Out-of-the-Blue: Depressive Symptoms are Associated with Deficits in Processing Inferential Expectancy-Violations Using a Novel Cognitive Rigidity Task

Reward processes in extinction learning and applications to exposure therapy

Anxiety disorders are common and highly distressing mental health conditions. Exposure therapy is a gold-standard treatment for anxiety disorders. Mechanisms of Pavlovian fear learning, and particularly fear extinction, are central to exposure therapy. A growing body of evidence suggests an important role of reward processes during Pavlovian fear extinction. Nonetheless, predominant models of exposure therapy do not currently incorporate reward processes. Herein, we present a theoretical model of reward processes in relation to Pavlovian mechanisms of exposure therapy, including a focus on dopaminergic prediction error signaling, coinciding positive emotional experiences (i.e., relief), and unexpected positive outcomes. We then highlight avenues for further research and discuss potential strategies to leverage reward processes to maximize exposure therapy response, such as pre-exposure interventions to increase reward sensitivity or post-exposure rehearsal (e.g., savoring, imaginal recounting strategies) to enhance retrieval and retention of learned associations.

Are depressive symptoms linked to a reduced pupillary response to novel positive information?-An eye tracking proof-of-concept study

Introduction

Depressive symptoms have been linked to difficulties in revising established negative beliefs in response to novel positive information. Recent predictive processing accounts have suggested that this bias in belief updating may be related to a blunted processing of positive prediction errors at the neural level. In this proof-of-concept study, pupil dilation in response to unexpected positive emotional information was examined as a psychophysiological marker of an attenuated processing of positive prediction errors associated with depressive symptoms.

Methods

Participants (N = 34) completed a modified version of the emotional Bias Against Disconfirmatory Evidence (BADE) task in which scenarios initially suggest negative interpretations that are later either confirmed or disconfirmed by additional information. Pupil dilation in response to the confirmatory and disconfirmatory information was recorded.

Results

Behavioral results showed that depressive symptoms were related to difficulties in revising negative interpretations despite disconfirmatory positive information. The eye tracking results pointed to a reduced pupil response to unexpected positive information among people with elevated depressive symptoms.

Discussion

Altogether, the present study demonstrates that the adapted emotional BADE task can be appropriate for examining psychophysiological aspects such as changes in pupil size along with behavioral responses. Furthermore, the results suggest that depression may be characterized by deviations in both behavioral (i.e., reduced updating of negative beliefs) and psychophysiological (i.e., decreased pupil dilation) responses to unexpected positive information. Future work should focus on a larger sample including clinically depressed patients to further explore these findings.

How to modify expectations of social rejection? An experimental study using a false-feedback paradigm

BACKGROUND AND OBJECTIVES

Negative expectations (NEs) are fundamental to various mental disorders. Finding ways to modulate NEs would help to improve clinical treatment. The present study investigated how previously formed expectations of social rejection are revised in the context of novel positive social experiences, and whether their revision can be modulated by differentially shifting participants' attentional focus.

METHODS

Our sample of 124 healthy participants was randomly assigned to four experimental conditions and received manipulated social feedback in multiple alleged webcam conferences. All groups went through three experimental phases that began with predominantly negative social feedback, then either transitioned to predominantly positive social feedback or continued to predominantly negative social feedback, and ultimately transitioning to a phase with no explicit social feedback. The experimental conditions differed in what they were instructed to focus on when receiving positive social feedback.

RESULTS

Receiving novel positive social feedback led to substantial changes in social expectations, but this effect was not modulated by the instructions the participants were given. Descriptive trends revealed that both instructions improved NE modification, although this effect was not robust to extinction in one condition.

LIMITATIONS

To prevent our cover story from being compromised, we could not perform an immediate manipulation check of the instructions given. Nevertheless, some of the sample seemed suspicious about the cover story.

CONCLUSION

Our results suggest that established expectations of social rejection can be revised when unexpectedly experiencing social acceptance. Nevertheless, more research is needed on potential instructions that could be used to optimize the modification of NEs.

Storm on predictive brain: A neurocomputational account of ketamine antidepressant effect

For the past decade, ketamine, an N-methyl-D-aspartate receptor (NMDAr) antagonist, has been considered a promising treatment for major depressive disorder (MDD). Unlike the delayed effect of monoaminergic treatment, ketamine may produce fast-acting antidepressant effects hours after a single administration at subanesthetic dose. Along with these antidepressant effects, it may also induce transient dissociative (disturbing of the sense of self and reality) symptoms during acute administration which resolve within hours. To understand ketamine's rapid-acting antidepressant effect, several biological hypotheses have been explored, but despite these promising avenues, there is a lack of model to understand the timeframe of antidepressant and dissociative effects of ketamine. In this article, we propose a neurocomputational account of ketamine's antidepressant and dissociative effects based on the Predictive Processing (PP) theory, a framework for cognitive and sensory processing. PP theory suggests that the brain produces top-down predictions to process incoming sensory signals, and generates bottom-up prediction errors (PEs) which are then used to update predictions. This iterative dynamic neural process would relies on N-methyl-D-aspartate (NMDAr) and α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic receptors (AMPAr), two major component of the glutamatergic signaling. Furthermore, it has been suggested that MDD is characterized by over-rigid predictions which cannot be updated by the PEs, leading to miscalibration of hierarchical inference and self-reinforcing negative feedback loops. Based on former empirical studies using behavioral paradigms, neurophysiological recordings, and computational modeling, we suggest that ketamine impairs top-down predictions by blocking NMDA receptors, and enhances presynaptic glutamate release and PEs, producing transient dissociative symptoms and fast-acting antidepressant effect in hours following acute administration. Moreover, we present data showing that ketamine may enhance a delayed neural plasticity pathways through AMPAr potentiation, triggering a prolonged antidepressant effect up to seven days for unique administration. Taken together, the two sides of antidepressant effects with distinct timeframe could constitute the keystone of antidepressant properties of ketamine. These PP disturbances may also participate to a ketamine-induced time window of mental flexibility, which can be used to improve the psychotherapeutic process. Finally, these proposals could be used as a theoretical framework for future research into fast-acting antidepressants, and combination with existing antidepressant and psychotherapy.

Biased belief updating in depression

Cognitive approaches to depression have benefitted from recent research on belief updating, examining how new information is used to alter beliefs. This review presents recent advances in understanding various sources of bias in belief updating in depression. Specifically, research has demonstrated that people with depression have difficulty revising negative beliefs in response to novel positive information, whereas belief updating in depression is not related to an enhanced integration of negative information. In terms of mechanisms underlying the deficient processing of positive information, research has shown that people with depression use defensive cognitive strategies to devalue novel positive information. Furthermore, the disregard of novel positive information can be amplified by the presence of state negative affect, and the resulting persistence of negative beliefs in turn perpetuates chronically low mood, contributing to a self-reinforcing negative feedback loop of beliefs and affect. Synthesising previous research, this review proposes a coherent framework of when belief change is likely to occur, and argues that future research also needs to elucidate why people with depression hesitate to abandon negative beliefs. Recent insights from belief updating have not only improved the understanding of the psychopathology of depression, but also have the potential to improve its cognitive-behavioural treatment.

Expectation focused and frequency enhanced cognitive behavioural therapy for patients with major depression (EFFECT): a study protocol of a randomised active-control trial

INTRODUCTION

The effectiveness of psychotherapy in depression is subject of an ongoing debate. The mechanisms of change are still underexplored. Research tries to find influencing factors fostering the effect of psychotherapy. In that context, the dose-response relationship should receive more attention. Increasing the frequency from one to two sessions per week seems to be a promising start. Moreover, the concept of expectations and its influence in depression can be another auspicious approach. Dysfunctional expectations and the lack of their modification are central in symptom maintenance. Expectation focused psychological interventions (EFPI) have been investigated, primarily in the field of depression. The aim of this study is to compare cognitive behavioural therapy (CBT) once a week with an intensified version of CBT (two times a week) in depression as well as to include a third proof-of-principle intervention group receiving a condensed expectation focused CBT.

METHODS AND ANALYSIS

Participants are recruited through an outpatient clinic in Germany. A current major depressive episode, diagnosed via structured clinical interviews should present as the main diagnosis. The planned randomised-controlled trial will allow comparisons between the following treatment conditions: CBT (one session/week), condensed CBT (two sessions/week) and EFPI (two sessions/week). All treatment arms include a total dose of 24 sessions. Depression severity applies as the outcome variable (Beck Depression Inventory II, Montgomery Asberg Depression Rating Scale). A sample size of n=150 is intended.

ETHICS AND DISSEMINATION

The local ethics committee of the Department of Psychology, Philipps-University Marburg approved the study (reference number 2020-68 v). The final research article including the study results is intended to be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00023203).

How negative mood hinders belief updating in depression: results from two experimental studies

BACKGROUND

In two experimental studies, we tested the hypothesis that negative mood would hinder the revision of negative beliefs in response to unexpectedly positive information in depression, whereas positive mood was expected to enhance belief updating.

METHODS

In study 1 (N = 101), we used a subclinical sample to compare the film-based induction of sad v. happy mood with a distraction control group. Subsequently, participants underwent a well-established paradigm to examine intra-individual changes in performance-related expectations after unexpectedly positive performance feedback. In study 2, we applied the belief-updating task from study 1 to an inpatient sample (N = 81) and induced sad v. happy mood via film-clips v. recall of autobiographic events.

RESULTS

The results of study 1 showed no significant group differences in belief updating; the severity of depressive symptoms was a negative predictor of belief revision, though, and there was a non-significant trend suggesting that the presence of sad mood hindered belief updating in the subgroup of participants with a diagnosed depressive episode. Study 2 revealed that participants updated their expectations significantly less in line with positive feedback when they underwent the induction of negative mood prior to feedback, relative to positive mood.

CONCLUSIONS

By indicating that the presence of negative mood can hinder the revision of negative beliefs in clinically depressed people, our findings suggest that learning from new experiences can be hampered if state negative mood is activated. Thus, interventions relying on learning from novel positive experiences should aim at reducing state negative mood in depression.

Exploring the path of persisting dysfunctional expectations-Development of the immunization scale IMS

Objectives

Persistent dysfunctional expectations seem to be core features of mental disorders. The aim of this study was to develop a questionnaire that assesses mechanisms responsible for the consistency of dysfunctional expectations. Processes before (i.e., assimilation) and after (i.e., immunization) expectation-violating experiences have been considered.

Design

The Immunization Scale (IMS) is constructed and validated with the help of an explorative (EFA) and confirmatory factor analysis (CFA) in two conducted studies.

Materials and methods

For the first study, the initially formulated 75-item version was completed online by 230 (range 18-69) participants from a convenience sample. For the second study, 299 (range 18-62) participants completed the reduced scale at the first measurement point, 75 participants thereof also 1 month later. For validity and reliability analyses, participants in both studies provided demographic information, the Beck Depression Inventory (BDI-II), the Depressive Expectation Scale (DES), the Beck Anxiety Inventory (BAI), and the German version of the Acceptance and Action Questionnaire (FAH-II).

Results

The initial 75 items were reduced to 23 items. The EFA revealed three main factors, namely, negative expectations, assimilation, and cognitive immunization. The three-factor structure could be confirmed in study 2 by the CFA. Reliability measures showed an excellent internal consistency for the entire IMS. A very good test-retest reliability was found. Significant correlations resulted between the IMS and DES, BDI-II, BAI, and FAH-II, the highest for DES and FAH-II.

Conclusion

Psychometric properties of the IMS are promising. Future studies should verify the reliability and validity measures in other population samples. The IMS can be very useful in expectation research, especially in the examination of expectation-focused therapy.

Neural substrates of expectancy violation associated with social feedback in individuals with subthreshold depression

BACKGROUND

Abnormal processing of social feedback is an important contributor to social dysfunction in depression, however the exact mechanisms remain unclear. One important factor may be the extent to which social processing depends on expectations, in particular whether social feedback confirms or violates expectations.

METHODS

To answer this question, we studied behavioral and brain responses during the evaluative processing of social feedback in 25 individuals with subthreshold depression (SD) and 25 healthy controls (HCs). Participants completed a Social Judgment Task in which they first indicated expectation about whether a peer would like them or not, and then received peer's feedback indicating acceptance or rejection.

RESULTS

Individuals with SD who reported greater depressive symptoms gave fewer positive expectations. Compared to HCs, individuals with SD showed reduced activation in the medial prefrontal cortex when expecting positive feedback. They also exhibited increased dorsal anterior cingulate cortex after receipt of unexpected social rejection, and reduced ventral striatum activity after receipt of unexpected social acceptance.

CONCLUSIONS

The observed alternations are specific to unexpected social feedback processing and highlight an important role of expectancy violation in the brain dysfunction of social feedback perception and evaluation in individuals at risk for depression.

Self-Actualization and the Integration of Psychedelic Experience: The Mediating Role of Perceived Benefits to Narrative Self-Functioning

There is a growing need in the field of psychedelic science for a unifying perspective of overall well-being to join seemingly disparate findings across clinical and non-clinical populations, and account for the unique role of post-psychedelic integration for promoting benefits. According to the eudaimonic perspective of well-being, the stories we create about who we are (self-insight) and who we can become (personal development) are key aspects of narrative self-functioning that either constrain or facilitate well-being. The present paper draws upon this perspective to investigate the relationship between extent of post-psychedelic integration and optimal well-being ( self-actualization), with perceived benefits to narrative self-functioning ( self-insight and personal development) as a mediator. The data for testing this model was collected from roughly 750 participants recruited from websites and social media forums. Because the sample contained clinical and non-clinical individuals, the model was able to be tested with mental health condition as a moderator. Results indicated that perceived benefits to narrative self-functioning is one pathway through which integration of psychedelic experience may promote optimal well-being for both clinical and non-clinical populations. Exploratory analyses indicated that integration techniques that are more self-referential in nature are the ones that indirectly relate to optimal well-being via perceived benefits. The results of the present study should be interpreted as a preliminary model for future longitudinal research to test, as our cross-sectional methods preclude any causal inferences to be made from these mediation analyses.

Unraveling Negative Expectations and Nocebo-Related Effects in Musculoskeletal Pain

This Perspective adapts the ViolEx Model, a framework validated in several clinical conditions, to better understand the role of expectations in the recovery and/or maintenance of musculoskeletal (MSK) pain. Here, particular attention is given to the condition in which dysfunctional expectations are maintained despite no longer being supported by confirmatory evidence (i.e., belief-lifting the arm leads to permanent tendon damage; evidence-after the patient lifts the arm no tendon damage occurs). While the ViolEx Model suggests that cognitive immunization strategies are responsible for the maintenance of dysfunctional expectations, we suggest that such phenomenon can also be understood from a Bayesian Brain perspective, according to which the level of precision of the priors (i.e., expectations) is the determinant factor accounting for the extent of priors' updating (i.e., we merge the two frameworks, suggesting that highly precise prior can lead to cognitive immunization responses). Importantly, this Perspective translates the theory behind these two frameworks into clinical suggestions. Precisely, it is argued that different strategies should be implemented when treating MSK pain patients, depending on the nature of their expectations (i.e., positive or negative and the level of their precision).

No Evidence for the Involvement of Cognitive Immunisation in Updating Beliefs About the Self in Three Non-Clinical Samples

BACKGROUND

Cognitive immunisation against disconfirmatory evidence (i.e., devaluing expectation-disconfirming information through cognitive mechanisms) has recently been discussed as an obstacle to the revision of dysfunctional beliefs in mental disorders such as depression. Yet, it is unclear whether cognitive immunisation is also involved in belief updating in non-clinical samples.

METHODS

Using a three-group modulation protocol (promotion vs. inhibition of cognitive immunisation vs. control group), we examined how cognitive immunisation influences belief updating in response to performance feedback in three non-clinical samples. In Experiments 1 (N = 99) and 2 (N = 93), participants received unexpectedly negative feedback, whereas participants from Experiment 3 (N = 118) received unexpectedly positive feedback. Depressive symptoms and dispositional optimism were examined as additional predictors of belief updating.

RESULTS

In all experiments, participants adjusted their expectations in line with the feedback received, but this effect was not influenced by the cognitive immunisation manipulation. In Experiment 3, expectation change remained stable over 2 weeks. Depressive symptoms were associated with a reduced integration of positive feedback, but not with an increased sensitivity to negative feedback.

CONCLUSIONS

Whereas previous research has shown that cognitive immunisation contributes to persistent beliefs in clinical populations, the present findings suggest that it does not affect belief updating in non-clinical samples.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10608-021-10256-y.

What Does CATS Have to Do With Cancer? The Cognitive Activation Theory of Stress (CATS) Forms the SURGE Model of Chronic Post-surgical Pain in Women With Breast Cancer

Chronic post-surgical pain (CPSP) represents a highly prevalent and significant clinical problem. Both major and minor surgeries entail risks of developing CPSP, and cancer-related surgery is no exception. As an example, more than 40% of women undergoing breast cancer surgery struggle with CPSP years after surgery. While we do not fully understand the pathophysiology of CPSP, we know it is multifaceted with biological, social, and psychological factors contributing. The aim of this review is to advocate for the role of response outcome expectancies in the development of CPSP following breast cancer surgery. We propose the Cognitive Activation Theory of Stress (CATS) as an applicable theoretical framework detailing the potential role of cortisol regulation, inflammation, and inflammatory-induced sickness behavior in CPSP. Drawing on learning theory and activation theory, CATS offers psychobiological explanations for the relationship between stress and health, where acquired expectancies are crucial in determining the stress response and health outcomes. Based on existing knowledge about risk factors for CPSP, and in line with the CATS position, we propose the SURGEry outcome expectancy (SURGE) model of CPSP. According to SURGE, expectancies impact stress physiology, inflammation, and fear-based learning influencing the development and persistence of CPSP. SURGE further proposes that generalized response outcome expectancies drive adaptive or maladaptive stress responses in the time around surgery, where coping dampens the stress response, while helplessness and hopelessness sustains it. A sustained stress response may contribute to central sensitization, alterations in functional brain networks and excessive fear-based learning. This sets the stage for a prolonged state of inflammatory-induced sickness behavior - potentially driving and maintaining CPSP. Finally, as psychological factors are modifiable, robust and potent predictors of CPSP, we suggest hypnosis as an effective intervention strategy targeting response outcome expectancies. We here argue that presurgical clinical hypnosis has the potential of preventing CPSP in women with breast cancer.

Assessing Pragmatic Language Skills in Adults with Major Depressive Disorder: An Exploratory Study

INTRODUCTION

There is increasing evidence that major depressive disorder (MDD) is associated with significant pragmatic language impairments. However, there is a lack of studies that use standardized tools and simultaneously investigate all pragmatic language skills among MDD patients. The aim of this study was to propose a more thorough investigation of all pragmatic language skills in patients with MDD.

METHODS

Twenty adults (aged 22-65) with a DSM-5 diagnosis of MDD were assessed using BLED Santa Lucia (Batteria sul Linguaggio dell'Emisfero Destro Santa Lucia), a battery designed to evaluate pragmatic language skills (comprehension of inferences, of picture and written metaphors, of indirect requests, of humoristic expressions, and of prosody). The performance of the MDD participants on all BLED Santa Lucia subscales was compared to 20 healthy control subjects (aged 20-60) matched for gender, age, years of education, and employment status.

RESULTS

MDD patients performed poorer than controls in comprehension of inferences (p < 0.01), picture metaphors (p < 0.001), written metaphors (p < 0.001), indirect requests (p < 0.01), humoristic expression (p < 0.05), and prosody (p < 0.05).

CONCLUSIONS

All pragmatic language skills can be significantly impaired in MDD patients. A valid assessment of all pragmatic language skills can allow, for each patient, the definition of a specific profile of risk and protective factors before and during psychotherapy.

How Depressive Symptoms Hinder Positive Information Processing: An Experimental Study on the Interplay of Cognitive Immunisation and Negative Mood in the Context of Expectation Adjustment

Background

People with depression maintain negative expectations despite disconfirming positive experiences by reappraising or discarding novel positive information, referred to as “cognitive immunisation”. A second body of literature suggests that negative mood can negatively affect information processing. Bridging these two lines of research, the present study examined the interplay of cognitive immunisation and negative mood in the context of expectation modification.

Methods

In a student sample (N = 152), we used a well-established experimental paradigm to examine the adjustment of performance expectations in response to positive performance feedback, and its relation to depressive symptoms. In a 2 × 2 design, participants received either a negative mood induction, a cognitive immunisation manipulation, both, or no further manipulation.

Results

Participants from all experimental groups revised their previous expectations significantly in line with positive performance feedback. However, depressive symptoms were a negative predictor of expectation adjustment, and a moderation analysis indicated that this effect was particularly pronounced if participants underwent the negative mood induction.

Conclusions

Consistent with previous work, depressive symptoms were associated with a reduced ability to integrate positive information. Furthermore, our results suggest that the activation of negative mood in people with elevated levels of depression may hamper learning from new positive experience.

When Beliefs Face Reality: An Integrative Review of Belief Updating in Mental Health and Illness

Belief updating is a relatively nascent field of research that examines how people adjust their beliefs in light of new evidence. So far, belief updating has been investigated in partly unrelated lines of research from different psychological disciplines. In this article, we aim to integrate these disparate lines of research. After presenting some prominent theoretical frameworks and experimental designs that have been used for the study of belief updating, we review how healthy people and people with mental disorders update their beliefs after receiving new information that supports or challenges their views. Available evidence suggests that both healthy people and people with particular mental disorders are prone to certain biases when updating their beliefs, although the nature of the respective biases varies considerably and depends on several factors. Anomalies in belief updating are discussed in terms of both new insights into the psychopathology of various mental disorders and societal implications, such as irreconcilable political and societal controversies due to the failure to take information into account that disconfirms one’s own view. We conclude by proposing a novel integrative model of belief updating and derive directions for future research.

Distorted Cognitive Processes in Major Depression: A Predictive Processing Perspective

The cognitive model of depression has significantly influenced the understanding of distorted cognitive processes in major depression; however, this model's conception of cognition has recently been criticized as possibly too broad and unspecific. In this review, we connect insights from cognitive neuroscience and psychiatry to suggest that the traditional cognitive model may benefit from a reformulation that takes current Bayesian models of the brain into account. Appealing to a predictive processing account, we explain that healthy human learning is normally based on making predictions and experiencing discrepancies between predicted and actual events or experiences. We present evidence suggesting that this learning mechanism is distorted in depression: current research indicates that people with depression tend to negatively reappraise or disregard positive information that disconfirms negative expectations, thus resulting in sustained negative predictions and biased learning. We also review the neurophysiological correlates of such deficits in processing prediction errors in people with depression. Synthesizing these findings, we propose a novel mechanistic model of depression suggesting that people with depression have the tendency to predominantly expect negative events or experiences, which they subjectively feel confirmed due to reappraisal of disconfirming evidence, thus creating a self-reinforcing negative feedback loop. Computationally, we consider too much precision afforded to negative prior beliefs as the main candidate of pathology, accompanied by an attenuation of positive prediction errors. We conclude by outlining some directions for future research into the understanding of the behavioral and neurophysiological underpinnings of this model and point to clinical implications of it.

Understanding persistent physical symptoms: Conceptual integration of psychological expectation models and predictive processing accounts

Persistent physical symptoms (PPS) are distressing, difficult to treat, and pose a major challenge to health care providers and systems. In this article, we review two disparate bodies of literature on PPS to provide a novel integrative model of this elusive condition. First, we draw on the clinical-psychological literature on the role of expectations to suggest that people with PPS develop dysfunctional expectations about health and disease that become increasingly immune to disconfirmatory information (such as medical reassurance) through cognitive reappraisal. Second, we invoke neuroscientific predictive processing accounts and propose that the psychological process of 'cognitive immunization' against disconfirmatory evidence corresponds, at the neurobiological and computational level, to too much confidence (i.e. precision) afforded to prior predictions. This can lead to an attenuation of disconfirming sensory information so that strong priors override benign bodily signals and make people believe that something serious is wrong with the body. Combining these distinct accounts provides a unifying framework for persistent physical symptoms and shifts the focus away from their causes to the sustaining mechanisms that prevent symptoms from subsiding spontaneously. Based on this integrative model, we derive new avenues for future research and discuss implications for treating people with PPS in clinical practice.

Belief updating in depression is not related to increased sensitivity to unexpectedly negative information

BACKGROUND

People with depression differ from healthy people in the extent to which they use novel positive information to adjust negative expectations. In this study, we examined whether the two groups also differ in updating positive expectations after receiving unexpectedly negative information.

METHODS

Examining 76 people with depressive symptoms and 81 healthy controls, we used an adapted version of a previously validated paradigm. After the initial establishment of positive performance expectations, participants worked on the TEMINT performance test, whereupon half of the participants received standardized feedback that confirmed previous positive expectations while the other half received disconfirming negative feedback. Subsequently, participants' performance expectations were assessed again. Additionally, we assessed participants' appraisal of the feedback, particularly whether they tended to disregard it.

RESULTS

Results indicated that healthy subjects had overall more positive expectations than people with depressive symptoms, but the two samples did not differ in updating their expectations: both groups changed their expectations in a negative direction after receiving negative feedback; similarly, there were no differences between the two samples after receiving confirmatory positive feedback. Both people with and without depressive symptoms were more likely to disregard the feedback received if the feedback was negative, and such a negative appraisal of the feedback was associated with smaller expectation update.

CONCLUSIONS

In combination with prior work, the current findings suggest that people with depressive symptoms do not over-sensitively react to unexpectedly negative information; rather, the main problem of depression seems to be the integration of novel positive information, as shown previously.

Why dysfunctional expectations in depression persist - Results from two experimental studies investigating cognitive immunization

BACKGROUND

Research has revealed that negative expectations impact depressive symptoms. However, research on the change of dysfunctional expectations in depression is lacking so far. Therefore, the present research aimed to fill this gap by testing the hypothesis that people with the major depressive disorder (MDD), contrary to healthy individuals, maintain their expectations despite experiences that positively disconfirm expectations. Further, it was hypothesized that cognitive immunization (a cognitive reappraisal of the disconfirming evidence) is a mechanism underlying the persistence of expectations.

METHOD

In Study 1, we compared individuals with MDD (N = 58) to healthy individuals (N = 59). Participants worked on the same performance test and received standardized feedback that either confirmed or disconfirmed their initial performance expectations. In Study 2, we investigated the effects of cognitive immunization on expectation change among 59 individuals reporting elevated levels of depression by varying the appraisal of expectation-disconfirming feedback.

RESULTS

Results from Study 1 show that in the expectation-disconfirming condition, healthy individuals changed their expectations, whereas individuals with MDD did not. No such difference between the two groups was found for expectation-confirming feedback. Results from Study 2 indicated that varying cognitive immunization impacted expectation change, thus suggesting a crucial role of cognitive immunization in expectation change.

CONCLUSIONS

These two studies indicated that individuals suffering from depression have more difficulties in changing their expectations after disconfirming experiences than do healthy individuals, and cognitive immunization might be a core mechanism underlying expectation persistence. Therefore, psychotherapeutic interventions should aim to inhibit cognitive immunization processes to enhance expectation change.

How to modify persisting negative expectations in major depression? An experimental study comparing three strategies to inhibit cognitive immunization against novel positive experiences

BACKGROUND

Research has shown that negative expectations in major depressive disorder (MDD) often persist despite positive disconfirming experiences. To explain this phenomenon, the concept of cognitive immunization has been introduced: that is, individuals with MDD reappraise disconfirming positive evidence in such a way that negative expectations are maintained. In this study, we examined whether it is possible to inhibit cognitive immunization to facilitate expectation update.

METHODS

We examined 113 people with MDD being treated in an inpatient psychosomatic hospital. Using a previously validated paradigm, participants worked on a standardized performance test; we examined changes in negative performance-related expectations after positive expectation-disconfirming feedback. One experimental group received additional information increasing the value of the positive feedback ('INFORMATION'). Another group was instructed to recall the feedback after completing the task ('RECALL'). In a third group, participants' attention was shifted to potential expectation-disconfirming feedback ('ATTENTION'). In addition, a control group underwent the standard procedure of the paradigm.

RESULTS

The results showed significant group differences in the change in generalized performance expectations, with the largest changes in participants from the INFORMATION group. All experimental groups had lower values for cognitive immunization than the control group.

LIMITATIONS

Given that this proof-of-concept study was the first to examine strategies to inhibit cognitive immunization, the findings need to be replicated in future studies.

CONCLUSIONS

The present study confirms that cognitive immunization in MDD can be inhibited, thus facilitating adjusting negative expectations. The most promising results were found for the INFORMATION group, providing information to emphasize the relevance of expectation-disconfirming information.

Revisiting the Cognitive Model of Depression: The Role of Expectations

The cognitive model of depression was highly stimulating for a better understanding and development of treatment for depression. However, the concept of “cognition” is rather broad and unspecific, and we suggest to focus on the cognitive subset of expectation.

We conducted a narrative review on the role of expectations, and present an expectation-focused model of explaining why depression tends to persist despite the occurrence of positive events.

Several results from basic neuroscience to effects in clinical interventions indicate that expectations play a special role not only for the understanding of the development of mental disorders and the effects of treatment approaches, but especially for an improved understanding of the persistence of mental disorders. If expectations are a major mechanism of depression, the treatment of depression must maximize the violation of dysfunctional expectations. We also introduce the concept of immunization that describes any cognitive or behavioral strategies to reduce the effect of expectation violation experiences, and hereby contributing to expectation maintenance despite expectation contradicting events. We postulate that the development of immunization strategies could help to better understand the transition from episodic to chronic depression.

While in early periods of depression development, a focus on expectation change might be sufficient in treatment, the treatment of patients with chronic depression requires addressing these cognitive and behavioral immunization strategies more intensively. Further implications for treatment and research are outlined that are derived from this balance between expectation violation and cognitive immunization in depression.

A focus on “expectations” helps to better understand the maintenance of depression

We offer a model that explains why depression persists even in the presence of positive experiences.

Many psychological treatments focus on the violation of negative expectations, but cognitive immunization can hinder treatment success.

We suggest strategies on how to improve psychological treatments for depression by maximizing expectation violation, and minimizing cognitive immunization.