Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 22, 637–646 (2015) Published online 24 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1923
Do People With Psychosis Have Specific Difficulties Regulating Emotions? Tania M. Lincoln,1* Maike Hartmann,1 Ulf Köther2 and Steffen Moritz2 1 2
Clinical Psychology and Psychotherapy, Institute of Psychology, University of Hamburg, Hamburg 20246, Germany Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg D-20246, Germany
Difficulties in emotion regulation (ER) are present in psychotic disorders, but their precise nature is not yet fully understood and it is unclear which difficulties are unique to psychosis compared with other disorders. This study investigated whether ER difficulties in psychosis are more prominent for the ability to modify emotions or for the ability to tolerate and accept them. Furthermore, it investigated whether ER difficulties occur for sadness, anxiety, anger and shame likewise. ER skills were assessed in participants with psychotic disorders (n = 37), participants with depression (n = 30) and healthy controls (n = 28) using the Emotion Regulation Skill Questionnaire that asks participants to rate the intensity of different emotions over the past week and the skills employed to handle each of them. Compared with healthy controls, participants with psychosis showed reduced skills related to awareness, understanding and acceptance of potentially distressing emotions, but not in the ability to modify them. These differences remained significant after controlling for depression. Participants with psychosis showed reduced ER skills in regard to all of the assessed emotions compared with the healthy controls, despite the fact that they only reported sadness as being significantly more intense. The participants with depression showed a similar pattern of ER skills to the psychosis sample, although with a tendency towards even more pronounced difficulties. It is concluded that psychosis is characterized by difficulties in using specific ER skills related to awareness, understanding and acceptance to regulate anger, shame, anxiety and sadness. These difficulties are not unique to psychosis but nevertheless present a promising treatment target. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message: • The participants with psychosis found it more difficult to be aware of their emotions, to understand them and to accept them than the healthy control group. However, they reported equal skills when it came to actively modifying emotions. • The difficulties in emotion regulation reported by the participants with psychosis were comparable with those reported by the participants with depression, and they occurred for all types of negative emotions likewise. • The difficulties in using specific ER skills related to awareness, understanding and acceptance are a promising target for psychological treatment of psychosis. • Interventions that are aimed specifically at increasing these skills need to be further developed. Keywords: Schizophrenia, Depression, Modification, Awareness, Acceptance, Regulation
INTRODUCTION It is well documented that elevated negative affect precedes psychotic episodes. This has been shown in longitudinal as well as experience sampling (Delespaul, deVries, & van Os, 2002; Kramer et al., 2014; Myin-Germeys & van Os, 2007) and experimental studies (Cohen & Docherty, 2004; Ellett,
*Correspondence to: Prof Dr Tania Lincoln, Clinical Psychology and Psychotherapy, Department of Psychology, University of Hamburg, Von-Melle-Park 5, Hamburg, 20146 Germany. E-mail: [email protected]
Copyright © 2014 John Wiley & Sons, Ltd.
Freeman, & Garety, 2008). Furthermore, experimental studies in non-clinical samples have shown negative affect to mediate between stressors and psychotic symptoms in persons vulnerable to psychosis (Lincoln et al., 2010; Lincoln, Peter, Schäfer, & Moritz, 2009). Thus, and in line with psychological conceptualizations of psychotic symptom formation (Garety et al., 2001; Preti & Celler, 2010) people with or vulnerable to psychosis bear the risk that negative affect will translate into symptoms. In contrast, mentally ‘healthy’ people seem to find ways of regulating distressing emotions that prevent them from developing symptoms.
638 Findings from general psychology indicate that people either consciously or automatically use various strategies to regulate their emotions (Gross, 2007; Koole, 2009). Some of these aim at modifying the emotion, for example, by reappraising the situation, self-soothing or diverting the attention away from the distressing stimulus. Another, rather different way of regulating emotions is to understand, accept and tolerate the feelings that are present. Most of these strategies require being aware of the emotion, and some researchers have suggested that being aware of emotions and their antecedents as well as labelling them without judgement should be considered as a skill in its own right (Berking et al., 2008). Clinical research on emotion regulation (ER) has strongly focused on the regulation of sad mood in people with depression (Gotlib & Joormann, 2010) and the regulation of anxiety in anxiety disorders (Hofmann, Heering, Sawyer, & Asnaani, 2009). Across different diagnostic groups, acceptance and reappraisal to regulate distressing emotions were shown to be related to lower psychopathology, whereas attempts to suppress or avoid emotions were related to higher psychopathology (Aldao, Nolen-Hoeksema, & Schweizer, 2010). Also, longitudinal studies suggest that problems in ER do not only correlate with subsequent mental health problems but also predict them (Berking et al., 2011). Several recent studies have looked at ER in psychotic disorders. Among these, some found individuals with psychosis to have problems in identifying (Kimhy et al., 2012; van der Meer, van’t Wout, & Aleman, 2009) and accepting their feelings (Perry, Henry, & Grisham, 2011; Perry, Henry, Nangle, & Grisham, 2012). In line with the difficulty to accept emotions, several studies found that psychosis is associated with more attempts to suppress emotions (Kimhy et al., 2012; Livingstone, Harper, & Gillanders, 2009; van der Meer et al., 2009). Thus, a reduced skill to identify and accept emotions may be relevant for psychosis. In regard to the ability to modify emotions, previous research focused on the use of reappraisal, with some (Kimhy et al., 2012; Livingstone et al., 2009; van der Meer et al., 2009) but not all (Henry et al., 2008; Perry et al., 2012) studies finding patients with psychosis to use less reappraisal than healthy controls. Thus, psychosis might also be associated with a reduced skill to modify emotions, but this is less clear. The interpretation of the findings on reappraisal is also complicated by the fact that—with the exception of the study by Perry et al. (2012)— none of the studies differentiated whether reappraisal was employed prior to the onset of the emotion or after the emotion had already emerged. However, as Gross emphasizes in his process model, it is helpful to distinguish the phase in which the regulation occurs because emotions ‘may be regulated either by manipulating the input to the system (antecedent-focused ER) or by manipulating its output (response-focused ER)’ (Gross, 1998, page 225). Reappraisal is categorized by Gross as an antecedent Copyright © 2014 John Wiley & Sons, Ltd.
T. M. Lincoln et al. strategy, but it might also be employed later in the process to reduce an emotional response that is already present. If we are interested in the question of how people deal with their feelings once they have arisen, it would be more conclusive to narrow the focus to strategies that are employed in response to an emotion. Knowing which difficulties exist in this stage of ER could provide a helpful basis for therapeutic interventions that go beyond what cognitive interventions already offer. For example, it could answer the important question of whether therapists should help patients to increase their ability to accept or rather actively attempt to reduce distressing emotions. Furthermore, it would be relevant to know whether individuals with psychosis experience difficulties in regulating all types of emotions likewise. With some exceptions (Livingstone et al., 2009; Perry et al., 2012), previous research on ER and psychosis has focused on ER related to negative emotions in general (Kimhy et al., 2012; van der Meer et al., 2009) or on combinations of specific emotions such as anxiety, sadness or low mood (e.g. Badcock, Paulik, & Maybery, 2011). A focus on anxiety and depression is intuitive as both are strongly related to and predictive of psychotic symptoms (Dunn et al., 2012; Freeman & Fowler, 2009; Hartmann, Sundag, & Lincoln, 2014; Myin-Germeys & van Os, 2007). The role of anxiety has also been stressed in the threat-anticipation model (Freeman, 2007), and depressed mood is the centrepiece of models that explain delusions as a maladaptive way of warding off painful depressive experiences (Bentall, Kinderman, & Kaney, 1994; Zigler & Glick, 1988). Therefore, it can be hypothesized that increased levels of anxiety and sadness and difficulties to regulate these emotions are crucial to psychosis. Nevertheless, people with psychosis might also experience difficulties in regulating other distressing emotions. Some studies found that anger was related to or even predicted paranoia (Thewissen et al., 2011; Yamauchi, Sudo, & Tanno, 2009). Furthermore, high levels of shame have been shown to be the characteristic of persons within the post-psychotic recovery phase (Michail & Birchwood, 2013; Turner et al., 2013). To derive specific interventions targeting ER, a more fine-grained understanding of ER difficulties related to different emotions is warranted. The present study aimed to extend previous research on ER in psychosis by investigating (1) the ability of individuals with psychosis to apply a variety of skills (with a focus on the modification and acceptance skills) to regulate emotions once present, and (2) the specific ability to regulate sadness, anxiety, anger and shame. Based on previous findings, we expected difficulties in individuals with psychosis compared with healthy controls for the ability to identify, accept and modify distressing emotions, and we aimed to clarify the hierarchy of these difficulties. Furthermore, we expected difficulties to be present for all basic negative emotions but to be the most pronounced when it comes to regulating anxiety and sadness. Clin. Psychol. Psychother. 22, 637–646 (2015)
Emotion Regulation and Psychosis Finally, to know whether the expected pattern of ER difficulties is unique to psychosis, we compared the ER difficulties for the psychosis sample with those found in persons with depression, which has a strong symptomatic overlap to psychosis (Buckley, Miller, Lehrer, & Castle, 2009; Sirius, 1991; Upthegrove, 2009). So far, studies comparing ER in psychotic and affective disorders have found comparable adaptive (Livingstone et al., 2009) and maladaptive strategy use (Rowland et al., 2013). However, no study has yet directly compared difficulties related to acceptance versus modification and difficulties in regulating different emotions in psychotic and affective disorders. It can be assumed that individuals with depression will show comparable types of difficulties but that these will be related uniquely to sadness, the core emotion in depression, whereas difficulties in applying ER skills in the participants with psychosis will be associated with a broader array of emotions.
METHOD Design and Procedure The study was part of a larger study conducted at the universities of Hamburg and Marburg (Germany). Participants with psychotic disorders were compared with participants with depression and healthy controls in regard to the emotions experienced during the last week and their ability to regulate them at baseline. Thereafter, they were exposed to various stress conditions using a randomized repeated measures design. Further details on the full study design can be found in Lincoln et al. (2014). The analyses for this study are based on the data assessed at baseline.
Recruiting Procedure and Sample Criteria Participants were recruited from inpatient and outpatient treatment settings, by advertisements in local newspapers and on the Internet. All participants were 18–65 years of age, able to provide informed consent, had no neurological disorders or dementia and had sufficient command of the German language. In addition, participants with psychosis are required to have a psychotic disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria (APA, 1994). The participants from the remaining groups were selected to correspond to the psychosis sample in regard to sex, age and degree of education. Participants with depression had a present or past DSM-IV affective disorder (excluding depression with psychotic symptoms), and no present or past psychotic disorders. All participants provided informed consent to participate. The healthy controls had no Copyright © 2014 John Wiley & Sons, Ltd.
639 clinically relevant present Axis I disorder as evidenced by the Mini-International Neuropsychiatric Interview (see below) or any disorder that required treatment in the past, were not taking medication for any type of mental health problem and had no first-degree relatives with psychotic disorders. Furthermore, they had no attenuated positive symptoms of psychosis, indicated by a score below 1.45 on the positive subscale of the Community Assessment of Psychic Experiences (Stefanis et al., 2002). The study was approved by the Ethical Committee of the German Medical Societies in Hamburg and Hessen.
Assessments All diagnostic criteria were verified with a structured diagnostic psychiatric interview for DSM-IV, the MiniInternational Neuropsychiatric Interview (Sheehan et al., 1998). To quantify psychotic symptoms in the group with psychotic disorders, we used the Positive and Negative Syndrome Scale for Schizophrenia (PANSS; Kay, Fiszbein, & Opler, 1987), a semi-structured interview measuring 30 symptoms divided into the subscales of positive symptoms, negative symptoms and general psychopathology. Symptoms are rated using a seven-point scale on the basis of detailed descriptions. Both assessors (U. K. and M. H.) were extensively trained in the conduct and rating of the PANSS. To assess the extent of subthreshold and clinically relevant psychotic and depressive symptoms in all participants, we used the frequency subscales of the positive and depressive dimensions of the Community Assessment of Psychic Experiences (CAPE; Hanssen, Bijl, Vollebergh, & Van Os, 2003), a self-report scale. The CAPE positive scale covers positive symptoms with 20 items (e.g. ‘Have you ever felt that you were being persecuted in any way?’) that are rated on four-point Likert scales from never to almost always. The depression subscale comprises eight items (e.g. ‘Have you ever felt sad?’). Previous studies have demonstrated good convergent validity and discriminative validity across groups of individuals with psychotic, affective and anxiety disorders and the general population (Hanssen, Peeters, et al., 2003). To assess ER skills, we used the German version of the emotion-specific Emotion Regulation Skills Questionnaire (ERSQ-ES; Ebert, Christ, & Berking, 2013) that assesses ER separately for specific emotions. The participant is asked to estimate the highest intensity of each respective emotional state during the previous week on an 11-point scale (zero indicating absence and 10 extreme presence of the emotion). For each emotion rated one or higher, the skills to regulate this specific emotion during the previous week are assessed on a Likert-type scale ranging from zero (‘not at all’) to four (‘almost always’). For example, Clin. Psychol. Psychother. 22, 637–646 (2015)
T. M. Lincoln et al.
640 if a participant rates anxiety as being present in the previous week, he or she is asked to rate each of the skills in relation to anxiety as follows: awareness (one item, ‘I paid attention to my anxiety’); clarity (one item, e.g. ‘I was clear about the anxiety I was experiencing’); understanding (one item, e.g. ‘I was aware of why I felt anxious’); acceptance (two items, e.g. ‘I accepted my feelings of anxiety’); tolerance (one item, e.g. ‘I felt I could cope with even intense anxiety’); self-support (one item, e.g. ‘I supported myself in situations in which I felt anxious)’; willingness to confront situations cuing undesired emotions when necessary to attain personally relevant goals (one item, e.g. ‘I did what I had planned, even if it made me feel anxious’; and modification (three items, ‘I was able to influence my anxiety’). Previous evaluation studies of the ERSQ-ES in large clinical and non-clinical samples suggest good to very good psychometric properties for the skill and the emotion-specific scales (Ebert et al., 2013). Skill-specific scores were computed by calculating the mean score across different emotions for each skill. Emotionspecific scores were calculated for anxiety, sadness, anger and shame as the mean score for all skills for each respective emotional state.
Participants The psychosis sample consisted of 37 patients with DSMIV schizophrenia (n = 31) and schizoaffective disorder (n = 6) of whom 25 patients were acutely psychotic and 12 were remitted. The mean PANSS positive syndrome score of this sample was 15.6 (SD = 4.8), 14.4 (SD = 4.2) for the negative syndrome score and 32.1 (SD = 6.6) for the general subscale score. Participants with depression comprised 30 patients with reoccurring depressive disorders (n = 20); present major (n = 6), past major (n = 1) or present minor (n = 2) depression; and bipolar disorder with present depression (n = 1). Healthy controls comprised 28 participants. The demographic and clinical information for each group is provided in Table 1. Table 1.
Strategy of Data-Analysis The analyses were conducted using IBM SPSS Statistics for Windows, Version 22.0 (Armonk, NY: IBM Corp). The ERSQ-ES subscales all showed an acceptable distribution for the planned main analyses, that is, skewness γ1 < 2 and kurtosis γ2 < 7 (Curran, West & Finch, 1996). We used analysis of variance (ANOVA) to analyse group differences in emotion intensity during the previous week. We used multiple ANOVA (MANOVA) to analyse group differences in the skill specific ERSQ-ES scores that were moderately intercorrelated. The MANOVAs were followed up with univariate ANOVAs for specific group differences. The ERSQ-ES scores are based on different numbers of participants due to the fact that ER was only assessed for the respective emotions that had been present during the previous week. Therefore, Bonferroni-corrected univariate ANOVAs were used in this case, and the degrees of freedom were Greenhouse–Geisser corrected if assumptions were violated. The univariate ANOVAs were followed up with Bonferroni post-hoc tests in cases of equal variances and Dunnett’s T3 in cases of unequal variances as both tests control well for Type I error. We will report effect-sizes (small: η2 partial ≈ 0.01; medium: η2 partial ≈ 0.06; large: η2 partial ≈ 0.14) for all significant findings in the analyses of variance.
RESULTS Group Differences in Emotion Regulation Skills The MANOVA of group on the skill specific ERSQ-ES subscales revealed a significant main effect for group, Λ = 0.558, F (16, 170) = 3.59, p < .001, η2 partial = 0.253. Table 2 lists the group differences on the ERSQ-ES skill specific scores. As can be seen, there was a significant group effect for each of the skills. Bonferroni’s post-hoc tests indicated that the psychosis sample showed lower skills than the healthy controls related to acceptance and understanding (p < .001), tolerating, clarity (p < .01),
Socio-demographic and clinical characteristics of the participants by group Statistics
Variable Mean age in years, M (SD) Gender in % [men/women] Final school degree in % [High/middle/low] Mean CAPE positive scores Mean CAPE depression scores
Psychosis (n = 37)
Depression (n = 30)
Healthy controls (n = 28)
40.3 (SD = 12.3) 57/43 47/33/19 1.83 (SD = 0.49) 2.33 (SD = 0.61)
41.7 (SD = 11.1) 53/47 50/37/13 1.30 (SD = 0.34) 2.33 (SD = 0.42)
35.6 (SD = 14.5) 57/43 61/25/14 1.25 (SD = 0.13) 1.63 (SD = 0.25)
F(2, 92) = 1.83, p = .167 χ2(2) = 0.11, p = .947 χ2(4) = 1.70, p = .792 F(2, 92) = 26.05, p < .001 F(2, 92) = 21.97, p < .001
CAPE = Community Assessment of Psychic Experiences; SD, standard deviation.
Copyright © 2014 John Wiley & Sons, Ltd.
Clin. Psychol. Psychother. 22, 637–646 (2015)
Emotion Regulation and Psychosis
641
Table 2. Difficulties in emotion-regulation skills Psychosis (P)
Depression (D)
Healthy controls (HC)
ERSQ-ES skills
M
SD
M
SD
M
SD
F(2,92)
p
Awareness Understanding Acceptance Tolerance Clarity Self-support Confronting Modification
2.56 2.80 2.24 2.50 3.03 2.55 2.67 1.93
0.92 0.84 0.63 0.97 0.83 1.05 0.85 0.79
2.20 2.83 2.13 2.17 2.97 2.09 2.20 1.53
0.91 0.69 0.76 0.85 0.63 1.10 0.94 0.81
3.22 3.67 3.04 3.18 3.59 3.20 3.20 2.18
0.66 0.41 0.56 0.73 0.44 0.70 0.86 0.96
8,54 14.11 17.00 9.95 6.93 7.62 11.91 4.43
P, D HC > D HC > P > D HC > D
ERSQ-ES = Emotion Regulation Skills Questionnaire—Emotion Specific (Ebert et al., 2013)
awareness and confronting (p < .05) and higher skills than the participants with depression related to confronting (p < .05). The participants with depression differed from the healthy controls in all skills (awareness, tolerating, acceptance, understanding, confronting, p < .001, clarity, self-support p < .01, modification p < .05).
Group Differences in Emotion Reports Figure 1 depicts the highest severity of each of the respective emotions during the previous week. The MANOVA of group on self-reported anxiety, anger, sadness and shame
revealed a significant effect of group, Λ = 0.76, F(8, 172) = 3.24, p < .01, η2 partial = 0.13. The univariate analyses indicated that the significant effect for group occurred for sadness F(2, 89) = 9.46, p < .001, η2 partial = 0.18 and shame, F (2, 98) = 3.39, p < .05, η2 partial = 0.07. For anxiety, univariate analyses marginally lacked significance F(2, 89) = 2.79, p = .067, η2 partial = 0.06. The Bonferroni-corrected post-hoc tests of the group effects indicated that sadness was significantly more intense in the participants with psychosis (p < .001) and depression (p < .001) compared with the healthy controls, with no significant difference between the psychosis and depression samples. Shame tended to be more intense in
Figure 1. Emotions experienced during the previous week
Copyright © 2014 John Wiley & Sons, Ltd.
Clin. Psychol. Psychother. 22, 637–646 (2015)
T. M. Lincoln et al.
642 the participants with psychosis compared with those with depression (p = .084) and to the healthy controls (p = .091). The direction of the non-significant numerical difference for anxiety was that the participants with psychosis and depression showed more intense anxiety compared with the healthy controls (p = .111 and p = .137, respectively).
Group Differences in Emotion-Specific Regulation Skills Table 3 presents the mean scores and standard deviations of the ERSQ-ES scores. The corresponding Bonferronicorrected ANOVAs revealed a significant effect for anxiety F(2, 71) = 12.31, pcorr ≤.001, η2 partial = 0.26, with the Bonferroni post-hoc test indicating the participants with depression to have fewer anxiety specific ER skills than the participants with psychosis (p ≤ .05) and the healthy controls (p ≤ .001), whereas the psychosis sample showed fewer skills than the healthy controls (p < .05). Similarly, there was a significant effect for anger, F(2, 78) = 5.94, pcorr = .015, η2 partial = 0.13), with the psychosis and depression samples reporting significantly fewer anger specific skills than the healthy controls (p < .05 and p < .01, respectively). A third significant effect was found for sadness, F(2,76) = 15.26, pcorr
Do People With Psychosis Have Specific Difficulties Regulating Emotions? Tania M. Lincoln,1* Maike Hartmann,1 Ulf Köther2 and Steffen Moritz2 1 2
Clinical Psychology and Psychotherapy, Institute of Psychology, University of Hamburg, Hamburg 20246, Germany Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg D-20246, Germany
Difficulties in emotion regulation (ER) are present in psychotic disorders, but their precise nature is not yet fully understood and it is unclear which difficulties are unique to psychosis compared with other disorders. This study investigated whether ER difficulties in psychosis are more prominent for the ability to modify emotions or for the ability to tolerate and accept them. Furthermore, it investigated whether ER difficulties occur for sadness, anxiety, anger and shame likewise. ER skills were assessed in participants with psychotic disorders (n = 37), participants with depression (n = 30) and healthy controls (n = 28) using the Emotion Regulation Skill Questionnaire that asks participants to rate the intensity of different emotions over the past week and the skills employed to handle each of them. Compared with healthy controls, participants with psychosis showed reduced skills related to awareness, understanding and acceptance of potentially distressing emotions, but not in the ability to modify them. These differences remained significant after controlling for depression. Participants with psychosis showed reduced ER skills in regard to all of the assessed emotions compared with the healthy controls, despite the fact that they only reported sadness as being significantly more intense. The participants with depression showed a similar pattern of ER skills to the psychosis sample, although with a tendency towards even more pronounced difficulties. It is concluded that psychosis is characterized by difficulties in using specific ER skills related to awareness, understanding and acceptance to regulate anger, shame, anxiety and sadness. These difficulties are not unique to psychosis but nevertheless present a promising treatment target. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message: • The participants with psychosis found it more difficult to be aware of their emotions, to understand them and to accept them than the healthy control group. However, they reported equal skills when it came to actively modifying emotions. • The difficulties in emotion regulation reported by the participants with psychosis were comparable with those reported by the participants with depression, and they occurred for all types of negative emotions likewise. • The difficulties in using specific ER skills related to awareness, understanding and acceptance are a promising target for psychological treatment of psychosis. • Interventions that are aimed specifically at increasing these skills need to be further developed. Keywords: Schizophrenia, Depression, Modification, Awareness, Acceptance, Regulation
INTRODUCTION It is well documented that elevated negative affect precedes psychotic episodes. This has been shown in longitudinal as well as experience sampling (Delespaul, deVries, & van Os, 2002; Kramer et al., 2014; Myin-Germeys & van Os, 2007) and experimental studies (Cohen & Docherty, 2004; Ellett,
*Correspondence to: Prof Dr Tania Lincoln, Clinical Psychology and Psychotherapy, Department of Psychology, University of Hamburg, Von-Melle-Park 5, Hamburg, 20146 Germany. E-mail: [email protected]
Copyright © 2014 John Wiley & Sons, Ltd.
Freeman, & Garety, 2008). Furthermore, experimental studies in non-clinical samples have shown negative affect to mediate between stressors and psychotic symptoms in persons vulnerable to psychosis (Lincoln et al., 2010; Lincoln, Peter, Schäfer, & Moritz, 2009). Thus, and in line with psychological conceptualizations of psychotic symptom formation (Garety et al., 2001; Preti & Celler, 2010) people with or vulnerable to psychosis bear the risk that negative affect will translate into symptoms. In contrast, mentally ‘healthy’ people seem to find ways of regulating distressing emotions that prevent them from developing symptoms.
638 Findings from general psychology indicate that people either consciously or automatically use various strategies to regulate their emotions (Gross, 2007; Koole, 2009). Some of these aim at modifying the emotion, for example, by reappraising the situation, self-soothing or diverting the attention away from the distressing stimulus. Another, rather different way of regulating emotions is to understand, accept and tolerate the feelings that are present. Most of these strategies require being aware of the emotion, and some researchers have suggested that being aware of emotions and their antecedents as well as labelling them without judgement should be considered as a skill in its own right (Berking et al., 2008). Clinical research on emotion regulation (ER) has strongly focused on the regulation of sad mood in people with depression (Gotlib & Joormann, 2010) and the regulation of anxiety in anxiety disorders (Hofmann, Heering, Sawyer, & Asnaani, 2009). Across different diagnostic groups, acceptance and reappraisal to regulate distressing emotions were shown to be related to lower psychopathology, whereas attempts to suppress or avoid emotions were related to higher psychopathology (Aldao, Nolen-Hoeksema, & Schweizer, 2010). Also, longitudinal studies suggest that problems in ER do not only correlate with subsequent mental health problems but also predict them (Berking et al., 2011). Several recent studies have looked at ER in psychotic disorders. Among these, some found individuals with psychosis to have problems in identifying (Kimhy et al., 2012; van der Meer, van’t Wout, & Aleman, 2009) and accepting their feelings (Perry, Henry, & Grisham, 2011; Perry, Henry, Nangle, & Grisham, 2012). In line with the difficulty to accept emotions, several studies found that psychosis is associated with more attempts to suppress emotions (Kimhy et al., 2012; Livingstone, Harper, & Gillanders, 2009; van der Meer et al., 2009). Thus, a reduced skill to identify and accept emotions may be relevant for psychosis. In regard to the ability to modify emotions, previous research focused on the use of reappraisal, with some (Kimhy et al., 2012; Livingstone et al., 2009; van der Meer et al., 2009) but not all (Henry et al., 2008; Perry et al., 2012) studies finding patients with psychosis to use less reappraisal than healthy controls. Thus, psychosis might also be associated with a reduced skill to modify emotions, but this is less clear. The interpretation of the findings on reappraisal is also complicated by the fact that—with the exception of the study by Perry et al. (2012)— none of the studies differentiated whether reappraisal was employed prior to the onset of the emotion or after the emotion had already emerged. However, as Gross emphasizes in his process model, it is helpful to distinguish the phase in which the regulation occurs because emotions ‘may be regulated either by manipulating the input to the system (antecedent-focused ER) or by manipulating its output (response-focused ER)’ (Gross, 1998, page 225). Reappraisal is categorized by Gross as an antecedent Copyright © 2014 John Wiley & Sons, Ltd.
T. M. Lincoln et al. strategy, but it might also be employed later in the process to reduce an emotional response that is already present. If we are interested in the question of how people deal with their feelings once they have arisen, it would be more conclusive to narrow the focus to strategies that are employed in response to an emotion. Knowing which difficulties exist in this stage of ER could provide a helpful basis for therapeutic interventions that go beyond what cognitive interventions already offer. For example, it could answer the important question of whether therapists should help patients to increase their ability to accept or rather actively attempt to reduce distressing emotions. Furthermore, it would be relevant to know whether individuals with psychosis experience difficulties in regulating all types of emotions likewise. With some exceptions (Livingstone et al., 2009; Perry et al., 2012), previous research on ER and psychosis has focused on ER related to negative emotions in general (Kimhy et al., 2012; van der Meer et al., 2009) or on combinations of specific emotions such as anxiety, sadness or low mood (e.g. Badcock, Paulik, & Maybery, 2011). A focus on anxiety and depression is intuitive as both are strongly related to and predictive of psychotic symptoms (Dunn et al., 2012; Freeman & Fowler, 2009; Hartmann, Sundag, & Lincoln, 2014; Myin-Germeys & van Os, 2007). The role of anxiety has also been stressed in the threat-anticipation model (Freeman, 2007), and depressed mood is the centrepiece of models that explain delusions as a maladaptive way of warding off painful depressive experiences (Bentall, Kinderman, & Kaney, 1994; Zigler & Glick, 1988). Therefore, it can be hypothesized that increased levels of anxiety and sadness and difficulties to regulate these emotions are crucial to psychosis. Nevertheless, people with psychosis might also experience difficulties in regulating other distressing emotions. Some studies found that anger was related to or even predicted paranoia (Thewissen et al., 2011; Yamauchi, Sudo, & Tanno, 2009). Furthermore, high levels of shame have been shown to be the characteristic of persons within the post-psychotic recovery phase (Michail & Birchwood, 2013; Turner et al., 2013). To derive specific interventions targeting ER, a more fine-grained understanding of ER difficulties related to different emotions is warranted. The present study aimed to extend previous research on ER in psychosis by investigating (1) the ability of individuals with psychosis to apply a variety of skills (with a focus on the modification and acceptance skills) to regulate emotions once present, and (2) the specific ability to regulate sadness, anxiety, anger and shame. Based on previous findings, we expected difficulties in individuals with psychosis compared with healthy controls for the ability to identify, accept and modify distressing emotions, and we aimed to clarify the hierarchy of these difficulties. Furthermore, we expected difficulties to be present for all basic negative emotions but to be the most pronounced when it comes to regulating anxiety and sadness. Clin. Psychol. Psychother. 22, 637–646 (2015)
Emotion Regulation and Psychosis Finally, to know whether the expected pattern of ER difficulties is unique to psychosis, we compared the ER difficulties for the psychosis sample with those found in persons with depression, which has a strong symptomatic overlap to psychosis (Buckley, Miller, Lehrer, & Castle, 2009; Sirius, 1991; Upthegrove, 2009). So far, studies comparing ER in psychotic and affective disorders have found comparable adaptive (Livingstone et al., 2009) and maladaptive strategy use (Rowland et al., 2013). However, no study has yet directly compared difficulties related to acceptance versus modification and difficulties in regulating different emotions in psychotic and affective disorders. It can be assumed that individuals with depression will show comparable types of difficulties but that these will be related uniquely to sadness, the core emotion in depression, whereas difficulties in applying ER skills in the participants with psychosis will be associated with a broader array of emotions.
METHOD Design and Procedure The study was part of a larger study conducted at the universities of Hamburg and Marburg (Germany). Participants with psychotic disorders were compared with participants with depression and healthy controls in regard to the emotions experienced during the last week and their ability to regulate them at baseline. Thereafter, they were exposed to various stress conditions using a randomized repeated measures design. Further details on the full study design can be found in Lincoln et al. (2014). The analyses for this study are based on the data assessed at baseline.
Recruiting Procedure and Sample Criteria Participants were recruited from inpatient and outpatient treatment settings, by advertisements in local newspapers and on the Internet. All participants were 18–65 years of age, able to provide informed consent, had no neurological disorders or dementia and had sufficient command of the German language. In addition, participants with psychosis are required to have a psychotic disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria (APA, 1994). The participants from the remaining groups were selected to correspond to the psychosis sample in regard to sex, age and degree of education. Participants with depression had a present or past DSM-IV affective disorder (excluding depression with psychotic symptoms), and no present or past psychotic disorders. All participants provided informed consent to participate. The healthy controls had no Copyright © 2014 John Wiley & Sons, Ltd.
639 clinically relevant present Axis I disorder as evidenced by the Mini-International Neuropsychiatric Interview (see below) or any disorder that required treatment in the past, were not taking medication for any type of mental health problem and had no first-degree relatives with psychotic disorders. Furthermore, they had no attenuated positive symptoms of psychosis, indicated by a score below 1.45 on the positive subscale of the Community Assessment of Psychic Experiences (Stefanis et al., 2002). The study was approved by the Ethical Committee of the German Medical Societies in Hamburg and Hessen.
Assessments All diagnostic criteria were verified with a structured diagnostic psychiatric interview for DSM-IV, the MiniInternational Neuropsychiatric Interview (Sheehan et al., 1998). To quantify psychotic symptoms in the group with psychotic disorders, we used the Positive and Negative Syndrome Scale for Schizophrenia (PANSS; Kay, Fiszbein, & Opler, 1987), a semi-structured interview measuring 30 symptoms divided into the subscales of positive symptoms, negative symptoms and general psychopathology. Symptoms are rated using a seven-point scale on the basis of detailed descriptions. Both assessors (U. K. and M. H.) were extensively trained in the conduct and rating of the PANSS. To assess the extent of subthreshold and clinically relevant psychotic and depressive symptoms in all participants, we used the frequency subscales of the positive and depressive dimensions of the Community Assessment of Psychic Experiences (CAPE; Hanssen, Bijl, Vollebergh, & Van Os, 2003), a self-report scale. The CAPE positive scale covers positive symptoms with 20 items (e.g. ‘Have you ever felt that you were being persecuted in any way?’) that are rated on four-point Likert scales from never to almost always. The depression subscale comprises eight items (e.g. ‘Have you ever felt sad?’). Previous studies have demonstrated good convergent validity and discriminative validity across groups of individuals with psychotic, affective and anxiety disorders and the general population (Hanssen, Peeters, et al., 2003). To assess ER skills, we used the German version of the emotion-specific Emotion Regulation Skills Questionnaire (ERSQ-ES; Ebert, Christ, & Berking, 2013) that assesses ER separately for specific emotions. The participant is asked to estimate the highest intensity of each respective emotional state during the previous week on an 11-point scale (zero indicating absence and 10 extreme presence of the emotion). For each emotion rated one or higher, the skills to regulate this specific emotion during the previous week are assessed on a Likert-type scale ranging from zero (‘not at all’) to four (‘almost always’). For example, Clin. Psychol. Psychother. 22, 637–646 (2015)
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640 if a participant rates anxiety as being present in the previous week, he or she is asked to rate each of the skills in relation to anxiety as follows: awareness (one item, ‘I paid attention to my anxiety’); clarity (one item, e.g. ‘I was clear about the anxiety I was experiencing’); understanding (one item, e.g. ‘I was aware of why I felt anxious’); acceptance (two items, e.g. ‘I accepted my feelings of anxiety’); tolerance (one item, e.g. ‘I felt I could cope with even intense anxiety’); self-support (one item, e.g. ‘I supported myself in situations in which I felt anxious)’; willingness to confront situations cuing undesired emotions when necessary to attain personally relevant goals (one item, e.g. ‘I did what I had planned, even if it made me feel anxious’; and modification (three items, ‘I was able to influence my anxiety’). Previous evaluation studies of the ERSQ-ES in large clinical and non-clinical samples suggest good to very good psychometric properties for the skill and the emotion-specific scales (Ebert et al., 2013). Skill-specific scores were computed by calculating the mean score across different emotions for each skill. Emotionspecific scores were calculated for anxiety, sadness, anger and shame as the mean score for all skills for each respective emotional state.
Participants The psychosis sample consisted of 37 patients with DSMIV schizophrenia (n = 31) and schizoaffective disorder (n = 6) of whom 25 patients were acutely psychotic and 12 were remitted. The mean PANSS positive syndrome score of this sample was 15.6 (SD = 4.8), 14.4 (SD = 4.2) for the negative syndrome score and 32.1 (SD = 6.6) for the general subscale score. Participants with depression comprised 30 patients with reoccurring depressive disorders (n = 20); present major (n = 6), past major (n = 1) or present minor (n = 2) depression; and bipolar disorder with present depression (n = 1). Healthy controls comprised 28 participants. The demographic and clinical information for each group is provided in Table 1. Table 1.
Strategy of Data-Analysis The analyses were conducted using IBM SPSS Statistics for Windows, Version 22.0 (Armonk, NY: IBM Corp). The ERSQ-ES subscales all showed an acceptable distribution for the planned main analyses, that is, skewness γ1 < 2 and kurtosis γ2 < 7 (Curran, West & Finch, 1996). We used analysis of variance (ANOVA) to analyse group differences in emotion intensity during the previous week. We used multiple ANOVA (MANOVA) to analyse group differences in the skill specific ERSQ-ES scores that were moderately intercorrelated. The MANOVAs were followed up with univariate ANOVAs for specific group differences. The ERSQ-ES scores are based on different numbers of participants due to the fact that ER was only assessed for the respective emotions that had been present during the previous week. Therefore, Bonferroni-corrected univariate ANOVAs were used in this case, and the degrees of freedom were Greenhouse–Geisser corrected if assumptions were violated. The univariate ANOVAs were followed up with Bonferroni post-hoc tests in cases of equal variances and Dunnett’s T3 in cases of unequal variances as both tests control well for Type I error. We will report effect-sizes (small: η2 partial ≈ 0.01; medium: η2 partial ≈ 0.06; large: η2 partial ≈ 0.14) for all significant findings in the analyses of variance.
RESULTS Group Differences in Emotion Regulation Skills The MANOVA of group on the skill specific ERSQ-ES subscales revealed a significant main effect for group, Λ = 0.558, F (16, 170) = 3.59, p < .001, η2 partial = 0.253. Table 2 lists the group differences on the ERSQ-ES skill specific scores. As can be seen, there was a significant group effect for each of the skills. Bonferroni’s post-hoc tests indicated that the psychosis sample showed lower skills than the healthy controls related to acceptance and understanding (p < .001), tolerating, clarity (p < .01),
Socio-demographic and clinical characteristics of the participants by group Statistics
Variable Mean age in years, M (SD) Gender in % [men/women] Final school degree in % [High/middle/low] Mean CAPE positive scores Mean CAPE depression scores
Psychosis (n = 37)
Depression (n = 30)
Healthy controls (n = 28)
40.3 (SD = 12.3) 57/43 47/33/19 1.83 (SD = 0.49) 2.33 (SD = 0.61)
41.7 (SD = 11.1) 53/47 50/37/13 1.30 (SD = 0.34) 2.33 (SD = 0.42)
35.6 (SD = 14.5) 57/43 61/25/14 1.25 (SD = 0.13) 1.63 (SD = 0.25)
F(2, 92) = 1.83, p = .167 χ2(2) = 0.11, p = .947 χ2(4) = 1.70, p = .792 F(2, 92) = 26.05, p < .001 F(2, 92) = 21.97, p < .001
CAPE = Community Assessment of Psychic Experiences; SD, standard deviation.
Copyright © 2014 John Wiley & Sons, Ltd.
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Table 2. Difficulties in emotion-regulation skills Psychosis (P)
Depression (D)
Healthy controls (HC)
ERSQ-ES skills
M
SD
M
SD
M
SD
F(2,92)
p
Awareness Understanding Acceptance Tolerance Clarity Self-support Confronting Modification
2.56 2.80 2.24 2.50 3.03 2.55 2.67 1.93
0.92 0.84 0.63 0.97 0.83 1.05 0.85 0.79
2.20 2.83 2.13 2.17 2.97 2.09 2.20 1.53
0.91 0.69 0.76 0.85 0.63 1.10 0.94 0.81
3.22 3.67 3.04 3.18 3.59 3.20 3.20 2.18
0.66 0.41 0.56 0.73 0.44 0.70 0.86 0.96
8,54 14.11 17.00 9.95 6.93 7.62 11.91 4.43
P, D HC > D HC > P > D HC > D
ERSQ-ES = Emotion Regulation Skills Questionnaire—Emotion Specific (Ebert et al., 2013)
awareness and confronting (p < .05) and higher skills than the participants with depression related to confronting (p < .05). The participants with depression differed from the healthy controls in all skills (awareness, tolerating, acceptance, understanding, confronting, p < .001, clarity, self-support p < .01, modification p < .05).
Group Differences in Emotion Reports Figure 1 depicts the highest severity of each of the respective emotions during the previous week. The MANOVA of group on self-reported anxiety, anger, sadness and shame
revealed a significant effect of group, Λ = 0.76, F(8, 172) = 3.24, p < .01, η2 partial = 0.13. The univariate analyses indicated that the significant effect for group occurred for sadness F(2, 89) = 9.46, p < .001, η2 partial = 0.18 and shame, F (2, 98) = 3.39, p < .05, η2 partial = 0.07. For anxiety, univariate analyses marginally lacked significance F(2, 89) = 2.79, p = .067, η2 partial = 0.06. The Bonferroni-corrected post-hoc tests of the group effects indicated that sadness was significantly more intense in the participants with psychosis (p < .001) and depression (p < .001) compared with the healthy controls, with no significant difference between the psychosis and depression samples. Shame tended to be more intense in
Figure 1. Emotions experienced during the previous week
Copyright © 2014 John Wiley & Sons, Ltd.
Clin. Psychol. Psychother. 22, 637–646 (2015)
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642 the participants with psychosis compared with those with depression (p = .084) and to the healthy controls (p = .091). The direction of the non-significant numerical difference for anxiety was that the participants with psychosis and depression showed more intense anxiety compared with the healthy controls (p = .111 and p = .137, respectively).
Group Differences in Emotion-Specific Regulation Skills Table 3 presents the mean scores and standard deviations of the ERSQ-ES scores. The corresponding Bonferronicorrected ANOVAs revealed a significant effect for anxiety F(2, 71) = 12.31, pcorr ≤.001, η2 partial = 0.26, with the Bonferroni post-hoc test indicating the participants with depression to have fewer anxiety specific ER skills than the participants with psychosis (p ≤ .05) and the healthy controls (p ≤ .001), whereas the psychosis sample showed fewer skills than the healthy controls (p < .05). Similarly, there was a significant effect for anger, F(2, 78) = 5.94, pcorr = .015, η2 partial = 0.13), with the psychosis and depression samples reporting significantly fewer anger specific skills than the healthy controls (p < .05 and p < .01, respectively). A third significant effect was found for sadness, F(2,76) = 15.26, pcorr
