An Examination of Visual Avoidance as an Emotion Regulation Strategy in Neurodegenerative Disease

Author(s): Otero, Marcela Cristina | Advisor(s): Levenson, Robert W | Abstract: Visual avoidance (VA) is the strategic positioning of the head and body to limit exposure to aversive stimuli in the environment. Despite VA being a basic behavioral response to aversive emotional stimuli and ubiquitous in everyday life, little is known about how it may function as a strategy for regulating emotion. Prior research finds VA deficits in behavioral variant frontotemporal dementia (bvFTD), a neurodegenerative disease characterized by progressive and marked changes in behavior and emotional responses. Clinically, deficits in VA among patients with bvFTD and Alzheimer’s disease (AD) have been tied to worse mental health in familial caregivers. Understanding VA in the context of neurodegenerative disease may help elucidate how VA relates to emotional responding, cognitive functioning, and how VA might uniquely contribute to caregiver wellbeing. The current study aimed to examine VA in neurologically intact individuals and patients with neurodegenerative disease. Specifically, objective behavioral coding of VA was used to examine how participant VA while watching a disgusting film clip (i.e., disgust reactivity task) related to indices of emotional responding (i.e., peripheral physiology and emotional facial behavior) during the task, emotion regulation on laboratory-based measures and in the home, and measures of neuropsychological functioning given VA’s possible reliance on cognitive processes to monitor and attend to emotional stimuli and re-orient visual attention. Given that deficits in emotional functioning have been tied with lower levels of caregiver mental health, the present study also examined whether patient VA impacted caregiver mental health (overall psychological distress, anxiety, and depression) independently from another domain of emotional functioning affected in neurodegenerative disease- the ability to recognize other’s emotion accurately (i.e., emotion recognition). The sample consisted of 67 patients with bvFTD, 67 patients with AD, 35 neurologically healthy control participants, and their spousal caregivers. 7 VA behaviors were coded for intensity and frequency while participants viewed a disgusting film clip, including head movements up, down, and to the side, gaze aversion, headshakes, blinks, and eye closures. Laboratory-based measures of emotion regulation included instructed and spontaneous suppression of emotional behavior following an acoustic startle, and instructed suppression of disgust behavior while watching a disgusting film clip. Domains of neuropsychological functioning assessed included cognitive flexibility, working memory, set-shifting, and response inhibition. Results indicated that greater increases in skin conductance prior to the onset of VA predicted greater overall VA across the disgust reactivity task. Additionally, greater cognitive flexibility predicted greater overall VA behavior. Both findings were moderated by diagnosis, such that greater increase in skin conductance prior to the onset of VA and greater cognitive flexibility predicted greater VA in controls, but not in either patient group. Lastly, patient deficits in VA significantly predicted greater caregiver depression independently from patient deficits in emotion recognition. Current findings extend our basic knowledge of VA by providing evidence for the context in which VA occurs (i.e., increasing sympathetic nervous system activation), suggesting that VA may represent the intent to down-regulate negative emotion via behavioral responding. Furthermore, cognitive flexibility may support VA by enabling the monitoring and updating of ongoing behavioral responses and flexible implementation of new regulatory strategies. Importantly, the current findings have clinical implications for dementia caregivers and patients. Examining VA deficits in patients with bvFTD and AD may help identify caregivers who are at-risk for depression, allowing for earlier psychosocial intervention and prevention of mental illness in dementia caregivers.