Emotional Expression and Health

Emotional Expression and Health
Advances in theory, assessment and clinical applications

Edited by
Ivan Nyklek, Lydia Temoshok and Ad Vingerhoets
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Library of Congress Cataloging-in-Publication Data
Emotional e*pression and health?edited by 3van Ny0l45e0,
6ydia 7emosho0, and Ad Vin&erhoets<
p<8 cm<
3ncldes biblio&raphical re=erences<
3)$N 1%.@+-1%@#+%# Ahb0B
1< Cedicine and psycholo&y< !< Emotions%Health aspects< +< Cind and
1
body< 3< Ny0l45e0, 3van< 33< 7emosho0, 6ydia< 333< Vin&erhoets, A<9<9<C<
DDN6CE 1< Emotions%physiolo&y< !< :sychophysiolo&y%methods<
+< A==ective )ymptoms%physiopatholo&y< #< :sychosomatic
Cedicine%methods< W6 1"+ E.+. !""#F
R'!G<.<E#+. !""#
G1G<"@%dc!! !""+"1'#"@
3)$N 1%.@+-1%@#+%# Ahb0B
Contents
List of figures *iii
List of tables *v
List of contributors *vii
c!no"ledgments **i
AD V3N;ERHOE7) 1
A!T I Theoreti"al perspe"tives #
(HAR6E) V<FORD $$
#ntroduction $$
The language of lying $$
%ocio-biology of deceit $&
Deceit as a normal de'elopmental s!ill $(
Deception and self-deception in health and disease $)
Pathological forms of deceit *+
%ummary,conclusions *(
References *-
),)ANNA (OR)3N3 %#
Tal!ing about emotional e.periences */
Does socially sharing an emotion contribute to emotional &$
!
reco'ery0
%ome other benefits of socially sharing an emotion &-
Concluding comments &1
c!no"ledgments (+
References (+
& Theoreti"al me"hanisms involved in dis"los're( )rom inhi*ition to sel)+
reg'lation
CE6AN3E A<;REEN$ER; AND
)7E:HEN 9<6E:ORE ,&
#ntroduction (&
Penneba!er2s disclosure paradigm3 ma4or findings (&
#nhibition or emotional self-regulation0 ((
5motional self-regulation mechanisms -+
5motional disclosure and cogniti'e regulation of self-images --
%ummary -6
c!no"ledgments -6
References -6
, Emotion s'ppression and "ardiovas"'lar disease( is hiding )eelings *ad )or
yo'r heart-
3R3) $<CA,)) AND
9ACE) 9<;RO)) .$
5motion and cardio'ascular disease 6*
The acute conse7uences of emotion suppression 6(
Bridging the gap bet"een acute and longer-term conse7uences 6/
%ummary )(
c!no"ledgments )(
References )(
/ The !eality Es"ape 0odel( the intri"ate relation *et1een alexithymia,
disso"iation, and anesthesia in vi"tims o) "hild sex'al a*'se
:E7ER :A,6 COORCANN, $O$ $ERCOND AND
FRAN(3NE A6$A(H 2%
#ntroduction 1*
The se7uelae of psychotraumata from a historical perspecti'e 1(
8n subtypes of ale.ithymia and the implications for psychotherapy 1-
The orienting reaction as the !ey to creati'e imagination 16
le.ithymia and fantasy 11
le.ithymia9 dissociation9 and anesthesia3 three manifestations of the same :non-
feeling : state 1/
Conclusion /&
References /-
. 3orry, perseverative thinking and health
9O) F<$RO))(HO7 AND
9,63AN F<7HAYER ##
#ntroduction //
;orry9 rumination and perse'erati'e thin!ing //
+
Perse'erati'e thin!ing and psychopathology $++
Perse'erati'e thin!ing9 somatic illness and physiology $+&
Conclusions $$$
References $$$
A!T II Individ'al di))eren"es and assessment $$/
4 5i))erent "on"epts or di))erent 1ords- Con"epts related to non+expression
o) negative emotions
$ER7 ;AR))EN AND
CAR;O7 REC3E $$4
#ntroduction $$)
<on-e.pression of negati'e emotions =<5> $$1
Conscious 'ersus unconscious processes $$/
%elf-deception and impression management $*+
%ocial and personal defensi'eness $**
Type C response style $*&
Concepts different from <5 $*(
%ummary and discussion $&+
References $&&
2 Alexithymia( %/ years o) theory and resear"h
;RAECE 9<7AY6OR $&4
#ntroduction $&)
?easurement and 'alidation of the ale.ithymia construct $&1
Relationships "ith other health-related constructs $(+
d'ances in ale.ithymia theory $($
le.ithymia and emotion regulation $(*
Relationships "ith medical and psychiatric disorders $(&
<eurobiological studies $(6
Therapeutic considerations $(1
Conclusions $(/
References $(/
# Emotional intelligen"e and physi"al health
A63)ON WOO6ERY AND
:E7ER )A6OVEY $/,
#ntroduction $-(
;hat is emotional intelligence0 $-(
Percei'ed emotional intelligence and health-rele'ant outcomes $-6
Traits and styles rele'ant to emotional intelligence and longer-term health
outcomes $6+
Conclusion $6(
c!no"ledgments $6-
References $66
$6 The repressive "oping style and avoidan"e o) negative a))e"t
6YNN $<CYER) AND
NAHAN3N DERAK)HAN $.#
#ntroduction $6/
Repressi'e coping and discrepancies bet"een self-reported an.iety9
physiological9 and beha'ioral indices of an.iety $)+
Defining repressi'e coping $)*
5liciting information from repressors $)&
#
Do repressors ha'e significantly "orse health outcomes0 $)/
Conclusions $)/
References $1+
$$ sy"hologi"al mindedness( a ne1 index to assess a ma7or emotion+)o"'sed
"oping style
9OHAN DENO66E7 AND
3VAN NYK6IJEK $2/
#ntroduction $1-
Coping "ith internal mood states $16
Theoretical frame"or! $1)
Theory-dri'en operationali@ation and assessment $/*
psychometric study of the LP? $/-
Concluding remar!s $//
References *++
$% The 8tan)ord Emotional 8el)+e))i"a"y 8"ale+Can"er( relia*ility, validity,
and generali9a*ility
9AN3NE ;3E)E%DAV3),
(HERY6 KOO:CAN,
63)A D<$,76ER,
9ENN3FER 9O)),
(A7HER3NE (6A))EN,
9OHN RO$ER7),
R3(HARD RO)EN$6,7H,
;ARY R<CORROW AND
DAV3D ):3E;E6 %6,
#ntroduction *+(
?ethod *+)
%viii%
Results *$$
Discussion *$6
c!no"ledgments *$1
References *$1
A!T III 5evelopmental aspe"ts %%&
$& Atta"hment representation and a))e"t reg'lation( "'rrent )indings o)
atta"hment resear"h and their relevan"e )or psy"hosomati" medi"ine
(AR6 ED,ARD )(HE3D7 AND
E63)A$E7H WA66ER %%/
#ntroduction **-
Basic concepts of attachment theory **-
The mental representation of attachment **)
ttachment theory and psychosomatic research **/
Conclusion *&(
References *&(
$, Children:s "on"eption o) the emotion pro"ess( "onse;'en"es )or emotion
reg'lation
HEDY )7E;;E,
CARK CEER,C 7ERWO;7,
A6$ER7 RE39N79E) AND
.
NA7HA63E VAN 739EN %,6
#ntroduction *(+
The coping tradition *($
The child2s theory of mind tradition *(*
Children2s perspecti'e on the strategic control of emotions3 the use of cognition
*(&
Children2s theori@ing about the =non->e.pression of emotion *(1
Conclusion *-+
References *-*
$/ Emotional in)ormation pro"essing in *oys 1ith disr'ptive *ehavior
disorders
$RAC ORO$3O DE (A)7RO,
W366EC KOO:) AND
CARK CEER,C 7ERWO;7 %//
#ntroduction *--
Theoretical approaches to emotion and social cognition *-6
5mpirical studies of emotional information processing in children "ith beha'ior
problems *-/
%i*%
Results *$$
Discussion *$6
c!no"ledgments *$1
References *$1
#ntroduction **-
Conclusion *&(
References *&(
reg'lation
HEDY )7E;;E,
#ntroduction *(+
*(&
Conclusion *-+
References *-*
G
disorders
W366EC KOO:) AND
#ntroduction *--
problems *-/
%i*%
Results *$$
Discussion *$6
c!no"ledgments *$1
References *$1
#ntroduction **-
Conclusion *&(
References *&(
reg'lation
HEDY )7E;;E,
#ntroduction *(+
*(&
Conclusion *-+
References *-*
disorders
W366EC KOO:) AND
#ntroduction *--
problems *-/
'
%i*%
To"ard an e.tension of the %#P model *6&
Discussion and conclusion *66
References *61
A!T IV Expression in spe"i)i" 1ays and gro'ps %4&
$. Crying, "atharsis, and health
),HANNE )7O,;3E,
AD V3N;ERHOE7) AND
RANDO6:H R<(ORNE63,) %4/
#ntroduction *)-
Theories of crying *)-
%cientific research on crying9 catharsis and health *)1
Crying and health3 e.ploring possible relationships *1&
%ummary and conclusions *1-
References *1-
$4 <emininity, mas"'linity and the riddle o) "rying
A;NE7A H<F3)(HER,
CARR3E H<9<$EKKER,
AD V3N;ERHOE7),
CAR6EEN (<$E(H7 AND
AN7ONY )<R<CAN)7EAD %2#
#ntroduction *1/
%e. differences in crying *1/
Crying9 masculinity and femininity */+
ntecedents and appraisal */$
Regulation of crying */(
Display rules and 4udgments of male and female tears */-
Do se. differences in "ell-being and health relate to differences in crying
beha'ior0 */6
Conclusion *//
References &++
$2 The heart o) the a"tor( let it all o't or keep a healthy distan"e-
E66Y A<KON39N &6&
#ntroduction &+&
%tudies on emotional e.pressions and e.periences &+(
tas!-emotion theory on actors2 emotional e.periences &+(
Concluding comments &$(
c!no"ledgments &$1
References &$1
%*%
$# Non+expression o) emotion and sel) among mem*ers o)
so"ially stigmati9ed gro'ps( impli"ations )or physi"al and
mental health
9ANE6
D<)EK7ON AND
9ACE)
W<:ENNE$AKER
@
&%$
#ntroduction &*$
Defining stigma &**
%ocial stigma and physical and mental health-general findings &*&
5.pression and non-e.pression of emotion and stigmati@ation &*-
#nter'entions-"riting and social stigma &*1
Potential mechanisms &*/
Conclusions &*/
c!no"ledgments &&+
References &&+
#nde. ++.
Introd'"tion
#'an <y!lABe!9 Lydia Temosho! and d Cingerhoets
3n poplar lay belie=s and /estern =ol0 psycholo&y the e*pression o= emotions,
incldin& cryin&, is o=ten considered to be bene=icial =or oneLs health< Accordin&ly,
inhibition and repression o= emotions are believed to reslt in maladaptive chronic
activation o= the body and, conseMently, ill health< 3n addition, people are &enerally
convinced that tal0in& abot emotional e*periences /ith others is bene=icial and
=acilitates emotional recovery< Fred encora&ed patients to remember tramatic
events and to re%e*perience the ne&ative emotions as vividly as possible AFred,
1-1.?1-.'B< Altho&h he already had some dobts concernin& the e==icacy o=
cathartic therapy and abandoned it, many others in the medical commnity did not< 3n
the 1-#"s, there /ere several e*amples o= pblications in /hich the positive e==ects o=
this approach /ere described< )ymonds A1-.#B, =or e*ample, conclded in his revie/
o= the literatre that catharsis /as the most =reMent case o= sccess in
psychotherapy<
7he past decade has /itnessed rene/ed interest in the role o= emotional e*pression
and non%e*pression in health Ae<&< Kennedy%Coore N Watson, 1---B< An increasin&
nmber o= stdies have been condcted on this theme, both in the tradition o= AMasi%B
e*perimental research on &eneral mechanisms Aincldin& intervention stdiesB and in
research into individal di==erences in emotional e*pression< For instance, a Cedline
search on Oemotional e*pressionP revealed 1,'@! hits, o= /hich 1,1'G /ere =rom the
past ten years< For :sycln=o the correspondin& =i&res /ere 1,#1- and '@!,
respectively, s&&estin& an even &reater increase in interest =rom the medical
commnity<
-
)tdies on emotional disclosre in relation to health, as developed by the social
psycholo&ist 9ames :enneba0er A:enneba0er N $eall, 1-@G8 see also revie/s by
:enneba0er, 1--'8 )myth, 1--@B, have stimlated research employin& the AMasiB
e*perimental approach< 7his athor introdced a paradi&m in /hich individals /rite
=or some days abot tramatic or emotional e*periences< 7he e==ects o= this /ritten
sel=%e*pression on psycholo&ical and physiolo&ical =nctionin&, and health, are then
e*amined< 3n addition, psychophysiolo&ists started stdyin& the immediate e==ects o=
e*pressin& or holdin& bac0 emotions on physiolo&ical, in particlar cardiovasclar,
processes Ae<&< $rosschot N 7hayer, 1--@8 ;ross N 6evenson, 1--+, 1--'8 6abott et
alD9 1--"B< 7his research has advanced theoretical thin0in&
%1%
in the =ield o= emotional e*pression rapidly< 3n :art 3 o= the present volme, some o=
the central theoretical perspectives related to emotional e*pression that may be
bene=icial or detrimental to oneLs health are discssed<
:art 3 opens /ith a chapter by Ford on lyin& and sel=%deception< Deceit sally
incldes either emotional non%e*pression or e*pression that is not in a&reement /ith
oneLs inner =eelin&s /ith the prpose to mislead the other or onesel=< 3t is ar&ed that
many =orms o= deception are actally adaptive and a prereMisite =or sccess=l livin&,
in particlar =or maintainin& social relations and oneLs o/n psycholo&ical and maybe
even physical health<
RimQ et alD discss emotional e*pression as a part o= the lar&er concept o= social
sharin&< 7hey have condcted several stdies on the potential bene=icial e==ects o=
social sharin& on emotional recovery< (ontrary to e*pectations, spontaneosly
occrrin& social sharin& a=ter tramatic events as /ell as e*perimentally indced
sharin& did not have clear impacts on emotional recovery< Ho/ever, individal
di==erences in emotional e*pression did a==ect emotional recovery in the e*pected
direction< 7he athors ar&e that social sharin&, incldin& emotional e*pression, is
more important =or co&nitive restrctrin& o= the tramatic events that too0 place and
=or receivin& social spport than =or direct emotional relie=<
;reenber& and 6epore discss the potential mechanisms /hich may be involved in
the bene=icial e==ects o= disclosre< 7hey s&&est that disclosre helps to tolerate and
re&late oneLs ne&ative emotions by means o= emotional habitation, co&nitive
reappraisal, and validation o= emotions< 3n addition, adRstin& oneLs co&nitive
schemata to the e*perienced ne&ative events is claimed to be crcial to /ell%bein& and
health< 3n this process, maintainin& a positive sel=%ima&e may play an important
mediatin& role<
7he sppression o= emotion as a potential etiolo&ic =actor relevant =or cardiovasclar
disease is discssed by Cass and ;ross< $ased on literatre =indin&s, mainly
epidemiolo&ical stdies on lon&%term health conseMences, and on reslts o= their o/n
laboratory e*periments on short%term e==ects o= emotional sppression, it is conclded
that sppression o= ne&ative emotion seems to e*plain an additional portion o= the
variance re&ardin& cardiovasclar abnormalities, over and above the variance
e*plained by the e*perience or e*pression o= ne&ative emotion< Additionally,
psychophysiolo&ical and psychosocial mechanisms are proposed that may be
1"
responsible =or the ptative elevated ris0 o= cardiovasclar disease related to
emotional sppression<
A discssion o= the mechanisms potentially involved in the development o=
ale*ithymia and related dys=nctions is the contribtion by Coormann et alD 7hey
di==erentiate bet/een t/o sbtypes o= ale*ithymia, /hich have di==erent relations /ith
other psychiatric conditions, sch as conversion, anesthesia, and hysteria< 3n their
Reality Escape Codel, it is proposed that all these conditions are di==erent e*pressions
o= the same nderlyin& non%=eelin& state, /hich may reslt =rom tramatic
e*periences<
$rosschot and 7hayer emphasi>e the potentially important role o= /orryin&, or
perseverative thin0in&, in both mental and physical health< Not only may
%!%
perseverative thin0in&, in /hich ne&ative emotions play an important role, be at the
core o= many psychopatholo&ies, bt it may also be related to physiolo&ical
dys=nctions, possibly resltin& in ill health< 3n addition to the o=ten hypothesi>ed
maRor role o= past or crrent stressors in the disease process, these athors emphasi>e
the importance o= distress resltin& =rom /orryin& abot all possible =tre stressors<
$ecase perseverative thin0in& may prolon& psychophysiolo&ical arosal beyond the
e*perience o= a stressor, it may be important =or the development o=
pathophysiolo&ical states, sch as cardiovasclar disease<
3n addition to e*perimental research, a second maRor tradition /ithin the emotional
e*pression =ield has been the individal di==erences approach< 7here has been a
&ro/in& interest o= psycholo&ists to e*amine the relationship bet/een individal
di==erences in emotional e*pression%considerin& it as a stable personality trait%and
health< Non%e*pression o= emotions seems to be a crcial element o= many personality
=eatres /hich have been related to health, sch as ale*ithymia A)i=neos, 1-'+B and
de=ensiveness?repression AWeinber&er et alD9 1-'-B< )ome o= the central individal
di==erences constrcts that may be important to health are discssed in :art 33<
7he =irst chapter o= :art 33 is by ;arssen and Remie< 7hey discss the conceptal
similarities and di==erences o= the varios constrcts connected /ith individal
di==erences related to non%e*pression o= emotions, sch as repression, de=ensiveness,
sel=%restraint, and the 7ype ( response pattern< 7hey ar&e =or a division o= the
emotional non%e*pression space alon& the dimensions o= social de=ensiveness and
personal de=ensiveness, /hich is related to the division into impression mana&ement
and sel=%deception< 3n addition, the 7ype ( copin& pattern is described as a
mltidimensional constrct encompassin& other elements besides its core o=
emotional non%e*pression< Finally, they discss brie=ly constrcts beyond their
de=inition o= emotional non%e*pression as a habital tendency, sch as sel=%disclosre,
repressed memories, bt also ale*ithymia<
Ale*ithymia is discssed e*tensively by 7aylor< 7he emphasis is on the history o= the
concept, incldin& its conceptal and psychometric development< No/adays,
ale*ithymia is sally conceptali>ed as re=errin& to an inability to nderstand and
e*press verbally oneLs emotions, to&ether /ith a co&nitive emphasis on e*ternal
11
details instead o= oneLs emotions< Ale*ithymia seems to be independent o= other non%
e*pression o= emotions concepts, in that it re=lects a redced co&nitive ability to
process emotions, rather than a co&nitive tendency to inhibit emotions or their
e*pression< Research =rom the =ield o= co&nitive neroscience, as /ell as stdies
re&ardin& its lin0s /ith both psychiatric and medical disorders, are discssed<
Woolery and )alovey =ocs on the possible association bet/een emotional
intelli&ence and physical health< Emotional intelli&ence is a set o= competencies
incldin& emotional e*pression, bt also the ability to identi=y, analy>e, nderstand,
and re&late oneLs o/n and other peopleLs emotions< 3t is ar&ed that some o= the
emotional e*pression related concepts, /hich have been sho/n to be associated /ith
better physical health, in =act re=lect aspects o= emotional intelli&ence< For instance,
emotional intelli&ence is claimed to be a prereMisite =or appropriate
%+%
emotional disclosre, /hich has been demonstrated to have bene=icial e==ects on both
mental and physical health< (onversely, emotional disclosre /ill probably enhance
sel=%perceived emotional intelli&ence< Finally, the athors plead =or the se o= an
ability%based approach =or measrin& ability concepts sch as emotional intelli&ence,
instead o= sel=%report measres, /hich o=ten may be biased<
Cyers and Dera0shan provide an overvie/ o= the literatre and their o/n e*periments
re&ardin& the concept o= repression, as de=ined by Weinber&er et alD A1-'-B< 7hey
present evidence =or a discrepancy bet/een the lo/ sel=%reported distress, on the one
hand, and both behavioral si&ns and elevated physiolo&ical arosal indicative o= hi&h
distress, on the other hand< 3n addition, methodolo&ical isses are considered
re&ardin& the problems associated /ith sel=%reports o= distress and /ell%bein& in
repressors, since they have a tendency to avoid ne&ative a==ect< Finally, stdies
=indin& lin0s bet/een repression and adverse physical health are discssed<
An old concept =rom the psychodynamic literatre, psycholo&ical mindedness, is
broadened and its relevance =or contemporary health psycholo&y and behavioral
medicine is advocated by Denollet and Ny0l45e0< 7hese athors propose that
psycholo&ical mindedness, de=ined as Othe intrinsic motivation to be in toch /ith
oneLs inner =eelin&s and tho&hts by monitorin& and analy>in& them in an adaptive
/ayP, may be revelant =or oneLs health< A short measre o= the constrct is presented,
incldin& some preliminary evidence =or its validity Abein& nrelated to a measre o=
repressionB< 7he e*tent to /hich this constrct overlaps /ith related constrcts, sch
as emotional intelli&ence and especially AinverselyB the e*ternally oriented thin0in&
=acet o= ale*ithymia, shold be considered in =tre research<
:art 33 concldes /ith a chapter on the psychometric properties o= a ne/ measre o=
emotional sel=%e==icacy =or cancer patientsE the )tan=ord Emotional )el=%e==icacy
)cale%(ancer A)E)E)%(8 by ;iesse%Davis and )pie&elB< 7his scale consists o= three
=acetsE AiB commnicatin& emotions, AiiB remainin& =ocsed in the moment, and AiiiB
con=rontin& death and dyin& isses< Reslts indicate adeMate vales o= psychometric
indices o= reliability and validity o= the scale< Emotional e*pression researchers have
&enerally ne&lected developmental isses, /hich nevertheless may be crcial
determinants o= emotional e*pression later in li=e< :art 333 is devoted to the
1!
developmental perspective on the e*pression o= emotions< )peci=ically, the roles o=
attachment representation, the development o= childrenLs conceptions o= emotional
re&lation, and emotional in=ormation processin& in children sho/in& problem
behaviors are discssed<
:art 333 starts /ith a contribtion by )cheidt and Waller, /ho emphasi>e the role o=
attachment representation in adeMate a==ect re&lation< Evidence is presented =or the
lin0 bet/een insecre attachment types and a narro/ed spectrm o= a==ect re&lation,
especially re&ardin& the e*pression o= ne&ative emotions< 3n addition, =indin&s are
discssed re&ardin& the hi&h prevalence o= insecre attachment styles in patients /ith
psychopatholo&y and the association bet/een insecre attachment styles and elevated
physiolo&ical reactivity to stressors, /hich is considered a ris0 =actor =or systemic
disease<
%#%
(hildrenLs conceptions o= the emotion process are the =ocs o= the chapter by )te&&e
et alD 3n a nmber o= stdies, these athors have e*amined the development o= ideas
children have concernin& strate&ies sed =or and strate&ies tho&ht to be e==ective in
emotion re&lation, especially improvin& oneLs mood< 7hese strate&ies inclde
behavioral and mental avoidance, behavioral and mental con=rontation, and the se o=
reappraisals< Reslts indicate that these conceptions normally develop alon& a certain
path, /hich may be important =or acMirin& an e==ective and healthy emotion
re&lation repertoire /hile &ro/in& p<
Orobio de (astro et alDLs chapter is devoted to the role o= emotional in=ormation
processin& in disrptive behavior in children< Empirical =indin&s are presented, /hich
sho/ that boys /ith disrptive behavior problems have deviant representations o=
oneLs o/n and other peopleLs emotions, and possess less adaptive emotion re&lation
strate&ies< A model is presented incorporatin& the varios in=ormation processin&
=actors relevant =or emotion re&lation at the varios sta&es leadin& to e*pression or
non%e*pression o= emotion in children /ith disrptive behavior< 7hese =actors may
play a casal role in disrptive behavior< 3nterventions aimed at chan&in& emotional
in=ormation processin& may lead to less problem behavior in these children<
3n the last part o= the present volme A3VB, a speci=ic =orm o= emotional e*pression
Acryin&B is discssed, as /ell as isses related to emotional e*pression in speci=ic
&rops< (rrent theoretical models o= cryin& are described by )to&ie et alD 7hese
athors =rther try to identi=y possible =nctions o= cryin&< 3n addition, empirical
=indin&s addressin& the e*tent to /hich cryin& enhances mood and health or is rather
associated /ith more n=avorable otcomes are discssed e*tensively< 3t is attempted
to reconcile the =reMent discrepancies re&ardin& the e==ects o= cryin& on /ell%bein&,
/hich have been =ond in research sin& di==erent methodolo&ical approaches<
Fischer et alD discss &ender di==erences in cryin& behavior, incldin& =actors that may
e*plain the lar&er cryin& proneness in /omen< 7hese are mechanisms related to
biolo&ical AendocrineB, psycholo&ical Aappraisal o= the sitationB, social, and cltral
=actors< 3t is conclded that =eelin&s o= po/erlessness, resltin& =rom an interplay o=
these potentially relevant =actors, may be 0ey =actors =or the &ender di==erences in
1+
cryin&< 3n addition, these athors brie=ly discss /hether these di==erences in cryin&
are related to se* di==erences in health<
7he se o= actors in psychophysiolo&ical stdies on emotion and emotional
e*pression is challen&ed in the chapter by KoniRn< 3n a series o= stdies, she has
e*amined the e*tent to /hich pro=essional actors =rom varios actin& traditions
e*perience the emotions they portray< )he =ond that even actors =rom the
involvement tradition e*perience emotions that are related to their per=ormance tas0
rather than to the emotions o= their characters< Also ta0in& into accont =indin&s =rom
other literatre, it is conclded that reslts re&ardin& psychophysiolo&ical
di==erentiation o= emotions obtained in stdies sin& actors portrayin& certain
emotions may not be valid re&ardin& the assmption that the physiolo&ical
concomitants =ond are indeed associated /ith the portrayal emotions<
%.%
3n the =inal chapter, )e*ton and :enneba0er discss the e==ects o= emotional
none*pression and disclosre in socially sti&mati>ed &rops< While non%e*pression
seems to have n=avorable e==ects on sel=%esteem and health otcomes, disclosre
enhances oneLs personal narrative and identity, /hich may have a protective e==ect
a&ainst the distress o= bein& sti&mati>ed<
From this overvie/ o= topics discssed in this volme, one may conclde that the
Mestion o= the role o= emotional e*pression and non%e*pression in health is addressed
=rom diverse an&les and research traditions, the combination o= /hich in one volme
is niMe< 3n addition, it nderscores the comple* natre o= emotional e*pression, in
/hich many =actors play a role< As ar&ed by Kennedy%Coore and Watson A1---B,
emotional Anon%B e*pression is the otcome o= a comple* co&nitive%decisional process
ta0in& place as several sbseMent sta&es< 3nternal Aco&nitive%a==ectiveB and e*ternal
Athe social environmentB =actors may in=lence this process at every sta&e, indicatin&
that the end otcome o= e*pression or none*pression may di==er Malitatively,
dependin& on the sta&e o= the process and the =actors that led to e*pression or non%
e*pression< 3n addition, these Malitatively di==erent /ays o= e*pression and non%
e*pression may be associated /ith di==erent e==ects on /ell%bein& and health< 3t is a
challen&e =or =tre researchers and clinicians to &et insi&ht into these processes and
the accompanyin& =actors associated /ith each sta&e o= the process leadin& to either
e*pression or inhibition o= emotion, as /ell as into the ptatively di==erent lin0s /ith
/ell%bein& and health<
!e)eren"es
$rosschot, 9<F< N 7hayer, 9<F< A1--@B< An&er inhibition, cardiovasclar recovery,
and va&al =nctionE a model o= the lin0s bet/een hostility and cardiovasclar
disease< nnals of Beha'ioral ?edicine,%6, +!G%++!<
Fred, )< A1-1.?1-.'B< Repression and the nconscios< 3n 9< )trachney Aed< and
transl<B, The standard edition of the complete psychological "or!s of %igmund
Freud, Vol< 1# App< 1#1%1-.B< 6ondonE Ho&arth :ress<
;ross, 9<9< N 6evenson, R<W< A1--+B< Emotional sppressionE physiolo&y, sel=%
report, and e*pressive behavior< Eournal of Personality and %ocial
1#
Psychology,.,, -'"%-@G<
;ross, 9<9< N 6evenson, R<W< A1--'B< Hidin& =eelin&sE the acte e==ects o=
inhibitin& ne&ative and positive emotion< Eournal of bnormal Psychology,$6.,
-.%1"+,
Kennedy%Coore, E< N Watson, 9<(< A1---B< 5.pressing emotionD ?yths9 realities9
and therapeutic strategies< Ne/ Yor0E ;il=ord :ress<
6abott, )<C<, Ahleman, )<, Wolever, C<E<, N Cartin, R<$< A1--"B< 7he
physiolo&ical and psycholo&ical e==ects o= the e*pression and inhibition o=
emotion< Beha'ioral ?edicine,$., 1@!%1@-<
:enneba0er, 9<W< A1--'B< Health e==ects o= the e*pression Aand non%e*pressionB o=
emotions thro&h /ritin&< 3n A<9<9<C< Vin&erhoets, F<9< Van $ssel, N A<9<W<
$oelho/er AedsB, The =non> e.pression of emotions in health and disease App<
!G'%!'@B< 7ilbr&, NetherlandsE 7ilbr& ,niversity :ress<
:enneba0er, 9<W< N $eall, )<K< A1-@GB< :ttin& stress into /ordsE health,
lin&istics, and therapetic implications< Eournal of bnormal Psychology,#/,
!'#%!@1<
)i=neos, :<E< A1-'+B< 7he prevalence o= Oale*ithymicP characteristics in
psychosomatic patients< Psychotherapy and Psychosomatics,%%, !..%!G!<
)myth, 9<C< A1--@B< Written emotional e*pressionE e==ect si>es, otcome types,
and moderatin& variables< Eournal of Clinical and Consulting Psychology,..,
1'#%1@#<
)ymonds, :<C< A1-.#B< A comprehensive theory o= psychotherapy< merican
Eournal of 8rthopsychiatry,%,, G-'%'1#<
Weinber&er, D<A<, )ch/art>, ;<E<, N Davidson, R<9< A1-'-B< 6o/%an*ios, hi&h%
an*ios, and repressive copin& stylesE psychometric patterns and behavioral and
physiolo&ical responses to stress< Eournal of bnormal Psychology,22, +G-%+@"<
%G%
art I
Theoreti"al perspe"tives
%-%
Chapter $
Lying and sel)+de"eption in health and disease
Charles CD Ford
Introd'"tion
1.
Deceit and the need to detect deception are prevalent in the animal 0in&dom, and
reaches their hi&hest evoltionary development in Fomo sapiens< Deceit is an
intricate part o= hman commnication involvin&, via a dynamic process, sel=%
deception and the deception o= others< When sed in OnormalP /ays, /e are o=ten
na/are o= or deceptive commnications to others< Deceit serves to promote social
spport and helps to sstain mental and physical health< Ho/ever, blatant
Apatholo&icalB =orms o= deceit may, to the contrary, be destrctive to the sel= and
others< 7he sophisticated person ses deceit in a sbtle manner /hile, in contrast,
crde and patholo&ic deceit is =reMently associated /ith neroco&nitive dys=nction
or distorted developmental processes<
The lang'age o) lying
OCan /as &iven a ton&e /ith /hich to spea0 and /ords to hide his tho&hts<P 7his
Hn&arian proverb indicates the biMity o= deceptive commnications< 3n =act, the
development o= di==erent lan&a&es and symbolic commnication has been
hypothesi>ed as bein& the reslt o= the need =or social &rops to maintain cohesion
and secrecy A)teiner, 1-'.B< 7he /ays in /hich man can deceive are almost endless<
3nclded are the /ords /e spea0, or donLt spea0, as /ell as or non%verbal channels o=
commnication< Frther, colloMialisms, /ords, and nonverbal commnication are
o=ten cltre speci=ic< 7hat /hich may be considered a polite commnication in one
cltre may be considered a lie in another< )ayin& ONoP in some cltres is
considered nacceptably rde and there=ore OYesP does not al/ays necessarily mean
yes<
7he =ollo/in& brie= descriptions o= varios =orms o= deceit /ill serve to lay a
=ondation =or topics considered in this commnication<
Definition
6yin&, by de=inition Ain American dictionariesB, involves the deliberate misstatement
o= in=ormation believed by the prota&onist to be =alse and /ith the intent
%11%
to deceive< 7his de=inition involves not only the content o= a commnication bt also
its intent< 3t is interestin& and important to note that one can spea0 Othe trthP /ith the
intent to deceive, thereby leadin& the Otar&etP to a =alse belie=< 7his is commonly done
by providin& only hal= the trth, leadin& the intended tar&et o= the commnication to a
=alse assmption< For e*ample, a person late to an appointment may say that there /as
an atomobile accident that had tied p tra==ic< 7he statement itsel= may be =actally
tre bt Oin trthP the atomobile accident had nothin& to do /ith the personLs
tardiness< 7he person /ho hears the pro==ered e*cse may assme, ho/ever, that the
tardiness /as de to the accident and not the =alt o= the late person<
Euphemisms
6ies, lyin& and accsations abot lyin& are hi&hly char&ed emotional /ords< 7he
statement Oyo are a liarP can be the basis o= a =ed or end a =riendship =orever< 3n an
e==ort to avoid sch hi&hly emotionally char&ed /ords, the En&lish lan&a&e has
evolved a nmber o= ephemisms that serve to commnicate the idea o= deceit yet =all
1G
short o= callin& someone a OliarP< 3t has been reported that the ;erman lan&a&e
contains even more ephemisms than the En&lish lan&a&e A)hibles, 1-@.B<
Non-verbalde"eit
Words are only one channel o= commnication bet/een persons< Other =orms o=
commnication inclde non%verbal messa&es that are both symbolic &estres Aand
o=ten very cltrally determinedB and e*pressions o= emotion Ae<&< an&erB, s0epticism,
a==ection, or o= oneLs somatic state Ae<&< painB ADe:alo, 1-@@B< Nonverbal
commnications inclde &estres, postre, bodily movements and in=lections o= voice
and other sonds Ae<&< si&hs, &roans, and chan&es in pitchB AE0man N Friesen, 1-G-8
9ohnson et alD9 1-'.B<
Levels of deceit
3n terms o= the sophistication o= the attempt to deceive another person, are at least
=or separate levels o= deceit have been described A6ee0am, 1--!8 Ford, 1--GB<
Ordinarily as children matre they develop the capacity to deceive at the third level8
hi&hly s0illed liars may achieve the =orth level< 7hese levels are as =ollo/s<
1 A simple =alse statement /ithot any capacity to determine /hat another person
may 0no/ or divine abot the sitation< For e*ample, a small child /ith coo0ie
crmbs smeared all over his?her =ace may ma0e a statement that he?she did not eat
the coo0ies<
! 7he liar ta0es into accont that the tar&et o= a lie may have some in=ormation by
/hich the veracity o= the statement can be Rd&ed< 7hs one /ill not say
%1!%
somethin& =alse /hen the tar&et o= the lie can readily detect that it is not tre< For
e*ample, at level t/o a liar /old not say that it is rainin& otside 0no/in& that
the recipient o= the commnication can Mic0ly loo0 otside to determine the
/eather<
+ 7his level o= lyin& involves the capacity, /hile ma0in& a =alse statement, to
read the non%verbal e*pressions o= the recipient o= the lie and, dependin& on the
de&ree o= credlity perceived, ma0e alterations in the statements bein& presented<
For e*ample, a stdent /ho is ma0in& an e*cse abot /hy home/or0 has not
been completed may chan&e the story mid%stream i= the teacher appears to be
non%convinced<
# 6yin& at this level, the hi&hest and most s0ill=l =orm o= deceit, involves the
capacity o= the liar to dissociate his or her non%verbal commnications =rom the
/ords bein& spo0en in sch a manner as to provide mi*ed messa&es< For
e*ample, a politician may praise another person /hile commnicatin& non%
verbally that in trth he has no respect =or that individal< As a reslt, he can say
OhonestlyP that he has said nothin& e*cept nice thin&s /hen in trth the
commnications have been damnin&<
Self-deception
7erminolo&y arond the isse o= sel=%deception has been the sbRect o= philosophical
treatises< 3n my opinion, and that o= at least some philosophers, sel=%deception can be
described in terms o= the varios Oe&o de=ense mechanismsP AHamlyn, 1-@.B< 3n
labelin& these =orms o= sel=%deception one is describin& phenomolo&y rather than
providin& e*planations< We can speclate that many, i= not all, o= these de=ense
mechanisms have nerophysiolo&ical mechanisms, /hich /ill ltimately be better
nderstood< 7hese mechanisms by /hich sel=%deception is initiated and?or maintained
1'
inclde, amon& others, denial, proRection, rationali>ation, isolation, dissociation and
repression<
8o"io+*iology o) de"eit
Prevalence in animal kingdom
Deceit is prevalent thro&hot the animal 0in&dom< 3n a /orld o= eat%or%be%eaten,
deceit may be the determinin& =actor as to /hether one has a meal in order to live
another day, and /hether one avoids bein& a meal in order to live another day<
(amo=la&e is a passive =orm o= deception< Active =orms o= deception inclde
de=ensive behaviors sch as piloerection in order to appear lar&er or more =ormidable,
or the emission o= =alse si&nals to attract /old%be se*al partners o= another species
/ho instead become a meal A6loyd, 1-@G8 6e/in, 1-@'8 )to/e et alD9 1--.B< Deceit=l
behaviors that are apparently /ill=l have been described in do&s, primates, and
elephants AdeWaal, 1-@G8 Corris, 1-@G8 Cills, 1--'B< From this /e can see that the
deceit=lness o= man has a rich phylo&enetic le&acy<
%1+%
Driving force in the evolution of the human brain
3t has been hypothesi>ed by Robert 7rivers A1-'1B that the evoltion o= the hman
brain /as propelled by an Oarms raceP in=lenced by the selective advanta&es o=
e==ective deception and, as the conterpoint, the capacity to detect deception by
others< 7rivers A1-@.B has also hypothesi>ed that deception is most e==ective /hen the
deceiver also believes the =alse messa&e bein& delivered< 7here=ore, sel=%deception
has evolved simltaneosly /ith deception o= others< One e*ample is the in=atated
person /ho ma0es statements o= love to intended se*al partners< Deceit can be sed
to create po/er or to compete =or se*al AreprodctiveB opportnities< )imilarly, the
capacity to detect sch maniplative ploys is to the advanta&e o= the /old%be victim<
3rrespective o= /hether deceit /as the drivin& =orce in the evoltion o= the hman
brain, there can be little Mestion that it is the neo%corte* o= the pre%=rontal cerebral
lobes that =nctions as the decoder and modlator o= the sbtleties o= social
interaction< Frther, this /ondros piece o= comptin& eMipment reMires an
e*tensive period o= time =or development and matration< Yon& hmans reMire
e*tensive parental investment and prolon&ed protection prior to the achievement o=
independence< We can postlate =rom this need =or protection drin& matration the
development o= =amilies and e*tended =amilies< Frther, =or &rops to remain
cohesive, there mst be commitment8 some individals sacri=ice =or the /hole
AaltrismB and loyalty one to another< 3 propose that the need to create and maintain
&rop cohesion, in order to provide protection =or the yon& and =or e==ective
collectin& and conservation o= =ood resorces, is responsible =or the codi=ication o=
moral vales< Accrate non%deceptive commnications "ithin the &rop are essential
=or the &rop to =nction e==ectively< Deceptive commnications to other competin&
&rops may also be e==ective /ays o= preservin& and e*tendin& the po/er o= a social
&rop< 7hs, in a hierarchy o= moral vales, loyalty ran0s hi&her than trth=lness Ain
the abstractB< One e*ample o= this principle is the sociolo&ical stdy o= a &an& in a
lar&e city, in /hich it /as =ond that lyin& to =ello/ &an& members /as condemned,
bt lyin& to otsiders /as praised ACiller et alD9 1-G1B<
1@
Research by De:alo and Kashy A1--@B can be interpreted in spport o= the above
postlate< 7hey =ond that OnormalP persons lied =reMently, bt more o=ten to persons
/ith /hom they did not have a close relationship A.G%'' percent o= all social
interactionsSB than to persons /ith /hom they had very close relationships sch as a
spose or lover A1" percent o= social interactionsB< Coreover, lies to a close
acMaintance /ere more li0ely to be altristic Ae<&< to protect the otherLs sel=%esteemB
than lies to stran&ers, /hich /ere li0ely to serve sel=%enhancement< )bRects also
reported more distress abot lyin& to persons close to them<
5e"eit as a normal developmental skill
6yin& is o=ten condemned as a Ona&htyP behavior in children and re&arded as
re=lectin& moral de=icits in adlts< O3n trthP, lyin& is a developmental s0ill, /hich
%1#%
is necessary =or the preservation o= the sense o= sel=, the maintenance o= individal
atonomy, and the capacity to relate /ell /ith other persons< :eople /hom /e call
OliarsP or Opatholo&ical liarsP are &enerally nsccess=l liars, /hile those /ho are
more sccess=l and s0ill=l are not identi=ied as sch< 7o provide an analo&y, the
prisons are =ll o= nsccess=l criminals8 sccess=l liars become chie= e*ective
o==icers o= health insrance companies< 7he =ollo/in& discssion otlines the
development o= deceit and ho/ it is incorporated as a healthy part o= oneLs copin&
mechanisms and interpersonal s0ills<
Defensive lies
7he =irst lies that children tell are o= denial or de=ensive, in order to protect one =rom
disapproval or pnishment< 7hey be&in to appear at appro*imately a&e t/o and
consist o= statements sch as O3 didnLt do itP or disclaimers o= 0no/led&e as to ho/
somethin& may have happened< 7hese lies are =airly primitive and it does not reMire
mch s0ill to detect them as ntrth=l statements< 3n addition to possible
incriminatin& evidence, the child has little control over the non%verbal e*pressions
that &ive him a/ay< )ome children /ill also lie in a play=l or hmoros /ay to
=rstrate parents or to provide entertainment8 =or e*ample, deliberately misnamin& an
animal<
Wish fulfillment lies
Yon& children have con=sion as to /ishes, =antasy, and reality< 7hey may tell
stories that represent that /hich they /ant, /ith perhaps the belie= that /hat they say
/ill become real< For e*ample, the da&hter o= divorced parents told her =ather that
she /anted to have a television set in her bedroom Rst as she had at her motherLs
hose< When con=ronted &ently /ith the idea that /hat she /as sayin& /as that she
really /anted a television at her motherLs hose A/hich she did not haveB and also one
at her =atherLs hose, she ac0no/led&ed that indeed this /as the sitation< Other
children may tell =alse stories o= planned trips to Disneyland or havin& relatives /ho
are =amos =ootball players or other tales that /old increase their sense o= sel=%
importance or personal /ishes =or &rati=ication< )ch stories have a soothin& =nction
and have similarity to the daydreams o= adolescents and adlts<
1-
Lies toesta*lish a'tonomy
Victor 7as0 A1-++B, a psychoanalytic pioneer, postlated that lyin& is an essential
component o= di==erentiatin& oneLs sel= =rom the mother< Yon& children have the
niversal belie= that the parents, particlarly the mother, can read their minds< 3t is
only thro&h sccess=l lies that children can establish that they have minds o= their
o/n /hich are private and separate =rom those o= the parents< (haracteristically these
lies start at a&e =or to =ive< 6ies o= this type are also prominent
%1.%
drin& adolescence /hen the adolescent, in order to e==ect separation, mst ma0e the
parents na/are o= his?her behaviors, tho&hts, and =eelin&s A;oldber&, 1-'+B< 7his
need =or atonomy occrs particlarly in the se*al realm and other e*crsions into
that /hich is re&arded as adlt behavior<
Pretense/impressionmanagement
7he yon& child is na/are o= ho/ his or her demeanor and emotions are si&naled to
other persons< )ch in=ormation can be sed by others =or maniplative prposes and
the person /ho does not learn the s0ill o= 0eepin& oneLs emotions secret is o=ten prey
to the nscrplos< 7hs, as a social s0ill, and necessary de=ense mechanism, the
child is pro&ressively ta&ht and learns to present a =ace to the /orld that is not
necessarily accrate o= the internal sel= A)aarni N von )alisch, 1--+B< 7his is called
pretense Aor impression mana&ementB and altho&h this /ord is sometimes sed
dero&atorily it is, in =act, a necessary developmental s0ill< One e*ample o= pretense is
that o= learnin& ho/ to control oneLs emotions in order not to ma0e another person
ncom=ortable, sch as ho/ to appear &racios and than0=l =or an n/anted &i=t or
invitation< )mall children, /hen &iven an inappropriate &i=t, /ill immediately voice
their displeasre< Older children, normally be&innin& at abot a&e ei&ht to nine, are
able to dis&ise their disappointment or nhappiness and =ei&n pleasre and?or
&ratitde< An e*ample is /hen a &randmother provides a &i=t that /old be more
appropriate =or mch yon&er children< )imilarly, stdents and employees learn to
dis&ise =eelin&s o= disli0e, displeasre, or an&er to/ard teachers and employers<
(hildren learn ho/ not to act hrt or vlnerable /hen teased by their classmates<
7hs, healthy and e==ective =nctionin& in society incldes the ability to dis&ise oneLs
tre emotional state to others and to =ei&n appropriate emotions and attitdes<
Lies of loyolty
(hildren are told, o=ten be&innin& in early childhood, that there Ois nothin& /orse
than a liarP< )imltaneosly, and particlarly as they start school, they are also told
Othere is nothin& /orse than a traitorP Aor O=in0P in the vernaclarB< 7hese t/o edicts
set p one o= the =irst ethical dilemmas =or children< Almost inevitably a child /ill be
as0ed to identi=y /hich o= his or her siblin&s and?or classmates /as responsible =or
some type o= misbehavior< One can respond by lyin&, O3 donLt 0no/P, or by betrayin&
a =riend< )tdents Mic0ly learn that it is =ar better to be pnished =or lyin& than to be
socially ostraci>ed =or disloyalty< 7his type o= lyin& then e*tends thro&hot li=e and
incldes sch behaviors as the provision o= incomplete or =alse letters o=
!"
recommendation, lies to cover absences or tardiness =or =ello/ employees, and so
=orth<
%1G%
ltruistic lies
With increasin& matrity, the child learns that at times the trth can be hrt=l, not
only to onesel= bt to others A;oldber&, 1-'+B< 7here is an increasin& sensitivity to the
=eelin&s and sensibilities o= others< 7o Mote Vase0 A1-@GB, O7he s0ills reMired in
deception are also sed in bein& compassionate and coordinatin& or actions /ith
those o= others and /ithot them society mi&ht not e*ist<P One may en&a&e in O/hite
liesP, =lattery, or otri&ht deceit in e==orts to ma0e other people =eel better A)atran,
1--+B< White lies have been called Othe lbricants o= polite societyP and all o= s are
&ilty o= providin& than0s and compliments =or somethin& /e, in trth, did not enRoy8
=or e*ample, a /retched meal at a =riendLs home< For e*ample, /e may sper=icially
a&ree /ith another personLs point o= vie/ rather than case pain or con=rontation< As
reported by De:alo and collea&es, /e o=ten say spportive thin&s /e do not believe
in or attempts to ma0e people =eel better abot themselves ADe:alo et alD9 1--G8
De:alo N $ell, 1--GB<
Other altristic lies may be to protect =ello/ hman bein&s even at the ris0 o= personal
sa=ety8 =or e*ample, the Dtch people /ho helped hide 9e/s drin& the )econd World
War and /ho lied abot 0no/led&e o= their /hereabots<
Altristic lies are also e*empli=ied by physiciansL statements to sic0?dyin& patients<
Which one o= s has not tried to provide n/arranted optimism or minimi>e
complications =or someone s==erin& =rom an a&oni>in& terminal illnessT
Lies to promote self-esteem
As each o= s matre, /e develop a sense o= personal identity< A part o= that identity
is the Opersonal mythP A;reen, 1--1B< 7his myth is composed o= or vie/s o=
orselves as competent e==ective people Aor sometimes as victimsB /ho have
persevered a&ainst adversity< We tend to minimi>e or =alts, e*a&&erate or
accomplishments, and see orselves in a &enerally =avorable li&ht< 7his positive vie/
helps sstain s thro&h di==iclt times and provides an otside =ace to the /orld o=
competence and &eniality< :alhs A1--@B =ond that sel=%enhancement and sel=%
promotion are intrapsychically adaptive in re&ard to =acilitatin& a positive vie/ o=
onesel=< 3ndividals /ith more o= these characteristics ma0e &ood =irst impressions,
appearin& to be a&reeable, /ell adRsted and competent< With increased contact,
ho/ever, the initial impression deteriorates and sch persons are perceived more
ne&atively<
5e"eption and sel)+de"eption in health and disease
6yin& and sel=%deception, as detailed above, are pervasive thro&hot li=e< 3n =act,
De:alo et alD A1--GB have =ond that colle&e stdents lie at least t/ice a day and
commnity sbRects once a day< 7his constittes a lie at a rate bet/een !. and ."
percent o= all social interactions that last ten mintes or lon&er<
!1
%1'%
We shold not be srprised then to =ind that lyin& is prevalent in medicine =or both
patients and physicians A)obel, 1--GB<
Physicians
:hysicians lie abot their Mali=ications in attempts to compete =or presti&ios trainin&
positions, and?or their interest in sch positions /ith the hope o= bein& =avorably
ran0ed A$odrea*, 1--!8 )e0as N Htson, 1--.8 Yon&, 1--'B, medical stdents
cheat on e*aminations AAnderson N Obenshain, 1--#B and medical =aclty may
en&a&e in research =rad ACiller N Hersen, 1--!B< 6yin& =or the bene=it o= patients
may occr in order to protect a patientLs secret Ae<&< a venereal diseaseB or to obtain
additional insrance bene=its =or patients o= limited =inancial means ANovac0 et alD9
1-@-B< 7hey may also lie abot treatments in an attempt to establish an accrate
dia&nosis%e<&< psedo%sei>res =rom &enine epilepsy AHo/e, 1--'B<
3n a possibly more positive li&ht, physicians and nrses, in their e==orts to ma0e
patients more com=ortable, to sstain hope and promote optimism, may se deceit=l
tactics< 7his is done by Obendin& the trthP thro&h the provision o= incomplete
in=ormation, silence, minimi>ation o= problems or pro&nosis or, at times, otri&ht lies
A7c0ett, 1--@B< 7he nmiti&ated trth may be brtal and sadistic A6ear, 1--+B<
Frther, the e==ective physician?nrse has learned to maintain the pretense
AimpressionB o= competence, con=idence, and eManimity< )ch a demeanor reassres
patients, redces an*iety, and =acilitates positive placebo responses< A =lstered,
=mblin& physician is not an e==ective healer irrespective o= his?her e*tent o= medical
0no/led&e< 7he s0ill=l provision o= these types o= deceit may be a component o=
&ood medical care in order to =acilitate patientLs bene=icial se o= sel=%deception and
sel=%enhancement<
Patients
:atients deceive both thro&h overt and conscios /ays and via sel=%deception?sel=%
enhancement to ma0e thin&s more positive than they really are< 7hey may lie to avoid
embarrassment or criticism or sel=%deceive in order to preserve optimism<
Overt lyin& is common in patients /ith sbstance abse problems, smo0in& or hi&h%
ris0 se*al behavior AFord, 1--GB< 6yin& is also a =reMent occrrence /ith the non%
compliant patient< For e*ample, a &rop o= asthmatics /ere &iven instrctions to se
their inhalers =or times a day ARand et alD9 1--!B< A microchip installed into the
inhaler, nbe0no/n to the patients, recorded actal se< 7he lar&e maRority o= patients
=alsely reported that they sed the inhaler more than they actally did< )ome patients
actally activated it repetitively be=ore retrn visits in order that it /old appear that
they /ere sin& it per instrctions< )imilarly, many sbRects o= a &rop o= diabetics
/ho /ere instrcted to 0eep lo& boo0s o= their blood &lcose levels sed meters that
had a secretly installed microchip /hich recorded date, time, and blood &lcose each
time it /as sed< 3t /as =ond that
%1@%
!!
over%reportin&, or the addition o= phantom readin&s, occrred abot #" percent o= the
time and !G percent o= lo&boo0 readin&s did not correspond /ith the actal readin&s
ACa>>e et alD9 1-@#B< 3n a stdy o= obese sbRects, it /as determined that, as a &rop,
they nder%reported actal =ood inta0e by #' percent and over%reported physical
activity by .1 percent A6ichtman et alD9 1--!B<
Kno/led&e o= =alse in=ormation by a patient may be very important in patient care
mana&ement, bt o= even &reater importance is the role o= sel=%deception?sel=%
enhancement< Cost people have Opositive illsionsP by /hich they maintain a better
vie/ o= themselves than /old be spported by reality< We see orselves as better
than others, in more control o= or lives than is tre, and have optimistic vie/s o= or
capabilities to /eather adversity incldin& physical disease ARssel, 1--+8 7aylor N
Armor, 1--GB< 7hese characteristics o= sel=%deception are so prevalent, and have been
con=irmed so repetitively by varios investi&ators, that /e mst re&ard them as
normal< )el=%deception Aco&nitive distortionsB and sel=%enhancement Aor deceptive
presentations o= orselves to othersB are closely tied to sel=%esteem and a sense o=
/ell%bein& A7aylor N $ro/n, 1-@@8 7aylor N Armor, 1--G8 Hoorens, 1--.B< Frther,
it has been proposed by 6ane and collea&es and others that sel=%deception may help
protect a&ainst mental illness A)ac0heim N ;r, 1-'-8 )ac0heim N We&ner, 1-@G8
6ane et alD9 1--"B< )everal investi&ators have =ond that depressed persons have a
more realistic vie/ o= themselves and their control over li=e events than do normal
people AAlloy N Abramson, 1-'-, 1-@!8 6e/insohn et alD9 1-@"B< 3t appears that
mental health is associated /ith the bias o= seein& onesel= /ith positive illsions, or
pt di==erently, vie/in& the /orld thro&h rose%tinted &lasses<
7he relationship o= sel=%deception and adRstment to physical disease has been
investi&ated thro&h nmeros stdies< 3n &eneral, the term sed to describe sch sel=%
deception has been OdenialP and the =ollo/in& discssion /ill se this term in a
&eneric manner that incldes the se o= varios other related e&o de=ense mechanisms<
Varyin& research =indin&s may lar&ely re=lect di==erin& operational de=initions o= these
psycholo&ical mechanisms A;oldbec0, 1--'B<
Cost investi&ations have =ond that denial =acilitates acte adRstment to severe
illness and is o=ten associated /ith lo/er morbidity?morality and increases
psycholo&ical /ell%bein& A;oldbec0, 1--'8 7aylor N Armor, 1--GB< For e*ample,
hi&h deniers /ith coronary heart disease hospitali>ed =or cardiac sr&ery spend =e/er
days in intensive care, have =e/er si&ns o= cardiac dys=nction drin& hospitali>ation,
and have better psycholo&ic adRstment drin& the =irst =e/ months o= their
convalescence A6evine et alD9 1-@'8 Fol0s et alD9 1-@@B< Findin&s at one year may be
more ominos in that hi&h deniers may do more poorly, presmably related to
decreased compliance /ith medical treatment A6evine et alD9 1-@'B< Related to this
&eneral concept o= denial is that positive illsions abot the capacity to control oneLs
disease process are related to a sense o= psycholo&ical /ell%bein& A7aylor N Armor,
1--GB< )ch optimism may even in=lence the nderlyin& disease process itsel= by
modi=yin& immne mechanisms in a positive direction A)e&erstrom et alD9 1--@B<
%1-%
7he descriptions o= sel=%deception AdenialB provided above shold be re&arded as that
/hich is characteristic o= normality< Frther, the se o= sch mechanisms may have
!+
both positive and ne&ative aspects< ;reater e*tremes o= sel=%deception are
maladaptive8 =or e*ample, =ailin& to ac0no/led&e si&ns or symptoms o= disease at
sta&es at /hich it can be treated or to believe that one is immne =rom the ill e==ects o=
smo0in& or ris0y se*al behavior< For most people their de&ree o= sel=%deception?sel=%
enhancement is 0ept /ithin acceptable limits by the capacity to respond to =eedbac0
=rom other persons and the environment< Frther, there may be Otime%otsP in /hich
decision ma0in& is =acilitated by reality%based considerations A7aylor N Armor,
1--GB<
3t seems ironic that one o= the principles o= psychoanalysis is that mental health is
associated /ith &reater sel=%a/areness and that the prpose o= psychotherapy is to
provide &reater 0no/led&e and nderstandin& o= the nconscios portions o= or
minds< 7he =indin&s above s&&est that the opposite may be more bene=icial and
increased introspection is not desirable< 7o =nction as a healthy matre adlt
involves the capacity to maintain sel=%esteem thro&h e==ective de=ensive operations
that can be best described as sel=%deceptive, and the presentation to the /orld o= the
pretense o= optimism and con=idence< Dysphoria, incldin& depression, reslts /hen
these =orms o= deceit brea0 do/n<
athologi"al )orms o) de"eit
7he precedin& discssion o= deceit has =ocsed on variations o= normal processes<
Deceit can become so predominant in a personLs li=e as to be the entire =ocs o= bein&
and destrctive to the individal liar himsel= or hersel=< 3nclded are varios =orms o=
impostreship and those /ho ma0e a career ot o= simlated disease< Cany other non%
medical =orms o= deceit are also destrctive to society, sch as varios =orms o= =rad
and =alse and misleadin& advertisin&<
Amon& the varios cate&ories o= patholo&ical =orms o= deceit that become a =ocs o=
attention in psychiatric and medical settin&s are the =ollo/in&<
!abitual lying
)ome persons lie repetitively even /hen the trth /old serve them better< 7hey lie
abot thin&s that apparently ma0e little di==erence to them in terms o= personal &ain,
and o=ten /hen the =alse in=ormation they provide to another person has little
si&ni=icance< Habital AcomplsiveB liars di==er =rom those /ith psedolo&ia =antastica
Asee belo/B in that the =ormer lie repetitively bt do not provide &randiose, =antastic
or lar&ely =abricated stories abot themselves< 7hey are not necessarily sociopathic
altho&h some antisocial behaviors may be mi*ed in amon& their varios
prevarications< As a &eneral rle, complsive liars are preoccpied /ith isses o=
atonomy and may also demonstrate oppositional behaviors< 3n their e==orts to
maintain their personal sense o= sel= they /ithhold in=ormation abot themselves =or
=ear that any disclosres /old represent intrsions pon their
%!"%
atonomy< For e*ample, a hsband /hen Mestioned as to /hy he /as late comin&
home =rom /or0 mi&ht say that he stopped at the dr& store /hen in trth he stopped
!#
at the library< 7hese persons =reMently have trobled interpersonal relationships
becase o= their inabilities to initiate or maintain &enine intimacy in the =ace o= their
pervasive deceit and their need to maintain ri&id interpersonal bondaries< 3n clinical
settin&s they are most =reMently seen by marital therapists in response to complaints
by trobled sposes< $ecase o= its e==ect on interpersonal relationships, habital
lyin& becomes ltimately destrctive to the individal himsel= or hersel=< Habital
liars /ere sally raised in =amilies in /hich there /as little /armth, a==ection and
nconditional acceptance o= the child< 3nstead these =amilies /ere characteri>ed by
athoritarianism, per=ormance%oriented approval, and ri&id controls that prevented the
development o= a matre di==erentiated individal<
Pseudologia fantastica
:sedolo&es en&a&e in a =ascinatin& phenomenon in /hich they not only prevaricate
bt tell stories that have a sli&htly =antastic Mality to them< 7he stories are not so
=antastic that they immediately create sspicion, bt they do have the Mality o=
ma0in& an individal special or niMe< For e*ample, an psedolo&e may tal0 abot
&radatin& =rom a presti&ios niversity, o= athletic e*ploits, o= 0no/in& important
persons, or o= havin& nsal adventres< One patient, previosly reported by me
AFord, 1-'+B, told tales A/hich /ere ori&inally believableB o= bein& an o==icial in the
World Health Or&ani>ation /ith involvement in rescin& orphaned children =rom /ar
>one areas< )he also tal0ed o= 0no/in& a variety o= nationally 0no/n people and
receivin& a/ards =or her hmanitarian e==orts< 3n =act, she /as a middle%class /oman
/ho had never been ot o= her nei&hborhood e*cept to &o to the hospital< :ersons
/ith psedolo&ia =antastica, at best, have mar&inal social adRstment< 7hey may
complete school and be employed, bt at times o= stress they tend to decompensate
and display a variety o= somati>in& disorders< O= importance to note, most persons
/ith psedolo&ia =antastica are the prodcts o= dys=nctional =amilies o= ori&in and?or
demonstrate evidence o= cerebral dys=imction Aespecially de=icits in non%dominant
hemispheric =nctionin&B and?or learnin& disabilities AKin& N Ford, 1-@@8 :ancrat> N
6e>a0, 1-@'B< :sedolo&ia =antastica is apparently the reslt o= e==orts to increase sel=%
esteem bt is also related to a =ailre in the ability to re&late thin0in& and separate
=antasy =rom oneLs verbali>ations<
Pathological denial
:ersons /ith normal development, as noted above, have the capacity to selectively
remember events that are positive and to minimi>e oneLs =ailin&s< Ho/ever some
persons se sel=%deception to an e*treme and patholo&ical e*tent< 7hese persons may
deny reality /hen it stares them in the =ace and they contine to =ail to ta0e
appropriate action and?or persist /ith sel=%inRrios behaviors< For e*ample, 3
%!1%
have seen physicians i&nore their o/n symptoms o= ischemic heart disease8 the reslt
o= /hich /as sdden death< :atients may contine to drin0 ethanol in the presence o=
hepatitis or smo0e ci&arettes /hile receivin& o*y&en =or emphysema< One /oman
/hom 3 sa/ in consltation had denied the presence o= her oran&e%si>e breast tmor
ntil it became lcerated and its malodoros dischar&e necessitated her =amily see0in&
medical care =or her< :ersons /ith addictive problems are characteri>ed by denial o=
!.
the e*tent o= their problems and also pervasive lyin& in their attempts to hide the
addiction =rom sel= and others<
Somati"ing disorders
Altho&h most people do not &enerally consider the somati>in& disorders to be =orms
o= deception, in =act they are< 7hey represent deceptive non%verbal behaviors that
imply disease /hen there is no disease or it is &rossly e*a&&erated< What
di==erentiates the somati>in& disorders =rom other =orms o= abnormal illness behavior
Asee belo/B is the de&ree o= self-deception involved< Altho&h there is considerable
overlap amon& the somato=orm disorders, each /ill be brie=ly and separately
considered<
#onversion symptoms
(onversion symptoms are amon& the most ancient o= all described medical
conditions< 7he person /ith a conversion disorder demonstrates an apparent lac0 o=
=nction in a sensory or motor =nction that implies the presence o= nderlyin& and
&enerally disablin& nerolo&ic disease< 7hese psedonerolo&ic symptoms have, in
recent years, been considered to be =orms o= non%verbal commnication that are
tili>ed /hen more e*plicit verbal commnication is bloc0ed =or any reason< Amon&
the reasons that verbal commnication may be impaired areE lo/ intelli&ence,
nderlyin& central nerolo&ic disease, poor edcation and lac0 o= psycholo&ic
sophistication, and social sitations in /hich a direct e*pression o= distress is
=orbidden Ae<&< on&oin& se*al abse o= a teena&e &irl by a =amily memberB AFord N
Fol0s, 1-@.B< Altho&h deception Ae<&< the =alse appearance o= diseaseB is involved,
the conversion symptom can also be re&arded as a copin& mechanism that serves to
resce a person =rom an intolerable sitation<
Somati"ationdisorder
)omati>ation disorder describes people /ho demonstrate repetitive se o= somatic
symptoms, incldin& pain and conversion symptoms, to obtain medical care and to
see0 the bene=its o= the sic0 role< )imilar to conversion, there is no nderlyin& or&anic
disease or there is &ross e*a&&eration o= any disease process present< )ymptoms
commnicate a deceptive messa&e o= disease to others and, similar to conversion, the
patient is sel=%deceptive concernin& the ori&in o= symptoms< Cost patients /ith
somati>ation disorder are comorbid =or another A*is 3 or A*is 33
%!!%
psychiatric disorder and sbstance abse is also common< Etiolo&ic =actors believed to
be important in the development o= somati>ation disorder inclde a dys=nctional
=amily o= ori&in, over/helmin& social stressors Ae<&< lo/ socioeconomic stats, poor
edcation, sin&le parent stats, absive relationshipsB and cerebral dys=nction AFord,
1-@+B< )omati>ation disorder can be vie/ed as a copin& mechanism8 sin& the sic0
role as a /ay to avoid or minimi>e that /hich is re&arded as over/helmin& li=e
responsibilities<
Pain disorder
!G
:ain disorder involves the e*perience and commnication o= the pain /ith the see0in&
o= medical care< 7he pain cannot be e*plained by 0no/n physiolo&ical? patholo&ical
processes and is s==iciently severe to case impairment?disability< 3t is o= importance
to note that chronic and relatively severe pain is =airly prevalent amon& the &eneral
poplation and only a sbset o= these persons repetitively see0 treatment =or their pain
and, in essence, ma0e a career ot o= pain AFord, 1--.B< 7he e*perience o= pain can be
sel=%deceptive and?or overtly deliberately deceit=l< (hronic pain Ae<&< lo/ bac0 painB
is one o= the most common reasons &iven =or disability and lar&e nmbers o= persons
receive disability bene=its based on their spposed inability to /or0 secondary to pain<
A complaint o= pain can be sed to obtain anal&esic medications incldin& opiates and
other controlled sbstances< 7he complaint o= pain is a =reMent e*cse or
rationali>ation =or =ailre to assme a variety o= adlt activities incldin& se*al
behavior< :ain is a sbRective symptom8 no one 0no/s e*actly /hat another person is
=eelin& and, there=ore, it is easy to deceive abot that /hich one is e*periencin&<
Frther, one can deceive by sin& non%verbal commnications, incldin& &rimacin&,
a/0/ard movements, and postrin& to imply the presence o= pain< 3n a stdy o= pain
clinic patients /ho /ere involved in liti&ation, covert srveillance determined that !"
percent o= them /ere overt malin&erers AKay N Corris%9ones, 1--@B< :sycholo&ic
investi&ations o= pain disorder patients discloses that many, bt by no means all, have
bac0&ronds o= childhood abse A$lmer N Heilbronn, 1-@1B<
$alingering
Calin&erin& is the deliberate prodction, =ei&nin&, or e*a&&eration o= a physical
symptom in order to obtain a discernible e*ternal incentive< E*amples o= malin&erin&
involve =ei&nin& o= a physical illness to avoid military conscription, simlatin&
psychiatric illness to avoid pnishment =or criminal activity, or the =ei&nin& or
prodction o= physical illness in an e==ort to obtain the a/ard o= money in a la/sit
and?or disability bene=its< $ecase malin&erin& is in essence an accsation o=
misbehavior, most physicians are loath to append this label to their patients< As a
reslt, the tre incidence o= malin&erin& is n0no/n, bt is certainly mch hi&her than
/old be reco&ni>ed by a revie/ o= medical records< :hysicians are not detectives
and, there=ore, the in=ormation necessary to detect the presence
%!+%
o= malin&erin& is o=ten absent< 3nsrance companies may, as mentioned above, en&a&e
in covert srveillance /ith videotape recordin&s o= nsspectin& patients< 3 have
vie/ed some o= these videotapes and it is remar0able ho/ di==erently the OpatientP
behaves at home or on vacation as opposed to the medical o==ice /hen they are not
a/are o= bein& observed< An irony is that many o= these individals, /ho mst /or0
hard to prove their illness and disability, ltimately assme the sic0 role as part o=
their identity8 thro&h the process o= pretendin& disability they become trly disabled<
%actitious disorders
Factitios disorders are similar to malin&erin& in that they are consciosly prodced
/ith the &oal o= =oolin& both physicians and acMaintances< Ho/ever, nli0e
malin&erin&, there is no discernible e*ternal incentive other than that o= see0in& the
sic0 role< 7he capacity o= some o= these patients to simlate rare or dramatic illnesses
!'
is trly remar0able AFeldman N Ford, 1--#8 Feldman N Eisendrath, 1--GB< Cany o=
the patients also en&a&e in a variety o= other types o= prevarication, incldin&
psedolo&ia =antastica< E*perience /ith a lar&e nmber o= these patients s&&ests that
many start as =actitios disorders, bt becase o= secondary bene=its =rom their
illnesses, symptoms are perpetated by e*ternal incentives8 ths, =actitios disorder
evolves into malin&erin& AEisendrath, 1--GB< 7he pervasive deceit o= these patients
/ith =actitios disorder ma0es it di==iclt to obtain accrate in=ormation abot their
personal histories< 7hat in=ormation /hich is available s&&ests that the maRority o=
these patients s==er =rom severe personality disorders and?or some =orm o= cerebral
dys=nction< Cany o= the patients come =rom clearly dys=nctional homes
characteri>ed by illness, abse, or abandonment AFord, 1-@+B<
3n smmary, this brie= revie/ o= persons =or /hom deceit has &one a/ry and become
patholo&ical s&&ests that many have some evidence o= cerebral dys=nction and?or
=ailed to achieve normal developmental tas0s that =acilitated their capacities =or
e==ective social interchan&e to obtain their needs< 3nstead o= sin& sophisticated =orms
o= Asel=%Bdeception, their crde employment o= deceit=l behaviors is maladaptive<
8'mmary="on"l'sions
Deceit, /hich is pervasive thro&hot the animal 0in&dom, reaches its hi&hest
evoltionary development in hmans< Deception?sel=%deception is a =act o= everyday
li=e, so common as to be =reMently ot o= or minte%to%minte conscios a/areness<
7he s0ills o= deception?sel=%deception represent developmental tas0s that reMire both
intact hi&her cortical =nctions and an e*tended period o= normal sociali>ation,
incldin& e==ective parentin&< )el=%deception in the =orms o= sel=%enhancement and
positive illsions helps to protect s =rom depression Aand other
%!#%
psycholo&ic distressB and provides stren&th to cope /ith physical disease< Or s0ills at
lyin& o=ten serve to help maintain social spport<
Obviosly not all deceit is positive8 in =act, it can be devastatin& to the sel= and others<
:atholo&ical lyin& involves lies to others and?or onesel= that are inRrios to the sel=< 3t
is, as a &eneral rle, associated /ith impaired hi&her co&nitive =nctions and?or
dys=nctional parentin&?sociali>ation< 7hs, patholo&ic lyin& re=lects de=icits in basic
e&o =nctions as /ell as in the spere&o< Ho/ever, =or normal persons lyin& and sel=%
deception provide mechanisms by /hich /e maintain sel=%esteem and spport others<
7o Mote Niet>sche%OWe need lies in order to live<P
!e)eren"es
Alloy, 6<$< N Abramson, 6<Y< A1-'-B< 9d&ment o= contin&ency in depressed and
nondepressed stdentsE sadder but "iser0 Eournal of 5.perimental Psychology3
General,$62, ##1%#@.<
Alloy, 6<$< N Abramson, 6<Y< A1-@!B< 6earned helplessness, depression, and the
illsion o= control< Eournal of Personality & %ocial Psychology,,%, 111#%11!G<
Anderson, R<E< N Obenshain, )<)< A1--#B< (heatin& by stdentsE =indin&s,
!@
re=lections, and remedies< cademic ?edicine,.#, +!+%++1<
$lmer, D< N Heilbronn, C< A1-@1B< 7he pain%prone disorderE a clinical and
psycholo&ical pro=ile< Psychosomatics,%%, +-.%#"!<
$odrea*, A<C< A1--!B< 3nte&rity in the National Resident Catchin& :ro&ram
AletterB< E?,%.2, ++1.<
De:alo, $<C< A1-@@B< Nonverbal aspects o= deception< Eournal of <on'erbal
Beha'ior,$%, 1.+%1G1<
De:alo, $<C< N $ell, K<6< A1--GB< 7rth and investmentE lies are told to those
/ho care< Eournal of Personality & %ocial Psychology,4$, '"+%'1G<
De:alo, $<C< N Kashy, D<A< A1--@B< Everyday lies in close and casal
relationships< Eournal of Personality & %ocial Psychology,4,, G+%'-<
De:alo, $<C<, Kashy, D<A<, Kir0endal, )<E<, Wyer, C<C<, N Epstein, 9<A<
A1--GB< 6yin& in everyday li=e< Eournal of Personality & %ocial Psychology,46,
-'-%--.<
deWaal, F< A1-@GB< Deception in the natral commnication o= chimpan>ees< 3n
R<W< Citchell N N<)< 7hompson AedsB, Deception3 Perspecti'es on human and
nonhuman deceit App< !!1%!##B< Albany, NYE )tate ,niversity o= Ne/ Yor0
:ress<
Eisendrath, )<9< A1--GB< When Cnchasen becomes malin&erin&E =actitios
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<ursing,$2, -+@%-#"<
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)ac0heim, H<A< N We&ner, A<H< A1-@GB< Attribtional patterns in depression and
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)atran, :<R< A1--+B< 7he lies /e tell =or love< Redboo!, 9an<, .G%.-<
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accomplishments by applicants =or &astroenterolo&y =ello/ships< nnals of
#nternal ?edicine,$%&, +@%#1<
)hibles, W< A1-@.B< Lying3 a critical analysis< White/ater, W3E 6an&a&e :ress<
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7aylor, )<E< N $ro/n, 9<D< A1-@@B< 3llsion and /ell%bein&E a social
psycholo&ical perspective on mental health< Psychological Bulletin,$6&, 1-+%!1"<
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Biology,,., +.%.'<
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7c0ett, A< A1--@B< O$endin& the trthPE pro=essionalsL narratives abot lyin& and
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Vase0, C<E< A1-@GB< 6yin& as a s0illE the development o= deception in children< 3n
nonhuman deceit App< !'1%!-!B< Albany, NYE )tate ,niversity o= Ne/ Yor0
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!!!<
%!@%
Chapter %
The so"ial sharing o) emotion
lll'sory and real *ene)its o) talking a*o't emotional experien"es
Bernard RimJ9 G"Jnola Ferbette and %usanna Corsini
Talking a*o't emotional experien"es
7al0in& abot an emotional e*perience is a /ell%0no/n and common conseMence o=
e*posre to very intense ne&ative emotional conditions< As early as 1-1", William
9ames, a=ter /itnessin& the )an Francisco earthMa0e, /rote to :ierre 9anet abot the
victimsL apparent need to tal0 abot their e*periences< At ni&ht, he noted, it /as
impossible to sleep in the tents /hich served as temporary hosin& =or the earthMa0e
victims, de to the continos verbal e*chan&es A9anet, 1-!G?1-'., p< +!GB< 7his early
anecdotal observation /as con=irmed in srveys condcted on )an Francisco residents
a=ter the 6oma :rieta EarthMa0e< :enneba0er and Harber A1--+B recorded that one
/ee0 a=ter this earthMa0e, the avera&e person still tho&ht and tal0ed abot it nine
times per day< )imilarly, one /ee0 a=ter the be&innin& o= the :ersian ;l= War, these
athors observed that the avera&e Dallas residents tho&ht and tal0ed abot the /ar
1! times daily< Accordin& to 9ano==%$lman A1--!, p< 1"@B, people /ho are e*posed
to stron& ne&ative emotional circmstances e*perience a seemin&ly insatiable need to
tell others abot their e*perience, as i= they =elt coerced into tal0in&< Data =rom
nmeros sorces docment the pervasiveness o= this phenomenon< 7he need to tal0
++
abot their e*perience /as mentioned by @@ percent o= rescers operatin& in a North
)ea oil plat=orm disaster AErsland et alD9 1-@-B, by @@ percent o= people /ho had
recently lost a relative A)choenber& et alD9 1-'.B, and by @G percent o= patients /ith a
recent dia&nosis o= cancer ACitchell N ;lic0man, 1-''B< 3n sm, there is stron&
evidence that e*posre to a maRor ne&ative emotional event elicits a need to be /ith
others and to tal0 abot it<
&he social sharing of emotion
Research condcted by or &rop at the ,niversity o= 6ovain in the past decade
revealed that a comparable behavior develops a=ter any emotional e*perience< 3t is not
typical solely o= trama or o= maRor ne&ative li=e events< 3t develops a=ter everyday
emotional events o= all 0inds< 7his is /hat /e =ond by investi&atin& Othe social
sharin& o= emotionP< 7he social sharin& o= emotion is a process that
%!-%
ta0es place drin& the hors, days, and even /ee0s and months =ollo/in& an
emotional episode< 3t involves the evocation o= an emotion in a socially shared
lan&a&e to some addressee by the person /ho e*perienced it ARimQ, 1-@-8 RimQ et
alD9 1--1aB< Or empirical research sho/ed that /hen people e*perience an emotion,
they very &enerally%in @" to -. percent o= cases%tal0 abot it ARimQ et alD9 1--1a,
1--1b8 =or revie/s, see RimQ et alD9 1--!, 1--@B< 7he stdies revealed that this
propensity is not dependent pon peopleLs level o= edcation< 3t is evidenced /hether
the persons hold a niversity de&ree, or /hether their edcation /as limited to
elementary school< 3t is also observed /ith appro*imately eMal importance in
cltres as diverse as Asian, North American and Eropean ones< 7he type o= primary
emotion =elt in the episode appears not to be a critical =actor /ith re&ard to the need to
tal0 abot it< Episodes /hich involved =ear, or an&er, or sadness are reported to others
as o=ten as episodes /hich involved happiness or love< Ho/ever, emotional episodes
involvin& shame and &ilt tend to be verbali>ed to a some/hat lesser de&ree<
7hese observations lead s to conclde that the process o= tal0in& a=ter emotional
e*periences has a very hi&h &enerality< 3n a maRority o= cases, it starts very early a=ter
the emotion%sally on the day it happened< 3t e*tends over /ee0s or even months
/hen the episode involved a hi&h intensity o= emotion and it is typically a repetitive
phenomenon, i<e< the emotions are &enerally shared o=ten or very o=ten, and /ith a
variety o= tar&et persons<
&heparadox o) so"ial sharing
Accessin& the memory o= an emotional episode &enerally has the e==ect o= reactivatin&
the varios components Ai<e< physiolo&ical, sensory, e*perientialB o= the emotion
involved Ae<&< $o/er, 1-@18 6an&, 1-@+8 6eventhal, 1-@#B< Does the same happen
drin& the social sharin& processT 3n order to ans/er that Mestion, RimQ et alD
A1--1bB had participants recall and describe at len&th a past emotional e*perience<
7hey /ere then as0ed Mestions abot /hat they e*perienced /hile recallin& and
sharin&< Nearly all o= them reported e*periencin& vivid mental ima&es o= the event<
Reports o= =eelin&s and bodily sensations /ere only sli&htly less =reMent< 7he type o=
primary emotion involved ARoy, an&er, =ear, or sadnessB had no si&ni=icant impact on
+#
these variables, altho&h it in=lenced the pleasantness o= the social sharin& sitation<
Not srprisin&ly, reportin& an e*perience o= Roy /as rated as more pleasant than
reportin& an emotion o= sadness, o= =ear, or o= an&er< Core srprisin& /as the =act that
reportin& =ear, sadness or an&er /as rated by only a minority o= the participants as
pain=l or e*tremely pain=l< Not/ithstandin& the reactivation o= vivid ima&es,
=eelin&s, and bodily sensations o= a ne&ative emotional e*perience, the sharin& did not
appear as aversive as one cold have e*pected< 7his /as con=irmed by participantsL
ans/ers to the Mestion o= /hether they /old be /illin& to nderta0e the sharin& o=
another emotional memory o= the same type as the =irst one< 3ndeed, -+<' percent o=
the participants &ave a positive ans/er< 7he proportion /as similar in all =or emotion
conditions< 7hese data ths de=initely
%+"%
reveal the parado*ical character o= social sharin& sitations< On one hand, social
sharin& reactivates the varios components o= the emotion, /hich, in the case o=
ne&ative emotion, shold be e*perienced as aversive< On the other hand, sharin& an
emotion, /hether positive or ne&ative, does seem to be a sitation in /hich people
en&a&e /illin&ly< 3n =act, =ield e*perience reveals that bein& open to the sharin& o=
peopleLs emotions is one o= the nicest &i=ts that can be o==ered to them<
5oes so"ially sharing an emotion "ontri*'te to emotional re"overy-
Why are people so /illin& to en&a&e in a social process in /hich they re%e*perience
ne&ative a==ectsT One /old assme that some po/er=l incentive drives them to do
so and that they =ind some important bene=it in it< What cold this pro=it beT (ommon
sense o==ers a ready%made ans/er to this Mestion< 3ndeed, /e commonly assme that
verbali>in& an emotional memory can trans=orm it and that a=ter verbali>ation, this
memory /old lose a si&ni=icant part o= its emotional load< A stdy by Hech A!"""B
sho/ed that more than @" percent o= the respondents in a lar&e sample o= adlt
laypersons endorsed sch a vie/< 3= this laypersonLs belie= /as tre, i= data cold
con=irm that verbali>in& emotions brin&s Oemotional recoveryP or Orelie=P, then the
parado* /old clear p< :eople /old tolerate re%e*periencin& ne&ative emotions
becase o= this =inal pro=it< We ths e*amined this Mestion in a lar&e nmber o=
stdies A=or a revie/, see RimQ et alD9 1--@8 Hech, !"""B< 3n all o= them, participants
rated the level o= emotional distress =elt /hen recallin& a speci=ic emotional episode<
We e*amined ho/ =ar this ratin& evolved as a =nction o= the social sharin& o= the
episode, i<e< to /hat e*tent sharin&, /hich develops spontaneosly a=ter an emotional
event, contribtes to relieve people =rom its emotional impact<
Spontoneousso"ial sharing and emotional re"overy
3n most o= or stdies on spontaneos social sharin&, the research desi&n &enerally
involved the assessment o= A1B the initial intensity o= the emotion elicited by the
episode, A!B the e*tent o= social sharin& that developed a=ter the event, and A+B the
residal intensity o= the emotion elicited /hen the episode /as recalled later< We
tested the hypothesis o= a positive association bet/een the amont o= social sharin&
developed spontaneosly a=ter the emotional event and the de&ree o= emotional
recovery, this latter variable bein& assessed by the di==erence bet/een A1B and A+B< We
+.
e*pected that the more people socially shared an emotional episode, the more they
/old =eel relieved<
7his hypothesi>ed association /as =irst considered in one o= the recall stdies
condcted by RimQ et alD A1--1a, )tdy GB, /hich demonstrated that neither the
amont nor the delay o= social sharin& /as related to emotional recovery< EMally, in
t/o stdies on emotional secrecy AFin0enaer N RimQ, 1--@aB, emotional recovery
=ailed to discriminate bet/een shared and non%shared emotional memories<
%+1%
Assessments o= stress=lness and tramatic impact also =ailed to spport the
prediction that secret events /old be less recovered =rom than shared ones< Overall,
or stdies on emotional secrecy s&&ested that tal0in& abot an emotional e*perience
does not contribte to emotional recovery< Additionally, in one o= the diary stdies
mentioned above ARimQ et alD9 1--#, )tdy +B, recovery /as assessed by the
di==erence bet/een the impact each daily event had /hen it occrred and its residal
impact as rated at =ollo/%p several /ee0s later< A&ain, no si&ni=icant relation /as
observed bet/een this recovery inde* and e*tent o= social sharin& mani=ested /hen
the event happened<
)imilar analyses /ere condcted in many other correlational stdies o= social sharin&<
7hey all consistently yielded the same ne&ative reslts, =ailin& to spport the
prediction that verbali>in& an emotional e*perience redces the emotional load
associated /ith the memory o= this e*perience< )hold /e ths conclde =rom these
diary data that the social sharin& o= emotion has no e==ect on emotional recoveryT
Research condcted by :enneba0er and collea&es A=or a revie/, see :enneba0er,
1-@-B s&&ested that certain Malitative aspects o= sharin& shold be considered< For
instance, :enneba0er and $eall A1-@GB had participants /rite essays on previosly
nrevealed tramas< Dependent on the condition they /ere assi&ned to, participants
had to describe either the =acts or the =eelin&s elicited by the episode, or both =acts and
=eelin&s< As compared to a control condition in /hich participants /rote on trivial
topics, =ollo/%p health assessments evidenced positive e==ects =or people /ho
described their =eelin&s, or their =eelin&s and the =acts, bt not =or those /ho only
&ave a description o= the =acts< Emphasi>in& the =eelin& dimension may ths be
critical =or social sharin& to have some impact< 3n sch terms, the e*tent to /hich
people e*press their emotions and =eelin&s is e*pected to correlate /ith recovery<
Ho/ever, assessin& Malitative aspects o= spontaneos social sharin& in srvey
research raises several di==iclties< 3n &eneral, respondents do not seem to be able to
speci=y /hat they tal0ed abot in their previos social sharin&, nor /hich aspect A=acts
or =eelin&sB they shared most< 7here=ore, sbseMent stdies /ere condcted sin& an
e*perimental indction o= social sharin& o= emotion<
'nduced sharing and emotionalre"overy
3n several e*perimental stdies, /e systematically e*plored ho/ =eelin&s
commnicated thro&h social sharin& mi&ht a==ect emotional recovery, comparin&
several types o= sharin&< RimQ et alD A1--GbB compared =or di==erent modes o=
sharin& emotions =or their e==ect pon emotional recovery< One hndred and thirty
+G
psycholo&y stdents enrolled in an advanced class on emotion each intervie/ed one
o= their relatives /ho had a&reed to contribte to the stdentLs trainin& in the practice
o= intervie/in&< )tdents =irst as0ed the volnteer to recall a recently e*perienced
ne&ative emotional event and then to indicate the emotional impact this memory still
had< A one%hor social sharin& intervie/ centered arond the ne&ative emotional
episode /as then condcted by the intervie/ee accordin& to
%+!%
one o= =or di==erent modes to /hich s?he had been randomly assi&ned< 7he stdents
/ere provided /ith detailed instrctions on ho/ to condct the intervie/< 3n a =irst
mode, the =ocs /as on =actal aspects< 3n the second, it /as on =eelin&s and emotions
e*perienced drin& the episode< 3n the third one, the accent /as on the meanin&s
elicited by the episode, /hile in the =orth mode, the relative tal0ed abot the episode
=reely /ith no speci=ic instrctions<
Dependent measres inclded seven di==erent indices o= emotional recovery obtained
=rom sbtractin& participantsL ratin&s collected one /ee0 a=ter the intervie/ =rom
those collected be=ore the intervie/< 3n &eneral, no si&ni=icant e==ect o= intervie/in&
mode /as =ond =or any o= these indices< )imilarly, no e==ect o= mode /as =ond on
e*tent o= social sharin& in the corse o= the /ee0 =ollo/in& the intervie/< 7hs, the
speci=ic intervie/in& modes did not di==er in their capacity to elicit emotional
recovery or emotional relie=<
3ntervie/ersL ratin&s o= the e*tent to /hich the participant had been emotionally
e*pressive drin& the sharin& sitation, ho/ever, s&&ested that this individal
di==erence variable /as correlated /ith emotional recoveryE the more participants
/ere perceived as e*pressin& their emotions, the &reater /as their recovery a=ter the
episode< 7hs, more attention shold be paid to the role o= individal di==erences in
emotional e*pression in this conte*t< Finally, ratin&s collected be=ore the intervie/ on
the impact the event still had si&ni=icantly predicted the e*tent o= social sharin&
reported by the person in the /ee0 =ollo/in& the intervie/< 7his reslt is clearly
consistent /ith =indin&s =rom previos stdies sho/in& that more intense emotions
are more e*tensively shared than less intense ones< All in all, this stdy led to the
conclsion that emotional recovery is better predicted by OnatralP individal
di==erences in sharin& mode than by e*perimentally indced ones< Also, episode%
related emotionality =elt be=ore the intervie/ cold predict the e*tent o= social sharin&
developed a=ter, /hereas intervie/in& modes =ailed to impact si&ni=icantly on this
variable<
replication in the laboratory
3n the stdy Rst described, stdents actin& in their natral environment condcted the
social sharin& intervie/s< We =elt the need to condct a similar stdy in the more
controlled conditions o= a laboratory environment< Hech A!"""B assi&ned
nder&radate volnteers to three conditions o= verbally sharin& an emotional
memory, each condcted by the same intervie/in& person< 3n t/o conditions,
participants /ere instrcted to tal0 e*tensively abot the most psettin& event o= their
li=e, /ith a =ocs either on =elt emotions AO=eelin& conditionPB or on =acts and
circmstances AO=act conditionPB< 3n a third condition AOcontrolPB, participants simply
+'
mentioned the psettin& event and then had to tal0 e*tensively abot a trivial topic<
Dependent variables Adistress /hen recallin& the psettin& event, bodily symptoms,
and emotional impactB /ere collected =or timesE A1B be=ore the sharin& sitation, A!B
immediately a=ter, A+B at one /ee0 =ollo/%p, and A#B at a =ollo/%p session t/o
months later<
%++%
Caniplation chec0s revealed mar0ed di==erences bet/een &rops in the e*pected
directions< :articipants in the emotion condition rated their sharin& as bein& more
emotionally e*pressive than participants in the =act and control conditions< Emotion
and =act participants rated their sharin& as deeper, more personal and more important
than control participants< Frthermore, compared /ith emotion and =act participants,
control participants reported havin& tal0ed in a more detailed manner abot &eneral
=acts and havin& been more descriptive<
3t /as predicted that participants in the t/o trama%disclosre conditions /old sho/
less distress, bodily symptoms, and emotional impact than control participants, and
that this e==ect /old be even stron&er =or participants in the OemotionP condition than
=or those in the O=actP condition< 3ndividal recovery scores AOtime 1Omins Otime +P8
Otime 1P mins Otime #PB /ere compted =or each dependent variable< (ontrary to
e*pectations, no si&ni=icant reslts /ere =ond< 7hs, social sharin& o= emotions /as
not sho/n to a==ect lon&%term /ell%bein& or emotional recovery =rom the event,
irrespective o= an emphasis on the emotional aspect or on the =actal aspect<
3n a =inal Mestionnaire, participants rated to /hat e*tent they =ond the e*periment
meanin&=l and interestin&, as /ell as the e*tent to /hich they tho&ht the intervie/
had in=lenced their vie/ o= the emotional event< Analyses o= their ans/ers yielded
si&ni=icant di==erences bet/een conditions< :articipants in the emotion condition rated
the social sharin& as more meanin&=l, more interestin&, and hi&her in overall
sbRective impact than participants in the other t/o conditions< 7hs, the emotional
social sharin& elicited the =eelin& that it ma0es sense to share events and that it may
help to alleviate the emotional memory more than the other t/o conditions< Yet, in
spite o= this evidence collected retrospectively thro&h overt declarative bases, indices
o= emotional recovery &athered in the stdy =ailed to provide data consistent /ith
these declarations<
7hese ne&ative reslts raise many Mestions< First, one may /onder /hether the
concept o= emotional recovery ma0es any sense at all< RimQ et alD A1--GaB addressed
this Mestion, /hen as0in& stdents to recall t/o recent npleasant emotional
e*periencesE one that they considered bein& recovered =rom and one that they had not
yet recovered =rom and /hich /as ths still considered as bein& a case o= distress<
For each e*perience, participants rated initial Aat the time o= the eventB and residal Aat
the time o= the e*perimentB emotional impact, as /ell as initial and residal sharin&<
7he reslts sho/ed that both types o= episodes elicited comparable initial emotional
impact as /ell as comparable initial sharin&< Ho/ever, con=irmin& that the notion o=
OrecoveryP ma0es sense, the t/o types o= episodes di==ered mar0edly in their residal
emotional impact and ths yielded mar0ed di==erences on the recovery inde*<
(onsistent /ith =ormer =indin&s sho/in& that more intense emotions are more
+@
e*tensively shared, data sho/ed that episodes not recovered =rom elicited more
residal sharin& than recovered ones<
%+#%
$ere sharing cannot change the memory of an emotion
Or data sho/ that a=ter e*periencin& an emotional episode, /hether positive or
ne&ative, people =eel compelled to tal0 abot it< A /idespread belie= pholds the idea
that socially sharin& an emotion brin&s emotional relie=< $oth laypersonsL naUve
representation and some pro=essional vie/s o=ten attach the old Ocathartic notionP to
the mere Opttin& o= emotion into /ordsP< 7hey e*pect that pttin& an emotion into
/ords /old have the e==ect o= b==erin& or o= eliminatin& the emotional memory<
Or data clearly =ailed to spport sch a notion< 7hey lead s to conclde that the
cathartic notion is an illsion8 the simple =act o= socially sharin& an emotion does not
have the po/er to chan&e the emotional memory< A=ter all, this idea does ma0e sense
in terms o= adaptation< An emotional memory carries important in=ormation re&ardin&
=tre sitations that may be encontered< 3= /e had the potential to alter the emotion%
arosin& capacities o= sch memories by merely tal0in& abot them, sch a tool /old
deprive s o= the vital =rits o= or e*perience<
7his conclsion shold be considered very care=lly< 6et s stress that it re&ards the
mere 'erbali@ation of an emotional e.perience9 a response re=lectin& the stron& r&e
to share &enerally mani=ested a=ter an emotional episode< Or conclsion, ho/ever,
does not imply that verbali>in& and sharin& o= emotion /old be devoid o= e==ects
/hen developed in a proper conte*t in /hich appropriate co&nitive and social =actors
/old come in response, sch as in conselin& and psychotherapy< )peci=yin& the
precise conditions nder /hich the sharin& o= an emotional e*perience can brin& relie=
and recovery, ho/ever, is still a Mestion lar&ely open to investi&ation<
8ome other *ene)its o) so"ially sharing an emotion
3= the sharin& o= emotions spontaneosly developed a=ter emotional e*posre does not
a==ect the recovery process, /hy does it accompany emotional e*periences almost
systematicallyT )hold it be conclded that the r&e to share &enerally elicited by
e*posre to emotional events is a seless mani=estationT Alternative potential e==ects
o= socially sharin& an emotion are probably nmeros and may involve important
health, co&nitive and social =nctions< Ho/ever, they may be mas0ed to or eyes
becase /e /ere =ocsed on the idea that social sharin& served emotional relie=
=nctions< 3n the =ollo/in&, /e discss some other possible bene=its that have already
been observed or are crrently nder investi&ation<
Sub(ective benefits of social sharing
Hech A!"""B instrcted a lar&e nmber o= psycholo&y stdents to condct an intervie/
in /hich a relative /old speci=y, rate, and then share an emotional episode, /hich
this person had not yet recovered =rom< 3n control conditions, an
%+.%
+-
emotional event o= the same 0ind /as also speci=ied and rated, bt the relative either
shared a non%emotional episode, or did not share at all< 7hree days later, the emotional
impact o= the tar&et event /as assessed a&ain< 3n addition, relatives /ere as0ed to rate
their perceived bene=its o= the sharin& session< (on=irmin& previos =indin&s, no
di==erences bet/een conditions occrred =or emotional recovery< Ho/ever,
participants /ho had shared an emotional event reported mch more other bene=its
than those in the t/o control conditions< 7he di==erences re&ardedE AiB &eneral bene=its
Ae<&< the session /as meanin&=lB8 AiiB relie= Ae<&< the session made them =eel betterB8
AiiiB co&nitive bene=its Ae<&< the session helped them nderstand themselves betterB8
and AivB interpersonal bene=its Ae<&< they =elt nderstoodB< 7hese observations
replicated those made in the laboratory stdy mentioned in the previos section<
Alto&ether, these data sho/ that, altho&h social sharin& does not brin& emotional
recovery, people e*perience the sharin& o= an emotion as clearly bene=icial< 3n or
crrent research, /e try to speci=y /hich =actors are instrmental in elicitin& sch
=eelin&s<
Self-disclosure andhealth
:enneba0er has been investi&atin& the e==ects o= e*pressin& emotion on physical
health< 3n his theory o= inhibition, :enneba0er Ae<&< 1-@., 1-@-B proposed that the
conscios e==orts e*erted in order to inhibit tho&hts, =eelin&s, or behavior reMire
physiolo&ical /or0< When sch e==orts are e*erted chronically, the probability o=
developin& stress%related physical and psycholo&ical problems increases< 7he
prediction that =ollo/s this theory is that pttin& stress or trama into /ords redces
the physiolo&ical /or0 and is ths bene=icial to health< Varios stdies tested this idea
and &enerally con=irmed that e*pression o= trama%related =eelin&s and tho&hts
impacts positively on health indicators Ae<&< Esterlin& et alD9 1--#8 :enneba0er et alD9
1-@-8 1--"8 :enneba0er N $eall, 1-@G8 :enneba0er N OLHeeron, 1-@#B< 7o illstrate,
as compared to stdents /ho merely reported =acts, those /ho disclosed a past
personal trama in enhancin& their deepest emotions and =eelin&s sho/ed less
=reMent visits to the camps health center and =e/er sel=%reported illnesses in a si*%
month =ollo/%p A:enneba0er N $eall, 1-@GB< 7hs, altho&h the sharin& o= emotions
does not relieve the emotional load o= the event, it is associated /ith physical health
improvement A=or a discssion, see :enneba0er et alD9 !""1B<
7his =indin& /as replicated by Fin0enaer and RimQ A1--@aB in the conte*t o= a stdy
on non%shared emotions and emotional secrecy< Anonymos participants indicated i=
they cold recall an important emotional li=e event that they 0ept secret< 3n addition,
they rated scales assessin& health stats, li=e satis=action, and ne&ative a==ectivity< 7he
data revealed that participants /ith the memory o= a non%shared emotion reported a
hi&her nmber o= health problems than those /ithot sch a memory< Also, they /ere
overall less satis=ied /ith their lives<
%+G%
#onsolidatingthe memory o) the emotional episode
$ecase o= its repetitive aspect, the social sharin& o= an emotion contribtes to the
consolidation o= the memory o= the emotional episode, leadin& to a vivid memory o=
those events that ca&ht people by srprise< Fin0enaer et alD A1--@B investi&ated the
#"
memory o= the ne*pected death o= $el&imLs 0in& $adoin in a lar&e sample o=
$el&ian citi>ens< 7he data revealed that the ne/s o= the 0in&Ls death had been /idely
socially shared< $y tal0in& abot the event, people &radally constrct a social
narrative and a collective memory o= the emotional event< At the same time, they
consolidated their o/n memory o= the personal circmstances in /hich the event too0
place< 7ho&h this in=ormation may not be critical to personal adaptation /here the
0in&Ls death is concerned, the in=ormation stora&e is probably o= hi&h srvival vale
/hen personal emotional events are involved< 7he more an event is socially shared,
the more it /ill be =i*ed in peopleLs minds< )ocial sharin& ths may help to conteract
some de=ense mechanisms< Natrally, people shold be driven to O=or&etP ndesirable
events< 7hs, someone /ho Rst lost a close relative o=ten inclines initially to deny the
death< 7he repetitive social sharin& o= the loss po/er=lly contribtes to realism<
Processingand "onstr'"ting the emotional memory
)ocial sharin& can also contribte to the constrction o= the memory o= emotions<
With their partnerLs aid, the person can add some o= the meanin&s that /ere missin&
so that a partially re/ritten interpretation can be stored in memory< Emotion
challen&es the belie=s that people hold in order to preserve a sense o= coherence,
predictability and control over themselves and the /orld A9ano==%$lman, 1--!8
:ar0es, 1-'!8 7ait N )ilver, 1-@-B< Hence, emotion elicits a mental O/or0in&
thro&hP process aimed either at the restoration o= belie=s or at =indin& meanin& in the
event Ae<&< )ilver N Wortman, 1-@"8 7ait N )ilver, 1-@-B< )ocial sharin& can be
e*pected to play some role in completin& the co&nitive bsiness elicited by the
emotion< (onsistent /ith this, Fin0enaer and RimQ A1--@bB observed that, as
compared to shared emotional memories, non%shared memories /ere associated /ith
A1B &reater search =or meanin&, A!B &reater e==orts at nderstandin& /hat had
happened, and A+B &reater attempts at Opttin& order in /hat happenedP< )imilar items
/ere later inclded in several stdies in /hich the memory o= an emotional
e*perience /as investi&ated some time a=ter the occrrence o= the event< 3n each o=
these stdies, a si&ni=icant positive correlation /as obtained bet/een need =or
completion and need =or sharin&< Ftre research shold e*amine ho/ =ar social
sharin& actally involves sch a completion tas0< 3t shold also e*plore to /hat e*tent
the considered process cold contribte to reinstate in the person a sense o= coherence
and predictability, as /ell as a sense o= control and mastery<
%+'%
Enhancing interpersonal relationships and socialintegrotion
)ocial sharin& has the po/er to re=resh and to stren&then social ties< )peci=ic
dynamics ta0e place bet/een the spea0er and the listener< A typical response o= the
listener is the e*pression o= interest in the emotional story A(hristophe N RimQ,
1--'B, as people tend to be particlarly attracted to this type o= story< Another
response o= the listener is empathy< 7he more emotional a story is, the more the
listener /ill e*perience emotion, and /ill conseMently e*press spport and /armth<
A third response is attraction< 7he more the story reMests his or her interest and
spport, the more the listener Oli0esP the spea0er< And this is also tre =or the other
/ay arond< 7he more the spea0er receives interest and spport, the more he or she
/ill Oli0eP the listener< (hristophe and RimQ observed that /hen intense emotions are
#1
shared, listeners redce their se o= verbal mediators in their responses< As a
sbstitte, they display non%verbal com=ortin& behaviors, li0e h&&in&, 0issin&, or
tochin&< 7his s&&ests that sharin& an intense emotional e*perience may decrease the
physical distance bet/een t/o persons, ths contribtin& to the maintenance and
improvement o= interpersonal relationships and social inte&ration<
#onstructionand dissemination o) so"ial kno1ledge on emotion
)ocial sharin& does not only have an impact on the individal memory< 7hro&h
OsecondaryP and OtertiaryP social sharin&, the commnity srrondin& the individal
is in=ormed abot /hat happened to him or her< A hi&h%intensity emotional
e*perience is sally shared /ith more than si* people in the =ollo/in& hors and
days< Each o= these people then has a hi&h probability o= en&a&in& in secondary social
sharin& /ith an avera&e o= at least t/o other persons /ho, in trn, are inclined to
share the emotional episode that they heard A(hristophe, 1--@B< 7hs, in a very short
time span, any emotional event o= some importance is spread across a broad social
&rop< Recently, it /as sho/n that people store a lar&e amont o= in=ormation abot
emotional events, emotional =eelin&s, and emotional responses Ae<&< Rssell et alD9
1--.B< 3t /as also sho/n that this 0no/led&e is represented collectively in the =orm o=
emotion prototypes A)haver et alD9 1-@'B, or o= social schemata ARimQ et alD9 1--"B<
7his social 0no/led&e abot emotion carries in=ormation that is critical to adaptation<
7he social sharin& o= emotion appears to be a maRor potential contribtor to the
continos e*tension and pdatin& o= this 0no/led&e<
Con"l'ding "omments
3n conclsion, the research described in this chapter /as consistently =aced /ith three
sets o= =acts< First, there is abndant evidence that people /ho e*perienced
%+@%
an emotional e*perience /ant to tal0 abot it and /ant to share it socially despite the
emotional reactivation that is arosed in the process< )econd, or stdies
systematically =ailed to provide evidence that sharin& an emotional e*perience has the
e==ect o= alleviatin& the emotional memory< 7hird, in the corse o= these stdies, /e
very consistently observed that a=ter havin& shared an emotion, participants e*pressed
positive =eelin&s and sbRective bene=its< 7his set o= =acts ths raises a nmber o=
Mestions< Why do people /ant to share their emotionsT Why do they have positive
=eelin&s a=ter havin& shared their emotionsT 7o be able to ans/er this Mestion, /e
need to reconsider /hat is &oin& on e*actly in an emotional e*perience<
We 0no/ that emotion arises =rom rapid and atomatic meanin& analyses o=
spervenin& events Ae<&< FriRda, 1-@G8 )cherer, 1-@#B< For e*ample, i= meanin&s sch
as Odan&erP, Ono controlP, Ono escapeP are elicited in a sitation one is =aced /ith, a
variety o= emer&ency reactions /ill develop in oneLs body and one /ill e*perience
=ear< 7here is, ho/ever, a second /ave o= meanin&s in emotion that people are
&enerally na/are o=< )itation%speci=ic meanin&s sch as Odan&erP, Ono controlP, Ono
escapeP spread to broader meanin&s sch as Othe /orld is nsa=eP, O3 am vlnerable
and helplessP, and Oli=e is n=airP< Ceanin&s o= this 0ind a==ect ho/ one vie/s the
/orld and ho/ one vie/s onesel=< 3n other /ords, they pervade /hat /e /old li0e to
#!
re=er to as OoneLs symbolic niverseP< What is meant by symbolic niverseT 3n crrent
li=e, people live and behave nder a sbRective canopy o= apparent order and meanin&%
a symbolic niverse< 7han0s to it, they can =ace the /orld and mana&e it relatively
peace=lly< 7han0s to it, they can act as i= it /as Rst normal that they stand here on
this planet, some/here bet/een the Cil0y Way and Eternity< Emotional events o=ten
have the po/er to ndermine this delicate architectre< 7hey challen&e the canopy<
7ramatic sitations have been sho/n to be particlarly deleterios in this re&ard
AEpstein, 1-@'8 9ano==%$lman, 1--!8 :ar0es, 1-'!B< $t in principle, any emotion
has an impact on this symbolic architectre becase emotion precisely develops at its
=issres%or /here thin&s &o npredicted, ne*pected, ot o= control, etc< $y ma0in&
=issres apparent, emotion ma0es people =eel the /ea0ness o= the constrction< 7his is
probably the sorce o= this obscre need =or co&nitive clari=ication, =or nderstandin&,
=or =indin& meanin&, abndantly reported by people /ho Rst /ent thro&h some
important emotional episode<
$t /hy do people also =eel the need to be /ith others and to tal0 /ith others a=ter an
emotionT 3t shold be stressed that the symbolic niverse is everythin& bt a solitary
constrction< No one cold ma0e sense o= the /orld alone< )ociolo&ists sho/ed that
people enter a cltrally shaped sbRective niverse early in li=e A$er&er N
6c0mann, 1-G'B< 7he attachment process is the basic tool thro&h /hich the
constrction is installed in the yon& hman bein&< All alon& the development
process, in everyday interactions, parents transmit to their children the vie/ o= the
/orld that is shared in their cltre< 6ater on, the constrction is 0ept alive, stron& and
valid by the social consenss in /hich everyone ta0es part minte a=ter minte
thro&hot their li=e as members o= or commnity< (onseMently, a
%+-%
crac0 in this symbolic niverse not only opens a breach in their meanin&s that /ill
elicit co&nitive needs< 3t also has the e==ect o= ma0in& people =eel insecre and lonely,
elicitin& a very stron& r&e to re%immerse themselves in the social consenss< 7hese
are probably the reasons /hy a=ter an emotion people =eel the need to be /ith their
intimates and to share the emotion /ith them< 7heir intimates are those /ho 0eep the
attachment process alive =or them, providin& them /ith social spport and secrity<
7heir intimates are those /ith /hom people share the social consenss, providin&
them /ith a coherent sbRective niverse<
$ein& /ith their intimates and sharin& the emotional e*perience /ith them /ill
probably not have the e==ect o= alterin& the memory o= the emotion and o= brin&in&
people emotional relie=< Ho/ever, bein& /ith them and sharin& the emotion /ith them
can reslt in enhancin& peopleLs e*perience o= social spport and in consolidatin&
their symbolic niverse< 3n other /ords, intimates /ill help people to ma0e =tre li=e
possible and meanin&=l in spite o= /hat happened<
A"kno1ledgments
Research reported in this paper /as spported by &rants FRF( @<#."G<-@ and
!<#.#G<-' =rom the $el&ian National Fnd =or )cienti=ic Research<
!e)eren"es
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process< Eournal of Personality and %ocial Psychology,/2, .!@%.+'<
:enneba0er, 9<W< N Harber, K<D< A1--+B< A social sta&e model o= collective
copin&E the 6oma :rieta earthMa0e and the :ersian ;l= /ar< Eournal of %ocial
#ssues,,#, 1!.%1#.<
:enneba0er, 9<W< N OLHeeron, R<(< A1-@#B< (on=idin& in others and illness rate
amon& sposes o= sicide and accidental%death victims< Eournal of bnormal
Psychology,#&, #'+%#'G<
:enneba0er, 9<W<, Hech, E<, N RimQ, $< A!""1B< Disclosin& and sharin& emotionE
psycholo&ical, social and health conseMences< 3n C< )troebe, W< )troebe, R<O<
Hansson, N H< )cht AedsB, <e" handboo! of berea'ement3 Conse7uences9
coping9 and care App< .1'%.##B< Washin&ton, D(E American :sycholo&ical
Association<
RimQ, $< A1-@-B< 6e parta&e social des emotions D7he social sharin& o= emotionsF<
#.
3n $< RimQ N K<R< )cherer AedsB, Les emotions KThe emotionsL App< !'1%+"+B<
Ne=chVtelE Delacha* et NiestlQ<
RimQ, $<, Fin0enaer, (<, 6minet, O<, Hech, E<, N :hilippot, :< A1--@B< )ocial
sharin& o= emotionE ne/ evidence and ne/ Mestions< 3n W< )troebe N C<
He/stone AedsB, 5uropean re'ie" of social psychology, Vol< - App< 1#.%1@-B<
(hichesterE Wiley<
RimQ, $<, Hay/ard, C<)<, N :enneba0er, 9<W< A1--GaB< Characteristics of
reco'ered 'sD unreco'ered emotional e.periences< ,npblished ra/ data<
%#1%
RimQ, $<, CesMita, $<, :hilippot, :<, N $oca, )< A1--1aB< $eyond the emotional
eventE si* stdies on the social sharin& o= emotion< Cognition and 5motion,/,
#+.%#G.<
RimQ, $<, NoWl, C<:<, N :hilippot, :< A1--1bB< Episode Qmotionnel,
reminiscences mentales et reminiscences sociales DEmotional episodes, mental
remembrances and social remembrancesF< Cahiers #nternationau. de Psychologie
%ociale,$$, -+%1"#<
RimQ, $<, :hilippot, :<, $oca, )<, N CesMita, $< A1--!B< 6on&%lastin& co&nitive
and social conseMences o= emotionE social sharin& and rmination< 3n W< )troebe
N C< He/stone AedsB, 5uropean re'ie" of social psychology, Vol< + App< !!.%
!.@B< (hichesterE Wiley<
RimQ, $<, :hilippot, :<, N (isamolo, D< A1--"B< )ocial schemata o= peripheral
chan&es in emotion< Eournal of Personality and %ocial Psychology,/#, +@%#-<
RimQ, $<, :hilippot, :<, Fin0enaer, (, 6e&ast, )<, Coor0ens, :<, N 7ornMvist, 9<
A1--#B< ?ental rumination and social sharing in current life emotion<
,npblished manscript, ,niversity o= 6ovain at 6ovain%la%Neve, $el&im<
RimQ, $<, Hech, E<, Fin0enaer, (<, 6minet, O<, N Do>ier, )< A1--GbB< Different
modalities of sharing emotions and their impact on emotional reco'ery< :oster
session presented at the 11th ;eneral Ceetin& o= the Eropean Association =or
E*perimental )ocial :sycholo&y, ;mnden, Astria<
Rssell, 9<A<, Fernande>%Dols, 9<C<, Canstead, A<)<R, N Wellen0amp, 9<(<
A1--.B< 5'eryday conceptions of emotionsD n introduction to the psychology9
anthropology and linguistics of emotion< Dordrecht, 7he NetherlandsE Kl/er<
)cherer, K<R< A1-@#B< Emotion as a mlticomponent processE a model and some
cross%cltral data< 3n :< )haver Aed<B, Re'ie" of personality and social
psychology, Vol< . App< +'%G+B< $everly Hills, (AE )a&e<
)choenber&, $<, (arr, A<(<, :eret>, D<, Ktscher, A<H<, N (herico, D<9< A1-'.B<
Advice o= the bereaved =or the bereaved< 3n $< )choenber&, 3< ;erber, A< Wiener,
#G
A<H< Ktscher, D< :eret>, N A<(< (arr AedsB, Berea'ement3 #ts psychological
aspects App< +G!%+G'B< Ne/ Yor0E (olmbia ,niversity :ress<
)haver, :<, )ch/art>, 9<, Kirson, D<, N OL(onnor, 6< A1-@'B< Emotion 0no/led&eE
=rther e*ploration o= a prototype approach< Eournal of Personality and %ocial
Psychology,/%, 1"G1%1"@G<
)ilver, R< N Wortman, (< A1-@"B< (opin& /ith ndesirable li=e events< 3n 9<
;arber N C<E<:< )eli&man AedsB, Fuman helplessness App< !'-%+#"B< Ne/ Yor0E
Academic :ress<
7ait, R< N )ilver, R<(< A1-@-B< (omin& to terms /ith maRor ne&ative li=e events<
3n 9<)< ,leman N 9<A< $ar&h AedsB, Mnintended thought App< +.1%+@!B< Ne/
Yor0E ;il=ord :ress<
Hech, E< A!"""B< The effects of the communication of emotional e.periences<
,npblished doctoral dissertation, ,niversity o= 6ovain, 6ovain%la%Neve,
$el&im<
%#!%
Chapter &
Theoreti"al me"hanisms involved in dis"los're
<rom inhi*ition to sel)+reg'lation
?elanie D Greenberg and %tephen ED Lepore
Introd'"tion
3ndividals /ho =reely e*press their tho&hts and =eelin&s abot stress=l li=e events
can bene=it both physically and psycholo&ically A)myth, 1--@B< 3nitially, emotional
disclosre /as tho&ht to =acilitate adRstment to previosly ne*pressed tramas<
7hen it /as sho/n to help individals deal /ith less severe and on&oin& stress=l
events< Recent research s&&ests an even =rther broadenin& o= the scope o=
disclosre< Health improvements occr in both healthy and medically ill poplations<
Writin& abot ima&inary tramas and /ritin& abot li=e &oals can also improve health<
Ho/ do /e ma0e sense o= these diverse =indin&sT We ar&e that a sel=re&lation
approach can e*plain many o= the apparent contradictions<
7his chapter be&ins /ith a brie= revie/ o= the e*perimental disclosre literatre< Ne*t,
/e trn to disclosre theories< We describe the in=lential inhibition model
A:enneba0er, 1-@-B and discss research that addresses its tility< Ne*t, /e discss
=indin&s s&&estin& that disclosre mi&ht enhance sel=%re&lation o= emotion< We then
hi&hli&ht research on disclosre, intrsive tho&hts, and social constraints that is
consistent /ith a sel=%re&lation approach< Ne*t, /e consider ho/ emotional
disclosre mi&ht help people to re&late their emotions and consider the processes o=
emotional habitation and co&nitive reappraisal o= oneLs emotional reactions< Finally,
/e revie/ stdies that s&&est disclosre can promote co&nitive re&lation o= sel=%
ima&es and &oals<
#'
enne*aker:s dis"los're paradigm( ma7or )indings
Nmeros investi&ators have replicated and e*tended :enneba0er and $eallLs ori&inal
A1-@GB =indin&s re&ardin& the health bene=its o= disclosre< 3n controlled e*perimental
stdies /ith healthy individals Amostly colle&e stdentsB, disclosre decreased
physician visits A;reenber& et alD9 1--G8 :enneba0er et alD9 1--"B, redced reported
physical symptoms A;reenber& N )tone, 1--!8 6epore N ;reenber&, !""!B, enhanced
immne otcomes A:enneba0er et alD9 1-@@8 :etrie et alD9 1--.B, diminished
psycholo&ical distress A6epore, 1--'a8 :ae> et alD9 1---B and =acilitated adaptive
behaviors A6epore N ;reenber&, !""!8 )pera et alD9 1--#B< Disclosre can
%#+%
also bene=it medical patients< Rhematoid arthritis ARAB patients /ho disclosed
tho&hts and =eelin&s abot a stressor reported less a==ective distrbance and physical
disability at three%month =ollo/%p than controls< Asthma patients assi&ned to a
/ritten disclosre intervention improved in ln& =nction and RA patients improved
in disease activity, relative to controls A)myth et alD9 1---B<
3n the =ollo/in& section, /e /ill trace theories that e*plain /hy this relatively brie=
intervention prodced sch stri0in& mental and physical health bene=its<
Inhi*ition or emotional sel)+reg'lation-
3n this section, /e describe :enneba0erLs A1-@-B inhibition model and empirical
stdies that spport and challen&e the model< We then introdce the concept o=
emotional sel=%re&lation as an alternative e*planatory mechanism to inhibition<
Emotional sel=%re&lation is part o= the broader constrct o= sel=%re&lation or sel=%
control and re=ers speci=ically to control over the Mality, =reMency, intensity, or
dration o= responses in any o= the three emotion channels%e*perience, physiolo&y,
and behavior< 7his process in=lences /hat types o= emotions people have, ho/
intensely they e*perience these emotions, and ho/ they e*press them Asee 6epore et
alD9 !""!, =or a more comprehensive de=initionB<
&he inhibition model
3n the ori&inal disclosre paradi&m A:enneba0er N $eall, 1-@GB participants /rote
mostly abot ndisclosed tramas< 7he rationale /as that individals typically inhibit
tramas becase o= their emotional intensity and to avoid ne&ative social responses<
3nhibition /as hypothesi>ed to adversely a==ect physiolo&ical systems, incldin& the
central nervos and immne systems< (hronic physiolo&ical strain de to inhibition
/as tho&ht to increase ssceptibility to illness< Disclosre, on the other hand, /as
seen as redcin& the ne&ative physiolo&ical e==ects o= chronic inhibition A:enneba0er,
1-@-B< (onsistent /ith this model, correlational stdies have revealed ne&ative e==ects
on health o= concealin& oneLs &ay identity A(ole et alD9 1--GB, not disclosin& past
tramas A:enneba0er N )sman, 1-@@B, and not discssin& oneLs =eelin&s abot a
sposeLs death /ith others A:enneba0er N OLHeeron, 1-@#B<
#hallenges to the inhibition model
#@
3ronically, the sccess o= some disclosre stdies posed a challen&e to the inhibition
model< Writin& abot recent, on&oin&, or pcomin& events had similar or better
psychosocial health bene=lts than /ritin& abot past tramas A)myth, 1--@B< (olle&e
stdents /ho /rote abot adRstin& to colle&e redced their physician visits and
improved their &rade point avera&es A(ameron N Nicholls, 1--@8 :enneba0er et alD9
1--"B< )tdents /ho /rote abot their reactions to an pcomin& e*amination redced
their depression, relative to controls A6epore, 1--'aB< ,nemployed
%##%
pro=essionals /ho /rote do/n their emotions abot Rob loss =ond Robs more Mic0ly
than controls A)pera et alD9 1--#B< )tdents /ho /rote abot a recent relationship
brea0p had =e/er pper respiratory symptoms, less tension, and less =ati&e than
controls A6epore N ;reenber&, !""!B< 7hese stdies s&&ested that release o= chronic
lon&%term inhibition may not be the most important component o= disclosre
interventions< When a stress=l event is on&oin& or anticipated, individals may
concrrently inhibit some o= their emotional reactions, bt inhibition /old not
cmlate over time and lead to physiolo&ical dama&e as described by the model<
Other =indin&s also challen&e the inhibition model Asee revie/ by 6ittrell, 1--@B< 3n a
sample o= bereaved sposes, emotional repressors and those /ho did not e*press &rie=
at si* months post%loss had especially &ood psycholo&ical otcomes at 1# months
post%loss A$onanno et alD9 1--.B< 7hese reslts /ere consistent /ith an earlier
e*tensive literatre revie/ AWortman N )ilver, 1-@-B that =ond very =e/ instances o=
delayed &rie= reactions in those /ho did not e*press &rie= initially< 7hese =indin&s
only indirectly challen&e inhibition, ho/ever< 6ac0 o= &rie= e*pression mi&ht be de
to consistently lo/ emotional e*perience, rather than deliberate inhibition< Frther,
there may have been adverse physiolo&ical e==ects in these stdies that /ere not
assessed<
)ome stdies also s&&est that ventin& previosly sppressed =eelin&s is not necessary
or s==icient to achieve bene=icial e==ects< Writin& abot both tho&hts and =eelin&s
enhanced the bene=its o= disclosre beyond those achieved by simple ventilation o=
=eelin&s A:enneba0er N $eall, 1-@GB< 3n a sample o= colle&e stdents assi&ned to
e*press their emotions thro&h movement alone, movement pls /ritin&, or to a non%
e*pressive control AKrant> N :enneba0erLs stdy as cited in :enneba0er, 1--'B,
e*pressive movement /ithot /ritin& /as o= little bene=it< A third stdy A:enneba0er
et alD9 1--"B, =ond no evidence that participants /ho had inhibited their tramas
more or /ere hi&her in sel=%concealment bene=ited more =rom emotional /ritin&<
Writin& abot positive aspects o= past tramas prodced the same health bene=its as
con=rontin& ne&ative =eelin&s abot these events AKin& N Ciner, !"""B<
7he abovementioned stdies call into Mestion /hether prior inhibition is necessary or
s==icient =or e==ective disclosre< 3n addition, some individals =eel the need to
e*press pain=l =eelin&s repeatedly, a phenomenon /hich the inhibition model cannot
easily e*plain< (old /ritten e*perimental disclosre be bene=icial even i= individals
had e*pressed their =eelin&s be=oreT
7o address this isse, /e randomly assi&ned participants to /rite abot ndisclosed
past tramas, previosly disclosed tramas, or to a netral events control A;reenber&
#-
N )tone, 1--!B< Follo/%p assessments t/o months later =ond no di==erential e==ects
o= /ritin& abot disclosed verss ndisclosed tramas on either reported health or
physician visits< )rprisin&ly, the disclosed trama &rop also reported &reater
ne&ative mood and physical symptom increases than the ndisclosed trama &rop at
immediate post%test< :revios disclosre /as there=ore associated /ith more intense
rather than attenated emotional reactions to the
%#.%
tramas disclosed< 7hese =indin&s s&&ested that prior inhibition did not necessarily
enhance the health e==ects o= disclosre< Yet /e cold not rle ot prior inhibition
alto&ether, becase even the disclosed trama &rop reported previosly holdin& bac0
their =eelin&s abot these tramas to a moderate de&ree Amean o= +<-1 on a '%point
scaleB<
Stimulus-and response+related emotional ha*it'ation
An early stdy in the clinical literatre AWatson N Car0s, 1-'!B raised additional
Mestions abot the necessity o= con=rontin& past personal e*periences to redce
ne&ative emotional reactions< 3n a sample o= phobic clients, e*posre to
phobiairrelevant stimli Ae<&< scenes o= bein& eaten by ti&ersB redced an*iety and
avoidance as mch as e*posre to the stimli involved in their phobias Ae<&< scenes
involvin& cro/ded placesB< 7he athors s&&ested that e*posre to =ear=l stimli
promoted physiolo&ical and psycholo&ical habitation, leadin& to a redction in the
=ear response over time< 7/o di==erent types o= habitation /ere hypothesi>ed< First,
bein& con=ronted /ith speci=ic =ear%related stimli =or lon& periods may decrease
emotional reactivity to these ces =stimulus-related habituation>< )econd, e*posre to
phobia%irrelevant stimli may promote response-related habituation9 resltin& in a
better ability to tolerate the e*perience o= =ear, re&ardless o= its conte*t<
7his stdy had potentially important implications =or the emotional disclosre
paradi&m< Writin& or tal0in& abot past tramas also involves e*posre to
emotionally%char&ed stimli and also stimlates ne&ative emotional e*perience<
:erhaps emotional disclosre maniplations are bene=icial becase they =acilitate
emotional sel=%re&lation via both stimls%related and response%related habitation<
7he ne*t set o= stdies addressed these isses<
Disclosingimaginary tra'mas and emotional sel)+reg'lation
3= disclosre cases response%related habitation, it =ollo/s that the e*perience o=
ne&ative emotion in a sa=e conte*t is all that is necessary to prodce health bene=its<
7he speci=ic content o= /ritin& does not necessarily have to be a past personal trama<
Writin& abot ima&inary tramas shold there=ore improve health as mch as /ritin&
abot real tramas<
7o address this isse, /e A;reenber& et alD9 1--GB e*perimentally maniplated event%
speci=ic inhibition by randomly assi&nin& participants to /rite abot past personal
tramas, ima&inary tramas that they had not previosly e*perienced, or non%
emotional events< 3ma&inary events cold not, by de=inition, have any inhibition
attached to them< 3ma&inary trama participants /ere yo0ed to their real trama
."
conterparts and /rote abot the same topics< Reslts indicated that, as hypothesi>ed,
the topic /ritten abot made little di==erence to the e==icacy o= the disclosre
intervention< As sho/n in Fi&re +<1, both real and ima&inary trama
%#G%
&rops visited the stdent health center =or illness less o=ten at one%month =ollo/%p,
relative to controls< 7he health e==ects in the ima&inary &rop cold not be e*plained
by inhibition alone< Findin&s /ere, ho/ever, consistent /ith response%related
habitation< :articipants in the ima&inary &rop cold accommodate to ne&ative
emotional e*perience in a sa=e conte*t< :erhaps this increased their sel=re&lation and
tolerance o= ne&ative emotion in other areas o= their lives<
Figure &D$ ;rop means =or illness visits at pretest and =ollo/%p< 2 1--G, American
:sycholo&ical Association< Reprinted /ith modi=ications by permission o= the
pblisher and athor =rom ;reenber& et alD A1--GB<
Whereas the previos stdy e*amined habitation to the e*perience o= ne&ative
emotion in &eneral, the ne*t set o= stdies =ocsed on ho/ opportnities =or disclosre
and social constraints srrondin& disclosre mi&ht a==ect individalsL emotional
responses to intrsive stress%related tho&hts and stimli<
Disclosureand rea"tions to stress+related tho'ghts and stim'li
One implication o= the sel=%re&lation perspective is that emotional e*pression in a
sa=e conte*t shold attenate ne&ative a==ective and physiolo&ical responses to stress%
related stimli< $y Osa=eP conte*t, /e mean one in /hich there are com=ortin& social
ces, encora&ement o= open emotional e*pression, or an absence o= critical
evalation< A sa=e conte*t can help individals to prolon& their e*posre to pain=l
stimli, thereby enablin& them to positively revise their vie/s and =eelin&s abot the
stimli Asee related discssions by Foa N Ko>a0, 1-@G8 6epore, !""18 6epore et alD9
1--GB< $y e*tension, /e /old e*pect that e*pression o= trama%related tho&hts and
=eelin&s in an nsa=e conte*t /old ndermine the bene=its o= emotional e*pression<
3n =act, emotional e*pression in an nsa=e conte*t mi&ht e*acerbate ne&ative
emotional and physiolo&ical responses to stressors by stirrin& p additional ne&ative
emotions and rein=orcin& =eelin&s o= helplessness<
%#'%
3n recent years, a nmber o= =indin&s have emer&ed that are directly relevant to these
predictions< 7hese stdies all =ocs on ho/ emotional e*pression in=lences
individalsL responses to stress%related intrsive tho&hts, /hich are nbidden
tho&hts, memories, and ima&es o= stressors< 3= emotional e*pression in a sa=e conte*t
=acilitates sel=%re&lation o= ne&ative responses to reminders o= stressors, then the
association bet/een intrsive tho&hts and mental and physical health otcomes
shold be attenated in individals /ho e*press their emotions in a sa=e conte*t<
E*pression in an nsa=e conte*t mi&ht even e*acerbate ne&ative responses<
.1
7/o e*perimental stdies have e*amined ho/ /ritten emotional e*pression
modlates responses to intrsive tho&hts< Written emotional e*pression provides a
=eelin& o= present sa=ety, becase emotional e*pression is encora&ed, there is no
social evalation o= the e*pression, and there is a certain de&ree o= anonymity< 3n the
=irst stdy A6epore, 1--'aB, e*pressive /ritin& attenated the association bet/een
intrsive tho&hts and depressive symptoms amon& individals /ho /ere anticipatin&
&radate%school entrance e*aminations< As sho/n in Fi&re +<!, intrsive tho&hts
measred one month prior to the e*am /ere positively related to depressive
symptoms three days prior to the e*am in the control%/ritin& &rop, bt not in the
e*pressive%/ritin& &rop< 3n the second stdy A6epore N ;reenber&, !""!B,
e*pressive /ritin& attenated the association bet/een a composite measre o=
intrsive?avoidant tho&hts and pper respiratory illness A,R3B symptoms amon&
individals /ho had a relationship brea0p< As sho/n in Fi&re +<+, a hi&her level o=
intrsive?avoidant reactions /as related to short%term increases in ,R3 symptoms in
participants /ho /rote abot a control topic, bt /as nrelated to ,R3 symptoms in
participants /ho /rote e*pressively abot their brea0p<
Figure &D* Relation bet/een intrsive tho&hts and chan&es in depression =rom 7ime
1 to 7ime ! Aresidali>edB as a =nction o= /ritin& condition< 2 1--', American
:sycholo&ical Association< Reprinted =rom 6epore A1--'aB<
%#@%
Figure &D& Relation bet/een level o= intrsions?avoidance at 7ime 3 and chan&es
in pper respiratory illness A,R3B symptoms =rom 7ime 1 to 7ime ! A7!%71B as a
=nction o= /ritin& condition< Reprinted =rom 6epore, )<9< N ;reenber&, C<A<
A!""!B<
While most o= the data presented above =ocs on nonsocial disclosre, disclosre
seldom occrs in a social vacm< 3ndeed, as /e discss in the ne*t section, the
responses o= others can be critical to the e==icacy o= disclosre in modlatin&
ne&ative tho&hts and emotions<
Negative social responses impede emotional regulation
A &ro/in& nmber o= Masi%e*perimental =ield stdies have investi&ated ho/ the
social conte*t o= disclosre moderates the relation bet/een intrsive tho&hts and
varios emotional, physical, and mental health otcomes< 7/o stdies involved
cancer patients< One stdy =ond that a sbset o= men reported social constraints in
tal0in& /ith si&ni=icant others abot their prostate cancer A6epore N Hel&eson,
1--@B< 7hese men, /hen compared /ith their peers /ho had =e/er constraints,
reported more cancer%related intrsive tho&hts and /ere more li0ely to avoid
thin0in& and tal0in& abot their cancer< Coreover, constraints potentiated the
association bet/een intrsive tho&hts and poor mental health< 7here /as a
.!
stron&er ne&ative association bet/een intrsive tho&hts and mental health in men
/ho had hi&h social constraints than in men /ho had relatively =e/ constraints< A
more ri&oros test o= the model /as provided in a lon&itdinal stdy on the
emotional adaptation o= /omen /ho had been treated =or locali>ed breast or colon
cancer A6epore, 1--'bB< Data /ere collected =rom /omen three months A71B and
11 months A7!B a=ter their dia&nosis< Re&ression analyses revealed that 71 social
constraints moderated the association bet/een 71 intrsive tho&hts abot cancer
and 7! ne&ative a==ect, a=ter statistically controllin& =or 71 ne&ative a==ectE a
hi&her
%#-%
level o= intrsive tho&hts /as associated /ith an increase in ne&ative a==ect in
/omen /ho had hi&h social constraints, bt /as nrelated to ne&ative a==ect in
/omen /ith relatively =e/ social constraints<
)tdies involvin& other trama poplations reveal a similar pattern o= reslts< 3n a
stdy o= bereaved mothers, intrsive tho&hts at three /ee0s post%loss /ere associated
/ith increases in depressive symptoms i= mothers =elt constrained in tal0in& abot the
loss bt not i= they =elt relatively nconstrained A6epore et alD9 1--GB< 3n children
e*posed to inner%city violence, violence e*posre /as associated /ith hi&her levels o=
internali>in& symptoms AKlie/er et alD9 1--@B< 7he hi&hest ris0 &rop =or internali>in&
symptoms consisted o= children /ith a hi&h level o= violence%related intrsive
tho&hts combined /ith a lo/ level o= social spport or a hi&h level o= social
constraints<
7he =indin&s =rom these stdies are Mite robstE they have emer&ed in people o=
many di==erent a&es Achildren, colle&e stdents, adltsB, in people e*periencin& very
diverse stressors Acancer, violence, e*aminations, relationship brea0psB, in both
e*perimental and Masi%e*perimental stdies, and =or many di==erent otcomes Ae<&<
depressive symptoms, pper%respiratory symptomsB< 3n addition to or stdies
reported above, other investi&ators have =ond that the social conte*t moderates the
e==ects o= intrsive tho&hts on psycholo&ical adRstment to stressors Ae<&< 6t&endor=
et alD9 1---8 CaRor N ;ram>o/, 1---8 Canne, 1---B< 3t appears that emotional
e*pression in a sa=e conte*t does indeed increase re&lation o= ne&ative responses to
intrsive tho&hts /hereas an nsa=e social conte*t e*acerbates ne&ative a==ective
reactions to intrsive tho&hts< What is not 0no/n is /hether this ne&ative a==ective
e*acerbation is actally the reslt o= pree*istin& lo/ social spport or ne&ative social
responses or /hether certain types o= people are ine==ective at e*pressin& emotions to
others and inadvertently drive a/ay spport and provo0e ne&ative reactions<
Emotional sel)+reg'lation me"hanisms
7he previos stdies s&&est that e==ective disclosre helps people to tolerate and
re&late ne&ative emotional responses< Dra/in& on both the disclosre and broader
clinical literatres, /e hi&hli&ht t/o emotional sel=%re&lation processesE emotional
habituation and cogniti'e reappraisal of emotionD
.+
Emotional habituation
One mechanism by /hich emotional disclosre mi&ht =acilitate adRstment is
habitation< O7he /ritin& assi&nment may prodce e*tinction o= ne&ative emotional
associations thro&h repetition and e*posreP A$oot>in, 1--', p< 1G'B< When
individals actively con=ront memories o= past tramas or on&oin& aversive sitations,
their physiolo&ical and sbRective emotional responses shold &radally diminish as
they accommodate to these events< As described above, a more &eneral habitation
process may also occr in /hich people learn to tolerate the e*perience
%."%
o= ne&ative emotions, re&ardless o= conte*t, so that the emotions themselves become
less aversive<
Foa and collea&es AFoa N Ko>a0, 1-@GB theori>ed that habitation a==ects co&nitive
strctres nderlyin& =ear< 7hey proposed that these co&nitive strctres provide
in=ormation abot sitations that evo0e =ear Ae<&< past tramas or predatorsB, the
natre o= =ear responses Ae<&< physiolo&ical arosal or =eelin&s o= terrorB, and the
sbRective meanin& o= these sitations and responses Ae<&< this sitation is dan&eros,
my response is badB< 7o decrease =ear, one shold =irst activate the =ear strctre and
then provide incompatible in=ormation< When a person e*periences habitation
=ollo/in& prolon&ed e*posre, this redction in the =ear response contradicts response
elements o= the strctre< 7his shold also chan&e meanin& elements so that the
sitation is vie/ed as less dan&eros and less ne&ative and the sel= as more
competent<
3n sccess=l habitation, individals shold e*perience stron& ne&ative emotions
initially, /ith &radal decreases in ne&ative emotion /ithin and across e*posre
sessions AFoa, 1--'B< 7/o recent stdies o= post%tramatic stress disorder A:7)DB
patients spport these hypotheses< Rape srvivors /ho sho/ed the most intense =acial
e*pressions o= =ear drin& the =irst session o= e*posre bene=ited the most =rom
treatment AFoa et alD9 1--.B< Assalt victims /ho reported hi&h initial an*iety drin&
e*posre and &radal habitation o= an*iety across sessions had lo/er levels o= :7)D
symptoms at =ollo/%p A9ayco* et alD9 1--@B< (ontrary to e*pectations, ho/ever,
/ithin%session habitation /as nrelated to treatment otcome< (lients /hose =ear
remained hi&h across an entire session did not necessarily bene=it any less =rom
treatment than those /hose an*iety &radally diminished drin& the session<
7he emotional disclosre paradi&m is similar to e*posre therapy in that it also
involves con=rontation /ith ne&ative stimli and emotions< 3s there any evidence that
emotional en&a&ement and habitation occr =ollo/in& disclosreT
)ome stdies spport the role o= emotional en&a&ement< Disclosre participants rated
by Rd&es as revealin& the most emotion in their voices had lo/er s0in condctance
levels drin& disclosre than those /ho e*pressed less emotion A:enneba0er et alD9
1-@'B< :articipants /ith a hi&her proportion o= emotion%=ocsed /ords in their essays
had lo/er levels o= antibody to Epstein%$arr virs AE$VB immediately a=ter /ritin&,
indicatin& better immne =nctionin&, than those /ho /rote =e/er /ords AEsterlin& et
alD9 1--"B< :articipants /ho demonstrated the hi&hest emotional involvement in
.#
disclosre had the &reatest decreases in antibody titers to E$V =rom pre%test to =or%
/ee0 post%test A6t&endor= et alD9 1--#B<
)tdies sin& pre%post mood measres have, ho/ever, provided only mi*ed spport
=or emotional en&a&ement< 3n arthritis patients, more ne&ative mood increases drin&
disclosre /ere associated /ith less obRectively%assessed Roint s/ellin& at =ollo/%p
AKelley et alD9 1--'B< A meta%analysis, ho/ever, =ond no association bet/een
chan&es in ne&ative a==ect drin& essay%/ritin& and the otcome o= disclosre A)myth,
1--@B< Avera&e mood chan&e may not, ho/ever, be a &ood measre o= habitation,
becase participants /ith hi&h initial ne&ative
%.1%
mood /ho habitated across sessions cold have the same avera&e score as those /ith
moderate initial mood /ho did not habitate<
Does habitation occr drin& disclosre sessionsT 3n one stdy A:etrie et alD9 1--@B,
colle&e stdents /ho /rote abot emotional topics sho/ed decreases in sel=%reported
tension across the three /ritin& days< Another stdy A)e&al N Crray, 1--#B did not,
ho/ever, =ind chan&es in reported ne&ative a==ect across =or days o= verbal
disclosre< Other evidence comes =rom stdies sin& physiolo&ical measres< (olle&e
stdents /ho /rote abot stress=l events sho/ed &reater decreases in s0in
condctance across the =or /ritin& days than non%emotional event controls A:etrie et
alD9 1--.B, s&&estin& that habitation occrred bet/een sessions< :articipants /ho
vie/ed an emotional =ilm and then tal0ed abot their responses /ere more
atonomically arosed initially /hen vie/in& the =ilm a&ain ACendolia N Klec0,
1--+B< Ho/ever, /hen the second vie/in& /as #@ hors later, emotion condition
participants had lo/er atonomic arosal than controls< 7his is consistent /ith clinical
literatre s&&estin& that habitation decreases emotional arosal bet/een sessions,
rather than /ithin%session<
3n smmary, emotional en&a&ement and habitation mechanisms are involved in
emotional disclosre interventions< When individals con=ront their ne&ative =eelin&s
abot stress=l events, the physiolo&ical and perhaps sbRective intensity o= these
=eelin&s is diminished over time<
#ognitivereappraisal o) emotion
We no/ trn to the second mechanism /hereby emotional disclosre interventions
mi&ht enhance emotional re&lation< Disclosre mi&ht lead to co&nitive chan&es in
ho/ people vie/ their emotional reactions< Actively con=rontin& ne&ative emotions
cold enhance perceptions o= sel=%e==icacy and control over emotion< 7nin& in to
oneLs o/n =eelin&s in a sa=e conte*t may also promote deeper nderstandin&,
validation and acceptance o= these reactions< We /ill discss each o= these processes<
Disclosre mi&ht provide mastery e*periences in /hich individals observe
themselves toleratin& and diminishin& ne&ative emotions< As a reslt, they mi&ht start
to see themselves as people /ho can handle ne&ative emotions< 3n other /ords, their
sel=%e==icacy =or emotional re&lation shold increase< 3n e*plainin& /hy /ritin&
abot ima&inary tramas prodces health bene=its, ;reenber& and collea&es /rote,
..
Othe bene=its o= disclosre may e*tend beyond revision o= speci=ic past events to
inclde more &eneral perceptions o= control and mastery over oneLs emotional
reactions, re&ardless o= ho/ these are tri&&eredP A;reenber& et alD9 1--G, p< .@-B<
When people =eel more control over their emotional e*periences, ne&ative moods
shold be less prolon&ed and intense, resltin& in less chronic sbRective stress<
7here is some empirical spport =or this proposition< )tron&er mood re&lation
e*pectancies /ere associated /ith lo/er distress and physical symptoms in colle&e
stdents and care&ivers o= Al>heimerLs patients A$rashares N (atan>aro, 1--#8
%.!%
Kirsch et alD9 1--"B< $t does disclosre chan&e peopleLs co&nitive appraisals o= their
o/n emotional reactionsT A recent stdy A:ae> et alD9 1---B spports this idea<
(olle&e stdents /ho /rote abot emotional reactions to ndisclosed tramas
reported decreases in the ne&ative a==ective valence indced by rememberin& at t/o%
month =ollo/%p, relative to controls< 7hs, disclosre helped them to vie/ their
emotional en&a&ement as less ne&ative and more bene=icial< 7his is consistent /ith
the emotional blntin& to intrsive tho&hts observed in previos stdies A6epore,
1--'a8 6epore N ;reenber&, !""!B< Frther, in the stdy by :ae> and collea&es,
e*perimental participants also perceived their tramatic e*periences as more
controllable at =ollo/%p<
7he idea that disclosin& emotions can promote emotional sel=%e==icacy /as e*amined
in a sample o= patients /ith metastatic breast cancer attendin& spportive%e*pressive
&rop psychotherapy A;iese%Davis et alD9 !"""B< Disclosin& emotions associated /ith
cancer and =ears o= death drin& &rop therapy enhanced perceived sel=%e==icacy to
tolerate these emotions, relative to controls< )pport &rop participants tended to
maintain their sel=%e==icacy to con=ront cancer%related =eelin&s over time, /hereas
controls evidenced a decrease< )pport &rop participants also decreased their
emotional sppression over time, relative to controls< :erhaps increased emotional
sel=%e==icacy /as associated /ith =ller emotional e*perience in these patients<
$ecase spportive% e*pressive therapy can increase srvival time /ith cancer
A)pie&el et alD9 1-@-B, it is possible that increased emotional sel=%e==icacy mi&ht play a
part in the health bene=its< :erhaps increased perceived control over emotion redces
sbRective stress and chronic atonomic arosal, /ith sbseMent immne bene=its<
Disclosre may also enhance emotional sel=%re&lation by providin& the opportnity
to nderstand, e*plore, and accept oneLs o/n emotional e*periences< 7his mechanism
may be particlarly applicable to trama victims becase trama can impair peopleLs
ability to e*perience and re&late emotion< (linical observations s&&est that Oamon&
the direct e==ects o= severe trama in adlts is a li=elon& dread o= the retrn o= the
tramatic state and an e*pectation o= it< Emotions are =reMently e*perienced as
trama screens8 hence, there is a =ear o= oneLs emotion and an impairment o= a==ect
toleranceP AKrystal, 1-@@, p< 1#'B< One stdy AVan der Kol0 N Dcey, 1-@-B =ond
that trama srvivors responded to ambi&os a==ectarosin& stimli in an all%or%none
manner< 7hey /ere nable to modlate emotion and there=ore either did not
e*perience their =eelin&s at all or /ere =looded /ith intense and over/helmin& a==ect<
.G
7heoretical models o= psycholo&ical adaptation to trama ACc(ann et alD9 1-@@B
e*plain this lac0 o= emotion%re&lation in trama srvivors as de to disrpted
sel=schemata in the areas o= trst and intimacy< Disrption o= sel=%trst schemata
means that people no lon&er trst their o/n perceptions, reactions, and Rd&ments<
$ecase they /ere nable to protect themselves =rom victimi>ation, they may not
consider their o/n reactions to be valid indicators o= e*ternal reality< 7his leaves them
vlnerable to invalidation by po/er=l others< 3= somebody else tells them they shold
not =eel a certain /ay, they are li0ely to pt aside their o/n =eelin&s<
%.+%
Even i= not invalidated by others, they Mestion and dobt the le&itimacy o= the
=eelin&s they e*perience< Disrption o= sel=%intimacy schemata means that people no
lon&er =eel connected /ith their o/n selves< 6ac0in& a stable sense o= sel= AKoht,
1-''B, they are nable to calm, soothe, or nrtre themselves so as to modlate
ne&ative a==ective states<
E*pressive /ritin& maniplations can help people to =eel more connected /ith their
o/n selves and to e*perience and accept their o/n emotional reactions< 7he typical
instrctions encora&e people to e*plore their deepest tho&hts and =eelin&s and
implicitly s&&est that sch =eelin&s are valid, and that it is permissible and even
potentially bene=icial to e*perience them< Delvin& deeply into oneLs o/n =eelin&s
/ithot havin& to monitor oneLs sel=%presentation, inclde other peopleLs perspectives,
or ma0e the story easier =or others to hear may enhance =eelin&s o= connection /ith
oneLs sel=< :eople may come to see their =eelin&s as an inte&ral part o= themselves,
rather than pshin& them a/ay< 3nte&ratin& =eelin&s /ith tho&hts and memories
drin& disclosre may enhance the sbRective validity o= these reactions< :eople may
be&in to nderstand the roots o= these =eelin&s in speci=ic past or on&oin& events<
Emotional disclosre maniplations, li0e certain types o= psychotherapy, may
there=ore set the sta&e =or Oallo/in& into a/areness an or&ani>ation o= oneLs
e*perience previosly re&arded as nacceptable and acceptin& itP A;reenber& N
)a=ran, 1-@', p< 1-+B<
Empirical stdies provide some spport =or these theories< 3n one stdy A;reenber& et
alD9 1--GB, some participants /rote poi&nantly in their essays abot dobtin& their
o/n =eelin&s and tryin& to sppress them< 3n another stdy A:ae> et alD9 1---B,
participants /ith more ale*ithymic de=icits in the ability to di==erentiate and describe
their =eelin&s had lar&er redctions in ne&ative mood than those /ith =e/er de=icits,
s&&estin& that disclosre may enhance emotional e*periencin&< A recent dissertation
stdy in the =irst athorLs laboratory =ond that &ay men /ho /rote abot their deepest
tho&hts and =eelin&s abot bein& &ay tended to report increased clarity o= &ay%related
=eelin&s and /ere less li0ely to avoid these =eelin&s at t/o%month =ollo/%p, relative
to trivial event controls< 7he e*perimental &rop also reported =e/er psychosomatic
symptoms at =ollo/%p, and decreases in avoidance /ere associated /ith concomitant
decreases in symptoms A)/anbon, 1---B<
A recent e*perimental stdy A6epore et alD9 !"""B also spports the emotional
re&lation hypothesis< ,nder&radates /ho /atched a hi&hly distressin& =ilm /ere
assi&ned to either a no%tal0 control condition or to tal0 alone, to a validatin&
con=ederate, or to an invalidatin& con=ederate< 7al0in& abot oneLs emotional
.'
reactions to the =ilm alone or to a validatin& con=ederate redced intrsive tho&hts
and perceived stress on ree*posre to the stressor, relative to not tal0in&< 7hose in the
invalidate condition did not, ho/ever, report the same redctions in intrsion or stress
as participants in the other disclosre conditions< 7hese =indin&s s&&est that
disclosre has an implicit emotionally validatin& =nction< 7al0in& alone had the same
psycholo&ical bene=its as receivin& social validation< 3nvalidation diminished
disclosreLs bene=icial impact<
%.#%
Emotional dis"los're and "ognitive reg'lation o) sel)+images
A recent disclosre stdy AKin&, !""1B e*tends the sel=%re&lation paradi&m to
co&nitive rather than emotional re&lation< :articipants /ere randomly assi&ned to
/rite narrative descriptions o= their best possible =tre selves, their tho&hts and
=eelin&s abot past tramas, both =tre selves and past tramas, or to a nonemotional
event control< 3n the =tre selves condition, participants ima&ined a =tre in /hich
all o= their li=e &oals had been reali>ed< Writin& abot =tre selves, past tramas, or
both, decreased health center visits over the ne*t =ive months, relative to control
/ritin&<
7he athors ar&ed that /ritin& abot =tre selves /as a =orm o= sel=%re&lation in
that it cold promote a/areness and clarity abot oneLs &oals and vales and lead to a
reor&ani>ation o= priorities< Writin& abot positive li=e &oals does not, ho/ever,
involve emotional con=rontation and cannot =it /ithin an emotion re&lation
=rame/or0< 7his s&&ests that disclosre may =acilitate a di==erent type o= sel=%
re&lation< :erhaps disclosre allo/s people to co&nitively re&late their vie/s o= sel=
so as to promote positive sel=%ima&es and motivate adaptive behavior< A Malitative
stdy that e*amined dr& addictsL narratives o= recovery ACclntosh N CcKe&aney,
!"""B =ond that recoverin& addicts sed narratives to reinterpret their dr&%sin&
li=estyle, describe trnin& points /hich led to their recovery, and reconstrct ne/ non%
addict identities< 3n their narratives, individals di==erentiated /ho they /ere Oat
heartP and their O=tre sel=L =rom their Osel= on dr&s<P 7his allo/ed them to =or&ive
themselves =or past mista0es and maintain hope<
7his perspective is consistent /ith CcAdamsLs A1--"B li=e%story theory o= adlt
identity /hich s&&ests that Othe process o= identity developmentXis the &radal
constrction and reconstrction o= a personal myth inte&ratin& oneLs perceived past,
present, and anticipated =tre, /hile speci=yin& /ays in /hich the individal =its into
and distin&ishes him% or hersel= in the social /orldP ACcAdams N de )t Abin,
1--!, p< 1""'B< Writin& e*pressive narratives may help people to constrct a stable
sense o= identity that &ives meanin& and prpose to their lives< 3t can also help them to
inte&rate their past e*periences, incldin& tramas, /ith their crrent vales and
&oals, perhaps leadin& to a deeper nderstandin& o= ho/ their lives have been shaped
by these events< (onstrctin& narratives may also help people adRst to an on&oin&
stressor by helpin& them to =rame this event /ithin the overall conte*t and direction o=
their lives<
E*pressive narratives may promote sel=%re&lation o= identity in helpin& people to
ma0e sense o= their lives overall and to incorporate speci=ic discrepant events into
.@
their sel=%vie/s< 7/o correlational stdies hi&hli&ht particlar types o= narratives that
are associated /ith optimal psychosocial adRstment< 3n one stdy, adlts rated as
hi&hly &enerative cold be distin&ished =rom their less &enerative conterparts by
li=e narratives that e*pressed a clear, temporally stable personal ideolo&y, trans=ormed
bad e*periences into &ood otcomes, and set &oals =or the =tre to bene=it society
ACcAdams et alD9 1--'B< 3n the other stdy AWon& N Watt,
%..%
1--1B, adlts Rd&ed to be a&in& sccess=lly and nsccess=lly reconted critical
past incidents that had si&ni=icantly in=lenced their lives< ,nsccess=l a&ers /ere
less able to reconcile, inte&rate, and accept past problematic e*periences in their
narratives< 3n contrast, sccess=l a&ers described more cohesive narratives that
accepted and inte&rated the past and more instrmental narratives that reconted past
achievements and sccess=l copin&<
Ftre disclosre interventions mi&ht be enhanced by sin& instrctions that promote
inte&ration o= past e*periences /ith crrent sel=%vie/s and =tre &oals or encora&e
to tell stories /hich emphasi>e their past history o= competence and problem%solvin&
abilities<
8'mmary
7his chapter revie/ed recent developments in the disclosre literatre and proposed a
sel=%re&lation theory< 3nitially, the bene=its o= disclosre /ere tho&ht de to
e*pressin& sppressed emotions abot tramas< Ho/ever, disclosre also enhances
adRstment to on&oin& or =orthcomin& events< Disclosre also diminishes the psychic
to*icity o= intrsive tho&hts, redcin& their associations /ith depression and illness<
Writin& abot ima&inary tramas or =tre possible selves also bene=its health< We
ar&e that disclosre interventions enhance emotional sel=%re&lation by promotin&
habitation, emotional sel=%e==icacy, and emotional validation, and they enhance
co&nitive sel=%re&lation by helpin& people to inte&rate stress=l events /ith &oals and
vales so as to maintain positive sel=%ima&es and motivate adaptive behavior<
A"kno1ledgments
(ontribtions to this chapter /ere partly spported by N3CH &rants 1%.#!1', 1%
#-#+!, (A%G@+.#, and (A%G1+"+, and by a &rant =rom 7he (ity ,niversity o= Ne/
Yor0 :)(%(,NY Research A/ard :ro&ram< We are &rate=l to Ce&an Holmes =or
assistin& /ith the library research =or this chapter<
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ale*ithymia as a dispositional de=icit in sel=%disclosre and psycholo&ical health<
Eournal of Personality and %ocial Psychology,44, G+"%G#1<
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:enneba0er, 9<W<, H&hes, (<F<, N OLHeeron, R<(< A1-@'B< 7he
psychophysiolo&y o= con=essionE lin0in& inhibitory and psychosomatic processes<
Eournal of Personality and %ocial Psychology,/%, '@1%'-+<
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and immne =nctionE health implications =or psychotherapy< Eournal of
Consulting and Clinical Psychology,/., !+-%!#.<
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:etrie, K<9<, $ooth, R<9<, :enneba0er, 9<W<, Davison, K<:<, N 7homas, C<;<
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)/anbon, 7< A1---B< The physical and psychological health effects of self-
disclosure in homose.ual males< ,npblished doctoral dissertation, (ali=ornia
)chool o= :ro=essional :sycholo&y, )an Die&o, (A<
Van der Kol0, $<A< N Dcey, (<R< A1-@-B< 7he psycholo&ical processin& o=
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%tress,%, !.-%!'#<
Watson, 9<:< N Car0s, 3<C< A1-'!B< Relevant and irrelevant =ear in =loodin&E a
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Won&, :<7<:< N Watt, 6<C< A1--1B< What types o= reminiscence are associated
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Wortman, (<$< N )ilver, R<(< A1-@-B< 7he myths o= copin& /ith loss< Eournal of
Personality and %ocial Psychology,/4, +#-%+.'<
%G"%
Chapter ,
Emotion s'ppression and "ardiovas"'lar disease
Is hiding )eelings *ad )or yo'r heart-
#ris BD ?auss and Eames ED Gross
7heorists have lon& claimed that the =ree play o= emotion is incompatible /ith
civili>ation AElias, 1-'@8 Fred, 1-G1B< 7here has been a lin&erin& sspicion, ho/ever,
G#
that the emotion control reMired by civili>ation may come at a steep price< 3n the
poplar literatre, this price has o=ten been represented in terms o= the adverse
conseMences emotion inhibition may have =or physical health Ae<&< Cartin, 1--@B< 3n
the scienti=ic literatre, too, there have been reports lin0in& emotion inhibition to a
variety o= diseases Ae<&< Friedman N $ooth%Ke/ley, 1-@'8 :enneba0er N 7rae,
1--+B< For e*ample, emotion inhibition has been implicated in asthma AFlorin et alD9
1-@.8 7eiramaa, 1-'@B, cancer ADenollet, 1--@8 ;reer N Watson, 1-@.8 ;ross, 1-@-8
7emosho0, 1-@'B, chronic pain disorders A$etler et alD9 1-@G8 Harrison, 1-'.8
,delman N ,delman, 1-@1B and cardiovasclar diseases A$rosschot N 7hayer, 1--@8
Haynes et al9 1-@"8 9or&ensen et alD9 1--G8 9lis et alD9 1-@GB<
Despite a lon& history o= poplar and scienti=ic interest in lin0s bet/een emotion
inhibition and disease, the comple*ity o= the processes involved in both emotion
inhibition and disease has meant that clear conclsions have been hard to come by<
Or strate&y in this chapter is to =ocs or discssion in t/o /ays< On the OinptP
side, /e =ocs on one particlarly common type o= emotion inhibition, namely
emotion sppression, or the inhibition o= on&oin& emotion%e*pressive behavior
A;ross, 1--@B< On the OotptP side, /e =ocs on cardiovasclar diseases<
(ardiovasclar diseases represent the sin&le most important sorce o= disability and
mortality /orld/ide A;yton N Hall, 1--'8 Crray N 6ope>, 1--'B, and they typi=y
the slo/%developin&, mlti=actorial disease processes that seem to be most in=lenced
by psychosocial =actors sch as emotion sppression ADepe N Conroe, 1-@G8
)apols0y, 1--@B<
We be&in /ith a selective revie/ o= the literatre on emotion and cardiovasclar
disease< 7his literatre s&&ests that intense emotional responses%/hether e*pressed
or sppressed%may play a role in the development and corse o= cardiovasclar
disease< 7o assess /hether emotion sppression ma0es a niMe contribtion to
cardiovasclar =nctionin&, /e revie/ a series o= laboratory stdies desi&ned to
speci=y the acte physiolo&ical conseMences o= emotion sppression< 7hese stdies
sho/ that emotion sppression leads to transient increases in
%G1%
sympathetic activation o= the cardiovasclar system< Finally, to help brid&e the &ap
bet/een the lon&%term correlational stdies discssed in the =irst section and the short%
term e*perimental stdies discssed in the second section, /e o==er several possible
psychophysiolo&ical and psychosocial path/ays by /hich emotion sppression mi&ht
have a lon&er%term impact on cardiovasclar health<
Emotion and "ardiovas"'lar disease
E==orts to lin0 emotional =actors to cardiovasclar diseases date bac0 to the earliest
days o= psychosomatic medicine Ae<&< Ale*ander, 1-+-8 Dnbar, 1-+.B< 7hese e==orts
/ere &iven ne/ visibility and credibility /hen a pair o= cardiolo&ists, Friedman and
Rosenman, observed that their coronary heart disease patients seemed to be nsally
competitive, hard%drivin&, impatient, and hostile AFriedman N Rosenman, 1-'#B<
Friedman and Rosenman re=erred to this constellation o= =actors as the 7ype A
behavior pattern< 7heir hypothesis that the 7ype A behavior pattern contribted to the
development o= cardiovasclar disease /as borne ot by a lar&e nmber o= empirical
G.
=indin&s, incldin& several lar&e prospective stdies Asee, =or revie/s, $ooth%Ke/ley
N Friedman, 1-@'8 (ooper et alD9 1-@18 Catthe/s, 1-@@8 )ie&el, 1-@#B<
Emotion e)perienceand expression
)ince it /as =irst articlated, the 7ype A concept has been re=ined considerably< We
no/ 0no/ that an&er and hostility seem to be the core =eatres o= the 7ype A behavior
pattern< For e*ample, $ooth%Ke/ley and Friedman A1-@'B =ond in their Mantitative
revie/ that an&er, hostility, and a&&ressiveness /ere si&ni=icant predictors =or
coronary heart disease, /ith combined e==ect si>es lar&er than that o= any o= the other
7ype A components< (ross%sectional and prospective stdies have con=irmed that a
hi&h level o= an&er and hostility is a ris0 =actor =or the incidence and pro&ression o=
(HD as /ell as hypertension Asee, =or revie/, Kb>ans0y N Ka/achi, !"""8
Catthe/s, 1-@@8 Ciller et alD9 1--G8 )mith, 1--!B< Adverse cardiovasclar health
otcomes have been =ond to be particlarly prononced =or individals /ho openly
e*press their an&ry =eelin&s Ae<&< Harbr& et alD9 1--18 Hec0er et al<, 1-@@8 )ie&man et
alD9 1-@'B<
Core recently, it has become clear that in addition to an&er and hostility, other
ne&ative emotions seem to be related to cardiovasclar disease< )everal stdies have
established that depression AAnda et alD9 1--+8 $are=oot, 1--'8 Csselman et alD9
1--@B, an*iety AFleet N $eitman, 1--@8 Haines et alD9 1-@'8 Ka/achi et alD9 1--#B and
&eneral emotional distress A(risp et alD9 1-@#8 ;llette et alD9 1--'8 Rosen&ren et alD9
1--1B are important =actors in the development and pro&ression o= coronary heart
disease A=or revie/s, see $are=oot, 1--'8 $ooth%Ke/ley N Friedman, 1-@'8 Fieldin&,
1--18 Kin&, 1--'8 Kb>ans0y N Ka/achi, !"""B< Despite some ne&ative =indin&s
Ae<&< Hearn et alD9 1-@-8 Helmer et alD9 1--18 6eon et alD9 1-@@B, a consenss has
developed that the coronary%prone person e*periences
%G!%
and e*presses hi&h levels o= a variety o= ne&ative emotions< As $ooth%Ke/ley and
Friedman A1-@'B conclded, a person prone to coronary heart disease may be not
simply a hostile person, bt rather a person O/ith one or more ne&ative emotionsE
perhaps someone /ho is depressed, a&&ressively competitive, easily =rstrated,
an*ios, an&ry, or some combinationP Ap< +.@B<
Emotions'ppression
One p>>le has emer&ed, ho/ever< While the stdies /e have revie/ed sho/ that the
e*perience and e.pression o= hi&h levels o= ne&ative emotion lead to increased ris0
=or cardiovasclar disease, other stdies have hi&hli&hted the role o= emotion
suppression A$rosschot N 7hayer, 1--@B< 7hs, Dembros0i et alD A1-@.B =ond that
hostility predicted severity o= atherosclerosis only in patients /ho /ere also li0ely to
sppress =eelin&s o= an&er AOAn&er%inPB< 3ndeed, in several stdies no/, measres o=
the inhibition o= ne&ative emotions have been =ond to predict all%case mortality as
/ell as the incidence o= coronary heart disease, hypertension, and related ris0%=actors
A;allacher et alD9 1---8;rossarth%Catice0 et alD9 1-@.8 Haynes et alD9 1-@"8 9lis et
alD9 1-@G8 9l0nen, 1--G8 Canc0 et alD9 1-@G8 )challin& N )vensson, 1-@#B< 3n their
GG
meta%analysis o= the literatre on emotion and blood pressre, )ls et alD A1--.B =ond
that an&er sppression plays an important role in essential hypertension<
An important Mali=ication recently has been added to this emer&in& sppression
hypothesis, namely that the tendency to inhibit emotions per se mi&ht not be harm=l,
only the tendency to inhibit stron& emotional implses Ae<&< $rns, 1--.B< For
e*ample, (ottin&ton et alD A1-@GB =ond that /or0ers /ith hypertension reported
sppression and hi&h levels o= an&er and stress< Denollet and co/or0ers have
hypothesi>ed that the tendency to sppress emotion%e*pressive behavior in social
interactions mi&ht interact /ith the individalLs level o= emotional distress in
determinin& the pro&ression o= coronary heart disease< 7o test this hypothesis,
Denollet et alD divided sbRects /ho had srvived a myocardial in=arction into =or
&rops, dependin& on their ne&ative a==ectivity Aan*iety, an&er, and chronic tensionB
and social inhibition Athe tendency to inhibit the e*pression o= emotions and distress
in social interactionsB< 7he sb&rop scorin& hi&h on both dimensions /as labeled
O7ype DP A=or distressedB< 3t /as =ond that 7ype D patients had a si&ni=icantly hi&her
death rate A!' percentB than non%7ype D patients A' percentB ADenollet et alD9 1--GB< 3t
/as pointed ot that the death rate in patients scorin& hi&h on ne&ative a==ectivity bt
lo/ on inhibition did not di==er si&ni=icantly =rom the death rate in patients /ith lo/
ne&ative a==ectivity%there=ore it /as the negati'e affecti'ity by social inhibition
interaction that had an adverse e==ect on pro&nosis<
3n addition to havin& an e==ect on pro&nosis, this emotional style also seems to be
involved in the de'elopment o= ris0 =actors =or coronary heart disease< 3n a meta%
analysis, 9or&ensen and collea&es A1--GB =ond that ta0en to&ether, ne&ative
a==ectivity and a==ect inhibition /ere the stron&est psycholo&ical predictors =or the
development o= essential hypertension< 7o&ether, these stdies s&&est that it may
%G+%
be the behavioral sppression o= relatively hi&h levels o= ne&ative emotions that
contribtes to the development and pro&ression o= cardiovasclar disease<
So1hi"h is it>expression or s'ppression-
Ho/ are /e to reconcile the literatre /hich s&&ests that it is the e.pression o=
ne&ative emotions that is patho&enic /ith the literatre /hich s&&ests that it is the
suppression o= ne&ative emotions that is patho&enicT 3= sppression is the opposite o=
e*pression, ho/ can both be associated /ith cardiovasclar diseasesT
One possibility is that sppression and e*pression are not OoppositesP, bt rather
behaviors that both may reslt =rom the e*perience o= intense ne&ative emotions
A9lis et alD9 1-@G8 )ie&man et alD9 1-@'B< 3ndeed, researchers repeatedly have sho/n
that An&er%in and An&er%ot are independent =rom one another, rather than ne&atively
correlated as lay intition mi&ht s&&est A)pielber&er et alD9 1--.8 Weidner et alD9
1-@-B< 3ndividals prone to the e*perience o= ne&ative emotions may try to cope /ith
these emotions in di==erent /ays, at times inhibitin& them and at times e*pressin&
them<
G'
7he natral con=ondin& o= intense ne&ative emotions /ith emotion sppression in
everyday li=e ma0es it di==iclt to assess clearly the niMe contribtion o= emotion
sppression to cardiovasclar otcomes on the basis o= correlational stdies sch as
the ones revie/ed in the previos section< 7o e*amine the contribtion o= emotion
sppression over and above the contribtions o= emotion e*perience and e*pression,
/e embar0ed on a series o= laboratory stdies desi&ned to assess the acte
conseMences o= emotion sppression< $y standardi>in& or emotion indction
procedres, and by randomly assi&nin& participants to either sppression or no
sppression conditions, /e so&ht to clari=y /hether emotion sppression per se had
any observable impact on cardiovasclar respondin& that mi&ht be consistent /ith
lon&er%term health conseMences<
The a"'te "onse;'en"es o) emotion s'ppression
Cost o= /hat /e 0no/ abot the acte e==ects o= emotion sppression has come =rom
the facial feedbac! literature< 7his literatre has its ori&ins in Dar/inL s A1@'!' 1-'-B
assertion that Othe =ree e*pression by ot/ard si&ns o= an emotion intensi=ies it< On
the other hand, the repression, as =ar as this is possible, o= all ot/ard si&ns so=tens
or emotionsP Ap< +G.B< As the phrase O=acial =eedbac0P s&&ests, the or&ani>in&
principle in this literatre is that emotion%e*pressive behavior has =eedbac0 e==ects,
sch that increasin& emotion%e*pressive behavior shold increase the emotion,
/hereas decreasin& emotion%e*pressive behavior shold decrease the emotion A$c0,
1-@"B< Cany o= the stdies in this area have compared sppression /ith e*a&&eration
Aand not /ith OnatralP e*pressionB, =indin& that e*a&&eration leads to lar&er
responses than sppression< 7his comparison ma0es it di==iclt to discern /hether
e*a&&eration and sppression both increase physiolo&ical respondin& A/ith
e*a&&eration providin& the lar&er boostB, or /hether%as is
%G#%
typically s&&ested%sppression actally leads to decreased physiolo&ical respondin&<
,n=ortnately, stdies that have inclded the critical comparison bet/een sppression
and natral respondin& have =ocsed on positive emotions Asch as amsementB, and
typically have limited themselves to e*aminin& the e==ects o= sppression on
sbRective emotional e*perience<
'nitial studies
7o clari=y the acte behavioral, e*periential, and physiolo&ical conseMences o=
sppressin& ne&ative emotion, in an initial pair o= stdies, /e sed a short =ilm that
sho/ed an arm amptation to elicit dis&st A;ross N 6evenson, 1--+B< We
administered speci=ic instrctions to participants /ho had been randomly assi&ned to
one o= t/o e*perimental conditions< Watch condition sbRects received instrctions to
simply /atch the =ilm clip care=lly< )ppression condition sbRects received
additional instrctions to Otry to behave in sch a /ay that a person /atchin& yo
/old not 0no/ yo /ere =eelin& anythin&P<
,nder normal circmstances, as sho/n in the top panel o= Fi&re #<1, sbRects move
arond a bit more /hen they are /atchin& a dis&stin& =ilm than they do in the restin&
baseline< When they sppress, ho/ever, they sti=le the natral increase in somatic
G@
activity associated /ith dis&st, yieldin& a =latter line =or the sppression sbRects
than =or the /atch sbRects< 3n the bottom panel o= Fi&re #<1, /e see that sppression
sbRectsL decreased body movement is associated /ith a slo/in& o= heart rate< Despite
these decreases in body movement and heart rate, Fi&re #<! sho/s that sppression
increased sympathetic activation< 3ncreases in sympathetic activation are sho/n both
by a theoretically derived composite o= sympathetic activation o= the cardiovasclar
system Acreated by standard scorin& =in&er plse amplitde, =in&er temperatre, and
plse transit times to the =in&er and earB and by s0in condctance level Anot depicted
hereB<
&esting*o'ndary "onditions o) emotion s'ppression
One p>>le is /hy reslts =rom the initial stdies /ere at odds /ith the =acial
=eedbac0 literatre< Why did sppressin& dis&st increase sympathetic activationT
Ci&ht the physiolo&ical and e*periential e==ects o= emotion sppression vary by
emotionT
7o test the bondary conditions o= the e==ects o= emotion sppression, /e e*amined a
second ne&ative emotion%sadness< ;iven /idespread a&reement that positive emotions
serve Mite di==erent =nctions =rom ne&ative emotions, /e also e*amined a positive
emotion, namely amsement< 7o rle ot the possibility that or initial =indin&s /ere
an arti=act o= the particlar sppression instrctions /e employed, /e also &ave
sbRects the same sppression instrctions drin& an a==ectively netral =ilm, /hen
there /old presmably be no emotion%e*pressive behavior to sppress A;ross N
6evenson, 1--'B<
We =ond that /atchin& a sad =ilm leads to decreases in overall body movement<
Watchin& an amsin& =ilm, by contrast, leads to increased body movement, as
%G.%
Figure (D$ :anel 3E )omatic activity =or sppression and no%sppression AWatchB
participants< :anel !E (ardiac interbeat interval =or sppression and no%sppression
AWatchB participants< Adapted =rom ;ross and 6evenson A1--+B<
%GG%
Figure (D* )ympathetic activation o= the cardiovasclar system =or sppression
and no%sppression AWathcB participants Aadapted =rom ;ross N 6evenson, 1--+B
%G'%
G-
sbRects la&h and move arond in their chair AFriRda, 1-@GB< 3n each case,
sppression decreases /hatever response tendency is associated /ith the tar&et
emotion< 7hs, sppression leads to lesser decreases in body movement drin& a sad
=ilm, and lesser increases in body movement drin& an amsin& =ilm< Heart rate
&enerally =ollo/s somatic activity<
Despite decreased body movement and heart rate, as /as the case =or dis&st,
sppressin& sadness and amsement leads to increased sympathetic activation o= the
cardiovasclar system, incldin& increased systolic and diastolic blood pressre, and
decreased =in&er plse amplitde, =in&er temperatre, and plse transit times<
)ppressin& sadness bt not amsement also leads to &reater electrodermal
respondin&< 3ncreased sympathetic activation o= the cardiovasclar system ths
appears to be the common core to emotion sppression across emotion conte*ts, and
sppressin& either ne&ative or positive emotions e*acts a palpable physiolo&ical cost<
3= these reslts really are the conseMence o= sppressin& on&oin& emotion%e*pressive
behavior, sppressin& non%emotional behavior drin& a netral =ilm shold have no
sch conseMences< 7o test this critical bondary condition, /e e*amined sbRectsL
responses drin& the netral =ilm< 7his =ilm prodced lo/ levels o= sel=%reported
emotion and non%emotional e*pressive behavior sch as lip%bitin& and ya/nin&< As
e*pected, sppression decreased non%emotional behavior, and no di==erences /ere
=ond bet/een sppress and /atch sbRects =or any o= the physiolo&ical variables<
7his is important, becase it s&&ests that the physiolo&ical impact o= emotion
sppression &ro/s ot o= the conterpoisin& o= attempts to inhibit e*pression a&ainst
stron& implses to e*press< 3n the absence o= a stimls that prodces implses to
e*press, behavioral inhibition has relatively little impact on physiolo&ical respondin&<
Doall )orms o) emotion reg'lation have similar "onse;'en"es-
Emotion re&lation incldes very di==erent strate&ies sch as thin0in& positive
tho&hts, sin& dr&s, tal0in& /ith =riends, and sppressin& emotional e*pression
Ae<&< :ar0inson et alD9 1--G8 7hayer et alD9 1--#B< Do all these =orms o= emotion
re&lation have similar conseMencesT On the one hand, i= the conseMences o=
sppression are de to the e==ort it ta0es to override emotion%e*pressive behavior,
other e==ort=l =orms o= emotion re&lation mi&ht have similar e==ects< On the other
hand, di==erent =orms o= emotion re&lation cold in=lence the emotion%&enerative
process at di==erent points, and ths have di==erent conseMences A;ross, !""1B< 7o
test this prediction, /e compared emotion sppression /ith another =orm o= emotion
re&lation, namely reappraisal, /hich involves re%evalatin& a potentially emotionally
evocative sitation in order to decrease emotion<
3n this stdy, sbRects /atched the same amptation =ilm that had been sho/n in the
initial stdies< 7his time, sbRects /ere randomly assi&ned to vie/ this dis&stin& =ilm
nder one o= three instrctional sets A;ross, 1--@B< 3n the =irst, sbRects
%G@%
/ere as0ed to thin! abot /hat they /ere seein& in sch a /ay that they did not =eel
anythin& at all AreappraisalB< 3n the second, sbRects /ere as0ed to hide their
'"
emotional reactions AsppressionB< 3n the third, sbRects simply /atched the =ilms
A/atchB<
Reslts indicated that emotion sppression and reappraisal cold indeed be
distin&ished< As observed previosly, emotion sppression decreased dis&st%
e*pressive behavior, and increased sympathetic activation o= the cardiovasclar and
electrodermal systems< 6i0e sppression, reappraisal decreased e*pressive behavior<
,nli0e sppression, ho/ever, reappraisal had no observable conseMences in terms o=
sympathetic activation o= the cardiovasclar or electrodermal systems< Whereas
sppress sbRects sho/ed &reater increases in sympathetic activation than /atch or
reappraise sbRects, these latter t/o &rops did not di==er =rom one another< Also
nli0e sppression, reappraisal decreased dis&st e*perience, /hereas sppression
had no e==ect on dis&st e*perience< 7hese =indin&s sho/ that the e==ects o=
sppression are not simply the reslt o= any attempt at in=lencin& oneLs emotions<
Ho/ one &oes abot achievin& an emotion re&latory &oal may be as important a
determinant o= the a==ective conseMences o= oneLs e==orts as the &oal one is tryin& to
achieve%not sho/in& emotion drin& a social interaction may be a re&latory strate&y
e*actin& hi&her physiolo&ical costs than other re&latory strate&ies< Altho&h mch
remains to be learned abot the details o= the physiolo&ical conseMences o= emotion
sppression, the available evidence s&&ests that one core =eatre o= emotion
sppression%at least in the passive =ilm and slide%vie/in& stdies condcted to date%is
sympathetic activation o= the cardiovasclar system<
?ridging the gap *et1een a"'te and longer+term "onse;'en"es
3n the precedin& sections, /e have sho/n that AaB in the short term, emotion
sppression leads to acte increases in sympathetic activation, and AbB over the lon&er
term, individals /ho sppress hi&h levels o= ne&ative emotion seem to be at &reater
ris0 =or cardiovasclar disease< 7o&ether, these =indin&s are s&&estive o= a casal
lin0< Ho/ever, it is =ar =rom clear ho/ the acte e==ects o= emotion sppression mi&ht
translate into lon&er%term conseMences that cold promote cardiovasclar diseases<
3n ans/erin& this Mestion it is important to 0eep in mind the hetero&eneity o=
cardiovasclar diseases, e<&< primary and secondary hypertension, cerebrovasclar
disease, arrhythmias, or myocardial in=arction, as /ell as the hetero&eneity o=
conditions leadin& to cardiovasclar diseases< :sychosocial =actors are almost
certainly involved to varyin& de&rees in di==erent cardiovasclar diseases and mi&ht in
some cases either be involved to a very limited e*tent or not be involved at all<
We consider t/o 0inds o= path/ays< First, /e consider psychophysiological
path"ays9 by /hich emotion sppression cold lead to transient increases in
sympathetic activation /hich%i= repeated many times%mi&ht precipitate a
%G-%
cascade o= processes that cold directly in=lence cardiovasclar health< )econd, /e
consider psychosocial path"ays9 by /hich emotion sppression mi&ht si&ni=icantly
alter the material and emotional spport that social partners provide, thereby
indirectly in=lencin& cardiovasclar health< 7he path/ays /e describe are
speclative, and are meant to illstrate rather than e*hast the mechanisms by /hich
emotion sppression mi&ht contribte to cardiovasclar disease< Altho&h it seems
'1
li0ely that the t/o 0inds o= path/ays interact Acompare 9or&ensen et alD9 1--G8 Cyers
N Cc(lre, 1--+B, /e describe psychophysiolo&ical and psycho%social mechanisms
separately =or the sa0e o= clarity<
Psychophysiological path*ays
Any one instance o= hei&htened sympathetic respondin&, sch as that seen in
laboratory stdies o= emotion sppression, /old seem nli0ely to have deleterios
conseMences< Ho/ever, an individal /ho sho/s an e*a&&erated sympathetic
response o= the cardiovasclar system in a laboratory sitation mi&ht be e*pected to
sho/ e*a&&erated sympathetic responses in many similar sitations in daily li=e<
Accordin& to the reactivity hypothesis Asee Fredri0son, 1--18 Krant> N Canc0,
1-@#B, the cmlative e==ects o= many sch instances mi&ht be e*pected to ta0e a toll<
3t is important to note that sympathetic activation is not al/ays harm=l ADienstbier,
1-@-B< Ho/ever, i= there is no time to recover Ae<&< 6inden et alD9 1--'8 CcE/en,
1--@B or i= the enhanced cardiac responses are in e*cess o= metabolic demands Ae<&<
Fisher, 1--18 Obrist, 1-@+8 )aab N )chneiderman, 1--+B, as mi&ht be the case in the
conte*t o= emotion sppression, sch increased sympathetic activation mi&ht lead to
chronic =nctional and strctral chan&es o= the cardio%vasclar system that
compromise its per=ormance<
7he available evidence seems to be &enerally consistent /ith this reactivity
hypothesis< (ardiovasclar hyperreactivity to di==erent stressors appears to be
involved in the development o= essential hypertension Ae<&< Everson et alD9 1--G8
Catthe/s et alD9 1--+8 Wood et alD9 1-@#8 see, =or revie/, Fredri0son, 1--1B and
atherosclerosis Ae<&< Keys et alD9 1-'18 Canc0 et alD9 1-@+B, /hich are the t/o maRor
ris0 =actors =or myocardial ischemia, in=arction, and sdden cardiac death Ae<&<
;illm, 1--G8 ;yton N Hall, 1--'8 Krant> N Canc0, 1-@#8 Witteman et alD9 1--@B<
3n the =ollo/in& sections, /e describe ho/ emotion sppression mi&ht lead to
hypertension and atherosclerosis via e*a&&erated cardiovasclar respondin&< Or
=ocs is the sympathoadrenomedllary a*is, altho&h there is evidence that the
adrenocortical a*is Ae<&< Fredri0son N 7omisto, 1--18 Henry N )tephens, 1-''8
Herd, 1-@G8 7ro*ler et alD9 1-''B and parasympathetic /ithdra/al Ae<&< $rosschot N
7hayer, 1--@8 Horsten et alD9 1---8 :or&es, 1--.B also may play important roles in the
development and pro&ression o= cardiovasclar diseases<
7he top part o= Fi&re #<+ sho/s several path/ays by /hich the =reMent incidents o=
sympathetic hyperreactivity associated /ith emotion sppression cold lead to
chronic hypertension< One sch path/ay /as proposed by Fol0o/ A1-@!B,
%'"%
/ho s&&ested that the repeated pressor episodes e*hibited by hi&hly reactive
individals mi&ht promote smooth mscle hypertrophy< 7his process and a concrrent
propensity =or e*cessive vasoconstriction can lead to narro/ed lmina AFol0o/, 1-@!8
9lis, 1--+B< Frthermore, cardiac otpt that is e*cessive relative to metabolic
demand can tri&&er atore&latory mechanisms, incldin& peripheral
vasoconstriction, to prevent tisse overper=sion AObrist et alD9 1-@+8 )her/ood et alD9
1-@GB< $oth narro/ed lmina and e*cessive vasoconstriction can contribte to
'!
chronically hei&htened peripheral resistance< Coreover, hi&h sympathetic drive mi&ht
promote sodim and =lid retention thro&h its e==ects on renal nerve activity< 3n the
lon& rn, this cold lead to renal dys=nction /ith chronically hi&her blood volme
Ae<&< ;yton N Hall, 1--'8 6i&ht et alD9 1-@+B< 7hs, chronically hei&htened
sympathetic activation, /ith its attendant smooth mscle hypertrophy, increased
peripheral resistance, and increased blood volme, mi&ht ltimately contribte to the
development o= chronic hypertension<
Fi&re #<+ also sho/s path/ays by /hich emotion sppression Aand its associated
increases in sympathetic activation o= the cardiovasclar systemB cold contribte to
atherosclerosis< )ome o= these path/ays involve the hemodynamic chan&es associated
/ith hei&htened sympathetic activation< Repeated episodes o= hi&her arterial pressre
can lead, thro&h hemodynamic =orces sch as sheer stress and trblence, to micro%
inRries o= the coronary arteries at vlnerable points in the arterial tree Ae<&< (lar0son
et alD9 1-@GB< Once the coronary endothelim is dama&ed, deposition o= lipids,
platelets, and =ibrin Aa clottin& material in the bloodB /ithin the lesioned area can
ense A;yton N Hall, 1--'8 Ross, 1--+8 )chneiderman, 1-@'B< Atherosclerosis can
then pro&ress /ith chronic in=lammatory cell proli=eration, blood clot =ormation, and
calci=ication and protrde into the lmen o= the artery AHerd, 1-@GB< 7he altered
composition o= the intima Athe inner layer o= the blood vesselB seems to provo0e
smooth mscles to move into the arterial intima and to proli=erate, thereby =rther
decreasin& the si>e o= the lmina AHerd, 1-@G8 Ross, 1--+8 )ch/art> et alD9 1-@1B<
Other possible path/ays lin0in& emotion sppression and cardiovasclar disease
involve the neroendocrine components o= hei&htened sympathetic medllary
activation, in particlar plasma catecholamines< Hi&her levels o= circlatin&
catecholamines can directly inRre the intimal endothelim o= the coronary arteries
AKrant> N Canc0, 1-@#8 )chneiderman, 1-@'B, tri&&erin& atherosclerotic plaMe
&ro/th< (atecholamines also indce a release o= =ree =atty acids and lipoproteins into
the blood stream, /hich can be athero&enic i= they reach concentrations in e*cess o=
metabolic reMirements A(arrthers, 1-G-8 Henry N )tephens, 1-''8 )chneiderman,
1-@'B< 7hese =actors contribte to the development o= atherosclerotic plaMe, /hich
can ltimately completely occlde arteries< 7his development can become li=e%
threatenin&, as atherosclerotic obstrctive lesions and ensin& thrombosis can tri&&er
myocardial ischemia, in=arction, and cardiac death<
%'!%
Psychosocial path*ays
As sho/n in the bottom o= Fi&re #<+, emotion sppression also may be lin0ed to
cardiovasclar disease otcomes via several psychosocial path/ays< One particlarly
important psychosocial path/ay is the patient%physician relationship< Roter and E/art
A1--!B analy>ed patient%physician intervie/s and =ond that patients /ith essential
hypertension /ere less li0ely to e*press ne&ative emotions than normotensive
sbRects< )ch sppression o= distress in clinical intervie/s mi&ht lead to a delayed
detection o= disease, less e==ective patient%physician commnication, an
nderestimation o= symptoms, and =e/er preventive and remedial steps bein& ta0en
by the physician to address social and emotional problems A$ars0y, 1-@18 Roter N
E/art, 1--!B< 7his in trn cold lead to decreased patient satis=action, and an ensin&
tendency o= noncompliance /ith therapy Ae<&< Haynes et alD9 1-@'8 6ieberman, 1--GB<
'+
3n other relationships, too, emotion sppression cold have costs that are relevant to
cardiovasclar health< E*pression o= emotions commnicates to others a personLs
/ishes and needs< 3= this commnication is interrpted, becase emotional e*pression
is inhibited, others may be less accommodatin&< 3ndividals /ith a tendency to inhibit
their ne&ative emotions mi&ht ths, thro&h reciprocal interactions, inadvertently
create an environment provo0in& the e*perience o= ne&ative emotions Asee )mith,
1--!B< :articlarly individals /ho e*hibit a pattern o= inhibition alternatin& /ith
inappropriately stron& e*pression o= emotion cold elicit ne&ative social reactions
ADavidson et alD9 1---B< FreMent e*perience o= ne&ative emotions mi&ht in trn, as
sho/n in Fi&re #<+, prompt the individal to sppress these emotions, ths tri&&erin&
a positive =eedbac0 loop<
3n addition, emotional ine*pressiveness and introversion have been related to less
see0in& o= social spport AAmir0han et alD9 1--.8 Von Dras N )ie&ler, 1--'B< 7/o
models have been proposed that lin0 lessened social spport to disease A)ch/ar>er N
6eppin, 1--1B< On the one hand, social spport serves a b==er =nction a&ainst other
stressors sch as /hen a person see0s emotional spport =rom her =riends a=ter her
spose dies< 3= an individal has lo/ social spport, this b==er =nction is not
a==orded anymore and stressors create lar&er psycholo&ical and physiolo&ical stress
responses Ae<&< 9ennison, 1--!B< On the other hand, lo/ social spport mi&ht have a
direct, ne&ative e==ect on the individal%social isolation mi&ht directly lead to
hei&htened ne&ative a==ect and poorer health%related behavior Ae<&< 7reiber et alD9
1--18 Himmerman N (onner, 1-@-B< Additionally, the none*pression o= emotions can
have ne&ative e==ects by preventin& the bene=icial e==ects o= verbali>ation, /hich
inclde restrctrin& o= the emotion%elicitin& event A:enneba0er, 1--'B< Withot
co&nitive restrctrin&, there may be prolon&ed rmination, more =reMent e*perience
o= ne&ative emotions, and inadeMate copin& /ith sbseMent events Asee, =or
e*ample, ;reen&lass, 1--G8 :enneba0er, 1--'8 )myth, 1--@B, =rther increasin& the
=reMency o= harm=l physiolo&ical responses<
$oth conseMences o= lo/ social spport%the missin& b==er =nction and the direct
ne&ative e==ects%cold have a detrimental impact on varios health
%'+%
otcomes, incldin& cardiovasclar diseases Ae<&< Adler N Catthe/s, 1--#8 $er0man,
1--.8 Kin&, 1--'8 )mith N :ope, 1--"8 ,chino et alD9 1--GB< )ch detrimental
psychosocial e==ects mi&ht be especially costly after a cardiac event, /hen patients
are in a vlnerable state Ae<&< $er0man et alD9 1--!8 Orth%;omQr et alD9 1-@@8
Rberman et alD9 1-@#B< )ppression ths mi&ht contribte both to the development o=
cardiovasclar diseases and to their pro&ression by impairin& patient%physician
interactions in particlar and social relationships more &enerally<
8'mmary
7he poplar press has lon& r&ed that emotion sppression may be bad =or or health<
3n this chapter, /e have selectively revie/ed the scienti=ic literatre on emotion and
cardiovasclar disease, and =ond that both emotion e*pression and emotion
sppression seem to play a role in cardiovasclar disease< 7o e*amine /hether
emotion sppression has any niMe contribtion to cardiovasclar respondin&, /e
'#
revie/ed a series o= laboratory stdies on the acte conseMences o= emotion
sppression< 7hese stdies sho/ed that sppressin& ne&ative emotions sch as dis&st
or sadness, or positive emotions sch as amsement, leads to acte increases in
sympathetic activation o= the cardiovasclar system< Altho&h any one o= these
moments o= increased activation is nli0ely to have any lon&%term health impact, /e
have s&&ested psychophysiolo&ical and psychosocial path/ays by /hich the acte
e==ects o= emotion sppression mi&ht translate into lon&er term threats to
cardiovasclar health< One important challen&e =or =tre research on emotion
sppression and health /ill be to test these s&&estions in the conte*t o= rich social
interactions, /ith a broad ran&e o= vlnerable and non%vlnerable research
participants< )ch stdy /ill permit a better nderstandin& o= the comple* health
e==ects o= di==erin& patterns o= emotion e*perience, e*pression, and sppression<
A"kno1ledgments
7his research /as spported by ;rant CH.@1#' =rom the National 3nstitte o= Cental
Health< 7he second athor be&an the research pro&ram described in the second section
o= this chapter as a &radate stdent at the ,niversity o= (ali=ornia, $er0eley, and
&rate=lly ac0no/led&es the in=lence o= his &radate mentor Robert W< 6evenson<
)ince movin& to )tan=ord ,niversity, the second athor has contined this line o=
/or0 on emotion sppression /ith his o/n &radate stdents<
!e)eren"es
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%'#%
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pressre in middle%a&ed men< Fypertension, %4, 1".-%1"G#<
Fieldin&, R< A1--1B< Depression and acte myocardial in=arctionE a revie/ and
reinterpretation< %ocial %cience and ?edicine,&%, 1"1'%1"!'<
Fisher, 6<A< A1--1B< )tress and cardiovasclar physiolo&y in animals< 3n C<R<
$ro/n, ;<F< Koob, N (< Rivier AedsB, %tressD <eurobiology and
neuroendocrinology App< #G+%#'#B< Ne/ Yor0E Carcel De00er<
Fleet, R<:< N $eitman, $<D< A1--@B< (ardiovasclar death =rom panic disorder
and panicli0e an*ietyE a critical revie/ o= the literatre< Eournal of
Psychosomatic Research,,,, '1%@"<
Florin, 6, Fredenber&, ;<, N Hollaender, 9< A1-@.B< Facial e*pressions o=
emotion and physiolo&ic reactions in children /ith bronchial asthma<
Psychosomatic ?edicine,,4, +@!%+-+<
Fol0o/, $< A1-@!B< :hysiolo&ical aspects o= primary hypertension< Physiological
Re'ie",.%, +#'%."+<
Fredri0son, C< A1--1B< :sychophysiolo&ical theories on sympathetic nervos
system reactivity in the development o= essential hypertension< %candina'ian
''
Eournal of Psychology,&%, !.#%!'#<
Fredri0son, C< N 7omisto, C< A1--1B< Neroendocrine and cardiovasclar stress
reactivity in middle%a&ed normotensive adlts /ith parental history o=
cardiovasclar disease< Psychophysiology,%2, G.G%GG#<
Fred, )< A1-G1?1-+"B< Ci'ili@ation and its discontents A9<7< )trachey, trans<B<
Ne/ Yor0E W<W< Norton N (o< AOri&inal /or0 pblished in 1-+"<B
Friedman, H<)< N $ooth%Ke/ley, )< A1-@'B< 7he Odisease%prone personalityPE a
meta%analytic vie/ o= the constrct< merican Psychologist,,%, .+-%...<
Friedman, C< N Rosenman, R< A1-'#B< Type beha'ior and your heart< Ne/
Yor0E Knop=<
FriRda, N<H< A1-@GB< The emotions< (ambrid&eE (ambrid&e ,niversity :ress<
;allacher, 9<E<, Yarnell, 9<W<;<, )/eetnam, :<C<, El/ood, :<(<, N )tans=eld,
)<A< A1---B< An&er and incident heart disease in the (aerphilly stdy<
Psychosomatic ?edicine,.$, ##G%#.+<
;illm, R<F< A1--GB< (oronary heart disease, stro0e, and hypertension in a ,<)<
national cohortE the NHANE) 3 Epidemiolo&ic Follo/%p )tdy< National Health
and Ntrition E*amination )rvey< nnals of 5pidemiology,., !.-%!G!<
;reen&lass, E<R< A1--GB< An&er sppression, cynical distrst, and hostilityE
implications =or coronary heart disease< 3n (<D< )pielber&er N 3<;< )arason AedsB,
%tress and emotion App< !".%!!#B< Washin&ton, D(E 7aylor N Francis<
%'G%
;reer, )< N Watson, C< A1-@.B< 7o/ards a psychobiolo&ical model o= cancerE
psycholo&ical considerations< %ocial %cience and ?edicine,%6, ''+%'''<
;ross, 9<9< A1-@-B< Emotional e*pression in cancer onset and pro&ression< %ocial
%cience and ?edicine,%2, 1!+-%1!#@<
;ross, 9<9< A1--@B< Antecedent% and response%=ocsed emotion re&lationE
diver&ent conseMences =or e*perience, e*pression, and physiolo&y< Eournal of
Personality and %ocial Psychology,4,, !!#%!+'<
;ross, 9<9< A!""1B< Emotion re&lation in adlthoodE timin& is everythin&<
Current Directions in Psychological %cience,$, !1#%!1-<
;ross, 9<9< N 6evenson, R<W< A1--'B< Hidin& =eelin&sE the acte e==ects o=
'@
inhibitin& positive and ne&ative emotions< Eournal of bnormal Psychology,$6.,
-.%1"+<
;rossarth%Catice0, R<, $astiaans, 9<, N Kana>ir, D<7< A1-@.B< :sychosocial
=actors as stron& predictors o= mortality =rom cancer, ischemic heart disease and
stro0eE the Y&oslav prospective stdy< Eournal of Psychosomatic Research,%#,
1G'%1'G<
;llette, E<(<D<, $lmenthal, 9<A<, $abya0, C, 9ian&, W<, Wa&h, R<A<, Frid,
D<9<, OL(onnor, (<C<, Corris, 9<9<, N Krant>, D<)< A1--'B< E==ects o= mental stress
on myocardial ischemia drin& daily li=e< Eournal of the merican ?edical
ssociation,%44, 1.!1%1.!G<
;yton, A<(< N Hall, 9<E< A1--'B< Fuman physiology and mechanisms of disease
AGth ednB< :hiladelphia, :AE W<$< )anders<
Haines, A<:<, 3meson, 9<D<, N Ceade, 7<W< A1-@'B< :hobic an*iety and ischemic
heart disease< British ?edical Eournal,%#/, !-'%!--<
Harbr&, E<, ;leiberman, 6<, Rssell, C<, N (ooper, C<6< A1--1B< An&er%copin&
styles and blood pressre in $lac0 and White malesE $==alo, Ne/ Yor0<
Psychosomatic ?edicine,/&, 1.+%1G#<
Harrison, R<H< A1-'.B< :sycholo&ical testin& in headacheE a revie/< Feadache,$/,
1''%1@.<
Haynes, R<$<, Wan&, E<, N Da Cota ;omes, C< A1-@'B< A critical revie/ o=
interventions to improve compliance /ith prescribed medications< Patient
5ducation and Counseling,$6, 1..%1GG<
Haynes, )<;<, Feinleib, C<, N Kannel, W<$< A1-@"B< 7he relationship o=
psychosocial =actors to coronary heart disease in the Framin&ham )tdy<
merican Eournal of 5pidemiology,$$$, +'%.@<
Hearn, C<D<, Crray, D<C<, N 6ep0er, R<V< A1-@-B< Hostility, coronary heart
disease, and total mortalityE a ++%year =ollo/%p stdy o= niversity stdents<
Eournal of Beha'ioral ?edicine,$%, 1".%1!1<
Hec0er, C<6<, (hesney, C<A<, $lac0, ;<W<, N Fratsch, N< A1-@@B< (oronary%
prone behaviors in the Western (ollaborative ;rop )tdy< Psychosomatic
?edicine,/6, 1.+%1G#<
Helmer, D<(<, Ra&land, D<R<, N )yme, )<6< A1--1B< Hostility and coronary artery
disease< merican Eournal of 5pidemiology,$&&, 11!%1!!<
Henry, 9<:< N )tephens, :<C< A1-''B< Fnctional and strctral chan&es in
response to psychosocial stimlation< 3n 9<:< Henry N :<C< )tephens AedsB,
Fealth and the social en'ironmentD sociobiological approach to medicine App<
1#1%1GGB< Ne/ Yor0E )prin&er<
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Herd, 9<A< A1-@GB< Neroendocrine mechanisms in coronary heart disease< 3n
K<A< Catthe/s, )<C< Weiss, 7< Detre, 7<C< Dembros0i, $< Fal0ner, )<$<
Canc0, N R<$<
%''%
Williams AedsB, Fandboo! of stress9 reacti'ity9 and cardio'ascular disease App<
#-%'"B< Ne/ Yor0E Wiley<
Horsten, C<, Ericson, C, :ers0i, A<, Wamala, )<:<, )chenc0%;sta=sson, K<, N
Orth;omQr, K< A1---B< :sychosocial =actors and heart rate variability in healthy
/omen< Psychosomatic ?edicine,.$, #-%.'<
9ennison, K<C< A1--!B< 7he impact o= stress=l li=e events and social spport on
drin0in& amon& older adltsE a &eneral poplation srvey< #nternational Eournal
of ging and Fuman De'elopment,&/, --%1!+<
9or&ensen, R<)<, 9ohnson, $<7<, Kolod>ieR, C<E<, N )chreer, ;<E< A1--GB<
Elevated blood pressre and personalityE a meta%analytic revie/< Psychological
Bulletin,$%6, !-+%+!"<
9lis, C<, Harbr&, E<, (ottin&ton, E<C<, N 9ohnson, E<H< A1-@GB< An&er%copin&
types, blood pressre, and all%case mortalityE a =ollo/%p in 7ecmseh,
Cichi&an A1-'1%1-@+B< merican Eournal of 5pidemiology,$%,, !!"%!++<
9lis, )< A1--+B< )ympathetic hyperactivity and coronary ris0 in hypertension<
Circulation,%$, @@G%@-+<
9l0nen, 9< A1--GB< )ppressin& yor an&erE &ood manners, bad healthT 3n (<D<
)pielber&er N 3<;< )arason AedsB, %tress and emotion3 n.iety9 anger9 and
curiosity App< !!'%!#"B< Washin&ton, D(E 7aylor N Francis<
Ka/achi, 6, ;raham, A<(<, Aschiero, A<, Rimm, E<$<, ;iovanncci, E<,
)tamp=er, C<9<, N Willett, W<(< A1--#B< :rospective stdy o= phobic an*iety and
ris0 o= coronary heart disease in men< Circulation,2#, 1--!%1--'<
Keys, A<, 7aylor, H<6<, $lac0brn, H<, $ro>e0, 9<, Anderson, 9<7<, N )imonson,
E< A1-'1B< Cortality and coronary heart disease in yon& men stdied =or !+
years< rchi'es of #nternal ?edicine,$%2, !"1%!1#<
Kin&, $<K< A1--'B< :sycholo&ic and social aspects o= cardiovasclar disease<
nnals ofBeha'ioral ?edicine,$#, !G#%!'"<
Krant>, D<)< N Canc0, )<$< A1-@#B< Acte psychophysiolo&ic reactivity and ris0
o= cardiovasclar diseaseE a revie/ and methodolo&ic critiMe< Psychological
Bulletin,#., #+.%#G#<
Kb>ans0y, 6<D< N Ka/achi, 3< A!"""B< ;oin& to the heart o= the matterE do
ne&ative emotions case coronary heart diseaseT Eournal of Psychosomatic
@"
Research,,2, +!+%++'<
6eon, ;<, Finn, )<E<, Crray, D<, N $ailey, 9<C< A1-@@B< 3nability to predict
cardiovasclar disease =rom hostility scores or CC:3 items related to 7ype A
behavior< Eournal of Consulting and Clinical Psychology,/., .-'%G""<
6ieberman, 9<A< A1--GB< (ompliance isses in primary care< Eournal of Clinical
Psychiatry,/4 A)ppl< 'B, 'G%@!<
6i&ht, K<(<, Koep0e, 9<:<, Obrist, :<A<, N Willis, :<W< A1-@+B< :sycholo&ical
stress indces sodim and =lid retention in men at hi&h ris0 =or hypertension<
%cience,%%6, #!-%#+1<
6inden, W<, Earle, 7<6<, ;erin, W<, N (hristen=eld, N< A1--'B< :hysiolo&ical
stress reactivity and recoveryE conceptal siblin&s separated at birthT Eournal of
Psychosomatic Research,,%, 11'%1+.<
CcE/en, $<)< A1--@B< :rotective and dama&in& e==ects o= stress mediators< <e"
5ngland Eournal of ?edicine,&&2, 1'1%1'-<
Canc0, )<$<, Kaplan, 9<R<, N (lar0son, 7<$< A1-@+B< $ehaviorally indced heart
rate reactivity and atherosclerosis in cynomol&s mon0eys< Psychosomatic
?edicine,,/, -.%1"@<
Canc0, )<$<, Kaplan, 9<R<, N Catthe/s, K<A< A1-@GB< $ehavioral antecedents o=
coronary heart disease and atherosclerosis< rteriosclerosis,., !%1#<
%'@%
Cartin, :< A1--@B< The healing mind< Ne/ Yor0E 7homas Dnne $oo0s<
Catthe/s, K<A< A1-@@B< (oronary heart disease and 7ype A behaviorsE pdate on
and alternative to the $ooth%Ke/ley and Friedman A1-@'B Mantitative revie/<
Psychological Bulletin,$6,, +'+%+@"<
Catthe/s, K<A<, Woodall, K<6<, N Allen, C<7< A1--+B< (ardiovasclar reactivity
to stress predicts =tre blood pressre stats< Fypertension,%%, #'-%#@.<
Ciller, 7<Y<, )mith, 7<W<, 7rner, (<W<, ;iRarro, C<6<, N Hallet, A<9< A1--GB< A
meta%analytic revie/ o= research on hostility and physical health< Psychological
Bulletin,$$#, +!!%+#@<
Crray, (<9<6< N 6ope>, A<D< A1--'B< Alternative proRections o= mortality and
disability by case 1--"%!"!"E ;lobal $rden o= Disease )tdy< The Lancet,&,#,
1#-@%1."#<
Csselman, D<6<, Evans, D<6<, N Nmero==, (<$< A1--@B< 7he relationship o=
depression to cardiovasclar diseaseE epidemiolo&y, biolo&y, and treatment<
rchi'es of General Psychiatry,//, .@"%.-!<
@1
Cyers, H<F< N Cc(lre, F<H< A1--+B< :sychosocial =actors in hypertension in
blac0sE the case =or an interactional perspective< 3n 9<(<)< Fray N 9<;< Do&las
AedsB, Pathophysiology of hypertension in blac!s App< -"%1"GB< Ne/ Yor0E O*=ord
,niversity :ress<
Obrist, :<A<, 6an&er, A<W<, 6i&ht, K<(<, N Koep0e, 9<:< A1-@+B< A cardiac%
behavioral approach in the stdy o= hypertension< 3n 7<C< Dembros0i, 7<H<
)chmidt, N ;< $lZmchen AedsB, Biobeha'ioral bases of coronary artery disease
App< !-"%+"+B< $aselE Kar&er<
Orth%;omQr, K<, ,nden, A<6<, N Ed/ards, C<E< A1-@@B< )ocial isolation and
mortality in ischemic heart disease< cta ?edica %candina'ia,%%,, !".%!1.<
:ar0inson, $<, 7otterdell, :<, $riner, R<$<, N Reynolds, )< A1--GB< Changing
moods3 the psychology of mood and mood regulation< 6ondonE 6on&man<
:enneba0er, 9<W< A1--'B< Health e==ects o= the e*pression Aand non%e*pressionB o=
emotions thro&h /ritin&< 3n A<9<9<C< Vin&erhoets, F<9< Van $rssel, N A<W<9<
!G'%!'@B< 7ilbr&, 7he NetherlandsE 7ilbr& ,niversity :ress<
:enneba0er, 9<W< N 7rae, H<(< A1--+B< 3nhibition and psychosomatic processes<
3n H<(< 7rae N 9<W< :enneba0er AedsB, 5motion9 inhibition9 & health App< 1#G%
1G+B< ;[ttin&en, ;ermanyE Ho&re=e N Hber :blishers<
:or&es, )<W< A1--.B< (ardiac va&al toneE a physiolo&ical inde* o= stress<
<euroscience and Biobeha'ioral Re'ie"s,$#, !!.%!++<
Rosen&ren, A<, 7ibblin, ;<, N Wilhelmsen, 6< A1--1B< )el=%perceived
psycholo&ical stress and incidence o= coronary artery disease in middle%a&ed
men< The merican Eournal of Cardiology,.2, 11'1%11'.<
Ross, R< A1--+B< 7he patho&enesis o= atherosclerosisE a perspective =or the 1--"s<
<ature,&.%, @"1%@"-<
Roter, D<6< N E/art, (<K< A1--!B< Emotional inhibition in essential hypertensionE
obstacle to commnication drin& medical visitsT Fealth Psychology,$$, 1G+%
1G-<
Rberman, W<, Weinblatt, E<, ;oldber&, 9<, N (hadhary, $<)< A1-@#B<
:sychosocial in=lences on mortality a=ter myocardial in=arction< <e" 5ngland
Eournal of ?edicine,&$$, ..!%..-<
)aab, :<;< N )chneiderman, N< A1--+B< $iobehavioral stressors, laboratory
investi&ation, and the ris0 o= hypertension< 3n 9< $lascovich N E<)< Kat0in AedsB,
Cardio'ascular reacti'ity to psychological stress and disease App< #-%@!B<
Washin&ton, D(E American :sychiatric Association<
@!
%'-%
)apols0y, R< A1--@B< ;hy @ebras don2t get ulcers A!nd ednB< Ne/ Yor0E Freeman<
)challin&, D< N )vensson, 9< A1-@#B< $lood pressre and personality< Personality
and #ndi'idual Differences,/, #1%.1<
)chneiderman, N< A1-@'B< :sychophysiolo&ic =actors in athero&enesis and
coronary artery disease< Circulation,4. A)ppl< 1B, 3#1%1#'<
)ch/art>, )<C<, ;aRdse0, (<C<, N )elden, )<(< A1-@1B< Vasclar /all &ro/th
controlE the role o= the endothelim< rteriosclerosis,$, 1"'%1!G<
)ch/ar>er, R< N 6eppin, A< A1--1B< )ocial spport and healthE a theoretical and
empirical overvie/< Eournal of %ocial and Personal Relationships,2, --%1!'<
)her/ood, A<, Allen, C<7<, Obrist, :<A<, N 6an&er, A<W< A1-@GB< Evalation o=
\%adrener&ic in=lences on cardiovasclar and metabolic adRstment to physical
and psycholo&ical stress< Psychophysiology,%&, @-%1"#<
)ie&el, 9<C< A1-@#B< 7ype A behaviorE epidemiolo&ic =ondations, and pblic
health implication< nnual Re'ie" of Public Fealth,/, +#+%+G'<
)ie&man, A W<, Dembros0i, 7<C<, N Rin&el, N< A1-@'B< (omponents o= hostility
and the severity o= coronary artery disease< Psychosomatic ?edicine,,#, 1!'%1+.<
)mith, (<A< N :ope, 6<K< A1--"B< (ynical hostility as a health ris0E crrent stats
and =tre direction< Eournal of %ocial Beha'ior and Personality,/, ''%@@<
)mith, 7<W< A1--!B< Hostility and healthE crrent stats o= a psychosomatic
hypothesis< Fealth Psychology,$$, 1+-%1."<
1'#%1@#<
)pielber&er, (<D<, Reheiser, E<(<, N )ydeman, )<9< A1--.B< Ceasrin& the
e*perience, e*pression, and control o= an&er< 3n H< Kassinove Aed<B, nger
disorders3 Definitions9 diagnosis9 and treatment App< #-%G'B< Washin&ton, D(E
7aylor N Francis<
)ls, 9<, Wan, (<K<, N (osta, :<7< A1--.B< Relationship o= trait an&er to restin&
blood pressreE a meta%analysis< Fealth Psychology,$,, ###%#.G<
7eiramaa, E< A1-'@B< :sychosocial and psychic =actors in the corse o= asthma<
Eournal of Psychosomatic Research,%%, 1!1%1!.<
7emosho0, 6< A1-@'B< :ersonality, copin& style, emotion, and cancerE to/ard an
inte&rative model< Cancer %ur'eys,., @+'%@+-<
@+
7hayer, R<E<, Ne/man, 9<R<, N Cc(lain, 7<C< A1--#B< )el=%re&lation o= moodE
strate&ies =or chan&in& a bad mood, raisin& ener&y, and redcin& tension< Eournal
of Personality and %ocial Psychology,.4, -1"%-!.<
7reiber, F<A<, $arano/s0i, 7<, $raden, D<)<, )tron&, W<$<, 6evy, C<, N Kno*,
W< A1--1B< )ocial spport =or e*erciseE relationship to physical activity in yon&
adlts< Pre'enti'e ?edicine,%6, '+'%'."<
7ro*ler, R<;<, )pra&e, E<A<, Albanese, R<A<, Fchs, R<, N 7hompson, A<9<
A1-''B< 7he association o= elevated plasma cortisol and early atherosclerosis as
demonstrated by coronary an&io&raphy< therosclerosis,%., 1.1%1G!<
,chino, $<N<, (acioppo, 9<7<, N Kiecolt%;laser, 9<K< A1--GB< 7he relationship
bet/een social spport and physiolo&ical processesE a revie/ /ith emphasis on
nderlyin& mechanisms and implications =or health< Psychological Bulletin,$$#,
#@@%.+1<
,delman, H<D< N ,delman, D<6< A1-@1B< Emotions and rhematolo&ic disorders<
merican Eournal of Psychotherapy,&/, .'G%.@'<
Von Dras, D<D< N )ie&ler, 3<(< A1--'B< )tability in e*traversion and aspects o=
social spport in midli=e< Eournal of Personality and %ocial Psychology,4%, !++%
!#1<
Weidner, ;<, 3stvan, 9<, N CcKni&ht, 9<D< A1-@-B< (lsters o= behavioral coronary
ris0
%@"%
=actors in employed /omen and men< Eournal of pplied %ocial
Psychology,$#, #G@%#@"<
Witteman, 9<(<, DLA&ostino, R<$<, )tiRnen, 7<, Kannel, W<$<, (obb, 9<(<, de
Ridder, C<A<, Ho=man, A<, N Robins, 9<C< A1--@B< ;%estimation o= casal
e==ectsE isolated systolic hypertension and cardiovasclar death in the
Framin&ham Heart )tdy< merican Eournal of 5pidemiology,$,2, +-"%#"1<
Wood, D<6<, )heps, )<;<, Elvebac0, 6<R<, N )chir&er, A< A1-@#B< (old pressor
test as a predictor o= hypertension< Fypertension,., +"1%+"G<
Himmerman, R<)< N (onner, (< A1-@-B< Health promotion in conte*tE the
e==ects o= si&ni=icant others on health behavior chan&e< Fealth 5ducation
Iuarterly,$., .'%'#<
%@1%
Chapter /
@#
The !eality Es"ape 0odel
The intri"ate relation *et1een alexithymia, disso"iation, and anesthesia in
vi"tims o) "hild sex'al a*'se
Peter Paul ?oormann9 Bob Bermond and Francine lbach
Introd'"tion
3n the present chapter, /e /ill otline a ne/ model on the seMelae o= child se*al
abse, in /hich dissociation, ale*ithymia and anesthesia are considered as three
di==erent mani=estations o= the same non%=eelin& state that is so characteristic o=
tramati>ed individals< 7he ne/ aspects o= the model in particlar concern the /ay
several lines o= research are combined arond the idea that individals /ho have been
tramati>ed as a yon& child may, later in li=e, apply several psycholo&ical
mechanisms directed at escapin& the terror and the horror o= reality<
A si&ni=icant nmber o= victims o= abse /ho have been con=ronted repeatedly /ith
hi&hly threatenin& and pain=l events appear to try to escape =rom reality by inventin&
a ObetterP /orld AAlbach et alD9 1--GB< 7his escape =rom reality by creatin& and livin&
in a =antasy /orld Ai<e< in a dissociative stateB implies that the normal controllin&
=nctions o= consciosness are disrpted A9anet, 1-118 Kihlstrom, 1--!B< On the
behavioral level, distrbances in conation Aloss o= initiativeB, emotion Aa==ective
bloc0in&B and co&nition Amemory impairmentsB may be observed AKrystal, 1-@@aB< 3n
addition, several hysterical symptoms A$riMet, 1@.-8 9anet, 1-11B may be present
sch as distrbances in sensory perceptions A=or instance Oles anesthQsiesP or
insensitivity to stimlation =rom the sensesB, and distrbances in motor behavior
Aconversion reactionsB<
Follo/in& Fred and $reer A1@-+?1-!#B and 9anet A1-11B, also in or model, intense
an*iety, one o= the most pain=l emotions in hman e*istence, is re&arded as the
implse leadin& to the disrption o= the normal controllin& =nctions o=
consciosness< As early as 1-11, 9anet &ave a detailed description o= this disrptive
po/er o= intense emotionsE
With respect to this AsbRectB, 3 have demonstrated the dissolvin& po/er o= emotions
on volntary decisions, =eelin& states, and conscios sensations, and 3 consider this
dissociation o= memories to be part o= the lar&er &rop o= dissociation o= coherent
strctres by emotions<
Ap< .+!, translationB
%@!%
$t ho/ can the parado* bet/een, on the one hand, intense a==ect and, on the other
hand, a==ective bloc0in& be e*plainedT Krystal A1-@@aB &ives the =ollo/in& ans/erE
O7he parado* in the tramatic state is that the nmbin& and closin& o== are
e*perienced as relie= =rom previosly pain=l a==ects sch as an*ietyP Ap< 1.1B< )een
=rom this perspective, this non%=eelin& state is =nctional and can be considered as a
sel=%protectin& mechanism< 7he Reality 5scape ?odel presented here ori&inated =rom
@.
the idea that the =ollo/in& three di==erent mechanisms may nderlie sch a non%
=eelin& state<
1 %plitting of consciousness Ae<&< dissociationB to escape realityE O3t is not me /ho
is e*periencin& this pain=l emotion< 3t is another person, and there=ore it does not
a==ect me<P 7he conseMences are time loss and memory &aps<
! %"itching off feeling emotions Ae<&< ale*ithymiaB a&ainst psycholo&ical painE
O7hose horrible events donLt a==ect me< 3 s/itch o== my =eelin&< 3 =eel nothin&<P 3t
implies a disconnection o= the co&nitions belon&in& to an emotional e*perience<
Ho/ever, the non%=eelin& state also a==ects other areas in li=e and may there=ore
lead to anhedonia<
+ %"itching off feeling physical stimulation Ae<&< anesthesiaB a&ainst physical pain
and discom=ortE O7hey may beat me p, bt 3 donLt =eel the pain<P 7his reaction
implies the loss or impairments o= sensations, /hich may reslt in insensitivity to
physical pain< One o= the conseMences in se*al abse is =ri&idity< Another is a
hei&htened ris0 =or &ettin& ill and serios physical problems, becase the system
that sed to /arn s a&ainst dan&er is s/itched o==<
All the symptoms described above are &enerally reported by victims o= child se*al
abse< Ho/ever, individals s==erin& =rom dissociation are mainly persons /ith a
history o= repeated abse =or a prolon&ed period o= time, at a very yon& a&e< For
instance, one o= the sbRects in or stdies reported the =ollo/in&E
Cy e*%hsband saidE OYo are li0e a lmp o= ice<P 3 still am Dse*al anesthesia or
=ri&idityF< 3= my hsband /old never toch me a&ain, 3 /oldnLt care at all< When 3
am ma0in& love, 3 am li0e a sort o= doll< 3 only thin0 abot cleanin& the /indo/s
Descapist =antasyF< 3t is as i= somethin& closes o== inside Dpsychic nmbin&F< 3 catch
mysel= thin0in& O:eter has to ta0e this and that to school tomorro/ Descapist
=antasyFP<
A=ter this brie= otline o= or model, /e /ill =irst discss some important theoretical
isses that in=lenced or thin0in&< As ale*ithymia is seen as one o= the most
important mani=estations o= the psycholo&ical non%=eelin& state, adeMate attention
/ill be paid to this constrct< Ne*t, the lin0 bet/een emotion e*citability and =antasy
or creative ima&ination /ill be e*plained< We then contine /ith a discssion o=
research =indin&s on ale*ithymia in se*ally absed /omen< Altho&h these /omen
appeared to s==er =rom the co&nitive de=iciencies =ond in ale*ithymia,
%@+%
they reported normal levels o= emotion e*citability and =antasy< We conclde this
contribtion by e*pandin& on theoretical isses relevant =or or model and research
=indin&s that illstrate the interrelationship bet/een ale*ithymia, dissociation, and
anesthesia<
The se;'elae o) psy"hotra'mata )rom a histori"al perspe"tive
Drin& the last decades, there has been a &ro/in& interest in the e==ects o= e*posre to
tramatic events< 7hese stdies inclde victims o= the First and )econd World Wars
A)immel, 1-1@8 )ar&ant N )later, 1-#1B, srvivors o= the Holocast AKardiner N
)pie&el, 1-#'8 Krystal, 1-G@B, Vietnam veterans AKeane et alD9 1-@.8 Cac;ee, 1-@#B,
and, more recently, soldiers /ho =o&ht in the ;l= War< 7he systematic investi&ation
o= complaints reported by srvivors o= /ar reslted in the description o= post%
@G
tramatic stress disorder A:7)DB< Other investi&ators have directed their attention at
child se*al abse AHerman, 1-@18 DraiRer, 1--"8 Ensin0, 1--!8 Albach, 1--+B<
3nitially, there /ere dobts on /hether se*al abse cold really be considered as a
tramatic event, bt no/adays there is considerable consenss that child abse also
shold be considered as a trama Asee Albach, 1--+8 Albach N Everaerd, 1--!8
Fin0elhor N $ro/ne, 1-@.8 Heitlin et alD9 1--+B< Altho&h the similarity in
complaints bet/een victims o= /ar and victims o= child abse is Mite remar0able, the
=ollo/in& obvios di==erences cannot be overloo0ed<
1 ge of onsetD 3n contrast /ith child abse, the maRority o= victims o= /ar are
&enerally tramati>ed in adlthood Ae*ceptions are the children in concentration
campsB< $ein& tramati>ed as a child &enerally has a &reater impact on =tre
personality Aas stated in $riMet A1@.-BB, becase the or&anism has not yet =lly
matred, and there=ore is more vlnerable to ne&ative in=lences Asee also
Keilson, 1-'-B<
! 7he nature of the trauma9 /hich is by de=inition se*al in child se*al abse<
(onsiderin& the =act that there is a &reater taboo on havin& se* /ith children than
on ma0in& /ar /ith enemies, child se*al abse is OsrrondedP by more
secrecy, disbelie=, and speclation on the e*act natre o= the tramatic eventE
ODid it really happen or is it based on =antasyTP 3n most cases a clear%ct ans/er
cannot be &iven, as there are no /itnesses other than the perpetrator
himsel=?hersel=, /ho &enerally is relctant to con=ess<
+ 7he theoretical frame"or!s behind research on victims o= /ar and victims o=
child se*al abse are not identical< :7)D is based on the symptomatolo&y o=
/ar victims and ori&inates =rom psychodynamic thin0in& AFred, 1-+-8 Horo/it>,
1-'G?1--GB< Dissociation is based on acconts o= child se*al abse and
ori&inates =rom 9anetian thin0in&< 7his has led to the se o= di==erent constrcts
=or the description o= the same psycholo&ical phenomena A=or instance
dissociative verss psycho&enic amnesiaB< 3t is interestin& to note that over the
past decade the impact o= 9anetian thin0in& A1@@-, 1-11, 1-!@B has
%@#%
become &reater< An e*ample o= its in=lence is the =act that in the ne/est
=ormlation o= :7)D psycho&enic amnesia Abased on the Fredian constrct o=
repressionB =rom the D)C%333%R AAmerican :sychiatric Association, 1-@'B has
been replaced by dissociative amnesia Abased on the 9anetian constrct o=
dissociationB in the D)C%3V AAmerican :sychiatric Association, 1--#B< 3n the
Reality Escape Codel on the seMelae o= child se*al abse, an e==ort has been
made to embed concepts sch as ale*ithymia, dissociation and anesthesia,
ori&inatin& =rom di==erent theories, in a ne/ coherent =rame/or0<
@n s'*types o) alexithymia and the impli"ations )or psy"hotherapy
3t cold be ar&ed that an emotional e*perience is not complete nless the person is
able AiB to e*perience emotional =eelin&s, AiiB to di==erentiate bet/een emotional
=eelin&s, AiiiB to verbali>e emotional =eelin&s, AivB to re=lect pon and to some e*tent
analy>e these =eelin&s, and AvB to =antasi>e Ae<&< to have a rich =antasy li=e and creative
ima&inationB< De=icits in all these =nctions are characteristic o= ale*ithymia
AVin&erhoets et alD9 1--.B<
@'
$ermond A1--., 1--'B reported empirical evidence stron&ly s&&estin& the e*istence
o= t/o di==erent types o= ale*ithymia, each /ith a speci=ic psycho%biolo&ical ma0e%p<
7ype 3 ale*ithymia A=ll%blo/n ale*ithymia, in /hich the emotion e*citability is
redced as /ellB is hypothesi>ed to reslt =rom a decreased =nctionin& o= the orbito%
pre=rontal corte*, redced neral dopaminer&ic innervation o= this area, and redced
=nctionin& o= the ri&ht hemisphere A$ermondLs hypothesis o= le=t hemispheric
hyperactivityB< 7ype 3 ale*ithymia shold be distin&ished =rom 7ype 33 ale*ithymia
=ond in victims o= se*al abse, /here the emotional e*perience is present, bt the
accompanyin& co&nitions are absent A=or empirical evidence see Coormann et al9
1--'B< 7ype 33 ale*ithymia is claimed to be cased by a redced =nctionin& o= the
corps callosm A$ermondLs =nctional commissrotomy hypothesisB< Amon&
researchers in the =ield o= ale*ithymia, it has been noted that the co&nitive and
a==ective distrbances =ond in ale*ithymic patients =orm a serios and bothersome
obstacle to psychotherapy A;roen et alD9 1-.18 Krystal, 1-'-, 1-@@b8 Resch, 1-#@8
)i=neos, 1-'.8 7aylor et alD9 1--'B< Ho/ever, in or opinion, the type o= ale*ithymia
shold be ta0en into accont /hen treatment otcomes are evalated< Assmin& that a
sccess=l psychotherapy =or ale*ithymic patients shold be directed at restorin&
distrbed a==ect re&lation, it /old be e*tremely di==iclt to re%edcate 7ype 3
ale*ithymics< 7heir emotion e*citability is seriosly impaired and there=ore there is
not eno&h potential available =rom /hich they can be ta&ht to learn to =eel< 3= there
is no emotional arosal, there is no need =or co&nitive processin& o= emotions<
7he pro&nosis =or 7ype 33 ale*ithymics seems more =avorable< With respect to 7ype 33
ale*ithymics, the hypothesis has been pt =orth that the t/o hemispheres donLt
commnicate very /ell /ith each other< 7his condition is =nctional =or tramati>ed
individals, becase this speci=ic dys=nction prevents pain=l
%@.%
emotions =rom reachin& the sta&e o= =ll a/areness, in that /ay providin& an
opportnity to escape reality< 7he point o= departre =or a sccess=l treatment is that
7ype 33 ale*ithymics are emotionally e*citable and there=ore possess the reMired
potential to learn to =eel< 7his does not mean that treatment is easy< 3t is time%
consmin& and a lot o= patience is needed, becase psychotherapy in case o= 7ype 33
ale*ithymics shold be directed at providin& the emotional e*perience /ith its
correspondin& co&nitions< Frthermore, verbal psychotherapy is seless in the
treatment o= these patients, as they are nable to describe /hat they =eel< 7here=ore,
other%than%verbal ces Aas =or instance in art therapyB mst be applied in order to
stimlate them to e*press their other%than%verbal consciosness Asee 7c0er N )achs,
1--+B<
The orienting rea"tion as the key to "reative imagination
From the above it cold be ar&ed that a lac0 o= emotional arosability is at the core
o= ale*ithymia< 7he sbdimensions describin&, identi=yin&, and analy>in& emotions all
are clearly dependent pon the capacity to become emotionally e*citable< $t is this
also the case =or redced =antasi>in& or the lac0 o= creative ima&inationT $ein&
deprived o= =antasy does not seem to be related to emotions, and there=ore it is
di==iclt to &rasp /hy the lac0 o= creative ima&ination is so characteristic =or
ale*ithymia< Ho/ever, the lin0 bet/een emotion and creative ima&ination can be
@@
=ond in art theories< $ell A1-1-?1-'.B, =or instance, sa/ the emotional e*perience as
the sorce =or the creative implse< 3n psychodynamic terms, $ellLs notion implies
that people /ho become emotionally e*cited try to dischar&e this physiolo&ical state
by en&a&in& in ima&inative activities sch as daydreamin&, /ish=l thin0in& and
=antasi>in&< 3n =act, this is e*actly /hat Fred A1-1G?."B meant /ith primary process
thin0in& Aa re&ression in the service o= the e&o, /hich enables a retrn to more
primitive, childish /ays o= thin0in& /ith plenty o= room =or =antasyB< Accordin& to
Krystal A1-@@bB, the 0ind o= operative thin0in& =pensJe opJratoire> =ond in
ale*ithymia in combination /ith the severe bloc0in& o= /ish%=l=illment =antasy and
the limited ability to thin0 abstractly and to se symbols and metaphors has a serios
impact on creativity< Krystal held =ailres in parental bondin&, particlarly in the
mother%child relation, responsible =or the development o= these symptoms< Ho/ever,
/e are more inclined to loo0 =or e*planations /here arosal Aand there=ore emotionB
is involved in creativity<
One o= the characteristics o= creativity is that it concerns somethin& ne/, somethin&
o= vale ACrray, 1-.-B< We speclate that creativity in hmans evolved =rom the
criosity drive in animals, /hich leads to e*ploratory behavior A=or the lin0 bet/een
creativity and e*ploratory behavior /e also re=er to the laboratory stdies on
aesthetics done by $erlyne, 1-'1B< 3n etholo&y, e*ploratory behavior is considered to
have srvival vale< A detailed 0no/led&e =rom the &eo&raphy o= their home area /ill
o=ten mean the di==erence bet/een li=e and death to a small mammal or bird as a
predator s/oops do/n ACannin&, 1-'!B< E*ploratory behavior
%@G%
is directed at the detection o= novel stimli, /hich reslts in the orientin& reaction<
:ribram A1-G'B investi&ated novelty in hmans by sin& a homeostatic model< He
scceeded in teasin& apart at least t/o components o= the orientin& reaction< One
component is an indicator o= searchin& and samplin&, /hile the other is mani=est
/hen a novelty is re&istered< 7he point to be made is that the t/o indicators o= the
orientin& reaction, e<&< searchin&?samplin& and novelty, are the parameters par
e.cellence to de=ine the creative problem< O=ten, the creative problem is treated as
that o= =indin& a soltion to an already de=ined problem< Accordin& to ;et>els and
(si0s>entmihalyi A1-'GB, scientists and artists ali0e have to be problem%=inders in the
=irst place< For them, problem%=indin& precedes problem%solvin&<
When the theoretical considerations above are applied to the mechanisms behind
ale*ithymia, the =ollo/in& cold be ar&ed< 7ype 3 ale*ithymics s==er =rom a redced
emotional arosability and /ill there=ore be less inclined to sho/ a stron& orientin&
reaction, /hich in trn /ill hamper their creative abilities Ai<e< no r&e =or problem%
=indin&, no criosityB and sel=%re&lation< 7his line o= reasonin& is in a&reement /ith
descriptions o= ale*ithymic individals /ho are rather dll and mndane< 7heir /ea0
orientin& reactions, de to ins==icient arosal, are not li0ely to lead to e*tensive
e*ploratory behavior in either overt Ae*pressivenessB or covert behavior Acreative
thin0in& and ima&inationB< 3t is di==iclt =or these individals to become =ascinated or
absorbed by a certain topic or sbRect8 they simply lac0 passion< Frthermore, the
/ea0 orientin& reaction also implies a lac0 o= initiative, /hich mi&ht e*plain the
de=icit in sel=%re&latory capacities o= ale*ithymics, /hich is seen as one o= the
&reatest obstacles in psychotherapy Asee Krystal, 1-@@a8 7aylor et alD9 1--'B< Already
@-
in the nineteenth centry, 9anet reported this redced /illpo/er< 3n his Ntat ?ental
des FystJri7ues9 9anet A1-11B described hysterical patients /ith les aboulies9 /ho
acted as i= e*periencin& passions /as menacin& to them and /ho had a severe
dimintion o= /illpo/er< 9anet Ap< 1".B Motes William :a&e, /ho characteri>ed this
lac0 o= sel=%re&lation as =ollo/sE O3 can notP loo0s li0e O3 /ill notP, bt it is O3 can
not /illP<
Additional circmstantial evidence =avorin& the hypothesi>ed relation bet/een
emotion arosability and ima&inative activities incldes the =ollo/in&< A1B Recent
research carried ot by Vorst N $ermond A!""1B on the validity and reliability o= the
$ermond Vorst Ale*ithymia Yestionnaire A$VAYB demonstrated that the principal
component analysis o= sbscale interrelations o= t/o lan&a&e &rops AFrench and
DtchB yields a clear%ct t/o%=actor strctre< One comprises an a==ective component
Aemotion arosability and =antasi>in&B and the other a co&nitive component
Aidenti=yin&, verbali>in&, and analy>in& emotionsB< A!B Accordin& to $ermond A1--.,
1--'B, the psychobiolo&ical ma0e%p o= 7ype 3 ale*ithymics Aredced emotion
e*citabilityB di==ers =rom that o= 7ype 33 ale*ithymics Anormal emotion e*citabilityB<
As mentioned above, 7ype 3 is cased by hyperactivity o= the le=t hemisphere and is
characteri>ed by a decreased =nctionin& o= the orbito%pre=rontal corte*, redced
neral dopaminer&ic innervation o= this area, and redced =nctionin& o= the ri&ht
hemisphere, or possibly redced =nctionin& o=
%@'%
the commisra anterior< As these re&ions are also 0no/n to a==ect ima&ination, it is =ar
=rom srprisin& that redced emotion e*citability is associated /ith impoverished
ima&ination in 7ype 3 ale*ithymia< 3n contrast, 7ype 33 ale*ithymics seem to s==er
not =rom hemispheric de=iciencies, bt =rom a commnication problem bet/een the
t/o hemispheres< 7here=ore 7ype 33 ale*ithymics e*perience di==iclties /ith the
co&nitive components o= emotions, e<&< /ith verbali>in&, identi=yin& and analy>in&
emotions< Ho/ever, they AsbRects o= se*al abse, =or instanceB can become
emotionally e*cited, in particlar by stimli /hich tri&&er the tramatic e*perience<
7hey can even dra/ /hat e*cites them, bt in most cases they cannot constrct a
narrative o= /hat they have dra/n Apersonal observation o= AlbachB< 3n art therapy
sch patients can be ta&ht to describe in /ords /hat they have e*pressed in their
other%than%verbal consciosness A7c0er N )achs, 1--+B<
Alexithymia and )antasy
Recent developments A7aylor et alD9 1--'B seem to s&&est that ale*ithymia not only
constittes an inherent personality aberration in its o/n ri&ht, bt also constittes a
secondary accompaniment o= trama, and also emer&es secondarily as a conseMence
o= attachment and bondin& =ailres Asee ;rotstein, 1--'B< Empirical spport =or the
latter t/o vie/s can be =ond in a Dtch stdy on victims o= child abse ACoormann
et alD9 1--'B< 7hese =indin&s seem to spport the notion that both psychotramata
Achild se*al abseB and attachment or bondin& =ailres Aemotional ne&lect by both
parentsB are associated /ith 7ype 33 ale*ithymia< 3n 7ype 33 ale*ithymia, /here the
emotion arosability is intact, a normal level o= =antasi>in& is e*pected< 7he concept
o= =antasy is particlarly interestin& in the debate on memory recovery o= childhood
se*al abse< 7he Onon%believersP A(romba& N Cerc0elbach, 1--G8 6o=ts, 1--'B
-"
ar&e that in memory recovery /e are not dealin& /ith real abse events, bt /ith
=abricated stories abot se*al abse /hich have become implanted memories< 3t is
spposed that those =abricated stories are either s&&ested to the patient by the
psychotherapist As&&estibility hypothesisB or de to =antasy%proneness o= the patient
ACerc0elbach et alD9 1--@B< Ho/ever, in the stdies /e have condcted on memory
recovery, /e =ailed to =ind empirical evidence spportin& the s&&estibility hypothesis
AAlbach et alD9 1--GB or the =antasy%proneness hypothesis A$ermond et alD9 sbmittedB<
3n the latter stdy, the $ermond Vorst Yestionnaire /as administered to '+ /omen
/ith child se*al abse A?]+'<G years o= a&e /ith a ran&e =rom !" to G1 years o=
a&eB< Women /ith memory recovery did not di==er si&ni=icantly on =antasi>in& =rom
/omen /ho had never =or&otten the abse A?%=antasi>in&]!G<!" A)D]@<1B and !.<-'
A)D]@<-B, respectivelyB< Coreover, =antasi>in& scores o= both abse &rops did not
di==er =rom scores o= non%absed a&e%matched controls Aconsistin& o= !"G /omen
ta0en randomly =rom the Dtch &eneral poplationB< Ho/ever, as e*pected, the
/omen /ith child se*al abse s==ered =rom 7ype 33 ale*ithymiaE severe redctions
in the capacity to verbali>e and identi=y emotions in combination /ith
%@@%
normal levels o= operative thin0in&, emotion e*citability, and =antasy< 7he point to be
made is that ale*ithymics can have normal levels o= =antasy as lon& as they are
emotionally arosable<
Alexithymia, disso"iation, and anesthesia( three mani)estations o) the same Anon+
)eelingB state
Another e*planation =or the =indin& that absed /omen still have their ability to
=antasi>e can be =ond in the relation bet/een dissociation and ale*ithymia,
particlarly in re&ard to the relation bet/een the dissociative =eatre Oabsorption%
ima&inative involvementP and the ale*ithymic =eatre O=antasi>in&P< 3n dissociation,
there is a Odisrption o= the normal inte&ration o= co&nition, a==ect, behavior,
sensation and identityP< Feelin&s o= depersonali>ation in the =orm o= detachment =rom
oneLs physical or psycholo&ical bein& are =reMently reported in connection /ith
stress=l events Asee $oon N DraiRer, 1--+8 Ensin0, 1--!8 Van der Hart, 1--1B<
7ramati>ed individals may =rther s==er =rom visal and aditory hallcinations, in
/hich they relive parts o= the tramatic event< 7hese dissociative phenomena are
described =or concentration camp srvivors A9a==e, 1-G@B, victims o= li=e%threatenin&
events ANoyes N Kletti, 1-''B, victims o= rape ARose, 1-@GB, and victims o= childhood
physical and se*al abse A(h N Dill, 1--"8 Ensin0, 1--!B< 7here are ample
indications that se*al abse drin& childhood can reslt in :7)D and ale*ithymia
Ae<&< Albach N Everaerd, 1--!8 Heitlin et alD9 1--+B< Coreover, there is evidence that
childhood se*al abse =ollo/ed by rape or se*al assalt drin& adlthood can reslt
in ale*ithymia as /ell A(loitre et alD9 1--'B< 7here=ore it is interestin& to have a closer
loo0 at the relation bet/een ale*ithymia and dissociation< $erenbam and 9ames
A1--#B reported that ale*ithymia /as si&ni=icantly correlated /ith dissociative
e*periences in a &rop o= nder&radates, /hile 3r/in and Celbin%Helber& A1--'B
=ond that some aspects o= ale*ithymia cold predict dissociation in tramati>ed
children< 3n a stdy on sel=%mtilative behavior, Hlotnic0 et alD A1--GB reported that
sel=%mtilators displayed a &reater de&ree o= dissociative symptoms ADissociative
E*perience )cale%DE)B and ale*ithymia A7oronto Ale*ithymia )cale%7A)B and a
-1
&reater nmber o= sel=%inRrios behaviors, as /ell as hi&her rates o= childhood se*al
abse than non%mtilators< Ho/ever, dissociative symptoms and ale*ithymia /ere
both independently associated /ith sel=%mtilative behavior< 7he reslts o= these
stdies are inconclsive, /hich may be e*plained by the se o= di==erent sbRect
samples, methodolo&ies and instrments< Frthermore, in=ormation on the relation
bet/een the sbscales o= dissociation and ale*ithymia is not al/ays presented< 3t is
there=ore prematre to conclde abot the e*act natre o= the relation bet/een
=antasi>in& and dissociation<
3n or stdy on se*al abse A.@ /omenB, /e tried to solve this problem by incldin&
the sbdimensions o= dissociation ADE)%$ernstein N :tnam, 1-@GB and ale*ithymia
A$ermond%Vorst Ale*ithymia Yestionnaire, 1--+B< 3n addition, the (on=sin&
E*periencin& )cale AAlbach, 1--+8 Ensin0, 1--!B /as administered
%@-%
to measre =eatres o= hysteria as described in the nineteenth%centry French
literatre< 7he (E) contains the =ollo/in& =or sbscalesE AiB anesthesia Aalpha ] <@@B,
AiiB sense o= body%=ra&mentation Aalpha]<-1B, AiiiB se*al provocative behavior
Aalpha]<'GB, and AivB sleep disorders Aalpha]<''B<
Dissociation and its three sbdimensions%A1B absorption%ima&inative involvement, A!B
activities o= dissociated states, and A+B depersonali>ation%dereali>ation%indeed sho/ed
sbstantial correlations /ith nearly all ale*ithymic =eatres A=or the sbscales o= the
DE) /e re=er to Ross et alD9 1--.B< A stri0in& otcome /as the ne&ative correlation
bet/een dissociation and the redced ability to =antasi>e< A=ter childhood se*al
abse, there appears to be a lin0 bet/een dissociation and /hat cold be called
O=antasy%pronenessP< 7he absorption%ima&inative involvement sbscale o= the DE)
had the hi&hest ne&ative correlation Ar]^<##, p _<"1B /ith the redced ability to
=antasi>e< 7his seems Mite lo&ical /hen the content o= the items o= this DE)
sbdimension is ta0en into consideration Ae*amples areE O)o involved in =antasy that
it seems realP, and ONot sre /hether the remembered event happened or /as a
dreamPB< 7he sbscale Activities o= Dissociated )tates Ae<&< OFindin& onesel= in a
place, bt na/are ho/ one &ot thereP, and O$ein& approached by people one does
not 0no/, /ho call one by a di==erent namePB also had a si&ni=icant ne&ative
association Ar]^<++, p _<".B /ith the redced ability to =antasi>e< Only the sbscale
depersonali>ation%dereali>ation A/ith items sch as ONot reco&ni>in& oneLs re=lection
in a mirrorP, and OOther people and obRects do not seem realPB /as not si&ni=icantly
correlated Ar]^<1"B /ith the redced ability to =antasi>e< 7hese =indin&s ths s&&est
that dissociation shares some =eatres /ith the ale*ithymia sbdimension =antasi>in&,
bt is not identical to ale*ithymia< Recent research by Wise et alD A!"""B rea==irms the
notion that dissociation di==ers basically =rom ale*ithymia<
7he =ollo/in& Mote =rom one o= the participants in or stdy nicely illstrates ho/
the relation bet/een =antasy and dissociation may contribte to dobts abot the
se*al abse< 9anet A1-11B re=ers to this phenomenon as la folie du doute3
3 o=ten dobt it, becase my mother sed to say that 3 /as al/ays ma0in& p thin&s<
As a child 3 had =led into a =antasy%/orld< 3 loved it< Ho/ever, my mother sometimes
=ond ot thin&s /ere not tre, and then she pnished me severely< 7here=ore 3 al/ays
-!
have the =eelin& that /hat 3 tell isnLt tre, and /ith these memories 3 also have that
=eelin&< 3t belon&s to the =antasy%tales o= my childhood, becase it is somethin& that
canLt have happened to me, 3 thin0< At the same time 3 0no/ very /ell that it did
happen< $t my mother has been so persistent in denyin& my =antasies and, at the
same time, &ivin& me a =eelin& o= &ilt abot it< 7here=ore 3 still thin0E 3t is tre, bt
perhaps it isnLt tre<
3n the section on emotion arosability and creative ima&ination above, /e claim that
individals /ho become emotionally e*cited try to dischar&e this physiolo&ical state
by en&a&in& in ima&inative activities sch as daydreamin&, /ish=l thin0in&, and
=antasi>in&< Ho/ever, not only do or data =ail to spport this notion, bt the
%-"%
opposite pattern o= =indin&s emer&ed< A redced rather than an increased emotional
e*citability /as reported as =ellin& =antasy emissions, as the $VAY sbscale
Oredced emotion e*citabilityP had a sbstantial positive correlation Ar]<#+, p _<"1B
/ith Oabsorption%ima&inative involvementP o= the DE)< Frthermore, the inability to
become emotionally arosed appeared to be related to the t/o other dimensions o= the
DE) as /ell, e<&< to Oactivities o= dissociated statesP Ar]<#., p _<"1B, and to
Odepersonali>ation%dereali>ationP Ar]#G, p _<"1B< 7he latter t/o =indin&s are not in
a&reement /ith /hat is described by leadin& theorists on the relation bet/een emotion
and dissociation< 3n short, all three reslts on emotional arosability contradict /hat
cold be e*pected =rom art theories A$ell, 1-1-?1-'.B and O&randP theories o=
dissociation< 9anet A1-11B, =or instance, statesE
7hs, the previos stdy sho/ed evidence =or a sbstantial role o= emotion in
brin&in& abot this dissociation o= the mental synthesis8 emotion, as 3 said at another
point A9anet, 1@@-, p< #.'B, has a dissolvin& in=lence o= the spirit, it diminishes its
synthesis and ma0es it immediately miserable<
Ap< .+!, translationB
A related vie/ on the bond bet/een dissociation and emotion is &iven in the early
/or0 o= Fred and $reer A1@-+?1-!#B< 7hey sa/ hypnoid states as the sine 7ua non
o= hysteriaE
7here is one thin& common to all these hypnoid states and to hypnosis, in spite o= all
their di==erences%namely that the ideas, /hich emer&e in them, are mar0ed by great
intensity of feeling9 bt are ct o== =rom associative connection /ith the rest o= the
content o= consciosness<
Ap< +.B
Ho/ can this seemin&ly contradictory reslt be e*plainedT 3n =act Mite simply, /hen
one assmes an in=lence o= the sedatin& e==ect o= anesthesia in the sel=%report o=
physiolo&ical arosal< )bRects /ho s==er =rom anesthesia have loss or impairments
o= sensations Aon the sbscale OanesthesiaP o= the (E), incldin& items sch as O)ome
people donLt have a sensation o= cold, even i= it is belo/ ^1"`(PB< 7here is
physiolo&ical reactivity, bt this physiolo&ical arosal is not perceived as sch< 3n the
-+
same vein, one may consider the ale*ithymic =eatre o= emotion arosability<
)==erin& =rom anesthesia implies that the physiolo&ical reaction is not perceived<
7here=ore, individals /ith anesthesia are not li0ely to report Aon a MestionnaireB that
they have become emotionally arosed< 7his is e*actly /hat /e =ond< Women /ith a
reportedly redced emotion arosability also indicated to s==er =rom anesthesia
Ar]<#+, p _<"1B< Hence, it mi&ht be e*pected that, even /hen persons do not report
that they become e*cited, their physiolo&ical indices nevertheless mi&ht reveal the
contrary< Ho/ever, note that this is mere speclation, since no physiolo&ical measres
/ere inclded in or stdy<
%-1%
Despite this /ea0ness, it is interestin& to note that or theori>in& is in a&reement /ith
KrystalLs A1-@@aB description o= the non%=eelin& reaction< When enterin& a tramatic
state Othere is a psycholo&ical paralysis that starts /ith a virtally complete bloc0in&
o= the ability to =eel emotions and pain, as /ell as other physical sensations, and
pro&resses to inhibition o= other mental =nctionsP Ap< 1.1B< Here it is e*plicitly stated
that emotions as /ell as physical sensations are bloc0ed< Accordin& to Krystal, these
patients are themselves able to observe and describe the bloc0in& o= their a==ective
responses%a phenomenon re=erred to as Opsychic nmbin&P, Opsycholo&ical closin&
o==L A6i=ton, 1-G'B, and Oa==ective anesthesiaP ACin0o/s0i, 1-#GB<
Additional data con=irm that the psycholo&ical paralysis pro&resses to inhibition o=
other =nctions as /ell< 3n addition to the already discssed relation bet/een emotion
arosability and anesthesia, /e =ond that anesthesia /as associated /ith the redced
ability to identi=y Ar]<#., p _<"1B, verbali>e Ar]<#-, p _<"1B, and analy>e Ar]<+#, p
_<".B emotions< Coreover, anesthesia /as rather stron&ly associated Ar]<'., p _<""1B
/ith dissociation Atotal score on the DE)B< 7he stron& lin0 bet/een anesthesia Aa
conversionB and dissociation is in a&reement /ith KihlstromLs A1--!B assertion that
both conversion and dissociative disorders are disrptions in the normal controllin&
=nctions o= consciosness< 7o pt it di==erently, dissociation and anesthesia shold be
re&arded as belon&in& to one disorder A/hen readin& 9anet /e are inclined to call this
disorder hysteriaB< 3n KihlstromLs vie/, it is a mista0e that conversion Asomato=orm
disorderB and dissociation Adissociative disorderB are separately classi=ied in the D)C%
3V Asee also Davison N Neale, 1--@BE
3n the dissociative disorders, there is a dissociation bet/een e*plicit and implicit
memory< 3t is the e*plicit memory, /hich re=ers to a personLs conscios recall o= some
e*perience, that is disrpted in dissociative disorders< 3mplicit memory re=ers to
behavioral chan&es elicited by an event that cannot be consciosly recalled<
A:< 1'!B
Kihlstrom A1--!B cites nmeros e*amples o= patients /ith dissociative disorders
/hose implicit memory remains intact< 7he same basic disrption o= consciosness is
=ond in conversion disorder, in this case a==ectin& perceptionE
As in the dissociative disorders, stimli that are not consciosly seen, heard, or =elt
nevertheless a==ect behavior Acases o= hysterical blindness are ta0en as an e*ample to
-#
ma0e this pointB< )o, /e mi&ht consider conversion disorder as a disrption in e*plicit
perception /ith nimpaired implicit perception<
AKihlstrom, cited in Davison N Neale, 1--@, p< 1'!B
3= Kihlstrom is correct, then it seems hi&hly li0ely that the e*plicit perception o= bein&
emotionally arosed is impaired in cases o= anesthesia Aa redced instead
%-!%
o= increased emotion arosability is there=ore reported on the $VAYB, /hile the
implicit perception mi&ht still be nimpaired<
Con"l'sion
Fi&re .<1 sho/s a &raphical representation o= the Reality Escape Codel< An
interestin& =eatre o= the model, /hich has not been discssed yet, concerns the
hypothesis that 7ype 3 ale*ithymics Apper part o= the modelB are less vlnerable to
s==erin& =rom :7)D related symptoms than 7ype 33 ale*ithymics Alo/er part o= the
modelB< 7he rationale o= this statement is that redced a==ect, /hich is so
characteristic o= 7ype 3 ale*ithymics, and /hich is spposed to lead to co&nitive
de=icits in a==ect re&lation, at the same time =nctions as a protection mechanism
a&ainst the ssceptibility to an*iety disorders<
Figure -D$ ;raphical representation o= the Reality Escape Codel<
3nstead it is hypothesi>ed that 7ype 3 ale*ithymics are more prone to develop classical
psychosomatic diseases Ai<e< peptic lcer, bronchial asthma, essential hypertension,
thyroto*icosis, lcerative colitis, rhematoid arthritis, and nerodermatitisB< 7his
statement is based on clinical observations Asee =or instance Resch, 1-#@, 1-.'B that
many patients Atramati>ed and non%tramati>edB /ith classical psychosomatic
diseases mani=est a rather primitive level o= psycholo&ical or&ani>ation, and sho/ a
lac0 o= ima&ination in their responses to proRective psycholo&ical tests< Frthermore,
these patients mani=est an absence o= verbal, &estral, and other symbolic e*pressions
o= a==ects, as /ell as a tendency to dischar&e emotional tension thro&h action A7aylor
et alD9 1--', p< !1@B< Hence patients /ith classical psychosomatic diseases =l=ill most
criteria o= 7ype 3 ale*ithymia< Resch Ocontrasted these characteristics Ai<e< 7ype 3
ale*ithymiaB /ith the co&nitive a==ective style o= psychonerotic patients, /ho
&enerally sho/ a hi&h level o= e*pressiveness and relatively easy access to a rich
inner li=e o= driverelated =antasiesP A7aylor et alD9 1--', p< !1-B< Hence,
psychonerotic patients have normal emotion arosability< 7here=ore, /hen
tramati>ed, they are more li0ely to develop 7ype 33 ale*ithymia<
Or data s&&est that symptoms associated /ith :7)D and psychosomatic diseases
seem to =it a diathesis%stress model Asee Nolen%Hoe0sema, !""1B, in /hich the
diathesis or vlnerability =actor is cased by early childhood e*periences Ase*al
abseB, biolo&ically determined personality traits Aemotion arosabilityB, and possibly
-.
hereditary determined ApsychosomaticB diseases< (hildhood se*al abse is
considered a vlnerability =actor here, becase the central nervos system has not yet
=lly matred, /hich ma0es it mch more vlnerable to =tre stressors< 7hreatenin&
events in later li=e Aincldin& abseB, /ith /hich or&anism has to cope, are considered
stressors< 7his model is able to e*plain /hy some people are predisposed to react
more adversely to environmental stressors<
7he most important Mestion is, o= corse, /hether the Reality Escape Codel has
some srpls vale compared /ith e*istin& models on the seMelae o= child se*al
abse< 3n or opinion, the stren&th o= the Reality Escape Codel concerns its eclectic
natre and its implications =or psychotherapy< (oncepts ori&inatin& =rom di==erent
theories have been embedded in a ne/ coherent =rame/or0, arond the idea that
victims o= child se*al abse try to escape reality by sin& di==erent psycholo&ical
mechanisms, all aimed at attainin& a non%=eelin& state< 7he vie/ that ale*ithymia,
dissociation and anesthesia are di==erent mani=estations o= this non%=eelin& state is
based on KrystalLs A1-@@a, 1-@@bB Oparado* in the tramatic stateP, i<e< the parado*
bet/een, on the one hand, the intense a==ect and, at the other hand, the a==ective
bloc0in&< Alternation o= a==ects /as initially described by Fred A1-+-B and later by
Horo/it> A1-'G?1--GB in his theory o= stress response syndromes< (rrent assessment
o= :7)D is still based on this alternation bet/een emotional nmbin& and
detachment, on the one hand Aavoidance componentB, and re%e*periencin& the trama
AintrsionsB and hypervi&ilance Aincreased arosalB, on the other hand< Ho/ever, the
vie/ that the alternation bet/een a==ective bloc0in& and a==ective =loodin& can only
happen in 7ype 33 ale*ithymics, i<e< only
%-#%
in individals /ho can become emotionally arosed, is ne/, and s&&ests a better
treatment pro&nosis =or 7ype 33 than =or 7ype 3 ale*ithymics< 7he theoretical &ronds
bro&ht =or/ard to e*plain /hy all ale*ithymic sbdimensions, incldin& the
sbdimension O=antasy or creative ima&inationP, are dependent on emotion
arosability is o= crcial importance in or theori>in&< O= particlar relevance is the
lin0 bet/een emotion e*citability and =antasy, becase it brid&es the &ap bet/een the
psycho%dynamic constrct o= ale*ithymia and the 9anetian constrcts o= dissociation
and conversion< We hope that or alternative conceptali>ation and inte&ration o=
concepts /ill stimlate researchers and clinicians to develop hypotheses and to desi&n
stdies that /ill increase or insi&hts into these intri&in& clinical phenomena<
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Van der Hart, O< Aed<B A1--1B< Trauma9 dissociatie en hypnose KTrauma9
dissociation and hypnosisLD AmsterdamE )/ets N Heitlin&er<
Vin&erhoets, A<9<9<C<, Van Hec0, ;<6<, ;rim, R<, N $ermond, $< A1--.B<
Ale*ithymiaE a =rther e*ploration o= its nomolo&ical net/or0< Psychotherapy
and Psychosomatics,.,, +!%#!<
Vorst, H<(<C< N $ermond, $< A!""1B< Validity and reliability o= the $ermond%
Vorst Ale*ithymia Yestionnaire< Personality and #ndi'idual Differences,&6,
#1+%#+#<
Wise, 7<N<, Cann, 6<)<, N )heridan, C<9< A!"""B< Relationship bet/een
ale*ithymia, dissociation, and personality in psychiatric otpatients<
Psychotherapy and Psychosomatics,.#, 1!+%1!'<
Heitlin, )<$<, CcNally, R<9<, N (assiday, K<6< A1--+B< Ale*ithymia in victims o=
se*al assaltE an e==ect o= repeated tramati>ationT merican Eournal of
Psychiatry,$/6, GG1%GG+<
Hlotnic0, (, )hea, C<7<, :earlstein, 7<, )impson, E<, (ostello, E<, N $e&in, A<
A1--GB< 7he relationship bet/een dissociative symptoms, ale*ithymia,
implsivity, se*al abse, and sel=%mtilation< Comprehensi'e Psychiatry,&4, 1!%
1G<
%-@%
Chapter .
3orry, perseverative thinking and health
1"1
Eos FD Brosschot and Eulian FD Thayer
Introd'"tion
,ntil recently the concept o= /orry /as mainly stdied /ithin the conte*t o= test
an*iety and an*iety disorders< Worry plays a role in nearly all an*iety disorders and is
a core characteristic o= &enerali>ed an*iety disorder A;ADB< Even in the area o=
an*iety, it /as not ntil the 1-@"s that the potential etiolo&ical importance o= the
concept became reco&ni>ed and systematically investi&ated Asee Davey N 7allis,
1--#B< 3n this contribtion, /e /ill attempt to sho/ that /orry may play a mch
broader role in psycholo&ical and somatic health< We /ill discss evidence o= a /ide
ran&e o= possible lon&%term health conseMences o= /orry, reachin& =rom an*iety
disorders and medically ne*plained somatic complaints to/ards pathophysiolo&ical
conditions sch as cardiovasclar disease A(VDB< Frthermore, the diverse processes
and mechanisms nderlyin& these conseMences /ill be otlined, incldin& some
crrently 0no/n physiolo&ical and nerovisceral concomitants o= /orry< 7he chapter
starts /ith some theoretical considerations o= the de=inition and natre o= /orry and
related concepts sch as rmination< Ne*t /e /ill discss their etiolo&ical role in
an*iety, ne*plained somatic complaints, and somatic disease, respectively<
3orry, r'mination and perseverative thinking
Definitions
$or0ovec et alD A1-@+, p< 1"B introdced as a /or0in& de=inition o= /orryE OWorry is a
chain o= tho&hts and ima&es, ne&atively a==ect%laden and relatively ncontrollable8 it
represents an attempt to en&a&e in mental problem%solvin& on an isse /hose =tre
otcome is ncertain bt contains the possibility o= one or more ne&ative otcomes8
conseMently, /orry is related closely to =ear process<P 6ater Davey and 7allis A1--#,
p< 'B added, O/orry is dominated by tho&ht, at the cost o= ima&eryP<
7he central co&nitive%emotional process in this de=inition, ho/ever, is not restricted to
/orryin& over threatenin& sitations per se< For e*ample, altho&h
%--%
/orry in this de=inition is stated to be related to O=ear processP, =ear can be replaced
by any other ne&ative emotional state, li0e depression or an&er< 3n sch cases one
tends to spea0 o= Orminative thin0in&P and Oan&ry broodin&P rather than o= /orry<
Altho&h =or an*iety theory a /orry =ormlation is the most lo&ical choice, =or many
other health conseMences o= /orry, or rather the co&nitive%emotional process that lies
at the heart o= the phenomenon, a more encompassin& term appears to be called =or<
For that reason /e propose the term Operseverative thin0in&P< 7he advanta&e o= this
term is that it is applicable to many ne&ative emotional sitations and, as /e /ill see,
is conceptally closer to the central =actors that are responsible =or the patho&enic
processes to be described belo/< We /ill se the terms O/orryP, OrminationP and
Operseverative thin0in&P interchan&eably thro&hot the chapter, o=ten dependin& on
ho/ it is sed in the stdies to be discssed<
%unctions of1orry
1"!
Worry is tho&ht to serve di==erent =nctions< 7he most strai&ht=or/ard or concrete
=nction that is attribted to /orry is an attempt at constrctive mental problem%
solvin&, albeit a th/arted attempt ADavey, 1--#B< 3n spport o= this =nction, Davey
=ond a positive correlation bet/een /orry and problem%=ocsed copin&, bt only
a=ter partiallin& ot the e==ect o= trait an*iety< 7hs, /orry /as associated /ith a
habital tendency =or active problem%solvin& combined /ith lo/ con=idence in
scceedin& in it< 7allis and Eysenc0 A1--1B proposed a tripartite =nction o= /orry<
7hey proposed that =irst, /orry serves an alarm =nction, actin& to interrpt on&oin&
behavior and directin& a/areness to/ard an isse demandin& immediate soltion<
)econd, /orry /old have a prompt =nction, continosly representin& nresolved
threatenin& sitations to a/areness< 7hird, /orry is tho&ht to have a preparation
=nction, anticipatin& threat and ma0in& the or&anism ready =or a sitation in /hich
hi&h or even vi&oros motor activation is needed< Obviosly, sch a sitation hardly
ever occrs in the case o= /orry, or in most other cases o= perseverative thin0in&<
7hs perseverative thin0in& theoretically leaves the individal in a prolon&ed state o=
psychophysiolo&ical Oaction preparationP<
erseverative thinking and psy"hopathology
Altho&h perseverative thin0in& is no/ tho&ht to be implicated in a ran&e o=
psychopatholo&ies, it has been most e*plicitly discssed in the conte*t o= an*iety
disorders< 3t is only since the early 1-@"s A$or0ovec et alD9 1-@+B that /orry has
&ained importance as a research sbRect in its o/n ri&ht< $e=ore that time, /orry /as
vie/ed as an epiphenomenon o= an*iety or not more than a co&nitive adaptation to the
disorder, /ithot etiolo&ical importance< 7he contemporary vie/, ho/ever, is that
/orry is an important or even core characteristic o= many an*iety disorders, especially
&enerali>ed an*iety disorder A;ADB< 7he =eelin& o= not bein& able to control
/orryin&, or Ometa%/orryP, is no/adays tho&ht o= as the basic mani=estation o=
;AD< 7his e*tension o= /orry /ith meta%/orry can be considered
%1""%
and it mi&ht be added that they o=ten contine to be so a=ter the &eneral physicianLs
consltation< 3n hypochondriasis and in less severe health%related an*ieties the role o=
perseverative thin0in& is &enerally similar to that otlined above =or phobia and
&enerali>ed an*iety disorder< 7hs, e*tensive /orryin& may sstain health%speci=ic
=ears by creatin& and stren&thenin& inadeMate co&nitive path/ays, and, as in phobia,
it mi&ht also prevent =ear%speci=ic emotional processin&< 3n addition, in these an*iety%
related syndromes as /ell as in other medically ne*plained somatic syndromes,
prolon&ed perseveration abot oneLs ptative%or yet to be medically con=irmed%illness
mi&ht sstain complaints in a more direct co&nitive /ay< 3t mi&ht case lon&%lastin&
activation and continin& reactivation o= speci=ic Apain%andB illness%related co&nitive
net/or0s< 9st as sch a hi&h activation leads to the perception o= more threat in
an*iety disorders AWilliams et alD9 1-@@B, activated illness net/or0s mi&ht be
hypothesi>ed to &ide in=ormation processin& to/ards overabndant illness
perception< As a reslt, more illness%related internal AbodilyB and e*ternal ces /ill be
detected, more ambi&os internal and e*ternal in=ormation /ill be interpreted in
terms o= illness, more misattribtion o= harmless si&nals to illness /ill occr, and
=inally, more and stron&er memory traces =or illness%related in=ormation /ill be
prodced< 3n combination /ith hi&hly salient and accessible illness in=ormation, this
1"+
mi&ht lead to enhanced symptom reportin& Asee also :enneba0er, 1-@!B< 7hs, &iven
the =act that%nderstandably%most patients s==erin& =rom medically ne*plained
somatic complaints spend a lot o= time /orryin& over their condition, this /orryin&
may continosly activate the co&nitive net/or0s< Above a certain level o= activation,
these net/or0s tri&&er a =eed%=or/ard process in /hich the e*perience or perception
o= illness leads to more and more perception o= illness<
7he literatre provides a limited set o= evidence =or the role o= over%activated
co&nitive illness net/or0s, also called Oco&nitive biasP in ne*plained or sbRective
somatic complaints< (o&nitive bias can be measred by attentional inter=erence tas0s,
sch as the modi=ied )troop tas0s, or by memory or interpretational bias tas0s
AWilliams et alD9 1-@@B< With respect to medically ne*plained complaints, hi&her
inter=erence by health%threat /ords in a modi=ied )troop tas0 /as =ond in
somato=orm disorder patients A6p0e N Ehlert, 1--@B and the same =or pain%related
/ords in chronic pain patients A:earce N Corley, 1-@-B< $etter memory =or pain%
related /ords /as =ond in pain patients Acited in :incs et alD9 1--@B and an
interpretational pain bias re&ardin& ambi&os in=ormation /as =ond in pain patients
Anpblished :hD and C)c stdies cited in :incs et alD9 1--@B< 7he notion o= a
hi&her AimplicitB pain memory and selective attention =or pain and enhanced pain
perception in pain patients /as spported by the =indin& that pain%related )troop
/ords, administered peri%threshold, enhanced the N1"" to N!"" evo0ed potentials
AFlor et alD9 1--'B< 3n addition, a stdy by )chmidt et alD A1--#B s&&ested that
physical symptoms cold be indced by attention maniplation alone, /ithot any
actal sensory stimlation< Finally, (io==i and Hollo/ay A1--+B spplied some
indirect evidence o= enhanced pain perception by activation o= pain%related co&nitive
schemata< 7hey =ond that in nder&radates, sppression
%1"!%
o= pain a=ter a pain=l stimls had the e==ect that a=ter some delay sbseMent pain
stimli /ere more stron&ly perceived Amore pain=lB than /hen the pain /as either
monitored or distracted =rom< 7his apparently parado*ical reslt can be e*plained by
the /ell%0no/n phenomenon that sppressin& mental content in =act only ma0es it
more accessible, by stren&thenin& its traces in the co&nitive net/or0 and e*tendin&
this net/or0 by the very in=ormation that is sed to sppress it< We&ner docmented
this phenomenon and very appropriately called it an OironicP process Asee e<&< We&ner
et alD9 1--+B<
3n smmary, e*tensive perseverative thin0in& abot illness or pain, or both, is
hypothesi>ed to indce a =eed%=or/ard process in /hich increasin&ly more illness
ces are perceived< 7he evidence in spport o= a hi&hly activated co&nitive net/or0 is
still scarce, bt seems to be consistent across di==erent co&nitive =nctions sch as
memory and attention< Ho/ever, it is not yet clear /hether and to /hat e*tent a
co&nitive bias =or illness actally contribtes to the development or maintenance o=
medically ne*plained complaints< 3t is also not clear to /hat e*tent =ear still plays a
crcial role in sch an etiolo&ical process< 7he =indin&s o= 6p0e and Ehlert A1--@B
mentioned above, o= a co&nitive bias =or health%threat /ords in somato=orm disorder
patients, raised the Mestion o= /hether =ear o= illness is a necessary condition =or a
co&nitive bias to have conseMences =or illness perception< When this /old not be
the case, mere over%e*posre to illness in=ormation or internal rehearsal o= it mi&ht in
1"#
itsel= be eno&h to prodce complaints< (learly, the ans/ers to these Mestions mi&ht
be relevant =or clinicians /or0in& /ith patients s==erin& =rom medically ne*plained
syndromes<
erseverative thinking, somati" illness and physiology
Perseverative thinking instress+"oping+disease theory
:erseverative thin0in& and the concepts it encompasses, sch as /orry and rmination
or, =or e*ample, anticipatory stress, appear to be lar&ely ne&lected in the area o= stress,
copin& and disease< 7he bl0 o= research in this area involves either discrete stressors,
sch as li=e events or daily hassles, or discrete copin& strate&ies, or both< When
chronic stress, li0e marital or social%economic stress, is stdied, the emphasis is
mostly on the stimls characteristics, or the individalLs perception o= them, and
seldom or never on endrin& co&nitive processes< 3n or vie/, there are several
potential reasons =or this absence o= perseverative thin0in& or comparable Omicro%
stressP in this maRor area o= health psycholo&y< One obvios reason is that /orry or
rmination is not spectaclar li0e maRor li=e events or tramatic events< For the same
reason, daily hassles have only been reco&ni>ed as important stressors since the 1-@"s
Ae<&< De6on&is et alD9 1-@!B, decades a=ter the interest in stressors started /ith the
stdy o= maRor li=e events and li=e chan&es< )ince then, evidence has been
accmlatin& that daily hassles have sbstantial health conseMences Ae<&< ;raham et
alD9 1-@GB that even seem to srpass those o=
%1"+%
li=e events Ae<&< De6on&is et alD9 1-@!B< Worry is even less reco&ni>able as a sorce o=
stress than daily hassles< 3n contrast to daily stressors and li=e events, /orry is sally
not associated /ith very clear emotional tension<
Another, less obvios reason =or the absence o= perseverative thin0in& and related
concepts in the stress literatre is that theoretical models that lin0 stressors to health
otcomes lac0 precision as to the psychobiolo&ical mechanisms nderlyin& this lin0<
3n particlar, a complete model has to accont =or the chronic patho&enic state that
ltimately cases disease< :erseverative thin0in& may lead to sch a state, by actin& as
an internal or co&nitive micro%stressor as /ell as by actin& as a mechanism mediatin&
the e==ects o= other stressors< 7his seemin&ly hybrid natre o= perseverative thin0in&,
i<e< bein& both a stressor and a mediatin& mechanism, is related to its co&nitive natre,
/hich it is hoped /ill become more clear in the sections to =ollo/< 7hs,
perseverative thin0in& mi&ht =acilitate the convertin& o= the immediate psycholo&ical
and physiolo&ical concomitants o= li=e events and daily stressors into prolon&ed
physiolo&ical activation, /hich in trn is necessary =or the development o= a chronic
patho&enic state A$rosschot N 7hayer, 1--@B< Altho&h many theorists may have
implicitly a&reed that sstained physiolo&ical activation is a crcial i= not necessary
condition =or stressors to lead to somatic patholo&y, only very =e/ have e*plicitly
stated so Ae<&< ,rsin N Crison, 1-@+B< 3nstead, nmeros investi&ators have al/ays
measred stressors as discrete events and copin& behavior as discrete and sin&lar
&oal%directed strate&ies, /ithot any prpose=l endeavor to stdy /hy some events
or copin& strate&ies have prolon&ed e==ects on physiolo&y<
1".
A =inal important reason =or the ne&lect o= /orry and perseverative thin0in& in stress
research is that the dominant measres Ali=e events and daily hasslesB al/ays =ocsed
on the past Aor sometimes on the presentB< Drin& =or decades o= stress research,
hardly any e*plicit attempt at measrin& anticipatory stress /as nderta0en< We
sspect that this too mst be a conseMence o= the lac0 o= a theoretical precision
re&ardin& the psychophysiolo&ical mechanism nderlyin& the stress%disease lin0<
7here has been a particlar =ailre to reco&ni>e the importance o= prolon&ed
activation%/ith the e*ception mentioned A,rsin N Crison, 1-@+B< An early
reco&nition o= the importance o= this =actor mi&ht have stimlated more theori>in&
abot the psycholo&ical mechanism nderlyin& sstained activation< 7he crrent
theory o= perseverative thin0in& may in =act be only one possible theoretical accont<
&he role of perseverotivethinking in stress+"oping+disease
As allded to above, the place o= /orry or perseverative thin0in& in stress theory may
be ri&ht bet/een stressors and health otcomes, mediatin& the e==ects o= stressors< 3t is
important to note that this is di==erent =rom copin& strate&ies, /hich are postlated to
modlate the e==ects o= stressors on health otcomes< (opin& strate&ies are re&arded
as /ays either to decrease or to eliminate the e==ects o= stressors by eliminatin& or
redcin& the intensity o= the stressor, =or instance, by
%1"#%
chan&in& its meanin&< Altho&h some copin& strate&ies, sch as e*pressin& or
sppressin& emotions, are believed to have physiolo&ical conseMences o= their o/n
Athe so%called Ophysiolo&ical costs o= inhibitin&PB, they are still not primarily vie/ed
as the mediators o= the e==ects o= emotional stressors< :erseverative thin0in&, on the
other hand, can be tho&ht o= as a direct mechanism by /hich the stressor has its
e==ects on physiolo&y< 3t does this by prolon&in& the stressor itsel=, in a
representational =orm that contines to activate the or&anism< Withot per%severative
thin0in& or a comparable mechanism prolon&in& the activation, an acte, in time
limited stressor cannot have an impact on health in a direct manner< 3n terms o= the
leadin& theories on emotion and co&nition AFriRda, 1-@@8 6a>ars, 1--18 Dal&leish N
:o/er, 1---B perseverative thin0in& may be re&arded as a prolon&ed state o= action
readiness that develops /hen somethin& hi&hly relevant =or the individal is at sta0e<
7his is primarily a hi&hly vi&ilant state, /ithot e*treme increases in physiolo&ical
activation< Remember that perseverative thin0in& is a predominantly verbal, abstract
co&nitive emotional state that can in =act prevent e*treme arosal in a condition li0e
phobia< 7he crcial patho&enic property then in perseverative thin0in& is not its
intensity or OamplitdeP, bt rather its dration and the inadeMate atonomic and
emotional re&lation associated /ith it< 6ater in this chapter /e /ill discss the
AneroBphysiolo&y o= perseverative thin0in& or /orry in more detail<
Altho&h its role in the stress%disease process may be di==erent than copin&,
perseverative thin0in& is theoretically connected to it< 3n or vie/, this relationship
can be e*plained as =ollo/s< As mentioned above, perseverative thin0in& or /orry can
be re&arded as =ritless attempts at mental problem%solvin& ADavey, 1--#B< 3n terms o=
6a>ars and Fol0manLs /ell%0no/n copin& theory AFol0man, 1-@#B, /orry can be
described as a =i*ation in the phase o= Osecondary copin&P< 3n perseverative thin0in&,
the Mestion O/hat can 3 do abot this threatenin& sitationTP is constantly and
1"G
repeatedly as0ed, bt not ans/ered Ac=< the Oprompt =nctionP mentioned aboveB<
3nterestin&ly, i= one care=lly e*amines copin& instrments, an implicit assmption
seems to be that copin& is a matter o= simply choosin& amon& co&nitive and
behavioral options and then reali>in& them< 7he instrments never as0 ho/ lon& it
ta0es respondents to ma0e their decision, ho/ lon& they oscillate bet/een options or
bet/een actally per=ormed behaviors, or /hether they simltaneosly se more than
one strate&y< 7hey also do not as0 i= and ho/ lon& respondents =eel ncertain abot
/hat to do, as o=ten happens in ambi&os sitations or in individals /ith a hi&h
tendency to persevere co&nitively< Altho&h seldom or never measred, it mi&ht be in
=act these intermediate co&nitive%emotional states, in /hich a stressor is repeatedly
and =ritlessly reappraised in a primary or secondary =ashion Aor both at the same
timeB, that are associated /ith prolon&ed states o= activation, /hich, /hen they are
=reMent or chronic, can have conseMences =or health< 7heoretically then,
perseverative thin0in& is both a stressor Aor more precisely, a reappraised stressorB and
a mediatin& mechanism, by the very natre o= this reappraisal process<
%1".%
Perseverativethinking and per"eived "ontrol
A core characteristic o= these perseverative states is the conviction that control over a
stressor is threatened< Only /hen a threat to control is perceived does the stressorLs
=ll potential =or activatin& the or&anism mani=est itsel=, since no /ay to diminish or
chan&e this threat is perceived< :erceived ncontrollability o= stress Aand associated
states sch as hopelessnessB has been docmented as an important i= not the most
important stressor as /ell as person characteristic responsible =or potentially
patho&enic physiolo&ical states and health problems A$rosschot et alD9 1--@8 Everson
et alD9 1--G8 Fran0enhbser, 1-@"8 )teptoe N Appels, 1-@-8 ,rsin N Hytten, 1--!B<
From this perspective, perseverative thin0in& mi&ht be vie/ed as the co&nitive
mani=estation and norisher o= the deeper nderlyin& e*perience o= perceived
ncontrollability< 7he concept o= perseverative thin0in& may ths be help=l =or a
better nderstandin& o= the health e==ects o= a /ell%0no/n psycholo&ical stress =actor,
namely perceived ncontrollability, by accontin& =or the prolon&ation o= its
physiolo&ical e==ects< 7o smmari>e, /e propose that perseverative thin0in& sstains
the physiolo&ical response to a stressor by prolon&in& the ncertain state in the copin&
process, the state in /hich lo/ control over the stressor is perceived< 3ncorporatin&
perseverative thin0in& in or theori>in& means ta0in& into accont the importance o=
the time dimension in stress research< ;iven this crcial role in the stress%disease lin0,
/e /old e*pect associations bet/een perseverative thin0in&, on the one hand, and
disease otcomes and physiolo&ical conseMences, on the other< 3n the ne*t sections,
/e /ill address these isses<
Worryand risk o) somati" disease
;iven the short research history o= /orry and rmination, it is not reasonable to
e*pect a lar&e nmber o= stdies lin0in& perseverative thin0in& /ith somatic disease<
Ho/ever, there is some recent evidence o= the /orry%disease lin0 and a :yscln=o
search /ith 0ey/ords re=errin& to /orry, rmination and anticipatory stress yielded
some more relevant =indin&s, scattered over the last decades, mostly =rom stdies that
/ere not e*plicitly directed at these topics< 3n =act, the only stdy that e*plicitly lin0s
1"'
/orry to disease otcome is one by Kb>ans0y et alD9 A1--'B, /hich sho/ed that a
tendency to /orry predicted cardiovasclar disease A(VDB, in this case a second
myocardial in=arction AC3B< Core indirectly, /orry is a core characteristic o= several
conditions that are 0no/n to be ris0 =actors =or (VD, sch as an*iety disorders, trait
an*iety, and depression A7hayer et alD9 1--G8 Wlsin et alD9 1---B< Va&al tone is
chronically lo/ in these conditions A7hayer et alD9 1--@8 Friedman N 7hayer, 1--@B,
Rst li0e in states o= /orry A6yon=ields et alD9 1--.8 7hayer et alD9 1--GB< )ince lo/
va&al control is a ris0 =actor =or (VD, it has been s&&ested that /orry is a potential
mediator o= the (VD ris0 o= an*iety disorders and depression A$rosschot N 7hayer,
1--@8 7hayer et alD9 1--GB<
$rosschot and collea&es =ond some preliminary evidence =or a positive association
bet/een dispositional /orry and &eneral health< 3n a yet npblished
%1"G%
e*ploratory stdy in over !." psycholo&y stdents, it /as =ond that a disposition to
/orry /as stron&ly associated Ar]<G#B /ith sbRective health complaints< 7he
association /as mch lo/er, bt still si&ni=icant, /hen the e==ect o= trait an*iety /as
controlled =or Apartial r]<1@B, /hich s&&ested that the association /as at least partly
de to OpreP /orry tendency and not entirely de to a tendency to e*press ne&ative
a==ect< 3n a related stdy in older, part%time stdents /e attempted to obtain more
evidence in spport o= a casal role o= /orry< We instrcted seven stdents to
postpone their /orryin& to a special +"%minte O/orry periodP later each day, drin&
one /ee0< (ompared to the three days prior to the intervention /ee0, the
postponement &rop had si&ni=icantly =e/er health complaints drin& the last three
days o= the intervention, as compared to ten control stdents /ho only re&istered their
/orry periods< 7hese reslts seem to s&&est that a lon&er time spent /orryin& mi&ht
lead to more sbRective health complaints< One e*planation o= the relationship
bet/een /orry and sel=%reported health complaints cold be over%activated co&nitive
illness net/or0s de to /orryin& abot health, as discssed in the section on
ne*plained or sbRective somatic complaints< Ho/ever, this can only be a partial
e*planation, becase the e==ects o= /orry postponement /ere stron&er =or common
cold or =l%li0e complaints and co&hin& than =or Oconventional psychosomaticP
complaints sch as headache or di>>iness< 7hese reslts instead s&&est a
psychoneroimmnolo&ical path/ay leadin& =rom perseverative thin0in& to in=ectios
disease and probably other immne%related diseases<
Worry+ rumination+and physiologi"al )'n"tioning
Worry and rmination have been =ond to be associated /ith enhanced levels o=
cortisol< Rminatin& be=ore e*ams /as associated /ith hi&her salivary cortisol levels
AHellhammer et alD9 1-@.B, and /orry drin& se*al stimlation /as =ond to be
positively related to plasma cortisol levels ARo/land et alD9 1-@'B< Frthermore, a
disposition to rehearse or rminate sho/ed a positive association /ith rinary cortisol
drin& and a=ter e*aminations, a relationship that /as stron&er than bet/een
neroticism and rinary cortisol ARo&er N NaRarian, 1--@B< E*cept =or the last stdy
none o= the /orry stdies mentioned so =ar has tried to distin&ish sel=%reports o=
/orry =rom more &eneral ne&ative response tendencies sch as neroticism or
ne&ative a==ectivity< On the other hand, it cold be speclated that perseverative
1"@
thin0in& mi&ht be the patho&enic in&redient in these &eneral response tendencies<
$oth e*perimental /orry and dispositional /orry have been =ond to be associated
/ith lo/ va&al tone A6V78 $or0ovec et alD9 1--@8 6yon=ields et alD9 1--.8 7hayer et
alD9 1--G8 Kb>ans0y et alD9 1--'B< As mentioned above, 6V7 has also been =ond in
depression and an*ios states or an*iety disorders that have /orry or rmination as a
core characteristic< Hence, as /e speclated above, /orry may mediate part o= the
(VD ris0 o= these conditions via prolon&ed cardiovasclar activation, especially by
chronic decreased va&al control o= the heart<
%1"'%
3n addition, a more notorios psycholo&ical (VD ris0 =actor, hostility Ae<&< Ciller et
alD9 1--GB, mi&ht also be partly e*plained by /orry or rmination< Recently, it has
been demonstrated that contined rmination abot an an&erin& sitation prolon&s
cardiovasclar responses to these sitations A;lynn et alD9 !""!B< 3t is reasonable to
e*pect that both hostility and dispositional /orry may prolon& this activated state by
enhancin& /orry a=ter an&er provocation< 7hs, these reslts spport the vie/ that
perseverative thin0in& may e*plain part o= the hi&h (VD ris0 associated /ith hi&h
hostility< As /e have proposed be=ore A$rosschot N 7hayer, 1--@B, hostile individals
mi&ht be especially prone to an&er reactions /hen no socially appropriate response is
possible< We ar&ed that in social reality these sitations are =ar more common than
sitations in /hich an&er can be =reely e*pressed< 7his /old imply that hostile
individals /ill have to inhibit their an&er =ar more o=ten than they are able to e*press
it, casin& slo/ cardiovasclar recovery or prolon&ed activation< 3t is becase o= this
chronic or =reMent inhibition o= an&er, /e =rther hypothesi>ed, that hostile
individals develop the patho&enic physiolo&ical state that can reslt in (VD<
$y =ar the most cardiovasclar laboratory e*periments on an&er have been =ocsed on
an&er e*pression and cardiovasclar reactivity, rather than on an&er inhibition and
prolon&ed activation< Also, hostility and an&er Mestionnaires typically, bt o=ten
implicitly, re=er to sitations in /hich e*pression options are =ree< Not/ithstandin&
this lon&standin& research bias, a reasonable%apparently o=ten i&nored%amont o=
evidence has been bilt p in the past =or decades sho/in& that havin& no
opportnity to e*press oneLs an&er in =rstratin& sitations is associated /ith
prolon&ed cardiovasclar activation< 7he line o= stdies sho/in& this starts /ith si*
stdies by Ho0anson and co/or0ers in the 1-G"s Asee Ce&ar&ee N Ho0anson, 1-'",
=or a revie/B and later &enerally replicated by others< 3n =act, 1+ ot o= 1. stdies
=ond that a lac0 o= opportnity to conteract a=ter bein& harassed slo/s
cardiovasclar recovery a=ter bein& harassed Asee $rosschot N 7hayer, 1--@B< 7he
speed o= recovery appeared to be dependent in a comple* /ay on several =actors,
incldin& characteristics o= the sbRects and harasser Ae<&< Ce&ar&ee N Ho0anson,
1-'"B< An analysis o= some o= these stdies A$rosschot N 7hayer, 1--@B s&&ests that
the perceived ability to conter%react in a pre=erred manner, and not actal
per=ormance o= this behavior, speeds cardiovasclar recovery< 7his seems to
nderscore the importance o= perceived control over the sitation, /hich /as
mentioned above< 3n terms o= emotion theory, as lon& as no control is perceived, the
or&anismLs psychophysiolo&ical state o= action readiness is maintained< 3t cold be
ar&ed that de to the lac0 o= response opportnity, an&ered individals /old tend to
rminate, or ObroodP or O=meP over the =rstratin& sitation, and that this an&ry
perseverative thin0in& is in =act the direct case o= their prolon&ed hi&h (V
1"-
activation< 7his e==ect o= perseverative thin0in& is e*actly /hat the recent stdy o=
;lynn et alD A!""!B demonstratedE rmination a=ter bein& an&ered prolon&s (V
activation<
,ndobtedly, hostile individals /ill be especially prone to this type o= sitation,
becase they /ill perceive or even indce many more an&erin& sitations and /ill
%1"@%
at the same time be more easily and more intensely an&ered< Other stdies, in /hich
hostility /as measred, bt in /hich behavioral response opportnity /as not
maniplated Aand there=ore nclearB, sho/ that hostility is related to slo/ recovery
a=ter an&er provocation tests< 7he hostility component o= the strctred intervie/ A)3B%
derived 7ype%A behavior pattern /as related to physiolo&ical reactivity to and
recovery =rom the )3 and a sbseMent standard )troop tas0 A;anster et al9 1--1B<
Anta&onistic, bt not nerotic, hostility on the (oo0 Cedley scale /as related to
&reater systolic blood pressre reactivity to and poorer recovery a=ter harassment
A)are> N Williams, 1--"B< Frthermore, an&er that /as held in and not an&er that
/as e*pressed /as related to slo/ recovery in several emotional and co&nitive tas0s
AVitaliano et alD9 1--.B< 7he =indin& that only inhibited an&er and anta&onistic
hostility /ere related to slo/ recovery seems to spport the emotion%theoretical
vie/point that a dispositional action tendency is the Oto*icP characteristic o= hostility,
via its prolon&ation o= physiolo&ical respondin& a=ter provocation< 7his vie/ is
=rther spported by the &eneral =indin& that especially anta&onistic hostility or
potential =or hostility is predictive o= (VD and hypertension A9or&ensen et alD9 1--GB<
nticipatorystress and physiologi"al )'n"tioning
A considerable part o= daily /orryin& consists o= anticipatory ne&ative thin0in&< 7he
idea o= considerin& =tre stressors is conspicosly absent in the bl0 o= stress
research, /hile it is not di==iclt to see that it can have important physiolo&ical e==ects<
7hs, in addition to the /ays that emotion can be e*tended a=ter stress sitations,
anticipatin& stressors and anticipatory /orryin& are yet other /ays to enlar&e the
dration o= physiolo&ical responses< 3n other /ords, not only the response to a stressor
and the recovery a=ter/ards are important =rom a prolon&ed activation vie/ on
emotional (VD ris0 =actors, bt also the start o= anticipatin& the stressor< Even more
than is the case /ith recovery, anticipatin& stress is di==iclt to simlate in the
laboratory, becase either the stressor doesnLt have s==icient impact or the sbRects
have to be 0ept na/are o= the e*act maniplation o= ne&ative emotions< Not
srprisin&ly, most stdies that have inclded anticipatory stress are amblatory< One
o= these, by Hellhammer et alD A1-@.B /as already mentioned, and sho/ed that
salivary cortisol level /as associated /ith rminatin& be=ore e*aminations< Core
recently )myth and collea&es A1--@B, in an amblatory stdy o= daily stressors,
sho/ed that both the e*perience o= a stressor and anticipatin& a stressor /ere
associated /ith enhancement o= salivary cortisol< )pan&ler A1--'B sho/ed pre%e*am
anticipatory cardiovasclar, cortisol and immnolo&ical responses be=ore an
e*amination< 7here /as also a hi&her response drin& the e*amination, bt drin& the
anticipation and recovery phases the di==erences /ith a /ithin%sbRect control
sitation /ere lar&er<
11"
%1"-%
Perseverative thinking, neurovisceral concomitants
:erseverative thin0in& is repetitive, abstract, involntary, and represents a =ailre o=
inhibitory neral processes< As sch, perseverative thin0in& is a disinhibition o= a
potentially adaptive mechanism in hi&her or&anisms associated /ith the =rontal lobes
A7hayer N 6ane, !""!B< 7he =rontal lobes have reciprocal neral connections /ith
thalamic strctres that are associated /ith more evoltionarily primitive neral
circits that are in part responsible =or basic approach and avoidance behavior< When
these strctres are disinhibited a nmber o= processes associated /ith threat are
nleashed incldin& hypervi&ilance, =ear, and atonomic activity associated /ith =i&ht
or =li&ht sch as increased heart rate and blood pressre< When this physiolo&ical
activation is prolon&ed, the chronic patho&enic state necessary =or the development o=
disease may ense<
7hayer and 6ane A!""!B have recently otlined the nerophysiolo&ical concomitants
o= perseverative thin0in&< 7hey have proposed a net/or0 o= neral strctres that
&enerate, receive, and inte&rate internal and e*ternal in=ormation in the service o=
&oal%directed behavior and or&anism adaptability< 7hese strctres =orm part o= an
inte&rated sel=%re&lation system that allo/s =or the e==icient interaction o= the
or&anism /ith its environment%both internal and e*ternal<
For e*ample, /ith respect to cardiovasclar disease there are at least t/o related
path/ays in /hich perseverative thin0in& may be casally related to cardiovasclar
disease< One path/ay is via decreased va&ally mediated heart rate variability AHRVB<
Another path/ay is via decreased medial pre=rontal corte* activity< 7hayer and 6ane
A!""!B have proposed that these t/o path/ays in =act represent the brea0do/n o= a
common reciprocal inhibitory cortico%thalamic neral circit< 7hey described a set o=
neral strctres that serve to lin0 the pre=rontal corte* /ith HRV< 7his net/or0 o=
reciprocally interconnected neral strctres allo/s the pre=rontal corte* to e*ert an
inhibitory in=lence on thalamic strctres associated /ith de=ensive behavior and
ths allo/s the or&anism to re&late its behavior =le*ibly in response to chan&in&
environmental demands< For e*ample, /hen =aced /ith threat, the tonic inhibitory
control o= thalamic strctres by the pre=rontal corte* can be rapidly decreased
AdisinhibitedB leadin& to sympathoe*citatory =i&ht or =li&ht responses necessary =or
srvival< Ho/ever, /hen this tonically inhibitory net/or0 is disrpted, a ri&id,
de=ensive behavioral pattern is allo/ed to emer&e /ith its associated perseverative
behavior mani=estin& in attentional, a==ective, and atonomic in=le*ibility<
)trctrally, this net/or0 incldes the anterior cin&late, inslar, and ventromedial
pre=rontal cortices, the central ncles o= the amy&dala, the paraventriclar and
related nclei o= the hypothalams, the periaMadctal &ray matter, the parabrachial
ncles, the ncles o= the solitary tract, the ncles ambi&s, the ventrolateral
medlla, the ventromedial medlla, and the medllary te&mental =ield< 7hese
strctres are reciprocally interconnected sch that in=ormation =lo/s in both
directions%top%do/n and bottom%p< 7he primary otpt o= this net/or0 is mediated
thro&h the pre&an&lionic sympathetic and parasympathetic nerons<
%11"%
111
Perseverative thinking, neurovisceral concomitants
:erseverative thin0in& is repetitive, abstract, involntary, and represents a =ailre o=
inhibitory neral processes< As sch, perseverative thin0in& is a disinhibition o= a
potentially adaptive mechanism in hi&her or&anisms associated /ith the =rontal lobes
A7hayer N 6ane, !""!B< 7he =rontal lobes have reciprocal neral connections /ith
thalamic strctres that are associated /ith more evoltionarily primitive neral
circits that are in part responsible =or basic approach and avoidance behavior< When
these strctres are disinhibited a nmber o= processes associated /ith threat are
nleashed incldin& hypervi&ilance, =ear, and atonomic activity associated /ith =i&ht
or =li&ht sch as increased heart rate and blood pressre< When this physiolo&ical
activation is prolon&ed, the chronic patho&enic state necessary =or the development o=
disease may ense<
7hayer and 6ane A!""!B have recently otlined the nerophysiolo&ical concomitants
o= perseverative thin0in&< 7hey have proposed a net/or0 o= neral strctres that
&enerate, receive, and inte&rate internal and e*ternal in=ormation in the service o=
&oal%directed behavior and or&anism adaptability< 7hese strctres =orm part o= an
inte&rated sel=%re&lation system that allo/s =or the e==icient interaction o= the
or&anism /ith its environment%both internal and e*ternal<
For e*ample, /ith respect to cardiovasclar disease there are at least t/o related
path/ays in /hich perseverative thin0in& may be casally related to cardiovasclar
disease< One path/ay is via decreased va&ally mediated heart rate variability AHRVB<
Another path/ay is via decreased medial pre=rontal corte* activity< 7hayer and 6ane
A!""!B have proposed that these t/o path/ays in =act represent the brea0do/n o= a
common reciprocal inhibitory cortico%thalamic neral circit< 7hey described a set o=
neral strctres that serve to lin0 the pre=rontal corte* /ith HRV< 7his net/or0 o=
reciprocally interconnected neral strctres allo/s the pre=rontal corte* to e*ert an
inhibitory in=lence on thalamic strctres associated /ith de=ensive behavior and
ths allo/s the or&anism to re&late its behavior =le*ibly in response to chan&in&
environmental demands< For e*ample, /hen =aced /ith threat, the tonic inhibitory
control o= thalamic strctres by the pre=rontal corte* can be rapidly decreased
AdisinhibitedB leadin& to sympathoe*citatory =i&ht or =li&ht responses necessary =or
srvival< Ho/ever, /hen this tonically inhibitory net/or0 is disrpted, a ri&id,
de=ensive behavioral pattern is allo/ed to emer&e /ith its associated perseverative
behavior mani=estin& in attentional, a==ective, and atonomic in=le*ibility<
)trctrally, this net/or0 incldes the anterior cin&late, inslar, and ventromedial
pre=rontal cortices, the central ncles o= the amy&dala, the paraventriclar and
related nclei o= the hypothalams, the periaMadctal &ray matter, the parabrachial
ncles, the ncles o= the solitary tract, the ncles ambi&s, the ventrolateral
medlla, the ventromedial medlla, and the medllary te&mental =ield< 7hese
strctres are reciprocally interconnected sch that in=ormation =lo/s in both
directions%top%do/n and bottom%p< 7he primary otpt o= this net/or0 is mediated
thro&h the pre&an&lionic sympathetic and parasympathetic nerons<
%11"%
11!
3mportantly, these nerons innervate the heart via the stellate &an&lia and the va&s
nerve< 7he interplay o= these inpts to the sino%atrial node o= the heart is the sorce o=
the comple* variability that characteri>es the heart rate time series A)al, 1--"B,
/hich implies that the otpt o= this net/or0 is directly lin0ed to HRV< 3n addition,
sensory in=ormation =rom the peripheral end or&ans sch as the heart are =ed bac0 to
this set o= neral strctres, one important e*ample o= /hich is cardiac pain
AForeman, 1---B< As sch, HRV may be re&arded as an inde* o= central%peripheral
neral =eedbac0 and central nervos system A(N)B%atonomic nervos system AAN)B
inte&ration< :erseverative activity in attention, a==ect, cardiac, and motor behavior
have all been lin0ed to disrption o= these =eedbac0 circits ACasterman N
(mmin&s, 1--'8 )pyer, 1-@-B<
Con"l'sions
3n this chapter /e have tried to provide the &rond/or0 =or a theoretical approach to
the relationship bet/een /orry or rmination and related concepts, on the one hand,
and health, on the other hand< We have introdced the term Operseverative thin0in&P
to describe the core co&nitive%emotional process involved in /orry, rmination,
=min&, and the li0e, ths allo/in& this concept to be applied to a /ider ran&e o=
emotional states and dispositions than has previosly been done< We have attempted
to sho/ that perseverative thin0in& may play a mch broader role in psycholo&ical
and somatic health than has hitherto been appreciated< Evidence o= a /ide ran&e o=
possible lon&%term health conseMences o= perseverative thin0in& incldin& an*iety
disorders, medically ne*plained somatic complaints, and cardio%vasclar disease has
been presented< Frthermore, the diverse processes and mechanisms nderlyin& these
conseMences /ere otlined, incldin& physiolo&ical and nerovisceral processes
involved in /orry<
7he co&nitive%emotional process that /e have termed perseverative thin0in& may be
the sorce o= prolon&ed physiolo&ical activation that e*pands the temporal dration o=
a stressor beyond the traditional reactivity period to inclde anticipation and recovery<
7hs, perseverative thin0in& may be the missin& lin0 in the relation%ship bet/een
psychosocial =actors and the chronic patho&enic state tho&ht to be casally related to
the development o= disease<
!e)eren"es
$or0ovec, 7<D< N 3n>, 9< A1--"B< 7he natre o= /orry in &enerali>ed an*iety
disorderE a predominance o= tho&ht activity< Beha'ioral Research and
Therapy,%2, 1.+%1.@<
$or0ovec, 7<D<, Ray, W<9<, N )t[ber, 9< A1--@B< WorryE a co&nitive phenomenon
intimately lin0ed to a==ective, physiolo&ical, and interpersonal behavioral
processes< Cogniti'e Therapy Research,%%, .G1%.'G<
$or0ovec, 7<D<, Robinson, E<, :r>ins0y, 7<, N De:ree, 9<A< A1-@+B< :reliminary
e*ploration o= /orryE some characteristics and processes< Beha'iour Research
and Therapy,%$, -%1G<
%111%
11+
$rosschot, 9<F<, ;odaert, ;<6<R<, $enschop, R<9<, Ol==, C, $allie*, R<E<, N
HeiRnen, (<9< A1--@B< E*perimental stress and immnolo&ical reactivityE a closer
loo0 at perceived ncontrollability< Psychosomatic ?edicine,.6, +.-%+G1<
and va&al =nctionE a model o= the lin0 bet/een hostility and cardiovasclar
disease< nnals ofBeha'ioral ?edicine,%6, 1%@<
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Personality and %ocial Psychology,.,, !'#%!@!<
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(hichesterE Wiley<
Davey, ;<(<6< A1--#B< :atholo&ical /orryin& as e*acerbated problem%solvin&< 3n
;<(<6< Davey N F< 7allis, ;orryingD Perspecti'es on theory9 assessment and
treatment App< +.%G"B< Ne/ Yor0E Wiley<
Davey, ;<(<6< N 7allis, F< A1--#B< ;orryingD Perspecti'es on theory9 assessment
and treatment< Ne/ Yor0E Wiley<
De6on&is, A<, (oyne, 9<(<, Da0o=, ;<, Fol0man, )<, N 6a>ars, R<)< A1-@!B<
Relationship o= daily hassles, pli=ts, and maRor li=e events to health stats<
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Eri0sen, H<R<, )vendsrod, R<, ,rsin, ;<, N ,rsin, H< A1--@B< :revalence o=
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salivary cortisol release and behavioral copin& nder e*amination stress< #RC%
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)pan&ler, ;< A1--'B< :sycholo&ical and physiolo&ical responses drin& an e*am
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hostility and cardiovasclar reactivity as a =nction o= tas0 characteristics<
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in=lences< Beha'ioural and Cogniti'e Psychotherapy,%%, +'%.G<
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o= &enerali>ed an*iety disorder and /orry< Biological Psychiatry,&#, !..%!GG<
7hayer, 9<F< N 6ane, R<D< A!""!B< :erseverative thin0in& and healthE
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7hayer, 9<F<, )mith, C<, Rossy, 6<A<, )ollers, 9<9<, N Friedman, $<H< A1--@B<
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Psychiatry,,,, +"#%+"G<
,rsin, H< N Hytten, K< A1--!B< Otcome e*pectancies and psychosomatic
conseMences< 3n $<N< (arpenter Aed<B, Personal coping3 Theory9 research9 and
application App< 1'1%1@#B< Westport, (7E :rae&er?;reen/ood<
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recovery =rom laboratory stress%biopsychosocial concomitants in older adlts<
Eournal of Psychosomatic Research,&#, +G1%+''<
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control o= mood and mood%related tho&ht< Eournal of Personality and %ocial
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%11#%
art II
Individ'al di))eren"es and assessment
%11.%
11'
Chapter 4
5i))erent "on"epts or di))erent 1ords-
Con"epts related to non+expression o) negative emotions
Bert Carssen and ?argot Remie
Introd'"tion
:eople di==er in their tendency to be open abot, or to hide, ne&ative emotions< 7his is
an important topic in behavioral medicine, since emotional inhibition is considered a
potential health ris0 =actor =or disorders as diverse as chronic pain A$etler et alD9
1-@GB, hypertension ACann N 9ames, 1--@B, and cancer A9ensen, 1-@'8 Weihs et alD9
!"""B<
7he =indin&s in this research area are o=ten presented as i= all stdies had addressed
the same concept< Ho/ever, the application o= the same term does not necessarily
imply sin& the same concept< For instance, the term OdenialP has di==erent meanin&s
in the psychodynamic literatre compared to behavioral medicine te*ts< 3n the =ormer
=ield, it re=ers to nconsciosly denyin& a threat in &eneral AVaillant, 1-'1B, /hile in
the latter it is o=ten restricted to, consciosly or nconsciosly, denyin& the
seriosness o= oneLs disease A;reer et alD9 1-'-, 1--"B< Neither is it clear to /hat
e*tent the many di==erent terms sed in this area, sch as non%e*pression o= ne&ative
emotions, repression, sppression, emotional disclosre, concealment, denial,
emotional control, emotional inhibition, rationality, anti%emotionality, de=ensiveness,
7ype ( and 7ype D response style, ale*ithymia and emotional nmbness, re=er to
di==erent or similar concepts< Related to this conceptal con=sion is the e*tent to
/hich the varios measrement instrments sed in this =ield assess similar or
di==erent concepts<
ONon%e*pression o= ne&ative emotionsP ANEB is the most &eneral term =or the
tendency not to e*press ne&ative =eelin&s< NE re=ers to a tendency that the person may
or may not be a/are o= Acalled sppression and repression, respectively, in
psychodynamic theoriesB< 3n behavioral medicine, the term OrepressionP is o=ten sed
as a synonym =or NE< 7his is di==erent =rom its meanin& in the psychodynamic
literatre, /here repression speci=ically re=ers to an nconscios de=ence mechanism
desi&ned to 0eep speci=ic memories or e*periences, sally involvin& ne&ative a==ect,
nconscios< 3n behavioral medicine, consciosness is &enerally not inclded in the
de=inition o= repression as a distinctive characteristic< For instance, Weinber&er stated
that Othe e*tent to /hich this de=ensive style is characteri>ed by the se o= repression
relative to other de=ences sch as
%11'%
sppression, denial and ne&ation is not crrently 0no/nP AWeinber&er et alD9 1-'-, p<
+'"B<
)ince the ncertainty and con=sion abot the precise meanin& o= terms hamper the
theoretical development o= the area, the present chapter discsses the meanin&s o= the
varios terms on a conceptal level< 7he =ocs is not on the description o= the
relationship bet/een NE concepts and health and disease, nor does it address
11@
assessment isses, e*cept i= they are se=l =or the conceptal discssion< First, a
description o= NE is provided< Ne*t, an attempt is made to delineate di==erent
conceptal dimensions /ithin the area o= NE, =ollo/ed by a characteri>ation o= the
7ype ( concepts, /hich partly overlap /ith NE bt inclde more elements< Finally,
concepts are described that have been related to NE in the literatre, bt /hich in or
vie/ in =act are clearly distinct =rom NE<
Non+expression o) negative emotions CNED
7he term NE re=ers to the response style or tendency to inhibit%consciosly or
nconsciosly%the e*pression o= ne&ative emotions, sch as an*iety, an&er, and
depression, in order to avoid that a positive ima&e o= onesel= and?or the /orld is
threatened< 3n line /ith many behavioral medicine te*ts, /e /ill se the term
OrepressionP here as a synonym< NE incldes both sel=%deception and other%deception
Aimpression mana&ementB and also Opersonal de=ensivenessP Aincldin& emotional
control, emotional inhibition, anti%emotionality and rationalityB, and Osocial
de=ensivenessP< 7hese di==erent aspects /ill be discssed belo/<
)ome =orms o= non%e*pression are not inclded in this concept, sch as those de to
shyness, social phobia, and introversion< )hy or social phobic people =ear social
sitations, /hich inhibits their emotional e*pression< Repressive people do not
typically =ear or avoid social sitations and their reason =or not sho/in& ne&ative
emotions is not social =ear< Another di==erence is that shyness, social phobia and
introversion re=er to non%e*pression o= both ne&ative and positive =eelin&s, /hile NE
re=ers to non%e*pression o= ne&ative =eelin&s only<
7he =ollo/in& intervie/ =ra&ment o= a /oman /ith breast cancer is presented as an
e*ample o= /hat /e mean by NE A3]intervie/er8 :]patientB<
#E Yo said to have been really shoc0ed /hen yor doctor le=t yo a=ter havin& told
/hat /as /ron&< Did yo cry then, or /ere yo tremblin&T
PE Yes, 3 cried, yes< Oh /ell, bt then 3 /ent home Mietly anyho/< And then /e
discssed it shortly in the evenin&, /hen my children arrived<
#E Were they also sadT
PE 7hen, hX$t, 3 am happy that it is over no/, and /e hope that all stays /ell<
DonLt /eT
#E Were yo =ri&htened abot anythin& concernin& yor illnessT
PE No, hTXNo, 3 have not =ri&htened mysel= abot that ever<
#E Have yo ever been an&ryT
%11@%
PE No, almost neverXOh /ell, 3 mean, i= yo have a &ood li=e to&ether, and /ith yor
childrenXand /e have many =riends< )o, yes< Well, yo hear, 3 am someone /ho
11-
/or0s it ot by mysel=< 3 do not &ive mysel= a/ay easily< 3 have been several times in
hospitals, bt 3 do not /hine abot it<
#E Have yo ever been sadT
PE X/ell, no< 3 cannot say soX7hin&s &o /ell lately< 3 did tell yo, last time /as
/hen my brother%in%la/ died<
#E Yo have not been sad abot yorsel= /hen yo discovered havin& cancerT
PE Well, yes, the =irst =e/ days< 7hen 3 o=ten cried< $t only /hen 3 /as alone<
7his =ra&ment describes a /oman /ho sho/s =e/ emotions abot the threatenin&
condition o= havin& breast cancer /ith its many dramatic e==ects =or hersel= and her
=amily< 3t is her &eneral copin& style to repress emotions, as she mentions bein& never
an&ry and rarely sad< )he is inclined to emphasi>e the &ood side o= sitations< 3t is not
that she never e*periences any emotions, as she remembers havin& cried brie=ly a=ter
havin& been in=ormed abot her dia&nosis< )he also remembers the &rie= abot the
death o= her brother%in%la/< 7his is probably a sitation that is distress=l bt not
threatenin& to her, in contrast to bein& dia&nosed /ith cancer< 3t is also remar0able
that she reports havin& e*perienced sadness abot her o/n sitation in the =irst =e/
days, bt only /hen bein& alone< )he appears to repress her emotions especially in
=ront o= her =amily< One reason =or this behavior cold be that e*pressin& emotions
abot a threatenin& sitation, especially to/ard other people that one is dependent on,
increases its threatenin& character<
On the basis o= similar intervie/ =indin&s /e /old conclde that A1B NE does not
preclde the possibility that one is ApartlyB a/are o= oneLs ne&ative emotional =eelin&s8
A!B the concept o= NE as a response style does not e*clde the possibility that the
tendency is also sitation%dependent8 A+B NE is in Aa sb&rop o=B repressors
especially prominent in social sitations8 and A#B a =nction o= NE is to avert the threat
o= a stress=l, o=ten ncontrollable sitation<
7here are several reasons /hy people /old e*press their emotions, and several
reasons /hy they /old not, and there is no reason to label NE as either positive or
ne&ative Ac=< Kennedy%Coore N Watson, 1---B< Repressive people /ill &enerally not
bother other people /ith their problems and may =acilitate social sitations by their
positive attitde< On the other hand, this copin& style may impoverish intimate social
interactions and may in the lon& rn be ne&ative =or their o/n =nctionin&, becase o=
a lac0 o= insi&ht into their o/n psycholo&ical =nctionin&, a redced variety o= their
copin& repertoire, and missin& si&nals that /old lead to timely see0in& o= medical
help<
Cons"io's vers's 'n"ons"io's pro"esses
As repressive styles are sometimes distin&ished on the basis o= a di==erentiation
bet/een conscios and nconscios process, it is important to devote special
%11-%
1!"
attention to this topic< 7he Mestion o= /hether it is important to ma0e sch a
distinction has been dispted mainly in psychodynamic theories< )ome athors
consider it as a sel=%evident and =ndamental di==erence, and emphasi>e the distinction
by sin& t/o di==erent termsE sppression AconsciosB and repression AnconsciosB<
Other athors, ho/ever, have Mestioned the se=lness o= the distinction< Erdelyi
A1--+B has ar&ed that this distinction is not spported by empirical =indin&s< For
instance, it has never been demonstrated that the psycholo&ical or physical health
conseMences o= a more conscios verss a more nconscios de=ense mechanism are
di==erent< Coreover, /hile many athors have re=erred to Fred /hen discssin& the
di==erence bet/een repression and sppression this is historically n/arranted,
accordin& to Erdelyi, since Fred sed these terms interchan&eably< Cost modern
athors describe repression in terms o= active co&nitive processes, sch as selective
inattention and motivated =or&ettin&, rather than as an nconscios de=ense
mechanism A$ameister N (airns, 1--!8 Cendolia et alD9 1--G8 Ne/ton N (ontrada,
1--!B<
:eople &enerally are not a/are o= most o= their intentions and mental processes, i=
only =or the =act that their capacity =or conscios mental operations is limited< Only
occasionally may repression accont =or the =act that a tho&ht content becomes and
remains nconscios, especially in the case o= a serios tramatic event< Even then,
the initial process that cases a person to =or&et emotionally psettin& material can be
conscios and intentional< (onsider the e*ample o= /ar victims< When /ar memories
retrn in veterans years a=ter havin& O=or&ottenP the terri=yin& e*periences, they o=ten
remember havin& consciosly decided at the end o= /ar Oto =or&et all abot itP< )o,
the distinction may be o= some relevance /ith respect to repression o= serios
tramatic events, bt the notion o= AnB consciosness seems o= limited vale /ith
respect to response styles in psycholo&ically healthy people<
For the present discssion it /ill s==ice to conclde that no sharp line can be dra/n
bet/een conscios and nconscios processes< O$ein& not clearly a/areP or Obein&
not conscios Ao= oneLs habital styleBP may be sed as descriptive Mali=iers, bt the
distinction bet/een conscios and nconscios processes%in or vie/%is sch a
&radal and di==se one that it is navailin& to se it as a basis =or a distinction in
repressive response styles<
8el)+de"eption and impression management
)o =ar, NE has been discssed as tho&h it /ere a nitary concept, /hile it can be
better conceived as a domain< 3n this domain, one relevant distinction that has been
made is bet/een sel=%deception and other%deception or impression mana&ement
A:alhs, 1-@#8 )ac0heim N ;r, 1-'@B<
E*pression o= ne&ative emotions may be deliberately avoided as part o= the tendency
to ma0e a =avorable impression on other people< 7his tendency is called impression
mana&ement or, ori&inally, other%deception< 3t is distin&ished =rom sel=%deception, in
/hich case the person actally believes his or her positive
%1!"%
1!1
sel=%reports A:alhs, 1-@#8 )ac0heim N ;r, 1-'@B< 7he t/o concepts can be
empirically distin&ished< 3n a stdy by :alhs A1-@#B, a secondary =actor analysis o=
several Osocial desirabilityP scales yielded t/o dimensionsE lie scales and similar
other%deception measres loaded hi&hly on one =actor, /hich /as labeled impression
mana&ement< 3n addition, a sel=%deception Mestionnaire and a repression%sensiti>ation
Mestionnaire loaded both hi&hly on a second =actor, labeled sel=%deception<
)el=%deception and other%deception can be considered as re=lectin& di==erent aspects o=
NE< Relationships bet/een these concepts and their predictive validity have been
stdied empirically< An older stdy sho/ed that impression mana&ement is only
modestly Aand ne&ativelyB related to reports o= ne&ative emotions and somatic
symptoms, /hile a sel=%deceptive response style redces symptom reportin& above
and beyond the e==ects o= deliberate impression mana&ement< Dependin& on the scale
sed, impression mana&ement e*plained +%# percent o= the variance in somatic
symptom reports, and @%1" percent o= the variance in psycholo&ical symptom reports<
)el=%deception added #%G percent and @%1G percent e*plained variance =or somatic and
psycholo&ical symptom reports, respectively A6inden et alD9 1-@GB<
A more recent stdy =ond that repressors scored hi&h on both other%deception and
sel=%deception Mestionnaires ADera0shan N Eysenc0, 1---B< Repressors /ere de=ined
accordin& to Weinber&er et alDLs A1-'-B classi=ication as scorin& lo/ on an*iety and
hi&h on Ode=ensivenessP, as measred by the Carlo/e%(ro/ne )ocial Desirability
)cale AC(%)D)8 (ro/ne N Carlo/e, 1-G#B< Ho/ever, this stdy also sho/ed that
repressors are more sel=%deceivers than other%deceivers< 7his /as demonstrated /ith
the so called Obo&s pipelineP method, in /hich the participants are connected via
electrodes to a piece o= apparats resemblin& a lie detector that can alle&edly detect
/hether they are tellin& the trth< (ompared to a control condition, people are more
/illin& to report trth=lly abot their emotional states in the bo&s line condition,
even i= this report is seen as socially ndesirable or embarrassin& =or the person< 3= the
inhibitory style o= repressors /as mainly socially determined Adetermined by
impression mana&ementB, one /old e*pect less e*pression o= ne&ative mood in the
control condition, in /hich =avorable reports cannot be chec0ed, than in the bo&s
pipeline condition< Ho/ever, repressors &enerally did not sho/ any di==erence in
an*iety scores bet/een the t/o conditions< 7his =indin& s&&ests that repressors
&eninely perceive themselves as bein& lo/ in an*iety< On the other hand, sel=%report
data indicated that they also sho/ed some tendency to present themselves deliberately
in a socially desirable /ay< 3n addition, some repressors did sho/ an increase in
an*iety in the e*perimental condition, s&&estin& that repressors are not a
homo&eneos &rop re&ardin& their tendency to sel=%deception<
7oma0a et alD A1--!B =ond di==erent physiolo&ical patterns =or sel=%deception and =or
Ode=ensivenessP Ameasred by the C(%)D)8 (ro/ne N Carlo/e, 1-G#B< )el=%
deception /as associated /ith decreased physiological reactivity to a stress=l tas0,
/hile Ode=ensivenessP /as associated /ith increased physiological reactivity<
%1!1%
7his di==erence in physiolo&ical respondin& may be the conseMence o= a basic
di==erence bet/een sel=%deception and other%deception<
1!!
3n conclsion, both sel=%deception and impression mana&ement are aspects o= NE<
)b&rops o= repressors may se these t/o aspects in varyin& de&rees< 3n addition,
some evidence e*ists that these t/o aspects may di==er re&ardin& their physiolo&ical
concomitants< )ome de&ree o= sel=%deception, ho/ever, is al/ays implied in NE, as
NE is de=ined as emotional inhibition or control Oto avoid that a positive ima&e o=
onesel= is threatenedP<
8o"ial and personal de)ensiveness
Related to the above, /hen scrtini>in& the descriptions o= the di==erent terms sed in
this =ield, one &ets the impression that some e*planations emphasi>e the social aspect
mch more than others< For instance, Weinber&er and )ch/art> A1--"B, /ho sed the
term Osel=%restraintP, stated that it concerns Odomains related to sociali>ation and sel=%
control and re=ers to repression o= e&oistic desires in the interest o= lon&%term &oals
and relations /ith othersP< 3n addition, it is stated that sel=%restraint encompasses
Otendencies to inhibit a&&ressive behavior, to e*ercise implse control, to act
responsibly, and to be considerate o= othersP AWeinber&er N )ch/art>, 1--", p< +@!B<
We propose the term Osocial de=ensivenessP to label sch tendencies, and de=ine it as
the socially related tendency not to e*press Ato inhibit or to controlB ne&ative
emotions< 7his tendency may be part o= the broader inclination to behave in a socially
acceptable /ay< 7his shold not, ho/ever, be conceived as simply the need to =ollo/
e*ternal norms, bt as re=lectin& a sel=%concept that depends on the approval o= other
people<
We s&&est sin& the label Opersonal de=ensivenessP =or a second cate&ory o= non%
e*pression o= emotions, /hich is not primarily socially related< We de=ine this
cate&ory as the &eneral tendency to control oneLs e*pression o= ne&ative emotions, and
not allo/ onesel= to be in=lenced by these ne&ative =eelin&s< 7hs, in contrast to
social de=ensiveness, social &oals and motives are lar&ely absent in personal
de=ensiveness< 7his concept also incldes emotional control, as sed by Watson and
;reer A1-@+B, becase their description did not speci=ically s&&est social
determination< Another e*ample is rationality, as de=ined by )pielber&er A1-@@BE O7he
e*tent to /hich an individal ses reason and lo&ic as a &eneral approach to cope /ith
the environment<P 7his tendency may li0e/ise occr /hen the person is alone or in
company, i<e< it is not speci=ically a socially related tendency< Antiemotionality is
de=ined by )pielber&er A1-@@B as the e*tent to /hich an individal ses reason and
lo&ic to avoid interpersonally related emotions< 7his de=inition &ives no certainty
/here to place this concept< 7he Ose o= reason and lo&icP s&&ests a close
association /ith rationality, /hile Ointerpersonally related emotionsP s&&ests a shi=t
in the direction o= social de=ensiveness, tho&h the de=inition does not seem to imply
Oa sel=%concept that depends on the approval o= other peopleP< 3t is conclded here
that anti%emotionality is tentatively placed in the domain o= personal de=ensiveness<
%1!!%
Empirical data are needed to prove the validity o= this theoretical division into t/o
types o= NE< 7his /old be sbstantiated i= there appeared to be no close relationship
bet/een personal de=ensiveness scales AOemotional controlP, Oemotional inhibitionP,
OrationalityP and Oanti%emotionalityPB, and scales assessin& social de=ensiveness
AOde=ensivenessP and Osel=%restraintPB< 3n addition, /e /old e*pect personal
1!+
de=ensiveness to be mainly associated /ith sel=%deception, /hereas social
de=ensiveness shold be related to both sel=%deception and other%deception< 3n an
e*perimental sitation /here an honest report o= =eelin&s can be pblicly chec0ed, a
socially de=ensive person is e*pected to report a hi&her level o= distress than in more
private sitations, /hereas a person scorin& hi&h on personal de=ensiveness shold
e*hibit consistently lo/ distress scores across sitations<
Type C response style
7emosho0 and Heller A1-@1B introdced the concept o= 7ype ( behavior, /hich /as
hypothesi>ed to be related to the pro&ression o= cancer, in a stdy o= psychosocial and
epidemiolo&ical =actors associated /ith mali&nant melanoma< Arond the same time,
$ritish researchers independently had posed the Mestion o= /hether there mi&ht be Oa
7ype ( =or cancerP ACorris N ;reer, 1-@"B< 7emosho0 A1-@', pp< ..@%.G"B describes
this copin& style asE
abro&atin& oneLs o/n needs in =avor o= those o= others, sppressin& ne&ative
emotions, and bein& cooperative, nassertive, appeasin&, and acceptin&X 7he 7ype (
individal is considered nice, =riendly and help=l to others, and rarely &ets into
ar&ments or =i&htsX 7he 7ype ( individal may be seen as chronically hopeless and
helpless, even tho&h this is not consciosly reco&ni>ed in the sense that the person
basically believes that it is seless to e*press oneLs needs< 7he 7ype ( individal does
not even try to e*press needs and =eelin&s8 these are hidden nder a mas0 o= normalcy
and sel= s==iciency<
One may divide these varios characteristics into three domains< 7he main domain is
non%e*pression o= ne&ative emotions, also described as bein& emotionally contained
or controlled< 3n addition, this is e*pressed in Omaintainin& a =acade o= contentmentP<
A second domain concerns varios behaviors directed at other peopleE bein& more
concerned abot the needs o= other people than abot oneLs o/n needs8 bein& sel=%
sacri=icin&, cooperative, sociable and appeasin&8 bein& compliant /ith e*ternal
athorities and nassertiveness< 7he third domain concerns =eelin& helpless and
hopeless in stress=l conditions<
7he description o= the =irst domain corresponds /ell to or description o= personal
de=ensiveness< 7he second domain has some similarity to or social de=ensiveness
concept, altho&h bein& compliant /ith athorities and nassertiveness have not been
inclded nder this headin&< 7he third domain is conceptally di==erent =rom NE< Not
all people /ho control their =eelin&s and?or do not sho/ them in social sitations are
inclined to respond in a helpless /ay to stress=l
%1!+%
sitations< 3t can be conclded that the 7ype ( copin& style is a mltidimensional
constrct, incldin& NE Apersonal de=ensiveness and?or social de=ensivenessB as a core
element, to /hich the dimensions o= helplessness and the elements o= bein& compliant
/ith athorities and nassertiveness are added<
Empirical stdies have to reveal /hether the combination o= varios components into
one mltidimensional 7ype ( copin& style constrct has additional vale, compared
1!#
to NE alone A;ross, 1-@-B< 7his cold be reali>ed by demonstratin& that the predictive
po/er /ith respect to e*ternal otcome variables, =or instance the level o=
e*perienced distress or somatic symptoms, or disease pro&ression, is hi&her =or the
combination than =or the separate components< 7he predictive po/er /ith respect to
the development and pro&ression o= cancer has been stdied =or several o= these
elements separatelyE repression, depression and other ne&ative emotional states, and
helplessness A=or an overvie/, see ;arssen N ;ood0in, 1---B< Ho/ever, the relative
contribtion o= each o= these elements has never been e*amined simltaneosly in one
stdy< Ftre investi&ations shold address this isse<
One o= the repressive types, as distin&ished by Weinber&er and )ch/art> A1--"B,
sho/s in or vie/ a remar0able resemblance to the 7ype ( copin& pattern< $ased on a
dipartition o= distress scores and a tripartition o= restraint scores they =ormed si*
&rops, amon& others an an*ios de=ensive &rop Ascorin& hi&h on both de=ensiveness
and distressB and a repressive &rop Ahi&h on de=ensiveness, bt lo/ on an*ietyB<
(ompared to the other &rops, the an*ios de=ensive &rop scored lo/ /ith respect to
assertiveness, ability to e*press onesel= in close relationships, sensitivity to oneLs o/n
needs and =eelin&s, sel=%esteem and sel=%control< 7hey also scored hi&h on avoidant
personality AshynessB and dependency Aemotional reliance on others and approval
dependenceB< 7hese characteristics resemble the ones described above =or individals
employin& 7ype ( copin&< 7he repressive &rop, on the other hand, /as characteri>ed
by hi&h scores =or intimacy, sel=%esteem, sel=%control Atendency to se sel=%
mana&ement techniMesB, de=ensiveness and ale*ithymia, /hile lo/ on avoidant
personality<
On the basis o= the s&&ested similarity, one /old predict that the 7ype ( response
pattern is associated /ith relatively hi&h levels o= AreportedB distress< 7his is in line
/ith the inclsion o= helplessness and hopelessness in the description o= the 7ype (
copin& pattern, and places a part o= this constrct at some conceptal distance =rom
NE<
Con"epts di))erent )rom NE
3n this section, /e /ill brie=ly discss concepts that seem clearly di==erent =rom NEE
the acts o= emotional disclosre and sppression, Orepressed memoriesP, concealment,
type D personality, denial, de=ense mechanisms, ale*ithymia, and emotional
nmbness<
%1!#%
cts ofdis"los're and vol'ntary s'ppression o) emotionally "harged material
:eople can be as0ed to disclose personal tho&hts abot an emotional sitation or to
try not to thin0 abot them in an e*perimental conte*t< Emotional disclosre and
tho&ht sppression /ith respect to a particlar sitation can also occr spontaneosly
in normal li=e< )ch acts can be per=ormed incidentally, by people hi&h or lo/ in NE<
7here=ore, the act shold be distin&ished =rom the habitual response style<
7here is a research tradition stdyin& e*perimentally the e==ects o= inhibitin&
emotional behavior A;ross N 6evenson, 1--+8 Cass N ;ross, this volme, (hapter
1!.
#B and another research tradition =ocsin& on the e==ects o= tho&ht sppression
AAbramo/it> et alD9 !""1B< :articipants in sch stdies are as0ed to re=rain =rom
emotional behavior, sch as =acial e*pressions, or not to thin0 o= a certain ima&e,
respectively<
7he term Oemotional sppressionP is sed by ;ross in the sense o= an act< He
describes it as the conscios inhibition o= behavioral si&ns o= emotion, /hile
emotionally arosed A;ross N 6evenson, 1--+B< 7he e==ect o= sppression on
physiolo&ical systems /as stdied in sbRects /atchin& dis&st%elicitin& =ilms<
3nstrctin& participants to sppress any si&ns o= emotions led to decreased body
movements and heart rate decelerations Aprobably de to the restricted movementB,
and to activation in other physiolo&ical systems< E*pression o= activatin& emotions,
sch as an&er, is in most stdies also associated /ith increased physiolo&ical arosal
Asee =or an overvie/ ;ross N 6evenson, 1--+8 Cass N ;ross, this volme, (hapter
#B< 7hs, e*perimentally maniplated sppression and e*pression o= emotions may
have similar physiolo&ical concomitants< 3t is important to note that the ;ross and
6evenson stdy A1--+B concerns one =orm o= acte sppression, namely behavioral
inhibition8 the sppression instrction did not a==ect the sbRective report o= the
e*perience o= dis&st<
7he conseMences o= the acts o= emotional disclosre or emotional sppression are not
necessarily similar to the psycholo&ical and somatic concomitants o= bein& a habital
e*pressor or repressor, respectively< 6on&%term e==ects o= emotional disclosre
&enerally inclde a decrease in reported psycholo&ical and somatic symptoms A)myth,
1--@B< On the other hand, habital repressors also report less distress compared to
non%repressors A$lei0er et alD9 1--+8 6inden et alD9 1-@G8 Cann N 9ames, 1--@8 )/an
et alD9 1--!8 7oma0a et alD9 1--!8 Ward et alD9 1-@@8 Weinber&er, 1--18 Weinber&er N
)ch/art>, 1--"B< )o, the act o= e.pression and the response style o= non-e.pression
are both associated /ith lo/ reported distress<
On the physiolo&ical level, ho/ever, there is a similarity bet/een the elevated
physiolo&ical arosal related to the act o= sppression A;ross N 6evenson, 1--+B and
habital repression AFrnham N 7rayner, 1---B<
%1!.%
-epressed memories
Repression o= memories o= tramatic events AOrepressed memoriesPB, as described in
psychiatric te*ts, concerns a comple* o= co&nitions and emotions that is mainly
limited to a certain theme or event, sch as se*al abse in childhood< 7his is
di==erent =rom NE, /hich concerns the tendency not to e*press ne&ative emotions in
&eneral< Repression o= memories is initiated by tramatic events, /hile NE is a
habital style applied in a variety o= sitations< Repressin& the memories o= tramatic
events cold lead to a habital style o= NE, or ma&ni=y an e*istin& tendency to NE,
bt that does not ndo the conceptal di==erence<7he in=lence o= a tramatic event%in
the =orm o= bein& dia&nosed /ith cancer%on habital NE has been demonstrated by
Kreitler et alD A1--+B< 7hey =ond an increase in nmber o= repressors a=ter
noti=ication o= a breast cancer dia&nosis, /hich /as not =ond in /omen /ho
appeared to have no cancer a=ter dia&nostic tests<
Self-concealment
1!G
6arson and (hastain A1--"B have introdced the concept sel=%concealment as the trait
version o= the inhibition act, stdied by :enneba0er A1-@-B< 7he athors de=ine sel=%
concealment as Oa predisposition to actively conceal =rom others personal in=ormation
that one perceives as distressin& or ne&ativeP< 3n addition, it is said that O)el=%
concealed personal in=ormation is consciosly accessible to the individalP A6arson N
(hastain, 1--", p< ##"B<3t is not Mite clear /hether this concept shold be placed
/ithin or otside the domain o= NE< 3= inclded, it is by its volntary concealment
to/ard other people close to other%deception and social de=ensiveness< 7here are some
&radal di==erences /ith NEE
1 )el=%concealment concerns speci=ic, distressin& secrets, /hile NE =ocses on
ne&ative =eelin&s in &eneral, tho&h it shold be admitted that the line bet/een
these t/o elements is rather thin<
! )el=%concealment is e*plicitly a tendency to/ard volntary and conscios
inhibition, /hile NE /as conceptali>ed as incorporatin& both nconscios and
conscios copin& strate&ies< 3t has also been conclded that NE al/ays incldes
some de&ree o= sel=%deception8 ths not e*clsively the volntary and conscios
=orm o= other%deception<
+ )el=%concealment implies the a/areness o= distressin& tho&ht contents, /hile
NE implies that sch tho&ht contents are inhibited to become =lly a/are o=<
Empirical =indin&s have spported the spposed conceptal di==erence< While NE is
o=ten ne&atively related to distress reportin&, a positive association has been =ond
bet/een sel=%concealment and depression, an*iety and physical symptoms A6arson N
(hastain, 1--"B< 3n addition, a ne&ative relationship has been reported /ith repression
measres AKin& et alD9 1--!8 Rit> N Dahme, 1--GB<
%1!G%
&ype D personality
7he term O7ype D personalityP /as introdced by Denollet A1--'B to describe those
people /ho are distressed, bt /ho also inhibit the e*pression o= emotions< Wor0in&
in the =ield o= cardiovasclar disorders, Denollet developed this concept as a
combination o= t/o =actors that appeared to be predictive =or the development o=
coronary heart disease and hypertension, namely, hi&h distress level Aan&er,
depression, an*iety and vital e*hastionB and social inhibition Ao= emotional
e*pressionB< 7he second =actor re=lects social inhibition and introversion< 3n his o/n
research, the t/o =actors in isolation appeared to have no e==ect on disease
pro&ression8 it /as the interaction that had an adverse e==ect on pro&nosis ADenollet,
1--'B<
3t is important to be a/are o= the =act that 7ype D individals consciosly sppress
their behavior in order to avoid disapproval by others< A critical di==erence bet/een
7ype D and 7ype ( is that the ne&ative emotions o= an&er, an*iety, and depression are
e*perienced consciosly bt not e*pressed by the 7ype D individal, /hile these
emotions are sally nreco&ni>ed by the 7ype ( person and repressors< A possible
di==erence is their relationship to repression< While it is not certain /hether the 7ype
( response style is closer to the repressive copin& style or to the an*ios de=ensive
copin& style, as /e have s&&ested, the 7ype D personality style is e*plicitly o= the
an*ios de=ensive type<
1!'
Denial
Denial is conceived here as denyin& or minimi>in& the seriosness o= a medical
condition, not as denial o= ne&ative a==ect A/hich /old come close to de=ensiveness8
Ketterer et alD9 1--@B< De=ined this /ay, there is a clear di==erence bet/een denial and
NE< 7he latter concept does not speci=ically re=er to the emotional conseMences o= a
disease, bt to ne&ative emotions in &eneral< One mi&ht repress emotions, /hile not
denyin& the seriosness o= the disease< 3n the same line, ;reer et alD A1-'-, p< '@GB
described denial in breast cancer asE OApparent active reRection o= any evidence abot
their dia&nosis /hich mi&ht have been o==ered, incldin& the evidence o= breast
removal, sch as Lit /asnLt serios, they Rst too0 o== my breast as a precationLP<
Cinimi>in& the impact o= the disease either can be an act Aan event%driven copin&
responseB or can re=lect a habital style o= minimi>in& the seriosness o= npleasant
events<
3t is interestin& that the conseMences o= the t/o phenomena seem opposite in cancer<
3n stdies sin& a prospective, lon&itdinal desi&n to investi&ate the role o=
psycholo&ical =actors on the corse o= cancer, t/o stdies =ond that NE predicted an
n=avorable corse A9ensen, 1-@'8 Weihs et alD9 !"""B< On the other hand, in t/o other
stdies denial /as =ond to have a =avorable in=lence on the corse o= cancer ADean
N )rtees, 1-@-8 ;reer et alD9 1-'-8 1--"B<
%1!'%
Defenseme"hanisms
De=ense mechanisms =orm an important concept in psychodynamic theories< 7he
concept re=ers to the varios /ays a person can mentally react to a real or ima&ined
threat, so as to protect him or her =rom e*cessive an*iety AVaillant, 1-'1B< De=ense
mechanisms inclde, amon& other concepts, denial, repression and sppression< As
mentioned previosly, these terms are sed in psychodynamic theories /ith di==erent
meanin&s than in behavioral medicine< Cost o= these di==erences are mentioned
above8 they are smmari>ed in 7able '<1<3t is di==iclt, i= not impossible, to establish
to /hat e*tent Ode=ense mechanismsP and ONEP are similar, sho/ some overlap, or
are clearly di==erent, de to their ori&in =rom completely di==erent bac0&ronds and
=rame/or0s< 3t is as i= the t/o concepts are described in di==erent lan&a&es that are
based on di==erent &rammars and /ays o= thin0in&, /hich preclde proper
translations< 7ho&h a complete comparison is impossible, some di==erences can be
indicated<
1 De=ense mechanisms are de=ined as mental strate&ies that serve the prpose o=
/ardin& o== emotional states by distortin& aspects o= reality< 7he mental operation
described nder the headin& NE has most o=ten to do /ith avoidin& threatenin&
in=ormation, rather than distortin& in=ormation<
! De=ense mechanisms re=er to processes preventin& nconscios implses =rom
becomin& conscios< NE does not imply a sharp distinction bet/een conscios
and nconscios tho&ht contents<
Table )D$ (oncepts o= non%e*pression sed in both psychodynamic theories and
behavioral medicine
1!@
#n psychodynamic
theories
#n beha'ioral medicine
Denial
An nconscios process
leadin& to ne&ation o= a
threat
AO=ten sed asEB Denyin& oneLs disease or its
seriosness8 no re=erence to bein& conscios or
nconscios
Repression
An nconscios process
preventin& threatenin&
material =rom becomin&
conscios
AO=ten sed asEB 7he tendency not to e*press
ne&ative emotions ANEB< 7his tendency may be
based on varios Aconscios or nconsciosB
processes
)ppression
(onsciosly pshin&
threatenin& in=ormation
ot o= a/areness
)ometimes sed synonymosly to NE, to
indicate a response style, bt emphasi>in& that
one is or can be a/are o= oneLs /ay o=
respondin&< At other times sed to indicate the
conscios inhibition o= the behavioral si&ns o=
emotion as an act
%1!@%
+ De=ense mechanisms inclde a variety o= intrapsychic processes, /hereas NE is
rarely divided into OsbconceptsP<
# 3n the description o= de=ense mechanisms, a distinction is made bet/een
OimmatreP and OmatreP de=enses< Repressive copin& styles are not placed into a
hierarchy<
le)ithymia
7he concept o= ale*ithymia is derived =rom clinical observations o= a clster o=
speci=ic co&nitive characteristics amon& patients s==erin& =rom psychosomatic
diseases, sbstance se disorders, and post%tramatic stress disorders A$a&by et alD9
1--'8 Nemiah et alD9 1-'G8 7aylor, this volme, (hapter @B< 3t evolved into a
theoretical constrct, /ith the =ollo/in& salient =eatresE A1B di==iclty identi=yin&
=eelin&s, A!B di==iclty describin& =eelin&s, and A+B e*ternally%oriented thin0in&
A$a&by et al<, 1--'B<
$ecase o= the di==iclty in identi=yin& =eelin&s, one mi&ht assme that emotions are
not e*pressed either< Ho/ever, ale*ithymic persons shold not be considered as bein&
emotionally =lat< Nemiah et alD A1-'GB reported a proneness to sdden otbrsts o=
cryin& and an&er in these persons, altho&h they /ere nable to connect these
behaviors /ith their tho&hts and =antasies< )i=neos A1-G'B reported that these patients
commonly mentioned an*iety or complained o= depression< Ho/ever, they displayed
a limited vocablary =or describin& their emotions< 7he emotions o= ale*ithymic
individals appear to be rather di==se, poorly di==erentiated and not /ell represented<
7aylor et alD A1--'B conclded that ale*ithymia shold be re&arded not as a de=ense
a&ainst distressin& a==ects or =antasies, bt rather as re=lectin& an individal di==erence
in the ability to process and re&late emotions co&nitively< 7hey there=ore s&&ested
1!-
that this constrct is di==erent =rom Oother emotion%related constrcts sch as
inhibition and the repressive%de=ensive copin& styleP<
7he di==erence bet/een ale*ithymia and NE is empirically spported< First, several
stdies have sho/n that the 7oronto Ale*ithymia )cale A7A)B%the most =reMently
sed and /ell%validated Mestionnaire =or assessin& ale*ithymic traits%is nrelated or
ne&atively related to varios measres o= NE, incldin& social de=ensiveness,
measred by the Weinber&er AdRstment 3nventory AWA38 Weinber&er, 1--1B and the
Carlo/e%(ro/ne )ocial Desirability )cale A(ro/ne N Carlo/e, 1-G#8 7aylor et alD9
1--'8 Weinber&er N )ch/art>, 1--"B, repression, de=ined by hi&h de=ensiveness
scores and lo/ an*iety scores ACyers, 1--.8 Ne/ton N (ontrada, 1--#8 7aylor et alD9
1--'B, and sel=%deception and other%deception A6inden et alD9 1--GB< )econd, the
discrepancy bet/een sbRective and physiolo&ical responses that is characteristic =or
repressors Aheart rate responses &reater than sel=%reported ne&ative a==ectB /as =ond
in persons scorin& lo" on ale*ithymia< Hi&h ale*ithymics e*hibited a response pattern
characteristic o= hi&h%an*ios persons Asel=%reported ne&ative a==ect &reater than heart
rate responses8 Ne/ton N (ontrada, 1--#B< Hi&h ale*ithymic persons seem
physiolo&ically hypoarosed, as inde*ed by redced heart rate responses to
challen&in& laboratory
%1!-%
conditions A6inden et alD9 1--G8 Ne/ton N (ontrada, 1--#B< 7hird, the 7A) is
nrelated A6inden et alD9 1--GB or positi'ely related to sel=%reported distress A7aylor et
alD9 1--'B, /hereas measres o= NE are &enerally negati'ely related to distress
A$lei0er et al<, 1--+8 6inden et alD9 1-@G8 Cann N 9ames, 1--@8 )/an et alD9 1--!8
7oma0a et al9 1--!8 Ward et alD9 1-@@8 Weinber&er, 1--18 Weinber&er N )ch/art>,
1--"B<
7hs, based on psychometric and psychophysiolo&ical comparisons, ale*ithymia
sho/s some correspondence /ith the sensiti>in& style o= hi&h%an*ios persons, rather
than the avoidant style o= repressors< While repressive individals o=ten report that
they are not pset despite obRective evidence to the contrary, ale*ithymic individals
ac0no/led&e that they are pset, bt have di==iclty in speci=yin& the natre o= their
distress<
Emotional numbness
7he term Oemotional nmbnessP Ae<&< ;lover, 1--!8 6it>, 1--!B is applied to describe
the phenomenon /hereby people, havin& been e*posed to a tramatic sitation,
e*perience di==iclties /ith e*periencin& and e*pressin& emotions< + is considered a
characteristic o= post%tramatic stress disorder and one o= its dia&nostic criteria is
limited a==ect< )ome athors emphasi>e the connection bet/een emotional nmbness
and secondary ale*ithymia, /hich also has been conceptali>ed as a distrbance in
a==ective =nctionin& a=ter tramatic e*periences Asee also (hapter .B<
8'mmary and dis"'ssion
7he aim o= this chapter /as to elcidate, on a conceptal level, the relationships
bet/een varios constrcts related to NE< )el=%deception and other%deception are
1+"
aspects o= NE distin&ished in the literatre< NE may imply a certain de&ree o=
impression mana&ement or other%deception, bt the core o= the response style is sel=%
deceptionE repressors A&enerallyB believe their sel=%reports< We have also s&&ested
di==erentiatin& NE into personal and social de=ensiveness< 7he main distinction
bet/een personal and social de=ensiveness is the de&ree to /hich the response style is
socially related< 3n personal de=ensiveness, the tendency to repress ne&ative =eelin&s
re=lects an intrapsychic need independent o= the social conte*t, /hereas in social
de=ensiveness the repressive style may re=lect the tendency to behave in a socially
accepted /ay and the need =or a sel=%ima&e that lar&ely depends on other peopleLs
approval<
7he core o= Type C response pattern is NE, bt this mltidimensional constrct also
incldes the socially related elements o= bein& more concerned abot the needs o=
other people than oneLs o/n needs and bein& sel=%sacri=icin&, cooperative, appeasin&,
compliant /ith e*ternal athorities, and nassertive< 3n addition, it incldes =eelin&
helpless and hopeless in stress=l conditions<
)everal concepts have been described as bein& basically di==erent =rom NE< 7he
%1+"%
di==erence may have been sharpened in this chapter, /hich, it is hoped, /ill reslt in
more conceptal clarity< First, the acts o= emotional disclosre and volntary
sppression have been distin&ished =rom the habital styles o= Oe*pressorsP and
OrepressorsP, respectively< 7his distinction not only re=lects obvios conceptal
di==erences, bt implies a /arnin& a&ainst assmin& too easily that the
psychophysiolo&ical concomitants o= these acts are similar to the psychophysiolo&ical
conseMences o= the correspondin& response styles< Repression of traumatic e'ents is
a concept developed in psychiatry, /hich re=ers to repression o= =eelin&s and tho&hts
abot a speci=ic event, or series o= correspondin& events, sch as se*al abse or /ar
sitations, leadin& to psychopatholo&ical symptoms< 3t di==ers =rom NE in bein& also
more an act Aor series o= actsB and in bein& restricted to certain events<
7he Type D personality and self-concealment concern the volntary and conscios
tendencies to inhibit the e*pression o= ne&ative emotions and distressin& secrets,
respectively< 7hey are both associated /ith hi&h levels o= reported distress, in contrast
to repression< Denial is o=ten sed in behavioral medicine in the sense o= minimi>in&
the seriosness o= the disease, /hich is clearly di==erent =rom NE< A person can
repress ne&ative emotions /hile not denyin& the seriosness o= the disease< Defense
mechanisms re=er to a Omini theoryP ori&inatin& =rom a psychodynamic =rame/or0,
incldin& Amostly nconsciosB processes directed at /ardin& o== threatenin& material
and sally preventin& it =rom becomin& conscios< 3t /as conclded that the
theoretical bac0&ronds o= de=ense mechanisms and NE are so di==erent that a
conceptal comparison is very complicated< le.ithymia is not a style o= de=ence
a&ainst distressin& a==ects, bt re=lects a dys=imction in processin& and re&latin&
emotions co&nitively, /hich is re=lected in a limited vocablary =or describin& these
emotions<
7he varios concepts discssed in the present chapter are depicted in Fi&re '<1, in
/hich they are divided accordin& to the scienti=ic domain they ori&inate =rom, i<e<
1+1
psychiatry =including psychodynamic theories> and psychology =including beha'ioral
medicine>D A second division is into acts and traits =response styles>D One may also
ma0e a division into concepts re=errin& to prely volntary and conscios =orms o=
inhibition Aemotional disclosre, volntary sppression, 7ype D personality and sel=%
concealmentB and the other concepts, /hich imply nconscios or mi*ed =orms o=
emotional inhibition<
Kennedy%Coore and Watson A1---B describe an e*tensive model o= the processes
leadin& =rom covert emotional e*perience to overt emotional e*pression, thro&h a
series o= co&nitive%evalative steps< 7he description also involves the disrptions that
can occr at di==erent points in these processes, resltin& in di==erent =orms o= non%
e*pression< We /ill shortly describe their model to compare their description and
terminolo&y /ith those sed in the present chapter<
7he =irst step in their model concerns the perception o= a threatenin& condition, the
atomatic preconscios processin& o= emotional in=ormation and the accompanyin&
physiolo&ical chan&es< One =orm o= non%e*pression occrs /hen the person sho/s no
or minimal primary a==ective reactions Ato both positive and
%1+1%
Figure )D$ Overvie/ o= the varios concepts, divided into concepts developed in
psychiatry or psycholo&y Aespecially behavioral medicineB, respectively8 and those
describin& acts or traits Aresponse styles?tendenciesB, respectively<
ne&ative eventsB< 7his =orm is not inclded in or =rame/or0 o= NE, since it is
atomatic and primary Anot motivatedB and since it re=ers to both positive and
ne&ative emotions< 3= it describes a trait, in order to di==erentiate this =orm =rom
NE, /e /old pre=er another term sch as Olo/ a==ect intensityP or Obasal
nresponsivenessP<
7he second step in Kennedy%Coore and WatsonLs A1---B model re=ers to the
conscios perception o= oneLs a==ective responses< One mi&ht bloc0 oneLs
emotional reactions at this step, /hich is called Omotivated lac0 o= a/arenessP<
7his type o= emotional control or inhibition cold be part o= a &eneral disposition
to avoid ac0no/led&in& npleasant emotional e*periences< 7he athors consider
the repressive copin& style described by Weinber&er A1--1B as an e*ample o= sch
a disposition< We are more inclined to see the personal de=ensive style, described
above, as more appropriate, becase the emotional inhibition at this step is not
described as speci=ically socially motivated<
7he third step involves labelin& and interpretin& the a==ective response< One may
lac0 the s0ill to label or interpret oneLs emotional e*periences, /hich is the core o=
ale*ithymia<
7he =orth step incldes the evalation o= the response in terms o= oneLs belie=s
and &oals< 7he evalation o= oneLs response as nacceptable leads to another =orm
1+!
o= NE, /hich in or vie/ is comparable to social de=ensiveness< 7his evalation
mi&ht stem =rom a &lobal ne&ative attitde to/ard emotions, or =rom more speci=ic
belie=s, sch as Oit is dan&eros to e*press an&erP<
%1+!%
7he perceived lac0 o= opportnity to e*press emotions is the =i=th and last step in the
process< 7he impediment to e*pression mi&ht be sitation%speci=ic or more &lobal, =or
instance /hen lac0in& close relationships< We have not inclded this =orm o= non%
e*pression, since its emphasis is on sitational determinants, rather than re=lectin& an
individalLs style<
7o smmari>e, Kennedy%Coore and Watson A1--1B presented a se=l model =or
describin& di==erent =orms o= Anon%Be*pression< 7heir theoretical model has the
advanta&e o= bein& comprehensive and sho/in& clearly the diversity o= the varios
=orms o= non%e*pression /ith respect to their nderlyin& processes and conseMences<
Ho/ever, it /ill be e*tremely di==iclt to test empirically the lin0 bet/een the varios
=orms o= non%e*pression and the co&nitive%evalative steps o= the model< We have
been more reserved in presentin& theoretical schemes, /hile pre=errin& the restriction
to testable hypotheses re&ardin& the relationships bet/een the varios constrcts<
3t is hoped that the conceptal discssion in this chapter contribtes to more clarity in
this comple* scienti=ic domain< What /e =rther need is a discssion o= the varios
measrin& methods developed in this =ield, analy>in& their relationship /ith the
concepts discssed in this chapter< 7his not only /ill advance the conceptal thin0in&
re&ardin& NE, bt also /ill aid the constrction o= speci=ic testable hypotheses
re&ardin& potential associations o= the varios NE constrcts /ith health otcomes<
!e)eren"es
Abramo/it>, 9<)<, 7olin, D<F<, N )treet, ;<:< A!""1B< :arado*ical e==ects o=
tho&ht sppressionE a meta%analysis o= controlled stdies< Clinical Psychology
Re'ie",%$, G@+%'"+<
$a&by, R<C<, 7aylor, ;<9<, N :ar0er, 9<D<A< A1--'B< 7he nomolo&ical domain o=
the ale*ithymia constrct< 3n A<9<9<C< Vin&erhoets, F<9<van $ssel N A<9<W<
-.%11+B< 7ilbr&, 7he NetherlandsE 7ilbr& ,niversity :ress<
$ameister, R<F< N (airns, K<9< A1--!B< Repression and sel=%presentationE /hen
adiences inter=ere /ith sel=%deceptive strate&ies< Eournal of Personality and
%ocial Psychology,.%, @.1%@G!<
$etler, 6<E<, En&le, D<, OroL%$etler, C<E<, Daldrp, R<, N Ceredith, K< A1-@GB<
3nability to e*press intense a==ectE a common lin0 bet/een depression and painT
Eournal of Consulting and Clinical Psychology,/,, '.!%'.-<
$lei0er, E<C<A<, :loe&, H<C<van der, Hendri0s, 9<H<(<6<, 6eer, 9<%W<H<, N
1++
KleiRn, W<(< A1--+B< Rationality, emotional e*pression and controlE psychometric
characteristics o= a Mestionnaire =or research in psycho%oncolo&y< Eournal of
Psychosomatic Research,&4, @G1%@'!<
(ro/ne, D<:< N Carlo/e, D< A1-G#B< The appro'al moti'e< Ne/ Yor0E Wiley<
Dean, (< N )rtees, :<;< A1-@-B< Do psycholo&ical =actors predict srvival in
breast cancerT Eournal of Psychosomatic Research,&&, .G1%.G-<
Denollet, 9< A1--'B< Non%e*pression o= emotions as a personality =eatre in
cardiac patients< 3n A<9<9<C< Vin&erhoets, F<9<van $ssel, N A<9<W< $oelho/er
AedsB, The
%1++%
=non> e.pression of emotions in health and disease App< 1@1%1-!B< 7ilbr&, 7he
NetherlandsE 7ilbr& ,niversity :ress<
Dera0shan, N< N Eysenc0, C<W< A1---B< Are repressors sel=%deceivers or other%
deceiversT Cognition & 5motion,$&, 1%1'<
Erdelyi, C<H< A1--+B< RepressionE the mechanism and the de=ence< 3nE D<C<
We&ner N 9<W< :enneba0er AedsB, Fandboo! of mental control App< 1!G%1#@B<
En&le/ood (li==s, N9E :rentice Hall<
Frnham, A< N 7rayner, 9< A1---B< Repression and e==ective copin& styles<
5uropean Eournal of Personality,$&, #G.%#-!<
;arssen, $< N ;ood0in, K< A1---B< On the role o= immnolo&ical =actors as
mediators bet/een psycholo&ical =actors and cancer pro&ression< Psychiatry
Research,2/, .1%G1<
;lover, H< A1--!B< Emotional nmbin&E a possible endorphin%mediated
phenomenon associated /ith post%tramatic stress disorders and other allied
psychopatholo&ic states< Eournal of Traumatic %tress,/, G#+%G'.<
;reer, )<, Corris, 7<, N :ettin&ale, K<W< A1-'-B< :sycholo&ical response to breast
cancerE e==ect on otcome< Lancet, 1+ Oct<, '@.%'@'<
;reer, )<, Corris, 7<, :ettin&ale, K<W<, N Haybittle, 9<6< A1--"B< :sycholo&ical
response to breast cancer and 1.%year otcome< Lancet,&&/, #-%."<
;ross, 9< A1-@-B< Emotional e*pression in cancer onset and pro&ression< %ocial
%cience & ?edicine,%2, 1!+-%1!#@<
1+#
9ensen, C<R< A1-@'B< :sychobiolo&ical =actors predictin& the corse o= breast
cancer< Eournal of Personality,//, +1'%+#!<
Kennedy%Coore, E< N Watson, 9<(< A1---B< 5.pressing emotion< Ne/ Yor0E
;il=ord :ress<
Ketterer, C<W<, H==man, 9<, 6mley, C<A<, Wasse=, )<, ;ray, 6<, Kenyon, 6<,
Kra=t, :<, $rymer, 9<, Rhoads, K<, 6ovallo, W<R<, N ;oldber&, A<D< A1--@B< Five%
year =ollo/%p =or adverse otcomes in males /ith at least minimally positive
an&io&ramsE importance o= OdenialP in assessin& psychosocial ris0 =actors<
Eournal of Psychosomatic Research,,,, !#1%!."<
Kin&, 6<A<, Emmons, R<A<, N Woodley, )< A1--!B< 7he strctre o= inhibition<
Eournal of Research in Personality,%., @.%1"!<
Kreitler, )<, (haitchi0, )<, N Kreitler, H< A1--+B< RepressivenessE case or reslt
o= cancerT Psycho-8ncology,%, #+%.#<
6arson, D<;< N (hastain, R<6< A1--"B< )el=%concealmentE conceptali>ation,
measrement, and health implications< Eournal of %ocial and Clinical
Psychology,#, #+-%#..<
6inden, W<, 6en>, 9<W<, N )tossel, (< A1--GB< Ale*ithymia, de=ensiveness and
cardiovasclar reactivity to stress< Eournal of Psychosomatic Research,,$, .'.%
.@+<
6inden, W<, :alhs, D<6<, N Dobson, K<)< A1-@GB< E==ects o= response styles on
the report o= psycholo&ical and somatic distress< Eournal of Consulting and
Clinical Psychology,/,, +"-%+1+<
6it>, $<7< A1--!B< Emotional nmbin& in combat related post%tramatic stress
disorderE a critical revie/ and re=ormlation< Clinical Psychology Re'ie",$%,
#1'%#+!<
Cann, )<9< N 9ames, ;<D< A1--@B< De=ensiveness and essential hypertension<
Eournal of Psychosomatic Research,,/, 1+-%1#@<
Cendolia, C, Coore, 9<, N 7esser, A< A1--GB< Dispositional and sitational
determinants o= repression< Eournal of Personality and %ocial Psychology,46,
@.G%@G'<
%1+#%
Corris, 7< N ;reer, )< A1-@"B< A O7ype (P =or cancerT 6o/ trait an*iety in the
patho&enesis o= breast cancer DabstractF< Cancer Detection and Pre'ention,&, 1"!<
Cyers, 6<$< A1--.B< Ale*ithymia and repressionE the role o= de=ensiveness and
trait an*iety< Personality and lndi'idual Differences,$#, #@-%#-!<
1+.
Nemiah, 9<(<, Freyber&er, H<, N )i=neos, :<E< A1-'GB< Ale*ithymiaE a vie/ o= the
psychosomatic process< 3n O<W< Hill Aed<B< ?odern trends in psychosomatic
medicine App< #+"%#+-B< 6ondonE $tter/orths<
Ne/ton, 7<6< N (ontrada, R< A1--!B< Repressive copin& and verbal%atonomic
response dissociationE the in=lence o= social conte*t< Eournal of Personality and
%ocial Psychology,.%, 1.-%1G'<
Ne/ton, 7<6< N (ontrada, R<9< A1--#B< Ale*ithymia and repressionE contrastin&
emotion%=ocsed copin& styles< Psychosomatic ?edicine,/., #.'%#G!<
:alhs, D<6< A1-@#B< 7/o%component models o= socially desirable respondin&<
Eournal of Personality and %ocial Psychology,,., .-@%G"-<
:enneba0er, 9<W< A1-@-B< (on=ession, inhibition and disease< 3n 6< $er0o/it>
Aed<B, d'ances in e.perimental social psychology App< !11%!##B< )an Die&o, (AE
Academic :ress<
Rit>, 7< N Dahme, $< A1--GB< Repression, sel=%concealment and
rationality?emotional de=ensivenessE the correspondence bet/een three
Mestionnaire measres o= de=ensive copin&< Personality and #ndi'idual
Differences,%6, -.%1"!<
)ac0heim, H<A< N ;r, R<(< A1-'@B< )el=%deception, sel=%con=rontation, and
consciosness< 3n ;<E< )ch/art> N D< )hapiro AedsB, Consciousness and self-
regulation3 d'ances in research App< 1+-%1-'B< Ne/ Yor0E :lenm :ress<
)i=neos, :<E< A1-G'B< (linical observations on some patients s==erin& =rom a
variety o= psychosomatic diseases< cta ?edicina Psychosomatica,4, 1%1"<
)myth, 9<C< A1--@B< Written emotional e*pressionE e==ect si>es, otcome types
1'#%1@#<
)pielber&er, (<D< A1-@@B< The Rationality,5motional Defensi'eness =R,5D> scale3
Preliminary test manual< 7ampa, F6E ,niversity o= )oth Florida<
)/an, ;<E<, (armelli, D<, Dame, A<, Rosenman, R<H<, N )pielber&er, (<D<
A1--!B< 7he Rationality?Emotional De=ensiveness )cale%33< (onver&ent and
discriminant correlational analysis in males and =emales /ith and /ithot cancer<
Eournal of Psychosomatic Research,&., +#-%+.-<
7aylor, ;<9<, :ar0er, 9<D<A<, N $a&by, R<C< A1--'B< Relationships bet/een
ale*ithymia and related constrcts< 3n A<9<9<C< Vin&erhoets, F<9<van $ssel, N
A<9<W< $oelho/er AedsB, The =non> e.pression of emotions in health and disease
App< 1"+%11+B< 7ilbr&, 7he NetherlandsE 7ilbr& ,niversity :ress<
7emosho0, 6< A1-@'B< :ersonality, copin& style, emotion and cancerE to/ards an
inte&rative model< Cancer %ur'eys,., .#.%.G'<
1+G
7emosho0, 6< N Heller, $<W< A1-@1B< )tress and O7ype (P verss
epidemiolo&ical ris0 =actors in melanoma< Proceedings of the 1/th nnual
Con'ention of the merican Psychological ssociation A6os An&eles, A&st
1-@1B< Washin&ton, D(E American :sycholo&ical Association<
7oma0a, 9<, $lascovich, 9<, N Kelsey, R<C< A1--!B< E==ects o= sel=%deception,
social desirability, and repressive copin& on psychophysiolo&ical reactivity to
stress< Personality and %ocial Psychology Bulletin,$2, G1G%G!#<
Vaillant, ;<E< A1-'1B< 7heoretical hierarchy o= adaptive e&o mechanismsE a +"%
year =ollo/%p stdy o= +" men selected =or psycholo&ical health< rchi'es of
General Psychiatry, %,, 1"'%11@<
%1+.%
Ward, )<E<, 6eventhal, H<, N 6ove, R< A1-@@B< Repression revisitedE tactics sed
in copin& /ith a severe health threat< Personality and %ocial Psychology
Bulletin,$,, '+.%'#G<
Watson, C< N ;reer, )< A1-@+B< Development o= a Mestionnaire measre o=
emotional control< Eournal of Psychosomatic Research,%4, !--%+".<
Weihs, K<6<, Enri&ht, 7<C<, )immens, )<9<, N Reiss, D< A!"""B< Ne&ative
a==ectivity, restriction o= emotions, and site o= metastases predict mortality in
recrrent breast cancer< Eournal of Psychosomatic Research,,#, .-%G@<
Weinber&er, D<A< A1--1B< %ocial-emotional ad4ustment in older children and
adults3 $D Psychometric properties of the ;einberger d4ustment #n'entory<
(leveland, OHE npblished manscript<
Weinber&er, D<A< N )ch/art>, ;<E< A1--"B< Distress and restraint as
sperordinate dimensions o= sel=%reported adRstmentE a typolo&ical perspective<
Eournal of Personality,/2, +@1%#1'<
an*ios, and repressive copin& stylesE psychometric patterns and behavioral and
%1+G%
Chapter 2
Alexithymia( %/ years o) theory and resear"h
Groeme ED Taylor
Introd'"tion
1+'
Amon& the varios emotion%related constrcts that have been associated /ith health
and disease, ale*ithymia has the lon&est history< Formlated by Nemiah et alD A1-'GB
in the mid% 1-'"s, the ale*ithymia constrct evolved =rom clinical observations and
theoretical ideas described by Resch A1-#@B and Cac6ean A1-#-B more than a hal=
centry a&o< At that time, and =or at least the sbseMent t/o decades, the prevailin&
psychosomatic theories o= disease emphasi>ed the role o= intrapsychic con=licts in
&eneratin& protracted states o= emotional arosal that /ere considered patho&enic to
the body< Resch and Cac6ean proposed an alternative theory that nmodlated
states o= emotional arosal that mi&ht adversely a==ect bodily processes are a
conseMence o= de=icits in the capacity to represent emotions /ithin the symbolic
system provided by lan&a&e< 3n their vie/, sch de=icits are evidenced by di==iclties
in identi=yin& and verbally describin& sbRective =eelin&s<
7/o decades later, )i=neos A1-G'B and Nemiah and )i=neos A1-'"B observed that
many patients s==erin& =rom classic psychosomatic diseases mani=est not only a
mar0ed di==iclty in identi=yin& and describin& =eelin&s bt also an impoverished
=antasy li=e and a tho&ht content characteri>ed by a preoccpation /ith the details o=
obRects and events in the e*ternal environment< While )i=neos A1-'+B coined the term
Oale*ithymiaP to re=er to the =ormer characteristics, the latter characteristics resembled
the pensJe opJratoire already described by the French psychosomaticists Carty and
de CL,>an A1-G+B< 7he entire clster o= characteristics became the salient =eatres o=
ale*ithymia in Nemiah et alDLs A1-'GB sbseMent de=inition o= the constrct<
Ale*ithymia, ho/ever, /as not considered speci=ic to patients /ith classic
psychosomatic diseases< )imilar characteristics /ere described independently by
$rch A1-'+B in patients /ith eatin& disorders, and by Krystal A1-G@8 Krystal N
Ras0in, 1-'"B in many dr& addicts and patients /ith post%tramatic stress disorders
A:7)DB< Nemiah A1-@#B later s&&ested that ale*ithymia mi&ht be associated also
/ith panic disorder<
Altho&h 3 =irst heard abot ale*ithymia in the early 1-'"s, 3 became better
acMainted /ith the constrct in 1-'G /hen 3 participated in the 11th Eropean
%1+'%
(on=erence on :sychosomatic Research< Held in the enchantin& city o= Heidelber&,
this con=erence /as devoted almost entirely to theory and research on ale*ithymia and
is considered a landmar0 event in the history o= the =ield< :rior to this con=erence,
there /as only a hand=l o= pblished papers on ale*ithymia and very =e/ clinicians
and researchers /ere =amiliar /ith the concept< Follo/in& the Heidelber& con=erence,
ho/ever, interest in ale*ithymia increased considerably and a lar&e amont o=
empirical research has no/ been &enerated< While abot ." articles /ere pblished on
ale*ithymia by the late%1-'"s, a recent search o= the :sycln=o database revealed /ell
over 1""" Rornal articles on ale*ithymia<
3n this chapter 3 revie/ the maRor developments that have occrred in the =ield o=
ale*ithymia theory and research over the past !. years<
0eas'rement and validation o) the alexithymia "onstr'"t
1+@
Altho&h there /as &eneral a&reement abot the de=inition o= the ale*ithymia
constrct at the Heidelber& con=erence, it /as conclded that validational stdies, and
also reliable and valid methods =or measrin& the constrct, /ere lac0in&< 3t too0
another 1. years, ho/ever, be=ore these de=iciencies /ere overcome< 3nitially
researchers relied on proRective techniMes or an nvalidated observer%rater
Mestionnaire developed by )i=neos A1-'+B to assess ale*ithymic characteristics< 6ater
several sel=%report measres o= ale*ithymia /ere introdced, incldin& the CC:3
Ale*ithymia )cale, the )challin&%)i=neos :ersonality )cale, and the Revised
)challin&%)i=neos :ersonality )cale8 these /ere rather hastily constrcted measres
that /ere sho/n sbseMently to lac0 reliability and?or validity A7aylor et alD9 1--'B<
Reco&ni>in& that the development o= a reliable and valid measre o= a constrct is a
/idely sed method o= constrct validation in personality research, my collea&es and
3 be&an a pro&ram o= research in the mid%1-@"s aimed at evalatin& the validity o= the
ale*ithymia constrct thro&h the development o= a sel=%report scale =or measrin& it<
7he =irst scale /e developed /as the !G%item 7oronto Ale*ithymia )cale A7A)B,
/hich demonstrated internal consistency and a =or=actor strctre that corresponded
to the salient =eatres o= the constrct, namely di==iclty identi=yin& =eelin&s,
di==iclty describin& =eelin&s, redced daydreamin&, and e*ternally oriented thin0in&
A7aylor et alD9 1-@.B< Altho&h the psychometric properties o= the 7A) /ere
satis=actory and provided considerable spport =or the validity o= the ale*ithymia
constrct, in the corse o= =rther evalatin& the scale /e =ond some limitations that
led s to create a lar&er pool o= items =rom /hich /e developed a revised and
improved !"%item version%the 7/enty%3tem 7oronto Ale*ithymia )cale A7A)%!"8
$a&by et alD9 1--#aB< $ecase o= limitations o= space, 3 /ill revie/ the psychometric
properties o= the 7A)%!" only8 ho/ever, the t/o versions o= the scale are hi&hly
correlated<
%1+@%
&he &*enty-'tem &oronto le)ithymia Scale
7he 7A)%!" has adeMate internal consistency and test%retest reliability and a
three%=actor strctre that is con&rent /ith the theoretical constrct o=
ale*ithymia%AFlB di==iclty identi=yin& =eelin&s8 AF!B di==iclty describin& =eelin&s
to others8 and AF+B e*ternally oriented thin0in& A$a&by et alD9 1--#aB< 7he redced
day%dreamin& =actor o= the 7A) is no lon&er present since all items assessin&
=antasy and other ima&inal activity /ere eliminated drin& the process o= scale
revision becase they =ailed to meet pre%established statistical criteria< )ome
researchers may mista0enly conclde that /ithot this =actor the 7A)%!" does not
measre ale*ithymia as it /as ori&inally conceptali>ed8 ho/ever, the e*ternally
oriented thin0in& =actor correlates ne&atively /ith a measre o= =antasy and
ima&inal activity and ths appears to assess the redced =antasy =acet o= the
constrct indirectly A$a&by et alD9 1--#bB< 7his is consistent /ith NemiahLs A1-@#B
observation that the absence o= the capacity to prodce =antasies restricts tho&ht
content to a preoccpation /ith e*ternal obRects, people, and environmental
events<
7he three%=actor strctre o= the 7A)%!" has been replicated by the se o=
con=irmatory =actor analysis in En&lish%spea0in& clinical and nonclinical
1+-
poplations, and also /ith translated versions o= the scale in cltrally diverse
poplations, incldin& Finnish, ;erman, 3ndian, 3talian, Korean, 6ithanian,
:ort&ese, )panish, and )/edish< $ecase the =irst t/o =actors o= the 7A)%!"
correlate hi&hly, some researchers have Mestioned the validity o= the three%=actor
strctre o= the scale< Analy>in& data obtained =rom several di==erent samples,
ho/ever, /e demonstrated that a three%=actor model provides a better =it than
either a one% or a t/o%=actor model A7aylor et alD9 !"""B<
(onver&ent validity o= the 7A)%!" and also o= its three =actor scales has been
demonstrated by si&ni=icant ne&ative correlations /ith =or closely related
constrcts, vi><, psycholo&ical mindedness, need%=or%co&nition, a==ective
orientation, and emotional intelli&ence< Coreover, contrary to ar&ments that
ale*ithymia cannot be assessed adeMately by sel=%report measres, scores on the
7A)%!" and its =actors sho/ moderate to hi&h levels o= a&reement /ith
ale*ithymia ratin&s by e*ternal observers A7aylor et alD9 !"""B<
3nasmch as the validity o= a personality constrct cannot be evalated
independently o= the tests that prport to measre that constrct, the psychometric
properties o= the 7A)%!" provide stron& empirical spport =or the validity o= the
ale*ithymia constrct itsel=< 7he scale is at present the most /idely%sed
ale*ithymia measre<
Ne* measures
Recently some ne/ measres o= ale*ithymia have been introdced incldin& a
(ali=ornia Y%)et Ale*ithymia :rototype AHaviland, 1--@B and the sel=%report
$ermond%Vorst Ale*ithymia Yestionnaire A$ermond N Vorst, 1--@B< Altho&h
the reslts =rom preliminary testin& o= the psychometric properties o= these
%1+-%
measres are encora&in&, as noted else/here A7aylor et alD9 !"""B, it is prematre to
recommend them =or clinical or research prposes ntil there is stron&er evidence o=
their reliability and validity< Cy collea&es and 3 A7aylor et alD9 !"""B developed a
modi=ied version o= the $eth 3srael Hospital :sychosomatic Yestionnaire that /as
introdced initially by )i=neos A1-'+B8 /hile this holds promise as a se=l observer%
rated measre o= ale*ithymia, it also reMires =rther tests o= reliability and validity<
!elationships 1ith other health+related "onstr'"ts
)everal researchers have Mestioned /hether ale*ithymia is distinct =rom other
personality and emotion%related constrcts that have been associated /ith physical
health< For e*ample, $onnano and )in&er A1--"B s&&ested that ale*ithymia may be
part o= the better%0no/n repressive copin& style, /hich is identi=ied by hi&h scores on
measres o= de=ensiveness and lo/ scores on measres o= an*iety despite evidence o=
hi&h levels o= physiolo&ical arosal< )bseMent empirical stdies have sho/n that
repressors score lo/ on the 7A) and 7A)%!" and that ale*ithymia is most similar to
1#"
the sensiti>in& style o= hi&h%an*ios individals /ho ac0no/led&e ne&ative emotional
e*periences bt have di==iclty re&latin& them ACyers, 1--.8 Ne/ton N (ontrada,
1--#B< Ale*ithymic individals are distin&ished =rom hi&h%an*ios individals,
ho/ever, by their di==iclties in accrately identi=yin& and commnicatin& sbRective
=eelin&s, diminished =antasy li=e, and e*ternally oriented co&nitive style<
Also lin0ed /ith emotional e*pression and physical health is the constrct o=
inhibition, /hich is de=ined by :enneba0er A1-@-B as a conscios process in /hich an
individal actively restrains, holds bac0, or in some /ay e*erts e==ort not to thin0,
=eel, or behave< As Kin& et alD A1--!B point ot, this broad de=inition incldes the
diverse constrcts o= constraint, restraint, emotional ine*pressiveness, and emotional
control< 3n a stdy /ith a nonclinical sample, Kin& et alD A1--!B =ond that the 7A)
correlated positively /ith a measre o= inhibition, ne&atively /ith a measre o=
emotional e*pressiveness, and /as nrelated to a measre o= restraint< Core recently,
Verissimo et alD A1--@B =ond that the 7A)%!" correlated ne&atively /ith a measre o=
emotional control in a &rop o= patients /ith in=lammatory bo/el disease, bt
ale*ithymia and emotional control independently in=lenced the sbRective health
stats o= the patients< 3ndeed, the reslts s&&ested that patients /ho are most a/are
o= their sbRective =eelin&s Ai<e< least ale*ithymicB, bt also e*ert the &reatest control
over their emotional reactions, enRoy a hi&her Mality o= li=e than patients /ho have
di==iclty 0no/in& /hat they are =eelin& and are less able to control their reactions
/hen distressin& emotions are e*perienced<
)ome psycholo&ists ar&e that many o= the personality constrcts that have been
lin0ed /ith physical illness and health lac0 niMeness and can be conceptali>ed as
part o= one or more o= the broad dimensions /ithin the =ive%=actor model o=
personality< 3n a recent stdy, 6minet et alD A1---B e*amined the relationship
bet/een the 7A)%!" and the Revised NEO :ersonality 3nventory, /hich assesses
%1#"%
the =ive maRor dimensions o= personality and also the =acets or lo/er%order traits that
constitte each o= these dimensions< 7he reslts sho/ed that ale*ithymia is
represented not by any sin&le dimension or trait /ithin the =ive%=actor model, bt by a
clster o= traits across the dimensions and =acets< 7A)%!" scores /ere predicted by
hi&h scores on the =acets o= modesty and proneness to depression and by lo/ scores
on proneness to positive emotions, assertiveness, openness to =eelin&s, openness to
action, altrism, tender%mindedness, and competence< 7hese =indin&s indicate that
ale*ithymia is not redndant /ith other personality constrcts, and spport it bein&
conceptali>ed as an individal di==erence that may have e*planatory po/er in health
research<
Advan"es in alexithymia theory
7he maRor advances in ale*ithymia theory over the past !. years have been to locate
the constrct /ithin the broad =ield o= emotion theory and to propose /ays /hereby it
mi&ht play a role in the development o= medical and psychiatric disorders< )everal
years a&o 3 s&&ested that the salient =eatres o= the constrct re=lect a de=icit in the
co&nitive processin& and re&lation o= emotions, and that the disorders /ith /hich
ale*ithymia is most stron&ly asssociated be conceptali>ed as Odisorders o= emotion
1#1
re&lationP A7aylor, 1--#B< As my collea&es and 3 elaborated sbseMently in a boo0
A7aylor et alD9 1--'B, this proposal is consistent not only /ith Resch A1-#@B and
Cac6eanLs A1-#-B idea o= a de=icit in the symbolic representation o= emotion, bt also
/ith contemporary models o= the co&nitive development and or&ani>ation o=
emotions<
Accordin& to a model otlined by 6ane and )ch/art> A1-@'B, =or e*ample, normal
a==ect development =ollo/s an epi&enetic seMence in /hich the emer&ence o=
symboli>ation and the pro&ressive learnin& o= lan&a&e lead to the =ormation o=
co&nitive schemata o= emotions o= increasin& comple*ity that &radally chan&e the
sbRective e*perience o= emotions =rom an a/areness o= bodily sensations and states
o= tension only to an a/areness o= blends o= =eelin&s and an ability to distin&ish
nances o= emotions< Altho&h hi&her de&rees o= ale*ithymia correspond to lo/er
levels in this dimensional model, $cci A1--'aB emphasi>es that the problem in
ale*ithymia is not simply a lac0 o= /ords =or emotions, bt rather a lac0 o= symbols
=or somatic states< 6i0e 6ane and )ch/art> A1-@'B, $cci also ar&es that drin&
normal a==ect development the earlier sta&es o= concrete sensory and motor
processin& o= emotions are not abandoned /hen levels o= =ormal, lo&ical processin&
are attained<
Dra/in& on recent 0no/led&e =rom co&nitive science and neroscience, $cci
A1--'bB proposes a Omltiple code theoryP, in /hich emotions are represented both
verbally and non%verbally< 7he non%verbal emotional schemata develop =irst and
inclde sbsymbolic processes Asensory, visceral, and 0inesthetic sensationsB as /ell
as symbolic ima&ery< 7he verbal emotional schemata develop later and are or&ani>ed
accordin& to the symbolic =ormat o= lan&a&e< (onsistent /ith these theoretical
=ormlations, the de=icit nderlyin& ale*ithymia is mani=est not only as
%1#1%
a di==iclty in describin& =eelin&s in /ords, bt also as an impoverished =antasy li=e,
an associated tilitarian tho&ht style, and a dissociation o= the AsbsymbolicB
representations o= sensory e*periences and patterns o= atonomic arosal =rom
AsymbolicB ima&es and /ords<
Accordin& to $cci A1--'aB, the dissociation bet/een sbsymbolic and symbolic
/ithin the non%verbal emotion schemata may allo/ physiolo&ical activation to occr
drin& emotional arosal /ithot a correspondin& co&nitive activation< Coreover, the
lac0 o= =ocs and re&lation by symbolic schemata may reslt in prolon&ed and
repetitive physiolo&ical activation< 7he type o= medical or psychiatric disorder that
may then arise /ill depend on the de&ree o= dissociation bet/een somatic and motor
patterns o= activation and symbolic representations, and also on the interaction /ith
constittional and other vlnerability =actors<
Alexithymia and emotion reg'lation
Empirical stdies over the past decade provide some spport =or the vie/ that
ale*ithymia re=lects de=icits in the co&nitive processin& and re&lation o= emotion< 3n
e*plorin& the perception and co&nitive appraisal o= non%verbal emotional stimli, =or
e*ample, three e*perimental stdies =ond that hi&h%ale*ithymia individals are less
1#!
accrate in identi=yin& posed =acial e*pressions o= emotion than are lo/%ale*ithymia
individals A9essimer N Car0ham, 1--'8 Cann et alD9 1--#8 :ar0er et alD9 1--+B< 3n
another stdy, hi&h%ale*ithymia individals had si&ni=icantly lo/er accracy rates
than did lo/%ale*ithymia individals on a series o= tas0s that reMire the matchin& o=
verbal or non%verbal emotional stimli /ith verbal or non%verbal emotional responses
A6ane et alD9 1--GB< Other stdies =ond that ale*ithymia is associated positively /ith
maladaptive styles o= emotion re&lation, sch as bin&ein& on =ood or drin0in&
alcohol, and ne&atively /ith adaptive behaviors, sch as thin0in& abot and tryin& to
nderstand distressin& =eelin&s or tal0in& to a carin& person A$ec0endam, 1--'8
:ar0er et alD9 1--@8 )cha==er, 1--+B< 7here is evidence also that ale*ithymia is
associated /ith insecre attachment styles, /hich indicates less e==ective emotion
re&latin& s0ills than =ond in individals /ith secre attachment styles A$ec0endam,
1--'8 )cha==er, 1--+8 )cheidt et al9 1---B<
3n e*plorin& the proposal that ale*ithymia involves a dissociation bet/een the
co&nitive%e*periential and physiolo&ical components o= the emotional response to
stress=l stimli, ho/ever, e*perimental stdies have yielded inconsistent =indin&s<
7his may be attribted in part to sin& di==erent emotion%provo0in& stimli Ae<&<
vie/in& emotional scenes, per=ormin& mental arithmetic, or tal0in& abot an psettin&
personal e*perienceB, and also to monitorin& di==erent physiolo&ical variables Aheart
rate, blood pressre, s0in condctance, or mscle tensionB< Whereas in several stdies
ale*ithymia /as associated /ith a hi&her tonic or baseline level o= sympathetic
activity, most stdies =ond either hypo%arosal or no ale*ithymia e==ect drin&
e*posre to a stressor AFriedlander et alD9 1--'8 6inden et alD9 1--G8 Roedema N
)imons, 1---8 Wehmer et alD9 1--.B< 3n a stdy that had research participants vie/ an
emotional =ilm, ho/ever, ale*ithymia /as associated /ith
%1#!%
increased sympathetic arosal, indicated by hi&her s0in condctance A3n=rasca, 1--'B<
)ch a stimls is more li0ely to en&a&e the participants emotionally< 3n another
recent stdy, 6minet and RimQ A1--@B also sed an emotional =ilm as the stressor8
consistent /ith the dissociation hypothesis, a hi&her de&ree o= ale*ithymia /as
associated /ith =e/er responses at the co&nitive%e*periential level, and &reater
physiolo&ical reactivity as indicated by increased heart rate<
Cch more research is needed sin& methodolo&ies that appro*imate stress=l
sitations in everyday li=e< One sch approach /as devised by 7roisi et alD A!"""B,
/ho videotaped the non%verbal behaviors o= an*ios or depressed patients /ithot
their 0no/led&e /hile they /ere bein& intervie/ed< Altho&h hi&h% and lo/%
ale*ithymia patients did not di==er on sel=%report ratin&s o= an*iety and depression, the
hi&h%ale*ithymia patients sho/ed si&ni=icantly more displacement activities sch as
hand%to%=ace or hand%to%moth movements, scratchin&, =mblin&, and bitin& o= lips8
these behaviors are presmed to re=lect bodily tension or s0in sensations associated
/ith emotional arosal ADelis, 1-G'B< Despite the limitation that sbRective =eelin&s
/ere assessed immediately prior to rather than drin& the intervie/, the reslts
s&&est a decoplin& o= physiolo&ical arosal =rom sbRective =eelin& states<
!elationships 1ith medi"al and psy"hiatri" disorders
1#+
;iven that many o= the early investi&ations o= ale*ithymia in clinical poplations sed
measres o= Mestionable validity, 3 /ill revie/ only stdies that sed the 7A) or
7A)%!"< Altho&h ale*ithymia is considered a dimensional constrct, empirically
established cto== scores =or these scales enable researchers to compare rates o= hi&h
ale*ithymia across stdies<
)rprisin&ly, there have been =e/ methodolo&ically sond investi&ations o=
ale*ithymia and classic psychosomatic diseases, perhaps becase o= the no/ 0no/n
hetero&eneity o= these disorders< 7he stron&est association is bet/een ale*ithymia and
essential hypertension< 3n a stdy condcted in 3taly, 7odarello et alD A1--.B =ond a
rate o= .. percent o= ale*ithymia in a &rop o= hypertensive patients, /hich contrasted
/ith rates o= ++ percent in a comparison &rop o= psychiatric otpatients and 1G
percent in a commnity sample< 3n a more recent stdy in Finland, 9la et alD A1---B
investi&ated a &rop o= ne/ly dia&nosed and as yet ntreated adlts /ith moderate to
severe hypertension and =ond rates o= .' percent in men and #G percent in /omen
compared /ith rates o= 1@ percent in normotensive men and - percent in
normotensive /omen<
3n another 3talian stdy, :orcelli et alD A1--.B =ond a rate o= +.<' percent o=
ale*ithymia in a &rop o= patients /ith in=lammatory bo/el disease A3$DB, /hich
compared /ith a rate o= #<. percent o= ale*ithymia in a control &rop o= healthy adlts
matched =or &ender, a&e, and edcation< Ale*ithymia /as not related to the dration
o= illness or the level o= disease activity< Altho&h a hi&h de&ree o= ale*ithymia /as
present in only sli&htly more than one third o= the 3$D &rop,
%1#+%
this =indin& may si&ni=y a sb=orm o= 3$D that di==ers psycholo&ically =rom other
sb=orms<
Despite the clinical impression that patients /ith medically ne*plained somatic
symptoms are o=ten ale*ithymic, there has been little attempt to assess prevalence
rates in patients /ho meet D)C criteria =or any o= the somato=orm disorders< 3n the
one stdy 3 am a/are o=, a rate o= .+ percent o= ale*ithymia /as =ond in a &rop o=
(anadian patients /ho met D)C%333%R criteria =or somato=orm pain disorder A(o* et
alD9 1--#B< No rates o= ale*ithymia are reported =or patients /ho meet D)C criteria
=or dia&noses o= hypochondriasis or somati>ation disorder< Ho/ever, &iven that many
researchers no/ conceptali>e somati>ation and hypochondriasis as personality traits
rather than dia&nostic cate&ories, it is note/orthy that several stdies have reported
si&ni=icant positive correlations bet/een the 7 A) or 7A)%!" and dimensional
measres o= somati>ation and hypochondriasis Asee 7aylor, !"""B< 7hese associations
may be e*plained by a tendency =or ale*ithymic individals to =ocs on, ampli=y, and
misinterpret the somatic sensations that accompany emotional arosal<
Notin& that patients /ith =nctional &astrointestinal disorders AF;3DsB o=ten complain
o= nmeros ne*plained non%&astrointestinal somatic symptoms, and ths sho/
some clinical overlap /ith patients s==erin& =rom somato=orm disorders, :orcelli et
alD A1---B recently investi&ated a &rop o= 3talian patients /ith these medical
disorders Amainly irritable bo/el syndrome and?or =nctional dyspepsiaB and =ond a
rate o= GG percent o= ale*ithymia< 7he F;3D patients /ere si&ni=icantly more
1##
ale*ithymic than a comparison &rop o= 3$D patients and the di==erence remained
a=ter controllin& =or hi&her levels o= an*iety and depression in the F;3D patients<
7hese reslts may not be &enerali>able, ho/ever, as the F;3D patients /ere selected
=rom a tertiary%care center and are li0ely there=ore to have had more psychiatric
disorders and abnormal illness behavior, and also hi&her rates o= li=e stress, than
F;3D patients re=erred to primary% and secondary%care settin&s<
(onsistent /ith clinical observations that patients /ith eatin& disorders are
be/ildered by their emotional =eelin&s and o=ten have di==iclty describin& them,
empirical stdies have reported rates o= ale*ithymia ran&in& =rom #@ percent to ''
percent =or patients /ith anore*ia nervosa and #" percent to G1 percent =or patients
/ith blimia nervosa Asee 7aylor et alD9 1--'B< 3nterestin&ly, ale*ithymia /as
associated /ith the traits o= ine==ectiveness, Alo/B interoceptive a/areness, and
interpersonal distrst in a &rop o= anore*ic /omen, bt the constrct sho/ed no
relationship /ith attitdes and behavior related to abnormal eatin& and body /ei&ht
and shape< 7he stron&est association /as /ith interpersonal distrst, /hich
encompasses not only a relctance to =orm close relationships bt also a relctance to
e*press tho&hts and =eelin&s to other people A7aylor et alD9 1--GB<
3nvesti&ations o= other psychiatric poplations have yielded empirical spport =or the
early clinical impressions that ale*ithymia is common also amon& patients /ith
sbstance se disorders, :7)D, or panic disorder< Rates o= arond ." percent o=
ale*ithymia have been reported in &rops o= men /ith sbstance se disorders Asee
7aylor et alD9 1--'B, /hich is consistent /ith the vie/ that many addicts
%1##%
become dependent on alcohol or dr&s becase o= enormos di==iclties in re&latin&
distressin&, and o=ten poorly%di==erentiated, a==ects< Amon& the an*iety disorders, a
rate o= G" percent o= ale*ithymia can be calclated =rom data collected =rom a &rop
o= male combat veterans /ith :7)D AHeitlin et alD9 1-@-B8 rates o= #' percent and G'
percent o= ale*ithymia have been reported in &rops o= patients /ith panic disorder,
compared /ith mch lo/er rates o= 1!<. percent in patients /ith simple phobias and
1+ percent in patients /ith obsessive complsive disorder Asee 7aylor et alD9 1--'B<
7hese =indin&s are consistent /ith the vie/ that panic attac0s and some o= the
intrsive and atonomic arosal symptoms o= :7)D are essentially over/helmin&
=loods o= ndi==erentiated emotions that have not been contained by hi&her order
symbolic processes<
State-dependentvers's trait alexithymia
$ecase the 7A) and 7A)%!" correlate positively /ith measres o= an*iety and
depression, some investi&ators s&&est that the association bet/een ale*ithymia and
varios medical and psychiatric disorders may re=lect a concomitant state reaction
secondary to the emotional distress evo0ed by illness rather than a predisposin& or
vlnerability =actor< Altho&h this distinction can be evalated adeMately only by
prospective stdies in /hich ale*ithymia is assessed be=ore the onset o= any disorder,
=indin&s =rom several lon&itdinal stdies spport the vie/ that the constrct re=lects
an endrin& personality trait< )alminen et alD A1--#B, =or e*ample, =ollo/ed a &rop o=
&eneral psychiatric otpatients over a one year period and =ond a si&ni=icant decrease
1#.
in psycholo&ical distress, bt no si&ni=icant chan&e in the mean ale*ithymia score<
Core recently, Cart4ne>%)cnche> et alD A1--@B demonstrated that ale*ithymia scores
remained stable over a 1'%/ee0 period in a &rop o= niversity stdents /hose levels
o= emotional and somatic distress initially decreased, and later increased, in
association /ith the timin& o= niversity e*aminations<
3t mst be noted, ho/ever, that these and other lon&itdinal stdies evalated absolte
stability only Ai<e< the e*tent to /hich personality scores chan&e over timeB and not
relative stability, /hich is the e*tent to /hich the relative di==erences amon&
individals remain the same over time< Frthermore, the chan&es in levels o=
emotional distress /ere relatively small< Cy collea&es and 3 there=ore condcted a
lon&itdinal investi&ation o= psychiatric otpatients /ith maRor depressive disorders8
/e =ond a lac0 o= absolte stability o= ale*ithymia as the depressive symptoms
lessened in response to antidepressant medications over a 1#%/ee0 period, bt there
/as stron& evidence =or the relative stability o= ale*ithymia A6minet et alD9 !""1B<
7hs, /hile there may be a state%dependent aspect o= ale*ithymia, especially /hen
depression or other ne&ative a==ects are intense, the demonstration o= relative stability
spports the conceptali>ation o= ale*ithymia as a personality trait<
Not/ithstandin& the =indin&s =rom these lon&itdinal stdies, it mst be emphasi>ed
that the associations bet/een ale*ithymia and the varios medical and
%1#.%
psychiatric disorders are correlational only and that no casal in=erences can be
dra/n< )ome research s&&ests that the association may be de to the e==ects o=
ale*ithymia on illness behavior Asch as symptom a/areness and complaintsB
A6mley N Norman, 1--GB, and it is possible that some o= the help%see0in& =or
medically ne*plained somatic symptoms can be acconted =or by neroticism /ith
/hich ale*ithymia is positively associated< Coreover, there is evidence that
ale*ithymia is associated /ith a redced ability to cope /ith stress=l sitations and
/ith poor relationship s0ills A:ar0er et alD9 1--@8 7aylor N $a&by, !"""B, /hich can
also in=lence a personLs disposition to illness and disease<
7here is preliminary evidence, ho/ever, that ale*ithymia has some vale in predictin&
health chan&es beyond the predictive ability o= other /ell%0no/n ris0 =actors< 3n a
prospective stdy o= over !,""" middle%a&ed Finnish men, ale*ithymia /as predictive
o= mortality by any case over =ive years, independently o= behavioral =actors
Asmo0in&, alcohol consmption, physical activityB, physiolo&ical =actors
Ahypertension, lo/%density lipoprotein, hi&h%density lipoprotein, body mass inde*B,
socioeconomic stats, prior diseases, marital stats, perceived health, depression, and
social connections< Aside =rom sicide, homicide and accidents, ho/ever, speci=ic
cases o= death /ere not reported AKahanen et alD9 1--GB<
Ne'ro*iologi"al st'dies
3n some o= their early theoretical papers, Nemiah A1-''B and his collea&es ANemiah
et alD9 1-'GB s&&ested that there may be a nerobiolo&ical basis =or ale*ithymia< 7hey
reiterated a hypothesis advanced many years earlier by Cac6ean A1-#-B that the
inability to represent emotions symbolically may re=lect a lac0 o= adeMate
1#G
connections bet/een the limbic system and the neocorte*< At the Heidelber&
con=erence, ho/ever, Hoppe and $o&en A1-''B described an impoverishment o=
=antasies and a limited ability to describe =eelin&s in patients /ho had lost the maRor
connection bet/een the ri&ht and le=t cerebral hemispheres8 these patients had
previosly nder&one commissrotomy =or treatment o= intractable epilepsy and /ere
nonale*ithymic be=ore the sr&ery< ;iven that the ri&ht hemisphere is pre=erentially
involved in the perception and e*pression o= nonverbal emotional behavior, and the
le=t hemisphere pre=erentially involved in verbal =nctionin&, the observation o=
ale*ithymic characteristics in the commissrotomised patients led Hoppe A1-''B to
s&&est that ale*ithymia in individals /ith intact brains may involve an interrption
in the =lo/ o= in=ormation bet/een the t/o hemispheres8 he re=erred to this as a
O=nctional commissrotomyP<
7his proposal has no/ been spported by =indin&s =rom t/o e*perimental stdies that
sed a tactile =in&er locali>ation tas0 to assess the e==iciency o= interhemispheric
trans=er< 3n both a &rop o= male combat veterans /ith :7)D AHeitlin et alD9 1-@-B and
a &rop o= nder&radate stdents A:ar0er et alD9 1---B, ale*ithymia /as associated
/ith a de=icit in the bidirectional trans=er o= sensorimotor in=ormation bet/een ri&ht
and le=t hemispheres< Altho&h these =indin&s need to be replicated
%1#G%
=or tas0s involvin& the trans=er o= emotion%laden in=ormation, the demonstration that
the interhemispheric trans=er de=icit is bidirectional s&&ests that the salient =eatres
o= the ale*ithymia constrct re=lect a limited capacity to coordinate and inte&rate the
activities o= the t/o hemispheres< 3ndeed, /hile each hemisphere is speciali>ed =or
di==erent =nctions, there is an increasin& vie/ that most co&nitive tas0s, incldin&
emotional processin& and ima&inal activity, normally reMire a varyin& amont o=
interhemispheric cooperation A:ally, 1--@B<
Over the past decade, the development o= =nctional brain ima&in& techniMes has
provided investi&ators /ith more sophisticated methods =or investi&atin& the neral
correlates o= emotions< )ome researchers have be&n to se these methods to identi=y
parts o= the brain that are associated /ith sbRective emotional e*perience< 3n a :E7
ima&in& stdy /ith a small &rop o= /omen, 6ane et alD A1--@B =ond a positive
relationship bet/een hi&h scores on the 6evels o= Emotional A/areness )cale
A6EA)B and increased activity in the ri&ht anterior cin&late corte* AA((B /hen
emotions /ere indced either by =ilms or by recall o= personal e*periences< ;iven that
hi&her scores on the 6EA) indicate &reater di==erentiation in the mental
representations o= emotion and &reater a/areness o= emotional comple*ity in sel= and
others, the reslts o= the stdy s&&est that the A(( plays an important role in
sbRective emotional e*perience<
Altho&h the 6EA) /as not developed as a measre o= ale*ithymia and correlates
only /ea0ly, albeit ne&atively, /ith the 7A)%!", the reslts led 6ane et alD A1--'B to
speclate that ale*ithymia mi&ht arise =rom disrption o= transmission o= interoceptive
emotion in=ormation to the A((< )ince the A(( also helps orchestrate the motor,
atonomic, and endocrine responses to emotional stimli, these researchers s&&est
that altered =nctionin& in this strctre mi&ht e*plain the lin0 bet/een ale*ithymia
and disease< 7hey cast dobt on the =nctional commissrotomy hypothesis o=
1#'
ale*ithymia, concldin& that it does not e*plain ho/ a =ailre o= interhemispheric
trans=er cold contribte to disease pathophysiolo&y<
Cost neroscientists, ho/ever, do not associate the neral processin& and re&lation
o= emotion /ith any one brain strctre< As 6eDo* A1--GB, Heilman A1--'B and
:an0sepp A1--@B point ot, the A(( and other parts o= the limbic system do not
operate in isolation bt are =nctionally intert/ined /ith hi&her and lo/er areas o= the
brain< 3ndeed, :an0sepp A1---B attribtes the &eneration o= emotional =eelin&s not Rst
to the =rontal lobe and hi&her limbic strctres, bt also to e*tensive sbcortical
Aincldin& brainstemB command circits< Coreover, in addition to the role played by
the A(( in orchestratin& the physiolo&ical component o= emotional respondin&, there
is evidence that the ri&ht hemisphere also mediates atonomic nervos system
responses to emotional stimli A)pence et alD9 1--GB and that the le=t hemisphere can
modlate an individalLs arosal response, perhaps by maintainin& some inhibitory
control over the ri&ht hemisphere AHeilman, 1--'B< (onseMently, rather than discard
any o= the hypotheses =or /hich there is some empirical spport, my collea&es and 3
proposed a more comprehensive model, /hich encompasses de=icits in
interhemispheric inte&ration and coordination as /ell as a de=icit in A(( activity
drin& emotional arosal
%1#'%
A7aylor N $a&by, !"""B< 7here are li0ely to be other neral correlates as /ell that
may be identi=ied in =tre brain ima&in& stdies< 3t mst be emphasi>ed, ho/ever,
that the =indin&s =rom all o= the nerobiolo&ical stdies are correlational only and do
not imply any case%e==ect relationships<
Therape'ti" "onsiderations
Altho&h it has lon& been ac0no/led&ed that patients /ith hi&h de&rees o=
ale*ithymia respond poorly to insi&ht%oriented psychotherapy, there has been little
attempt to devise and evalate alternative treatments =or these patients< )i=neos A1--GB
and Nemiah et alD A1-'GB =avor individal or &rop psychotherapies that are
spportive in natre =or ale*ithymic patients< Krystal A1-'-8 1-@!?@+B, ho/ever,
recommends a modi=ied =orm o= individal psychotherapy, /hich ses speci=ic
psychoedcational techniMes to address de=icits in a==ect a/areness and a==ect
tolerance< 7hese inclde ma0in& patients a/are o= ho/ their sbRective e*perience o=
emotion di==ers =rom that o= other people8 directin& their attention to behavioral
e*pressions o= emotion Asch as si&hs, &estres, and movementsB8 helpin& them to
reco&ni>e, di==erentiate, and label their =eelin&s8 teachin& them to attend to their
dreams8 and teachin& them to vie/ =eelin&s as in=ormation si&nals that can be
re=lected pon and sed to &ide behavior< )ome clinicians have applied KrystalLs
techniMes and other approaches in &rop therapy settin&s, bt reports abot their
e==ectiveness are mainly anecdotal<
A recent stdy evalated the e==ectiveness o= &rop psychotherapy in redcin&
ale*ithymic characteristics in post%myocardial in=arction Apost%C3B patients, and also
its potential bene=its on the sbseMent corse o= coronary heart disease
A$eresnevaite, !"""B< 7he techniMes that /ere sed drin& =or months o= /ee0ly
&rop psychotherapy inclded rela*ation trainin&, role playin&, and promotin& non%
1#@
verbal commnication, as /ell as interventions to =acilitate verbal emotional
e*pression and attention to dreams and =antasies< A comparison &rop o= post%C3
patients received t/o edcational sessions /ithin a period o= one month that provided
in=ormation abot coronary heart disease< Altho&h at the start o= the stdy the mean
ale*ithymia scores /ere similar =or the t/o patient samples, the patients /ho received
&rop psychotherapy sho/ed a si&ni=icant redction in the mean ale*ithymia score by
the end o= treatment that /as maintained thro&hot a t/o%year =ollo/%p period< 7he
comparison sample sho/ed no si&ni=icant chan&e in mean ale*ithymia scores bet/een
the initial testin& and at varios intervals drin& the t/o%year =ollo/%p< Coreover,
those patients /hose de&ree o= ale*ithymia had decreased =rom hi&h to moderate, or
=rom moderate to lo/, in response to &rop psychotherapy e*perienced =e/er cardiac
events Arein=arction, sdden cardiac death, or rehospitali>ation =or rhythm disorder or
severe an&inaB than patients /hose de&ree o= ale*ithymia had remained nchan&ed<
Altho&h this stdy needs to be replicated by other researchers and /ith di==erent
dia&nostic patient &rops, the reslts s&&est that speci=ic psychotherapetic
techniMes, at least /hen applied to patients in small &rops, can not only modi=y
%1#@%
ale*ithymia bt possibly have positive health bene=its as /ell< Applyin& $cciLs
A1--'bB mltiple code theory, it is temptin& to speclate that the psychotherapetic
techniMes that /ere employed in this stdy led to an increase in the verbal symbolic
elements o= emotion representations and to enhanced connections bet/een symbolic
and sbsymbolic elements<
Con"l'sions
Ale*ithymia theory and research have advanced considerably over the past !. years<
7here is no/ stron& spport not only =or the validity o= the constrct, bt also =or its
association /ith certain medical and psychiatric disorders that involve problems in
emotion re&lation< And /hile the constrct contines to interest psychosomatic
physicians and health psycholo&ists, it has also be&n to captre the attention o=
emotion theorists and researchers and to bene=it =rom advances in the related =ields o=
co&nitive science, nerobiolo&y, and attachment research< Ftre collaboration
bet/een these disciplines is li0ely to =rther or nderstandin& o= the comple* /ays
/hereby ale*ithymia and emotions mi&ht in=lence physical and mental health<
!e)eren"es
$a&by, R<C<, :ar0er, 9<D<A<, N 7aylor, ;<9< A1--#aB< 7he 7/enty%3tem 7oronto
Ale*ithymia )cale%3E 3tem selection and cross%validation o= the =actor strctre<
Eournal of Psychosomatic Research,&2, !+%+!<
$a&by, R<C, 7aylor, ;<9<, N :ar0er, 9<D<A< A1--#bB< 7he 7/enty%3tem 7oronto
Ale*ithymia )cale%33E (onver&ent, discriminant, and concrrent validity< Eournal
of Psychosomatic Research,&2, ++%#"<
$ec0endam, (<(< A1--'B< Dimensions of emotional intelligence3 ttachment9
affect regulation9 ale.ithymia and empathy< Doctoral dissertation, 7he Fieldin&
3nstitte, )anta $arbara, (A<
1#-
$eresnevaite, C< A!"""B< E*plorin& the bene=its o= &rop psychotherapy in
redcin& ale*ithymia in coronary heart disease patientsE a preliminary stdy<
Psychotherapy and Psychosomatics,.#, 11'%1!!<
$ermond, $< N Vorst, H<(< A1--@B< Calidity and reliability of the Bermond-Corst
le.ithymia Iuestionnaire< ,npblished manscript, ,niversity o= Amsterdam,
7he Netherlands<
$onnano, ;<A< N )in&er, 9<6< A1--"B< Repressive personality styleE theoretical
and methodolo&ical implications =or health and patholo&y< 3n 9<6< )in&er Aed<B,
Repression and dissociation3 implications for personality theory9
psychopathology and health App< #+.%#'"B< (hica&o, 36E ,niversity o= (hica&o
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$rch, H< A1-'+B< 5ating disorders3 obesity9 anore.ia ner'osa9 and theperson
"ithin< Ne/ Yor0E $asic $oo0s<
$cci, W< A1--'aB< )ymptoms and symbolsE a mltiple code theory o=
somati>ation< Psychoanalytic #n7uiry,$4, 1.1%1'!<
$cci, W< A1--'bB< Psychoanalysis and cogniti'e science3 a multiple code theory<
Ne/ Yor0E ;il=ord<
%1#-%
(o*, $<9<, Kch, K<, :ar0er, 9<D<A<, )hlman, 3<D<, N Evans, R<9< A1--#B<
Ale*ithymia in somato=orm disorder patients /ith chronic pain< Eournal of
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ale*ithymia hypothesisE physiolo&ical and sbRective responses drin& rela*ation
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Haviland, C<;< A1--@B< 7he validity o= the (ali=ornia Y%set ale*ithymia
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Heilman, K<C< A1--'B< 7he nerobiolo&y o= emotional e*perience< Eournal of
<europsychiatry and Clinical <euroscience,#, #+-%##@<
Hoppe, K<D< A1-''B< )plit brains and psychoanalysis< Psychoanalytic
Iuarterly,,., !!"%!##<
Hoppe, K<D< N $o&en, 9<E< A1-''B< Ale*ithymia in t/elve commissrotomi>ed
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Psychotherapy and Psychosomatics,.., !'G%!@"<
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Ale*ithymia and ris0 o= death in middle%a&ed men< Eournal of Psychosomatic
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Kin&, 6<A<, Emmons, R<A<, N Woodley, )< A1--!B< 7he strctre o= inhibition<
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Krystal, H< A1-'-B< Ale*ithymia and psychotherapy< merican Eournal of
Psychotherapy,&&, 1'%+1<
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@+#%@##<
6ane, R<D<, Reiman, E<C<, A*elrod, $<, 6an&%)hen&, Y<, Holmes, A<, N
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corte*< Eournal of Cogniti'e <euroscience,$6, .!.%.+.<
6ane, R<D< N )ch/art>, ;<E< A1-@'B< 6evels o= emotional a/arenessE a co&nitive
developmental theory and its application to psychopatholo&y< merican Eournal
of Psychiatry,$,,, 1++%1#+<
6ane, R<, )echrest, 6<, Reidel, R<, Weldon, V<, Kas>nia0, A<, N )ch/art>, ;<
A1--GB< 3mpaired verbal and nonverbal emotion reco&nition in ale*ithymia<
Psychosomatic Cedicine, /2, !"+%!1"<
6eDo*, 9<E< A1--GB< The emotional brain3 the mysterious underpinnings of
emotional life< Ne/ Yor0E )imon and )chster<
%1."%
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6inden, W<, 6en>, 9<W<, N )tossel, (< A1--GB< Ale*ithymia, de=ensiveness and
cardio%vasclar reactivity to stress< Eournal of Psychosomatic Research,,$, .'.%
.@+<
6minet, O< N RimQ, $< A1--@B< ssessing the empirical 'alidity of ale.ithymia3
its predicti'e 'alue for 'arious le'els of emotional responding "hen e.posed to
an eliciting situation and "hen re-e'o!ing it 'erbally< :aper presented at the 1"th
con=erence o= the 3nternational )ociety =or Research on Emotion, WZr>br&,
;ermany<
6minet, O<, $a&by, R<C<, Wa&ner, H<, 7aylor, ;<9<, N :ar0er, 9<D<A< A1---B<
7he relationship bet/een ale*ithymia and the =ive =actor model o= personalityE a
=acet level analysis< Eournal of Personality ssessment,4&, +#.%+.@<
6minet, O<, $a&by, R<C<, N 7aylor, ;<9< A!""1B< An evalation o= the absolte
and relative stability o= ale*ithymia in patients /ith maRor depression<
Psychotherapy and Psychosomatics,46, !.#%!G"<
6mley, C<A< N Norman, )< A1--GB< Ale*ithymia and health care tili>ation<
Psychosomatic ?edicine,/2, 1-'%!"!<
Cac6ean, :<D< A1-#-B< :sychosomatic disease and the Ovisceral brainPE recent
developments bearin& on the :ape> theory o= emotion< Psychosomatic
?edicine,$$, ++@%+.+<
Cann, 6<)<, Wise, 7<N<, 7rinidad, A<, N Kohans0i, R< A1--#B< Ale*ithymia, a==ect
reco&nition, and the =ive%=actor model o= personality< Psychological Reports,4,,
.G+%.G'<
Cart4ne>%)cnche>, F<, Ato%;arc4a, C<, Adam, E<(<, Cedina, 7<$<H<, N Espada,
9<)< A1--@B< )tability in ale*ithymia levelsE a lon&itdinal analysis on varios
emotional ans/ers< Personality and #ndi'idual Differences,%,, 'G'%''!<
Carty, :< N de CL,>an, C< A1-G+B< 6a OpensQe opQratoireP< Re'ue FranTaise de
Psychoanalyse,%4 AspplB, 1+#.%1+.G<
Cyers, 6<$< A1--.B< Ale*ithymia and repressionE the role o= de=ensiveness and
trait an*iety< Personality and #ndi'idual Differences,$#, #@-%#-!<
Nemiah, 9<(< A1-''B< Ale*ithymiaE theoretical considerations< Psychotherapy and
Psychosomatics,%2, 1--%!"G<
Nemiah, 9<(< A1-@#B< 7he psychodynamic vie/ o= an*iety< 3n R<O< :asna Aed<B,
Diagnosis and treatment of an.iety disorders App< 11'%1+'B< Washin&ton, D(E
American :sychiatric :ress<
Nemiah, 9<(<, Freyber&er, H<, N )i=neos, :<E< A1-'GB< Ale*ithymiaE a vie/ o= the
psychosomatic process< 3n O<W< Hill Aed<B, ?odern trends in psychosomatic
medicine, Vol< + App< #+"%#+-B< 6ondonE $tter/orths<
1.!
Nemiah, 9<(< N )i=neos, :<E< A1-'"B< A==ect and =antasy in patients /ith
psychosomatic disorders< 3n O<W< Hill Aed<B, ?odern trends in psychosomatic
medicine, Vol< ! App< !G%+#B< 6ondonE $tter/orths<
:ally, R< A1--@B< $ilateralityE hemispheric speciali>ation and inte&ration<
#nternationalEournal of Psychoanalysis,4#, .G.%.'@<
:an0sepp, 9< A1--@B< ffecti'e neuroscience3 the foundations of human and
animal emotions< Ne/ Yor0E O*=ord ,niversity :ress<
:an0sepp, 9< A1---B< Emotions as vie/ed by psychoanalysis and neroscienceE an
e*ercise in consilience< <euro-Psychoanalysis,$, 1.%+@<
:ar0er, 9<D<A<, Kei&htley, C<6<, )mith, (<7<, N 7aylor, ;<9< A1---B<
3nterhemispheric trans=er de=icit in ale*ithymiaE an e*perimental stdy<
Psychosomatic ?edicine,.$, #G#%#G@<
%1.1%
:ar0er, 9<D<A<, 7aylor, ;<9<, N $a&by, R<C< A1--+B< Ale*ithymia and the
reco&nition o= =acial e*pressions o= emotion< Psychotherapy and
Psychosomatics,/#, 1-'%!"!<
:ar0er, 9<D<A<, 7aylor, ;<9<, N $a&by, R<C< A1--@B< Ale*ithymiaE relationship
/ith e&o de=ense and copin& styles< Comprehensi'e Psychiatry,&#, -1%-@<
:enneba0er, 9<W< A1-@-B< (on=ession, inhibition, and disease< d'ances in
5.perimental and %ocial Psychology,%%, !11%!##<
:orcelli, :<, 7aylor, ;<9<, $a&by, R<C<, N De (arne, C< A1---B< Ale*ithymia and
=nctional &astrointestinal disordersE a comparison /ith in=lammatory bo/el
disease< Psychotherapy and Psychosomatics,.2, !G+%!G-<
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in in=lammatory bo/el disease< A case%control stdy< Psychotherapy and
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Roedema 7<C< N )imons, R<F< A1---B< Emotion%processin& de=icit in
ale*ithymia< Psychophysiology,&., +'-%+@'<
Resch, 9< A1-#@B< 7he in=antile personality< Psychosomatic ?edicine,$6, 1+#%
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)alminen, 9<K<, )aariRbrvi, )<, ebirelb, E<, N 7amminen, 7< A1--#B< Ale*ithymia%
state or traitT One%year =ollo/%p stdy o= &eneral hospital psychiatric
consltation otpatients< Eournal of Psychosomatic Research,&2, G@1%G@.<
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)cha==er, (<E< A1--+B< The role of adult attachment in the e.perience and
regulation of affect< Doctoral dissertation, Yale ,niversity, Ne/ Haven, (7<
)cheidt, (<E<, Waller, E<, )chnoc0, (, $ec0er%)toll, F<, Himmerman, :<, 6Zc0in&
(<H<, N Wirschin&, C< A1---B< Ale*ithymia and attachment representation in
idiopathic spasmodic torticollis< Eournal of <er'ous and ?ental Disease,$24, #'%
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)i=neos, :<E< A1-G'B< (linical observations on some patients s==erin& =rom a
variety o= psychosomatic diseases< cta ?edicina Psychosomatica,4, 1%1"<
)i=neos, :<E< A1-'+B< 7he prevalence o= Oale*ithymicP characteristics in
psychosomatic patients< Psychotherapy and Psychosomatics,%%, !..%!G!<
)i=neos, :<E< A1--GB< Ale*ithymiaE past and present< merican Eournal of
Psychiatry,$/&, 1+'%1#!<
)pence, )<, )hapiro, D<, N Haidel, E< A1--GB< 7he role o= the ri&ht hemisphere in
the physiolo&ical and co&nitive components o= emotional processin&<
Psychophysiology,&&, 11!%1!!<
7aylor, ;<9< A1--#B< 7he ale*ithymia constrctE conceptali>ation, validation, and
relationship /ith basic dimensions o= personality< <e" Trends in 5.perimental
and Clinical Psychiatry,$6, G1%'#<
7aylor< ;<9< A!"""B< Recent developments in ale*ithymia theory and research<
Canadian Eournal of Psychiatry,,/, 1+#%1#!<
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R< $ar%On N 9<D<A< :ar0er AedsB, Fandboo! of emotional intelligence App< #"%
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sel=%report and observer%rated measres< 3n R< $ar%On N 9<D<A< :ar0er AedsB,
Fandboo! of emotional intelligence App< +"1%+1-B< )an Francisco, (AE 9ossey%
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regulation3 le.ithymia in medical and psychiatric illness< (ambrid&eE
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bet/een ale*ithymia and psycholo&ical characteristics associated /ith eatin&
disorders< Eournal of Psychosomatic Research,,$, .G1%.G@<
%1.!%
7aylor, ;<9<, Ryan, D<, N $a&by, R<C< A1-@.B< 7o/ard the development o= a ne/
1.#
sel=%report ale*ithymia scale< Psychotherapy and Psychosomatics,,,, 1-1%1--<
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essential hypertensive and psychiatric otpatientsE a comparative stdy< Eournal
of Psychosomatic Research,&#, -@'%--#<
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A==ect re&lation in ale*ithymiaE an etholo&ical stdy o= displacement behavior
drin& psychiatric intervie/s< Eournal of <er'ous and ?ental Disease,$22, 1+%
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ale*ithymia, emotional control, and Mality o= li=e in patients /ith in=lammatory
bo/el disease< Psychotherapy and Psychosomatics,.4, '.%@"<
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%1.+%
Chapter #
Emotional intelligen"e and physi"al health
lison ;oolery and Peter %alo'ey
Introd'"tion
7hin0ers =rom Kin& )olomon and Hippocrates to Walter (annon and Norman
(osins have all sspected that the emotions play an important role in the
maintenance o= physical health and recovery =rom disease< Empirical evidence =or this
idea has accmlated rapidly in the past t/o decades, and it no/ appears rather clear
that =lctations in emotional arosal are lin0ed to chan&es in the immne system
Ae<&< Herbert N (ohen, 1--+8 )tone et alD9 1--GB, the interpretation o= physical
symptoms Ae<&< )alovey N $irnbam, 1-@-B, cardiovasclar =nctionin& Ae<&< )mith,
1--!B, the acceptance o= health ris0 in=ormation Ae<&< Reed N Aspin/all, 1--@B,
health dama&in& behaviors Ae<&< $ameister, 1--18 $randon, 1--#B, and other
otcomes relevant to health and illness Arevie/ed by )alovey et alD9 !"""B<
3ncreasin&ly, investi&ators have =ocsed on individal di==erences in the /ay
emotions are e*perienced as a potential ris0 =actor or protective =actor Ae<&< Kennedy%
Coore N Watson, 1---8 Watson, !"""B< 7his chapter /ill =ocs on one set o=
individal di==erences relevant to emotion%emotional intelli&ence%and present some
preliminary evidence =or connections bet/een it and health%relevant otcomes<
1..
3hat is emotional intelligen"e-
Emotional intelli&ence is de=ined as the ability to nderstand =eelin&s in the sel= and
others, and to se these =eelin&s as in=ormational &ides =or thin0in& and action
A)alovey N Cayer, 1--"B< Or =rame/or0 o= emotional intelli&ence encompasses a
set o= emotional competencies, incldin& ho/ people AaB identi=y and e*press their
o/n =eelin&s and identi=y the =eelin&s o= others, AbB se emotions to =acilitate
thin0in&, AcB nderstand and analy>e emotions, and AdB re&late their o/n and othersL
emotions ACayer N )alovey, 1--'B< 3denti=ication and e*pression inclde both verbal
and non%verbal behavior< We need to nderstand /hat /e are =eelin&, and /e need to
be able to commnicate or =eelin&s sin& /ords and non%verbal behaviors<
Coreover, /e need to nderstand the =eelin&s o= other people%both in their /ords and
in their e*pressions%and to be able to =eel the emotions o= other
%1.#%
people, i<e< to empathi>e /ith them< )econd, /e mst reco&ni>e that emotions
prioriti>e thin0in&, shape memory, create di==erent problem%solvin& perspectives, and
=acilitate creativity< 7hird, to ma0e se o= or emotions, /e mst have a rich
emotional vocablary, and /e mst be able to nderstand emotional nances, blends
o= =eelin&s, and transitions =rom one emotion to another< Finally, /e need to learn to
re&late or emotions so that they are most appropriate to the tas0 or sitation at hand,
and /e need to learn to re&late the emotions o= other people, to cheer them p /hen
they are do/n, to en&a&e them /hen /e /ant them to listen to s<
)ince )alovey and Cayer A1--"B =irst s&&ested the idea o= an emotional intelli&ence,
researchers and the poplar media have been Mic0 to propose their o/n, /ide%
ran&in& models o= emotional intelli&ence< )ome have &one so =ar as to trn emotional
intelli&ence into a clster o= personality traits said to determine character and li=e
achievements Ae<&< ;oleman, 1--., 1--@B< We pre=er or ori&inal conceptali>ation o=
emotional intelli&ence, /hich =ocses on mental abilities speci=ic to emotion< 7his
=rame/or0 helps s to speci=y /hat it means /hen /e as0 /hether emotional
intelli&ence is lin0ed to physical health< What /e really /ant to determine is /hether
speci=ic emotional competencies enhance health, and /hether the absence o= these
competencies predicts illness or health%dama&in& behavior< 7o ans/er these Mestions
directly, /e /old need to assess emotional intelli&ence sin& s0ill%based tests that
assess these competencies< For e*ample, one test, the Clti%Factor Emotional
3ntelli&ence )cale ACE3)B, incldes tas0s that as0 people to identi=y consensal
=eelin&s s&&ested by msic and abstract desi&ns, analy>e blends and pro&ressions o=
emotions, and assess ho/ they and other people can best mana&e their emotions in
di==erent scenarios ACayer et alD9 1---B<
$ecase tas0%based measres sch as the CE3) Aand its sccessor, the C)(E37B are
still bein& re=ined, many stdies o= emotional intelli&ence and health have relied on
sel=%report scales to assess emotional intelli&ence< )el=%report assess%ments have
obvios limitations in the stdy o= emotional intelli&ence8 they do not tap directly into
peopleLs emotional competencies, bt rather assess peopleLs belie=s abot ho/ they
identi=y, se, nderstand, and re&late their o/n and othersL emotions< We /old
never consider peopleLs belie=s abot their intelli&ence%Q# thin! #2m a bright personR%
1.G
necessarily to be valid measres o= 3Y8 analo&os Mestions abot emotional
intelli&ence are similarly troblesome<
7hs, past stdies have not e*plored the lin0 bet/een emotional intelli&ence per se
and health, bt rather /hat /e have termed perceived emotional intelli&ence A:E3B%
peopleLs belie=s abot their emotional intelli&ence%in conRnction /ith health
variables< Altho&h it does not measre emotional competencies per se9 :E3 is an
interestin& variable in and o= itsel=< We can thin0 o= it as a 0ind o= emotional
intelli&ence sel=%e==icacy< :eople /ho report hi&h :E3 may be con=ident that they can
sccess=lly apply emotional intelli&ence s0ills in diverse sitations< 7his sel=%
e==icacy e*pectation cold predict an actal ability to demonstrate emotional
competencies, becase sel=%e==icacy e*pectations and ability in &eneral are hi&hly
correlated< )een in this li&ht, the Mestion =or s becomes ho/ :E3 a==ects health<
%1..%
(old peopleLs belie=s abot ho/ they identi=y, nderstand, and re&late their
emotions promote their lon&%term health and protect them =rom diseaseT
er"eived emotional intelligen"e and health+relevant o't"omes
A series o= stdies condcted in or laboratory s&&ests that :E3 is associated /ith
nmeros health%related otcomes< 7hese stdies have all assessed :E3 sin& the 7rait
Ceta%Cood )cale A7CC)B< 7he 7CC) taps into three aspects o= emotional
intelli&enceE
1 ttention-the de&ree to /hich people report that they typically attend to their
moods
! Clarity-the de&ree to /hich people report that they can clearly nderstand and
discriminate amon& their moods
+ Repair-the de&ree to /hich people report that they can maintain positive and
repair ne&ative mood states<
)cores on the 7CC) predict recovery =rom ne&ative mood and rminative tho&ht
=ollo/in& an e*perimental stressor< 3ndividals /ho reported that they e*perience
their =eelin&s clearly /ere more li0ely to rebond =rom indced ne&ative mood and
sho/ed a decline in rminative tho&ht across time /hen compared to individals
/ho reported bein& nclear abot their moods A)alovey et alD9 1--.B<
Early stdies sin& the 7CC) e*amined ho/ belie=s abot mood a==ect illness and
symptom reportin& nder stress=l conditions A;oldman et alD9 1--GB< ;oldman et alD
assessed 1+# stdent volnteers at three di==erent times drin& the semesterE at the
start o= the year, drin& midterm e*aminations, and drin& =inal e*aminations< At
these times, they administered the 7rait Ceta%Cood )cale A7CC)B as /ell as
measres o= stress, physical symptoms, and health center visits< When they divided
the sample into three &rops o= people Athose /ith a hi&h de&ree o= s0ill in repairin&
ne&ative moods, those /ith avera&e s0ills in this area, and those /ith lo/ s0illsB,
interestin& trends in health center visits emer&ed dependin& on the level o= stress
people e*perienced< When stress /as lo/, the three &rops di==ered very little< As
stress increased, those individals /ho said that they cannot easily re&late their
=eelin&s /ere more li0ely to visit the health center, and those individals /ho /ere
&ood at repairin& ne&ative moods actally visited the health center less o=ten<
3ndividals /ho cannot repair or re&late their =eelin&s may loo0 to others =or help in
1.'
doin& so< As a reslt, they may be more li0ely to see0 the attention o= a physician
/hen they are =eelin& stressed becase they do not 0no/ ho/ to re&late these
=eelin&s themselves< )ch individals may simply be sin& the health care system as a
mood re&lation strate&y< O= corse, it is also possible that these individals are
actally more li0ely to become physically ill /hen nder stress<
7/o recent stdies e*amined the relations amon& :E3 Aas measred by the 7CC)B
and psychophysiolo&ical responses to laboratory stressors A)alovey et alD9 !""!B< 3n
one, G" /omen /ere presented /ith visiospatial p>>les, serial
%1.G%
sbtraction tas0s, and a videotaped speech tas0 nder conditions o= nrealistic time
constraints< Women /ho reported that they can repair their moods tended to perceive
these laboratory stressors as less threatenin& and sed =e/er state and trait passive
copin& strate&ies< Women /ho reported that they can perceive their moods clearly
tended to release less cortisol at baseline and thro&hot repeated stress e*posres,
indicatin& that (larity may be associated /ith lo/er adrenocortical responses to
stress<
3n a second stdy, #@ men and /omen /ere randomly assi&ned to an achievement or
interpersonal stress condition A)alovey et alD9 !""!B< :eople in the achievement
condition had to solve di==iclt arithmetic problems and memori>e a comple* poem
nder considerable time constraints< 3n the interpersonal condition, participants
attempted to have conversations /ith t/o con=ederates /ho intentionally reRected
them< :eople /ho reported that they can repair their moods /ere more li0ely to
demonstrate active copin& in response to these distressin& sitations< )el=%reported
repair /as also associated /ith lo/er levels o= rmination and hi&her levels o=
distraction a=ter stressor e*posre< :eople /ho reported that they =reMently attend to
their moods sho/ed attenated cortisol, systolic blood pressre A)$:B, and diastolic
blood pressre AD$:B reactivity to the laboratory stressors, controllin& =or baseline
levels as /ell as the other 7CC) sbscales< 7hese t/o stdies indicate that people
/ho believe that they attend to their moods =reMently and?or perceive their moods
clearly may sho/ lo/er adrenocortical responses to stress< :eople /ho attend to their
moods may also demonstrate a more adaptive cardiovasclar response to stress<
A third stdy in or laboratory e*tended these physiolo&ical =indin&s by e*aminin&
interactions bet/een :E3 and cardiovasclar reactivity drin& an emotional disclosre
tas0< Emotional disclosre is the process o= /ritin& or tal0in& abot tramatic or other
emotional li=e e*periences Ae<&< :enneba0er N $eall, 1-@GB< Nmeros stdies
condcted by diverse investi&ators across mltiple poplations have demonstrated
that en&a&in& in emotional disclosre elicits bene=icial health otcomes<
E*perimentally indced disclosre o= tho&hts and =eelin&s abot emotional li=e
e*periences has been associated /ith =e/er colle&e health center visits AKin& N
Ciner, !"""8 :enneba0er N $eall, 1-@G8 :enneba0er et alD9 1--"B, decreases in sel=%
reported physical symptoms, decreases in distress and depression Ae<&< ;reenber& N
)tone, 1--!B, adaptive chan&es in atonomic response A:enneba0er et alD9 1-@'B,
positive immnolo&ical chan&es A:enneba0er et alD9 1-@@8 :etrie et alD9 1--.B, and
improvements in the corse o= asthma and arthritis A)myth et alD9 1---8 =or a revie/,
see )myth, 1--@8 ;reenber& N 6epore, this volme, (hapter +B<
1.@
(rrent e*planations =or positive otcomes =ollo/in& disclosre =ocs on co&nitive
processes< Accordin& to these e*planations, en&a&in& in disclosre =acilitates the
transdction o= tramatic memories into an or&ani>ed, lin&istic strctre that redces
the emotional arosal and distress elicited by trama, sch as intrsive tho&hts,
rminations, and =lashbac0s A:enneba0er et alD9 1--'8 :enneba0er N )ea&al, 1---8
)myth, 1---8 ;reenber& N 6epore, this volme, (hapter +B<
%1.'%
Altho&h /e do not discont these e*planations, /e /old add that emotional
re&latory processes may also be important mechanisms in disclosre<
:eople disclosin& past tramas mst re&late their =eelin&s on t/o levels< First, they
mst cope /ith the emotional arosal that disclosre evo0es, in part by distin&ishin&
and moderatin& the moods they are crrently =eelin& as a reslt o= tal0in& abot their
past e*periences< At the same time, they mst process and assimilate the emotions
srrondin& their past e*periences into a meanin&=l co&nitive narrative< For e*ample,
a male stdent /ho /rites abot =ailin& a class =or the =irst time in his li=e may
remember the intense sadness he =elt /hen the event happened< He may re%e*perience
this sadness as he /rites8 he may also e*perience ne/ emotions evo0ed by his
recollection, sch as an&er at his past =ailin&s< He mst identi=y and cope /ith this
an&er at the same time that he assimilates his =eelin&s o= sadness into a coherent
narrative o= =ailin& his class< 7hese emotional re&latory processes cold necessitate
the ability to perceive oneLs emotions clearly and to nderstand and discriminate
amon& them A)alovey et alD9 1---,!""1B< (onversely, this act o= processin& and
imposin& strctre on tramatic events /hile copin& /ith crrent emotional arosal
may enhance peopleLs belie=s abot their abilities to perceive their emotional states
clearly<
;iven this potential interaction bet/een emotional intelli&ence Aperceived or actalB
and emotional disclosre and in li&ht o= or =indin&s in the t/o stress stdies
discssed previosly, /e predicted that people reportin& hi&h :E3 /old demonstrate
more adaptive physiolo&ical reactivity /hen /ritin& abot emotional li=e events<
)i*ty%ei&ht participants /ere as0ed to /rite t/o ten%minte essays, one abot an
emotional event in their lives, and the other abot a relatively mndane AcontrolB topic
Acleanin& and doin& landryB< Follo/in& each /ritin& period, participants sat Mietly
=or a three%minte rest period<
All participants tended to e*hibit hei&htened cardiovasclar arosal /hen they /rote
abot emotional real%li=e e*periences, relative to the control topic< Ho/ever,
compared to people reportin& lo/ (larity, people /ho reported that they can perceive
their moods clearly tended to sho/ &reater )$: increases immediately a=ter /ritin&
abot their emotional e*periences Acontrollin& =or baselineB< Follo/in& the post%
/ritin& rest period, people reportin& hi&h (larity had lo/er )$: than people reportin&
lo/ (larity Acontrollin& =or baseline and initial reactivityB< :eople /ho sho/ed the
&reatest )$: increase immediately a=ter /ritin&, =ollo/ed by the steepest )$:
decrease a=ter the rest period, reported the hi&hest levels o= (larity<
3t is particlarly interestin& that people /ho reported hi&h (larity tended to sho/ an
increase in )$: immediately a=ter /ritin& abot their emotional e*periences< 7hese
1.-
people may simply have been more arosed and en&a&ed in the /ritin& process than
/ere people reportin& lo/ (larity< Alternatively, it may be that everyone /as arosed
drin& the emotional /ritin& condition, bt that people hi&h in (larity /ere
particlarly open to and?or s0illed at perceivin& the Mality and intensity o= the
emotions that emer&ed as they /rote< 7his hei&htened a/areness o= the emotionality
o= the emotional /ritin& condition may have corresponded to a &reater immediate
)$: increase<
%1.@%
Drin& the rest period, people reportin& hi&h mood (larity may have processed and
assimilated the emotions they e*perienced /hile /ritin&< (onseMently, their elevated
)$: levels tended to recover most e==iciently< :eople reportin& lo/ (larity may have
en&a&ed in rmination in an attempt to identi=y and nderstand the =eelin&s evo0ed
/hen they /rote abot their emotional e*periences Aas in the stdy reported in
)alovey et alD9 1--.B8 this maladaptive copin& style may have reslted in sstained
elevation o= or even increases in )$: Asee (hapter G, and (arels et alD9 1--@B< :eople
lo/ in (larity ths had si&ni=icantly hi&her )$: levels three mintes a=ter /ritin&
abot their emotional e*periences than people hi&h in (larity< :eople /ho believe
they can clearly perceive their moods tend to e*perience more adaptive cardiovasclar
responses /hen they /rite abot emotional li=e events, compared to people /ho do
not believe that they can perceive their moods<
7o smmari>e, these stdies =rom or laboratory s&&est a stron& relationship
bet/een :E3 and physiolo&ical otcomes relevant to health< :eople /ho believe that
they attend to and clearly perceive their moods seem to cope e==ectively /ith a /ide
array o= distressin& sitations, as indicated by their adaptive physiolo&ical responses<
Over time, these adaptive physiolo&ical responses to stress may protect people hi&h in
:E3 =rom disease8 lar&e increases in physiolo&ical responses to acte stressors as /ell
as an inability to habitate to chronic stressors may dama&e or&ans and lead to disease
ADienstbier, 1-@-8 Canc0 N Krant>, 1-@#8 CcE/en N )tellar, 1--+B< 7hs, :E3
may be lin0ed to health thro&h psychophysiolo&ical stress reactivityE people
reportin& hi&h :E3 may tend to e*perience adaptive physiolo&ical responses in
stress=l sitations, ma0in& them less prone to disease in the lon& rn<
O= corse, /e shold be catios in attribtin& casality /ith respect to these
physiolo&ical =indin&s< 7he e*planations above imply that :E3 a==ects physiolo&ical
arosal8 ho/ever, it may be the case that physiolo&ical arosal a==ects peopleLs belie=s
abot their abilities to attend to, distin&ish, and repair their moods< :eople /ho
e*perienced adaptive physiolo&ical reactions to stress e*posre and /ritin& abot
emotional e*periences may have been more /illin& and?or able to attend to and
discern their emotions than people /ho e*perienced discom=ortin&, sstained
physiolo&ical arosal< :eople e*periencin& adaptive physiolo&ical responses may ths
be more li0ely to report that they attend to their moods and?or can perceive their
moods clearly< Ftre stdies cold attempt to resolve this casal directionality by
Oteachin& peopleP (larity, Attention, and Repair, perhaps thro&h a series o=
/or0sheets or verbal instrction< 3= people /ho receive this Otrainin&P sbseMently
demonstrate more adaptive physiolo&ical responses to stress, relative to a control
&rop, casality =rom :E3 to physiolo&ical response cold be in=erred< Another stdy
desi&n mi&ht employ a sel=%e==icacy indctionE participants cold be primed to believe
1G"
that they can sccess=lly perceive and repair their moods in emotional sitations, and
their sbseMent physiolo&ical reactivity cold be compared /ith that o= people not
primed /ith this e*pectation<
,ltimately, it may be a mista0e to assme that the relationship bet/een :E3 and
health%relevant otcomes is monodirectional, that it either in=lences or is
%1.-
in=lenced by the dimensions /ith /hich it is correlated< :E3 may actally operate
/ithin a bidirectional =eedbac0 loop< :eople /ho believe that they can attend to,
clearly perceive, and repair their moods conseMently tend to demonstrate adaptive
physiolo&ical recovery /hen they con=ront stress=l sitations8 this adaptive recovery
enhances their belie= that they can attend to, discriminate, and repair their moods,
ma0in& it more li0ely that they /ill demonstrate these responses to disclosre in the
=tre<
3t is important to note that or stdies o= :E3 and health e*amined short%term,
physiolo&ical arosal in laboratory settin&s< We cannot ma0e any absolte claims
abot the e*tent to /hich peopleLs physiolo&ical reactivity in these e*perimental
sitations predicts their lon&%term health< 3deally, /e /old address this isse /ith a
lon&itdinal stdy, observin& peopleLs physiolo&ical reactivity to stress in diverse
sitations and trac0in& their health over time< 7his 0ind o= stdy /old help s
determine /hether peopleLs :E3 predicts the physiolo&ical reactivity they typically
demonstrate in stress=l sitations, and /hether this reactivity in trn predicts lon&%
term health otcomes<
Traits and styles relevant to emotional intelligen"e and longer+term health
o't"omes
3n the absence o= any lon&itdinal stdies to date e*aminin& :E3, physiolo&ical
reactivity, and health otcomes, /e can trn to nmeros stdies that have loo0ed at
lon&%term health in conRnction /ith personality traits and copin& styles that are
conceptally relevant to emotional intelli&ence< Altho&h =e/ o= these stdies have
e*amined physiolo&ical reactivity to stress as a mediator bet/een any El%relevant
variables and lon&%term health, they nonetheless provide intri&in& spport =or a
possible association bet/een emotional intelli&ence and health<
3n one emotional disclosre stdy, :enneba0er and collea&es e*amined /hether
sin& speci=ic 0inds o= /ords to describe emotional e*periences predicts sbseMent
physical health A:enneba0er et alD9 1--'B< :eople /ho sed increased nmbers o=
/ords indicatin& insi&ht and casal thin0in& across several days o= /ritin& sho/ed
improved physical health%as &a&ed by their symptom reports and ho/ o=ten they
visited their doctors%p to si* months a=ter /ritin&< Demonstratin& insi&ht and casal
nderstandin& into emotional li=e events may reMire 0ey emotional intelli&ence
s0illsE in order to analy>e an emotional e*perience in casal terms, a person needs to
identi=y their =eelin&s abot the event, nderstand ho/ those =eelin&s pro&ressed
drin& and a=ter the event, reco&ni>e the emotional impact the event had on others and
ho/ their emotions, in trn, in=lenced their e*perience o= the event, and re&late the
emotions they e*perienced /hile recollectin& the event< Armed /ith these
1G1
competencies, people hi&h in emotional intelli&ence may be more li0ely to se insi&ht
and casal /ords /hen /ritin& abot emotional e*periences in their lives, /hich
mi&ht optimi>e their health in the lon& rn<
Other stdies have lin0ed co&nitive processin& and immne otcomes< 3n one
disclosre stdy, people /ho sho/ed hi&her levels o= e*periential involvement in
%1G"%
their disclosre and decreased co&nitive avoidance o= their stress=l topics over the
corse o= three disclosre sessions sho/ed decreased E$V antibody titers A6t&endor=
et alD9 1--#B< (o&nitive processin& and the discovery o= meanin& have also been
e*amined amon& men /ith H3V /ho had recently lost a close =riend or partner to
A3D) A$o/er et alD9 1--@B< Cen /ho actively and deliberately tho&ht abot the
death /ere more li0ely to =ind meanin& in the event< 7hey e*perienced a maRor shi=t
in vales, priorities, or perspectives in response to the loss< Cen /ho =ond meanin&
sho/ed less rapid decline in (D# 7%cell levels t/o and three years later and had
lo/er rates o= A3D)%related mortality< Findin& meanin& in a tramatic event may
reMire the same emotional intelli&ence s0ills that /e have s&&ested nderlie the se
o= insi&ht and casal /ords in emotional disclosre< 7he men /ho =ond meanin& in
the deaths o= their =riends and partners may have been particlarly apt at identi=yin&,
nderstandin&, and re&latin& their emotions, /hich allo/ed them to nderstand and
reinterpret li=e events in ne/, meanin&=l /ays< Frther research investi&atin& the role
o= emotional intelli&ence in co&nitive processin& and the discovery o= meanin& is
/arranted<
Another health area that bears conceptal relevance to emotional intelli&ence is trait
hostility, as it may re=lect an inability to re&late ne&ative =eelin&s< )cienti=ic interest
in hostility &re/ ot o= /or0 on 7ype A behavior< No/ a clichQ commonly applied to
Wall )treet ban0ers, corporate la/yers, and 3vy 6ea&e stdents, the 7ype A behavior
pattern /as ori&inally characteri>ed by impatience, time r&ency, competitiveness,
and easily arosed overt hostility AFriedman et alD9 1-@GB< Altho&h many laboratory,
clinical, and epidemiolo&ic stdies =ond lin0s bet/een 7ype A behavior and the
prevalence and incidence o= coronary heart disease A(HDB, more recent /or0
Aincldin& re%analysis o= past stdiesB has =ond that hostility is the only component
o= 7ype A behavior that reliably and independently predicts heart disease ACiller et
alD9 1--GB<
We s&&est that overt hostility is mar0ed by an absence o= 0ey emotional intelli&ence
competencies, particlarly the abilities to identi=y and re&late oneLs emotions< :eople
hi&h in trait hostility e*press intensely ne&ative reactions to everyday stressors8
/hether they are /aitin& in a lon& line at the ban0, ar&in& /ith a spose, or tryin& to
order airline tic0ets over the 3nternet, they do not attempt to moderate these reactions<
Hostile people mi&ht be nable to identi=y the detrimental impact that their hostility
has on themselves and others8 in =act, their hostility mi&ht be so habital that they
cannot even identi=y their behaviors as hostile<
)everal stdies have e*amined trait hostility and cardiovasclar arosal< 3n nmeros
laboratory stdies comparin& hostile and non%hostile poplations, hostile people
demonstrated &reater cardiovasclar responses to social provocation, incldin& bein&
1G!
interrpted drin& a tas0 A)are> N Williams, 1-@-B, =acin& a dispara&in& opponent
drin& a ri&&ed &ame A;lass et alD9 1-@"B, role%playin& a social con=lict AHardy N
)mith, 1-@@B, attemptin& nsolvable tas0s /ith bad instrctions AWeidner et alD9
1-@-B, and discssin& a marital problem /ith a spose ACiller et alD9 1---B<
%1G1%
A recent stdy that measred amblatory blood pressre over three days =ond that
people hi&h in trait hostility consistently sho/ed elevated )$:, D$:, and heart rate
re&ardless o= concrrent mood8 people lo/ in hostility only e*hibited hi&h $: /hen
they e*perienced ne&ative mood ARai00onen et alD9 1---B< 7his sstained
cardiovasclar arosal may be one mechanism by /hich overt hostility and, by
e*tension, 7ype A behavior increase a personLs ris0 o= (HD ARai00onen et alD9 1---B<
7hese =indin&s s&&est interestin& parallels to or o/n< $oth people lo/ in :E3 and
people hi&h in hostility have sho/n hei&htened physiolo&ical arosal a=ter e*posre
to Mite similar laboratory stressors, incldin& social con=lict, impossible tas0s, and
time constraints< ;iven these shared patterns o= response to laboratory stress and or
proposed association bet/een hostility and emotional intelli&ence de=icits, some
people reportin& lo/ :E3 may tend to e*perience hei&htened cardiovasclar arosal
on a re&lar, everyday basis, even in the absence o= stressors and ne&ative mood< 7his
sstained reactivity cold predispose these people to increased ris0 o= (HD< Note that
not all people reportin& lo/ :E3 necessarily =it this model8 /hether people /ho report
lo/ :E3 bt do not demonstrate hi&h trait hostility /old sho/ these cardiovasclar
patterns is nclear< 3t is also nclear /hether :E3 /old predict cardiovasclar arosal
independently o= hostility in people both lo/ in :E3 and hi&h in hostility< Ftre
research shold e*amine potential de=icits in emotional intelli&ence amon& people
hi&h in trait hostility, as /ell as lin0s bet/een :E3, amblatory blood pressre, and
cardiovasclar morbidity and mortality<
Fortnately, the impact o= hostility and potential emotional intelli&ence de=icits on
(HD mi&ht be reversible< 3n a stdy by Friedman et alD A1-@GB, .-! post myocardial
in=arction patients received 7ype A behavioral conselin& in addition to &rop cardiac
conselin&< At the end o= #<. years, +.<1 percent o= these patients sho/ed redced
7ype A behavior, compared to only -<@ percent o= people in a control &rop< 7he
cardiac recrrence rate =or people in the e*perimental &rop /as only 1!<- percent,
compared to !1<! percent in the control &rop and !@<! percent in a standard care
&rop< 3n a hi&hly pblici>ed stdy by Ornish and collea&es A1--@B, patients /ith
moderate to severe (HD participated in an intensive =ive%year li=estyle modi=ication
pro&ram that involved a ve&etarian diet, e*ercise, smo0in& cessation, and%most
relevant to this discssion%stress mana&ement trainin& and &rop psychosocial
spport< :atients in this e*perimental pro&ram evidenced reversals in their coronary
atherosclerosis a=ter =ive years8 control &rop patients sho/ed contined thic0enin& in
their arteries and e*perienced t/ice as many cardiac events< Ornish has not
determined the e*tent to /hich each o= the pro&ramLs components Adiet, e*ercise,
psycholo&ical trainin&, etc<B speci=ically contribted to cardiac otcomes< Ho/ever, a
recent stdy connectin& 7ranscendental Ceditation trainin& /ith re&ression in
atherosclerosis indicates that stress mana&ement trainin& alone%/ithot diet or
e*ercise interventions % may have a si&ni=icant impact on cardiac otcomes A(astillo%
Richmond et alD9 !"""B<
1G+
%1G!%
Each o= these interventions emphasi>ed s0ills relevant to emotional competencies<
Friedman and his collea&es conseled people on their 7ype A behavior8 as /e have
discssed, 7ype A behavior may involve de=iciencies in emotional competencies
relevant to the mana&ement o= hostility, and so conselin& that serves to alleviate
7ype A behavior cold also promote emotional intelli&ence s0ills, sch as identi=yin&
and re&latin& the e*pression o= ne&ative emotions< :atients in OrnishLs pro&ram very
li0ely learned to moderate their ne&ative emotions in the stress mana&ement
component o= his trainin& sessions, and to e*press and better nderstand their =eelin&s
thro&h &rop psychosocial activities< :eople practicin& 7ranscendental Ceditation
presmably learned to observe, ac0no/led&e, and release their ne&ative emotions< 3t
ths seems that interventions aimed at cardiovasclar patients may =oster emotional
intelli&ence s0ills8 becase these pro&rams have been sho/n to enhance lon&%term
health, they mi&ht s&&est a lin0 bet/een emotional intelli&ence and health<
,n=ortnately, these speclations rest on ambi&ities abot casal directionality and
rather nspeci=ied mechanisms< Emotional s0ills &leaned =rom psychosocial
interventions mi&ht enhance health thro&h health behavior, stress physiolo&y, or
some other mechanism sch as an increased ability to elicit social spport =rom others
AKennedy%Coore N Watson, 1---B8 or, emotional intelli&ence and enhanced health
may both be independent prodcts o= these pro&rams< Ftre research is needed to
clari=y these isses<
:sychosocial intervention stdies /ith cancer and A3D) poplations also bear
relevance to the emotional intelli&ence%health lin0< 3n )pie&el et alDLs A1-@-B no/%
=amos intervention stdy, metastatic breast cancer patients /ere randomly assi&ned
to an e*pressive spportive &rop therapy condition< 7he &rop met /ee0ly =or one
year and helped patients deal /ith e*pressin& their tho&hts and =eelin&s, copin& /ith
illness, enhancin& relationships, and directly =acin& their =ears and sadness abot
cancer< A ten%year =ollo/%p sho/ed that /omen in this intervention condition
srvived si&ni=icantly lon&er than /omen in the control &rop A+G<G months vs< 1@<-
monthsB<
)imilarly, researchers at the ,niversity o= Ciami randomly assi&ned +@ post%sr&ical
mali&nant melanoma patients to a strctred psychiatric intervention pro&ram that
emphasi>ed stress a/areness, stress in=ormation, enhancement o= copin& s0ills and
development o= copin& s0ills AFa/>y et alD9 1--"a, 1--"b, 1--+B< (ompared to a
control &rop, melanoma patients in the intervention &rop sho/ed redced a==ective
distress, more active copin&, and enhanced immnity si* months later< At a
sbseMent si*%year =ollo/%p, intervention patients had a si&ni=icantly hi&her
srvival rate A-1 percentB than people in the control &rop A!1 percentB< 3ncreases in
active behavioral copin& over the si*%month intervention period predicted lo/er rates
o= recrrence or death<
Other intervention pro&rams o= this 0ind have sho/n encora&in& reslts =or
individals /ith H3V< For e*ample, Antoni et alD A1--1B assi&ned &ay men na/are o=
their H3V serostats to a co&nitive behavioral stress mana&ement intervention< Cen in
the intervention &rop e*plored a/areness o= stress and ne&ative tho&hts, co&nitive
restrctrin& techniMes, and rela*ation methods, amon& other thin&s<
1G#
%1G+%
Five /ee0s into the pro&ram, the men /ere tested =or H3V and in=ormed o= their
serostats8 the intervention contined =or another =ive /ee0s< Relative to men in the
control &rop, men in the intervention &rop /ho discovered that they /ere H3V
positive sho/ed a stress%b==erin& advanta&e in their immne titers across the
noti=ication period and consistent, positive immne chan&es over the ten%/ee0
intervention period AAntoni et alD9 1--18 Esterlin& et alD9 1--!B< Over the ne*t t/o
years, the H3V positive men /ho coped by en&a&in& denial and /ere lo/ in
adherence drin& the intervention period A=reMently missin& &rop sessions and not
practicin& rela*ation methods, =or e*ampleB sho/ed =aster disease pro&ression, even
a=ter controllin& =or initial disease severity A3ronson et alD9 1--.B<
7hese stdies are only e*amples o= an on&oin& area o= research8 it is /orth notin& that
other psychosocial intervention pro&rams have not al/ays a==ected the immnity
and?or srvival rates o= cancer and A3D) patients Ae<&< (oates et alD9 1-@-8 ;ellert et
alD9 1--+B< Nonetheless, the =indin&s discssed o==er spport =or an association
bet/een emotional intelli&ence and lon&%term health otcomes< Altho&h the
intervention pro&rams /ere not speci=ically desi&ned to enhance emotional
intelli&ence, they mi&ht have done so indirectly by teachin& people to identi=y and
e*press their emotions in spportive &rop environments< Coreover, all o= the
pro&rams emphasi>ed active copin&8 as /e have discssed else/here, e==ective copin&
involves core emotional intelli&ence competencies, incldin& nderstandin& the
implications o= ho/ /e are =eelin& and re&latin& or emotional e*periences A)alovey
et alD9 1---B< 7hese interventions ths seem to have promoted emotional
competencies8 becase they also predicted improved lon&%term health otcomes, they
s&&est a lin0 bet/een emotional intelli&ence and health< Obviosly, these
s&&estions are speclative8 =tre interventions are needed that speci=ically teach and
assess emotional intelli&ence and its potential relationship to health otcomes< As a
start in desi&nin& sch an emotional intelli&ence enhancin& intervention, one may
/ish to loo0 at school%based crricla that have been developed /ith these &oals Ae<&<
Elias et alD9 1--'8 )chillin&, 1--GB<
Con"l'sion
7he s0ills relevant to emotional intelli&ence may be lin0ed in si&ni=icant /ays to
health and illness< 7he mechanisms accontin& =or these connections may be
discovered at mltiple levels%psychophysiolo&ical, co&nitive, and behavioral< At
present, ho/ever, research in this potentially re/ardin& area has been limited becase
o= the reliance on sel=%report measres o= emotional competencies, incldin& the
biases and errors that are a part o= the process o= re=lectin& on oneLs o/n mental and
emotional states and behavioral s0ills< 7his isse compromised the conclsions that
cold be dra/n =rom the br&eonin& literatre on ale*ithymia in previos decades,
and it threatens to comprise the emotional intelli&ence area in the present decade as
/ell< 3t is /ith pleasre, then, that /e reco&ni>e the emer&ence o= ability%based
assessment tools =or captrin& individalsL stren&ths and /ea0nesses in this domain
Ae<&< Cayer et alD9 1---, !""+B< We sspect that by
%1G#%
1G.
the time this volme is pblished, these measres /ill be easily available, and /e
encora&e investi&ators o= lin0s bet/een emotional s0ills and competencies and
health otcomes to ta0e the time to assess patients and healthy participants /ith them<
Kin& )olomon proclaimed that Oa merry heart doeth &ood li0e a medicineP A:roverbs
1'E!!B< We sspect, ho/ever, that mere merriment /ill not be eno&h< Health seems
more li0ely to reslt =rom bein& able to e*press and appraise emotions clearly,
nderstand them, se them to =acilitate co&nitive activities, and re&late them
adaptively Aand not Rst hedonisticallyB< We loo0 =or/ard to the inevitable
brea0thro&hs and insi&hts spported by systematic inMiry in this =ield<
A"kno1ledgments
:reparation o= this chapter /as =acilitated by the =ollo/in& &rantsE American (ancer
)ociety AR:;%-+%"!@%".%:$:B, National (ancer 3nstitte AR"1%(AG@#!'B, and
National 3nstitte o= Cental Health A:"1%CH?DA.G@!GB< We also ac0no/led&e
=ndin& =rom the Ethel F< Dona&he Fondation WomenLs Health 3nvesti&ator
:ro&ram at Yale ,niversity<
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stressor disclosre indction< Eournal of Psychosomatic Research,&2, G+%'@<
CcE/en, $< N )tellar, E< A1--+B< )tress and the individalE mechanisms leadin&
to disease< rchi'es of #nternal ?edicine,$/&, !"-+%!1-1<
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traditional standards =or an intelli&ence<#ntelligence,%4, !G'%!-@<
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N D< )lyter AedsB, 5motional de'elopment and emotional intelligence3
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Cayer, 9<D<, )alovey, :<, (arso, D<R<, N )itacenios, ;< A!""+B< Ceasrin&
emotional intelli&ence /ith C)(E37 v!<"< 5motion,&, -'%1".<
Ciller, ;<E<, Dopp, 9<C<, Cyers, H<F<, Fahey, 9<6<, N )tevens, )<Y< A1---B<
:sychosocial predictors o= natral 0iller cell mobili>ation drin& marital con=lict<
1G@
Fealth Psychology,$2, !G!%!'1<
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N $rand, R<9< A1--@B< 3ntensive li=estyle chan&es =or reversal o= coronary heart
disease< Eournal of the merican ?edical ssociation,%26, !""1%!""'<
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Psychology,,#, 1#!'%1#++<
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:enneba0er, 9<W<, H&hes, (<F<, N OLHeeron, R<C< A1-@'B< 7he
psychophysiolo&y o= con=essionE lin0in& inhibitory and psychosomatic processes<
Eournal of Personality and %ocial Psychology,/%, '@1%'-+<
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%1G@%
Chapter $6
The repressive "oping style and avoidan"e o) negative a))e"t E
Lynn BD ?yers and <a@anin Dera!shan
Introd'"tion
7his chapter presents evidence that individals /ho possess a repressive copin& style
ArepressorsB avoid ne&ative a==ect and conseMently ans/er many sel=%report measres
in an overly positive =ashion< A potential lin0 bet/een repressive copin& and adverse
physical health is also discssed<
3t has been more than !" years since interest /as rene/ed in repression as an
individal di==erence variable< Weinber&er et alD A1-'-B sed measres o= trait an*iety
and de=ensiveness to identi=y a &rop o= individals /ho /ere described as possessin&
a repressive copin& style< Repressors are identi=ied by their lo/ scores on sel=%report
measres o= trait an*iety Ameasred by varios trait an*iety scales, e<&< the $endi&
version o= the Cani=est An*iety )cale8 $endi&, 1-.GB and hi&h scores on
de=ensiveness Asally measred /ith the Carlo/e%(ro/ne )ocial Desirability )cale8
(ro/ne N Carlo/e, 1-G#B< Apart =rom the repressor &rop, three control &rops are
sally identi=ied sin& the same typolo&yE a =rther lo/ trait an*iety &rop /ho are
lo/ on de=ensiveness Alo/%an*iosB and t/o hi&h trait an*iety &rops, one o= /hich is
lo/ on de=ensiveness Ahi&h%an*iosB and one /hich is hi&h on de=ensiveness
Ade=ensive hi&h%an*iosB< 7he seminal Weinber&er et alD A1-'-B stdy and nmeros
later stdies Ae<&< $enRamins et alD9 1--#8 Dera0shan N Eysenc0, 1--'8 9amner N
)ch/art>, 1-@G8 Ne/ton N (ontrada, 1--!B =ond that repressors dissociate their
somatic reactions =rom their perceptions o= distress, reportin& lo/ levels o= distress
and an*iety bt e*hibitin& hi&h levels o= physiolo&ical activity8 /hereas hi&h%an*ios
participants e*hibit the opposite pattern o= response and lo/%an*ios participants
report similar lo/ levels o= distress to repressors bt are not hi&h on physiolo&ical
stress measres< )tdies /hich have inclded a de=ensive hi&h%an*ios &rop have
1'1
=ond that this &rop do not sho/ the repressorsL style o= dissociation Ae<&< Asendorp=
N )cherer, 1-@+B< As this discrepancy bet/een physiolo&ical and sel=%report measres
o= distress is one o= the de=inin& aspects o= possessin& a repressive copin& style, it is
discssed in more detail in the ne*t section<
f 7his chapter is based on Cyers, 6<$< A!"""B< 3denti=yin& repressorsE a
methodolo&ical isse =or health psycholo&y< Psychology and Fealth9$/, !".%!1#<
A///<tand=<co<0B
%1G-%
!epressive "oping and dis"repan"ies *et1een sel)+reported anxiety,
physiologi"al, and *ehavioral indi"es o) anxiety
7he =indin&s reported in the previos section indicate that repressors appear to be
more emotionally reactive than lo/%an*ios individals and at least as emotionally
reactive as the hi&h%an*ios individals< 3t is believed that repressors employ a /ide
variety o= de=ensive strate&ies to minimise the conscios level o= e*perienced an*iety
and in =act are capable o= not e*periencin& an*iety at the conscios level o= a/areness
ADera0shan N Eysenc0, 1--@,1---B< Frthermore, it has been stated that repressors
have di==iclty comin& to terms /ith this discrepancy< 9amner and )ch/art> A1-@.B
reported that it too0 a nmber o= months =or a repressor client to sho/ positive
correlations bet/een his sbRective e*perience and his physiolo&ical responses o=
an*iety<
(onseMently, Olo/%an*ietyP individals are no lon&er a homo&eneos &rop bt are
divided into repressors and AtrlyB lo/%an*ios as the lo/%an*ios &rop do not sho/
the repressor pattern o= discrepancy< 3n an*iety research it has been sho/n that the
hi&h%an*ios individals sho/ a stron& tendency to attend selectively to threatenin&
material in the environment Aselective attentional biasB and a tendency to interpret
potentially ambi&os stimli in a threatenin& manner Ainterpretive biasB8 on the other
hand, the Olo/%an*ietyP &rop are believed not to sho/ any bias Asee Catthe/ N
Cac6eod, 1--#, =or revie/B< 3n Eysenc0Ls A1--'B revised theory o= an*iety, it is
ar&ed that repressors and not the trly lo/%an*ios sho/ opposite biases to that o=
the hi&h%an*ios, i<e< they are believed to avoid threatenin& material and interpret
ambi&os material in a non%threatenin& manner< As a conseMence o= these biases
A/hich are stron&er nder conditions o= hi&h stressB, repressors shold e*perience less
an*iety and the hi&h%an*ios more an*iety< 7he e*istence o= these biases can help
e*plain in part the discrepancies that are consistently =ond in the repressor &rop< 3n
addition, Eysenc0 A1--'B predicted that these biases shold apply to internal
in=ormation Abehavior and physiolo&yB as /ell as e*ternal in=ormation<
Dera0shan and Eysenc0 A1--', 1---, !""1B condcted a series o= e*periments to test
the above predictions systematically< 7hey e*amined behavioral an*iety Ae<&< bodily
movements, =acial an*iety, speech an*ietyB as /ell as physiolo&ical an*iety< Altho&h
physiolo&ical and atonomic reactivity can be sed to indicate the e*perience o=
an*iety, it is not yet nderstood /hether this reactivity is de to e*citatory or
inhibitory processes or both, and /hether it re=lects the nconscios or conscios
e*perience o= an*iety< 7he time corse =or the e*perience o= an*iety is crrently bein&
investi&ated by Dera0shan et alD A!""!B<
1'!
Dera0shan and Eysenc0 A1--'B e*amined /hether repressors /old sho/ opposite
interpretive biases =or behavioral and physiolo&ical measres o= an*iety< Repressors,
lo/%an*ios, hi&h%an*ios, and de=ensive hi&h%an*ios &rops /ere as0ed to &ive a
pblic speech in =ront o= a small adience o= si*, /hile their heart rate reactivity /as
recorded and they /ere videotaped< Varios sel=%reported
%1'"%
an*iety measres /ere ta0en drin& the speech< While repressorsL heart rate indicated
that they /ere as an*ios as the hi&h%an*ios and de=ensive hi&h%an*ios individals,
their reported an*iety levels /ere as lo/ as the lo/%an*ios individals< When &iven
=eedbac0 abot their heart rate reactivity, repressors denied that their heart rate ever
did increase and claimed that even i= it did, the increase /as de to the pblic speech
tas0 bein& e*citin& and challen&in& rather than it bein& threatenin& and stress=l< 7he
hi&h%an*ios and de=ensive hi&h%an*ios individals sho/ed the opposite pattern and
the lo/%an*ios did not sho/ any bias<
With respect to behavioral an*iety, t/o independent Rd&es sed the 7imed
$ehavioral (hec0list A:al, 1-GGB to rate the participantsL level o= an*iety on varios
scales sch as speech an*iety, =acial an*iety, eye contact, and passive and active
behavioral an*iety< 7he Rd&es rated repressors as bein& as behaviorally an*ios as
the hi&h%an*ios and de=ensive hi&h%an*ios individals and si&ni=icantly more
an*ios than the lo/%an*ios individals, and this e==ect /as more pro=ond =or
speech an*iety ratin&s< Ho/ever, this /as inconsistent /ith repressorsL ratin&s o= their
o/n behavioral an*iety< When as0ed to rate their behavioral an*iety levels sin& the
videotape, it /as =ond that repressorsL ratin&s =or their o/n behavioral an*iety /ere
mch lo/er than the Rd&esL ratin&s< Ho/ever, repressorsL ratin&s o= other participantsL
behavioral an*iety did not di==er =rom those o= the Rd&es< 7his =indin& indicates that
repressorsL minimi>ation o= threat seems to be con=ined to Osel=L and did not e*tend to
ratin&s o= other peopleLs behavioral an*iety<
RepressorsL denial o= their increased heart rate reactivity drin& stress=l sitations,
sch as the one sed above, can indicate that repressors are &enerally na/are o= their
internal states< 3n order to test this hypothesis, Dera0shan and Eysenc0 A!""1B
maniplated the level o= sel=%=ocsed attention in a pblic speech tas0 /hile
measrin& heart rate and sel=%=ocsed attention, and videotapin& participants< 7here
/ere t/o conditionsE a sel=%=ocs condition, /here the participant /as instrcted to
=ocs on himsel= or hersel=, and an Oother%=ocsP condition in /hich they /ere
instrcted to =ocs on e*ternal srrondin&s< :hysiolo&ical recordin&s sho/ed that
repressorsL heart rate reactivity /as hi&hest in the sel=%=ocs Astress=lB condition and
lo/est in the other%=ocs Anon%stress=lB conditions< Ho/ever, measrements o= sel=%
=ocsed attention and state an*iety indicated that they /ere lo/est on these measres
in the sel=%=ocs condition, compared to the other &rops< 3t /as statistically sho/n
that repressorsL lo/ level o= sel=%=ocsed attention acconted =or a lar&e part o= their
lo/ levels o= reported an*iety< 7his =indin& s&&ests that in order not to e*perience
hi&h levels o= an*iety, repressors may avoid en&a&in& in sel=%re&latory processes as
indicated by their avoidance in =ocsin& on their internal states once directed to do so<
7he athors also e*amined discrepancies bet/een standardi>ed scores o=
physiolo&ical reactivity as measred by heart rate, behavioral an*iety Aas measred by
independent Rd&es sin& the videotape in=ormationB, and sel=%reported an*iety<
1'+
Repressors had consistently hi&her levels o= behavioral an*iety and physiolo&ical
reactivity than sel=%reported an*iety in the stress=l condition Asel=%=ocsB as opposed
to the other conditions<
%1'1%
Discrepancies bet/een hei&htened levels o= behavioral an*iety and lo/ sel=%reported
an*iety can be sed as a more direct indication o= repressorsL e*perience o= an*iety at
least =rom ho/ they appear to an observer?independent Rd&eLs vie/< Overall, it seems
that discrepancies bet/een atonomic indicators o= stress and reported stress need to
be e*amined more systematically< For e*ample, it is not clear /hether physiolo&ical
reactivity at early sta&es o= in=ormation processin& re=lects vi&ilance =or threat%related
material or avoidance o= sch material< 3t seems lo&ical to assme, =rom a
motivational perspective, that repressors se their inhibitory or de=ensive strate&ies at
later sta&es o= processin& in order to minimise the impact o= early re&istration o=
threat< (han&es in time corse o= sch processes can be assessed thro&h detailed
e*amination o= online physiolo&ical recordin&s accompanied /ith chan&es in
electrical activities in the brain, e<&< pre=rontal brain asymmetry< 7his needs to be
investi&ated in =tre stdies<
5e)ining repressive "oping
7here are a nmber o= important and comple* isses in this area o= research<
Altho&h the Weinber&er et alD A1-'-B trait an*iety?de=ensiveness method has become
an increasin&ly poplar method o= de=inin& repressive copin&, di==erent measres o=
trait an*iety and de=ensiveness are sed as /ell as varyin& /ays o= identi=yin&
repressors and control &rops ACyers, 1--.B<
&rait an)iety
7he Cani=est An*iety )cale is a =reMently sed measre o= trait an*iety in repressive
copin& research, in both its ori&inal =orm A7aylor, 1-.+8 e<&< Weinber&er et alD9 1-'-B
and the short =orm A$endi&, 1-.G8 e<&< Davis, 1-@'B< Other trait an*iety measres sch
as the )pielber&er 7rait An*iety scale A)pielber&er et alD9 1-'"8 e<&< Da/0ins N
Frnham, 1-@-B and the Neroticism )cale o= the Eysenc0 :ersonality 3nventory
AE:3, Eysenc0 N Eysenc0, 1-G#8 e<&< ;dRonsson, 1-@1B have also been sed<
Ceasres o= trait an*iety have been =ond to be hi&hly correlated Ae<&< )lo&h et alD9
1-@#8 )llivan N Roberts, 1-G-B<
Defensiveness
7he Carlo/e%(ro/ne )ocial Desirability )cale is invariably sed to measre
de=ensiveness< Ho/ever, the E:3%6ie scale has occasionally been sed as a measre o=
de=ensiveness< For e*ample, ;dRonsson A1-@1B sed the latter scale, altho&h de to
the small nmber o= items on the 6ie scale he inclded the Carlo/e%(ro/ne )ocial
Desirability )cale as an additional de=ensiveness score< He reported a hi&h positive
correlation bet/een the t/o de=ensiveness scales Ar]"<'1B<
%1'!%
1'#
.ther measures
Core recently, Weinber&er developed the Weinber&er AdRstment 3nventory AWA38
Weinber&er, 1-@-, reported in Weinber&er, 1--"B /hich can be sed to measre
repressive copin&< Dera0shan and Eysenc0 A1--'B =ond that this /as a comparable
method to the trait an*iety?de=ensiveness method, /ith the distress sbscale o= the
WA3 correlatin& hi&hly /ith trait an*iety A"<'-B and the repressive de=ensiveness and
the sel=%restraint sbscales o= the WA3 correlatin& /ith the Carlo/e%(ro/ne )ocial
Desirability )cale A"<G@ and "<#' respectivelyB<
'dentifying groups
One o= the maRor di==iclties /ith this area o= research is the =act that the trait
an*iety?de=ensiveness method depends on cate&ori>in& people into &rops based on
their location alon& t/o dimensions< For e*ample, varios stdies identi=y their
participants at the be&innin& o= the stdy by screenin& a lar&e nmber o= potential
participants and choosin& e*treme scorers on trait an*iety and de=ensiveness to de=ine
repressors, lo/%an*ios, hi&h%an*ios and ApossiblyB de=ensive%hi&h%an*ios &rops
Ae<&< Dera0shan N Eysenc0, 1--', 1--@8 Cyers N $re/in, 1--#, 1--.8 Cyers N
)teed, 1---B< Other stdies have sed the entire available pool o= participants and
hence do not se sch strin&ent measres in de=inin& di==erent &rops, sally sin&
median splits on trait an*iety and de=ensiveness to identi=y repressors and control
&rops, thereby not losin& any potential participants Ae<&< $rns, !"""8 )ha/ et alD9
1-@GB< 7here=ore, altho&h measrin& instrments sed to identi=y repressors are
comparable, it is important to note ho/ repressors and control &rops have been
de=ined in di==erent stdies<
Eli"iting in)ormation )rom repressors
Repressors constitte a si&ni=icant proportion o= the poplation, /ith prevalence
estimates ran&in& bet/een 1" and !" percent ACyers N Reynolds, !"""8 :hipps N
)rivastava, 1--'B< 7here is a debate over the best /ay o= elicitin& in=ormation =rom
repressors, as many stdies over the past ten years have sho/n repressors to be
individals /ho avoid ne&ative a==ect and this is re=lected in the /ay that they ans/er
sel=%report measres< 7hese isses are discssed belo/<
-epressive coping and avoidance of negative affect
What is the evidence that repressors avoid ne&ative a==ectT 3n a comprehensive
revie/, Weinber&er A1--"B conceptalised the repressive copin& style as consistin& o=
Opeople /ho =ail to reco&nise their o/n a==ective responsesX/ho consider
maintainin& lo/ levels o= ne&ative a==ect central to their sel=%concept DandF are li0ely
to employ a variety o= strate&ies to avoid conscios 0no/led&e o= their &enine
reactionsP Ap< ++@B< An e*tensive literatre stron&ly indicates that repressors
%1'+%
do indeed avoid ne&ative a==ect< For e*ample, a nmber o= stdies have demonstrated
lin0s bet/een the repressive copin& style and poor accessibility o= ne&ative
atobio&raphical memories Ae<&< Davis, 1-@'8 Cyers et alD9 1--!B< Other stdies sin&
1'.
both intentional and incidental recall tas0s indicate that these =indin&s are not speci=ic
to atobio&raphical memories and may operate on non%atobio&raphical ne&ative
material as /ell ACyers N $re/in, 1--.8 Cyers et alD9 1--@B< Repressors have been
=ond to se avoidant style o= in=ormation processin& Ae<&< Fo*, 1--+8 Cyers N
CcKenna, 1--GB and they appear to employ strate&ies in maintainin& =avorable
ima&es o= their sel=%concept /hen this is threatened A$ameister N (airns, 1--!8
Ne/ton N (ontrada, 1--!B, /hich seems to be de to sel=%deception rather than
impression mana&ement AWeinber&er N Davidson, 1--#B< (onseMently, repressorsL
avoidance o= ne&ative a==ect /old ma0e it e*tremely li0ely that they /old ans/er
sel=%report measres sch as Mestionnaires and chec0lists in an overly positive
=ashion<
-epressive"oping and sel)+report instr'ments
7here is a body o= research sho/in& that repressors do indeed ans/er many sel=%
report measres overly positively< Cyers and $re/in A1--GB /ere interested in
investi&atin& /hether repressors /old display Oillsions o= invlnerabilityP Asee
7aylor N $ro/n, 1-@@B more than nonrepressors< 7his /as investi&ated /ith t/o o=
the illsionsE nrealistic optimism or comparative optimism Athe belie= that /e are
more li0ely to e*perience pleasant events and less li0ely to e*perience ne&ative events
than or peersB and overly positive sel=%evalations Athe =indin& that individals
evalate themselves more positively than othersB< ,sin& sel=%report measres,
repressors sho/ed both o= these illsions to a si&ni=icantly &reater e*tent than
nonrepressors =or ne&ative sel=%related material< Cyers and $re/in A1--GB sed
mainly e*treme%scorin& participants on an*iety and de=ensiveness, omittin& nearly ."
percent o= the poplation< 3n a later stdy sin& a /hole sample ACyers N Reynolds,
!"""B, the comparative optimism =indin&s /ere replicated and e*tended to solely
health%related events Ae<&< asthma, bronchitisB< Overall, repressors e*hibited
si&ni=icantly &reater comparative optimism than all nonrepressors =or health%related
events<
7/o stdies /hich sed sel=%report instrments A;ome> N Weinber&er, 1-@G,
reported in Weinber&er, 1--"8 Cyers, 1--GB =ond that repressors /ere si&ni=icantly
more li0ely to rate hypothetical ne&ative events as bein& cased by a composite o=
e*ternal, nstable and speci=ic =actors compared to nonrepressors< 7his is an
OoppositeP attribtional style to depressive%prone individals, /ho typically attribte
casality o= ne&ative events to internal, stable, and &lobal cases AAbramson et al<,
1-'@B<
7he relationship bet/een repressive copin& and ale*ithymia /as e*plored in t/o
stdies< Ale*ithymia is a personality style derived =rom clinical observations o=
patients /ith traditional psychosomatic diseases ANemiah N )i=neos, 1-'"a8 (hapter
@ o= this volmeB< Ale*ithymic individals sho/ redced or absent
%1'#%
symbolic thin0in& as /ell as di==iclties in reco&ni>in& and describin& their o/n
=eelin&s and di==iclties discriminatin& bet/een bodily sensations and emotional
states Asee (hapter @ =or detailed descriptionsB< 3t has been proposed that ale*ithymia
and repression are similar constrcts ANemiah N )i=neos, 1-'"b8 Weinber&er N
1'G
)ch/art>, 1--"B or alternatively that ale*ithymia may be an aspect o= repressive
copin& A$onanno N )in&er, 1--"B< Ho/ever, stdies sin& Mestionnaire measres o=
ale*ithymia indicated that repressors score si&ni=icantly lo/er on ale*ithymia than
nonrepressors ACyers, 1--.8 Ne/ton N (ontrada, 1--#B< 7hese reslts may mean that
repressors are trly lo/ on ale*ithymia, or they may be de to limitations o= the
Mestionnaire methodolo&y<
7/o recent stdies investi&ated the /ay in /hich repressors ans/er health%related
Mestionnaires ACyers N Vetere, 1--'B< 3n the =irst stdy, repressors completed the
(opin& Resorces 3nventory A(R38 Hammer N Cartin&, 1-@@B, a G"%item
Mestionnaire sed to identi=y resorces crrently available to individals =or
mana&in& stress< 3t measres resorces in =ive domainsE physical, co&nitive,
emotional, social, and spirital?philosophical< Repressors rated themselves as havin&
more total copin& resorces than nonrepressors< 7he same pattern o= reslts /as
e*hibited =or each o= the sbscales< 3n the second stdy, repressorsL responses /ere
e*tended to other health%related measres< 7/o Mestionnaires /ere sedE a measre
o= psycholo&ical symptoms Athe 1!%item ;eneral Health Yestionnaire, ;HY%1!8
;oldber&, 1--!B and a measre o= physical symptoms A:enneba0er 3nventory o=
6imbic 6an&idness, :3668 :enneba0er, 1-@!B< Repressors compared to
nonrepressors scored si&ni=icantly lo/er on the :366 and the ;HY%1!, indicatin& that
repressors sel=%report lo/ levels o= both physical and psycholo&ical symptomatolo&y<
3n a recent stdy o= children /ith cancer it /as noted that repressors sel=%reported the
lo/est levels o= depression A:hipps N )rivastava, 1--'B< )imilar =indin&s have been
reported in earlier stdies o= patients /ith cancer A(annin& et alD9 1--!8 9ensen, 1-@'B<
3t shold be noted that the maRority o= the above stdies A(annin& et alD9 1--!8 Cyers,
1--.8 1--G8 Cyers N $re/in, 1--G8 Cyers N Reynolds, !"""8 Cyers N Vetere,
1--'8 :hipps N )rivastava, 1--'B compared repressors /ith the hi&h de=ensive &rop
/ho are hi&h on an*iety, the de=ensive hi&h%an*ios, and =ond that repressors
si&ni=icantly di==ered =rom this &rop< 7his indicated that the =indin&s discssed /ere
de to repressorsL niMe combination o= lo/ trait an*iety and hi&h de=ensiveness and
/ere not de to repressorsL hi&h scores on de=ensiveness alone<
3n smmary, the above stdies indicate that repressors are overly positive on varios
sel=%report measres< 7hese =indin&s may be seen as another mani=estation o= the
repressive copin& style /hich is associated /ith avoidance o= ne&ative a==ect<
7here=ore, it appears that sel=%report measres may be a poor /ay o= collectin& data
=rom this &rop< 7his is potentially problematic =or health psycholo&y as the maRority
o= measrin& instrments tili>ed are sel=%report instrments<
%1'.%
.thermethodologies that have *een 'sed to assess repressive "oping
Are there /ays to circmvent repressorsL avoidance o= ne&ative a==ectT 7here is some
evidence that repressors score di==erently on Mestionnaires compared to intervie/
methodolo&y< Firstly, evidence =rom three stdies on repressorsL childhood e*perience
indicates that reslts are very di==erent dependin& on the method o= elicitin&
in=ormation< 3t /as hypothesi>ed that repressors /old have had more npleasant
1''
childhood e*periences than nonrepressors ACyers N $re/in, 1--#B< 3n this stdy, a
semi%strctred intervie/ /as sed /hich allo/ed raters to Rd&e reports o= childhood
e*periences accordin& to their o/n predetermined criteria rather than relyin& simply
on respondentsL o/n Rd&ments abot the si&ni=icance o= these e*periences< 3n the
intervie/ there are a nmber o= speci=ic Mestions sch as ODo yo thin0 yor parents
approved o= yo p to the time /hen yo /ere a teena&erTP 3ndependently o= /hether
participants ans/er yes or no to this Mestion, speci=ic e*amples o= occasions /hen
their parents did?did not approve o= them are elicited and =orm the basis o= the
intervie/er ratin&s< (onsistent /ith the hypothesis, repressors held a ne&ative vie/ o=
their =athers, /ith repressors reportin& si&ni=icantly more paternal antipathy and
indi==erence and bein& si&ni=icantly less emotionally or physically close to their
=athers compared to nonrepressors ACyers N $re/in, 1--#B< Ho/ever, a later stdy
sed a Mestionnaire measre o= &lobal childhood e*perience, the :arental $ondin&
3nstrment A:$38 :ar0er et alD9 1-'-8 Cyers et alD9 1---B< 7he :$3 reMires
participants to consider &enerally the /hole period o= their childhood be=ore they le=t
home< :articipants ans/er a series o= Mestions abot their mother and =ather and
consider, =or e*ample, /hether s?he Omade me =eel 3 /asnLt /antedP, or O=reMently
smiled at meP< Reslts indicated that repressors reported a mch more positive vie/
o= their =athers than nonrepressors, depictin& their =athers as si&ni=icantly more carin&
and less overprotectin& ACyers et alD9 1---B< )imilarly, repressors compared to
nonrepressors scored si&ni=icantly lo/er on paternal overprotection and paternal
reRection on another &lobal measre o= parentin&E the E&na Cinnen $etrb==ande
,pp=ostran AEC$,8 Cyers, 1---B< 7he reslts o= the semi%strctred intervie/ sin&
speci=ic e*amples o= childhood spported the hypothesis that repressors had
e*perienced npleasant childhood e*periences, compared /ith the &lobal
Mestionnaire measres in /hich repressors reported more positive childhood
e*periences, s&&estin& that the intervie/ /as a more appropriate measre o=
repressorsL childhood e*periences< 3t shold be noted that it /as not possible to
ascertain =rom these reslts /hether the di==erence /as de to the natre o= the
Mestions Aspeci=ic vs< &lobalB or the natre or the instrment Aintervie/ vs<
MestionnaireB, or both< 7hese isses need e*plorin& in =rther stdies<
)econdly, repressors have sho/n a si&ni=icantly lo/er score on a Mestionnaire
measre o= 7ype A behavior A9en0ins Activity )rvey8 9en0ins et alD9 1-'-B than
nonrepressors< Ho/ever, on an intervie/ measre Athe )trctred 3ntervie/8
%1'G%
Friedman N :o/ell, 1-@#B, they scored similarly to lo/%an*ios non%repressors, a
lo/%an*ios &rop ADenollet, 1--1B<
7hirdly, there is some indirect evidence =rom research on Ode=ensive deniersP
A)hedler et alD9 1--+, p< 111'B< :articipants /ere divided into three &rops on the
basis o= clinical assessment and sel=%report measres o= mental healthE A1B de=ensive
deniers reported psycholo&ical /ell%bein& bt /ere Rd&ed as distressed8 A!B a healthy
&rop reported psycholo&ical /ell%bein& and /ere Rd&ed as healthy8 and A+B a
distressed &rop reported psycholo&ical distress and /ere Rd&ed as distressed<
De=ensive deniers sho/ed si&ni=icantly hi&her physiolo&ical reactivity than the other
t/o &rops8 hence, they e*hibited a comparable physiolo&ical dissociation /ith lo/
levels o= sel=%reported distress to repressors Ae<&< Dera0shan N Eysenc0, 1--'B< 3n
1'@
addition, the athors proposed that de=ensive deniers are not healthy bt may be prone
to physical illness< 7he possible similarities bet/een repressors and de=ensive deniers
needs to be directly investi&ated in =tre stdies<
What type of measuressho'ld 1e 'se-
7he stdies discssed above /hich investi&ated repressorsL childhood e*periences
may &ive some cles as to ho/ to elicit in=ormation =rom repressors ACyers N
$re/in, 1--#8 Cyers et alD9 1---B< Ceasres /hich either reMire participants to be
speci=ic in their ans/ers, rather than ma0in& &lobal ratin&s, or allo/ an independent
rater to Rd&e participantsL responses may bypass the problem o= repressorsL avoidance
in reportin& ne&ative a==ect<
One /ay o= achievin& this /old be by sin& semi%strctred intervie/s, a
methodolo&y &ainin& poplarity in health psycholo&y< For e*ample, a nmber o=
researchers Ae<&< (oyne N ;ottlieb, 1--GB have s&&ested the se o= semi%strctred
intervie/s in the stdy o= copin& as a process, /here the se o= chec0lists is
problematic< 7he problems o= sin& chec0lists to stdy copin& are /ell discssed in
the literatre Asee (oyne N ;ottlieb, 1--G8 :ar0er N Endler, 1--!B< Altho&h it mst
be reco&ni>ed that semi%strctred intervie/s are time%consmin&, costly and reMire
trainin& o= intervie/ers and raters, some o= these problems may be overcome< For
e*ample, the Cyers and $re/in A1--#B stdy sed a brie= parentin& intervie/ to
investi&ate repressorsL childhood e*perience< 7his intervie/ overcame many o= the
potential problems de to its brie= administration Aappro*imately !" mintesB and
brie= trainin& reMired Aa one%/ee0 corseB< 7his semi%strctred intervie/ identi=ied
a nmber o= scales< 3nter%rater reliability /as calclated =or these scales and /as
=ond to be &ood< Kappa /as hi&h =or each o= the ratin&s A"<-"%"<-.B, /ith a&reement
bet/een -! and -G percent<
Altho&h there is considerable evidence to spport the hypothesis that repressors
ans/er sel=%report instrments in a positive =ashion, repressors may do this less /ith
certain sel=%report instrments< RepressorsL =ailre to report ne&ative a==ect may be
limited to do/nplayin& the ne&ative rather than overstatin& the positive< For e*ample,
repressors did not di==er =rom nonrepressors in their optimistic bias =or positive events
and they did not describe themselves more positively /hen
%1''%
sin& positive descriptors ACyers N $re/in, 1--GB< Repressors have been =ond to be
more optimistic than nonrepressors abot individal health events /hich /ere seen as
personally controllable, sch as s==erin& =rom asthma, bt not =or ncontrollable
events, sch as s==erin& =rom diabetes ACyers N Reynolds, !"""B< 3n a repertory &rid
stdy, repressors compared to nonrepressors /ere more positive abot certain
elements in their lives, sch as their =ather, bt not others, e<&< Oa person 3 li0eP
ACyers et alD9 1---B< On a measre o= dispositional optimism Athe 6i=e Orientation
7est8 )cheier N (arver, 1-@.B, repressors compared /ith nonrepressors reported
si&ni=icantly lo/er pessimism Ane&ative itemsB, bt not hi&her optimism Apositive
itemsB ACyers N )teed, 1---B<
1'-
Other stdies s&&est that i= repressors are allo/ed to e*press themselves positively
on some items o= a sel=%report measre, they may rate themselves less positively on
other items< For e*ample, individals /ho e*hibit an avoidant adlt attachment style
have been described as devalin& the importance o= relationships, reportin& e*tremely
positive relationships /ith their parents and do/nplayin& the in=lence o= childhood
e*periences ADo>ier N Koba0, 1--!B, and there=ore may be hypothesi>ed as bein&
similar to repressors< 3n a stdy investi&atin& avoidant attachment and repressive
copin&, repressors compared to nonrepressors /ere si&ni=icantly more li0ely to rate
themselves as havin& an avoidant style o= romantic attachment Aa ne&ative responseB,
as lon& as they cold also rate themselves as havin& a secre style Aa positive
responseB, bt this pattern /as not seen i= they had to e*clsively choose one style,
/here they /old rate themselves as secrely attached ACyers N Vetere, in pressB<
)imilarly, repressors may rate themselves ne&atively on some items bt not others<
For e*ample, a stdy sed the 7ho&ht (ontrol Yestionnaire AWells N Davis, 1--#B
to investi&ate /hether individals /ith di==erent copin& styles report sin& di==erent
strate&ies to sppress ne&ative tho&hts ACyers, 1--@B< Repressors compared to
nonrepressors reported sin& si&ni=icantly more distraction strate&ies and si&ni=icantly
=e/er pnishment strate&ies< Distraction may be seen as less ne&ative than
pnishment<
Frther research shold investi&ate /hether other methods are able to bypass
repressorsL tendency to report less ne&ative a==ect and, hence, may be a se=l /ay o=
collectin& data =rom repressors< 7hese methods cold inclde in=ormation%processin&
paradi&ms /hich have become poplar in pain research< For e*ample, in response to
ambi&os ces, pain patients compared to control participants systematically
prodced more pain%related associations A:incs et alD9 1--#B< ,sin& an emotional
)troop tas0, pain patients selectively processed pain%related ces at a strate&ic level
bt not an atomatic level A)nider et alD9 !"""B< )ch in=ormation%processin&
approaches cold be e*tended to other areas o= health psycholo&y research< Core
Malitative methods may also be considered, sch as diary stdies and =ocs &rops<
%1'@%
5o repressors have signi)i"antly 1orse health o't"omes-
7here is considerable evidence /hich indicates that the repressive copin& style as
de=ined by Weinber&er et alD A1-'-B may be associated /ith adverse physical health<
)ome o= this evidence is discssed belo/<
7here are a nmber o= stdies /hich s&&est a lin0 bet/een repressive copin& and
cancer< 9ensen A1-@'B condcted a prospective stdy o= /omen /ith a history o=
breast carcinoma /ho /ere =ollo/ed p =or t/o years< :atients e*hibitin& a repressive
copin& style /ere at &reater ris0 o= death =rom cancerE o= 11 patients /ho died drin&
=ollo/%p, ei&ht /ere repressors and repressors displayed more rapid pro&ression o=
the disease than nonrepressors A1, '.. daysL remission =or nonrepressors vs< 1,!"#
days =or repressorsB< Other stdies have =ond an increased incidence o= repressors
amon& cancer s==erers in children A:hipps N )rivastava, 1--'B, adolescents A(annin&
et alD9 1--!B, and /omen /ith breast cancer AKreitler et alD9 1--+B<
1@"
A stdy by 9amner et alD A1-@@B s&&ested an association bet/een repressive copin&
and impaired immne =nctionin&< 7he athors =ond that repressors demonstrated
decreased monocyte conts and elevated eosinophile conts< )imilarly, $ro/n et alD
A1-@-8 reported in OL6eary, 1--"B =ond that repressive copin& /as associated /ith
redced response to mito&ens :HA and (onA<
7here is also some evidence lin0in& repressive copin& /ith cardiovasclar disease<
For e*ample, )ha/ et alD A1-@GB e*amined the relationship bet/een repressive copin&,
cardiac in=ormation and medical complications in predominantly male patients
nder&oin& treatment =or narro/ed coronary arteries< )i* months a=ter treatment,
repressors /ith hi&h 0no/led&e levels abot cardiac disease and no history o=
myocardial in=arction had a si&ni=icantly hi&her ris0 o= medical complications Ae<&<
hospitalisation =or chest pain, myocardial in=arctionB< )imilarly, Niara et alD A1--!B
=ond raised blood cholesterol levels in male repressors<
Repressive copin& has also been lin0ed to impaired pain perception A$rns !"""8
9amner et alD9 1-@GB, hi&h arosal drin& dental sr&ery AFo* et alD9 1-@-aB and
colonoscopy AFo* et alD9 1-@-bB, and chan&es in the menstral cycle AAltems et alD9
1-@@B<
7here=ore, it appears that possessin& a repressive copin& style is associated /ith
ne&ative health otcomes< 3t is postlated that this association is de to repressors not
attendin& to somatic in=ormation Ae<&< )ch/art>, 1--"B< 3t seems li0ely that repressorsL
=ailre to pay attention to distress, as demonstrated by their dissociation bet/een sel=%
report and physiolo&ical measres o= arosal, /old prodce adverse health
otcomes, as somatic si&ns /old be less li0ely to tri&&er health behaviors to relieve
distress< 7his may be a critical =actor in the development o= disease<
Con"l'sions
A sbstantial amont o= research e*ists to indicate that people /ho possess a
repressive copin& style, /ho =orm bet/een 1" and !" percent o= the poplation,
%1'-
avoid ne&ative a==ect and ans/er many sel=%report measres in an overly positive
=ashion< (onseMently, the e*clsive reliance on standard sel=%report methods is not a
satis=actory /ay o= elicitin& in=ormation =rom repressors< Core than one method o=
data collection shold be sed to overcome this problem< 7hese methods may inclde
semi%strctred intervie/s and a care=lly constrcted sel=%report measre< 7hese sel=%
report measres shold contain some items /hich allo/ repressors to e*press
themselves positively so they may rate themselves less positively on other items and,
/here appropriate, cold also reMire repressors to &ive descriptions o= speci=ic events
/ithot allo/in& them to evalate those events emotionally< Wherever possible, a
third method cold be sed, sch as an in=ormation processin& approach, or a more
Malitative method< Research needs to be condcted on these methods, to determine
their advanta&es and disadvanta&es in the conte*t o= repressive copin&<
3n addition, the potential lin0 bet/een repressive copin& and adverse physical health
ma0es repressors an important &rop =or health psycholo&ists to stdy in their o/n
1@1
ri&ht< 7he implications o= nderstandin& the repressive copin& style, in terms o= its
contribtion to health otcomes, is crcial< 3n =tre stdies it may be advisable to
identi=y repressorsL speci=ic contribtion to the reslts rather than to i&nore this
potentially si&ni=icant sorce o= individal di==erences<
!e)eren"es
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1@'
%1@#%
art III
5evelopmental aspe"ts
%!!+%
Chapter $&
Atta"hment representation and a))e"t reg'lation
C'rrent )indings o) atta"hment resear"h and their relevan"e )or psy"hosomati"
medi"ine
Carl 5duard %cheidt and 5lisabeth ;aller
Introd'"tion
De=icits o= a==ect re&lation and a==ect reco&nition have been considered as
vlnerability =actors =or the development and corse o= psychosomatic illness< 3n the
present chapter, the a==ect re&lation is considered =rom an attachment theory
perspective< We claim that the e*pression and reco&nition o= a==ects are central
=eatres o= the in=ant%mother interaction< A==ects re&late distance and closeness and
si&nal the in=antLs need =or spport and reassrance< 7he motherLs sensitivity to/ards
the in=antLs a==ective si&nals has trned ot as an in=lential predictor o= the in=antLs
attachment secrity in later development< 3t may be assmed that the capacity =or
a==ect reco&nition and a==ect e*pression and the development o= attachment secrity
share a common developmental path/ay<
3n the =ollo/in& para&raphs, /e /ill =irst smmari>e some o= the basic concepts o=
attachment theory< We /ill then discss the isse o= mental representation o=
attachment, /hich is particlarly important =or the stdy o= attachment in adlthood<
Finally, /e /ill otline the contribtion o= attachment research to the nderstandin&
o= psychopatholo&ical conditions in adlthood /ith special re=erence to
psychosomatic illnesses<
?asi" "on"epts o) atta"hment theory
$o/lby A1-'.B de=ined attachment as an innate system o= motivation and behavior
/ith the =nction to provide those /ho are not yet sel=%viable a=ter birth /ith a sense
o= closeness and secrity as protection a&ainst e*ternal dan&ers< 7he term
OattachmentP re=ers to a system o= behavior servin& to establish or protect the close
vicinity to an attachment person, &enerally, the mother< With hmans, in the =irst
months o= li=e this behavior is characteri>ed by sc0in&, clin&in&, cryin&, and smilin&<
$y the end o= the =irst year, the di==erent reactions small in=ants sho/ to separation
=rom the attachment person demonstrate varyin& behavior patterns< 3ndividal
di==erences in the attachment behavior are bro&ht into the =ore&rond
%!!.%
1@@
see Ains/orth et alD9 1-'@8 $els0y, 1-@#8 E&erland N Faber, 1-@#8 ;rossmann et alD9
1-@.B< 7he connection bet/een maternal sensitivity and Mality o= attachment drin&
the =irst year has been con=irmed in nmeros =rther stdies A$els0y, 1-@#8 E&erland
N Faber, 1-@#8 ;rossmann et alD9 1-@.B<
Frther observations in the 1-@"s led to a discovery o= another attachment behavior
pattern, /hich /as termed the disorgani@ed attachment beha'ior< Researchers
/or0in& /ith maltreated and psycholo&ically conspicos parents had reali>ed that
some children, /ho had been maltreated, had been scored as OsecreP in their
attachment behavior altho&h they simltaneosly demonstrated behavior patterns
typical =or insecre%avoidin& as /ell as insecre%ambivalent children A(rittenden,
1-@.8 Rad0e%Yarro/ et alD9 1-@.B< Cain and Weston A1-@1B reported that some 1+
percent o= the children o= the O$ay Area sampleP cold not be cate&ori>ed accordin&
to the sal rles o= classi=ication by Ains/orth< A later reanalysis o= the videotapes
sho/in& children /ho /ere di==iclt to cate&ori>e proved that the maRority o= non%
cate&ori>ed children demonstrated disor&ani>ed attachment behavior in the presence
o= the parents ACain N )olomon, 1-@G, 1--"B< 7his disor&ani>ed attachment behavior
appears to be associated /ith non%directed or bro0en%o== movements, vocali>ations to
the stran&er /hile the mother le=t the room drin& the )tran&e )itation, non%directed
hits to the =ace Ao=ten the eyesB o= the parents, movement stereotypes, asymmetrical
and temporally ncoordinated movement and postre abnormalities, =ree>in&, starin&
e*pressions or a &enerally slo/ed movement and movement o= e*pression< 7hese
behaviors /ere labeled disor&ani>ed becase they /ere not re&arded as a distinct,
consistent, and coherent attachment strate&y ACain, 1--.B< 3n non%clinical samples,
the percenta&e o= children sho/in& disor&ani>ation lies at 1.%!. percent< 3n samples
o= maltreated children, ho/ever, the percenta&e amonts to @" percent A(arlson et alD9
1-@-8 6yons%Rth et alD9 1--1B< )ch =indin&s s&&est that disor&ani>ation is a
conseMence o= trama a==ectin& attachment behavior<
The mental representation o) atta"hment
3n later child and adlt li=e the co&nitive processin& o= social e*perience as /ell as the
se o= symbolical commnication becomes increasin&ly important< 7his led to
attachment research =rom the mid%1-@"s becomin& increasin&ly interested in
e*aminin& the Mality o= attachment at levels o= mental, symbolical representation o=
the attachment e*perience< 7his cannot be assessed by the observation o= behavior
only< Rather it /as assmed that in adlthood individal di==erences o= attachment
reveal themselves in the lin&istic discorse on attachment e*periences, sch as
drin& an in%depth intervie/< )ecrely attached individals /old be able to &ive
access to e*periences /ith attachment =i&res in childhood in a more complete and
coherent manner than individals /ith an insecre attachment representation<
7he development o= the intervie/ method o= e*amination to record the di==erences o=
attachment representation in adlt li=e served to e*amine the trans&enerational
%!!'%
involvement in previos attachment e*periences< 3nstead, the description o= the
attachment persons chan&es in Mic0 sccession bet/een positive and ne&ative
Rd&ements< 7he sbRects lose the line o= discssion /ithot reali>in& this themselves<
1@-
7hey are nable to abstract speci=ic e*periences and recollections and to dra/ &eneral
conclsions< 7he intervie/ is characteri>ed by mainly episodic memories, /hich are
not bro&ht to&ether /ith one coherent &eneral pictre o= the attachment
history<Analo&osly to the disorgani@ed =D> cate&ory o= in=ant attachment behavior,
an unresol'ed =M> cate&ory =or adlthood /as set p ACain N ;old/yn, 1--G8 Cain
N Hesse, 1--"B< 7he main characteristic o= the disor&ani>ed and nresolved
attachment representation is the nsccess=l or incomplete /or0in& thro&h o= loss
or trama Amaltreatment or misse by the attachment personB, /hich has led to a
disor&ani>ed behavior or thin0in& process< 3n discssin& the e*periences o= loss or
trama in the intervie/, disor&ani>ation is demonstrated by a chan&e in the lo&ical
and lin&istic strctre o= the discorse, /hereby =acts in connection /ith loss or
maltreatment are mi*ed p, denied, bro&ht into Mestion or =alsi=ied<7o conclde,
observations =rom attachment research s&&est that individal di==erences in
attachment sho/ a considerable stability over time< Di==erences o= attachment style
may be considered as central or&ani>in& patterns o= social behavior and emotional
e*perience< 3n adlthood, attachment mst be considered on the level o=
representational processes< 3n the =ollo/in& section /e /ill report on some clinical
implications o= attachment theory /ith special re=erence to psychosomatic illness<
Atta"hment theory and psy"hosomati" resear"h
From the perspective o= attachment theory, three Mestions present themselves =or
psychosomatic research, /hich /ill be discssed =rther on< 7hese Mestions areE
A1B 3s the prevalence o= insecre patterns o= attachment increased in clinical
conditions and in particlar in patients /ith psychosomatic distrbancesT
A!B Does attachment secrity di==erentially a==ect physiolo&ical arosal in
response to stressT
A+B 3s insecre attachment associated /ith distrbances o= a==ect re&lation,
etiolo&ically relevant =or psychosomatic illnessT
Differences inatta"hment representation *et1een "lini"al and non+"lini"al gro'ps
and non+"lini"al gro'ps
7he assmption that the Mality o= previos attachment e*perience has an in=lence on
the copin& /ith later developmental tas0s is a =ndamental postlate o= attachment
theory< Nmeros stdies con=irm the connection bet/een attachment
%!!-%
behavior in early childhood and later socioemotional development Asee )chieche,
1--G, =or an overvie/B< 7hese investi&ations &enerally s&&est a more =avorable
corse o= psycholo&ical and social adaptation in children /ith a secre pattern o=
attachment in early in=ancy< 3t there=ore seemed reasonable to e*amine the prevalence
o= secre or insecre attachment representation in clinical &rops< )tdies inclded
in=ants and adolescents /ith condct disorders A(ro/ell N Feldman, 1--18
Rosenstein N Horo/it>, 1--+B as /ell as adlts /ith varios symptoms sch as
sleepin& disorders A$enoit et alD9 1--!B, depression A:atric0 et alD9 1--#8 Rosenstein N
Horo/it>, 1--+B, borderline disorder AFona&y, 1--+B and others A(rittenden et alD9
1--18 Fona&y, 1--+B< Van 39>endoorn and $a0ermans%Kranenbr& A1--GB smmari>e
1# clinical stdies in /hich a total o= #+- participants /ere e*amined /ith the Adlt
Attachment 3ntervie/< Only 1+ percent o= them proved to have a secre attachment
representation, #1 percent had an insecre%dismissin&, and #G percent an insecre%
ambivalent attachment representation< 7he =reMency o= the t/o insecre attachment
1-"
patterns varied in the individal stdies dependin& on the type o= disorder< 3n
borderline patients, =or e*ample, a hi&h proportion o= sbRects /ith an insecre%
ambivalent attachment representation /as observed AFona&y, 1--+8 :atric0 et alD9
1--#B, /hile patients /ith sleepin& disorders A$enoit et alD9 1--!B more =reMently
had an insecre%dismissin& attachment representation<
7here are almost no stdies to date on attachment representation in psychosomatic
syndromes< One e*ception is a stdy by )la/sby A1--.B, in /hich patients /ith
chronic atypical =acial pain and patients /ith neral&ia o= the tri&emins nerve /ere
compared< A si&ni=icantly hi&her prevalence o= insecre attachment representation
/as =ond in patients /ith atypical =acial pain<
3n conclsion, sbstantial empirical evidence spports the hypothesis that insecre
patterns o= attachment are si&ni=icantly more =reMent in clinical than in non%clinical
poplations< 3n addition, some stdies s&&est a di==erential prevalence o= the t/o
insecre patterns in di==erent clinical conditions< For instance, the insecre ambivalent
pattern seems more prevalent in borderline personality disorder, /hereas in
psychosomatic and somato=orm disorders an insecre dismissin& attachment
representation prevails<
Patterns of attachment andpsy"hophysiologi"al aro'sal in response to stress
Research on the psychobiolo&y o= attachment has provided evidence that the
=ormation and disrption o= social relationships has important physiolo&ical
conseMences< 7he physiolo&ical reactions, /hich /ere observed sbseMent to
separation in yon& primates, inclde chan&es in body temperatre, heart rate,
endocrine and immne =nctions, body /ei&ht and sleep patterns A(oe, 1--+8 (oe et
alD9 1-@.8 Ho=er, 1-'+, 1-@#, 1--#8 Reite N $occia, 1--#B< (onsiderin& the
psychobiolo&ic aspects o= attachment in hmans, $o/lby A1-G-B s&&ested that the
attachment behavior system is interrelated /ith physiolo&ical systems in a seMential%
hierarchical mannerE physiolo&ical responses occr i= the behavioral
%!+"%
adaptation to chan&es in the environment is ins==icient< Accordin& to this hypothesis,
physiolo&ical arosal in response to separation indicates that co&nitive and behavioral
copin& strate&ies are e*hasted<
Evidence =rom developmental psycholo&ical research points ot that drin& the early
sta&es o= development the re&lation o= physiolo&ical processes stron&ly depends on
the Mality o= the attachment relationship to a primary care provider< :articlarly,
maternal sensitivity has been demonstrated to in=lence the in=antsL physiolo&ical
response to stress< (hildren o= less sensitive mothers sho/ed si&ni=icantly hi&her
levels o= salivary cortisol than children o= sensitive mothers drin& periods o= =ree
play and e*ploration in the a&e o= three to si* months A)pan&ler et alD9 1--#B< At the
a&e o= 1! months, observations drin& the )tran&e )itation AAins/orth et alD9 1-'@B
sho/ed that in=ants /ith insecre%avoidant attachment behavior have hi&her levels o=
salivary cortisol in response to separation than secrely attached in=ants A)pan&ler N
;rossmann, 1--+B<
1-1
)tdies investi&atin& the lin0 bet/een attachment and the psychophysiolo&ical
response to stress in adlts demonstrated that sbRects /ith dismissin& attachment
sho/ a si&ni=icantly hi&her increase in the level o= s0in condctance /hile ans/erin&
Mestions re=errin& to separation, reRection or threat =rom the parents than sbRects
/ith secre attachment ADo>ier N Koba0, 1--!B< Frthermore, heart rate and blood
pressre levels /ere elevated in insecre%dismissin& and insecreambivalent sbRects
drin& a stress=l laboratory tas0, /hen their romantic partners /ere present
A(arpenter N Kir0patric0, 1--GB<
3n sm, these =indin&s s&&est that insecre patterns o= attachment and in particlar an
insecre%dismissin& attachment pattern mi&ht be a determinant o= an elevated
psychophysiolo&ical response to stress and there=ore shold be considered as a ris0
=actor predisposin& to physical illness<
ffect regulation and psychosomatic illness
7he sppression o= a==ect e*pression is also considered as bein& an important =actor in
the etiolo&y and corse o= psychosomatic illness< 7he assmption o= an inverse
relationship bet/een emotional e*pression and physiolo&ical arosal in response to
stress historically can be traced bac0 to Ale*ander A1-#-B< 7his athor postlated that
physiolo&ical processes belon&in& to non%reali>ed =i&ht%or%=li&ht reactions chan&ed
into a dys=nctional permanent activation i= they /ere not reali>ed by action<
7he clinical =indin&s that persons s==erin& =rom a psychosomatic illness o=ten are not
able to reali>e and e*press their =eelin&s led Nemiah and )i=neos A1-'"B to the
concept o= ale*ithymia< 7hese athors characteri>ed a personality strctre mar0ed by
a distrbance in the e*perience and reco&nition o= emotions< 7he concept incldes the
idea that in ale*ithymic individals a==ects have lost their =nction as lin0s bet/een
psycholo&ical and physiolo&ical processes< As descriptive characteristics o=
ale*ithymia, a narro/in& and paralysis o= the emotional and =antasy li=e /ere
emphasi>ed A6esser, 1-@1B< 3n addition, athors o= the French
%!+1%
psychosomatic school ACarty N de CL,>an, 1-G+B bro&ht =or/ard the co&nitive
characteristics o= Ooperational tho&htP =pensJe operatoire>9 /hich mani=est
themselves in a de=icit o= =antasy and an inner li=e /hich centered on the details o=
e*ternal reality< 7aylor A1--#B cites empirical evidence /hich s&&ests that a decisive
aspect o= ale*ithymia consists o= de=iciencies in the interpersonal re&lation o=
emotions< :atients scorin& hi&h on ale*ithymia sho/ed a Odissociation o= the
physiolo&ical and sbRective response to stress=l stimli as /ell as hi&h tonic levels
o= sympathetic activity that are not modlated by a chan&in& environmentP A7aylor,
1--#, p< G+B< Ho/ever, ale*ithymic characteristics are etiolo&ically relevant =or
psychosomatic illnesses in only a minority o= cases< Ale*ithymia there=ore shold be
nderstood more &enerally as one component amon& several in a model o=
'ulnerability =or psychosomatic illness<
De to a lac0 o= appropriate assessment tools, =or lon& ale*ithymia did not &et
attention in psychophysiolo&ical research< Hypotheses on an inverse lin0 bet/een
a==ect e*pression and physiolo&ical activation /ere not systematically elaborated in
1-!
ale*ithymia research< Ho/ever, the clinical validity o= the concept to&ether /ith the
more recent availability o= a reliable measre A$a&by et alD9 1--#a, 1--#bB has
contribted to the most recent series o= stdies that have been carried ot on this isse
Asee (hapter @B<
Another important emotional non%e*pression constrct is the Orepressive copin&
styleP A$yrne, 1-G18 Weinber&er, 1--"8 Weinber&er et alD9 1-'-B< Repression relates
e*plicitly to the connection bet/een a==ect re&lation and physiolo&ical arosal<
Repression is a habital personality characteristic that re&lates the processin& o=
=ear%arosin& or stress%related in=ormation AWeinber&er, 1--"B< :ersons /ith a
repressive copin& style sppress =ear%releasin& in=ormation that cold lead to a
contradiction in sel=%perception< 7he opposite pole to a repressive copin&%style is a
Osensiti>in&P in=ormation processin& style< 7his is connected to a stren&thened =ocs
on =ear%arosin& in=ormation AAspendor= N )cherer, 1-@+8 Krohne N Ro&ner, 1-@.B<
7he validity o= the repression constrct has been demonstrated in varios
psychophysiolo&ical stdiesE repression has been associated /ith increased
cardiovasclar reactivity AKin& et alD9 1--"B, increased plasmalipids ANiara et alD9
1--!B and a redced celllar immne competence AEsterlin& et alD9 1--"B< A
repressive copin& style is also connected to speci=ic characteristics o=
atobio&raphical memoriesE persons /ith hi&her repression have less access to their
childhood memories< On the /hole, they report =e/er recollections, especially o=
ne&ative e*periences, and they need lon&er to recollect ne&ative e*periences than non%
repressors ACyers N $re/in, 1--#B<
7he relationship bet/een a==ect e*pression and physiolo&ical arosal has been
repeatedly stdied over the past years AAnderson, 1-@18 )bn&er%Alt et alD9 1-@-8
7rae, 1-@-B< $erry and :enneba0er A1--+B conclded in a revie/ paper that persons
/ho sppress emotional e*pression =or /hatever reason have a hi&h ris0 =or a nmber
o= illnesses< Ho/ever, to date no evidence has been provided =or the idea that the
sppression o= a==ects is speci=ically related to psychosomatic illness AAnderson,
1-@1B or that the selective sppression o= ne&ative emotions is more
%!+!%
=reMent in patients /ith psychosomatic illnesses than in other persons A)bn&er%Alt et
alD9 1-@-B<
One can conclde that there have been stdies lin0in& de=icits in a==ect re&lation and
e*pression to physiolo&ical =nctionin& and health< Ho/ever, this has not been
obtained e*clsively =or psychosomatic symptoms and illnesses<
'nsecure attachmentand a))e"t reg'lation
From the attachment theory perspective, the reali>ation and e*pression o= a==ects
serves to conserve the relationship to the attachment person< Normally, a==ective
e*pression%especially the e*pression o= ne&ative a==ects%is an important si&nal in order
to receive spport =rom parents A(assidy, 1--#B< Ho/ever, i= the e*pression o=
emotions specially intended to attract the care o= the attachment person Ae<&<
e*pressions o= =ear and an&erB continosly leads to reRection, a style o= a==ect
behavior develops that is based on minimi>in& a==ect e*pression and mas0in& o=
1-+
ne&ative emotions< $ased on =indin&s o= Ains/orth et alD A1-'@B /ith respect to the
ori&in o= attachment behavior in insecre%avoidin& in=ants, it can be assmed that the
avoidin&%attachment behavior develops as a conseMence o= reRection to/ards the
in=antLs search =or closeness and contact< 7he minimi>in& o= attachment behavior and
emotional e*pression, and the mas0in& o= ne&ative a==ects, allo/s the in=ant to
preserve perceived closeness to the attachment =i&re, in spite o= the reRection ACain,
1-@18 Cain N Weston, 1-@1B< 7he narro/in& o= emotional e*pression in insecre%
avoidin& in=ants can be nderstood as part o= a commnicative strate&y to indicate
that the child sta0es no claims A(assidy, 1--#B< Escher%;rbb N ;rossmann A1-@+B
tested the behavior o= t/o%year%old in=ants and their mothers drin& an episode o= =ree
play and observed that the mothers o= secrely attached in=ants only participated in
the play and spported this /hen the in=ants sho/ed si&ns o= ne&ative a==ects Atension
and annoyanceB< 3n contrast, the mothers o= insecre%avoidin& in=ants participated
especially /hen the in=ants /ere satis=ied and /ithdre/ /hen ne&ative a==ects /ere
e*pressed< 3t can be conclded that in the interaction /ith the mother, in=ants /ith
avoidin& attachment =ind less spport than secrely attached in=ants in toleratin&
ne&ative emotions and learnin& to cope /ith them<
Recent stdies on the psychosocial conditions in /hich ale*ithymia arises sho/ed a
connection bet/een a lo/ emotional e*pressiveness in the =amily and hi&her scores o=
ale*ithymia in the o==sprin&< 3n addition, a lo/er sense o= secrity /as observed
/ithin the =amily relationships o= ale*ithymic individals A$erenbam N 9ames,
1--#B< Coreover, an association /as =ond bet/een ale*ithymic characteristics o=
in=ants or adolescents and their mothers A6mley N Norman, 1--GB, s&&estin& a
trans&enerational lin0 =or ale*ithymia< Finally, in patients /ith idiopathic spasmodic
torticollis, secre attachment representation correlated ne&atively, and an insecre%
dismissin& attachment strate&y correlated positively, /ith ale*ithymia A)cheidt et alD9
1---B<
3t can ths be conclded that conver&ence can be observed bet/een the reslts
%!++%
o= AiB attachment research into dyadic a==ect re&lation in childhood, s&&estin& an
association bet/een insecre attachment and narro/in& o= emotional e*pressiveness,
especially /ith respect to ne&ative a==ect, and AiiB the retrospective tests into the
ori&ins o= ale*ithymia, pointin& at potential lin0s /ith the presence o= ale*ithymia in
the parents and /ith =eelin&s o= insecrity /ithin the =amily< Frther stdies are
necessary to clear the relationship bet/een developmental roots o= attachment
representation and the clinically described distrbances o= a==ectre&lation later in
li=e<
Con"l'sion
7he application o= attachment theory concepts and methods in psychosomatic
medicine is still in an early sta&e< 7he aim o= this chapter is to indicate that
psychosomatic research cold ma0e better pro&ress /hen incorporatin& =indin&s =rom
attachment research< 7he attachment theory o==ers a scienti=ic =rame/or0 =or the
developmental and etiolo&ical aspects o= psychosomatic distrbances, /hich are
=reMently encontered in clinical practice< :reviosly developed methods =or
1-#
attachment research shold be applied also in clinical psychosomatic research< Only
then /ill it be possible to nderta0e empirical stdies on a patho&enetic model o=
psychosomatic illnesses based on psycholo&ical developmental concepts<
!e)eren"es
Ains/orth, C<D<)< A1-'+B< 7he development o= in=ant%mother attachment< 3n
$<C< (ald/ell N H<N< Ricciti AedsB, Re'ie" of Child De'elopment Research,
Vol< + App< 1%--B< Ne/ Yor0E )a&e<
Ains/orth, C<D<)< A1-''B< )0alen >r Er=assn& mZtterlichen VerhaltensE
Fein=Zhli&0eit verss ,nemp=indlich0eit &e&enZber den )i&nalen des $abys
D)cales to assess maternal behavior< )ensitivity verss insensitivity =or the babyLs
si&nalsF< 3n K<E< ;rossmann Aed<B, 5nt"ic!lung der LernfUhig!eit KDe'elopment
of Learning %!illsL App< -G%1"'B< CnichE Kindler<
Ains/orth, C<D<)< N Witti&, $<A< A1-G-B< Attachment and the e*ploratory
behavior o= one%year%olds in a stran&e sitation< 3n $<C< Foss Aed<B, Determinants
of infant beha'ior, Vol< # App< 11+%1+GB< 6ondonE Cethen<
Ains/orth, C<D<)<, $ell, )<C<, N )tayton, D< A1-'1B< 3ndividal di==erences in
stran&esitation behavior o= one%year%olds< 3n H<R< )cha==er Aed<B, The origins of
human social relations App< 1'%.'B< Ne/ Yor0E Academic :ress<
Ains/orth, C<D<)<, $lehar, C<, Waters, E<, N Wall, )< A1-'@B< Patterns of
attachment< Hillsdale, N9E 6a/rence Erlbam<
Ains/orth, C<D<)< N Eichber&, (<;< A1--1B< E==ects on in=ant%mother attachment
o= mothersL nresolved loss o= attachment =i&re, or other tramatic e*perience< 3n
(<C< :ar0es, 9< )tevenson%Hinde, N :< Carris AedsB, ttachment across the life
cycle App< 1G"%1@+B< 6ondon, Ne/ Yor0E 7avistoc0, Rotled&e<
Ale*ander, F< A1-#-B< Psychosomatische ?edi@inD Grundlagen und
n"endungsgebiete KPsychosomatic medicineD Basics and fields of applicationLL,
#th edn A1-@.B< $erlinE de ;ryter<
%!+#%
Anderson, (<D< A1-@1B< E*pression o= a==ect and physiolo&ical response in
psychosomatic patients< Eournal of Psychosomatic Research,%/, 1#+%1#-<
Aspendor=, 9<$< N )cherer, K<R< A1-@+B< 7he discrepant repressorE di==erentiation
bet/een lo/ an*iety, hi&h an*iety, and repression o= an*iety by atonomic%
=acial%verbal patterns o= behavior< Eournal of Personality and %ocial
Psychology,,/, 1++#%1+#G<
$a&by, R<C<, :ar0er, 9<, N 7aylor ;<9< A1--#aB< 7he t/enty%item 7oronto
Ale*ithymia )cale%3< 3tem selection and cross%validation o= the =actor strctre<
Eournal of Psychosomatic Research,&2, !+%+!<
1-.
$a&by, R<C<, :ar0er, 9<, N 7aylor ;<9< A1--#bB< 7he t/enty%item 7oronto
Ale*ithymia )cale%33< (onver&ent, discriminant, and concrrent validity< Eournal
of Psychosomatic Research,&2, ++%#"<
$els0y, 9< A1-@#B< 7he determinants o= parentin&< A process model< Child
De'elopment,//, '1@%'!@<
$enoit, D<, Heanah, (<H<, $ocher, (, N Cinde, K< A1--!B< )leep disorders in
early childhoodE association /ith insecre maternal attachment< Eournal of the
merican cademy of Child and dolescent Psychiatry,&$, @G%-+<
$erenbam, H< N 9ames, 7< A1--#B< (orrelates and retrospectively reported
antecedents o= ale*ithymia< Psychosomatic ?edicine,/., +.+%+.-<
$erry, D<)< N :enneba0er, 9<W< A1--+B< Nonverbal and verbal emotional
e*pression and health< Psychotherapy and Psychosomatics,/#, 11%1-<
$o/lby, 9< A1-G-B< ttachment and loss9 Col $3 ttachment< Ne/ Yor0E $asic
$oo0s<
$o/lby, 9< A1-'.B< BindungD 5ine nalyse der ?utter-Pind-Be@iehung
KttachmentD n analysis of the mother-infant relationshipLD CnichE Kindler<
$yrne, D< A1-G1B< 7he repression%sensiti>ation scaleE rationale, reliability, and
validity< Eournal of Personality,%#, ++#%+#-<
(arlson, V<, (icchetti, D<, $arnett, D<, N $ran/ald, K< A1-@-B<
Disor&ani>ed?disoriented attachment relationships in maltreated in=ants<
De'elopmental Psychology,%/, .!.%.+1<
(arpenter, E<C< N Kir0patric0, 6<A< A1--GB< Attachment style and presence o= a
romantic partner as moderators o= psychophysiolo&ical responses to a stress=l
laboratory sitation< Personal Relationships,&, +.1%+G'<
(assidy, 9< A1--#B< Emotion re&lationE in=lences o= attachment relationships< 3n
N<A< Fo* Aed<B, The de'elopment of emotion regulation3 biological and
beha'ioral considerationsD ?onographs of the %ociety for Research in Child
De'elopment,/#, !!@%!#-<
(oe, (<6< A1--+B< :sychosocial =actors and immnity in nonhman primatesE a
revie/< Psychosomatic ?edicine,//, !-@%+"@<
(oe, (<6<, Wiener, )<;<, Rosenber&, 6<7<, N 6evine, )< A1-@.B< Endocrine and
immne responses to separation and mental loss in nonhman primates< 3n C<
Reite N 7< Field AedsB, The psychobiology of attachment and separation App< !!+%
!..B< Orlando, F6E Academic :ress<
(rittenden, :<C< A1-@.B< Caltreated in=antsE vlnerability and resilience< Eournal
of Child Psychology and Psychiatry,%., @.%-G<
1-G
(rittenden, :<C<, :artrid&e, C<F<, N (lassen, A<H< A1--1B< Family patterns o=
relationship in normative and dys=nctional =amilies< De'elopment and
Psychopathology,&, #-1%.1!<
(ro/ell, 9<A< N Feldmann )<)< A1--1B< CotherLs /or0in& models o= attachment
relationships and mother and child behavior drin& separation and renion<
De'elopmental Psychology,%4, .-'%G".<
Do>ier, C< N Koba0, R<R< A1--!B< :sychophysiolo&y in attachment intervie/sE
conver&in& evidence =or deactivatin& strate&ies< Child De'elopment,.&, 1#'+%
1#@"<
%!+.%
E&erland, $< N Faber, E<A< A1-@#B< 3n=ant%mother attachment< Factors related to
its development and chan&es over time< Child De'elopment,//, '.+%''1<
Escher%;rbb, (<D< N ;rossmann, K<E< A1-@+B< Bindungssicherheit im @"eiten
Lebens4ahrD Die Regensburger Iuerschnittsuntersuchung Kttachment security in
the second year of lifeD The Regensburger cross-sectional studyLD ,npblished
report, ,niversity o= Re&ensbr&<
Esterlin&, $<A<, Antoni, C<H<, Kmar, C<, N )chneiderman, N< A1--"B<
Emotional repression, stress disclosre responses, and Epstein%$arr viral capsid
anti&en titers< Psychosomatic ?edicine,/%, +-'%#1"<
Fona&y, :< A1--+B< The relationship bet"een the emotional de'elopment of the
child and the history and current mental function of the parents< :aper presented
at the )ymposim on :ersonalityE Developmental :sycholo&y and Developmental
:sychopatholo&y, 6eiden, 7he Netherlands<
Fona&y, :<, )teele, H<, N )teele, C< A1--1B< Caternal representations o=
attachment drin& pre&nancy predict the or&ani>ation o= in=ant%mother attachment
at one year o= a&e< Child De'elopment,.%, @-1%-".<
Fremmer%$ombi0, E< A1-@'B< Beobachtungen @ur Bindungs7ualitUt im @"eiten
Lebens4ahr und ihre Bedeutung im Lichte mOtterlicher Pindheitserinnerungen
K8bser'ations of the attachment 7uality in the second year of life and their
meaning in the light of mother2s memoriesL9 ,npblished CasterLs 7hesis,
,niversitbt Re&ensbr&<
;eor&e, (<, Kaplan, N<, N Cain, C< A1--.B< dult attachment inter'ie"<
,npblished manscript, Department o= :sycholo&y, ,niversity o= (ali=ornia,
$er0eley<
;rossmann, K<, Fremmer%$ombi0, E<, Rdolph, 9<, N ;rossmann, K<E< A1-@@B<
Caternal attachment representations as related to patterns o= in=ant%mother
attachment and maternal care drin& the =irst year< 3n R<A< Hinde N 9< )tevenson%
Hinde AedsB, Relationships "ithin families3 mutual influences App< !#1%!G"B<
1-'
O*=ordE (larendon :ress<
;rossmann, K<, ;rossmann, K<E<, )pan&ler, ;<, )ess, ;<, N ,n>ner, 6< A1-@.B<
Caternal sensitivity and ne/bornsL orientation responses as related to Mality o=
attachment in northern ;ermany< 3n 3< $retherton N E< Waters AedsB, Gro"ing
points of attachment theory and researchD ?onographs of the %ociety for
Research in Child De'elopment,/6, 1%!<
Hamilton, (<E< A!"""B< (ontinity and discontinity o= attachment =rom in=ancy
thro&h adolescence< Child De'elopment,4$, G-"%G-#<
Hinde, R<A< N )tevenson%Hinde, 9< AedsB< A1-@@B< Relationships "ithin families3
?utual influences< O*=ordE (larendon :ress<
Ho=er, C<A< A1-'+B< 7he e==ects o= brie= maternal separations on behavior and
heart rate o= t/o /ee0 old rat pps< Physiology and Beha'ior,$6, #!+%#!'<
Ho=er, C<A< A1-@#B< Relationships as re&latorsE a physiobiolo&ic perspective on
bereavement< Psychosomatic ?edicine,,., 1@+%1-'<
Ho=er, C<A< A1--#B< Hidden re&lators in attachment, separation and loss< %ociety
of Research on Child De'elopment,/#, 1-!%!"'<
Kin&, A<(<, 7aylor, (<$<, Albri&ht, (<A<, N Has0ell, W<6< A1--"B< 7he
relationship bet/een repressive and de=ensive copin& styles and blood pressre
responses in healthy, middle%a&ed men and /omen< Eournal of Psychosomatic
Research,&,, #G1%#'1<
Krohne, H<W< N Ro&ner, 9< A1-@.B< Cehrvariablen%Dia&nosti0 in der
$e/blti&n&s%=orschn& DClti%variable dia&nostics in copin& researchF< 3n H<W<
Krohne Aed<B, ngstbe"Ultigung in Leistungssituationen App< #.%G!B< Weinheim,
;ermanyE Edition :sycholo&ie<
%!+G%
6esser, 3<C< A1-@1B< Revie/ o= the ale*ithymia concept< Psychosomatic
?edicine,,&, .+1%.#+<
6mley, C<A< N Norman, )< A1--GB< Ale*ithymia and health care tili>ation<
Psychosomatic ?edicine,/2, 1-'%!"!<
6yons%Rth, K<, Repacholi, $<, Cc6eod, )<, N )ilva, E< A1--1B< Disor&ani>ed
attachment behavior in in=ancyE short%term stability, maternal and in=ant
correlates, and ris0%related sbtypes< De'elopment and Psychopathology,&, +''%
+-G<
Cain, C< A1-@1B< Avoidance in the service o= attachmentE A /or0in& paper< 3n ;<
3mmelmann, ;< $arlo/, C< Cain, N 6< :etrinovich AedsB, Beha'ioral
de'elopment3 the Bielefeld interdisciplinary pro4ect App< G.1%G-+B< Ne/ Yor0E
1-@
Cain, C< A1--.B< Recent stdies in attachmentE overvie/ /ith selected
implications =or clinical /or0< 3n )< ;oldber&, R< Cir, N 9< Kerr AedsB,
ttachment theoryD %ocial9 de'elopmental and clinical perspecti'es App< #"'%#'#B<
Hillsdale, N9 and 6ondonE 7he Analytic :ress<
Cain, C< N (assidy, 9< A1-@@B< (ate&ories o= response /ith the parent at a&e si*E
predicted =rom in=ant attachment classi=ications and stable over a one%month
period< De'elopmental Psychology,%,, #1.%#!G<
Cain, C< N ;old/yn, R< A1--GB< dult attachment scoring and classification
systems AGth ednB< ,npblished manscript, ,niversity o= (ali=ornia, $er0eley<
Cain, C< N Hesse, E< A1--"B< :arentsL nresolved tramatic e*periences are
related to in=ant disor&ani>ed attachment statsE is =ri&htened and?or =ri&htenin&
parental behavior the lin0in& mechanismT 3n C<7< ;reenber&, D< (icchetti, N
E<C< (mmin&s AedsB, ttachment in the preschool years3 Theory9 research and
inter'ention App< 1G1%1@!B< (hica&o, 36E ,niversity o= (hica&o :ress<
Cain, C< N )olomon, 9< A1-@GB< Discovery o= a ne/, disor&ani>ed?disoriented
attachment pattern< 3n 7<$< $ra>elton N C< Yo&man AedsB, ffecti'e de'elopment
in infancy App< -.%1!#B< Nor/ood, N9E Able*<
Cain, C< N )olomon, 9< A1--"B< :rocedres =or identi=yin& in=ants as
disor&ani>ed? disoriented attachment pattern drin& the Ains/orth )tran&e
)itation< 3n C<7 ;reenber&, D< (icchetti, N E<C< (mmin&s AedsB, ttachment
in the preschool years3 Theory9 research and inter'ention App< 1!1%1G"B<
(hica&o, 36E ,niversity o= (hica&o :ress<
Cain, C< N Weston, D<R< A1-@1B< 7he Mality o= the toddlerLs relationship to
mother and =ather related to con=lict behavior and readiness to establish ne/
relationships< Child De'elopment,/%, -+!%-#"<
Carty, :< N de CL,>an, C< A1-G+B< Das operative Den0en< DOperative thin0in&F<
Psyche,&%, -'#%-@#<
Cyers, 6<$< N $re/in, (h<R< A1--#B< Recall o= early e*perience and the
e*pressive copin& style< Eournal of bnormal Psychology,$6&, !@@%!-!<
Nemiah, 9<(< N )i=neos, :<E< A1-'"B< :sychosomatic illnessE a problem in
commnication< Psychotherapy and Psychosomatics, $2, 1.#%1G"<
Niara, R<, Herbert, :<C<, CcCahon, N<, N )ommerville, 6< A1--!B< Repressive
copin& and blood lipids in men and /omen< Psychosomatic ?edicine,/,, G-@%
'"G<
:atric0, C<, Hobson, R<:<, (astle, :<, Ho/ard, R<, N Ca&han, $< A1--#B<
:ersonality disorder and the mental representation o= early social e*perience<
De'elopment and Psychopathology,., +'.%+@@<
1--
Rad0e%Yarro/, C<, (mmin&s, E<C<, Kc>yns0i, 6<, N (hapman, C< A1-@.B<
:atterns o=
%!+'
attachment in t/o% and three%year%olds in normal =amilies and =amilies /ith
parental depression< Child De'elopment,/., .-1%G1.<
Reite, C< N $occia, C<6< A1--#B< :hysiolo&ical aspects o= adlt attachment< 3n
C<$< )perlin& N W<H< $erman AedsB, ttachment in adults3 Clinical and
de'elopmental perspecti'es App< -@%1!'B< 6ondon, Ne/ Yor0E ;il=ord :ress<
Rosenstein, D<)< N Horo/it>, H<A< A1--+B< ;or!ing models of attachment in
psychiatrically hospitali@ed adolescents3 Relation to psychopathology and
personality< :aper presented at the si*th Ceetin& o= the )ociety =or Research in
(hild Development, Ne/ Orleans, 6A<
)bn&er%Alt, (<, )teimer%Krase, E<, Wa&ner, ;<, N Krase, R< A1-@-B< Cimisches
Verhalten psychosomatischer :atienten D7he =acial e*pression o= psychosomatic
patientsF< Seitschrift fOr Plinische Psychologie,$2, !#+%!.G<
)cheidt, (<E<, Waller, E<, )chnoc0, (h<, $ec0er%)toll, F<, Himmermann, :<,
6Zc0in&, (<H<, N Wirschin&, C< A1---B< Ale*ithymia and attachment
representation in idiopathic spasmodic torticollis< Eournal of <er'ous and ?ental
Disease,$24, #'%.!<
)chieche, C< A1--GB< 5.ploration und physiologische Rea!tionen bei
@"ei4Uhrigen Pindern mit unterschiedlichen Bindungserfahrungen K5.ploration
and physiological reactions of t"o year old infants "ith different attachment
e.periencesLD ,npblished doctoral dissertation, ,niversity o= Re&ensbr&,
;ermany<
)la/sby, E<A< A1--.B< Psychosocial factors of pain in chronic atypical facial
pain< ,npblished doctoral dissertation< ,niversity o= Cassachsetts, $oston<
)pan&ler, ;< N ;rossmann, K<E< A1--+B< $iobehavioral or&ani>ation in secrely
and insecrely attached in=ants< Child De'elopment,.,, 1#+-%1#."<
)pan&ler, ;<, )chieche, C<, 3l&, ,<, Caier, ,<, N Ac0ermann, (< A1--#B< Caternal
sensitivity as an e*ternal or&ani>er =or biobehavioral re&lation< De'elopmental
Psychobiology,%4, #!.%#+'<
7aylor, ;<9< A1--#B< 7he ale*ithymia constrctE conceptali>ation, validity and
relationship /ith basic dimensions o= personality< <e" Trends in 5.perimental
and Clinical Psychiatry,$6, G1%'#<
7rae, H<(< A1-@-B< GefOhlsausdruc!9 Femmung und ?us!elspannung unter
so@ialem %treV3 Cerhaltensmedi@in myogener Popfschmer@en K5.pression of
!""
emotion9 inhibition and muscle tension under social stress3 Beha'ioral medicine
of myogenous headacheLD ;[ttin&en, ;ermanyE Ho&re=e<
Van 39>endoorn, C< N $a0ermans%Kranenbr&, 9< A1--GB< Attachment
representations in mothers, =athers, adolescents and clinical &ropsE a meta%
analytic search =or normative data< Eournal of Consulting and Clinical
Psychology,.,, @%!1<
Ward, C<9< N (arlson, E<A< A1--.B< Association amon& adlt attachment
representations, maternal sensitivity, and in=ant%mother attachment in a sample o=
adolescent mothers< Child De'elopment,.., G-%'-<
Wartner, ,<;<, ;rossmann, K<, Fremmer%$ombi0, E<, N )ess, ;< A1--#B<
Attachment patterns at a&e si* in )oth ;ermanyE predictability =rom in=ancy and
implications =or preschool behavior< Child De'elopment,,#, #@+%#-#<
Waters, E< A1-'@B 7he reliability and stability o= individal di==erences in in=ant%
mother attachment< Child De'elopment,,#, #@+%#-#<
Waters, E<, Cerric0, )<K<, Albersheim, 6<, N 7rebo*, D< A1--.B< ttachment
security from infancy to early adulthood3 a *+-year longitudinal study< :oster
presented at the $iennial Ceetin& o= the )ociety =or Research in (hild
Development, 3ndianapolis, 3N<
%!+@
Weinber&er, D<A< A1--"B< 7he constrct validity o= the repressive%de=ensive
copin& style< 3n 9<6< )in&er Aed<B, Repression and dissociation3 Defense
mechanisms and personality styles App< ++'%+@GB< (hica&o, 36E ,niversity o=
(hica&o :ress<
an*ios, and repressive copin& styles< :sychometric patterns and behavioral and
Himmermann, :<, Fremmer%$ombi0, E<, )pan&ler, ;<, N ;ro\mann, K<E< A1--.B<
ttachment in adolescence3 a longitudinal perspecti'e< :oster presented at the
$iennial Ceetin& o= the )ociety =or Research in (hild Development,
3ndianapolis, 3N<
%!+-%
Chapter $,
Children:s "on"eption o) the emotion pro"ess
Conse;'en"es )or emotion reg'lation
Fedy %tegge9 ?ar! ?eerum Ter"ogt9 lbert Rei4nt4es and <athalie 'an Ti4en
!"1
Introd'"tion
(ontemporary emotion theories consider emotions to be basically adaptive< 7hey
si&nal the relevance o= events to personal concerns and prepare the individal to
respond so as to ensre the satis=action and protection o= these concerns AFriRda,
1-@GB< 7he essential =nction o= an emotion is or&ani>ationE once the system is
s/itched on, it coordinates the activity o= disparate response systems Aphysiolo&y,
perception, motor behavior, e*pression, and also hi&her mental processesB in order to
deal appropriately /ith the emotion%elicitin& event A6evenson, 1---8 )cherer, 1-@#B<
Emotions are not only re&latory, they also need to be adeMately re&lated< Recently,
6evenson A1---B has eloMently e*plicated this conception o= emotions as both
re&latory and re&lated phenomena< 3n his Ot/o system desi&n o= hman emotionsP,
6evenson distin&ishes a core system that =nctions Mite atomatically and provides
Mic0, standard soltions to a limited nmber o= prototypical li=e problems< $y
synchroni>in& the activity o= the relevant response modes, the core system enables s
to escape a dan&er, adapt to a loss, or =i&ht an attac0< Ho/ever, the script%li0e,
stereotypical emotional response o= the core system o=ten /ill be modi=ied by the
activity o= the srrondin& control system in order to provide a more adeMate =it /ith
the prevailin& sitation< Accordin& to 6evenson, emotion re&lation re=ers to Othe
li=elon& process o= /or0in& ot an etiMette o= action and interaction bet/een the t/o
emotion systemsP Ap< #-1B< As hman bein&s /e have the need to =eel, /hile at the
same time e*periencin& a sense o= control over or emotional li=e A7om0ins, 1-G!B<
$ein& able to accomplish adaptive &oals in emotionally arosin& sitations is one o=
the most important tas0s the developin& person =aces< An emotionally competent
individal is capable o= re=lective re&lation o= emotion to promote personal &ro/th
and the Mality o= social relationships ACayer N )alovey, 1--'8 )aarni, 1---B<
Emotions become increasin&ly sel=%re&lated as a reslt o= nerophysiolo&ical
matration, the &ro/th o= lan&a&e and co&nition, and the development o= emotional
nderstandin& A;ross, 1---B< 3n this chapter, /e /ill discss the development o=
childrenLs vie/ o= the emotion process /ithin the conte*t o= emotion re&lation<
%!#"%
Ceta%emotive nderstandin& stimlates the emer&ence o= sel=%re&latory processes
that can be employed deliberately and /ith strate&ic prpose in a variety o= sitations
ACayer N )alovey, 1--'8 Ceerm 7er/o&t N Oltho=, 1-@-B< 7/o research areas are
o= interest =or the domain nder stdy hereE AiB the stress and copin& tradition, /hich
=ocses on the /ay in /hich people deal /ith stress=l sitations, and AiiB the poplar
research tradition that has become 0no/n as the stdy o= the OchildLs theory o= mindP<
We /ill provide a short overvie/ o= the most important =indin&s =rom each o= these
research domains<
The "oping tradition
3n their Ostress and copin&P model, 6a>ars and Fol0man A1-@#B de=ine copin& as the
co&nitive and behavioral e==orts to mana&e a trobled person%environment
relationship< 3n classi=yin& peopleLs copin& behaviors, these athors distin&ish t/o
broad cate&oriesE problem%=ocsed copin& and emotion%=ocsed copin&< :roblem%
!"!
=ocsed copin& concerns the se o= strate&ies aimed at diminishin& the actal
problems presented by the sitation< Emotion%=ocsed copin&, on the other hand,
involves behavior that is directly aimed at improvin& the resltin& emotional state< A
closely related dichotomy /as introdced by Rothbam et alD A1-@!B, /ho distin&ish
primary control =rom secondary control< :rimary control involves a chan&e in the
actal conditions that &ave rise to the emotional e*perience, /hereas secondary
control concerns a ma*imi>ation o= oneLs &oodness o= =it /ith the conditions as they
are< Cost problem%=ocsed strate&ies can be considered e*amples o= primary control,
/hile the &reater part o= the emotion%=ocsed strate&ies can be tho&ht o= as instances
o= secondary control<
3n the copin& literatre, it has consistently been reported that /hereas even yon&
children ac0no/led&e the se=lness o= problem%=ocsed or primary copin& strate&ies,
the vale o= emotion%=ocsed or secondary copin& options is appreciated only /ith
increasin& a&e A$and N Weis>, 1-@@B< 7his a&e shi=t can be e*plained by childrenLs
increasin& nderstandin& o= emotions as a mental process ACeerm 7er/o&t N
)te&&e, 1--.B< :rimary control strate&ies involve a chan&e in the actal conditions in
the otside /orld and can be applied even /ithot an nderstandin& o= the inner
emotional e*perience that motivates the childLs copin& behavior< 3n secondary copin&,
on the other hand, the child tries to in=lence its sbRective reaction to the emotion%
elicitin& event and may se co&nitive maniplations to reach this re&latory &oal< 3n
order to ac0no/led&e the se=lness o= these co&nitive strate&ies, the child needs a
conception o= emotion as a mental process< 3t has to nderstand that an emotional
reaction is not determined by the obRective sitation as sch, bt rather by oneLs
appraisal, the interpretation o= the event<
3n the past t/o decades, psycholo&ists have e*tensively stdied childrenLs acMisition
o= 0no/led&e abot the mental /orld< 7his =lorishin& research area has become
0no/n nder the headin& o= the childLs theory o= mind A7oCB< 3n the ne*t section, /e
/ill discss the development o= a mentalistic conception o= emotion as stdied /ithin
this tradition<
%!#1%
The "hild:s theory o) mind tradition
Researchers stdin& Otheory o= mindP development have mainly =ocsed on childrenLs
conceptions o= t/o =ndamental components o= the mind, desires and belie=s, and
their 0no/led&e o= ho/ these mental states are casally lin0ed to behavior and to
other mental states sch as emotions< 3t has been sho/n that bet/een the a&es o= three
and si*, children rapidly acMire an nderstandin& o= the desire% and belie=%dependent
natre o= emotions< First, they come to nderstand the lin0 bet/een desires and
emotionE &ettin& /hat yo /ant reslts in a positive emotion AhappinessB, /hereas not
&ettin& /hat yo /ant cases a ne&ative emotion sch as sadness or an&er A)tein N
6evine, 1-@-,1---B< 3nitially, this 0no/led&e is limited in that desires are conceived
o= as bein& rather obRectiveE yon& children assme that everyone /ill be happy abot
&ettin& a piece o= chocolate to eat and rather nhappy abot &ettin& potatoes ARie==e
et alD9 !""1B< 3t is only /hen they have come to nderstand adeMately the sbRective
natre o= desires that they reali>e that person A may be happy /hen &ettin& a present
becase it is somethin& that AsBheLs /anted to have all alon&, /hereas person $ may
!"+
be nhappy /ith the same present becase AsBhe pre=ers somethin& else< )till
some/hat later, as children have also come to nderstand the relation bet/een belie=s
and emotions, they 0no/ that it is not the actal sitation that determines ho/ yo
=eel abot it, bt rather yor tho&hts abot it< 3= yo believe that the closed m& in
yor hand contains yor =avorite drin0, yoLll be happy, even i= yor belie= is
mista0en becase someone has secretly s/itched the content AHarris et alD9 1-@-B< $y
the a&e o= si*, children are Mite able both to e*plain and to predict a personLs
emotional state on the basis o= his or her sbRective desires and belie=s< 7hey have
acMired a mentalistic conception o= the emotion process AHarris, 1-@-B<
,ntil no/, the lin0 bet/een desires and belie=s on the one hand and emotions on the
other has never been e*amined =rom an emotion re&lation perspective< :artly, this
may be cased by the =act that theory o= mind researchers have mainly =ocsed on the
demonstration o= the early 0no/led&e o= basic principles amon& yon& children,
rather than the application o= this elementary 0no/led&e to more comple* problems,
sch as a sitation in /hich a child needs to chan&e a ne&ative =eelin& state< 3t is this
applied theory o= mind =ocs AFlavell, !"""B that /e have adopted in or research on
emotion re&lation<
(hildren nderstand that emotions are cased by a personLs sbRective desires and
belie=s rather than by the obRective sitation some/here arond the a&e o= si*<
Ho/ever, to date it is n0no/n /hether 0no/led&e abot the lin0s bet/een
sbRective mental states and emotions is also applied in their reasonin& abot emotion
re&lation< 3= emotions are cased by desires, belie=s or tho&hts abot a sitation, one
possible /ay o= chan&in& an n/anted emotion is by chan&in& oneLs desires, belie=s,
or the content o= oneLs tho&hts<
A revie/ o= past research on emotion re&lation stron&ly spports an a&e%related
trend to/ard an increased pre=erence =or co&nitive or mental strate&ies o= emotion
re&lation< 3n an early intervie/ stdy AHarris et alD9 1-@1B, it /as sho/n that
%!#!%
/hereas si*%year%old children mainly s&&est sitational or behavioral chan&es /hen
as0ed ho/ to re&late a ne&ative =eelin& state, ten%year%olds also ac0no/led&e the
se=lness o= mental maniplations< 7he &eneral developmental shi=t to an emphasis
on co&nitive strate&ies o= emotion re&lation has been replicated in nmeros other
stdies since then A=or recent revie/s see Denham, 1--@8 )aarni, 1---B<3n
developmental psycholo&y, the =ocs o= stdies on a&e%related chan&es in emotion
re&lation has lar&ely been con=ined to the broad distinction bet/een sitational or
behavioral strate&ies verss mental strate&ies Aor Oe*ternalP verss OinternalP
strate&ies, as $renner and )alovey A1--'B have called themB< Relatively little attention
has been paid to developments /ithin the e*tensive domain o= co&nitive
maniplations< Nonetheless, it is Mite plasible that some co&nitive strate&ies are
more easily nderstood than others< 7hese developments are the =ocs o= the present
chapter< We /ill e*amine to /hat e*tent children o= di==erent a&es consider varios
0inds o= mental maniplations se=l to chan&e a ne&ative =eelin& state< $ased on the
reslts o= empirical research, /e /ill present some important chan&es in childrenLs
conception o= the emotion process, seen =rom a re&lation perspective<
Children:s perspe"tive on the strategi" "ontrol o) emotions( the 'se o) "ognition
!"#
3n a =irst intervie/ stdy, a&e chan&es in childrenLs theori>in& abot the se=lness o=
di==erent strate&ies o= emotion re&lation /ere e*amined A)te&&e N Ceerm 7er/o&t,
1--@B< (hildren A=or%year%olds, <]+-8 si*%year%olds, <].@8 ten%year%olds, <].-B and
adlts A<]##B /ere presented /ith t/o ne&ative stimls sitations, one intended to
elicit an&er and one intended to elicit sadness< For sadness, t/o prototypical sitations
/ere sedE the death o= a pet do& and the move o= oneLs best =riend to another to/n< A
sitation in /hich a promise /as bro0en Aa trip to the beach /as cancelledB and a
sitation in /hich a valed possession /as dama&ed by a yon&er siblin& /ere sed
to elicit an&er< Hal= o= the sbRects =rom each a&e &rop ans/ered Mestions abot the
sitation in /hich the prota&onist /as sad becase his?her pet do& died and the
sitation in /hich the story character /as an&ry abot a bro0en promise< 7he other
hal= o= the sbRects /ere presented /ith the t/o parallel stimls sitations<A=ter the
stimls sitation /as described, sbRects /ere presented /ith si* alternative
reactions< 3n each case, they /ere as0ed /hether or not the strate&y o==ered /old
reslt in a decrease in the prota&onistLs ne&ative =eelin& state and /hy that /old or
/old not be the case< 7hese si* reactions /ereE
1 behavioral avoidance Ae<&< &o and play otside /ith a =riendB
! behavioral con=rontation Ae<&< pt a/ay the belon&in&s o= the do& that diedB
+ mental avoidance Ae<&< try to =or&et abot /hat had happenedB
# mental con=rontation Ae<&< &o to sit do/n and thin0 o= yor beloved petB
%!#+%
. a positive reappraisal Arememberin& the &ood times yo spent /ith yor pet
=riendB
G a ne&ative reappraisal Athin0in& that yo can never play /ith yor do&
anymoreB<
3n 7able 1#<1, childrenLs evalations o= the di==erent re&lation options presented are
smmari>ed<
Table $(D$ Cean percenta&es o= participants in each a&e &rop that predicted an
increase or decrease in the intensity o= the ne&ative emotion as a reslt o= the se o=
di==erent re&lation strate&ies
(-
year-
olds
6-
year-
olds
$+-
year-
olds
dults
Decrease by behavioral avoidance @1g '@g @@g @@g
3ncrease by behavioral con=rontation #"g G"g '!g G!g
Reappraisalsf G+g '1g -"g -!g
Decrease by mental avoidance Aan&erB @"g @!g -.g @"g
3ncrease by mental con=rontation Aan&erB .@g ."g -1g -+g
!".
(-
year-
olds
6-
year-
olds
$+-
year-
olds
dults
Decrease by mental avoidance AsadnessB 'Gg '-g @-g +Gg
3ncrease by mental con=rontation AsadnessB +#g G"g @#g #.g
fCean percenta&es o= participants /ho correctly
predicted mood improvement Apositive reappraisalsB or
mood deterioration Ane&ative reappraisalsB<
/ehavioral avoidance and confrontation
(hildren o= all a&es, as /ell as adlts, /ere o= the opinion that see0in& distraction is
an e==ective strate&y to re&late both an&er and sadness< 3nspection o= the
Rsti=ications sho/ed that =or%year%olds mainly e*plained their ans/ers in terms o=
sitational responses AOthe person =eels better becase he or she is &oin& to do an
activityPB, /hereas ten%year%olds and adlts almost e*clsively re=erred to the mental
process AOthe person =eels better becase he or she =or&ets abot /hat has happenedPB<
7he &rop o= si*%year%olds &ave both sitational and mentalistic Rsti=ications< 7hs,
/hereas the maRority o= sbRects =rom all a&e &rops /ere able to predict that a person
=eels better /hen he or she en&a&es in some pleasant activity, older sbRects
evidenced &reater 0no/led&e o= ho/ mental activity can chan&e a personLs emotions<
(lear a&e di==erences /ere =ond in childrenLs tho&hts abot the e==ect o= behavioral
con=rontation< As a&e increased, sbRects more o=ten indicated that the ne&ative
emotional reaction /old be intensi=ied by bein& con=ronted /ith somethin& that
/old remind one o= the ne&ative stimls sitation< 3nspection o= the Rsti=ications
sho/ed that this re=lects an increasin& nderstandin& o= the mechanism that is re=erred
to in the literatre as co&nitive cein& AWhitta0er et alD9 1-@.B< Whereas =or%year%
olds, and to a lesser e*tent si*%year%olds, o=ten did not seem to reali>e that
con=rontation /ith an other/ise netral element related to the
%!##%
ori&inal stimls sitation /old remind one o= the ne&ative event, ten%year%olds and
adlts proved to be /ell a/are o= this e==ect<
-eappraisals
Ne*t to the behavioral strate&ies, di==erent types o= co&nitive strate&ies /ere
presented< 7he so%called reappraisals are e*amples o= /hat is called Opre co&nitionP
in the copin& literatre A6a>ars N Fol0man, 1-@#B< We as0ed the children to evalate
the e==ect o= both strate&ies that spposedly /old decrease the ne&ative =eelin& state
Apositive reappraisalsB and strate&ies that /old probably intensi=y the ne&ative
reaction Ane&ative reappraisalsB< 7he strate&ies o==ered concerned a =rther
interpretation o= the /ay in /hich the ne&ative otcome /as achieved A=or e*ample,
the prota&onist tho&ht that the other person had dama&ed a car on prposeB or a
!"G
reappraisal o= the ne&ative otcome itsel= A=or e*ample, the prota&onist tho&ht that
the dama&ed car /asnLt that nice any/ayB< (onsistent /ith or hypothesis, the
nderstandin& o= the e==ect o= the reappraisals increased si&ni=icantly /ith a&e Asee
7able 1#<1B<
3nspection o= childrenLs Rsti=ications provides s /ith an insi&ht into some o= the
problems that yon& children =ace in nderstandin& the e==ect o= the reappraisals<
$oth =or% and si*%year%olds seem to be inclined to interpret the co&nitive chan&e in
perspective presented as a chan&e in reality< When as0ed, =or e*ample, to e*plain /hy
it /old help to thin0 that yo can al/ays visit yor =riend /ho has been moved, they
ar&e that it helps becase it is nice to visit yor =riend and play /ith him or her< 3n
contrast, older sbRects Aten%year%olds and adltsB most o= the time e*plicitly re=er to a
chan&e in perspectiveE Oyo reali>e that yor =riend is still yor =riend, even tho&h
AsB heLs livin& =ar a/ay no/P< 7he t/o yon&est a&e &rops seem to have sbstantial
di==iclties nderstandin& the possibility o= sch a deliberate chan&e in perspective<
When as0ed, =or e*ample, /hether it /old help to thin0 that yo didnLt li0e the
destroyed car that mch any/ay, they either deny that sch a chan&e is possible Abt
he did li0e the carB, or they say OnoP and ar&e that yoLd =eel more sad becase o= a
ne&ative e*perience AOyo donLt li0e the carPB< 7he t/o oldest a&e &rops, in contrast,
correctly ar&e that sch a chan&e in perspective Aa previosly very mch appreciated
car Ois madeP less valedB /old ma0e yo =eel less sad, as losin& somethin& that yo
didnLt li0e very mch is not as bad as losin& somethin& that yo really loved< 3t seems
as i= yon& children base their ans/ers on the positive or ne&ative content o= the
phrase as sch, /hereas older participants actally compare the di==erential e==ect o=
t/o di==erent appraisals o= the same sitation on the resltin& emotional reaction<
#ognitiveavoidan"e and "on)rontation
Finally, /e as0ed sbRects /hether or not mental avoidance or mental con=rontation
/old decrease the intensity o= the ne&ative emotion< As the Rd&ments in this case
%!#.%
proved to be dependent on the type o= emotion, /e present the reslts =or sadness and
an&er separately<
3n the case o= an&er, the reslts parallel those obtained /ith the strate&ies o=
behavioral avoidance and behavioral con=rontation< Even =or%year%olds nderstand
that a ne&ative emotion decreases i= one tries to stop thin0in& abot the sitation that
cased the emotion< When as0ed to Rsti=y their ans/ers, the three oldest a&e &rops
Aand even some o= the =or%year%oldsB re=erred to the relation bet/een =eelin& and
thin0in&E /hen yo stop thin0in& abot a ne&ative sitation, yoLll =eel better< 3n
contrast, the e==ect o= mental con=rontation is o=ten not adeMately evalated by the
t/o yon&est a&e &rops< Almost hal= o= the yon&er children do not nderstand that
co&nitive con=rontation increases the ne&ative =eelin& state< 3nspection o= childrenLs
Rsti=ications revealed that yon& childrenLs problems are cased by their reliance on
the speci=ic ne&ative, netral or positive content o= the tho&hts presented< When
as0ed /hether it /old help to thin0 abot the beach in case o= the cancelled trip, they
ar&e Oyes, becase it is nice to thin0 abot the beachP< Older sbRects, in contrast,
!"'
correctly ar&e Ono, becase that only reminds yo o= ho/ mch yo /anted to &o to
thereP<
For sadness, similar reslts /ere =ond, /ith one e*ception< A sbstantial proportion
o= the adlts =elt that mental avoidance is not an e==ective strate&y to re&late =eelin&s
o= sadness, /hereas mental con=rontation is considered to be a se=l strate&y =or
dealin& /ith this emotion< 7he analysis o= the Rsti=ications sho/ed that adlts
typically re=er to the lon&%term conseMences o= the di==erent strate&ies< Whereas
avoidance may be e==ective in the short rn, the lon&%term conseMences are
considered to be more ne&ative< One has to =ace the loss in order to be able to come to
terms /ith oneLs sadness< Yite a nmber o= adlts opted =or this lon&%term
perspective, ar&in& that con=rontation Aboth behavioral and mentalB is an e==ective
/ay o= dealin& /ith sadness, /hereas avoidance /ill be e==ective in the short rn bt
problematic as time passes by<
7he reslts o= this stdy convincin&ly sho/ an increase in childrenLs nderstandin& o=
the se=lness o= co&nitive strate&ies o= emotion re&lation, based on their
nderstandin& o= the lin0 bet/een sitation, co&nition and emotion< 7he =indin&s
seem to s&&est the =ollo/in& developmental seMence<
Negative/positive situations
(hildren nderstand that en&a&in& in a pleasant activity or /ithdra/in& =rom a
distressin& one reslts in mood improvement<
Negative/positive thoughts
(hildren have acMired an insi&ht into the relation bet/een thin0in& and =eelin&E a
ne&ative =eelin& state can be improved by thin0in& o= somethin& pleasant or not
thin0in& o= somethin& npleasant< )imilarly, a ne&ative emotion /ill be intensi=ied by
thin0in& o= somethin& npleasant<
%!#G%
#ognitive cueing
(hildren 0no/ that an other/ise netral or even positive stimls Areal or mentalB
may intensi=y a ne&ative =eelin& state, as it tri&&ers tho&hts abot the ori&inal
ne&ative stimls sitation<
#hange inperspe"tive
(hildren nderstand that one can deliberately chan&e oneLs sbRective perspective on
the ori&inal sitation in the service o= mood improvement< As mentioned above,
emotional nderstandin& is especially important =or the deliberate, strate&ic control o=
ne&ative =eelin& states< We /ill no/ discss some o= the implications o= childrenLs
&ro/in& nderstandin& o= the mechanisms described above<
First, 0no/in& that the en&a&ement in pleasant activities reslts in a pleasant =eelin&
state allo/s children to see0 these 0inds o= activities /il=lly and avoid npleasant
!"@
ones< When, in the ne*t step, children also come to nderstand the elementary lin0
bet/een thin0in& and =eelin&, sitational chan&es are not necessary anymore< Yo can
also opt =or a mental chan&e in order to =eel better A=or e*ample, thin0in& o=
somethin& more pleasant in a borin& or other/ise ne&atively valenced sitation, /hen
it is not allo/ed to actally leave the sitationB< )bseMently, children may come to
reali>e that certain stimli Areal ones and mental ones ali0eB may tri&&er other
tho&hts< ,nderstandin& the principle o= co&nitive cein& not only helps children to
better nderstand their o/n emotional reactions, bt also allo/s them to anticipate
=tre reactions more precisely< As a person reali>es that certain obRects or tho&hts
/ill remind him or her o= an earlier ne&ative e*perience, these stimli can be avoided
strate&ically< )ome participants in this stdy actally re=erred to these =tre
anticipations by statin&, =or e*ample, that it /old be /ise to pt a/ay the belon&in&s
o= yor beloved do& in order not to be reminded too o=ten abot /hat had happened<
Finally, children also come to nderstand the so%called reappraisals< )ome
reappraisals are relatively easy to nderstand< 7o some e*tent, all children appear to
0no/ that =ocsin& on a positive aspect o= the stimls sitation diminishes the
ne&ative =eelin& state< Yon& childrenLs nderstandin& seems to be limited, ho/ever,
in that they are tied to one co&nitive representation o= reality< 7hey do not seem to
reali>e that one can s/itch perspective deliberately in order to in=lence oneLs
emotions< 3n the case o= a valed loss, =or e*ample, they either deny a possible chan&e
in perspective Abt he did li0e the carB, or they base their Rd&ments on the absolte
valence Apositive or ne&ativeB o= the tho&hts presented< 7hs, altho&h they 0no/
that the loss o= somethin& nimportant /ill not ma0e yo =eel sad, it is not very li0ely
that they /ill actively try to reach sch a state o= mind< Older participants Aadlts and,
to a some/hat lesser e*tent, ten%year%oldsB actally 0eep several perspectives in mind
and compare their di==erential e==ects on the tar&et emotion< 7his 0no/led&e o= the
coe*istence o= di==erent perspectives is also re=lected in their appreciation o= the short%
term verss the lon&%term e==ects o= di==erent strate&ies<
;iven the developmental chan&es in childrenLs reasonin& abot emotion
%!#'%
re&lation, one /old e*pect some strate&ies to be sed more =reMently at yon&er
a&es, /hereas others /ill be sed more =reMently Aor maybe even e*clsivelyB at
older a&es< Altho&h /e do not have data yet allo/in& s to relate childrenLs
nderstandin& o= emotion re&lation to their actal se o= di==erent strate&ies, the
developmental seMence presented here /as spported by another set o= data<
$e=ore they evalated the se=lness o= the re&lation options presented above, the
participants /ere as0ed to &enerate all the possible strate&ies they cold thin0 o= that
/old be se=l to diminish their sadness or an&er in the prevailin& stimls
sitations< $ehavioral distraction /as =reMently mentioned by all a&e &rops,
incldin& =or%year%olds< Cental avoidance /as =reMently mentioned by si*%and ten%
year%olds, and to some e*tent by =or%year%olds, /hereas adlts did not mention this
strate&y very o=ten and re=erred to mental reappraisals instead< Cental reappraisals
/ere =reMently mentioned by this oldest a&e &rop and, to a certain e*tent, also by
ten%year%olds, /hereas this strate&y /as completely absent in the t/o yon&est a&e
&rops< Finally, only adlts Aand a =e/ ten%year%oldsB spontaneosly mentioned
con=rontation as an e==ective strate&y in response to loss<
!"-
7o smmari>e, t/o maRor a&e chan&es became evident in the present stdyE AiB a
&ro/in& nderstandin& o= the e==ect o= mental maniplations, especially those that
rely heavily on the nderstandin& o= the representational natre o= mental processes,
and AiiB an increased tendency to ac0no/led&e the lon&%term e==ects o= con=rontational
strate&ies as opposed to the short%term se=lness o= avoidant behavior< (hildren
initially seem to assme a one%to%one correspondence bet/een sitation, tho&ht
content and emotionE a sad sitation evo0es sad tho&hts and reslts in a sad =eelin&
state< 3n the ne*t step, children are able to disconnect these relationships to some
e*tent< $y association, even a netral stimls may evo0e sadness< And the
con=rontation /ith a sad sitation need not evo0e sad tho&hts and ths sad =eelin&s<
7he person may =ocs on a di==erent aspect o= the sitation or even adopt a completely
di==erent perspective, thereby chan&in& the resltin& =eelin& state<
3n this stdy, the main =ocs /as on the co&nitive%e*periential component o= the
emotion process< An additional component o= the emotion process that may be
in=lenced by re&latory activities is the emotional e*pression A$renner N )alovey,
1--'B< 3n the ne*t section, /e /ill discss some empirical =indin&s concernin& a&e%
related chan&es in childrenLs vie/s on the Anon%Be*pression o= emotion<
Children:s theori9ing a*o't the Cnon+Dexpression o) emotion
3n stdies on childrenLs nderstandin& o= emotion re&lation, their ideas abot the
e*pressive component o= the emotion process and its se=lness =or re&lation
prposes have been relatively ne&lected so =ar< Wor0 that has been done in the area o=
emotional e*pression has predominantly concentrated on childrenLs 0no/led&e o=
display rles A)aarni, 1---B< 7his certainly is an important topic, as rles abot the
e*pression o= emotion play an important role in the re&lation o= daily social
%!#@%
interaction< Ho/ever, =rom a =nctionalist perspective on emotion, it has been ar&ed
that the e*pressive component serves other re&latory =nctions as /ell, both
intrapsychic and interpersonal< )ome e*amples o= /idely ac0no/led&ed =nctions are
the redction o= tension, the spport o= emotion%speci=ic action tendencies, and the
commnication o= the personal =eelin& state in the service o= problem soltion AFriRda,
1-@G8 ;ross, 1--@8 :hilippot N RimQ, 1--@B< We there=ore investi&ated a&e chan&es
in childrenLs theori>in& abot the se=lness o= the Anon%B e*pression o= emotion =or
re&lation prposes<
As part o= the stdy on re&lation described above, /e as0ed children /hether or not
the e*pression o= the emotion A=or e*ample &oin& to oneLs room and startin& to cry, or
rnnin& pstairs and slammin& the doorB /old diminish the intensity o= the
sbRective =eelin& state< )imilarly, in a second Mestion, they /ere as0ed /hether or
not the non%e*pression o= the emotion Ano lon&er pttin& on an an&ry =ace, stoppin& to
cry and /ipin& oneLs eyesB /old help to diminish its intensity<
7able 1#<! &ives the mean percenta&es o= participants in each o= the a&e &rops /ho
consider the e*pression or non%e*pression o= the emotion to be e==ective< 3nspection
o= 7able 1#<! sho/s that adlts are convinced that e*pressin& the ne&ative emotion is
e==ective in diminishin& its intensity, /hereas the inhibition o= the e*pression /ill not
!1"
be e==ective< For children, itLs e*actly the other /ay rond< $y analy>in& the
participantsL Rsti=ications, it /as =ond that children o= all a&es consider the
e*pression o= the emotion to be intrinsically lin0ed p /ith other components o= the
ne&ative emotional e*perience< 7hey seem to see little opportnity =or re&lation o=
the ne&ative =eelin& state by means o= the e*pressive component< A&e chan&es /ere
nonetheless evident< 3t /as sho/n that /ith increasin& a&e, the e*pressive component
is lin0ed /ith di==erent and probably more essential aspects o= the emotional
e*perience< 7he emphasis on sitational chan&es ma0es /ay =or a relative emphasis
on co&nitive content and the sbRective =eelin& state< (haracteristic o= childrenLs
theori>in& is that they assme a one%to%one%correspondence bet/een the emotion%
speci=ic e*pression and the inner e*perience< 7hs, altho&h research /ithin the 7oC
tradition sho/s that even children yon&er than si* are able to distin&ish inner
e*perience and oter e*pression AHarris N ;ross, 1-@@B, the reslts o= this stdy
s&&est that they do not consider the distinction relevant /hen as0ed abot the e==ects
o= e*pression on the intensity o= the sbRective =eelin& state< Rather, they seem to
assme a one%to%one correspondence bet/een the t/o components o= the emotion
process< (onseMently, i= the aim is to improve the sbRective =eelin& state, the
emotional e*pression shold =irst be made consistent /ith the direction o= this chan&e<
7hat is, stoppin& e*pressin& the ne&ative emotion is a =irst reMirement<
Adlts, in contrast, seem to consider the e*pressive component to be relatively
independent =rom other aspects o= the emotion process< 7hey =reMently ar&e that not
e*pressin& the emotion does not necessarily diminish its intensity, becase the
e*pression o= emotion does not coincide /ith its inner e*perience< 3n addition, they
=eel that the e*pression o= emotion has a =nction o= its o/n< Cost adlts ar&e that
the emotion shold be e*pressed in one /ay or another, and re=er to the
%!#-%
Table $(D* Cean percenta&es o= participants that predicted an increase or decrease
in the intensity o= the ne&ative emotion as a reslt o= Anon%Be*pression o= the
emotion
Children dults
3ncrease by e*pressin& the emotion @"g 1'g
Decrease by e*pressin& the emotion !"g @+g
3ncrease by not e*pressin& the emotion +"g G!g
Decrease by not e*pressin& the emotion '"g +@g
ne&ative mental health conseMences o= sppression< 3n =act, they are re=errin& to
the notion o= catharsis, /hich shold be nderstood not so mch%or at least not
only%as short%term implse release, bt also as a rene/ed con=rontation needed to
see the sitation in terms o= /hat it really means to the person< (ryin&, =or
e*ample, is an essential part o= /hat is called the /or0 o= &rie=, /hich may help
!11
the person to come to &rips /ith a loss AFriRda, 1-@GB<
7he reslts o= this stdy s&&est some interestin& a&e chan&es in implicit theories
abot the e*pressive component o= the emotion process, its relation to other
components, and its re&latory =nctions< Obviosly, there is an intrinsic lin0
bet/een e*pression and emotional e*perience< We have seen that children p to
the a&e o= ten are inclined to stress this intrinsic relationship bet/een e*pression
and other components o= the emotion processE cryin& prevents one =rom en&a&in&
in positive activities Alin0 bet/een sitation and e*pressionB, tri&&ers ne&ative
tho&hts Alin0 bet/een e*pression and co&nitionB, and ma0es yo =eel miserable
Alin0 bet/een e*pression and sbRective =eelin& stateB< 3n =act, their relative
pre=erence =or non%e*pression becase o= these =actors indicates that they mainly
consider the short%term e==ects o= e*pressionE &ivin& =ree rein to an&er or sadness
may instate a sel=%rein=orcin& cycle, /here the e*pression o= the emotion
intensi=ies the ne&ative e*perience< Ho/ever, in the lon& term, there is mch to
&ain by e*pressin& the emotionE it may allo/ =or a rene/ed con=rontation /ith the
stimls sitation, open p the possibility =or co&nitive chan&e Aas in relivin& a
tramatic event and learnin& ho/ to deal /ith itB and thereby prevent ne&ative
mental health conseMences A:enneba0er, 1--.8 :enneba0er N Hoover, 1-@.8
:hilippot N RimQ, 1--@B<
Con"l'sion
7he emotional core system as described by 6evenson A1---B comprises o= a set o=
response tendencies in di==erent domains Aphysiolo&ical, e*pressive, behavioral,
co&nitiveB that are intrinsically lin0ed and /hose activity is choreo&raphed
care=lly so as to deal sccess=lly /ith prototypical stimls sitations< 7he
control system can chan&e the corse o= the core system by actin& on one or
several o= the di==erent components< 3n line /ith sch a t/o%system vie/ o=
emotion, $renner and )alovey A1--'B de=ine emotion re&lation as Othe process o=
mana&in&
%!."%
responses that ori&inate /ithin co&nitive%e*periential, behavioral%e*pressive and
physiolo&ical%biochemical components Do= the emotion processFP Ap< 1'"B< 3n this
chapter, /e have =ocsed on childrenLs theori>in& abot re&lation strate&ies that act
pon the =irst t/o components o= the emotion system<
1
7he research presented here has sho/n that in their reasonin& abot emotion
re&lation, yon& children A=or% and si*%year%oldsB assme a one%to%one
correspondence bet/een di==erent components o= the emotion processE the
con=rontation /ith a sad event tri&&ers sad tho&hts, a sad e*pression, a sad =eelin&
state and problematic =nctionin& Ayo canLt play, yo canLt concentrate /hen yo are
sadB< 7he presence o= one o= these ne&atively valenced components is considered to
be the startin& point o= an associative chain o= ne&ative elements< 3n order to improve
a ne&ative =eelin& state, then, yon& children ar&e that one shold avoid the ne&ative
!1!
stimls, e*pel ne&ative tho&hts and?or thin0 o= somethin& =n instead, and stop
e*pressin& the ne&ative emotion< Older children, in contrast, no lon&er seem to be
committed to these one%to%one relationships bet/een di==erent components o= the
emotional e*perience< With a&e, children increasin&ly consider con=rontation to be the
startin& point o= an emotional process that is re&lated by co&nitionE bein& con=ronted
/ith somethin& sad, thin0in& abot somethin& sad, or e*pressin& a ne&ative emotion
may indeed tri&&er ne&ative =eelin&s at =irst, bt also open p ne/ perspectives< As
older children have a better nderstandin& o= the mind as an interpretative device
A(arpendale N (handler, 1--GB, they nderstand that one can actally try to see
thin&s =rom di==erent an&les, and compare the e==ect o= di==erent interpretations o= one
and the same sitation on the prevailin& mood state<
7he development o= an adeMate inner theory o= emotion ACeerm 7er/o&t N
)te&&e, 1--'B reMires t/o levels o= 0no/led&eE AiB an nderstandin& o= the proto%
typical associations bet/een di==erent components o= the emotional e*perience, and
AiiB the ability to disconnect these relationships at least partially and to nderstand that
every sin&le element /ithin the emotion process can become the tar&et o= re&latory
activities< Drin& the corse o= development, children =irst acMire 0no/led&e abot
the prototypical elements o= di==erent emotional e*periences< 7hey learn, =or e*ample,
/hat ma0es them an&ry, /hat an an&ry =ace or voice loo0s li0e, and /hich behaviors
are characteristic o= an an&ry person< 7his type o= 0no/led&e enables children to
reco&ni>e an&er in themselves and others and to 0no/ /hen re&lation is called =or
ACeerm 7er/o&t N Oltho=, 1-@-B< (oncernin& the Mestion o= ho/ to re&late, /e
ar&e that a stron& =ocs on the intrinsic relations bet/een sitation, e*pression,
behavior and emotion as evidenced in yon& childrenLs theori>in& abot emotion /ill
stimlate re&latory activities aimed at O0eepin& a distanceP =rom the ne&ative
e*perience< 3n order to re&late their an&er, yon& children /ill choose to leave the
aversive sitation, to direct
1 7he physiolo&ical%biochemical component can be considered less relevant /ithin
the =rame/or0 o= emotional nderstandin& A$renner N )alovey, 1--'B<
%!.1%
their attention else/here, and to re=rain =rom an&ry e*pressions or behaviors< 3n
contrast, older childrenLs theori>in& /ill allo/ =or more con=rontative re&lation
optionsE payin& attention to the ne&ative event and?or the ne&ative emotion /ill help
yo solve the problem by pttin& it in Aa di==erentB perspective<
For children to be able to =nction in a comple* /orld, the development o= emotion
re&lation capacities is critical< 3ndeed, behavioral or emotional problems are o=ten
associated /ith an inability to re&late ne&ative emotions adeMately A(ole et alD9
1--#8 Oatley N 9en0ins, 1--G8 )te&&e et alD9 1--@B< 3n line /ith the increased interest
in emotional competence, in both the scienti=ic commnity and the society at lar&e
A;oleman, 1--.B, a==ective edcation no/adays =orms an inte&rative part o=
prevention and intervention pro&rams Ae<&< ;reenber& et alD9 1--.8 6ochman N Wells,
1--G8 )tar0 N Kendall, 1--GB< 7he ltimate &oal o= most o= these trainin& corses is
to teach children ho/ to better re&late emotional distress so as to promote sbRective
/ell%bein& and improve the Mality o= social relationships< Empirical research may
provide practitioners /ith valable s&&estions to =rther develop and validate the
!1+
in&redients o= their pro&rams< Or stdies on childrenLs reasonin& abot emotion
re&lation have sho/n that some strate&ies are more demandin& than others, in terms
o= both childrenLs 0no/led&e o= the emotion process and their /illin&ness to endre at
least some amont o= ne&ative a==ect< Kno/led&e o= the developmental trends
otlined in this chapter can be sed not only to direct children o= di==erent a&es to se
appropriate strate&ies, bt also to determine the optimal seMencin& o= the strate&ies
to be proposed to a sin&le individalE a depressed child needs to start ot /ith tryin&
relatively Osa=eP strate&ies allo/in& him or her to avoid a con=rontation /ith the
ne&ative event and trn to somethin& pleasant instead< )imilarly, a=ter an a&&ressive
child has learned to become a/are o= his or her o/n an&er, AsB he /ill initially need to
be instrcted to react by leavin& the sitation< 3n either case, it is only at a later
moment in time that the therapist can trn to the more demandin& re&lation options
o= con=rontation and co&nitive restrctrin& A)te&&e et alD9 !""1B<
!e)eren"es
$and, E<$< N Weis>, 9<R< A1-@@B< Ho/ to =eel better /hen it =eels badE childrenLs
perspectives on copin& /ith everyday stress< De'elopmental Psychology,%,, !#'%
!.+<
$renner, E<C< N )alovey, :< A1--'B< Emotion re&lation drin& childhoodE
developmental, interpersonal and individal considerations< 3n :< )alovey N D<9<
)lyter AedsB, 5motional de'elopment and emotional intelligence< Ne/ Yor0E
$asic $oo0s<
(arpendale, 9<3< N (handler, C<9< A1--GB< On the distinction bet/een =alse belie=
nderstandin& and sbscribin& to an interpretative theory o= mind< Child
De'elopment,.4, 1G@G%1'"G<
(ole, :<, Cichel, C<K<, N OLDonnell%7eti, 6< A1--#B< 7he development o=
emotion re&lation and dysre&lationE a clinical perspective< 3n N< Fo* Aed<B,
?onographs of the %ociety for Research in Child De'elopment,/#, '+%1"+<
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;il=ord :ress<
%!.!%
Flavell, 9<H< A!"""B< Development o= childrenLs 0no/led&e abot the mental
/orld< #nternational Eournal of Beha'ioral De'elopment,%,, 1.%!+<
FriRda, N<H< A1-@GB< The emotions< (ambrid&eE (ambrid&e ,niversity :ress<
;oleman, D< A1--.B< 5motional intelligence< Ne/ Yor0E $antam $oo0s<
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the :A7H) (rriclm< De'elopment and Psychopathology,4, 11'%1+G<
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diver&ent conseMences =or e*perience, e*pression, and physiolo&y< Eournal
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Harris, :<6< A1-@-B< Children and emotion3 the de'elopment of psychological
understanding< O*=ordE $lac0/ell<
Harris, :<6< N ;ross, D< A1-@@B< (hildrenLs nderstandin& o= real and apparent
emotion< 3n 9<W< Astin&ton, :<6< Harris N D<R< Olson AedsB, De'eloping
theories of mind App< !".%+1#B< (ambrid&eE (ambrid&e ,niversity :ress<
Harris, :<6<, 9ohnson, (<N<, Htton, D<, Andre/s, ;<, N (oo0, 7< A1-@-B<
Yon& childrenLs theory o= mind and emotion< Cognition and 5motion,&, +'-%
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Harris, :<6<, Oltho=, 7<, N Ceerm 7er/o&t, C< A1-@1B< (hildrenLs 0no/led&e
o= emotion< Eournal of Child Psychology and Psychiatry,%%, !#'%!G1<
6a>ars, R<)< N Fol0man, )< A1-@#B< %tress9 appraisal and coping< Ne/ Yor0E
)prin&er<
6evenson, R<W< A1---B< 7he intrapersonal =nctions o= emotions< Cognition
and 5motion,$&, #@1%."#<
6ochman, 9< N Wells, K< A1--GB< A social%co&nitive intervention /ith
a&&ressive childrenE prevention e==ects and conte*tal implementation isses<
3n R< :eters N R< CcCahon AedsB, Pre'enting childhood disorders9 substance
abuse and delin7uency App< 111%1#+B< 7hosand Oa0s, (AE )a&e<
Cayer, 9<D< N )alovey, :< A1--'B< What is emotional intelli&enceT 3n :<
)alovey N D<9< )lyter AedsB, 5motional de'elopment and emotional
intelligence App< +%+#B< Ne/ Yor0E $asic $oo0s<
Ceerm 7er/o&t, C< N Oltho=, 7< A1-@-B< A/areness and sel=%re&lation o=
emotion in yon& children< 3n (< )aarni N :<6< Harris AedsB, The child2s
understanding of emotion App< !"-%!+'B< Ne/ Yor0E (ambrid&e ,niversity
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Ceerm 7er/o&t, C< N )te&&e, H< A1--.B< (hildrenLs nderstandin& o= the
strate&ic control o= ne&ative emotions< 3n 9<A< Rssell Aed<B, 5'eryday
conceptions of emotionsD <T8 %# %eries App< +'+%+-"B< Dordrecht, 7he
NetherlandsE Kl/er<
Ceerm 7er/o&t, C< N )te&&e, H< A1--'B< De positie van emoties binnen de
O7heory o= CindP D7he position o= emotions /ithin the L7heory o= CindLF<
Ti4dschrift 'oor 8nt"i!!elingspsychologie,%&, 1@+%1-!<
!1.
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$lac0/ell<
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American :sycholo&ical Association<
:enneba0er, 9<W< N Hoover, (<W< A1-@.B< 3nhibition and co&nitionE to/ard an
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Eournal of De'elopmental Psychology,$#, !.-%!'#<
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%!.#%
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