The role of attentional deployment during distancing in adolescents with major depression

Highlights

• We tested the role of attentional deployment during distancing in youth MD.

• Depressed and healthy adolescents completed a distancing task.

• During distancing, gaze focus was directed to emotional or non-emotional aspects.

• Regulation success differed between groups dependent on gaze focus.

• Data suggests that an emotional context interferes with regulatory aims in youth MD.

Abstract

Individuals with major depression (MD) show deficits in cognitive reappraisal. It is yet unexplored how the act of directing visual attention away from/towards emotional aspects impacts on cognitive reappraisal in MD. Thus, we examined the role of attentional deployment during cognitive reappraisal (specifially during distancing) in adolescent MD.

36 MD adolescents and 37 healthy controls (12–18 years) performed a cognitive reappraisal task during which they a) down-regulated self-reported negative affective responses to negative pictures via distancing, or b) simply attended to the pictures. During the task, attentional focus was systematically varied by directing participants’ gaze to emotional vs. non-emotional picture aspects. The validity of this experimental manipulation was checked by continuous eye-tracking during the task.

Across groups and gaze focus conditions, distancing diminished negative affective responses to the pictures. Regulation success significantly differed between groups dependent on gaze focus: MD adolescents showed relatively less regulation success than controls in the emotional gaze focus condition, while the reverse was true for the non-emotional gaze focus condition.

The results suggest that in MD adolescents, an emotional context might interfere with emotion regulatory aims. The findings can provide an important starting point for the development of innovative training regimes that target deficient reappraisal processes in adolescents suffering from MD.

Introduction

Major depression (MD) is among the most debilitating, costly and common psychiatric disorders worldwide (Kessler & Bromet, 2013). The risk of suffering from a depressive episode sharply rises during adolescence, with prevalence rates of about 7% (Kessler et al., 2012). Depression during adolescence is associated with increased suicidal risk and forecasts severe psychosocial problems as well as mental health problems in adult life (Thapar, Collishaw, Pine, & Thapar, 2012). Adolescents with MD show deficits in emotion regulation (Kovacs & Yaroslavsky, 2014), which means that they are impaired in the ability to modulate emotional responses by regulatory processes (Ochsner & Gross, 2005). Disturbances in emotion regulation and the underlying neural networks have been suggested to be an important risk factor for the development and maintenance of MD during adolescence (Ahmed, Bittencourt-Hewitt, & Sebastian, 2015; Kovacs & Yaroslavsky, 2014). Thus, insight into deficient emotion regulation mechanisms in adolescents with MD is crucial for a comprehensive understanding of the disorder (Trinkl et al., 2015) and can form an important basis for novel intervention approaches.

Cognitive reappraisal (CR) is a frequently studied emotion regulation strategy and is a form of cognitive change. It involves changing the meaning of a stimulus or the personal connection to the stimulus to modify the emotional response (Ochsner, Silvers, & Buhle, 2012). The two most commonly studied variants of CR are reinterpretation and distancing. Reinterpretation involves mentally changing the meaning of a stimulus (e.g., by imagining that a situation is not as bad as it first appeared). The second tactic, distancing, involves mentally changing the psychological distance of an emotion-eliciting event (e.g., by imagining that a situation has happened a long term ago or happened far away) (Denny & Ochsner, 2014).

CR substantially draws on cognitive control capacities. Among other lines of evidence, this is supported by neuroimaging findings showing that during CR, cognitive control brain regions in the prefrontal cortex down-regulate brain responses in emotion-generative regions, including the amygdala (for reviews see Ochsner & Gross, 2005; Ochsner et al., 2012). CR is a particularly adaptive emotion regulation strategy and the habitual use of CR has been demonstrated to be related to several indices of mental well-being, such as good interpersonal functioning and positive affect (Cutuli, 2014; Gross, 2013).

Notwithstanding these findings on the overall beneficial effects of CR, recent work has challenged the uniform view of adaptive versus maladaptive emotion regulation strategies (for reviews see Bonanno & Burton, 2013; Aldao, 2013). In this context, it has been shown that the efficacy of CR is influenced by several factors, including the type of stress individuals experience (Troy, Wilhelm, Shallcross, & Mauss, 2010), or aspects related to the emotional event. With respect to the latter, it has been shown that CR is particularly effective when initiated early in the emotion regulation process or when the intensity of the emotion-eliciting situation is relatively low. By contrast, when reappraisals are initiated late or the emotional intensity is high, this strategy is less effective compared to another major emotion regulation strategy (“distraction”) (Sheppes & Meiran, 2007, 2008; Sheppes, Brady, & Samson, 2014).

In line with expectations, questionnaire studies have found that depression and depressive symptoms in youths and adults are associated with less habitual use of CR (Garnefski & Kraaij, 2007; Joormann & Gotlib, 2010; Schäfer, Naumann, Holmes, Tuschen-Caffier, & Samson, 2017). To experimentally investigate CR in the context of depression, several studies applied variants of a well-established CR paradigm. In this paradigm, effects of CR are studied by instructing participants to reappraise negative pictures in a way that lessens their emotional impact (e.g., by imagining that the situation is not real or by taking the view of a detached observer; “regulate condition”). This regulate condition is compared to an unregulated “attend” condition during which participants are asked to simply attend to negative stimuli without trying to alter the natural response towards them. Within the framework of this paradigm, a number of studies in MD collected behavioral measures of self-reported affect in response to negative images to assess regulation success, which reflects the difference score in affect ratings between the attend and the regulate condition. Contrary to expectation, most studies found no group differences between adult and youth MD samples and healthy controls in this behavioral index of CR (e.g., Dillon & Pizzagalli, 2013; LeWinn et al., 2018; Murphy, Barch, Pagliaccio, Luby, & Belden, 2016; Sheline et al., 2009; but see; Greening, Osuch, Williamson, & Mitchell, 2014; Stephanou, Davey, Keretes, Whittle, & Harrison, 2017).

However, it is important to note that in these investigations, visual attention processes were not controlled for based on eye-tracking methods. As a consequence, it remains unclear whether regulation success a) can be attributed to the implementation of the CR strategy per se or can - at least in part - b) be attributed to effects of attentional deployment. Attentional deployment is a distinct emotion regulation strategy that refers to the way individuals direct their attention towards or away from an emotion-eliciting event to influence the emotional response (Gross & Thompson, 2007).

Several studies have demonstrated that depressed individuals show deviant attentional patterns when processing negative stimuli. There is growing evidence to suggest that depression is associated with difficulties in disengaging attention from negative information (Armstrong & Olatunji, 2012; De Raedt & Koster, 2010; Koster, Lissnyder, Derakhshan, & De Raedt, 2011; Peckham, McHugh, & Otto, 2010). This bias might well impact on CR processes, as the successful disengagement from negative information is considered to be an important factor when implementing a positive reappraisal (Koster, De Lissnyder, Derakshan, & De Raedt, 2011). Therefore, it is of particular importance to control for these issues and to disentangle attention related aspects from effects of CR.

In healthy controls, a number of studies have recorded gaze behaviour during CR tasks to relate the proportion of gaze directed towards or away from emotional aspects to behavioral or neural indices of regulation success (see, e.g., Bebko, Franconeri, Ochsner, & Chiao, 2011; Manera, Samson, Pehrs, Lee, & Gross, 2014; Strauss, Ossenfort, & Whearty, 2016; van Reekum et al., 2007). Studies that applied this approach have shown that regulation success during CR as indexed by behavioral ratings (Manera et al., 2014; Strauss et al., 2016) or neural indices (van Reekum et al., 2007) is negatively correlated to the amount of visual attention directed towards emotional aspects of negative scenes (but see Bebko et al., 2011). However, while these studies suggest that attention is involved in CR, inferences on whether attentional deployment plays a causal role in regulatory success during CR remain restricted as this factor was not experimentally manipulated.

Experimental control over attentional deployment during CR tasks can be achieved by a) directing gaze towards emotional aspects in one condition and b) directing gaze away from emotional aspects in a second condition. The rationale behind this approach is that regulation success cannot be attributed to attentional deployment if regulation success is similar across both gaze conditions (Bebko, Franconeri, Ochsner, & Chiao, 2014). Two studies applied this approach in emerging adults (17–24 years) and found that regulation success during CR of negative pictures as assessed by behavioral ratings was similar across both gaze locations (Bebko et al., 2014; Urry, 2010). These finding suggests that in healthy young individuals, attentional deployment does not seem to causally impact on the ability to regulate negative behavioral responses via CR.

To reconcile these findings with results from studies that applied a correlational approach to examine the role of attentional deployment in CR, it has been proposed that attention deployment might be related to regulation success but might not be necessary for successful emotion regulation during CR(Bebko et al., 2014).

While the role of attention deployment in CR has been examined by an increasing number of studies in healthy individuals, to our knowledge, no study has addressed this research question in individuals with MD. However, insight into this field of research is important for a number of reasons. First, findings from experimental studies are inconsistent on whether or not MD patients show impairments in down-regulating negative affect via CR as indexed by neural and behavioral parameters (e.g., Dillon & Pizzagalli, 2013; Greening et al., 2014; Platt et al., 2015; Sheline et al., 2009). Differing results between studies might in part be explained by the fact that attentional deployment was not accounted for. Thus, insight into the role of attentional deployment during CR can inform future research and might explain inconsistencies between previous studies, thereby promoting a more comprehensive understanding into emotion regulation disturbances in the context of depression. Second, recent findings in adults with MD suggest that an additional training of emotion regulation is a promising avenue to improve CBT treatment effects (Berking, Ebert, Cuijpers, & Hofmann, 2013; Berking et al., 2008). In this regard, a targeted, task-based training in CR might be a fruitful and cost-effective approach (Denny & Ochsner, 2014) (for evidence from anxious youth see De Witte, Sutterlin, Braet, & Mueller, 2017). However, a thorough understanding of factors influencing emotion regulation processes during CR is mandatory for future attempts to adapt such training protocols for depressive patients.

The aim of this study was thus to examine the influence of attentional deployment during CR in MD thereby focusing on an adolescent population. We collected behavioral and eye-tracking data while adolescents with MD and healthy controls completed a well-established CR task that involved the down-regulation of negative affect to negative images. During the task, attentional deployment was systematically manipulated by directing gaze a) towards or b) away from emotional areas of negative images. We expected that during CR, regulation success as measured by self-reported affect ratings would be compromised in MD compared to healthy adolescents when gaze was directed towards emotional picture aspects. By contrast, we hypothesized that regulation success would be intact in MD patients when gaze was directed away from negative picture aspects. These hypotheses were based on related research findings showing that in depression, emotional context interferes with cognitive control processes (Dichter, Felder, & Smoski, 2009; Kaiser et al., 2015), known to be critically involved in CR (Ochsner et al., 2012; Ochsner & Gross, 2005). With regard to healthy adolescents, we expected that regulation success during CR as assessed by self-reported affect ratings would be comparable across the two gaze focus conditions. This hypothesis was based on prior research in healthy emerging adults (Bebko et al., 2014; Urry, 2010).