effects of mindfulness-based cognitive therapy on the ...€¦ · • wichers, et al. (2008)....

Effects of Mindfulness-Based Cognitive Therapy on the experience of positive emotions in daily life:

A randomized controlled trial

Nicole Geschwind

[email protected]

Centre for Psychology of Learning and Psychopathology; Research Group on Health Psychology

Overview

• Positive emotions, why bother?

• Experience Sampling Method

• Mindfulness-Based Cognitive Therapy

• MindMaastricht trial

• Results

• Conclusion

Faculty of Health, Medicine, and Life Sciences

MHeNS School for Mental Health and Neuroscience

Introduction: Positive Emotions

• Associated with longevity and health

• Positive and negative emotions = different subsystems

•

(Cohn & Fredrickson, 2009; Geschwind, 2011)

Emotions

Negative emotions

Positive Emotions

time

inte

nsi

ty

Experience Sampling Method

• At random

• 10 times per day

• 6 days

• Emotions

• Situation / activity

Right now, I feel… not at all moderately very Cheerful 1 2 3 4 5 6 7 Anxious 1 2 3 4 5 6 7

Daily life person-context interaction

Experience sampling procedure

Day 1 Day 2 Day 3 Day 4 Day 5

beep

beep

beep

beep

beep

beep

beep

beep

beep

beep

one ESM day

7.30 22.30

Positive

emotions

Activity

Pleasantness

Day 6

Daily-

life

context

Daily-Life Reward Experience

Daily life

Po

siti

ve e

mo

tio

ns

How to increase positive emotions?

a t t e n t i o n a l

b r o a d e n i n g

Positive emotions

Reward

Mindfulness-Based Cognitive Therapy

• 8 week training, 10-15 participants

• In touch with and aware of the present moment

• Non-evaluative and non-judgmental

• Daily homework: attention exercises

MindMaastricht RCT

• Sample: 130 participants with residual symptoms of depression, not currently depressed

6 days Experience Sampling

6 days Experience Sampling

Mindfulness Training (MBCT)

Control

Positive emotions

• Happy

• Satisfied

• Strong

• Enthusiastic

alpha = 0.89

• Curious

• Animated

• Inspired

• [Relaxed]

Pleasantness of current activity

• Factor analysis:

– I enjoy this activity

– I am skilled at doing this

– This activity requires effort

– I would prefer to do s.th. else

– [I feel I’m being active]

– [This is a challenge]

Activity Pleasantness

Results

Total Entries Invalid Participants Entries per participant

12.453 559 (4 %) 130; 1 excluded

49 (SD 7.6)

After mindfulness training…

• More positive emotions

• Activities appraised as more pleasant

Also: Increased reward experience

Daily life

Po

siti

ve e

mo

tio

ns

before

after

PA change

CONTROL MBCT

pre

post

***

Activity pleasantness change

CONTROL MBCT

pre

post

Reward Experience change

CONTROL MBCT

pre

post

Increases in positive emotions

low medium high

Reduction in residual symptoms

Related to reduction in residual symptoms?

***

pre

post

low medium high



pre

post



pre

post

But…

• Original idea behind MBCT: learn to disengage from automatic negative thinking patterns that arise during dysphoric mood and facilitate relapse (Teasdale, 2000)

• So: Rumination, worry, NA PA etc. ?

• Independent of changes in rumination, worry, NA, and stress sensitivity

Conclusions

• Reward experience can be learned

• Living in the moment more receptive higher experience of positive emotions during pleasant activities

• More research necessary into underlying mechanisms!

• MBCT has another, less often studied face: it facilitates the experience of positive emotions.

• Changes in PA-related variables possibly contribute to the protective effects of MBCT against future relapse

Conclusions



Thanks to:

(VENI grant nr 916.76.147 to Dr Wichers)

Marieke Wichers

Jim van Os

Frenk Peeters



[email protected]

Geschwind, N., Peeters, F., Drukker, M., van Os, J., & Wichers, M. (2011). Mindfulness training increases momentary positive emotions and reward experience in adults vulnerable to depression: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 79(5), 618-628.



References • Geschwind et al. (2010). Meeting risk with resilience: high daily life reward experience preserves mental health. Acta Psychiatrica

Scandinavica.

• Geschwind et al. (2009). The role of affective processing in vulnerability to and resilience against depression. In C. M. Pariante, R. M. Nesse, D. Nutt & L. Wolpert (Eds.), Understanding Depression: A translational approach (pp. 181-192). NY: New York: Oxford University Press Inc.

• Wichers et al. (2007). Evidence that moment-to-moment variation in positive emotions buffer genetic risk for depression: a momentary assessment twin study. Acta Psychiatrica Scandinavica, 115, 451-457.

• Wichers et al. (2009). Reduced stress-sensitivity or increased reward experience: The psychological mechanism of response to antidepressant medication. Neuropsychopharmacology, 34, 923-931.

• Wichers et al. (2007). Genetic risk of depression and stress-induced negative affect in daily life. British Journal of Psychiatry, 191, 218-223.

• Wichers, Schrijvers, Geschwind et al. (2009). Mechanisms of gene-environment interactions in depression: Evidence that genes potentiate multiple sources of adversity. Psychological Medicine, 39, 1077–1086.

• Wichers et al. (2008). The psychology of psychiatric genetics: Evidence that positive emotions in females moderate genetic sensitivity to social stress associated with the BDNF Val(66)Met polymorphism. Journal of Abnormal Psychology, 117, 699-704.

• Wichers, et al. (2008). Susceptibility to depression expressed as alterations in cortisol day curve: a cross-twin, cross-trait study. Psychosomatic Medicine, 70, 314-318.

• Wichers, Geschwind et al. (2009). Transition from stress sensitivity to a depressive state: longitudinal twin study. The British Journal of Psychiatry, 195(6), 498-503.

• Wichers, et al. (2008). The catechol-O-methyl transferase Val(158)Met polymorphism and experience of reward in the flow of daily life. Neuropsychopharmacology, 33, 3030-3036.

• Wichers, Geschwind et al. (2010). Scars in depression: is a conceptual shift necessary to solve the puzzle? Psychological Medicine, 40(3), 359-365.



Introduction: Positive Affect (PA)

• PA reduces stress-induced psychiatric and physiological symptoms

• PA also reduces the expression of genetic vulnerability for affective disorders

• Effects PA > NA on resilience & well-being (Cohn & Fredrickson,

2009)

• PA preserves, and possibly improves, mental health.



0

0,05

0,1

0,15

0,2

0,25

0,3

0,35

0,4

Responders Nonresponders Responders Nonresponders

Mindfulness Control

Incr

eas

e in

Po

siti

ve A

ffe

ct

Activity-related reward experience

pre

post



0

0,05

0,1

0,15

0,2

0,25

0,3

0,35

0,4

Responders Nonresponders Responders Nonresponders

Mindfulness Control

Incr

eas

e in

Ne

gati

ve A

ffe

ct

Activity-related stress sensitivity

pre

post



NA change pre/post: Mindfulness vs. Controls

1,00

1,20

1,40

1,60

1,80

2,00

2,20

pre post

NA

Mindful

Control



Maastricht

Measuring emotions in daily life?

• NA and PA fluctuate…

NA PA

time

inte

nsity



• 49 depressed patients (randomized to Imipramine or placebo)

Week 1

• HAM early improvement

• PA early change

• NA early change

Method

Week 6:

• HAM score

• Remission

• Recovery

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Reward Experience & Resilience • High reward experience should contribute to the

preservation of mental health – Especially when at risk for low mood

• Childhood trauma • Recent Stressful Life Events • Genetic Risk



Differential relapse prevention effect

• Finding: MBCT reduces relapse only in 3+ patients, not in 2- (Teasdale et al., 2000; Ma & Teasdale, 2004)

• Assumptions:

1) MBCT works mainly via cognitive processes (Rumination , meta-cognition )

2) Automatic negative thinking patterns stronger and more related to relapse in 3+

• Consequence: Most studies exclude 2-



Differential relapse prevention effect

• (Teasdale et al., 2000; Ma & Teasdale, 2004)

2-

3+



Assumptions

1) MBCT works mainly via cognitive processes (rumination , meta-cognition )

2) Automatic negative thinking patterns stronger and more related to relapse in 3+



Consequence

• Most later studies excluded 2- patients: – Bondolfi, et al., 2010; Godfrin & van Heeringen, 2010; Kuyken, et al., 2008;

Kuyken, et al., 2010; Segal, et al., 2010

• Even when not directly examining risk for relapse: – Barnhofer, et al., 2009; Hargus et al., 2010; Kingston et al., 2007

2-



Exclusion justified?

• Arguments against exclusion:

– Subpopulation overlap argument

– Diversity argument

– Continuity argument

– Confounder argument



Subpopulation overlap argument

3+

2-

2-

3+



Diversity Argument (1)

• Diverse effects:

– Changes in emotion regulation:

• Positive emotions increase (Geschwind et al, submitted; Fredrickson et al.,

2008)

• Upward spiral (Garland et al, 2010)

• Related to reduction of dep. symptoms

– Various other reported effects works on more basal level



Diversity Argument (2)

• Beneficial for diverse populations not suffering from major depression

• working people, cancer, pregnancy, anxiety, …

effectiveness

No dep 2- 3+



Continuity Argument (1)

• Relapse = dichotomous

• Evidence for continuity of symptoms

• Problems with dichotomous classifications

• Useful to examine continuous measures



Continuity Argument (2)

• Residual depressive symptoms

– Continuous

– Predict risk for relapse (Judd et al., 1999; Nierenberg, et al., 2010)

– MBCT associated with reduction residual symptoms (Kenny &

Williams, 2007; Kingston, et al., 2007; Mathew et al., 2010)

– No comparison yet between 2- and 3+



Confounder argument

• MBCT vs TAU trial in 3+ patients only (Segal et al.,

2010)

– MBCT only effective among unstable remitters = with

intermittent residual symptoms

– No effect in stable remitters = residual symptoms <7

– Patients with residual symptoms were actually excluded in original studies!

– MBCT in 2- with residual symptoms???



Hypotheses

• MBCT residual symptoms

• Independent of 2- or 3+ subgroup

= no interaction treatment*subgroup

• Explore whether MBCT works via diff. mechanisms in the 2- and 3+ subgroups (rumination, worry, mindfulness positive and negative emotions)



No evidence for interaction Treatment*Subgroup

Measure β p

HDRS 0.45 0.162

IDS 0.33 0.240

Rumination 0.34 0.206

Worry 0.23 0.332

KIMS observe 0.09 0.743

KIMS describe 0.25 0.236

KIMS act aware -0.18 0.522

KIMS accept -0.27 0.236

PA 0.08 0.210

NA -0.07 0.284



By subgroup: Hamilton Depression Rating Scale

5

6

7

8

9

10

11

12

pre post

HD

RS

2- TAU

3+ TAU

2- MBCT

3+ MBCT

MBCT



Same for self-report…

10

12

14

16

18

20

22

24

26

28

pre post

ID

S-S

R

2- TAU

3+ TAU

2- MBCT

3+ MBCT



Effect Size of Treatment per Subgroup

-0,8

-0,7

-0,6

-0,5

-0,4

-0,3

-0,2

-0,1

0

HDRS IDS-SR Rumination Worry

2-

3+



Conclusions

• Need to re-examine and reconsider:

– MBCT just as effective in 2- as in 3+

– At least when looking at participants with residual symptoms

effects of mindfulness-based cognitive therapy on the ...€¦ · • wichers, et al. (2008)....

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