Impact of Psychosis on Emotion Regulation

Introduction

The ability to regulate emotions is a necessary skill to maintain one’s psychological well-being, but psychosis may interfere with this ability, as it is associated with abnormalities in emotion regulation (Ludwig et al., 2020). Psychosis consists of various symptoms that arise from experiencing a disconnection from reality (National Institute of Mental Health, 2023). The major symptoms of psychosis include, but are not limited to, delusions, hallucinations, and disordered thoughts and speech. Psychosis is associated with impairment in emotion regulation (Ludwig et al., 2019). Emotion regulation (ER) refers to the processes that shape an individual’s emotional experience in terms of which emotions are experienced, when they are experienced, and how they are expressed (Gross, 1998). ER is a skill acquired gradually, starting from infancy and continuing throughout adulthood (Livingstone et al., 2009). Regulating emotions involves being aware of emotions and accurately evaluating them. When a person has strong ER skills, they can have control over the emotions they experience, meaning they have more authority over how and when they express their emotions. This relative control over emotional experiences is important because it allows people to maintain their mental well-being and emotional state when necessary. When an individual changes their perception of a situation to alter its impact on their emotions, they are using the adaptive regulation strategy of reappraisal (Gross, 1998). An individual who takes in negative stimuli can use reappraisal to decrease their experience of negative emotions. To reappraise successfully, an individual must be able to identify and describe their own emotions, but previous research has found that this ability is impaired in psychosis (Opoka et al., 2020). This finding implies that individuals who experience psychosis have difficulty with using reappraisal, an adaptive strategy. This is one reason why these individuals have been found to have challenges with regulating their emotions. 

Mental illnesses, specifically psychotic disorders, are a factor that can create obstacles when it comes to regulating emotions. Many studies have found that individuals who experience psychosis experience higher rates of negative emotions than those who experience no psychotic symptoms (Suslow et al., 2003). 

In the field of abnormal psychology, the emotional experience of people who have psychotic disorders is not a well-studied topic (Birchwood, 2003). Psychotic disorders have a much lower prevalence than mental illnesses such as depression and anxiety, which has resulted in less prioritization of this area of research. Advancing this area of research is essential because understanding the association between psychosis and ER may inform treatment strategies for individuals with psychotic disorders. If the reasoning for the high comorbidity between psychosis and other mental illnesses (Livingstone et al., 2009), was better understood, mental health professionals could utilize new or different methods of treatment that were not considered before.

Different studies concerning psychosis and ER have similarities and differences in their methodologies. Most studies that investigate the link between psychosis and ER conclude that a correlation exists between these two variables (Lincoln et al., 2015; Livingstone et al., 2009; Ludwig et al., 2020). However, some studies stray from these popular findings and reject the association between the two (Opoka et al., 2021). Furthermore, I will provide overviews and comparisons of recent studies investigating the association between psychosis and ER, and I will discuss how researchers’ methodologies have implications and limitations for the results found. 

Discussion
 

Emotional State

Previous research has identified a relationship between psychosis and challenges in emotion regulation. A study by Livingstone et al. (2009) found evidence that ER is likely impacted negatively by the experience of psychosis. In this study, the researchers hypothesized that the emotional state of patients with psychosis or depression and anxiety differs markedly from that of the control group of non-patients. Three groups of participants took part in the study, which included people who have had psychotic episodes, people who have depression and anxiety without experiencing psychosis, and people who do not have psychosis or depression and anxiety. The methodology required that the participants answer three questionnaires. These included ER self-report questionnaires and a self-report questionnaire that assesses basic emotions. The results supported the hypothesis that people with psychosis and those with depression and anxiety have different emotional experiences than people without these mental illnesses. Based on the results of the study, it was inferred that psychosis interferes with ER.

Emotional Regulation

Lincoln et al. (2015) investigated emotion regulation skills in individuals with psychotic disorders (PDs) by looking at subjective, physical, and symptomatic responses to stressors. The researchers hypothesized that differences in ER abilities would predict the responses of PDs to stress compared to healthy controls (HCs). The PD group was recruited from clinical settings, while the HC group was recruited through advertisements in the newspaper. The groups' ER abilities were assessed under different conditions: baseline and exposure to noise stressors. In the baseline condition, the participants completed the German version of the emotion-specific Emotion-Regulation Skills Questionnaire (ERSQ-ES), which assesses ER skills separately for a variety of emotional experiences. The scores of these questionnaires represent how well participants can regulate their emotions in the absence of stressors. In the noise stressor condition, participants were exposed to a noise, and the researchers assessed participants’ self-reported stress responses, skin conductance levels (SCLs), and state paranoia. It was found that self-reported stress and SCLs were increased in the PD group compared to HCs. A decrease in awareness of negative emotions predicted an increase in self-reported stress in the PD group. A decreased ability to control and regulate negative emotions predicted an increase in SCLs. These findings display an association between psychosis and a reduced ability to regulate emotions in the presence of stressors. This aligns with the inference made in the study by Livingstone et al. (2009). 

In the study by Ludwig et al. (2020), it was hypothesized that patients with psychotic disorders and current delusions (PDs) would use more maladaptive strategies for regulating emotions than nonclinical, or healthy, controls (NCs). Maladaptive strategies are ways of coping that have been found to correlate with high levels of psychological distress, including symptoms of depression and anxiety (Thompson et al., 2010). Simply put, maladaptive strategies are coping mechanisms that could have negative consequences on an individual’s well-being. In the context of the study by Ludwig et al. (2020), strategies such as rumination, self-blaming, and suppression are considered to be maladaptive. The researchers predicted that maladaptive strategies would increase negative affect and decrease positive affect. In psychology, “affect” refers to one’s internal experience that is associated with emotions (Barrett & Bliss-Moreau, 2009). In other words, positive affect corresponds to positive emotions, while negative affect corresponds to negative emotions. The researchers also hypothesized that PDs would be less effective in down-regulating negative affect compared to NCs. The data of this study was collected as a contribution to a cognitive-behavioral therapy treatment trial. Eighty participants with psychotic disorders contacted the clinic or were recruited by mental health professionals. Forty-three healthy control participants found the study through advertisements or participated in previous studies by the same researchers. Measurements in the study included a symptom assessment and self-report questionnaires that assessed habitual ER, daily emotions, and ER in everyday life. The results of the study showed that participants with psychotic disorders used maladaptive strategies more often than healthy controls. The researchers found that habitual reappraisal predicted lower negative affect in everyday life. These findings imply that individuals with psychotic disorders are less effective in regulating emotions because they use maladaptive strategies, which aligns with the results from the studies by Livingstone et al. in 2009 and Lincoln et al. in 2015. 

Opoka et al. (2021) hypothesized that patients with psychotic disorders (PD) would apply less reappraisal than healthy controls (HC) and that PD would not be as successful in regulating negative emotions through reappraisal compared to HC. To investigate these hypotheses, PD, anxiety disorder patients (AD), and HC completed various tests. These included ER questionnaires as well as tests on neurocognitive function and bias for jumping to conclusions. Participants were also asked to regulate induced negative emotions, such as anxiety and sadness. The results concluded that there was no difference between PD and HC in the ability to use reappraisal successfully. However, individuals with psychotic disorders used reappraisal more frequently as an ER strategy than anxiety disorder patients. Each group was able to regulate their emotions upon instruction. The researchers’ findings suggested that people with psychosis can successfully use reappraisal, and the experience of psychosis does not impair ER. These findings contradict those of previous studies. 

Comparisons Between Studies

Though all these studies were within the same specific area of research, the questions asked and varying focuses led to slightly different methods and designs and, ultimately, contradictory results. Based on prior research cited in each of these studies, the negative impact psychosis has on ER was a widely accepted idea in the field of psychology. So, all of these studies formed hypotheses that aligned with this common theory. However, Opoka et al. (2021) had surprising results that challenged this perspective. 

Implications and Limitations of Methodologies

This difference in results may be due in part to the focus of the study by Opoka et al. (2021), which was on a specific strategy of emotion regulation: reappraisal. Meanwhile, Ludwig et al. (2020) and Lincoln et al. (2015) had a more general approach to ER; Ludwig et al. (2020) focused on maladaptive strategies, and Lincoln et al. (2015) focused on responses to stressors. Livingstone et al. (2021) did not directly assess ER abilities but made an inference based on data of emotional states alone. Opoka et al. (2021) had a based assumption that individuals with psychosis would use reappraisal less and not be as effective at regulating emotions compared to healthy controls. Given their unexpected findings, the methods used to assess reappraisal abilities may not have been objective enough. Another possibility is that reappraisal was only used by individuals with psychosis because the researchers asked them to utilize that strategy. 

It is possible that the methods of recruitment caused biases in participant populations. The control group in the study by Lincoln et al. (2015) volunteered upon seeing advertisements in the newspaper, and Ludwig et al. (2020)'s control group consisted of people who found advertisements for it or were participants in previous studies. These recruitment methods could lead to biased results because people who see the same advertisements are likely to come from the same geographic location. Also, people who participated in previous studies are different from the general population; they likely already had some research interest or wanted monetary rewards. These are participant biases that could set them apart from the general population, which makes them less reliable for accurately representing the population.

All four studies used self-report assessments to collect emotional state and regulation data on participants. However, it is difficult to know how objective and accurate these assessments are for individuals who have psychotic disorders if we are under the notion that this group experiences and expresses emotion differently than healthy controls. Lincoln et al. (2015) assessed physiological responses to stressors in addition to self-report responses, which helped combat the limitations of having self-report methods alone. 

Future Research

As future research will build off the content of these studies, researchers need to take note of the limitations mentioned in this review. Future researchers should strive to develop more thorough and unique methodologies for assessing the link between psychosis and emotion regulation. It would also be beneficial for researchers to investigate this link further to discover potential skills and strategies that individuals with psychosis can use to aid in regulating their emotions. Implementing this goal in future research will shift the focus of studies and could lead to novel methodologies, which may give us a deeper understanding of the experience of psychosis and the individuals who live with these disorders. 

References

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Birchwood, M. (2003) Pathways to emotional dysfunction in first-episode psychosis. British Journal of Psychiatry, 182, 373-375.

Gross, J. J. (1998). The emerging field of emotion regulation: An integrative review. Review of General Psychology, 2(3), 271-299. http://dx.doi.org/10.1037/1089-2680.2.3.271 

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Ludwig, L., Mehl, S., Krkovic, K., & Lincoln, T. M. (2020). Effectiveness of emotion regulation in daily life in individuals with psychosis and nonclinical controls—An experience-sampling study. Journal of Abnormal Psychology, 129(4), 408-421. http://dx.doi.org/10.1037/abn0000505

Ludwig, L., Werner, D., & Lincoln, T. M. (2019). The relevance of cognitive emotion regulation to psychotic symptoms–A systematic review and meta-analysis. Clinical Psychology Review, 72. https://doi.org/10.1016/j.cpr.2019.101746 

National Institute of Mental Health. (2023). Understanding Psychosis (NIH Publication No. 23-MH-8110). https://www.nimh.nih.gov/health/publications/understanding-psychosis 

Opoka, S. M., Sundag, J., Riehle, M., & Lincoln, T. M. (2021). Emotion-regulation in psychosis: Patients with psychotic disorders apply reappraisal successfully. Cognitive Therapy and Research, 45(1), 31-45. http://dx.doi.org/10.1007/s10608-020-10163-8 

Suslow, T., Roestel, C., Ohrmann, P., & Arolt, V. (2003) The experience of basic emotions in schizophrenia with and without affective negative symptoms. Comprehensive Psychiatry, 44, 303-310. http://dx.doi.org/10.1016/S0010-440X(03)00085-3 

Thompson, R. J., Mata, J., Jaeggi, S. M., Buschkuehl, M., Jonides, J., & Gotlib, I. H. (2010). Maladaptive coping, adaptive coping, and depressive symptoms: Variations across age and depressive State. Behaviour Research and Therapy, 48(6), 459–466. https://doi.org/10.1016/j.brat.2010.01.007