Friday, September 17, 2010

Bell & McBride - Affect Regulation and Prevention of Risky Behaviors

From last month, a good commentary in JAMA on affect regulation as it relates to public health. The NIH is actually seeking research designs on this topic, so it seems that people are starting to understand more than risky behaviors, including most unhealthy behaviors, are related to an inability to control impulses, to manage anxiety, and so on. For the health community this is a HUGE step in the direction of a more holistic approach to health.

Just in case you are not versed in psychology, here is a definition of affect regulation. This comes from an excellent article by Jaydip Sarkar and Gwen Adshead, "Personality disorders as disorganisation of attachment and affect regulation" (Advances in Psychiatric Treatment (2006) 12: 297-305)
Regulation in any homoeostatic system (including that of affect) means not only initiating a response to a stimulus, but also modulating it appropriately and turning it off when no longer required. Regulation also implies that the response itself is organised and effective. Phillips et al(2003) suggest that affective experience involves:

  1. identification of the emotional significance of a stimulus;
  2. production of an affective state in response;
  3. regulation of the affective state.

Identification of emotional significance
Two areas of the brain – the amygdala and the insula – are involved in the identification of the emotional significance of a stimulus. The amygdala is responsible for modulation of vigilance and attention to emotionally salient information. The insula conveys aversive sensory information to the amygdala, and the two areas act in concert to detect and respond to threatening and aversive stimuli. They can be conceptualised as a defence radar alerting the organism to the presence of threat in its environment and stimulating a fight or flight self-preservative response (see Phillips et al, 2003).

Production of a responding affective state
Sites implicated in triggering the production of affective states in response to a stimulus include the amygdala, insula, parts of the anterior cingulate gyrus, striatum, and orbitofrontal and ventromedial prefrontal cortices.

The amygdala subserves fear-conditioning (Bechara et al, 1995) and autonomic reactions associated with feelings of fear (Gloor, 1992). The insula is implicated in induced sadness, and anticipatory, phobic and traumatic anxiety (Charney & Drevets, 2002). It is also activated during internally generated self-directed disgust, i.e. social emotions such as guilt and shame (Shin et al, 2000). Stimulation of the ventral (affective) division of the anterior cingulate gyrus evokes autonomic and visceromotor changes and spontaneous emotional vocalisations (Bancaud & Talaraich, 1992). The ventral striatum appears to be involved in craving (Breiter et al, 1997), anticipation of reward (Pagnoni et al, 2002) and romantic love (Bartels & Zeki, 2000). The orbitofrontal cortex is associated with autonomic changes accompanying affective states such as anger (Dougherty et al, 1999) and physical aggression (Pietrini et al, 2000). The ventromedial prefrontal cortex is involved in induction of sad mood (Pardo et al, 1993) and guilt and in responding to facial expressions of negative emotions (Sprengelmeyer et al, 1996).

Regulation of the affective state
Affect regulation is largely dependent on the functioning of two neural systems: a ventral and a dorsal system (Phillips et al, 2003).

The ventral system includes the amygdala, insula, ventral striatum and ventral (affective) regions of the anterior cingulate gyrus and prefrontal cortex. It is important for rapid appraisal of emotional material, and automatic affective regulation in response to social interactions, including the capacity for interpersonal empathy.

The dorsal system includes the hippocampus and dorsal (cognitive) regions of the anterior cingulate gyrus and prefrontal cortex. It supports selective and sustained attention, planning and effortful (rather than automatic) regulation of affective states, and autonomic responses to those states. Here affect regulation involves cognitive appraisals: using logic and rational evaluations, based on past experience and anticipated future outcomes.

These contributions of the two systems might be summarised as insight and foresight respectively (Freeman, 1999: p. 124).

Box 2 The neural systems that govern affect regulation

Insight is mediated by the ventral system:

  • amygdala
  • insula
  • ventral striatum
  • ventral (affective) regions of the anterior cingulate gyrus and prefrontal cortex

Foresight is mediated by the dorsal system:

  • hippocampus
  • dorsal (cognitive) regions of the anterior cingulate gyrus and prefrontal cortex
  • So with that definition, here is the JAMA article. They seem to be pointing to the neuroscience of affect dysregulation in terms of how the amygdala can generate feelings (often fear or anger) that cannot be tolerated, which then leads to an attempt to self-regulate or self-medicate through risky behaviors (addictions, over-eating sex, etc.).,204,203,200_PIsitb-sticker-arrow-click,TopRight,35,-76_AA300_SH20_OU01_.jpg
    I highly recommend these two books by Allan Schore - he is the one of the best there is in this field. He's psychoanalytic, but he is an expert in attachment and affect regulation.
    Affect Regulation and Prevention of Risky Behaviors

    Carl C. Bell, MD; Dominica F. McBride, PhD

    JAMA. 2010;304(5):565-566. doi:10.1001/jama.2010.1058

    Affect is the behavioral expression of emotion and affect regulation is a set of processes individuals use to manage emotions and their expression to accomplish goals. However, structures involved in affect regulation are among the last to mature in the developing brain; therefore, many adolescents may not be adequately equipped to regulate their affect. Consequently, adolescents are at increased risk of adverse health outcomes associated with poor affect regulation.

    Embryologically, the central nervous system develops from bottom to top and from inside to out.1 The limbic system, which engages flight, fight, or freeze behaviors and is located deep within the cerebral hemispheres, is the first part of the brain to develop, whereas the prefrontal cortex, which is the seat of affect regulation, judgment, deductive reasoning, and discernment, does not fully develop until approximately 26 years.1 Therefore, youthful brains are underdeveloped with respect to affect regulation. Metaphorically, emotions and their expression are the "gasoline" that propels the lives of adolescents and adults, and judgment steers the vehicle on course and applies the brakes when necessary to maneuver through life. In other words, youth are neurodevelopmentally predisposed to being "all gasoline, no brakes, and no steering wheel."

    Most individuals have experienced emotional upset and engaged in behaviors that could have resulted in premature mortality or morbidity. Engaging in risky behaviors is often motivated by misdirected and mismanaged affect stemming from the limbic system, in essence being the gasoline fueling the behavior. As a car without brakes and steering will inevitably crash, the lack of affective "brakes and steering" often leads to adverse health outcomes, such as psychiatric disorders, addiction, unplanned pregnancies, violence, and sexually transmitted diseases. Throughout human history, adults have continuously struggled with how to provide "brakes and steering" for youth until they can appropriately apply affect regulation themselves.

    Affect regulation may be protective against adverse physical and mental health outcomes.1 One source of affect regulation for adolescents and young adults is the social support of families and communities, which can provide sufficient scaffolding to prevent their limbic systems from being overstimulated and overwhelmed. This social infrastructure protects many youth by providing them with formal and informal social controls that act as "brakes and steering." Social support is important for all adolescents and young adults, regardless of whether their affect regulation has been impaired by exposure to adverse childhood experiences, because all adolescents confront some degree of affect dysregulation.

    However, many youth are exposed to adverse childhood experiences, which can predispose them to poor affect regulation and subsequent sequelae, including psychiatric disorders, substance abuse, and violence. Such childhood adversities stemming from "maladaptive family functioning clusters" (including parental mental illness, substance abuse disorder, and criminality; family violence; physical and sexual abuse; and neglect) may be associated with subsequent mental health disorders, explaining (in a predictive sense) 32.4% of all disorders, 41.2% of disruptive behavior disorders, 32.4% of anxiety disorders, 26.2% of mood disorders, and 21.0% of substance use disorders.2-3

    Strong evidence asserts there are effective prevention interventions to help young children,4 preadolescents,5 and adolescents6 develop necessary social and emotional skills for optimal affect regulation. The following programs are exemplars for providing scaffolding for affect regulation in youth. The Nurse-Family Partnership4 is an effective intervention that targets the mother-infant bond, which directly affects later affect regulation of the offspring. The study by Olds et al4 found that the Nurse-Family Partnership improved pregnancy outcomes, maternal caregiving, and the maternal life course, preventing antisocial behavior. A meta-analysis7 of 60 home visiting programs revealed benefits for children in 3 of 5 areas of children's cognitive and social-emotional functioning compared with controls. Another intervention, the Incredible Years program,5 which included parent, teacher, and social training components, demonstrated positive interactions and communications between parents and children, the value of praise and reward, and the use of time-out (an affect-regulating strategy). These components have been extensively evaluated and found effective in treating children with conduct disorders and preventing aggressive behaviors.5

    The Positive Parenting Program is a multilevel intervention with universal, selective, and indicated components. The intervention has significantly reduced disruptive behavior and emotional problems through targeting parent-child relations.8 The Aban Aya Youth Project6 was a randomized controlled trial designed to prevent risky behaviors of violence, provoking behavior, substance use, school delinquency, and early risky sexual activity. In an effort to decrease impulsivity, this intervention used a "Stop, Think, Act" technique specifically aimed at affect regulation. The program was found to be effective in reducing the rate of increase in negative behaviors between the fifth and eighth grades. In 2 experimental conditions of the study, there was a decrease in violence by 35% and 47%; provoking behavior by 41% and 59%; school delinquency by 31% and 66%; drug use by 32% and 34%; and recent sexual intercourse by 44% and 65%. This research informed the Chicago Public Schools Violence Prevention Initiative that substantially decreased such behaviors in the entire school system.9

    All these prevention interventions work by 2 basic mechanisms. First, they provide caregivers with social and emotional skills to support youth rather than traumatizing them. Second, they provide youth with an environment that cultivates the social and emotional skills necessary for healthy affect regulation. These examples are characteristic of the multitude of efficacious and effective programs described in the 2009 Institute of Medicine prevention report,1 which makes a strong case that intervention strategies can prevent mental and behavioral problems, and thus bolster health and longevity.

    Considering the evidence for the effectiveness of interventions to assist youth with affect regulation, the logical next step is to disseminate these interventions widely. Helping adolescents regulate their affect, and consequently their behavior, is a public health intervention analogous to adding iodine to table salt to prevent hypothyroidism or restricting the diets of individuals who are unable to metabolize phenylalanine. However, in contrast with biomedical technologies such as iodized salt intake and use of restriction diets, which are designed to prevent specific diseases, psychosocial technologies for affect regulation may prevent a wide range of adverse health outcomes, such as mental disorders, substance abuse, and problem behaviors in youth.1 Moreover, as strategies for affect regulation are disseminated, they can potentially break the intergenerational cycle of risky behaviors within families and neighborhoods.

    When it comes to applying public health prevention science to thwart disorders stemming from affect dysregulation, the United States has so far failed to take advantage of its psychosocial technologies. Richmond, who helped Head Start, the preschool readiness program, become a ubiquitous US reality, proposed that in order to institutionalize a program or process, several elements are needed: a strong evidence base that what is being put in place works; a mechanism to adapt, disseminate, and implement the intervention; and political will to do it.10 These elements are as applicable to a strategy for improving affect regulation among adolescents and young adults as they were to the institutionalization of Head Start for preschool children. Evidence for affect regulation programs is available1 and emerging systems for prevention under health care reform could provide the mechanism. What is lacking, thus far, is the political will to implement them.


    Corresponding Author: Carl C. Bell, MD, Community Mental Health Council Inc, 8704 S Constance, Chicago, IL 60617 (

    Financial Disclosures: None reported.

    Author Affiliations: Community Mental Health Council Inc and Institute for Juvenile Research, Department of Psychiatry, University of Illinois (Dr Bell); and Holism, Empowerment, Leadership, and Personhood (HELP) Institute, Huntsville, Alabama (Dr McBride).


    1. National Research Council and Institute of Medicine. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. O’Connell ME, Boat T, Warner KE, eds. Washington, DC: National Academies Press; 2009.
    2. Green JG, McLaughlin KA, Berglund PA; et al. Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: associations with first onset of DSM-IV disorders. Arch Gen Psychiatry. 2010;67(2):113-123. FREE FULL TEXT
    3. McLaughlin KA, Green JG, Gruber MJ, Sampson NA, Zaslavsky AM, Kessler RC. Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication II: associations with persistence of DSM-IV disorders. Arch Gen Psychiatry. 2010;67(2):124-132. FREE FULL TEXT
    4. Olds DL, Sadler L, Kitzman H. Programs for parents of infants and toddlers: recent evidence from randomized trials. J Child Psychol Psychiatry. 2007;48(3/4):355-391. FULL TEXT | WEB OF SCIENCE | PUBMED
    5. Webster-Stratton C, Reid MJ, Hammond M. Treating children with early onset conduct problems: intervention outcomes for parent, child, and teacher training. J Clin Child Adolesc Psychol. 2004;33(1):105-124. FULL TEXT | WEB OF SCIENCE | PUBMED
    6. Flay BR, Graumlich S, Segawa E, Burns JL, Holliday MY, Aban Aya Investigators. Effects of 2 prevention programs on high-risk behaviors among African American youth: a randomized trial. Arch Pediatr Adolesc Med. 2004;158(4):377-384. FREE FULL TEXT
    7. Sweet MA, Appelbaum ML. Is home visiting an effective strategy? a meta-analytic review of home visiting programs for families with young children. Child Dev. 2004;75(5):1435-1456. FULL TEXT | WEB OF SCIENCE | PUBMED
    8. Sanders MR, Ralph A, Sofronoff K; et al. Every family: a population approach to reducing behavioral and emotional problems in children making the transition to school. J Prim Prev. 2008;29(3):197-222. FULL TEXT | PUBMED
    9. Bell CC, Gamm S, Vallas P, Jackson P. Strategies for the prevention of youth violence in Chicago public schools. In: Shafii M, Shafii S, eds. School Violence: Contributing Factors, Management, and Prevention.Washington, DC: American Psychiatric Press; 2001:251-272.
    10. Richmond JR, Fein R. The Health Care Mess: How We Got Into It and What It Will Take to Get Out. Cambridge, MA: Harvard University Press; 2005.

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