ArticlePDF AvailableLiterature Review

Image and Emotion: From Outcomes to Brain Behavior

Authors:
  • Center for Health Design


Abstract and Figures

Aim: A systematic review of neuroscience articles on the emotional states of fear, anxiety, and pain to understand how emotional response is linked to the visual characteristics of an image at the level of brain behavior. Background: A number of outcome studies link exposure to visual images (with nature content) to improvements in stress, anxiety, and pain perception. However, an understanding of the underlying perceptual mechanisms has been lacking. In this article, neuroscience studies that use visual images to induce fear, anxiety, or pain are reviewed to gain an understanding of how the brain processes visual images in this context and to explore whether this processing can be linked to specific visual characteristics. Conclusions: The amygdala was identified as one of the key regions of the brain involved in the processing of fear, anxiety, and pain (induced by visual images). Other key areas included the thalamus, insula, and hippocampus. Characteristics of visual images such as the emotional dimension (valence/arousal), subject matter (familiarity, ambiguity, novelty, realism, and facial expressions), and form (sharp and curved contours) were identified as key factors influencing emotional processing. The broad structural properties of an image and overall content were found to have a more pivotal role in the emotional response than the specific details of an image. Insights on specific visual properties were translated to recommendations for what should be incorporated-and avoided-in healthcare environments.
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Image and Emotion: From Outcomes to
Brain Behavior
Upali Nanda, PhD, Assoc. AIA, EDAC; Xi Zhu, PhD; and Ben H. Jansen, PhD
Abstract
Aim: A systematic review of neuroscience articles on the emo-
tional states of fear, anxiety, and pain to understand how emotional
response is linked to the visual characteristics of an image at the
level of brain behavior.
Background: A number of outcome studies link exposure to visual
images (with nature content) to improvements in stress, anxiety,
and pain perception. However, an understanding of the underlying
perceptual mechanisms has been lacking. In this article, neurosci-
ence studies that use visual images to induce fear, anxiety, or pain
are reviewed to gain an understanding of how the brain processes
visual images in this context and to explore whether this process-
ing can be linked to specic visual characteristics.
Conclusions: The amygdala was identied as one of the key
regions of the brain involved in the processing of fear, anxiety, and
pain (induced by visual images). Other key areas included the thal-
amus, insula, and hippocampus. Characteristics of visual images
such as the emotional dimension (valence/arousal), subject matter
(familiarity, ambiguity, novelty, realism, and facial expressions), and
form (sharp and curved contours) were identied as key factors
Author Afliations: Dr. Nanda is a Research Consultant for The Center for
Health Design and serves as Chair for the Advisory Council of the RED Center
at American Art Resources (AAR) in Houston, TX. At the time of submission,
Dr. Nanda was Vice President, Director of Research at AAR. The project was
completed by the research team at AAR in collaboration with the University
of Houston. Dr. Zhu is a recent graduate of the Department of Electrical and
Computer Engineering at the University of Houston. Dr. Jansen is a professor
in the Departments of Electrical and Computer Engineering, and Biomedical
Engineering at the University of Houston.
Corresponding Author: Dr. Upali Nanda, 3260 Sul Ross, Houston, TX 77098
(upali.nanda@gmail.com)
Preferred Citation: Nanda, U., Zhu, X., & Jansen, B. H. (2012). Image and
emotion: From outcomes to brain behavior. Health Environments Research &
Design Journal, 5(4), 40–59.
Acknowledgments: The review of the literature was funded by a grant from
The Center for Health Design. We would like to thank the Center for its support.
We would also like to thank Kathy Hathorn and Robyn Bajema of American Art
Resources for their help on this project.
Background: Impact of Visual Images
on Health
A compelling body of evidence in place today ar-
gues for the role of nature images in visual art to im-
prove the patient experience of healthcare through
reduced stress, anxiety, and pain perception, and
improved perception of quality of care (Hathorn &
Nanda, 2008; Nanda, 2011; Ulrich, 2009).
A signicant amount of evidence on the impact
of visual images (through dierent media) has
focused on stress reduction from viewing nature
images (Coss, 1990; Parsons, Tassinary, Ulrich,
Hebl, & Grossman-Alexander, 1998; Ulrich,
1991; Ulrich, Lunden, & Eltinge, 1993). Stress
has a strong physiological component and is
manifested in increased heart rate, blood pres-
sure, and skin conductance (Ulrich, 1992). Re-
search shows that even short-term visual contact
with nature can be restorative.
inuencing emotional processing. The broad structural properties
of an image and overall content were found to have a more
pivotal role in the emotional response than the specic details of
an image. Insights on specic visual properties were translated
to recommendations for what should be incorporated—and
avoided—in healthcare environments.
Key Words: Visual image, healthcare art, emotion, neurosci-
ence, health
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According to Korpela, Klemettila, and Hietanen
(2002), positive changes in physiological activity
that occur within 4 to 40 minutes are called res-
toration, and the environments that induce these
changes are called restorative environments. For
example, physiological data collected by measur-
ing skin conductance, muscle tension, and pulse
transit time from subjects who watched photo-
graphic simulations of natural settings showed
faster recovery than subjects who viewed simu-
lated urban settings (Ulrich et al., 1991). ere
were similar ndings for heart rate measurements
collected in a dental clinic; patients experienced
lower stress on days that a large mural depicting
a natural scene was hung on the waiting room
wall versus days when the wall was left blank
(Heerwagen, 1990). In another study, patients
on gurneys viewing ceiling-mounted scenes of
nature and/or water had systolic blood pressure
levels 10 to15 points lower than patients exposed
to either aesthetically pleasing “arousing” pictures
or a control condition of no picture (Coss, 1990).
Many of the studies investigating the impact of
positive distractions on health outcomes have ad-
dressed short-term exposure to visual images in
simulated experiments (such as Tse, Ng, Chung,
& Wong, 2002; Ulrich, 1991; Vincent, Battisto,
Grimes, & McCubbin, 2010). Whereas the stud-
ies in real-life settings are typically in high-stress
areas such as before, during, or after a painful
or stressful procedure (e.g., Coss, 1990; Diette,
Lechtzin, Haponik, Devrotes, & Rubin, 2003;
Ulrich et al., 1993). All of these studies suggest
that the response to images can be quick, but few
theories explain this rapid response. In the fol-
lowing section, some of the prominent theories
within the environmental psychology literature
that could explain this response are discussed.
Visual Properties and Underlying
Theories
Ulrich (2009) shares two theories supporting
the impact of nonthreatening nature scenes on
improved physiological and psychological out-
comes. e rst is the evolutionary theory or bio-
philia theory, which holds that millions of years of
evolution have left humans genetically prone to
respond positively to nature settings that fostered
well-being and survival for early humans. As out-
lined in Appletons (1975) evolutionary theory,
specic attributes of landscapes that dictate aes-
thetic preference concern prospect (opportunity/
vantage point) and refuge (safety/shelter)—both
essential for survival. e second theory Ulrich
identies is the emotional congruence theory, the
A precognitive, rapid
assessment of the
environment based on certain
gross elements of an image is
at the core of human survivial,
with some properties of visual
images eliciting an affective
response even when they are
insufcient for basic cognitive
judgments like recognition.
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notion that emotional states bias human percep-
tion of environmental stimuli in ways that are
congruent or match feelings (Ulrich, 2009).
Zajonc (1980) argued that a precognitive, rapid
assessment of the environment based on certain
gross elements of an image is at the core of hu-
man survival, with some properties of visual im-
ages eliciting an aective response even when
they are insucient for basic cognitive judg-
ments like recognition. is led Ulrich (1983) to
outline a psychoevolutionary framework that ar-
gues that aect precedes cognition (and therefore
aesthetic preference). Based on Zajonc’s work,
Ulrich proposed a theory of preferenda, outlining
gross visual properties that could elicit an aec-
tive response, including (1) gross congurational
or structural aspects of settings; (2) gross depth
properties that require little inference; and (3)
general classes of environmental content (e.g.,
water, vegetation, and mountains). Specic prop-
erties outlined by Ulrich based on preference
studies include focality(degreeto which ascene
contains an area that attracts the observer’sat-
tention), depth of eld, ground surface texture
(ground surfaces in the natural environment
andthedierenttextures, patterns, andelements
that help discern depthinascene), deected vis-
tas (whenalineof sight is deected or curved,
which implies that new landscape informa-
tionisjustbeyondthevisual bounds), and lack of
threat and tension.
Parsons (1991) proposed that any encounter with
an environment engages two aective analyses.
e rst is immediate and subcortical, based on
simple stimulus information that is presented to
hard-wired environmental feature detectors and
mediated by the amygdala. e second is more
deliberate, involves neocortical processing and
the comparison of incoming information with
stored information (possibly including the com-
munication of the comparison outcome to the
amygdala for evaluation), and is mediated by the
hippocampus. Parsons’ work is one of the earli-
est to address the need to understand aective
responses to environmental stimuli at the level of
brain behavior.
Although various studies have established a corre-
lation between viewing images and experiencing
an emotional or physiological state, it is unclear
what perceptual mechanisms explain the varied
responses to an image. Little is known about
which specic properties of an image evoke spe-
cic emotional responses. is paper conducts a
systematic literature review to help answer some
of these questions from a design practitioner’s
perspective by tapping into the most fundamen-
tal measure of human perception: brain behavior.
Scope of Review
According to the Society for Neuroscience
(2011), neuroscience is the study of the nervous
system including the brain, spinal cord, and net-
works of neurons throughout the body. e cen-
tral nervous system is made up of the brain and
the spinal cord. A branch of neuroscience known
as cognitive neuroscience studies functions such as
perception and memory in animals and humans.
In humans, noninvasive brain scan techniques are
used to understand the route of neural process-
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ing. ese include fMRI (functional magnetic
resonance imaging to measure neural activity by
changes in the blood-oxygen-level-dependence
[BOLD] signal), EEG (electroencephalography:
a measure of the electrical activity generated by
the brain) or MEG (magnetoencephalography: a
measure of the magnetic elds produced by elec-
trical activity in the brain), and PET (positron
emission tomography). Of these technologies,
fMRI provides high-spatial-resolution images of
brain activation as good as 1 mm without the bias
toward the cortical surface of EEG or MEG, and
with a much better time resolution than other
techniques such as PET.
In this study the authors focused on the fMRI
studies to gain an understanding of the “neural
address” of specic emotional responses via a sys-
tematic review of the neuroscience literature link-
ing emotional response and visual properties. In
a typical fMRI, experiment subjects are asked to
lie still in the scanner and their heads are usually
restrained with soft pads to prevent movement.
During this time, visual stimuli are delivered to
the subjects by using a mirror, and brain activ-
ity is monitored. e setup required for an fMRI
study limits its application in real-life situations,
such as in hospital ICUs or waiting rooms. All
studies reviewed were conducted in lab settings,
using visual images to induce emotional states.
According to the American Psychological Associ-
ation, emotion is “a complex pattern of changes,
including physiological arousal, feelings, cogni-
tive processes, and behavioral reactions, made in
response to a situation perceived to be personally
signicant” (Frijda, 2000, p. 208). Emotion is a
complex subject dened by numerous theoreti-
cal constructs. What comes rst—the thought,
behavior, or physiological arousal associated with
emotion—remains unclear, and dierent theories
oer dierent frameworks to explain the cause
and eect.
One prominent theory is the James-Lang theory,
which proposes that an event causes physiological
arousal rst and then this arousal is interpreted
(Lange & James, 1922). Only after the arousal
is interpreted is emotion experienced. In anoth-
er theory, by contrast, Lazarus (1982) proposes
that a thought must come before any emotion or
physiological arousal. e causality of emotion is
beyond the scope of this review. Because it is such
a huge topic, to limit the scope the authors fo-
cused on feelings directly relevant to the patient
experience in the hospital. According to Gordon,
Sheppard, and Anaf (2010), it is common to
“feel” fear, anxiety, and pain in a hospital setting.
Although these emotions are certainly not an ex-
haustive list of what a patient can experience in a
healthcare setting, they helped create a road map
for how to navigate the neuroscience literature.
Accordingly, key word searches using emotional
state (fear/pain/anxiety), fMRI, and visual were
conducted in PubMed (an online database for
biomedical literature). Initial responses revealed
that although hundreds of articles used visual
stimuli to study brain responses to emotional
states or the neural underpinnings of dierent
emotional states, very few of them addressed spe-
cic properties of the image that could explain
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the results. is review concentrated on the stud-
ies that clearly identied the properties of the vi-
sual stimuli. Overview articles on emotional pro-
cessing, visual processing, and specic emotional
states were used to establish the context.
Before the literature review, specic inclusion and
exclusion criteria were identied. Inclusion crite-
ria were (1) published, full-text, English-language
journal articles; (2) for experiments, visual stim-
uli; and (3) for review articles, relevance to visual
stimuli or overall emotional context
and papers published after 2001.
Exclusion criteria included (1) stud-
ies involving patients with specic
neurological disorders and/or le-
sions and/or other damage to the
brain; (2) studies involving patients
diagnosed with specic psychologi-
cal disorders (e.g., for fear studies,
with phobia; for anxiety, studies of
post-traumatic sress disorder); (3)
studies with pediatric or geriatric
populations; and (4) studies that
tested the roles of certain chemical
substances.
After an initial screening using in-
clusion and exclusion criteria, ar-
ticles were reviewed in terms of
study purpose. e focus of this
review was to match brain response
to the visual properties of stimuli as
they pertained to specic emotional
states, and to provide an adequate
context for the response. e ab-
stract and methodology of each article were then
reviewed to evaluate whether a clear link had
been made between the visual property and the
emotion measured by brain response. e refer-
ence list from each of these articles was reviewed
to identify other articles of potential interest. e
same inclusion and exclusion criteria, along with
screening toward the purpose of the study, were
used. Twenty-three articles were identied, which
included experiments, meta-analyses, and review
articles. Table 1 lists the short-listed articles iden-
Article Type of Study Emotion Visual Stimuli; Visual
Property
No. Reference Experiment Review Fear Anxiety Pain
1 Irwin et al., 1996 X X Facial expressions and
scenes; valence
2 Whalen et al., 1998 X X Facial expression; valence
3 Whalen, 1998 X X N/A
4 Whalen et al., 2001 X X Facial expression;
valence
5 Phan et al. , 2002 X X N/A
6 Glascher & Adolphs,
2003 X X
Scenes, animals, people,
objects;
arousal
6 Vuilleumier et al.,
2003 X X Facial expression;
spatial frequency
7 Simm ons et al.,
2004 X X X X Aver sive images;
valence
8 Ongur et al., 2005 X Pentagon or ellipsoid
shapes; novelty
9 Sengupta & Kumar,
2005 X X N/A
10 Britton et al., 2006 X X
Facial expressions,
evocative scenes; valence,
arousal
11 Nitschke et al., 2006 X X X X Aversive images;
valence
12 Gu & Han, 2007 X X Pictures or cartoons of
hands; reality
13 Bar & Neta, 2007 X X O bjects, patterns; contour,
spatial frequency
14 Cheng, 2007 X X Painful events; N/A
15 Ogino et al., 2007 X X X Painful events; N/A
16 Saarela et al., 2007 X X Faces of chronic pain
patients; N/A
17 Anders et al ., 2008 X X
Humans or animals
pictures;
valence, arousal
18 Chiao et al., 2008 X X Facial expressions;
valence
19 Kober, 2008 X X N/A
20 Onoda et al., 2008 X X Positive and negative
pictures; valence
21 Roy et al., 2009 X X Positive and negative
pictures; valence
22 Weierich et al.,
2010 X
Pictures with different
arousal and valence;
novelty
Table 1. Overview of Articles Reviewed
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tied, along with the type of study, specic emo-
tions involved, and visual stimuli used.
The Neural Underpinnings of
Emotional Processing
A key article identied early in the literature
review was a comprehensive meta-analysis of
studies on the functional neuroanatomy of
emotion. Phan, Wager, Taylor, and Liberzon
(2002) reviewed 43 PET and 12 fMRI studies
spanning 1993 to 2000 to determine whether
common or segregated patterns of activation
existed across various emotional tasks. e au-
thors analyzed activation results from the short-
listed studies and grouped them as follows: (1)
regions associated with individual
emotions (fear, sadness, disgust, an-
ger, and happiness); (2) regions as-
sociated with the induction method,
which refers to the kind of stimuli
used to induce the emotion includ-
ing visual, auditory, autobiographi-
cal recall/imagery; and (3) regions
associated with the presence and ab-
sence of cognitive demand. en the
authors grouped together conditions
in which the emotional task had
no explicitly cognitive component
(such as passive listening or viewing)
to isolate the impact of the cognitive
component on emotional tasks.
To bring the various studies to a com-
mon platform, the authors divided the
brain into 20 overlapping regions and
characterized each region by its respon-
siveness across the preceding categories.
A key nding of this important study was that
no specic brain region is consistently activated
across individual emotions and induction meth-
ods. However, it was determined that the medial
prefrontal cortex (the anterior part of the frontal
lobe [see Figure 1]), known to interface between
cognitive and emotional systems, was commonly
activated across emotional tasks. is is supported
by another meta-analysis of neuroimaging stud-
ies on emotional processing (Kober, 2008). Phan
et al. (2002) also found that fear induction had
a strong association with the amygdala (which is
widely supported in the literature and is discussed
further in the following sections).
Figure 1: Anatomy of the brain. LEFT: A side view of the outside
of the brain, showing the major lobes and brain stem structures.
RIGHT: A side view showing the location of the limbic system
inside the brain. The insula is not visible in this figure; it is located
in the cerebral cortex, folded deep between the temporal and
frontal lobes. See Table 2 for descriptions of the amygdala, insula,
thalamus, and hippocampus. A full description of brain areas is
available at http://www.ahaf.org/alzheimers/about/understanding/
anatomy-of-the-brain.html
Source: The medical illustration is provided courtesy of Alzheimer’s Disease Research, a
program of the American Health Assistance Foundation. © 2011.
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Relevant to this study, the authors found that
emotionally evocative visual stimuli activated
parts of the occipital/visual cortex. In itself this
is not surprising because visual stimuli should
trigger a response in the visual processing center
of the brain, but the studies evaluated controlled
for simple sensory processing. e authors con-
cluded that the modulation of the occipital/visual
cortex might be driven by (a) the processing of
emotionally loaded content, or (b) an interac-
tion between visual perception and emotional
processing. Phan et al. (2002) explain this ana-
tomically by pointing out that projections from
limbic regions like the amygdala extend to all the
processing steps in the visual system, including
the visual cortex. In a way, the limbic regions act
as a relay center for the emotional salience of vi-
sual information (see Figure 1).
Fear and Anxiety
e amygdala is part of the limbic system, which
receives information from all sensory modali-
ties and is also connected to various cortical and
lower-brain centers, including the insula, which
enables it to cause rapid changes in the brain and
regulate physiological responses such as heart rate
or blood pressure (Davidson & Irwin, 1999).
ese physiological responses are typical of the
“stress response” that has been discussed in the
background section, which is used as a metric to
determine the ecacy of viewing visual images. A
key role of the amygdala is the processing of fear
(Irwin et al., 1996; Whalen et al., 1998; Whalen
et al., 2001).
According to Fellous, Armony, and LeDoux (2002)
fearful stimuli (learned or innate) can be processed
through two main routes: the fast route and the slow
route. e fast route involves the thalamo-amygdala
pathway, which responds best to simple stimulus
features (such as a tone); the slow route involves the
thalamo-cortical-amygdala pathway, which carries
more complex features (such as context). Both pro-
cesses occur simultaneously. Response to fear can
also be thought of in terms of expression and experi-
ence. e expression of fear as emotion is manifest-
ed in physiological responses such as blood pressure,
freezing, and hormonal change, and it is mediated
by the outputs of the amygdala to lower-brain cen-
ters (insula, hypothalamus), whereas the experience
of fear is a feeling, a conscious higher-level recogni-
tion of being scared, involving the frontal and sen-
sory cortices (Nanda, Pati, & McCurry, 2009).
A key insight into the mechanism of fear comes
from how it is connected to previous memories
of stressful experiences. According to Sapolsky
(2003), severe stress can harm the hippocampus,
preventing the consolidation of a conscious, ex-
plicit memory of an event. At the same time,
the implicit memory machinery of the amyg-
dala could be enhanced. In subsequent events,
the amygdala may respond to preconscious in-
formation, but conscious awareness or memory
may not follow, resulting in the experience of
a free-oating anxiety. For example, a specic
image or a particular tone of voice might cause
anxiety (because of a prior stressful or harmful
event), but people cannot “place” it and do not
remember why.
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Similarly, elements of the healthcare environment
associated with stress on one occasion are likely
to trigger the same response preconsciously dur-
ing a later visit. In healthcare settings, fear and
anxiety are common among patients and caregiv-
ers. Anxiety may be the more prevalent emotion,
driven by the anticipation of painful procedures
or serious diagnoses. e link between fear and
anxiety is critical to understanding the impact of
visual images. In a hospital setting where patients
must come back, a stressful setting could initiate
a chain reaction of fear and anxiety responses that
can compound this response on subsequent visits.
Anticipation
Anticipation is a critical component of aective
processing in general and of anxiety in particu-
lar. Researchers suggest that the anticipation of
emotional events is critical for individual survival
and cognitive control of emotions (Herwig et
al., 2007). Nitschke, Sarinopoulos, Mackiewicz,
Schaefer, and Davidson (2006) found that several
key regions of the brain, including the amygdala
and the hippocampus, become activated when a
subject is anticipating aversive photographs like
mutilated bodies or attack scenes. ey propose
that the amygdala is associated with the forma-
tion of emotional memories, whereas the hippo-
campus helps the brain form long-term recollec-
tions. ey indicated that the anticipation of a
dicult situation probably starts up an “arousal
or fear circuitry” in the brain, which in turn helps
to reinforce old memories (Nitschke et al., 2006).
Visual stimuli can trigger this emotional re-
sponse. Onoda et al. (2008) suggest that a neural
network including the anterior cingulate cortex
(ACC), prefrontal cortex, insula, and amygdala
is involved in the anticipation of negative images.
e authors indicated that the anterior brain re-
gions of the network might provide top-down
modulation to perceptual processing areas during
certain negative anticipation.
In another fMRI study, Simmons, Matthews,
Stein, and Paulus (2004) found that a network
including the anterior insula and parahippocam-
pal cortex was activated when anticipating aver-
sive emotional stimuli like photographs of spiders
and snakes. e anterior insula has been shown
to play an important role in the anticipation of
physical pain (Ploghaus et al., 1999). us, their
study provides evidence that anticipation of emo-
tionally aversive stimuli involves brain structures
that are involved in the anticipation of physically
painful stimuli. In fact, it makes the case that
looking at something that we nd emotionally
aversive can be perceptually comparable to physi-
cal pain.
Pain
Pain is distinct from fear and anxiety in that it is a
sensation with a strong subjective and emotional
component (Fields, 1999; Ogino et al., 2007). In
a review of the emerging evidence from neuropsy-
chological and empirical studies, Sengupta and
Kumar (2005) provide a comprehensive insight
into the neuroanatomic basis of the perception
of pain. Pain can act as a stressor, which aects a
patient’s emotional state. Conversely, a patient’s
emotional state can inuence the perception of
pain. Roy, Piche, Chen, Peretz, and Rainville
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(2009) found that study participants subjected
to electric shocks reported stronger pain while
viewing unpleasant pictures than while looking
at pleasant pictures.
In another imaging study using photographs of
faces in pain, researchers found that subjective
pain ratings and pain-related activation of the
ACC were higher in the sad emotional context
compared to happy and neutral contexts (Yoshi-
no et al., 2010).
Empathy plays a key role in pain perception. A
study using photographs of faces in pain showed
that viewing pictures of others in pain triggers a
“mirroring system,” with a remarkable overlap
between areas of the brain activated when a sub-
ject undergoes painful sensory stimulation and
when he or she observes others in pain (Saarela et
al., 2007). In a study comparing responses to im-
ages of painful events with images evoking emo-
tions of fear and rest, Ogino et al. (2007) identi-
ed an overlap between the regions activated for
pain and fear (e ACC and the amygdala). As
discussed previously, the ACC has a role in an-
ticipation, which links it to anxiety. Interestingly,
research shows that stress and anxiety cause a re-
lease of adrenaline, which can lead to increased
muscle contraction and that could be the source
of pain (Atkinson & Hilgard, 2000). e recipro-
cal relationship between fear, anxiety, and pain is
an important insight in the context of healthcare.
In the next section the connection between spe-
cic components of the visual image and the
neural response that denes emotional process-
ing, based on the literature that was identied in
this review, are discussed. Please see Table 2 for a
description of the key brain areas identied and
Figure 1 for the illustration.
Image Content and Neural Response
Emotional Dimensions of Valence
and Arousal
Components of the visual stimuli used were care-
fully identied and classied during the literature
Brain Area Role
Amygdala An almond-shaped cluster located in the medial temporal lobe. Critical to
fear-related emotional processing or stimulus salience.
Insula Located in the cerebral cortex between the temporal and frontal lobes.
Regulates physiological responses such as heart rate and blood pressure and
produces an emotional context for convergent (sensory) information. Also
plays a role in the experience of pain and the emotions of anger, fear,
disgust, and happiness.
Thalamus
Located between the cerebral cortex and the midbrain. Acts as a relay
between the subcortical areas and the cerebral cortex.
Hippocampus Located in the medial temporal lobe. Stores and retrieves conscious
memories; processes sets of stimuli to establish context.
Table 2. Key Brain Areas Identified in the Emotional Processing of Visual Stimuli
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review. A key discovery during the review was
the availability of a database of images called the
International Aective Picture System (IAPS)
(Lang, Bradley, & Cuthbert, 2008), which pro-
vides access to more than 1,000 images that have
been rated based on a series of experiments along
the following emotional dimensions: valence
(ranging from pleasant or positive to unpleasant
or negative); arousal (ranging from calming or
soothing to exciting or agitating); and dominance
(ranging from large-gure to small-gure). ese
include pictures depicting mutilations, snakes,
insects, attack scenes, accidents, contamination,
illness, loss, pollution, puppies, babies, and land-
scape scenes, among others that are often used to
induce emotional states.
Britton, Taylor, Sudheimer, and Liberzon (2006)
state that the IAPS serves as a common emotional
probe, depicting emotion-laden scenes to induce
aective states for fMRI studies. Mikels and col-
leagues (2005) provide insight into the dier-
ent uses of the IAPS images and their impact on
physiological outcomes such as heart rate and fa-
cial electromyographic activity. Figure 2 presents
a conceptual framework for how emotions can be
organized along the dimensions of valence and
arousal (based on the model developed by Co-
libazzi et al., 2010). Sample images are included
based on images from the IAPS Technical Report
(Lang, Bradley, & Cuthbert, 2008). Because of
copyright issues, the original IAPS images could
not be used. Instead, the authors have identied
Figure 2. Example of images based on the dimensions of valence and arousal. The horizontal
axis represents the valence dimension (pleasant—unpleasant), and the vertical axis represents
the arousal dimension (exciting—non-exciting). Based on diagram by Colibazzi et al. (2010),
where authors argue that valence and arousal are not mutually exclusive but simply different
conceptual frameworks. IAPS images were selected based on their valence and arousal ratings
in the IAPS technical report (Lang, Bradley, & Cuthbert, 2008). Comparable examples were found
from stock imagery and are included in the figure above.
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IAPS images with valence and arousal values rep-
resentative of each quadrant (high valence, high
arousal; high valence, low arousal; low valence,
high arousal; and low valence, low arousal), and
found similar images to illustrate the dierent
emotional dimensions.
e use of IAPS images has been particularly
common in fMRI studies investigating the mech-
anism of fear using images with low valence (un-
pleasant) and high arousal (exciting) properties.
However, for many of these studies, it has been
dicult to dissociate brain circuits involved in
the processing of valence and arousal. e dis-
tinction is important because studies show that
valence and arousal have dierent physiological
manifestations (see Table 1). According to Mikels
et al. (2005), physiological outcomes such as
heart rate and facial electromyographic activity
(or movement of facial muscles) dier between
negative and positive valence, whereas outcomes
like skin conductance increase with arousal. e
latter has been reinforced by an fMRI study by
Glascher and Adolphs (2003), which correlates
amygdala activation and skin conductance re-
sponse (SCR) in reaction to arousing images to
amygdala activation. Heart rate and skin con-
ductance have been used as measures for stress
responses to visual images in previous work by
various researchers (for overview of articles, see
Ulrich, 2009).
Anders, Eippert, Weiskopf, and Veit (2008) dis-
sociated stimulus valence and stimulus-related
arousal and conrmed that the amygdala was
sensitive to stimulus valence even when arousal
was controlled for. eir paper provides insight
into the processes by which the amygdala de-
rives emotional meaning. ey also found that
increased amygdala activity in response to emo-
tional pictures of humans and animals was bet-
ter explained by valence than by arousal, and
that the amygdala was sensitive to the valence of
emotional stimuli even when it was equated for
arousal. e amygdala responded to both nega-
tive and positive stimuli, and this response did
not increase with arousal.
In contrast, thalamic and cortical activity in-
creased with arousal. SCRs were also collected
and were greater for arousing stimuli. Glascher
and Adolphs (2003) show that in fact the right
and left amygdala have dierent roles in the
processing of arousing images: the left amygda-
la decodes the information presented by a visual
stimulus, and the right provides a global level of
autonomic activation triggered “automatically”
by any arousing stimulus. is is in line with
the role of the amygdala in the primal ght-or-
ight response. Although determining the exact
neural networks at work during the processing
of unpleasant or pleasant images (valence) or
exciting or non-exciting images (arousal) is be-
yond the scope of this work, it is important to
understand that although these two factors can
overlap, they function independently.
Familiarity and Novelty
In addition to valence and arousal, novelty is a
critical stimulus dimension for amygdala engage-
ment. Weierich, Wright, Negreira, Dickerson,
and Barrett (2010) conducted an fMRI study
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that examined the contributions of novelty, va-
lence, and arousal to amygdala activation. e
study showed that in comparison to negative (vs.
positive) and high (vs. low) arousal stimuli, the
amygdala had higher peak responses and a lon-
ger period of activation to novel (vs. familiar)
stimuli. ey also found that novelty could be
dissociated from valence and arousal and have
independent aective signicance. On a behav-
ioral level, the authors found a strong relation-
ship between novelty and arousal, demonstrating
that subjects found novel images more arousing,
which would, in turn, also have an impact on the
amygdala. Because amygdala activation links to
fear and anxiety, the novelty of stimuli should
be considered carefully in settings where people
might be vulnerable.
In another study, Ongur et al. (2005) found sig-
nicantly greater activation of the right hippo-
campus when subjects were discriminating previ-
ously seen stimuli as opposed to novel pairs of
visual stimuli. is result indicates that the hip-
pocampus also plays an important role in recog-
nizing relationships with previously seen stimuli,
but not with novel stimuli. e activation of the
hippocampus is relevant to the retrieval of previ-
ous memories and the creation of context. Failure
to retrieve memories and create a context links
to the notion of free-oating anxiety discussed
previously.
Culture
Some research shows that culture can also play
a role in emotional response to visual images.
Chiao et al. (2008) used fMRI to measure amyg-
dala response to a fearful, neutral, happy, or an-
gry expression in two distinct cultures: Japanese
and Caucasian. e authors found that the fear
response (measured by amygdala activation)
increased when fear was detected in members
of one’s own culture relative to other cultural
groups. Chiao et al. (2008) cited signicant be-
havioral studies on how recognition of emotional
expressions is greater for one’s own culture. is
is an interesting insight for multicultural societies
such as the United States. e role of culture may
relate to the response to familiar vs. novel stimuli.
Realism
Although the authors did not nd many arti-
cles that addressed the issue of style (for more
information on issues of style, the eld of neu-
roaesthetics must be studied), they did nd
that the level of realism in an image contrib-
uted to emotional response. For example, neu-
ral activity associated with empathy for pain
was found to be higher in response to realistic
pictures compared to cartoons (Gu & Han,
2007). In the previous section, the role of em-
pathy was discussed in the work of Saarela et
al. (2007), which showed that a pain response
can be triggered by empathy when seeing oth-
ers in pain. e issue of realism also connects
with familiarity and novelty. Abstracted images
may be more novel than realistic images viewed
in a persons day-to-day life. is review did
not locate any articles that compared abstrac-
tion to realism in the context of fear, anxiety,
and pain.
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Facial Expression
Another key property of visual content identied
in the literature was the presence of direct or in-
direct information. Irwin et al. (1996) found that
fearful stimuli like pictures of snakes, spiders, or
medical procedures (direct threat) can cause the
emotion of fear, but so can fearful expressions on
other people’s faces (indirect threat). Studies of
expressive faces and IAPS pictures suggest that
similar regions are involved in processing both
types of emotional stimuli. In a review of some of
the early neuroimaging studies on the role of the
amygdala, Whalen (1998) discusses the nding
that viewing a fearful face induces more fear than
viewing an angry face.
is seems counterintuitive because looking at
someone’s angry face can be construed as a direct
threat. Whalen proposed that fearful faces convey
the threat more ambiguously than angry faces by
signaling the presence of threat or danger with-
out identifying the source of the threat, whereas
angry faces signal a more direct and immediate
negative consequence. us, Whalen argues that,
because fearful faces require more information
about a probable threat than angry faces, they in-
duce greater activation of the amygdala. To quote
Whalen, “A system that modulates vigilance will
be preferentially activated by a stimulus that re-
quires additional information to be understood”
(Whalen, 1998, p. 181). is hypothesis was
tested in a neuroimaging study conducted by
Whalen et al. (2001), which found that the re-
sponses in the amygdala were more pronounced
for fearful faces than for angry faces.
Rapid Extraction of Information
Independent of the issues of subject matter, style,
or expression is the issue of how quickly informa-
tion can be extracted from an image. is is key
to the notion of a “quick evaluative system” that
denes emotional processing as discussed in the
previous section. is literature review revealed
two key components of the rapid extraction of
information: context and spatial frequency.
Visual objects in the environment tend to appear in
specic and typical contexts and seem out of place
beyond these contexts. Bar and Amino (2003)
demonstrated that the cortical regions activated
when people recognize visual objects that are highly
associated with a certain context (e.g., a hardhat)
compared to those not associated with any context
in particular (e.g., a y). eir ndings indicate that
part of the cortical region surrounding the hippo-
campus (the parahippocampal cortex) and a region
in the retrosplenial cortex together comprise a sys-
tem that mediates contextual processing. ey base
their research on an earlier work by Carr, McCauley,
Sperber, and Parmelee (1982), which argues that se-
mantic meaning about context is extracted from in-
put at an early stage, possibly even before perceptual
processing is complete.
Neural activity associated with
empathy for pain was found
to be higher in response to
realistic pictures compared to
cartoons.
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According to Bar (2004), the swift extraction of
contextual meaning from an image is mediated
by global cues conveyed by the low spatial fre-
quencies of an image. Bar explains that dierent
spatial frequencies convey dierent information
about the appearance of a stimulus. High spa-
tial frequencies (HSFs) represent abrupt spatial
changes in an image, such as edges, and they
generally correspond to congural information
and ne detail. Low spatial frequencies (LSFs),
on the other hand, represent global information
about shape, such as general orientation and
proportion. Every image contains both types of
frequencies, which can be obtained by the two-
dimensional Fourier transform (Bone, Bachor, &
Sandeman, 1986).
Vuilleumier, Armony, Driver, and Dolan (2003)
investigated whether high and low spatial fre-
quency are processed by distinct neural chan-
nels. ey decomposed fearful face stimuli into
their HSF and LSF components. e results
indicated that amygdala responses to fearful
expressions were greater for LSF faces than for
HSF faces. LSF cues support perception of face
conguration but lack information for detailed
identication and are rapidly extracted; on the
other hand, visual recognition mechanisms are
attuned to encode HSF information.
Contour
Proof of the role of elements rapidly extracted
from an image is the impact of contours on
amygdala activation. In a preference study com-
paring responses to everyday objects with curved
or sharp edges, Bar and Neta (2006) found that
respondents preferred objects with curved con-
tours compared with comparable objects that
had pointed features and sharp-angled contours.
ey hypothesized that this partiality stemmed
from an inherent perception of potential threat
conveyed by sharp visual elements.
A follow-up study by these researchers used fMRI
to test this hypothesis, and it was found that the
amygdala was signicantly more active in sub-
jects viewing everyday sharp objects (e.g., a sofa
with sharp corners) compared with their curved-
contour counterparts. is dierence was more
signicant for the LSF compared to the HSF fea-
tures in the image. e authors concluded that
a “preference bias towards a visual object can be
induced by low-level perceptual properties, in-
dependent of semantic meaning, via visual ele-
ments that on some level could be associated with
threat. Our brains might be organized to extract
these basic contour elements rapidly for deriving
an earlier warning signal in the presence of po-
tential danger” (Bar & Neta, 2007).
Research on spatial frequencies indicates that
the emotional response to a visual image is im-
The amygdala was signicantly
more active in subjects
viewing everyday sharp
objects (e.g., a sofa with sharp
corners) compared with their
curved-contour counterparts.
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mediate, extracted from the global properties of
an image including shape, orientation, and pro-
portions, which supports Zajonc’s classic work
(1980) on global properties of images, and the
subsequent work by Ulrich (1991) on the theory
of preferenda discussed earlier in the theoretical
foundation section.
Discussion
Emotional Response to Visual Images:
Key Brain Areas
As discussed in the Phan et al. (2002) article, it
is important to remember that whenever a visual
stimulus is viewed, the visual cortex is activated.
An entire complex process is in place, which en-
ables “seeing.” But during emotional processing
certain regions of the brain are activated in addi-
tion to the visual cortex. e activation of these
areas indicates that the brain has processed the vi-
sual image beyond the sensory perception of “see-
ing” something. In other words, mapping brain
areas indicates how what a person “sees” makes
him or her “feel.
Key brain areas identied in the literature review
include the medial prefrontal cortex, which has
been shown to play a general role in emotional
processing across all individual emotions. For pain
perception, the ACC acts as a central component
in the modulation of pain. It is also activated when
anticipating incoming aversive events. In addition
to these cortical structures (situated in the cortex,
which forms the outermost sheet of neural tissue
in the human brain), Table 2 lists some of the
prominent subcortical brain structures involved
in this process, which have been discussed in this
article. e subcortical region of the brain is lit-
erally “anything beneath the cortex.” ese brain
areas include the amygdala, insula, hippocampus,
and thalamus. e amygdala, insula, and thalamus
are responsible for the rapid-processing emotional
response, and the hippocampus is responsible for
memory. ese four areas can be identied as re-
gions of interest (ROI) for future fMRI studies to
investigate how visual images can aect feelings in
the hospital setting.
It is important to note, however, that many more
areas, both cortical and subcortical, are involved
in the processing of a single visual stimulus, and
this is not an exhaustive list. e amygdala can
be considered the single most important ROI in
the brain when considering the impact of visual
images on fear, anxiety, and pain. e important
role of the limbic regions (amygdala, thalamus,
and hippocampus), which are older than other
parts of the brain, in the emotional response to
stimuli and associated with the primal ght-or-
ight response, supports Zajonc’s theory of a
quick evaluative system that denes human re-
sponse to visual images, especially under stress.
Visual Properties and Emotional Response
A valuable insight gleaned from the review of the
literature was mapping the “emotional” proper-
ties of images along the dimension of valence and
arousal. For example, images with low valence
and high arousal (the second quadrant in Figure
2) would typically be used to induce fear or anxi-
ety. By contrast, images with high valence and
low arousal (the fourth quadrant) would have the
opposite eect and be considered restorative. In-
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terestingly, given that arousal has an independent
link to increased stress response (skin conduc-
tance), even positive images that are too “excit-
ing” (rst quadrant) could be inappropriate for
high-stress areas in healthcare. e relationship of
novelty, arousal, and activation in the amygdala
suggests that highly novel stimuli can trigger a
fear response and therefore may be inappropriate
in extremely high-stress settings where the primal
response does not have time to be overridden by
a higher-level reective response.
Research on the impact of facial expressions on
emotional processing is relevant from the per-
spective of image selection for hospital-based art
programs, popular media for distribution, and pa-
tient-provider interactions. Facial expressions indi-
cating fear (indicative of the presence of a threat)
can be as fear-inducing as the source of the threat.
Ambiguity in facial expressions can induce fear
and anxiety. Facial expressions that are dicult to
read, or that might seem anxious or fearful, should
be avoided. Research that establishes that fear re-
sponses are greater when facial expressions belong
to one’s own cultural group can be extrapolated to
imply that the same holds for positive emotions.
is nding argues for cultural diversity in images
selected for hospital environments.
e research on rapid extraction of context by
low spatial frequencies of an image (which pro-
vide information on broad structural properties
such as contours and conguration rather than
details that aid recognition) ties back to the theo-
ry of a quick evaluative system and the theory of
preferenda, which argue that global properties of
the same image can shape the viewer’s perception
and trigger a ght-or-ight response. e rapid
extraction of contour information and its im-
pact on the amygdala suggest that issues of con-
tent and form must be addressed together. e
quick evaluation system of any image provides a
fundamental sense of well-being (whether or not
there is a threat). is response forms the basis of
subsequent emotional belief and aesthetic judg-
ment, which involve higher-level cortical pro-
cesses. is review does not address the issue of
aesthetic judgment, but a previous work (Nanda
et al., 2009) explores the issue of neuroaesthetics
in the context of emotional processing.
Insights on Specic Image Content
A look at the neuroscience literature conrms that
a quick evaluative process is in place when viewing
visual images; it triggers an emotional response (of
fear, anxiety, or pain), which is closely linked to
physiological responses. It also oers clues about
image properties that elicit negative emotional re-
sponses and should therefore be avoided, includ-
ing (1) fearful or angry faces; (2) ambiguous sub-
ject matter; (3) high novelty and unfamiliarity; (5)
lack of realism; and (4) sharp contours.
The amygdala can be
considered the single most
important region of interest in
the brain when considering the
impact of visual images on fear,
anxiety, and pain.
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e classication of images along the emotion-
al dimensions of valence (from unpleasant to
pleasant) and arousal (from exciting to relaxing)
provides a useful tool to determine appropriate
content for images in healthcare settings. Argu-
ably, images in high-stress areas of the hospital
should have high valence (positive content) and
low arousal (calming). Other areas of a hos-
pital could be suitable for more medium- to
high-arousal images while maintaining positive
content. e ability to map emotion along two
discrete dimensions (valence and arousal), and
to evaluate visual images according to these, is a
valuable tool to guide image selection for dier-
ent areas of a hospital.
ese insights from the literature review cannot be
considered an exhaustive guide for image selection
in hospitals, although they do support previous
work on this subject by Ulrich (2009) and Ha-
thorn and Nanda (2008). ey also raise some red
ags to be aware of when selecting images for hos-
pitals—whether art, media, or an overall theme.
Limitations
e subject matter of this review was too large
for the scope of this study. Emotion is a big
subject, and each subsection—fear, anxiety,
and pain—comprises a signicant body of fre-
quently overlapping literature. is review, al-
though systematic, does not provide an exhaus-
tive synopsis of neuroimaging studies on the
emotions of fear, pain, and anxiety. In com-
parison to fear, the body of literature on anxi-
ety and the emotional aspect of pain is smaller.
Moreover, with new articles being published
every day, a literature review can become dated
very quickly and must be updated with new
information constantly. Table 1 lists the key
articles identied in this review dating from
1996 to 2010. Secondly, detailed information
on image properties and image selection was
lacking in many articles, which narrowed the
pool of articles considerably. Many key articles
were identied by using reference lists rather
than the rst key word search in the PUBMED
database.
Although initially the authors were interested in
seeing how images of nature—especially images
that had been shown to be restorative—aected
fear, anxiety, and pain, no articles in the review
addressed this issue specically. Arguably, images
in the neural literature reviewed were used to in-
duce an emotion, or to be emotionally evocative
rather than restorative, i.e., returning to a state of
calm. is made it dicult to tie the neurosci-
ence data to the guidelines and theories that form
the cornerstone of image selection in evidence-
based design today.
Future Directions
is article attempts to navigate some of the
new information in the eld of cognitive sci-
ences, such as cutting-edge neuroimaging stud-
ies, from the perspective of design and visual
imagery. It also identies the key brain areas
responsible for processing fear, anxiety, and
pain to provide a basis for future studies that
seek to link brain behavior to specic design ele-
ments that could have an impact on emotional
response. Although signicant work has been
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done in the eld of neuroesthetics (see Nanda et
al., 2009, for a short introduction), it has been
more about cognitive rather than emotional re-
sponses to visual images.
In healthcare design, the primary focus on
health, well-being, and aesthetics is closely
linked to emotional concerns. Two clear lines
of investigation emerge from this review: (1) to
undertake fMRI studies on identied regions of
interest in the brain in response to image types
supported by the evidence-based design litera-
ture after carefully analyzing the visual proper-
ties of the images. Such an exercise could also
address fundamental questions about whether
the content or form of an image has a larger
impact on perception, and oer insights into
the interaction between the two; (2) to under-
take a literature review of studies that address
activation of the identied regions of interest
in response to visual stimuli. Focusing on spe-
cic regions of interest in the brain rather than
on overarching emotional frameworks (which
extend the scope of the study), enables a more
focused investigation into visual properties and
corresponding brain activation. Of particular
interest are studies of the amygdala, because
the amygdala has a critical role in processing
emotions, as well as in our fundamental, pri-
mal sense of well-being.
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Implications for Practice
• Viewing images can have a direct impact on emotional processing centers in the brain; thus,
art for healthcare facilities must be carefully selected.
• “Restorative” images are dened by content with high valence (positive) and low arousal
(calming).
• When viewing novel/unfamiliar images, the brain struggles to create a context. is typi-
cally involves a failure to retrieve memories, which is linked to anxiety. is struggle often
contributes to making great abstract art by allowing viewers to come up with their own
interpretation. For highly vulnerable patients, however, the anxiety related to this process
may be more acute and the primal emotional response can override the higher-level cogni-
tive response. Art should be selected with this trade-o in mind.
• Fearful expressions on faces can trigger a greater fear response in a viewer than viewing a
direct threat; thus, facial expressions should be carefully considered when selecting gura-
tive art.
• e following elements in a visual image should be carefully evaluated and, if possible,
avoided in high-stress areas: fearful/angry faces; ambiguous subject matter; high levels of
novelty and unfamiliarity; lack of realism; and sharp-edged contours.
• e primal response to images is triggered by a quick evaluative system that rapidly extracts
information from an image; this depends on global cues rather than a high level of detail.
Form and content relate to global cues and must be addressed together when choosing art.
• Emotional impact must be balanced with aesthetic value in the context of healthcare art.
... Also, short-term visual contact alone can be restorative (Ulrich, 1992). Nanda et al. (2012), in a review of neuroscience articles on emotional states and characteristics of images, found that viewing some types of nature images lowered blood pressure and heart rate. These images were noted to be more restorative. ...
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The authors employed an affective priming paradigm to provide direct evidence for the rapid evaluation of natural and urban environments suggested in evolutionary models of environmental perception and restoration. Pictures classified as urban and nature environments differing in restorative and affective quality were presented as prime stimuli. They were followed by presentations of human vocal expressions of joy, anger, and emotional neutrality as target stimuli. The participants were required to judge the vocal one-word expressions and produce a forced-choice reaction between joy and anger. The reaction times to vocal expressions of anger were shorter after the presentation of urban scenes associated with low restorative potential and negative affect than after nature scenes associated with high restorative potential and positive affect. The reaction times to vocal expressions of joy were shorter after the presentation of a nature scene than of an urban environment. The results provide support for the rapid and automatic affective evaluations of environmental scenes.
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Recently, there has been a convergence in lesion and neuroimaging data in the identification of circuits underlying positive and negative emotion in the human brain. Emphasis is placed on the prefrontal cortex (PFC) and the amygdala as two key components of this circuitry. Emotion guides action and organizes behavior towards salient goals. To accomplish this, it is essential that the organism have a means of representing affect in the absence of immediate elicitors. It is proposed that the PFC plays a crucial role in affective working memory. The ventromedial sector of the PFC is most directly involved in the representation of elementary positive and negative emotional states while the dorsolateral PFC may be involved in the representation of the goal states towards which these elementary positive and negative states are directed. The amygdala has been consistently identified as playing a crucial role in both the perception of emotional cues and the production of emotional responses, with some evidence suggesting that it is particularly involved with fear-related negative affect. Individual differences in amygdala activation are implicated in dispositional affective styles and increased reactivity to negative incentives. The ventral striatum, anterior cingulate and insular cortex also provide unique contributions to emotional processing.
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Echo-Planar functional magnetic resonance imaging (EP-fMRI) was used to study the activity of the amygdala while three normal female subjects viewed alternating blocks of affectively neutral and affectively negative still pictures. Bilateral activation in the amygdala that was significantly correlated with the changing valence of the visual stimuli was found in all three subjects. These findings are consistent with the large corpus of data from non-human studies suggesting that the amygdala is a key structure for extracting the affective significance from external stimuli. This is the first known report of phasic amygdala activation detected with EP-fMRI in normal human subjects responding to affective stimuli.