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Emotion and Mental Health – Associations, Assessments, And 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
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