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Bylsma, Lauren M.
Examining emotional reactivity to daily events in major and minor depression
h [electronic resource] /
by Lauren M. Bylsma.
[Tampa, Fla] :
b University of South Florida,
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Thesis (M.A.)--University of South Florida, 2008.
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Text (Electronic thesis) in PDF format.
ABSTRACT: Major depressive disorder (MDD) is a debilitating disorder characterized by significant mood disturbance. In laboratory studies, MDD has been characterized by both blunted positive (PER) and negative emotional reactivity (NER). However, mood disordered persons' emotional reactivity has rarely been studied in naturalistic settings, and it is unknown how less severe forms of depression relate to emotional reactivity. To address these issues, the current study utilized two naturalistic sampling methods (the Day Reconstruction Method and the Experience Sampling Method) to examine PER and NER to daily life events in 35 individuals currently experiencing a major depressive episode (MDD), 26 individuals currently experiencing a minor depressive episode (mD), and 38 healthy controls. Both methods demonstrated that individuals with major and minor depression exhibited blunted PER relative to controls. In surprising contrast to previous laboratory findings, both individuals with MDD and mD showed increased NER relative to controls. Correlational analyses with severity measures indicated that depression and anxiety severity were positively related to NER and negatively related to PER. Findings suggest that NER in mood disorders may diverge as a function of assessment context and may be heightened in naturalistic environments. Despite the fact that mD is a milder mood disorder, findings suggest that mD results in similar emotional impairments as found in MDD.
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Advisor: Jonathan Rottenberg, Ph.D.
Major depressive disorder
Minor depressive disorder
t USF Electronic Theses and Dissertations.
Examining Emotional Reactivity to Daily Events in Major and Minor Depression by Lauren M. Bylsma A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Psychology College of Arts and Sciences University of South Florida Major Professor: Jonathan Rottenberg, Ph.D. Jennifer Bosson, Ph.D. Kristen Salomon, Ph.D. Date of Approval: April 23, 2008 Keywords: depression severity, major depressi ve disorder, minor depressive disorder, emotional responding, experience samp ling, ESM, day reconstruction, DRM Copyright 2008, Lauren M. Bylsma
i Table of Contents List of Tables iii List of Figures iv Abstract v Introduction 1 Depression and the Continuity Debate 3 Theories of Emotiona l Reactivity in MDD 5 Laboratory Studies of Emo tional Reactivity in MDD 8 Do the Emotional Characteristics of MDD Differ From Less Severe Forms of Depressive Symptomatology? 9 Does MDD Emotional Functioning in th e Laboratory Generalize to Everyday Life? 10 Overview of the Present Study 15 Specific Aims 15 Specific Aim 1 16 Hypothesis 1 16 Specific Aim 2 17 Hypothesis 2 17 Method 18 Participants 18 Recruitment and Screening 18 Demographics 19 Procedure Overview 20 Diagnostic Procedure 21 Severity Measures 22 ESM Procedure 22 DRM Procedure 23 Computation of Affect and Emotional Reactivity 24 Positive Affect (PA) 24 Negative Affect (NA) 25 Positive Emotional Reactivity (PER) 25 Negative Emotional Reactivity (NER) 26 Hypothesis Testing 26
ii Results 28 Overview 28 Overall Daily Affect by Group 30 Event Characteristics 32 Positive and Negative Emotional Reactivity to Everyday Life Events 37 Relationship of Depression and Anxiety Severity to Emotional Reactivity 41 Discussion 44 Emotional Reactivity and Diagnostic Status 45 Emotional Reactivity and Symptom Severity 46 Event Characteristics 47 Correspondence between the ESM and DRM Sampling Techniques 49 Why Might Naturalistic and Laboratory Findings Diverge? 49 Conclusions and Future Directions 51 References 53 Appendices 64 Appendix A: DRM Survey Packet 65 Appendix B: The ESM Questions 84
iii List of Tables Table 1 Demographic Charact eristics of the Sample 20 Table 2 Clinical and Treatment Ch aracteristics of the Sample 29 Table 3 Averaged Daily Affect 32 Table 4 Correlations Between Measures of PA and NA 32 Table 5-A Characteristics of Events R ecorded in the DRM: Activity Type 34 Table 5-B Characteristics of Events Recorded in the DRM: Event Location 35 Table 5-C Characteristics of Events Record ed in the DRM: Soci al Interactions 35 Table 6 DRM Event Appraisals 37
iv List of Figures Figure 1. PER means as measured by the DRM 40 Figure 2. NER means as measured by the DRM 40 Figure 3. Scatterplot of BDI and NER in the DRM data 43 Figure 4. Scatterplot of BAI and NER in the DRM data 43
v Examining Emotional Reactivity to Daily Events in Major and Minor Depression Lauren M. Bylsma ABSTRACT Major depressive disorder (MDD) is a debil itating disorder charac terized by significant mood disturbance. In laboratory studies, MDD has been characterized by both blunted positive (PER) and negative emotional react ivity (NER). However, mood disordered personsÂ’ emotional reactivity has rarely been studied in naturalistic settings, and it is unknown how less severe forms of depression rela te to emotional reactivity. To address these issues, the current study utilized tw o naturalistic sampling methods (the Day Reconstruction Method and the Experience Sa mpling Method) to examine PER and NER to daily life events in 35 individuals curren tly experiencing a majo r depressive episode (MDD), 26 individuals currently experiencing a minor depressive episode (mD), and 38 healthy controls. Both methods demonstrat ed that individuals with major and minor depression exhibited blunted PER relative to controls. In surp rising contrast to previous laboratory findings, both indivi duals with MDD and mD show ed increased NER relative to controls. Correlational analyses with seve rity measures indicated that depression and anxiety severity were positively related to NER and negatively related to PER. Findings suggest that NER in mood disorders may dive rge as a function of assessment context and may be heightened in naturalistic environments Despite the fact that mD is a milder mood disorder, findings suggest that mD results in simila r emotional impairments as found in MDD.
1 Introduction Major Depressive Disorder (MDD) is a de bilitating disorder that affects as many as 10-25% of women and 9-12% of men at so me point in their lifetime (DSM-IV; APA, 2000) and is a leading cause of disability wo rldwide (Murray & Lopez, 1997). The point prevalence in adult community samples varies from 5-9% for women and 2-3% for men (DSM-IV; APA, 2000). MDD is characterized by extremely high recurrence rates Â– over 70% of depressed patients have more than one episode and may spend only 22% of the 12 years following a major depressive episode symptom-free (Judd et al., 1998). Furthermore, approximately 40% of individua ls with 3 or more episodes of major depression relapse within 12-15 weeks of rec overy (Keller et al., 1992; Mueller et al., 1996). The high burden of MDD has motivated considerable research designed to uncover risk factors and characteristics th at are associated with MDD. One strand of research on MDD has sought to clarify how this disorder influences different aspects of affective functioning such as moods and emotions. Reflecting the profound disturbance of affective functioning in MDD, it is classified as a Mood Disorder by The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 2000). DSMÂ–IV diagnostic criteria specify symptoms of at least 2 we eks duration that implicate deficient positive affect and loss of interest in pleasurable activities (e.g., anhedonia), excessive negative affect (e.g., sadness), or bo th. When queried, patients who have been diagnosed with depression reliably report lo w positive affect and elevated negative affect on a variety of questionnaire and interview measures (C lark, Watson, & Mineka, 1994).
2 Durable disturbance of mood is thus one of the most salient features of MDD. MDD symptoms also include several associ ated somatic and cognitive symptoms which include loss or increase in appetite, weight ga in or loss, sleep disturbance, psychomotor agitation or retardation, fatigue feelings of worthlessness or guilt, concentration or decision-making difficulties, a nd suicidal ideation or beha vior (DSM-IV; APA, 2000). Based in part upon the prevalent assumption that moods facilitates emotions when the mood and emotion are matching in vale nce (Rosenberg, 1998), researchers have suggested that negative mood in MDD may potentiate negati ve emotional reactions (e.g., Golin, Hartman, Klatt, Munz, & Wolfga ng, 1977; Lewinsohn, Lobitz, & Wilson, 1973), and the absence of positive mood may attenuat e positive emotional reactions (Berenbaum & Oltmanns, 1992; Sloan, Strauss, Quirk, & Sa jatovic, 1997; Sloan, Strauss, & Wisner, 2001). However, accumulating evidence from la boratory studies indicates that MDD may actually involve blunted emotional reactivity independent of valence (Bylsma, Morris & Rottenberg, 2008), a pattern that has been la beled emotion context insensitivity (ECI; Rottenberg, 2005; Rottenberg, Gross, & Gotlib, 2 005). Given that laboratory results with diagnosed MDD samples do not appear to uphold the assumptions that the mood states in MDD facilitate negative emotions, two important questions become: (1) whether less severe depressive mood states (e.g., minor depressive disorder) facilitate negative emotional reactivity and (2) wh ether the findings of ECI are also obtained when data is collected outside of the laboratory, in naturalis tic settings. In the following sections we review the body of theory a nd data relevant to these i ssues, and then describe a naturalistic study design ed to address them.
3 Depression and the Continuity Debate In recent years, there has been disagreem ent in the literature regarding whether many DSM disorders are truly cat egorical, as the current DS M defines them, or whether they are best conceptualized along a continuum of varying symptom severity (Widiger & Samuel, 2005). In regard to depression, MDD may have unique ch aracteristics that distinguish it categorically from minor depression (mD), and dysphoria (Fechner-Bates, Coyne & Schwenk, 1994). However, recent re search suggests that depression may be better conceptualized as a continuum of de pressive symptoms (e.g., Geiselmann & Bauer, 2000). The possibility of a latent qualitat ive difference between MDD and subclinical forms of depressions has not been ruled out (Solomon, Haaga & Arnow, 2001). Recent taxometric investigations of epidemiologi cal samples of depression have provided evidence that depression occurs along a con tinuum of symptom seve rity (Prisciandaro & Roberts, 2005). However, research in this debate has yet to consider many central features of MDD, such as cha nges in emotional reactivity. Many researchers use dysphor ic populations (individua ls who indicate low mood and score high on symptom checklists), ope rating under the assumption that findings from this population will generalize to indi viduals with a clini cal diagnosis of MDD (Vredenburg, Flett, & Krames, 1993). This pr actice assumes that ordinary dysphoria can be placed along the depression continuum and shares the same symptoms, mood states, and emotion regulation difficulties as MDD (Coyne, 1993; Ca ssano et al, 2004; Prisciandaro & Roberts, 2005; Hankin, Fraley & Lahey, 2005). According to this view, the diagnostic threshold pres ents an arbitrary cutpoint, which does not recognize that distress and impairment are a monotonic func tion of increasing symptoms. By contrast,
4 the disease state model sugge sts that the individuals w ith MDD suffer from mood and physical symptoms that are qualitatively differe nt than those symptoms of an individual with ordinary sad mood (e.g., Fechner-Bates et al. 1994, Rottenberg, Gross, & Gotlib, 2005). One means to examine the question of c ontinuity is to study well-defined mood disorders that are less severe than MDD a nd to contrast them with MDD itself. The DSM-IV currently lists one form of less se vere depression, minor depressive disorder (mD), in the appendix as a diagnosis that me rits further research (DSM-IV; APA, 2000). Minor depression is defined as a period of 2 or more weeks during which at least 2-4 of the 9 symptoms for a major depressive episode are present. As in MDD, one symptom must be either depressed mood or anhedoni a (DSM-IV; APA, 2000). Minor depression may differ from MDD by its general lack of neurovegetative sympto ms (Rapaport et al., 2002). Because of the lack of research on mD, prevalence rates are largely unknown. Estimates vary depending on the degree of a dherence to DSM-IV diagnostic criteria. Data from the nationally representative popul ation of the National Comorbidity Survey found lifetime prevalence rates for mD with no prior histor y of MDD of 10% (Kessler, Zhao, Blazer, & Swartz, 1997). Those studies which utilize the DSM-IV criteria for mD found lower prevalence rates than those studi es that defined mD based on dimensional depression scales, indicating that even mD may differ from n on-clinical dysphoric states (Hermens, et al., 2004). Research indicates that mD results in si milar, but less severe impairments than those observed in MDD. As in MDD, rese arch suggests that i ndividuals with mD experience significant incomplete resolution of episodes (Kessler et al., 1997). mD
5 results in significant functional disability and interferes with employment attendance to a similar degree as mild MDD (Cuijpers, de Gr aaf, & van Dorsselaer, 2004; Kessler et al., 1997). Furthermore, individuals with mD ar e at an increased risk for developing MDD compared to individuals with no depressive symptoms (Cuijpers et al., 2004; Fogel, Eaton, & Ford, 2006). It is possible that mD may represent a transient mood state preceding or following a major depressive episode rather than a discrete disorder. Alternatively, mD may consist of a period of maladaptive func tioning that is precipitated by distress, but is not biologica lly, physiologically, or functi onally equivalent to MDD. Surprisingly, there has been no prior research on emotional characte ristics of mD that may differentiate it from MDD, an important means to determine whether the emotional characteristics of depressive mood states ar e best conceived of as a continuum or a discrete disease state. Theories of Emotional Reactivity in MDD Although theories of emotional functioni ng in mood disorders have thus far centered on MDD, it is useful to generate a theoretical framework that could also be potentially applied to mD. Given that MDD is quintessentially a disorder of mood, one way to conceptualize the problem of emotion in MDD (and potentially to mD) is to ask how a pervasive mood disturbance will influe nce ongoing emotional reactivity to positive and negative stimuli in the environment. A ddressing this problem requires a distinction between the constructs mood and emotion (e .g., Rottenberg & Gross, 2003). Moods have been defined as diffuse, slow-moving feeling states that are weakly tied to specific stimuli in the environment (e.g., Watson, 2000). By contrast, emotions have been defined as quick-moving reactions that occur when an individual processes a meaningful
6 stimulus, and these reactions typically involve coordinated changes in subjective feelings, behavior, and physiology (Ekman, 1992; Keltner & Gross, 1999). When mood and emotion are so distinguished, it becomes appare nt that the various diagnostic criteria for depression, such as pervasive sadness or anhedonia, indicat e alterations in mood, but do not indicate alterations in emotion with corresponding specificity. Although the constructs are distinguishable, moods and emotions are generally seen as interconnected, with moods altering the probability of having specific emotions (e.g., Rosenberg, 1998). Although there have been surprisingly few empirical demonstrations of explicit links between moods and emotions, moods are widely believed to potentiate like-valenced or matching emo tions (e.g., irritable mood facilitates angry reactions, an anxious mood facilitates pa nic, etc; Rottenber g, 2005). By extension, excessive negative mood in MDD would potentiate negative emotional reactivity. Furthermore, a lack of positive mood in depression would attenuate positive emotional reactivity. Indeed, the idea of mood facilitation is one sour ce of guidance for the major viewpoints regarding emotional reactivity in MDD that appear in the literature: (1) negative potentiation (2) positive attenuation and (3) emotion context insensitivity. Negative potentiation, the first view, holds that the pervasive negative mood states that are prevalent in MDD contribute to potentiated emotional reactivity to negative emotional cues. Perhaps most relevant to this view, cognitive theorists have advanced a view of MDD in which negative moods and ne gative emotions are mutually reinforcing (e.g., Beck, 1967; Beck, Rush, Shaw, & Emery, 1979). BeckÂ’s schema model and related theories of MDD (e.g., Bower, 1981) conceptu alize the disorder in terms of cognitive structures, or schemas, that serve to negativ ely distort the processing of emotional stimuli.
7 Importantly, according to these theories, nega tive mood states prime, or activate, these cognitive structures (Scher, Ingram & Sega l, 2005). Once activated, these structures precipitate depressotypic emotional respons es (e.g., crying spells) whenever schemamatching negative emotion stimuli are encount ered, presumably potentiating reactivity to negative emotional stimuli in MDD. Positive attenuation, the second view, holds that individuals with MDD will have reduced reactivity in response to positive em otional stimuli. Because this hypothesis applies primarily to positive emotional stimuli, positive attentuation is compatible with negative potentiation (individuals with MDD can exhibit both patterns simultaneously). The starting point for this hypothesis is depr essed personsÂ’ strong tendency to exhibit low positive mood. Indeed, anhedonia (the reduced abili ty to experience pleasure) is one of the cardinal symptoms of MDD, and depressed individuals exhibit several other signs that are also indicative of deficient appetitive motivation (e.g., psyc homotor retardation, fatigue, anorexia, apathy). Not surprisingly, several theorists have center ed their accounts of emotion dysregulation in MDD on this constella tion of motivational deficits (e.g., Clark, et al., 1994; Depue & Iacono, 1989; He nriques & Davidson, 1991). Emotion context insensitiv ity (ECI), the third view holds that depressed individuals will exhibit reduced reactivity to all emotion cues, regardless of valence (Rottenberg, 2005). By this account, individu als with MDD should exhibit less reactivity to both positive and negative stimuli and events compared to healthy individuals. ECI is derived from evolutionary accounts that describe depression as characterized by disengagement with the environment (Nesse, 2000). According to this view, depressed mood states evolved as an internal signal to bias organisms agains t action. Depressed
8 mood may have evolved as a defensive mech anism to prevent a response in adverse situations where continued act ivity could potentially be dangerous or wasteful (e.g. famine, loss of a status conflict, etc.). T hus, according to ECI, severe depressed mood states in MDD are postulated to inhibit em otional reactivity across a broad range of stimuli. In sum, ECI makes similar predic tions as the positive attenuation view for positive stimuli; however, ECI opposes the nega tive potentiation view for negative stimuli. Laboratory Studies of Emo tional Reactivity in MDD Laboratory studies have a ttempted to clarify the e ffects of MDD on emotional reactivity. Empirical research that supports negative potentiation in diagnosed samples is scarce; interestingly, however, there appears to be some support for negative potentiation in dysphoric (non-diagnosed) samples (Golin, Hartman, Klatt, Munz, & Wolfgang, 1977; Lewinsohn, Lobitz, & Wilson, 1973). There is fairly consistent empirical support for the positive attenuation theory. For example, depr essed individuals have shown diminished emotion response to pleasant film stimuli co mpared to healthy c ontrols (Berenbaum & Oltmanns, 1992). Similarly, depressed individua ls also report reduced emotional responses to positive picture stimuli (Sloan, Strauss, Quirk, & Sajatovic, 1997; Sloan, Strauss & Wisner, 2001). Furthermore, there has been empirical research in support of ECI across different emotional response systems. For ex ample, depressed patients have shown less electromyography (EMG) modulation to affec tive stimuli (Gehricke & Shapiro, 2000) and less facial reactivity to expr essive faces (Wexler, Levenson, Warrenburg, & Price, 1994). In addition, a lack of physiol ogical reactivity to affective film stimuli has been found to predict a worse clinical outcome for patie nts with MDD (Rottenberg, Kasch, Gross, &
9 Gotlib, 2002). In fact, a recent meta-analytic revi ew of 19 laboratory studies of MDD found blunting of emotional reactivity, cons istent with ECI view, with reasonable generalization of findings across emotion re sponse systems (Bylsma et al., 2008). Do the Emotional Characteristics of MDD Differ From Less Severe Forms of Depressive Symptomatology? A critical question related to mood-emo tion interaction concerns whether the changes in emotional reactivity that are seen in MDD (i.e., ECI) are similar to or are different from those evidenced in less se vere forms of depressive symptomatology. Again, very little research has been conducte d that examines emo tional reactivity across the full range of depressive symptoms. In fact, to our knowledge no prior research has been conducted examining emotional reactivity for minor depression (mD), as defined by DSM criteria. Some research has examined emotional reactivity in dysphoric college student samples; however, these studies ha ve not found consistent differences in emotional reactivity when comparing dysphoric samples and health controls (e.g., Persad, 1993; Gehricke & Shapiro, 2001; Hughes & Stone y, 2000). Further, the personality trait neuroticism has been associated with increa sed vulnerability to developing depression, and individuals with clinical and subclinical levels of depression te nd to score higher on measures of neuroticism (Kendler, Gatz, Gar dner, & Pederson, 2006). Some research in nonclinical samples suggests that higher levels of neuroticism are correlated with greater emotional reactivity to stre ssful or negative events (S uls, Green, & Hilis, 1998; Berenbaum & Williams, 1995), and in turn, reduced reactivity to positive stimuli (Berenbaum & Williams, 1995), both findings that are broadly consistent with the idea of mood facilitation. However, not all st udies have found a relationship between
10 neuroticism and emotional reactivity (Affl eck, Tennen, Urros & Higgins, 1994; David, Green, Martin & Suls, 1997) and it is unc lear how these findings might relate to depression severity. In sum, it still remains unclear how em otional reactivity relates to diagnostic status or depression severit y. Previous laboratory resear ch suggests that negative mood facilitation may hold for lower levels of ne gative mood (Gross, Sutton & Ketelaar, 1998), while other research demonstrates that em otional reactivity may be blunted in more severe forms of mood disturbance, such as that present in MDD (see Bylsma et al., 2008 for review). As important, it is not clear whether results obt ained from depressed persons in laboratory contexts are a faithful repres entation of their emotional functioning, as it might be ascertained in every day life settings. Does MDD Emotional Functioning in the L aboratory Generalize to Everyday Life? Laboratory assessments of emotional reactiv ity have been criticized as lacking ecological and external valid ity (Cacioppo & Gardner, 1999). Fortunately, several day sampling methods have been developed to a ssess emotional reactiv ity in naturalistic settings across oneÂ’s daily life. One advantage of day sampling methods is that a relatively large sample of behavior can be obtained relative to a si ngle-point laboratory sessions, potentially providing a more reli able estimate of emotional reactivity. Furthermore, a wide variety of eliciting stim uli that are ecologically valid can be sampled over the course of the day. Two commonl y used day sampling methods, the Day Reconstruction Method and the Experience Sampling Method, are described below. The Day Reconstruction Method (DRM) is a self-report surv ey instrument designed to collect data desc ribing the experience a person has on a given day, through a
11 systematic reconstruction conducted on the following day (Kahneman, Krueger, Schkade, Schwarz, & Stone, 2004; Stone, Schwartz, Schwarz, Schkade, Krueger, & Kahneman, 2006). The DRM builds on the strengths of ESM with the added advantage that it is less time consuming and expensive. Empirica l findings indicated a close correspondence between the DRM and established results fr om ESM methods in healthy populations, including examination of fact ors that are previously known correlates of well-being and positive affect (e.g., Kahneman, Krueger, Sc hkade, Schwarz, & Stone, 2004). Key advantages of the DRM method over ESM met hods include joint asse ssment of activities and subjective experiences, information a bout the duration of each experience, lower respondent burden, and more complete covera ge of the day (Kahneman et al. 2004). Furthermore, since the DRM method does not in terrupt individuals dur ing their daily life, it does not disturb the natural fl ow of daily life events, an e ffect that other day sampling methods, such as ESM, might potentially have Other advantages of in comparison to other self-report measures include potentia lly lower susceptibility to retrospective reporting biases typical for global reports of daily experience compared to questionnaires that ask about events or emotions that occur in the more distant past, and the DRM has high flexibility in adapting the content of the survey based on the needs of the study (Kahneman et al. 2004). The DRM has been used in previous re search to examine emotion and diurnal mood variation (Stone et al., 2006); however, this method has not been extended to clinical populations. To va lidate the use of the DRM with depressed populations, the DRM was utilized in conjunction with ESM (described in the next section), which has been used successfully in prev ious research with MDD partic ipants (e.g., Peeters et al.,
12 2003; Barge-Schaapveld, Nicolson, Gerritsen van der Hoop & DeVriew, 1995; BargeSchaapveld, Nicolson, Befkhof & DeVries, 1999) For example, poten tial threats to the validity of the DRM are the retrospective memory impairments (Burt, Zembar & Niederehe, 1995) as well as negative memo ry biases (Matt, Vasquez & Campbell, 1992) often found in depressed populati ons. Since the DRM asks part icipants about events that happened the previous day, memory impairments or systematic memory biases could affect the depressed groups, making their re ports less accurate and/or more negatively biased than those of the nondepressed gr oup, which could make group differences in emotional reactivity less interpretable. Howe ver, since the ESM uses momentary reports that inquire about participantsÂ’ current moods and most recent activities, memory impairments or memory biases should be minimized. The Experience Sampling Method (ESM) is another powerful method for understanding a range of psychological phenomen a as they occur in the daily lives of individuals (Christensen, Ba rrett, Bliss-Moreau, Lebo & Ka schub (2003). This method is designed to allow respondents to document their thoughts, feelings and actions in a naturalistic setting with in the context of daily life. The advantage of ESM methods is that they capture the representation of e xperience as it occurs, which minimizes any retrospective memory bias, which might be of concern when testing depressed populations. However, ESM methods are ti me and resource consuming to both the researchers and participants. Furtherm ore, because the ESM method interrupts individuals at various mome nts throughout the day, it can be intrusive and potentially disturb the natural flow of daily life ev ents. For these reasons, the DRM may hold advantages over the ESM method. ESM can be implemented with either paper-and-pencil
13 or computerized methods (Christensen et al., 2003). One advantage of using a computerized data collection protocol is th at compliance can be car efully monitored and the time an individual responds can be va lidated; by contrast, in paper-and-pencil methods it is possible that individuals will wa it until the end of the day to fill out their responses. Some studies have demonstrated poor rates of compliance with the paper and pencil methods compared to the computerized methods (e.g., Stone, Shiffman, Schwartz, Broderick & Hufford 2002); however, others found similar rates of compliance (Green, Fafaeli, Bolger, Shrout & Reis, 2006). A further advantage with the computerized method is that branching questions adapted to the individualÂ’s res ponses are easier to implement in a computer program. Because of its multiple advantages, computerized ESM was used in the present study. ESM methods have been validated with a variety of research questions and clinical and healthy populati ons. Specifically, ESM has been used to examine emotional and mood reactivity in various populations, such as those with a history of psychosis (Myin-Germeys, Krabbendam, Delespaul & van Os, 2004), adolescents at risk for developing psychopathology (Schneiders, Nico lson, Berkhof, Feron, van Os & deVries, 2006), and major depression (Peeters et al., 200 3). ESM techniques have also been used with participants dia gnosed with MDD to evaluate res ponse to antidepressant treatment and its relationship to daily life activities (Barge-Schaapveld, Nicolson, Gerritsen van der Hoop & DeVriew, 1995) and to assess quali ty of life (Barge-Schaapveld, Nicolson, Befkhof & DeVries, 1999), and to examine diur nal mood variation (Peeters et al., 2006). Despite the development of these instrume nts, to our knowledge, there has been only one naturalistic study of emotional re activity in a diagnosed MDD sample and no
14 studies of diagnosed mD samples. Peeter s, Nicolson, Berkof, Delespaul, and deVries (2003), examined emotional reactivity to da ily life events among MDD participants and healthy controls using paper-a nd-pencil ESM. They found th at both the MDD and control groups reported a similar number of nega tive events, but the MDD group reported fewer positive events. MDD participants experienced blunted NA and PA responses to negative life events, and NA responses pers isted longer in MDD individuals In contrast to previous laboratory findings of positive attenuation in MDD, MDD individuals in this sample reported greater reductions in NA and larger increases in PA when responding to positive events relative to controls. The authors al so tested the relations hip between depression severity and emotional reactivity to positiv e and negative events and found no significant relationship, though their sample only included individuals meeting cr iteria for MDD, so less severe forms of depression were not examined. Reporting on the same sample, Peeters, Berkhof, Delespaul, and Rottenberg (2006) examined diurnal mood variation patterns and found distinct patterns of positive and negative affect over the course of the day and found that depressed individuals ex hibited a more pronounced NA diurnal rhythm that was more variable moment -to-moment compared to healt hy individuals. In sum, these findings suggest that there may be important differences in emotional functioning in the laboratory in comparison to emotional situations that occur in an indi vidualÂ’s daily life. However, there are no known studies that ex amine emotional reactivity in MDD using the computerized Experience Sampling Method (ESM) or the Day Reconstruction Method (DRM), and there have been no naturalistic studies of emotional reactivity in minor depression (mD).
15 Overview of the Present Study The present study examined positive and negative emotional reactivity to daily life events in a mood disordered sample of individuals diagnosed with MDD, mD, and healthy controls with no hi story of depression. The Da y Reconstruction Method (DRM) was the primary means to examine emotiona l reactivity in a natu ralistic setting. The DRM is a relatively new survey instrume nt which inquires about daily events and emotional responses to these events from th e previous day. However, since the DRM has not yet been validated in c linical populations, the com puterized Experience Sampling Method (ESM) was also used with Palm Pilo ts over a 3 day period, with the last ESM sample day corresponding to the day being sampled with the DRM. Specific Aims Existing research on emotional reactivity in depression has focused on the high end of depressive symptomatology (i.e. indi viduals who meet full criteria for MDD) in laboratory settings. Therefore, ECI may only ex plain emotional reactivity at the high end of the depressive continuum and may be specific to laboratory studies. The idea of negative mood facilitation (i.e., that nega tive mood potentiates negative emotional reactivity) may be relevant to low levels of depressed mood, but not to more severe levels of depressed mood. To provide clear cut-off points for low and high depression severity, the current study examined individuals with MDD and mD, as diagnosed according to DSM-IV-TR criteria (APA, 2000). These groupings afforded us both categorical (based on the SCID diagnoses) and dimensional analys es of severity (e.g., based on BDI severity measures). Finally because it is unclear how we ll previous laboratory findings generalize
16 to real life situations, emotional reactiv ity was examined using two naturalistic day sampling methods. The general aim of this study was to investigate emotional reactivity across varying levels of depression severity in a naturalistic setting. This study can help to elucidate whether the symptoms of depression are best conceived as occurring along a continuum (i.e., minor dysphoria to severe depr ession) or a discrete disease state defined by the diagnostic threshold of MDD. Furthermore, this study can inform our understanding of emotion in regard to whether milder levels of negative affect influence ongoing emotional reactivity differently from th e more severe negative affect present in MDD. In addition, this study will elucidat e whether emotional responding in daily life follows the same pattern found in laboratory studies. The specific aims and hypotheses for the research project are as follows: Specific Aim 1 To examine whether emotional reactivity differs between DSMIV diagnostic variants of depression and to assess the continuous relationship between depression severity and emotional re activity in a natu ralistic setting. Hypothesis 1. Emotional reactivity of MDD individuals to positive and negative daily events will be significantly different from the emotional reactivity patterns of control subjects and subjects with mD. Sp ecifically, individuals with MDD will have blunted positive and negative reactivity to daily life events (as measured by the DRM and ESM) compared to controls and individuals with mD will have increased negative reactivity to daily life events. In other wo rds, as depression severity increases from controls to mD, emotional reactivity will incr ease, and as depression severity increases from mD to MDD, emotion reactivity will decrease creating an inverted U pattern. For
17 positive reactivity, positive reactivity will decrease as depression severity increases. Therefore, those with MDD will have the l east positive reactivity, followed by the mD, followed by controls who will have the greatest positive reactivity. Specific Aim 2. A secondary aim is to validate the use of the DRM method in depressed populations by examining th e correspondence between ESM and DRM methods for capturing emotion experi ence in depressed populations. Hypothesis 2. Results derived from the DRM and will produce comparable data to ESM sampling, as manifested by a simila r pattern group of differences and similar emotional reactivity effect sizes when bot h methods are examined for the same day.
18 Method Participants Recruitment and Screening. Participants were recrui ted from fliers and online forum postings in and around the Tampa Ba y community. A total of 474 potential participants were ini tially screened by tele phone. Of those individua ls, 271 were invited into the lab to complete the Structured C linical Interview base d on the Diagnostic and Statistical Manual of Mental Disorders, F ourth Edition (DSM-IV-TR) Axis I Disorders, Research Version, Patient Edition with Ps ychotic Screen (SCID-I/P W/ PSY SCREEN; First et al., 2002). A total of 164 participan ts completed the SCID (107 did not show up for their first appointment and were not able to be rescheduled), and of those participants who completed a SCID, approximately 57 were excluded for failing to meet inclusion or exclusion criteria, leav ing 107 eligible participants who were invited to come back to participate in the ESM and DRM protocols. In addition, 7 individuals failed to complete the ESM and DRM due to scheduling difficultie s. Two participants were not able to complete ESM and DRM within 3 weeks of th e initial SCID and ha d to be re-screened for the mood disorders module of the SCID, and one person no longer met the criteria for an mD diagnosis and was excluded. Particip ants in all groups were excluded from the study for the following reasons: history of a major head injury, hearing impairment, diagnosis of bipolar disorder substance abuse occurring within 6 months prior to entry into the study, or any history of primar y psychotic symptoms, as assessed by the
19 telephone screen and SCID. Included participants met cr iteria for Major Depressive Disorder with a current episode ( n = 35), Minor Depressive Disorder with a current episode ( n =26), or had no past or present psyc hopathology (i.e., no history of any Axis I disorder as assessed by the SCID; n = 38). Provisional DSM-IV-TR criteria recommend an absence of past episodes of MDD for an mD diagnosis. To improve study feasibility, we loosened this criterion, a nd 32% of mD participants e xperienced at least one major depressive episode (MDE). In these included subjects we required a period of at least eight weeks with no residual depressive symp toms between the major depressive episode and the minor depressive episode. Demographics. Final participants were primarily females (77.8%) and all were fluent in English and between the ages of 18 and 55 (mean age = 28.3). The final sample approximated the ethnic di stribution of the Tampa Ba y area: 60.6% Caucasian, 17.2% African American, 10.1% Latino/ Hispanic, 6.1% Asian, 1.0% Nativ e American, 1.0% Native Hawaiian/Pacific Islander, 1% Middl e Eastern, 3% Other. Table 1 contains demographic information of the sample according to diagnostic group. Groups were matched on age, ethnicity, gender, educati on level, income, and marital status (all p s > .05 for Cramer V tests).
20 Table 1. Demographic Characteristics of the Sample Group MDD mD Control Variable (n = 34) (n = 26) (n = 32) Age, M (SD) 28.85 (9.42) 27.00 (7.58) 28.78 (8.55) % Caucasian 62.9% 73.1% 50.0% % Female 88.6% 65.4% 76.3% Education (SD) 5.30 (1.73) 5.28 (1.67) 5.94 (2.06) Income (SD) 5.30 (3.37) 4.39 (3.18) 6.41 (3.64) % Married 25.7% 19.2% 28.9% Number of Children (SD) .48 (.94) .44 (.86) .47 (.92) Education was assessed on an 8-point scale with higher numbers representing more educationÂ—a score of 5-6 reflects graduation from a 2-year or a technical college. Income was assessed on a 12-point scaleÂ—a score of 5-6 represents an income of between $25,000 and $34,999. Procedure Overview Individuals responding to research ads via email and phone were initially screened over the phone to determine potenti al eligibility. Scr eening questions were based on key diagnostic questions from the St ructured Clinical Interview based on the Diagnostic and Statistical Ma nual of Mental Disorders, Fourth Edition (DSM-IV-TR) Axis I Disorders, Research Version, Patient Edition with Psychotic Screen (SCID-I/P W/ PSY SCREEN; First et al., 2002). Based on this initial screen ing, potential participants were invited to complete a complete SCID w ith a doctoral student in clinical psychology. Final diagnoses for study inclusion were made based on the SCID administration. Participants also completed a Beck Depr ession Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) and demographics qu estionnaire at this session. Participants deemed eligible based on th e initial SCID interview were invited to begin the ESM protocol or to return to the lab within 2-3 weeks to complete the ESM and DRM protocol (2 appointments). The ES M protocol began on a Monday and ended on a
21 Friday, with data collection Tuesday-Thursd ay. Participants completed the DRM the Friday of the ESM week, so that the questions would corr espond to Thursday, the last day of the ESM data collection. At the time of the DRM, participants also completed a current mood rating (using the same mood ratings of the DRM and ESM), and measures of depression and anxiety severity. Three part icipants were not able to come back for their scheduled appointments on Friday and ha d to come on Thursday instead, so their DRM data covered Wednesday instead of Thursday. One additional participant was not able to come back until Monday to return the Palm Pilot and did not complete the DRM. Diagnostic Procedure The Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition with Psychotic Scr een (SCID-I/P W/ PSY SCREEN; First et al., 2002) is a semi-structured interview desi gned to diagnose individuals based on the Diagnostic Statistical ManualIV (DSM-IV). Reliability a nd validity measures for the SCID differ according to population and diagnos is, but reliability for diagnosing MDD is relatively high with inter-rater reliabi lity kappas ranging from .80 -.93 (Zanarini & Frankenburg, 2001; Zanarini et al., 2000; Skre, Onstad & Torgersen, 1991). Using the SCID, screening was conducted for the followi ng diagnoses: bipolar I and II disorder, major depressive disorder, dysthymic di sorder, psychotic symptoms, substance dependence, social phobia, specific phobia, obs essive compulsive disorder, generalized anxiety disorder, and post-tra umatic stress disorder. Th is session generally lasted between 1-2 hours.
22 Severity Measures The Beck Depression Inventory-II (B DI-II; Beck, Steer & Brown, 1996) was administered to obtain a depression severity score. The BDI-II is a well-validated 21item self-administered scale of depression sy mptom severity. Scores range from 0 to 63 with higher scores representing higher seve rity. Coefficient alphas for the BDI-II are high (alpha = .91; Beck, Steer, Ba ll, & Ranieri, 1996). The test -retest reliability is also high at r = .93 (Beck, Steer, & Brown, 1996). To assess the severity of anxiety symp toms, the Beck Anxiety Inventory (BAI) was administered (Beck, Epstein, Brown, & St eer, 1988). The BAI is a 21-item selfadministered questionnaire of anxiety sympto ms. Symptoms are rated on a 4-point scale, with higher scores indicating mo re severe anxiety symptoms. The internal consistency of the BAI is high (alpha = .92), and the BAI co rrelates highly with the SCL-90-R Anxiety Subscale (r = .81) (Steer, Rani eri, Beck, & Clark, 1993). Positive and negative affect (PA and NA) we re also measured in the lab at the beginning of the DRM session. For PA, 7 pos itive mood items rated on a 7-point Likert scale from Â“not at allÂ” to Â“veryÂ” were summed (talkative, enthusiastic, confident, cheerful, energetic, satisfied, and happy). For NA, 7 negative mood items rated on the same scale were summed (tense, anxious, dist racted, restless, irritable, depressed, and guilty). Internal consistency for all severity measures used was high in all cases for this sample (alphas >.90). ESM Procedure The computerized ESM procedure was empl oyed using Palm Pilots (Zire22) and the ESP software (Barrett & Feldman-Barrett, 2004). Participants carried a Palm Pilot
23 around with them as they engaged in their daily activities over 3 weekdays (weekends were not used, in order to have a more hom ogenous sampling of days). Participants completed at least 4 practice beeps on the evening prior to the first ESM sampling day. On each of the 3 days, the Palm Pilots were programmed to alarm 10 times a day semirandomly between 8:00am and 10:00pm. Partic ipants were given 15 minutes to respond after they were beeped. If they did no t respond in 15 minutes, the questionnaire would disappear and be marked as a missed questionnaire. On each beep, participants were first asked to report on their current mood by rating 14 mood adjectives (7 for positive affect and 7 for negative affect) by sliding a bar from Â“not at allÂ” to Â“veryÂ”, which is coded by the computer as a continuous value between 1 and 100. The mood adjectives chosen are similar to those used in other day sampling studies (e.g., Peeters et al., 2003) and are the same it ems used for the laboratory measure of PA and NA described earlier. Fo llowing this, participan ts were asked about the context and nature of the most important emotional event sin ce their last report by responding to a list of choices about what they were doing, th e nature of the event, the location of the event, and who they were inte racting with. Participants selected options from a list of choices for each question, and they could select more than one answer choice if more than one was applicable to the situation (e.g., eating while watching TV would involve selecting two type s of activities from th e list). Further, they were asked to rate how important, stressful, pleasant, a nd unpleasant the event was by using the same sliding bar scale as the mood adjectives. Th e entire questionnaire generally takes less than 5 minutes to complete after practice. See Appendix for a complete list of questions and response choices. Afte r the 3 ESM sampling days we re completed, participants
24 returned to the lab to comple te the DRM (which inquired about the previous day, the last day of the ESM sampling) and to return the Palm Pilots. DRM Procedure Participant came back to the lab the day after their 3rd ESM day to complete the DRM survey packet. The DRM asks about the previous day, which corresponded to the 3rd ESM day, to allow us to compare the data from the two sampling procedures. The DRM survey packet (Kahneman et al., 2004) was tailored to the needs of this study, including insuring the questions correspond as closely as possible to those used in the ESM method (see Appendix for a copy of the DRM survey packet). The DRM asked participants to reconstruc t the previous day, by thinking of their day as a continuous series of episodes. For each episode, participants were asked to give details such as what they were doing, time of episode, duration or episode, and what their thoughts and feelings were during the episode. As in the ESM, they were also asked to respond to the same questions regarding what they were doing, the nature the event, the location of the event, and who they were intera cting with. Furthermore, they were also asked to rate the importance, stressfulness, pleasantness, and unpleasan tness of the event, but on a 7-point Likert scale (0 being Â“not at allÂ” and 6 being Â“veryÂ”). Participants were also asked to rate their mood during the epis ode on the same 7-point Likert scale, using the same mood adjectives in the ESM. Computation of Affect a nd Emotional Reactivity Positive Affect (PA). A PA scale score was computed for each episode in the DRM and ESM data by adding together 7 positive mood adjectives (talkative, enthusiastic, confident, cheerful, energe tic, satisfied, and happy). The internal
25 consistency of this scale was very high (a lpha=.97). For the DRM data, each item was coded on a 7-point Likert scale from 0 (not at all) to 6 (very). For the ESM data, the palm pilots stored responses on a continuous scale from 1-100 based on responses participants gave by sliding a bar from Â“not at allÂ” to Â“v ery.Â” These ESM ratings were rescaled to be on the same scale as the DR M mood ratings so that scores on the two measures could be compared. To compute overall PA for the day, for both the ESM and DRM data, the composite PA scores for each episode across the day were averaged to compute an overall average PA rating for the day. Negative Affect (NA). An NA scale score was computed for each episode in the DRM and ESM data by adding together 7 ne gative mood adjectives (tense, anxious, distracted, restless, irritated, depressed, guilty) The internal consistency for this scale was also very high (alpha=.94). Similar to the computations for PA, the ESM scores were first rescaled, then composite NA scores were computed for each episode, and these were averaged over the day to compute an overall NA average. Positive Emotional Reactivity (PER). In order to obtain a measure of PER, defined as a positive emotional response to a positively valenced event, first positive events were identified based on participantÂ’s ratings. Participants rated each episode on overall Â“PleasantnessÂ” using a 0 to 6 Likert scale for the DRM data and a 1-100 sliding bar scale for the ESM data. The ESM scores we re rescaled to be on the same scale as the DRM data. Episodes rating 4 to 6 on Pleasan tness as well as 0 to 3 on Unpleasantness were considered to be positive episodes. Then, average PA ratings for these positively rated episodes were computed to obtain a meas ure of PER. In order to better isolate the effects of reactivity to events, PER responses to neutral episodes were also computed and
26 used as a covariate in the statistical analyses This practice is consis tent with past work that has used a neutral comparison point to distinguish reactivity differences from differences in dispositional mood (e.g., Byls ma et al., 2008). Neutral episodes were defined as those which were rated low (<4) on both Pleasantness and Unpleasantness. PA responses to neutral episodes were then averaged to obtain a measure of PER to neutral episodes. Negative Emotional Reactivity (NER). Similarly, in order to obtain a measure of NER, defined as a negative emotional respons e to a negatively va lenced event, first negative events were identified based on participantÂ’s overa ll rating of the Â“UnpleasantnessÂ” of the event, which was c oded in the same way as Â“PleasantnessÂ”. Episodes rating 4 to 6 on Unpleasantness as well as 0 to 3 on Pleasantness were considered to be negative episodes. Then, average NA ratings for these positively rated episodes were computed to obtain a measure of NER. As in the PER analyses, in order to account for baseline differences in reactivit y, NER responses to neutral episodes were computed and used as a covariate. NA respons es to neutral episodes were then averaged to obtain a measure of PER to neutral episodes. Hypothesis Testing Two Repeated Measures ANCOVAÂ’s were computed with measure (DRM or ESM) as the within subjects factor and group as the between subjects factor. The first ANCOVA examined PER to positively rated even ts as the dependent variable with PER to neutrally rated events as a covariat e and the second ANCOVA examined NER to negatively rated events as the dependent variab le with NER to neutrally rated events as a covariate.
27 In order to address Hypothesis 1a for PE R and NER, the group effects of the two Repeated Measures ANCOVAÂ’s were examined and post-hoc t-tests were computed to examine specific group differences. Based on positive attenuation and ECI theory, as well as previous laboratory findings, it was e xpected that there would be a significant group effect and that post-hoc tests compari ng groups would reveal that MDD individuals have the lowest PER, mD individuals would have the second lowest PER, and healthy control individuals would ha ve the greatest PER, with all groups differing from one another. Based on ECI and previous labor atory findings, it was predicted that mD participants would have signi ficantly higher NER compared to controls, but that MDD participants would have si gnificantly lower NER compared to both mD and control participants. In order to test whether measur es of symptom severity would be related to emotional responding (Hypothesis 1b), correlatio ns were computed between the severity measures (BDI and BAI) and the r eactivity variables (NER and PER). In order to assess whether data obtained from the DRM and ESM were comparable (Hypothesis 2), the effect of measure in the two Repeated Measures ANCOVAÂ’s described above was examined as well as the group by meas ure interactions. A significant measure effect would indicate th at the data obtained from the two methods are significantly different. A group by measure interaction would show that the effect of measure differs by group. Further, to examine the strength of the reliability between the affect reports in the DRM and ESM data, corre lations were computed between the overall daily NA and PA reported by individuals as well as for NER and PER.
28 Results Overview A total of 38 healthy controls, 35 MDD, and 26 mD participants completed the DRM. Of these participants, a total of 31controls, 30 MDD, and 21 mD participants completed the ESM protocol on the third day of data collection (the day corresponding to the DRM). Of the participants who complete d ESM, 7 were excluded from analyses for having completed less than 3 questionnaires on Day 3. ESM results for Day 1 and Day 2 are not presented here. Clinical Characteristics of the Sample In the MDD sample, 76.5% were recurrent (i.e., had experienced at least one previous MDE) and 3% also met criter ia for dysthymia (i.e., double depression). Concerning MDD subtypes, 39.4% were melancho lic and 36.4% were atypical. In the mD sample, 32% experienced at least one MDE in the past. Clinical characteristics of each group on the severity measures are in Table 2. Analyses comparing group differences in depression severity scores were in line with the diagnostic categor izations. A one-way ANOVA co nfirmed that BDI scores varied significantly among all three groups [ F (2, 94) = 123.79, p < .001], such that MDD individuals had the highest de pression severity scores, fo llowed by mD individuals and then control individuals (p<.001 for all comp arisons). Similarly, Beck Anxiety Inventory (BAI) scores also differed significan tly between groups [F(2, 95) = 46.50, p < .001].
29 Follow-up tests indicated that MDD indi viduals and mD indi viduals endorsed significantly higher symptoms of anxi ety than did healthy individuals ( p < .001), and MDD individuals endorsed significantly higher anxiety severity th an mD individuals (p<.01). Expected group differences in reported posit ive and negative aff ect at the time of the diagnostic assessment were also obtaine d. For PA an overall effect was observed [ F (2, 98) = 42.61, p < .001], with MDD and mD indivi duals both showing significantly lower levels of PA than control individuals ( p < .001), but not differi ng from one another. Similarly, NA differed signifi cantly between groups [ F (2, 98) = 40.64, p <. 001], such that MDD and mD individuals had significantly higher NA compared to controls ( p < .01). However, MDD and mD individuals di d not differ significantly on reported NA. Table 2 Clinical and Treatment Characteristics of the Sample Group MDD mD Controls ( n = 35) ( n = 26) ( n = 38) Variable Mean (SD) Mean (SD) Mean (SD) BDI 28.96 (9.71) 19.78 (8.52) 2.41 (3.42) BAI 18.07 (10.24) 11.94 (9.19) 1.78 (2.01) PA (Lab) 11.11 (6.76) 14.39 (9.44) 26.94 (7.98) NA (Lab) 21.74 (10.06) 18.56 (6.35) 5.56 (6.17) % Antidepressants 20.0% 7.7% 0.0% % Psychotherapy 11.4% 3.8% 0.0% Note: BDI = Beck Depression Inventory BAI = Beck Anxiety Inventory PA = Positive Affect NA = Negative Affect
30 Overall Daily Affect by Group To set a context for understanding emotional responses to positive and negative events, overall reported positive and negative affect across all episodes were first examined. Overall positive (PA) and negativ e affect (NA) were computed by averaging reported affect for each episode over the da y for each individual for both the DRM and ESM data. The means are reported in Table 3. To examine group and measurement differe nces in PA, a Repeated Measures ANOVA was computed with measure (DRM or ESM) as the within subjects factor, group as the between subjects factor, and PA Average as the dependent variable. As expected, the analyses re vealed a significant gro up effect [F(2, 81) = 31.98, p < .001]. However, there was also a significant e ffect of measure t ype [F(1, 81) = 8.87, p < .01], with ESM mean PA values being slightly higher than mean PA values for the DRM across groups. There was no group by measur e interaction. Follow-up t-tests revealed that the control group reported more averag e PA compared to both the MDD and mD groups (p<.001). However, the mD and MDD groups did not significantly differ on average PA. Similarly, to examine group and measurement differences in NA, a Repeated Measures ANOVA was computed with NA Averag e as the dependent variable. Again, as expected, the analyses re vealed a significant gro up effect [F(2, 81) = 55.16, p < .001]. However, there was also a significant e ffect of measure t ype [F(1, 81) = 50.27, p < .001], with ESM mean NA values being higher than mean NA values for the DRM. There was also no group by measure interaction for NA. Follow-up t-tests reveal ed that the control
31 group reported significantly less NA overall co mpared to both the MDD and mD groups (p<.001); however, the mD and MDD gr oups did not differ on average NA. In order to examine the concurrent relation between the DRM and ESM data, pairwise PearsonÂ’s correlations were computed between average daily PA and NA. For these analyses the three pa rticipants who completed the DRM on a non-corresponding day were excluded. All correlations were significant and large in magnitude (all p s<.001; see Table 4). These results were also highl y correlated with the assessment of PA and NA during the participants laboratory visit (S ee also Table 4). In sum, the expected differences in average NA and PA were f ound between MDD and cont rol participants. Interestingly, although MDD and mD particip ant differed in their depression severity, they did not significantly diffe r on their overall PA and NA, suggesting that individuals with mD had a similar level of affective dist urbance as those with MDD. Furthermore, although there was a significant measurement effect, the NA and PA averages obtained by the DRM and ESM data were strongly corr elated and ANOVAs computed separately for ESM and DRM revealed the same pattern of group effects. It a ppears that ratings on the ESM tended to be slightly higher acr oss groups for both NA and PA, perhaps due to differences in the response format.
32 Table 3 Averaged Daily Affect Group Method Valence MDD mD Controls (n = 35) (n = 26) (n = 38) DRM Mean (SD) Mean (SD) Mean (SD) PA 12.93 (6.27) 13.05 (6.66) 22.99 (7.60) NA 17.65 (7.78) 16.95 (7.24) 5.52 (5.14) ESM (n = 30) (n = 31) (n = 21) PA 16.55 (6.73) 15.03 (6.06) 25.37 (6.15) NA 22.02 (6.50) 21.86 (6.24) 7.74 (5.91) *Ratings are based on the sum of seven positive and seven negative mood ratings, each on a 0-6 point scale, averaged over the day. The possible range is 0 to 42. Table 4 Correlations between Measures of PA and NA Variable PA (Lab) PA (DRM)PA (ESM)NA (Lab) NA (DRM) NA (ESM)PA (Lab) .72* .62* -.67* -.59* -.64* PA (DRM) .75* -.45* -.54* -.62* PA (ESM) -.50* -.57* -.65* NA (Lab) .78* .85* NA (DRM) .84* NA (ESM) Note: p < .001 Event Characteristics Before reporting on PER and NER to everyda y life events in the sample, we first report contextual information about the events that were recorded in the DRM in order to provide more information about what it wa s that participants were reacting to. Information about the type of activity, the natu re of the event, locat ion of the event, and interactions with others were recorded for each event. Av erage proportions of each type of context are presented by group in Tables 5a, 5b, and 5c by group. These are computed
33 by calculating the proportions of each contextu al feature within individual then averaging across groups, so that all participants are we ighted equally regardless of the number of events they reported. A wide va riety of contextual features were endorsed by participants for all three groups. Exploratory ANOVAs were used to test for group differences on each of the contextual variables, and were all non-significant (p>.01), with the exception of the experience of Â“personal failure.Â” This type of even t had a significant group effect [F(2, 98) = 4.96, p < .01]. Follow-up t-tests revealed that the control group reported significantly fewer events rated as personal fa ilures compared to both the mD (p=.01) and MDD (p<.01) groups. However, the mD a nd MDD groups did not significantly differ from one another in the number of personal fa ilure events. Overall the groups were very similar in the activity types, nature of the ev ents, location of the ev ents, and interactions with others as reported in the DRM, with the excepti on of personal failures.
34 Table 5-A Characteristics of Events Recorded in the DRM: Activity Type Activity Type ControlmDMDD Praying, Meditating 0.00 0.00 0.01 Exercising 0.01 0.02 0.02 Errands 0.02 0.03 0.02 Reading 0.02 0.04 0.02 Housework, Chores 0.03 0.05 0.03 Shopping 0.04 0.02 0.02 Taking Care of Children 0.04 0.04 0.04 On Computer 0.06 0.08 0.07 Other 0.06 0.06 0.05 Napping, Resting 0.06 0.06 0.09 Grooming, Self-care 0.06 0.05 0.06 Watching TV 0.07 0.09 0.08 Studying, Schoolwork 0.07 0.06 0.05 Paid Work 0.08 0.08 0.08 Commuting 0.12 0.11 0.13 Socializing 0.12 0.10 0.10 Eating, Cooking 0.150.120.13 Nature of the Event ControlmDMDD Personal Failure 0.00 0.04 0.04 Goal Blocked 0.01 0.04 0.04 Negative Social 0.03 0.06 0.05 Thought, Idea, Realization 0.04 0.10 0.06 Neutral Social 0.05 0.09 0.08 Caught up in the Moment 0.07 0.08 0.10 Free from Thought 0.09 0.08 0.15 Reaction to Something 0.10 0.06 0.06 Personal Success 0.13 0.08 0.06 Other 0.14 0.11 0.12 Goal Accomplished 0.16 0.12 0.09 Positive Social 0.17 0.14 0.15
35 Table 5-B Characteristics of Events Record ed in the DRM: Event Location Location of Event ControlmDMDD Family Member's Home 0.00 0.00 0.02 Place of Entertainment 0.01 0.01 0.00 Friend's Home 0.02 0.02 0.03 Outside 0.02 0.07 0.03 Restaurant 0.03 0.04 0.04 Other 0.03 0.06 0.03 Store, Shopping 0.05 0.04 0.04 School 0.09 0.06 0.05 Work 0.10 0.08 0.10 Car, Bus 0.14 0.10 0.13 Home 0.52 0.52 0.53 Table 5-C Characteristics of Events Recorded in the DRM: Social Interactions Interacting ControlmD MDD Proportion Interacting with others 0.53 0.51 0.55 Interacting With Pets 0.03 0.01 0.06 Boss, Supervisor 0.06 0.06 0.06 Other 0.07 0.07 0.03 Own Children 0.08 0.09 0.12 Strangers 0.08 0.11 0.07 Co-workers 0.09 0.06 0.09 Parents, Relatives 0.10 0.09 0.10 Clients, Customers, Students, Patients 0.12 0.08 0.09 Spouse, Significant Other 0.13 0.22 0.20 Friends 0.23 0.19 0.18 ParticipantsÂ’ ratings on subjective charac teristics of the events were also computed. Mean ratings are presented in Table 6 for ratings of how Â“Pleasant,Â” Â“Unpleasant,Â” Â“Important,Â” or Â“In ControlÂ” th ey considered the events to be. ANOVAs were used to explore group differences for each of the ratings. There was a significant
36 group effect for both ratings of Â“PleasantÂ” [F(2, 98) = 8.80, p < .001] and Â“UnpleasantÂ” [F(2, 98) = 8.21, p < .01]. Follow-up t-tests revealed that control participants rated events as significantly more pleasant compared to both the MDD (p<.01) and the mD groups (p<.001), though the mD and MDD groups did not differ. Similarly, the control participants rated events as significantly less unpleasant compared to both the MDD (p<.01) and the mD groups (p<.001). The ove rall group effects were also significant for the average number of re ported positive F(2, 98) = 5.52, p < .01] and negative [F(2, 98) = 5.00, p < .01] events (which are based on the pleasantness and unpleasantness ratings), and the groups showed a similar pattern with control group expe riencing significantly more events rated as positive when compared to both the MDD (p<.01) and mD groups (p<.05). Control participants also experi enced less events rated as negative when compared to the mD group (p<.05) and the MDD group, though this comparison was only marginally significant (p=.08). The groups did not differ on the number of events rated as neutral (low on pleasantness and unpleas antness). Overall, there were consistent differences in the subjective event ratings between the control and depressed groups; though no differences between the mD and MDD groups emerged. Similar to the differences for ratings of the unpleasantness of an event, the groups also significantly differed in their ratings of the events as Â“StressfulÂ” [F(2, 98) = 15.54, p < .001], with control particip ants rating events as signi ficantly less stressful when compared to both the MDD and mD groups (p <.001). There was also a significant group effect for Â“In ControlÂ” [F(2, 98) = 4.35, p < .05], with control participants rating events as significantly more in control than mD part icipants, which reflects how in control
37 participants felt about their s ituation. Groups did not signifi cantly differ in their ratings of how Â“ExpectedÂ” or Â“Importa ntÂ” an event was (p>.05). Table 6 DRM Event Appraisals Event Rating Control Mean (SD) mD Mean (SD) MDD Mean (SD) Pleasant 4.07 (.83) 3.17 (1.06) 3.34 (.97) Unpleasant 1.33 (.92) 2.34 (1.19) 2.16 (1.18) Stressful 1.49 (1.00) 2.91 (1.29) 2.77 (1.25) Important 4.13 (1.02) 3.38 (1.27) 3.71 (1.56) In Control 4.39 (.85) 3.57 (1.36) 4.09 (1.10) Expected 4.25 (.91) 3.73 (1.25) 3.94 (1.43) Number Rated Positive 8.37 (4.91) 5.65 (4.08) 5.11 (4.17) Number Rated Negative 1.55 (1.59) 3.19 (2.62) 2.40 (2.03) Number Rated Neutral 2.79 (2.66) 3.00 (3.24) 3.66 (3.44) Positive and Negative Emotional Reac tivity to Everyday Life Events To examine positive and negative emoti onal reactivity (PER and NER), a Repeated Measures ANCOVA was computed w ith measure (DRM or ESM) as the within subjects factor, group as the be tween subjects factor, PER av erage (average PA rating to positively rated events) as the dependent variable s, and PA ratings to neutral events as a covariate. Participants that did not have a ny positively rated events (n=5) or who did not have any neutrally rated even ts (n=18) in both the DRM and ESM data were dropped from the analyses. As expected, the analyses revealed a significant group effect [F(2, 51) = 8.21, p < .001]. There was no effect of measure, or any group by measure interaction. Follow-up tests revealed that the control gr oup experienced more average PER compared to both the MDD and mD groups (p<.001). However, the mD and MDD groups did not significantly differ from one a nother. Although the neutral covariate was a significant
44 Discussion Although major depressive disorder (MDD) involves affective disturbance, it still remains unclear how chronic mood disturban ce effects emotional responding. While there is a growing laborator y evidence of blunted emoti onal reactivity (ECI) in MDD (Bylsma et al., 2008), it still remains unclear how the severity of depression influences emotional reactivity. Specifica lly, it is unknown whether less severe forms of depression, such as minor depression (mD), involve si milar or distinct patterns of emotional responding as observed in MDD. No prev ious studies have examined emotional reactivity in mD as defined by DRM criteria Furthermore, naturalistic studies of emotion in depression have been rare, so it is not yet known how well emotional responding in the laboratory ge neralizes to daily life. This study was the first to examine the relationship between emotional reactivity to pleasant (PER) and unpleasant (NER) daily li fe events in a sample of diagnosed MDD individuals, mD individuals, a nd healthy controls in a natura listic assessment. This study utilized the DRM and ESM day sampling met hods to provide convergent evidence on emotional reactivity in this sample. The general aim of the current study was to examine the differences in emotion reactivity between healthy individuals and individuals with mD and MDD in two naturalistic settings. Further, to clarify the role of symptom severity in emotional reactivity, we exam ined the relationship between emotional reactivity (NER and PER) with depression a nd anxiety severity, as measured by the BDI and BAI. A secondary aim was to eval uate the correspondence between two day
44 sampling methods, the computerized Experi ence Sampling Method (ESM), and the Day Reconstruction Method (DRM) in order to ev aluate whether these two methods obtain similar findings. Emotional Reactivity and Diagnostic Status The primary hypothesis for PER predicted that controls would experience the greatest PER, and that mD individuals w ould experience more PER relative to MDD individuals. Group differences in PER were as predicted: healthy controls reported significantly more positive emotional reactivity to positively rated events compared to both mD and MDD individuals. These findings are in line with both positive attenuation and ECI. However, contrary to expectati ons, mD and MDD individua ls did not differ in PER, suggesting that they experience a simila r level of impairment in PER despite their different diagnostic status. For NER, the primary hypothesis predic ted that MDD individuals would show blunted reactivity compared to controls a nd mD individuals, and that mD individuals would show increased emotional reactivity re lative to controls. When examining group differences in NER, contrary to expectations healthy controls reported significantly less NER in comparison to both the mD and MDD individuals, which supports negative potentiation. Again, surprisingly, the mD a nd MDD individuals did not differ, suggesting a similar level of impairment in PER despite differences in diagnostic status. These findings are in contrast to the predictions of ECI (Rottenberg, 2005) and recent metaanalyses of laboratory findings that MDD individuals report reliable blunting of NER in comparison to healthy controls (Bylsma et al., 2008).
45 The findings of this study of enhanced NER and blunted PER for MDD are in contradiction to the findings of Peeters et al. (2003) wh ich demonstrated blunted NER responses and enhanced PER responses in MDD individuals. This difference in findings is quite puzzling given that P eeters et al. (2003) also used a similar ESM procedure to measure emotional reactivity in MDD. It is possible that differences in their data collection or analyses may have produced di fferent findings. While their ESM procedure was very similar, important differences were that the procedure was not computerized (leaving the possibility that pa rticipants did not always comp lete their questionnaires on time), and instead of asking participants to report on their most emotional event since their last beep, participants were asked whether they had any positive or negative events to report on. Because of the way the ques tion was asked, in some cases there were no positive or negative events reported, and intern al events such as thinking about a painful memory were not included in the analyses. Therefore, the multi-level regression analyses they used may not have taken into account al l important emotional events from the day. Further notable differences are that the population under study in the Peeters et al. (2003) sample was Dutch, unmedicated, and history of mania or bipolar disorder was not part of their exclusion criteria. Emotional Reactivity and Symptom Severity Regression analyses were used to be tter understand the re lationship between depression and co-morbid anxiety severity with emotional reactivity. For PER, as predicted, BDI and BAI scores both exhibite d negative linear relationships with PER, such that as depression and anxiety severity increased, positive emotional reactivity decreased. These findings correspond to the predictions of positive attenuation and ECI
46 and laboratory findings demonstrating positive attenuation in MDD individuals (Bylsma et al., 2008). For NER, it was predicted that NER woul d show a non-linear relationship with severity measures, such that as severity in creased NER would initially increase but then decrease in the more severe range of severi ty. However, contrary to predictions, both BDI and BAI scores showed a significant po sitive linear relationship, such that as depression and anxiety severity increased, negative emotiona l reactivity increased. Since a non-linear relationship was pr edicted for the relationship of NER with severity, the fit of the linear and quadratic models were comp ared. For the relationship of NER with BDI scores, it was clear that a linear model was the best fit of the data, contrary to expectations and the predictions of ECI. It is possible that a quadratic trend was not observed because our MDD sample was not as representative of the severe end of depressive symptomatology (mean BDI of the MDD group was 29), however, our sample is comparable to samples used in laborato ry findings that have found blunted NER in MDD individuals (e.g., Rottenberg et al., 2005). For the relationship of NER and BAI findings were more ambiguous, with some sugge stion that the quadrat ic model may be a better fit of the data. However, the quadrati c fit was driven by a few subjects on the high end of BAI severity, and it is unclear how we ll the model would be maintained if there were more individuals on the high end of anxiety severity in the sample. That emotional reactivity was largely a linear f unction of symptom severity across a wide range of severity provides support for the conc eptualization of depre ssion as a continuum rather than representing a distinct disease state. Event Characteristics
47 Examination of the context of the daily life events revealed a wide variety of situations with different cont extual features repo rted in the data across groups, suggesting that the findings for PER and NER may gene ralize to a wide variety of stimuli in a naturalistic environment. Reported event characteristics were very similar for controls, MDD, and mD individuals. This is somewhat surprising given that previous research has found that individuals with depression repor t less positive social interactions, more interpersonal stress, more daily stressors, etc (e.g., Nezlek, Imbrie & Shean, 1994; OÂ’Neill, Cohen, Tolpin, & Gunthert, 2004). The only significant group difference found was that MDD and mD individu als reported significantly mo re personal failures than healthy controls. It is possi ble that this finding may be due to the negative attributions found in depressed individuals, in that depressed individua ls are more likely to see themselves or their actions as a failure ev en if that attributi on is not supported by objective evidence (e.g., Beck et al., 1979). The similar reports of events and event contexts across the groups suggest that gr oup differences in emotional reactivity are unlikely to be completely driven by differe nces in the types of events experienced, though it is possible that there ar e subtle differences in the event contexts that are not captured by the data. However, in terms of the subjective ra tings of the events, there were group differences, with healthy controls rated ev ents as significantly more pleasant and less unpleasant in comparison to both MDD and mD individuals. These findings suggest the potential importance of event appraisal fo r the experience of em otional reactivity. Previous research has found that depressed i ndividuals tend to appraise events as more negative (e.g., Beck et al., 1979). It may be that appraisal of daily life events and
48 laboratory emotional stimuli is critical to understanding group differences in emotional reactivity and the relationship between severity and emotional reactivity. Specifically, the negative appraisal of part icular events may predict negative emotional reactivity. Indeed, some theorists have argued that apprai sals (i.e., cognitive ev aluations of events and situations) are critical for eliciting em otion and can explain emotion differentiation (see Roseman & Smith, 2001). Correspondence between the ESM and DRM Sampling Techniques Analyses of ESM and DRM intended to examine their correspondence showed remarkably high correspondence between thes e sampling procedures. No effect of measurement was found in the analyses of PER and NER, nor were there group by measure interactions. There was some concer n that in a retrospec tive measure such as the DRM, depressed individuals might show more negative memory bias; however, there was no evidence that the DRM report of negative emotion was higher for depressed persons. Overall, results s uggest that the DRM may valid and reliable measure of emotional reactivity in depr essed samples. Further, correspondence between the measures was quite high in correlational analyses of emotional reactivity, which is impressive in light of clear differences in the measurement techniques. Specifically, the times of the measurements differ, since in the DRM individuals choose how they break up their day into events, but for the ESM data they are que stioned at random times. The close correspondence in findings between these two measures gi ve further validity to the findings for NER and PER and give confidence that these findings are likely to also generalize to other natura listic sampling techniques. Why Might Naturalistic and L aboratory Findings Diverge?
49 Findings for NER demonstrated a surpri sing divergence from a growing body of laboratory findings that MDD may be characterized by bl unted NER. This study revealed the opposite pattern, in which NER was found to be potentiated in MDD. This suggests that previous laboratory fi ndings of emotional reactivity in the laboratory may not generalize well to real life, and that the speci fic contextual features of emotional stimuli may be critical for understanding emotional reactivity. Examination of event characteristics reveal ed that a large diversity of types of events were sampled. Although a wide range of emotion-eliciting procedures are used in the laboratory, these assessments are restricted in the types of stimuli that are generally used and are criticized for lacking ecologica l validity. It may be that an important difference is that events in an individualÂ’s daily life are more personally important and relevant. Stimuli in a laboratory setting may not elicit potentiated NER because the stimuli are not particularly salient to depr essed individuals who are showing increased NER in their daily lives to more personally meaningful stimuli. A previous laboratory study has used idiographic stimuli (videotape s of participants de scribing peak happy and sad events from their lives) and still found blunted NER in MDD individuals (e.g., Rottenberg et al., 2005). However, this study only used one type of emotional stimuli (videos) and participants were describing even ts that they had already previously reacted to in their daily lives. The use of idiographic stimuli in the laboratory to elicit emotional reactivity has been rare, and stimuli or contexts that more closely resemble natura listic situations (e.g., interpersonal conflicts, social support, failing an important task, etc.) have not been used to study emotional reactivity in MDD in a c ontrolled laboratory setting. The possibility
50 remains that types of events and the contex t surrounding them is pa rticularly important for understanding differences in emotional reacti vity. For example, there may be specific types of common daily events, such as interp ersonal stressors, that relate to increased NER in depressed individuals but have not been used in laboratory studies of emotional reactivity in MDD. Further, since positive and negative events were identified by participantsÂ’ appraisals of their daily life ev ents, only events apprai sed as highly positive or negative were included in the analyses. In laboratory studies, participants may not necessarily appraise the stimu li as strongly positive or nega tive. As discussed earlier, appraisal may be particularly important for understanding emotional reactivity in depression. Conclusions and Future Directions In conclusion, this study found clear rela tionships between emotional reactivity, diagnostic status, and symptom severity. Sp ecifically it was found that both MDD and mD individuals reported more NER and less PER in comparison to healthy controls and correlation analyses with symptom severity revealed a linear relationship for both. Surprisingly there were no differences in em otional reactivity found when comparing the MDD and mD groups, suggesting that both groups experience a similar degree of impairment in affective functioning. Thes e findings suggest that depression may be better conceptualized as a continuum of sy mptom severity rather than a categorical disease state. Findings for NER diverged from laboratory findings, suggesting that emotional functioning from daily life may ha ve important differences from emotional responses to stimuli in the lab. Further, a close correspondence was found between the
51 two naturalistic methods used, suggesting that these results are a good measure of emotional reactivity in daily life. Because the findings for NER diverge fr om laboratory findings, it will be important to examine how specific event character istics relate to emotional reactivity. In addition, because PER and NER were defined by participantsÂ’ subjec tive ratings of their events and the depressed groups reported experiencing more negative and fewer positive events, it would be important to examine whethe r their ratings of these events are biased and to examine the importance of appraisal in understanding emo tional reactivity, which would also apply to laboratory studies. It w ould also be useful fo r laboratory studies to use more idiographic stimuli or stimuli more like situations experienced in daily life in order to examine these factors in a controlled setting. Further, since depression severity and co-morbid anxiety demonstrated a similar relationship to emotional reactivity, it will be important for future research to exam ine the specific influence of depression and anxiety on emotional reactivit y. Although this study is cr oss-sectional, emotional reactivity to everyday life events could poten tially serve as a relatively inexpensive and noninvasive predictor of the c ourse of mood disorders. T hus, another important future direction of the current study would be to c onduct a longitudinal follow-up of this sample in order to examine whether PER and NER pr edict the course of mD and MDD.
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64 Appendix A: DRM Survey Packet First we have some general questions about your life. Please answer these questions by placing a check mark next to the answer that best describes your opinion 1. Taking all things together, how satisfied are you with your life as a whole these days? Are you: __ very satisfied, __ satisfied, __ not very satisfied, __ not at all satisfied? 2. Next, letÂ’s turn to your life at home. Over all, how satisfied are you with your life at home? Are you: __ very satisfied, __ satisfied, __ not very satisfied, __ not at all satisfied? 3. And how about your job? Overall, how sa tisfied are you with your present job? Are you: __ very satisfied, __ satisfied, __ not very satisfied, __ not at all satisfied? 4. Now we would like to know how you feel and what mood you are in when you are at home. When you are at home, what percentage of the time are you: in a bad mood ____% a little low or irritable ____% in a mildly pleasant mood ____% in a very good mood ____% Sum 100% 5. Now we also like to know how you feel and what mood you are in when you are at work When you are at work, what percentage of the time are you: in a bad mood ____% a little low or irritable ____% in a mildly pleasant mood ____% in a very good mood ____% Sum 100%
65 Appendix A: (Continued) Yesterday We would like to learn what you did and how you felt yesterday. Not all days are the same Â– some are better, some are worse and others are pretty typical. Here we are only asking you about yesterday. Because many people find it difficult to remember what exactly they did and experienced, we will do this in three steps: 1. On the next page, we will ask you when you woke up and when you went to sleep yesterday. 2. We'd like you to reconstruct what your day was like, as if you were writing in your diary. Where were you? What did you do and experience? How did you feel? Answering the questions on the next page will help you to reconstruct your day. 3. After you have finished reconstructing your day in your diary, we will ask you specific questions about this time. In answering these questions, weÂ’d like you to consult your diary page and the notes you made to remind you of what you did and how you felt. To begin, please circle the day of the week that YESTERDAY was: Monday Tuesday Wednesday Thursday Friday Saturday Sunday
66 Appendix A: (Continued) Diary Pages About what time did you wake up yesterday? __________ And when did you go to sleep? __________ On the next three pages, please describe your day. Think of your day as a continuous series of scenes or episodes in a film. Give each episode a brief name that will help you remember it (for example, Â“commuting to workÂ”, or Â“at lunch with BÂ”, where B is a person or a group of people). Write down the approximate times at which each episode began and ended. The episodes people identify usually last between 15 minutes and 2 hours. Indications of the end of an episode might be going to a different location, ending one activity and starting another, or a change in the people you are interacting with. There is one page for each part of the day Â– Morning (from waking up until noon), Afternoon (from noon to 6:00 pm) and Evening (from 6:00 pm until you went to bed). There is room to list 10 episodes for each part of the day, although you may not need that many, depending on your day. It is not neces sary to fill up all of the spaces Â– use the breakdown of your day that makes the most sense to you and best captures what you did and how you felt. Try to remember each episode in detail, and write a few words that will remind you of exactly what was going on. Also, try to remember how you felt, and what your mood was like during each episode. What you write only has to make sense to you, and to help you remember what happened when you are answering the questions about the specific episodes in your day.
67 Appendix A: (Continued) Morning (from waking up until just before lunch) What happened? Time Began Time Ended What did you feel? What were you thinking? 01A Lunchtime 02A 03A 04A 05A 06A 07A 08A 09A 10A
68 Appendix A: (Continued) Afternoon (from lunch until just before) What happened? Time Began Time Ended What did you feel? What were you thinking? 01A Lunchtime 02A 03A 04A 05A 06A 07A 08A 09A 10A
69 Appendix A: (Continued) Evening (from dinnertime until just before you went to sleep) What happened? Time Began Time Ended What did you feel? What were you thinking? 01E Dinnertime 02E 03E 04E 05E 06E 07E 08E 09E 10E
70 Appendix A: (Continued) Please look over your diary once more. Are there any other episodes that youÂ’d like to revise or add more notes to? Is there an episode that you would want to break up into two parts? If so, please go back and make the necessary adjustments on your diary pages. If not, you may go on to the next section. Thank You You may now start on the next section.
71 Appendix A: (Continued) How Did You Feel Yesterday? Before we proceed, please look back at your diary pages. How many episodes did you record for the Morning? _____ How many episodes did you record for the Afternoon? _____ How many episodes did you record for the Evening? _____ Now, we would like to learn in more detail about how you felt during those episodes. For each episode, there are several questions about what happened and how you felt. Please use the notes on your diary pages as often as you need to. Please answer the questions for every episode you recorded, beginning with the first episode in the Morning. To make it easier to keep track, we will ask you to write down the number of the episode that is at the end of the line where you wrote about it in your diary. For example, the first episode of the Morning was number 1M, the third episode of the Afternoon was number 3A, the second episode of the Evening was number 2E, and so forth. It is very important that we get to hear about all of the episodes you experienced yesterday, so please be sure to answer the questions for each episode you recorded. After you have answered the questions for all of your episodes, including the last episode of the day (just before you went to bed), you can go on to the next section.
72 Appendix A: (Continued) First Morning Episode Please look at your Diary and select the earliest episode you noted in the Morning. When did this first episode begin and end (e.g., 7:30am)? Please try to remember the times as precisely as you can. This is episode number _____, which began at _______ and ended at _______. What were you doing? (please check all that apply): __ paid work __ studying, schoolwork __ commuting __ shopping __ housework, chores __ eating or cooking __ watching TV __ reading __ socializing __ napping/resting __ exercising __ on computer __ taking care of children __ praying or meditating __ grooming/self-care __ errands __ other (please specify:________________) What was the nature of this episode? __ A personal success __ A personal failure __ A positive social interaction __ A negative social interaction __ A neutral social interaction __ A thought, idea, or realization __ A goal was accomplished __ A goal was blocked __ Being free from thought __ Caught up in the moment __ A reaction to something I saw or heard __ Other (please specify: ________________)
73 Appendix A: (Continued) Where were you? __ At home __ At work __ At school __ At a friendÂ’s home __ At a family memberÂ’s home __ At a store/shopping __ At a restaurant __ At a place of entertainment __ In the car/bus __ Outside __ Somewhere else (please specify: ________________) Were you interacting with anyone (including on the phone, in a teleconference, etc)? __ yes __ no one skip next question. If you were interacting with someone (please check all that apply) __ spouse, significant other __ friends __ co-workers __ boss, supervisor __ clients,customers,students, patients __ my children __ parents,relatives __ strangers __ pets __ other (please specify: ________________) How IMPORTANT would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How PLEASANT would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How UNPLEASANT would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How STRESSFUL would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How EXPECTED would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How IN CONTROL of this episode were you? Not at all Very 0 1 2 3 4 5 6
74 Appendix A: (Continued) First Morning Episode How did you feel during this episode? Please rate each feeling on the scale given. A rating of 0 means that you did not experience that feeling at all. A rating of 6 means that this feeling was a very important part of the experience. Please circle the number between 0 and 6 that best describes how you felt. Not at all Very 0 1 2 3 4 5 6 Talkative Enthusiastic Tense Confident Cheerful Anxious Energetic Satisfied Happy Distracted Restless Irritated Depressed Guilty Snobbish Ashamed Regretful Successful Embarrassed Self-Conscious Accomplished Stuck-up Humiliated
75 Appendix A: (Continued) Next Episode Now look at your Diary and select the episode that immediately followed the one you just rated. When did this first episode begin and end (e.g., 7:30am)? Please try to remember the times as precisely as you can. This is episode number _____, which began at _______ and ended at _______. What were you doing? (please check all that apply): __ paid work __ studying, schoolwork __ commuting __ shopping __ housework, chores __ eating or cooking __ watching TV __ reading __ socializing __ napping/resting __ exercising __ on computer __ taking care of children __ praying or meditating __ grooming/self-care __ errands __ other (please specify:________________) What was the nature of this episode? __ A personal success __ A personal failure __ A positive social interaction __ A negative social interaction __ A neutral social interaction __ A thought, idea, or realization __ A goal was accomplished __ A goal was blocked __ Being free from thought __ Caught up in the moment __ A reaction to something I saw or heard __ Other (please specify: ________________)
76 Appendix A: (Continued) Where were you? __ At home __ At work __ At school __ At a friendÂ’s home __ At a family memberÂ’s home __ At a store/shopping __ At a restaurant __ At a place of entertainment __ In the car/bus __ Outside __ Somewhere else (please specify: ________________) Were you interacting with anyone (including on the phone, in a teleconference, etc)? __ yes __ no one skip next question. If you were interacting with someone (please check all that apply) __ spouse, significant other __ friends __ co-workers __ boss, supervisor __ clients,customers,students, patients __ my children __ parents,relatives __ strangers __ pets __ other (please specify: ________________) How IMPORTANT would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How PLEASANT would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How UNPLEASANT would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How STRESSFUL would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How EXPECTED was this episode? Not at all Very 0 1 2 3 4 5 6 How IN CONTROL of this episode were you? Not at all Very 0 1 2 3 4 5 6
77 Appendix A: (Continued) Next Episode How did you feel during this episode? Please rate each feeling on the scale given. A rating of 0 means that you did not experience that feeling at all. A rating of 6 means that this feeling was a very important part of the experience. Please circle the number between 0 and 6 that best describes how you felt. Not at all Very 0 1 2 3 4 5 6 Talkative Enthusiastic Tense Confident Cheerful Anxious Energetic Satisfied Happy Distracted Restless Irritated Depressed Guilty Snobbish Ashamed Regretful Successful Embarrassed Self-Conscious Accomplished Stuck-up Humiliated
78 Appendix A: (Continued) Next Episode Now look at your Diary and select the episode that immediately followed the one you just rated. When did this first episode begin and end (e.g., 7:30am)? Please try to remember the times as precisely as you can. This is episode number _____, which began at _______ and ended at _______. What were you doing? (please check all that apply): __ paid work __ studying, schoolwork __ commuting __ shopping __ housework, chores __ eating or cooking __ watching TV __ reading __ socializing __ napping/resting __ exercising __ on computer __ taking care of children __ praying or meditating __ grooming/self-care __ errands __ other (please specify:________________) What was the nature of this episode? __ A personal success __ A personal failure __ A positive social interaction __ A negative social interaction __ A neutral social interaction __ A thought, idea, or realization __ A goal was accomplished __ A goal was blocked __ Being free from thought __ Caught up in the moment __ A reaction to something I saw or heard __ Other (please specify: ________________)
79 Appendix A: (Continued) Where were you? __ At home __ At work __ At school __ At a friendÂ’s home __ At a family memberÂ’s home __ At a store/shopping __ At a restaurant __ At a place of entertainment __ In the car/bus __ Outside __ Somewhere else (please specify: ________________) Were you interacting with anyone (including on the phone, in a teleconference, etc)? __ yes __ no one skip next question. If you were interacting with someone (please check all that apply) __ spouse, significant other __ friends __ co-workers __ boss, supervisor __ clients,customers,students, patients __ my children __ parents,relatives __ strangers __ pets __ other (please specify: ________________) How IMPORTANT would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How PLEASANT would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How UNPLEASANT would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How STRESSFUL would you rate this episode? Not at all Very 0 1 2 3 4 5 6 How EXPECTED was this episode? Not at all Very 0 1 2 3 4 5 6 How IN CONTROL of this episode were you? Not at all Very 0 1 2 3 4 5 6
80 Appendix A: (Continued) Next Episode How did you feel during this episode? Please rate each feeling on the scale given. A rating of 0 means that you did not experience that feeling at all. A rating of 6 means that this feeling was a very important part of the experience. Please circle the number between 0 and 6 that best describes how you felt. Not at all Very 0 1 2 3 4 5 6 Talkative Enthusiastic Tense Confident Cheerful Anxious Energetic Satisfied Happy Distracted Restless Irritated Depressed Guilty Snobbish Ashamed Regretful Successful Embarrassed Self-Conscious Accomplished Stuck-up Humiliated
81 Appendix A: (Continued) If you have more episodes to rate, please ask the researcher for additional forms. Have you rated all of your episodes, in cluding the last ep isode of the day, just before you went to bed? If so, you may go on to the next section.
82 Appendix A: (Continued) A Few More Questions about Yesterday Now that you have told us about your day in detail, we have a few more general questions. Now we would like to know overall how you felt and what your mood was like yesterday. Thinki ng only about yesterday what percentage of the time were you: in a bad mood ____% a little low or irritable ____% in a mildly pleasant mood ____% in a very good mood ____% Sum 100% Now weÂ’d like to know how typical yesterday was for that day of the week (i.e.,for a Monday, for a Tuesday, or so on). Com pared to what that day of the week usually is like yesterday was (please circle one): Much Worse Somewhat Worse Pretty TypicalSomewhat Better Much Better 1 2 3 4 5
83 Appendix B: The ESM Questions Questions about sleep patterns, only asked at first report of the day: What time did you wake up this morning? 4am or earlier 5am 6am 7am 8am 9am 10am 11am noon or later What time did you go to sleep last night? 4pm or earlier 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12am 1am 2am 3am or later Current Mood ratings, asked at each beep (responses given on a sliding Likert scale from Â“Not at allÂ” to Â“VeryÂ”): How TALKATIVE do you feel? How ENTHUSIASTIC do you feel? How TENSE do you feel? How CONFIDENT do you feel? How CHEERFUL do you feel? How ANXIOUS do you feel? How ENERGETIC do you feel? How SATISFIED do you feel? How HAPPY do you feel? How DISTRACTED do you feel? How RESTLESS do you feel? How IRRITATED do you feel? How DEPRESSED do you feel? How GUILTY do you feel? How SNOBBISH do you feel? How ASHAMED do you feel? How REGRETFUL do you feel? How SUCCESSFUL do you feel? How EMBARRASSED do you feel? How SELF-CONSCIOUS do you feel? How ACCOMPLISHED do you feel? How STUCK-UP do you feel? How HUMILIATED do you feel?
84 Appendix B: (Continued) Questions about current activity, asked at each beep: What are you doing RIGHT NOW? paid work studying, schoolwork commuting shopping housework, chores eating or cooking watching TV reading socializing napping/resting exercising on computer taking care of children praying or meditating grooming/self-care errands other WHERE are you RIGHT NOW? At home At work At school At a friendÂ’s home At a family memberÂ’s home At a store/shopping At a restaurant At a place of entertainment In the car/bus Outside Somewhere else Are you INTERACTING with someone RIGHT NOW? Yes No WHO are you interacting with? Check all that apply: spouse, significant other friends co-workers boss, supervisor clients,customers,students my children parents,relatives strangers pets
85 Appendix B: (Continued) Questions about the event, asked at each beep: Think about the MOST IMPORTANT EMOTIONAL EVEN T that happened SINCE YOUR LAST REPORT, in what CONTEXT did this event occur? paid work studying, schoolwork commuting shopping housework, chores eating or cooking watching TV reading socializing napping/resting exercising on computer taking care of children praying or meditating grooming/self-care errands other What was the NATURE OF THIS EVENT? A personal success A personal failure A positive social interaction A negative social interaction A neutral social interaction A thought, idea, or realization A goal was accomplished A goal was blocked Being free from thought Caught up in the moment A reaction to something I saw or heard WHERE were you during the event? At home At work At school At a friendÂ’s home At a family memberÂ’s home At a store/shopping At a restaurant At a place of entertainment In the car/bus Outside Somewhere else
86 Appendix B: (Continued) Were you INTERACTING with someone during the event? Yes No WHO were you interacting with? Check all that apply: spouse, significant other friends co-workers boss, supervisor clients,customers, students, patients my children parents,relatives strangers pets Ratings about the event (responses given on a slidin g Likert scale from Â“Not at allÂ” to Â“VeryÂ”): How IMPORTANT would you rate this event? How PLEASANT would you rate this event? How UNPLEASANT would you rate this event? How STRESSFUL would you rate this event? How EXPECTED was the event? How IN CONTROL of the event were you? Questions about crying: Did you cry during this event? If Yes: How did you feel after crying? (sliding scale from worse then before to better than before)