Showing posts with label emotions. Show all posts
Showing posts with label emotions. Show all posts

Friday, January 5, 2018

Ways the VA Healthcare Program is Hurting Local Veterans

            Prior to moving to the Durango, Colorado area, I had been enrolled in what is called the Choice Program, which provides military veterans, as well as their dependents, to obtain care from community resources that are not provided through the VA system. This is the system I used to receive services such as rheumatology, gastroenterology, and dermatology. For the most part, this system helped to provide me with the resources I require to tend to my health needs. Sure, the physicians and specialists could have just as well been military doctors, as I received the same quality of care from them...and that is not saying much, considering my previous experience with military doctors, but I digress.
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            When I had my initial appointment with my new primary care provider, I was told something that just came across as blatantly wrong. See, my doctor told me that my only options to see these types of specialists would be to drive nearly 4 hours each way to the large VA facility in Albuquerque, which is insane to suggest, or not see any specialists. Sure, they have a courtesy shuttle van that takes patients to the larger facility, but you must plan your day around the appointments of others, so you would either leave early, or must stay late, depending on the schedule for that day. The other option just was not feasible either, as I have a family history of colon and bone cancer, as well as having been diagnosed with a myriad of chronic pain conditions.
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I live at a Level E on a daily basis, just for reference
            You know the saying “if it sounds too good to be true, it probably is?” Well, that is applicable to my situation, but rather replace “good” with “wrong” and you see where I am going with this, right? Well, when I met with the social worker at my local VA clinic, she repeated the same incorrect information regarding the Choice Program. She told me that, while there are services in town, such as support groups, there is little in the way of community resources that address symptoms. I can’t really go to a support group for my colonoscopy or endoscopy now, can I?
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            My social worker also told me that I am my own advocate for my health, which is a phrase that she might be wishing she didn’t say. See, I thought that the information I was provided by not just one, but two medical professionals at my local VA clinic, sounded incorrect. Just in case though, I called the Choice Program directly, and boy, am I glad. The representative that I spoke with was just as befuddled by what I was told as I was when I heard it. It helped to put my mind at ease, knowing that I was correct about this program, as well as the fact that I would (hopefully) be able to see a provider here in the community, as my symptoms have increased since my last visit to the shoddy rheumatologist who reprimanded me for crying out in pain when he took a biopsy from my thigh at 5:30 in the morning, before I was fully numb. But again, I digress and that, along with the other numerous experiences I have had with military health officials and those covered by the Choice Program.
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            So, here is my conundrum. Yes, I am my strongest advocate for both my mental and physical health. The soonest they could schedule me with a mental health professional (to address my depression, anxiety, PTSD, and MST) is the end of February, and even then, it would be only via tele-health. That falls outside of the 30 days or 30-mile rule that applies to the Choice Program (maybe not the distance, but certainly the time-frame). In the past, I have conveniently fallen through the VA health cracks, as it had taken me 18 months to even get an appointment with a rheumatologist, as the original request somehow got lost. I know that I am in the right and have a whole organization and website that provides me with the answers to help to support my position. I know that I am most likely not the only veteran in the area who has been fed this lie. However, I may be the only one to raise a little hell over the incorrect information that could have potentially affected the lives of a significant number of veterans living in the area.
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            I have been known to let my emotions get the best of me, particularly when I know that I am in the right. This isn’t just relegated to my health, but also where we used to live, I have been physically threatened when I spoke up for the poor treatment of the dogs I would witness running in the street. As if it were my fault that I recognized this behavior as wrong and dangerous. I am not kidding. I wish I were. So, I need to come up with a game plan of sorts, as I know that I need to go into the clinic and let them know that they are wrong, that I qualify to see community providers that honor the Choice Program in the area. I know that other veterans have experienced this same type of treatment. The sooner the better, but, dude, I am not looking forward to it. I just need to keep my cool, and remember why I am doing this...for the health of not only myself, but the countless veterans who have received the same misinformation. Sadly, I know that this not only applies to my local clinic, but the Portland, Oregon one too, as that is who contacted me to set up my appointment for the tele-health mental health sessions...I was told that since they can provide me with the tele-health services, then I don’t qualify for community care. Well, that is not true either.
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Saturday, April 27, 2013

The Facial Feedback Hypothesis: Applications and Implications


ABSTRACT

Is it possible to improve your mood, just by smiling?  Research into the facial feedback hypothesis indicates that there may be some credence to the old adage of “grin and bear it.”  Originally sparked by Charles Darwin in his book, The expression of the emotions in man and animals, in 1872, the concept of physiological changes having an impact on the experience of emotions had been addressed by researchers looking for confirmation ever since.  There have been a myriad of researchers who have addressed the facial feedback hypothesis from many angles.

There are many contributors involved in the expression of an emotion, supplied from external stimuli, internal states, and even culture.  While the exact neurological reason behind the impact outward expression has on emotional experience is still unclear, the psychological effects are evident.

THEORIES AND RESEARCH ON THE FACIAL FEEDBACK HYPOTHESIS

The facial feedback hypothesis is the thought that facial movement can influence emotional experience.  In a well documented experiment, participants were asked to hold a pen in their mouth, either between their lips or with their teeth, then asked to rate the humor of a cartoon (Strack, Martin, & Stepper, 1988).  Holding the pen between their lips, the participants contracted the orbicularis oris muscle, resulting in a frown, and were unable to contract the zygomatic major muscle involved in smiling.  However, those who held the pen between their teeth were able to contract this muscle and forced them to smile.  The results indicated that the participants who smiled while holding the pen in their teeth, were more likely to rate the cartoon as more funny.  This is quite an amazing discovery, considering the cartoon was the same in each condition, with the only difference lying in the contracting of the zygomatic major muscle.

The muscle contracted during the mouth pen holding experiment, the zygomatic major muscle, which causes the cheek muscles to draw lip corners up toward the cheekbones, is the same one that is associated with the Duchenne, or genuine smile.  This type of smile is usually thought of a more felt smile and also involves activation of the orbicularis oculi, or the muscle of the eye that causes the “crow’s feet” in the corners of the eye.  It is hypothesized that an individual experiences greater pleasure when displaying a genuine, Duchenne smile when compared to a non-Duchenne smile, which supports the facial feedback hypothesis (Surakka & Hietanen, 1998).

Another, more recent study, involved participant evaluation ratings regarding the pleasantness of pictures, composed of neutral faces or nature scenes (trees, forests, and landscapes).  The two experimental conditions in this study required the participants to look at the pictures while either elevating their cheeks (similar to a smile), or contracting their eyebrows (associated with frowning).  As with the Strack study, the results confirmed the facial feedback hypothesis, since the participants who were in the smiling group rated the pictures as more pleasant when compared to the frowning group (Dimberg & Söderkvist, 2010).

While there appears to be a plethora of research supporting the facial feedback hypothesis, there have been some opponents who have voiced their own opinions.  One of the first to suggest an alternative to the facial feedback hypothesis was William James who posited in 1884 that instead of a change in the muscles and facial expression producing the emotion, the emotion leads to the changes.  James proposed four steps in the generation of subjective experience of an emotion, which consist of: a sensory stimulus transmitted to the cortex and perceived; the reflex impulses travel to muscle and skin; the changes in these areas are transmitted back to the brain; the return impulses are perceived, and when combines with the original stimulus perception, produce the “object-emotionally-felt” effect (James, 1890).  James’ theory of emotion is similar to the facial feedback hypothesis, but in reverse, starting with the appraisal of the stimuli which leads to a change in the facial muscles, followed by an assessment by the brain, producing the emotional experience.

The Differential Emotions Theory, developed by Carroll Izard in 1971, suggested that the primary components of emotion include neural activity, striate muscle, and subjective experience of the individual.  Izard suggested that each emotion operates as a system of interacting neural, expressive, and experiential components, and upon cognition occurring, the emotion is expressed.  According to the differential emotions theory, emotions retain their adaptive and motivational functions, which aid in social interactions (Abe & Izard, 1999).

Another theory that arose in the light of the facial feedback hypothesis was that of the self-attribution theory of emotion, which suggests that emotions are a mixture of autonomic arousal and cognitive processing (Schachter, 1964).  The interesting part of the self-attribution theory is that the reaction to the emotion being experienced is able to be operationalized, therefore, less subjective, and possibly more reliable than the results gathered during self-reports from participants.

In 1980, Ross Buck suggested that there may be two different renderings of the facial feedback hypothesis, the between-subjects and the within-subjects versions.  The between-subjects design suggests that individual differences contribute to the experience of emotions, for example, if one person freely expresses their emotions, they will have a greater response when compared to someone who shows little expression.  Studying of the between-subject version has led to objective supporting evidence, particularly regarding nonexpressive people.  While holding in an emotional expression, it has been noted that there is an increase of heart rate and skin conductance when reacting to a stimuli.  This finding may suggest that facial feedback is not necessary for the experience of an emotion to occur. The within-subject aspect of Buck’s theory holds that when the free expressor is experiencing a given emotion, if they outwardly express rather than stifle the emotion, they will have a greater external response and the emotion will increase in intensity.

Building on Buck’s within-subject aspect of the facial feedback hypothesis, the difference between internalizers and externalizers needs to be addressed.  Individuals in the internalizing group do not freely express emotions, whereas externalizers freely express what they are feeling and experiencing.  According to a somewhat unethical study involving electric shock, those who exaggerated the intensity of the shock were actually experiencing more pain than a group who suppressed their pained expressions while receiving a shock of equal value (Lanzetta, Cartwright-Smith, & Kleck, 1976).  This research also revealed that when compared to the baseline, hiding a facial response to the shock also reduced the galvanic skin response (GSR). These findings suggest that when suppressing, or internalizing the reaction to a stimulus, the experience is actually less intense.  While the externalizer-internalizer distinction doesn’t seem to fit with, and may even contradict the facial feedback hypothesis, they are actually quite similar, since both examine the link between the external expression and the internal experience of emotions.

COGNITIVE LINK BETWEEN THE INTERNAL AND EXTERNAL

There is a complex network of nerves, muscles, and brain functions associated with the expression of an emotion that lies beneath the skin.  Although it has not been empirically shown, research has speculated that the feedback from the muscles of the face and skin during genuine and imitation expressions is sent to the amygdala and the neural network, where it leads to the experience of the expressed emotion (Hennenlotter, Dresel, Castrop, Cebellos-Baumann, Wohlschläger, & Haslinger, 2009).  The amygdala is a key component in the processing of emotions, and has been considered “the gateway to the emotions” (Aggleton & Mishkin, 1986).  Some of the roles of the amygdala include evaluating if a stimulus is dangerous or harmless, pleasant or unpleasant, and is a major contributor to the facial expressions of emotions, both intentional and unintentional (Habel, Windischberger, Derntl, Robinson, Kryspin-Exner, Gur, & Moser, 2007).

In order to research the role of the amygdala in the processing of emotions, researchers used functional magnetic resonance imaging (fMRI) to monitor activity in the brain when exposing participants to pictures of five basic emotions (happiness, sadness, anger, fear, and disgust) along with neutral faces.  Participants were also asked to provide an approximate age for the person that was displaying the emotion.  Results show that when participants attempt to identify which emotion they are seeing, there is activation in the amygdala in both conditions (emotions and age); however, there was far greater activity present when trying to identify the emotion.  This suggests that the amygdala plays a large role in the identification of emotions, as well as appraisal of the emotions viewed (Habel et al., 2007).  It has also been noted that when processing a fearful expression, activity in the orbitofrontal cortex also occurs (Neta & Whalen, 2010).

INTERNALIZERS AND EXTERNALIZERS

As mentioned earlier in Buck’s within-subject version of the facial feedback hypothesis, there are two different kinds of individuals, those that freely express their emotions, externalizers, and those that stifle their expressions, internalizers.  Personal differences between internalizers and externalizers may also dictate which category a person may fall into.  Previous research has suggested that females are more facially expressive than males in emotion-provoking situations.

In a study conducted by Thurnberg and Dimberg (2000), researchers set out to determine whether females were generally more facially reactive, or if they were more emotionally reactive in general, compared to men.  Participants were deceived as to what the exact nature of the experiment was, in order to prevent bias or demand characteristics.  Two groups, composed of either male of female participants, were exposed to fear-relevant and fear-irrelevant stimuli while an electromyography machine monitored the activity from the corrugator supercilii muscle region (activity in this region is associated with the exhibition of the fear expression, which consists of the eyebrows being raised, opening the eyes widely).

In order to effectively induce a fear response in the participants, researchers used pictures of snakes, which has been shown to reliably produce an increase in corrugator muscle activity, and are usually consistently rated as being unpleasant.  Participants were also exposed to fear-irrelevant stimuli (flowers), which have been shown to induce either a neutral of slightly positive facial reaction (Dimberg, 1997), in order to determine if the changes in activity were due to the individual or the stimuli.  After exposure to each set of pictures, fear-relevant (snakes) and fear-irrelevant, the participants were asked to rate how unpleasant they experienced the stimuli.

When evaluating the results of the corrugator muscle activity, there was not a significant difference when comparing the fear-relevant and fear-irrelevant stimuli; however, there was a difference in the activity level between the two groups.  It was discovered that females not only produced a larger response than males to the fear-relevant stimuli (snake pictures), but the responses of the females differed between both stimuli as well; females showed a larger corrugator response to the fear-relevant than the fear-irrelevant stimuli.  In this experiment, the participants in the male group would be considered internalizers and the participants in the female group would be considered externalizers, since there was more corrugator muscle activity in response to the fear-stimuli.

Researchers have suggested many reasons as to why this difference between males and females exist, including genetics differences in the central nervous system, cultural influences that have worked to inhibit the fear expression in males (Brody & Hall, 1993), and even a possibility that females are more perceptually sensitive than males (Buck, 1984).  Females may also have a genetically evolved fear response that has developed out of necessity for protection of offspring in dangerous situations.

Many studies have supported the hypothesis of increased facial expressiveness of emotion is correlated with increased physiological arousal.  In a study involving exposing participants to pictures of people exhibiting happiness, sadness, anger, or fear, while monitoring blood pressure and heart rate, researchers discovered that there was a measureable correlation between the stimuli photos and the physiological reactions.  Fear and happiness were linked with and increased heart rate, however, in the fear condition, the heart rate increased more (Schwartz et al., 1981).  This increase in heart rate as a response to fear may be an example of the fight-or-flight response that has evolved in order to keep a species alive and able to escape danger.

The increase in emotional expression among externalizers has been thought of as a form of cathartic discharge, since according to some, emotion must find an exit, and if it cannot be vented outwardly through expression, it is routed inward, resulting in physiological changes.  According to Jones (1948), individuals who outwardly express emotion but show little arousal, or physiological changes, are externalizers; whereas those who show little to no outward emotion, but substantial autonomic physiological activity are internalizers.

When studying the physiological differences between internalizers and externalizers, the results are mixed.  Research involving voluntary facial expressions of anger, disgust, neutral, and control conditions during anger imagery showed that the voluntary facial anger reduced blood flow volume, but did not show an increase in heart rate, contrary to the findings of Schwartz et al. in the previous study (Ianni, Stettner, & Freedman, 1986).

It is suggested by researchers Boden and Dale, that internalizers are individuals who habitually and effectively control their emotions and that there are immediate and significant consequences to such regulation.  While devoting tremendous energy to prevent externalizing behavior from surfacing, there may be not only higher blood pressure and pulse present, but also possibly a diminished memory and cognitive processes (Boden & Baumeister, 1997).  It appears that internalizers may have a way of protecting themselves from unpleasant events, possibly by generating pleasant thoughts; they are able to avoid processing of unpleasant emotions.

WHAT HAPPENS WHEN THE FACIAL FEEDBACK PATHWAY IS BLOCKED?

In a quest to maintain a youthful appearance, many women, and some men, have turned to injections of botulinum toxin, or Botox, to prevent the appearance of wrinkles.  Botox, a deadly poison, causes temporary muscle paralysis by preventing acetylcholine release at the neuromuscular junction, acting as a roadblock to expression formation (Dastoor, Misch, & Wang, 2007).  Patients are advised that Botox will not keep them from expressing themselves, just their facial expressions.  Some of the more popular areas for injection of Botox includes the glabellar rhytides (involved in furrowing of the brow), horizontal forehead lines, and crow’s feet, all areas involved in routine facial expressions (Alam, Barrett, Hodapp, & Arndt, 2007).  With these locations being paralyzed, would the inhibition of facial expressions lead to an interrupted facial feedback pathway?  Since the theory of the facial feedback hypothesis suggests that posing a facial expression should increase the intensity of the emotional experience, inhibiting the facial expression should decrease it.

Research into how Botox affects emotional experience suggests that when the facial feedback pathway is blocked, the strength of the emotional experience is decreased.  One study compared self-reports of emotional experience of participants before and after they received one of two types of cosmetic facial injections, either Botox or Restylane (Davis, Senghas, Brandt, & Ochsner).  Unlike Botox, Restylane acts as a filler and does not cause temporary muscle paralysis.  In order to evaluate any changes between the pre and post injection responses, emotional response to positive and negative video clips were recorded.  Upon analyzing the within-group results, there were no statistically significant findings, however, when comparing the between-group data, the participants who received Botox injections showed a significant decrease in the strength of emotional experience.  These results suggest that when the facial feedback pathway is inhibited, there is indeed a diminished experience of emotion, confirming the facial feedback hypothesis.

By paralyzing the target muscles, specifically the orbicularis oculi, less Duchenne-type smiles may occur, however, it may also result in a more positive mood.  By reducing the furrowing of the brow associated with negative emotional expressions, it may lead to a more positive emotional expression (Alam et al.).

According to the facial feedback hypothesis, expressing more positive emotions may lead to more smiling and a happier emotion, however, on the other side, by losing the ability to display negative emotions, the expressions of disgust, fear, and anger may be diminished.  With the possibility of losing the ability to express emotions, physicians who perform Botox injections are urged to consult with their patients, especially those who rely on demonstrative facial expressions (actors, salespersons, teachers), a side effect to injections may include distress due to the inability to effectively transmit their emotions (Singh, 2003).

CLINICAL APPLICATIONS

If our emotional states are a result of our facial expressions, it would be presumed that by smiling, individuals who are depressed could improve their mood.  Impairment in the ability to smile may elevate the risk for depression, since according to the facial feedback hypothesis, if an emotion is not able to be expressed, that emotion will not be fully experienced (VanSwearingen, Cohn, & Bajaj-Luthra, 1999).  In addition to not being able to experience the emotion, another side effect to an inability to smile is that some may experience increased social isolation due to their impaired ability to communicate positive emotion in social contexts (Fridlund, 1991).  In a different study of individuals with depression, researchers discovered a positive correlation between patients with a higher level of EMG activity measurements of the corrugator and zygomatic face muscles and more positive treatment outcomes (Greden, Price, Genero, Feinberg, & Levine).
In studies involving individuals without smile impairment, some research has supported that facial expressions can influence emotions.  In an experiment, participants experienced increased positive moods when they engaged in positive facial expressions and decreased positive moods when they engaged in negative facial expressions (Kleinke, Peterson, & Rutledge, 1998).

Since, according to the facial feedback hypothesis, we are able to deliberately control and change our feelings and emotions, we are also able to control the physiological responses associated with them.  This idea would be quite useful in a clinical setting, and has been employed in many relaxation-based therapeutic practices.  It is suggested that relaxing facial and other muscles may produce a positive experience of relaxation, while reducing muscle tension and negative emotions (Duclos & Laird, 2001).

CONCLUSION

The debate over the facial feedback hypothesis, which was started over 200 years ago, is far from being over.  As with any good scientific method, researchers will continue to try to find supporting evidence as well as contrary evidence regarding how, and if, facial expressions do indeed have an impact on the emotional experience.  Some of the debate regards the inner workings of the brain and how it relays information; others are concerned primarily about the objectivity involved in the collection of data.  No matter which side of the hypothesis you may find yourself, you will find controversy, which is a sign of progress.

**References available upon request**