Mindfulness: Top–down or bottom–up emotion regulation strategy?
Highlights
► Mindfulness training (MT) has shown efficacy for many clinical conditions. ► Little is known about the neural correlates supporting the clinical benefits of MT. ► MT could be associated with top–down emotion regulation in short-term practitioners. ► MT could be associated with bottom–up emotion regulation in long-term practitioners. ► Different instructions or mental conditions could influence the neural mechanisms of MT.
Introduction
In the last decade a surge of interest has been directed towards the exploration of mindfulness as a means to treat a variety of physical and psychological conditions (Chiesa and Serretti, 2010, Ludwig and Kabat-Zinn, 2008). Many different definitions of mindfulness exist and mindfulness is therefore differently interpreted and practiced across different mindfulness based interventions (MBIs; Chiesa and Malinowski, 2011, Malinowski, 2008). However, there is some consensus on defining mindfulness as the act of “paying attention in a particular way: on purpose, in the present moment, and nonjudgementally” (Kabat-Zinn, 1994, p.4).
The empirical evidence suggesting the beneficial effects of cultivating mindfulness has grown in both quantity and complexity in recent years. Results from randomized controlled trials are increasingly supporting the efficacy of MBIs for a large number of psychological and physical disorders (Chiesa and Serretti, 2010, Keng et al., 2011). As an example, Mindfulness based Stress Reduction (MBSR) has been found to reduce pain, stress and psychological problems in healthy individuals, chronic pain patients and cancer patients (Chiesa and Serretti, 2011a, Ledesma and Kumano, 2009, Shennan et al., 2011). Furthermore, systematic reviews and randomized controlled trials have shown that Mindfulness based Cognitive Therapy (MBCT) might be an effective intervention for currently depressed patients as well as for the prevention of depression relapses in patients with three or more prior depressive episodes (Chiesa et al., 2012, Chiesa and Serretti, 2011b, Manicavasgar et al., 2011, Piet and Hougaard, 2011). These findings are in line with traditional accounts of mindfulness suggesting that significant positive changes occur in the psycho-physiological processes of individuals cultivating mindfulness in their daily life (Grabovac et al., 2011, Olendzki, 2006). Until recently, however, the mechanisms behind the effects of mindfulness practice were relatively unknown to Western psychology and neurobiology (Chiesa, Brambilla, & Serretti, 2010).
To address the current gap, several authors have recently examined the mechanisms of mindfulness within the context of emotion regulation strategies (e.g. Chambers et al., 2009, Garland et al., 2010, Hoffman and Asmundson, 2008). Emotion regulation can be defined as the ability to regulate one's own emotions and emotional responses (Gross, 1998a, Gross, 1998b). Current evidence suggests that there are several partially overlapping ways by which an individual can regulate his/her own emotions (Gross, 1998b, Gross and Munoz, 1995). However, at least two distinct emotion regulation strategies have been clearly distinguished from one another (Chiesa et al., 2010, Gross, 1998a, Gross and John, 2003, for a more detailed description see below). In particular, some emotion regulation strategies, such as cognitive reappraisal, are thought to manipulate the input to the emotion-generative system by actively reinterpreting emotional stimuli in a way that modifies their emotional impact (Gross, 1998b). This kind of emotion regulation has been found to involve a “top–down” regulation of prefrontal brain regions on emotion-generative brain regions, such as the amygdala (Lorenz et al., 2003, Quirk and Beer, 2006).
Another way to regulate one's own emotions has been described as a direct modulation of emotion-generative brain regions without cognitively reappraise emotionally salient stimuli (e.g. Chambers et al., 2009, Westbrook et al., 2011). This kind of emotion regulation strategy has been termed “bottom–up” because it is characterized by a direct reduced reactivity of “lower” emotion-generative brain regions without an active recruitment of “higher” brain regions, such as the prefrontal cortex (PFC; e.g. van den Hurk et al., 2010, Westbrook et al., 2011).
There is currently no consensus as to how mindfulness practice helps regulate disruptive emotions (Chambers et al., 2009, Garland et al., 2010, Hoffman and Asmundson, 2008). According to some authors, mindfulness should be described as a top–down emotion regulation strategy facilitating positive cognitive reappraisal (Garland et al., 2009, Garland et al., 2010). According to this view, the psychological and neurobiological mechanisms of MBIs would not be significantly different from those observed in common Western psychological approaches, such as psychotherapy (Chiesa et al., 2010, Garland et al., 2009, Garland et al., 2010). On the other hand, other authors have argued that mindfulness could be best described as a bottom–up emotion regulation strategy (e.g. Chambers et al., 2009, Grabovac et al., 2011, Lutz, Dunne and Davidson, 2008). Still other authors have claimed that the relationship existing between mindfulness training and different emotion regulation strategies, as well as with the activation of related brain areas, could vary as a function of overall mindfulness experience (Taylor et al., 2011).
A better understanding of whether mindfulness involves a top–down or a bottom–up emotion regulation strategy could have important clinical implications. As an example, if mindfulness training is primarily a bottom–up process, MBIs might be effective for patients not responding to traditional psychotherapies. Indeed, psychotherapy frequently relies upon top–down mechanisms, such as cognitive reappraisal, to regulate unpleasant emotions (DeRubeis et al., 2008, Roffman et al., 2005). However, the possibility to reappraise one's own emotions is often impaired in psychological disorders (e.g. Keightley et al., 2003, Liotti et al., 2002). As a consequence, the effects of MBIs might be superior to the effects of traditional psychotherapies for patients with an impairment of their ability to reappraise unpleasant emotions.
Neuro-imaging studies focusing on the exploration of mindfulness practice and employing emotion regulation paradigms might provide particularly fruitful insights into the understanding of mindfulness as a specific emotion regulation strategy (Chambers et al., 2009, Garland et al., 2010, Lutz, Dunne and Davidson, 2008). Indeed, they could allow for the understanding of which brain areas are activated or de-activated when mindfulness practitioners are asked to regulate their own emotions during tasks that require emotional regulation. This, in turn, would help clarify whether mindfulness could be best described as a bottom–up or as a top–down emotion regulation strategy, as well as related clinical implications. The aim of this review is, therefore, to assess whether mindfulness practice can be best described as a top–down emotion regulation strategy, as a bottom–up emotion regulation strategy, or as a combination of both strategies, on the basis of functional neuro-imaging studies employing emotion regulation paradigms.
First, we will explore critical issues concerning current discrepancies in the definitions of mindfulness. Then, we will review current studies investigating the functional neural correlates of mindfulness training that are relevant for the understanding of mindfulness within the context of emotion regulation strategies. Finally, we will present a preliminary theoretical integration of our findings and will provide suggestions for future research on this topic.
Section snippets
Critical issues related to the definition of mindfulness
Early descriptions of mindfulness can be found in traditional Buddhist scriptures such as the Abhidhamma (Kiyota, 1978) and the Vishuddimagga (Buddhaghosa, 1976). The original term of what is commonly referred to as mindfulness is Sati, a Sanskrit word that has been both used to indicate a lucid awareness of what is occurring within the phenomenological field and as a term that could be translated as “remembrance” or memory (Bhikku Bodhi, 2011). Indeed, mindfulness has traditionally been
Mindfulness as an emotion regulation strategy
Emotion regulation can be defined as the ability to regulate emotions and emotional responses (Gross, 1998b). The interest towards emotion regulation relies on the notion that adaptive emotion regulation is supposed to subsume adaptive functioning and mental health (Gross & Munoz, 1995). Indeed, deficits of emotion regulation can be found in a large number of psychiatric disorders (Gross and Munoz, 1995, Repetti et al., 2002).
There is not yet complete consensus as to how emotion regulation
The default mode network
Research has identified a default-mode network (DMN) of brain regions active when the brain is not engaged in task-induced activity (Buckner and Vincent, 2007, Gusnard et al., 2001). The DMN is characterized by specific coherent low frequency neuronal oscillations (< 0.1 Hz) (Buckner & Vincent, 2007) localized in the medial prefrontal cortex (mPFC), posterior cingulate cortex (PCC), precuneus, anterior cingulate cortex (ACC), parietal cortex, and sometimes also the hippocampus (Buckner et al.,
Different conceptions of mindfulness as an emotion regulation strategy
On the basis of reviewed findings two main conceptions of mindfulness could be hypothesized. The first conception suggests that mindfulness training can be described as an increased attention to present moment experience with a non-judgmental attitude and no attempt to cognitively reappraise emotionally salient, particularly unpleasant, stimuli (Brown et al., 2007, Chambers et al., 2009, Gunaratana, 2002, Hart, 1987). This is a clear description of a bottom–up process. Accordingly, mindfulness
Studies suggesting bottom–up regulation
Five studies have suggested that mindfulness training could reduce emotional reactivity without concurrent activation of modulatory PFC regions. Four of these studies employed a cross-sectional design (Gard et al., 2012, Grant et al., 2011, Taylor et al., 2011, Westbrook et al., 2011) whereas a single study employed a prospective design (Goldin & Gross, 2010). Building on current findings suggesting that MBIs could be effective for smoking cessation (e.g. Altner, 2002, Davis et al., 2007), a
Studies suggesting top–down regulation
Four studies have been published so far that preliminary suggest that mindfulness training could recruit areas of the PFC to regulate emotional brain areas. In this case, three studies employed a prospective design whereas a single study employed a cross-sectional design. Therefore, prospective studies will be reviewed first. In an early study, Farb et al. (2007) investigated the effects of a standard 8-week MBSR program on brain activity by means of a paradigm aimed at evoking self-referential
An integration of current evidence
The majority of studies reported in the previous two sections converge on suggesting the significant role of mindfulness training in the reduction of activation of cortical midline structures previously associated with the DFM, probably reflecting the reduction of self-referential processing associated with mindfulness practice. Furthermore, they strongly point to the increased activation of areas involved with somatic awareness, such as the insula, as a consequence of mindfulness training.
Clinical implications
Although reviewed findings should be considered as preliminary, on account of the several limitations discussed above, they could have important clinical implications. First of all, our findings, in association with clinical findings suggesting the beneficial effects of MBIs (Keng et al., 2011), support the notion that mindfulness training could lead to these benefits, at least in part, by means of processes distinct from cognitive reappraisal. This issue is particularly important if one
Limitations of current research and suggestions for future studies
As reported above, reviewed studies suffer from several methodological shortcomings that limit the possibility to generalize observed findings and to draw definitive conclusions. Major limitation of reviewed studies include: 1) small sample size, which reduces the generalizability of observed findings to subjects other than those under investigation in the study; 2) the lack of control groups, that does not allow to exclude that pre-post findings are simply related to task or neuro-imaging
Conclusion
In spite of the consistent methodological shortcomings and some discrepancies between experimental paradigms, definitions of mindfulness and experience levels of meditators, reviewed findings preliminary suggest that in healthy subjects mindfulness training could be associated with top–down emotion regulation in short-term practitioners and with bottom–up emotion regulation in long-term practitioners. Alternatively, both processes could be more or less associated with mindfulness training
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