated conceptualization (an image of adding epistemologically novel functions to bees making honey) as Brain State C at Time sensory input and action. Said another way, T + 1, decreasing the probability of a rac- an emotion is constructed when embodied ing heart and sweating, and so forth. From conceptual knowledge is enacted to shape this perspective, an emotion, such as fear, the perception of sensory information from is itself not a process but instead represents the body and the world, binding a physical a category of phenomena—a collection of state to an event in the world (as opposed to instances of probabilistic situated conceptu- being merely a physical sensation or action). alizations. This example also illustrates that A body state or an action has a certain situated conceptualizations are not indepen- physical function (e.g., changes in respira- dent from one another in time—each occurs tion might regulate autonomic reactivity, or in a context of what came before, and what widened eyes might increase the size of the is predicted in the future. visual field), but these events do not intrinsi- cally have certain functions as an emotion; Furthermore, we hypothesize that each events are assigned those functions in the act situated conceptualization (as a brain state of categorizing them as emotion during the or series of states) can be understood as a construction of a situated conceptualization. construction of more basic, domain-general operations and their interactions. These If a situated conceptualization is repre- operations can themselves be characterized sented as a distributed brain state (with both at both the psychological level (e.g., Barrett, FIGURE 27.3. A depiction of the probabilistic state-space metaphor of brain function.
456 PSYCHOPATHOLOGY 2006, 2012) and at the level of brain net- linkages in which cognitive systems in the works that emerge from neural integration brain modulate separate and anatomically across time and space within the brain (e.g., distinct affective or emotional systems. Barrett & Satpute, 2013; Lindquist & Bar- Emotion regulation strategies describe the rett, 2012). Such basic operations are like changes from one mental state to another, the “mental state variables” (see Salzman but these changes can themselves be decom- & Fusi, 2010), facets or core systems that posed into more basic facets (i.e., the men- describe the brain state, or, to return to our tal operations and their associated networks kitchen metaphor, these can be thought of as that create the situated conceptualizations). the mind’s “basic ingredients.” Rather than As a consequence, the process model (Gross, presuming that these ingredients function this volume) can be thought of as offering in a modular, mechanistic way, each oper- a more abstract description of what occurs ation can be thought of as a set of “func- during emotion regulation, whereas the core tional motifs” arising from the structural systems that implement situated conceptu- motif that undergirds each network (e.g., alizations are a more mechanistic approach Sporns & Kotter, 2004). Moreover, if these that produces reappraisals, distraction, sup- operations serve as the functional architec- pression, and other instances of emotion ture for how mental events and behaviors regulation. are constructed, then this implies that the science of emotion should focus on mod- This distinction between levels of analy- eling emotions as high dimensional brain sis maps onto the three levels of analysis states (reflecting the engagement of domain- described by Marr (1982), which include: a general networks, their internal operations, computational level that describes the phe- and their interactions). Such a componen- nomenon at hand (What problem does the tial, constructionist functional architecture system try to solve? What is the goal when of the human brain would not only reveal transforming input to output?), an algorith- the distinctions between social, affect, and mic level that describes how the transforma- cognitive neuroscience to be artificial (Bar- tion from input to output is achieved (How rett & Satpute, 2013), but it would also pres- does the system do what it does? What are ent a set of hypotheses for how the phenom- the representations used by the system? What ena that we refer to as emotion and emotion processes act on these representations?) and regulation are derived within a common an implementation or physical level (How mechanistic framework. is the system physically realized?). Our hypothesis is that the process model, with Emotion Regulation as Changing its emphasis on situation selection, situa- Situated Conceptualizations tion modification, and so on, describes emo- To the extent that emotions are situated tion regulation at Marr’s computational conceptualizations grounded in the modal level, whereas our situated conceptualiza- systems of the brain, then shifting from tion account describes emotion regulation one situated conceptualization to another at Marr’s algorithmic and implementational intensifies, diminishes, or alters the auto- levels. Each class of regulatory strategies nomic and endocrine responses that underlie discussed within the process model of emo- actions and feelings. We propose that a situ- tion regulation can be understood as situ- ated conceptualization framework offers an ated conceptualizations that are constructed account of emotion regulation that under- from more basic domain-general core sys- girds the process model (Gross, this volume) tems. The componential, constructionist at a different level of analysis, which has the functional architecture of the human brain potential to inspire new scientific research for emotion is also the architecture that cre- and practical applications. Our hypoth- ates instances of emotion regulation. esis is that stages of emotion regulation are often describing the difference between Situation selection can be understood as a two consecutive situated conceptualizations case in which situated conceptualizations are rather than individual processes that can be constructed to anticipate what will happen in chained together by a series of linear causal the future. Elsewhere, Barrett and colleagues (2009; Barrett & Satpute, 2013; Lindquist & Barrett, 2012; Lindquist et al., 2012) have hypothesized that the nodes within the “men-
Emotion Regulation as Situated Conceptualizations 457 talizing” network (e.g., Andrews-Hanna et allow for situation modification (i.e., they al., 2010) interact to help guide the construc- provide a perceiver with the ability to pre- tion of situated conceptualizations by inte- dict what actions in the present will facili- grating elements of prior experience (which tate a change in mental state in the future; are represented modally across the brain). for example, using a branch as a weapon These regions help to produce the multi- to swat a bee). A situated conceptualiza- modal simulations that are strongly situated tion approach draws attention to the under- in a particular background context, mak- lying processes that facilitate or detract ing sensory input meaningful and support- from taking actions to modify the external ing specific courses of situated action. Using environment to alter its emotional impact. prior knowledge to simulate possible future Because a situation is already in place dur- situations may guide the decision making ing situation modification, an individual is that underlies situation selection. More spe- drawing on prior knowledge about specific cifically, situated conceptualizations support facets present in the situated conceptual- simulating what it would be like to experi- ization to modify the situation itself. For ence specific situations (by reenacting and example, when the individual focuses on reassembling prior knowledge) that produce a nearby tree branch with the goal of kill- information about their value and potential ing the bee to avoid being stung, he or she outcomes (e.g., deciding whether to walk in now infers that the branch could be used a a meadow or a forest depending on the prob- weapon because it can be manipulated much ability of encountering a bee). This hypoth- like a baseball bat or a fly swatter (i.e., prior esis is consistent with the idea that the “men- knowledge about using a bat to strike an talizing” network constructs mental models object is being dynamically applied within or simulations that facilitate future behavior the situated conceptualization). In this way, (Buckner, 2011). the situated conceptualization used to inter- pret the environment is shifting dynamically Because situated conceptualizations are as its multimodal facets change (e.g., height- dynamically constructed when thinking ened arousal and hyperfocus on the environ- about future events, their dynamic assembly ment), which guides action. is likely influenced by a number of factors, including the current state of the individual Cognitive change (e.g., a stinging bee (and the situated conceptualization that is transformed into a flower-loving honey pro- being used to interpret this state) and the ducer) and response modulation (e.g., to keep executive control resources available (e.g., walking forward rather than to run away) via the “salience” and “frontoparietal con- naturally unfold as the brain shifts from trol” networks) to help guide the situated one situated conceptualization to another, conceptualization. These factors can influ- making predictions about how to act (i.e., a ence elements of the situation that become predicted action) and what the homeostatic the focus of the simulation and how detailed and metabolic consequences will be (i.e., or vague the simulation becomes, both of affective changes). Cognitive framing and which would impact the inferred outcomes response modulation are perhaps two of the and thus the decision making that underlies most obvious goals of the brain’s functional situation selection. The complexity inherent architecture—knowing what the current sen- to situation selection is often acknowledged sory array means and how to act on it. They in the literature on emotion regulation (e.g., are not unique to emotion regulation; they Gross, 2008), but the dynamics involved in describe what happens during the construc- creating such complexity remain unclear, tion of every mental state. During emotion perhaps because these discussions tend regulation, though, an individual is often draw on traditional approaches to emotion more aware of these changes because he or that overlook such dynamics. In contrast, she has an explicit goal to regulate through our approach highlights investigating the cognitive change or response modulation. dynamic integration of multimodal facets An important prediction of a situated con- involved in situated conceptualization as an ceptualization approach is that these types important goal for future research. of changes can also occur without aware- ness if they become habitual. Bringing situ- The predictive and inferential capacities ated conceptualizations into awareness and provided by situated conceptualizations also
458 PSYCHOPATHOLOGY manipulating them with effort, intention, cult to achieve, and it usually requires train- and a feeling of agency appears to be one key ing. If you were to attempt to learn to paint characteristic that distinguishes the mental an image of a bee on a flower, you would events people refer to as “emotion regula- have to train yourself over a series of months tion” (vs. those they refer to as “emotion”). not to see objects (a bee and flower) but to “undo” this perception and paint pieces of If conceptual knowledge is enactive, and if light. Only by doing this can you render a situated conceptualizations actually have the reasonable three-dimensional image on capacity to shape the physiology and actions a two-dimensional page. Similarly, when that are observed in any mental state, then learning to deconstruct emotion, you would changing a conceptualization via any core have to train yourself not to experience emo- system can modify said physiology and tions, but to experience physical sensations action (as well as the feelings to which they instead. Meditation practices offer a variety give rise). Such regulation might occur when of tools for deconstructing emotion experi- the same physical sensations and actions are ence that may work in this manner (e.g., Hol- conceptualized as a different emotion (e.g., zel et al., 2011; Papies, Barsalou, & Custers, tears are not sadness but anger; a racing 2012). In other meditation approaches, an heart is not fear but excitement), or when the existing emotion is deconstructed and then intensity of physical activation is enhanced is replaced with an alternative, more positive or reduced by changing the conceptualiza- experience (Lutz, Brefczynski-Lewis, John- tion (e.g., a bee means the pain of a sting or stone, & Davidson, 2008; Lutz, Greischar, the tranquility of a meadow). In such cases, Perlman, & Davidson, 2009). our hypothesis is that emotion regulation is the result of conceptual knowledge being Recent empirical evidence from our labo- activated as part of a situated conceptualiza- ratory also suggests that this may be a pro- tion. At the level of subjective experience, it ductive strategy. During a neuroimaging may feel as if a special mechanism is being study (Wilson-M endenhall et al., 2011), used to down-regulate fear, such as reap- participants immersed themselves in affec- praisal or suppression, or to up-regulate tively charged situations that involved either anger. Our hypothesis is that these emo- physical danger or social evaluation. After tion regulation constructs reflect changes in immersing in a situation, a word cued partic- emotions (as mental states) that result from ipants to emote in the situation (experience successive situated conceptualizations, using fear or anger) or to observe in the situation. the same operations that constitute an emo- Significantly greater activity in visual cor- tion in the first place. Thus, an instruction tex and significantly less activity in medial to reappraise, to distract by shifting atten- prefrontal cortex occurred when partici- tion, and so forth, actually manipulates the pants experienced situations by observing underlying core systems of situated concep- the scenes from a third-person perspec- tualizations, which in turn alters the biologi- tive rather than experiencing them as first- cal signals that produce sensations, not just person, self-relevant emotions. These results how bodily sensations are understood (i.e., it suggest that sensations became the focus of alters the experience of them). the affectively charged situation when par- ticipants were observing in the situation. In A situated conceptualization framework this study, observing was an explicit goal, also suggests a novel hypothesis that is not but a situated conceptualization approach discussed within the process model: Decon- suggests that this process of observing could structing an emotion, by attempting to undo eventually occur automatically (without its situated conceptualization, is another effort) if repeatedly used in specific situa- form of emotion regulation. When the per- tions (e.g., potential anger-inducing situa- ception and experience of physical sensations tions). from the body are decoupled from the con- cept knowledge (e.g., a deactivated unpleas- Finally, psychotherapy—p articularly cognitive- ant feeling conceptualized more basically as behavioral therapy (CBT) approaches— fatigue or glucose depletion as opposed to might be understood as helping clients to sadness in a specific situation), they become construct new situated conceptualizations less potent and result in less suffering. This (thereby modifying their conceptual sys- suspension of conceptualization can be diffi- tem) that either reduce the intensity of their
Emotion Regulation as Situated Conceptualizations 459 physical responses, or better calibrate the specific. Deficits in the vocabulary or con- constructed meaning of those responses to tent of emotion concepts (perhaps due to the situation at hand. CBT interventions poor socialization), or problems in accessing also appear to provide training for when to and using this knowledge (perhaps associ- use these alternative situated conceptualiza- ated with problems with long-term memory tions. The psychotherapeutic process might or executive function) might result in a fail- be thought of as creating a new population ure to regulate autonomic (and therefore of learned neural assemblies (for the same affective) reactivity using situated concep- emotion categories, or for new categories) tualizations, as in alexithymia (for a dis- that would be available to create new or dif- cussion, see Lindquist & Barrett, 2008), or ferent emotional meaning for the same sen- might produce inappropriate or ritualized sations, or that would modify those sensa- situated conceptualizations. To the extent tions (particularly those related to the body). that repeated processing of a situated con- The emotional changes that occur with psy- ceptualization omits situational details and chotherapy, then, might result from changes focuses instead on general abstract themes, in the conceptual system, or how conceptual chronic emotional responses develop that knowledge is used to construct the situated operate inappropriately across too many sit- conceptualizations that are emotion. uations. For example, imagine that a situated conceptualization develops for shame asso- Psychopathology ciated with performing poorly on math tests and Dysregulation from a Situated during elementary school. Subsequently, if Conceptualization Framework attention focuses too much on shame associ- From a situated conceptualization frame- ated with poor performance and omits the work, psychopathology would result from situational details associated with elemen- two classes of problems. First, we hypoth- tary school math classes, a decontextualized esize that emotional deficits within certain shame for poor intellectual performance types of psychopathology (e.g., schizophre- could develop that pervades experience nia, autism spectrum disorders), and neuro- inappropriately. Psychopathology also arise degenerative diseases (e.g., frontotemporal from problems in forming situated concep- dementia) arise due to damage to the brain’s tualizations that are not well calibrated to structural architecture for situated concep- the immediate situation, resulting in dys- tualizations, making it difficult to construct regulated autonomic responses and less meaning for sensory inputs that constitute effective actions. To the extent that situated normal mental states. Perhaps deficits in conceptualizations are learned assemblies of white matter connectivity, such as those perceptual, conceptual, interoceptive, and seen in autism (Zikopoulous & Barbas, action processes, psychological disorders of 2010), compromise the ability to construct one type or another might appear to be dis- and use the distributed conceptual structure orders of specific emotions (e.g., posttrau- that underlies situated conceptualizations. matic stress disorder [PTSD] as a disorder Similarly, autism is related to deficits in con- of fear) because a person’s learning history nectivity that develop during the final stages has created a “conceptual habit” or regular- of cortical development in paralimbic areas, ity of certain situated conceptualizations, particularly within the supragranular layers resulting in a sort of entrenchment of cer- of cortext (Zikopoulous & Barbas, 2010). tain changes in bodily state, central repre- These layers mainly contain the corticocor- sentations of that state, and meanings that tical connections that are important for syn- emerge regardless of the immediate situation chronizing the distributed neuronal assem- (e.g., even when no actual threat is present). blies responsible for constructing normal situated conceptualizations. More generally, psychopathology might also occur when sensations from the body In addition to structural consider- are overly personalized and inaccurately ations, psychopathology could result from construed to be self-evaluative as a func- entrenched conceptualizations that are overly tion of how situated conceptualizations are ritualized and not sufficiently situation- constructed. Even an overreliance on such conceptual knowledge (e.g., conceptualizing interoceptive cues as psychological instead of
460 PSYCHOPATHOLOGY physical) would also result in psychopathol- could happen in a variety of ways) could ogy, and might help explain sex differences produce actions that are not effective in a in certain disorders such as depression and particular cultural context. anxiety. Problems might also arise when sit- uated conceptualizations are too internally To understand how the content of disor- driven (from the body and prior experience) dered situated conceptualizations emerge, it and insufficiently incorporate external sen- is important to focus on the mechanisms of sory input, as in depression. For example, the core systems or “ingredients” that cre- the subgenual portion of the anterior cin- ate instances of emotion or implement the gulate cortex (Brodmann Area 25), which moment-to-moment changes that are expe- is an important cortical site for regulating rienced as emotion regulation, such as an homeostasis and other autonomic functions overly active autonomic nervous system that (Ongur, Ferry, & Price, 2003), appears to is experienced as affective reactivity, and keep the mentalizing network in a state of other related problems with attention, work- continual engagement via its connections ing memory, and context insensitivity (e.g., to BA 10 in ventromedial prefrontal cortex; Kring & Moran, 2008; Poch & Campo, this region is part of the mentalizing net- 2012; Williamson & Allman, 2012). These, work core (Andrews-Hanna et al., 2010) and in turn, can be understood in terms of the is a hub in a range of phenomena, including dynamics and structure of core networks, homeostatic- and allostatic-related phenom- such as the “salience” network, the “fronto- ena (e.g., subjective emotional experiences, parietal control” network, and the “mental- autonomic and neuroendocrine function, izing” network (Barrett & Satpute, 2013). reward, pain), social cognition and self- Indeed, these networks, which are intrin- relevance, and memory-related phenomena sic to the human brain and are structured (e.g., memory, mind-w andering, etc.) (Roy, by anatomical connectivity (and which we Shohamy, & Wager, 2012). It is a region understand as the core systems that imple- that allows brainstem autonomic function ment situated conceptualizations; Barrett to be guided by conceptual information & Satpute, 2013), are implicated in a range about past, present and future outcomes, of psychopathologies, including not only and is important to the creation of affec- schizophrenia, autism, and frontotemporal tive meaning (Roy et al., 2012; Lindquist et dementia, but also depression and anxi- al., 2012). This connection between BA 25 ety disorders (Menon, 2011). For example, and BA 10 keeps depressed people locked instead of understanding PTSD as an exag- “inside their own heads” and suffering a gerated activation of fear circuitry, it is pos- constant state of anguish that is marked sible that PTSD symptoms are the result of by all consuming self-focus that paralyzes hyperaffective reactivity (associated with the them. Deep brain stimulation to the white “salience” network) combined with prob- matter tract that connect these two regions lems in conceptualization (associated with in effect releases the mentalizing network, the “mentalizing” network) related to work- allowing people to experience relief and to ing memory deficits (associated with the focus more on events in the world (May- “frontoparietal” control network) (Suvak & berg, personal communication; also see Barrett, 2011). Holtzheimer, Kelly, Gorss, Filkowski, Gar- low, et al., 2012; Lujan, Chaturvedi, Choi, These ideas present an alternative to the Holdzheimer, Gross, et al., 2013). From traditional approach to mental illness, in this research, it is easy to hypothesize that which all forms of psychopathology (and overly internally focused situated concep- many forms of physical illness, e.g., cardio- tualizations might occur because a person vascular disease and cancer) are conceived possesses a very reactive autonomic nervous of as involving either excessive or deficient system, producing frequent and intense amounts of one emotion or another. For internal sensations that demand conceptu- example, various anxiety disorders, such as alization, or because of limited executive PTSD and panic disorder, are presumed to control resources. Moreover, conceptualiza- be disorders of fear, thought to arise from tions that are not well-tailored to the situa- a hyperreactivity of fear processing. Depres- tion in terms of sociocultural norms (which sion is presumed to be a disorder of sadness and guilt. Hypertension is thought to involve an excess amount of anger. And so on. From
Emotion Regulation as Situated Conceptualizations 461 the perspective of the traditional machine bucolic garden or the terror of a bee attack- metaphor, each type of illness would arise ing and stinging the body, it is possible to from problems with emotions being trig- retrieve different associations of bees in the gered too frequently or not enough. Also, the next instance, which in turn has the capac- development and maintenance of psychiatric ity to change the sensations that your brain disorders involve problems in emotion regu- receives from your body. Our hypothesis is lation (Kring & Sloan, 2010), so psychopa- that the same processes that were engaged thology might also arise from an inability during the initial instance of meaning mak- to regulate said emotions once they erupt. ing (creating tranquility or fear) are engaged Our situated conceptualization approach again, and again, and again. When your connects these insights with transdiagnos- bodily response changes, along with the cor- tic approaches that attempt to identify psy- responding feelings and actions, you experi- chological and biological processes that are ence this as emotion regulation. If this is cor- common to many types of psychological rect, then what we call “emotion regulation” disorders (e.g., Fairholme, Boisseau, Ellard, is grounded in the more basic meaning- Ehrenreich, & Barlow, 2010; Harvey, Wat- making processes that are operating all the kins, Mansell, & Shafran, 2004; Haslam, time to create the flow of mental states that 2002; Kendler, 2008; Kring, 2008; Krueger, constitutes your mind. Reappraisal, distrac- Watson, & Barlow, 2005; Millan, 2003; tion, and other terms might refer not to Sanislow et al., 2010). Just as science is com- processes per se, but to changes that occur ing to the conclusion that emotion categories as one mental state flows into another (and are not natural kinds (Barrett, 2006), clini- one physical state transitions to another) cal science is also coming to the conclusion as meaning changes. A series of sequential that categories for disorders of emotion do mental states that are experientially distinct not cut nature at its joints (Haslam, 2002; is easy to understand as distinct psychologi- Kendler, 2008). cal processes, even though scientists have known for a long time that experiences don’t Summary reveal the processes that make them. Situated conceptualizations can be thought of as cognitive tools used by the human Notes brain to modify and regulate the body (i.e., homeostasis and allostasis, metabolism, 1. Hereafter in this chapter, we use italics to and/or inflammatory processes), to create indicate a concept (e.g., fear) and quotes to feelings, and to create dispositions toward indicate the word or phrase associated with it action. In this sense, they provide an alter- (e.g., “fear”). native framework for describing how mental states arise, and how actions and feelings, 2. Theory and research strongly suggest that and the physiological changes that support concepts do not have conceptual cores (i.e., them, are formulated and regulated. A focus information that is necessary and sufficient on how situated conceptualizations are con- for membership in the associated category). structed from patterns (or functional motifs) Instead, concepts are represented with loose across the brain’s core systems (or structural collections of situated exemplars that are motifs) adds utility to existing explana- related by family resemblance. Exemplar tory frameworks for emotion and emotion theories of categorization further illustrate regulation by focusing on the mechanistic that loose collections of memories for cat- changes that produce emotional and regula- egory members can produce sophisticated tory phenomena to which we give abstract classification behavior, demonstrating that names. abstractions for prototypes and rules are not necessary. Neural net systems similarly dem- Perhaps the final lesson of the bee exam- onstrate that only loose statistical coherence ple is that states and processes are easy to is necessary for sophisticated categorization. confuse when it comes to meaning making. To the extent that abstraction does occur for Regardless of whether you automatically a category, it may only occur partially across experience the calm of a bee buzzing in a small sets of category instances, reflect the abstraction of nondefining properties and
462 PSYCHOPATHOLOGY relations that can be used to describe category dox: Categorization and the experience of members in a dynamical manner, or reflect emotion. Personality and Social Psychology an online abstraction at retrieval rather than Review, 10(1), 20–46. stored abstractions in memory. Nevertheless, Barrett, L. F. (2009). The future of psychology: people often believe mistakenly that catego- Connecting mind to brain. Perspectives on ries do have cores, perhaps because a word Psycholical Science, 4(4), 326–339. can lead people to essentialize. Barrett, L. F. (2012). Emotions are real. Emo- 3. As goal-directed categories that develop to tion, 12(3), 413–429. guide action, the most typical member of a Barrett, L. F., & Bar, M. (2009). See it with feel- category such as fear is not the one that is most ing: Affective predictions in the human brain. frequently encountered, but rather the one that maximally achieves the theme or goal of Philosphical Transactions of the Royal Soci- the category (Barsalou, 2003). As a result, the ety B: Biological Sciences, 364, 1325–1334. most typical instances of a category contain Barrett, L. F., & Bliss-Moreau, E. (2009). Affect properties that represent the ideal form of the as a psychological primitive. Advances in category, that is, whatever is ideal for meeting Experimental Social Psychology, 41, 167–218. the goal around which the category is orga- Barrett, L. F., & Gross, J. J. (2001). Emotion rep- nized, not those that most commonly appear resentation and regulation: A process model as instances of the category. From a situated of emotional intelligence. In T. Mayne & G. conceptualization viewpoint, prototypes do Bonnano (Eds.), Emotion: Current issues and not exist as stored representations in memory, future directions (pp. 286–310). New York: but they can be constructed (or simulated) Guilford Press. when needed (Barsalou et al., 2003). Barrett, L. F., & Lindquist, K. (2008). The 4. Highly different instances for the same cat- embodiment of emotion. In G. Semin & E. egory can become integrated over time, and Smith (Eds.), Embodied grounding: Social, become available to construct novel simula- tions that have never been experienced before. cognitive, affective, and neuroscience This, in part, may help to explain why people approaches (pp. 237–262). New York: Cam- believe that emotions such as anger, sadness, bridge University Press. fear, and so on, have specific response signa- Barrett, L. F., Lindquist, K. A., & Gendron, M. tures, even though the available data do not (2007). Language as context for the percep- support this view. A simulation of fear could tion of emotion. Trends in Cognitive Sciences, allow a person to go beyond the information 11(8), 327–332. given to fill in aspects of a internal sensa- Barrett, L. F., Ochsner, K. N., & Gross, J. J. tion that are not present at a given percep- (2007). On the automaticity of emotion. In J. tual instance. In such a case, the simulation Bargh (Ed.), Social psychology and the uncon- essentially produces an illusory correlation between response outputs, helping to explain scious: The automaticity of higher mental why researchers continue to search for coordi- processes (pp. 173–217). New York: Psychol- nated autonomic, behavioral, and experiential ogy Press. aspects of a fear response. Barrett, L. F., & Satpute, A. (2013). Large-scale brain networks in affective and social neuro- References science: Towards an integrative architecture of the human brain. Current Opinion in Neuro- Anderson, E., Siegel, E. H., White, D., & Bar- biology, 23, 1–12. rett, L. F. (2012). Out of sight but not out of Barrett, L. F., Tugade, M. M., & Engle, R. W. mind: Unseen affective faces influence evalu- (2004). Individual differences in working ations and social impression. Emotion, 12, memory capacity and dual-process theories 1210 –1221. of the mind. Psychological Bulletin, 130(4), 553–573. Andrews-H anna, J. R., Reidler, J. S., Sepulcre, J., Barsalou, L. W. (1999). Perceptual symbol sys- Poulin, R., & Buckner, R. L. (2010). Functional– tems. Behavioral and Brain Sciences, 22(4), anatomic fractionation of the brain’s default 577– 609. network. Neuron, 65(4), 550–562. Barsalou, L. W. (2003). Situated simulation in the human conceptual system. Language and Barrett, L. F. (2006). Solving the emotion para- Cognitive Processes, 18, 513–562. Barsalou, L. W. (2008). Grounded cognition. Annual Review of Psychology, 59, 617–645.
Emotion Regulation as Situated Conceptualizations 463 Barsalou, L. W. (2009). Simulation, situated con- Gross, J. J. (2008). Emotion regulation. In M. ceptualization, and prediction. Philosophical Lewis, J. M. Haviland-Jones, & L. F. Bar- rett (Eds.), Handbook of emotions (3rd ed., Transactions of the Royal Society B: Biologi- pp. 497–512). New York: Guilford Press. cal Sciences, 364(1521), 1281–1289. Barsalou, L. W., & Hale, C. R. (1993). Compo- Gross, J. J. (this volume, 2014). Emotion regula- nents of coceptual representation: From fea- tion: Conceptual and empirical foundations. ture lists to recursive frames. In J. Hampton, In J. J. Gross (Ed.), Handbook of emotion R. Michalski, & P. Theuns (Eds.), Categories regulation (2nd ed., pp. 3–20). New York: Guilford Press. and concepts: Theoretical views and inductive data analysis (pp. 97–144). San Diego, CA: Harvey, A., Watkins, E., Mansell, W., & Shafran, Academic Press. R. (2004). Cognitive behavioural processes Barsalou, L. W., Niedenthal, P. M., Barbey, A., & Ruppert, J. (2003). Social embodiment. In across psychological disorders: A transdiag- B. Ross (Ed.), The psychology of learning and nostic approach to research and treatment. motivation (Vol. 43, pp. 43–92). San Diego, New York: Oxford Univeristy Press. CA: Academic Press. Haslam, N. (2002). Kinds of kinds: A conceptual Bradley, M. M., Codispoti, M., Cuthbert, B. N., taxonomy of psychiatric categories. Philoso- & Lang, P. J. (2001). Emotion and motivation phy, Psychiatry, and Psychology, 9, 203–217. I: Defensive and appetitive reactions in picture Holzel, B. K., Lazar, S. W., Gard, T., Schuman- processing. Emotion, 1(3), 276–298. Oliver, Z., Vago, D. R., & Ott, U. (2011). Buckner, R. L. (2011). The serendipitous discov- How does mindful meditation work?: Propos- ery of the brain’s default network. NeuroIm- ing mechanisms of action from a conceptual age, 62, 1137–1145. and neural perspective. Perspectives on Psy- Carey, S. (2009). The origin of concepts. New chological Science, 6(6), 537–559. York: Oxford University Press. Holtzheimer, P. E., Kelley, M. E., Gross, R. E., Clore, G. L., & Ortony, A. (2008). Appraisal Filkowski, M. M., Garlow, S. J., Barrocas, A., theories: How cognition shapes affect into et al. (2012). Subcallosal cingulate deep brain emotion. In M. Lewis, J. M. Haviland-Jones, stimulation for treatment-resistant unipolar & L. F. Barrett (Eds.), Handbook of emotions and bipolar depression. Archives of General (3rd ed., pp. 628–642). New York: Guilford Psychiatry, 69(2),150–158. Press. Jones, C. R., Kirkland, T., & Cunningham, W. Dewar, K. M., & Xu, F. (2009). Do early nouns A. (this volume, 2014). Attitudes, evaluation, refer to kinds or distinct shapes?: Evidence and emotion regulation. In J. J. Gross (Ed.), from 10-month old infants. Psychological Sci- Handbook of emotion regulation (2nd ed., ence, 20, 252–257. pp. 251–266). New York: Guilford Press. Edelman, G. M. (1998). The remembered pres- Kendler, K. S. (2008). Explanatory models for ent: A biological theory of consciousness. psychiatric illness. American Journal of Psy- New York: Basic Books. chiatry, 165(6), 695–702. Fairholme, C. P., Boisseau, C. L., Ellard, K. K., Kober, H., Barrett, L. F., Joseph, J., Bliss- Ehrenreich, J. T., & Barlow, D. H. (2010). Moreau, E., Lindquist, K., & Wager, T. D. Emotions, emotion regulation, and psycholog- (2008). Functional grouping and cortical– ical treatment: A unified perspective. In A. M. subcortical interactions in emotion: A meta- Kring & D. M. Sloan (Eds.), Emotion regu- analysis of neuroimaging studies. NeuroIm- lation and psychopathology (pp. 283–309). age, 42(2), 998–1031. New York: Guilford Press. Kring, A. M. (2008). Emotion disturbances as Fine, I., Wade, A. R., Brewer, A. A., May, M. transdiagnostic processes in psychopathology. G., Goodman, D. F., Boynton, G. M., et al. In M. Lewis, J. M. Haviland-Jones, & L. F. (2003). Long-term deprivation affects visual Barrett (Eds.), Handbook of emotion (3rd ed., perception and cortex. Nature Neuroscience, pp. 691–705). New York: Guilford Press. 6, 915–916. Kring, A. M., & Moran, E. K. (2008). Emotional Golland, Y., Golland, P., Bentin, S., & Malach, response deficits in schizophrenia: Insights R. (2008). Data-driven clustering reveals a from affective science. Schizophrenia Bulletin, fundamental subdivision of the human cortex 34(5), 819–834. into two global systems. Neuropsychologia, Kring, A. M., & Sloan, D. M. (Eds.). (2010). 46(2), 540–553. Emotion regulation and psychopathology. New York: Guilford Press.
464 PSYCHOPATHOLOGY Krueger, R. F., Watson, D., & Barlow, D. H. McClelland, J. L. (2010). Emergence in cogni- (2005). Introduction to the special section: tive science. Topics in Cognitive Science, 2, Toward a dimensionally based taxonomy of 751–770. psychopathology. Journal of Abnormal Psy- chology, 114(4), 491–493. Menon, V. (2011). Large-scale brain networks and psychopathology: A unifying triple net- Lang, P. J., Bradley, M. M., & Curthbert, B. N. work model. Trends in Cognitive Sciences, (2008). International affective picture sys- 15(10), 483–506. tem (IAPS): Affective ratings of pictures and Mesquita, B., Barrett, L. F., & Smith, E. (Eds.). instruction manual. Gainsville: University of (2010). The mind in context. New York: Guil- Florida. ford Press. Legrand, D., & Ruby, P. (2009). What is self- specific?: Theoretical investigation and critical Millan, M. J. (2003). The neurobiology and con- review of neuroimaging results. Psychological trol of anxious states. Progress in Neurobiol- Review, 116(1), 252–282. ogy, 70(2), 83–244. Lindquist, K., & Barrett, L. F. (2008). Emotional complexity. In M. Lewis, J. M. Haviland-J ones Murphy, G. L. (2002). The big book of concepts. & L. F. Barrett (Eds.), Handbook of emotion Cambridge, MA: MIT Press. (pp. 513–530). New York: Guilford Press. Lindquist, K. A., & Barrett, L. F. (2012). A Neumeister, A., Henry, S., & Krystal, J. H. functional architecture of the human brain: (2007). Neural circuitry and neuroplasticity Insights from the science of emotion. Trends in PTSD. In M. J. Friedman, T. M. Keane, & in Cognitive Sciences, 16, 533–540. P. A. Resick (Eds.), Handbook of PTSD: Sci- Lindquist, K. A., Wager, T. D., Kober, H., Bliss- ence and practice (pp. 151–165). New York: Moreau, E., & Barrett, L. F. (2012). The brain Guilford Press. basis of emotion: A meta-analytic review. Behavioral and Brain Sciences, 35(3), 121– Northoff, G., Heinzel, A., de Greck, M., Berm- 143. pohl, F., Dobrowolny, H., & Panksepp, J. Lujan, J. L., Chaturvedi, A., Choi, K. S., Hold- (2006). Self-referential processing in our zheimer, P. E., Gross, R. E., Mayberg, H. S., brain—A meta-analysis of imaging studies on et al. (2013). Tractography–a ctivation models the self. NeuroImage, 31(1), 440–457. applied to subcallosal cingulate deep brain stimulation. Brain Stimulation. Ongur, D., Ferry, A. T., & Price, J. L. (2003). Lutz, A., Brefczynski-L ewis, J., Johnstone, T., & Architectonic subdivision of the human orbital Davidson, R. J. (2008). Regulation of the neu- and medial prefrontal cortex. Journal of Com- ral circuitry of emotion by compassion medi- parative Neurology, 460, 425–449. tation: Effects of meditative expertise. PLoS ONE, 3(3), e1897. Papies, E. K., Barsalou, L. W., & Custers, R. Lutz, A., Greischar, L. L., Perlman, D. M., & (2012). Mindful attention prevents mindless Davidson, R. J. (2009). BOLD signal in insula impulses. Social Psychological and Personal- is differentially related to cardiac function ity Science 3, 291–299. during compassion meditation in experts vs. novices. NeuroImage, 47(3), 1038–1046. Poch, C., & Campo, P. (2012). Neocortical– Martin, A. (2001). Functional neuroimaging of hippocampal dynamics of working memory semantic memory. In R. Cabeza & A. King- in healthy and diseased brain states based on stone (Eds.), Handbook of functional neu- functional connectivity. Frontiers in Human roimaging of cognition (pp. 153–186). Cam- Neuroscience, 6, 36. bridge, MA: MIT Press. Martin, A. (2007). The representation of object Rips, L. J. (2010). Lines of thought. New York: concepts in the brain. Annual Review of Psy- Oxford University Press. chology, 58, 25–45. Marr, D. (1982). Vision: A computational inves- Roy, M., Shohamy, D., Wager, T. D. (2012). Ven- tromedial prefrontal–subcortical systems and tigation into the human representation and the generation of affective meaning. Trends in processing of visual information. New York: Cognitive Science, 16, 147–156. Freeman. Russell, J. A. (2003). Core affect and the psycho- logical construction of emotion. Psychological Review, 110, 145–172. Salzman, C. D., & Fusi, S. (2010). Emotion, cognition, and mental state representation in amygdala and prefrontal cortex. Annual Review of Neuroscience, 33, 173–202. Sanislow, C. A., Pine, D. S., Quinn, K. J., Kozak, M. J., Garvey, M. A., Heinssen, R. K., et al.
Emotion Regulation as Situated Conceptualizations 465 (2010). Developing constructs for psychopa- (2000b). Theoretical neuroanatomy: Relat- thology research: research domain criteria. ing anatomical and functional connectivity Journal of Abnormal Psychology, 119(4), in graphs and cortical connection matrices. 631– 639. Cerebral Cortex, 10(2), 127–141. Schell, T. L., Marshall, G. N., & Jaycox, L. H. Suvak, M. K., & Barrett, L. F. (2011). Consider- (2004). All symptoms are not created equal: ing PTSD from the perspective of brain pro- The prominent role of hyperarousal in the cesses: A psychological construction approach. course of posttraumatic psychological dis- Journal of Traumatic Stress, 24(1), 3–24. tress. Journal of Abnormal Psychology, Van Overwalle, F. (2009). Social cognition and 113(2), 189–197. the brain: A meta-analysis. Human Brain Schyns, P. G., Goldstone, R. L., & Thibaut, J. P. Mapping, 30(3), 829–858. (1998). The development of features in object Williamson, P. C., & Allman, J. M. (2012). A concepts. Behavioral and Brain Sciences, framework for interpreting functional net- 21(1), 1–17. works in schizophrenia. Frontiers in Human Simmons, W. K., & Barsalou, L. W. (2003). The Neuroscience, 6, 184. similarity-i n-topography principle: Reconcil- Wilson-M endenhall, C. D., Barrett, L. F., & ing theories of conceptual deficits. Cognitive Barsalou, L. W. (in preparation). Emoting vs. Neuropsychology, 20(3), 451–486. Simmons, W. K., Reddish, M., Bellgowan, P. S., observing: Conceptualizing affective situa- & Martin, A. (2010). The selectivity and func- tional connectivity of the anterior temporal tions as self-relevant emotions or sensory- lobes. Cerebral Cortex, 20(4), 813–825. focused mental states. Sporns, O., & Kotter, R. (2004). Motifs in brain Wilson-M endenhall, C. D., Barrett, L. F., Sim- networks. PLoS Biology, 2, e369. mons, W. K., & Barsalou, L. W. (2011). Sporns, O., Tononi, G., & Edelman, G. M. Grounding emotion in situated conceptualiza- (2000a). Connectivity and complexity: The tion. Neuropsychologia, 49(5), 1105–1127. relationship between neuroanatomy and brain Wundt, W. (1897). Outlines of psychology (C. H. dynamics. Neural Networks, 13(8–9), 909– Judd, Trans.). Leipzig: Wilhelm Engelmann. 922. Zikopoulous, B., & Barbas, H. (2010). Changes Sporns, O., Tononi, G., & Edelman, G. M. in prefrontal axons may disrupt the network in autism. Journal of Neuroscience, 30, 14595–14609.
Part VIII Interventions
Chapter 28 Emotion Regulation Therapy Douglas S. Mennin David M. Fresco Over the past 25 years, considerable prog- symptoms) was most treatment refractory ress has been achieved in treating adult (Farabaugh et al., 2010). psychiatric disorders (e.g., Butler, Chap- man, Forman, & Beck, 2006). Despite these One characteristic common to these dis- significant advances, a sizable subgroup of orders, which are often comorbid (Kessler, individuals with commonly co-occurring Berglund, Demler, Jin, & Walters, 2005), is disorders such as generalized anxiety dis- that they both strongly (more so than other order (GAD) and major depressive disorder conditions) reflect heightened emotional (MDD) fail to make sufficient treatment experience (often referred to as emotional- gains, thereby prolonging their deficits in life ity, neuroticism, or emotional intensity; see functioning and satisfaction. For example, in Barlow, 2002; Mennin, Heimberg, Turk, a meta-analysis of cognitive-behavioral ther- & Fresco, 2005; Mennin, Holaway, Fresco, apy (CBT) for GAD, Borkovec and Ruscio Moore, & Heimberg, 2007). Factor-a nalytic (2001) found that only 50–60% of treated evidence demonstrates that these disorders individuals demonstrated clinically mean- jointly reflected a higher order factor of ingful change. Furthermore, although more prolonged negative affect or distress that efficacious, the difference between current has been distinguished from a “fear” factor psychological treatments for MDD and non- that relates to disorders more characterized directive supportive therapy reflects only by acute arousal (e.g., Krueger & Markon, a small effect size (Cuijpers, van Straten, 2006; Watson, 2005). Furthermore, both Andersson, & van Oppen, 2008). Also, GAD and MDD possess heritability factors among individuals who have GAD with reflective of increased emotionality (e.g., comorbid MDD, gains in treating depres- Kendler, Gardner, Gatz, & Pedersen, 2006). sion are not especially durable (Newman, One possibility is that the “distress” in these Przeworski, Fisher, & Borkovec, 2010). disorders reflects an inherent dispositional Finally, in the recently concluded Sequenced tendency for heightened emotional salience Treatment Alternatives to Relieve Depres- related to motivational impetuses such as the sion Study,funded by the National Institute need to avoid threat. These underlying emo- of Mental Health (NIMH), the subgroup of tional and motivational factors may be more individuals with mixed anxiety–depressive difficult to ameliorate and change (Brown, disorder (e.g., MDD + apprehensive anxious 2007). Indeed, these higher order emotional factors, in particular, have been found to 469
470 INTERVENTIONS account for the underperformance of other- identifying factors that promote or dimin- wise efficacious treatments (Olatunji, Cisler, ish the effectiveness of evidence-b ased treat- & Tolin, 2010). ments. The first of these, called the Research Domain Criteria Initiative (RDoC; Craske, Repetitive or perseverative thought (Wat- 2012), aims to understand what is expected kins, 2008) represents another characteristic in these domains at different levels of common to the distress disorders that may inquiry, so that these normative findings can arise as a desperate means of coping or com- be contrasted with disordered subgroups to pensating with strongly felt emotional expe- identify mechanistic regions of interest that riences. For instance, pathological worry may in turn become the targets of treatment (Borkovec, Alcaine, & Behar, 2004) func- development. The second initiative comes tions as a regulatory strategy aimed at reduc- from a recent NIMH’s National Advisory ing distress that arises from conflicting emo- Mental Health Council report emphasizing tional and motivational states (e.g., Mennin “treatment personalization” as a means to & Fresco, 2009; Newman & Llera, 2011). identify factors that predict who will ben- Similarly, depressive rumination represents efit from a given intervention process, then a perseverative cognitive process commonly to determine systematically ways of match- defined as repetitive thinking about past mis- ing patients to a particular treatment, as takes and failures, and is strongly associated well as to optimize and augment care. Taken with worry (e.g., Nolen-Hoeksema, Wisco, together, these initiatives highlight the need & Lyubomirsky, 2008; Watkins, 2008). In to specify transdiagnostic mechanisms essence, individuals with distress disorders within individuals to further the develop- may be more prone to utilize perseverative ment of treatment processes that specifically cognitive strategies (e.g., worry, rumination) target these mechanisms. to escape or dampen emotionality at the cost of accurately gleaning the motivational mes- Congruent with current directions in sage that is being conveyed, undermining affect science, these NIMH initiatives, and immediate behavioral action in response to advances in the science of behavior therapy, their emotions, and ultimately, losing sight we have developed an emotion regulation of the enriching and fulfilling aspects of life. therapy (ERT; Mennin & Fresco, 2009) to improve treatment of distress disorders Thus, given the emerging profile of this including GAD and MDD. ERT integrates difficult to treat, distress-disordered patient traditional and contemporary CBT principles (e.g., strong motivational impetuses accom- and practices, and emotion-focused inter- panied by excessive reliance on compen- ventions within a framework that reflects satory strategies to escape or avoid these basic and translational findings in affect sci- impetuses reactively, and impoverished ence. The result is a theoretically derived, contextual learning repertoires), there is evidence-based treatment that builds on the increasing interest in understanding the solid foundation of CBT by identifying and role of emotions and how this knowledge targeting putative mechanisms common to might generate new targets for intervention, the distress disorders (e.g., motivational– particularly for more treatment-resistant emotional activation, perseverative think- cases. The affective science field provides an ing, and resultant narrowed learning reper- opportunity to expand paradigms regard- toires) while striving to normalize emotion ing the role of emotion-related processes in generation and regulation functioning. In conceptualizing and treating psychopathol- the remainder of this chapter, we (1) describe ogy. Increasingly, treatments have adopted a and review relevant work related to norma- functional approach to emotions to improve tive and disordered motivation, regulation, existing interventions a variety of disorders and contextual learning consequences; (2) (e.g., Barlow et al., 2011; Linehan, 1993). demonstrate how ERT reflects an approach to treatment that draws from common prin- Articulating a model of distress disorders ciples of CBT and affective science to target predicated on underlying emotional and proposed mechanisms directly and provide motivational mechanisms and processes preliminary efficacy and mechanism find- aligns with two recent initiatives promoted ings; and (3) provide an overview of future by the NIMH with the goal of accelerat- directions for ERT. ing the payoff from basic and translational research into treatment application and
Emotion Regulation Therapy 471 Normative and Disordered Stein & Paulus, 2009) and dissociable (e.g., Emotional Processing the orbitofrontal cortex [OFC], involved in and Learning Consequences assigning reward values to stimuli; Berridge An affect science perspective on adult psy- et al., 2009) neurobehavioral correlates. In chopathology and its treatment includes (1) terms of neurochemistry, liking is primar- motivational mechanisms, reflecting the ily associated with endogenous opioids and functional and directional properties of an endorphins (Stein & Paulus, 2009), whereas emotional response tendency; (2) regula- wanting chiefly involves dopamine, which is tory mechanisms, reflecting the alteration of involved in marshaling organisms to exert response trajectories to be more congruent the effort required to obtain a reward (Ber- with contextual demands and constraints, ridge et al., 2009; Stein & Paulus, 2009). as well as one’s personal values or goals; and (3) contextual learning consequences, By contrast, a security system instigates reflecting, optimally, the promotion of avoidance of novel, potentially threatening, broad and flexible behavioral repertoires. or painful stimuli or end states, as well as In distress disorders, dysfunction may occur engagement of safety stimuli that protect via strong motivational salience and con- an individual from such perceived threats flict, as well as deficits in systems of regula- and can reinstate a state of quiescence and tion, which may result in diminished, nar- calm. This system encompasses both reflex- row, and rigid behavioral repertoires. In the ive motivational behavior and reflective, remainder of this section, we discuss both goal-setting, behavior (Carver, Avivi, & a normative account of these characteristics Laurenceau, 2008; Gray & McNaughton, and how these normative processes may go 2000; Higgins, 1997) aimed toward avoid- awry in the emotional dysfunction of dis- ance of threats and engagement of safety tress disorders. signals. At the neural level, whereas the amygdala is activated in response to novel Normative Emotional Functioning and immediate threats, the bed nucleus of Motivation the stria terminalis is activated in response One of our most basic, primary directives to more distal or prolonged threats (Lang, is to bring balance with respect to engag- Davis, & Öhman, 2000). Furthermore, the ing reward and minimizing loss, while ventromedial prefrontal cortex (vmPFC) is seeking safety and avoiding threat (Dol- involved in higher order processing of goals lard & Miller, 1950). As we increasingly reflective of safety seeking and threat avoid- become creatures of habit over the course ance. Neurochemically, norepinephrine and of our lives, we are continually pushed and gamma-a minobutyric acid (GABA) are cen- pulled by motivations to maintain security trally involved in threat detection and safety and gain reward. Our actions and prepara- signaling (Stein & Paulus, 2009). tion for actions are guided by the motiva- tional salience of the stimuli we encounter The security and reward systems are (Gray & McNaughton, 2000). In particu- relatively independent and can be activated lar, a reward system mobilizes a behavioral alone or in unison, in response to a prompt approach toward rewarding or appetitive (Stein & Paulus, 2009). In essence, norma- stimuli or to minimize loss. Reward can be tive functioning represents a constant state further specified in relation to consumma- of engaging and resolving situations that tory pleasure (i.e., liking, the hedonic impact provoke conflicts of motivational systems that a reward produces) and anticipatory in the service of taking effective behavioral pleasure (i.e., wanting, the incentive salience action. Stein and Paulus suggest that the associated with a particular reward; Ber- insula, in relation to the vmPFC, may be ridge, Robinson, & Aldridge, 2009). These important for detecting motivational con- two facets of the reward system have shared flict and helping to shape, and be shaped (e.g., nucleus accumbens, comprising a large by, goal intentions and implementation. part of a region called the ventral striatum; Similarly, Aupperle and Paulus (2010) pro- pose that optimal balancing of approach and avoidance systems is coordinated by a network consisting of the OFC (valuation of stimuli in service of making choices; inhibit- ing limbic regions and behavioral responses
472 INTERVENTIONS during fear processing), the ventral striatum fication of a situation, early stages of emo- (orientation toward reward), amygdala (pro- tional processing chiefly involving attention, viding salience/intensity of fear and avoid- later stages of emotional processing chiefly ance stimuli), and the insula (monitoring involving verbal representation and cogni- current and predicting future interoceptive tive change, or, once an emotional response states in relation to reward and fear). Cor- has occurred, by attempting to impact the respondingly, engaging behavioral actions quality of that response. Influencing the to achieve or restore motivational balance information-p rocessing aspects of an emo- likely consists of responding in a manner tion (i.e., antecedent-focused strategies) is reflecting a contextually and situationally more effective than acting on the products appropriate balance of reward and safety– of that processing, such as physiological threat systems, while also informing one’s responses (i.e., response-focused strategies). actions with higher order, values-based deci- Building on these structural and temporal sion making (Wilson & Murrell, 2004). characteristics, regulation efforts can be dif- Attaining goals that reflect motivational ferentiated by degree of elaboration, which salience and one’s personal values provides essentially refers to the degree of cognitive feedback relating one’s behavioral effort to effort required to engage a particular capac- an outcome. ity, from less elaborative regulatory compo- nents, such as attention, to more elaborative Regulation regulatory components, such as working Emotions are part of a larger self-r egulation memory and verbal representations (Badre system that allows us to respond flexibly to & D’Esposito, 2007), which, at the neural events in our lives in accordance with both level, are associated with greater recruit- personal goals/values and changing con- ment of dorsal and lateral areas of the PFC texts. In some instances, the optimal tuning (Ochsner, Bunge, Gross, & Gabrieli, 2002). in a given situation results in the accentua- Activation of these elaborative areas is asso- tion (i.e., up-regulation) of the emotional ciated with greater mental effort and can salience of the situation; in other instances, result in greater resource depletion given toning down (i.e., dampening) the emotional competition for these resources (Muraven & aspects of the situation is warranted. Neuro- Baumeister, 2000). Optimal emotion regu- biological evidence supports the notion that lation may begin by engaging less elabora- there are multiple pathways to emotion gen- tive capacities, followed by more elabora- eration, including automated, “hard-wired” tive capacities as needed (Sheppes & Gross, or lower order systems (largely involving 2011). Nonetheless, both less elaborative physiological responses and their subcortical and more elaborative regulation efforts control) and more controlled, higher order modify security- and reward-based moti- systems (largely involving subjective, corti- vational patterns according to contextual cal responses) that are separate but inter- demands (e.g., Delgado, Gillis, & Phelps, active and mutually essential for differing 2008; Sokol-H essner, Camerer, & Phelps, aspects of emotional experience (LeDoux, 2013). 1996). These higher order and lower order neural systems also actively regulate each Broad and Flexible Contextual Learning other (LeDoux, 1996). A functional systems Adaptation refers to the process by which approach to emotion regulation argues that an organism becomes better suited to pros- these systems work together to maintain pering in their habitats (Dobzhansky, 1970). dynamic homeostasis between bodily sys- Knowing and providing the contextually tems and internal and external stimuli in a appropriate behavioral response may mean context-a ppropriate manner. the difference between life and death, and between love and loss. Adaptive and flexible Gross (2002) highlights the importance of behavioral responses are dependent on the the temporal unfolding of emotional expe- ability to increase awareness of cues and con- rience in understanding how individuals tingencies in the environment and respond in self-r egulate. Specifically, one can impact an ways to promote survival and success. Adap- emotional event via early selection or modi-
Emotion Regulation Therapy 473 tive motivational responses and regulatory Aupperle and Paulus (2010) model of moti- capacities provide a foundation for behav- vation balancing, individuals with anxi- ioral flexibility in that they help us attain ety and mood disorders likely struggle to maximal emotional clarity (e.g., Gohm & overcome motivational conflicts because Clore, 2002) and subsequently implement they possess one or more of the follow- effective and goal-relevant responses for ing deficits: (1) an over-representation of optimal behavioral outcomes. safety–threat valuation as reflected in lim- bic (amygdala, insula) overactivation; (2) Optimal reward learning requires us to over- or underrepresentation of approach take behavioral actions that are informed by valuation as a function of either attenuated the assignment of value to possibly reward- or exaggerated striatal activation, respec- ing stimuli and subsequent predictions about tively; and (3) insufficient mediation or arbi- when and where we might encounter these tration of approach and/or avoidance valu- stimuli (O’Doherty, 2004). Bogdan and Piz- ations resulting from attenuated OFC and zagalli (2006) have examined factors such vmPFC activation. Klenk, Strauman, and as reward sensitivity (increased likelihood Higgins (2011) offer a similar view of moti- of responding to “rich” rewarding stimuli vational conflict, especially with respect to based on past learning history) as evidence GAD and MDD, by drawing from regula- of the influence of emotion and accurate cue tory focus theory (RFT; Higgins, 1997), a detection on reward learning and behavior. normative model of promotion (i.e., reward) Similarly, reliably detecting and respond- and prevention (i.e., security) motivations, ing to cues that signal a clear and present in which these two systems are conceptual- danger are crucial for survival (LeDoux, ized as separate and mutually inhibitory of 1996). However, equally important is learn- one another. In accounting for GAD, espe- ing to detect safety cues accurately and dif- cially when it co-o ccurs with MDD, Klenk ferentiate these signals from threat, so that et al. (2011) postulate primary failure in the we do not expend valuable resources (e.g., prevention system (i.e., hyperactivation) that time and energy) in attempts to escape from in turn can lead to failure (e.g., hypoactiva- “nonthreats.” Contemporary models of tion) in the promotion system. One possibil- threat and safety learning are predicated on ity is that salience in one or both of these principles of Pavlovian conditioning and the motivational systems may increase levels of knowledge that successful fear extinction subjective intensity and corresponding dis- represents new, inhibitory learning (Bouton, tress. Although more rigorous experimental Mineka, & Barlow 2001). Emotion regula- and biobehavioral research is needed, pre- tion plays an important role in inhibitory liminary findings support a role for both learning via selection of optimal responses motivational dysfunction (i.e., Campbell- that promote abolishment of a conditioned Sills, Liverant, & Brown, 2004) and subjec- emotional response. Commensurately, acti- tive intensity (i.e., Mennin, D. S., Heimberg, vation in the vmPFC, an area central to R. G., Turk, C. L., & Fresco, D. M., 2005; implementation of emotion regulation inten- Mennin, Holaway, Fresco, Moore, & Heim- tions, has been found to decrease during berg, 2007) in the distress disorders. acquisition of conditioned responses and increase during fear extinction (Schiller & Regulatory Dysfunction Delgado, 2010). Rather than processing emotion informa- tion and utilizing its motivational value, Dysfunctional Emotional Functioning individuals with distress disorders often fail Motivational Dysfunction to enhance or diminish emotional experi- Individuals with distress disorders may be ences in a manner appropriate to a par- subject to frequent conflicting pulls from ticular environmental context. Emotion reward and safety–threat systems. How- regulation deficits commonly occur in GAD ever, unlike healthy individuals, they may (Etkin, Prater, Hoeft, Menon, & Schatz- be relatively less effective in resolving these berg, 2010; Etkin & Schatzberg, 2011; Men- motivation conflicts. Drawing upon the nin et al., 2005; Mennin et al., 2007) and
474 INTERVENTIONS MDD (Johnstone, van Reekum, Urry, Kalin, vantage point regarding an emotionally pro- & Davidson, 2007). Rottenberg and Gross vocative event; see Gross, 2002) or accept (2003) recommend that investigators need (i.e., defined as openly turning toward, to parse emotion-generative processes from allowing, and remaining in personal contact regulation efforts and to recognize that, with an emotional experience; see Hayes, similar to conceptualizations of healthy reg- Strosahl, & Wilson, 2012). Participants ulation, dysregulation occurs dynamically with GAD showed a paradoxical pattern of throughout different points in the emotion- decreased HRV when trying to implement generative process. Individuals with distress these more elaborative strategies, suggesting disorders demonstrate deficits earlier in less a failure of efficiency of these strategies for elaborative, attentional regulation, as well as these individuals. Furthermore, studies com- later in more verbally elaborative, regulation paring individuals with MDD (Johnstone et in response to motivationally salient stimuli. al., 2007) to healthy control participants found dissociable patterns of neural activity At a less elaborative level, these individu- when participants were instructed to reap- als are characterized by attentional rigidity praise. Whereas control participants demon- in processing both interoceptive and extero- strated a negative relationship between acti- ceptive emotional stimuli (Clasen, Wells, vation in the vlPFC and the amygdala that Ellis, & Beevers, 2013; Mogg & Bradley, was mediated by the vmPFC, MDD partici- 2005). For example, GAD with and with- pants showed a positive association between out MDD is characterized by a failure to the vmPFC and the amygdala as well as no regulate emotional conflict spontaneously vlPFC activation. Rather than effectively by shifting attention in response to a moti- engaging adaptive strategies, there is consid- vationally salient emotional stimulus in con- erable evidence that individuals with distress flict adaptation tasks (Etkin et al., 2010; disorders alternatively employ perseverative Etkin & Schatzberg, 2011). Each day, we strategies to compensate for a negative emo- are confronted with the simultaneous occur- tional state, chiefly by enveloping it in elab- rence of emotionally conflicting information orative self-conscious processing (Borkovec that may perturb our goal-d irected behavior, et al., 2004; Nolen-Hoeksema et al., 2008). requiring us to attend to, consider, and pos- However, cognitively elaborative process- sibly inform our actions before completing ing, such as repetitive thought, is depleting the task at hand. The ability to handle these and requires an expenditure of resources instances efficiently is called conflict moni- to employ (Muraven & Baumeister, 2000). toring (Botvinick, Braver, Barch, Carter, & This depletion may come at the cost of not Cohen, 2001). This capacity represents a only effective emotion management and facet of normative emotion regulation and maintenance of distress but it also appears consistently corresponds to activation of the to preclude effective emotional processing anterior cingulate cortex (ACC), a region and learning. associated with attentional and motivational processes. By contrast, individuals with Narrow and Rigid Contextual Learning GAD + MDD struggle to regulate emotional Individuals with distress disorders often conflict, fail to engage the ventral ACC in exhibit impoverished and inflexible reper- ways that dampen amygdala activity, and toires of behavior in response to the situ- do not show regulation-related connectivity ations that typically function to promote between the ventral ACC and the amygdala escape, avoidance, or inactivity as a means (Etkin et al., 2010). of attempting to manage emotional– motivational signals (e.g., Ferster, 1973). Individuals with distress disorders also These behavioral patterns negatively impact struggle to implement more verbally elabo- reward learning. For example, in contrast to rative strategies. Aldao and Mennin (2012) healthy controls, depressed individuals are found that control individuals, while watch- less responsive to future opportunities for ing emotionally evocative films, demon- reward, despite a firsthand learning history strated increased heart rate variability for the availability of reward (Bogdan & Piz- (HRV; an index of parasympathetic flex- ibility; Porges, 2001) when instructed to reappraise (i.e., employ a different cognitive
Emotion Regulation Therapy 475 zagalli, 2006). Similarly, depressed individu- Clinical Application of the Emotion als, when given the choice between rewards Regulation Perspective of different sizes, fail to distinguish between As we have argued elsewhere (Mennin, options yielding large versus small rewards Ellard, Fresco, & Gross, 2013), one impor- (Forbes, Shaw, & Dahl, 2006). Bar (2009) tant step in advancing behavioral treatments proposes a model of optimal functioning for refractory conditions such as distress characterized by broad and contextual asso- disorders is the delineation of core principles ciative processing of historical and environ- that underlie various efficacious therapeutic mental factors to imagine future events and processes and corresponding mechanistic outcomes accurately. Depressive rumination targets refined from our growing knowledge is one strategy common to distress disorders of normative behavioral, biological, and that narrows associative processing, and in social functioning. Change principles can turn decreases the likelihood of new reward- be defined as broad frameworks for guiding based learning and obfuscates focusing on both what is being targeted in a given inter- purposeful action (Bar, 2009). In support of vention recipient and characteristics of the this assertion, Whitmer and Gotlib (2012) intervention itself. Target mechanisms refer found that instructing depressed individuals to the characteristics within the recipient of to ruminate during a laboratory-b ased task the intervention that are the focus of change reduced sensitivity to stimuli associated with for a given principle (Mennin et al., 2013). reward and punishment. ERT reflects these common principles and target mechanisms by drawing therapeutic With respect to threat and safety learning, processes from (1) CBT (e.g., psychoeduca- adaptively attending to motivational and tion, self-monitoring, cognitive perspective emotional signals can facilitate inhibitory taking, problem solving, relaxation and dia- learning. By contrast, one factor important phragmatic breathing exercises; Borkovec et to achieving durable inhibitory learning is al., 2004; Dugas & Robichaud, 2007); (2) the degree of stimulus generalization that an acceptance-, dialectic-, and mindfulness- individual displays in relation to the acquisi- based behavioral treatments (e.g., mindful- tion of a conditioned stimulus (CS; Lissek, ness exercises to broaden awareness of sen- 2012). In particular, individuals prone to sations, bodily responses, and emotions in anxiety disorders are less successful in dis- the present moment; exercises to increase criminating the properties of stimuli that willingness to accept emotions, commitment share characteristics with a training CS, to action related to personal values; Hayes et thereby resulting in stimulus overgeneral- al., 2012; Linehan, 1993; Roemer & Orsillo, ization and eliciting fear in response to a 2009; Segal, Williams, & Teasdale, 2002); broader array of stimuli. Similarly, for most and (3) experiential therapy (e.g., a focus organisms, signals or cues in the environ- on empathic attunement, the importance ment of unambiguous safety from fear leads of agency, delineation of emotion function, to new inhibitory learning that helps to engagement of experiential tasks, see Elliot, abolish the conditioned emotional response. Watson, Goldman, & Greenberg, 2004). Individuals prone to anxiety disorders are ERT also deliberately seeks to integrate find- less likely to achieve a durable and broad- ings from basic and translational affect sci- based abolishment of a conditioned fear ence, while simultaneously being responsive response because of deficits in detecting cues to emerging NIMH priorities. The net effect of unambiguous safety. Instead, their search is an integrated, mechanism-targeted CBT for safety is often characterized by hyper- that strives to improve the acute and endur- vigilance and overactivity, thereby result- ing treatment efficacy for individuals suffer- ing in an inferior and less durable acquisi- ing from distress disorders such as GAD and tion of inhibitory learning (Lohr, Olatunji, MDD, especially when the conditions are & Sawchuck, 2007; Woody & Rachman, comorbid. 1994). Further, resorting to worry to regu- late perceived threat experiences has been ERT is organized around core principles shown to encourage avoidance of emotional and target mechanisms related to an affect processing (Borkovec et al., 2004; Newman science framework, which, specifically seeks & Llera, 2011).
476 INTERVENTIONS to (1) increase motivational awareness, From a treatment perspective, motiva- (2) develop regulatory capacities, and (3) tional interviewing (MI) represents a stand- engage new contextual learning repertoires. alone or adjunctive intervention that strives ERT comprises 16 weekly sessions and uti- to bring awareness to one’s motivations, and lizes a phasic structure that helps clients the discrepancies between one’s stated goals build skills in the first half of treatment that and actions as a means of enhancing one’s are deployed in the second half of therapy willingness to change. Westra, Arkowitz, during exposure exercises. This phasic and Dozois (2009) reported that the addi- structure draws from Gross’s (2002) emo- tion of MI to traditional CBT was associated tion regulation model, which distinguishes with greater clinical efficacy in GAD, espe- between efforts to regulate emotions ear- cially among clients with higher pretreat- lier (i.e., antecedent-focused strategies) and ment levels of pathological worry. Finally, later (i.e., response-focused strategies) in training in mindfulness meditation may be the emotion-generative process. Specifically, one means of enhancing emotional aware- clients progress through ERT first by learn- ness and clarity. For example, Farb et al. ing skills to increase mindful awareness of (2010) found that a sadness provocation is emotional and motivational states; learning associated with activation of self-r eferencing skills to increase adaptive emotion regula- neural circuits (e.g., medial PFC), but train- tory responses congruent with contextual ing in mindfulness meditation is associated demands (“counteractive” as an alternative with activation of additional neural regions to reactive response-focused regulation); associated with visual attention (e.g., pulvi- and increasing values-informed behavioral nar nucleus), as well as visceral and somato- actions that strike a balance between secu- sensory areas (e.g., right insula). Greater rity and reward motivational pulls (“proac- activation of these neural regions was also tive” regulation akin to antecedent-focused negatively correlated with concurrent levels regulation). of depression. Motivational Awareness Skills Training Drawing from this empirical basis, ERT The first component of ERT is the cultiva- helps clients develop motivational awareness tion of skills to increase motivational aware- initially through psychoeducation aimed at ness (i.e., the accurate and rapid detection of increasing understanding of emotions and cues that signal the arrival of motivational underlying motivations in the context of pulls). The benefit of emotional and motiva- personally relevant historical and proximal tional clarity is a consistent finding across events. Clients receive a rationale for the numerous studies. For instance, Lanaj, benefits of observing emotions with greater Chang, and Johnson (2012) offer meta- granularity and clarity (i.e., better differen- analytic support for RFT (Higgins, 1997) tiation of each emotion even when multiple in relation to workplace performance, such emotions are present). For instance, clients that a promotion (reward) focus was posi- imagine a musical orchestra in which each tively associated with task performance and musical instrument represents a different innovativeness in the workplace, and nega- emotion. The orchestral composition rep- tively associated with counterproductive resents the motivational pulls in their lives. workplace behaviors. In contrast, a preven- Ideally, the composition is harmonious and tion (security) focus that was unrelated to the music moves clients to take some action task performance but positively associated in their lives. Clients are encouraged to lis- with engaging in safe workplace practices ten in such a way that each and every part of was also associated with counterproductive the orchestra can be heard and discerned for workplace behaviors. Furthermore, Gohm its contribution to the overall composition. and Clore (2002), in a series of studies, have consistently shown that emotional clarity, As noted by Aupperle and Paulus (2010), assessed via self-report, is associated with a individuals with distress disorders struggle variety of beneficial wellness characteristics to resolve motivational conflicts that occur and the tendency to approach life circum- in their lives, via overrepresentation of stances with planful, active coping. threat valuation, inconsistent representa- tion of approach valuation, and impaired arbitration of these motivation systems. The net result of this imbalance of motivational
Emotion Regulation Therapy 477 pulls is that the discrepancy becomes the the temporal model of emotion regulation salient signal, and individuals with distress and how less effort is required when emo- disorders often respond reactively in a des- tions are handled closer to their arrival in perate attempt to resolve the discrepancy. the temporal unfolding. Thus, building on the orchestra metaphor, clients also engage in a motivational anchor- Drawing from this snowball metaphor, ing exercise that begins their training in cul- ERT clients are then encouraged to practice tivating greater motivational and emotional a form of self-monitoring called Catch Your- awareness. Specifically, clients imagine an self Reacting (CYR). This practice begins as important but difficult situation in their lives a simple exercise to help identify triggers of that likely is marked by pulls for approach clients’ emotions, the actual emotions them- and avoidance. As clients imagine this situ- selves (fear, anxiety, disgust, etc.), and the ation, they envision the kinds of behavioral intensity of each emotion they listed. Later responses they are likely to take from that in ERT, the CYR is also utilized to practice particular balance of approach and avoid- the emotion regulation skills clients will ance motivations. ERT therapists then sys- learn in the course of treatment (see below). tematically help clients to envision this situ- CYRs are completed at home, then reviewed ation from various motivational stances, in the subsequent session with the therapist. with the goal of helping them see that most When clients experience difficulties with life circumstances comprise both approach CYR, therapists may choose to conduct a and avoidance motivations, and different “Do-Over.” This activity resembles both the responses are possible when one attends and cognitive rehearsal task, derived from tradi- follows to differing degrees one’s emotions tional cognitive therapy of depression (Beck, and motivations. Rush, Shaw, & Emery, 1979), and evocative unfolding in experiential therapy (Elliott et As clients gain an appreciation and under- al., 2004). The CYR “Do-Over” essentially standing for how emotions and motivations represents a therapist-supervised opportu- can effectively inform their lives, they are nity to shape and solidify self-monitoring introduced to a metaphor designed to help and cue detection. them improve the accuracy and rapidity of detecting cues in their lives. This work is Regulatory Skills Training predicated on the well-v alidated behavioral A principle of regulatory skills training interventions of self-m onitoring (e.g., Line- assumes that individuals with psychopa- han, 1993) and functional analysis (e.g., thology do not have immutable regulation Ferster, 1973), in which clients are taught to deficits; rather, with appropriate training, increase their self-awareness of life situations these capacities can be grown and utilized in as a means of better identifying antecedents their lives. Based on Gross’s model and the (triggers), thoughts, feelings, and behaviors extant clinical and experimental literature, that are prompted by these antecedents, and ERT targets different regulatory capacities the consequences of these behavioral actions. by utilizing a number of CBT intervention Self-m onitoring helps individuals identify processes that vary in their entry points patterns of responding reactively, often with along the trajectory of unfolding emotional little awareness of the emotional and moti- experience. Specifically, we promote four vational pulls as a first step in bringing more increasingly elaborative (i.e., that use work- conscious, deliberate, and ideally effective ing memory/verbal representations and are action when certain cues arise. In ERT, the resource intensive; Badre & D’Esposito, therapist begins self-m onitoring and cue 2007) regulatory capacities that rely on detection by asking clients to imagine a pris- antecedent-focused processing: attending tine snowball (i.e., a pure emotional experi- (i.e., the ability to focus, sustain, and flexibly ence) rolling down a hill, and in the course move attention); allowance (i.e., the ability of its travel, picking up dirt and twigs, and to openly turn toward, allow, and remain in becoming hard and icy (i.e., the unfolding personal contact with an emotional experi- of emotional experience, particularly in the ence); distancing (i.e., the ability to identify, aftermath of failures in nonelaborative and observe, and generate psychological perspec- elaborative emotion capacities). Essentially, tive from inner experiences); and reframing the snowball metaphor informs clients about
478 INTERVENTIONS (i.e., the ability to change one’s evaluation of can be felt in the body (e.g., Craig, 2009), an event such that the event is altered in its thereby enhancing the ability to disengage emotional significance). from elaborative processes about sensory experiences. Clients are taught diaphrag- Attending matic breathing as a brief, nonelaborative A capacity for directed attention implies practice that focuses attention on sensa- flexible responsivity to different contexts. tions in the body (e.g., Roemer & Orsillo, Whereas constricted, narrowly focused 2009). Clients also learn a practice adapted attention is adaptive during times of poten- from the body scan work common in MBSR tial threat, broadened attention facilitates (Kabat-Zinn, 1990) and MBCT (Segal et exploratory behavior, thereby allowing for al., 2002), coupled with an awareness-b ased the possibility of increased detection of new progressive muscle relaxation approach that information and novel incentives (Friedman has been effectively utilized in the treatment & Forster, 2010). One facet of directed atten- of GAD (Roemer & Orsillo, 2009). After tion is focused attention, which involves experiencing some success with directed actively choosing the stimulus to which one attention practices, clients learn an “on the will attend (Kabat-Zinn, 1990). Similarly, spot” skill of detecting tension and imple- sustained attention refers to maintaining menting relaxation techniques to promote this focus on the target stimulus (see Posner greater flexibility in musculature response. & Rothbart, 1992), as well as actively redi- recting attention back to the target stimulus Finally, although not every emotion expe- when attention has wandered (e.g., Small- rienced is necessarily adaptive, broadening wood & Schooler, 2006). Finally, flexible awareness to the full spectrum of emotional attention entails deliberately attending to experience can help clients move through various aspects of an experience (Kabat- “cloudy” (i.e., secondary emotional reac- Zinn, 1990). Converging lines of research tions) toward “clear” (i.e., primary emo- suggest that reduced attentional flexibility tions that convey initial action tendencies and rigid attentional biases distinguish indi- and their associated meanings for behav- viduals with distress disorders from healthy ior) emotions that better reflect the array of controls (Clasen et al., 2013; Mogg & Brad- motivational cues that may be present (Elliot ley, 2005). et al., 2004; Linehan, 1993). Specifically, cli- ents learn a mindfulness of emotions exer- ERT targets directed attention by promot- cise in which the goal is to bring to mind a ing skills to encourage greater awareness situation that possesses conflicting emotions of emotions, including sensations, bodily and motivations (i.e., simultaneous security responses, and subjective experience. Mind- and reward impetuses), and they are invited ful attention training is utilized to increase to sit with the experience until they can hold a healthy awareness of motivations and and more clearly delineate the emotions and emotional responding, with a particular motivational pulls in the situation. emphasis on less elaborative, less linguistic processing of one’s experience (Kabat-Zinn, Allowing 1990). Both in-session and daily practices Emotional allowance involves maintaining are derived from mindfulness-based stress contact with feeling states, without being reduction (MBSR; Kabat-Zinn, 1990) dissuaded by elaborative thought processes, and mindfulness-based cognitive therapy such as judgments about the experience (MBCT; Segal et al., 2002). ERT promotes (see Hayes et al., 2012). Individuals with directed attention toward external stimuli by highly developed capacities to accept their increasing mindfulness of senses. A broad- emotions are less likely to avoid certain ened awareness of appetitive and aversive endeavors wherein difficult emotions could stimuli alike is encouraged through practices arise and are more likely to stay in contact that increase mindful ingestion of senses with emotions associated with aversiveness, (e.g., eating a raisin mindfully; Kabat-Zinn, increasing the possibility of updating con- 1990). ERT also promotes directed attention tingencies related to their valuation (Hayes to internal, nonverbal stimuli or stimuli that et al., 2012). Individuals with psychopathol-
Emotion Regulation Therapy 479 ogy demonstrate difficulties acknowledging that one’s thoughts, feelings, and urges are their emotional experiences, which includes transient internal events rather than inher- being dissuaded by negative beliefs about ent, permanent aspects of the self or accu- difficult emotions, aversion toward difficult rate representations of reality (Fresco et emotional experiences, engaging in mal- al., 2007; Segal et al., 2002). Studies reveal adaptive elaborative responses when diffi- psychological benefits from promoting dis- cult emotions arise (e.g., worrying, brood- tance from the self in time (e.g., viewing ing, self-criticizing), attempting to reduce inner experiences as temporary; Watkins, their awareness and limit their experience Teasdale, & Williams, 2000) and in space of difficult emotions, and avoiding situa- (e.g., viewing inner experiences as physi- tions and activities that could provoke dif- cal objects that are separate from oneself; ficult emotions, even when such activities Kalisch et al., 2005). Distress disorders have are important to them (Barlow et al., 2011; been associated with deficits in cognitive Hayes et al., 2012; Linehan, 1993; Roemer distancing (e.g., Fresco al., 2007) and can & Orsillo, 2009; Segal et al., 2002). be reduced by experimental techniques that promote an observational distance from the By accepting and exploring emotions, self (e.g., Kross & Ayduk, 2009). clients gain an ability to be present with emotions and learn how to determine their Distancing is targeted through two offline functional utility in guiding actions. Spe- mindfulness practices and their correspond- cifically, clients conduct an “offline” prac- ing on-the-spot versions. In the mountain tice that involves imaginally engaging and meditation, derived from MBSR (Kabat- remaining in contact with sensations, emo- Zinn, 1994), clients are invited to internal- tions, and cognitions that arise in pursuit ize a living, breathing mountain to provide of a difficult to achieve but motivationally solidarity and permanence in their lives to enhancing action—in effect, a personally help them “weather” the transient emotional salient approach–avoidance conflict. The upheavals in their lives. The mountain medi- on-the-spot version of this practice involves tation provides a decentered perspective encouraging clients to “pause” by sustaining through the lens of time—helping clients their connection to a cloudy, diffuse situa- tell themselves “This too will pass.” Clients tion until they are able to connect to the pri- then practice a brief version of the mountain mary emotions that reflect both motivations meditation designed to be utilized on the for reward and safety. Another borrowed, spot in moments that call for a security-first on-the-spot practice, designed to sustain or response to help sustain or regain a decen- regain allowance is the 3-minute breathing tered stance. Similarly, drawing primarily space (Segal et al., 2002), which helps clients from acceptance and commitment therapy anchor themselves in an event with strong (ACT; Hayes et al., 2012), ERT promotes pulls to respond reactively. a focus on mental spatial distance and is designed to teach clients to bring situations to Distancing mind, then to granulize the constituent parts Various theorists (e.g., Hayes et al., 2012; of the situation by placing them externally Kross & Ayduk, 2009; Segal et al., 2002) on objects in the room. This offline practice have emphasized the importance of distanc- is an invitation to create healthy distance in ing or decentering, the metacognitive abil- one’s mind’s eye so that these products of ity to observe items that arise in the mind mind are more readily observable, and in (thoughts, feelings, memories, etc.) with turn, can inform our deliberate actions from healthy psychological distance, greater self- a decentered perspective. This practice also awareness, and perspective taking. Cogni- has a corresponding on-the-spot skill, where tive distancing helps individuals disengage clients imaginally place products of their from an intense emotion, its corresponding mind on objects that they ordinarily carry in motivational impetus, and associated mal- their daily lives. One of our clients actually adaptive self-referential processing, in favor carried around a shoehorn he crafted, which of adopting a more experiential perspec- he used to “pry” himself away from prod- tive. This ability also involves recognizing ucts of his mind to promote better observa- tion and nonjudgment.
480 INTERVENTIONS Reframing telling a very caring, interested, compassion- Reframing refers to the ability to change ate individual about their difficult thoughts one’s evaluation of an event so as to alter its and feelings, and reminding themselves of emotional significance (Gross, 2002). Three their strengths and coping ability (Gilbert, of the most common methods include real- 2009; Segal et al., 2002). Noticing one’s self-Â
Search
Read the Text Version
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- 57
- 58
- 59
- 60
- 61
- 62
- 63
- 64
- 65
- 66
- 67
- 68
- 69
- 70
- 71
- 72
- 73
- 74
- 75
- 76
- 77
- 78
- 79
- 80
- 81
- 82
- 83
- 84
- 85
- 86
- 87
- 88
- 89
- 90
- 91
- 92
- 93
- 94
- 95
- 96
- 97
- 98
- 99
- 100
- 101
- 102
- 103
- 104
- 105
- 106
- 107
- 108
- 109
- 110
- 111
- 112
- 113
- 114
- 115
- 116
- 117
- 118
- 119
- 120
- 121
- 122
- 123
- 124
- 125
- 126
- 127
- 128
- 129
- 130
- 131
- 132
- 133
- 134
- 135
- 136
- 137
- 138
- 139
- 140
- 141
- 142
- 143
- 144
- 145
- 146
- 147
- 148
- 149
- 150
- 151
- 152
- 153
- 154
- 155
- 156
- 157
- 158
- 159
- 160
- 161
- 162
- 163
- 164
- 165
- 166
- 167
- 168
- 169
- 170
- 171
- 172
- 173
- 174
- 175
- 176
- 177
- 178
- 179
- 180
- 181
- 182
- 183
- 184
- 185
- 186
- 187
- 188
- 189
- 190
- 191
- 192
- 193
- 194
- 195
- 196
- 197
- 198
- 199
- 200
- 201
- 202
- 203
- 204
- 205
- 206
- 207
- 208
- 209
- 210
- 211
- 212
- 213
- 214
- 215
- 216
- 217
- 218
- 219
- 220
- 221
- 222
- 223
- 224
- 225
- 226
- 227
- 228
- 229
- 230
- 231
- 232
- 233
- 234
- 235
- 236
- 237
- 238
- 239
- 240
- 241
- 242
- 243
- 244
- 245
- 246
- 247
- 248
- 249
- 250
- 251
- 252
- 253
- 254
- 255
- 256
- 257
- 258
- 259
- 260
- 261
- 262
- 263
- 264
- 265
- 266
- 267
- 268
- 269
- 270
- 271
- 272
- 273
- 274
- 275
- 276
- 277
- 278
- 279
- 280
- 281
- 282
- 283
- 284
- 285
- 286
- 287
- 288
- 289
- 290
- 291
- 292
- 293
- 294
- 295
- 296
- 297
- 298
- 299
- 300
- 301
- 302
- 303
- 304
- 305
- 306
- 307
- 308
- 309
- 310
- 311
- 312
- 313
- 314
- 315
- 316
- 317
- 318
- 319
- 320
- 321
- 322
- 323
- 324
- 325
- 326
- 327
- 328
- 329
- 330
- 331
- 332
- 333
- 334
- 335
- 336
- 337
- 338
- 339
- 340
- 341
- 342
- 343
- 344
- 345
- 346
- 347
- 348
- 349
- 350
- 351
- 352
- 353
- 354
- 355
- 356
- 357
- 358
- 359
- 360
- 361
- 362
- 363
- 364
- 365
- 366
- 367
- 368
- 369
- 370
- 371
- 372
- 373
- 374
- 375
- 376
- 377
- 378
- 379
- 380
- 381
- 382
- 383
- 384
- 385
- 386
- 387
- 388
- 389
- 390
- 391
- 392
- 393
- 394
- 395
- 396
- 397
- 398
- 399
- 400
- 401
- 402
- 403
- 404
- 405
- 406
- 407
- 408
- 409
- 410
- 411
- 412
- 413
- 414
- 415
- 416
- 417
- 418
- 419
- 420
- 421
- 422
- 423
- 424
- 425
- 426
- 427
- 428
- 429
- 430
- 431
- 432
- 433
- 434
- 435
- 436
- 437
- 438
- 439
- 440
- 441
- 442
- 443
- 444
- 445
- 446
- 447
- 448
- 449
- 450
- 451
- 452
- 453
- 454
- 455
- 456
- 457
- 458
- 459
- 460
- 461
- 462
- 463
- 464
- 465
- 466
- 467
- 468
- 469
- 470
- 471
- 472
- 473
- 474
- 475
- 476
- 477
- 478
- 479
- 480
- 481
- 482
- 483
- 484
- 485
- 486
- 487
- 488
- 489
- 490
- 491
- 492
- 493
- 494
- 495
- 496
- 497
- 498
- 499
- 500
- 501
- 502
- 503
- 504
- 505
- 506
- 507
- 508
- 509
- 510
- 511
- 512
- 513
- 514
- 515
- 516
- 517
- 518
- 519
- 520
- 521
- 522
- 523
- 524
- 525
- 526
- 527
- 528
- 529
- 530
- 531
- 532
- 533
- 534
- 535
- 536
- 537
- 538
- 539
- 540
- 541
- 542
- 543
- 544
- 545
- 546
- 547
- 548
- 549
- 550
- 551
- 552
- 553
- 554
- 555
- 556
- 557
- 558
- 559
- 560
- 561
- 562
- 563
- 564
- 565
- 566
- 567
- 568
- 569
- 570
- 571
- 572
- 573
- 574
- 575
- 576
- 577
- 578
- 579
- 580
- 581
- 582
- 583
- 584
- 585
- 586
- 587
- 588
- 589
- 590
- 591
- 592
- 593
- 594
- 595
- 596
- 597
- 598
- 599
- 600
- 601
- 602
- 603
- 604
- 605
- 606
- 607
- 608
- 609
- 610
- 611
- 612
- 613
- 614
- 615
- 616
- 617
- 618
- 619
- 620
- 621
- 622
- 623
- 624
- 625
- 626
- 627
- 628
- 629
- 630
- 631
- 632
- 633
- 634
- 635
- 636
- 637
- 638
- 639
- 640
- 641
- 642
- 643
- 644
- 645
- 646
- 647
- 648
- 649
- 650
- 651
- 652
- 653
- 654
- 655
- 656
- 657
- 658
- 659
- 660
- 661
- 662
- 663
- 664
- 665
- 666
- 667
- 668
- 669
- 670
- 671
- 672
- 673
- 674
- 675
- 676
- 677
- 678
- 679
- 680
- 681
- 682
- 683
- 684
- 685
- 686
- 687
- 688
- 689
- 1 - 50
- 51 - 100
- 101 - 150
- 151 - 200
- 201 - 250
- 251 - 300
- 301 - 350
- 351 - 400
- 401 - 450
- 451 - 500
- 501 - 550
- 551 - 600
- 601 - 650
- 651 - 689
Pages:
