Abstract
Emotion processing has been demonstrated to have a strong impact on somatic symptom perception. In the current quasi-experimental trial associations between the application of emotion regulation strategies and symptom-related outcomes were examined in subjects with medically unexplained physical symptoms (MUS; n = 48) and in mentally healthy individuals (n = 48). Somatic symptoms were repeatedly induced four times in both samples. After each symptom induction, participants were instructed to apply another of four emotion regulation strategies. Symptom-related outcomes were rated before and after a strategy was applied. Hierarchical linear models showed that in the MUS group cognitive reappraisal was significantly and acceptance was marginally associated with lower symptom annoyance scores compared with compassionate self-support. In healthy subjects distraction was associated with better mood scores compared with compassionate self-support. Future research should examine the effects of acceptance and cognitive reappraisal strategies applied by MUS subjects over a longer period of time.
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Maria Kleinstäuber, Japhia-Marie Gottschalk, Judith Ruckmann, Thomas Probst and Winfried Rief declare that they have no conflicts of interest.
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Appendix: Emotion Regulation Task Instructions
Appendix: Emotion Regulation Task Instructions
Acceptance Strategy
First, please focus on your somatic symptom right now, even if it is unpleasant. [Short break]
We will start this strategy by practicing mindfulness; focus on your breathing sensations without trying to control them. When you become distracted, you should find a word to describe what is happening and gently bring your attention back to your breathing. Now, we are going to practice shifting your focus and awareness onto your somatic symptom, your thoughts, and your emotions in the moment. Consider that when emotions, symptoms, and thoughts are accepted, they can no longer control behavioral tendencies and cannot interfere with your personal goals. Try to label your somatic symptoms, your feelings, and your thoughts with short mental notes without evaluating them. Name everything as accurately as possible at this moment. Then, try to rate the intensity of these symptoms, feelings, and thoughts on a scale from 0 to 10. Now, do your best to create a positive attitude toward your feelings, symptoms, and thoughts. Next, remind yourself that you can tolerate challenging feelings, symptoms, and thoughts, at least for a while. Think of ways you have been able to endure intensely negative situations in the past. Now, continue by reminding yourself that feelings, symptoms, and thoughts are not permanent.
Now, you will hear the audio recording of your symptom report again. Try to accept all of your thoughts, your emotions, and your symptoms to make it easier for you to deal with and to put up with your somatic symptom. Try to apply the strategy you just heard described. [Two-minute break] Now, slowly bring your attention back to this room at your own pace and open your eyes.
Cognitive Reappraisal Strategy
[Material needed: sheet of paper, pen]
First, please focus on your somatic symptom right now, even if it is unpleasant. [Short break] Please write down on this sheet of paper two different thoughts concerning your somatic symptom. For example, you might think that it is getting worse, it will never stop, or that you cannot put up with it. [One-minute break] Now, I would like you to put down your pen. [Short break]
Sometimes, it helps to consider a situation from different perspectives and to develop another point of view. Depending on how we judge a certain situation, we have different feelings and behavioral tendencies. On the one hand, negative thoughts may influence bodily sensations in a negative way. On the other hand, positive thoughts may cause pleasant bodily sensations. The way you feel and the way your body responds depends on how you appraise the situation. Unpleasant thoughts can be replaced by helpful thoughts. Therefore, you act differently depending on your point of view. Please read again through your thoughts. I want you to try to develop another point of view of the somatic symptoms. Here are some examples of helpful thoughts: “I feel really bad right now, but I’m certain I do not have a serious illness” or “Other people are worse off than me.” To help yourself, imagine what a good friend might advise you to do when you experience somatic symptoms. Try to modify your thoughts and evolve alternative and helpful thoughts that will make it easier for you to endure the discomfort. Please collect these thoughts and write them down. [One-minute break]
Now, you will hear the audio recording of your symptom report again. Try to use your alternative and helpful thoughts to make it easier for you to deal with and to put up with your somatic symptom. Try to apply the strategy you just heard described. [Two-minute break] Now, slowly bring your attention back to this room at your own pace and open your eyes.
Compassionate Self-Support Strategy
First, please focus on your somatic symptom right now, even if it is unpleasant. [Short break]
Do your best to let a feeling of compassion toward yourself rise within you—a strong and warm feeling of empathy for yourself that is accompanied by the desire to help yourself and to end your suffering. Visualize yourself entering this scene. Observe yourself and try to become aware of what distresses you in this scenario. Tell yourself that this somatic symptom creates a difficult situation. Normalize your negative emotions and provide reassurance by telling yourself that you are there to support and reassure yourself (not to give advice). If it seems appropriate, visualize giving yourself a gesture of compassion (e.g., laying a hand on your shoulder or giving yourself a hug). Provide encouragement to yourself. You might say something like, “You have gone through a lot in the past and you will get through this too. I will be with you as you work through this. We will get through this together.” Give yourself a big, kind, reassuring smile. Take your time as you give yourself all the support you need in this situation. Then, when the moment feels right, you can begin to mentally say goodbye to yourself at your own pace. Remember that this is not a goodbye forever. You will always be able to mentally return to this place and provide support for yourself when needed. If there is something you want to say to yourself before leaving, feel free to do so now.
Now, you will hear the audio recording of your symptom report again. Try to provide support for yourself to make it easier for you to deal with and to put up with your somatic symptom. Try to apply the strategy you just heard described [Two-minute break]. Now, slowly bring your attention back to this room at your own pace and open your eyes.
Distraction Strategy
First, please focus on your somatic symptom right now, even if it is unpleasant. [Short break]
Distraction can lead to reduced perception of thoughts, feelings, and somatic symptoms. Our attention works like a spotlight. Therefore, shifting attention to other aspects can help us to cope with somatic symptoms, unpleasant thoughts, and feelings. [At this point, a story about a famous botanic garden and its gardener was narrated. The story is written in a way to stimulate an imagining which arouses all senses and distracts the participant.]
Now, you will hear the audio recording of your symptom report again. Try to shift your attention and apply the strategy you just heard described. [Two-minute break] Now, slowly bring your attention back to this room at your own pace and open your eyes.
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Kleinstäuber, M., Gottschalk, JM., Ruckmann, J. et al. Acceptance and Cognitive Reappraisal as Regulation Strategies for Symptom Annoyance in Individuals with Medically Unexplained Physical Symptoms. Cogn Ther Res 43, 570–584 (2019). https://doi.org/10.1007/s10608-018-9973-y
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DOI: https://doi.org/10.1007/s10608-018-9973-y