Research paperExtreme sensory processing patterns show a complex association with depression, and impulsivity, alexithymia, and hopelessness
Introduction
Major affective disorders are worldwide associated with long-term disability, psychosocial impairment, and poor intervention outcomes including suicidal behavior (Pompili et al., 2011, 2012). The involvement of deficits in emotional processes and sensory processing has been hypothesized in the pathophysiology of major affective disorders (Van Rheenen and Rossell, 2013, Leitman et al., 2010). Sensory processing refers to the ability to register and modulate sensory information and organize this sensory input to respond to situational demands (Humphry, 2002; Miller et al., 2007). Extreme sensory processing patterns include hyper- or hyposensitivity to non-aversive stimuli (Miller et al., 2007).
Existing studies on sensory processing disorders (SPD) generally refer to individuals with hypersensitivity suggesting that they often perceive daily sensory events as noxious (Bundy et al., 2002), or express exaggerated behavioral reactions of "fight or flight" to harmless sensory input (Hanft et al., 2000; Engel-Yeger and Dunn, 2011a, Engel-Yeger and Dunn, 2011b). SPD are supposed to have a genetic basis (Dunn, 1997, Dunn, 2001) as well as developmental origin as they are frequently reported among children with developmental disabilities such as Attention-Deficit/Hyperactivity Disorder (ADHD), learning disabilities and clumsiness (Talay-Ongan and Wood, 2000). SPD are likely to become more apparent in transferring stages (Miller et al., 2007, Miller et al., 2012) and, although they are mostly reported in children, they may persist into adulthood with related social and emotional difficulties (Kinnealey et al., 2011).
In the present study we refer to the model of sensory processing which was suggested by Dunn (1997). This model describes the relationship between the person's neurological thresholds and behavioral self-regulation strategy (Brown et al., 2002, Dunn, 1997). Individuals with hypersensitivity have lower neurological threshold while those with hyposensitivity have higher neurological threshold. However, individuals who utilize a passive behavioral strategy allow stimuli to occur in accordance with their threshold, whereas individuals who use an active behavioral strategy counteract their threshold and control the amount/type of sensory input they receive (Dunn, 1997, Dunn, 2001). Dunn's model yielded four patterns of sensory processing. The first two refer to hyposensitivity: (1) individuals with low registration who fail to detect sensation and do not actively seek for sensory input that are usually depicted as inattentive, withdrawn, and unmotivated; (2) individuals who are sensory seekers and enjoy rich sensory environments/activities. Sensation seekers may show impulsivity, appear as disinhibited, lack future planning, and engage in risk-taking behaviors. The other two patterns refer to a low neurological threshold (hypersensitivity): (3) individuals who are sensory sensitive and feel discomfort with regular sensations but they do not actively limit their exposure to the uncomfortable stimuli; (4) individuals who are sensation avoiders and are usually described as introspective or reclusive since they actively limit exposure to sensory information. When sensory processing does not interfere with daily life activities, it is considered as a part of our unique characteristics, as a trait (Dunn, 2001). However, when sensory processing patterns are extreme and interfere with function and participation in daily life, they may be considered as sensory processing disorders (SPD) (Miller et al., 2007, Dunn, 2001) (see Fig. 1).
Dunn (1997) suggests that there are well established relationships of sensory processing patterns with stable, trait-like or personality variants. Ben-Avi et al. (2012) found that individuals with SPD frequently express lower self-esteem, more social discomfort, more distress and less ego strength. Specifically, “sensory sensitivity”, “sensory avoidance”, and “low registration” traits correlated with elevated anxiety, somatization, distress characteristics, interpersonal difficulties, lack of ego strength, thought distortions and poignancy. The term ‘sensory affective disorder’ has been already used by some researchers several decades ago to refer to sensory defensiveness in children (Wilbarger and Wilbarger, 1991). Extreme sensory processing patterns have been also proposed as a stable dimension which are able to characterize individuals with major affective disorders (Engel-Yeger et al., 2016b, Engel-Yeger et al., 2016a, Serafini et al., 2016). Indeed, subjects with extreme sensory processing patterns frequently presented impairments in modulating emotional/behavioral responses. Fear, anxiety or discomfort may accompany everyday situations that involve sensory stimuli and may disrupt daily routines (Parham and Mailloux, 2001) significantly impairing the daily life functioning and restricting participation in various life situations (Engel-Yeger et al., 2013a, Engel-Yeger et al., 2013b, Engel-Yeger and Ziv-On, 2011, Engel-Yeger, 2008).
According to behavioral and neurophysiological studies, SPD have been associated with emotional and arousal processes (Ben-Avi et al., 2012). Hyposensitivity has been predominantly associated with depression and lower levels of arousal whereas hypersensitivity has been linked with anxiety and higher levels of attention and arousal (Kinnealey and Fuiek, 1999, Pfeiffer et al., 2005). Moreover, based on our recent study (Engel-Yeger et al., 2016b, Engel-Yeger et al., 2016a) the hyposensitive extreme pattern of lower registration was found to be related with enhanced depressed mood whereas the hyposensitive extreme pattern of sensory seeking resulted as a resilient factor. Sensation seeking seems to be also correlated with elevated hyperthymia, which was previously reported as a protective factor against depression and suicidality (Rihmer et al., 2010). Interestingly, hypersensitivity has been associated with abnormal gating together with "over-inclusion" of not relevant stimuli in the focus of attention (Kisley et al., 2001) with subsequent difficulties of habituation (Miller et al., 2012).
Similarly to SPD, impulsivity may be considered as a quite stable behavioral trait in clinical populations although there are few studies investigating the nature of this construct and its association with SPD in patients with major affective disorders. Impulsivity may frequently occur in multiple psychiatric disorders, substance abuse, and suicidal behavior (Moeller et al., 2001). According to various proposed personality models (Lijffijt et al., 2012; Dickman, 2000; Eysenck, 1993; Humphreys and Revelle, 1984), it seems to be related to early sensory processing (Swann et al., 2013). Importantly, subjects with lower impulsivity may have a lower sensitivity to warning signals and are less tolerant to the attenuation of simple behavioral performance (Dickman, 2000, Revelle et al., 1980). Automatic sensory processing investigated using sensory gating may be significantly correlated with behavioral assessments in populations of patients with major affective disorders (Soshi et al., 2015). Disruption of pre-attentional processes may interfere with filtering of inappropriate stimuli and may lead to overstimulation or insufficient modulation of behavioral responses (Freedman et al., 1987). The sensory disturbance may be described as the inability to filter out environmental stimuli with a subsequent impaired ability to focus on attention. In addition, SPD and impulsivity may be associated with other stable factors potentially altering emotional functioning such as alexithymia. Alexithymia is a multifaceted construct including difficulties in identifying feelings and distinguishing between feelings and bodily sensations of emotional arousal, and difficulties in describing feelings to others (Taylor et al., 1997). Alexithymic traits may be conceptualized along a continuum as important deficits in emotional processing (Heaton et al., 2012, Lumley et al., 2007), they may be significantly related to mood states (De Gucht et al., 2004, Parker et al., 2005, Vermeulen et al., 2007), and associated with higher rates of anxiety/depression (Bankier et al., 2001; Berthoz et al., 2002; Honkalampi et al., 2000).
Alexithymia has been associated with an heterogeneous range of sensory modulation related to either hypo- or hypersensitivity. While some studies reported that alexithymic subjects have lower awareness and registration of internal bodily signals as well as reduced multisensory integration (Ernst et al., 2014, Grynberg and Pollatos, 2015), other studies found, hypersensitivity to sensory input such as lower tolerance of pain and heat and over-responsivity to visceral stimulation in alexithymic subjects (Kano et al., 2007, Katz et al., 2009, Nyklicek and Vingerhoets, 2000). Thus, patients with major affective disorders and alexithymic traits may present several emotion processing deficits.
A recent study (Alpaslan, 2015) suggested that the presence of alexithymia is a significant predictor of suicide probability in a large sample (N=381) of females with disordered eating attitudes. According to cognitive assumptions, suicidal behavior has been conceptualized as an exit of hopelessness and despair (Minkoff et al., 1973). Hopelessness indicates a pessimistic cognitive structure for the future and has been identified as a robust and independent predictor of suicidal behavior (Pompili et al., 2011, Pompili et al., 2012). Unfortunately, there are no studies in the current literature investigating the complex relationship between extreme sensory processing patterns/SPD and hopelessness neither studies on the interaction between SPD, impulsivity, alexithymia, and state affect during emotion processing have been conducted yet.
Given this background, the present study aimed to: (1) examine whether significant correlations exist between extreme sensory processing patterns, depression, impulsivity, alexithymia, and hopelessness; (2) based on the correlations between the mentioned variables, explore whether extreme sensory processing patterns might predict depression, alexithymia, impulsivity, and hopelessness; (3) explore the relative contribution of extreme sensory processing patterns, depression, alexithymia, and impulsivity in predicting hopelessness.
First, we hypothesized multiple correlations between extreme sensory processing patterns, depression, impulsivity, and alexithymia. Furthermore, we supposed that SPD expressed in specific extreme sensory processing patterns as mentioned in the Dunn's model may be more common among subjects with higher hopelessness and that, conversely to other sensory profiles, sensory seeking may exert a protective pattern against depression. Moreover, we hypothesized that extreme sensory processing patterns (being not state-related but quite independent of acute mood states across the lifespan) may differentially predict impulsivity, alexithymia, and hopelessness. Finally, we presume, as generally sustained by existing evidence, that depression may significantly contribute to the prediction of hopelessness in the analyzed sample.
Section snippets
Participants and procedure
The sample consisted of 281 currently euthymic affective disorder patients of which 175 diagnosed with unipolar and 106 with bipolar disorder with an age ranging from 18 to 65 years (mean=47.4±12.1). Participants were distributed as follows when admitted: 63.1% of subjects were diagnosed with unipolar major depressive disorder (MDD), 16.2% with bipolar disorder type I (BD-I), and 20.7% type II (BD-II). They were all consecutive outpatients receiving only maintenance treatment that have been
The Adolescent/Adult Sensory Profile (AASP)
The AASP (Brown and Dunn, 2002) is a self-report psychometric tool with 60 items, including questions pertaining to each of the sensory systems. The items are sorted equally into four traits reflecting Dunn's model: Low Registration (e.g., "I miss the street, building or room signs when trying to go somewhere new"), Sensation Seeking (e.g., "I like to go to places that have bright lights and that are colourful"), Sensory Sensitivity (e.g., "I am uncomfortable wearing certain fabrics…") and
Clinical profile of the recruited sample
Table 2 depicts the clinical profile of participants as measured by the ranges, mean, and SD scores regarding depression, impulsivity, alexithymia, and hopelessness. Mean and SD of depression as assessed by BDI-II together with other measures are as follow: BDI-II (22.2±12.7), TAS-20 total scores (60.7±12.9), possible alexithymia (N=63, 22.4%), alexithymia (N=68, 24.2%), BIS total scores (63.8±12.2), BIS attentional (15.4±3.6), BIS motor (21.5±5.6), BIS non-planning (26.8±5.7), BHS total scores
Discussion
This is, to the best of our knowledge, the first study evaluating the association between extreme sensory processing patterns/SPD, impulsivity, depression, alexithymia, and hopelessness. We identified a characteristic pattern of association indicating the involvement of both hypo- and hyper sensitivity that may shed light on the etiological role and mechanisms of these variables in the emergence of affective disorders.
Conclusion
Individuals with major affective disorders may suffer from consistent difficulties in processing sensory input which have been significantly linked with higher depression, impulsivity, alexithymia, and hopelessness. Notably, these preliminary findings need to be further explored in order to develop targeted treatment interventions and improve subjective adaptive strategies together with functional behaviors.
Acknowledgements
Xenia Gonda is recipient of the Janos Bolyai Research Fellowship of the Hungarian Academy of Science.
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