Emotion and Mental Health –
Associations, Assessments, and Clinical Implications
Dissertation
submitted in partial fulfillment of the requirements for the degree of
Doctor rerum naturalium (Dr. rer. nat.)
August, 2019
Christina Totzeck
Faculty of Psychology
Ruhr-Universität Bochum
Printed with permission of the Faculty of Psychology,
Ruhr-Universität Bochum
First reviewer: Prof. Dr. Jürgen Margraf, Ruhr-Universität Bochum
Second reviewer: Prof. Dr. Stefan G. Hofmann, Boston University
Date of the thesis defense: October 17th, 2019
To the most wonderful Mom
Hallelujah
You were an angel in the shape of my mum
You got to see the person I have become
Spread your wings and I know
That when God took you back he said, "Hallelujah
You're home"
- Ed Sheeran -
Preface
Abstract
Emotion research, especially in the context of clinical psychology, is essential in order to promote the understanding of the complex interplay of emotions and mental health. The present thesis sets out to gain more insight into this association by addressing five specific aspects:
Emotion induction, habitual emotion regulation in particular clinical populations as well as its changes through cognitive behavioral therapy (CBT), and furthermore the effects of positive interventions on mental health including the role of positive mental health. To address these objectives, five research studies have been conducted. The results of Study 1 showed that the three targeted emotions happiness, sadness, and fear as well as a neutral state could be selectively induced in a German sample (N = 120). The findings of Study 2 revealed an association of affective styles with psychopathology in a large clinical outpatient sample (N =
917). In Study 3, changes of affective styles throughout exposure-based therapy were found in patients suffering from panic disorder, agoraphobia and specific phobia (N = 101). The results of Study 4 showed short- and long-term effects of a positive intervention on negative and positive mental health factors in German university students (N = 55), who significantly improved when compared to a matched control group (N = 55). Finally, Study 5 found positive mental health to be a strong predictor of treatment outcome in an anxiety disordered population
(N = 130) receiving exposure-based therapy. The results of the five studies are discussed in the broader context of emotion research and translated into clinical implications. Future research perspectives are suggested.
III Preface
Statement
I hereby declare that I have prepared this submitted thesis independently and without the help of others. I assure that I have not used any other sources or aids than those indicated. Those parts that have been taken literally or correspondingly from published or unpublished texts or other sources have been cited completely and correctly. This thesis has not been submitted before at this or any other institution. Furthermore, I assure that the electronic version submitted is completely consistent with the written version.
This thesis comprises five empirical studies; the reports of these studies have been submitted, are currently under review for publication or have already been published in peer-reviewed journals. The references below provide the relevant publication information:
Totzeck, C., Zhang, X.C., Pflug, V., Teismann, T., Margraf, J., & Adolph, D. Old movies vs. new movies – Development and validation of an emotional film set. Manuscript submitted for publication.
Totzeck, C., Teismann, T., Hofmann, S.G., Pflug, V., von Brachel, R., Zhang, X.C. & Margraf, J. (2018). Affective styles in mood and anxiety disorders – Clinical validation of the “Affective Style Questionnaire” (ASQ). Journal of Affective Disorders, 238, 392-398.
Totzeck, C., Teismann, T., Hofmann, S.G., von Brachel, R., Zhang, X.C., Wannemüller, A., Pflug, V., & Margraf, J. (in press). Affective styles in panic disorder and specific phobia: Changes through cognitive behavior therapy and prediction of remission. Behavior Therapy.
Totzeck, C., Teismann, T., Hofmann, S.G., von Brachel, R., Pflug, V., Wannemüller, A., & Margraf, J. May you be happy – Loving-kindness meditation promotes mental health in university students. Manuscript submitted for publication.
Teismann, T., Brailovskaia, J., Totzeck, C., Wannemüller, A., & Margraf, J. (2018). Predictors of remission from panic disorder, agoraphobia and specific phobia in outpatients receiving exposure therapy: The importance of positive mental health. Behaviour Research and Therapy, 108, 40–44.
IV Preface
Own contributions to these publications:
Publication 1: I was involved in the study conception and design as well as in the data acquisition. I analyzed and interpreted the data. I wrote the draft of the manuscript and incorporated the co-authors’ comments into the final version of the report.
Publication 2: I was responsible for the conception and design as well as the data analysis and interpretation. In addition, I wrote the draft of the manuscript and revised it with assistance of the co-authors’ feedback.
Publication 3: This was a secondary analysis of a study on genetic factors in exposure treatments. I was responsible for the conception and design as well as the data analysis and interpretation. I drafted and revised the manuscript. All co-authors provided essential conceptual, statistical, and editorial support and gave important intellectual feedback to all drafts of the manuscript.
Publication 4: I was responsible for the study design, data acquisition, analysis and interpretation. I translated the treatment manual, and I conducted the majority of treatment sessions. I was involved in data acquisition, I wrote the draft of the manuscript and incorporated the co-authors’ comments into the final report.
Publication 5: I contributed to the study design and provided feedback to the manuscript.
Date:
Signature:
V Preface
Acknowledgments
First of all, I would like to express my deepest gratitude to my supervisors and mentors Prof. Dr. Jurgen̈ Margraf and Prof. Dr. Stefan Hofmann for their enthusiastic encouragement, trust, and outstanding support. Without your excellent guidance and committed help, this dissertation would not have been possible. I would like to thank my wonderful colleagues and co-authors, especially PD Dr. Tobias Teismann, Dr. XiaoChi Zhang, and my good friend Verena Pflug for their valuable support, advice, and honesty. In addition, I would like to thank Helen Copeland-Vollrath: kiitos kaikesta, olet upea! My gratitude is extended to the Konrad-Adenauer Foundation: I feel honored and appreciative for receiving a PhD scholarship, and I am deeply grateful for the financial and individual support, for an amazing seminar program, and for unforgettable experiences and memories. I would also like to thank my dear brothers, PD Dr. Matthias Totzeck, Dr. Andreas Totzeck, and Dr. Markus Totzeck, and my brother in law, Dr. Björn Weiß, for their awesome support and encouragement throughout my study, and Jan Ellebrecht for his love and patience with me.
Special thanks go to my office colleagues Ike, Sam, and Franzi: Thank you for making every day bueno.
Zuguterletzt möchte ich meinem größten Vorbild danken: Meinem geliebten Vater, Dr. Baldur Totzeck. Danke für deine Unterstützung, für deinen unerschütterlichen Glauben an uns, dass du immer die richtigen Worte findest und diesen Weg überhaupt erst ermöglicht hast.
VI Contents
Table of Contents
Preface Abstract III
Statement IV
Acknowledgements VI
Contents Table of Contents VII
Figure Directory IX
List of Abbreviations X
CHAPTER 1 General Introduction 1
Definition of Emotion, Affect, and Mood 2
The Concept of Basic Emotion 5
Neural Substrates of Emotions 9
Emotion Regulation 10
Assessing Inter-Individual Differences in Emotion Regulation 12
Neurobiology of Emotion Regulation 14
Emotions and Psychopathology 16
Effects of Treatment 17
Positive Mental Health 19
Aims of this Thesis 20
CHAPTER 2 Study 1 Old movies vs. new movies – Development and validation of a new emotional film set 23
CHAPTER 3 Study 2 Affective styles in mood and anxiety disorders – Clinical validation of the “Affective Style Questionnaire” (ASQ) 46
VII Contents
CHAPTER 4 Study 3 Affective styles in panic disorder and specific phobia – Changes through cognitive behavior therapy and prediction of remission 53
CHAPTER 5 Study 4 May you be happy – Loving-kindness meditation promotes mental health in university students 64
CHAPTER 6 Study 5 Predictors of remission from panic disorder, agoraphobia and specific phobia in outpatients receiving exposure therapy: The importance of positive mental health 86
CHAPTER 7 General Discussion 91
Summary of the Main Findings 92
Answers to the Research Questions 94
Conclusions and Clinical Implications 100
Final Evaluation 103
References 104
Appendix
Curriculum Vitae 117
List of Publications 118
Conference Presentations 120
VIII Contents
Figure Directory
Figure 1. A schematic representation of circumplex model of affect. p. 4
Figure 2. A consensual process model of emotion generation. p. 6
Figure 3. Plutchik’s theoretical model of basic emotions. p. 7
Figure 4. Similarities and differences of basic emotions concepts. p. 7
Figure 5. Emotion regulation model. p. 11
Figure 6. The heuristic model of neural processing of emotion regulation. p. 14
Figure 7. The Cognitive-Neurobiological Information Processing Model of Fear and Anxiety. p. 15
Figure 8. Affective styles in different populations. p. 101
Figure 9. A hierarchical conception of affect regulation. p. 102
IX Contents
Abbreviations
ACC = anterior cingulate cortex. aMCC = anterior midcingulate cortex.
ASQ = Affective Style Questionnaire.
CBT = cognitive behavioral therapy. dlPFC = dorsolateral prefrontal cortex.
ERQ = Emotion Regulation Questionnaire.
LKM = Loving-kindness Meditation.
PFC = prefrontal cortex.
PMH-scale = Positive Mental Health-scale.
SMA = supplementary motor area.
STG = superior temporal gyrus. vlPFC = ventrolateral prefrontal cortex.
X CHAPTER 1
General Introduction Emotions are the music of our soul.
Emotions define our everyday lives; they shape how we feel, what we think and how we behave. They contribute to important decisions, such as who we fall in love with, what we want to work on, or what we prefer to avoid. Every human being is affected by emotions, as we all feel several different emotional states, daily. This applies not only to beautiful and positive emotions, but also, in particular, to negative ones. We all know the feeling of grief when we lose somebody we love, or the feeling of being afraid of something strange or unknown.
Although all these different emotions are part of being a human being, they can also give rise to psychological problems. When their intensity, frequency, or duration leads to suffering, or when they can no longer be managed and controlled, help is needed. Patients seek psychotherapeutic counseling because they feel sad, anxious or angry. Or they might no longer feel anything. The primary goal of psychotherapy, therefore, is to make the patient feel better.
In order to do so, we have to understand the exact mechanisms of emotions themselves, the process how we handle these emotions as well as what we need to change to optimize treatment.
In other words: We have to fully translate emotion research into clinical implications.
The present thesis sets out to build a bridge between emotion research and clinical implications by addressing the following research questions: How can we reliably induce emotional states in order to examine their impact on cognitive, social, and behavioral functioning (Study 1)? How do people suffering from mental disorders handle their emotions
(Study 2)? How do these strategies change through psychotherapeutic treatment (Study 3)?
What happens to mental health when we directly address positive emotions (Study 4)? And finally, how are positive factors of mental health associated with therapy outcome (Study 5)?
The introduction section of this thesis covers an overview of the most important definitions and differentiations between emotions, affects, and moods, followed by a brief outline of current findings on basic emotions, including neurobiological information.
1 CHAPTER 1
Afterwards, the most important findings of emotion regulation as well as its association with psychopathology are presented. Subsequently, the effects of psychotherapeutic treatment on emotional dysregulation and the effects of positive intervention on mental health are elaborated.
Finally, the role of positive mental health is presented. The introduction concludes with an overview of the main goals of the five empirical studies conducted as part of this thesis.
Definition of Emotion, Affect, and Mood The beginning of wisdom is the definition of terms. -Socrates-
Although the current definitions of the terms emotion, affect, and mood in psychological research will be presented below, this does not mean that these constructs should and can be considered completely independently as they are all part of affective phenomena (Ekkekakis,
2012). The definitions intend to promote clarity in the differences and similarities of the constructs.
The most frequently examined construct is emotion with its variety of associated definitions which express the complexity of emotions. However, there is mutual consensus that an emotion comprises not only physiological changes (e.g. on the neuroendocrine level through the release of hormones or reactions of the automatic nervous system), but also expressive, cognitive, motivational, and affective components (Lochner 2016). Whereas the expressive component refers to the expression of the emotion, such as nonverbal expression through mimic or gestural moves, the cognitive component includes all individual evaluations, the motivational component implies all action tendencies evoked, and the affective component refers to an individual’s experience of the emotion (Lischetzke & Eid, 2011; Lochner, 2016;
Scherer, 2005).
The definition of emotion by Hofmann (2016) comprises all contributing factors: “An emotion is (1) a multidimensional experience that is (2) characterized by different levels of
2 CHAPTER 1 arousal and degrees of pleasure-displeasure; (3) associated with subjective experiences, somatic sensations, and motivational tendencies; (4) colored by contextual and cultural factors; and that
(5) can be regulated to some degree through intra- and interpersonal processes” (Hofmann,
2016, p. 2).
The most difficult differentiation of the terms is the distinction between emotion and affect, because these two constructs are closely related (Hofmann, 2016). Philosophers have searched for definitions over centuries (Bradley & Lang, 2000). In psychology, the debate is on-going with respect to the question how to differentiate affect from emotion; most authors use the term affect as an umbrella term for emotion and mood (Frijda, 1994; Lochner, 2016).
However, some authors suggest that, at its core, affect refers to the subjective experience of an emotional state, which can be either positive or negative as well as arousing or calming (Barrett,
Mesquita, Ochsner, & Gross, 2007; Hofmann, 2016). This core affect is described as a state accessible to consciousness as a single and simple feeling, such as feeling either good or bad, tired or energized (Yik, Russell, & Steiger, 2011). This differentiation of valence and arousal has been labelled as “circumplex model of affect” (Russell, 1980; Colibazzi et al., 2010), which is presented in Figure 1. Its dimensions have also been referred to as core affect (Hofmann,
2016; Russell & Barrett, 1999; Yik, Russell, & Steiger, 2011). It is one of the most widely empirically supported dimensional models of affect (Russell & Barrett, 1999; Yik, Russell, &
Steiger, 2011), because of its robustness, utility, and parsimony (Hofmann, 2016). Although the model cannot account for all individual differences among affects, it provides an applicable way to describe the complexity of emotional experiences (Hofmann, 2016; Yik, Russell, &
Steiger, 2011).
Core affect is part of emotions and moods, but unlike them, it is seen to be accessible continuously: “Whenever asked, people can tell you how they feel” (Yik, Russell, & Steiger,
2011, p. 705). Thereby, the concept of core affect captures simple feelings that are present
3 CHAPTER 1 continuously, yet not always salient. “Core Affect is not equivalent to ‘mood’ or ‘emotion’, but is a key ingredient in both” (Yik, Russell, & Steiger, 2011, p. 723). Therefore, affect can be seen as an umbrella term for psychological states that involve valuating a relatively quick
“good-for-me/bad-for-me discrimination” (Gross, 2015; Scherer, 1984).
In the first study of this thesis, both emotions as well as core affect are assessed using different measures (see Study 1, Chapter 2). Furthermore, the differentiation between emotion and affect also plays an important role when examining the different patterns of regulation (see
Study 2 and Study 3, Chapters 3-4).
ACTIVATION
tense alert nervous excited stressed elated upset happy
UNPLEASANT PLEASANT sad contented depressed serene bored relaxed fatigue calm
DEACTIVATION
Figure 1. A schematic representation of circumplex model of affect. The horizontal axis represents the valence dimension (pleasant–unpleasant), and the vertical axis represents the arousal dimension. Modified from Colibazzi et al. (2010).
Although the terms emotion and mood are also often used interchangeably (Batson,
Shaw, & Oleson, 1992), they can be separated as they describe distinct phenomena (Lochner,
2016). Emotions mostly have a stimulus event; they are rather intense but short in duration, and they have behavioral implications (Scherer, 2005). When compared to these properties, moods differ from emotions as they contain global, undirected, and rather unconscious background sensations that are more stable than emotions (Lischetzke & Eid, 2011; Lochner, 2016). And
4 CHAPTER 1 finally, mood can be defined as “purely inner experience – an individual’s perception of his or her own inner state” (Lochner, 2016, p. 43).
In reference to the initial metaphor of emotions being the music of our soul in this introduction, affect would be like standing next to a booming base box and feeling the arousing bodily reaction to the vibration, whereas mood would be like a consistent background sound, such as elevator music that keeps playing without being constantly noticed. Emotion, on the other hand, would be like listening to a song that makes you sing and dance, feeling happy and excited.
The Concept of Basic Emotions Emotions are the captains of our lives, and we obey them without realizing it. -Vincent van Gogh-
Each palpitation or arousing feeling does not result in an emotion, because only our very individual evaluations based on our subjective individual experiences transform physical changes into an emotion. Van Gogh might have been correct in his view that we feel intense emotional experiences once in a while without having noticed their arising. Indeed, several previous studies investigated how emotions impact our cognitions, for example, our attention, memory, and decision-making, which we might not always be consciously aware of (Dolan
2002). However, we do not obey them as van Gogh assumed (Torre, 2011). Instead, we are rather capable of modulating our own emotions. As depicted in Figure 2, emotions arise whenever we evaluate a situation as offering important challenges or opportunities (Gross,
1998b; Tooby & Cosmides, 1990a, 1990b, 2008).
5 CHAPTER 1
Emotional Response Emotional Tendencies Emotional Cues - Behavioral Responses - Experiential - Physiological
Evaluation Modulation
Figure 2. A consensual process model of emotion generation. Modified from Gross (1998b).
We decide which stimuli to attend to and which to ignore. We, then, label what we feel and categorize the feeling in order to help our brain to react adequately. When we categorize something, we render it meaningful (Lindquist, Wager, Kober, Bliss-Moreau, & Barrett, 2012).
Although the concept of categorization dates back at least to a first-century Chinese encyclopedia (Fu, 2012), which identifies “like, dislike, joy, anger, sorrow and pleasure” as seven ‘feelings of men’, the categorization of basic emotions has been integrated in psychology research only since Paul Ekman’s studies (e.g. 1972, 1973). At first, his categorization of six basic emotions (happiness, sadness, fear, anger, disgust, and surprise) was proposed and often used in further emotion research. All of our other emotions are seen to build upon these basic emotions. For instance, jealousy originates from a combined feeling of anger and sadness, while admiration can be a type of happiness. However, Ekman’s categorization has often been criticized. Plutchik (1980), for instance, argued that eight instead of six basic emotions exist, which he grouped into four pairs of polar opposites (joy-sadness, anger-fear, trust-distrust, surprise-anticipation; see Figure 3). All other emotions are seen as different levels of arousal intensity of these basic emotions.
6 CHAPTER 1
optimism
aggressiveness love interest serenity
anticipation joy
annoyance acceptation vigilance ecstasy anger trust rage admiration contempt submission loathing terror disgust grief fear boredom amazement apprehension
sadness surprise
pensiveness distraction remorse awe
disapproval
Figure 3. Plutchik’s theoretical model of basic emotions. Modified from Plutchik (1980).
In 2011, Ekman and Cordaro (2011), Izard (2011), Levenson (2011), and Panksepp and
Watt (2011) outlined the latest instantiation of their theoretical models of basic emotions (Tracy
& Randles, 2011). Their models differ in the number and in some forms of basic emotions (see
Figure 4).
PANKSEPP EKMAN IZARD & LEVENSON & WATT CORDARO
Happiness Play Enjoyment Happiness Sadness Panic/Grief Sadness Sadness Fear Fear Fear Fear Anger Rage Anger Anger Disgust - Disgust Disgust Interest Seeking Interest? - Contempt? - - Contempt - Lust Love? - - Care Relief? Surprise
Figure 4. Similarities and differences of basic emotions concepts. Modified from Tracy and Randles (2011). Note: ? = Included in the authors’ model (by Tracy & Randles, 2011), but the author(s) suggested that clear-cut supporting evidence is not yet available.
7 CHAPTER 1
These theoretical models share the categorization of the four emotions, although label them differently: Happiness (or play or enjoyment), sadness (or grief), anger (or rage), and fear.
Using facial expression signals, Jack, Garrod, and Shyns (2014) also suggest exactly this distinction of four instead of six basic emotions: Happiness, sadness, anger/disgust and fear/surprise. Their results revealed that facial expressions of anger and disgust as well as fear and surprise were not as distinct as previously assumed (Jack, Garrod, & Shyns, 2014). Similar results were presented in a meta-analysis by Lench, Flores, and Bench (2011), who examined the extent to which discrete emotions elicit changes in cognition, judgment, behavior, and physiology. They included 687 studies using emotion elicitation methods to induce happiness, sadness, anger, and anxiety. In line with basic emotion theory, they found differences among these discrete emotions as well as correlated changes in behavior, experience, and physiology
(Lench, Flores, & Bench, 2011).
Although the discussion about categorization models continues, it is crucial to define fundamental categories to promote the investigation of emotions. In order to examine the exact mechanism of emotion and emotional processing, we rely on categorization. It enables us to make reasonable inferences about (a) what we perceive, (b) to predict what to do with it, and
(c) to communicate our experience to others (Lindquist et al., 2012). So besides the ongoing debate about how categorization works, the fact that it functions is not in question (Lindquist et al., 2012). The first study of this thesis adds on this aspect by developing and validating a new set of emotion induction film sequences that address the three main basic emotion categories (happiness, sadness, and fear) while assessing the previous six (happiness, sadness, fear, anger, disgust, and surprise) basic emotions (see Study 1, Chapter 2).
8 CHAPTER 1
Neural Substrates of Emotions The brain is not the mind. -David Brooks-
One way to underscore the concept of categorization is the examination of specific patterns of neural activation. Although it is impossible to predict or even understand emotions, affects, and moods only based on brain activation pattern, neural underpinnings are helpful in a further understanding of the exact mechanism of emotional experiences and furthermore in grasping the development of mental disorders. For instance, a meta-analysis by Fusar-Poli,
Placentino, Carletti and colleagues (2009) that included 105 functional Magnet Resonance
Imaging (fMRI) studies using emotional face processing showed that, at least with respect to the level of resolution of fMRI, there appear to be limbic and insular differences between the basic emotions. The following regions have been found to be relevant (adapted from Fusar-Poli et al., 2009):
1. Happy faces are associated with neural activation in the bilateral amygdala, left
fusiform gyrus and right anterior cingulate cortex.
2. Sad faces activate the right amygdala and the left lingual gyrus.
3. Angry faces are associated with increased neural response in the left insula and right
inferior occipital gyrus.
4. Fear is associated with activation in the bilateral amygdala and the fusiform and
medial frontal gyri.
5. Disgust is associated with neural activation in the insula bilaterally, right thalamus
and left fusiform gyrus.
Interestingly, the authors detected bilateral activation of the amygdala only when processing fearful and happy faces. Furthermore, they directly compared happy, fearful, and
9 CHAPTER 1 sad faces, which confirmed that amygdala sensitivity was greater during the fearful stimulus than in the other two conditions. Amygdala engagement during processing of fearful faces is therefore a strong and consistent finding in the available fMRI literature, which corresponds to previous findings showing a particularly important role of the amygdala in processing fear and anxiety (e.g., LeDoux, 2003).
Taken together the findings suggest that the processing of emotional faces is implemented by neural systems that are at least partially separable, although they are not represented by entirely distinct neural circuits (Fusar-Poli et al., 2009). When it comes to more general emotional processing above and beyond emotional faces, there are opposing findings:
A meta-analysis by Lindquist and colleagues (2012) which included fMRI studies on emotional processing in a more general way underscores the assumption that discrete emotion categories are constructed of more general brain networks not specific to those categories. Overall, a better understanding of emotional experiences can be promoted by a more complete knowledge of their accompanying neurology and physiology. Therefore, studies investigating which brain regions are activated during specific emotional experiences (e.g., Koenig & Mecklinger, 2008), and also which emotions are elicited by the stimulation of specific brain regions (e.g., Singer et al., 2008), will be helpful in the next stage of emotion research (Tracy & Randles, 2011).
The principal use of prudence or self-control is Emotion Regulation that it teaches us to be masters of our passions. -Descartes-
Just as we all differ in our taste of music, we differ in our minds’ and bodies’ creation of emotions. This relies to the speed and intensity of emotional reactions to similar threats and rewards and to the use of response strategies to these emotions (Dennis, 2007). As Gross
(1998b) defined, emotion regulation refers to “the processes by which individuals influence
10 CHAPTER 1 which emotions they have, when they have them, and how they experience and express these emotions” (Gross, 1998b, p. 275). These regulatory processes may be either automatic or controlled, they can be conscious or unconscious, and they have the goal to start, stop or otherwise modulate the trajectory of an emotion (Etkin, Büchel, & Gross, 2015; Gross, 1998b;
2015). Generally, we can regulate our own emotions (intrinsic/intrapersonal) or someone else’s emotions (extrinsic/interpersonal) (Gross & Jazaieri, 2014). Beside the fact that we typically try to decrease the experiential and/or behavioral aspects of negative emotions (Gross,
Richards, & John, 2006), we also down-regulate positive emotions to some extent (Gross,
2015). This, for example, happens when we try to avoid laughing at an inappropriate circumstance (Giuliani, McRae, & Gross, 2008), or when we try to look less happy about a positive message when a friend is feeling bad. Furthermore, we not only practice down- regulating but also up-regulating of positive emotions, as when we, for example, maintain enthusiasm in order to determine a thesis, or when we enhance joy and gratitude about a gift we do not really like. Gross (1998a, 1998b) categorized regulatory strategies as either antecedent-focused used to manipulate the input to the emotion generation system (see Figure
2) or alternately as response-focused when the output is manipulated. Figure 5 presents this emotion regulation model.
Situations Aspects Meanings Responses S1 S1x A1 M1 • B+ Emotional Response B • B Tendencies • B- S2x A1 A2 M1 • E+ S2 - Behavioral S2y A3 E • E - Experiential • E- S2z A4 M2 A5 - Physiological • P+ M3 P • P • P-
Situation Situation Attentional Cognitive Response Selection Modification Deployment Change Modulation
Antecedent-Focused Response-Focused Emotion Regulation Emotion Regulation
Figure 5. Emotion regulation model. Modified from Gross (1998b, 2015).
11 CHAPTER 1
According to Gross’ model, many situations (S2), although not all (S1), can be selected, modified (S2x-S2z), and selectively attended to (A1-A5). Using Cognitive Change refers to our selection out of the various possible meanings (M1-M3), and the attachment of this chosen meaning (M2) to the situation. It is this meaning (M2) that evokes emotional response tendencies, including behavioral, experiential, and physiological components. Once the emotional response tendencies have been evoked, response modulation is used to influence these tendencies (Gross, 1998b; 2015).
Two important aspects of this model have received particular empirical attention:
Cognitive reappraisal (as a part of Cognitive Change) and expressive suppression (Gross &
John, 2003; Ochsner, Bunge, Gross, & Gabrieli, 2002). Cognitive reappraisal as an antecedent- focus strategy serves to change the negative emotional impact before distress is fully activated.
Expressive suppression, on the other hand, as a response-focused strategy is used to avoid an ongoing negative emotion. The use of these two concrete emotion regulation strategies can be assessed with the “Emotion Regulation Questionnaire” (ERQ; Gross & John, 2003). Research using the ERQ has shown that antecedent-focused strategies are relatively effective, whereas response-focused strategies tend to paradoxically increase negative emotions (Gross, 1998a;
Aldao, Nolen-Hoeksema, & Schweizer, 2010).
Assessing Inter-Individual Differences We are all alike, on the inside. -Mark Twain- in Emotion Regulation
We all have our own specific habits in the use of the above-described strategies. Some people tolerate feeling sad or anxious, whereas others react to such emotions by immediately appraising them as intolerable and subsequently engage in maladaptive response-focused strategies (Gross & John, 2003). They try to suppress feeling sad or escape from an argument with a partner in order to suppress feeling angry. This broad range of individual responses to
12 CHAPTER 1 emotional stimuli is referred to as affective style (Davidson, 1998, 2000, 2002; Hofmann,
Sawyer, Fang, & Asnaani, 2012).
In order to promote the understanding of an adaptive versus maladaptive use of regulatory strategies, we need to gain more insight into affective styles, in particular of those people suffering from mental disorders. With the development of the “Affective Style
Questionnaire” (ASQ), Hofmann and Kashdan (2010) aimed to provide a tool to assess such inter-individual differences in the habitual use of emotion regulation strategies. Based on
Gross’ (1998b) process model of emotion regulation (see Figure 5), the ASQ distinguishes three main affective styles: concealing, adjusting, and tolerating (Hofmann et al., 2012). The concealing style includes suppression and other response-focused strategies aimed at concealing and avoiding emotions after they arise. Previous studies have shown that especially men tend to prefer to conceal emotions (Hofmann & Kashdan, 2010; Graser et al., 2012). The adjusting style involves the modulation of negative emotions by balancing and successfully readjusting emotional experiences and expressions as needed in a particular context. The tolerating style encompasses accepting and non-defensive responses to arousing emotional experiences as they exist in the present moment. The tolerating style, including acceptance strategies, allows tolerance of strong emotions and is more often used by women than men
(Hofmann & Kashdan, 2010; Graser et al., 2012). The results of previous validation studies provided evidence for the applicability of the ASQ within nonclinical populations (Hofmann &
Kashdan, 2010; Graser et al., 2012; Ito & Hofmann, 2014). However, there is still a lack of clinical data. The second study addresses this paucity (see Study 2, Chapter 3).
13 CHAPTER 1
Neurobiology of Emotion Regulation We are not thinking machines that feel; rather, we are feeling machines that think. -Antonio Damasio-
Besides the investigation of neural correlates of emotional experiences (see section
Neurobiology of emotions), previous studies have aimed to elucidate neurobiological processes that are involved in emotion regulation (e.g., Greening, Lee, & Mather, 2014). Kohn and colleagues (2014) published a meta-analysis examining the neural pathways involved in emotion regulation. In their conclusion, they present a heuristic model of neural processing of emotion regulation that relates to the modal model of emotion regulation by Gross (1998b; see
Figure 5). Briefly summarized, they propose that affective arousal is relayed via amygdala and basal ganglia to the anterior midcingulate cortex (aMCC), the ventrolateral prefrontal cortex
(vlPFC), and the anterior insula as well as supplementary motor area (SMA), the superior temporal gyrus (STG) and angular gyrus (see Figure 6.1). The vlPFC then initiates the appraisal and signals the need for regulation to the dorsolateral prefrontal cortex (dlPFC; see Figure 6.2).
Finally, the dlFPC processes the regulation itself and gives a feedforward signal (via the aMCC or directly) to angular gyrus, SMA, STG, amygdala and basal ganglia, which generate a
(regulated) emotional state (see Figure 6.3).
SMA SMA SMA dlPFC dlPFC dlPFC
aMCC aMCC aMCC angular gyrus angular gyrus angular gyrus
vlPFC/Insula STG vlPFC/Insula STG vlPFC/Insula STG Amygdala/ Amygdala/ Amygdala/ Basal ganglia Basal ganglia Basal ganglia
Figure 6.1 Figure 6.2 Figure 6.3
Figure 6. The heuristic model of neural processing of emotion regulation. Modified from Kohn et al. (2014). Note: aMCC = anterior midcingulate cortex, dlPFC = dorsolateral prefrontal cortex, SMA = supplementary motor area, STG = superior temporal gyrus, vlPFC = ventrolateral prefrontal cortex.
14 CHAPTER 1
Integrating previous findings, Hofmann, Ellard, and Siegle (2012) proposed their cognitive-neurobiological information processing model (see Figure 7).
Stimulus
Perception of Amygdala Early Potential Threat
Detection of Hippocampus Threat
Temporal Processing Selection of Insular Behavioral Coping Strategies Cortex Response
Emotion Autonomic PFC ACC Late Regulation Response
Psychological Biological Psychophysiological Level Level Level
Figure 7. The Cognitive-Neurobiological Information Processing Model of Fear and Anxiety. Modified from Hofmann, Ellard, & Siegle (2012). Note: PFC = prefrontal cortex, ACC = anterior cingulate cortex.
The model displays the interplay and relationship between different brain structures and the information processing stages on the psychological, biological, and psychophysiological levels. For instance, a pathological state, such as depression, appears to be associated with a decreased prefrontal function that then causes a decreased regulatory control. The patient has, therefore, less access to adaptive strategies to adequately regulate the depressive mood.
Excessive fear and abnormal anxiety, on the other hand, seem to involve preserved regulatory control. Here, learned beliefs regarding the appropriateness and use of avoidant coping strategies are activated. These strategies can then contribute to the maintenance of the maladaptive emotional states (Hofmann, Ellard, & Siegle, 2012). The authors understand anxious cognitions partially as decision points during the processing of a threatening stimulus.
15 CHAPTER 1
When the stimulus has been perceived and detected, these decision points activate the selection and use of an adequate coping strategy in order to regulate a fear response. The decision points are associated with an activation of brain structures such as the amygdala (see section
Neurobiology of emotions), which is followed by the hippocampus and the insular cortex, and afterwards the anterior cingulate and prefrontal cortices (Hofmann, Ellard, & Siegle, 2012).
Emotions and Psychopathology Conceal, don’t feel, don’t let it show. -Elsa in Disney’s Frozen-
Emotions, affects, and moods not only shape our everyday lives, they also determine the clinical picture of several mental disorders, such as major depression, bipolar disorder or anxiety disorder (Patel et al. 2015). These mental disorders are amongst the most common and most deleterious diseases facing society but are still far from being understood (Beddington et al. 2008). One reason is the complex interplay of emotions and mental health, which has not been fully investigated so far. Research has shown that deficits in the ability to regulate emotions seem to not only cultivate the experience of more intense and enduring maladaptive emotions, but also lead to a variety of psychological disorders (Campbell-Sills & Barlow, 2007;
Gross and Muñoz, 1995; Mennin, Heimberg, Turk, & Fresco, 2005; Putnam & Silk, 2005). In addition to mental disorders, such as affective or anxiety disorders, where the key component is either a disturbance in the person's mood or excessive fear, according to the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5; APA, 2013), dysregulation has also been described in other mental disorders, such as borderline personality disorder (Linehan 1996a,
1996b; Levine, Marziali & Hood, 1997), bulimia nervosa (Sim & Zeman, 2004) or substance abuse (Kober, 2014).
With regard to depressive and anxiety disorders, a study by D’Avanzato, Joormann,
Siemer, and Gotlieb (2013) detected that patients suffering from depressive disorders assessed
16 CHAPTER 1 with the ERQ reported a less frequent use of reappraisal than patients suffering from anxiety disorders, who in turn showed more use of suppression. As described in the information processing model, this might partially be due to different prefrontal activation patterns in patients with mood and anxiety disorders (see also Davidson, 1998, 2000, 2002). However, less is known about the association of affective styles and mental disorders. So, is the strategy to conceal and not feel, a helpful way to regulate emotions or is concealing associated with psychopathology? What is the role of adjusting and tolerating when it comes to mental disorders? In the second study (Chapter 3), these questions were addressed by assessing the affective styles of a large outpatient sample suffering from affective and anxiety disorders.
Effects of Treatment May you be happy. May you be free from suffering. -Loving-kindness Meditation-
This part of the introduction of this thesis focuses on the research questions (a) what exactly happens to emotion regulation through psychotherapy, (b) whether patients’ habitual use of strategies change throughout treatment, and (c) if so, whether the remission from the specific disorder is associated with this change. This section concentrates on therapeutic effects on anxiety disorders that was the main goal of the third study (see Chapter 4).
So far, cognitive behavioral therapy (CBT) is empirically the best supported psychological treatment for anxiety disorders (e.g., Hofmann & Smits, 2008; Ruhmland &
Margraf, 2001a, 2001b, 2001c). Therefore, CBT appears to be strongly effective in helping patients overcome their anxiety. The main effect is based on reducing avoidance behavior, which contributes to extinction learning and, thereby regaining control over feeling anxious
(Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). But does CBT really change the patient’s habitual use of regulating anxiety and how? A patient suffering from spider phobia
17 CHAPTER 1 undergoing CBT could serve as an example: Which precise impact has this effective treatment on the regulatory processes? Does the patient learn to tolerate anxiety? Does the patient conceal less afterwards? Or does the patient learn a superior adjusting strategy when confronted with a spider? The prior goal of exposure exercises within CBT is the prevention of the manifestation of avoidant patterns (Abramowitz, Deacon, & Whiteside, 2011; Barlow et al., 2011; Craske,
Treanor, Conway, Zbozinek, & Vervliet, 2014), which allows patients to experience the entire range of emotional reactions. Affective styles should therefore be measurably influenced by treatment. Furthermore, CBT aims to decrease anxiety symptoms by preventing maladaptive concealing styles and by promoting more adaptive adjusting and tolerating styles (Ito &
Hofmann, 2014). However, these effects have not yet been empirically examined. Therefore, whether this indeed occurs in an anxiety-disordered population undergoing CBT was the main research question of the third study (see Chapter 4).
Psychotherapeutic interventions mostly focus on helping patients to overcome negative emotions. However, as described above, people also regulate positive emotions at least to some extent. Since previous research on how we savor or dampen our positive emotions is scarce, the understanding of associations between positive emotion regulation and mental health is still at its beginning (Quoidbach, Berry, Hansenne, & Mikolajczak, 2010). In the search of ways to strengthen positive emotions, traditional Buddhist exercises, for example, have found their way into clinical psychological research and treatment. Besides mindfulness-based interventions, which have been shown to be associated with decreased symptoms of anxiety and lower levels of depression and cortisol (Regehr, Glancy, & Pitts, 2013), positive forms of interventions, such as Loving-kindness meditation (LKM), have only recently been examined as a potential intervention for mental health.
Loving-kindness (or metta in Pali) describes a mental state of unconditional kind attitudes toward all beings. LKM contains the practice of mindfulness (Hofmann, Grossmann,
18 CHAPTER 1
& Hinton, 2011), and its core psychological operation is to generate one’s kind intentions toward certain targets. The silent repetition of phrases such as “may you be happy” or “may you be free from suffering” toward targets are the key component. Targets change gradually with practice, from easy to difficult; generally beginning with oneself, followed by loved ones, then neutral people, difficult individuals, and finally all beings. The practice of LKM exercises is believed not only to broaden attention, but also to enhance positive emotions, and lessen negative emotional states (Dalai Lama & Cutler, 1998; Hofmann, Grossmann, & Hinton, 2011).
So is it possible to up-regulate positive emotions through LKM treatment? And if so, what happens to mental health then? This was the main goal of the fourth study of this thesis, which is presented in Chapter 5.
Positive Mental Health Happiness is the highest form of health. -Dalai Lama-
The traditional understanding of mental health in psychology has been defined as the absence of psychopathology (Keyes, 2005), where an individual was seen as being either mentally ill or mentally healthy. More recently, research has developed a wider understanding of mental health focusing on positive factors (Keyes, Fredrickson & Park, 2012). The field of positive psychology addresses not only positive emotions but also positive characteristics of the individual: talents, abilities, values, and strengths of character (Peterson, 2006). Research has, therefore, acknowledged that positive mental health and psychopathology are not to be seen as opposite ends of a continuum but instead as correlated axes (Trompetter, Lamers,
Westerhof, Fledderus, & Bohlmeijer, 2017). Two dimensions of positive mental health have been described (Deci & Ryan, 2008): Hedonic and eudaimonic components. Whereas the hedonic component contains positive affect and life satisfaction, the eudaimonic component concentrates on human potential and optimal functioning (Schönfeld, Brailovskaia & Margraf,
19 CHAPTER 1
2017). Taking these two key components into account, positive mental health can be defined as the presence of subjective and psychological well-being (Keyes, 2005; Keyes, Shmotkin, &
Ryff, 2002).
The Positive Mental Health Scale (PMH-scale; Lukat, Margraf, Lutz, van der Veld, &
Becker, 2016) assesses these aspects of subjective and psychological well-being. Addressing not only the decrease of negative mental health factors but also considering the increase of positive mental health factors appears to be a new way of investigating treatment outcomes.
The fourth study of this thesis investigated the effects of LKM on negative mental health factors, such as depression, anxiety, and stress, but additionally aimed to examine the role of positive mental health prior to and after LKM intervention. Finally, the last study of this thesis examined whether positive mental health might also be predictive of symptom severity and remission from anxiety disorders in patients receiving exposure therapy. The fifth study is presented in Chapter 6.
Aims of this Thesis
The main goal of this thesis is the attempt to build a bridge between emotions and mental health by stretching an arc from emotion induction via emotion regulation to mental health.
Picking up on the questions from the introduction of this thesis, the following studies were conducted:
• How can we reliably induce emotional states in order to examine their impact on
cognitive, social, and behavioral functioning (Study 1)?
The aim of the first study was the development and validation of a new emotional film set that would provide an emotion induction method for the clinically most relevant emotions: happiness, sadness and fear. Overall, N = 120 German participants viewed previously validated and novel film clips and rated each film on multiple dimensions. After each film presentation,
20 CHAPTER 1 participants were asked to rate the intensity of the six basic emotions (happiness, sadness, fear, anger, disgust, and surprise) as well as the valence and intensity of the emotional arousal. In addition, participants were asked, whether the just rated emotional reaction would last after the termination of questionnaires. Further background information as well as the methods and results of this study are presented in Chapter 2.
• How do people suffering from mental disorders handle their emotions (Study 2)?
The second study aimed to investigate three aspects: The main goal was the validation of the ASQ within a large clinical sample (N = 917 treatment-seeking patients). We, further, examined possible differences of the three affective styles concealing, adjusting, and tolerating between patients suffering from affective versus anxiety disorders. Finally, we aimed at investigating associations of these three affective styles and anxiety, depression, and stress symptoms. The study procedures, data analysis, results, and implications are presented in
Chapter 3.
• How do these strategies change through psychotherapy (Study 3)?
Based on the findings of Study 2, we were interested to examine how CBT changes the three affective styles concealing, adjusting, and tolerating of patients undergoing treatment. The aims of this third study were, therefore, to investigate changes in affective styles of patients with panic disorder and specific phobia, as a result of undergoing CBT, and to identify a possible link between specific affective styles and remission from disorder. The sample consisted of N = 101 outpatients suffering from panic disorder, specific phobia, or agoraphobia who completed the ASQ before and after therapy, as well as at 6-month follow-up assessment.
Further information, the methods and results of this study are presented in Chapter 4.
• What happens to mental health when we directly address positive emotions (Study 4)?
The main goal of the fourth study was to examine the effects of LKM intervention on positive and negative mental health in university students. The sample (N = 110) consisted of
21 CHAPTER 1 university students in Germany. One half of them (N = 55) underwent LKM treatment. They were compared to a matched control group (N = 55) that did not receive treatment. All participants completed positive and negative mental health measures at baseline and at the one- year follow-up assessments. LKM completers additionally completed all measures prior to and after intervention. A detailed description of research background, as well as the study procedures, data analysis, results, and implications are presented in Chapter 5.
• And finally, how are positive factors of mental health associated with therapy outcome
(Study 5)?
This last study aimed at investigating whether positive mental health as assessed with the PMH-scale is predictive of symptom severity and remission from anxiety disorders in patients receiving exposure therapy. The sample (N=130) consisted of outpatients suffering from panic disorder, agoraphobia, or specific phobia who received exposure-based therapy. The patients completed the PMH-scale prior to and after therapy as well as at follow-up assessment six months after treatment termination. Further information, the methods and results of this study are presented in Chapter 6.
A summary and discussion of the results of the five studies as well as conclusions for future research are presented in Chapter 7.
22 CHAPTER 2
Study 1: Old movies vs. new movies: Development and validation of an emotion film set. Manuscript submitted for publication.
Cognition and Emotion Page 2 of 34
1 2 3 4 Old movies vs. new movies: Development and validation of an 5 6 7 emotional film set 8 9 10 Christina Totzeck a*, Xiao Chi Zhang a, Verena Pflug a, Tobias Teismann a, 11 12 Jürgen Margraf a, and Dirk Adolph a 13 14 15 aDepartment of Clinical Psychology and Psychotherapy, Ruhr University Bochum, 16 17 Bochum, Germany 18 For Peer Review Only 19 20 21 Christina Totzeck, Dept. of Clinical Psychology and Psychotherapy, Ruhr 22 23 University Bochum; Xiao Chi Zhang, Dept. of Clinical Psychology and Psychotherapy, 24 25 26 Ruhr University Bochum; Verena Pflug, Dept. of Clinical Child and Adolescent 27 28 Psychotherapy, Ruhr University Bochum; Tobias Teismann, Dept. of Clinical 29 30 Psychology and Psychotherapy, Ruhr University Bochum; Jürgen Margraf, Dept. of 31 32 33 Clinical Psychology and Psychotherapy, Ruhr University Bochum; Dirk Adolph, Dept. 34 35 of Clinical Psychology and Psychotherapy, Ruhr University Bochum. 36 37 This research did not receive specific grants from funding agencies in the public, 38 39 commercial, or not-for-profit sectors. 40 41 a 42 *Correspondence concerning this article should be addressed to Christina 43 44 Totzeck, Dept. of Psychology and Psychotherapy, Ruhr University Bochum, 45 46 Massenbergstrasse 11, 44787 Bochum, Germany. E-mail: [email protected] 47 48 49 50 51 52 53 54 55 56 57 58 59 60
URL: http://mc.manuscriptcentral.com/pcem Email: [email protected]
23 CHAPTER 2
Old movies vs. new movies: Development and validation of an emotional film set
The aim of the present study was the development and validation of a new emotional film set that would provide an emotion induction method for the three basic emotions: happiness, sadness and fear. At first, students were asked to name emotional films. The 20 most frequently mentioned films were selected and cut into film clips. The new film excerpts were compared to 12 previously validated emotional film sequences. Next, N = 120 German participants (age range 20-67 years) viewed the film clips in small group sessions and rated each film on multiple dimensions: After each film presentation, every participant was asked to rate the intensity of basic emotions (happiness, sadness, fear, anger, disgust, and surprise) as well as the valence and intensity of the emotional arousal using visual analogue scales (based on SAM; Bradley & Lang, 1994). In addition, the duration of emotional reactions was examined. The results showed that three target emotions happiness, sadness and fear as well as a neutral state could be selectively induced. They were effective with regard to several criteria such as emotional discreteness, arousal, positive and negative affect. Therefore, the effectiveness and validity of the new emotional and neutral film excerpts could be confirmed.
Keywords: emotion induction; film set; basic emotions; moods; SAM
24 CHAPTER 2
Introduction Emotions are the center of everyday lives. In order to examine the association of emotions and social, cognitive, and behavioral functioning, it is necessary to evoke emotional states under laboratory conditions. This creates a need for reliable methods for emotion induction
(Schaefer, Nils, Philippot, & Sanchez, 2010).
A variety of methods has been developed, validated and applied in research so far, for instance: music listening (Västfjäll, 2015), the Velten technique (Velten, 1968), respiratory feedback (Philippot, Chapelle, & Blairy, 2002), or autobiographical recollection (Schaefer &
Philippot, 2005). In addition, the presentation of emotional film clips (e.g. Gross & Levenson,
1995; Rottenberg, Ray, & Gross, 2007; Schaefer, Nils, Philippot, & Sanchez, 2010; Uhrig,
Trautmann, Baumgärnter, et al., 2016) has also established itself as a research method. Since the earliest beginning of psychological research on movies in the 1910s (Tan, 2018), film sequences have been used to examine several phenomena, such as sad mood induced smoking behavior (Fucito, & Juliano, 2009),subjective and autonomic responses in psychopaths
(Pham, Philippot, & Rime, 2000), affective reactions related to frontal brain-asymmetry
(Tomarken, Davidson, & Henriques, 1990), or the association of emotion and chocolate eating behavior (Macht, Roth, & Ellgring, 2002).
When compared to other emotion induction methods, the presentation of film clips has several advantages (Schaefer et al., 2010): First of all, the fact that probably everyone has watched a movie in the past makes the situation familiar and comfortable for participants.
Second, presenting a film is very easy to implement technically. Third, film sequences provide a multimodal set of stimuli, as they provide visual and acoustic information mostly combined with a story to follow. Fourth, film scenes provide a model of reality, without causing ethical and practical problems of real-life techniques. Finally, according to the results of several studies, the presentation of film sequences has been shown to provoke strong subjective and physiological changes (e.g., Frazier, Strauss, & Steinhauer, 2004; Gross, 1998;
25 CHAPTER 2
Palomba, Sarlo, Angrilli, Mini, & Stegagno, 2000). A meta-analysis by Westermann, Spies,
Stahl, and Hesse (1996) has even shown that the presentation of film clips was the strongest method to elicit positive and negative emotional states in viewers.
Previous studies have demonstrated that films have the capacity to induce distinct target emotions like fear (Bosse, Gerritsen, de Man, & Stam, 2014), sadness (Kuijsters, Redi, de Ruyter, & Heynderickx, 2016) or happiness (Fredrickson & Branigan, 2005). However, several important aspects have rarely been taken into account: The development of most film databases relied exclusively on college students as participants. This is reasonable as students are often easy to recruit for participation in research studies. However, findings are obviously limited in their generalizability. Jenkins and Andrewes (2012) addressed this issue by developing a new standardized film database using a sample with a wider age range (18–88 years). In their study, all animated movies were excluded because of previous critique of their ecological validity (Rottenberg, Ray, & Gross, 2007). In fact, these animated movies, such as the Disney movie “Bambi”, have been shown to reliably provoke emotional states (Gross &
Levenson, 1995). The present study, therefore, included animated movies and aimed to compare these old and previously validated scenes (from Gross & Levenson, 1995, and
Tomarken et al., 1990) to new ones.
In addition, we aimed at assessing two distinct aspects of emotion that have received much attention and tend to be very popular dimensions (Bradley & Lang, 2000; Gray, 2001):
Emotional valence (the dissociation between positive and negative states) and arousal (the intensity of the emotion; Ford, Addis, & Giovanello, 2012). Furthermore, we examined the duration of the emotional reaction to each movie clip in order to gain more insight into the question, whether emotional states or moods might be evoked. Although the terms emotion and mood are often used interchangeably in emotion research (Batson, Shaw, & Oleson,
1992), they can be separated as they describe distinct phenomena (Lochner, 2016). Emotions mostly have a stimulus event; they are rather intense but short in duration, and they have
26 CHAPTER 2 behavioral implications (Scherer, 2005). When compared to these properties, moods differ from emotions as they contain global, undirected, and rather unconscious background sensations that are more stable than emotions (Lischetzke & Eid, 2011; Lochner, 2016). The technique of using short emotional film sequences may be limited to the capacity to induce emotional states but not moods, which is linked to the important conceptual distinction between mood and emotion (Ekman & Davidson, 1994; Frijda, 1993; Schaefer et al., 2010).
The purpose of the present study was the development of a validated film set comprised out of the most potent clips from old and new movies (Gross & Levenson, 1995;
Tomarken et al., 1990; Rottenberg, Ray, & Gross, 2007; Hewig et al., 2005) that would provide an emotion induction method for the three basic emotions happiness, sadness and fear as well as a neutral state. We aimed at validating this new film set using a wider age range of participants in order to examine not only gender- but also age-related differences.
Furthermore, since intensity and duration are two salient features of an emotional response
(Frijda, 2007), we additionally examined the duration of emotional reactions.
Methods
Participants A total of n = 120 German speaking participants (60 females, 50%) took part in the film-viewing sessions. The subjects were 20-67 years old (M= 34.18, SD = 13.64) and were not paid for participation. Participants were included when their native language was German, and when they had normal or corrected vision and auditory functions. Prior to the experimental procedure, participants gave written and informed consent. The Ethics
Committee of the Faculty of Psychology at the Ruhr University Bochum approved the study.
27 CHAPTER 2
Stimulus Material In order to collect stimulus material the first step was the selection of a relatively large number of film excerpts suggested by students. They were asked to name films corresponding to four a priori emotional categories: sadness, fear, happiness, and a neutral state. In the next step, a film preselection was drawn by the research group consisting of five clinical psychology students, a certified psychotherapist and a psychophysiologist. Decisions were based on the following criteria: (1) the length of the film clip; (2) statutorily regulated age limits; (3) accessibility of the movie; (4) understandable thematic content without additional explanation; (5) the film elicited only one target emotion; and (6) appropriately high level of arousal of emotion. For each emotional category, the most frequently mentioned films were selected and cut into film clips. These 14 new film excerpts were compared to 10 previously validated emotional film sequences (from Gross & Levenson, 1995; Tomarken et al., 1990;
Rottenberg, Ray, & Gross, 2007). In addition, 2 previously validated (Hewig et al., 2005) and
6 new neutral film sequences were presented. Each cut scene lasted between 1.05 and 4.27 minutes. An overview of the stimulus material is presented in Table 1.
Measures
Basic Emotions The intensity of the six basic emotions was assessed using Emotion Report Forms; they contained visual analogue scales (VAS) in the form of six horizontal lines ranging from
0 (“Not at all”) to 10 (“Totally”). After each film, participants rated the levels felt with respect to all six emotions (happiness, anger, sadness, fear, surprise, and disgust).
Self-Assessment Manikin The SAM (Bradley, & Lang, 1994) is a pictorial assessment technique that measures the valence and arousal associated with the participant’s affective reaction to stimuli. For the valence rating, the scale ranges from (-4) = very negative to (4) = very positive. The arousal 28 CHAPTER 2 scale ranges from (8) = the highest level of arousal to (0) = the lowest level. The SAM-scale has been shown to be a useful instrument in both healthy as well as clinical populations
(Bynion & Feldner, 2017). It was presented after each film sequence.
Duration and subjective effectiveness ratings In addition to the above-mentioned scales, participants were asked whether the just rated emotion would still continue (yes/no) after having completed all above-mentioned ratings (within three minutes after the movie clip). Furthermore, participants rated the potential of the movie to elicit the same target emotion in others, again on a VAS raging from
(0) = not at all to (10) = totally.
Procedure Prior to the first movie, participants rated their initial emotional state using the above- mentioned ratings. Afterwards, participants viewed the selected clips in small group sessions.
Each group had an average of 5 participants (max: 6 and min: 3); each participant watched eleven film sequences. After each film presentation, every participant was asked to rate the intensity of the six emotions (happiness, anger, sadness, fear, surprise, and disgust) as well as the valence and intensity of the emotional arousal using the above-mentioned scales. To control for potential order effects, each group differed in the order of presented stimuli. In addition, the order of presentation was also set in such a way that films targeting the same emotion were not shown consecutively, and participants never watched more than two films of the same valence consecutively. Overall, each movie was watched and rated by n = 40 participants.
Data analysis The Statistical Package for the Social Sciences (SPSS) 24.0 was used to analyze the data. Generalized linear models (GLM) with the three target emotions (happiness, sadness,
29 CHAPTER 2 and fear) and the neutral condition as within-subject factors were performed. Movies served as between-subject factors. In order to examine gender and age effects, the two variables were included in the analyses as covariates. The same GLM were conducted for the arousal level and valence rating. In order to examine emotion-specific differences, multivariate analyses of variance (MANOVA) were computed including further pairwise comparisons between the different emotions. Homogeneity of error variances was tested using the Mauchly-test for sphericity. In case of significant results of the Mauchly-test, if Epsilon < .75, a Greenhouse-
Geisser correction was conducted; if Epsilon >.75, a Huynh-Feldt correction was recommended. All post-hoc multiple pairwise comparisons were performed using
Bonferroni's correction. The level of statistical significance was set as p < .05. Partial η2 was calculated as an estimate of effect size. According to Cohen (1988; 1992) a partial η2 of 0.01 can be viewed as small, 0.06 as medium, and 0.14 as large effect.
Results
Main effects The results of the GLM revealed a significant main effect of emotions, F(2, 1366) =
40.75, p < .001 (ηp² = .06), as well as a significant interaction effect of emotions and movies,
F(64, 2734) = 133.69, p < .001 (ηp² = .76). Further pairwise comparisons of mean scores among all emotional categories revealed significant differences between each target emotion and the further assessed emotions: Within each specific category, the happiness, F(7, 1907) =
5.17, p < .001 (ηp² = .019), sadness, F(7, 1907) = 8.16, p < .001 (ηp² = .03), and fear level,
F(7, 1907) = 9.99, p < .001 (ηp² = .03), were significantly higher than the other emotions.
However, within the neutral category, happiness was also significantly evoked, F(7, 1907) =
2.84, p = .006 (ηp² = .01).
30 CHAPTER 2
Movie-specific effects in each category Mean scores and standard deviations of all emotional ratings are presented in Table 2.
Happiness Movies
The highest ratings in the happiness category were found for the new movie “500
Days of Summer” (M = 7.32, SD = 2.01) and the old movie “The Jungle Book” (M = 7.16, SD
= 2.51). The old movie “An Officer and a Gentleman” was rated the lowest (M = 5.42, SD =
2.86).
Sadness Movies
The highest ratings in the sadness category were found for the new movies “My
Sister’s Keeper” (M = 7.84, SD = 1.56) and “The Green Mile” (M = 7.62, SD = 2.12). The lowest rating in this category was found for the old movie “The Champ” (M = 6.72, SD =
2.69).
Fear Movies
The highest ratings in the fear category were found for the old movies “Halloween”
(M = 7.16, SD = 2.01) and “The Shining” (M = 7.16, SD = 2.50). The new movie “The White
Noise” was rated the lowest (M = 3.82, SD = 2.86) in this category.
Neutral Movies
In the neutral category, three (new) movies significantly evoked emotional reactions:
“Brokeback Mountain”, F(2, 1366) = 42.19, p < .001 (ηp² = .06), “Railroads” F(2, 1366) =
25.83, p < .001 (ηp² = .04), and “Earth-NEUTRAL”, F(2, 1366) = 16.77, p < .001 (ηp² = .02).
Here, happiness was rated significantly high. The other five neutral sequences did not evoke any emotions significantly.
Arousal level The results of the GLM revealed an overall significant interaction effect of movies and arousal, F(31, 1247) = 26.78, p < .001 (ηp² = .040). Mean scores of arousal levels are presented in Figure 1. In addition to the eight neutral scenes, three further movie clips 31 CHAPTER 2 provoked significantly lower arousal levels: “An Officer and a Gentleman” (M = 3.22, SD =
2.39), “Eat Pray Love” (M = 3.45, SD = 2.01), and “Earth-HAPPINESS” (M = 3.77, SD = 2.57).
The highest arousal levels were found for “The Green Mile” (M = 6.22, SD = 1.86),
“My Sister’s Keeper” (M = 6.00, SD = 1.89), and “Bambi” (M = 5.95, SD = 2.29), all part of the sadness category. The highest arousal levels of fear-categorized movies were found for
“Inglourious Basterds” (M = 5.90, SD = 2.27), “The Silence of the Lambs-OLD” (M = 5.87, SD
= 2.46), and “Halloween” (M = 5.87, SD = 2.42). In the happiness category, the highest arousal levels were rated for “500 Days of Summer” (M = 5.47, SD = 1.89) and “The
Intouchables” (M = 5.02, SD = 1.91).
Valence Ratings Mean scores of all valence ratings are also presented in Figure 1. All movies of the happiness category were positively rated, whereas all movies of the sadness and fear category were negatively rated. In the neutral category, the movie “All the President’s Men” was also negatively rated, whereas the other neutral movies were slightly positively rated.
Age and gender effects The results revealed no significant effect of age, F(2, 1364) = 0.65, p = .519 (ηp² <
.01). With regard to gender effects, a significant interaction effect of emotion and gender was found, F(2, 1364) = 4.60, p = .010 (ηp² < .01). Further pairwise comparisons resulted in significantly higher ratings of female participants in the fear, F(1, 1366) = 9.56, p = .002 (ηp²
< .01), as well as in the sadness category, F(1, 1366) = 12.05, p = .001 (ηp² < .01). No gender differences were found in the happiness category, F(1, 1366) = 0.38, p = .537 (ηp² < .01).
32 CHAPTER 2
Duration of emotional reactions and subjective potential of each movie The results of the MANOVA revealed a significant main effect of effectiveness of all movies, F(31, 1247) = 18.53, p < .001 (ηp² = .31) based on participants’ subjective ratings of the potential to induce the same emotions in others.
In the happiness category, the highest ratings were found for “500 Days of Summer”
(M = 7.49, SD = 2.06), “The Jungle Book” (M = 6.99, SD = 2.70), and “Titanic-HAPPINESS” (M
= 6.63, SD = 2.87). The lowest rating was found for “An Officer and a Gentleman” (M = 4.97,
SD = 3.24). In the sadness category, the highest effectiveness ratings were found for “My
Sister’s Keeper” (M = 8.00, SD = 1.37), “Hachiko” (M = 7.84, SD = 2.03), and “The Green
Mile” (M = 7.73, SD = 1.42). The lowest rating in this category was found for “The Champ”
(M = 6.38, SD = 2.82). In the fear category, “Halloween” (M = 7.76, SD = 2.02), “The
Shining-FEAR” (M = 6.36, SD = 2.90), and “The Silence of the Lambs-OLD” (M = 6.31, SD =
2.54) were rated the highest, and “The White Noise” (M = 4.48, SD = 2.74) was rated the lowest.
With respect to the duration of emotional reactions, a significant overall effect was found, F(1, 1247) = 9.42, p < .001 (ηp² = .19). Although the duration of the previously highest rated emotional reactions (“500 Days of Summer”, “My Sister’s Kepper”, “Bambi”, “The
Green Mile”, and “Halloween”) was significantly higher than the duration of the lowest rated as well as neutral movies (all p values < .047), all mean scores ranged from M = 0.00 to M =
1.00 (range: 0-10). Mean ratings of effectiveness as well as mean scores of duration of emotional reactions are presented in Figure 2.
Discussion The main goal of the present study was the development and validation of a new emotional film set that would provide an emotion induction method for the three basic emotions happiness, sadness, and fear as well as a neutral state. We compared 12 previously validated movies (from Gross & Levenson, 1995; Tomarken et al., 1990; Rottenberg, Ray, & 33 CHAPTER 2
Gross, 2007; Hewig et al., 2005) to 20 new ones in order to select the most potent emotion induction film scenes.
Our results revealed that the three target emotions happiness, sadness, as well as fear were selectively evoked. The results also show, that it remains necessary to update stimulus material; when compared to previously validated older movies, the majority of the newly selected film sequences was superior in the induction of emotions. In the happiness and sadness category, the new film sequences (e.g. “500 Days of Summer” or “My Sister’s
Keeper”) evoked a more intense emotion when compared to the old movies (e.g. “When
Harry Met Sally” or “The Champ”). Only within the fear category, the older movies (e.g.
“Halloween”) induced a more intense emotion than the new movies (e.g. “The White Noise”).
With regard to the presentation of neutral film sequences, which were supposed to not induce any emotional reactions, we found an increase of happiness in three movies; in particular the sequences showing nature (“Earth-NEUTRAL”, “Brokeback Mountain”, and
“Railroads”) evoked an emotional reaction. Although the arousal ratings of these movies were low, they appear to be too intense to be used as a neutral movie clip. Since the concept of happiness has been described as multifaceted including other positive emotions (Hagemann et al., 1999), these sequences might have induced feelings of contentment and serenity as previous studies have used to evoke positive emotions (e.g. Fredrickson & Branigan, 2005).
We included different forms of neutral sequences; in addition to report and documentary scenes, we added neutral scenes of movies which also provide emotion induction scenes. As previous researchers have pointed out, neutral film sequences often differ from emotional film stimuli because they have not been taken from commercially available feature films (Hewig et al., 2005; Jenkis & Andrewes, 2012). Our results show that these scenes, although taken from movies such as “The Girl with the Dragon Tattoo”, can be used as neutral film sequences in future research studies.
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Furthermore, we aimed at validating this new film set using a wider age range of participants. Our results did not reveal any age-related differences. This finding is in line with the results of the study by Jenkins and Andrewes (2012) showing no specific differences in age groups. These results suggest that the presentation of film sequences provides an applicable emotion induction method for all age groups. Therefore, age appears to be less important when the researcher is interested in eliciting intense and discrete emotional reactions (Jenkins & Andrewes, 2012).
With regard to gender-related specificities, our results revealed differences in the negative emotion induction categories; whereas women reported higher levels of negative emotions than men, in both the sadness as well as fear category, no significant gender differences were found in the happiness category. These results are also in line with previous studies using emotion induction via film presentation (Gross & Levenson, 1995; Hagemann et al., 1999; Schaefer et al., 2010) and are consistent with many studies showing that women usually report more intense emotions than men (Brody & Hall, 2008). Moreover, taking the very small effect sizes of these differences into account, gender-specific differences in this present sample can even be neglected.
Finally, the duration of emotional reactions was very short as they mostly did not last until the termination of questionnaires. This finding underlines the assumption, that the duration of emotional stimuli is connected to the kind of emotional reaction being evoked
(Uhrig et al., 2016). Using short film sequences appears to induce emotional states and affects but not moods, which needs to be considered when conducting laboratory studies.
To sum up, several conclusions can be drawn from the data obtained in this study.
First of all and most importantly, short film clips appear to be an effective method for eliciting basic emotions. Secondly, they can be used for all age-groups. Thirdly, short film clips do not appear to elicit moods but rather basic emotions. The question of whether this is due to the length of the film clips needs to be addressed in future research studies.
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Limitations The following limitations must be taken into consideration while evaluating the present study. First of all, our arousal measurement was based on self-report ratings instead of physiological measures. We, therefore, caution against overestimating these results as subjective ratings of arousal level may differ from actual physiological changes. Secondly, the assessment of the duration of emotional reactions was based on the final question, whether the just rated emotions would still continue. We did not implement within-assessments or stepwise examination of emotional reactions and arousal. Future studies should imbed these information in order to gain more insights into the exact duration of emotional experiences.
Finally, our film database was validated using Western film material and a German population. Therefore, the results cannot be generalized as previous studies have already pointed out that culture-specific differences have mostly been ignored when using emotion induction techniques (Deng, Yang, & Zhou, 2017).
Conclusions The results of the present study provide a new emotional film set that can be used in future laboratory studies using emotion induction techniques. The newly validated film sequences have the potential to evoke happiness, sadness, and fear responses in all age groups.
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Table 1: Overview of the Stimulus Material Emotion Movie Old/New Scene Length Movie (min)
Happiness 500 Days of Summer New The main actor is singing and dancing through the city after he had a sexual experience. 2:06
The Jungle Book Old Mogli is singing and dancing with his friends. 1:55
Titanic-HAPPINESS New Irish party scene, where Rose and Jack are dancing together. 3:00
When Harry met Sally Old Harry and Sally discuss about whether Harry would notice a fake orgasm. 2:35
Eat Pray Love New Liz makes a poor family happy with a successful collection of donations. 1:36
The Intouchables New The two friends Philippe and Driss are joking around and having fun together. 1:51
Earth-HAPPINESS New Polar bear babies are rolling and playing around. 2:53
An Officer and a Old Romantic scene between Paula and her marine officer Zack 1:51 Gentleman
Sadness My Sister's Keeper New At the hospital, Anna gives her mother a book she made with all of her family 3:36 memories.
The Green Mile New John Coffey is being unjustly executed. 3:42
Bambi Old Bambi’s mother dies. 2:19
Hachiko New The dog Hachiko has lost his owner and best friend, who had died at work. Hachiko is 3:31 waiting for his return every day at the train station until he passes away.
Titanic-SADNESS New Good-bye scene between Rose and Jack. 4:27
The Lion King Old Simba’s Dad dies. 1:47
Return to me Old Bob has lost his wife due to an accident, he is sitting on the floor with his dog crying. 3:36
The Champ Old Billy got severely injured in a boxing match and is lying on a table, when his little son 2:51 enters.
Fear Halloween Old Laurie is working as a babysitter at a friend’s house, where she finds a corpse and is 3:28 being pursued by the killer.
The Shining-FEAR Old Wendy is hiding from a serial killer who finds her in the bathroom. 2:08
Silence of the Lambs- Old The FBI agent Clarice is searching for a serial killer. She follows him into a basement. 3:22 OLD
96 Hours New Kim is watching her friend being kidnapped and is hiding from the perpetrators. 2:43
Silence of the Lambs- New A serial killer in the dark follows Clarice. 1:38 NEW
Titanic-FEAR New Cal is trying to kill Rose and Jack. 3:37
Inglourious Basterds New Nazi soldiers are searching Jews, who are hiding in a farmer’s house. 2:45
The White Noise New Lukas loses his mind. 1:25
Neutral All the President’s Men Old Bob is reporting about a court case and asks one of the attendees what had just 1:05 happened.
Brokeback Mountain New Ennis and Jack are watching over their sheep. 1:12
Railroad New Reporting scene about railroads. 2:02
Hannah and her Sisters Old Hannah and Holly are shopping and talking about last night. 1:32
Machines New Reporting scene about working machines. 1:45
The Shining-NEUTRAL New A hotel manager is showing his guests around. 1:28
Earth-NEUTRAL New Reporting scene about nature. 1:30
The Girl with the New Mikael is sitting on a table talking to a woman. 1:33 Dragon Tattoo
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Table 2: Mean scores and standard deviations of all basic emotion ratings Happiness Sadness Fear Anger Surprise Disgust Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
500 Days of Summer 7.32(2.01) 0.18(0.55) 0.15(0.32) 0.11(0.19) 2.40(2.51) 0.21(0.78) The Jungle Book 7.16(2.51) 0.15(0.21) 0.13(0.15) 0.32(0.58) 0.79(1.05) 0.35(0.59)
Titanic-HAPPINESS 6.60(2.21) 0.16(0.26) 0.25(0.8) 0.17(0.35) 1.01(1.32) 0.10(0.16) When Harry met Sally 6.44(2.31) 0.22(0.46) 0.20(0.26) 0.40(0.64) 1.31(1.54) 0.21(0.40) Eat Pray Love 6.27(2.13) 1.41(1.40) 0.26(0.4) 0.32(0.60) 2.05(2.45) 0.18(0.33) The Intouchables 6.23(2.24) 0.84(1.74) 0.29(0.91) 1.35(2.07) 2.50(2.45) 0.21(0.53)
Earth-HAPPINESS 6.00(2.23) 0.34(0.89) 0.37(0.92) 0.30(0.90) 1.33(1.72) 0.12(0.21) An Officer and a Gentleman 5.42(2.86) 0.23(0.30) 0.17(0.29) 0.20(0.37) 1.79(2.38) 0.14(0.24) My Sister’s Keeper 1.04(1.43) 7.84(1.57) 2.92(2.48) 1.12(2.05) 1.10(2.26) 0.39(0.82) The Green Mile 0.23(0.54) 7.62(2.12) 2.28(2.17) 3.01(2.89) 0.70(1.62) 2.36(2.75) Bambi 0.33(0.62) 7.42(2.13) 1.63(1.93) 2.62(2.54) 0.44(0.85) 0.97(1.55) Hachiko 2.20(2.45) 7.29(2.49) 0.93(1.65) 0.75(1.84) 2.00(2.60) 0.11(0.24)
Titanic-SADNESS 0.38(0.59) 7.23(2.43) 1.85(2.26) 0.81(1.54) 0.42(0.70) 0.82(1.78) The Lion King 0.18(0.41) 7.07(2.36) 1.04(1.52) 0.65(1.3) 0.69(1.02) 0.14(0.22) Return to me 1.24(2.13) 6.82(2.30) 1.73(2.07) 0.73(1.44) 3.45(2.70) 0.16(0.45) The Champ 0.24(0.56) 6.72(2.69) 0.77(1.46) 1.14(1.79) 0.96(1.51) 0.82(1.57) Halloween 0.37(0.93) 0.40(0.90) 7.33(2.12) 0.69(1.10) 3.54(2.82) 2.18(2.41)
Shining-FEAR 0.51(1.32) 0.89(1.84) 5.99(2.84) 2.00(2.38) 1.70(1.94) 2.87(3.12)
The Silence of the Lambs-OLD 0.21(0.39) 0.42(0.91) 5.96(2.22) 1.17(1.43) 3.39(2.52) 2.04(2.33) 96 Hours 0.84(1.57) 1.90(2.20) 5.69(2.46) 2.00(2.29) 3.80(2.83) 1.15(1.40)
The Silence of the Lambs-NEW 0.18(0.38) 0.43(0.67) 5.62(2.47) 0.58(0.94) 3.00(2.70) 1.13(2.06)
Titanic-FEAR 0.57(1.12) 2.17(1.93) 5.16(3.02) 1.84(2.26) 2.45(2.50) 0.25(1.02) Inglourious Basterds 0.53(1.53) 3.67(2.97) 4.72(3.23) 3.8(3.38) 2.49(2.61) 2.42(3.04) The White Noise 0.18(0.18) 1.39(1.46) 3.82(2.62) 1.30(1.63) 1.30(1.49) 0.78(1.61) Brokeback Mountain 3.41(2.60) 0.33(0.40) 0.15(0.16) 0.19(0.25) 0.53(1.34) 0.16(0.36) Railroads 2.68(2.34) 0.21(0.43) 0.20(0.50) 0.16(0.22) 0.36(0.69) 0.10(0.12)
Earth-NEUTRAL 2.29(2.20) 0.42(1.15) 0.15(0.46) 0.27(0.95) 0.60(1.60) 0.07(0.18) Machines 1.53(1.89) 0.34(0.98) 0.40(1.24) 0.31(1.02) 1.09(2.02) 0.12(0.17)
The Shining-NEUTRAL 1.00(1.68) 0.22(0.28) 0.43(0.62) 0.3(0.41) 0.87(1.80) 0.14(0.19) The Girl with the Dragon Tattoo 0.92(1.60) 0.55(1.69) 0.24(0.65) 0.27(0.49) 0.35(0.71) 0.09(0.17) Hannah and her Sisters 0.89(1.53) 0.69(1.12) 0.23(0.52) 0.31(0.74) 0.69(1.23) 0.31(0.75) All the President’s Men 0.38(0.69) 0.21(0.24) 0.37(0.63) 0.67(1.24) 0.73(0.97) 0.25(0.46) Note: Mean scores sorted from high to low; SD = standard deviation. Highest ratings of each category are bold.
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Figure 1: Mean scores of arousal (range: 0 to 10) and valence ratings (range: -4 to 4) of all movies.
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Figure 2: Mean scores of duration of emotional reactions and subjective ratings of potential to induce the same emotional reaction in others (both ranges: 0-10).
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Study 2: Affective styles in mood and anxiety disorders – Clinical validation of the “Affective Style Questionnaire” (ASQ).