Reappraisal generation after acquired brain damage: The role of laterality and cognitive control

"I felt like I was missing 'me'": Long-term experiences of intrapersonal loss, grief, and change in adults with an acquired brain injury

Experiences of loss and change following acquired brain injury (ABI) are frequent and multi-contextual, yet the long-term experiences of people with ABI are not well understood. This study explored the experiences of intrapersonal loss, grief and change in people with ABI, a decade after their injury. Twelve adults with ABI were interviewed 10-13 years post-injury. Using interpretative phenomenological analysis, we identified four overarching themes: a dawning realization of the impact of injury; loss of personhood; loss and liminality; and learning to live with loss and grief. Our findings indicate that in the decade following ABI, people continue to develop awareness of the impact of their injury and experience oscillating acceptance towards enforced changes. Participants reported a diminished sense of agency and autonomy in how they were perceived by and interacted with following injury. Additionally, identity may be lost, suspended, and renegotiated. Findings suggest dynamic, active, and flexible coping strategies that continue to be present over the long term. Considering the persistent nature of the injury and the evolving needs of the individual, a longer term view of rehabilitation outcomes may be required, contextualised by relational and intrapersonal challenges that may present over the longer term.

Experiences of loss and grief in adults with acquired brain injury (ABI): A systematic review and meta synthesis of qualitative studies

OBJECTIVE

To synthesise the qualitative research related to the processes of loss and grief experienced by adults who have sustained a moderate to severe ABI.

METHOD

We conducted a systematic review and thematic synthesis of the experiences of loss and grief in adults with moderate to severe ABI. Five electronic database searches (PubMed, CINAHL, EMBASE, PsycINFO and Scopus) were conducted, identifying 2434 studies, of which 25 met inclusion criteria.

FINDINGS

Thematic synthesis generated four overarching analytical themes: the loss within me; devaluation of social roles and social identity; acceptance of grief and loss as an active process; and an ambivalent experience of loss. Our findings indicate that the experiences of grief and loss following brain injury are dynamic processes, requiring significant adjustment to and reappraisal of the sense of self, an often uncomfortable reconstruction and sometimes reluctant acceptance of new personal and social identities, and development of tolerance for the ambiguity of one's experience.

CONCLUSION

Findings suggest that people with moderate to severe ABI go through a significant process of change and adaptation in relation to grief and loss and their sequelae. Given the enduring nature of the injury and changing needs of the individual, rehabilitation may need to be increasingly personalised and responsive.

"We can all relate": patient experience of an emotion-oriented group intervention after Acquired Brain Injury

Introduction

Group interventions are carried out routinely across neuropsychological rehabilitation services, to improve understanding of brain injury and aspects of impairment. Treatment provided in a group modality can bring additional perceived benefits, such as co-operative learning. However, there are very few studies which explore patient perceptions and experiences of such interventions. In the present study we investigated the experience of attending a group-based educational intervention for the consequences of acquired brain injury (ABI), which had a strong focus on emotion and emotion regulation.

Methods

Using qualitative semi-structured interviews (approximately 20 minutes), the study explores the lived experience of participating in the seven-session programme, the better to identify the perceived efficacy, salience and value of individual elements. Twenty participants with ABI took part in individual interviews, after completion of the group programme (the Brain Injury Solutions and Emotions Programme, BISEP). The study adopted a descriptive phenomenological philosophy, which focuses on lived experience to explore a phenomenon (i.e. the experience of BISEP). As regards methods, the study employed thematic analysis to cluster experiences into themes of meaning.

Results

Five themes were identified: (1) 'Long term consequences and psychological needs', which related to the persistent nature of direct consequences of injury and adjustment, and how these result in a need for interventions such as BISEP. (2) 'Positive experiences of participating in the programme', referred to participants' overall experience of the programme and valued elements within it. The remaining themes referred to the programme as (3) a social milieu; (4) a place to learn; and (5) a place to promote positive emotional experiences.

Discussion

Similar to previous studies, many people reported high acceptability and perceived value of the group programme, and its role in facilitating adjustment and understanding of injury. Of particular importance was the opportunity to socialise with people who "can all relate", in line with a growing emphasis on social rehabilitation. The findings especially highlight the relevance of emotion-focused group programmes for ABI, promoting emotion regulation, and practical tools that are delivered optimistically. Further implications for practice and future research include to focus on long term rehabilitation, a social milieu, and strategies to support adjustment.

Exploring the relationship between emotion regulation, inhibitory control, and eating psychopathology in a non-clinical sample

OBJECTIVE

The present study aimed to explore the relationship between difficulties in emotion regulation and deficits in inhibitory control, and the role of these processes in eating psychopathology in a non-clinical sample. We also explored the specificity in which deficits in inhibitory control may underlie eating psychopathology, namely whether they can be conceptualised as context specific or more extensive in nature.

METHOD

Participants were 107 healthy individuals recruited at a major Portuguese university, aged between 18 and 43 years-old (M = 21.23, SD = 4.79). Two computerised neuropsychological tasks (i.e., emotional go/no-go and food go/no-go tasks) were used to assess response inhibition in the presence of general versus context-specific stimuli. A set of self-report measures was used to assess variables of interest such as emotion regulation and eating psychopathology.

RESULTS

Results indicated higher response inhibition deficits among participants with higher difficulties in emotion regulation comparing to those with lower difficulties in emotion regulation, particularly in the context of food-related stimuli. In addition, the relationship between difficulties in emotion regulation and eating psychopathology was moderated by inhibitory control deficits in both the context of food and pleasant stimuli.

CONCLUSIONS

The present findings highlight inhibitory control as an important process underlying the relationship between difficulties in emotion regulation and eating psychopathology in non-clinical samples. Findings have important implications for clinical practice and the prevention of eating psychopathology in healthy individuals and individuals with eating disorders.

"Talk and Chalk": An emotion regulation intervention for anger after acquired brain injury

Uncontrollable anger is a debilitating consequence of acquired brain injury (ABI). This proof-of-concept study investigated the preliminary efficacy of an emotion regulation intervention for managing post-ABI anger. A secondary objective was to determine which participant characteristics were related to intervention gains. With a pre-post intervention design and three-month follow-up, there were five individually administered meetings on Zoom, over a four-month period. 24 adults who had sustained an ABI were enrolled. Participants were mostly males, from 24 to 85 years old. A series of one-way repeated-measures ANOVAs were conducted to determine the intervention's efficacy, and Spearman's rho bivariate correlations for the association between participant characteristics and intervention gains. Significant differences were observed in external anger from baseline to post-treatment; there were no further changes from post-treatment to follow-up. Of the participant characteristics, only readiness to change and anxiety were correlated. The proposed intervention presents a brief, feasible, and preliminary efficacious alternative for regulating post-ABI anger. Intervention gains are associated with readiness to change and anxiety, which has important implications for clinical delivery.

Shades of Rage: Applying the Process Model of Emotion Regulation to Managing Anger After Brain Injury

Uncontrollable anger is common following an acquired brain injury (ABI), with impaired emotion regulation (ER) being one of the main contributors. Existing psychological interventions appear moderately effective, though studies typically include limitations such as small sample sizes, issues of long-term efficacy, and standardization of content. While ER has been a popular research field, the study of ER for anger management after ABI is less well investigated, and contains few interventions based on the widely used Process Model of ER. This review surveys the efficacy of ER strategies in individuals with ABI, and proposes a novel research design for future interventions. Recommendations are made about: strategy number and type, shared decision-making, approaches to data analysis, and mode of delivery.

The Neuropsychology of Emotion and Emotion Regulation: The Role of Laterality and Hierarchy

Over the last few decades, work in affective neuroscience has increasingly investigated the neural basis of emotion. A central debate in the field, when studying individuals with brain damage, has been whether emotional processes are lateralized or not. This review aims to expand this debate, by considering the need to include a hierarchical dimension to the problem. The historical journey of the diverse literature is presented, particularly focusing on the need to develop a research program that explores the neural basis of a wide range of emotional processes (perception, expression, experience, regulation, decision making, etc.), and also its relation to lateralized cortical and deep-subcortical brain structures. Of especial interest is the study of the interaction between emotional components; for example, between emotion generation and emotion regulation. Finally, emerging evidence from lesion studies is presented regarding the neural basis of emotion-regulation strategies, for which the issue of laterality seems most relevant. It is proposed that, because emotion-regulation strategies are complex higher-order cognitive processes, the question appears to be not the lateralization of the entire emotional process, but the lateralization of the specific cognitive tools we use to manage our feelings, in a range of different ways.

Inner Speech Moderates the Relationship Between Autism Spectrum Traits and Emotion Regulation

Inner speech processes are thought to be associated with decreases in cognitive performance in autism spectrum disorder (ASD). Although verbal thinking is also a key component in emotional responses, no studies have investigated whether inner speech is linked to emotion regulation in ASD. The aim of this study was to investigate whether inner speech moderates the relationship between ASD traits and emotion regulation strategies. Our results indicate that only the evaluative/motivational form of inner speech moderates the relationship between ASD traits and cognitive reappraisal; inner speech processes did not moderate the association between ASD traits and expressive suppression. These findings are a first step to further investigate the role of inner speech in affective and self-regulatory processes in ASD.

Good things better? Reappraisal and discrete emotions in acquired brain injury

There has been substantial interest in emotion after acquired brain injury (ABI), but less attention paid to emotion regulation (ER). Research has focused primarily on the ER strategy of reappraisal for regulating negative emotions, without distinguishing between classes of emotion, and there has been no attempt at exploring these differences in patients with ABI. The present study explored components of reappraisal, across classes of emotion, and their associated neuropsychological mechanisms. Thirty-five patients with ABI and twenty-two matched healthy control participants (HCs) completed two questionnaires, a battery of cognitive tasks, and an emotion regulation task (the Affective Story Recall Reappraisal task). Results suggest that those with ABI take longer, and generate fewer reappraisals than HCs across several discrete emotions. Notably, their ability to decrease emotional intensity did not differ significantly to HCs for negative emotions, but findings suggest that their reappraisals are less effective when up-regulating neutral emotions to positive. Working memory was the only significant predictor of the total number of reappraisals generated, and the time taken to produce a first reappraisal. Implications of these findings are discussed in the context of neuropsychological rehabilitation, including the role of the relatives in implementing and reinforcing micro-interventions.

Explicit and implicit emotion regulation: a multi-level framework

The ability to adaptively regulate emotion is essential for mental and physical well-being. How should we organize the myriad ways people attempt to regulate their emotions? We explore the utility of a framework that distinguishes among four fundamental classes of emotion regulation strategies. The framework describes each strategy class in terms their behavioral characteristics, underlying psychological processes and supporting neural systems. A key feature of this multi-level framework is its conceptualization of the psychological processes in terms of two orthogonal dimensions that describe (i) the nature of the emotion regulation goal (ranging from to implicit to explicit) and (ii) the nature of the emotion change process (ranging from more automatic to more controlled). After describing the core elements of the framework, we use it to review human and animal research on the neural bases of emotion regulation and to suggest key directions for future research on emotion regulation.

Preserved re-experience of discrete emotions: Amnesia and executive function

Amnesic patients can re-experience emotions elicited by forgotten events, suggesting that brain systems for episodic and emotional memory are independent. However, the range of such emotional memories remains under-investigated (most studies employing just positive-negative emotion dyads), and executive function may also play a role in the re-experience of emotions. This is the first investigation of the intensity of the emotional re-experience of a range of discrete emotions (anger, fear, sadness, and happiness) for a group of amnesic patients. Twenty Korsakoff syndrome (KS) patients and 20 neurologically normal controls listened to four novel emotional vignettes selectively eliciting the four basic emotions. Emotional experience was measured using pen-and-paper Visual Analogue Mood Scales and episodic memory using verbal recollections. After 30 min, the recollection of stories was severely impaired for the patient group, but the emotional re-experience was no different from that of controls. Notably, there was no relationship between episodic recall and the intensity of the four emotions, such that even profoundly amnesic patients reported moderate levels of the target emotion. Exploratory analyses revealed negative correlations between the intensity of basic emotions and executive functions (e.g., cognitive flexibility and response inhibition) for controls but not patients. The results suggest that discrete emotions can be re-experienced independently of episodic memory, and that the re-experience of certain discrete emotions appears to be dampened by executive control. KS patients with absent or mild cognitive symptoms should benefit from emotion-regulation interventions aimed at reducing the recognized affective burden associated with their episodic memory deficit.

Consequences of brain tumour resection on emotion recognition

Emotion processing impairments are common in patients undergoing brain surgery for fronto-temporal tumour resection, with potential consequences on social interactions. However, evidence is controversial concerning side and site of lesions causing such deficits. This study investigates visual and auditory emotion recognition in brain tumour patients with the aim of clarifying which lesion sites are related to impairments in emotion processing from different modalities. Thirty-four patients were evaluated, before and after surgery, on facial expression and emotional prosody recognition; voxel-based lesion-symptom mapping (VLSM) analyses were performed on patients' post-surgery MRI images. Results showed that patients' performance decreased after surgery in both visual and auditory modalities, but, in general, recovered 3 months after surgery. In facial expression recognition, left brain-damaged patients showed greater post-surgery deterioration than right brain-damaged ones, whose performance specifically decreased for sadness and fear. VLSM analysis revealed two segregated areas in the left hemisphere accounting for post-surgery scores for happy (fronto-temporo-insular region) and surprised (middle frontal gyrus and inferior fronto-occipital fasciculus) facial expressions. Our findings demonstrate that surgical removal of tumours in the fronto-temporal region produces impairment in facial emotion recognition with an overall recovery at 3 months, suggesting a partially different representation of positive and negative emotions in the left and right hemispheres for visually - but not auditory - presented emotions; moreover, we show that deficits in specific expression recognition are associated with discrete lesion locations.

Confabulation: Developing the 'emotion dysregulation' hypothesis

Confabulations offer unique opportunities for establishing the neurobiological basis of delusional thinking. As regards causal factors, a review of the confabulation literature suggests that neither amnesia nor executive impairment can be the sole (or perhaps even the primary) cause of all delusional beliefs - though they may act in concert with other factors. A key perspective in the modern literature is that many delusions have an emotionally positive or 'wishful' element, that may serve to modulate or manage emotional experience. Some authors have referred to this perspective as the 'emotion dysregulation' hypothesis. In this article we review the theoretical underpinnings of this approach, and develop the idea by suggesting that the positive aspects of confabulatory states may have a role in perpetuating the imbalance between cognitive control and emotion. We draw on existing evidence from fields outside neuropsychology, to argue for three main causal factors: that positive emotions are related to more global or schematic forms of cognitive processing; that positive emotions influence the accuracy of memory recollection; and that positive emotions make people more susceptible to false memories. These findings suggest that the emotions that we want to feel (or do not want to feel) can influence the way we reconstruct past experiences and generate a sense of self - a proposition that bears on a unified theory of delusional belief states.

'Just can't hide it': a behavioral and lesion study on emotional response modulation after right prefrontal damage

INTRODUCTION

Historically, emotion regulation problems have been reported as a common consequence of right prefrontal cortex (rPFC) damage. It has been proposed that the rPFC, particularly the rIFG, has a key role inhibiting prepotent reflexive actions, thus contributing to emotion regulation and self-regulation. This study is the first to directly explore this hypothesis, by testing whether damage to the rIFG compromises the voluntary modulation of emotional responses, and whether performance on inhibition tasks is associated with emotion regulation.

METHOD

10 individuals with unilateral right prefrontal damage and 15 matched healthy controls were compared on a well-known response modulation task. During the task participants had to amplify and suppress their facial emotional expressions, while watching film clips eliciting amusement. Measures of executive control, emotion regulation strategies usage and symptomatology were also collected.

RESULTS

As a group, individuals with rPFC damage presented a significantly reduced range of response modulation compared with controls. In addition, performance in the suppression task was associated with measures of cognitive inhibition and suppression usage. Interestingly, these effects were driven primarily by a subgroup of individuals with rPFC damage, all of whom also had damage to the right posterior insula, and who presented a marked impairment in suppressing facial emotional expressions.

Localized or diffuse: the link between prefrontal cortex volume and cognitive reappraisal

Despite functional brain imaging research pointing to the role of prefrontal cortex in cognitive reappraisal, the structural correlates of habitual engagement of reappraisal are unclear. Functional imaging studies of reappraisal have shown broad engagement of bilateral middle frontal cortex (MFC) and left superior frontal cortex (SFC), and specific engagement of the right SFC. However, volumetric studies have not identified clear associations between reappraisal and these regions. This discrepancy between functional and structural studies suggests that broad functional engagement associated with reappraisal might not be detectable at a structural level using highly localized volumetric measures. This study addressed the discrepant structural findings by assessing the relation between reappraisal and grey matter volume, using methods that allow both region-level broad/diffuse assessments (surface-based morphometry), and voxel-level specific/localized (voxel-based morphometry) measures. Results were consistent with diffuse positive volumetric associations with reappraisal in the right MFC and left SFC, and a localized positive volumetric association in the right SFC, thus resolving the discrepancy between functional and structural studies. This study provides novel evidence supporting the idea that functional engagement related to transient manipulations of reappraisal can be linked to structural associations related to habitual engagement of similar operations, within the same brain regions.

Detaching from the negative by reappraisal: the role of right superior frontal gyrus (BA9/32)

The ability to reappraise the emotional impact of events is related to long-term mental health. Self-focused reappraisal (REAPPself), i.e., reducing the personal relevance of the negative events, has been previously associated with neural activity in regions near right medial prefrontal cortex, but rarely investigated among brain-damaged individuals. Thus, we aimed to examine the REAPPself ability of brain-damaged patients and healthy controls considering structural atrophies and gray matter intensities, respectively. Twenty patients with well-defined cortex lesions due to an acquired circumscribed tumor or cyst and 23 healthy controls performed a REAPPself task, in which they had to either observe negative stimuli or decrease emotional responding by REAPPself. Next, they rated the impact of negative arousal and valence. REAPPself ability scores were calculated by subtracting the negative picture ratings after applying REAPPself from the ratings of the observing condition. The scores of the patients were included in a voxel-based lesion-symptom mapping (VLSM) analysis to identify deficit related areas (ROI). Then, a ROI group-wise comparison was performed. Additionally, a whole-brain voxel-based-morphometry (VBM) analysis was run, in which healthy participant's REAPPself ability scores were correlated with gray matter intensities. Results showed that (1) regions in the right superior frontal gyrus (SFG), comprising the right dorsolateral prefrontal cortex (BA9) and the right dorsal anterior cingulate cortex (BA32), were associated with patient's impaired down-regulation of arousal, (2) a lesion in the depicted ROI occasioned significant REAPPself impairments, (3) REAPPself ability of controls was linked with increased gray matter intensities in the ROI regions. Our findings show for the first time that the neural integrity and the structural volume of right SFG regions (BA9/32) might be indispensable for REAPPself. Implications for neurofeedback research are discussed.