نقش تنظیم احساسات در توهمات شنوایی

Emotion regulation involves the use of strategies to influence the experience and expression of emotions. Anxiety and depression are strongly associated with the positive symptoms of schizophrenia, such as auditory hallucinations (AHs). Individuals usually try to down-regulate (decrease) such emotions, consequently abnormal or maladaptive use of one or more of these down-regulatory processes (e.g. increased use of expressive suppression or maladaptive attentional deployment, i.e. rumination/worry) may play an important role in AHs (e.g. increasing AH severity and distress). This study examined the self-reported use of a range of emotion regulation strategies in individuals with schizophrenia and current AHs (SZ AH; N = 34) and healthy controls (N = 34). Two separable dimensions of hallucinatory experiences (severity and distress) were assessed together with measures of anxiety, depression and happiness. Within the SZ AH group, greater use of expressive suppression was associated with an increase in severity of AHs and greater disruption in daily life. In addition, rumination was significantly positively correlated with the distress (but not with the severity) associated with AHs. Within the control group, expressive suppression, rumination and worry were associated with more anxiety/depression and less happiness, as predicted. The implications of different emotion regulation strategies for the treatment of individuals with schizophrenia and AHs are discussed.

Emotion regulation broadly refers to “people's active attempts to manage their emotional states” (Koole, 2009, p. 10). Various emotion regulation strategies are available to increase, maintain or decrease positive and negative emotions, and individuals vary in which of these control processes they tend to select (John and Gross, 2007). Different strategies for emotion regulation are associated with different affective, cognitive and social consequences (Gross, 2002) and different underlying neural circuits (Ochsner et al., 2004, Ochsner & Gross, 2005 and Goldin et al., 2008). Individuals with schizophrenia show significant abnormalities in the experience, expression and perception of emotion (Aleman & Kahn, 2005, Tremeau, 2006, Pinkham et al., 2007 and Kring & Moran, 2008). Recent evidence also points to the existence of dysfunctional emotion regulation (Henry et al., 2007, Henry et al., 2008 and van der Meer et al., 2009), which may be an important predictor of coping with psychotic symptoms (Bak et al., 2008). For example, Henry et al. reported that although emotion regulation skills, assessed with the Emotion Regulation Questionnaire (ERQ; reappraisal and suppression), were not significantly lower in schizophrenia patients as a group, compared to healthy controls, within the schizophrenia group, blunted affect (a negative symptom of psychosis) was associated with difficulties amplifying (up-regulating) emotional expression and not with the over-use of suppression (Henry et al., 2007 and Henry et al., 2008). These findings highlight the potential importance of understanding the interplay between emotion regulation strategies and individual symptoms of schizophrenia. Elsewhere van der Meer et al. (2009) have reported that schizophrenia patients use significantly more suppression and somewhat less reappraisal as measured with the ERQ; however, to our knowledge no studies to date have examined the relationship between these different emotion regulation strategies and the positive symptoms of psychosis. The positive symptoms of schizophrenia, such as auditory hallucinations (AHs) are strongly associated with the experience of heightened anxiety and depressed mood (Morrison, 2001, Birchwood, 2003, Freeman & Garety, 2003, Smith et al., 2006 and Lysaker & Salyers, 2007) which are normally under the control of down-regulatory strategies (John and Gross, 2007) such as changing attention to the meaning of, or bodily expression of emotions (Koole, 2009). Consequently, AHs may be linked to deficient or inappropriate regulation in one or more of these processes. Expressive suppression involves inhibiting behavioural responses (e.g. facial or vocal expressions) to emotional stimuli. Suppression is, in fact, an ineffective strategy for reducing the experience of unwanted emotions, and repeated use of this strategy typically leads to reduced control of emotion, poor memory, a lower level of happiness, increased depression and poor social interactions (Gross, 2002 and Gross & John, 2003). No studies have specifically examined emotional suppression in individuals with AHs, however, recent evidence clearly shows that successful emotional down-regulation draws heavily on executive functioning (Gyurak et al., 2009), which is typically impaired in schizophrenia. For example, intentional inhibition of non-emotional stimuli is abnormal in individuals with schizophrenia and is significantly correlated with the severity of AHs (Waters et al., 2003). Recent evidence also suggests that these various forms of (inhibitory) self-control rely on limited, common resources (Baumeister et al., 2007 and Goldin et al., 2008). Consequently, the tendency to utilize emotional suppression to handle unwanted emotions (e.g. anxiety) in individuals with schizophrenia may contribute to the development or maintenance of AHs by taxing already depleted executive abilities — such as inhibitory control. Unsuccessful or less frequent inhibition might be expected to increase the frequency or duration of AHs (Waters et al., 2003). Thus, the severity of AHs in schizophrenia may be associated with an abnormality (increased use) of expressive suppression. Alternative strategies for emotional down-regulation involve changing attention to, or the meaning (beliefs or appraisals) of emotionally relevant information. These forms of emotion regulation generally result in more favourable health outcomes, including more happiness and less anxiety or depression (John and Gross, 2007). Cognitive models of psychosis have clearly emphasized the importance of abnormal attention (e.g. worry and rumination), appraisal1 or reappraisal in the onset, maintenance and, in particular, the distress associated with positive symptoms (Fowler, 2000, Morrison, 2001, Bentall, 2003, Birchwood, 2003 and Morrison & Wells, 2007). For example, in individuals with schizophrenia, negative beliefs about the self are specifically associated with the heightened distress related to AHs rather than the severity of the experience (Smith et al., 2006). Repeatedly thinking about negative events (i.e. worrying or ruminating) may increase the likelihood that such negative beliefs are triggered by inadvertently prolonging negative emotional states (Nolen-Hoeksema et al., 1994). Alternatively, rumination or worry may repetitively focus an individual's attention on the possible causes, content or future implications of AHs in such a way as to preclude active problem solving (Lyubomirsky and Nolen-Hoeksema, 1995) and thereby enhance subjective distress. Consequently, the distress associated with AHs (but not the severity) may be linked to excessive worrying or rumination, though only limited empirical support for this association has so far been provided (Morrison and Wells, 2007). In summary, the aim of the current study was to examine the relationship between emotion regulation and the experience of AHs; specifically whether the separable dimensions of AHs – distress and severity – may be related selectively to maladaptive attentional deployment (i.e. worry or rumination) and to abnormal use of expressive suppression, respectively. In order to test these predictions, we assessed multiple forms of emotion regulation in a group of individuals with schizophrenia who were currently experiencing AHs. In order to check that the pattern of relationships observed in individuals with schizophrenia does not simply reflect atypical responses to the ERQ in Australian participants (Haga et al., 2009) we also examined emotion regulation in a healthy control group.