Thesis
Reference
Cognitive-behavioural therapy: a tool to facilitate emotional adjustment to brain disorders
ABOULAFIA BRAKHA, Tatiana
Abstract
Nous avons investigué si les thérapies cognitivo-comportementales sont adaptées pour améliorer la régulation émotionnelle chez les patients cérébrolésés et diminuer le stress chez les proches. Les quatre études de la thèse ont montré que: 1) les manifestations psychophysiologiques durant les réactions émotionnelles chez les patients cérébrolésés peuvent être détectées et apaisées; 2) les patients ont la possibilité d'être conscients de leurs manifestations émotionnelles et de leurs modulations; 3) il est possible de promouvoir auprès de ces patients des techniques de régulation émotionnelle basées sur un travail sur les pensées, et ce malgré la présence de troubles cognitifs; 4) intervenir auprès des proches contribue non seulement à diminuer les effets physiologiques du stress, mais également à diminuer les manifestations neurocomportementales chez les patients. Malgré la nécessité d'études supplémentaires dans le domaine, les thérapies cognitivo-comportementales peuvent être un outil avantageux pour faciliter l'ajustement émotionnel à la nouvelle réalité induite par [...]
ABOULAFIA BRAKHA, Tatiana. Cognitive-behavioural therapy: a tool to facilitate emotional adjustment to brain disorders. Thèse de doctorat : Univ. Genève, 2015, no.
FPSE 602
URN : urn:nbn:ch:unige-750297
DOI : 10.13097/archive-ouverte/unige:75029
Available at:
http://archive-ouverte.unige.ch/unige:75029
Disclaimer: layout of this document may differ from the published version.
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Section de Psychologie
Sous la direction de Docteur Radek PTAK, PhD, Chargé de Cours
COGNITIVE-BEHAVIOURAL THERAPY: A TOOL TO FACILITATE EMOTIONAL ADJUSTMENT TO BRAIN DISORDERS
THESE
Présentée à la
Faculté de psychologie et des sciences de l’éducation de l’Université de Genève
pour obtenir le grade de Docteur en Psychologie
par
Tatiana ABOULAFIA BRAKHA
De Sao Paulo (Brésil) Thèse No 602
GENEVE
Juin 2015
No d’étudiant : 08.345.068
Avec mes sincères remerciements à tous les membres du jury (Dr. Radek Ptak-Directeur de
thèse, Prof. Jean-Marie Annoni, Prof. Guido Bondolfi, Prof. Guido Gendolla, et Prof. David
Sander); Merci également à ma famille, mes amis, mon mari et surtout à ma fille Gabriela, pour sa patience et compréhension pendant toute
la durée de ma thèse (et pour l’énorme joie de
vivre qu’elle me transmet !).
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SUMMARY (FRENCH)
Les problèmes de régulation émotionnelle et les changements comportementaux sont fréquemment observés dans différentes atteintes cérébrales. Ces problèmes ont un impact négatif sur la réinsertion sociale et professionnelle des patients et constituent une source supplémentaire de stress pour les proches. La santé émotionnelle du proche interférant avec la qualité du soutien fourni, elle peut à son tour retentir sur l’état émotionnel du patient. Malgré l’importance de cette problématique, les études portant sur la prise en charge psychothérapeutique des troubles émotionnels dans les atteintes cérébrales sont largement moins nombreuses que celles ciblant sur la rééducation des troubles cognitifs ou physiques.
Dans cette thèse, nous avons investigué si les thérapies cognitivo-comportementales sont adaptées pour améliorer la régulation émotionnelle chez les patients cérébrolésés et diminuer le stress chez les proches. Nous avons ciblé sur la régulation de la colère, qui est un problème fréquent dans les atteintes cérébrales et sur le stress du proche qui est en même temps cause et conséquence des troubles neurocomportementaux chez le patient. Dans l’étude 1 nous avons utilisé un design expérimental pour examiner les effets psychologiques et psychophysiologiques de l’expression et de la régulation de la colère chez les patients cérébrolésés; dans les études 2 et 3 nous avons évalué la faisabilité et les effets d’une thérapie cognitivo-comportementale en groupe sur la gestion de la colère chez les patient cérébrolésés;
finalement, dans l’étude 4 nous avons évalué les effets de la thérapie comportementale sur les marqueurs de stress chez les proches-aidants de patients ayant une maladie d’Alzheimer ainsi que sur les troubles neurocomportementaux des malades. En conclusion, les quatre études de la thèse ont contribué à mettre en évidence l’utilité des thérapies cognitivo-comportementale pour améliorer la gestion émotionnelle chez les patients cérébro-lésés en montrant que: 1) les manifestations psychophysiologiques durant les réactions émotionnelles chez les patients cérébrolésés peuvent être détectées et apaisées ; 2) les patients ont la possibilité d’être conscients de leurs manifestations émotionnelles et de leurs modulations; 3) il est possible de promouvoir auprès de ces patients des techniques de régulation émotionnelle basées sur un travail sur les pensées, et ce malgré la présence de troubles cognitifs ; 4) intervenir auprès des proches contribue non seulement à diminuer les effets physiologiques du stress, mais également à diminuer les manifestations neurocomportementales chez les patients. Malgré la nécessité d’études supplémentaires dans le domaine, nos résultats indiquent que la thérapie cognitivo-comportementale peut être un outil avantageux pour faciliter l’ajustement émotionnel à la nouvelle réalité induite par une atteinte cérébrale.
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SUMMARY (ENGLISH)
Emotional and behavioural problems are frequent in patients with various diseases affecting the brain. They contribute to poor social re-insertion and to increased stress in family members who provide care and support. Despite the importance of this topic, psychotherapeutic treatments for emotional problems in brain disorders remain understudied compared to the numerous studies focusing on rehabilitation of cognitive or physical symptoms. In this thesis we investigated whether cognitive-behavioural therapy (CBT) may improve emotion-regulation in patients with brain disorders and reduce caregiver’s stress. We focused on anger regulation, a frequent problem in patients with brain injury and in caregiver’s stress, which is both a consequence and a predictor of emotional problems in cared-for patients. Our study 1 examined psychophysiological and psychological outcomes of anger expression and regulation in patients with brain injury; studies 2 and 3 assessed feasibility and effects of a CBT group program for managing anger following acquired brain injury; and finally, study 4 assessed the effects of CBT on stress markers of caregivers of patients with Alzheimer’s disease and neurobehavioural problems of cared-for patients. In conclusion, the four studies provided evidence that CBT may improve emotion regulation in patients with brain disorders by showing that 1) patients do display physiological arousal to emotional events that can be detected and down-regulated, 2) patients may become aware of their emotional manifestations and their modulations, 3) it is possible to promote cognitive emotion regulation strategies despite the presence of cognitive impairment, 4) interventions for caregivers not only reduce their stress but facilitate emotional adjustment of cared-for patients. Though further studies in the field are needed in order to create or adapt CBT protocols to brain-injured patients, our findings show that CBT is a valuable tool to improve emotional adjustment to the new reality imposed by the disease.
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TABLE OF CONTENTS
I. THESIS OBJECTIVES ...5
II. GENERAL INTRODUCTION...6
1. Psychosocial impact of brain disorders: emotional changes and caregiver’s stress ...6
1.1. Characteristics and prevalence ...6
1.2 Emotion regulation mechanisms ...7
1.3 Origins of emotion dysregulation in brain disorders ...9
1.4 Social impact and caregiver’s stress ...12
1.5. Assessing emotion regulation ...13
1.6 Treatment options for emotion dysregulation in brain disorders ...16
2. Cognitive-behavioural therapy and brain disorders ...17
2.1 Cognitive-Behavioural therapy models...17
2.2 Cognitive-behavioural therapy for patients with brain disorders ...19
2.3 Cognitive Behavioural Therapy for caregivers... 21
3. Rationales for studies included in this thesis ...22
3.1 Psychophysiological expression of emotion modulation in patients with brain injury………...23
3.2 CBT anger management programs for patients with brain injury……….24
3.3 CBT interventions for caregivers and their effects on psychophysiological parameters………..24
III. RESULTS (Research articles) ... 26
1. Study 1. Emotion regulation after traumatic brain injury: distinct patterns of sympathetic activity during anger expression and recognition (in press)...27
2. Study 2. Feasibility and initial efficacy of a cognitive-behavioural group programme for managing anger and aggressiveness after traumatic brain injury (published) ... 49
3. Study 3. A controlled trial assessing the effects of an anger management program following acquired brain injury (under review) ... 71
4. Study 4. Cognitive-behavioural group therapy improves a psychophysiological marker of stress in caregivers of patients with Alzheimer’s disease: (published). ... 91
IV. GENERAL DISCUSSION ... 109
V. FRENCH SUMMARY ... 125
VI REFERENCES ... 145
5 I. THESIS OBJECTIVES
Emotional and behavioural problems are frequent in patients with various diseases affecting the brain. They contribute to poor social re-insertion and to increased stress in family members who provide care and support. Despite the importance of this topic, psychotherapeutic treatments for emotional problems in brain disorders remain understudied compared to the numerous studies focusing on rehabilitation of cognitive or physical symptoms. In this thesis we investigated whether cognitive-behavioural therapy (CBT) may improve emotion-regulation in patients with brain disorders and reduce caregiver’s stress. We focused on assessment and intervention for anger regulation, a frequent problem in patients with brain injury and in caregiver’s stress, which is a consequence and a predictor of emotional problems in cared-for patients. We specifically studied 1) the impact of anger regulation strategies on perceived anger and psychophysiological responses in patients with brain injury; 2) the utility of a CBT intervention protocol in the management of anger following brain injury and 3) the impact of CBT for caregivers on stress parameters and on emotional and behavioural symptoms of cared-for patients. In order to apprehend the complexity of emotional processes we used a variety of outcome measures covering psychological and psychophysiological aspects.
6 II. GENERAL INTRODUCTION
1. Psychosocial impact of brain disorders: emotional changes and caregiver’s stress 1.1 Characteristics and prevalence
Brain disorders of different origins are not only characterized by cognitive, sensory or motor problems, but also by changes of emotion regulation and behaviour, also termed neuropsychiatric or neurobehavioural problems (Starkstein & Tranel, 2012). Among such changes figures apathy, exacerbated irritability and anger, increased anxiety and deep sadness, as well as mania or psychotic symptoms, such as hallucinations or delusions. These symptoms often overlap and depending on their severity they may result in psychopathological conditions, such as mood disorders or specific anxiety disorders, as documented in the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (Hackett, Kohler, O'Brien,
& Mead, 2014). Indeed, persistent inability to regulate emotional and behavioural processes leads to a broad range of mental health problems that may vary from minor distress to severe psychopathology (Campbell-Sills & Barlow, 2007; Davidson, Jackson, & Kalin, 2000; J.
Gross & Munoz, 1995). For example, increased anger and irritability is one of the defining characteristics of depressed mood and constitutes a common symptom of depression (Seel et al., 2003).
Nature, intensity, duration and prevalence of emotional problems in brain disorders vary according to the type of injury and its stage. In brain disorders of abrupt onset such as stroke or traumatic brain injury, these problems may be perceptible already in the acute stage and may persist or even increase long after cognitive or motor deficits have regressed (Hoofien, Gilboa, Vakil, & Donovick, 2001). In progressive brain disorders (eg. Alzheimer’s disease, multiple sclerosis, Parkinson’s disease, Fronto-temporal dementia), emotional and behavioural changes are sometimes apparent before the manifestation of cognitive or motor problems and usually aggravate with disease progression (Starkstein & Tranel, 2012). In terms of prevalence, anxiety, depression or proneness to exacerbated anger and aggressiveness affect up to 70% of patients with traumatic brain injury (Dikmen, Machamer, Fann, & Temkin, 2010; Grafman et al., 1996; O'Connor, Colantonio, & Polatajko, 2005).
Depression and anxiety are diagnosed in around 30% of stroke patients from three months to several years after injury, whereas estimated prevalence of irritability varies between 12 to
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50% (Hackett et al., 2014). Patients with mild to moderate Alzheimer’s disease often present anxiety, irritability, agitation and apathy. For instance, it is estimated that 20 to 50 % of patients present problems with the management of anger and aggressiveness (Lyketsos et al., 2011). As the disease progresses, depression with marked apathy and psychotic symptoms usually prevail (Starkstein & Tranel, 2012).
In sum, emotion regulation problems as well as psychopathological diagnosis of anxiety and mood disorders are commonly found in patients with brain disorders irrespective of etiology and stage of the disease.
1.2 Emotion regulation mechanisms
Emotions are valenced responses of the organism to a specific trigger (external stimuli or internal mental representations). These responses are characterized by a combination of physical reactions, cognitions (thoughts about others and the situation) and behaviours that interact continuously (Ochsner & Gross, 2005). A commonly accepted categorization of emotion distinguishes basic emotions (believed to be transcultural) (Eckman, 1999) from secondary and tertiary emotions that derive from these basic emotions (Parrot, 2001). For instance, anxiety is associated with fear, frustration with anger, whereas shame and depression derive from sadness. However, to date the literature on emotion regulation has mainly focused on basic emotions. According to Gross and collaborators (Goldin, McRae, Ramel, & Gross, 2008; J. J. Gross, 2002; Ochsner & Gross, 2005), emotion regulation is the ability to influence when and how emotions are experienced and expressed. These authors elaborated a broad conceptual framework to explain emotion regulation, but their work essentially focused on two main processes: expressive suppression and cognitive reappraisal. The first involves changing an ongoing behaviour (or expression of emotion) in order to change subjacent emotional processes. It involves hiding, inhibiting or reducing emotion-expressive behaviours when they are just happening. For example, a person who is angry with his colleague may not show his discontent, just smile, pretend everything is alright and leave the room. Even though this person prevents verbalising unpleasant thoughts or scolding his colleague, thoughts about the person and the situation remain unchanged. Thus, behavioural suppression limits undesired emotional expression, but unpleasant feelings and physiological activation may remain unchanged or even increase. The second emotion regulation strategy, termed cognitive reappraisal, implies that an emotional experience can be influenced by the way a situation is
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cognitively appraised (J. J. Gross, 2002). Therefore, the manipulation of thoughts that allow taking a different perspective towards the event (reappraisal) contributes to a change in emotion regulation. For example, reappraisal decreases negative experience of emotion, increases positive experience, decreases activation of the sympathetic nervous system and favours social support (contrasting with suppression, which is associated with decreased social support and being ‘less liked’) (Butler, Lee, & Gross, 2007; J. J. Gross, 2002). In sum, according to Gross (2002), reappraisal is the most effective emotion regulation strategy. This strategy is also contrasted with thinking repetitively about an emotional event without changing its appraisal, a process termed rumination. Rumination contributes to the maintenance or amplification of maladaptive and unhealthy psychological and physiological expression of emotions (Ray, Wilhelm, & Gross, 2008). For instance, thinking again and again about sequences of events or recalling own emotional reactions is not necessarily helpful for solving an interpersonal conflict or decreasing emotional suffering.
Another relevant distinction within regulatory processes was added by Phillips and collaborators (Phillips, Drevets, Rauch, & Lane, 2003; Phillips, Ladouceur, & Drevets, 2008).
According to these authors, emotions can be regulated automatically or voluntarily.
Automatic emotion regulation occurs when the process is implicit and does not necessarily imply the identification of the nature of emotion or the strategy used to regulate it. In voluntary emotion regulation the subject is clearly aware of emotional manifestations as well as regulation strategies. The distinction between automatic and voluntary processes is particularly important when considering treatment approaches to emotion dysregulation. In many cases, treatments involve replacing maladaptive automatic strategies by more adaptive voluntary processes, and ultimately automatizing the newly acquired process.
It is important to point out that emotions, even the negative ones, are crucial for personal development and social relationships. Therefore, down-regulation of emotion is not always a necessity. For example, consider the case of anger. Anger is an adaptive human emotion, usually elicited during threatening and aversive events. As for other emotions, its multifaceted response includes physical reactions, cognitions and behaviours that interact continuously (Deffenbacher, 1999; Novaco, 1976a). The activation of these responses helps the individual to deal more effectively with some situations (Mayne & Ambrose, 1999).
However, anger may become dysfunctional when its frequency, intensity or duration increases disproportionately with respect to environmental triggers (Deffenbacher, Oetting, Lynch, &
Morris, 1996; Denson, 2009). In this case, anger may motivate aggressive behaviour towards
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oneself or others and may contribute to the occurrence of mood disorders and general health problems (Deffenbacher, Demm, & Brandon, 1986).
1.3 Origins of emotion dysregulation in brain disorders
Emotional changes and dysregulation in brain disorders may be explained by an association of damage to brain tissue, neuropsychological impairment and psychosocial adaptation to the disease.
1.3.1. Neurobiological basis
Neuroimaging and lesion studies show that the right hemisphere is particularly involved in emotional processing, but this is mainly the case for emotion recognition (Adolphs, 2003a, 2003b; Adolphs, Damasio, Tranel, Cooper, & Damasio, 2000). In contrast, emotional experience implicates both hemispheres with differential activation depending on emotional valence (whether emotions are positive or negative) (Davidson et al., 2000;
Davidson, Maxwell, & Shackman, 2004; Davidson, Shackman, & Maxwell, 2004).
Several brain regions such as the prefrontal cortex, basal ganglia, amygdala and other limbic structures have been particularly linked to emotion regulation processes (Fabiansson, Denson, Moulds, Grisham, & Schira, 2012; Goldin et al., 2008). However, it is difficult to have a clear understanding of how each region contributes to emotion regulation, since they seem to work tightly together in a functional network (Cutuli, 2014). In addition, the nature of emotion and of the regulatory process contributes differently to the involvement of particular regions. For example, the use of reappraisal is highly dependent on the orbito-frontal cortex, while expressive suppression relies more on the anterior cingulate cortex and the medial prefrontal cortex (see Cutuli, 2014 for review).
However, though specific cerebral regions are implicated in emotion regulation processes, the belief that emotional and behavioural changes following brain disorders are predominantly explained by damage to these regions has gradually been replaced by a biopsychosocial explanation (Yeates, Gracey, & McGrath, 2008). For example, anger dysregulation following brain injury may be present irrespective of location or severity of brain damage (King & Wray, 2012). According to Yeates and collaborators (2008) a purely neurobiological explanation of emotion dysregulation leads to ‘a clinical dead end’ as no
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changes in emotion regulation are expected and treatment is limited to ‘palliative’ measures of acceptance.
1.3.2. Neuropsychological explanation
Damage to brain regions mentioned above may lead to executive dysfunction, which may in turn contribute to diminished emotional and behavioural control (Adair, Williamson, Schwartz, & Heilman, 1996; Salmond & Sahakian, 2005). Executive functions are defined as the ability to carry out goal-directed behaviour, in particular in non-routine and unstructured situations (Lezak, 2004). They include monitoring of ongoing actions, engaging and disengaging attention from different tasks (shifting) and inhibiting preponderant, but undesirable responses (inhibition). Executive functions also involve anticipating outcomes (planning) and replacing old, irrelevant with new information (updating) (Fisk & Sharp, 2004;
Miyake et al., 2000). Emotion regulation processes can be seen as strongly goal-directed behaviour and may implicate the same processes as those involved in the control of non- emotional behaviour (Ochsner & Gross, 2008). In line with this, Tate (1999) found a significant correlation between self-reported emotional dyscontrol following traumatic brain injury (including impulsivity, aggression and restlessness) and errors in tests assessing cognitive inhibition. More recently, Gyurak et al. (2009) found that performance in a task assessing cognitive flexibility predicted abilities to down-regulate emotions (startle response to an acoustic stimulus) in patients with Alzheimer’s disease, fronto-temporal dementia as well as controls without neurological pathology. Further, in a study of patients with traumatic brain injury, an index of executive dyscontrol positively correlated with increased negative mood after watching anger-inducing clips (McDonald, Hunt, Henry, Dimoska, & Bornhofen, 2010). On the other hand, good performance in tasks assessing inhibition and verbal fluency predicted faster implementation of reappraisal in patients with acquired brain damage of different origins (Salas, Gross, & Turnbull, 2014). Thus, cognitive emotion regulation (such as using reappraisal and avoiding rumination) seems to be related to cognitive control.
In a model of anger regulation proposed by Denson (2013) inhibitory and attentional control abilities as well as task switching enable the individual to stop ruminating about an emotional event and shift to more adaptive ways of viewing the situation. This model also posits that engaging in activities that use executive control prevents using these abilities to cease rumination. Thus, cognitive effort would contribute to a depletion of anger control resources. This could possibly explain anger problems in patients with brain disorders, as
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these patients make increased cognitive effort to carry out activities that were previously carried out more or less automatically.
Impaired abilities to recognize emotional features (facial expressions, body postures and voice tone) in others and in themselves are also associated with emotion regulation problems in patients with brain disorders (Dethier, Blairy, Rosenberg, & McDonald, 2013;
Herwig, Kaffenberger, Jancke, & Bruhl, 2010; Knox & Douglas, 2009; McDonald, Li, et al., 2011; Spikman et al., 2013). These deficits not only preclude the generation of socially adapted behavioural responses, but may also compromise recognition of own affective states, which is a first step towards appropriate emotion regulation (D. Neumann, Zupan, Malec, &
Hammond, 2014).
1.3.3. Psychosocial explanation
In addition to neurobiological and neuropsychological factors, psychosocial issues contribute considerably to changes of emotion regulation in brain disorders. For instance, physical and cognitive impairments due to brain injury result in changes in how patients perceive themselves and relate to others, leading to changes in their social network. Indeed, even minor modifications of activities of daily living such as the ability to drive, pay bills independently, or go to the grocery store may compromise the accomplishment of larger life goals and result in an altered sense of identity and ‘self’ (Cantor et al., 2005; Nochi, 1998).
This loss of independence might be lived with frustration, anger, anxiety and finally depression, when ‘behaviours cease and the cherished goals are relinquished’ (Yeates et al., 2008). Furthermore, patients may find themselves uninteresting to others or incapable of keeping with rhythms of their peers. For example they may feel that they can no longer keep concentrated in discussions with friends in a noisy restaurant, or go for a whole day skiing as they did before. As a consequence, they spontaneously withdraw from their groups. On the other hand, their social partners may also perceive them differently, leading to a change in the nature of relationships (e.g. they may perceive them as people who need help, have ‘enough own problems’ and cannot be charged with their sorrows) (Obonsawin et al., 2007). These changes have a further impact on how patients perceive themselves, which leads to further changes in emotionality and behaviour. Therefore, feelings of shame, sadness, anxiety and anger may all arise from a loss of independence, while habitual coping strategies may no longer be adaptive (Baguley, Cooper, & Felmingham, 2006).
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Prior to brain disorders individuals lived lives in which, as everyone else, they faced worries of different nature in their professional, affective or social lives, and these ‘problems’
continue to affect their life with the disease. Hence, prior social responsibilities as well as the life period during which brain damage occurs strongly affect abilities to manage emotions, together with ‘premorbid’ personality traits or disorders. (Andrews et al., 2002; MacMillan, Hart, Martelli, & Zasler, 2002; L. A. Taylor, Kreutzer, Demm, & Meade, 2003).
1.4 Social impact of emotion dysregulation in brain disorders and caregiver’s stress
Due to the diversity of problems related to brain injury (sensory-motor alterations, cognitive dysfunction and changes of experience and expression of emotions) the social and professional roles of patients may be compromised (Oddy & Herbert, 2003). As a consequence, family members are frequently compelled to assume new roles, such as household activities, financial responsibilities and provision of care (Ennis, Rosenbloom, Canzian, & Topolovec-Vranic, 2013; Parks & Novielli, 2000; Rigby et al., 2009). These so- called informal caregivers often experience social isolation, decreased leisure activities and financial problems, leading to increased psychological distress, anxiety and depression (Garcia-Alberca, Lara, & Berthier, 2011). Interestingly, emotional and behavioural problems in cared-for patients are better predictors of caregiver’s stress than cognitive or physical changes (Allegri et al., 2006; Ergh, Rapport, Coleman, & Hanks, 2002; Weddell & Leggett, 2006). This is partly due to poorer psychosocial adjustment of patients presenting neurobehavioural disorders, which pushes them to rely even more on their relatives (Baguley et al., 2006; Weddell & Leggett, 2006). In addition, behavioural problems by their own such as tantrums, anger outbursts and depressive mood might turn caregiving into a hard task and contribute to further social isolation of the caregiver (Saban, Hogan, Hogan, & Pape, 2014).
Some studies have shown that the relationship between caregiver’s stress and patient’s emotional and behavioural problems is reciprocal (Winstanley, Simpson, Tate, & Myles, 2006). Therefore, caregiver’s emotional health also has an impact on emotional status and functional recovery of patients with brain disorders (Ponsford & Schonberger, 2010;
Schonberger, Ponsford, Olver, & Ponsford, 2010).
In the last decades, the number of family members providing informal care has increased (King & Wray, 2012; Thies, Bleiler, & Alzheimer's, 2013). This is in part due to increased chance of survival of patients with acute brain injury (due to improved medical
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care) and increased prevalence of neurodegenerative diseases in an ageing population. Thus, caregiver’s stress is a common problem irrespective of the etiology of brain disease, as it has been evidenced in stroke (Rigby et al., 2009), traumatic brain injury (Ennis et al., 2013) and Alzheimer’s disease (Pinquart & Sorensen, 2003). For instance, around 75% of caregivers of patients with traumatic brain injury report increased stress (Hanks, Rapport, & Vangel, 2007).
Following mild brain injury, these changes may be provisional, but long-term reorganisation may be needed when it comes to more severe brain injuries or neurodegenerative diseases.
In addition to psychological stress, caregivers are particularly prone to physical health problems, due to engagement in “risky behaviours” (nicotine and alcohol abuse, altered sleep patterns, etc.) and to altered psychophysiological reactions to chronic stress (Losada Baltar &
Montorio Cerrato, 2005). Health problems may interfere with the quality and quantity of provided care. Therefore, caring for the caregiver is also essential for preserving the family system and helping the brain-injured patient in his trajectory of adaptation to the disease.
1.5 Assessing emotion regulation
As discussed in the previous sections, emotion is a multifaceted concept englobing physical responses, perceived feelings, cognitions and affective expressions. Therefore, assessment usually relies on these different components. A distinction can be made between subjective and objective measures. The only way to access feelings and cognitions is through subjective approaches such as self-report questionnaires or interviews, while objective measures are used to assess emotional expression and physiological reactions.
For instance, self-report questionnaires allow apprehending various features of emotion expression and regulation (Wilhelm & Grossman, 2010). They basically rely on self- observation in natural settings (usually daily life events) or following emotion induction in experimental settings. Ratings concern inward feelings, physical sensations, manners of expression and emotion regulation strategies. Some questions may also take into account how emotion expression of the subject affects his environment. Administration of self-report questionnaires is practical, as it can be done in any setting and without necessarily involving the experimenter. However, individual differences in self-observation abilities (due to its highly subjective nature) and the accuracy of these questionnaires have been questioned (Mauss & Robinson, 2009). Some studies suggest that questionnaires referring to ongoing
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emotional experience are less biased than those assessing general emotional experience (Robinson & Clore, 2002). This finding favours the use of such instruments in experimental settings. Parallel versions given to proxies (who usually know well the participant) may help to assess emotion regulation, but these may also be subjectively biased because they may reflect a view based on intimate relationship established between the proxy and the participant, rather than the interaction between the latter and a larger environment (Cavallo, Kay, & Ezrachi, 1992).
Emotion expression can also be measured with observational methods. This may be done by external raters (sometimes with the help of specific observation grids) in specific natural settings such as hospitals, or in laboratory settings in which emotions are induced. In addition, specific apparatus such as facial electromyography provide important data regarding expressive aspects of emotional states (Cacioppo & Gardner, 1999).
Finally, psychophysiological measures have been extensively used to assess the physiological component of emotions. They provide an alternative to self-report methods in participants whose subjective ratings may be biased due to a lack of insight (C. Williams &
Wood, 2012). In order to assess psychophysiological reactions related to acute emotional states, emotions are artificially induced in experimental settings. This can be done with emotion-eliciting clips (Stephens, Christie, & Friedman, 2010), artificially arranged situations (Kazen, Kuenne, Frankenberg, & Quirin, 2012) or autobiographical recall of emotional events (Marci, Glick, Loh, & Dougherty, 2007). Though standardized paradigms of emotion induction such as emotion-eliciting films may be more easily replicated, auto-biographical recall is emotionally more relevant to the person and induces higher levels of physiological arousal (Marci et al., 2007). Psychophysiological activity related to more general affective states (unrelated to specific situations) can also be assessed in natural contexts, without prior emotion induction, but this depends on the type of physiological marker used. For instance, some physiological markers cannot be assessed outside the laboratory.
Physiological markers of emotions may rely on autonomous nervous system activity (ANS) or hormonal activity mediated by the hypothalamus-pituitary-adrenal axis (HPA) (Cacioppo et al., 2000). The ANS is responsible for the regulation of peripheral functions reflecting the activation (sympathetic) or relaxation (parasympathetic) of the organism.
Besides physiological manifestations of emotion, it regulates digestion, attentional processes and other functions related to homeostasis such as body temperature and water balance (Kenney & Ganta, 2014). Activity of this system can be captured by measuring responses of
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sweat glands (electrodermal activity) or of the cardiovascular system (such as heart rate, blood pressure) (Mauss & Robinson, 2009). For instance, sympathetic activation leads to increased electrodermal activity (skin conductance levels or skin conduction reaction), blood pressure and heart rate (Gerin, Davidson, Christenfeld, Goyal, & Schwartz, 2006; Marci et al., 2007; Ray et al., 2008). Psychophysiological measures of the activity of the autonomous nervous system are particularly sensitive to arousal (intensity of emotions) and cannot capture the emotional valence (positive or negative emotions) or allow discriminating the type of emotion (Mauss & Robinson, 2009). Also, while some authors observed that the use of reappraisal may down-regulate response of the ANS in healthy participants, others describe increased activation, which they attribute to increased cognitive effort necessary for successful reappraisal (Denson, Pedersen, Friese, Hahm, & Roberts, 2011).
Activity of the HPA axis is usually measured through cortisol secretion, which is the end-point of the axis cascade (Jacobson, 2014). HPA activity increases during acute negative emotions such as fear, anger and sadness and is an important marker of long lasting affective states such as chronic stress. Regarding its mechanism, the hypothalamus releases corticotropine releasing hormone that triggers secretion of the adrenocorticotropic hormone by the pituitary gland into the bloodstream, which in turn leads to secretion of cortisol by the adrenal glands. This axis usually functions as a positive feed-back loop, where increased cortisol levels inhibit subsequent secretion of corticotropine releasing hormone by the hypothalamus. However, in chronic stress this positive feed-back loop may be dysfunctional, leading to continuous hyperactivity of the hypothalamus and pituitary glands irrespective of cortisol levels in the bloodstream. As a consequence, diurnal secretion of cortisol is increased in people suffering from chronic stress. Cortisol secretion is generally highest in the morning and decreases progressively throughout the day (O'Donnell, Badrick, Kumari, & Steptoe, 2008). Flattened daily cortisol slopes are markers of psychological stress and are associated with increased health risks (Cohen et al., 2006; Kumari, Shipley, Stafford, & Kivimaki, 2011). Chronic excessive release of cortisol may lead to depression, lowered immune activity (as cortisol inhibits the immune system) (Vedhara et al., 1999) and chronic health problems (Chrousos, 2009). Cortisol may be quantified in the serum, urine or saliva (Turpeinen &
Hamalainen, 2013). Salivary cortisol has become a classical biomarker in stress research. It is a very simple low-cost method that can be performed by individuals in their daily life (participants are asked to chew ‘salivettes’, which are pieces of cotton that can be further
16
stored in a tube at room temperature prior to laboratory analyses) (Hellhammer, Wust, &
Kudielka, 2009).
In sum, emotion and emotion regulation abilities can be assessed with observational methods, self- and proxy-report questionnaires as well as physiological measures. However, these different measures of emotion expression do not necessarily converge (Mauss &
Robinson, 2009). There is little evidence of convergence and only weak correlation between measures. This may be due to psychometric properties of questionnaires, or the lack of precision of observational and psychophysiological instruments. Furthermore, despite limitations of self-report questionnaires, they seem to be so far the only method that captures phenomenological aspects of emotion.
1.6 Treatment options for emotion dysregulation in brain disorders
Until recently, the primary choice of treatment for emotional disturbances in brain disorders was pharmacologic (Bernardo, Singh, & Thompson, 2008; Hackett, Anderson, House, & Xia, 2008). However, treatment response is not always optimal and interaction between different medications in the context of brain disorders may not be well tolerated (Arciniegas & Wortzel, 2014; Bernardo et al., 2008). In addition, medication alone affects physiological symptoms and general mood, but does not automatically lead to an experience of emotional and behavioural adaptation. Therefore, medication should ideally be combined with, and in some cases replaced by psychological treatment.
The ultimate goal of rehabilitation following brain injury is to improve functional outcome and re-integrate patients into the community. Emotional problems are a major obstacle to this objective. Therefore, it seems evident that treatment should target emotional processes (Yeates et al., 2008). However, emotional disorders are not always targeted directly in rehabilitation. For example, neuropsychological interventions may have indirect effects on emotions by focusing on executive impairment associated with ‘personality’ changes. These interventions focus on self-awareness, inhibition, mental flexibility and goal management training for stress reduction (K. Cicerone, Levin, Malec, Stuss, & Whyte, 2006; K. D.
Cicerone et al., 2000). A more direct and broad approach is used during treatment focusing on the psychosocial impact of brain disorders such as comprehensive holistic rehabilitation programs (Malec & Basford, 1996). This approach gives particular importance to behavioural and emotional problems after brain injury and is based on a theoretical framework combining
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both psychological and neuropsychological theories. Practically, the goal of this approach is to exchange maladaptive patterns of behaviour with more adaptive ones. This is done in a series of planned interactions with therapists focusing on different aspects of rehabilitation, but keeping in mind a common general goal (e.g, developing awareness of patient’s functional potential, improving personal organisation or developing psychological coping skills).
Holistic rehabilitation programs combine neuropsychological rehabilitation with a focus on cognitive and affective aspects, with group interventions targeting awareness, acceptance and social skills as well as occupational therapy aiming to foster independent living skills and professional re-integration (K. D. Cicerone, Mott, Azulay, & Friel, 2004). Therefore, holistic rehabilitation programs usually require residential settings or at least a strict environmental structure, which makes them more suitable for in-patients than patients who have returned to the community.
As an alternative, different psychotherapeutic approaches have been described for patients with brain disorders integrated in the community. This includes psychodynamic, systemic and existential frameworks as well as cognitive-behavioural therapies. According to Mateer and collaborators (Mateer & Sira, 2006; Mateer, Sira, & O'Connell, 2005), psychotherapy should be part of neurorehabilitation programs, irrespective of the approach.
However, although the usefulness of different approaches has been demonstrated (Ruff, 2013), cognitive-behavioural therapy is considered to be particularly adapted to the needs of patients with brain disorders as well as their caregivers (Coetzer, 2009).
2. Cognitive-behavioural therapy and brain disorders
2.1 Cognitive-Behavioural therapy models
Cognitive-behavioural therapy (CBT) is a type of psychotherapy that has its origins in behavioural therapy. The latter is based on the empirical approach of operant conditioning, which considers that a behaviour is more likely to occur if the same behaviour (or a similar one) was reinforced in the past (Fontaine & Fontaine, 2011). Reinforcers can be primary (such as food or sex) or generalized (such as money or social attention). In the context of pure behavioural therapy (Skinner, 1965), emotions are conceived as hidden behaviours, and therefore considered to be governed by similar ‘rules’ as ‘external’ behaviour. However,
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though pure behaviourist models are still used in therapeutic practice, subsequent theories considering internal events (such as emotions and cognitions) as distinct phenomena that do not follow strict stimulus-response relations gained considerable importance in the second half of the XXth century (Fontaine & Fontaine, 2011).
Modern CBT theories are grounded in early cognitive models of depression proposed by Beck (A. T. Beck, Rush, Shaw, & Emery, 1979). A core feature in these theories is the notion that emotions arise in a given context and are influenced by cognitions (thoughts and beliefs about the situation), behaviour and physical reactions. This relationship is not unidirectional as emotions also influence physical reactions and behaviour (attitudes), with repercussions in the environment (for example an interlocutor may be verbally aggressed, or the physical environment of the angry person may be changed due to isolation). The approach to understand this complex interrelationship is termed functional analysis, and is a key component of cognitive-behavioural treatments. In addition, CBT emphasizes therapeutic relationship as an important part of the treatment. Treatments differ depending on the importance given to each component of the functional analysis and to the attitude toward it.
CBT has gained importance in the scientific community due to its straightforward nature, experimental character and liability to study effects of intervention (McMain, Newman, Segal, & DeRubeis, 2015). Treatments are usually adapted to very specific goals and there is an attempt to quantify progress and/or treatment success. Several randomized controlled trials assessed the effects of cognitive-behavioural therapy on different psychopathological parameters. These studies show that CBT effectively reduces anxiety and depression in different populations (children, adult and elderly) (Hundt, Mignogna, Underhill,
& Cully, 2013; Rooksby, Elouafkaoui, Humphris, Clarkson, & Freeman, 2015; Watts, Turnell, Kladnitski, Newby, & Andrews, 2014) and this approach is considered a treatment of choice for anxiety (Hofmann & Smits, 2008). It is also employed in the treatment of personality or psychotic disorders (Gratz, Bardeen, Levy, Dixon-Gordon, & Tull, 2015; Li et al., 2014) and to facilitate coping in several chronic diseases such as diabetes, coronary disease, tumours or chronic pain (Dowd et al., 2015; Eccleston, Palermo, de, et al., 2012;
Eccleston, Palermo, Fisher, & Law, 2012; Mann et al., 2012). Due to its limited length and proven effectiveness, the popularity of CBT also extends to treatment targeting specific emotional conditions such as anger regulation (R. Beck & Fernandez, 1998).
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2.2 Cognitive-behavioural therapy for patients with brain disorders
CBT for patients with brain disorders has gained interest in the last decade for several reasons (Coetzer, 2009). First, emotional and behavioural changes are increasingly recognized as major consequences of brain disorders, while previously attention had predominantly been directed to cognitive and physical consequences. In addition, CBT has been scientifically proven effective in populations with different psychiatric conditions, and recent studies with neurological patients have shown promising outcomes. Qualitative observations made by clinicians in their daily practice also suggest that this type of intervention should be encouraged (Judd & Wilson, 2005). Indeed, the goal-directed and structured nature of CBT makes it particularly suitable for patients with various forms of brain injury (Coetzer, 2009;
Kangas & McDonald, 2011). Working on concrete examples of current life situations and application of specific strategies such as visual support (schemes, written handouts…) and role-playing make it accessible to patients with attention, executive or memory deficits.
Despite being naturally adaptive to brain disorders, CBT given to this population needs particular care regarding delivery methods. For instance, therapists should ensure a distraction-free environment, constantly summarize contents of discussions, shorten sessions and be very directive in order to compensate for eventual memory problems and executive dysfunction (Coetzer, 2009).
CBT has proven its effectiveness for the reduction of anxiety and improvement of mood following brain injury, the promotion of adaptive coping skills and attenuation of symptoms of post-traumatic stress disorders (Anson & Ponsford, 2006b; Waldron, Casserly,
& O'Sullivan, 2013). For instance, Mitchell and collaborators (2009) reported greater reduction of post-stroke depression symptoms in patients who had participated in a CBT program compared to those receiving treatment as usual (appointments with the rehabilitation physician or general physician as well as antidepressants if used). Anson and Ponsford (2006a) observed better coping skills after a CBT group intervention for patients with traumatic brain injury. In subsequent work these authors described that greater self-awareness, less severe impairment and greater anxiety prior to intervention were predictors of better outcome (Anson & Ponsford, 2006b). On the other hand, effects of specific CBT programs targeting important neurobehavioural issues such as social skills and anger management have been examined to a lesser extent (Hart, Brockway, Fann, Maiuro, & Vaccaro, 2014;
McDonald et al., 2008; Medd & Tate, 2000; Walker et al., 2010).
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Unfortunately, despite positive outcomes, evidence-based reviews indicate that methodological quality of trials in the field is limited. For instance, Catellani and collaborators (2010) and Doering and Exner (2011) reviewed levels of evidence of studies focusing on CBT for patients with acquired brain injury and proposed clinical guidelines.
They used a rating system based on the guidelines of the European Federation of Neurological Societies (Cappa et al., 2005), which had previously been used in a review concerning cognitive rehabilitation programs (K. D. Cicerone, Azulay, & Trott, 2009). According to this rating system a well-designed randomized controlled trial is rated “class 1 evidence”. Case- control studies or non-randomized controlled studies are rated as “class 2 evidence”, while case series or case reports are rated “class 3 evidence”. The presence of at least one class 1 study with eventual support of class 2 studies is necessary to consider intervention as specifically recommended (practice standard) for people with emotional and behavioural problems related to brain disorders. Probable effectiveness (practice guidelines) is defined when at least one class 1 study with methodological limitations or several class 2 studies are available, whereas a poor degree of evidence (practice option) is considered to be present when there are conflicting results of class 2 and class 3 studies. Catellani and collaborators (2010) found 13 studies using CBT for patients with acquired brain injury (one class 1, three class 2 and nine class 3). The only class 1 study did not report positive outcomes and class 2 studies reported mixed results. As a consequence, CBT for patients with brain injury was considered a practice option (similar conclusions were reached for neuropsychological rehabilitation programs in the review carried out by Cicerone, 2011). Hence, results of these reviews reflect the paucity of studies in the field, particularly compared to programs focusing on cognitive issues, as well as a poor degree of controllability. This is in part related to the early stage of research focusing on CBT for patients with brain disorders and to the numerous practical concerns in designing a well-controlled-study in psychotherapy.
The study rated class 1 evidence in the review by Catellani and colleagues (2010) was a randomized controlled trial which compared the effects of a CBT intervention on post- stroke depressive symptoms to a control program in which therapists provided attention and support, but did not use any CBT technique, and to a third group without any intervention (Lincoln & Flannaghan, 2003). Their CBT program began between one to six months post- injury and was administered individually once-a-week for 10 weeks. Although there was an overall decrease in depressive symptoms over time, no differences in improvement were observed between groups. This study was performed in a post-acute stage of stroke, when
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cognitive consequences such as slow processing speed and decreased self-activation may be confounded with depression. Hence, spontaneous recovery of these symptoms is expected and may be unrelated to emotional adjustment. In addition, a strong limitation of the study, which was emphasized by the authors is that treatment was delivered at home. This implies that explicit commitment to therapy was not necessarily required, which could potentially explain the absence of CBT effects due to lack of ‘ understanding, willingness and belief in therapy’
(Lincoln & Flannaghan, 2003) . In turn, the delivery method avoided drop-outs, which can be a major obstacle in clinical trials, particularly in the control conditions.
Choosing an adequate control condition is a major challenge in psychotherapy trials (Hart, Fann, & Novack, 2008). It requires a balance between ethical issues, acceptability to participants, credibility of intervention, management of resources (e.g. therapist availability) and above all drop-out prevention. The following conditions have been employed in different studies: no treatment at all for the control group, comparison to ‘usual care’ (also termed
‘treatment as usual’ where patients receive usual care such as physical therapy, neuropsychological rehabilitation and occupational therapy but no psychotherapy is given), wait list-control (in which control participants wait to receive the active intervention) or
‘placebo analogue’. The latter consists of administering an intervention with resemblance regarding the format, but which is not useful to treat the condition. It has more resemblance with medication trials, but leads to an increased rate of drop-outs since intervention may not be acceptable or credible to participants or therapists (Hart et al., 2008). Other solutions include dose-control treatment (for example providing fewer sessions) or dismantling designs (changing the order of sessions), but in these large samples are required in order to achieve satisfactory statistical power.
In sum, even though CBT for patients with brain disorders may be a promising approach to improve emotion regulation in this population, the quantity and quality of current studies so far are insufficient to provide strong scientific evidence for its recommendation in clinical practice.
2.3 Cognitive-behavioural therapy for caregivers
Intervention for caregivers of patients with brain disorders intend to reduce burden and increase well-being, but also to improve the quality of care by providing information on the
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disease and on patients’ particular needs (Losada Baltar & Montorio Cerrato, 2005). CBT may support the caregiver in understanding the impact their relative’s brain disorder has on their own life and in identifying personal beliefs about the disease. It helps in the clarification of their role as caregiver and encourages the involvement of other family members in the care (Dunkin & Anderson-Hanley, 1998; Vernooij-Dassen, Draskovic, McCleery, & Downs, 2011). These topics are of particular importance since social support and learning adaptive coping strategies are associated with decreased psychological distress in caregivers of patients with traumatic brain injury (Ergh et al., 2002; Stejskal, 2012). Several interventions for caregivers of patients with acquired brain injury (patients with traumatic brain injury, stroke or brain tumours) focused on increasing caregiver’s knowledge and building skills for dealing with the patient, but much fewer focused on emotional adjustment (Ramkumar & Elliott, 2010). Nonetheless, results of the latter studies suggest a decrease in caregiver distress and increased abilities to cope with problems related with caregiving. They also show a positive impact on symptoms of depression. For instance, in a randomized-controlled trial for caregivers of patients with traumatic brain injury, depressive symptoms significantly decreased following a CBT intervention whereas they increased in the control group (P. A.
Rivera, Elliott, Berry, & Grant, 2008). Interestingly, care-recipients of this study also presented a significant decrease in depressive symptoms, suggesting that interventions targeting caregivers also have an impact on emotional disorders of cared-for patients. In line with this, a systematic review of psychological interventions for caregivers of patients with dementia (Selwood, Johnston, Katona, Lyketsos, & Livingston, 2007) showed that CBT is not only effective in improving psychological well-being of caregivers, but may also reduce neurobehavioural symptoms of cared-for patients.
3. Rationales for studies included in this thesis
The major goal of this thesis was to provide scientific evidence for the usefulness of CBT in facilitating emotional adjustment to consequences of brain disorders in patients and family members providing care. We address specific gaps in the literature regarding experimental studies on emotion regulation as well as clinical trials.
Specific literature details are found in the introduction of each article. In this section we will therefore briefly summarize the state of the art related to studies included in this thesis and provide the rationale for them.
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The four studies included in this thesis focused on three main topics:
1) Psychophysiological and psychological expression of anger modulation in patients with brain injury (Study 1); 2) The effects of a CBT program for managing anger following acquired brain injury (Studies 2 and 3); 3) The effects of CBT on stress markers of caregivers of patients with Alzheimer’s disease (Study 4).
3.1 Psychophysiological expression of emotion modulation in patients with brain injury
Since CBT approaches presume that emotions are tightly related to physiological reactions, thoughts and environmental triggers it is important to understand psychophysiological reactions in patients with brain injury and whether they can be modulated by strategies of emotion regulation. However, regarding physiological manifestations following brain injury, previous studies mainly focused on emotion recognition. During emotion recognition tasks patients show not only impaired performance, but also reduced arousal (hyporesponsiveness) as compared to control participants, irrespective of emotional valence (Hopkins, Dywan, & Segalowitz, 2002; McDonald, Rushby, et al., 2011). One recent study focusing on emotion experience rather than recognition showed that patients with traumatic brain injury also display lower skin conductance levels than controls when they watch unpleasant video-clips, but not for neutral or pleasant clips (de Sousa, McDonald, & Rushby, 2012). However, passive observation may not result in comparable emotional activation as active experience of emotion (Salas, Radovic, &
Turnbull, 2012). For example, emotion-inducing methods that rely on auto-biographical recall of emotional events generate greater arousal since contents are more personally relevant for the participant (Foster & Webster, 2001; Jallais & Gilet, 2010; Marci et al., 2007). This may be of particular importance when measuring effects of induced emotions in brain-injured patients since these patients frequently present impaired empathy and affect recognition (de Sousa et al., 2012). Further, while effects of emotion regulation strategies have previously been addressed in participants without brain injury (Ray et al., 2008), no studies have examined psychological or pychophysiological effects of cognitive emotion regulation strategies in brain-injured participants. Therefore, the primary goal of study 1 was to assess
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self-perceived and psychophysiological outcomes of emotion regulation strategies in patients with traumatic brain injury using recall of previously experienced emotional events.
3.2 CBT anger management programs for patients with brain injury
With respect to clinical trials using CBT for patients with brain injury, previous studies largely focused on anxiety disorders and depression. Conversely, more specific programs tackling emotion regulation such as anger management were reported to a much lesser extent. For instance, at the time when our first feasibility study on anger management for patients with traumatic brain injury was conceived and implemented (study 2), there was only one published group study reporting the use of a CBT anger management program (Medd & Tate, 2000). The goal of the feasibility study was to examine if our semi-structured program, held during eight weekly sessions in small groups, was suitable for a larger controlled trial. Among feasibility criteria we considered demand and acceptability by participants as well as practicality, implementation and evidence of initial efficacy.
Meanwhile, two other studies have been published (Hart, Vaccaro, Hays, & Maiuro, 2012;
Walker et al., 2010), but given the frequency of post-injury emotional disturbances this remains an understudied topic. In addition, in the few published studies, only the one carried out by Medd and Tate (2000) had a control group, but control participants did not receive any treatment. In our study 3 (a randomised-controlled study) we therefore compared the group anger management program previously tested in study 2 to a period in which patients received treatment as usual, but no group psychotherapy, and to a control intervention focusing on psychosocial consequences of brain injury. This intervention lasted four weeks and was held either before or after the main program, with assessments every four weeks throughout the entire intervention period.
3.3 CBT interventions for caregivers and their effects on psychophysiological parameters
Regarding CBT for caregiver’s stress, the literature is vast, particularly studies addressing caregivers of patients with progressive brain disorders such as Alzheimer’s disease. These studies agree that interventions reduce psychological distress. However,
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caregivers of patients with brain disorders present psychophysiological alterations due to chronic stress, in particular excessive cortisol release (Bauer et al., 2000). Increased release of cortisol may lead to endocrine problems and decreased immune activity, which may subsequently impair the capacity of caregivers to keep up with their caregiving role. We were therefore interested in assessing effects of a CBT group intervention on cortisol patterns. Two previous studies performed similar research (Vedhara et al., 2003; V. P. Williams et al., 2010), but no significant changes were observed in salivary cortisol following the CBT treatment. However, in the study of Williams and collaborators (2010) the intervention was delivered through videos providing coping skills, which may not have the same effects as interactive interventions. Vedhara (2003) used a CBT group approach, but assessment of salivary cortisol did not take account of individual circadian variations with respect to time of awakening, which is of particular importance when examining patterns related to stress.
Therefore, in our study 4 we compared the effects of a CBT group intervention to a structured psychoeducation program on self-perceived a psychophysiological parameters of stress, by respecting circadian patterns of cortisol level.
26 III. RESULTS (Research articles)
Four different studies constitute this thesis. Three of them focus on patients with brain injury and one on caregiver’s stress.
# Study Design Status
(July 2015)
1
Emotion regulation after traumatic brain injury: distinct patterns of sympathetic activity during anger expression and recognition
Experimental Published
2 Feasibility and initial efficacy of a cognitive- behavioural group programme for managing anger and aggressiveness after traumatic brain injury
Clinical trial Published
3
A controlled trial assessing the effects of an anger management program following acquired brain injury
Clinical trial Under review
4
Cognitive-behavioural group therapy improves a psychophysiological marker of stress in caregivers of patients with Alzheimer’s disease
Clinical trial Published
Emotion regulation after traumatic brain injury: distinct patterns of sympathetic activity during anger expression and recognition
*Abstract
Objective: To assess psychological and psychophysiological correlates of emotion recognition and anger experience in participants with traumatic brain injury (TBI).
Participants and design: 20 participants with TBI presenting anger problems and 22 healthy controls participated in tasks assessing emotion recognition (The French Evaluation Task) and anger expression (Anger regulation task). The latter was designed to elicit and modulate anger feelings through verbal recall of a self-experienced event. It involved four recall conditions that followed a resting period: neutral, uninstructed anger recall, anger rumination and anger reappraisal. Measures: Skin conductance levels during recall and a self-report anger questionnaire between each condition. Results: In the TBI and control groups, self-reported anger was similarly modulated across emotion regulation conditions. However, only in the TBI group skin conductance levels significantly increased between neutral and uninstructed anger recall conditions. Conclusions: Impaired emotion regulation in TBI participants could be related to increased levels of autonomic system activity during emotional experience.
However, anger feelings in these participants can also be modulated with the use of emotion regulation strategies, including adaptive strategies such as reappraisal. Thus, promoting awareness and management of physiological activation, and encouraging cognitive restructuring can be recommended for interventions targeting emotion regulation in TBI patients.
Keywords: Anger, Traumatic Brain Injury, Emotion regulation, STAXI, Skin Conductance
*This study is a reprint of the article: Aboulafia-Brakha, T.; Allain, P.; Ptak, R. (2015) Emotion regulation after traumatic brain injury: distinct patterns of sympathetic activity during anger expression and recognition. Journal of Head Trauma Rehabilitation (in press).
28 1. Introduction
Patients with traumatic brain injury (TBI) of varied severity frequently present impaired emotion recognition and emotional dysregulation (Dikmen et al., 2010; McDonald, 2013; Metting, Spikman, Rodiger, & van der Naalt, 2014; Prigatano, 1992). Both factors are predictors of poor social and professional integration (Alderman, 2003; Knox & Douglas, 2009; O'Connor et al., 2005). While in the past decade emotion recognition has increasingly been examined in TBI patients (McDonald, 2013), psychological and psychophysiological correlates of emotion regulation have been addressed to a lesser extent.
TBI patients show impaired identification of negative emotions (Babbage et al., 2011;
McDonald, 2013) and emotional prosody (McDonald, 2013; McDonald et al., 2013).
Compared to healthy controls they do less well when asked to adopt anger postures (Dethier et al., 2013) or to mimic angry facial expressions (McDonald, Li, et al., 2011). When observing stimuli portraying anger, they exhibit lower skin conductance levels (SCL) than controls, which is a potential physiological marker of poor emotion recognition (de Sousa et al., 2010; Hopkins et al., 2002). Tasks using stimuli that integrate dynamic facial expressions, prosody and contextual information facilitate emotion recognition, but TBI participants still perform worse than controls (McDonald et al., 2006; McDonald, Flanagan, Rollins, & Kinch, 2003). Impaired abilities to decode emotion in others not only preclude the generation of socially adapted behavioral responses in TBI patients, but may also compromise recognition of one’s own affective states, which is a first step for appropriate emotion regulation (Spikman et al., 2013).
Emotion regulation relates to the ability to modulate subjective experience and expression of emotions (J. J. Gross, 2002). An emotional experience such as anger can be influenced by the way a situation is perceived (cognitive appraisal). In healthy participants, anger rumination – repetitive thinking about an emotional event without changing its initial appraisal – amplifies psychological and physiological correlates of anger (J. J. Gross, 2002;
Ray et al., 2008). In contrast, modifying negative thoughts in order to take a different perspective towards the event (reappraisal) diminishes angry feelings and decreases physiological arousal (Denson, Moulds, & Grisham, 2012; J. J. Gross, 2002). Reappraisal is considered a powerful emotion regulation strategy (J. J. Gross, 2002). Intervention studies with participants with TBI showed that anger management can be improved following specific psychotherapeutic programs (Aboulafia-Brakha, Greber Buschbeck, Rochat, &
