effects of brain disease on our loved ones and relationships

Effects of Brain Disease On Our Loved Ones and Relationships

Virginia Sturm, Ph.D. April 25, 2015

Positive Emotions

Emotional Change

How do emotions foster close relationships?

Chagall

Caregiving is Hard-Wired in Highly Social Species

Plotnik & deWaal, 2014

deWaal, 2007

deWaal & Suchak, 2010

Douglas et al., 2006

helping

consolation

Prosocial Behaviors Occur Spontaneously

Horner et al., 2011 Plotnik et al., 2011

Altruistic Helping Behavior

Plotnik et al., 2011

What are emotions?

Short-lived phenomena – Psychological

• Alter attention, shift certain behaviors upward in response hierarchies, activate memory networks

– Physiological • Rapidly organize the responses of disparate biological

systems (e.g., facial expression, somatic muscular tonus, voice, ANS)

Levenson, 1994

Antecedent Event

Emotional Response Tendency

Emotional Response

Reappraisal Suppression

Amplification Substitution

Appraisal Reactivity

Regulation

visceromotor

reactivity

emotional brain networks

emotional reactivity

emotion regulation

appraisal

interoception

afferent representation

Emotions Shape Our Responses in Diverse Contexts

threat loss contamination unfairness play kinship bond faux pas achievement

fear sadness disgust anger amusement nurturant love embarrassment pride

NEGATIVE

SELF- CONSCIOUS

POSITIVE

Positive Emotions Serve Important Social Functions

• Family of positive emotions – Compassion, nurturant love,

awe, enthusiasm, amusement, calm, gratitude

• Facilitate: – Approach behavior – New relationships – Creativity, generation, and

expansive thinking Fredrickson, 2004; Griskevicius et al., 2010

Positive Emotions: Restore and Buffer

• Positive emotions: – “Undo” negative

emotional states – Counter effects of

chronic stress – Foster resilience – Are associated with lower

physiological arousal

Levenson, 1988; Moskowitz, 2003

The Autonomic Nervous System Connects Brain to Body

Sympathetic

Fight or flight

Physiological increase

Parasympathetic

Tend and befriend

Physiological decrease

The Parasympathetic Nervous System Lowers Autonomic Arousal

brain

lungs

heart

inspiration

expiration

increases heart rate

decreases heart rate

Parasympathetic Activity is Advantageous

• Slower breathing: – Decreases heart rate – Increases heart rate

variability

• Higher heart rate variability is associated with: – Positive emotion – Prosocial behavior

Parasympathetic Tone Promotes Positive Emotion

• Lower negative emotion • Greater positive experience to neutral

situations • Higher positive mood • Greater optimism and agreeableness • Sweet spot for parasympathetic functioning?

Fabes & Eisenberg, 1997; Oveis et al., 2009; Kogan et al., 2014

Presenter

Presentation Notes

Upward spiral Gratitude Awe Deep breathing

Compassion Motivates Helping

Singer & Klimecki, 2014

Sharing Positive Emotions is Rewarding in the Brain

• Compassion activates reward networks

• Sharing others’ positive emotions also activates reward networks

Klimecki et al., 2013; Morelli et al., 2014

photo credit: ahaparenting.com

Presenter

Presentation Notes

Can be trained and brain activity increases It feels good to be understood and to share the positive feelings of others

Gratitude Helps to Sustain Close Relationships

• Important social functions • Find-remind-and-bind

theory • Gratitude solidifies

relationships with supportive, loyal partners

Algoe, 2012

Presenter

Presentation Notes

Find: new relationship partners Remind: us of quality partners Bind: recipient and benefactor together

Awe is Good for Your Mind and Body

• Feeling of wonder when in the presence of something vast, large, or hard to grasp

• Associated with: – Cognitive restructuring – Decreased self-focused

attention – Lower inflammatory

levels

Keltner & Haidt, 1999; Shiota et al., 2007; Stellar et al., 2015

Presenter

Presentation Notes

Cannot be accounted for by current understanding of the world

Positive Emotion and the Upward Spiral

Kok & Fredrickson, 2010

parasympathetic activity

social interaction and connection











How do changes in patients’ emotions alter relationships?

Modigliani

Brain Diseases Change Relationships by Altering Emotion

Behavioral Variant Frontotemporal Dementia

(bvFTD) Alzheimer’s Disease

(AD)

Brain Lesions From Various Causes Have Similar Impact on Behavior

• Individual patients have taught us an enormous amount about brain-behavior relationships

• Diseases/tumors/ injuries that target these regions will have similar impact on thinking and behavior

AD • Cognitive symptoms

primary • Social and emotional

preservation • Posterior: parietal and

medial temporal

bvFTD • Socioemotional symptoms

primary • Social and emotional

impairment • Anterior: medial frontal

and insula

bvFTD Example: Loss of Empathy

AD Example: Preservation of Social Decorum

Antecedent Event

Emotional Response Tendency

Emotional Response

Reappraisal Suppression

Amplification Substitution

Appraisal Reactivity

Regulation

Loss of Emotion May Alter Behavior

Autonomic Reactivity Facial Expression Subjective Experience

I feel sad.

Reactivity

social faux pas others’ emotions

I feel embarrassed. I feel happy.

embarrassment deficits

in bvFTD

emotional empathy deficits

in bvFTD

embarrassment emotional empathy

Laboratory Measurement of Emotion

• Physiological Reactivity – Heart rate, respiration, skin

conductance, finger temperature, ear pulse, finger pulse, somatic activity, blood pressure, heart rate variability, cardiac impedance, facial EMG, pupil diameter

• Facial Behavior • Self-Report Did you feel sad while watching the film?

1 2 3 4 5 No A little A lot

Self-Conscious Emotions Serve Interpersonal Functions

• Social emotions – Guilt, pride, shame, and embarrassment – Social evaluation

• Embarrassment

– Emerges after violation of a social convention – Characteristic facial display and physiological

activation – Promotes reparation of disrupted social bonds

• Self-representations are progressively more complex across phylogeny (Povinelli & Cant, 1995)

• Self-recognition is seen in highly social species - Human infants (Papousek, 1974)

- Great apes (Gallup, 1970)

- Elephants (Plotnik, 2006)

- Dolphins (Reiss, 2001)

Self-Representations: Uniquely Human?

Neural Correlates of Self-Processing

• Medial networks • Medial prefrontal

cortex

Northoff et al., 2006

Laboratory Assessment: Karaoke Task

baseline

1 min.

singing

~2.5 min.

watch baseline

1 min.

watch self singing

~2.5 min.

X X

30 sec.

Sturm et al., 2008

Facial Behavior • Anger, sadness, disgust, fear, surprise,

confusion, contempt, happiness, embarrassment

• Intensity: 0-3

Autonomic Reactivity • Heart rate • Respiration • Skin conductance level • Finger pulse • Temperature

Diminished Self-Conscious Emotional Reactivity in bvFTD

0

5

10

15

20

25

30

bvFTDControls

Sturm et al., 2008; Sturm et al., 2012

*

Mea

n To

tal E

mot

iona

l Beh

avio

r

• bvFTD < controls in embarrassment behavior and ANS reactivity

• Smaller volume in right pregenual anterior cingulate cortex is associated with lower ANS and behavioral response

* = p< .05

Embarrassment Examples

bvFTD Healthy Control

What is empathy?

photograph by Dorthea Lange

Emotional Empathy Cognitive Empathy

Prosocial Behavior

Perception Detection of Socioemotional Stimuli

Facial Mimicry Autonomic Reactivity

Emotion Recognition Perspective-Taking

Affiliation Compassion

Emotional Empathy is Affect-Sharing

• Mirroring of others’ emotions – Mimicry – Autonomic simulation – Rapidly – Without conscious awareness

• Evolutionarily conserved – Present in other species – Present in human infants

• Depends on emotion generation brain systems – Insula, ACC central amygdala,

hypothalamus PAG

Photo credit: Mancini, 2013

• Clinical observations – Intact (enhanced?) social behavior in AD

• Emotional symptoms are common – In MCI (35-85%) and AD (75%)

• Increased salience network connectivity in AD (Zhou, 2010)

– Relates to agitation, irritability, aberrant motor behavior (Balthazar, 2013)

Socioemotional Preservation in AD

• Increased emotional contagion in AD?

0

2

4

6

8

10

Controls MCI AD

MenWomen

0

5

10

15

20

25

Controls MCI AD

MenWomen

Em

otio

nal C

onta

gion

D

epre

ssiv

e S

ympt

oms

A.

B.

** *

**

*= p<.01 and **= p<.001

Right Temporal Lobe Degeneration is Associated with Higher Emotional Contagion

blue= p<.001, uncorrected, and hot= pFWE<.05

Laboratory Assessment of Emotional Empathy

Task • 4 film clips in which the

character displayed: - enthusiasm - calm - affection - amusement

X

baseline

35 seconds

film clip

37 seconds

questions

Facial Behavior • Tuning of facial expression

to that of character • Total happiness/ total

emotion displayed

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Enthusiasm Calm Affection Amusement

bvFTD

HC

AD

Facial Mimicry in Diminished in bvFTD Pr

opor

tion

of P

ositi

ve F

acia

l Beh

avio

r

* *

* denotes Bonferroni-adjusted, p< .05 covariates: sex, age, and education

*

Resting Parasympathetic Tone is Low in bvFTD

*

*

covariates: sex, age, education

*

0

20

40

60

80

100

bvFTD HC

RSA

(ms)

*

Healthy Controls

bvFTD * = p< .05

Sturm et al., in prep.

How do patients’ emotional changes impact caregivers’ health?

Picasso

Potential Costs to Caregiving

• Increased burden • Increased depression and anxiety • Lower self-rated physical health, greater

health care utilization, greater decline in cellular immune functioning

• Lower self-rated well-being • There are large individual differences in these

outcomes

(e.g., Schulz et al., 1990, 1995; Dura et al., 1991; Kiecolt-Glaser et al., 1991)

Presenter

Presentation Notes

About 20% more depression and 9% more anxiety than controls (some studies by symptom report and some by DSM diagnosis) Schulz, R, O'Brien, AT, Bookwala, J, and Fleissner, K. Psychiatric and physical morbidity effects of dementia caregiving: Prevalence, correlates, and causes. The Gerontologist. 1995; 35(6): 771-791. 5.Schulz, R and Beach, SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA : the journal of the American Medical Association. 1999; 282(23): 2215-9. 6.Plassman, BL, Langa, KM, Fisher, GG, Heeringa, SG, Weir, DR, Ofstedal, MB, Burke, JR, Hurd, MD, Potter, GG, Rodgers, WL, Steffens, DC, Willis, RJ, and Wallace, RB. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology. 2007; 29(1-2): 125-32. PMCID: 2705925. 7.Kawas, CH and Brookmeyer, R. Aging and the public health effects of dementia. The New England Journal of Medicine. 2001; 344(15): 1160-1. 8.Schulz, R, Visintainer, P, and Williamson, GM. Psychiatric and physical morbidity effects of caregiving. J Gerontol. 1990; 45(5): P181-91. 9.Baumgarten, M, Battista, RN, Infante-Rivard, C, Hanley, JA, Becker, R, and Gauthier, S. The psychological and physical health of family members caring for an elderly person with dementia. J Clin Epidemiol. 1992; 45(1): 61-70. 10.Vitaliano, PP, Russo, J, Young, HM, Teri, L, and Maiuro, RD. Predictors of burden in spouse caregivers of individuals with Alzheimer's disease. Psychol Aging. 1991; 6(3): 392-402. 11.Spitzer, RL, Williams, JB, Gibbon, M, and First, MB. The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry. 1992; 49(8): 624-9. 12.Dura, JR, Stukenberg, KW, and Kiecolt-Glaser, JK. Anxiety and depressive disorders in adult children caring for demented parents. Psychol Aging. 1991; 6(3): 467-73. 13.Grafstrom, M, Fratiglioni, L, Sandman, PO, and Winblad, B. Health and social consequences for relatives of demented and non-demented elderly. A population-based study. J Clin Epidemiol. 1992; 45(8): 861-70. 14.Blazer, D. Geriatric psychiatry, in Hales, Robert E.; Yudofsky, Stuart C.; Talbott, John A. (1994). The American Psychiatric Press textbook of psychiatry (2nd ed.). (pp. 1405-1421). Washington, DC, US: American Psychiatric Association. xxiii, 1694 pp. 1994; American Psychiatric Association: Washington, DC. 15.Moritz, DJ, Kasl, SV, and Ostfeld, AM. The health impact of living with a cognitively impaired elderly spouse: Blood pressure, self-rated health, and health behaviors. Journal of Aging and Health. 1992; 4(2): 244-267. 16.Kiecolt-Glaser, JK, Dura, JR, Speicher, CE, Trask, OJ, and Glaser, R. Spousal caregivers of dementia victims: longitudinal changes in immunity and health. Psychosom Med. 1991; 53(4): 345-62. 17.Uchino, BN, Kiecolt-Glaser, JK, and Cacioppo, JT. Age-related changes in cardiovascular response as a function of a chronic stressor and social support. J Pers Soc Psychol. 1992; 63(5): 839-46.

What are the sources of individual differences in caregiver outcomes

CaregiverOutcomes

Caregiver Characteristics

CognitiveDeficits

Emotional Functioning

PhysicalHealth

FunctionalDeficits

Emotional Functioning

Patient Characteristics

Patient Characteristics

Well-being

Burden

Mental Health

Genes

Personality

Study led by Robert Levenson, PhD and Jennifer Merrilees, RN, PhD

Disease-Specific Impacts on Caregivers’ Language and Marital Satisfaction

• Couples in which one person had bvFTD or AD had a conversation about an area of conflict

• Caregivers of patients with bvFTD used more negative words than caregivers of patients with AD

• Couples with FTD had lower marital satisfaction than couples with AD

Ascher et al., 2009

Changes in Connectedness Can Accompany Disease

• Inclusion of Other in Self Scale • Decreases in inclusion predict:

– decreases in life satisfaction and – Increases in caregiver burden

Connelly et al., in prep.

Positive Emotions

Emotional Change

Acknowledgements • UCSF

• Bruce Miller, M.D. • William Seeley, M.D. • Howard Rosen, M.D. • Katherine Rankin, Ph.D. • Joel Kramer, Psy.D. • Jennifer Yokoyama, Ph.D. • Alice Hua • Jessica Zakrzewski

• UC Berkeley • Robert Levenson, Ph.D. • Sandy Lwi • Anna Sapozhnikova • Alice Verstaen • Michaela Simpson • Jim Casey • Marcela Otero • Casey Brown • Luma Muhtadie • Deepak Paul • Scott Newton

• Funding • NIH-NIA K23 Award • The Larry L. Hillblom Foundation • Alzheimer’s Disease Research Center

• Our patients, controls, and their families

effects of brain disease on our loved ones and relationships

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