Numerous studies emphasise the pivotal role of negative affect in the formation and maintenance of positive symptoms, which moves emotion regulation (ER) as a contributing factor into focus. We ...systematically reviewed and meta-analysed case-control studies reporting cross-sectional, correlative and experimental data of ER strategies in patients with psychotic disorders. In total, 42 studies were eligible, providing data for 2498 subjects and 3381 healthy controls. Questionnaire-based cross-sectional data (k=39) indicated strongest effects for rumination (g=-0,67 -0,85 to -0,48), self-blaming (g=-0,56; -0,76 to -0,37) and distraction (g=0,55 0,11 to 0,98). Suppression was more frequently (g=-0,36 -0,56 to -0,16) and cognitive reappraisal less frequently used (g=0,41 0,28 to 0,55), but heterogeneity was high. Correlative data (k=6) supported the assumption of an association between maladaptive strategies and positive symptoms (r=0,34 0,22 to 0,44). Less evidence of group differences was found in the experimental studies (k=3). The findings support the notion that ER is markedly impaired in patients with psychotic disorders. However, future research will need to further clarify the extent to which difficulties continue to exist after controlling for context and emotion intensity. The large effects for rumination and self-blaming point to promising treatment targets but also raise questions concerning the specifity of findings.
•Emotion regulation (ER) is markedly impaired in patients with psychotic disorders.•Maladaptive ER is more frequently and adaptive ER less frequently used.•Maladaptive but not adaptive ER strategies are associated with severity of positive symptoms.•No differences are evident in experimental studies, in which patients were instructed to use ER strategies.
Studies on cognitive behavioural therapy for psychosis (CBTp) have developed from evaluating generic approaches to focusing on specific symptoms. The evidence for targeted studies on delusions and ...hallucinations was reviewed. We included randomized controlled trials (RCTs) examining the effect of individualized CBT-based interventions focusing either on delusions or on hallucinations. Twelve suitable RCTs were identified. Four RCTs focused on delusions, of which three took a focused approach targeting mechanisms assumed causal to persecutory delusions. Eight RCTs focused on hallucinations, a common component of these studies being a focus on the perceived power imbalance between the voice(s) and the voice-hearer, to reduce distress and dysfunction. Only three RCTS were powered adequately; the remainder were pilot trials. All trials reported effect sizes against treatment-as-usual above d=0.4 on at least one primary outcome at post-therapy, with several effects in the large range. Effects on the primary outcome were maintained for five of the seven studies that had significant outcomes and reported a follow-up comparison, but most of the follow-up periods were brief.
Although targeted studies are still in their infancy, the results are promising with a tendency towards higher effects compared to the small-to-moderate range found for generic CBTp. In clinical practice, CBTp will need to continue including a range of approaches that can be adapted to patients in a flexible manner according to the primary goals and prevalent combination of symptoms. However, symptom-focused and causal-interventionist approaches are informative research strategies to evaluate the efficacy of separate components or mechanisms of generic CBTp.
•Emotion regulation is related to the stress response but not to the recovery.•High maladaptive emotion regulation is related to a stronger affective stress response.•High maladaptive emotion ...regulation is related to a blunted endocrine stress response.
Stress is associated with the development of mental disorders such as depression and psychosis. The ability to regulate emotions is likely to influence how individuals respond to and recover from acute stress, and may thus be relevant to symptom development. To test this, we investigated whether self-reported emotion regulation predicts the endocrine, autonomic, affective, and symptomatic response to and recovery from a stressor. Social-evaluative stress was induced by the Trier Social Stress Test (TSST) in N = 67 healthy individuals (53.7% female, Mage = 29.9). Self-reported habitual emotion regulation skills were assessed at baseline. We measured salivary cortisol, heart rate, negative affect, state depression and state paranoia at three time points: pre-TSST, post-TSST, and after a 10 min recovery phase. Repeated-measures ANOVA showed all indicators to significantly increase in response to the stressor (p < .001) and decrease during the recovery phase (p < .001), except for salivary cortisol, which showed a linear increase (p < .001). The habitual use of maladaptive emotion regulation (e.g., rumination, catastrophizing) significantly predicted an increased affective and reduced cortisol response. Adaptive emotion regulation (e.g., acceptance, reappraisal) was not predictive of the stress response for any of the indicators. Neither type of emotion regulation predicted response during the stress recovery phase. Individuals who habitually resort to maladaptive emotion regulation strategies show a stronger affective and a blunted endocrine stress response, which may make them vulnerable to mental health problems. However, further research is needed to identify the full scope of skills required for effective stress-regulation before this knowledge can be used to develop effective prevention programs.
High levels of stress play a crucial role in the development of psychotic symptoms, such as paranoia, and may stem in part from recovery deficits after stress exposure. However, it remains unclear ...whether deficient recovery causes a build-up of heightened stress levels that increases stress sensitivity and symptoms when exposed to another stressor. To test this, we investigated the effect of subjective stress recovery on the response to a subsequent stressor and paranoia.
We applied two consecutive runs of the same combined physical and cognitive stressor separated by a recovery phase of 60 min in individuals with schizophrenia spectrum disorders (n = 49). We repeatedly assessed self-reported stress, negative affect, heart rate, heart rate variability, salivary cortisol, and paranoia. Recovery of self-reported stress was defined as the geometric mean of the percentage changes of self-reported stress during recovery after the first stressor, and was regressed on the response to the second stressor controlling for self-reported stress during the first stressor.
Lower subjective stress recovery predicted higher levels of self-reported stress, negative affect, and paranoia in response to the second stressor. The subjective stress recovery was not predictive of the physiological stress response (heart rate, heart rate variability, or salivary cortisol).
Taken together, the findings indicate that recovery deficits could contribute to high levels of self-reported stress, negative affect, and paranoia in schizophrenia spectrum disorders and that the improvement of stress recovery could be a promising approach for interventions.
Heightened stress levels in individuals with psychosis (PSY) are associated with psychotic symptom occurrence and may be partially attributed to well-established deficits in resting-state heart rate ...variability (HRV) and emotion regulation. In healthy participants, resting-state HRV and self-reported emotion regulation skills have been linked to recovery after a stressor; however, it is unclear whether stress recovery is altered in PSY. Thus, we compared the autonomic and subjective recovery of PSY to healthy controls (HC) and investigated the predictive value of resting-state HRV and emotion regulation skills.
We assessed resting-state HRV and self-reported emotion regulation one week prior to a combined physical and cognitive stress induction. After the stress exposure, we assessed the autonomic (decrease in heart rate HR, increase in HRV) and subjective (decrease in subjective stress and negative affect) recovery in PSY (n = 50) and HC (n = 50) over 60 min.
Repeated-measures ANOVA revealed the expected interaction of time × group for subjective stress but not negative affect or autonomic stress. Resting-state HRV predicted recovery of HR, and emotion regulation skills predicted recovery of HRV but not of the other parameters.
Although subjective stress recovery was delayed in PSY, the absence of autonomic recovery deficits suggests that a prolonged stress response may not contribute to heightened stress levels to the expected extent. Improving resting-state HRV and emotion regulation may support autonomic recovery, but further investigation is required to test the impact of such improvements on psychotic symptoms.
Abstract Negative symptoms, e.g. social withdrawal, reduced initiative, anhedonia and affective flattening, are notoriously difficult to treat. In this review, we take stock of recent research into ...treatment of negative symptoms by summarizing psychosocial as well as pharmacological and other biological treatment strategies. Major psychosocial approaches concern social skills training, cognitive behavior therapy for psychosis, cognitive remediation and family intervention. Some positive findings have been reported, with the most robust improvements observed for social skills training. Although cognitive behavior therapy shows significant effects for negative symptoms as a secondary outcome measure, there is a lack of data to allow for definite conclusions of its effectiveness for patients with predominant negative symptoms. With regard to pharmacological interventions, antipsychotics have been shown to improve negative symptoms, but this seems to be limited to secondary negative symptoms in acute patients. It has also been suggested that antipsychotics may aggravate negative symptoms. Recent studies have investigated glutamatergic compounds, e.g. glycine receptor inhibitors and drugs that target the NMDA receptor or metabotropic glutamate 2/3 (mGlu2/3) receptor, but no consistent evidence of improvement of negative symptoms was found. Finally, some small studies have suggested improvement of negative symptoms after non-invasive electromagnetic neurostimulation, but this has only been partly replicated and it is still unclear whether these are robust improvements. We address methodological issues, in particular the heterogeneity of negative symptoms and treatment response, and suggest avenues for future research. There is a need for more detailed studies that focus on different dimensions of negative symptoms.
Cardiac vagal tone, indexed by heart rate variability (HRV), is a proxy for the functional integrity of feedback mechanisms integrating central and peripheral physiology.
To quantify differences in ...HRV in individuals with schizophrenia compared with healthy controls.
Databases were systematically searched for studies eligible for inclusion. Random effect meta-analyses of standardised mean differences were calculated for vagal activity indicated by high-frequency HRV and the root mean square of successive R-R interval differences (RMSSD).
Thirty-four studies were included. Significant main effects were found for high-frequency HRV (P = 0.0008; Hedges' g = -0.98, 95% CI -1.56 to -0.41, k = 29) and RMSSD (P<0.0001; g = -0.91, 95% CI -1.19 to -0.62, k = 24), indicating lower vagal activity in individuals with schizophrenia than in healthy controls. Considerable heterogeneity was evident but effects were robust in subsequent sensitivity analyses.
Given the association between low HRV, threat processing, emotion regulation and executive functioning, reduced vagal tone may be an endophenotype for the development of psychotic symptoms.
Affective functioning is compromised in people who develop persecutory delusions, but the specifics of these affective disturbances remain unclear. To better understand the precise nature of ...affective disturbances in this group, it could prove helpful to focus not only on average or momentary affect intensities but also on the dynamic properties of affect, that is, the patterns and regularities with which affect fluctuates over time. This study used experience-sampling in a community sample with varying levels of paranoid ideation (n = 144) to capture different aspects of temporal affect dynamics in the two affective dimensions of valence and arousal. Specifically, we aimed to elucidate whether paranoid ideation is associated with high affective instability (i.e., both high affective variability and low inertia) or only with high affective variability or low affective inertia and whether these effects would be maintained when mean affect levels are controlled for. Results showed that the intensity and frequency of paranoid ideation were significantly associated with high variability of affective arousal, but for paranoia frequency, the effect was not robust against controlling for average arousal levels. Paranoia frequency was also associated with low inertia in affective valence, and paranoia intensity was associated with high valence variability. We discuss the implications of these findings for future research and clinical practice.
Purpose
Beliefs that emotions can be changed (i.e., malleability beliefs) are relevant to emotion regulation. Emotion regulation plays a crucial role in severe mental health symptoms, such as ...paranoid delusions, but it remains unknown to which extent malleability beliefs contribute to a dysfunctional pattern of emotion regulation in individuals experiencing paranoid ideation. Therefore, we investigated whether malleability beliefs are associated with paranoid ideation and whether emotion regulation accounts for this association.
Methods
We conducted a cross-sectional assessment in a sample of individuals with psychotic disorders (
n
= 50) and a community sample (
n
= 218) and collected self-report data on malleability beliefs, the use of emotion regulation strategies (reappraisal, acceptance, rumination, expressive suppression, experience suppression), and paranoid ideation.
Results
Multivariate regressions showed that greater beliefs that emotions are malleable predicted more reappraisal and acceptance in both samples and less rumination in the community sample. Malleability beliefs did not predict the strategies of suppressing an emotion or its expression. In the community sample, but not in the clinical sample, greater beliefs that emotions are malleable were associated with less frequent paranoid ideation and emotion regulation accounted for significant variance in the relationship.
Conclusions
The findings indicate that malleability beliefs do not contribute to paranoid delusions in individuals with psychotic disorders. However, in individuals with subclinical paranoid ideation, a failure to perceive emotions as malleable could hinder adaptive attempts to regulate emotions leading to increased negative affect and thereby pave the way for paranoid ideation. Malleability beliefs may thus represent a promising target for prevention.
Abstract Reliable and valid assessment of negative symptoms is crucial to further develop etiological models and improve treatments. Our understanding of the concept of negative symptoms has ...undergone significant advances since the introduction of quantitative assessments of negative symptoms in the 1980s. These include the conceptualization of cognitive dysfunction as separate from negative symptoms and the distinction of two main negative symptom factors (avolition and diminished expression). In this review we provide an overview of existing negative symptom scales, focusing on both observer-rated and self-rated measurement of negative symptoms. We also distinguish between measures that assess negative symptoms as part of a broader assessment of schizophrenia symptoms, those specifically developed for negative symptoms and those that assess specific domains of negative symptoms within and beyond the context of psychotic disorders. We critically discuss strengths and limitations of these measures in the light of some existing challenges, i.e. observed and subjective symptom experiences, the challenge of distinguishing between primary and secondary negative symptoms, and the overlap between negative symptoms and related factors (e.g. personality traits and premorbid functioning). This review is aimed to inform the ongoing development of negative symptom scales.
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