What are they and where are they formed?

E(x)motion indicates a departure from a basic state of calm (Reference FreemanFreeman, 1999: p. 124) (emotions and affects are essentially similar terms and we use them interchangeably in this article). Reference DamasioDamasio (1994) posits that emotions are bodily experiences (somatosensory states) in response to external and internal influences. Several areas of the somatosensory cortex are associated with the recall of emotional experiences, especially the insula, cingulate cortex, hypothalamus and several nuclei of the brain-stem tegmentum (Reference DamasioDamasio, 2003). The bodily states created include autonomic, neuroendocrine and somatomotor responses that are subjectively experienced as feelings and are expressed through a range of somatomotor responses, including facial, gestural, vocal and behavioural reactions. Thus, behaviour is merely one expression of an affective state; individuals also use words (written and spoken) and facial expression to communicate affective states.

What are their functions?

Affects act as a driving force or catalyst to assist humans in pursuit of goal-directed behaviours that help us to find sources of energy, fend off external obnoxious agents, and make and maintain social relationships to support a life-sustaining homoeostasis (Reference PankseppPanksepp, 1998; Reference RoseRose, 1998; Reference DamasioDamasio, 2003). This is achieved by a complex interplay of multiple systems and events within the body that lead to an automated regulation of life. The ‘machinery’ involved includes a number of systems (Box 1), nested within each other, that are ultimately driven by emotions. No one system acts in isolation: simple systems are regulated by more complex ones (Reference DamasioDamasio, 2003). Affect regulation is one aspect of the more complex systems required for optimal homoeostasis. This nested principle, with the emotions governing the motivational machinery of the body, includes, but goes beyond, the reductionist view of affects simply as states elicited by rewards and punishments (Reference RollsRolls, 2000).

Humans are unique among animals in their long period of total dependence on others for survival after birth. Like other non-human primates that live in social groups, people instinctively make and maintain different types of social relationship for survival. These relationships are a function of time, complexity and interpersonal attachments. Interpersonal affective responses need to be both regulated and organised to be effective. In particular, the most favourable management of relationships requires the capacity to regulate negative affects such as anger and anxiety. This is especially true of relationships characterised by discrepancies of power and those that involve dependency and neediness, for example relationships with partners, children, family members and professional carers.

We suggest that the need and the ability to coexist with others in order to survive optimally are fundamental to the development and maintenance of affect regulation. In other words, the affects fine-tune the organism’s struggle for survival, but affect regulation can improve the quality of that survival.

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 Reference Phillips, Drevets and RauchPhillips 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 (Reference Bechara, Tranel and DamasioBechara et al, 1995) and autonomic reactions associated with feelings of fear (Reference Gloor and AggletoGloor, 1992). The insula is implicated in induced sadness, and anticipatory, phobic and traumatic anxiety (Reference Charney, Drevets, Davis, Charney and CoyleCharney & Drevets, 2002). It is also activated during internally generated self-directed disgust, i.e. social emotions such as guilt and shame (Reference Shin, Dougherty and OrrShin et al, 2000). Stimulation of the ventral (affective) division of the anterior cingulate gyrus evokes autonomic and visceromotor changes and spontaneous emotional vocalisations (Reference Bancaud and TalaraichBancaud & Talaraich, 1992). The ventral striatum appears to be involved in craving (Reference Breiter, Gollub and WeiskoffBreiter et al, 1997), anticipation of reward (Reference Pagnoni, Zink and MontaguePagnoni et al, 2002) and romantic love (Reference Bartels and ZekiBartels & Zeki, 2000). The orbitofrontal cortex is associated with autonomic changes accompanying affective states such as anger (Reference Dougherty, Shin and AlpertDougherty et al, 1999) and physical aggression (Reference Pietrini, Guazzelli and BassoPietrini et al, 2000). The ventromedial prefrontal cortex is involved in induction of sad mood (Reference Pardo, Pardo and RaichlePardo et al, 1993) and guilt and in responding to facial expressions of negative emotions (Reference Sprengelmeyer, Young and CalderSprengelmeyer 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 (Reference Phillips, Drevets and RauchPhillips 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 (Reference FreemanFreeman, 1999: p. 124) (Box 2).

Secure attachment

In humans, attachment operates through the interaction of two behavioural systems: caregiving and care-eliciting (Reference George and SolomonGeorge & Solomon, 1996). These foster identification of affects, the response to them and the regulation of the affective system. It is useful to conceptualise the interaction between a caregiver and care-elicitor as one that regulates the experience of emotions through a crescendo–decrescendo process (Reference SchoreSchore, 2002). A distressed infant responds to threats in his (or her) environment by experiencing a high degree of arousal, mediated by the sympathetic division of the autonomic nervous system. This is a catabolic system, making available large amounts of energy to prepare the infant for a self-preservative action repertoire of a fight/flight mode. The infant experiences the peripheral and central effects of noradrenaline (norepinephrine) (e.g. more rapid heart and pulse rate, increased blood pressure, dilated pupils), which are uncomfortable. By soothing the infant, the mother helps in recruiting the infant’s parasympathetic system, which has opposite effects and restores homoeostasis. There is a return to normal rate and rhythm of the autonomic system. The sympathetic system supports an action-consuming state, whereas the parasympathetic system supports a withdrawal–conservation state.

The earliest attachment figure conceivably acts as a primary affect regulator, one that ameliorates and terminates the infant’s distress, augments within reasonable limits its experience of happiness and pleasure, and offers predictable and replicable affect regulation. The basic language of attachment relationships thus consists of episodes of interactive signals produced by the autonomic nervous system in both infant and caregiver. These episodes emerge at about 2 months of age, and they are highly arousing, affect-laden and short interpersonal events that expose the infant to high levels of cognitive and social information (Reference Feldman, Greenbaum and YirmiyaFeldman et al, 1999). As the infant grows, it is the relationship, rather than a particular caregiver, that becomes the (accessory) affect regulator.

A right prefrontal cortex regulation of the autonomic nervous system lies at the heart of the development of affect regulation in an infant. The right hemisphere is also centrally involved in corporeal self-identity and its relation to the environment, distinguishing the self from non-self (Reference DevinskyDevinsky, 2000). Infant–maternal attachment behaviour is almost exclusively body to body, and it is now accepted that the right hemisphere is involved in the social and biological functions of the attachment system in the infant (Reference WangWang, 1997). Furthermore, this hemisphere is crucial in the receptive and expressive empathic processes (Reference Adolphs, Damasio and TranelAdolphs et al, 2000), which are processed unconsciously using extensive reciprocal connections with both the limbic systems.

A good-quality affect regulatory system, based on secure attachment, leads to optimal right hemispheric maturation at a critical period during the first 2–3 years of life (Reference SchoreSchore, 2002). Any experience that disturbs the development of secure attachment at a time of heightened dependence (e.g. abuse, neglect or inconsistent caring) will lead to impaired development of neural pathways that subserve emotional behaviours, such that impaired emotional regulation is likely to persist throughout the individual’s lifetime.

The final task in terms of emotion processing involves the internalisation of affect-regulating capacity. Up to about 5 years of age, children locate both affects and their stimuli outside of the self. Any adverse emotional experience is therefore ascribed to the object (including humans) causing it: an externalisation of affects. Later, children locate emotions internally and still later they can identify mixed and conflicting emotions (Reference Levine, Marziali and HoodLevine et al, 1997). Thus, emotion is initially perceived as being caused, and is in reality regulated, by others, but over the course of early development it becomes increasingly self-regulated as a result of neurophysiological development (Reference Thompson and DienstbierThompson, 1990: p. 371).

Insecure attachment

The successful outcome of secure attachment is the development of the basic machinery to self-regulate affects later in life (Reference Fonagy, Gergely and JuristFonagy et al, 2002). Insecure attachment prevents the development of a proper affect regulatory capacity. The individual is left with either an inability to balance sympathetic hyperarousal in response to threat, or the production of an untimely or inadequate parasympathetic response. Dysregulation of this nature leads to prolonged persistence of a catabolic state of fight/flight hyperarousal, or a sudden and inappropriate shift into an anabolic withdrawal–conservation state of ‘freezing’. The latter occurs when a situation is perceived to be hopeless and one’s own agency inadequate, leading to inhibition and avoidance in order to become ‘unseen’ (a state of dissociation) as a defensive strategy of last resort (see Reference SchoreSchore, 2002). Alternatively, there could be rapid cycling between states of hyperarousal and withdrawal, resulting in gross disorganisation of both affects and associated behaviours.

Regulation of negative affect

The problem is not that people with personality disorders are ‘affectless’ but that they have too much or too little affect, depending on the perceived social stimulation, i.e. the affective system is dysregulated and the responses disorganised. Affective dysregulation also implies an unpredictability that goes beyond either an excessive or diminished response.

Heightened perception of threat seems to be a major problem for people with personality disorders, one that emphasises a lack of safety with and an essential untrustworthiness of others. This is compounded by an inability to repair the emotional states stimulated by threat or fear. They seem to lack the capacity to soothe themselves after fearful experiences (Reference Van der Kolk and Fislervan der Kolk & Fisler, 1994), becoming and remaining hyper-aroused in an uncontrollable, dysregulated manner. Their difficulty in providing an internal discourse for themselves to manage negative affects leads to the expectation or requirement of an external solution when they feel bad – preferably from another person whom they identify as having a caring role.

In people with personality disorders there appears to be a deficit, if not an absence, of the shift in locus from external to internal affect regulation. They appear to continue to believe that emotions are almost always an outcome of external developments caused by other people. This is a problem of excessive externalisation of experience of negative affects, a task that should have been resolved around 5 years of age. Such responses are therefore age inappropriate and immature.

Regulation and specific personality disorders

Both ICD–10 (World Health Organization, 1992) and DSM–IV (American Psychiatric Association, 1994) implicitly endorse, without prioritisation, the characteristic disturbances in affect regulation found in most personality disorders and all personality clusters (Reference Geiger, Crick, Ingram and PriceGeiger & Crick, 2001) (Box 3).

Substance misuse

Substance misuse is a common feature of personality disorders. It is likely that the pathways that mediate the hedonic properties of psychostimulants evolved as neural systems for social attachment. There is evidence that brain activation patterns in adults responding to attachment figures (partners or children) are similar to neural responses to cocaine-induced euphoria (Reference Bartels and ZekiBartels & Zeki, 2000). The brain structures involved include bilateral activation in the anterior cingulate gyrus, medial insula and ventral striatum. These findings suggest that the high rates of substance misuse by people with personality disorders may therefore lie, in part at least, in their dysfunctional or absent social attachments. Substance use (and misuse) acts as a social ‘integrator’, both externally with peers and internally through the induction of a pleasurable state. This state replaces the very basic human quality of gregariousness. Furthermore, substances are used as external regulators of negative affects because the individual perceives these affects to be externally, not internally, caused.

Violence

Some personality disorders are associated with high rates of violence and rule-breaking. Reference BlairBlair (2001) suggests that violence can take one of two forms: reactive violence, which is elicited in response to frustration or threat, and instrumental violence, which is goal-directed, purposeful and apparently unprovoked.

Reactive violence has been conceptualised as a response to perceived threat, mediated by the hypothalamus–periacqueductal grey matter system. The amygdala feeds information into the periacqueductal grey matter system on the current state of threat, thus determining whether the response is fight or flight. The orbitofrontal cortex has extensive projections to autonomic control centres in the medial hypothalamus and periacqueductal grey matter, and it is damage specifically to this part of the frontal lobe that leads to greatest risk of reactive violence (Reference Grafman, Schwab and WardenGrafman et al, 1996). Thus, reactive violence is a consequence of inadequate regulation of threat-based affects, largely by the dorsal prefrontal cortex.

Instrumental violence is a function of cruelty and lack of empathy (Reference Hare, Hart and HarpurHare et al, 1991), which in turn has been linked to muted autonomic responses to sad and fearful facial expressions. In this type of violence, it has been speculated that the affect regulating system of the prefrontal cortex remains intact, but there is a fundamental problem within the amygdala, the area concerned with properly identifying fearful and sad emotions (Reference BlairBlair, 2001). Other studies have implicated bilateral frontotemporal-based cognitive strategies for processing affective material (Reference Blair, Jones and ClarkBlair et al, 1997), and disturbed functional connectivity of brain areas related to emotion processing (Reference Müller, Sommer and WagnerMüller et al, 2003). Clearly, the final word has not been said on this issue.