The Cognition of Depression: Attentional Control, Cognitive Biases and Emotional Regulation

Transcription

1 The Cognition of Depression: Attentional Control, Cognitive Biases and Emotional Regulation Word count: 15,587 Dirix Andreas Supervisors: Prof. Dr. Rudi De Raedt, Alvaro Sanchez A dissertation submitted to Ghent University in partial fulfilment of the requirements for the degree of Master of Science in Psychology: Specialization Clicinal Psychology Academic year:

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3 2 Acknowledgements First I would like to thank my supervisor, Alvaro Sanchez. The time and effort you put in helping me discover the world of academic research, combined with your continuous feedback, support and motivation helped me to take my master thesis to a higher level. Furthermore I would like to thank my promotor, Professor De Raedt for your constructive critique and suggestions on my work. I would like to end with thanking my family, girlfriend and friends for both their feedback and their moral support during the time I spent working on this master thesis.

4 3 Index Acknowledgements... 2 Index... 3 Abstract... 5 Samenvatting... 6 Introduction... 7 Depression: definition of the problematic and its consequences... 7 Cognitive schemas and cognitive biases in depression... 9 Attention bias Attentional control processes in depression: Mechanisms underlying attentional bias Attentional control The mechanisms of emotional regulation in depression Emotional regulation Current study Method Sample Materials Questionnaires Eye-tracking-system Tasks Mixed antisassacade paradigm Attentional disengagement task Emotional regulation task State Rumination Procedure Analytic plan Results Sample Characteristics Correlations between variables Proposed models Inhibition from emotional information Reappraisal ability Negative emotions Inhibition from emotional information Reappraisal ability Negative emotions State rumination Discussion General Discussion... 48

5 4 Theoretical Implications Limitations and recommendations for future research Conclusion References... 52

6 5 Abstract This study combines several eye-tracking experiments to test the prediction that cognitive control capabilities influence the adaptive versus maladaptive usage of reappraisal and rumination through underlying cognitive biases in depression. The results partially show an involvement of general attentional control functions in cognitive biases. Furthermore the results are in line with previous studies, indicating an association between cognitive control capabilities and emotional regulation tendencies. Finally the results highlight the importance of individual differences in attentional control abilities to predict the capacity to use adaptive versus maladaptive emotion regulation strategies. The results are discussed in detail, as well as theoretical implications and recommendations for future research.

7 6 Samenvatting Deze studie combineert diverse eye-tracking experimenten teneinde de voorspelling te testen dat cognitieve controle van invloed is op het adaptief gebruik van tot herinterpreteren en piekeren via onderliggende cognitieve biases in depressie. De resultaten tonen een gedeeltelijke impact van de algemene cognitieve controle op cognitieve bias. De resultaten zijn in overeenstemming met eerder onderzoek, die een verband aantonen tussen cognitieve controle en de mogelijkheid tot emotieregulatie. Tot slot onderlijnen de resultaten het belang van de individuele verschillen in cognitieve controle om de bekwaamheid te voorspellen in adaptieve versus niet-adaptieve emotieregulatie strategieën. De resultaten worden gedetailleerd besproken, net als de theoretische implicaties en aanbevelingen voor toekomstig onderzoek.

8 7 Introduction Depression: definition of the problematic and its consequences With a lifetime prevalence ranging between 15 and 30%, major depressive disorder (MDD) is one of the most common psychiatric disorders (Kessler et al., 2005). Major depressive disorder involves changes regarding affect, cognition, motivation, behavior and neuronal functions. These changes are observed in at least 5 of the following symptoms: 1) frequent depressed mood, 2) diminished interest or pleasure, 3) significant weight loss or gain, 4) insomnia or hypersomnia, 5) psychomotor agitation or retardation, 6) fatigue or loss of energy, 7) feelings of worthlessness or excessive quilt, 8) diminished ability to think or concentrate, or indecisiveness, 9) recurrent thoughts of death or suicide. The specific composition of these symptoms within an individual causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Major depressive disorder is characterized by episodes lasting at least 2 weeks but can last considerably longer. Finally, there are several exclusion criteria such as the existence of a medical-condition-based explanation, a (recent) significant loss, substance abuse, a previous manic or hypomanic episode or a better explanation of the symptoms by another psychological disorder (schizoaffective, delusional, )(APA, 2013). A wide range of therapeutic interventions such as cognitive behavioral therapy (CBT) have been shown efficacious for treating depression. CBT is based on the premises that maladaptive schema s lead to inaccurate beliefs, repetitive negative thinking and biased information processing, which contribute to the development and maintenance of depression (Beck & Bredemeier, 2016). Therefore CBT is mainly focused on modifying depressive schema s and correcting repetitive maladaptive thinking processes such as biased interpretations and maladaptive automatic thoughts (Driessen & Hollon, 2010; Gotlib & Joormann, 2010). According to a meta-analysis by Cuijpers, Pim, Berking, Andersson, Quigley & Kleiboer

9 8 (2013) CBT has an effect size of 0.71 (95% CI: ) compared with care as usual, waitlists, placebo and other control groups. These results are similar to a meta-analysis performed by Cuijpers, Andersson, Donker & Van Straten (2011), where CBT had an effect size of 0.67 (95% CI: ). Although these interventions have shown to be effective on short term, there are still high rates of recurrence in depression. According to a meta-analysis by Vittengl, Clark, Dunn & Jarrett (2007), in spite of receiving CBT, the proportion of patients experiencing MDD relapse is 29% in the first and 54% in the second year. In addition, Solomon et al. (2000) reports that nearly two-thirds of formerly depressed individuals encounter a relapse at some point. In the same longitudinal study, Solomon and colleagues (2000) report that recurrent depressive episodes increase vulnerability for another episode by 16% with each successive episode. These high rates and increased risks stress the importance of rethinking our current approaches to understand depression. This indicates that current treatments fail to thoroughly affect vulnerabilities within depression. Further research is required to increase our understanding of the specific mechanisms contributing to the etiology and maintenance of depression, in order to develop interventions targeting those specific processes. Depression is characterized by multiple psychological factors (emotional, motivational, cognitive, and behavioral). These factors include cognitive dysfunctions such as negative thinking, decreased concentration, processing biases and rumination. Importantly, current research identifies some of these cognitive impairments (attentional control deficits, cognitive biases favoring the processing of negative information) as key features in depression, as they would contribute to a sustained negative affect (De Raedt & Koster, 2010), via its influence in emotional regulation impairments (Joormann & D Avanzato, 2010).

10 9 I will review proposed theoretical accounts on the specific ways that cognitive-emotional impairments are proposed to emerge, and which mechanisms and factors contribute to depression s development and maintenance. After that, a review on empirical research supporting the assumptions from each of those theoretical accounts will be provided. Based on this review, I ll propose an integrative theoretical model considering the interplay between attentional control, cognitive biases and emotion regulation processes in depression. Finally, a new research proposal derived from these theoretical account and empirical findings will be provided in order to test: 1) the interplay between attentional control and cognitive biases (particularly attention biases) and, 2) how these factors may contribute to depression through their influence on emotion regulation processes. The aim of this research is to increase our knowledge on the specific mechanisms that may act in the development and maintenance of depression. Evidence derived from this research may be used to develop new methods of intervention targeting specific mechanisms that might be relevant to disrupt observed emotion regulation impairments in depression. Cognitive schemas and cognitive biases in depression There are several psychological theories and models explaining the mechanisms of depression. One of the major cognitive models of depression is proposed by Beck (1967). In this model it is postulated that depression is developed and maintained by cognitive structures known as schemas. These schemas consist of core convictions: sustainable ideas, expectations, beliefs and attitudes about what is defined as the cognitive triad : the self, the others and the future (e.g. I am incompetent or I am competent ). These cognitive structures are thought to organize and help to selectively attend to, interpret, and recall information that is congruent

11 10 with the contents of the individual s schemas. The content of these schemas is based on previous interactions and experiences. According to Beck, these schemas remain dormant until evoked by a cue similar or referent to its content (e.g. a scheme involving a self-view of confidence in one s skills as a cyclist will be most probably triggered during of a cycling race). Beck suggests that depressed individuals are characterized by maladaptive schemas which typically include themes such as loss, failure, worthlessness, separation and rejection. These schemas would subsequently lead to a preference to selectively attend to, interpret and remember emotional information that is congruent with the content of such schemas. Therefore, once active, these cognitive structures would provide a framework, guiding the attention towards congruent information (i.e., negative information; Sheppard & Teasdale, 2004). Overall, this model assumes that depression would be developed and maintained by schema-congruent attentional, interpretation and memory biases in the processing of information that result from the activation of maladaptive schemas (Everaert, Koster & Derakshan, 2012). Attention bias Attention bias in depression can be defined as the disproportionate allocation of attention towards schema-congruent, negative information combined with the disability or difficulty to disengage attention from this type of information (De Raedt & Koster, 2010; Sanchez, Vazquez, Marker, LeMoult & Joormann, 2013). Next I will discuss several experimental paradigms that are employed to derive proxy estimations of attention biases to emotional information in depression. Attention bias: empirical data Whether depressed individuals are characterized by attention biases to emotional information has been studied through a large number of experimental paradigms. For instance, in an affective lexical decision task, Siegle, Ingram and Matt (2002) select 10 positive, neutral and

12 11 negative words (e.g. happy, library, hopeless ) and 15 non-words (e.g. cousip, mendion ). In this task the participants have to decide whether a word or non-word is shown, thus ignoring the possible emotional valence of the word. The participants also complete an affective valence identification task with a similar setup in which they have to decide whether a word is positive, neutral or negative, thus specifically focusing on the valence. Results on both tasks show that depressed participants are considerably slower at identifying the valence of positive information and the non-emotional aspects of negative information. Siegle et al. (2002) suggest an affective-interference hypothesis to explain these results. According to this hypothesis, difficulties in depressed patients processing would be caused by an attention bias towards negative emotional information, at the expense of all other provided aspects of information. Because depressed individuals often ruminate (a style of thought and behavior, characterized by focusing the attention on continuously recurring negative thoughts, negative ideas or the current negative mood state; Nolen-Hoeksema, 1991), they might recognize negative information more quickly since the content is more aligned with their current mood states and activated schemas. Attention bias to emotional information is also tested with the visual dot-probe task (Macleod, Mathews & Tata, 1986). In the visual dot-probe task words or faces with a positive, neutral or sad content are presented as stimuli. In each trial a neutral and emotional face or word are displayed simultaneously in opposite locations in the screen. Immediately after the offset a dot appears at the location of one of the previously presented stimuli. Participants have to indicate the dot s location by pressing a corresponding button. Attention bias is measured by comparing reaction times when the dot is presented in the spatial location of an emotional stimulus, compared to a neutral stimulus. Although there is no indication of attentional bias during short stimuli representations (e.g. 500 ms; Mogg, Bradley & Williams, 1995; Bradley, Mogg & Lee, 1997), Joormann and Gotlib (2007) reported that during longer stimuli presentations (at least

13 ms) depressed individuals showed an attentional bias for negative information. The attention is pulled towards the negative stimuli, resulting in a longer reaction time when the attention has to be switched. According to this pattern, De Raedt and Koster (2010) state that depression appears to be characterized by attentional bias in the later stages of processing, characterized by difficulties disengaging from negative information. Gotlib and Joormann (2007) also conclude that, based on these findings, depressed people might not tend to direct their attention towards negative information more frequently, but show diminished inhibitive capabilities to disengage their attention from it. Fox, Russo, Bowles and Dutton (2001) developed an emotional equivalent of the exogenous cueing task (Posner, 1980). In this task a fixation cue is presented in a given position of the screen (e.g., left), followed by a target stimulus which is either displayed at the same location of the cue (e.g., left) or at the opposite location of the cue (e.g., right). Participants are instructed to indicate the location of the cue by pressing the corresponding button as fast as possible. By evaluating the reaction times to detect the cue position, this task is aimed to estimate the attentional disengagement form a previous stimulus (cued position) and attentional deployment towards a new stimulus (new target position). Fox et al. (2001) alter the displayed cues, presenting pictures with an altering valence (neutral, positive, negative) in order to make assumptions on the interplay between reaction time and a specific cued emotional content. Using this paradigm, Leyman, De Raedt, Schacht and Koster (2006) report that depressed patients show maintained attention for angry compared to neutral faces. Whereas the non-depressed controls disengage their attention more rapidly from angry faces as compared to neutral faces. These results would suggest depressed individuals have increased difficulties in disengaging their attention from negative information (De Raedt & Koster, 2010).

14 13 Nonetheless, researchers argue that attention bias evidence from these traditional paradigms is not unequivocal. Multiple explanations for the witnessed effects, such as the cognitive avoidance of certain emotional topics are possible to explain the results (De Ruiter & Brosschot, 1994). Other paradigms such as the lexical decision task suffer from interpretation difficulties as well. Due to the presentation of emotional material as to-be-ignored, task irrelevant information whilst performing a primary task, emotional information might not be attended to as in a more natural situation. This could result in an underestimation of the presence and interference of attentional bias (De Raedt & Koster, 2010). Furthermore, results from the dotprobe task are ambiguous due to two reasons. Firstly, the simultaneous presentation of both emotional and neutral information makes it difficult to deduce how emotional stimuli are processed since competing neutral information has to be processed simultaneously. Secondly, the sudden appearance of stimuli will automatically lead to a bottom-up allocation of attention, regardless of its content. This might interfere with clear deductions from the results, leaving them open to interpretation (Baert, De Raedt & Koster, 2010; Mathews & MacLeod, 2005). Finally all previously discussed research is based on reaction times, where a supposedly continuous and unhampered relation is assumed between deployment of attention and the pressing on a corresponding button. Furthermore researchers argue depressed patients suffer from cognitive impairments such as response slowing. Those traits may interfere with an unambiguous interpretation of the results in these studies (Rock, Roiser, Riedel & Blackwell, 2014; De Raedt & Koster, 2010; Armstrong & Olatunji, 2012). More direct evidence for attention bias is provided using eye-tracking technology to online monitor depressed individuals attention to emotional information. Allowing a more direct and continuous monitoring of visual attention, eye-tracking has the advantage of distinguishing between spatial and temporal characteristics, offering a more efficient and precise way of measuring attention processes. Eye-tracking allows to online detect and compute visual

15 14 fixations (holding a steady gaze upon a specific target) made to relevant stimuli during the performance of an attention task (Armstrong & Olatunji, 2012; Caseras, Garner & Bradley & Mogg, 2007). A task frequently used to assess attentional biases in depression via eye-tracking is the naturalistic visual scanning task (Eizenman et al., 2003). In these studies, participants are placed in front of an eye-tracker while looking at slides with several pictures of a different valence. Meanwhile several parameters such as the participant s first fixation, fixation time and fixation frequency are measured. Eizenman, et al. (2003) report that depressed participants show longer fixation times in the processing of stimuli with a negative content compared to a non-depressed control group. Using a similar task, other researchers have reported that depressed individuals do not initially orient their attention to negative information more often than a control group. However, depressed individuals show longer fixation times towards pictures containing negative themes such as loss and sadness, suggesting a prolonged attentional elaboration once attention has been captured by these images. This tendency, congruently with evidence from dot-probe tasks (Mogg, Bradley & Williams, 1995; Bradley, Mogg & Lee, 1997; Joormann & Gotlib, 2007), suggests that depressed participants might have more difficulties disengaging attention from negative, mood-congruent information, resulting in a more sustained maladaptive manner of information processing. Furthermore depressed participants demonstrate a blunted orientation toward positive stimuli compared to a non-depressed control group (Caseras et al., 2007; Leyman, De Raedt, Vaeyens & Phillipaerts, 2011; Ellis, Beevers & Wells, 2011). This indicates a double bias of both sustained processing of negative information and reduced processing of positive information (Duque & Vazquez, 2015). The most direct evidence of attention biases in the disengagement from negative information in depression has been provided with a novel eye-tracking based attention task developed by

16 15 Sanchez et al. (2013). This task is aimed to directly measure both attentional engagement with and attentional disengagement from emotional contents. Participants are presented with a fixation cross, followed by a random number which they have to name in order to assure the central fixation. Afterwards, a happy-neutral, sad-neutral or angry-neutral face pair is presented for 3000 ms to assess natural viewing. After it, in an engagement trial the image remain unaltered until the participants makes a visual fixation on the neutral face for at least 100 ms, which trigger a frame (i.e., a square or a circle) surrounding the opposite face. Participants task is to indicate the type of frame, thus requiring to move their gaze from one location to the opposite, engaging attention towards the emotional presented content. In a disengagement trial the valence sequence is reversed, requiring the participants to move their gaze from the emotional stimulus location to the framed opposite neutral face location, requiring to disengage attention from the emotional to the neutral stimuli to provide the response. Latency in disengaging attention from the emotional to the neutral face in sad-neutral trials and prolonged lingering of attention towards negative stimuli indicates an attentional bias. In line with previous research, Sanchez et al. (2013) report no increased initial orientation towards negative stimuli between depressed and the control participants during the first 3,000 ms period of natural viewing. Depressed participants differ from control participants by fixating longer on negative faces and shorter on positive faces during the first 3,000 ms period of natural viewing. Furthermore, in the direct measurement of engagement and disengagement patterns, depressed participants show specific higher latencies to move their gaze (i.e., disengage attention) from depression-related themes (sad faces). Finally, the participants in this study are submitted to a stress induction. Depressed participants with an increased difficulty to disengage attention from depression-related stimuli report higher levels of sadness and anxiety whilst anticipating the stressful situation. Overall these results indicate that attentional bias consisting on delayed disengagement from negative information is not only a key aspect of depression s cognitive

17 16 processing, but it can also influence the regulation of emotions, as it will be explained later (Gotlib & Jooormann, 2010). Attention bias: conclusion. Overall there is sufficient support for the presence and interplay of attentional bias under certain situational circumstances. During a depressive episode, individuals tend to be disproportionally attentive towards negative compared to positive or neutral stimuli. A possible explanation for this bias implies emotional self-relevant stimuli attracting disproportionately more resources through attentional control difficulties, thus causing an attentional bias through the activation of maladaptive schemas (Mogg, Mathews & Weinman, 1989; Beck, 1967; Williams, Mathews & MacLeod, 1996). The elongated stimulus representation required to witness attentional bias could be seen as evidence for attentional bias in the later stages of processing (De Raedt & Koster, 2010). This would suggest involvement of more complex cognitive control processes (Mathews & MacLeod, 2005). Other researchers suggest attentional bias is caused by the negative emotional stimuli activating task irrelevant, self-focused processing, consuming attentional capacity and causing an elaborated processing (Nolen-Hoeksema, 1991). The latter may contribute to rumination, making it more difficult to disengage from stimuli related to activated negative cognitive content as proposed by Koster, De Lissnyder, Derakshan and De Raedt (2011). Overall these characteristics implicate attentional bias in depression obstructs an adaptive regulation of emotions by ensuring an increased presence and elongated processing of negative material, thus leading to a more persistent negative affect (Joormann & D avanzato, 2010; Sanchez et al., 2013). Nonetheless it remains unclear how attentional bias specifically interplays with other mechanisms characterizing depression. The specific mechanisms by which such biased

18 17 attention processing, possibly related to cognitive control impairments, contributes to dysfunctional emotional regulation, may require to better understand how it interplays with the subsequent elaboration of the attended information. In the next section I will elaborate on proposed theories of attentional control impairments, and how they are proposed to instigate previously described cognitive biases. Attentional control processes in depression: Mechanisms underlying attentional bias De Raedt and Koster (2010) provide a new explanation for these mechanisms characterizing depression. These authors propose that attentional factors can hold the key to understand depression vulnerability trough the presence of cognitive biases. Specifically, decreased attentional control would play a crucial role in sustained negative cognitions and affect. De Raedt and Koster (2010) state that a depressed mood caused by every day stressors will more easily activate negatively biased processing patterns. Because after each episode the association between depressed mood and negative thinking patterns is strengthened, negative thinking patterns (maladaptive schemas) become more reactive upon negative mood and stressors with increasing depressive episodes. Moreover, the elaborative processing of negative information (rumination) can also act as an internal stressor, activating the stress system. A key aspect of De Raedt and Koster (2010) proposal is that not only the activation of maladaptive schemas and the resulting ruminative thoughts, but also presence of deficits on top-down attentional control to override them, would be on the basis of vulnerability to depression. The inability to exert attentional control (e.g., inhibiting or shifting away the

19 18 processing of activated negative information) would consequently contribute to a negative and elaborative processing of negative information, causing a sustained negative effect. This assumption is in line with Sheppard and Teasdale s (2000) proposal, which considers both a more readily access to dysfunctional schemas and a decreased monitoring of the products of these schemas (e.g. diminished top-down control on associated thoughts and feelings), as factors on the basis of vulnerability to depression. A ruminative thinking style has been forwarded as an important cognitive risk factor in the development of depression (Nolen- Hoeksema et al., 2008). De Raedt and Koster (2010) postulate that attentional biases resulting from impaired prefrontal control strongly contribute to a biased elaborative processing of negative information. Rumination is defined as a style of thought and behavior, characterized by focusing attention on continuously recurring negative thoughts, ideas or the current negative mood state (Nolen-Hoeksema, 1991). It is stated that rumination can be aggravated trough cognitive biases because of its accompanying difficulties in disengaging from negative information, leaving individuals unable to escape from this continuous processing (De Raedt & Koster, 2010). Overall, these authors specify attentional control as crucial explanatory factor. More specifically decreased inhibitory control and maintained attention for negative material, causing an impaired ability to override negative elaborative processes like rumination and, in last term, resulting negative affect. Attentional control. Attentional control: theoretical assumptions. Attentional or cognitive control consists of several factors such as: 1) the ability to allocate and update attentional and/or cognitive resources towards relevant, goal-oriented stimuli, 2) inhibit irrelevant or no longer relevant material, and 3) the capacity to shift attention between relevant

20 19 mental sets and maintain problem-solving strategies (Hertel, 2004; Harvey et al., 2004; Gotlib & Joormann, 2010). This cognitive control system, which regulates the focus of attention and temporary activation of cognitive representations, has limited capacity. Inhibiting refers to the ability to override certain tendencies or prepotent responses. Researchers have proposed that attentional control functions (e.g., shifting, inhibition) would be diminished in depression, reducing the capability of exerting top-down control to inhibit or shift away from negative information (Gotib & Joormann, 2010; Joormann & Tanovic, 2015). Considering the suggested importance of attentional control, the reduced ability to exert it might obstruct recovery from negative affect (Joormann, 2010; De Raedt & Koster, 2010). Joormann and Gotlib (2007) suggest an impaired cognitive control account in depression (see Figure 2), where several mechanisms work as a cascade, each impairment subsequently causing a consequent impairment. Specifically, impairments in attentional control would cause impairments in disengaging the attention of negative stimuli, disabling the adaptive tendency to limiting the access of irrelevant negative information and removing negative content that is no longer relevant. Consequently, impairments in the central executive system that is responsible for controlling and regulating cognitive processes would contribute to a continuous presence of negative information (i.e., attentional disengagement bias), which would lead to a prolonged elaborations of the negative activated content (i.e., rumination). Attentional control: empirical data. I will now give an overview of research supporting the presence of attentional control deficits in depression and its possible role in depression-related problems (rumination, inefficient emotion regulation).

21 20 In a dysfunctional attitude scale (Weissman, 1978) several dysfunctional ( I am nothing if a person doesn t love me ), functional ( I can enjoy myself even when others don t like me) and neutral ( It s important to eat fruit every day ) statements are presented. Participants are asked to agree or disagree with each statement by pressing a corresponding button. Faster response times suggest a more automatic, schema consistent processing, whereas latencies in response time suggest a more reflective and controlled processing of the statements. Sheppard and Teasdale (2000) reports that depressed participants responses differed from non-depressed in multiple ways. Firstly, depressed participants show more agreement with dysfunctional statements. Secondly, response times reveal that depressed patients have prolonged reaction times, suggesting a more elaborate processing concerning functional schemas. Specifically, depressed patients are slower to agree with functional statements and faster to agree with dysfunctional statements. Furthermore they report more negative thoughts and feelings arising from these schemas in depressed individuals compared to non-depressed individuals. This would suggest the absence of adequate attentional control makes depressed individuals more vulnerable to negative ideas, beliefs and attitudes derived from these schemas, facilitating and sustaining a depressed mood. Indeed, in a linked study, remission and recovery is accompanied by an increase of attentional control and a reduced access to dysfunctional schemas. However, dysfunctional schema accessibility would remain heightened in formerly depressed compared to never depressed individuals, suggesting that sustained remission is mainly influenced by the ability to monitor or control negative thoughts (Sheppard & Teasdale, 2004). A negative priming task (Tipper, 1985) is used to assess the capability of selectively steering attention and inhibiting distractors. In this task participants have to pinpoint the correct stimuli in the presence of a distractor. In several trials the target stimuli is a distractor from a previous trial, thus creating a negative priming effect. MacQueen, Tipper, Young, Joffe and Levitt (2000) reported response latencies in depressed patients during negative priming trials, indicating a

22 21 reduced inhibition of the distractors. During the affective variant of the negative priming task (Joormann, 2004), participants have to specifically inhibit the processing of emotional information. In this particular task the stimuli are words with a positive or negative valence (sad, happy, pretty, depressed, etc.). Every test trial consisting of two presented stimuli with a different valence is preceded by a prime trial with stimuli related in valence to the test trial. Using this affective variant, Joormann (2004) reports that depressed participants responded more quickly to a negative target word when a negative, to be ignored distractor is primed in the previous trial. Goeleven, De Raedt, Baert and Koster (2006) report similar results in a negative affective priming task using emotional faces, where depressed participants illustrated a diminished inhibition towards negative facial expressions. These facilitated responses indicate a reduced inhibition of negative emotional material. Joormann and Gotlib (2008) also used a modified Sternberg task (Oberauer, 2001) to explore the hypothesis that depression not only coincides with inhibiting primed negative material but also with difficulties in inhibiting the processing of negative material that is no longer relevant. In this task participants have to memorize two lists of emotional words simultaneously. Afterwards participants have to decide whether a presented word came from the relevant list, which is indicated by a cue. Words from the irrelevant list or new words have to be rejected. Joorman and Gotlib (2008) report an increased intrusion of the irrelevant material in participants who reported an increased tendency to ruminate, suggesting an association between inhibitory difficulties and rumination. Davis and Nolen-Hoeksema (2000) provided additional evidence in this line using the Wisconsin Card Sorting Test (WCST; Heaton, Chelune, Talley, Kay, & Curtiss, 1993), a cognitive test designed to assess attentional control and cognitive flexibility. In this test, participants have to determine according to which changing rules cards have to be sorted whilst receiving feedback, thus requiring different cognitive strategies. Davis and Nolen-Hoeksema (2000) report that ruminating participants, according to the Response

23 22 Styles Questionnaire (Nolen-Hoeksema & Morrow, 1991), make more mistakes than nonruminators. Ruminators specifically encountered difficulties with inhibiting perseverative tendencies and maintaining adaptive tendencies, overall suggesting that rumination disrupts attentional control. Davis and Nolen-Hoeksema (2000) suggest that rumination might be a consequence of cognitive inflexibility and perseveration. De Raedt & Koster (2010) theorize supposed that the lack in inhibitive capabilities leaves people trapped in a continuous elaboration on their negative mood state. Furthermore, the task switching paradigm (Mayr & Keele, 2000) is used to assess participants capability to switch attention away from old towards new information and to inhibit the processing of previously relevant information. Whitmer and Banich (2007) modified the original task to assess whether a high tendency to ruminate is related to the previously described cognitive functions. In this task, participants are required to identify the spatial location of a deviant object by pressing a corresponding button. The task starts with a fixation cue, which identifies the dimension (size, motion or orientation) that should be used to identify the deviant object. Switching capabilities are assessed by comparing the reaction times between consecutive trials with the same or a different declared dimension to identify the deviant object, implying the time needed to reconfigure the involved cognitive processes. Whitmer and Banich (2007) stated that switching difficulties in ruminators would be revealed through an increased set-switching cost in ruminating participants. Inhibition capabilities are assessed trough comparing the performance on an inhibitory trial and a control trial. The results indicated that rumination is moderately linked to increased switching difficulties and strongly linked to inhibition difficulties. Whitmer and Banich (2007) suggest ruminating individuals get trapped in negative information such as sad thoughts because they lack the switching and inhibitive cognitive capabilities to block them from their attention.

24 23 More direct evidence on external attentional control functions is derived from a modernized version of the antisaccade task (Hallet, 1978) using eye-tracking technology, which serves to assess top-down attentional control in the form of inhibition. In this task a fixation cross is presented, followed by a sudden-onset cue. Participants have to inhibit the reflex to engage in this cue, and instead have to generate a correct saccade towards its empty mirror position as soon as possible. Errors in this task reflect failures in the attentional control system to override the pro-saccade reflex to engage with the suddenly appearing cue. Using emotional (happy & sad) and neutral facial expressions as the onset cues, Derakshan, Salt and Koster (2009) studied the effect of depression on attentional control processes. They reported higher error rates in the depressed compared to the control group for emotional faces. However, no differences are found when comparing error rates concerning neutral faces, implicating the necessity of the specific emotional nature in the stimuli that contributes to this tendency. This finding implies that depressed participants would suffer from a cognitive impairment in the inhibition of emotional material. Depressive participants appear to fail to effectively apply attentional control when they are required to inhibit emotional stimuli, providing support for Joormann and Gotlib s (2007) impaired cognitive control hypothesis. De Lissnyder, Derakshan, De Raedt and Koster (2011) used a mixed antisaccade task (Ansari, Derakshan & Richards, 2008) to examine the relation between depression, rumination and the cognitive functions inhibition and switching. This is a modification of the antisaccade task in which a fixation cross is followed by a geometric shape (e.g. circle, diamond) indicating whether participants have to perform an antisaccade (look away to the mirror position) or prosaccade (engage towards) regarding the presented stimuli, which is an oval cue. Anti- and prosaccade trials are mixed, obligating participants to switch between task sets, resulting in faster response latencies and increased error rates. Saccade latencies (latency of the first correct saccade) and error rates (saccade towards the wrong position) indicate participants cognitive

25 24 capabilities concerning inhibition and switching. De Lissnyder et al. (2011) report slower antisaccade latencies in high ruminators, indicating cognitive inhibition impairments. Error rates for the non-emotional content however, are equal between high and low ruminators. Attentional control: conclusion. Empirical data provides support for the proposed attentional models from De Raedt and Koster (2010) and Joormann and Gotlib (2007). Ellis and Ashbrook (1988) propose a resource allocation hypothesis to explain this reduced cognitive capacity in depression. They suggest that limited access to cognitive resources in depression is due the simultaneously processing of task-irrelevant emotional information during other cognitive tasks, thus limiting the remaining cognitive resources. Indeed depressed individuals do not appear to be prone to negative material. Once it has captured their attention, however, depressed individuals would tend to elaborate and appear to be lacking the attentional control abilities to adequately inhibit the negative information. There is evidence suggesting that these deficits are related to or are even stimulated by rumination tendencies. (Levens & Gotlib, 2010, De Lissnyder et al., 2011; Joormann & Tanovic, 2015). In line of previous research, Gotlib and Joormann (2010) argue that adaptive handling of emotional situations might be determined by a person s cognitive ability to overcome attentional biases which would otherwise lead to maladaptive processing, assessments and emotions. They postulate that inhibiting the presence of, or shifting away from negative content, or generating alternative, more adaptive assessments does indeed seem like a matter of attentional control. Joormann (2004) suggest the extensive presence of rumination and negative automatic thoughts in depression leads to a valence-specific inhibitory deficit of negative information. In line with De Raedt and Koster s (2010) proposed model (see Figure 1), it could be argued that depression related activated schemas facilitate and guide attention and

26 25 interpretation during the processing of new emotional information, contributing to this inhibitory deficiency. This in term facilitates elongated processing of negative material and ruminating, thus enabling a maintained negative mood and complicating recovery. Because a negative mood is associated with congruent cognitions, cognitive impairments and cognitive biases, the ability to exert attentional control over these mechanisms may hold the key to an adaptive emotional regulation (Joormann & D Avanzato, 2010) The mechanisms of emotional regulation in depression Emotional regulation Emotional regulation: theoretical assumptions Emotion regulation is a broad term, but is usually employed to describe strategic processes aimed to influence the occurrence, magnitude, duration and expression of emotions (Gross, 2015; Joormann & Tanovic, 2015). There are several typical ways in which individuals try to cope with difficult circumstances, endeavoring to regulate emotional responses. Possible adaptive emotion regulation strategies include trying to select different situations (e.g. distraction), reappraisal (reinterpreting an emotion-eliciting event, thought or feeling, thus minimizing its negative impact; Gross, 1998) or redirect attention elsewhere, whereas maladaptive emotion regulation strategies include rumination, catastrophizing and self-blame (Garnefski, Kraai & Spinhoven, 2001). Emotions do not appear out of nowhere but unfold in a process. To explain this process Barrett, Mesquita, Ochsner and Gross (2007) propose the modal model of emotion (see Figure 3), where a situation-attentionappraisal-response sequence is proposed to explain the emerging of emotions. Appraisal can be defined as the assessment or interpretation of an occurrence, person, mood state or situation. According to this model, a

27 26 psychologically relevant internal or external situation is attended to and appraised in accordance with an individual s current goals and mood state, resulting in contextually based evaluations. These evaluations will in turn result in the experiential, behavioral and physiological responses that characterize an emotion (Gross, 2015). Joormann and D Avanzato (2010) propose that the ability to regulate emotional responses when confronted with negative events might be a key factor in understanding depression vulnerability. They argue that depression-related characteristics such as cognitive control disabilities and cognitive biases may cause maladaptive emotion regulation strategies such as rumination, rather than adaptive strategies such as reappraisal, resulting in a more sustained negative affect. Considering that most emotion-eliciting situations are ambiguous (e.g. does a frowning face in the audience mean that my presentation was a failure?), the importance of interpretation and appraisal increases, and therefore cognition is a primary route through which emotions are regulated (Gotlib & Joormann, 2010; Siemer, Mauss & Gross 2007). The ability to disengage from a negative emotion-eliciting stimuli and consciously deploy attention elsewhere, for instance, might lead to a more adaptive regulation of emotions. Typical attentional control difficulties, and subsequent cognitive biases however, may cause inflexible and automatic appraisals indirectly affect the ability to an adaptive regulation of emotions and mood states (Siemer & Reisenzein, 2007; Joormann & D Avanzato, 2010). Particularly of interest in this study are the roles that rumination and reappraisal play in emotional regulation. Nolen-Hoeksema (1991) conceptualizes rumination in the response styles theory, where rumination is defined as a response mode to distress characterized by repetitively and passively focusing on the symptoms of this distress. Instead of active problem solving, rumination typically leads to fixation on the problem and negative feelings (Nolen-Hoeksema et al., 2008). In the reponse style theory, Nolen-Hoeksema (1991) states that rumination has a

28 27 particular interaction with depression and that the course and development of depression is greatly influenced by the manner of coping. Individuals who tend to use rumination as an emotional regulation strategy and focus on the negative aspects to resolve their problems, face a worse outcome in a dysfunctional abstract thinking mode. (Joormann & D Avanzato, 2010). These thoughts specifically concern focus on symptoms of distress ( I feel so lonely ; Why do I always respond this way ) and the meaning of their distress ( Will I ever feel any better ). Rumination can be seen a consequence of negative affect which contributes to a sustained negative mood and hinders recovery from it (Nolen-Hoeksema, 1991; Nolen-Hoeksema et al., 2008). It differs from other principles such as automatic thoughts because it concerns a certain style of thoughts and behavior, not the specific content. Furthermore it specifically focusses the attention on the emotional state and obstructs recovery from the negative mood state. Nolen- Hoeksema (1991) continues stating that ruminative tendencies will elongate a depressive episode through the focus recurring on negative information and mood states, its tendency to negatively influence cognitive biases and its obstruction of more adaptive responses. Research has for instance found that individuals focused on ruminating about their depressed mood are less successful in generation possible solutions to a life problem than participants distracted from their mood (Morrow & Nolen-Hoeksema, 1990). Nolen-Hoeksema (1991) concludes with stating that rumination might increase and elongate the typical negative thinking that is associated with a depressed mood, which may eventually cause this mood to become more severe and evolve into a major depressive episode. Reappraisal can be seen as a more successful emotion regulation strategy. It is defined as reinterpreting an emotion-eliciting event, thought or feeling, thus minimizing its negative impact (Gross, 1998; Everaert et al., 2017). Gross, Richards & John (2006) state that cognitive reappraisal enables putting the meaning and significance of emotional events into perspective, facilitating a more adaptive regulation of emotions. Previous research has shown that, amongst

29 28 other adaptive indicators of healthy functioning, reappraisal is correlated with fewer depressive symptoms and the reduction of negative affect (Gross, 1998; Gross et al., 2006). Previous research also suggests that attentional mechanisms could be a critical factor in successful reappraisal, and failure could be attributed to impairments in attentional control and biases in processing emotional material (e.g. Sanchez, Everaert, & Koster, 2016; Everaert, Grahek & Koster, 2016; Everaert et al., 2017). Emotional regulation: empirical data I will now give a review of empirical findings in research concerning emotional regulation in depression, particularly on reduced reappraisal capacity and increased ruminative thinking. Subsequently I will consider the specific mechanics through which attentional control impairments and attention biases are linked to aspects of emotional regulation. In a prospective study, participants where tested regarding emotional health and response styles to a negative mood before and several weeks after an earthquake. Nolen-Hoeksema and Morrow (1991) report that the tendency to ruminate on negative mood states coincided with more depressive symptoms after the earthquake. Given that the effect remained significant after controlling for the initial level of depression, Nolen-Hoeksema and Morrow postulate that a ruminative style of thought contributes to a more sustained negative mood through the intensification of the effect a negative mood has on an individual s thoughts and behavior. Similar results are found in a longitudinal study using several questionnaires such as the Beck Depression Inventory (Beck & Beck, 1972), the Hamilton Rating Scale for Depression (Hamilton, 1960) and the Response Style Questionnaire (Nolen-Hoeksema & Morrow, 1991). Nolen-Hoeksema (2000) reports that rumination predicts more severe depressive symptoms and an increased risk for a major depressive episode. Lyubomirsky, Caldwell and Nolen-Hoeksema (1998) propose that this coincidence is influenced by an increased memory and interpretation

30 29 bias and more thoughts and feelings regarding hopelessness whilst ruminating in a negative mood state. Using an Emotional Stroop task (Williams, Mathews & MacLeod, 1996), Compton et al. (2011) compared response latencies due to interference of a negative content with self-reported daily stress and coping in a two-weeks follow-up. To overcome previously reported biases in the selfreport of coping and daily stress (Todd, Tennen, Carnet, Armeli & Affleck, 2004), Compton et al. (2011) opted to use experience-sampling methods, providing the participants with the Inventory of college students recent life experiences (Kohn, Lafreniere & Gurevich, 1990) and the Daily stress inventory (Brantley & Jones, 1989). On these questionnaires participants have to indicate to which extent several events occurred to them that particular day on a fourpoint scale. The results show decreased cognitive control abilities, as indicated by errors and response latencies by the emotional Stroop task, coincide with less negative affect and adaptive coping in response to everyday stressors. Compton and coworkers (2011) conclude by stating that their findings imply emotion regulation in daily life can be predicted best by the way individuals respond to cognitive failures in an emotional context. Garnefski et al., (2001) developed the Cognitive Emotion Regulation Questionnaire (CERQ) to assess the cognitive aspects of emotional regulation. The deployment of nine different cognitive emotional regulation strategies such as acceptance, rumination, catastrophizing and positive reappraisal is estimated after negative life events. Garnefski and Kraai (2007) report more depressive symptoms in participants who often used catastrophizing, rumination and selfblame as regulation strategies, whereas positive reappraisal appeared to coincide with less depressive symptoms. These results support the hypothesis that difficulties in the inhibition of continuously processing negative information leads to more maladaptive emotional regulation, aggravating depressive symptoms (De Raedt & Koster, 2010).

31 30 The cognitive bias modification paradigm (MacLeod, Rutherford, Campbell, Ebsworthy & Holker, 2002) trains participants to overcome cognitive biased processes. If effective, this should subsequently lead to the usage of more adaptive emotion regulation strategies through the suppression or reduction of cognitive biases. In this particular version of the task a positive and neutral word are presented simultaneously, followed by a fixation cross. In the control group this cross appears at the location of the neutral word. In the experimental condition however, the fixation cross is presented consistently at the location of the positive word, attempting to alter negative attentional bias towards negative information. After putting their participants through this training, Wadlinger and Isaacowitz (2008) induced a stressor in order to assess the transfer of effect. They report that, after inducing the stressor, participants who underwent the experimental condition looked significantly less time at presented negative stimuli compared to the control group. These results indicate the interplay between cognitive biases and emotion regulation tendencies. McRae, Jacobs, Ray, John and Gross (2012) assessed the connection between reappraisal ability, well-being and cognitive control. In this task pictures consisting of a negative content are displayed with different possible instructions. Half of the trials carry the instruction to simply look at the picture and perceive the emerging emotions. The other half has to be appraised in such a way that it would make the participant feel less negative about the image. Reappraisal ability is computed by comparing the indicated reduction in negative affect on a nine-point scale between a reappraisal and natural response trial. Cognitive control components such as working memory, set shifting and response inhibition capacities are also measured. The results show cognitive control capacities are related to the ability to successfully reappraise negative situations, which is related to reported overall well-being. These results indicate the influence of cognitive aspects in the successful regulation of emotion.

32 31 Everaert et al. (2017) combine a computerized version of the Scrambled Sentence Task (Wenzlaff & Bates, 1998) with eye-tracking technology to assess cognitive biases. In this task a fixation point is presented, followed by six scrambled words that participants have to order into the first meaningful neutral or emotional sentence that comes to mind, (e.g. born I winner am a loser, cinema visit I theater often the ) which they have to report. This instigates participants have to decide which valence to give the sentence by using either the positive or negative word. The ratio of negatively formulated unscrambled sentences indicates the presence of a negative cognitive bias. Using more direct eye-tracking technology to assess the participants performance, this design overcomes several limitations in earlier studies. While formulating the sentences an eye tracker is measuring attentional bias by recording the fixation frequency and fixation duration of emotional key words from the scrambled sentences. The total fixation time on positive words is divided by the total fixation time on negative words, providing a relative cognitive bias score. A disproportionate allocation of attention towards negative stimuli indicates an emotional cognitive bias. In addition to this test participants are asked to fill in the positive reappraisal subscale of the Ruminative Response Scale (Raes et al., 2009) and the Cognitive Emotion Regulation Questionnaire (Garnefski et al., 2001). These scales measured ruminative tendencies as a response to a depressed mood and the usage of positive reappraisal when confronted with negative life events. The results show that higher levels of depression coincided with less positive reappraisal. Furthermore positive reappraisal is related to cognitive bias, which in line with previous research, indicates the interplay of attentional aspects in the reappraisal of emotional material (Everaert et al., 2017; Sanchez et al., 2015). Additionally Everaert et al. (2017) report a positive correlation between cognitive biases and ruminative tendencies. To explain these results, Everaert et al. (2017) suggest that cognitive biases could interfere with one s ability to successfully reappraise emotional material, consecutively increasing ruminative tendencies. They conclude these results suggest cognitive

33 32 biases both hinder adaptive emotion regulation processes and facilitate maladaptive processes, thus maintaining symptoms of depression. Emotional regulation: conclusion Overall the reviewed studies support the significance of emotion regulation strategies in depression, where depressed and non-depressed individuals tend to use different emotion regulation strategies (Joormann & D Avanzato, 2010). Negative cognitive biases appear to cause automatic maladaptive appraisals of emotion-eliciting situations, obstructing depressed individuals to effectively use of adaptive emotion regulation strategies such as reappraising or redirecting attention. Given the stated importance of these cognitive concepts in the emerging of emotions it can be reasoned they leave people trapped in the prolonged processing of negative emotion-eliciting stimuli, contributing to the generation and selection of more negative interpretations of ambiguous situations. This process in turn, influences perceived emotion and substantiates Gross (2015) modal model for the emergence of emotion (See figure 3). Furthermore, demonstrated difficulties in disengaging from no longer relevant, moodcongruent information, ensures the continuous presence of negative information, which consecutively appears to contribute to rumination as maladaptive emotion regulation strategy through. The coincidence of these several factors and tendencies leads to a sustained negative affect (Gross, 2015; Nolen-Hoeksema et al., 2008). Furthermore, the effective use of adaptive emotion regulation strategies depends on the ability to exert top-down attentional control, overriding automatic negative attentional bias and interpretation bias tendencies, which would otherwise lead to continuous processing and maladaptive appraisals (Joormann & D Avanzato, 2010). Since it has already been stated that depressed individuals have decreased attentional control capacities, which is even exacerbated concerning negative material (Gotlib & Joormann, 2010), it would seem they do not only suffer

34 33 from increased cognitive biases which tend to lead to a more negative outcome, but also lack the necessary resources to counter these tendencies. These characteristics would then seem not only to cause a sustained negative mood, but also hinder recovery through obstructing the usage of adaptive emotion regulation strategies. Current study Plenty of research concerning cognitive models, processes and interfering factors in depression has provided ample evidence for their existence, interplay and interference. Nonetheless several aspects of depressive mechanisms require further research. It remains unclear if inhibition difficulties, as an aspect of decreased attentional control, is a general impairment or if this disability occurs specifically when processing a negative content. Furthermore it needs to be clarified if such attentional control impairments account for biases in attentional disengagement from emotional information. Finally, it remains unclear whether those impairments and their interplays also account for impairments in the use and strategies of emotion regulation associated to depression (Everaert et al., 2017). Specifically it remains unclear whether these impairments influence reduced reappraisal and increased rumination tendencies, since little is known about the connection between these concepts. Therefore I propose an addition to De Raedt and Koster s (2010) model. In this adapted framework (see Figure 4), attentional control impairments which characterize depression lead to specific attentional biases for emotional information. These impairments will subsequently hinder adaptive emotion regulation strategies such as positive reappraisal, and facilitate the use of maladaptive emotion regulation strategies such as rumination. Specifically, a reduced reappraisal capacity and its effect on reduced emotion regulation capacity might enforce the activation of ruminative thinking (Everaert et al., 2017). This would in last term aggravate or increase the risk of depression through the prolonged presence of a negative mood state. The

35 34 interplay between these mechanisms ensures depressed individuals remain trapped in this vicious cognitive-emotional cycle. The current study is developed in order to evaluate the interplay between cognitive control impairments, cognitive biases, emotional regulation difficulties and rumination tendencies. In order to analyze this proposal several tests are required. To assess attentional control the mixed antissacade task paradigm is used (De Lissnyder et al., 2011), given its more precise and adequate assessment trough eye-tracking. The procedure is slightly modified by using both positive, neutral and negative stimuli, allowing to clarify both the role of general impairments in attentional control or specific impairments for information with a negative content in relation to attention biases. The attentional disengagement task (Sanchez et al., 2013) is used to assess attentional bias towards negative information through the participants ability to disengage from negative presented information. This eye-tracking task provides a more direct measurement of attentional bias through the recording of several parameters. Subsequently an emotional regulation task designed by Sanchez, Everaert and Koster (2016) (see also Vanderhasselt, Kühn & De Raedt, 2013) is used, since it has the capability of both measuring re-interpretation processes (i.e. the ability to reappraise negative images) and emotion regulation (i.e. reported negative emotions after confrontation with negative content). Finally, after completing the emotion regulation paradigm, the tendency to generate ruminative thinking patterns during the viewing of negative scenes is assessed.

36 35 Derived from this model, I will test the following hypotheses: 1) Attentional control impairments in the inhibition function will subsequently lead to an increase in attentional bias, expressed in increased disengagement difficulties from negative information in comparison to positive emotions. 2) Reappraisal ability will account for the effects of attentional control impairments and attention biases on emotion regulation abilities indicated by experienced negative emotions. 3) Reappraisal ability and subsequent emotional regulation impairments (indicated by experienced negative emotions) will account for the effect of attentional control impairments and attention biases on the generation of ruminative responses. Method Sample A sample of 69 undergraduates of Ghent University, with a mean age of years (SD = 5.44) is recruited via internet posting to participate in this study. All participants (23 males and 46 females) had normal or corrected to normal (using glasses or contact lenses) vision. Participants are paid 20 Euro. The institutional ethical committee of Ghent University approved the study protocol.