Understanding adherence to physiotherapy: Findings from an experimental simulation and an observational clinical study

This article reports two studies assessing the influence of self-efficacy, outcome expectancies and aversive feedback on different aspects of adherence. Study 1 employed a computer simulation of physiotherapy to test experimentally the effects of aversive feedback (i.e., loud noise) experienced during simulated therapy on adherence behaviour in a student population. Study 2 examined whether similar effects of aversive feedback (i.e., pain) experienced during physiotherapy in a clinical setting would be observed in a longitudinal questionnaire study of predictors of adherence. In both studies, self-efficacy and outcome expectancies were assessed at baseline and after experience of the task (performing simulated or actual physiotherapy). Study 1 found that self-efficacy and outcome expectancies predicted persistence with simulated physiotherapy (i.e., completing the experimental session), whereas aversive feedback influenced adherence during sessions (i.e., correct response rate). Study 2 found that self-efficacy and outcome expectancies predicted persistence with actual physiotherapy (i.e., completing the prescribed number of sessions). Aversive feedback and outcome expectancies influenced adherence during sessions. We conclude that different factors predict different aspects of adherence behaviour. It is therefore important to measure both persistence over time and adherence during sessions, and to investigate the predictors of each dimension of adherence.     

Emotional responses to objective and normative performance feedback

The effect of objective and normative feedback on emotional responses to tasks was assessed in kindergarten age and 2nd- and 4th-grade children. Children completed a task on which they received objective (few errors vs. many errors) and normative (superior vs. inferior to same-aged peers) feedback. After receiving the feedback they were asked to rate the intensity of their emotional responses (global affect, good, bad, proud, and embarrassed), and their competency on the task. Both objective and normative feedback affected most emotional responses. The effect of the evaluation feedback generally did not vary as a function of the child's grade. Girls' comptency ratings were more affected by normative feedback than boys', but boys were more embarrassed following objective failure than girls.     

Reaction time task as unconditional stimulus

Nonaversive unconditional stimuli (USs) are seldom used in human classic conditioning of autonomic responses. One major objection to their use is that they produce deficits in electrodermal (ED) second- and third-interval response conditioning. However, a nonaversive reaction time (RT) task that includes feedback of success has been shown to be an effective US while avoiding this disadvantage (Lipp and Vaitl 1988). The present study compared this new RT task (RT-new) with a traditional RT task (RT-old) and with a standard aversive US (shock) in differential classic conditioning of ED, heart rate (HR), and digital pulse volume (DPV) responses. Eight-second-delay differential conditioning was applied in three groups of 12 subjects each. Simple geometric features (square, cross) displayed on a television screen served as conditional stimuli (CS⁺ and CS^?). In acquisition, there were no statistically significant differences among the groups; differential conditioning did occur in HR, first- and second-interval ED responses, and first-interval DPV responses. Separate analyses within each group, however, revealed that there was no second-interval ED conditioning in the RT-old group. During extinction, neither DPV nor second-interval ED conditioning could be obtained, whereas HR and first-interval ED conditioning occurred in each group. In third-interval omission ED responses, RT-old and shock groups exhibited extinction, while response differentiation was maintained in the RT-new group throughout extinction. The RT task including feedback proved to be as reliable a US as a standard aversive US, whereas application of a traditional RT task again yielded some weaknesses in second-interval ED conditioning.     

From gains to losses: Age-related differences in decisions under risk in a non-monetary gambling task

Lifespan theory suggests a shift from a primary orientation towards attaining gains in young adulthood to preventing losses in older adulthood. The current research tested if this motivational shift is reflected in behavioural and emotional responses to risks in non-monetary gains and losses. Study 1 established in a sample of N = 168 younger (18–30 years) and older adults (65–79 years) that a non-monetary gambling task was experienced similarly by the age groups with respect to arousal and valence of the task, and the willingness to continue playing. In Study 2 (N = 83), differences between young (18–30 years) and older (64–85 years) adults’ risk-taking in this non-monetary gambling task with mixed gambles were tested while assessing physiological responses (event-related heart rate change) to gain and loss feedback. Behavioural – but not physiological – results confirm hypotheses derived from a lifespan motivational framework regarding age-differential effects of gains and losses.     

Sex differences in aversive memory in rats: Possible role of extinction and reactive emotional factors

Studies usually show better spatial learning in males and stronger emotional memory in females. Spatial memory differences could relate to diverse strategies, while dissimilar stress reactions could cause emotional memory differences. We compared male and female rats in two emotional (classical emotional conditioning and aversive discrimination memory) and two emotionally “neutral” tasks: (1) plus-maze discriminative avoidance, containing two open and two enclosed arms, one of which presenting aversive stimuli (light/noise). No differences were found in learning, retrieving, or basal emotional levels, while only male rats presented extinction of the task; (2) contextual fear conditioning – a cage was paired to mild foot shocks. Upon reexposure, freezing behavior was decreased in females; (3) spontaneous alternation – the animals were expected to alternate among the arms of a four-arm maze. No differences between genders were found and (4) open-field habituation was addressed in an arena which the rats were allowed to explore for 10 min. Habituation was similar between genders. Differences were found only in tasks with strong emotional contexts, where different fear responses and stress effects could be determinant. The lack of extinction of discriminative avoidance by females points out to stronger consolidation and/or impaired extinction of aversive memories.     

Effects of learned helplessness training on instrumental heart rate control in humans

In Experiment 1, subjects who received feedback contingent on short interbeat intervals (relative to a baseline period) learned to accelerate their heart rates, but subjects who received noncontingent feedback did not. In Experiment 2, subjects who were exposed to noncontingent aversive noises later showed significant performance deficits on both an instrumental and a cognitive task. Attributional style predicted helplessness deficits on the cognitive but not the instrumental task. Experiment 3 demonstrated that experimentally induced helplessness interferes with biofeedback learning. Attributional style did not predict the occurrence of helplessness deficits in this context. Results are discussed in terms of the nature of biofeedback training and the range of behaviors that learned helplessness training affects.     

Experiential avoidance and aversive visual images: response delays and event-related potentials on a simple matching task

In Experiment 1, participants high (n=15) or low in avoidance (n=14), as measured by the Acceptance and Action Questionnaire, completed a simple matching task that required them to choose whether or not to look at an aversive visual image. Only the high-avoidance participants took longer to emit a correct response that produced an aversive rather than a neutral picture. Additionally, the high-avoiders reported greater levels of anxiety following the experiment even though they rated the aversive images as less unpleasant and less emotionally arousing than their low-avoidant counterparts. In Experiment 2, three groups, representing high-, mid- and low-avoidance (n=6 in each) repeated the matching task with the additional recording of event-related potentials (ERPs). The findings of Experiment 1 were replicated in terms of reaction times and subjective ratings. The ERPs confirmed that the participants attended to the content of the images and differentiated between the aversive and neutral image types. The ERPs also showed significantly greater negativity for electrodes over the left hemisphere relative to the midline for only the high-experiential avoidance (EA) group. Given the left hemisphere dominance for language, the data suggest that the high-EA group engaged in verbal strategies to regulate their emotional responses.     

Psychopathy and physiological response to emotionally evocative sounds

Despite considerable evidence that psychopathic criminals are deviant in their emotional reactions, few studies have examined responses to both pleasurable and aversive stimuli or assessed the role of different facets of psychopathy in affective deviations. This study investigated physiological reactions to emotional sounds in prisoners selected according to scores on the 2 factors of Hare's Psychopathy Checklist--Revised (PCL-R; R. D. Hare, 1991). Offenders high on the PCL-R emotional-interpersonal factor, regardless of scores on the social deviance factor, showed diminished skin conductance responses to both pleasant and unpleasant sounds, suggesting a deficit in the action mobilization component of emotional response. Offenders who scored high only on the social deviance factor showed a delay in heart rate differentiation between affective and neutral sounds. These findings indicate abnormal reactivity to both positive and negative emotional stimuli in psychopathic individuals, and suggest differing roles for the 2 facets of psychopathy in affective processing deviations.     

Prediction and control as determinants of behavioural uncertainty: Effects on task performance and heart rate reactivity

Control or control-belief is often viewed as being directly instrumental in facilitating coping mechanisms in aversive situations, and yet the empirical evidence for the beneficial effects of control is inconclusive. In this study we investigated the role of predictability in determining the effects of perceived control during an aversive reaction time task. Fifty-six subjects were allocated to one of four groups; predictable-control, predictable-no control, unpredictable-control, unpredictable-no control. In the predictable conditions, subjects could temporally predict the occurrence of an aversive noise. In the perceived control conditions, duration of the aversive tone was contingent on subject’s performance. All subjects were matched in terms of the nature of the task and in the number and time of receipt of both the warning signal and noise. Heart rate reactivity and two performance parameters were measured, reaction time and performance increase. Both predictability and control-belief led to a reduction in heart rate reactivity, although they appeared to function independently and at different points in the sequence of events. That is, predictability or perceived control was sufficient to mitigate the effects, of an aversive situation. Neither perception of control or predictability led to better task performance. These results are discussed in terms of behavioural uncertainty explanations.     

Prediction and control as determinants of behavioural uncertainty: effects on task performance and heart rate reactivity.

Control or control-belief is often viewed as being directly instrumental in facilitating coping mechanisms in aversive situations, and yet the empirical evidence for the beneficial effects of control is inconclusive. In this study we investigated the role of predictability in determining the effects of perceived control during an aversive reaction time task. Fifty-six subjects were allocated to one of four groups; predictable-control, predictable-no control, unpredictable-control, unpredictable-no control. In the predictable conditions, subjects could temporally predict the occurrence of an aversive noise. In the perceived control conditions, duration of the aversive tone was contingent on subject's performance. All subjects were matched in terms of the nature of the task and in the number and time of receipt of both the warning signal and noise. Heart rate reactivity and two performance parameters were measured, reaction time and performance increase. Both predictability and control-belief led to a reduction in heart rate reactivity, although they appeared to function independently and at different points in the sequence of events. That is, predictability or perceived control was sufficient to mitigate the effects of an aversive situation. Neither perception of control or predictability led to better task performance. These results are discussed in terms of behavioural uncertainty explanations.     

Emotional appraisal is influenced by cardiac afferent information

Influential models highlight the central integration of bodily arousal with emotion. Some emotions, notably disgust, are more closely coupled to visceral state than others. Cardiac baroreceptors, activated at systole within each cardiac cycle, provide short-term visceral feedback. Here we explored how phasic baroreceptor activation may alter the appraisal of brief emotional stimuli and consequent cardiovascular reactions. We used functional MRI (fMRI) to measure brain responses to emotional face stimuli presented before and during cardiac systole. We observed that the processing of emotional stimuli was altered by concurrent natural baroreceptor activation. Specifically, facial expressions of disgust were judged as more intense when presented at systole, and rebound heart rate increases were attenuated after expressions of disgust and happiness. Neural activity within prefrontal cortex correlated with emotionality ratings. Activity within periaqueductal gray matter reflected both emotional ratings and their interaction with cardiac timing. Activity within regions including prefrontal and visual cortices correlated with increases in heart rate evoked by the face stimuli, while orbitofrontal activity reflected both evoked heart rate change and its interaction with cardiac timing. Our findings demonstrate that momentary physiological fluctuations in cardiovascular afferent information (1) influence specific emotional judgments, mediated through regions including the periaqueductal gray matter, and (2) shape evoked autonomic responses through engagement of orbitofrontal cortex. Together these findings highlight the close coupling of visceral and emotional processes and identify neural regions mediating bodily state influences on affective judgment.     

Granting forgiveness or harboring grudges: implications for emotion, physiology, and health

Interpersonal offenses frequently mar relationships. Theorists have argued that the responses victims adopt toward their offenders have ramifications not only for their cognition, but also for their emotion, physiology, and health. This study examined the immediate emotional and physiological effects that occurred when participants (35 females, 36 males) rehearsed hurtful memories and nursed grudges (i.e., were unforgiving) compared with when they cultivated empathic perspective taking and imagined granting forgiveness (i.e., were forgiving) toward real-life offenders. Unforgiving thoughts prompted more aversive emotion, and significantly higher corrugator (brow) electromyogram (EMG), skin conductance, heart rate, and blood pressure changes from baseline. The EMG, skin conductance, and heart rate effects persisted after imagery into the recovery periods. Forgiving thoughts prompted greater perceived control and comparatively lower physiological stress responses. The results dovetail with the psychophysiology literature and suggest possible mechanisms through which chronic unforgiving responses may erode health whereas forgiving responses may enhance it.     

Underpredicted pain disrupts more than correctly predicted pain, but does not hurt more

One of the explanations for the negative effects of underpredicted aversive experiences is that they have more impact than correctly predicted aversive experiences. In a laboratory experiment 40 normal female subjects executed an auditory discrimination task. Subjects were randomly assigned to a correct information condition and an underprediction information condition. After ten trials (baseline) subjects were informed that they would receive some painful (correct prediction) or non-painful tingling (underprediction) stimuli during the discrimination task. Starting just before five of the following 20 discrimination trials, 2 s of painful electrical stimulation was given. Subjects rated sensations and painfulness of the electrical stimulation, subjective anxiety, and degree of distraction from the task, after each pain stimulus. Reaction times of the discrimination task and heart rate were measured. Underprediction information resulted in lower pain ratings, but stronger heart rate responses and higher disruption on the discrimination task, compared to correct information. This suggests that while underpredictions of pain do not hurt more, disruption on primary tasks and physiological impact are higher. Underpredicted pain has more impact than correctly predicted pain, not because it hurts more, but because it conveys inherent danger information.     

The role of perceived physiological activity in affective judgments

This study assessed the physiological and cognitive effects of Valins' (Valins, S. Journal of Personality and Social Psychology, 1966, 4, 400–408) false heart rate procedure. Twenty-two male subjects were exposed to two feedback conditions during which measures of actual heart rate and skin conductance were obtained. In each condition, eight slides of nude females were presented; some slides were associated with false heart rate increases, while for other slides the feedback remained stable. In one condition, subjects were told that the heart rate was that of another subject; in the other condition, subjects were told that the feedback was their own heart rate. In both conditions, subjects judged the attractiveness of the slides from their own point of view and from the point of view of the other subject. Slides associated with false heart rate increases were rated as more attractive than stable slides when subjects (1) heard their own heart rate and rated their own attraction; (2) heard the other subject's heart rate and rated their own attraction; and (3) heard the other subject's heart rate and rated the other subject's attraction. Skin conductance responses and actual cardiac decelerations were greater when subjects heard what was allegedly their own heart rate and when the slides were accompanied by apparent cardiac acceleration. However, these actual physiological responses did not play a causal role in relation to the affective judgments. Instead, the relationship between perceived physiological changes and feelings of attractiveness was mediated by cognitive processes associated with informational and directive influences of the feedback.     

Cultures of moderation and expression: emotional experience, behavior, and physiology in Chinese Americans and Mexican Americans

Ethnographic accounts suggest that emotions are moderated in Chinese cultures and expressed openly in Mexican cultures. The authors tested this notion by comparing subjective, behavioral, and physiological aspects of emotional responses to 3 (warned, unwarned, instructed to inhibit responding) aversive acoustic startle stimuli in 95 Chinese Americans and 64 Mexican Americans. Subjective reports were consistent with ethnographic accounts; Chinese Americans reported experiencing significantly less emotion than Mexican Americans across all 3 startle conditions. Evidence from a nonemotional task suggested that these differences were not artifacts of cultural differences in the use of rating scales. Few cultural differences were found in emotional behavior or physiology, suggesting that these aspects of emotion are less susceptible to cultural influence.     

Priming of mental operations by masked stimuli

Motor responses can be affected by visual stimuli that have been made invisible by masking. Can masked visual stimuli also affect nonmotor operations that are necessary to perform the task? Here, I report priming effects of masked stimuli on operations that were cued by masking stimuli. Cues informed participants about operations that had to be executed with a forthcoming target stimulus. In five experiments, cues indicated (1) the required response, (2) part of the motor response, (3) the stimulus modality of the target stimulus, or (4) the task to be performed on a multidimensional stimulus. Motor and nonmotor priming effects followed comparable time courses, which differed from those of prime recognition. Experiment 5 demonstrated nonmotor priming without prime awareness. Results suggest that motor and nonmotor operations are similarly affected by masked stimuli.     

Modulation of the conflict monitoring intensity: The role of aversive reinforcement,cognitive demand,and trait-BIS

According to Botvinick’s (2007) integrative account, conflict monitoring is aversive because individuals anticipate cognitive demand, whereas the revised reinforcement sensitivity theory (rRST) predicts that conflict processing is aversive because individuals anticipate aversive reinforcement of erroneous responses. Because these accounts give different reasons for the aversive aspects of conflict, we manipulated cognitive demand and the aversive reinforcement as a consequence of wrong choices in a go/no-go task. Thereby, we also aimed to investigate whether individual differences in conflict sensitivity (i.e., in trait anxiety, linked to high sensitivity of the behavioral inhibition system [trait-BIS]) represent the effects of aversive reinforcement and cognitive demand in conflict tasks. We expected that these manipulations would have effects on the frontal N2 component representing activity of the anterior cingulate cortex. Moreover, higher-trait-BIS individuals should be more sensitive than lower-trait-BIS individuals to aversive effects in conflict situations, resulting in a more negative frontal N2 for higher-trait-BIS individuals. In Study 1, with N = 104 students, and Study 2, with N = 47 students, aversive reinforcement was manipulated in three levels (within-subjects factor) and cognitive demand in two levels (between-subjects factor). The behavioral findings from the go/no-go task with noncounterbalanced reinforcement levels (Study 1) could be widely replicated in a task with counterbalanced reinforcement levels (Study 2). The frontal mean no-go N2 amplitude and the frontal no-go N2 dipole captured predicted reinforcement-related variations of conflict monitoring, indicating that the anticipation of aversive reinforcement induces variations in conflict monitoring intensity in frontal brain areas. The aversive nature of conflict was underlined by the more pronounced conflict monitoring in higher- than in lower-trait-BIS individuals.     

Visual search under conditions of very rapid sequential Input rates

The purposes of the present experiment were to provide information on rate of information processing in visual perception and to determine the degree to which the “sequential blanking” effect found by Mayzner. Tresselt, and Cohen (1966) constituted a limitation on rapid sequential input rates. A 10-channel tachisto scope was employed that permitted controlled durations of each of the 10 channels and the 9 inter channel intervals. The S’s task was one of visual search or detection in which he searched for a target letter among noise letters. A temporal interval forced-choice procedure was used. In addition to varying the rate at which letters were sequentially presented, various irregular temporal spatial orders of presentation of the letter sequences were employed and the direction and orientation of the display in the visual field was varied as was also the spacing between adjacent stimuli. No evidence of “sequential blanking” was found either in terms of the detection criterion or in the Ss’ phenomenal reports. Detection performance was as good at a rate of 2 1/2 msec per letter as it was at a rate of 30 msec per letter.     

Attentional capture by emotional faces is contingent on attentional control settings

Attentional capture by schematic emotional faces was investigated in two experiments using the flanker task devised by Eriksen and Eriksen (1974). In Experiment 1, participants were presented with a central target (a schematic face that was either positive or negative) flanked by two identical distractors, one on either side (schematic faces that were positive, negative, or neutral). The objective was to identify the central target as quickly as possible. The impact of the flankers depended on their emotional expression. Consistent with a threat advantage hypothesis (negative faces are processed faster and attract more processing resources), responses to positive faces were slower when these were flanked by (response incompatible) negative faces as compared with positive or neutral faces, whereas responses to negative faces were unaffected by the identity of the flankers. Experiment 2 was a standard flanker task with letter stimuli except that the task-neutral flankers were schematic faces that were either positive, negative, or emotionally neutral. In this case, in which faces and emotional expressions were to be ignored, performance seemed entirely unaffected by the faces. This result suggests that attentional capture by emotional faces is contingent on attentional control settings.     

Attentional capture by emotional faces is contingent on attentional control settings

Attentional capture by schematic emotional faces was investigated in two experiments using the flanker task devised by Eriksen and Eriksen (1974). In Experiment 1, participants were presented with a central target (a schematic face that was either positive or negative) flanked by two identical distractors, one on either side (schematic faces that were positive, negative, or neutral). The objective was to identify the central target as quickly as possible. The impact of the flankers depended on their emotional expression. Consistent with a threat advantage hypothesis (negative faces are processed faster and attract more processing resources), responses to positive faces were slower when these were flanked by (response incompatible) negative faces as compared with positive or neutral faces, whereas responses to negative faces were unaffected by the identity of the flankers. Experiment 2 was a standard flanker task with letter stimuli except that the task-neutral flankers were schematic faces that were either positive, negative, or emotionally neutral. In this case, in which faces and emotional expressions were to be ignored, performance seemed entirely unaffected by the faces. This result suggests that attentional capture by emotional faces is contingent on attentional control settings.