Emotion regulation deficits in frontotemporal lobar degeneration and Alzheimer's disease

Predictive utility of emotional regulation abilities for assessing cognitive improvement in depression

OBJECTIVE

To construct a predictive model for the improvement of cognitive function in patients with depressive disorder treated with SNRIs, based on emotional regulation abilities, and to provide personalized treatment for depressed patients.

METHODS

Clinical data from 170 patients with depressive disorder treated with SNRIs at Tongji Hospital, Shanghai, from December 2017 to May 2023 were collected. Based on whether the MoCA-B total score at 3-6 months post-treatment was at least 2 points higher than at baseline, patients were divided into the cognitive function improved group (n = 80) and the cognitive function not improved group (n = 90). Stepwise logistic regression and LASSO regression were used to select predictive factors, and logistic regression analysis was applied to construct predictive models solely based on emotional regulation abilities, combined with executive functions and HAMD scores. The models were further validated through Bootstrap internal validation, calibration curve plotting, and C-index calculation, and a comparison between the two models was performed.

RESULTS

An ER model with an area under the ROC curve of 0.817was established using four emotional regulation ability indicators: the valence of reappraised images, the arousal of negative images, the arousal of neutral images, and the success of reappraisal (arousal). Internal validation using Bootstrap showed a C index of 0.817, and clinical decision curves indicated that this model has a significant net benefit with a probability of improved cognitive function ranging from about 20 to 85%. Additionally, an EREH model including emotional regulation ability, executive function, and HAMD score as predictors was constructed using Lasso and logistic regression methods. This model reached an area under the ROC curve of 0.859and clinical decision curves showed high net benefits with probabilities of improved cognitive function ranging from 10 to 100%. The calibration curves of both models coincided well with the actual curves, with the latter having a higher AUC and significant statistical differences between the two models.

CONCLUSION

This study suggests that emotional regulation ability may serve as a predictor for the improvement of cognitive functions in patients with depression depressive disorder treated with SNRIs. However, it is important to note that there may be other factors not covered or included in this study.The predictive model that includes executive functions and HAMD scores offers better differentiation and consistency and is more feasible in clinical practice.

Elevated unanticipated acoustic startle reactivity in dyslexia

People with dyslexia, a neurodevelopmental disorder of reading, are highly attuned to the emotional world. Compared with their typically developing peers, children with dyslexia exhibit greater autonomic nervous system reactivity and facial behaviour to emotion- and empathy-inducing film clips. Affective symptoms, such as anxiety, are also more common in children with dyslexia than in those without. Here, we investigated whether the startle response, an automatic reaction that lies at the interface of emotion and reflex, is elevated in dyslexia. We measured facial behaviour, electrodermal reactivity (a sympathetic nervous system measure) and emotional experience in response to a 100 ms, 105 dB unanticipated acoustic startle task in 30 children with dyslexia and 20 comparison children without dyslexia (aged 7-13) who were matched on age, sex and nonverbal reasoning. Our results indicated that the children with dyslexia had greater total facial behaviour and electrodermal reactivity to the acoustic startle task than the children without dyslexia. Across the sample, greater electrodermal reactivity during the startle predicted greater parent-reported anxiety symptoms. These findings contribute to an emerging picture of heightened emotional reactivity in dyslexia and suggest accentuated sympathetic nervous system reactivity may contribute to the elevated anxiety that is often seen in this population.

Emotion regulation in people living with dementia and their spouses: the role of neuropsychiatric symptoms

OBJECTIVES

People with dementia (PwD) and their care partners (CP) may have difficulties in emotion regulation, and individual differences in emotion regulation may be related to PwD's neuropsychiatric symptoms. This study explores whether there is self-awareness of PwD's difficulties in emotion regulation and whether CP's emotion regulation relates to the PwD's neuropsychiatric symptoms, potentially revealing bias or interpersonal effects.

METHOD

We used data from the Wish Outcome Obstacle Plan Study with a sample of 45 PwD and their spousal CP (n = 90 individuals). Multivariate linear regression models were used to investigate the associations between the CP-reported neuropsychiatric symptoms in PwD and self-reports of emotion regulation in both dyad members, net of sociodemographic and health factors. Separate analyses were conducted for each neuropsychiatric subsyndrome and each domain of difficulties in emotion regulation.

RESULTS

Increasing severity of neuropsychiatric symptoms was associated with higher difficulties in emotion regulation in PwD (ß = 1.23, p < 0.05), but not with CP's difficulties in emotion regulation. When CP reported more severe neuropsychiatric symptoms in PwD, PwD reported that they had difficulties in accepting emotions, controlling impulses, goal-directed behaviors, and accessing emotion regulation strategies, but not in emotion awareness and clarification. Proxy-reports of hyperactivity and psychosis subsyndromes are significantly related to PwD's self-reported difficulties in emotion regulation.

CONCLUSION

PwD reported difficulties in emotion regulation at the early stage of dementia. Proxy-reported neuropsychiatric symptoms may capture PwD's emotion regulation capability and not be biased by CP's difficulties in emotion regulation.

Emotion Regulation in Dementia Caregiving: The Role of Neuropsychiatric Symptoms and Attachment Orientation

Family caregivers are usually the main source of support for persons living with dementia, being exposed to a loved one's suffering, which can lead to experiencing strong and negative emotions. This study aimed to identify factors capable of explaining individual differences in the way caregivers regulate their emotions. This cross-sectional study included 78 informal caregivers (M = 64.84 years; SD = 13.32) and 84 controls (non-caregivers) (M = 77 years; SD = 7.59). Neuropsychiatric symptoms (NPS), attachment orientations, and emotion regulation were measured using self-report scales. Caregivers of persons living with dementia used more expressive suppression in comparison to non-caregivers. NPS and attachment avoidance were associated with expressive suppression. Moderation analyses showed that NPS only predicted expressive suppression when attachment avoidance was low or medium. The present study showed that caregivers are more likely to suppress their emotions in the presence of NPS, especially those with lower/middle levels of attachment avoidance. Psychological interventions targeting emotion regulation should be offered especially to caregivers that face NPS of persons living with dementia and present lower/middle levels of attachment avoidance.

The control patterns of affective processing and cognitive reappraisal: insights from brain controllability analysis

Perceiving and modulating emotions is vital for cognitive function and is often impaired in neuropsychiatric conditions. Current tools for evaluating emotional dysregulation suffer from subjectivity and lack of precision, especially when it comes to understanding emotion from a regulatory or control-based perspective. To address these limitations, this study leverages an advanced methodology known as functional brain controllability analysis. We simultaneously recorded electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) data from 17 healthy subjects engaged in emotion processing and regulation tasks. We then employed a novel EEG/fMRI integration technique to reconstruct cortical activity in a high spatiotemporal resolution manner. Subsequently, we conducted functional brain controllability analysis to explore the neural network control patterns underlying different emotion conditions. Our findings demonstrated that the dorsolateral and ventrolateral prefrontal cortex exhibited increased controllability during the processing and regulation of negative emotions compared to processing of neutral emotion. Besides, the anterior cingulate cortex was notably more active in managing negative emotion than in either controlling neutral emotion or regulating negative emotion. Finally, the posterior parietal cortex emerged as a central network controller for the regulation of negative emotion. This study offers valuable insights into the cortical control mechanisms that support emotion perception and regulation.

Diminished preparatory physiological responses in frontotemporal lobar degeneration syndromes

Researchers typically study physiological responses either after stimulus onset or when the emotional valence of an upcoming stimulus is revealed. Yet, participants may also respond when they are told that an emotional stimulus is about to be presented even without knowing its valence. Increased physiological responding during this time may reflect a 'preparation for action'. The generation of such physiological responses may be supported by frontotemporal regions of the brain that are vulnerable to damage in frontotemporal lobar degeneration. We examined preparatory physiological responses and their structural and functional neural correlate in five frontotemporal lobar degeneration clinical subtypes (behavioural variant frontotemporal dementia, n = 67; semantic variant primary progressive aphasia, n = 35; non-fluent variant primary progressive aphasia, n = 30; corticobasal syndrome, n = 32; progressive supranuclear palsy, n = 30). Comparison groups included patients with Alzheimer's disease (n = 56) and healthy controls (n = 35). Preparatory responses were quantified as cardiac interbeat interval decreases (i.e. heart rate increases) from baseline to an 'instruction period', during which participants were told to watch the upcoming emotional film but not provided the film's valence. Patients' behavioural symptoms (apathy and disinhibition) were also evaluated via a caregiver-reported measure. Compared to healthy controls and Alzheimer's disease, the frontotemporal lobar degeneration group showed significantly smaller preparatory responses. When comparing each frontotemporal lobar degeneration clinical subtype with healthy controls and Alzheimer's disease, significant group differences emerged for behavioural variant frontotemporal dementia and progressive supranuclear palsy. Behavioural analyses revealed that frontotemporal lobar degeneration patients showed greater disinhibition and apathy compared to Alzheimer's disease patients. Further, these group differences in disinhibition (but not apathy) were mediated by patients' smaller preparatory responses. Voxel-based morphometry and resting-state functional MRI analyses revealed that across patients and healthy controls, smaller preparatory responses were associated with smaller volume and lower functional connectivity in a circuit that included the ventromedial prefrontal cortex and cortical and subcortical regions of the salience network. Diminished preparatory physiological responding in frontotemporal lobar degeneration may reflect a lack of preparation for actions that are appropriate for an upcoming situation, such as approaching or withdrawing from emotional stimuli. The ventromedial prefrontal cortex and salience network are critical for evaluating stimuli, thinking about the future, triggering peripheral physiological responses, and processing and interpreting interoceptive signals. Damage to these circuits in frontotemporal lobar degeneration may impair preparatory responses and help explain often-observed clinical symptoms such as disinhibition in these patients.

Autonomic factors do not underlie the elevated self-disgust levels in Parkinson's disease

INTRODUCTION

Parkinson's disease (PD) is manifested along with non-motor symptoms such as impairments in basic emotion regulation, recognition and expression. Yet, self-conscious emotion (SCEs) such as self-disgust, guilt and shame are under-investigated. Our previous research indicated that Parkinson patients have elevated levels of self-reported and induced self-disgust. However, the cause of that elevation-whether lower level biophysiological factors, or higher level cognitive factors, is unknown.

METHODS

To explore the former, we analysed Skin Conductance Response (SCR, measuring sympathetic activity) amplitude and high frequency Heart Rate Variability (HRV, measuring parasympathetic activity) across two emotion induction paradigms, one involving narrations of personal experiences of self-disgust, shame and guilt, and one targeting self-disgust selectively via images of the self. Both paradigms had a neutral condition.

RESULTS

Photo paradigm elicited significant changes in physiological responses in patients relative to controls-higher percentages of HRV in the high frequency range but lower SCR amplitudes, with patients to present lower responses compared to controls. In the narration paradigm, only guilt condition elicited significant SCR differences between groups.

CONCLUSIONS

Consequently, lower level biophysiological factors are unlikely to cause elevated self-disgust levels in Parkinson's disease, which by implication suggests that higher level cognitive factors may be responsible.

Alterations in facial expressions of emotion: Determining the promise of ultrathin slicing approaches and comparing human and automated coding methods in psychosis risk

Alterations in facial expressions of emotion are a hallmark of psychopathology and may be present before the onset of mental illness. Technological advances have spurred interest in examining alterations based on "thin slices" of behavior using automated approaches. However, questions remain. First, can alterations be detected in ultrathin slices of behavior? Second, how do automated approaches converge with human coding techniques? The present study examined ultrathin (i.e., 1-min) slices of video-recorded clinical interviews of 42 individuals at clinical high risk (CHR) for psychosis and 42 matched controls. Facial expressions of emotion (e.g., joy, anger) were examined using two automated facial analysis programs and coded by trained human raters (using the Expressive Emotional Behavior Coding System). Results showed that ultrathin (i.e., 1-min) slices of behavior were sufficient to reveal alterations in facial expressions of emotion, specifically blunted joy expressions in individuals at CHR (with supplementary analyses probing links with attenuated positive symptoms and functioning). Furthermore, both automated analysis programs converged in the ability to detect blunted joy expressions and were consistent with human coding at the level of both second-by-second and aggregate data. Finally, there were areas of divergence across approaches for other emotional expressions beyond joy. These data suggest that ultrathin slices of behavior can yield clues about emotional dysfunction. Further, automated approaches (which do not require lengthy training and coder time but do lend well to mobile assessment and computational modeling) show promise, but careful evaluation of convergence with human coding is needed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Application of the Rorschach Inkblot Test in the Study of Neural and Cognitive Aging

Abstract. The Rorschach Inkblot test has been adopted and adapted by many researchers to assess and predict different aspects of human experience and cognitive performance. The present review examines research that incorporates the Rorschach to evaluate neural and cognitive aging as well as decline in age-related disease. Specifically, differences in amygdala and cortical regions, as well as mirror neuron and asymmetrical hemisphere activity that correlate with specific responses to Rorschach stimuli are discussed in the context of typical changes in brain structure and function in the course of aging. In addition, the present review provides a proposed framework for expanding the use of the Rorschach to evaluate other domains of neural and cognitive function. The authors conclude that, despite a need for increased research, the Rorschach is a viable measure to evaluate certain aspects of cognitive function and decline throughout the lifespan.

Neuroanatomy of expressive suppression: The role of the insula

Expressive suppression is a response-focused regulatory strategy aimed at concealing the outward expression of emotion that is already underway. Expressive suppression requires the integration of interoception, proprioception, and social awareness to guide behavior in alignment with personal and interpersonal goals-all processes known to involve the insular cortex. Frontotemporal dementia (FTD) provides a useful patient model for studying the insula's role in socioemotional regulation. The insula is a key target of early atrophy in FTD, causing patients to lose the ability to represent the salience of internal and external conditions and to use these representations to guide behavior. We examined a sample of 59 patients with FTD, 52 patients with Alzheimer's disease (AD), and 38 neurologically healthy controls. Subjects viewed 2 disgust-eliciting films in the laboratory. During the first film, subjects were instructed to simply watch (emotional reactivity trial); during the second, they were instructed to hide their emotions (expressive suppression trial). Structural images from a subsample of participants (n = 42; 11 FTD patients, 11 AD patients, and 20 controls) were examined in conjunction with behavior. FreeSurfer was used to quantify regional gray matter volume in 41 empirically derived neural regions in both hemispheres. Of the 3 groups studied, FTD patients showed the least expressive suppression and had the smallest insula volumes, even after controlling for age, gender, and emotional reactivity. Among the brain regions examined, the insula was the only significant predictor of expressive suppression ability, with lower insula gray matter volume in both hemispheres predicting less expressive suppression. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Replicable brain signatures of emotional bias and memory based on diffusion kurtosis imaging of white matter tracts

Diffusion MRI (dMRI) is sensitive to anisotropic diffusion within bundles of nerve axons and can be used to make objective measurements of brain networks. Many brain disorders are now recognised as being caused by network dysfunction or are secondarily associated with changes in networks. There is therefore great potential in using dMRI measures that reflect network integrity as a future clinical tool to help manage these conditions. Here, we used dMRI to identify replicable, robust and objective markers that meaningfully reflect cognitive and emotional performance. Using diffusion kurtosis analysis and a battery of cognitive and emotional tests, we demonstrated strong relationships between white matter structure across networks of anatomically and functionally specific brain regions with both emotional bias and emotional memory performance in a large healthy cohort. When the connectivity of these regions was examined using diffusion tractography, the terminations of the identified tracts overlapped precisely with cortical loci relating to these domains, drawn from an independent spatial meta‐analysis of available functional neuroimaging literature. The association with emotional bias was then replicated using an independently acquired healthy cohort drawn from the Human Connectome Project. These results demonstrate that, even in healthy individuals, white matter dMRI structural features underpin important cognitive and emotional functions. Our robust cross‐correlation and replication supports the potential of structural brain biomarkers from diffusion kurtosis MRI to characterise early neurological changes and risk in individuals with a reduced threshold for cognitive dysfunction, with further testing required to demonstrate clinical utility.

Emotion recognition in objects in patients with neurological disease

OBJECTIVE

Considerable research indicates that individuals with dementia have deficits in the ability to recognize emotion in other people. The present study examined ability to detect emotional qualities of objects.

METHOD

Fifty-two patients with frontotemporal dementia (FTD), 20 patients with Alzheimer's disease (AD), 18 patients awaiting surgery for intractable epilepsy, and 159 healthy controls completed a newly developed test of ability to recognize emotional qualities of art (music and paintings), and pleasantness in simple sensory stimuli (tactile, olfactory, auditory), and to make aesthetic judgments (geometric shapes, room décor). A subset of participants also completed a test of ability to recognize emotions in other people.

RESULTS

Patients with FTD showed a marked deficit in ability to recognize the emotions conveyed in art, compared with both healthy individuals and patients with AD (relative to controls, deficits in patients with AD only approached significance). This deficit remained robust after controlling for FTD patients' ability to recognize pleasantness in simple sensory stimuli, make aesthetic judgments, identify odors, and identify emotions in other people. Neither FTD nor AD patients showed deficits in recognizing pleasant sensory stimuli or making aesthetic judgments. Exploratory analysis of patients with epilepsy revealed no deficits in any of these domains.

CONCLUSION

Patients with FTD (but not AD) showed a significant, specific deficit in ability to interpret emotional messages in art, echoing FTD-related deficits in recognizing emotions in other people. This finding adds to our understanding of the impact these diseases have on the lives of patients and their caregivers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Cortical Network of Emotion Regulation: Insights From Advanced EEG-fMRI Integration Analysis

The ability to perceive and regulate emotion is a key component of cognition that is often disrupted by disease. Current neuroimaging studies regarding emotion regulation have implicated a number of cortical regions and identified several EEG features of interest, including the late positive potential and frontal asymmetry. Unfortunately, currently applied methods generally lack in the resolution necessary to capture focal cortical activity and explore the causal interactions between brain regions. In this paper, electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) data were simultaneously recorded from 20 subjects undergoing emotion processing and regulation tasks. Cortical activity with high-spatiotemporal resolution and accuracy was reconstructed using a novel multimodal EEG/fMRI integration method. A detailed causal brain network associated with emotion processing and regulation was then identified, and the network changes that facilitate different emotion conditions were investigated. The cortical activity of the ventrolateral prefrontal (VLPFC) and posterior parietal cortices depicted conditionally-sensitive spike and wave patterns evidenced in inter-regional communication. The VLPFC was found to behave as a main network source, with conditionally-specific interactions supporting emotional shifts. The results provide unique insight into the cortical activity that supports emotional perception and regulation, the origins of known EEG phenomena, and the manner in which brain regions coordinate to affect behavior.

Stress and Illness: A Role for Specific Emotions

Research on stress and disease has often afforded an important role to emotion, typically conceptualized in broad categories (e.g., negative emotions), viewed as playing a causal role (e.g., anger contributing to pathophysiology of cardiovascular disease), and measured using self-report inventories. In this article, I argue for the value of evaluating specific emotions, considering bidirectional causal influences, and assessing actual emotional responding when considering the role that emotions play in the stress-disease relationship. In terms of specificity, specific emotions (e.g., anger, sadness, and embarrassment) can be linked with particular health outcomes (e.g., cardiovascular disease and musculoskeletal disease). In terms of bidirectionality, the influences of emotions on disease as well as the influences of disease on emotional functioning can be considered. In terms of assessing actual emotional responding, emotions can be studied in vivo under controlled conditions that allow behavioral, physiological, and subjective responses to be measured during different kinds of emotional functioning (e.g., responding to emotional stimuli, interacting with relationship partners, and downregulating emotional responses). With these considerations in mind, I review early theories and empirical studies in psychosomatic medicine that considered the role of specific emotions and emotion-related behaviors. Studies from our laboratory are presented that illustrate a) differences in patterns of autonomic nervous system responding associated with specific emotions, b) relationships between specific emotions and particular health outcomes in the context of social relationships, c) age as a moderator of the relationship between specific emotions and well-being, d) bidirectional influences (emotions influencing disease and disease influencing emotional functioning), and e) impact of changes in emotional functioning in individuals with neurodegenerative diseases on the health of familial caregivers.

Emotion regulation via visual avoidance: Insights from neurological patients

Visual avoidance of unpleasant stimuli (i.e., strategic positioning of eyes, head and torso away from an environmental stimulus) is a common attentional control behavior that may down-regulate emotion by reducing visual input. Despite its ubiquity, relatively little is known about how visual avoidance is affected by neurological diseases that impact neural circuits involved in emotional functioning. We examined visual avoidance in 56 behavioral variant frontotemporal dementia (bvFTD) patients, 43 Alzheimer's disease (AD) patients, and 34 healthy controls. Participants came to our laboratory and viewed an extremely disgusting film clip while visual avoidance was measured using behavioral coding of head, body, and eye position. Controlling for differences in cognitive functioning, bvFTD patients were less likely to engage in visual avoidance behaviors than both AD patients and healthy controls. Additional analyses revealed that diminished visual avoidance in this task was associated with lower levels of real-world emotion regulation but not with emotion reactivity as reported by the primary caregiver.

Skin Conduction Levels Differentiate Frontotemporal Dementia From Alzheimer's Disease

Patients with behavioral variant frontotemporal dementia (bvFTD) and Alzheimer's disease (AD) differ in basic emotional tone. Skin conduction levels (SCLs), a measure of sympathetic tone, may be a sensitive test for discriminating these two dementias early in their course. Previous research has shown differences in resting SCLs between patients with bvFTD and AD, but no study has evaluated the discriminability of SCLs during different environmental conditions. The authors compared bvFTD patients (N=8), AD patients (N=10), and healthy control subjects (N=9) on SCL measures pertaining to real-life vignettes or scenarios differing in valence and emotional intensity. The SCLs among the bvFTD patients were decreased across all conditions, whereas the SCLs among the AD patients were increased compared with control participants. On analysis, the SCLs in response to emotional stimuli differentiated bvFTD from AD with an area under the receiver operator characteristic curve of 95.3%. At a cutoff ≤0.77 μS, emotional vignettes distinguished bvFTD from AD with a sensitivity of 86% and a specificity of 96%. These preliminary results indicate the potential utility of SCLs for differentiating bvFTD from AD early in their course, regardless of environmental condition.

Greater Experience of Negative Non-Target Emotions by Patients with Neurodegenerative Diseases Is Related to Lower Emotional Well-Being in Caregivers

BACKGROUND

Behavioral symptoms in patients with neurodegenerative diseases can be particularly challenging for caregivers. Previously, we reported that patients with frontotemporal dementia (FTD) and Alzheimer's disease (AD) experienced emotions that were atypical or incongruent with a given situation (i.e., non-target emotions).

AIM

We tested the hypothesis that greater experience of non-target emotions by patients is associated with lower caregiver emotional well-being.

METHODS

178 patients with FTD, AD, or other neurodegenerative diseases and 35 healthy individuals watched 3 films designed to induce amusement, sadness, and disgust, and then reported their emotions during the films. Caregivers of the patients reported their own emotional well-being on the Medical Outcomes Study 36-item Short-Form Health Survey.

RESULTS

In response to the amusement and sadness (but not disgust) films, greater experience of non-target emotions by patients was related to lower caregiver emotional well-being. These effects were specific to patients' experience of negative non-target emotions (i.e., not found for positive non-target emotions or for negative or positive target emotions).

CONCLUSION

The findings reveal a previously unstudied patient behavior that is related to worse caregiver emotional well-being. Future research and clinical assessment may benefit from evaluating non-target emotions in patients.

Lower Visual Avoidance in Dementia Patients Is Associated with Greater Psychological Distress in Caregivers

Caring for a spouse with dementia can lead to increased health problems in caregivers. The present study examined whether patient deficits in visual avoidance, a common form of emotion regulation, are related to greater psychological distress in caregivers. Participants were 43 Alzheimer disease (AD) patients, 43 behavioral variant frontotemporal dementia (bvFTD) patients, and their spousal caregivers. Patient visual avoidance (e.g., gaze aversion) was measured using behavioral coding of head, body, and eye position while viewing a disgusting film. Caregiver psychological distress was measured using a standard self-report symptom inventory. Lower use of visual avoidance by patients was associated with greater psychological distress in their caregivers. This relationship was partially mediated by patient overall emotional functioning (as reported by caregivers), such that patients with less visual avoidance were seen as having worse emotional functioning, which in turn related to greater caregiver psychological distress. Dementia diagnosis moderated this effect, with diminished patient visual avoidance particularly detrimental to psychological distress of bvFTD caregivers. Findings suggest that the use of visual avoidance may serve as a marker of overall emotional functioning in patients and that preservation of this emotion regulatory behavior may help reduce the negative effects of caregiving.

'Just can't hide it': a behavioral and lesion study on emotional response modulation after right prefrontal damage

INTRODUCTION

Historically, emotion regulation problems have been reported as a common consequence of right prefrontal cortex (rPFC) damage. It has been proposed that the rPFC, particularly the rIFG, has a key role inhibiting prepotent reflexive actions, thus contributing to emotion regulation and self-regulation. This study is the first to directly explore this hypothesis, by testing whether damage to the rIFG compromises the voluntary modulation of emotional responses, and whether performance on inhibition tasks is associated with emotion regulation.

METHOD

10 individuals with unilateral right prefrontal damage and 15 matched healthy controls were compared on a well-known response modulation task. During the task participants had to amplify and suppress their facial emotional expressions, while watching film clips eliciting amusement. Measures of executive control, emotion regulation strategies usage and symptomatology were also collected.

RESULTS

As a group, individuals with rPFC damage presented a significantly reduced range of response modulation compared with controls. In addition, performance in the suppression task was associated with measures of cognitive inhibition and suppression usage. Interestingly, these effects were driven primarily by a subgroup of individuals with rPFC damage, all of whom also had damage to the right posterior insula, and who presented a marked impairment in suppressing facial emotional expressions.

The use of facial expressions for pain assessment purposes in dementia: a narrative review

Facial expressions convey reliable nonverbal signals about pain and thus are very useful for assessing pain in patients with limited communicative ability, such as patients with dementia. In this review, we present an overview of the available pain observation tools and how they make use of facial expressions. Utility and reliability of facial expressions to measure pain in dementia are discussed, together with the effect of dementia severity on these facial expressions. Next, we present how behavioral alterations may overlap with facial expressions of pain, and may even influence the extent to which pain is facially expressed. The main focus is on disinhibition, apathy and emotional changes. Finally, an overview of theoretical considerations and practical implications is presented for assessing pain using facial expressions in clinical settings.

Processing of Self versus Non-Self in Alzheimer's Disease

Despite considerable evidence for abnormalities of self-awareness in Alzheimer's disease (AD), the cognitive mechanisms of altered self-processing in AD have not been fully defined. Here we addressed this issue in a detailed analysis of self/non-self-processing in three patients with AD. We designed a novel neuropsychological battery comprising tests of tactile body schema coding, attribution of tactile events to self versus external agents, and memory for self- versus non-self-generated vocal information, administered in conjunction with a daily life measure of self/non-self-processing (the Interpersonal Reactivity Index). Three male AD patients (aged 54-68 years; one with a pathogenic mutation in the Presenilin 1 gene, one with a pathogenic mutation in the Amyloid Precursor Protein gene, and one with a CSF protein profile supporting underlying AD pathology) were studied in relation to a group of eight healthy older male individuals (aged 58-74 years). Compared to healthy controls, all patients had relatively intact tactile body schema processing. In contrast, all patients showed impaired memory for words previously presented using the patient's own voice whereas memory for words presented in other voices was less consistently affected. Two patients showed increased levels of emotional contagion and reduced perspective taking on the Interpersonal Reactivity Index. Our findings suggest that AD may be associated with deficient self/non-self differentiation over time despite a relatively intact body image: this profile of altered self-processing contrasts with the deficit of tactile body schema previously described in frontotemporal dementia associated with C9orf72 mutations. We present these findings as a preliminary rationale to direct future systematic study in larger patient cohorts.

Learning from Normal Aging: Preserved Emotional Functioning Facilitates Adaptation among Early Alzheimer's Disease Patients

Alzheimer's disease (AD) has been largely characterized by severe deterioration of cognitive functioning. Only recently has more attention been shifted to identifying the preserved capacity and functioning of AD patients. By reviewing the AD literature, we observe that despite the various cognitive impairment and deficits, early Alzheimer's patients perform certain types of automatic emotion regulation and display a positivity effect in emotion recognition and emotional memory. Moreover, we argue that, like their healthy aged peers, the optimization of such preserved emotion-based capacities helps early AD patients increase positive emotions, which may counteract the negative effects of the disease, thus maintaining their socio-emotional functioning. Finally, we discuss the emotion-based capacities strategies that AD patients may use to facilitate their adjustment to a life with Alzheimer's.

Emotion recognition in frontotemporal dementia and Alzheimer's disease: A new film-based assessment

Deficits in recognizing others' emotions are reported in many psychiatric and neurological disorders, including autism, schizophrenia, behavioral variant frontotemporal dementia (bvFTD) and Alzheimer's disease (AD). Most previous emotion recognition studies have required participants to identify emotional expressions in photographs. This type of assessment differs from real-world emotion recognition in important ways: Images are static rather than dynamic, include only 1 modality of emotional information (i.e., visual information), and are presented absent a social context. Additionally, existing emotion recognition batteries typically include multiple negative emotions, but only 1 positive emotion (i.e., happiness) and no self-conscious emotions (e.g., embarrassment). We present initial results using a new task for assessing emotion recognition that was developed to address these limitations. In this task, respondents view a series of short film clips and are asked to identify the main characters' emotions. The task assesses multiple negative, positive, and self-conscious emotions based on information that is multimodal, dynamic, and socially embedded. We evaluate this approach in a sample of patients with bvFTD, AD, and normal controls. Results indicate that patients with bvFTD have emotion recognition deficits in all 3 categories of emotion compared to the other groups. These deficits were especially pronounced for negative and self-conscious emotions. Emotion recognition in this sample of patients with AD was indistinguishable from controls. These findings underscore the utility of this approach to assessing emotion recognition and suggest that previous findings that recognition of positive emotion was preserved in dementia patients may have resulted from the limited sampling of positive emotion in traditional tests.

Damage to left frontal regulatory circuits produces greater positive emotional reactivity in frontotemporal dementia

Positive emotions foster social relationships and motivate thought and action. Dysregulation of positive emotion may give rise to debilitating clinical symptomatology such as mania, risk-taking, and disinhibition. Neuroanatomically, there is extensive evidence that the left hemisphere of the brain, and the left frontal lobe in particular, plays an important role in positive emotion generation. Although prior studies have found that left frontal injury decreases positive emotion, it is not clear whether selective damage to left frontal emotion regulatory systems can actually increase positive emotion. We measured happiness reactivity in 96 patients with frontotemporal dementia (FTD), a neurodegenerative disease that targets emotion-relevant neural systems and causes alterations in positive emotion (i.e., euphoria and jocularity), and in 34 healthy controls. Participants watched a film clip designed to elicit happiness and a comparison film clip designed to elicit sadness while their facial behavior, physiological reactivity, and self-reported emotional experience were monitored. Whole-brain voxel-based morphometry (VBM) analyses revealed that atrophy in predominantly left hemisphere fronto-striatal emotion regulation systems including left ventrolateral prefrontal cortex, orbitofrontal cortex, anterior insula, and striatum was associated with greater happiness facial behavior during the film (pFWE < .05). Atrophy in left anterior insula and bilateral frontopolar cortex was also associated with higher cardiovascular reactivity (i.e., heart rate and blood pressure) but not self-reported positive emotional experience during the happy film (p < .005, uncorrected). No regions emerged as being associated with greater sadness reactivity, which suggests that left-lateralized fronto-striatal atrophy is selectively associated with happiness dysregulation. Whereas previous models have proposed that left frontal injury decreases positive emotional responding, we argue that selective disruption of left hemisphere emotion regulating systems can impair the ability to suppress positive emotions such as happiness.

Emotion and aging: evidence from brain and behavior

Emotions play a central role in every human life from the moment we are born until we die. They prepare the body for action, highlight what should be noticed and remembered, and guide decisions and actions. As emotions are central to daily functioning, it is important to understand how aging affects perception, memory, experience, as well as regulation of emotions. The Frontiers research topic Emotion and Aging: Evidence from Brain and Behavior takes a step into uncovering emotional aging considering both brain and behavioral processes. The contributions featured in this issue adopt innovative theoretical perspectives and use novel methodological approaches to target a variety of topics that can be categorized into three overarching questions: How do cognition and emotion interact in aging in brain and behavior? What are behavioral and brain-related moderators of emotional aging? Does emotion-regulatory success as reflected in brain and behavior change with age? In this perspective paper we discuss theoretical innovation, methodological approach, and scientific advancement of the 13 papers in the context of the broader literature on emotional aging. We conclude by reflecting on topics untouched and future directions to take.

Emotional working memory and Alzheimer's disease

A number of recent studies have reported that working memory does not seem to show typical age-related deficits in healthy older adults when emotional information is involved. Differently, studies about the short-term ability to encode and actively manipulate emotional information in dementia of Alzheimer's type are few and have yielded mixed results. Here, we review behavioural and neuroimaging evidence that points to a complex interaction between emotion modulation and working memory in Alzheimer's. In fact, depending on the function involved, patients may or may not show an emotional benefit in their working memory performance. In addition, this benefit is not always clearly biased (e.g., towards negative or positive information). We interpret this complex pattern of results as a consequence of the interaction between multiple factors including the severity of Alzheimer's disease, the nature of affective stimuli, and type of working memory task.

Emotion regulation predicts marital satisfaction: more than a wives' tale

Emotion regulation is generally thought to be a critical ingredient for successful interpersonal relationships. Ironically, few studies have investigated the link between how well spouses regulate emotion and how satisfied they are with their marriages. We utilized data from a 13-year, 3-wave longitudinal study of middle-aged (40-50 years old) and older (60-70 years old) long-term married couples, focusing on the associations between downregulation of negative emotion (measured during discussions of an area of marital conflict at Wave 1) and marital satisfaction (measured at all 3 waves). Downregulation of negative emotion was assessed by determining how quickly spouses reduced signs of negative emotion (in emotional experience, emotional behavior, and physiological arousal) after negative emotion events. Data were analyzed using actor-partner interdependence modeling. Findings showed that (a) greater downregulation of wives' negative experience and behavior predicted greater marital satisfaction for wives and husbands concurrently and (b) greater downregulation of wives' negative behavior predicted increases in wives' marital satisfaction longitudinally. Wives' use of constructive communication (measured between Waves 1 and 2) mediated the longitudinal associations. These results show the benefits of wives' downregulation of negative emotion during conflict for marital satisfaction and point to wives' constructive communication as a mediating pathway.

On the selection of non-invasive methods based on speech analysis oriented to automatic Alzheimer disease diagnosis

The work presented here is part of a larger study to identify novel technologies and biomarkers for early Alzheimer disease (AD) detection and it focuses on evaluating the suitability of a new approach for early AD diagnosis by non-invasive methods. The purpose is to examine in a pilot study the potential of applying intelligent algorithms to speech features obtained from suspected patients in order to contribute to the improvement of diagnosis of AD and its degree of severity. In this sense, Artificial Neural Networks (ANN) have been used for the automatic classification of the two classes (AD and control subjects). Two human issues have been analyzed for feature selection: Spontaneous Speech and Emotional Response. Not only linear features but also non-linear ones, such as Fractal Dimension, have been explored. The approach is non invasive, low cost and without any side effects. Obtained experimental results were very satisfactory and promising for early diagnosis and classification of AD patients.

Language, executive function and social cognition in the diagnosis of frontotemporal dementia syndromes

Frontotemporal dementia (FTD) represents a spectrum of non-Alzheimer's degenerative conditions associated with focal atrophy of the frontal and/or temporal lobes. Frontal and temporal regions of the brain have been shown to be strongly involved in executive function, social cognition and language processing and, thus, deficits in these domains are frequently seen in patients with FTD or may even be hallmarks of a specific FTD subtype (i.e. relatively selective and progressive language impairment in primary progressive aphasia). In this review we have attempted to delineate how language, executive function, and social cognition may contribute to the diagnosis of FTD syndromes, namely the behavioural variant FTD as well as the language variants of FTD including the three subtypes of primary progressive aphasia (PPA): non-fluent/agrammatic, semantic and logopenic. This review also addresses the extent to which deficits in these cognitive areas contribute to the differential diagnosis of FTD versus Alzheimer's disease (AD). Finally, early clinical determinants of pathology are briefly discussed and contemporary challenges to the diagnosis of FTD are presented.

The behavioral variant of frontotemporal dementia: linking neuropathology to social cognition

The behavioral variant of frontotemporal dementia (bvFTD) is one of the most frequent neurodegenerative disorders with a presenile onset. It is characterized by a long phase of subclinical behavioral changes and social conduct disorders, associated with a progressive modification of personality. Recently, an international consortium of experts developed revised guidelines for its clinical diagnosis, which highlight the supportive role of biomarkers in the diagnostic process. According to new criteria, bvFTD can be classified in "possible" (requiring three of six specific clinical features), "probable" (in the presence of functional disability and typical neuroimaging features), and "with definite frontotemporal lobar degeneration" (requiring the presence of a known causal mutation or a histopathological confirmation). Familial aggregation is frequently reported in bvFTD and frontotemporal lobar degeneration in general, with an autosomal dominant transmission in about 10 % cases. The aim of this paper is to review and discuss recent advances in the knowledge of clinical, neuropsychological, and imaging features of bvFTD. We also briefly summarize the available genetic information about the frontotemporal lobar degeneration spectrum.

Abnormal network connectivity in frontotemporal dementia: evidence for prefrontal isolation

INTRODUCTION

Degraded social function, disinhibition, and stereotypy are defining characteristics of frontotemporal dementia (FTD), manifesting in both the behavioral variant of frontotemporal dementia (bvFTD) and semantic dementia (SD) subtypes. Recent neuroimaging research also associates FTD with alterations in the brain's intrinsic connectivity networks. The present study explored the relationship between neural network connectivity and specific behavioral symptoms in FTD.

METHODS

Resting-state functional magnetic resonance imaging was employed to investigate neural network changes in bvFTD and SD. We used independent components analysis (ICA) to examine changes in frontolimbic network connectivity, as well as several metrics of local network strength, such as the fractional amplitude of low-frequency fluctuations, regional homogeneity, and seed-based functional connectivity. For each analysis, we compared each FTD subgroup to healthy controls, characterizing general and subtype-unique network changes. The relationship between abnormal connectivity in FTD and behavior disturbances was explored.

RESULTS

Across multiple analytic approaches, both bvFTD and SD were associated with disrupted frontolimbic connectivity and elevated local connectivity within the prefrontal cortex. Even after controlling for structural atrophy, prefrontal hyperconnectivity was robustly associated with apathy scores. Frontolimbic disconnection was associated with lower disinhibition scores, suggesting that abnormal frontolimbic connectivity contributes to positive symptoms in dementia. Unique to bvFTD, stereotypy was associated with elevated default network connectivity in the right angular gyrus. The behavioral variant was also associated with marginally higher apathy scores and a more diffuse pattern of prefrontal hyperconnectivity than SD.

CONCLUSIONS

The present findings support a theory of FTD as a disorder of frontolimbic disconnection leading to unconstrained prefrontal connectivity. Prefrontal hyperconnectivity may represent a compensatory response to the absence of affective feedback during the planning and execution of behavior. Increased reliance upon prefrontal processes in isolation from subcortical structures appears to be maladaptive and may drive behavioral withdrawal that is commonly observed in later phases of neurodegeneration.

Meditation and the startle response: a case study

The effects of two kinds of meditation (open presence and focused) on the facial and physiological aspects of the defensive response to an aversive startle stimulus were studied in a Buddhist monk with approximately 40 years of meditation experience. The participant was exposed to a 115-db, 100-ms acoustic startle stimulus under the 2 meditation conditions, a distraction condition (to control for cognitive and attentional load) and an unanticipated condition (startle presented without warning or instruction). A completely counterbalanced 24-trial, single-subject design was used, with each condition repeated 6 times. Most aspects of the participant's responses in the unanticipated condition did not differ from those of a comparison group of 12 age-matched male controls. Both kinds of meditation produced physiological and facial responses to the startle that were smaller than in the distraction condition. Within meditation conditions, open presence meditation produced smaller physiological and facial responses than focused meditation. These results from a single highly expert meditator indicate that these 2 kinds of meditation can differentially alter the magnitude of a primitive defensive response.

Personality and social cognition in neurodegenerative disease

PURPOSE OF REVIEW

Neurodegenerative diseases often cause focal damage to brain structures mediating social cognition and personality, resulting in altered interpersonal communication and behavior. We review recent research describing this phenomenon in various aspects of social cognition.

RECENT FINDINGS

Corresponding to their pervasive socioemotional deficits, patients with frontotemporal dementia perform poorly on laboratory-based tasks including recognizing emotions, attending to salient information that guides social behavior, representing social knowledge, comprehending others' mental states, and maintaining insight to their own difficulties. Together with poor executive and regulation mechanisms, these social cognition deficits ultimately impact behavior. Patients with logopenic and nonfluent primary progressive aphasia have some deficits recognizing emotional prosody, whereas those with the semantic variant show more widespread deficits in social comprehension. Although Alzheimer's disease patients perform poorly on some social cognition tasks, this typically reflects general cognitive impairment, and their real-life social functioning is less affected than in diseases targeting frontotemporal structures. Studies in motor diseases such as Parkinson's suggest some degradation of emotion recognition and social comprehension, which should be investigated further.

SUMMARY

We summarize recent findings concerning perception and evaluation of socioemotional information, social knowledge storage and access, advanced information processing mechanisms, and behavioral response selection and regulation across various neurodegenerative diseases.

Comprehension of insincere communication in neurodegenerative disease: lies, sarcasm, and theory of mind

Comprehension of insincere communication is an important aspect of social cognition requiring visual perspective taking, emotion reading, and understanding others' thoughts, opinions, and intentions. Someone who is lying intends to hide their insincerity from the listener, while a sarcastic speaker wants the listener to recognize they are speaking insincerely. We investigated whether face-to-face testing of comprehending insincere communication would effectively discriminate among neurodegenerative disease patients with different patterns of real-life social deficits. We examined ability to comprehend lies and sarcasm from a third-person perspective, using contextual cues, in 102 patients with one of four neurodegenerative diseases (behavioral variant frontotemporal dementia [bvFTD], Alzheimer's disease [AD], progressive supranuclear palsy [PSP], and vascular cognitive impairment) and 77 healthy older adults (normal controls--NCs). Participants answered questions about videos depicting social interactions involving deceptive, sarcastic, or sincere speech using The Awareness of Social Inference Test. All subjects equally understood sincere remarks, but bvFTD patients displayed impaired comprehension of lies and sarcasm compared with NCs. In other groups, impairment was not disease-specific but was proportionate to general cognitive impairment. Analysis of the task components revealed that only bvFTD patients were impaired on perspective taking and emotion reading elements and that both bvFTD and PSP patients had impaired ability to represent others' opinions and intentions (i.e., theory of mind). Test performance correlated with informants' ratings of subjects' empathy, perspective taking and neuropsychiatric symptoms in everyday life. Comprehending insincere communication is complex and requires multiple cognitive and emotional processes vulnerable across neurodegenerative diseases. However, bvFTD patients show uniquely focal and severe impairments at every level of theory of mind and emotion reading, leading to an inability to identify obvious examples of deception and sarcasm. This is consistent with studies suggesting this disease targets a specific neural network necessary for perceiving social salience and predicting negative social outcomes.

Alexithymia in neurodegenerative disease

We investigated alexithymia, a deficit in the ability to identify and describe one's emotions, in a sample that included patients with neurodegenerative disease and healthy controls. In addition, we investigated the relationship that alexithymia has with behavioral disturbance and with regional gray matter volumes. Alexithymia was examined with the Toronto Alexithymia Scale-20, behavioral disturbance was assessed with the Neuropsychiatric Inventory, and regional gray matter volumes were obtained from structural magnetic resonance images. Group analyses revealed higher levels of alexithymia in patients than controls. Alexithymia scores were positively correlated with behavioral disturbance (apathy and informant distress, in particular) and negatively correlated with the gray matter volume of the right pregenual anterior cingulate cortex, a region of the brain that is thought to play an important role in self and emotion processing.

Executive functions and the down-regulation and up-regulation of emotion

This study examined the relationship between individual differences in executive functions (EF; assessed by measures of working memory, Stroop, trail making, and verbal fluency) and ability to down-regulate and up-regulate responses to emotionally evocative film clips. To ensure a wide range of EF, 48 participants with diverse neurodegenerative disorders and 21 older neurologically normal ageing participants were included. Participants were exposed to three different movie clips that were designed to elicit a mix of disgust and amusement. While watching the films they were either instructed to watch, down-regulate, and up-regulate their visible emotional responses. Heart rate and facial behaviours were monitored throughout. Emotion regulatory ability was operationalised as changes in heart rate and facial behaviour in the down- and up-regulation conditions, controlling for responses in the watch condition. Results indicated that higher verbal fluency scores were related to greater ability to regulate emotion in both the down-regulation and up-regulation conditions. This finding remained significant even after controlling for age and general cognitive functioning. No relationships were found between emotion regulation and the other EF measures. We believe these results derive from differences among EF measures, with verbal-fluency performance best capturing the complex sequence of controlled planning, activation, and monitoring required for successful emotion regulation. These findings contribute to our understanding of emotion-cognition interaction, suggesting a link between emotion-regulatory abilities and individual differences in complex executive functions.

Effects of aging on experimentally instructed detached reappraisal, positive reappraisal, and emotional behavior suppression

Emotion regulation includes multiple strategies that rely on different underlying abilities and that may be affected differently by aging. We assessed young, middle-aged, and older adults' ability to implement 3 emotion regulation strategies (detached reappraisal, positive reappraisal, and behavior suppression) in a laboratory setting, using standardized emotional stimuli and a multimethod approach to assessing regulation success. Results revealed age-related decline in ability to implement detached reappraisal, enhancement of ability to implement positive reappraisal, and maintenance of ability to implement behavior suppression. We discuss these findings in terms of their implications for emotion theory and for promoting successful aging.