BEN-GURION UNIVERSITY OF THE NEGEV
THE FACULTY OF HUMANITIES AND SOCIAL SCIENCES
DEPARTMENT OF PSYCHOLOGY
Does affect labeling improve exposure effects in high obsessive-compulsive symptom participants?
THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
MASTER OF ARTS DEGREE (M.A)
OMRI GOLDWAY
UNDER THE SUPERVISION OF DR. GIDEON ANHOLT
SEPTEMBER 2019
BEN-GURION UNIVERSITY OF THE NEGEV
THE FACULTY OF HUMANITIES AND SOCIAL SCIENCES
DEPARTMENT OF PSYCHOLOGY
Does affect labeling improve exposure effects in high obsessive-compulsive symptom participants?
THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
MASTER OF ARTS DEGREE (M.A.)
OMRI GOLDWAY
UNDER THE SUPERVISION OF DR. GIDEON ANHOLT
Signature of student: Date: 26.9.2019
Signature of supervisor: Date: 27.9.2019
Signature of chairperson of the M.A. committee: Date:
SEPTEMBER 2019 AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS i
Abstract
Affect Labeling (AL) was found to enhance the beneficial effect of exposure to an anxiety evoking stimuli, as reducing distress in anxiety-related disorders. Additionally, AL was suggested to have a similar effect on exposure to a distressing thought or impulse in obsessive- compulsive disorder (OCD), previous research showed a similar pattern of effect in short exposure duration (2.5 min) with high obsessive-compulsive symptom participants. We expected to find similar results in longer duration exposure. Surprisingly, using hierarchical linear modeling (HLM), we found that the addition of AL to prolonged exposure of an idiosyncratic obsessive thought in participants with high obsessive-compulsive symptoms, hampered the effectiveness of exposure. Alexithymia (the inability to identify and describe emotions) was found to moderate the expected within-session habituation prosses. This is the first study to examine the effect of AL on prolonged exposure (30 min) and our results might have important implications to the addition of AL to the treatment of choice for OCD- exposure and response prevention (ERP). Suggested mechanisms for this inverse effect on exposure in OCD and future directions are discussed.
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS ii
.
Table of Contents Introductio between between n ...... 1
Method ...... 6
Participants ...... 6
Procedure ...... 7
Measures between ...... 8
Data Analyses ...... 8
Manipulation Check ...... 9
Reliability and Validity ...... 9
Results ...... 10
HLM ...... 10
The Overall Effect of The Exposure Procedure ...... 12
Interactions ...... 13
Moderation ...... 15
Discussion ...... 17
References ...... 25
Appendix ...... 38
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS iii
List of Tables
Table 1: Intercepts and slopes for all three contions in Self-Report...... 14
Table 2: Intercepts and slopes with Alexithymia as a moderator ...... 16
Table A1: Means and SD for age, Obsessive-Compulsive symptoms and Alexithymia scores .. 38
Table A2: Means and SD for one pre and six post-manipulation time samples in Self-Report ... 38
List of Figures
Figure 1: simple slope decomposing for a two-way interaction: time * condition ...... 15
Figure 2: Simple slope decomposing for a two-way interaction: time * alexithymia ...... 17
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS iv
List of Appendices
Appendix A: ...... 38
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 1
Introduction
Emotion regulation refers to the processes by which individuals influence their emotions- when they have them, and how they experience and express them (Gross, 1998).
Difficulties in regulating emotions were found to be associated with impairments in social, career and academic functioning (Mayer, Salovey, Caruso, & Sitarenios, 2003). Furthermore, emotional dysregulation may be a predisposing factor for the development of a wide range of emotional disorders and is integrated into models of psychopathology in children and adults (Greenberg,
2002; Mennin & Farach, 2007; Barlow, Rapee, & Brown, 1992). Indeed, difficulties in emotion regulation seem to exist in various psychopathologies such as; anxiety (Nolen-Hoeksema, Wisco,
& Lyubomirsky, 2008), eating disorders (McCarthy, 1990; Polivy & Herman, 2002), and substance abuse (Sher & Grekin, 2007; Tice, Bratslavsky, & Baumeister, 2001). Moreover, symptoms in various psychopathologies have been suggested to serve as a maladaptive form of emotion regulation (e.g., self-harm in borderline personality disorder (Gratz & Gunderson,
2006); consuming alcohol and drugs in substance abuse (Aldao, Nolen-Hoeksema & Schweizer,
2010); and binge eating and other food-related behaviors in eating disorders (McCarthy, 1990;
Polivy & Herman, 2002)).
Obsessive-Compulsive Disorder (OCD) is a psychiatric syndrome characterized by recurrent obsessive thoughts, images, or impulses that evoke anxiety and by compulsive behaviors aimed at decreasing discomfort, or preventing harm (American Psychiatric
Association, 2013). Some researchers have suggested that compulsions in OCD may be viewed as a dysfunctional form of emotion regulation (Calkins, Berman & Wilhem, 2013). Accordingly, various findings support the association between OCD and deficits in emotion regulation. For example, obsessive-compulsive (OC) symptom distress was significantly related to poor AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 2
understanding of emotions and fear of emotions, including negative and positive emotions
(Aldao, Nolen-Hoeksema & Schweizer, 2010). Additionally, an association between OC symptoms, limited access to strategies of emotion regulation, and lack of emotional clarity was found (de la Cruz et al., 2013). Another study demonstrated an association between the maladaptive emotion regulation strategy of thought suppression, negative affect and the occurrence of obsessive thoughts (Magee, Harden & Teachman, 2012). Furthermore, Liberman
& Dar (2009) suggested the Seeking Proxies for Internal States (SPIS) model. The model postulates that individuals with OCD have attenuated access to their internal states, and therefore, rely on external proxies. Proxies are defined as substitutes for the internal state that the individual perceives as more easily discernible or less ambiguous, such as rules, procedures, and behaviors. Additionally, Fergus & Bardeen (2014) demonstrated a unique association between
OC symptoms and low emotional clarity, and a study by Robinson & Freeston (2014), found an association between OCD and alexithymia (the inability to identify and describe emotions;
Sifneos, 1973).
Affect Labeling (AL) is an explicit linguistic processing of emotions, which comprises of identifying and naming the emotions that arise in certain situations. It involves verbally labeling the emotional content of an external stimulus or one's affective responses with or without an intentional goal of altering the emotional response (Burklund, Creswell & Lieberman, 2014;
Lieberman et al., 2007). It has been shown that AL can attenuate negative emotional experiences
(Lieberman et al., 2011). Moreover, it has been recently suggested that AL can be used to promote the treatment of anxiety disorders (Craske at el., 2014). Currently, a central intervention in the treatment of anxiety and OC-related disorders is exposure to feared stimuli (Abramowitz,
Foa & Franklin, 2003; Abramowitz, Deacon & Whiteside 2011). Exposure therapy is derived AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 3
from early models of extinction learning, and Inhibitory learning is regarded as being central to extinction. (Bouton, 1993; Wagner, 1981). Inhibitory learning suggests that during exposure, the association learned during fear conditioning between conditioned stimulus (CS) and unconditioned stimulus (US) is not erased during extinction, but a secondary learning about the
CS–US develops; the CS acquires a new meaning in addition to its original excitatory one (CS–
US) and now has an additional inhibitory meaning (CS–noUS)(Bouton, 1993). According to
Craske at el (2014) AL may enhance associative inhibitory processes within extinction or may work in an independent but complementary manner to extinction learning. Recently, several studies have supported this claim and demonstrated that exposure combined with AL is more useful then exposure alone. For example, a study by Tabibnia, Lieberman & Craske (2008) demonstrated that AL with unrelated negative words during exposure reduced anxiety in subjects who were fearful of spiders. Another study by Niles et al., (2015) demonstrated that participants with social phobia who used AL during exposure showed a greater reduction in physiological activation than control participants. This effect was particularly enhanced in participants who used more labels during exposure.
Currently, exposure and response prevention (ERP) is the treatment of choice for OCD (Öst,
Havnen, Hansen & Kvale., 2015). ERP focuses on engaging in situations or with stimuli that evoke obsessional fears without committing compulsions (Lehmkuhl, Storch, Bodfish, &
Geffken, 2008). Habituation occurs naturally and leads to reductions in both fear and OC symptoms (Foa & Kozak, 1985). Since individuals who suffer from OCD often show low emotional clarity (de la Cruz et al., 2013), and have attenuated access to their internal states
(Lazarov et al., 2015), it is plausible that by using AL, participants with high OC symptoms will have increased access to their emotions during exposure, which will, eventually, facilitate a more AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 4
efficient exposure. In a recent study Kreiser, Moyal, & Anholt, (2019) we exposed participants to a self-selected distressing thought (an internal stimulus) based on a procedure described by
Clerkin, Magee Parsons (2014) in which participants were asked to read and rate a list of 75 potentially distressing thoughts (e.g., a thought that one’s eyes will be/are harmed; Rachman &
Silva, 1978). Next, participants were asked to choose two personally relevant thoughts, write one of them down and concentrate on it for 2.5 minutes. Subsequently, participants were randomly assigned to three conditions. In the first group, participants were asked to spontaneously label the emotion they experienced (emotion generation; EG). In the second group, participants were asked to choose an emotion out of forced-choice options (emotion category; EC; i.e., fear, sadness, anger, worry, disgust, shame, and guilt). The third group entailed instructions for concentration on the thought alone (exposure only; control group). Each subject underwent three rounds of exposure (30 sec), labeling the emotion (except the control group) and rating their momentary feeling on a 100-point visual analog scale (VAS, 1= very negative, 100= very positive; 30 sec). Arousal was measured by subjective self-report (SR) and by an objective measure of skin conductance response (SCR). Exposure was repeated one week later to test long- term maintenance and consolidation (session 2). Results suggested that the only difference between the groups was a greater SCR reduction for the EC group in session 1. No differences were found in SR.
The present study addresses methodological and theoretical limitations in the aforementioned study in the four following aspects: I) the SR measurement was conducted using a bipolar VAS where negative and positive emotions were rated on the same scale. However, in a recent study, (Kron, Pilkiw, Banaei, Goldstein, & Anderson, 2015) it was found that arousal and valence are two different components of emotional experience, yet the ability of subjects to AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 5
reflect on them as distinct appears to be limited. They suggested that the use of a bipolar scale can disguise effects and that the use of unipolar in psychological research is more reliable.
Therefore, we used a unipolar scale and asked participants to rate the intensity of their emotions.
Since the manipulation is designed to induce negative emotions and we used a unipolar scale, participants' adherence to the manipulation was verified and participants who reported positive emotions were excluded from analyses. II), In the former study, the self-selected distressing thought may have been too general and not sufficiently idiosyncratic, resulting in relatively low levels of distress reported (SR distress mean of 47.3/100). Therefore, in the present study participants were requested to adjust the sentence they choose from the list of distressing thoughts to the first person and modify it in a way that will make it relevant to a thought they often experience (e.g., changing the sentence "a thought that one of my close relatives will be harmed" to a thought that "a terrorist is entering my house and murdering my mother"). We expected that a more idiosyncratic thought will be more relevant to participants, resulting in a more ecological and real-like experience of arousal and distress. III) since in the former study, the significant difference between the groups was found in the objective- physiological measure
(SCR) but not in subjective SR, another objective dependent variable was added (Heart Rate
Variability, HRV) to try and better understand the origins of the differences between objective and subjective arousal measurement. IV) in the former study subjects underwent 3 rounds of exposure (3min). The exposure time that is typically used in OCD treatment is 45-120 min per session (Franklin et al., 2000). In addition, Niles et al., (2015), suggested that SR anxiety may require a longer duration to feel and modify compared with physiological measurements of anxiety. Hence, the effect of AL on SR ratings may require longer exposure duration. Therefore, AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 6
we have prolonged the exposure time to 30 minutes (30 reminders of the distressing thought) instead of three reminders.
Despite the widespread suggestion that AL may improve the effect of exposure
(Kircanski, Lieberman, & Craske, 2012; Tabibnia, Lieberman & Craske, 2008; Niles et al., 2015;
Torre, & Lieberman, 2018), AL effects on prolonged exposure to internal stimuli have been scarcely studied. Therefore, the purpose of the current study is to examine the effect of adding
AL to prolonged exposure to distressing thoughts. Hypothesis: (1) All conditions will show a decrease in arousal over time, yet (2) the exposure only group will exhibit less anxiety reduction than the AL groups. Additionally, individuals with high OC symptoms often show low emotional clarity and reduced access to internal stats and therefore we expect that (3) the EC group will outperform the EG group since the optional emotions presented in the EC condition will assist participants to label their emotions. (4) These differences are expected in both the subjective and objective measurements and (5) we expect that the effect of exposure on arousal will be moderated by Alexithymia
Method
2.1 Participants
One hundred undergraduate students from Ben-Gurion University of the Negev, who filled-in a pre-screen and scored at the top 25% (≥23) on the Obsessive-Compulsive Inventory
(OCI-R; Foa et al., 2002) (clinical cutoff scores is 21 (Senanayake, Rajasuriya, Suraweera, &
Arambepola, 2018)) were recruited to participate in this experiment in exchange for course credit or payment of 10 $ (35 Shekels). Exclusion criteria for the analyses included: reported positive emotions during the exposure (n=9), and a score lower than 23 on the repeated OCI-R administration at the laboratory (n=39). Applying these inclusion and exclusion criteria yielded AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 7
the final study sample of n=52 (n=42 females, average age= 23.25, mother tongue: Hebrew n=47, English n=2 (one was randomly assigned to the EC condition and one to the EG condition), Arabic=3 (one was randomly assigned to the EC conation and two to the EG condition). All participants were randomly assigned to one of the three experimental conditions:
(1) EC(n=19), (2) EG(n=16), and (3) exposure only (n=17). The dependent variables included:
(1) SR, (2) SCR, and (3) HRV. There were no significant differences between the conditions in age, OCI-R or TAS scores. (note Table A1- appendix)
2.2 Procedure
This study was approved by the institutional ethics committee and subjects signed an informed consent and were instructed that they could discontinue the experiment at any point without any negative consequences prior to the beginning of the experiment. In order to measure the pre-exposure distress level, participants watched a series of nature photos for 3 minutes and rated the intensity of their emotion, on a 100-point scale (0= low intensity, 100= high intensity).
Next, to provoke anxiety, participants completed a procedure described by Clerkin, Magee &
Parsons (2014). They were asked to read a list of intrusive thoughts (e.g., the thought that one's eyes will be/ are harmed) devised by Rachman & Silva (1978) and, to choose one personally relevant/ distressing thought. In order to increase the effectiveness of the manipulation, we asked participants to personalize the relevant/ distressing thought (i.e., use the first person and change it in a way to resemble a distressing thought they often have). Participants were asked to type the sentence on the keyboard and concentrate on it for 30 seconds. Subsequently, participants rated the intensity of their momentary emotion, on a visual analog scale (VAS; 0= low intensity,
100= high intensity) (SR). This rating constituted the post manipulation baseline. AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 8
Subsequently, participants went through 30 exposure trials that included: (a) The self- selected distressing thought was presented on the screen and they were asked to concentrate on it, (b) depending on the randomly assigned condition: (1) participants were asked to spontaneously label the emotion they experience (EG) (15sec) and then rate the intensity of their emotion at the moment on VAS (15sec), (2) participants were asked to choose an emotion out of forced-choice options (EC; i.e., fear, sadness, anger, worry, disgust, shame, and guilt) (15 sec) and then rate the intensity of their emotion at the moment on the VAS (15sec), and (3) participants were asked only to rate the intensity of their emotion at the moment on the VAS
(exposure only; this group received 30 seconds to rate their emotion to adjust exposure time to the labeling groups). During the task, SCR and HRV were measured. At the end of the session, participants answered two manipulation check questions: (1) what was the valence of the main emotion you felt during the experiment? (positive or negative), and (2) during the experiment did you feel any different emotional valence? if so, how many times?
2.3. Measures
At the end of the exposure participants filled in (1) the Toronto Alexithymia Scale
(TAS; Taylor, Ryan & Bagby, 1985). The TAS-26 retains 26 items clustered in four factors in accordance with the alexithymia construct: (a), difficulty to identify and distinguish between feelings and bodily sensations; (b), difficulty to describe feelings; (c), reduced daydreaming; and
(d), externally oriented thinking. The TAS test re-test reliability is 0.78 and internal consistency as measured in Cronbach’s alpha is 0.73 (Kauhanen, Julkunen & Salonen, 1992). Alexithymia refers to people who have trouble identifying and describing emotions and who tend to minimize emotional experience and focus attention externally (Kocijan, Gelo & Karlović, 2015), and (2) AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 9
the OCI-R. The OCI-R test re-test reliability is 0.82 and internal consistency as measured in
Coefficients alpha is 0.81. (Foa al el., 2002)
2.3.1. Physiological Activity
Throughout the experiment, participants’ arousal was measured by SCR and HRV using IOM SENSORS hardware with two SCR and one HR finger electrodes (Unyte Health
Inc.,2019). SCR and HRV data were collected with AliveTM software (Somatic Vision) and further analyzed with Kubios HRV Standard 3.1.0 (Kubios Oy). SCR is defined in uSiemens
(Mho) and HRV was measured as log of the high frequency (HF) (0.15–0.4 Hz) centered at respiratory sinus arrhythmia (RSA) frequency of HRV.
2.3.2 Self- Report
SR emotion intensity was measured on a VAS (0= low intensity, 100= high intensity).
The experiment was designed using OPEN SESAME (Mathôt, Schreij, & Theeuwes, 2012).
2.4 Data Analyses
All analyses were conducted using SPSS (version 21.0). The SR scores ranged from 0 to 100 (M = 60.23, SD = 28.88). SR was normally distributed, with skewness of -0.49
(SE = 0.06) and kurtosis of -0.84 (SE = 0.12). The HRV scores ranged from 3.62 to 10.36
(M = 6.43, SD = 1.01). HRV was normally distributed, with skewness of 0.06 (SE = 0.06) and kurtosis of 0.17 (SE = 0.12). The SCR scores ranged from 0.62 to 14.06 (M = 4.69, SD = 2.50).
Since SCR was non-normally distributed, with skewness of 1.12 (SE = 0.04) and kurtosis of 1.25
(SE = 0.08), we applied a log 10 transformation (Winer, 1974) which resulted in SCR scores ranging from -0.20 to 1.15 (M = 0.61, SD = 0.24) and a normal distribution, with skewness of
0.37 (SE = 0.043) and kurtosis of 0.15 (SE = 0.09)
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 10
2.5 Manipulation Check
In order to check our manipulation, a dependent-samples t-test was conducted to compare
SR, HRV, and SCR pre and post-manipulation. There were significant differences in all the dependent variables; SR pre- manipulation (M=40.88, SD=24.81) and SR post-manipulation
(M=73.37, SD=16.79); (T(51)=-9.11, p=0.000. HRV pre- manipulation (M=6.39, SD=0.96) and
HRV post-manipulation (M=6.65, SD=1.05); T(51)=-2.97, p=0.005. SCR pre-manipulation
(M=0.45, SD=0.24) and SCR post-manipulation (M=0.64, SD=0.21); T(51)=-12.9, p=0.00.
These results show an increase in all three indices suggesting that the manipulation evoked increased arousal, as measured by SCR, and emotion intensity by SR. It is important to note that the increase in HRV has a different meaning than the other two indices. In a recent meta-analysis by Kim et al., (2018) low parasympathetic activity (which is related to stress and arousal) was characterized in a decrease in high-frequency (HF) band (the factor we used for HRV -log HF) whereas our manipulation seems to have created an increase in HRV. However, these results correspond with the suggestion that an increase in HF-HRV reflects self-regulatory effort
(Segerstrom, & Nes, 2007; Butler, Wilhelm, & Gross, 2006; Smith et al., 2011).
2.6 Reliability and Validity
In order to test reliability and validity, we measured SC during rest and while watching stress evoking clips (Eisenberg et al., 1988). The measures were made using the sensors and software that are used in the experiment, and another measuring device
(Acknowledge system of Biopac company). Next, we applied a Pearson correlation and the results showed high reliability and validity as the correlation coefficient between measuring tools was significant r(1935)=0.9,p=0.00. and in accordance with the changes between rest and stress. AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 11
Results
3. HLM
Regression analyses were conducted using hierarchical linear modeling (HLM; see
Raudenbush & Bryk, 2002, for a review). HLM is useful in analyzing repeated-measures data
(Level 1) nested within-subjects (Level 2) (Olsson et al., 2017) since it does not require the assumption of independence of observations (Bryk, Raudenbush, & Congdon, 1996).
Furthermore, HLM improves the estimate of effects within individual units and has lower Type I error rates (Raudenbush & Bryk, 2002). The covariant structure tape we chose was: first-order autoregressive (AR1). The AR1 structure indicates that measurements that are closer in time could be more highly correlated than those farther apart in time (Keselman, Algina, &
Kowalchuk, 2001). In order to increase reliability, we used sample aggregation (Appendix)
(Kamarck, Thomas & Lovallo, 2003). We expected a linear pattern only in the post-manipulation trials and therefore, in the HLM analysis, we used only these samples. SR and physiological scores of the exposure with and without AL across the trials are summarized in Appendix Table
A2- (means and SD). The most important time point to examine the effects between conditions was the final time sample. Therefore, the time variable was shifted so that 0 was set to be the final measure, and the measures before were -1,-2…-6) (Brush, Ehmann, Hajcak, Selby, &
Alderman, 2018; Hoffman & Rovine, 2007). The shift was made only for analysis requirements, and therefore, the graphs show the timeline as reflecting the experiment itself (i.e., 0 is baseline pre-manipulation, and 1-6 are post-manipulation).
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 12
3.1 The Overall Effect of the Exposure Procedure
3.1.1 Time
In accordance with our first hypothesis, we found that across all three conditions, the procedure was efficient in reducing SR arousal levels over time (trials): An HLM analysis revealed a main fixed effect for time F(1,308)=27.6, p<0.001. However, contrary to our hypothesis regarding the physiological indices, no significant main effects for time were shown in: HRV, F(1,303)=0.01, p=0.93 or SCR, F(1,286)= 2.97.p=0.09.
3.1.2 Condition
After establishing the overall effectiveness of the procedure, we tested our second hypothesis: that the AL conditions will lead to a larger reduction on arousal levels than the ME condition. The results of the HLM revealed a significant main fixed effect for condition
F(2,76)=4.68,p=0.01 for SR.
However, contrary to our hypothesis, the estimates of fixed effects showed that on the final sample of the procedure, the exposure only condition had a 37.42 (6.15) intercept, which was significantly different from the EG: B=22.51, SE=8.47, T(76)=2.66, p=0.01, CI=[5.64, 39.39], and from the EC condition in that time point: B=23.44, SE=8.84, T(76)=2.65, p=0.01, CI=[5.84,
41.05]. These results imply that the effect of the procedure was greater in the exposure only condition compared with both EC and EG.
Furthermore, estimates of fixed effects for time, showed that the exposure only condition had a B= -6.49(1.14) (the average decrease from sample to sample), and that there was a significant difference in B between the exposure only and the EG condition: B=4.71, SE=1.57,
T(306)=3.00, p=0.03, CI=[1.62, 7.80], and between the exposure only and the EC condition: AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 13
B=4.21, SE=1.64, T(306)=2.57, p=0.01, CI=[0.99, 7.44]. These results suggest that the exposure only condition demonstrated a steeper slope (by 4.71 from EG and by 4.21 from EC) and lower scores at the final measure (by 22.51 from EG and by 23.44 from EC).
No significant difference was shown between EG and EC conditions: B=-0.49, SE=1.60,
T(306)=-0.31, p=0.76, CI=[-3.64, 2.65]. these results are relevant to our third hypothesis, that the EC condition will show a lager decrease over time than the EG condition. Again, contrary to our expectation, no significant difference was shown between EG and EC: B=0.93, SE=8.61,
T(76)=0.11, p=0.91, CI=[-16.22, 18.01].
As for the physiological measures, contrary to our forth hypothesis, no significant main fixed effects for condition were found, in HRV: F(2,80)=0.59 ,p=0.55 nor in SCR:
F(2,80)=0.36, p=0.70.
3.2.1 Interactions
Significant differences in slopes of emotion intensity (SR) between the conditions, were shown by a significant linear time*condition interaction, F(2,306) = 5.24, p < 0.01. No significant effects were shown for this interaction in the physiological measures: HRV
F(2,301)=0.43,p=0.65 and SCR F(2,284)=0.83, p=0.44. In order to further understand the origin of this effect, we conducted simple slopes analysis and decomposing.
3.2.2 Simple slopes
Since we found significant interaction effects only in the SR, simple slope analysis was conducted only for this dependent variable. The simple slope analysis was done using computational tools for Probing Interactions in Multilevel Modeling (Preacher, Curran, & Bauer,
2006). For the interaction of time*condition there was a significant difference between exposure AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 14
only and EG: T=(3.0,p=0.00) and between exposure only and EC (T=2.57,p=0.01). The difference between the slopes of the two labeling conditions, EG and EC was not significant (T=-
0.3, p=0.76). All three regression lines showed significant intercepts at the final sample of the exposure session, and significant slopes as shown in Table 1 and Figure 1.
Table 1. Intercepts and slopes for all three conditions (SR).
Intercept z,p Slope z,p
Exposure Only 37.42(6.15), z=6.08, p=0** -6.49(1.14) z=-5.69, p=0**
EC 60.86(6.34) z=9.59, p=0** -2.27(1.18) z=-1.93, p=0.05*
EG 59.94(5.82) z=10.30, p=0** -1.78(1.08) z=-1.65, p=0.01*
** p<0.01 *p<0.05, EC, Emotion Category; EG, Emotion Generation
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 15
Figure 1 simple slope decomposing for a two-way interaction: time*condition
Distress Over Time
75 70 65 60
55
Report -
50 Self 45 40 35 30 1 2 3 4 5 6
Exposure Only EG EC
EC, Emotion Category; EG, Emotion Generation; SR, Self-report.
Overall, the ME group showed a mean delta of -31.2 in emotion intensity (SR) levels
(from post-manipulation to the last sample) compared to EG (-13.37) and EC (-11.13).
These results suggest that the largest reduction over time and the lowest rate of emotion intensity in the final measurement were observed in the ME condition and not in the AL conditions (EG and EC) as we predicted. Furthermore, no difference between the two AL conditions (EG and
EC) was found.
3.3 Moderation
In order to test our fifth hypothesis, we conducted a moderation HLM analysis according to Preacher, Curran & Patrick (2006) as an interaction (time*condition*alexithymia). For SR:
The three-way interaction time *condition* alexithymia was not significant, yet the two-way AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 16
interaction: time * alexithymia was found significant F(1,308)=6.93.57, p=0.01. This interaction suggests that the effect of exposure with and without labeling over time was moderated by the scores of the TAS. The simple slope analysis shows that, for scores at the mean and 1SD under the mean in the TAS 26, the intercept and slope are significant. 1SD above the mean, the intercept (at the final time sample) is higher in 12 points compared with 1SD under the mean and
8 points higher than the mean, and the slope is no longer significant as shown in Table 2 and
Figure 2. In the physiological measures, no interaction effects were found.
Table 2 Intercepts and slopes with alexithymia as a moderator
Alexithymia Intercepts z,p Slope z,p
-1SD 46.88(5.08) z=9.23, p=0** -5.21(0.93) z=-5.60, p=0**
MEAN 52.87(3.59) z=14.74, p=0** -3.47(0.66) z=-5.28, p=0**
+1SD 58. 85 (5.08) z=11.59, p=0** -1.74(0.93), z=-1.87, p=0.06
** p<0.01 *p<0.05, -1SD, one standard deviation under the mean; +1SD one standard deviation over the mean;
Alexithymia, TAS 26 (Toronto Alexithymia Scale) scores.
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 17
Figure 2 Simple slope decomposing for a two-way interaction: time*alexithymia
Distress Over Time Moderated by Alexithymia
75 70 65
60 Report - 55
Self 50 45 40 1 2 3 4 5 6
-1SD MEAN +1SD
-1SD, one standard deviation under the mean; +1SD one standard deviation over the mean, Alexithymia, TAS 26
(Toronto Alexithymia Scale) scores.
Discussion
The goal of the current study was to test whether AL enhances the effectiveness of exposure to a personalized self-generated obsessive-like thought for individuals with high OC symptoms. Furthermore, we wished to explore if EC will have a more beneficial effect on exposure than EG, and to test the effect of alexithymia as a moderator of exposure. Overall, we found that the exposure procedure resulted in a reduction in SR. However, in opposition to our prediction, we found that AL hampered the effectiveness of exposure on measures of self- reported distress. Moreover, we found a moderating effect for alexithymia such that the exposure with and without AL was more beneficial for participants who presented lower alexithymia scores. No difference in SCR reduction was found between the two AL conditions, and all the effects were found only in SR and not in the physiological measures. AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 18
A previous study in our lab using a similar experimental procedure, (Kreiser, Moyal, &
Anholt, 2019) found that EC was more beneficial as an addition to exposure, compared with EG and exposure alone, as reflected in a decline in SCR. This pattern of results was found only in the first session and not in the follow-up session conducted a week later, suggesting that no differences in between-session habituation were evident. The current study aimed at addressing several shortcomings in the design of the previous study. To this end, we personalized the obsessive-like thought or impulse that participants had been exposed to and elongated the duration of the exposure (from 2.5 to 30 min). Therefore, the current procedure was more ecological and relevant to the clinical practice of ERP, and we assumed that such changes would enable further understanding regarding the effect of AL on exposure in the context of within- session habituation.
Despite the theoretical suggestion that AL may be an efficient addition to exposure in treating anxiety and OCD related disorders (Kircanski, Lieberman, & Craske, 2012), empirical support for this idea is rather scarce, and only limited research had been done on variables that might facilitate or impede this effect. Research in this area is conducted mostly with anxiety- related disorders, entailing differential forms of AL such as labeling a situation, a facial expression or the momentary emotion, and using relatively short exposure duration (Tabibnia et al., 2008; Kircanski, Lieberman, & Craske, 2012; Niles, Craske, Lieberman, & Hur, 2015). In contrast, the clinical practice of ERP requires long exposure duration, typically 45-120 minutes per session (Franklin et al., 2000). Therefore, the duration of exposure was prolonged in the current study. To our knowledge, this is the first study to examine the effect of AL on extended exposure duration (30min) in a high OC sample. AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 19
Our main hypothesis concerning AL as a potential enhancer of the effect of exposure on indices of distress was not supported. This prediction was based on current literature in the field of emotion regulation (Tabibnia et al., 2008; Kircanski, Lieberman, & Craske, 2012; Niles,
Craske, Lieberman, & Hur, 2015; Torre & Lieberman, 2018) suggesting that AL may be a beneficial increment for exposure in anxiety-related disorders. The unexpected results observed in this study may contribute to a more informed discussion regarding the effect of AL on exposure in the context of OC symptoms. We suggest that these relations can be explained by several perspectives.
In a recent review, Torre & Lieberman (2018) suggested a few possible candidates that can explain the beneficial mechanism of AL, such as distraction and reduction of uncertainty. AL requires the application of language-related processes while encountering an evocative stimulus.
It has been suggested that this language-dependent abstraction process may result in a momentary distraction that prevents one from fully processing and engaging with the emotional stimulus. This distraction may partly account for the diminished emotional effects evident during
AL (Torre & Lieberman, 2018). Although distraction is known to be an effective emotion regulation strategy (Sheppes, Scheibe, Suri & Gross, 2011), in the context of exposure, previous studies with OCD patients have shown that attention focusing during exposure led to lower levels of anxiety compared with distraction during exposure (Grayson, Foa, & Steketee, 1982).
Taken together, it might be suggested that the instruction to label the emotion felt, in the AL conditions led to distraction from stimuli, that hampered the exposure procedure.
Another suggested mechanism by which AL is assisting emotion regulation is by reduction of uncertainty (Torre & Lieberman, 2018). Individuals with high OC symptoms were found to present with lack of emotional clarity (the extent to which individuals know (and are AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 20
clear about) the emotions they are experiencing; Gratz & Roemer, 2004) (de la Cruz et al., 2013), and intolerance of uncertainty (a broad construct representing cognitive, emotional, and behavioral reactions to uncertainty in everyday life situations; Freeston, Rhéaume, Letarte,
Dugas, & Ladouceur, 1994), to a greater degree than other anxiety-related disorders (Steketee,
Frost & Cohen, 1998; Tolin, Abramowitz, Brigidi & Foa, 2003; Fergus & Bardeen, 2014).
Furthermore, uncertainty may lead to significant anxiety until certainty is obtained (Holaway,
Heimberg, & Coles, 2006). In the current study, we assumed that adding AL will reduce uncertainty and thus would be a beneficial addition to exposure. As our results indicate, not only did the AL intervention did not improve the effect of the exposure, it rather blocked the
“naturally occurring” desensitization for the negative emotional stimulus. Prospectively, we suggest that such an effect might be explained by the idea that the AL intervention, paradoxically, increased rather than decreased uncertainty regarding the OC participants’ emotional state. Studies on repeated checking in OCD (e.g., van den Hout & Kindt, 2003;
Boschen & Vuksanovic, 2007) showed that repeated checking led to more uncertainty in both healthy and OCD (with and without checking tendencies) participants. Additionally, intolerance of uncertainty was suggested to be an important domain in OCD (Obsessive Compulsive
Cognitions Working Group (OCCWG),1997) and individuals with OCD display greater doubt about the correctness of their decisions (Frost & Shows 1993). Therefore, it is plausible that the instruction to label the emotion felt (every minute), served as repeated checking, combined with the tendency for uncertainty and doubt about the correctness of the answer (particularly in a vague internal stimulus such as emotion), resulted in higher levels of distress and less effective exposure. AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 21
According to the self-perception theory (Bem, 1972) particularly in vague situations, individuals come to know their emotions and other internal states, by inferring them from observations of their own behavior. The SPIS model by Liberman & Dar (2009) further suggests that individuals with OCD have attenuated access to and reduced confidence in their internal states. Therefore, they rely on proxies such as acts, compositions and "information from the outside world" as a compensation strategy to overcome a deficit in implicit processing. Although we expected that AL will assist the participants to feel less distressed and intimidated by their emotions, it might be that the AL served as a proxy, increasing participants' distress (i.e., "I wrote that I am ashamed, so I am ashamed, should be ashamed", etc.)
Another explanation for the differences in results between previous studies regarding AL as an addition to exposure (Niles et al .,2015; Tabibnia et al .,2008; Kircanski, Lieberman &
Craske, 2012) and our current study, could be the differences in characteristics of the relevant disorder (anxiety vs OCD) and differences in the design (the duration of exposure and the way labeling was carried out (emotional vs non-emotional, self vs other\object)). In previous editions of the DSM (APA, 2000) and ICD (World Health Organization, 1992), OCD belonged to the anxiety disorders category. However, in the DSM-5 it was removed from the anxiety disorders section and reclassified under the new category of obsessive-compulsive and related disorders
(OCRDs) (APA, 2013). Although obsessions and compulsions are commonly accompanied by symptoms of anxiety, OCD may be associated with distressing experiences other than anxiety, such as disgust in contamination obsessions or a sense of incompleteness and feelings of “just not feeling right” in symmetry obsessions. Furthermore, although obsessive thinking is common in all anxiety disorders, taboo obsessions, such as those related to sex, violence, and religion, occur almost exclusively in OCD (Krzanowska & Kuleta, 2017). Unlike previous research in AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 22
AL, in which participants have experienced and labeled mostly fear and anxiety (emotions that are common in phobia and anxiety-related disorder (Niles et al., 2015; Torrisi, Lieberman,
Bookheimer, & Altshuler, 2013)), in the current study the content of the distressing sentences was personalized to an idiosyncratic obsessive thought that cold evoke different feelings such as; disgust, shame, guilt, etc. Previous studies have suggested that there is a difference in the course of fear and disgust habituation during exposure-based treatment and that disgust is more resistant to extinction then fear (during repeated exposure to relevant stimuli) (Olatunji, Wolitzky-Taylor,
Willems, Lohr, & Armstrong, 2009). It is possible that labeling emotions like disgust, shame and guilt might create a different effect than labeling fear and anxiety. Therefore, no habituation effect was detected in the AL conditions.
Moreover, the procedure for the administration of AL in research is largely diverse.
Several studies instructed participants to label the characteristics of a situation or a stimulus
(Kircanski, Lieberman & Craske, 2012; Niles at el .,2015), others, to label the emotion of a face expression (Lieberman et al., 2011; Creswell, Way, Eisenberger, & Lieberman, 2007) and yet others, (as in the current study) asked participants to label their own emotions (Niles at el .,2015;
Kircanski, Lieberman & Craske, 2012). These differences in AL administration may explain inconsistencies in results. Torre & Lieberman (2018) have suggested that a major advantage of
AL is that it is an implicit form of emotion regulation that dos do not require effort to deploy.
Yet, it is possible that the unique characteristics of OCD such as, low emotional clarity and reduced access to internal stats (Robinson & Freeston, 2014; de la Cruz et al., 2013; Lazarov,
Dar, Oded, & Liberman, 2010; Liberman & Dar, 2009) together with the administration of AL used in the current study (labeling their own emotions) created a task that is effortful and even AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 23
stress-provoking for the participants, and therefore might have hampered the effect of the exposure.
As we hypothesized, alexithymia moderated the effect of exposure with and without labeling, making the exposure session more beneficial to participants that were lower in alexithymia. Although alexithymia was found to be related to OC symptoms (Carano, 2014;
Robinson & Freeston, 2014; Roh, Kim & Kim, 2011), the literature about the effect of alexithymia on treatment results of CBT demonstrated that alexithymia is not predictive of treatment outcome (Rufer et al., 2010, 2004). We suspect that the effect of alexithymia is more dominant in the AL conditions since AL requires understanding and recognizing emotions.
Therefore, we expected to find a significant three-way interaction (time * alexithymia * condition). We speculate that the moderating effect of alexithymia was not detected in the three- way interaction (time * alexithymia * condition) because of the relatively small sample size.
Detecting significance in a three-way interaction requires four times the power that is needed for a two-way interaction (Heo & Leon, 2010), and insufficient power to detect significant cross- level interaction effects is a common problem in HLM (Mathieu, Aguinis, Culpepper, & Chen,
2012).
In contrast to our hypothesis, we found no effect on physiological measures. We tested for reliability and validity of our tools as presented above, and high reliability and validity were found. Additionally, the analysis of the manipulation effect showed a significant change in SR,
SCR, and HRV, suggesting that this disassociation (between the SR and the physiological measures the correlations throughout the measurements between SR and HRV was 0.081 and between SR and SCR was -0.074) is not a result of technical problems in the measurement tools.
Various studies show a disassociation between SR and physiological measures (e.g., Wilhelm, AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 24
Kochar, Roth, & Gross, 2001) and specifically in emotion regulation and labeling related experiments (e.g., Niles et al., 2015; Kircanski et al., 2012). However, these studies have found effect only in physiological measures, which was attributed to the implicit effect of AL (Torre &
Lieberman, 2018), whereas we found the effect only in SR. Such divergence between SR and physiological insides may indeed be counter-intuitive but seems to be a reoccurring phenomenon. A recent study by Zanten & Annie (2019), demonstrated that perceived, subjective heart rate (HR) change, rather than actual HR change was associated with subjective anxiety intensity. Here, we did not focus on the subjective experience of introspective signals that would perhaps enable us to produce a similar result, yet the fact that the effect was evident only on the
SR measure might indicate that the subjective experience is more relevant than assumed before.
It is important to note that the results of this study stand in contrast to the literature regarding AL and to our original hypothesis, and several study limitations should be taken under consideration.
First, the sub-clinical characteristics of the sample and the use of an obsessive like distressing thought which are analog to a clinical sample and a real obsessive thought. Another limitation is the relatively small sample size that caused low power at level 2 and might explain the null effect in the physiological measures.
Conclusions
Our results suggest that AL might not be a beneficial strategy for individuals with high OC symptoms, but these results do not necessarily imply that OC individuals can not benefit from AL at all. Further research should examine if individuals with OCD or high OC symptoms might gain from different forms and administration schedules of AL. Moreover, additional research is needed in order to test for between-session habituation (long-term) effects of the addition of AL to exposure. AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS 25
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Appendix
Table A.1 Means and Standard Deviations for age, Obsessive-Compulsive symptoms and alexithymia scores.
Mean (SD)
ME EC EG F(2,49) p
Age 23.47(1.7) 23.31(1.7) 23(1.9) .33 .72 OCI-R 35.8(7.6) 34.0(10.4) 34.89(8.6) .17 .84 TAS 26 68.8(18.4) 73.3(13.9) 73.6(15.3) .48 .62
OCI-R, obsessive compulsive inventory-revised; TAS26, Toronto Alexithymia Scale; ME=Mere Exposure, EC=Emotion Category EG=Emotion Generation
Table A.2. Means and standard deviations for one pre and six post-manipulation time samples in SR.
Condition\ Time sample 0 1 2 3 4 5 6 ME MEAN 46.06 70.54 60.82 51.48 46.53 43.33 38.06 SD 22.74 14.59 22.63 25.79 26.68 29.65 30.67
EC MEAN 38.56 72.60 69.29 64.49 64.71 60.79 61.24 SD 21.41 14.20 17.98 21.59 23.14 27.37 26.86
EG MEAN 38.21 68.60 67.16 66.86 65.89 62.29 59.68 SD 29.43 24.10 29.03 28.28 28.50 30.28 32.27
ME=Mere Exposure, EC=Emotion Category EG=Emotion Generation Aggregation procedure The system sampling rate is 175 times per 1 min for HRV and SCR. First, every 1 min was aggregated into 1 trial, resulting in 30 scores for each participant. Next, the 3 pre and every 5 post-manipulation trials were aggregated into 1 resulting in 7 points of measurements, 1 pre- manipulation, and 6 post-manipulation.
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS
רשימת נספחים
נספח A ...... 38
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS רשימת טבלאות טבלה 1: ...... 14
טבלה 2: ...... 16
טבלה A1: ...... 38
טבלה A2: ...... 38
רשימת איורים
איור 1: פירוק לשיפועים פשוטים של האינטראקציה הזוגית תנאי X זמן ...... 15
איור 1: פירוק לשיפועים פשוטים של האינטראקציה הזוגית זמן X אלקסיטמיה ...... 17
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS תוכן עניינים מבוא ...... 1
שיטה ...... 6
נבדקים ...... 6
מהלך המחקר ...... 7
כלים ...... 8
ניתוח נתונים ...... 8
בדיקת מניפולציה ...... 9
תוקף ומהימנות ...... 9
תוצאות ...... 10
מודלים היררכים לינאריים ...... 10
האפקט הכללי של החשיפה ...... 12
אינטראקציות ...... 13
מיתון ...... 15
דיון ...... 17
מקורות ...... 25
נספחים ...... 38
AFFECT LAEBELING & EXPOSURE FOR HIGH OBSESSIVE-COMPULSIVE SYMPTOMS תקציר
נמצא כי שיום רגשי מגביר את השפעתה המיטיבה של חשיפה לגירוי מעורר חרדה, בהפחתת מצוקה בהפרעות
הקשורות בחרדה. בנוסף, הוצע שלשיום רגשי השפעה דומה גם על חשיפה למחשבה או דחף המעורר מצוקה, בהפרעה
טורדנית- כפייתית. ואכן במחקר קודם במעבדתינו עלה דפוס דומה לפיו שיום רגשי שיפר את השפעתה של חשיפה
קצרה, בת 2.5 דקות, לגירוי מעורר מצוקה, בנבדקים עם תסמינים של טורדנות וכפיתיות. בעבודה הנוכחית הוארכה
החשיפה ל30 דקות, ונמצא כי שיום רגשי בחשיפה ממושכת פגע בהשפעת החשיפה. אלקסתמיה )חוסר היכולת לתאר
ולהבחין ברגשות( מיתנה את ההתרגלות בתוך זמן החשיפה.
מנגנוני הפעולה דרכם שיום רגשי משפיע, כמשפר השפעת חשיפה במשך קצר, אך פוגע בהשפעת החשיפה במשך
ארוך בהפחתת המצוקה, נידונים בעבודה. ממצאי העבודה עשויים לסייע בהבנת המנגנון, ודיוק הטיפול בעזרת שיום
רגשי, להפחתת מצוקה בהפרעות הקשורות בטורדנות וכפיתיות.
אוניברסיטת בן גוריון בנגב הפקולטה למדעי הרוח והחברה המחלקה לפסיכולוגיה
האם שיום רגשי משפר את השפעתה של חשיפה בנבדקים עם סיפטומים גבוהים של אובססיביות וקומפולסיביות
חיבור זה מהווה חלק מהדרישות לקבלת התואר "מוסמך למדעי הרוח והחברה" (.M.A)
מאת:עמרי גולדווי בהנחיית דר' גדעון אנהולט
חתימת הסטודנט/ית: תאריך: 27.9.2019
חתימת המנחה: תאריך: 27.9.2019
חתימת יו"ר המ"א המחלקתי: תאריך
ספטמבר 2019
אוניברסיטת בן גוריון בנגב הפקולטה למדעי הרוח והחברה
המחלקה לפסיכולוגיה
האם שיום רגשי משפר את השפעתה של חשיפה בנבדקים עם סיפטומים גבוהים של אובססיביות וקומפולסיביות
חיבור זה מהווה חלק מהדרישות לקבלת התואר "מוסמך למדעי הרוח והחברה" (.M.A)
מאת: עמרי גולדווי בהנחיית: דר' גדעון אנהולט
אלול תשע"ט ספטמבר 2019