University of Groningen
Psychopathology and positive emotions in daily life
Heininga, Vera E.; Kuppens, Peter
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Current Opinion in Behavioral Sciences DOI:
10.1016/j.cobeha.2020.11.005
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Heininga, V. E., & Kuppens, P. (2021). Psychopathology and positive emotions in daily life. Current Opinion in Behavioral Sciences, 39, 10-18. https://doi.org/10.1016/j.cobeha.2020.11.005
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Psychopathology
and
positive
emotions
in
daily
life
Vera
E
Heininga
1and
Peter
Kuppens
2Inthisshortreview,wedescriberecenttrendsfromEcological MomentaryAssessment(EMA)researchinvestigatingpositive affect(PA)inrelationtomooddisorders.Asidefromnotable exceptions(e.g.mania),mostmooddisordersinvolverelatively lowerlevelsofPAindailylife,oftencombinedwithalargerlevel ofvariabilityinPA.Inreactiontopositiveevents,studiesshowa puzzling‘moodbrightening’effectinindividualswithmood disordersymptomsthatsuggestshyperresponsivenessto real-liferewards.Studiesintoanhedonia(i.e.lackof,orlower levelsofPA)suggestthathigh-arousalPAandanticipatoryPA arepotentialtargetsforintervention.DespitePA-focused EMA-interventionsbearpromisesofgreatertherapeutic
effectiveness,sofar,thesepromiseshavenotmaterializedyet.
Addresses
1UniversityofGroningen,FacultyofBehaviouralandSocialSciences,
DepartmentofDevelopmentalPsychology,GroteKruisstraat2/1, 9712TSGroningen,TheNetherlands
2LeuvenUniversity,FacultyofPsychologyandEducationalSciences,
QuantitativePsychologyandIndividualDifferences,Tiensestraat102, Box3713,3000Leuven,Belgium
Correspondingauthor:Heininga,VeraE(v.e.heininga@rug.nl)
CurrentOpinioninBehavioralSciences2020,39:10–18 ThisreviewcomesfromathemedissueonPositiveAffect
EditedbyGillesPourtois,DisaSauter,BlairSaundersandHenkvan Steenbergen
https://doi.org/10.1016/j.cobeha.2020.11.005
2352-1546/ã2020TheAuthor(s).PublishedbyElsevierLtd.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons. org/licenses/by/4.0/).
Introduction
Inmood disorders feelingsor emotions are distorted or
inconsistent with its context to such an extent that it
interferes with one’s ability to function [1]. Mood
dis-ordersincludeBipolarDisorder,Dysthymia,Cyclothymic
Disorder, Premenstrual Dysphoric Disorder, and Major
Depressive Disorder (MDD), and affect approximately
10% of the population each year [2,3]. Research on
affective psychopathology is predominantly focused on
stressand Negative Affect (NA). In recent years,
how-ever,therehasbeenincreasingattentionandrecognition
thatrewarding experiencesandPositive Affect(PA), or
thelackthereof(i.e.anhedonia),isatleastequally
impor-tant for the understanding, treatment of, and recovery
from,mooddisorders.
PA generally refers to the experience of pleasurable
emotions, such as happiness, relaxation, enthusiasm,
andjoy, andvaries over time asa function of
subjec-tivelyappraisedcontext[4,5].Whenitcomesto
under-standing the nature of PAin the context of people’s
daily life, Ecological Momentary Assessment (EMA)
studieshaveexaminedthelevelofPA,itsfluctuations,
and interaction with contexts in both healthy and
clinical populations. EMA is a structured diary
tech-niquetosamplesubjective experiences,behaviorand
contextintheflowofdailylife,typicallyusing
smart-phone technology. Its naturalistic approach ensures
ecologicallyvalid data (i.e. generalizable to real-life),
Participantstypically fill out structureddiaries
multi-pletimesaday(e.g.fivetimesaday),thatareassessed
at fixed or random time points, and across multiple
consecutives days (e.g. for 30 days). The high
fre-quency in longitudinal sampling enables researchers
toshed light on the nature of mood disorders on the
micro-level.Forexample,towhatextentdepressionis
linkedtoPAchangesacrossminutesorhours,andthe
extenttowhichtheseshort-termchangesinPAco-vary
withbehaviororothercontextualfactorsovertime.In
addition, compared to retrospective questionnaires
that asks patients to report on symptoms during the
pastweeks ormonths,the frequentsamplinginEMA
studiesreduces recallbias.Inthatsense, EMA
meth-ods can not only validate diagnostic criteria in daily
life,butalsogobeyondbyprovidingnovelinsightsinto
the micro-processes and mechanisms of mood
disorders.
Inwhatfollows,wereview someof themostimportant
advancementsofEMAresearchinPAand
psychopathol-ogyover thelastfiveyears.
Positive
Affect
(PA)
in
daily
life
In EMA studies, PA is typically operationalized as the
mean of a set of adjective rating scales. For example,
participantsareasked‘Howdoyoufeelatthemoment?’
followed by the adjectives ‘relaxed’, ‘happy’, and
‘cheerful’ and a slider-scale anchored with ‘not at all’
(outerleft)and‘verymuch’(outerright).Often,butnot
always,thesetofaffectiveitemsisbasedonthePositive
AffectandNegative AffectSchedule[6],or isbasedon
circumplexmodelsofaffect[7,8]withtheselectionmade
to balance high and low arousal items [9]. The most
frequently used adjectives used to describe PA in
EMAresearchinrelationtomooddisordersoverthelast
two years are feeling relaxed, happy, and cheerful (see
EMA studies have linked compromised mental health
andmooddisorderstovariousalterationsinPA
function-ing,suchasreducedPAcomplexityandPAflexibilityin
daily life [10],blunted PA reactivityto daily life stress
([11]) and reduced expectations of future PA (Note:
when having a history of depression, but not bipolar
disorder; [12]). The most robust finding, however, is
theconsistentlinkbetweenlowerpsychological
wellbe-ing or increased mood disorder symptomatology and
lower mean levels of PA [10,12,13,14,15,16,17,18,20].
One exceptionshould be noted though,namely in the
manicphasesofbipolardisorder,whichmanifestsas(too)
high levelsofPA.
PA
dynamics
in
mood
disorders
Inadditiontotherobustlinkbetweenmooddisordersand
lower mean level is PA in daily life, EMA researchers
explored the link between mood disorders and the
dynamic nature of PA. PA dynamics are quantitative
descriptions of PA summarizing how PA unfolds and
fluctuatesovertime.Forexample,emotionalvariability,
operationalizedas theaveragewithin-personvariancein
affectoraveragewithin-personStandardDeviation(SD)
in affect, summarizes the dispersion in PA levels. In
addition,therearemorecomplexaffectivedynamicssuch
as inertia (i.e. auto-correlation or auto-regression
coeffi-cient;summarizeshowself-predictiveaffectisovertime),
PsychopathologyandPAindailylifeHeiningaandKuppens 11
Figure1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 3 3 4 4 4 4 4 6 7 7 8 9 11 0 2 4 6 8 10 12 alert amazed at ease confident content delighted enjoying myself even temper euphoric globally feeling well jittery safe surprised warm active attentive inspired strong excited lively calm determined interested joyful proud energetic enthusiastic satisfied cheerful happy relaxed
Current Opinion in Behavioral Sciences
TheEcologicalMomentaryAssessments(EMA)itemsusedtoassessPositiveAffect,extractedfrom17EMAstudiesthatreportedonPAand mooddisordersbetween2018andJune2020.NumberontheX-axisreflectsnumberofstudiesthatusedtheEMA-itemdipictedontheY-axis. WesearchedinWebofScience(WoS)CoreCollectionelectronicdatabaseforEnglish-languagepaperspublishedbetween2018andJune 2020usingthefollowingkeyterms:‘positiveemotion*’OR‘positiveaffect*’OR‘positivemood*’ORpleasur*ORwell?beingOReudaimon*;and ‘Mooddisorder*’OR‘Affect*disorder*’OR‘Bipolar*’OR‘BipolarDisorder*’ORDepress*OR‘MajorDepressiveDisorder’ORMDDORanhedoni*; and‘Experiencesampling’OR‘EcologicalMomentaryAssessment*’OR‘ExperienceSamplingMethod’OR‘structureddiarymethod*’OR ‘intensivelongitudinalassessment*’OR‘real-timedatacapturestud*’OR‘eventsampl*’OR‘beeperstud*’OR‘ambulatorystud*’intitle,abstract, authorkeywords,andKeywordsPlus.Fromthe90articles,24weremarkedasrelevantbecausethey(1)explicitlyorimplicitlyhandledthesubject ofpositiveaffectoranhedonia;(2)hadafocusonmentalhealthormooddisorder,and(3)usedEMA.Weexcludedstudiesthatfocusedon(1) genetics,orneurologicalunderpinnings;(2)methodologicalstudies;and(3)studiesthatdidnotreportonPAitems,leaving17recentEMAstudies forextractionofPAitems.
summarizeshowunstableaffectisovertime).Foravisual
illustrationof thesedynamics,seeFigure2.
Recent EMA studies report paradoxical results in this
respect. Whereas some studies found no association
between PA dynamics and mood disorders [14,17],
others have linked symptoms of mood disorders and
low psychological well-being to greater variability in
PA ([15]in high-arousal PA; first studyof [16,19,21]),
and/ormoreinertPA[16,22,23].Inthemeta-analyseson
therelation betweenaffectdynamicsand psychological
well-being, lowerwell-being was characterized byboth
greater variability and inertiairrespective of ESM time
frame [16]. However, this inertia-variability paradox is
resolved when taking the overlap among the mean,
variability, and inertia into account (i.e. by controlling
foroneortheother).Indeed,althoughPAdynamicsare
interrelated,thedifferencesbetweengroupsinthelevel
ofvariability(e.g. variance)andthelevelofinertia(e.g.
autocorrelation)inPAaretypicallyexaminedinisolation.
EMAresearchonnegativeaffectandwellbeingsuggests
that, when adjusted for the overlap, inertia adds little
predictivevalueinthepredictionofmooddisordersover
andabovethelowerlevelofPAandlargerspreadinPA
levels([24,25,26];seealsoFigure 2).
In people with bipolar disorder, after controlling for
differences in individuals’ mean PA, variability in PA
stillprovidesuniqueandadditionalinformation[19,21].
However, over-and-abovethe PA mean and variability,
the auto-correlation of PA (inertia) likely adds limited
informationinpredictingpsychologicalhealth[25].
Real-life
reward
responsiveness
and
mood
brightening
The EmotionContext Insensitivitytheory andpositive
attenuation hypothesis predict attenuated emotional
reactivitytopositiveemotionalstimuliinthedailylives
ofdepressedindividuals[27].Inlinewiththishypothesis
and theory, depression is consistently associated with
reduced reward responsiveness in experimental studies
andneurologicalstudiesinthelaboratory[28–31].Instark
contrast,resultsfromEMAstudiesshoweitherno
differ-encesindepressedindividuals’rewardresponsiveness,or
evidence for theopposite: a ‘mood brightening effect’,
defined as a greater improvement in the mood of
depressed individuals in the hours after they report
havingexperiencedapositiveevent.3
alarger decreasein NA and larger increase in PA after
positiveeventsin depressedversusnon-depressed
indi-viduals[32].MostEMAstudiesthereafterpredominantly
focused on the brightening in NA (e.g. Ref. [33]).
Althoughinstarkcontrasttotheoryandempiricalresults
fromthelaboratory, themoodbrightening effectin PA
seemsrobustand,comparedtoanxiety,specificto
depres-sion—withmoreseverelydepressedindividualsshowing
greaterbrightening[34].Interestingly,anticipating
next-daypositiveeventsseemtoproducesimilarmood
bright-eningeffects [35].
Sofar,severalfactorshavebeenexcludedasthedriving
forcebehindthemoodbrighteningeffect[36].First,the
scarcity in positive events that is often observed in
depressed patients (i.e. contrast hypothesis). Second,
thelowerthresholdtoappraisepositiveeventsaspositive
and,third, flooreffects in PAthatmaycreate relatively
larger room for improvement in the PA of depressed
individuals Perhaps, emotion regulation might (partly)
explain mood brightening effects. For NA, depressed
individuals’tendencytoruminate(i.e.focusedattention
tonegativeeventsandmoods)mightbeloweredbythe
experience of a positive event to an extent that they
ruminate less than controls, and the subsequent lower
levelof NApresentsitselfasamoodbrighteningeffect
[33].
Anotherexplanationforthediscrepancybetweentheory
andEMAresultsonrewardresponsivenesscouldbethat
PAreactivitytotheself-reportedpleasantnessofanevent
is a suboptimal operationalization. Bakker et al. [37]
arguedthatexperimentaltasksandbehavioralactivation
therapy typically involve approach-based rewards,
sug-gestingthat situationsin whichone canencounter
rela-tivelymanyrewards(e.g.engagingwithfriends,working
orbeingphysicallyactive;hereafter‘activebehavior’)isa
betteroperationalizationortranslationofrewardsindaily
life than (pleasantness ratings of) positive events.
Remarkably, when operationalizing reward
responsive-nessindailylifeasPAreactivitytoactivebehavior,inline
withtheory,theauthorsindeedobserveabluntedreward
responsivenessinindividualswithdepressivesymptoms.
However, the new operationalization is still awaiting
replication.Heininga et al. [14] exploredboth
operatio-nalizationsofrewardresponsivenessinthedailylivesof
depressed patients and healthy controls, but found no
differencebetweenbothgroupsinPAreactivityto
posi-tiveevents,norinPAreactivity toactive behavior.
Anhedonia
in
daily
life
TobetterunderstandPAinmooddisorders,itmayalsobe
useful to shift the focus from syndromes to symptoms
[38]. Anhedonia is one of the two core symptoms of
depression and is clinically understood as ‘a markedly
diminished interest or pleasure in all, or almost all,
3
ItshouldbenotedthatonerecentEMAstudyreportedreduced reward responsiveness in depressedindividuals, but, instead of the changeinPAafterpleasantactivitiesorevents,rewardresponsiveness wasoperationalizedasthepleasantnessratingofdailyactivities[61], betterknownasappraisal.
activitiesoftheday’duringthepasttwoweeks[1].Based
onadvances inneurologyandexperimentalpsychology,
anhedonia is now understood as impairments in the
ability toexperience reward(i.e.deficit in‘liking’;
con-summatory anhedonia), pursue reward (i.e. deficit in
‘wanting’; anticipatory anhedonia) and/or learn about
reward ([39–42];butseeRef.:[43]).
Withregardto‘liking’indailylife,anhedoniaislinkedto
lowerappraisalofpositiveevents(i.e.positiveeventsare
rated less pleasurable; [15]; but see Ref.: [20]), fewer
positiveeventexperiences[20],andlowerlevelsofPAin
daily life[14,15,20,44]. Beyondthese descriptive
statis-tics, anhedonic versus non-anhedonic individuals also
show differences in their associations between events
and PAover time.Consummatoryhigh-arousal PA(e.g.
feeling ‘energetic’, ‘enthusiastic’, and ‘cheerful’) might
beofspecialinteresttobetterunderstandanhedonia,as
individuals with anhedoniashow ‘mood brightening’in
high-arousalPAbutnotlow-arousalPA[15],andshowa
diminished favorableimpactonaffectiveexperiencesin
individuals with anhedonia [44]. That is, compared to
healthy controls, high-arousal PA in individuals with
anhedonia istypically followed byagreater increase in
NAandstress,andagreaterdecreaseinPAandphysical
activityapproximatelysixhourslater (seeFigure 3).
With regard to ‘wanting’, EMA studies suggest that
alterations in motivationand anticipation mightalso be
avulnerabilitymarkerformooddisorders.Forexample,
low PA in anhedoniais associated with lower levelsof
motivationsixhourslater[45],andtheresultssuggestthat
individualswithanhedoniaareatriskforanegativespiral
of low PAandlow motivation.Furthermore,depressive
symptoms are also linked to diminished anticipatory
pleasure experiences[46], and a weaker link between
anticipatorypleasureandactivebehavior[37].Together,
theseEMAadvancessuggestthat,inadditiontoalower
meanlevelofPA,individualswithdepressivesymptoms
are less able or less motivated to modify their daily
behaviorsasafunctionof rewardanticipation.
Withregardtodeficitsinrewardlearninginthedailylives
of individuals with anhedonia, advances show that the
EMA timeframe is key. Without conscious processing,
individualslearnabouttherewardvalueofeachcontext
and activity by creating associations with co-occurring
rewarding experiencessuch asPA. Theseimplicit
asso-ciations,in turn,increasethelikelihoodthatindividuals
engage insimilar contexts and activitiessemi-randomly
assessed approximately 90min later and the next day
[47].However,suchassociativelearningeffectswerenot
replicated when using a short-term retrospective ESM
design with fixed beeps approximately six hours apart
[48].MoreEMAresearchisthusneededtodeterminethe
optimaldesigntoinvestigaterewardlearningindailylife.
PA-focused
daily
life
interventions
Giventhattheone-size-fits-alltreatmentapproachisnot
alwayseffective, EMAInterventions(EMIs) havebeen
put forward as a promisingtool to personalize affective
disordertreatmentsandimprovetheireffectiveness(e.g.
Refs.[49–52]).Sofar,threeEMIshavebeendeveloped
thatfocusonPAand (symptomsof) mooddisorders.
PsychopathologyandPAindailylifeHeiningaandKuppens 13
Figure2
Current Opinion in Behavioral Sciences
HypotheticalexampleofhowPAunfoldsovertimeinindividualswithmooddisorderversushealthycontrols.Basedonindividualpatientdata fromHeiningaetal.[14].
InthefirstRandomizedControlledTrials(RCT)ESM-I
study,depressivesymptomswereeffectivelyreducedby
sixweeklysessionsofESM-basedPA-feedback[53].The
feedback purely descriptive, for example, graphically
showingpatients’ownlevelofPAacrossdifferent
situa-tions. A follow-up study revealed that the decrease in
depressive symptoms was preceded by a decrease in
sedentary behaviorsandan increasein physicalactivity
and social behaviors [54], suggesting that lifestyle
changesmaybepart oftheremedy.Itshould benoted
though that, although patients’ depressive complaints
reduced according to the Hamilton Depression Rating
ScaleandtheInventoryofDepressiveSymptoms,
accord-ingtotheEMAassessments,patients’momentarylevels
ofPAdidnotchangeduringtheintervention[55].
Next, beyond mere descriptive feedback, van Roekel
etal. [20,56,57]showed thatevaluative feedbackin the
formofESM-basedrecommendationsonhowtochange
one’slifestylemight beamore effectivewayto reduce
depressivesymptoms–atleastinasubclinicalsample.
Albeiteffectsizesweresmall,andparticipantsshowedno
marked decrease in depressive symptoms according to
the Patient Health Questionnaire, self-monitoring in
No anhedonia Anhedonia
Current Opinion in Behavioral Sciences
AdaptedfromFigure2ofBosetal.[44].Networksofanhedonicandnon-anhedonicindividualsshowingthestrengthoftheIRFassociations estimatedthroughautomatedimpulseresponsefunctionanalysis(IRF).Green(solid)arrowsindicatepositiveassociationsbetweenvariables;red (dashed)arrowsnegativeones.Thestrongeraparticularassociation,thethickerandbrighterthecolorofthearrow.
combinationwithspecific recommendationsforlifestyle
changes effectively increased participants’ PA levels
throughout daily life, suggesting evaluative feedback
may also be an effective way to augment the efficacy
of regulardepressiontreatment.Inlinewiththese
find-ings, indeed, recent advances on Behavioral Activation
treatments suggest that these treatments may work by
targeting(low)reward responsivenessdirectly[42,58].
Finally,Bastiaansenetal.[59,60]translatedthese
find-ingstoclinicalpracticebyprovidingbothdescriptiveand
evaluative Behavioral Activation based feedback on
patients’ PA, but found noevidence for improvements
compared to patients’ PA who followed treatment as
usual, nor evidence for an increase in EMI-specific
empowerment or social functioning of patients. When
comparingthestudyofBastiaansenetal.to thestudyof
PsychopathologyandPAindailylifeHeiningaandKuppens 15
Figure4
Time in months
Time in months
Current Opinion in Behavioral Sciences
Upperpart:adaptedFigure3bfromKrameretal.[53].Lowerpart:adaptedFigure2fromAppendixDfromBastiaansenetal.[60].Plotsshow predictedlinesplottedacrosstime(intention-to-treatanalysis).IDS=InventoryofDepressiveSymptomatology.Post-EMA=assessmentinthe weekafterthe28-dayinterventionperiod.FU=FollowUpassessment.InthestudyofBastiaansenetal.[60],duringthe28-dayintervention period,patientsreceivedweeklyfeedbackoneitherpositiveaffectandactivities(Do-module;experimental1)ornegativeaffectandthinking patterns(Think-module;experimental2).
control groups of both studies (i.e. treatment as usual).
Whereas in Kramer’s study the treatment as usual was
medication which only marginally improved patients
moods, in the study of Bastiaansen et al., treatment as
usualconsistedofmedicationcombinedwith
psychother-apy which was more effective in improving patients’
moods in the control group. Although the PA-focused
EMIdidnot gobeyond theefficacy of medicationand
psychotherapy,Bastiaansenetal.,concludethatitmaybe
worthwhiletoinvestigatewhetherEMIscanbeblended
with routine mental health services as they have the
potential to make psychotherapy treatments more
time-efficientfor therapistswithoutsacrificingefficacy.
Conclusions
Recentadvances in the fieldof PositiveAffective (PA)
andmooddisordersindailylifesuggestthatpeoplewith
mood disorders typically experience relatively lower
levels of PA in daily life, possibly combined with a
reduced anticipatory PA, and moment-to-moment
vari-abilityinPAinbipolardisorder.FutureEMAstudiesinto
mood disorders may benefit from incorporating both
consummatoryPA (as experienced in-the-moment) and
anticipatory PA (looking forward to future activities or
contexts). Social contexts, stress and motivation seem
closelyrelatedtoPAinthedailylivesofindividualswith
anhedonia, and unravelling its underlying mechanisms
maybeanimportantnextstepinfine-tuningtreatments
formooddisorder.
Evidencefrom laboratory settings versusEMA appears
paradoxical, as laboratory studies show blunted reward
responses in depression, whereas EMA studies show
evidencefor theopposite(i.e. a‘PAbrighteningeffect’
inresponsetopositiveevents).Toreconcilebothstrands
ofliterature,futurestudiesmaybenefitfromamore
in-depthanalysisintothetypeofpositiveevents,aswellas
theoperationalizationsofrewardresponsivenessindaily
life.Forexample,byexploring possiblerelevant
differ-encesin thetypesof positiveevents(e.g. intrapersonal/
interpersonalevents,orsocial/non-socialevents),andPA
reactivity to positive events active behavior, while also
includingreward-related laboratory test batteriesin the
sameEMAstudyparticipants.Thatway,reward
respon-sivenessindailylifecouldbe‘calibrated’bycomparing
correlational patterns. Another promising direction for
futureresearch wouldbe to investigatethe moderating
effectsofPAregulationstrategiesonPAbrighteningafter
positiveeventsand/oractive behavior.
AlthoughthepromisedtherapeuticefficacyofEMIshas
notfullymaterialized(yet),PA-focusedEMIsthataimto
alterbehaviorindailylifeseemacost-effectiveandeasily
accessible alternative for patients who cannot receive
standardBehavioral Activationtherapy,or notyet.
Fur-thermore,EMIsmayhelptounderstandthemechanisms
treatment.ThereareindicationsthatfuturePA-focused
EMIs may bemost effective whentargeting both
con-summatoryandanticipatoryPAaswellasthestrengthof
the connection between both, and involve a type of
evaluativefeedbackwhich ispreferablyintegratedwith
face-to-facetherapistguidancesessions.
Conflict
of
interest
statement
Nothingdeclared.
CRediT
authorship
contribution
statement
VeraEHeininga:Conceptualization,Investigation,
Visu-alization,Datacuration,Writing-originaldraft,Writing
-review & editing. Peter Kuppens: Conceptualization,
Writing-review& editing.
Acknowledgement
ThisworkwassupportedbytheC1grantbytheKULeuvenResearch Council(C14/19/054).
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