Neuroimaging cognitive reappraisal in clinical populations to define neural targets for enhancing emotion regulation. A systematic review

Neural connectivity during affect labeling predicts treatment response to psychological therapies for social anxiety disorder

BACKGROUND

Although psychological treatments for social anxiety disorder (SAD) can be highly effective, many individuals do not respond to treatment. Identifying factors associated with improved outcomes can facilitate individualized treatment choices. We investigated whether patterns of neural connectivity predicted treatment responses and whether treatment type, cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT), moderated this effect.

METHODS

Participants with SAD (n = 34) underwent fMRI prior to treatment and completed implicit and explicit emotion regulation tasks. Neural connectivity measures were estimates of amygdala-prefrontal cortex connectivity. Treatment responder status was defined using the 'clinically significant change index' (Loerinc et al., 2015).

RESULTS

Right amygdala-right ventrolateral prefrontal cortex connectivity during implicit emotion regulation was a significant predictor of treatment response (OR = 9.01, 95% CI = 1.77, 46.0, p = .008). Stronger inverse connectivity was associated with greater likelihood of treatment response. There were no significant neural moderators of treatment response to CBT versus ACT.

LIMITATIONS

The primary limitation of this work was the small sample size which restricted the power to detect significant moderation effects, and results should be interpreted as preliminary.

CONCLUSIONS

Amygdala-vlPFC connectivity during affect labeling predicted treatment responder status following CBT or ACT for social anxiety disorder. This suggests that the functioning of neural circuitry supporting emotion regulation capacities may be a 'gateway' to receiving benefit from psychological treatments. Future work should aim to replicate this effect in a larger sample and consider methods for enhancing functional connectivity within this circuitry as a potential treatment adjunct.

A Neuroscience-Oriented Research Approach to Borderline Personality Disorder

Traditionally, the study of personality disorders had been based on psychoanalytic or behavioral models. Over the past two decades, there has been an emerging neuroscience model of borderline personality disorder (BPD) grounded in the concept of BPD as a condition in which dysfunctional neural circuits underlie its pathological dimensions, some of which include emotion dysregulation (broadly encompassing affective instability, negative affectivity, and hyperarousal), abnormal interpersonal functioning, and impulsive aggression. This article, initiated at a joint Columbia University- Cornell University Think Tank on BPD with representation from the Icahn School of Medicine at Mount Sinai, suggests how to advance research in BPD by studying the dimensions that underlie BPD in addition to studying the disorder as a unitary diagnostic entity. We suggest that linking the underlying neurobiological abnormalities to behavioral symptoms of the disorder can inform a research agenda to better understand BPD with its multiple presentations.

Targeting the affective brain-a randomized controlled trial of real-time fMRI neurofeedback in patients with depression

Functional magnetic resonance imaging neurofeedback (fMRI-NF) training of areas involved in emotion processing can reduce depressive symptoms by over 40% on the Hamilton Depression Rating Scale (HDRS). However, it remains unclear if this efficacy is specific to feedback from emotion-regulating regions. We tested in a single-blind, randomized, controlled trial if upregulation of emotion areas (NFE) yields superior efficacy compared to upregulation of a control region activated by visual scenes (NFS). Forty-three moderately to severely depressed medicated patients were randomly assigned to five sessions augmentation treatment of either NFE or NFS training. At primary outcome (week 12) no significant group mean HDRS difference was found (B = -0.415 [95% CI -4.847 to 4.016], p = 0.848) for the 32 completers (16 per group). However, across groups depressive symptoms decreased by 43%, and 38% of patients remitted. These improvements lasted until follow-up (week 18). Both groups upregulated target regions to a similar extent. Further, clinical improvement was correlated with an increase in self-efficacy scores. However, the interpretation of clinical improvements remains limited due to lack of a sham-control group. We thus surveyed effects reported for accepted augmentation therapies in depression. Data indicated that our findings exceed expected regression to the mean and placebo effects that have been reported for drug trials and other sham-controlled high-technology interventions. Taken together, we suggest that the experience of successful self-regulation during fMRI-NF training may be therapeutic. We conclude that if fMRI-NF is effective for depression, self-regulation training of higher visual areas may provide an effective alternative.

Regulating emotion through distancing: A taxonomy, neurocognitive model, and supporting meta-analysis

Distancing is a type of emotion regulation that involves simulating a new perspective to alter the psychological distance and emotional impact of a stimulus. The effectiveness and versatility of distancing relative to other types of emotion regulation make it a promising tool for clinical applications. However, the neurocognitive mechanisms of this tactic are unclear, and inconsistencies in terminology and methods across studies make it difficult to synthesize the literature. To promote more effective research, we propose a taxonomy of distancing within the broader context of emotion regulation strategies; review the effects of this tactic; and offer a preliminary neurocognitive model describing key cognitive processes and their neural bases. Our model emphasizes three components-self-projection, affective self-reflection, and cognitive control. Additionally, we present results from a supporting meta-analysis of neuroimaging studies of distancing. These efforts are presented within the overarching goals of supporting effective applications of distancing in laboratory, clinical, and other real-world contexts, and advancing understanding of the relevant high-level cognitive functions in the brain.

Limited prefrontal cortical regulation over the basolateral amygdala in adolescent rats

Cognitive regulation of emotion develops from childhood into adulthood. This occurs in parallel with maturation of prefrontal cortical (PFC) regulation over the amygdala. The cellular substrates for this regulation may include PFC activation of inhibitory GABAergic elements in the amygdala. The purpose of this study was to determine whether PFC regulation over basolateral amygdala area (BLA) in vivo is immature in adolescence, and if this is due to immaturity of GABAergic elements or PFC excitatory inputs. Using in vivo extracellular electrophysiological recordings from anesthetized male rats we found that in vivo summation of PFC inputs to the BLA was less regulated by GABAergic inhibition in adolescents (postnatal day 39) than adults (postnatal day 72-75). In addition, stimulation of either prelimbic or infralimbic PFC evokes weaker inhibition over basal (BA) and lateral (LAT) nuclei of the BLA in adolescents. This was dictated by both weak recruitment of inhibition in LAT and weak excitatory effects of PFC in BA. The current results may contribute to differences in adolescent cognitive regulation of emotion. These findings identify specific elements that undergo adolescent maturation and may therefore be sensitive to environmental disruptions that increase risk for psychiatric disorders.

Neural response during emotion regulation in monozygotic twins at high familial risk of affective disorders

PURPOSE

We investigated the neural correlates of emotion regulation and -reactivity in adult unaffected monozygotic twins with a co-twin history of unipolar or bipolar disorder (high-risk), remitted or partially remitted twins with a personal history of unipolar or bipolar disorder (affected) and twins with no personal or first-degree family history of unipolar or bipolar disorder (low-risk).

METHODS

We assessed 37 high-risk, 56 affected and 28 low-risk participants. Participants viewed unpleasant and neutral pictures during functional magnetic resonance imaging and were instructed to down-regulate their emotional response through reappraisal or mental imagery, as well as to maintain the elicited emotion.

RESULTS

After adjusting for subsyndromal depressive symptoms, bilateral supplementary motor areas, posterior dorsal anterior cingulate cortices and the left frontal eye field showed less activity during reappraisal of unpleasant pictures in high-risk than low-risk participants. Notably, affected participants did not differ from high-risk or low-risk participants in neural response during reappraisal. There were no group differences in ventrolateral prefrontal cortex seed based functional connectivity during reappraisal or neural response during mental imagery or emotional reactivity.

CONCLUSION

Lesser response in dorsal midline areas might reflect familial risk related abnormalities during down regulation of emotional reactivity through reappraisal.

Psychiatry and developmental psychopathology: Unifying themes and future directions

In the past 35 years, developmental psychopathology has grown into a flourishing discipline that shares a scientific agenda with contemporary psychiatry. In this editorial, which introduces the special issue, we describe the history of developmental psychopathology, including core principles that bridge allied disciplines. These include (1) emphasis on interdisciplinary research, (2) elucidation of multicausal pathways to seemingly single disorders (phenocopies), (3) description of divergent multifinal outcomes from common etiological start points (pathoplasticity), and (4) research conducted across multiple levels of analysis spanning genes to environments. Next, we discuss neurodevelopmental models of psychopathology, and provide selected examples. We emphasize differential neuromaturation of subcortical and cortical neural networks and connectivity, and how both acute and protracted environmental insults can compromise neural structure and function. To date, developmental psychopathology has placed greater emphasis than psychiatry on neuromaturational models of mental illness. However, this gap is closing rapidly as advances in technology render etiopathophysiologies of psychopathology more interrogable. We end with suggestions for future interdisciplinary research, including the need to evaluate measurement invariance across development, and to construct more valid assessment methods where indicated.

Disruption of superficial white matter in the emotion regulation network in bipolar disorder

Bipolar disorder (BD) is characterized by emotion dysregulation and involves changes in the gray matter (GM) and white matter (WM). Although previous diffusion tensor imaging (DTI) studies reported changes in the diffusion properties of the deep WM (DWM) in BD patients, the diffusion properties of the superficial WM (SWM) are rarely investigated. In this study, we tried to determine whether the diffusion parameters of the SWM were altered in BD patients compared to controls and whether the changes were associated with the disrupted emotion regulation of the BD patients. We collected DTI data from 37 BD patients and 42 gender- and age-matched healthy controls (HC). Using probabilistic tractography, we defined a population-based SWM mask based on all the subjects. After performing the tract-based spatial statistical (TBSS) analyses, we identified the SWM areas in which the BD patients differed from the controls. This study showed significantly reduced fractional anisotropy in the SWM (FA_SWM) in the BD patients compared to the HC in the bilateral dorsolateral prefrontal cortex (dlPFC), ventrolateral prefrontal cortex (vlPFC), medial prefrontal cortex (mPFC), and the left parietal cortex. Moreover, compared to the controls, the BD patients showed significantly increased mean diffusivity (MD_SWM) and radial diffusivity (RD_SWM) in the SWM in the right frontal cortex. This study presents altered cortico-cortical connections proximal to the regions related to the emotion dysregulation of BD patients, which indicated that the SWM may serve as the brain's structural basis underlying the disrupted emotion regulation of BD patients. The disrupted FA_SWM in the parietal cortex may indicate that the emotion dysregulation in BD patients is related to the cognitive control network.

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BD patients showed altered FA_SWM in the regions related to emotion dysregulation.

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Disrupted SWM may be the brain's structural basis underlying emotion dysregulation in BD patients.

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FA_SWM between the vlPFC and dlPFC was negatively correlated with disease exacerbations in BD patients.

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Emotion dysregulation in BD patients may be related to a disrupted cognitive control network.

Intrinsic Functional Network Connectivity Is Associated With Clinical Symptoms and Cognition in Late-Life Depression

BACKGROUND

Late-life depression (LLD) has been associated with alterations in intrinsic functional networks, best characterized in the default mode network (DMN), cognitive control network (CCN), and salience network. However, these findings often derive from small samples, and it is not well understood how network findings relate to clinical and cognitive symptomatology.

METHODS

We studied 100 older adults (n = 79 with LLD, n = 21 nondepressed) and collected resting-state functional magnetic resonance imaging, clinical measures of depression, and performance on cognitive tests. We selected canonical network regions for each intrinsic functional network (DMN, CCN, and salience network) as seeds in seed-to-voxel analysis. We compared connectivity between the depressed and nondepressed groups and correlated connectivity with depression severity among depressed subjects. We then investigated whether the observed connectivity findings were associated with greater severity of common neuropsychiatric symptoms or poorer cognitive performance.

RESULTS

LLD was characterized by decreased DMN connectivity to the frontal pole, a CCN region (Wald χ²₁ = 22.33, p < .001). No significant group differences in connectivity were found for the CCN or salience network. However, in the LLD group, increased CCN connectivity was associated with increased depression severity (Wald χ²₁ > 20.14, p < .001), greater anhedonia (Wald χ²₁ = 7.02, p = .008) and fatigue (Wald χ²₁ = 6.31, p = .012), and poorer performance on tests of episodic memory (Wald χ²₁ > 4.65, p < .031), executive function (Wald χ²₁ = 7.18, p = .007), and working memory (Wald χ²₁ > 4.29, p < .038).

CONCLUSIONS

LLD is characterized by differences in DMN connectivity, while CCN connectivity is associated with LLD symptomology, including poorer performance in several cognitive domains.

Central serotonin modulates neural responses to virtual violent actions in emotion regulation networks

Disruptions in the cortico-limbic emotion regulation networks have been linked to depression, anxiety, impulsivity, and aggression. Altered transmission of the central nervous serotonin (5-HT) contributes to dysfunctions in the cognitive control of emotions. To date, studies relating to pharmaco-fMRI challenging of the 5-HT system have focused on emotion processing for facial expressions. We investigated effects of a single-dose selective 5-HT reuptake inhibitor (escitalopram) on emotion regulation during virtual violence. For this purpose, 38 male participants played a violent video game during fMRI scanning. The SSRI reduced neural responses to violent actions in right-hemispheric inferior frontal gyrus and medial prefrontal cortex encompassing the anterior cingulate cortex (ACC), but not to non-violent actions. Within the ACC, the drug effect differentiated areas with high inhibitory 5-HT1A receptor density (subgenual s25) from those with a lower density (pregenual p32, p24). This finding links functional responses during virtual violent actions with 5-HT neurotransmission in emotion regulation networks, underpinning the ecological validity of the 5-HT model in aggressive behavior. Available 5-HT receptor density data suggest that this SSRI effect is only observable when inhibitory and excitatory 5-HT receptors are balanced. The observed early functional changes may impact patient groups receiving SSRI treatment.

Please Don't Leave Me-Separation Anxiety and Related Traits in Borderline Personality Disorder

PURPOSE OF REVIEW

In light of the apparent symptomatic resemblance of separation anxiety disorder (SAD) symptoms on the one hand and abandonment fears, anxiousness, and separation insecurity central to borderline personality disorder (BPD) on the other hand, a comprehensive overview of separation anxiety and related traits in BPD is provided.

RECENT FINDINGS

Epidemiological, environmental, psychological, and neurobiological data connecting BPD to separation events, feelings of loneliness, insecure attachment styles, dimensional separation anxiety as well as SAD per se suggest a partly shared etiological pathway model underlying BPD and SAD. Differential diagnostic aspects and implications for treatment are discussed, highlighting separation anxiety as a promising transdiagnostic target for specific psychotherapeutic and pharmacological treatment approaches in BPD. This innovative angle on cross-disorder symptomatology might carry potential for novel preventive and therapeutic avenues in clinical practice by guiding the development of interventions specifically targeting separation anxiety and attachment-related issues in BPD.

Real-time fMRI amygdala neurofeedback positive emotional training normalized resting-state functional connectivity in combat veterans with and without PTSD: a connectome-wide investigation

Self-regulation of brain activation using real-time functional magnetic resonance imaging neurofeedback (rtfMRI-nf) is an emerging approach for treating mood and anxiety disorders. The effect of neurofeedback training on resting-state functional connectivity warrants investigation as changes in spontaneous brain activation could reflect the association between sustained symptom relief and brain alteration. We investigated the effect of amygdala-focused rtfMRI-nf training on resting-state functional connectivity in combat veterans with and without posttraumatic stress disorder (PTSD) who were trained to increase a feedback signal reflecting left amygdala activity while recalling positive autobiographical memories (Zotev et al., 2018). The analysis was performed in three stages: i) first, we investigated the connectivity in the left amygdala region; ii) next, we focused on the abnormal resting-state functional connectivity identified in our previous analysis of this data (Misaki et al., 2018); and iii) finally, we performed a novel data-driven longitudinal connectome-wide analysis. We introduced a longitudinal multivariate distance matrix regression (MDMR) analysis to comprehensively examine neurofeedback training effects beyond those associated with abnormal baseline connectivity.

These comprehensive exploratory analyses suggested that abnormal resting-state connectivity for combat veterans with PTSD was partly normalized after the training. This included hypoconnectivities between the left amygdala and the left ventrolateral prefrontal cortex (vlPFC) and between the supplementary motor area (SMA) and the dorsal anterior cingulate cortex (dACC). The increase of SMA-dACC connectivity was associated with PTSD symptom reduction. Longitudinal MDMR analysis found a connectivity change between the precuneus and the left superior frontal cortex. The connectivity increase was associated with a decrease in hyperarousal symptoms. The abnormal connectivity for combat veterans without PTSD - such as hypoconnectivity in the precuneus with a superior frontal region and hyperconnectivity in the posterior insula with several regions - could also be normalized after the training. These results suggested that the rtfMRI-nf training effect was not limited to a feedback target region and symptom relief could be mediated by brain modulation in several regions other than in a feedback target area. While further confirmatory research is needed, the results may provide valuable insight into treatment effects on the whole brain resting-state connectivity.

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fMRI neurofeedback training effect on resting-state connectivity was examined

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Left amygdala activity was trained to increase with positive memory

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Neurofeedback normalized altered connectivity in veterans with and without PTSD

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PTSD symptom reductions were significant but not specific to group (exp/ctrl)

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Connectivity-symptom association was seen in mPFC and precuneus

Subtle behavioural responses during negative emotion reactivity and down-regulation in bipolar disorder: A facial expression and eye-tracking study

Abnormal processing of emotional information and regulation are core trait-related features of bipolar disorder (BD) but evidence from behavioural studies is conflicting. This study aimed to investigate trait-related abnormalities in emotional reactivity and regulation in BD using novel sensitive behavioural measures including facial expressions and eye movements. Fifteen patients with BD in full or partial remission and 16 healthy controls (HCs) were given a computerised task in which they were instructed to 'react to' unpleasant and neutral pictures or 'dampen' their emotional response to aversive pictures. Participants rated their emotional response after each picture block, and eye-movements and facial expressions were recorded. Patients generally gazed less at unpleasant and neutral pictures during emotion processing and regulation. During emotional reactivity, patients exhibited stronger facial expressions to neutral pictures, a lack of facial expressions to unpleasant pictures, and more surprised facial expressions to both neutral and unpleasant pictures compared to HCs. The results point to subtle abnormalities in visual gaze patterns and facial displays of emotion between patients with BD during emotion processing and regulation. Aberrant eye-movements and facial displays could provide a more sensitive measure of emotional reactivity in BD than traditional behavioural measures, which could aid future diagnostic accuracy.

Trait attentional control modulates neurofunctional response to threat distractors in anxiety and depression

Accumulating data suggest attentional control capability varies across psychiatric diagnostic boundaries. The Attentional Control Scale (ACS) assesses self-reported trait attentional control (TAC) and tracks the anterior attention system. Greater TAC is associated with less negative affect, however, its mechanisms in anxiety and depression are poorly understood. Therefore, we examined whether individual differences in TAC modulated top-down mechanisms in a clinical sample. During fMRI, 104 patients with social anxiety, generalized anxiety, and/or major depression and 34 healthy participants completed a validated attentional control paradigm comprising strings of letters superimposed on threatening and neutral face distractors. In the low perceptual load condition, a target letter was in a string of identical letters. In the high load condition, a target letter was in a mixed letter string. Whole-brain regression results for low load revealed more activation to threat (vs. neutral) distractors in the pregenual anterior cingulate cortex was predicted by better TAC (i.e., higher ACS scores). For high load, regression results showed less activation to threat (vs. neutral) distractors in the inferior frontal gyrus was predicted by better TAC. An exploratory whole-brain ANOVA revealed a main effect of group in the superior temporal gyrus and a main effect of perceptual load in parietal, frontal, and limbic regions. No other effects were detected and activation derived from significant ANOVA results did not correlate with ACS scores. In conclusion, regression findings suggest individual differences in brain-behavioral ACS-related activity in frontal structures may be useful in identifying phenotypes in internalizing conditions.

Prefrontoparietal dysfunction during emotion regulation in anxiety disorder: a meta-analysis of functional magnetic resonance imaging studies

OBJECTIVE

Impairments in emotion regulation, and more specifically in cognitive reappraisal, are thought to play a key role in the pathogenesis of anxiety disorders. However, the available evidence on such deficits is inconsistent. To further illustrate the neurobiological underpinnings of anxiety disorder, the present meta-analysis summarizes functional magnetic resonance imaging (fMRI) findings for cognitive reappraisal tasks and investigates related brain areas.

METHODS

We performed a comprehensive series of meta-analyses of cognitive reappraisal fMRI studies contrasting patients with anxiety disorder with healthy control (HC) subjects, employing an anisotropic effect-size signed differential mapping approach. We also conducted a subgroup analysis of medication status, anxiety disorder subtype, data-processing software, and MRI field strengths. Meta-regression was used to explore the effects of demographics and clinical characteristics. Eight studies, with 11 datasets including 219 patients with anxiety disorder and 227 HC, were identified.

RESULTS

Compared with HC, patients with anxiety disorder showed relatively decreased activation of the bilateral dorsomedial prefrontal cortex (dmPFC), bilateral dorsal anterior cingulate cortex (dACC), bilateral supplementary motor area (SMA), left ventromedial prefrontal cortex (vmPFC), bilateral parietal cortex, and left fusiform gyrus during cognitive reappraisal. The subgroup analysis, jackknife sensitivity analysis, heterogeneity analysis, and Egger's tests further confirmed these findings.

CONCLUSIONS

Impaired cognitive reappraisal in anxiety disorder may be the consequence of hypo-activation of the prefrontoparietal network, consistent with insufficient top-down control. Our findings provide robust evidence that functional impairment in prefrontoparietal neuronal circuits may have a significant role in the pathogenesis of anxiety disorder.

Critical role of the right VLPFC in emotional regulation of social exclusion: a tDCS study

There is abundant evidence suggesting that the right ventrolateral prefrontal cortex (rVLPFC) plays an important role in down-regulating the emotional response to social exclusion. However, a causal relationship between rVLPFC function and explicit emotional regulation is not clear in the context of social exclusion. This study employed anodal transcranial direct current stimulation (tDCS) to activate rVLPFC while participants used emotional regulation to reappraise pictures of social exclusion. Forty-four participants were randomly assigned to an active tDCS group or a sham group. Both groups viewed social exclusion images under two conditions: in the no-reappraisal condition, participants were instructed to passively view social exclusion images; in the reappraisal condition, they reappraised the images to down-regulate negative emotional responses. Compared to sham stimulation, anodal tDCS over the rVLPFC resulted in less negative emotion ratings, and produced significantly smaller pupil diameter in the reappraisal, compared to no-reappraisal block. The tDCS also led to longer fixation durations to rejectees and shorter fixation durations to rejecters. Taken together, these findings suggest a causal role for rVLPFC in down-regulation of negative emotions produced by social exclusion. This study has implications for clinical interventions targeting emotional regulation deficits.

Reappraisal inventiveness: impact of appropriate brain activation during efforts to generate alternative appraisals on the perception of chronic stress in women

BACKGROUND AND OBJECTIVES

Previous research indicated that more left-lateralized prefrontal activation during cognitive reappraisal efforts was linked to a greater capacity for generating reappraisals, which is a prerequisite for the effective implementation of cognitive reappraisal in everyday life. The present study examined whether the supposedly appropriate brain activation is relevant in terms of more distal outcomes, i.e., chronic stress perception.

DESIGN AND METHODS

Prefrontal EEG alpha asymmetry was recorded while female participants were generating reappraisals for stressful events and was correlated with their self-reported chronic stress levels in everyday life (n = 80).

RESULTS

Women showing less left-lateralized brain activity in the ventrolateral prefrontal cortex during cognitive reappraisal efforts reported experiencing more stress in their daily lives. This effect was independent of self-efficacy beliefs in managing negative emotions.

CONCLUSION

These findings underline the practical relevance of individual differences in appropriate brain activation during emotion regulation efforts and the assumedly related basic capacity for the generation of cognitive reappraisals to the feeling of being stressed. Implications include the selection of interventions for the improvement of coping with stress in women in whom the capability for appropriate brain activation during reappraisal efforts may be impaired, e.g., due to depression or old age.

Speech Disfluency-dependent Amygdala Activity in Adults Who Stutter: Neuroimaging of Interpersonal Communication in MRI Scanner Environment

Affective states, such as anticipatory anxiety, critically influence speech communication behavior in adults who stutter. However, there is currently little evidence regarding the involvement of the limbic system in speech disfluency during interpersonal communication. We designed this neuroimaging study and experimental procedure to sample neural activity during interpersonal communication between human participants, and to investigate the relationship between the amygdala activity and speech disfluency. Participants were required to engage in live communication with a stranger of the opposite sex in the MRI scanner environment. In the gaze condition, the stranger gazed at the participant without speaking, while in the live conversation condition, the stranger asked questions that the participant was required to answer. The stranger continued to gaze silently at the participant while the participant answered. Adults who stutter reported significantly higher discomfort than fluent controls during the experiment. Activity in the right amygdala, a key anatomical region in the limbic system involved in emotion, was significantly correlated with stuttering occurrences in adults who stutter. Right amygdala activity from pooled data of all participants also showed a significant correlation with discomfort level during the experiment. Activity in the prefrontal cortex, which forms emotion regulation neural circuitry with the amygdala, was decreased in adults who stutter than in fluent controls. This is the first study to demonstrate that amygdala activity during interpersonal communication is involved in disfluent speech in adults who stutter.

Functional connectivity changes following interpersonal reactivity

Attachment experiences substantially influence emotional and cognitive development. Narratives comprising attachment-dependent content were proposed to modulate activation of cognitive-emotional schemata in listeners. We studied the effects after listening to prototypical attachment narratives on wellbeing and countertransference-reactions in 149 healthy participants. Neural correlates of these cognitive-emotional schema activations were investigated in a 7 Tesla rest-task-rest fMRI-study (23 healthy males) using functional connectivity (FC) analysis of the social approach network (seed regions: left and right Caudate Nucleus, CN). Reduced FC between left CN and bilateral dorsolateral prefrontal cortex (DLPFC) represented a general effect of prior auditory stimulation. After presentation of the insecure-dismissing narrative, FC between left CN and bilateral temporo-parietal junction, and right dorsal posterior Cingulum was reduced, compared to baseline. Post-narrative FC-patterns of insecure-dismissing and insecure-preoccupied narratives differed in strength between left CN and right DLPFC. Neural correlates of the moderating effect of individual attachment anxiety were represented in a reduced CN-DLPFC FC as a function of individual neediness-levels. These findings suggest specific neural processing of prolonged mood-changes and schema activation induced by attachment-specific speech patterns. Individual desire for interpersonal proximity was predicted by attachment anxiety and furthermore modulated FC of the social approach network in those exposed to such narratives.

Dorsomedial frontal cortical metabolic differences of comorbid generalized anxiety disorder in refractory major depression: A [18F] FDG PET brain imaging study

BACKGROUND

Refractory major depressive disorder (MDD) is a severe mental disorder, chronic and difficult to treat. Although generalized anxiety disorder (GAD) is frequently observed as a comorbid diagnosis, little is known on the comorbid neurobiological substrate. Better insights may improve adequate treatment algorithms.

OBJECTIVE

To examine this poorly understood clinical question, we recruited 52 individuals to participate in a [¹⁸F] FDG PET brain imaging study.

METHODS

Twenty-two refractory MDD patients were diagnosed with and 15 refractory MDD patients without comorbid GAD. To compare to the none-depressed state a sample of 15 age and gender matched never-depressed individuals were included.

RESULTS

Compared to healthy control subjects, all patients showed significantly higher metabolic activity in the bilateral parahippocampal areas. Compared to MDD patients, healthy subjects displayed significant higher metabolic activity in distinct (bi)frontotemporal and parietal cortices. Refractory MDD patients without comorbid GAD showed significant higher metabolic activity in the dorsomedial parts of the frontal cortex (dmFC).

CONCLUSIONS

The impaired dmFC metabolic activity observed in comorbid GAD within refractory MDD may be indicative of specific emotional dysfunctional top-down processing in this subgroup, conform the anxiety state. Additional psychotherapeutic interventions may be warranted.

Impaired Voluntary Control in PTSD: Probing Self-Regulation of the ACC With Real-Time fMRI

Background: Post-traumatic stress disorder (PTSD) is characterized by deficits in the self-regulation of cognitions and emotions. Neural networks of emotion regulation may exhibit reduced control mediated by the anterior cingulate cortex (ACC), contributing to aberrant limbic responses in PTSD. Methods: Real-time fMRI neurofeedback (rt-fMRI NF) assessed self-regulation of the ACC in nine patients with PTSD after single trauma exposure and nine matched healthy controls. All participants were instructed to train ACC upregulation on three training days. Results: Both groups achieved regulation, which was associated with wide-spread brain activation encompassing the ACC. Compared to the controls, regulation amplitude and learning rate was lower in patients, correlating with symptom severity. In addition, a frontopolar activation cluster was associated with self-regulation efforts in patients. Conclusions: For the first time, we tested self-regulation of the ACC in patients with PTSD. The observed impairment supports models of ACC-mediated regulation deficits that may contribute to the psychopathology of PTSD. Controlled trials in a larger sample are needed to confirm our findings and to directly investigate whether training of central regulation mechanisms improves emotion regulation in PTSD.

Modulating Emotion Perception: Opposing Effects of Inhibitory and Excitatory Prefrontal Cortex Stimulation

BACKGROUND

Excitatory repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex (dlPFC) is approved by the U.S. Food and Drug Administration for the treatment of adult patients with treatment-resistant major depressive disorder (MDD). This stimulation is supposed to restore excitability of prefrontal cortex regions that exhibit diminished regulation of emotion-generative systems in MDD. Based on the valence lateralization hypothesis, inhibitory rTMS of the right dlPFC has also been applied in MDD. This approach has proved to be effective, although meta-analyses of emotional perception and affective regulation in healthy control subjects and patients with depression do not support functional asymmetries within dlPFC regions.

METHODS

To shed more light on this discrepancy, the effects of excitatory and inhibitory rTMS of the right dlPFC on visual emotional perception were compared in two groups of 41 healthy participants overall. Before and after rTMS stimulation, participants viewed fearful and neutral faces while whole-head magnetoencephalography was recorded and supplemented by behavioral tests.

RESULTS

Visual sensory processing of fearful facial expressions, relative to neutral facial expressions, was reduced after excitatory stimulation and was increased after inhibitory stimulation within right occipital and right temporal regions. Correspondingly, after excitatory rTMS compared with inhibitory rTMS, participants displayed relatively reduced reaction times in an emotion discrimination task and showed reduced emotional arousal.

CONCLUSIONS

These results support the hypothesis that excitatory rTMS compared with inhibitory rTMS of the right dlPFC strengthens top-down control of aversive stimuli in healthy control subjects, which should encourage more research on mechanisms of excitatory/inhibitory dlPFC-rTMS protocols in general and on neuromodulatory treatment of MDD.

Recent Advances in Non-invasive Brain Stimulation for Major Depressive Disorder

Non-invasive brain stimulation (NBS) is a promising treatment for major depressive disorder (MDD), which is an affective processing disorder involving abnormal emotional processing. Many studies have shown that repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) over the prefrontal cortex can play a regulatory role in affective processing. Although the clinical efficacy of NBS in MDD has been demonstrated clinically, the precise mechanism of action remains unclear. Therefore, this review article summarizes the current status of NBS methods, including rTMS and tDCS, in the treatment of MDD. The article explores possible correlations between depressive symptoms and affective processing, highlighting the relevant affective processing mechanisms. Our review provides a reference for the safety and efficacy of NBS methods in the clinical treatment of MDD.

Nicotine and networks: Potential for enhancement of mood and cognition in late-life depression

Late-life depression is characterized by both lower mood and poor cognitive performance, symptoms that often do not fully respond to current antidepressant medications. Nicotinic acetylcholine receptor (nAChR) agonists such as nicotine may serve as a novel therapeutic approach for this population. Both preclinical and preliminary clinical studies suggest that nAChR agonists can improve depressive behavior in animal models and improve mood in depressed individuals. Substantial literature also supports that nAChR agonists benefit cognitive performance, particularly in older populations. These potential benefits may be mediated by the effects of nAChR stimulation on neural network function and connectivity. Functional neuroimaging studies detail effects of nAChR agonists on the default mode network, central-executive network, and salience network that may oppose or reverse network changes seen in depression. We propose that, given the existent literature and the clinical presentation of late-life depression, nicotine or other nAChR agonists may have unique therapeutic benefits in this population and that clinical trials examining nicotine effects on mood, cognition, and network dynamics in late-life depression are justified.

Prefrontal and amygdala engagement during emotional reactivity and regulation in generalized anxiety disorder

BACKGROUND

Emotion dysregulation is prominent in generalized anxiety disorder (GAD), characterized clinically by exaggerated reactivity to negative stimuli and difficulty in down-regulating this response. Although limited research implicates frontolimbic disturbances in GAD, whether neural aberrations occur during emotional reactivity, regulation, or both is not well understood.

METHODS

During functional magnetic resonance imaging (fMRI), 30 individuals with GAD and 30 healthy controls (HC) completed a well-validated explicit emotion regulation task designed to measure emotional reactivity and regulation of reactivity. During the task, participants viewed negative images ('Look-Negative' condition) and, on some trials, used a cognitive strategy to reduce negative affective response ('Reappraise' condition).

RESULTS

Results from an Analysis of Variance corrected for whole brain multiple comparisons showed a significant group x condition interaction in the left amygdala and left inferior frontal gyrus (IFG). Results from post-hoc analyses showed that the GAD group engaged these regions to a greater extent than HCs during Look-Negative but not Reappraise. Behaviorally, the GAD group reported feeling more negative than the HC group in each condition, although both groups reported reduced negative affect following regulation.

LIMITATIONS

As comorbidity was permitted, the presence of concurrent disorders, like other anxiety disorders and depression, detracts our ability to classify neural engagement particular to GAD alone.

CONCLUSIONS

Individuals with GAD exhibited over-engagement of amygdala and frontal regions during the viewing of negative images, compared to HCs. Together, these aberrations may indicate that deficits in emotional reactivity rather than regulation contribute to emotion dysregulation in those with GAD.

Subjective and objective sleep quality modulate emotion regulatory brain function in anxiety and depression

BACKGROUND

Disturbances in emotion regulation and sleep are shared across anxiety and mood disorders. Poor sleep has been shown to impair cognitive processes which may undermine cognitive regulatory function. However, it remains unknown if sleep quality impacts regulatory mechanisms in clinical anxiety and depression.

METHODS

During fMRI, 78 patients with social anxiety disorder, generalized anxiety disorder, and/or major depressive disorder completed a validated emotion regulation task, which involved reappraisal (i.e., decrease negative affect) as compared to viewing aversive images. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI) and actigraphy, representing subjective and objective measures of sleep, respectively. Regression analysis was conducted with the PSQI and actigraphy sleep efficiency, duration, and wake-after sleep onset variables.

RESULTS

PSQI and actigraphy measures indicated that the majority of patients experienced problematic sleep, however, subjective and objective sleep measures were uncorrelated. Whole-brain voxel-wise regression analysis, controlling for diagnosis, revealed worse self-reported sleep corresponded with less reappraise-related activation in the dorsal anterior cingulate cortex (DACC). The same analysis performed with actigraphy data showed less sleep efficiency positively corresponded with DACC activation. Post-hoc stepwise regression analysis showed these sleep measures predicted DACC activity whereas anxiety and depression symptoms did not.

CONCLUSIONS

Individual differences in self-perceived and objective sleep quality differentially modulated the DACC, which is implicated in cognitive reappraisal. Findings suggest neural correlates of emotion regulation tracks different aspects of the sleep experience. Results also indicate sleep disturbance may play a role in the emotion dysregulation observed in anxiety and depressive disorders.

Treatment for social anxiety disorder alters functional connectivity in emotion regulation neural circuitry

Social anxiety disorder (SAD) is characterized at a neurobiological level by disrupted activity in emotion regulation neural circuitry. Previous work has demonstrated amygdala hyperreactivity and disrupted prefrontal responses to social cues in individuals with SAD (Kim et al., 2011). While exposure-based psychological treatments effectively reduce SAD symptoms, not all individuals respond to treatment. Better understanding of the neural mechanisms involved offers the potential to improve treatment efficacy. In this study, we investigated functional connectivity in emotion regulation neural circuitry in a randomized controlled treatment trial for SAD. Participants with SAD underwent fMRI scanning while performing an implicit emotion regulation task prior to treatment (n=62). Following 12 weeks of cognitive behavioral therapy, acceptance and commitment therapy, or wait-list, participants completed a second scan (n=42). Psychophysiological interaction analyses using amygdala seed regions demonstrated differences between SAD and healthy control participants (HC; n=16) in right amygdala-vmPFC connectivity. SAD participants demonstrated more negative amygdala-to-vmPFC connectivity, compared to HC participants, an effect that was correlated with SAD symptom severity. Post-treatment symptom reduction was correlated with altered amygdala-to-vm/vlPFC connectivity, independent of treatment type. Greater symptom reduction was associated with more negative amygdala-to-vm/vlPFC connectivity. These findings suggest that effective psychological treatment for SAD enhances amygdala-prefrontal functional connectivity.

Neural mechanisms of implicit cognitive reappraisal: Preceding descriptions alter emotional response to unpleasant images

The importance of reappraising negative events to reduce negative emotional responses has been widely acknowledged. However, most neuroimaging studies have explored the neural mechanisms of deliberate and intentional reappraisal, while little is known about the neural correlates of reappraisal that occurs outside of one's awareness. Electrophysiological studies suggest that precedent neutral descriptions could implicitly reduce neural responses to unpleasant images. To investigate the neural mechanism underlying implicit reappraisal, functional magnetic resonance imaging was conducted on 25 participants while they passively viewed unpleasant images that were previously neutrally/positively or negatively described. Increased activity in prefrontal areas including the dorsolateral and dorsomedial prefrontal cortices, lateral orbitofrontal cortex, and temporal cortex, and decreased activation in the amygdala was observed-similar to the pattern reported in deliberate emotion regulation-when unpleasant images were preceded by neutral/positive versus negative descriptions. Functional connectivity analysis revealed significant negative couplings between prefrontal regions and the amygdala. These findings suggest that implicit reappraisal recruits prefrontal regions to change semantic representations in the temporal cortex, in turn modulating the emotional response of the amygdala.

Prediction of subjective ratings of emotional pictures by EEG features

OBJECTIVE

Emotion dysregulation is an important aspect of many psychiatric disorders. Brain-computer interface (BCI) technology could be a powerful new approach to facilitating therapeutic self-regulation of emotions. One possible BCI method would be to provide stimulus-specific feedback based on subject-specific electroencephalographic (EEG) responses to emotion-eliciting stimuli.

APPROACH

To assess the feasibility of this approach, we studied the relationships between emotional valence/arousal and three EEG features: amplitude of alpha activity over frontal cortex; amplitude of theta activity over frontal midline cortex; and the late positive potential over central and posterior mid-line areas. For each feature, we evaluated its ability to predict emotional valence/arousal on both an individual and a group basis. Twenty healthy participants (9 men, 11 women; ages 22-68) rated each of 192 pictures from the IAPS collection in terms of valence and arousal twice (96 pictures on each of 4 d over 2 weeks). EEG was collected simultaneously and used to develop models based on canonical correlation to predict subject-specific single-trial ratings. Separate models were evaluated for the three EEG features: frontal alpha activity; frontal midline theta; and the late positive potential. In each case, these features were used to simultaneously predict both the normed ratings and the subject-specific ratings.

MAIN RESULTS

Models using each of the three EEG features with data from individual subjects were generally successful at predicting subjective ratings on training data, but generalization to test data was less successful. Sparse models performed better than models without regularization.

SIGNIFICANCE

The results suggest that the frontal midline theta is a better candidate than frontal alpha activity or the late positive potential for use in a BCI-based paradigm designed to modify emotional reactions.

Degrading traumatic memories with eye movements: a pilot functional MRI study in PTSD

BACKGROUND

Eye movement desensitization and reprocessing (EMDR) is an effective treatment for posttraumatic stress disorder (PTSD). During EMDR, the patient recalls traumatic memories while making eye movements (EMs). Making EMs during recall is associated with decreased vividness and emotionality of traumatic memories, but the underlying mechanism has been unclear. Recent studies support a "working-memory" (WM) theory, which states that the two tasks (recall and EMs) compete for limited capacity of WM resources. However, prior research has mainly relied on self-report measures.

METHODS

Using functional magnetic resonance imaging, we tested whether "recall with EMs," relative to a "recall-only" control condition, was associated with reduced activity of primary visual and emotional processing brain regions, associated with vividness and emotionality respectively, and increased activity of the dorsolateral prefrontal cortex (DLPFC), associated with working memory. We used a randomized, controlled, crossover experimental design in eight adult patients with a primary diagnosis of PTSD. A script-driven imagery (SDI) procedure was used to measure responsiveness to an audio-script depicting the participant's traumatic memory before and after conditions.

RESULTS

SDI activated mainly emotional processing-related brain regions (anterior insula, rostral anterior cingulate cortex (ACC), and dorsomedial prefrontal cortex), WM-related (DLPFC), and visual (association) brain regions before both conditions. Although predicted pre- to post-test decrease in amygdala activation after "recall with EMs" was not significant, SDI activated less right amygdala and rostral ACC activity after "recall with EMs" compared to post-"recall-only." Furthermore, functional connectivity from the right amygdala to the rostral ACC was decreased after "recall with EMs" compared with after "recall-only."

CONCLUSIONS

These preliminary results in a small sample suggest that making EMs during recall, which is part of the regular EMDR treatment protocol, might reduce activity and connectivity in emotional processing-related areas. This study warrants replication in a larger sample.

HIGHLIGHTS OF THE ARTICLE

Script driven imagery (SDI) before and after recall of traumatic memories is feasible to investigate working mechanisms of degrading of traumatic memories with eye movements (EMs) in PTSD. Right amygdala and rostral ACC activity was significantly lower after "recall with EMs" than after "recall-only". Functional connectivity from amygdala to rostral ACC was decreased after "recall with EMs" vs. "recall-only". This study warrants replication in a larger sample.