Emotional awareness is correlated with ambulatory heart rate variability: A replication and extension.

OBJECTIVE: A positive association has previously been observed in healthy volunteers between emotional awareness (EA), the ability to identify and describe emotional experiences in oneself and others, and resting heart rate variability (HRV), which is dominated by vagus nerve activity. The current study aimed to investigate the EA-HRV association across multiple assessments in a "real-world" ambulatory context in patients with long QT syndrome (LQTS) who are at genetic risk for sudden cardiac death. METHOD: Participants (157 LQTS patients; MeanAge = 35.1, SDAge = 10.4; 115 women) completed the levels of emotional awareness scale (LEAS) on one occasion, which served as our measure of EA. In an ecological momentary assessment study involving 10 assessments per day over three days, multiple 5-minute ECG assessments (Mean = 24.6, SD = 5.1) were obtained in each patient using a Holter monitor, from which high-frequency HRV (HF-HRV) was computed on each occasion. RESULTS: There was a significant positive association between LEAS scores and HF-HRV controlling for biobehavioral covariates. We also detected a similar inverse relation between EA and mean heart rate. CONCLUSION: These findings suggest that, in patients with a well-defined genetic risk for ventricular arrhythmia and sudden death, the ability to experience emotions in a complex and differentiated way covaries with greater parasympathetic influences on the heart. These findings are consistent with the overlapping neural substrates of EA and HRV and their common contribution to adaptive emotional responding, consistent with the Neurovisceral Integration Model.

Unconscious Activation of Negative Emotional Memories Increases Pain Unpleasantness.

OBJECTIVE: The influence of unconscious emotional processes on pain remains poorly understood. The present study tested whether cues to forgotten unpleasant images might amplify pain (i.e., in the absence of conscious recall). METHODS: Seventy-two healthy female adults (19 to 34 years) performed an adapted Think/No-think paradigm (T/NT) using 72 combinations of neutral face images (cues) paired with 36 neutral and 36 unpleasant images. After completion of the T/NT task, cues associated with forgotten neutral or unpleasant images were identified. Cues to either neutral or unpleasant images from the NT condition were then presented in randomized order while participants received intermediate-level thermal pain stimulation on the left hand. Ratings of both pain intensity and unpleasantness were acquired after each trial. RESULTS: Mean pain unpleasantness ratings were greater during presentation of cues to forgotten negative versus neutral images (5.52 [SD = 2.06] versus 5.23 [SD = 2.10]; p = .02). This pattern was also present when comparing cues to remembered negative versus neutral images (5.62 [SD = 1.94] versus 5.04 [SD = 1.90]; p < .001). Mean pain intensity ratings were higher for cues to negative versus neutral images when remembered (5.48 [SD = 1.79] versus 5.00 [SD = 1.69]; p < .001), but not when forgotten (5.27 [SD = 1.96] versus 5.16 [SD = 1.93]; p = .30). CONCLUSIONS: Using an adapted T/NT-Pain paradigm, this study demonstrated that cues to nonrecallable (but potentially unconsciously activated) negative emotional memories amplify pain unpleasantness, similar to known effects of conscious negative emotions.

Emotional awareness for self and others and empathic abilities in clinical depression during acute illness and recovery.

BACKGROUND: The present longitudinal investigation had two major goals. First, we intended to clarify whether depressed patients are characterized by impairments of emotional awareness for the self and the other during acute illness and whether these impairments diminish in the course of an inpatient psychiatric treatment program. Previous research based on the performance measure Levels of Emotional Awareness Scale (LEAS) provided inconsistent findings concerning emotional self-awareness in clinical depression. Second, we investigated whether cognitive and affective empathic abilities change from acute illness to recovery in depressed patients. METHODS: Fifty-eight depressed patients were tested on admission and after 6-8 weeks of inpatient psychiatric treatment. A sample of fifty-three healthy individuals were also examined twice at an interval of 6-8 weeks. The LEAS and the Interpersonal Reactivity Index (IRI) were administered to assess emotional awareness and empathic abilities. Written texts were digitalized and then analyzed using the electronic scoring program geLEAS, the German electronic Levels of Emotional Awareness Scale. RESULTS: Depressed patients reported more depressive symptoms than healthy controls and less severe depressive symptomatology at time 2 compared to time 1. Independent of time, depressed individuals tended to show lower geLEAS self scores and had lower geLEAS other scores than healthy individuals. Depressed patients showed higher personal distress scores than healthy individuals at both measurement times. No group differences were observed for the cognitive empathy scales of the IRI (perspective taking and fantasy) and empathic concern, but empathic concern decreased significantly in depressed patients from time 1 to time 2. Empathic abilities as assessed by the IRI were not significantly correlated with emotional awareness for others, neither in the whole sample, nor in the patient and control subsample. CONCLUSIONS: Depressed patients seem to be characterized by impairments in emotional awareness of others during acute illness and recovery, but they also tend to show deficits in emotional self-awareness compared to healthy individuals. Self-reported cognitive empathic abilities seem to be at normal levels in depressed patients, but their heightened self-focused affective empathy may represent a vulnerability factor for depressive disorders.

Thinking through others' emotions: Incorporating the role of emotional state inference in thinking through other minds.

The active inference framework offers an attractive starting point for understanding cultural cognition. Here, we argue that affective dynamics are essential to include when constructing this type of theory. We highlight ways in which interactions between emotional responses and the perception of those responses, both within and between individuals, can play central roles in both motivating and constraining sociocultural practices.

An Embodied Neurocomputational Framework for Organically Integrating Biopsychosocial Processes: An Application to the Role of Social Support in Health and Disease.

OBJECTIVE: Two distinct perspectives-typically referred to as the biopsychosocial and biomedical models-currently guide clinical practice. Although the role of psychosocial factors in contributing to physical and mental health outcomes is widely recognized, the biomedical model remains dominant. This is due in part to (a) the largely nonmechanistic focus of biopsychosocial research and (b) the lack of specificity it currently offers in guiding clinicians to focus on social, psychological, and/or biological factors in individual cases. In this article, our objective is to provide an evidence-based and theoretically sophisticated mechanistic model capable of organically integrating biopsychosocial processes. METHODS: To construct this model, we provide a narrative review of recent advances in embodied cognition and predictive processing within computational neuroscience, which offer mechanisms for understanding individual differences in social perceptions, visceral responses, health-related behaviors, and their interactions. We also review current evidence for bidirectional influences between social support and health as a detailed illustration of the novel conceptual resources offered by our model. RESULTS: When integrated, these advances highlight multiple mechanistic causal pathways between psychosocial and biological variables. CONCLUSIONS: By highlighting these pathways, the resulting model has important implications motivating a more psychologically sophisticated, person-specific approach to future research and clinical application in the biopsychosocial domain. It also highlights the potential for quantitative computational modeling and the design of novel interventions. Finally, it should aid in guiding future research in a manner capable of addressing the current criticisms/limitations of the biopsychosocial model and may therefore represent an important step in bridging the gap between it and the biomedical perspective.

The importance of identifying underlying process abnormalities in alexithymia: Implications of the three-process model and a single case study illustration.

We present an in-depth case study of a rare individual (whom we will refer to as "Jane") who reported an inability to experience emotion. Jane completed a range of assessments measuring alexithymia, emotional awareness, and emotion recognition ability. She, along with 22 control participants, also underwent skin conductance (SC) measurement and facial electromyography (EMG) during exposure to affective images, and self reported the valence/arousal of their responses to those images. Jane scored high on alexithymia and low on emotional awareness; yet she performed well on emotion recognition measures and showed a typical pattern of valence ratings. Her SC responses and subjective arousal ratings were atypically low, and some of her EMG responses were also atypical. Jane's deficit profile highlights the dissociability of self-focused emotional awareness and other-focused emotion recognition ability, as well as the dissociability between the generation and representation of valence and arousal (with both subjective and objective measures).

Developmental Contributions to Emotional Awareness.

The Levels of Emotional Awareness Scale (LEAS) has received considerable support as a reliable and valid measure of individual differences in emotional awareness (EA) since the original report involving 40 participants (Lane, Quinlan, Schwartz, Walker, & Zeitlin, 1990 ). However, the hypothesized developmental nature of EA (conceptualized as a cognitive skill) has thus far only been examined in that 1 early study. Here we report multiple regression analyses on the entire sample of 94 participants who completed the LEAS as part of that original study, as well as the same developmental and affective measures used in the original report. We first observed that different developmental measures, including the Object Relations Inventory and the Sentence Completion Test of Ego Development, accounted for unique portions of the variance in LEAS scores. We also observed that higher LEAS scores were associated with greater within-category variance in the self-reported positive and guilt- and shame-related emotions people reported experiencing on a typical day. Based on these findings, we introduce a 3-dimensional cognitive-developmental framework that LEAS scores plausibly track, including (a) the transition from focusing on external/physical to internal/psychological characteristics, (b) greater conceptual complexity, and (c) self-other differentiation. We then discuss the implications of this framework for understanding the nature of EA and for future research.

Treating anxiety disorders by emotion-focused psychodynamic psychotherapy (EFPP)-An integrative, transdiagnostic approach.

Anxiety disorders are characterized by high levels of anxiety and avoidance of anxiety-inducing situations and of negative emotions such as anger. Emotion-focused therapy (EFT) and psychodynamic psychotherapy (PP) have underscored the therapeutic significance of processing and transforming repressed or disowned conflicted or painful emotions. Although PP provides sophisticated means of processing intrapsychic and interpersonal conflict, EFT has empirically tested a set of techniques to access, deepen, symbolize, and transform emotions consistent with current conceptualizations of emotions and memory. Based on our clinical experience, we propose that an integrative emotion-focused and psychodynamic approach opens new avenues for treating anxiety disorders effectively, and we present a transdiagnostic manual for emotion-focused psychodynamic psychotherapy. The therapeutic approach takes into account both the activation, processing, and modification of emotion and the underlying intrapsychic and interpersonal conflicts. The short-term treatment is based on the three phases of initiating treatment, therapeutic work with anxiety, and termination. Emotional poignancy (or liveliness) is an important marker for emotional processing throughout treatment. Instead of exposure to avoided situations, we endorse enacting the internal process of generating anxiety in the session providing a sense of agency and access to warded-off emotions. Interpretation serves to tie together emotional experience and insight into the patterns and the nature of underlying intrapersonal and interpersonal conflict. Treatment modules are illustrated by brief vignettes from pilot treatments.

Biased Competition Favoring Physical Over Emotional Pain: A Possible Explanation for the Link Between Early Adversity and Chronic Pain.

BACKGROUND: Early adversity predisposes to chronic pain, but a mechanistic explanation is lacking. Survivors of early adversity with chronic pain often seem impaired in their ability to be aware of, understand, and express distressing emotions such as anger and fear in social contexts. In this context, it has been proposed that pain may at times serve as a "psychic regulator" by preventing awareness of more intolerable emotions. METHOD: This narrative review builds on the premise that physical pain and emotional pain are conscious experiences that can compete for selective attention. We highlight mechanisms whereby the consequences of early adversity may put emotional pain at a competitive disadvantage. A case history, supportive research findings, and an evidence-based neurobiological model are presented. RESULTS: Arising from abuse or neglect in childhood, impairments in the adult capacity to attend to and/or conceptualize the emotional meaning of felt distress may be associated with impaired engagement of the default network and impaired top-down modulation of affective response generation processes. Persistent and poorly conceptualized affective distress may be associated with reduced emotion regulation ability, reduced vagal tone, increased inflammation, and amplified nociceptive signals. Attention to physical pain may be reinforced by the temporary reduction in negative emotions that it causes. CONCLUSIONS: These processes jointly promote biased competition favoring attention to physical pain and away from one's own emotions. They may constitute an unintentional analog of the phenomenon of self-injury in patients with borderline personality disorder in whom the intentional infliction of physical pain serves to downregulate intense emotional distress. Attending to, expressing, and understanding previously unacknowledged psychological distress unrelated to pain may facilitate recovery from chronic pain after early adversity. Mechanistic studies that can validate this clinically derived neurobiological hypothesis are urgently needed.

Vagal Mediation of Low-Frequency Heart Rate Variability During Slow Yogic Breathing.

OBJECTIVE: Changes in heart rate variability (HRV) associated with breathing (respiratory sinus arrhythmia) are known to be parasympathetically (vagally) mediated when the breathing rate is within the typical frequency range (9-24 breaths per minute [bpm]; high-frequency HRV). Slow yogic breathing occurs at rates below this range and increases low-frequency HRV power, which may additionally reflect a significant sympathetic component. Yogic breathing techniques are hypothesized to confer health benefits by increasing cardiac vagal control, but increases in low-frequency HRV power cannot unambiguously distinguish sympathetic from parasympathetic contributions. The aim of this study was to investigate the autonomic origins of changes in low-frequency HRV power due to slow-paced breathing. METHODS: Six healthy young adults completed slow-paced breathing with a cadence derived from yogic breathing patterns. The paced breathing took place under conditions of sympathetic blockade, parasympathetic (vagal) blockade, and placebo. HRV spectral power was compared under 11 breathing rates during each session, in counterbalanced order with frequencies spanning the low-frequency range (4-9 bpm). RESULTS: HRV power across the low-frequency range (4-9 bpm) was nearly eliminated (p = .016) by parasympathetic blockade (mean (SD) spectral power at breathing frequency = 4.1 (2.1)) compared with placebo (69.5 (8.1)). In contrast, spectral power during sympathetic blockade 70.2 (9.1) and placebo (69.5 (8.1)) was statistically indistinguishable (p = .671). CONCLUSIONS: These findings clarify the interpretation of changes in HRV that occur during slow-paced breathing by showing that changes in low-frequency power under these conditions are almost entirely vagally mediated. Slow-paced breathing is an effective tool for cardiac vagal activation.

Nested positive feedback loops in the maintenance of major depression: An integration and extension of previous models.

Several theories of Major Depressive Disorder (MDD) have previously been proposed, focusing largely on either a psychological (i.e., cognitive/affective), biological, or neural/computational level of description. These theories appeal to somewhat distinct bodies of work that have each highlighted separate factors as being of considerable potential importance to the maintenance of MDD. Such factors include a range of cognitive/attentional information-processing biases, a range of structural and functional brain abnormalities, and also dysregulation within the autonomic, endocrine, and immune systems. However, to date there have been limited efforts to integrate these complimentary perspectives into a single multi-level framework. Here we review previous work in each of these MDD research domains and illustrate how they can be synthesized into a more comprehensive model of how a depressive episode is maintained. In particular, we emphasize how plausible (but insufficiently studied) interactions between the various MDD-related factors listed above can lead to a series of nested positive feedback loops, which are each capable of maintaining an individual in a depressive episode. We also describe how these different feedback loops could be active to different degrees in different individual cases, potentially accounting for heterogeneity in both depressive symptoms and treatment response. We conclude by discussing how this integrative model might extend understanding of current treatment mechanisms, and also potentially guide the search for markers to inform treatment selection in individual cases.

Greater cortical thickness within the limbic visceromotor network predicts higher levels of trait emotional awareness.

Previous studies of trait emotional awareness (EA) have not yet examined whether differences in cortical structure might account for differences in EA. Based on previous research on the relationship between EA and both emotion conceptualization and visceromotor control processes, we tested two hypotheses in a sample of 26 healthy participants: that higher EA would be predicted by greater cortical thickness within (1) regions of the default mode network (DMN; linked with conceptualization processes), and/or (2) regions of the limbic network (linked with affect generation and visceromotor control processes). A non-significant correlation was found between EA and cortical thickness in the DMN. In contrast, a significant positive correlation was observed between EA and cortical thickness within the limbic network. These findings suggest that the structural integrity of cortical regions involved in the generation of affective bodily reactions may play a more important role in explaining differences in EA than previously thought.

Resting state functional connectivity correlates of emotional awareness.

Multiple neuroimaging studies have now linked emotional awareness (EA), as measured by the Levels of Emotional Awareness Scale (LEAS), with activation in regions of neural networks associated with both conceptualization (i.e., default mode network [DMN] regions) and interoception (i.e., salience network [SN] regions) - consistent with the definition of EA as one's ability to appropriately recognize, conceptualize, and articulate the emotions of self and other in fine-grained, differentiated ways. However, no study has yet tested the hypothesis that greater LEAS scores are associated with greater resting state functional connectivity (FC) within these networks. Twenty-six adults (13 female) underwent resting state functional magnetic resonance imaging, and also completed the LEAS. Using pre-defined functional ROIs from the DMN and SN, we observed that LEAS scores were significantly positively correlated with FC between several regions of both of these networks, even when controlling for differences in general intelligence (IQ). These results suggest that higher EA may be associated with more efficient information exchange between brain regions involved in both interoception- and conceptualization-based processing, which could plausibly contribute to more differentiated bodily feelings and more fine-grained conceptualization of those feelings.

Mechanisms Underlying the Association Between Early-Life Adversity and Physical Health: Charting a Course for the Future.

Early-life adversities (ELA) are associated with subsequent pervasive alterations across a wide range of neurobiological systems and psychosocial factors that contribute to accelerated onset of health problems and diseases. In this article, we provide an integrated perspective on recent developments in research on ELA, based on the articles published in this Special Issue of Psychosomatic Medicine. We focus on the following: 1) the distinction between specific versus general aspects of ELA with regard to the nature of exposure (e.g., physical and sexual abuse, emotional abuse or neglect, relative socioeconomic deprivation), biological and behavioral correlates of ELA, and differences across diseases; 2) the importance of timing in the critical phases of exposure to ELA; and 3) adaptive versus dysfunctional responses to ELA and their consequences for biological and behavioral risk factors for adverse health outcomes. This article concludes with outlining important new targets for research in this area, including the neurobiology of affect as a mechanism linking ELA to adverse health outcomes, and the need for large-scale longitudinal investigations of multisystem processes relevant to ELA in diverse samples, starting prenatally, continuing to late adolescence, and with long-term follow-up assessments that enable evaluation of incident disease outcomes.

Prolonged Non-metabolic Heart Rate Variability Reduction as a Physiological Marker of Psychological Stress in Daily Life.

BACKGROUND: Prolonged cardiac activity that exceeds metabolic needs can be detrimental for somatic health. Psychological stress could result in such "additional cardiac activity." PURPOSE: In this study, we examined whether prolonged additional reductions in heart rate variability (AddHRVr) can be measured in daily life with an algorithm that filters out changes in HRV that are purely due to metabolic demand, as indexed by movement, using a brief calibration procedure. We tested whether these AddHRVr periods were related to worry, stress, and negative emotions. METHODS: Movement and the root of the mean square of successive differences (RMSSD) in heart rate were measured during a calibration phase and the subsequent 24 h in 32 participants. Worry, stress, explicit and implicit emotions were assessed hourly using smartphones. The Levels of Emotional Awareness Scale and resting HRV were used to account for individual differences. During calibration, person-specific relations between movement and RMSSD were determined. The 24-h data were used to detect prolonged periods (i.e., 7.5 min) of AddHRVr. RESULTS: AddHRVr periods were associated with worrying, with decreased explicit positive affect, and with increased tension, but not with the frequency of stressful events or implicit emotions. Only in people high in emotional awareness and high in resting HRV did changes in AddHRVr covary with changes in explicit emotions. CONCLUSIONS: The algorithm can be used to capture prolonged reductions in HRV that are not due to metabolic needs. This enables the real-time assessment of episodes of potentially detrimental cardiac activity and its psychological determinants in daily life.

Unwanted reminders: The effects of emotional memory suppression on subsequent neuro-cognitive processing.

The neural basis of voluntarily suppressing conscious access to one's own memories (retrieval suppression [RS]) has recently received considerable attention. However, to date there has been limited research examining the effects of RS on subsequent processing of associated retrieval cues. In this study 47 healthy participants completed a Think/No Think task for memories of emotionally unpleasant visual scenes. While undergoing functional magnetic resonance imaging (fMRI), participants were then presented with cues associated with both suppressed ("no-think-cues") and non-suppressed ("think-cues") memories, and then asked to perform simple arithmetic problems. We observed that, compared to think-cues, no-think-cues were associated with greater left mid/anterior insula activation and with greater insula-anterior cingulate functional connectivity; left insula activation also predicted worse arithmetic performance. These results suggest that cues associated with suppressed negative memories may lead to greater activation of the brain's "salience" network, and reduced available cognitive resources for completion of an ongoing goal-directed task.

Affective Change in Psychodynamic Psychotherapy: Theoretical Models and Clinical Approaches to Changing Emotions.

OBJECTIVES: Affective change has been considered the hallmark of therapeutic change in psychoanalysis. Psychoanalytic writers have begun to incorporate theoretically the advanced understanding of emotional processing and transformation of the affective neurosciences. We ask if this theoretical advancement is reflected in treatment techniques addressing the processing of emotion. METHODS: We review psychoanalytic models and treatment recommendations of maladaptive affect processing in the light of a neuroscientifically informed model of achieving psychotherapeutic change by activation and reconsolidation of emotional memory. RESULTS: Emotions tend to be treated as other mental contents, resulting in a lack of specific psychodynamic techniques to work with emotions. Manualized technical modifications addressing affect regulation have been successfully tested in patients with personality pathology, but not for psychodynamic treatments of axis I disorders. CONCLUSIONS: Emotional memories need to be activated in order to be modified, therefore, we propose to include techniques into psychodynamic therapy that stimulate emotional experience.

Partial Amelioration of Medial Visceromotor Network Dysfunction in Major Depression by Sertraline.

OBJECTIVES: Major depression is associated with reduced cardiac vagal control, most commonly indexed by heart rate variability. To examine the dynamics of this abnormality, we examined within-participant covariation over time between brain activity, cardiac vagal control, and depressive symptoms in depressed patients treated with sertraline and in healthy volunteers. METHODS: Patients with depression and nondepressed control participants were enrolled in a 12-week protocol. After Week 0 assessment, patients began treatment with sertraline. Neural activity and vagal control were measured for all participants at Weeks 0, 2, 6, and 12 using functional magnetic resonance imaging and synchronized electrocardiographic recordings. At each of the four assessments, a moving window analysis was used to estimate vagal control as assessed by respiratory sinus arrhythmia (RSA) from the electrocardiographic data, which was then regressed onto functional magnetic resonance imaging activity. RESULTS: At baseline, patients showed reduced blood oxygen level-dependent RSA covariation compared with controls within multiple a priori brain regions associated with vagal control, collectively described as the medial visceromotor network (MVN). Sertraline treatment led to a significant increase in brain-RSA covariation for patients compared with controls, despite a lack of improvement in mean RSA. CONCLUSIONS: These data suggest a partial normalization of MVN dysfunction in depression during sertraline treatment. Specifically, results indicate a partial recovery of MVN function. However, this recovery was insufficient to cause a significant change in RSA levels. These results may help to explain both improvements with and limitations of sertraline treatment of depression.

Role of theory of mind in emotional awareness and alexithymia: Implications for conceptualization and measurement.

The goal of this study was to determine whether alexithymia, which is characterized by difficulty in recognizing and describing emotions, is associated with impairments in the ability to mentally represent emotional states. We studied 89 outpatients including 29 conversion disorder patients, 30 functional somatic syndrome [e.g. fibromyalgia] patients and 30 medical controls. Groups did not differ on affective or cognitive Theory of Mind (ToM) measures, the Levels of Emotional Awareness Scale (LEAS) or the Twenty-Item Toronto Alexithymia Scale (TAS-20) after adjusting for Positive and Negative Affect Scale (PANAS) variables. Across all patients, LEAS but not TAS-20 correlated positively with affective and cognitive ToM measures after adjusting for PANAS scores. Impairments in ToM functioning influence LEAS performance but not TAS-20 scores. These findings support the distinction between a milder "anomia" form of alexithymia associated with impaired emotion naming and a more severe "agnosia" form associated with impaired mental representation of emotion.