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The aim of the present study was to examine the intra- and interpersonal emotion regulation of patients with somatic symptom disorders (SSDs) during interactions with significant others (i.e., romantic partners). We presented two case couples for analysis. The first couple consisted of a patient with SSD and his healthy partner, whereas the second couple consisted of two healthy partners. The couples underwent an interpersonal experiment that involved baseline, anger and relaxation tasks. During each task, partners’ cutaneous facial temperature, heart rate and skin conductance levels were measured simultaneously. Participants’ trait-emotion regulation, state-affect reports for self and other, and attachment styles were also examined. The experimental phases were successful in creating variations in physiological processes and affective experience. As expected, emotion regulation difficulties predicted higher increase in the course of temperature at each phase. Besides, the patient showed restricted awareness and reflection to emotions despite his higher autonomic activity compared to healthy controls. Both partners of the first couple revealed limited ability in understanding the other’s emotions, whereas the second couple performed relatively better in that domain. The temperature variations between the patient and his partner were significantly correlated while the correlations of temperature changes between the second couple were negligible except anger task. The study supported the merits of an embodied interpersonal approach in clinical studies. The tentative results of the cases were discussed in the light of findings in emotion regulation and attachment research.
Somatic symptom disorder (SSD) is characterized by persistent somatic disturbances, which cause severe impairment in patients’ daily life (DSM-V). The disturbances are accompanied by excessive and dysfunctional thoughts, affects, behaviors or health concerns. Psychological factors contribute to the development, course and treatment of these disorders (
An increasing number of studies highlight the presence of emotion regulation disturbances in SSD, such as emotion suppression (
Theories that explain the nature and development of SSD put an emphasis on the role of emotion regulation disturbances (see
The theoretical models mentioned above as well as existing empirical research imply a pattern of emotion regulation in SSD, which is characterized by incoherence between emotion constituents. Supporting the postulation of incoherent emotional processing, a systematic review on emotion regulation in SSD (Okur et al., in revision) revealed that patients with SSD tend to detach from the emotion by means of disengaging the cognitive- behavioral components of emotion from the emotional perturbations. For instance, patients were shown to have higher levels of alexithymia and reduced ability in emotion recognition and affective theory of mind (
Emotion theories generally agree that emotion response system has multiple components coordinating with each other (
We also argue that, since emotional process is a continuous, inseparable regulating and regulated system (
These findings illustrate the potential effects of emotion regulation on concordance between emotion response systems. Emotion regulation patterns, which patients with SSD unconsciously or deliberately deploy, might affect the coherence between emotional constituents. Hence, in the light of the literature on emotion regulation in SSD, we hypothesize that incoherence in emotional process characterizes the regulation patterns of patients with SSD, which is moderated by attachment and trait emotion regulation styles. This incoherent process is described by disengagement of cognitive components from the emotional perturbations but greater physiological stress responses marked by higher activity or vigilance at the somatic components of emotion. Our proposed assessment of intrapersonal emotional incoherence relies on the extent of discrepancy between emotional responses, which is manifested by restricted expression of and reflection on emotions. Simultaneously, we expect an aberrant and reactive sympathetic nervous system response.
Interpersonal factors, which are proposed to play a role in the development of emotion regulation disturbances in SSD, continue to trigger and maintain the psychosomatic symptoms later in life. There is quite a consensus on the role of interpersonal interactions, attachment and trauma history in dysregulated affect of SSD that is linked to alterations in the endocrine, immune, and pain regulating systems (
In the developmental history of SSD, an “emotional avoidance culture” with significant adults was described, which was associated with patients’ disconnection of awareness from stress reactions in the body (
Although studies exist having examined the perceived social interactions with significant others in SSD, there is a scarce literature on how on going affects during patients’ interaction with significant others are co-regulated. Self-report studies show less supportive and cohesive family environment, conflicts in marital relationship (
We believe that studies from social cognition and developmental research on intersubjectivity can provide much insight to clinical research by introducing the constitutive aspects of social interaction, such as coordination or reciprocity. In fact, it is highlighted that the process of social interaction cannot be sufficiently grasped by examining the mere static interaction of individual elements, since social interactions possess dynamic features such as self-organization and autonomy (
In the context of these recent developments in social cognition and emotion research, we inquire how affect dysregulation takes place in interactions of patients with SSD with significant others (i.e., romantic/life partner). We propose that: (1) Intrapersonal emotional incoherence in SSD is more likely to be reciprocated by an emotional incoherence in the interaction partner. This may leave the affective exchange dysregulated and generate a system of incoherent interpersonal emotional processing. This persisting dysregulated affect at intra- and interpersonal levels might exacerbate bodily disturbances. Here, we define interpersonal emotional coherence as the correlation between interaction partners’ physiological and subjective affective response systems. (2) The parameters of autonomic nervous system activity will be less concordant during emotional interactions between dyads with SSD as compared to healthy control dyads. This concordance will be moderated by the attachment and trait emotion regulation styles of the partners.
We deemed it necessary to employ a paradigm involving real-time dyadic emotional interaction tasks (i.e., dyadic stress interview paradigms) that allows for the measurement of temporal affective exchange between persons. A base-line interpersonal task without an emotional manipulation would enable the comparison between different affective states as well as the acclimation of the participants to the experiment. Following that, an emotional interaction task that elicits a high level of arousal and negative valence, ensued by a relaxation task low in arousal and positive in valence, would permit us to examine the down- and up-regulation of emotions.
Concerning participants, comparing patient-healthy partner dyads with both healthy partner dyads would be elucidative in understanding the affective interaction patterns, that may exacerbate the symptoms, such as the reciprocal nature of dysregulated affect. In order to provide homogeneity in the sample of forthcoming studies, we aimed to focus on a certain group of SSD; somatoform pain disorder.
Anger was reported as both a particular predictor and outcome of chronic pain (
This study was approved by the Ethics Commission for the Faculty of Medicine of the Technical University of Munich (TUM). The first couple invited to participate in the study consisted of one patient and her partner. The patient was admitted to the Department of Psychosomatic Medicine at TUM and fulfilled the diagnostic criteria of persistent somatoform pain disorder (ICD-10 F45.40). As a comparison case, a healthy control couple who were found through the internal communication network of TUM was also recruited to the study. The first couple was between 40 and 50 years old and the second was between 30 and 40 years old.
The experiment appointments were arranged by telephone interviews. In the telephone interview, participants were screened for the existence of any medical or psychological disturbance, as well as for use of painkillers or any other medication, particularly for control purposes. Participants were asked not to take any stimulants (e.g., coffee, tea, nicotine) less than 2 h prior to testing. Upon arrival at the laboratory, couples were given oral and written briefing about the experiment and informed consent was obtained. All participants were screened for medical and psychological health status, use of medication, pain or any received treatment with an anamnestic questionnaire. The control couple and the partner of the patient did not report any health-related disturbances. Following the demographic and health screening, both partners filled in questionnaires on emotion regulation and pain experience. Thereafter, participants were invited to the experiment room and prepared for the physiological measurement. Couples underwent three phases during the experiment, which were composed of interactions with their partners. A trained interviewer, who was blind to the study hypotheses, led the couple interactions. During the entire three phases of the experiment, video recordings and physiological responses were taken of two partners. Immediately after each phase, participants reported their emotional experience and their perceptions of their partner’s emotional experience. In addition, after the dyadic anger induction task, participants were given questionnaires to assess attachment styles and state-anger experience (See
Continuous thermal imaging recordings of the face, and measures of heart rate (HR) and electrodermal activity were taken from each partner simultaneously during the entire phases of baseline, anger, and relaxation phases.
Before the experiment, participants’ trait emotion regulation patterns were assessed by subjective measures of emotional awareness (Level of Emotional Awareness Scale, LEAS;
Participants’ experience of pain intensity and pain sensations was examined by the Brief Pain Inventory (BPI;
For thermal imaging data, temporal course of the temperature change was included for the statistical analyses. For heart rate and skin conductance levels, the arithmetic mean of the entire data within each experimental phase was computed and then described in detail for each couple.
Firstly, we tested whether experimental condition and participant status (i.e., patient, partner of the patient, and healthy controls) could determine the temporal change of the nose tip and forehead temperature. We applied hierarchical linear models with experimental condition, participant status and temporal course (i.e., number of frames) as fixed effects and the participant as random factor (
We examined the relationship of emotion regulation and anger regulation with thermal changes by including the scores of the corresponding questionnaires (i.e., LEAS, TAS-20, and STAXI) as covariates in the model. We tested the influence of these psychological measures by introducing them as fixed effects. Additionally, we included a condition * course * psychological measure interaction in the model to allow condition specific analyses of their association with the temperature changes. Each psychological domain was tested separately in order to prevent possible effects due to multicollinearity. We did not include the attachment scores in the model due to missing data in Couple 1.
To examine the relationship of physiological processes between partners, based on a previous study (
In the following sections, firstly, the results of the statistical analyses are presented. Following that, for each couple, the results of heart rate, skin conductance levels, and subjective report measures are described in detail.
During the experiment, the average skin temperature of the nose tip was rising for all participants except for the patient’s partner, whose nose tip temperature slightly decreased (see
All temporal courses were significantly different for each participant for the whole session (see
Temporal course of the changes in cutaneous temperature of the participants.
Partner | Baseline | Slope* | Anger | Slope* | Relaxation | Slope* | Sig. p (condition * frame) | |
---|---|---|---|---|---|---|---|---|
mean (SD) | mean (SD) | mean (SD) | ||||||
Patient (Mr 1A) | Nose tip | 30.03 (0.55) | 0,258 | 30.93 (0.84) | 0.188 | 33.24 (0.72) | 0,182 | 0.000 |
Forehead | 30,95 (0.20) | 0.099 | 32,04 (0.71) | 0.171** | 32,74 (0.73) | 0.184** | 0.000 | |
Patient’s partner (Ms 1B) | Nose tip | 31.09 (0.10) | 0.040 | 30.89 (0.13) | 0.023 | 30.03 (0.24) | -0.035 | 0.000 |
Forehead | 34,66 (0.02) | 0.002 | 34,73 (0.05) | 0.011 | 34,62 (0.04) | 0.009 | 0.000 | |
Healthy partner (Mr 2A) | Nose tip | 30.82 (0.07) | -0,004 | 31.74 (0.49) | 0,100 | 33.73 (0.17) | 0,042 | 0.000 |
Forehead | 34,36 (0.04) | -0.002 | 34,27 (0.06) | 0,008 | 34,63 (0.10) | -0,016 | 0.000 | |
Healthy partner (Ms 2B) | Nose tip | 27.15 (0.12) | 0.069 | 29.22 (0.81) | 0,170 | 34.18 (0.73) | 0,055 | 0.000 |
Forehead | 35,04 (0.09) | 0.053 | 35,25 (0.07) | 0,007 | 35,16 (0.05) | -0,011 | 0.000 | |
Full model | 0.000 |
When the psychological factors (i.e., TAS-20, LEAS, STAXI) were included in the model, condition specific associations of these factors with the thermal variations were observed. Although the relationship of the psychological factors with the overall temperature was negligible, high associations were found between these psychological measures and condition specific temperature changes (see
Psychological predictors of change in nose tip temperature within experimental conditions.
Overall* b | b** for temperature change per condition per psychological measure |
||||
---|---|---|---|---|---|
Baseline | Anger | Relaxation | |||
TAS | 0,003 | 0.96 | 0.0051 | 0.0027 | 0.0005 |
LEAS-self | -0.070 | 0.42 | 0.0001 | 0.0010 | 0.0015 |
LEAS-other | -0,043 | 0.69 | -0.0014 | -0.0008 | -0.0009 |
LEAS-total | -0.015 | 0.87 | -0.0023 | -0.0017 | -0.0019 |
STAXI-trait | 0.015 | 0.85 | 0,0103 | 0,0051 | 0,0001 |
STAXI-in | 0.084 | 0.93 | 0,0118 | 0.0052 | -0.0012 |
STAXI-out | -0,016 | 0.87 | 0,0119 | 0.0056 | 0.0003 |
STAXI-control | 0,311 | 0.41 | 0,0012 | -0,0029 | -0,0067 |
Correlation analysis of nasal tip temperature of the dyads showed significant relationships at
Correlation coefficients of the relationship between partners’ nasal tip temperature during each experimental phase.
Couples | Baseline (rdyads) | Anger (rdyads) | Relaxation (rdyads) |
---|---|---|---|
Couple 1 (Patient and partner) | 0.89* | 0.62* | -0.71* |
Couple 2 (Healthy control and partner) | -0.007 | 0.84* | 0.20* |
Ms 1B did not report experiencing pain except a little pain in some body parts that affect her at a minimum level. She described her health as very good although she reported some general life stress to a little extent and some relationship difficulties with her partner.
Participants’ scores for measures of emotion regulation and attachment styles.
Subject | TAS-20 total | LEAS total (mean) | LEAS-self (mean) | LEAS-other (mean) | STAXI-trait anger | STAXI anger-out | STAXI anger-in | STAXI anger-control | ECR-R anxiety | ECR-R avoidance |
---|---|---|---|---|---|---|---|---|---|---|
Mr 1A | 65 | 47 (2.35) | 44 (2.2) | 44 (2.2) | 30 | 29 | 29 | 25 | – | – |
Ms 1B | 37 | 59 (2.95) | 57 (2.85) | 45 (2.25) | 20 | 19 | 12 | 24 | – | – |
Mr 2A | 44 | 61 (3.05) | 49 (2.45) | 53 (2.65) | 22 | 16 | 12 | 24 | 1,72 | 1,72 |
Ms 2B | 38 | 66 (3.3) | 62 (3.1) | 60 (3) | 18 | 11 | 11 | 21 | 3,44 | 1,55 |
In terms of anger regulation, he reported high trait-anger, which means a general disposition to become angry (within the 99th percentile of the men sample). He reported expressing anger in a poorly controlled manner (99th percentile) or suppressing his anger (99th percentile). Yet, his expenditure of energy to monitor and control his anger was at a moderate to high level (70th percentile).
Ms 1B’s TAS-20-based alexithymia score (raw score = 37) indicated her good ability to be aware of her feelings, and to identify and describe them. Similarly, her total LEAS score (LEAS sum scores = 0 59,
Her anger scales showed a moderate to high level of trait anger (75th percentile of the women sample). She reported a high tendency to suppress anger expression (80th percentile) and low-moderate tendency (50th percentile) to express anger in an outwardly negative and poorly controlled manner. She also reported a moderate to high (70th percentile) level of effort to monitor and regulate her anger.
With regard to SCL, Mr 1A showed a slight increase from baseline (
Mr 1A reported a pronounced increase in pain experience at relaxation phase compared to other phases. In terms of experience of pleasure, arousal and dominance, he reported himself quite unhappy, a bit aroused and a bit being controlled at almost all phases, which did not show much variance (see
Affective experience ratings of the participants for self and other.
Affect |
|||||||||
---|---|---|---|---|---|---|---|---|---|
Pleasure |
Arousal |
Dominance |
|||||||
Base | Anger | Relax | Base | Anger | Relax | Base | Anger | Relax | |
Mr 1A (self*) | 3 | 4 | 4 | 4 | 4 | 4 | 4 | 4 | 4 |
Mr 1A (other*) | 3 | 4 | 4 | 3 | 3 | 4 | 6 | 4 | 4 |
Ms 1B (self) | 9 | 3 | 8 | 1 | 6 | 1 | 1 | 4 | 2 |
Ms 1B (other) | 8 | 4 | 7 | 2 | 5 | 2 | 1 | 8 | 4 |
Mr 2A (self) | 9 | 5 | 8 | 3 | 1 | 1 | 7 | 6 | 8 |
Mr 2A (other) | 9 | 3 | 8 | 5 | 6 | 1 | 7 | 5 | 8 |
Ms 2B (self) | 8 | 7 | 8 | 4 | 5 | 2 | 5 | 3 | 5 |
Ms 2B (other) | 8 | 7 | 7 | 4 | 4 | 2 | 5 | 4 | 5 |
Ms 1B reported more differing affective experience for herself and her partner among phases. At baseline, she reported to be happy and her arousal and dominance were at low levels, while she reported feeling quite unhappy, a bit aroused and a bit controlled at anger phase. At relaxation phase, she reported feeling happy, relaxed and a bit controlled. Similar to her own ratings, she rated her partner also as quite happy, relaxed and controlled at baseline. At anger phase she appraised Mr 1A’s affective experience also similar to her own, quite unhappy, a bit aroused but quite controlling. At relaxation phase, she also rated her partner as relaxed again with higher level pleasure and an average level of dominance.
Regarding anger regulation, Mr 2A reported a high level of trait anger (80th percentile). His tendency to suppress anger, to express anger negatively and to try to control and modulate his anger was at moderate level (55, 55, and 60th percentile, respectively). On the other hand, Ms 2B had a moderate level of trait anger (55th percentile) and anger modulation (50th percentile), but a low level of suppressing anger (15th percentile) and expressing anger negatively (40th percentile).
According to the ECR-R, which assesses attachment styles, Ms 2B had a high score in anxious attachment style (
Ms 2B reported very few variances in terms of her own, and her partner’s pleasure levels, remaining almost stable across phases. She reported herself and her partner feeling quite happy. On the other hand, she reported both herself and her partner a bit aroused at baseline and anger phases and then relaxed at relaxation phase. Consistent with her partner’s appraisal, she felt being less dominant compared to her partner at anger phase.
The theoretical accounts of SSD accentuate a network of bi-directional relationships between interpersonal interactions, emotion regulation and bodily disturbances (
In this case study, we aimed to examine how intra- and interpersonal emotion regulation at physiological and experiential levels is related to SSD. Previous studies suggest some kind of discordance between physiological, experiential and behavioral components of emotional process in SSD (
In this paper, following an introduction of the accounts of emotion regulation in SSD, we presented an interpersonal experimental paradigm that included two case couples consisting of a patient with somatoform pain and his partner, and a couple of healthy controls. We chose anger and positive affect as central affects since these were reported to play particular roles in chronic pain (
The paradigm was successful in generating physiological and experiential changes in an ecologically valid and a structured interpersonal setting, which allowed for a dynamic emotional interaction. Trait emotion regulation, namely, alexithymia, level of emotional awareness and anger regulation predicted the course of cutaneous temperature changes across phases. The patient, his partner and the healthy couple showed some distinctive patterns of emotion regulation, as well. However, it should be noted that the results should be interpreted cautiously as we examined only two cases in this study.
The temporal analysis of the course of temperature changes on nose tip and forehead showed significant variances across phases, pointing to the effectiveness of experimental manipulation. Nasal tip temperature increased from baseline to relaxation in all participants except the patients’ partner, whose nasal tip temperature slightly decreased. This regulation pattern of the patients’ partner might suggest a complementary down-regulation of physiology in her interaction with the patient, who showed higher autonomic activity. In fact, as predicted, the patient showed higher stress responses as compared to his partner and healthy controls depicted by significant temperature increase on forehead in anger and relaxation phases. In addition, his mean SCL and HR were higher than his partner throughout the experimental phases. Such vigilant autonomic activity in SSD has been shown in previous studies, as well (
Trait emotion regulation patterns also predicted the course of temperature changes. Higher alexithymia, increased anger regulation difficulties and lower scores in emotional awareness predicted higher changes in nasal tip temperature. This result supports the previous findings that have connected emotion regulation deficits with aberrant and higher physiological stress responses (
The second couple consisting of healthy partners showed indications of relatively enhanced emotion regulation. They both showed greater ability of being aware of, identifying and describing their own and other’s emotions. However, some degree of trait anger existed in both partners’ reports classifying Mr 2A as having high trait anger and a moderate level of anger regulation difficulties and Ms 2B as having a moderate level of trait anger.
The relationship of state affective experience and accompanying physiological changes were quite distinctive between participants. Although the patient’s cutaneous temperature, HR and SCL showed noticeable variations across experimental phases, he reported quite stable and moderate level of arousal and pleasure, which were inconsistent with his higher autonomic reactivity. This discrepancy points to incoherence between his affective experience and somatic concomitants. In fact, the patient’s high alexithymia and low emotional awareness scores could explain his restricted access to his feelings and accompanying autonomic changes. The subjective reports of Ms 1B, on the other hand, were, as expected, much more consistent with her physiological changes except for the baseline. The lack of consistency at baseline might be due to the possible performance stress at the beginning as well as her attempt to give a desired response suitable to a neutral baseline task.
For the partners of the control couple, the concordance of the subjective reports and physiological changes seemed to be superior than the patient to a certain extent. At anger phase, the nasal tip temperature and mean SCL increased in both partners, and they both reported a decrease in pleasure. Ms 2B reported that her arousal rose at anger phase, which was accompanied by a rise in nasal tip temperature and mean SCL although her mean HR declined. At relaxation phase, she reported lower arousal but her values of physiological imprints except her decreasing mean HR continued to increase. However, Mr 2A reported few changes in terms of arousal and pleasure, despite his declining mean HR and increasing mean SCL and thermal imprints from baseline to relaxation. Explaining this discordance, he scored low in LEAS-self subscale indicating some difficulties in consciously experiencing and describing his own emotions.
Analyses of interpersonal level of emotion regulation brought forward more multifaceted results than we proposed. The graphical trends of temporal changes in nasal tip temperature suggested discordance between the patient-partner dyads (Couple 1) and concordance in healthy control-partner dyads (Couple 2). However, correlation analysis of these temporal courses between partners, which are apparently more sensitive to the changes than visual inspection, suggested more concordance between the first dyad compared to the second one. At baseline, a positive correlation between nose tip temperatures of the partners was found only in the first couple. At anger phase, the partners of both Couple 1 and 2 presented strong positive correlations in nose tip temperature. At relaxation, only between the first couple, a strong negative correlation of temperature change was found. These findings might suggest a pattern of interpersonal emotion regulation in patients with SSD, which is quite the reverse of our predictions. The patient and his partner seem to show more interrelated change of temperature compared to the control couple.
The strong correlations of temperature between the first couple might be explained with the reciprocal nature of social interactions, which connotes the adaptive and complementary behavior of the interaction partner. It might be speculated that, by down-regulating the physiological responses, the partner of the patient complemented the patient’s higher autonomic activity and vice versa. In fact, the couple’s affective reports for self and other lend some support to this complementarity. While the patient reported experiencing almost similar levels of pleasure and arousal, his partner reported experiencing more variance in these domains. Moreover, the patient underrated his partner’s pleasure and arousal levels, while his partner overrated these affective experiences of him. The couple’s poor performance on recognizing the other’s affective experience was consistent with previous studies, which have reported emotion recognition difficulties in patients with SSD (
The second couple with the healthy partners performed well in LEAS-other subscale, which implies a better ability of consciously recognizing the other’s emotions compared to the first couple. They also performed relatively better in perceiving the trend of affective change in the partner. They correctly appraised each other’s arousal to decrease at relaxation phase, and dominance to lessen at anger and rise at relaxation phases. Mr 2A was also accurate in perceiving the rise of his partner’s arousal at anger although Ms 2B was not. The couple also could not accurately evaluate the changes in the other’s feeling of pleasure. It seems that Mr 2A attributed some emotionality and fluctuating emotional responses to his partner. It may be speculated that the anxious attachment style of Ms 2B could contribute to her partner’s attributions.
Our study has a number of limitations. Although our study demonstrates how embodied and intersubjective emotion models can be integrated into psychosomatic research, it involves only two cases and therefore provides scarce evidence for our hypotheses. Future research with greater sample size and robust statistical methods should examine the affective processes of interacting couples empirically. Secondly, despite previous recommendations (
Our study illustrates the scientific yield of an embodied interpersonal paradigm for studying emotion regulation in SSD, in particular for regulation of anger and positive affect. An enhanced understanding of this intra- and interpersonally, and dynamically regulated phenomenon will provide potential for an optimized clinical regime and psychotherapy.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
This work is supported by the Marie-Curie Initial Training Network, “TESIS: Toward an Embodied Science of InterSubjectivity” (FP7-PEOPLE-2010-ITN, 264828).