All's Bad That Ends Bad: There Is a Peak-End Memory Bias in Anxiety

A review of the peak-end rule in mental health contexts

The peak-end rule, a memory heuristic in which the most emotionally salient part of an experience (i.e., peak) and conclusion of an experience (i.e., end) are weighted more heavily in summary evaluations, has been understudied in mental health contexts. The recent growth of intensive longitudinal methods has provided new opportunities for examining the peak-end rule in the retrospective recall of mental health symptoms, including measures often used in measurement-based care initiatives. Additionally, principles of the peak-end rule have significant potential to be applied to exposure-based therapy procedures. Additional research is needed to better understand the contexts in which, and persons for whom, the peak-end rule presents a greater risk of bias, to ultimately improve assessment strategies and clinical care.

Psychological Status as an Effect Modifier of the Association Between Allergy Symptoms and Allergy Testing

OBJECTIVE

Patient-reported outcome measures, while valuable, may not correlate with diagnostic test results. To better understand this potential discrepancy, our objective was to determine whether psychological health is an effect modifier of the association between patient-reported allergy outcome scores and allergy test results.

STUDY DESIGN

Prospective outcomes study.

SETTING

Tertiary care hospital and community-based clinic.

METHODS

This study included 600 patients at least 18 years of age who presented for symptoms related to allergic rhinitis and completed the related sinonasal outcome test (SNOT), which includes validated nasal, allergy, and psychological domains. Stratified analyses of odds ratios and Spearman correlation coefficients were utilized to assess for effect modification by psychological status.

RESULTS

Worse patient-reported allergic rhinitis symptoms were significantly associated with positive allergy test results (odds ratio [OR] 1.69, 95% confidence interval [CI] 1.22-2.34, P = .002) in patients with better psychological health. In contrast, there was no association in patients with worse psychological health (OR 1.06, 95% CI 0.36-3.10, P = .92). These findings were corroborated by assessments of correlation: allergy domain scores were positively correlated with allergy testing scores (Spearman rho 0.18, 95% CI 0.10-0.25, P < .001) in patients with better psychological health, while there was no correlation in patients with worse psychological health (-0.02, 95% CI -0.16-0.12, P = .77).

CONCLUSIONS

Psychological status was an effect modifier of the association between allergy domain and allergy testing data. When assessing the relationship between subjective measures, such as sinonasal validated instruments, and objective measures, such as allergy test results, accounting for effect modifiers such as psychological state can provide clinical and research-related insights.

Placebo Effects Are Small on Average in the 7.5% CO2 Inhalational Model of Generalized Anxiety

BACKGROUND

Anxiety disorders are highly prevalent and socio-economically costly. Novel pharmacological treatments for these disorders are needed because many patients do not respond to current agents or experience unwanted side effects. However, a barrier to treatment development is the variable and large placebo response rate seen in trials of novel anxiolytics. Despite this, the mechanisms that drive placebo responses in anxiety disorders have been little investigated, possibly due to low availability of convenient experimental paradigms. We aimed to develop and test a novel protocol for inducing placebo anxiolysis in the 7.5% CO2 inhalational model of generalized anxiety in healthy volunteers.

METHODS

Following a baseline 20-minute CO2 challenge, 32 healthy volunteers were administered a placebo intranasal spray labelled as either the anxiolytic "lorazepam" or "saline." Following this, participants surreptitiously underwent a 20-minute inhalation of normal air. Post-conditioning, a second dose of the placebo was administered, after which participants completed another CO2 challenge.

RESULTS

Participants administered sham "lorazepam" reported significant positive expectations of reduced anxiety (P = .001), but there was no group-level placebo effect on anxiety following CO2 challenge post-conditioning (Ps > .350). Surprisingly, we found many participants exhibited unexpected worsening of anxiety, despite positive expectations.

CONCLUSIONS

Contrary to our hypothesis, our novel paradigm did not induce a placebo response, on average. It is possible that effects of 7.5% CO2 inhalation on prefrontal cortex function or behavior in line with a Bayesian predictive coding framework attenuated the effect of expectations on subsequent placebo response. Future studies are needed to explore these possibilities.

Acute Stress Disorder among 2022 Ukrainian war refugees: a cross-sectional study

Introduction

Fleeing from war can be terrifying and result in Acute Stress Disorder (ASD), a mental health condition that can occur in the first month after a traumatic event. The study aimed to identify the prevalence of ASD among Ukrainian refugees and identify its risk factors to create a profile of the most vulnerable refugees.

Methods

This cross-sectional study of 637 Ukrainian war-displaced persons and refugees in 2022 used the Acute Stress Disorder Scale.

Results

The prevalence of ASD among participants was high (93.5%). Several factors increasing the risk of developing ASD in the sample were identified, e.g., witnessing Russian attacks (OR 2.92, 95% CI 1.26-6.78), insufficient financial resources (OR 3.56, 95% CI 1.61-7.91), and feeling of loneliness in the host country (OR 3.07, 95% CI 1.58-8.69). Pre-existing depression and the death of a close person, among others, were found to significantly (p < 0.05) exacerbate the ASD symptoms. At the same time, neither age, the distance traveled, time spent on fleeing the country, nor the type of companionship during refuge (escaping alone, with children, pets or the older adults) correlate with the severity of symptoms.

Conclusion

The study shows extreme levels of trauma among Ukrainian war refugees and displaced persons. Knowledge regarding ASD vulnerabilities in the present conflict may facilitate prompt and adequate psychological help. Since ASD can be an antecedent of PTSD and several autoimmune disorders, these results may also serve as a predictor of future challenges for Ukrainian society.

Past Adversity Influencing Now (PAIN): perspectives on the impact of temporal language on the persistence of pain

Persistent pain is a significant healthcare issue, often unresponsive to traditional treatments. We argue for incorporating non-biomedical perspectives in understanding pain, promoting more comprehensive solutions. This article explores how language, specifically time-related terms, may affect the persistence (stickiness) of pain. We delve into how language influences one's experience of the world, especially in understanding pain through spatial metaphors. Notably, time perceptions differ across languages and cultures and there is no absolute construct of temporal pain experience. In English, time is viewed linearly as past, present, and future. We introduce a framework called Past Adversity Influencing Now (PAIN) which includes various temporal phases of pain; Past Perfect, Past Imperfect, Present, Future Imperfect, and Future Perfect. We suggest that past negative memories (emotional memory images) can "trap" individuals in a "sticky" pain state. We speculate that the process of diagnosing pain as "chronic" may solidify this "stickiness", drawing from the ancient Greek idea of "logos", where pain communicates a message across time and space needing recognition. Our PAIN framework encourages examining pain through a temporal lens, guiding individuals towards a more positive future.

Numeracy, gist, literal thinking and the value of nothing in decision making

The onus on the average person is greater than ever before to make sense of large amounts of readily accessible quantitative information, but the ability and confidence to do so are frequently lacking. Many people lack practical mathematical skills that are essential for evaluating risks, probabilities and numerical outcomes such as survival rates for medical treatments, income from retirement savings plans or monetary damages in civil trials. In this Review, we integrate research on objective and subjective numeracy, focusing on cognitive and metacognitive factors that distort human perceptions and foment systematic biases in judgement and decision making. Paradoxically, an important implication of this research is that a literal focus on objective numbers and mechanical number crunching is misguided. Numbers can be a matter of life and death but a person who uses rote strategies (verbatim representations) cannot take advantage of the information contained in the numbers because 'rote' strategies are, by definition, processing without meaning. Verbatim representations (verbatim is only surface form, not meaning) treat numbers as data as opposed to information. We highlight a contrasting approach of gist extraction: organizing numbers meaningfully, interpreting them qualitatively and making meaningful inferences about them. Efforts to improve numerical cognition and its practical applications can benefit from emphasizing the qualitative meaning of numbers in context - the gist - building on the strengths of humans as intuitive mathematicians. Thus, we conclude by reviewing evidence that gist training facilitates transfer to new contexts and, because it is more durable, longer-lasting improvements in decision making.

Adding a nonpainful end to reduce pain recollection of Pap smear screening: a randomized controlled trial

ABSTRACT

The pain experienced during Pap tests is a crucial gap in reducing cervical cancer burden. This study sought to investigate whether adding a nonpainful step at the end of Pap tests helps women recall less pain. We conducted a randomized controlled trial on women aged 30 to 70 years at a cervical cancer screening center. A nonpainful step was added at the end of Pap test in the modified Pap group. The outcomes included recalled pain after Pap smear screening, real-time pain, and 1-year willingness to receive further Pap tests. Among 266 subjects in the intention-to-treat analysis, the modified Pap group (n = 133) experienced lower 5-minute recalled pain than the traditional Pap group on a 1 to 5 numeric scale (mean [SD], 1.50 [0.77] vs 2.02 [1.12]; P < 0.001) and a 0 to 10 visual analog scale (2.12 [1.79] vs 3.12 [2.23]; P < 0.001). In exploratory subgroup analyses, the association between the modified Pap test and reduced 5-minute recalled pain was not affected by predicted pain, demographic, or socioeconomic characteristics, but it was more apparent in postmenopausal women. Consistently, the modified Pap test attenuated 1-year recalled pain on both pain scales. Furthermore, the modified Pap test increased 1-year willingness grade to receive further Pap tests (adjusted β [SE], 2.11 [0.27]; P < 0.001). In conclusion, adding a nonpainful step at the end of Pap smear screening reduces on-site and long-term recalled pain and strengthens willingness to undergo subsequent Pap tests regularly. The modified Pap test contributes to cervical cancer screening participation.

Peak-end bias in retrospective recall of depressive symptoms on the PHQ-9

Mental health care is built around patient recall and report of clinical symptoms. However, memories of events and experiences rely on cognitive heuristics that influence our recall. The peak-end bias, which refers to the tendency for the most intense and proximate aspects of an experience to disproportionately influence our memory, has been understudied in the context of mental health symptoms and may unduly influence self-reported symptoms, even in the context of standardized assessments. To determine whether the peak-end bias applies to the report of depressive symptoms on the standardized Patient Health Questionnaire-9 (PHQ-9) assessment, we compared two scores from daily mood assessments collected over a 2-week period from 4,322 medical interns (56% women; 60% non-Hispanic White). The peak-end-mood score, which averaged the single lowest and most recent mood scores over 2 weeks had a significantly stronger correlation with the PHQ-9 than the mean-mood score, which averaged all mood scores during the 2 weeks. Likelihood ratio tests and fit statistics provided further support that the peak-end-mood score was a significantly better predictor of depression than the mean-mood score. Results were consistent when limiting the sample to those with mild-to-severe depressive symptoms, and when only examining the two primary mood items as the dependent variable. These findings provide evidence for a modest peak-end recall bias for mood and depressive symptoms. There may be benefits to implementing intermittent assessment strategies to support clinical decision-making. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Automatic facial coding predicts self-report of emotion, advertisement and brand effects elicited by video commercials

Introduction

Consumers' emotional responses are the prime target for marketing commercials. Facial expressions provide information about a person's emotional state and technological advances have enabled machines to automatically decode them.

Method

With automatic facial coding we investigated the relationships between facial movements (i.e., action unit activity) and self-report of commercials advertisement emotion, advertisement and brand effects. Therefore, we recorded and analyzed the facial responses of 219 participants while they watched a broad array of video commercials.

Results

Facial expressions significantly predicted self-report of emotion as well as advertisement and brand effects. Interestingly, facial expressions had incremental value beyond self-report of emotion in the prediction of advertisement and brand effects. Hence, automatic facial coding appears to be useful as a non-verbal quantification of advertisement effects beyond self-report.

Discussion

This is the first study to measure a broad spectrum of automatically scored facial responses to video commercials. Automatic facial coding is a promising non-invasive and non-verbal method to measure emotional responses in marketing.

Time is a great healer: Peak-end memory bias in anxiety - Induced by threat of shock

Recently, we demonstrated that the peak-end memory bias, which is well established in the context of pain, can also be observed in anxiety: Retrospective evaluations of a frightening experience are worse when peak anxiety is experienced at the end of an episode. Here, we set out to conceptually replicate and extend this finding with rigorous experimental control in a threat of shock paradigm. We induced two intensity levels of anxiety by presenting visual cues that indicated different strengths of electric stimuli. Each of the 59 participants went through one of two conditions that only differed in the order of moderate and high threat phases. As a manipulation check, orbicularis-EMG to auditory startle probes, electrodermal activity, and state anxiety confirmed the effects of the specific threat exposure. Critically, after some time had passed, participants for whom exposure had ended with high threat reported more anxiety for the entire episode than those for whom it ended with moderate threat. Moreover, they ranked their experience as more aversive when compared to other unpleasant everyday experiences. This study overcomes several previous limitations and speaks to the generalizability of the peak-end bias. Most notably, the findings bear implications for exposure therapy in clinical anxiety.

Sociodemographic and Clinical Characteristics Associated With Worst Pain Intensity Among Cancer Patients

AIMS

Patients with cancer have pain due to their cancer, the cancer treatment and other causes, and the pain intensity varies considerably between individuals. Additional research is needed to understand the factors associated with worst pain intensity. Our study aim was to determine the association between worst pain intensity and sociodemographics and cancerspecific factors among patients with cancer.

DESIGN

A total of 1,280 patients with cancer recruited from multiple cancer centers over 25 years in the United States were asked to complete a questionnaire that collected respondents' demographic, chronic pain, and cancer-specific information.

SETTINGS

Worst, least, and current pain intensities were captured using a modified McGill Pain Questionnaire (pain intensity measured on 0-10 scale). A generalized linear regression analysis was utilized to assess the associations between significant bivariate predictors and worst pain intensity scores.Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (β = 0.6859), previous toothache pain (β = 0.0960), headache pain (β = 0.0549), and stomachache pain (β = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain.

CONCLUSIONS

Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (β = 0.6859), previous toothache pain (β = 0.0960), headache pain (β = 0.0549), and stomachache pain (β = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain. Findings identified being Hispanic and having previous severe toothache, stomachache, and headache pain as significant predictors of worst pain intensity among patients with cancer. After controlling for selected covariates, we did not note statistical differences in worst pain during a 25-year period. Therefore,studies focused on improving the management of pain among patients with cancer should target interventions for those with Hispanic heritage and those with past history of severe common pain.

The Hedonics of Debt

Psychologists and economists often discuss the “pain” of paying for our purchases. Four experiments examine how people evaluate prospective debt payments, analyzing how different features of a loan (down payment, final payment, duration, monthly payments) affect willingness to accept the loan. Akin to previous findings on physical pain, participants exhibited duration neglect and overweighted final moments. However, participants also focused heavily on the monthly or average payment (unlike in retrospective studies of physical pain where only peak-end moments seem to count). In Experiment 2, participants’ willingness to accept the loan was not significantly diminished by making it more expensive through keeping the same monthly payment but extending the length of the loan by 40% (evincing duration neglect). Further, in Experiments 3 and 4, we show that participants increased their willingness to buy if loans were made longer and more expensive by adding smaller, less “painful” payments to the end.

Dealing With the COVID-19 Infodemic: Distress by Information, Information Avoidance, and Compliance With Preventive Measures

In the ongoing coronavirus disease 2019 (COVID-19) pandemic, media reports have caused anxiety and distress in many. In some individuals, feeling distressed by information may lead to avoidance of information, which has been shown to undermine compliance with preventive health behaviors in many health domains (e.g., cancer screenings). We set out to examine whether feeling distressed by information predicts higher avoidance of information about COVID-19 (avoidance hypothesis), and whether this, in turn, predicts worse compliance with measures intended to prevent the spread of COVID-19 (compliance hypothesis). Thus, we conducted an online survey with a convenience sample (N = 1,059, 79.4% female) and assessed distress by information, information avoidance, and compliance with preventive measures. Furthermore, we inquired about participants' information seeking behavior and media usage, their trust in information sources, and level of eHealth literacy, as well as generalized anxiety. We conducted multiple linear regression analyses to predict distress by information, information avoidance, and compliance with preventive measures. Overall, distress by information was associated with better compliance. However, distress was also linked with an increased tendency to avoid information (avoidance hypothesis), and this reduced compliance with preventive measures (compliance hypothesis). Thus, distress may generally induce adaptive behavior in support of crisis management, unless individuals respond to it by avoiding information. These findings provide insights into the consequences of distress by information and avoidance of information during a global health crisis. These results underscore that avoiding information is a maladaptive response to distress by information, which may ultimately interfere with effective crisis management. Consequently, we emphasize the need to develop measures to counteract information avoidance.

Examination of emotional contagion and social anxiety using novel video stimuli

BACKGROUND AND OBJECTIVES

Socially anxious individuals often exhibit signs of anxiety that might elicit discomfort in others and negatively influence their interactions, due in part to emotional contagion. However, there is limited research examining the phenomenon of emotional contagion in social anxiety, which is the topic of the current study.

DESIGN AND METHODS

An experimental design was used in which undergraduate psychology students (N = 128) were assigned to either an experimental condition (watching a video of a socially anxious presenter) or a control condition (watching a video of a nonanxious presenter). Various measures were administered to assess social anxiety, emotional contagion, state anxiety, and related constructs.

RESULTS

After controlling for baseline anxiety levels, participants in the experimental condition reported significantly higher levels of anxiety during and immediately after watching the video compared to individuals in the control condition (multivariate analysis of covariance, analysis of variance). Similar results were found across both conditions in participants with higher levels of trait social anxiety and higher public speaking anxiety (moderated regression analyses).

CONCLUSIONS

The findings suggest that social anxiety may be emotionally contagious, and provides insight into the role that emotional contagion may play in the association between social anxiety and interpersonal functioning.

Effect of the trajectory of exertional breathlessness on symptom recall and anticipation: A randomized controlled trial

Background

Breathlessness is a major cause of physical limitation. Recalled breathlessness intensity may differ from experienced intensity and be influenced by the intensity trajectory including the ‘peak-end rule’. The primary aim was to test if adding two minutes of low intensity exercise at the end of an exercise test would change the recalled breathlessness. Secondary aims included to analyse the impact of the peak and end exertional breathlessness intensity on breathlessness recall.

Methods

Randomized controlled trial of 92 adults referred for exercise testing who were randomized (1:1), at test end, to 2 minutes of additional low intensity exercise (intervention; n = 47) or stopping at peak exertion (control; n = 45). Experienced breathlessness during the test and recalled intensity (30 min after the test) was assessed using the Borg CR10 scale.

Results

Participants were aged a mean 59 years; 61% men; 79% reported a mMRC ≥1. There was no between-group difference in recalled breathlessness intensity, 5.51 ([95% CI] 5.00 to 6.01) vs. 5.73 (5.27 to 6.20; p = 0.52) in controls, even though the intervention group had a significantly lower end breathlessness (mean difference 0.96; 0.24 to 1.67; p = 0.009). Recalled exertional breathlessness was most strongly related to peak breathlessness (r² = 0.43). When analyzed together, end breathlessness did not add any explanatory value above that of peak breathlessness.

Conclusion

Adding an episode of two minutes of lower exercise and breathlessness intensity at the end of an exercise test did not affect symptom recall, which was most strongly related to peak breathlessness intensity.

Trial registration

ClinicalTrials.gov (NCT03468205).

Social comparison modulates coping with fear in virtual environments

Social comparison can guide adaptive behavior in fear-related situations. The aim of this study was to investigate the effects of social comparison standards on acute anxiety levels and phobic symptoms. The sample comprised 159 individuals (M_age = 23.4) with self-reported fear of flying (22.6 %) or fear of heights (77.4 %) who were randomly assigned to an upward assimilation (UA) manipulation, a downward assimilation (DA) manipulation, or a control condition (no manipulation of social comparison) and entered a fear-related scenario in virtual reality (i.e., flying in an airplane or walking in a tall building, respectively). Results revealed that individuals in the UA condition reported significantly attenuated increases in anxiety levels from pre-exposure to both during- and post-exposure relative to the control condition. The DA condition did not significantly differ from either condition regarding increases in acute anxiety levels from pre-exposure to either during or post-exposure. At post-assessment, participants in the UA condition also reported fewer phobic symptoms compared to both the DA and the control condition. Our results suggest that social comparison can indeed modulate coping with fearful situations. Future research needs to investigate the underlying processes of social comparison and the extent to which social comparison can facilitate treatment of anxiety disorders.