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Autonomic Effects of Expressive Writing in Individuals with Elevated Blood Pressure

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We evaluated systolic and diastolic blood pressure, heart rate variability and skin conductance at baseline, and 1 and 4 months in 38 participants with elevated blood pressure, randomly assigned to expressive writing or control groups. There was a significant interaction such that the very low frequency wave of heart rate variability increased over time only in controls, suggesting potentially protective buffering in expressive writing. Systolic and diastolic blood pressure also decreased significantly from baseline to 1 month in expressive writing. Consistent with inhibition, Anger-In moderated effects of writing on 4-month DBP. Overall, expressive writing demonstrated short-term autonomic benefits and longer-term moderated effects.
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197
Autonomic Effects of
Expressive Writing in
Individuals with
Elevated Blood
Pressure
KIMBERLY M. BECKWITH MCGUIRE,
Licensed Clinical Psychologist, USA
MELANIE A. GREENBERG, &
RICHARD GEVIRTZ
Alliant International University, USA
KIMBERLEY M. BECKWITH MC GUIRE, PhD, is a
Licensed Clinical Psychologist in private practice in
San Diego and is active in the area of clinical health
psychology.
MELANIE A. GREENBERG (PhD State University of
New York, Stony Brook, NY) is a Professor of Clinical
Psychology at Alliant International University, San
Diego, CA. She has published in the areas of health
psychology, emotional expression interventions and
cognitive-emotional adjustment to life stress.
RICHARD GEVIRTZ (PhD De Paul University,
Chicago, IL) is a Professor of Clinical Psychology at
Alliant International University, San Diego, CA. He
has published in the areas of biofeedback and heart
rate variability.
Journal of Health Psychology
Copyright © 2005 SAGE Publications
London, Thousand Oaks and New Delhi,
www.sagepublications.com
Vol 10(2) 197–209
DOI: 10.1177/1359105305049767
Abstract
We evaluated systolic and
diastolic blood pressure, heart
rate variability and skin
conductance at basline, and 1
and 4 months in 38 participants
with elevated blood pressure,
randomly assigned to expressive
writing or control groups. There
was a significant interaction
such that the very low
frequency wave of heart rate
variability increased over time
only in controls, suggesting
potentially protective buffering
in expressive writing. Systolic
and diastolic blood pressure
also decreased significantly
from baseline to 1 month in
expressive writing. Consistent
with inhibition, Anger-In
moderated effects of writing on
4-month DBP. Overall,
expressive writing
demonstrated short-term
autonomic benefits and
longer-term moderated effects.
Keywords
Anger-In, blood pressure,
expressive writing, heart rate
variability
ACKNOWLEDGEMENTS. The authors would like to thank Gregory
Berkoff, D.O., and Daniel Michaels, M.D., for referring patients to the
study and Jessica Schutte, M.S., and Dawn Dilley, M.S., for their help
with data collection. William Gerin, PhD, provided valuable
information regarding study design and conceptualization.
COMPETING INTERESTS: None declared.
ADDRESS. Correspondence should be directed to:
MELANIE A. GREENBERG, PhD, Clinical PhD Program, Alliant
International University, 10455 Pomerado Rd, San Diego, CA 92131,
USA. [email:
KIMBERLEY M. BECKWITH MC GUIRE at
kbmcguire@cox.net or
MELANIE A. GREENBERG at
mgreenberg@alliant.edu.]
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THIS CONTROLLED study examined the
efficacy of an expressive writing intervention for
individuals with elevated blood pressure (BP).
An estimated 50 million adult Americans are
diagnosed with hypertension, yet three-fourths
are unable to control their BP with medication
and/or lifestyle changes (JNC VI, 1997; JNC 7,
2003), resulting in a myriad of health problems.
Complications of elevated BP, including heart
failure, end-stage renal disease, stroke and
coronary heart disease (CHD) have remained
stable or increased in incidence recently (JNC
VI, 1997). Direct and indirect costs of
hypertension were 40.4 billion dollars in 2001
(AHA, 2000). In their 1997 report, the JNC
discussed the importance of non-pharmacologi-
cal interventions, especially in hypertensives
that do not respond to antihypertensive medi-
cation. They acknowledged, ‘Emotional stress
can raise blood pressure acutely’ (JNC VI, 1997,
p. 2423). This provided the impetus for the
current intervention designed to facilitate
emotional expression and resolution of life
stresses.
Recently, the JNC’s seventh report (JNC 7,
2003) has replaced the category of high normal
BP with a prehypertension category. This report
acknowledges that as BP increases, the chance
of cardiovascular disease (CVD) increases. This
represents increasing recognition that indi-
viduals in the high normal/prehypertension
stage are also at risk for hypertension and later
CVD. Therefore, we included this subgroup in
the study as well.
The cause of essential hypertension is yet to
be known, but theories suggest a possible role of
genetics, inadequate nutrition, lack of exercise
and/or emotional stress (e.g. Brosschot &
Thayer, 1998; Guyton, 1991; Ornish, 1992;
Turner & Boerwinkle, 2003). In this study, we
adopted a biopsychosocial approach (Engel,
1977), which suggests the interplay of emotional
stressors and biological reactions plays a signifi-
cant role in establishing and maintaining
elevated BP.
According to Pennebaker’s Inhibition-
Confrontation Theory (Pennebaker, 1982;
Pennebaker & Beall, 1986), an individual’s
inability to confront traumatic/stressful events
produces both chronic physiological inhibition
and intrusive rumination, leading to chronic
activation of the autonomic nervous system,
with resultant increased vulnerability to disease.
Therefore, deliberately confronting these events
and associated thoughts and emotions should
decrease chronically elevated BP. More recent
theories (Greenberg & Lepore, 2004; Green-
berg, Wortman, & Stone, 1996; Lepore,
Greenberg, Bruno, & Smyth, 2002) emphasize
the emotional self-regulatory effects of writing,
including autonomic and cognitive habituation
to trauma stimuli and responses following
repeated confrontation in a safe context. Thus,
trauma-related stimuli should lose their ability
to trigger chronic sympathetic elevations, result-
ing in lower resting levels of BP and other
sympathetic indicators.
Research supports the hypothesized link
between short-term emotional inhibition and
elevated autonomic arousal and between long-
term inhibition and CVD. Controlled studies
demonstrate that experimentally induced
emotional inhibition or behavioral suppression
produces immediate elevations on sympathetic
measures, including finger pulse amplitude,
finger temperature, heart rate (HR) and skin
conductance (SC) (e.g. Gross, 1998; Gross &
Levenson, 1997; Pennebaker & Chew, 1985).
Additionally, expressive writing studies have
demonstrated a decrease in SC levels for those
writing about traumas (Petrie, Booth, Penne-
baker, Davison, & Thomas, 1995). Experi-
mental studies of emotional expression and BP
in healthy populations have, however, shown
mixed results (Lepore, Ragan, & Jones, 2000;
Pennebaker, Hughes, & O’Heeron, 1987).
However, these studies all examined verbal
disclosure in non-medical samples. Therefore,
they do not directly address the effects of
expressive writing in a population at medical
risk.
Another psychophysiological theory (Bross-
chot & Thayer, 1998) suggests that chronic
emotional inhibition leads to persistently low
vagal tone, which increases HR and decreases
heart rate variability (HRV), which in turn
decreases cardiac control of BP and signifies
essential hypertension. These authors theorized
that chronic anger inhibition is associated with
consistently low vagal tone, as well as slow
cardiovascular recovery. Vagal tone is involved
in general emotional expression and emotional
regulation. When there is low vagal tone, an
individual is in a relatively inflexible state, and
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chronic low vagal tone can slow down cardio-
vascular recovery and increase HR and BP
(Brosschot & Thayer, 1998). Low HRV is a
good predictor of all-cause mortality, cardiac
mortality and sudden death (Dekker et al., 1997;
Katz, Liberty, Porath, Ovsyshcher, & Prys-
towsky, 1999; LaRovere, Bigger, Marcus,
Mortara, & Schwartz, 1998).
Yet another model suggests that expressive
techniques can reduce BP for individuals who
have not ‘adequately cognitively integrated
their stressful experience’ (Davidson et al.,
2002, p. 23). These authors hypothesized that
expressive writing should be beneficial for indi-
viduals who are prone to anger or who demon-
strate excessive levels of anger inhibition, anger
expression or both. This theory implies that a
personality style involving chronic anger inhibi-
tion could moderate the effects of the inter-
vention on physiological functioning. In other
words, writing should be more beneficial for
those high in Anger-In than those without
substantial prior anger inhibition.
A growing body of research supports the
efficacy of written expression interventions in
medically ill populations. Expressive writing
has produced improvement in biological
measures (e.g. skin conductance, immune func-
tioning) in healthy participants (Booth &
Petrie, 2002; Petrie et al., 1995; Smyth, 1998)
and in disease status in participants with
rheumatoid arthritis and asthma (Smyth, Stone,
Hurewitz, & Kaell, 1999). This technique has
also decreased fatigue in terminally ill cancer
patients (Moore et al., 2002), and decreased
medical visits for breast cancer patients
(Stanton & Danoff-Burg, 2002).
A recent, controlled study of expressive
writing in normotensives provides preliminary
support for beneficial effects on BP. Crow,
Pennebaker and King (submitted) assessed 52
adult normotensives randomly assigned to
either an expressive writing condition or a non-
emotional writing condition. BP was measured
two times and then averaged, one day prior to
writing and at 6-week follow-up. Results indi-
cated a significant decrease in diastolic BP for
the experimental group relative to the control
group, with an almost significant decrease noted
for systolic BP. These findings, together with
those demonstrating beneficial effects of writing
in medically ill populations, suggest that this
intervention could plausibly decrease BP, and
autonomic arousal in individuals with elevated
BP. There is also theoretical support suggesting
potential decreases in HRV and increases in
vagal tone. Given the high costs and potential
risks of elevated BP and the lack of demon-
stratedly effective non-pharmacoloigcal treat-
ments for this population, this low cost, and
easily administered psychosocial intervention, if
shown to be effective, has the potential for
widespread clinical use.
We hypothesized that a brief expressive
writing intervention would decrease systolic and
diastolic BP and SC levels and increase HRV in
this elevated BP sample. We also hypothesized,
that Anger-In would moderate the effects of
expressive writing on BP.
Methods
Participants
Forty-nine participants were recruited with 38
of these (78% of original sample) included in
the final sample. Participants were 26 males and
12 females, ranging in age from 25 to 60 (M =
43.34, SD = 10.17). A majority (73.7%) was
Caucasian, and 55.2 percent were married.
More than half of the sample (61%) indicated
an education level of college graduate or
graduate school and 61 percent were engaged in
full-time employment. There were no significant
between-group differences in percentage of
participants in each BP category,
2
(d.f. = 2, N
= 38) = .09, NS for systolic BP and
2
(d.f. = 2,
N = 38) = .73, NS for diastolic BP.
1
The sample was recruited from referrals by
local physicians (18), self-referrals (10) and
from advertisements (10) posted at medical
clinics, local colleges and graduate institutions,
pharmacies, a local newspaper and family
centers (e.g. YMCA). The advertisements
invited individuals to participate in a study
on ‘stress and high blood pressure; a non-
medication technique aimed at reducing your
blood pressure’. Participants received US$30.00
for their participation.
Interested individuals were screened by tele-
phone to determine potential eligibility. The
BP guidelines in effect at the time of this study
were derived from the JNC VI report. Indi-
viduals with a reported history of high normal
to moderate hypertension (130–179 mm
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Hg/85–109 mm Hg) were initially eligible to
participate (Table 1). A reported history was
defined as self-reported elevated BP on at least
two visits to a physician’s office within the
previous 12 months. Hypertension history
reports have demonstrated 94.2 percent accu-
racy, when compared with medical records
(sensitivity = 95.4 percent; specificity = 92.4
percent; Page & France, 2001). To be included
in the final data analyses, potential participants
also had to have BP readings of high normal or
above on either systolic BP or diastolic BP at
baseline. At baseline, 39 percent of participants
had high normal BP, 47 percent had mild and 13
percent had moderate hypertension. Means,
standard deviations and ranges for BP at base-
line and both follow-ups are shown in Table 2.
Other inclusion criteria were proficiency in
English and ability to read English at a 7th grade
level. Exclusion criteria were diabetes, co-
morbid heart disease or history of heart disease,
severe psychiatric disorder or illiteracy (unable
to write for 20 minutes).
Attrition and white coat hypertension Eleven
of the recruited participants were not included
in the final sample, due to either white coat
hypertension (6 participants; 12%) or dropout
due to personal reasons (5 participants; 10%).
White coat hypertension was defined as the
average of the 17 baseline systolic and diastolic
BP readings falling below the high normal
range. Two of the five dropouts completed the
one-month follow-up, while the other three
discontinued after baseline. Neither dropout
status,
2
(2, N = 49) = .47, NS, nor white coat
hypertensive status,
2
(2, N = 49) = .37, NS, was
systematically related to group assignment.
Non-completers were more likely than
completers to identify partner status as single,
2
(2, N = 49) = 6.71, p < .05; percentages single
were 66.7 percent of white coat hypertensives,
40 percent of dropouts and 18.4 percent of
completers. Dropouts also had more comorbid
medical conditions (e.g. hepatitis C, hernia),
2
(2, N = 49) = 6.46, p < .05; 60 percent of drop-
outs, 18.4 percent of completers and 0 percent
of white coat hypertensives had comorbid
conditions. White coat hypertensives indicated
significantly more number of times exercised
per week (M = 5.33, SD = 2.42) than completers
(M = 1.95, SD = 1.81), F (2, 46) = 8.72, p < .001.
Measures
Demographics A demographics questionnaire
assessed gender, relationship status, ethnicity,
education, employment, family history of heart
disease, medication consumption, diet, exercise
and medical status. A health questionnaire
assessed consumption of caffeine, nicotine and
involvement in physical exercise during the
hour prior to physiological assessment.
Manipulation checks The Positive and Nega-
tive Affect Schedule (PANAS; Watson, Clark,
& Tellegen, 1988) assessed positive and negative
affect pre- and post-writing. The PANAS has 20
adjectives, 10 positive (PA) and 10 negative
(NA), and respondents rate their present mood
on a 5-point scale ranging from 1 (very slightly/
not at all) to 5 (very much). This measure validly
assesses short-term mood fluctuations, with
consistent psychometric results in varying
populations and over various time-frames
(Watson et al., 1988). Internal consistency
alphas in the current sample were .87 for PA and
.84 for NA.
Subjective responses to essay-writing were
assessed as per Greenberg et al. (1996). Partici-
pants rated the extent to which their essays were
personal, stressful, meaningful and revealing of
their emotions on a unipolar 7-point scale
ranging from ‘not at all’ (1) to ‘a great deal’ (7).
Anger-In The State-Trait Anger Expression
Inventory (STAXI) Anger-In (AX/In) subscale
(Spielberger, 1988) assessed anger suppression.
Anger-In is the characteristic frequency with
which an individual does not express his/her
anger in anger-arousing situations. Individuals
rate on a 4-point scale ranging from 1 (almost
never) to 4 (almost always), how often they
generally react or behave in the manner
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200
Table 1. Blood pressure guidelines according to the
JNC VI report (1997)
Blood pressure Range
Normal 120 mmHg/80 mmHg
High normal 130–139 mmHg/85–89 mmHg
Mild/borderline 140–159 mmHg/90–99 mmHg
Moderate 160–179 mmHg/100–109 mmHg
Severe 180 mmHg/110 mmHg or higher
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described when they feel angry or furious.
Coefficient alpha for the current sample was .73.
Blood pressure At baseline and each follow-
up, the first author (KB) or research assistant
took three BP readings, separated by two
minutes, using a ReliOn/Omron (HEM412-C)
home BP monitor. Participants also self-
monitored their systolic and diastolic BP at
home for 1 week at baseline, taking daily
measures, one in the morning and one in the
evening, using the same ReliOn/Omron BP
monitor. These 17 measures (3 laboratory, 14
home) were averaged for each participant to
obtain a baseline BP measure.
Skin conductance At baseline and each follow-
up, SC was assessed every 10 seconds, for a 15-
minute period during which the participant was
sitting quietly. The 15-minute sessions were
divided into two parts (time 1 and time 2), to
facilitate examination of within session differ-
ences. These scores were averaged separately for
each assessment period, resulting in three
overall SC scores. An electrode was placed on
the tip of the palmar side of a finger, along with
a grounding electrode on the forefinger. SC
increases as the number of activated sweat
glands increase and is measured in ‘micromhos’.
High test–retest reliability (r = .89) has been
shown for skin conductance (Schwartz, 1995).
Heart rate variability HRV is the rhythmic
activity ‘in the interval between consecutive
heart beats as well as the oscillations [rhythmic
activity] between consecutive instantaneous
heart rates’ (Task Force of the European
Society of Cardiology and the North American
Society of Pacing and Electrophysiology
(TFENA, 1996). HRV measures degree of auto-
nomic modulation and not level of autonomic
tone (TFENA, 1996), has three frequencies:
(very low frequency (VLF), low frequency (LF)
and high frequency (HF), and can be measured
by various methods using electrocardiogram
(ECG) recordings. The method we used was
spectral analysis (i.e. frequency domain
method), which provides information on the
variance distribution of the frequencies. More
specifically, the non-parametric method Fast
Fourier Transform (FFT) was implemented to
analyze the inter-beat-interval data (IBI). IBI is
the time between the R-waves of the QRS
complex of the electrocardiogram, representing
the ventricular activity of the heart (Gevirtz,
Lehrer, & Andrasik, 2003).
The J & J-300 C2 computerized physiological
monitoring system was used. One electrode was
placed on each wrist to produce the recordings
necessary. The device sampled ECG at over
1000 samples per second. Each session’s HRV
data were averaged every 10 seconds, for a
15-minute period in which the participant was
sitting quietly. The 15-minute sessions were
divided into two parts (time 1 and time 2) to
facilitate examination of within-session differ-
ences.
Procedures
To minimize between-group expectancy differ-
ences, all potential participants were told that
the study would examine the effects of stress on
elevated BP. At the first session, participants
met with the first author or trained research
assistant at either a physician’s office (n = 17),
2
or another quiet setting (n = 21), signed
informed consent forms and filled out baseline
questionnaires including the demographic and
medical status questionnaire, and psychosocial
measures (PANAS, STAXI). There were no
effects of setting on baseline measures (all
ps > .05). HRV and SC baselines were also
BECKWITH ET AL.: EXPRESSIVE WRITING AND BLOOD PRESSURE
201
Table 2. Descriptive statistics for blood pressure at three time points
Variable Mean SD Minimum Maximum Range
Baseline SBP 140.66 12.02 125 171 46
Baseline DBP 90.39 6.27 78 106 28
1-month SBP 135.18 15.56 102 167 65
1-month DBP 87.42 9.31 67 107 40
4-month SBP 138.03 13.02 109 168 59
4-month DBP 86.71 8.16 67 99 32
Notes: SBP = systolic blood pressure; DBP = diastolic blood pressure. All values are in mm Hg. N = 38
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measured after a 5-minute period of rest and
recorded for a 15-minute period, using J & J
biofeedback equipment, one week prior to the
first writing session. Participants were scheduled
to begin the intervention one week after base-
line assessment and were randomly assigned to
either the expressive writing or control groups.
Instructions to participants were derived from
previous studies using the expressive writing
intervention (Pennebaker & Beall, 1986; Smyth,
1998; Smyth et al., 1999). Participants had to
write for 20 minutes on each of three consecu-
tive days. To facilitate adherence checks, they
were told to record the dates of each essay.
Expressive writing participants had to express
their deepest thoughts and feelings about a
personally traumatic/stressful life experience
that previously was undisclosed or minimally
disclosed, while controls had to write objectively
(i.e. non-emotionally) about how they spent
their time the day before (day 1), and that day
(day 2), and what their plans were for the next
week (day 3). This was presented as a time-
management exercise. The first author called all
participants the day before writing to remind
them of the study requirements.
Participants completed a brief health status
questionnaire prior to each writing session to
assess possible medication change, the PANAS
before and after each writing session, and a
post-writing questionnaire after each writing
session. At 1- and 4-month follow-ups, BP, SC
and HRV were assessed using the baseline
procedure, and the STAXI was re-administered.
Results
Baseline comparisons and
manipulation checks
At baseline, there were almost significant differ-
ences between groups on marital status,
2
(1, N
= 38) = 3.98, p = .05, with the experimental
group having more married participants (n = 13)
than the control group (n = 8), and on
Asian/Pacific Islander (yes or no);
2
(1, N = 38)
= 4.02, p = .05, with the control group having
more participants identified as Asian/Pacific
Islander (n = 4) than the experimental group (n
= 0). Marital status and Asian/Pacific Islander
ethnicity were not significantly correlated with
any outcomes and therefore were not controlled
in subsequent analyses.
Examination of recorded essay dates
confirmed that 36 participants (95%) adhered to
instructions to write on three consecutive days.
All participants’ essays conformed to the
assigned writing condition topics. EW partici-
pants wrote about a range of stressful/traumatic
experiences, including death of a family member
(33%), extreme job situations (33%), self-
deprecation (17%), marital difficulties (12%)
and childhood stress (5%). Mean essay lengths
were 1.55 pages (SE = .11) and 1.37 pages
(SE = .12) for the EW and control groups
respectively, and these means did not differ
between groups F (1, 36) = 1.26, NS. These
checks established adequate adherence to the
experimental procedures.
A series of three-way ANOVAs (group
writing session time), with two repeated
measures (writing session and time) examined
between-group differences in PANAS PA and
NA from pre- to post-writing. The EW group
reported a significant increase in negative affect,
F (2, 35) = 8.98, p = .01, and no significant differ-
ences in positive affect from pre- to post-writing
task across days, F (2, 35) = .001, p = .97,
compared to controls. There were no signifi-
cant effects of session or session by time inter-
actions.
Daily post-writing assessments were also
analyzed. To reduce Type I error, a three
(session) two (group) MANOVA was
performed on six dependent variables: personal,
meaningful, expression of emotions, stressful,
description of thoughts and/or feelings and
awareness of new thoughts and/or feelings. EW
participants indicated significantly greater
overall involvement in writing (p < .001 for
domains 1–5 and p = .04 for domain 6), relative
to controls ( = .47, p < .001).
Blood pressure effects
Two-way (group time) ANOVAs with one
repeated measure examined between-group
differences in BP from baseline to 1- and 4-
month follow-ups. There was a significant main
effect of time for both systolic, F (2, 72) = 4.57,
p < .02, and diastolic, F (2, 72) = 4.35, p < .02,
indicating that participants decreased in BP
over time, regardless of group (see Table 3). The
hypothesized group time interactions were
not significant for either systolic, F (2, 72) = 1.96,
p = .15,
2
= .05, or diastolic BP, F (2, 72) = .26,
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NS,
2
= .01, however, the former exhibited a
trend in the hypothesized direction.
To further investigate BP data, paired-samples
t-tests were conducted separately within each
group from baseline to 1-month and from 1-
month to 4-month assessments (see Table 3 for
descriptive statistics). These indicated a statisti-
cally significant decrease in systolic BP, t (17) =
3.06, p < .01, d = .36, and in diastolic BP, from
baseline to 1-month follow-up, t (17) = 2.26, p <
.05, d = .21 in the expressive writing group.
Decreases in the control group were not signifi-
cant for either systolic or diastolic BP during
this same time period, t (19) = 1.10, p = .29 and
t (19) = .99, p = .33, respectively. From 1- to 4-
month follow-ups, however, there was a signifi-
cant increase in systolic BP in the expressive
writing group, t (17) = –3.04, p < .01, but no
significant changes in the control group, t (19) =
.49, NS. Neither the expressive writing group,
t (17) = .27, NS, nor the control group, t (19) =
.49, NS, evidenced significant changes in dias-
tolic PB during this period. Thus, there was
some partial support for beneficial effects of
writing on 1-month BP.
Skin conductance and heart
rate variability effects
A series of 3 (time) 2 (session; time 1 and time
2) by 2 (group) ANOVAs evaluated group
differences in SC and HRV.
3
Significant main
effects of session indicated that participants
increased in SC on average from the first half to
the second half of each 15-minute period of
recording biofeedback data, F (1, 31) = 8.82, p <
.01. Contrary to predictions, no significant main
effects of time or group time interactions
were found. Means, standard deviations and
interaction statistics are shown in Table 4.
For heart rate variability, very low frequency
(VLF), low frequency (LF) and high frequency
(HF) waves were analyzed separately. See Table
4 for results. The VLF is considered to be
sympathetically mediated, with lower VLF indi-
cating less arousal and therefore less rumination
and worry (Gevirtz, 2000). The LF correlates
with baroreceptor reflexes, which play an
important role in BP regulation (Gevirtz et al.,
2003). The HF is a measure of vagal tone, which
is parasympathetically mediated, and higher
levels indicate better vagal tone (Gevirtz et al.,
2003).
There was a significant group time inter-
action for VLF such that the control group
increased in VLF from baseline to 1- and 4-
month follow-ups, whereas the expressive
writing group’s VLF scores remained the same
over time, F (2, 29) = 3.50, p < .05; d = .12.
Additionally there was a non-significant trend
(p = .17) indicating increased HF from baseline
to 1-month follow-up in the expressive writing
group and decreased HF in the control group,
which, when accompanied by the concurrent
decreased BP for expressive writing partici-
pants, provides weak support for beneficial
effects of writing on vagal tone.
Moderator effects
To evaluate Anger-In as a moderator of the
relationship between group status and BP, four
multiple regression analyses were performed
using systolic and diastolic BP at 1- and 4-month
follow-ups as the respective dependent vari-
ables. Baseline Anger-In was mean-centered
BECKWITH ET AL.: EXPRESSIVE WRITING AND BLOOD PRESSURE
203
Table 3. Means, standard deviations and ANOVAs for blood pressure
Expressive writing
a
Control
b
F
Variable M (SD) M (SD) Time (T) T X Group
Systolic BP 4.57* (1.96
Baseline 141.79 (10.41) 139.50 (13.08)
1 month 134.11 (11.76) 136.15 (18.58)
4 months 140.78 (13.48) 135.55 (12.40)
Diastolic BP 4.35* ( .26
Baseline 90.26 (5.27) 89.95 (7.16)
1 month 86.94 (7.03) 87.85 (11.14)
4 months 86.44 (8.00) 86.95 (8.50)
Notes: BP = blood pressure. All values are in mmHg.
a
n = 18;
b
n = 20; *p < .05
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to reduce potential multicollinearity prior to
computing the interaction terms. Group was
dummy coded (expressive writing = 1; control =
0). Baseline systolic or diastolic BP (respec-
tively) group, baseline Anger-In and the group
Anger-In interaction term were entered as
predictors. In all four analyses, baseline levels
significantly positively predicted 1- and 4-month
BP. Interactions were not significant for 1-
month diastolic or for systolic BP. Anger-In
interacted significantly with group, however, to
predict 4-month diastolic BP with medium
effect size (sr
2
= .11). Results are shown in Table
5 and Fig. 1. Control group participants who
were high in Anger-In at baseline, had a higher
residualized diastolic BP at 4-month follow-up,
relative to low Anger-In controls. However,
high Anger-In expressive writing group partici-
pants had a lower residualized diastolic BP at
4-months, compared to expressive writing
participants with lower Anger-In.
Discussion
This study evaluated the effects of an expressive
writing intervention on BP in individuals with
elevated BP. The groups were similar at pretest
on all demographics, medications and health
behaviors that were correlated with the
outcomes. Consistent with previous studies
(Greenberg et al., 1996; Pennebaker & Beall,
1986), participants in the expressive writing
group reported an increase in negative mood
from pre- to post-writing task across sessions.
There was no habituation of negative mood
across sessions. The expressive writing group
also rated their essays as more personal and
meaningful, the disclosed events as more stress-
ful and disclosed more thoughts and/or feelings,
as well as becoming aware of more new
thoughts and/or feelings, in comparison with
controls. Adherence checks established that
participants obeyed instructions with respect to
essay content and the timing of essay-writing.
These results suggest that the manipulation
worked mostly as intended.
Although no significant interaction effects
were found for SC, as has been found in
previous studies (Petrie et al., 1995), a signifi-
cant group time interaction was found on one
of three measures of heart rate variability.
Controls increased in the very low frequency
wave of HRV (VLF) from baseline to 1 and 4
month follow-ups, but expressive writing
JOURNAL OF HEALTH PSYCHOLOGY 10(2)
204
Table 4. Means, standard deviations and ANOVAs for skin conductance and heart rate variability
Expressive writing Control
F
Variable M (SD) M (SD) (Time X Group)
VLF HRV (%) 3.50*
Baseline .51 (.01) .48 (.14)
1 month .51 (.01) .53 (.01)
4 months .51 (.01) .54 (.01)
LF HRV (%) 1.09
Baseline .31 (.01) .31 (.01)
1 month .32 (.00) .31 (.01)
4 months .30 (.01) .31 (.01)
HF HRV (%) 1.81
Baseline .18 (.01) .21 (.14)
1 month .23 (.20) .17 (.01)
4 months .19 (.01) .16 (.01)
SC 1.20
Baseline 3.23 (4.62) 2.07 (1.06)
1 month 4.54 (4.59) 2.63 (1.57)
4 months 2.54 (2.37) 2.50 (1.66)
Notes: VLF = very low frequency wave; LF = low frequency wave; HF = high frequency wave; HRV = heart
rate variability. % = percentage of total power for that wave. HRV values are in Hz and SC values are in
micromhos. Expressive writing group ns were 14 for HRV and 16 for SC
Control group ns were 15 for HRV and 17 for skin conductance
*p < .05
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participants maintained a constant level of VLF
over time. The VLF is sympathetically medi-
ated, with lower VLF indicating less arousal.
VLF is also a physiological correlate of rumina-
tion and worry (Gevirtz, 2000). The protective
effects of expressive writing on VLF are
consistent with theories and empirical studies
(Pennebaker & Susman, 1988; Wegner,
BECKWITH ET AL.: EXPRESSIVE WRITING AND BLOOD PRESSURE
205
Table 5. Summary of standard multiple regression analyses for group, Anger–In and their interaction predict-
ing SBP and DBP
Dependent variable Predictor B SE B
sr
2
R
2
1-month SBP
Baseline SBP .79 .18 .61*** .36 .42**
Group –3.76 4.10 –.12 .01
Baseline Anger-In .90 .77 .21 .02
Group Anger-In –1.01 1.14 –.16 .01
4-month SBP
Baseline SBP .65 .14 .60*** .34 .44**
Group 3.56 3.37 .14 .02
Baseline Anger-In .35 .64 .10 .00
Group Anger-In –.94 .94 –.18 .02
1-month DBP
Baseline DBP .78 .22 .53*** .26 .35**
Group –1.14 2.59 –.06 .00
Baseline Anger-In 1.12 .49 .45* .10
Group Anger-In –.47 .72 –.13 .01
4-month DBP
Baseline DBP .49 .20 .38* .13 .28*
Group –1.01 2.39 –.06 .00
Baseline Anger-In .71 .45 .32 .05
Group Anger-In –1.49 .66 –.46* .11
Note: SBP = systolic blood pressure; DBP = diastolic blood pressure; N = 38
*p < .05; **p < .01; ***p < .001
Figure 1. Interaction of mean-centered Anger-In and group predicting residualized 4-month diastolic BP. The
interaction was significant at p < .05.
–1
–0.5
0
0.5
1
Low High
An
g
er-In
Residualized four-month DBP
Expression
Control
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Schneider, Carter, & White, 1987), which
suggest that deliberate cognitive or emotional
inhibition produces chronic rumination and
worry, and with studies by Lepore and
colleagues (e.g. Lepore, 1997; Lepore & Helge-
son, 1998) suggesting that emotional disclosure
inures participants to the negative psychological
and physiological sequelae of intrusive
thoughts. Future research could clarify the
relationship between expressive writing, intru-
sive thoughts and VLF by using a uniform stres-
sor (e.g. a film) and including a measure of
intrusive thoughts at each assessment. Intrusive
thoughts and VLF could be assessed as both
moderators and outcomes of expressive writing.
VLF may also mediate expressive writing
effects on intrusive thoughts.
There were significant time main effects, indi-
cating decreases in both types of BP, regardless
of group, from baseline to the two follow-ups.
The group time interaction for SBP showed a
trend (p < .15) in the hypothesized direction.
Posthoc analyses indicated significant reduc-
tions in both types of BP in the expressive
writing group from baseline to 1 month follow-
up. The effect sizes (d = .36 for systolic BP and
d = .21 for diastolic BP) suggest this finding is
unlikely due just to chance or repeated
measurement. However, expressive writing
group systolic BP increased significantly from 1
to 4 month follow-ups, relative to the control
condition, whereas controls maintained steady
systolic BP levels from 1 to 4 months. There was
also an increase in the high frequency wave
(HF) of HRV from baseline to 1-month follow-
up in the expressive writing group with a
concurrent decrease in the control group. This
trend, together with the simultaneous decrease
in BP, indicates a possible short-term beneficial
increase in vagal tone resulting from expressive
writing and is consistent with psychophysio-
logical theories (Brosschot & Thayer, 1998)
linking chronic emotional inhibition to persist-
ently low vagal tone, decreased HRV and
decreased cardiac control of BP.
How do the reductions in BP in this study
compare to other studies? Crow et al. (submit-
ted), using a normotensive sample, reported a
drop in both systolic and diastolic BP of almost
3 mmHg in the expressive writing group over 6
weeks, whereas between-group differences at 6
weeks in this study were 5.6 mmHg for systolic
and 3.4 mmHg for diastolic BP. In this study,
significant within-group differences were also
found for the expressive writing group from
baseline to 1-month follow-up, systolic BP
decreased 7.68 mmHg and diastolic BP
decreased 3.32 mm Hg. Although the group
time interaction was not significant in this study,
the BP decreases in both groups are similar to
or larger than those found in the Crow et al.
(submitted) study. These decreases are poten-
tially important because the risk for future
cardiac complications, such as stroke or
myocardial infarction, can be reduced with
even small reductions in BP (AHA, 2000).
Anger-In moderated the effects of EWon
autonomic arousal. In the control group, high
Anger-In participants had higher residualized
diastolic BP at 4-month follow-up, relative to
low Anger-In participants. Conversely, expres-
sive writing group participants with higher
Anger-In had lower residualized diastolic BP at
4-month follow-up than low Anger-In partici-
pants. Expressive writing decreased diastolic BP
for characteristic anger inhibitors, yet it
increased diastolic BP for those with low anger
inhibition. Furthermore, control group partici-
pants high in Anger-In, increased their BP more
over time than low Anger-In participants. These
findings are consistent with theoretical asser-
tions regarding the negative physiological
effects of chronic inhibition. Expressive writing
may have inured high Anger-In individuals to
these detrimental effects by providing a safe
context for emotional expression.
The moderating effect of Anger-In and the
protective effects of writing on a physiological
marker of cognitive rumination are consistent
with the theory (Davidson et al., 2002) suggest-
ing that expressive writing is most beneficial for
those with chronic problems in anger modula-
tion or inadequate cognitive integration of
stressful events. This intervention appears less
useful for individuals who do not typically
inhibit emotion. Individuals with undermodu-
lated anger may benefit more from learning how
to decrease emotional arousal or constructively
express anger in an interpersonal context. Those
whose high BP is due to dietary or genetic
factors may do better with medical or health
behavior interventions. Future research might
employ more individualized selection of
appropriate participants.
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Some caveats are in order. First, the relatively
small sample limited the power to detect
outcome differences. Second, there are some
limits to generalizability. Participants were
largely Caucasian (73.7%) and of higher
socioeconomic status (81.6%), although
hypertension is typically more common in
African-Americans (JNC 7, 2003) than Whites.
Dropouts were more likely than completers to
be single and to have comorbid medical
conditions. Third, this was a mixed population
with regard to JNC VI BP category, although all
had elevated BP. Fourth, although these effect
sizes are clinically important, BP decreases in
the expressive writing group were not main-
tained at 4 months and effects were not
consistent across all measures.
Future studies should attempt to replicate
these findings with a larger sample size and
address maintenance issues. Perhaps a greater
frequency or duration of intervention writing
sessions, more structured writing instructions,
booster sessions, or assistance in applying
writing insights to cope with internal or external
stressors are necessary for longer-term main-
tenance of physiological gains in this medical
population. Future research should also include
a no treatment control group to tease apart the
effects of the different conditions.
Conclusions
The immediate effects of expressive writing
were similar to previous studies in that the
expressive writing group reported greater
overall emotional engagement in writing and
had greater pre–post writing NA increases than
controls. Additionally, BP decreased over time
for both groups.
Only expressive writing participants exhib-
ited significant within-group decreases in
systolic and diastolic BP from baseline to 1
month follow-up. The magnitude of effect was
similar to previous studies with normotensives.
These within-group findings, together with a
trend suggesting increased HF HRV in the
expressive writing group at 1 month follow-up,
suggests that expressive writing may have
produced short-term beneficial increases in
vagal tone. Additionally, the significant group
time interaction for VLF indicates that expres-
sive writing may have protected participants
from the increase in sympathetically mediated
arousal and, possibly, cognitive rumination,
found in the control group.
Overall this study found no effects of
expressive writing on SC, and some short-term
beneficial effects on BP and HRV. Longer-term
effects of expressive writing were moderated by
Anger-In, such that expressive writing
increased 4-month diastolic BP for low Anger-
In participants, relative to controls, but
decreased diastolic BP for those high in Anger-
In.
Notes
1. Participants who were physician-referred were of
higher SES and less likely to have a family history
of medical illness than those who were self-
referred or recruited by advertisement/flyers,
2
(4, N = 38) = 13.63, p < .01;
2
(2, N = 38) = 10.13,
p < .01, for SES and family history, respectively.
The expressive writing and control groups did not
differ in the proportion of participants from the
three different referral sources,
2
(2, N = 38) =
1.77, NS, therefore, referral source was not used as
a covariate.
2. One of 18 physician-referred participants chose to
do the writing at his home instead of the
physician’s office.
3. The ns were reduced in these analyses because two
participants at baseline, two participants at 1-
month follow-up and one participant at 4 month
follow-up did not register any SC data. Addition-
ally, the computer did not register the ECG waves
necessary to measure HRV for nine participants.
Therefore, the ns were 33 for SCL (16 expressive
writing, 17 control) and 29 for HRV (14 expressive
writing, 15 control).
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... Moreover, participants in the expressive group produced more antibodies against the hepatitis B vaccine as compared to controls. In another study on individuals with elevated blood pressure, McGuire et al. (2005) measured SCL for 15 minutes, one week before the expressive writing sessions, and at 1-and 4-months follow-ups. Participants wrote on 3 consecutive days about a trauma (expressive group) or about how they spend time (control group). ...
... We examined SCL before, during, and after the writing tasks. To the best of our knowledge, only two other studies have measured EDA changes during writing (see McGuire et al., 2005;Petrie et al., 1995). Based on the limited literature available, we expected participants in both studies to show: (i) increased skin conductance level (SCL) upon starting the writing task as a result of receiving the writing prompt; (ii) perhaps due to habituation, the initial rise in SCL might decrease throughout the writing session; (iii) due to the emotional load of the traumatic event, the expressive groups might exhibit higher SCL than the control groups, and (iv) finally in post writing, as a consequence of resting, SCL might decrease to baseline in both groups, since the SNS is expected to decrease activity during periods of rest and relaxation. ...
... Both groups showed similar levels of SCL during and after writing the texts. This finding is similar to the result of McGuire et al. (2005), who also did not find a change in SCL induced by the writing topic. ...
Article
Full-text available
Writing about traumas can influence mood and bodily changes. In three studies we researched the influence of writing on affective and physiological changes by measuring electrodermal activity (EDA) during expressive writing sessions and manipulating self-distancing. In Study 1, we randomly assigned 57 participants to write about control or expressive topics using a first-person perspective (I). In Study 2, we assigned 55 participants to write about control or expressive topics using a third-person perspective (She/He). And in Study 3, we compared the effects of perspective (first or third-person) in the data collected in the preceding studies. Across Study 1 and 2 results showed that EDA consistently rose at the beginning of the writing session, reached a plateau, and then rose again upon completing the writing task, irrespective of the writing topic or perspective. While the initial EDA increase seems related to the start of a demanding task, the post-writing increase might signal reward-seeking behavior upon task completion. Results of Study 3 confirmed that EDA increases in the beginning and upon writing completion are magnified by adopting a third-person perspective. These results show that expressive writing and self-distancing have measurable impacts on writers’ electrodermal activity.
... These findings are consistent with previous literature showing that both the parasympathetic nervous system (PNS) and sympathetic nervous system (SNS) increase during emotional tasks [43]. For example, a study using physiological measures found that writing, regardless of the topic, increases SNS activity among subjects [44]. Thus, it is not surprising to see a significant change in BPS in DURING and POST compared to NA. ...
... This significant difference suggests that after BPS, a higher self-regulatory effect in participants is found. These results are in line with previous research where HRV levels are higher after expressive writing tasks [44]. Although, the writing task, sample profile, and HRV features that show this higher effect differ from our study. ...
... In a related vein, expressive writing studies (e.g., Pennebaker, 1997) have shown that putting thoughts and feelings surrounding traumatic events into words goes along with decreases in physiological arousal (e.g., blood pressure; McGuire et al., 2005;Petrie et al., 1995) and improvements in physical health (Pennebaker, 1997) from the first to the last day of writing. Individuals who used a lot of positive emotion words in their writings showed the biggest improvements (e.g., Pennebaker, 1997). ...
... Similarly, psychological language studies have seen emotion word use as a reflection of an individual's focus on negative or positive emotions (e.g., Boyd & Schwartz, 2021;Markowitz, 2022). Another perspective, supported by affect labeling (Torre & Lieberman, 2018) and some expressive writing studies (McGuire et al., 2005;Petrie et al., 1995), suggests the opposite, namely that the use of negative emotion words would be associated with reduced cardiovascular reactivity. The present findings support the former perspective, converging with other studies, which have shown that partners use more negative emotion words when they feel annoyed (Han et al., 2021) and less satisfied with their relationship (Karan et al., 2017). ...
Preprint
Putting feelings into words is often thought to be beneficial. Few studies, however, have examined associations between natural emotion word use and cardiovascular reactivity. This laboratory-based study examined emotion word use (i.e., from computerized text analysis) and cardiovascular reactivity (i.e., interbeat interval changes from baseline) across two interaction contexts (i.e., conflict and positive conversations) in 49 mixed-sex married couples (age: M = 43.11, SD = 9.20) from diverse socioeconomic backgrounds. We focused on both frequency (i.e., relative proportion of emotion words) and diversity (i.e., relative proportion of unique emotion words) of emotion words. Data were collected between 2015 and 2017 and analyzed treating both partners and conversations as repeated measures, resulting in 196 observations overall (four per dyad). Findings showed that (1) when spouses used more negative emotion words (especially anger), they showed higher cardiovascular reactivity. This finding was robust when controlling for covariates; generalized across gender, interaction contexts, and socioeconomic status. Moreover, (2) when spouses used a more diverse negative emotion vocabulary, they showed higher cardiovascular reactivity, but this was not robust when controlling for negative emotion word frequency. Associations between (3) positive emotion word use and cardiovascular reactivity were not statistically significant. Verbalizing negative emotions thus seems to go along with higher cardiovascular reactivity, at least in the short term. Replication is needed across other relationship types, genders, and sexual orientations. These findings highlight emotion word use as an indicator of cardiovascular reactivity, which has implications for the identification of potential health risks that emerge during marital interactions.
... In a related vein, expressive writing studies (e.g., Pennebaker, 1997) have shown that putting thoughts and feelings surrounding traumatic events into words goes along with decreases in physiological arousal (e.g., blood pressure; McGuire et al., 2005;Petrie et al., 1995) and improvements in physical health (Pennebaker, 1997) from the first to the last day of writing. Individuals who used a lot of positive emotion words in their writings showed the biggest improvements (e.g., Pennebaker, 1997). ...
... Similarly, psychological language studies have seen emotion word use as a reflection of an individual's focus on negative or positive emotions (e.g., Boyd & Schwartz, 2021;Markowitz, 2022). Another perspective, supported by affect labeling (Torre & Lieberman, 2018) and some expressive writing studies (McGuire et al., 2005;Petrie et al., 1995), suggests the opposite, namely that the use of negative emotion words would be associated with reduced cardiovascular reactivity. The present findings support the former perspective, converging with other studies, which have shown that partners use more negative emotion words when they feel annoyed (Han et al., 2021) and less satisfied with their relationship (Karan et al., 2017). ...
Article
Full-text available
Putting feelings into words is often thought to be beneficial. Few studies, however, have examined associations between natural emotion word use and cardiovascular reactivity. This laboratory-based study examined emotion word use (i.e., from computerized text analysis) and cardiovascular reactivity (i.e., interbeat interval changes from baseline) across two interaction contexts (i.e., conflict and positive conversations) in 49 mixed-sex married couples (age: M = 43.11, SD = 9.20) from diverse socioeconomic backgrounds. We focused on both frequency (i.e., relative proportion of emotion words) and diversity (i.e., relative proportion of unique emotion words) of emotion words. Data were collected between 2015 and 2017 and analyzed treating both partners and conversations as repeated measures, resulting in 196 observations overall (four per dyad). Findings showed that (a) when spouses used more negative emotion words (especially anger), they showed higher cardiovascular reactivity. This finding was robust when controlling for covariates; generalized across gender, interaction contexts, and socioeconomic status. Moreover, (b) when spouses used a more diverse negative emotion vocabulary, they showed higher cardiovascular reactivity, but this was not robust when controlling for negative emotion word frequency. Associations between (c) positive emotion word use and cardiovascular reactivity were not statistically significant. Verbalizing negative emotions thus seems to go along with higher cardiovascular reactivity, at least in the short term. Replication is needed across other relationship types, genders, and sexual orientations. These findings highlight emotion word use as an indicator of cardiovascular reactivity, which has implications for the identification of potential health risks that emerge during marital interactions.
... Greater HRV is considered to be a physiological indicator of adaptive emotional regulation (Denson, Grisham, & Moulds, 2011), and chronically lower HRV is associated with worry (Aldao, Mennin, & McLaughlin, 2013), anxiety disorders, chronic inflammation, and cardiovascular disease (Shaffer, McCraty & Zerr, 2014). In adults with hypertension, EW has been thought to buffer increases in a very low frequency wave of HRV (found only in controls) (Beckwith, McGuire, Greenberg, & Gervitz, 2005). Because EW may provide the opportunity for both emotional expression and cognitive change (Niles, Byrne Hamilton, Lieberman, Hur, & Stanton, 2016), this finding is consistent with research demonstrating that cognitive reappraisal of an anger-inducing event is associated with increases in HRV, compared to suppression of emotions or a control condition (Denson et al., 2011). ...
... As outlined previously, EW has effects on cortisol levels (Sloan & Marx, 2004a;, heart rate variability (Beckwith McGuire et al., 2005;Seeley et al., 2017), and immune functioning (Pennebaker, Kiecolt-Glaser, & Glaser, 1988;Petrie, Booth, Pennebaker et al., 1995;Petrie et al., 2004). However, pathway models, in which psychological processes lead to physiological processing, which subsequently lead to physical health changes, require further investigation. ...
Chapter
and Keywords Expressive writing (EW) was developed in the 1980s by Pennebaker and colleagues, who defined it as "writing focusing on traumatic, stressful or emotional events, and the feelings inspired by these." There have been developments in terms of process, covering a range of instructions, target groups, and writing conditions and, more recently, benefit-finding writing (BFW) about benefits derived from stress or traumatic situations. EW has now been trialed across a broad range of situations, involving mental and physical health domains. Results from meta-analyses find small but significant improvements more related to physical health than mental health parameters. It is thought to be best suited to people with mild-to-moderate psychological distress who are addressing stress-related conditions and situations. The chapter describes common forms of EW and explores the place of BFW. Some mechanisms for expressive writing are discussed, but these are still speculative.
... Depression and anxiety are commonly experienced by individuals with lifestyle-related diseases (Dennick et al., 2015;Hevey & Wilczkiewicz, 2014;Wilmott et al., 2011), and the findings of numerous studies support EW as an effective brief intervention for psychological health . Physiological factors are strong predictors of morbidity and mortality related to a range of lifestyle-related diseases (Bourassa et al., 2017), and evidence suggests that EW interventions can influence these factors and reduce the associated risks (Hevey & Wilczkiewicz, 2014;McGuire et al., 2005;Wilmott et al., 2011). Some health-related behaviours, such as smoking and alcohol consumption, are believed to occur as a response to stress, and EW has shown efficacy in reducing stress (Ames et al., 2005;Ames et al., 2007). ...
... Short-term autonomic effects and longterm moderated effects were noted for patients with cardiovascular disease, including improved physiological measures (Bourassa et al., 2017;McGuire et al., 2005), decreased hospital and GP presentations (Wilmott et al., 2011), and improved subjective wellbeing and quality of life (Hevey & Wilczkiewicz, 2014;Wilmott et al., 2011). Narrative EW appears to provide an avenue which can improve cardiovascular function and health outcomes and decrease incidence of a range of cardiovascular conditions (Bourassa et al., 2017). ...
... İrritabl bağırsak sendromu olan hastalarda hastalığın şiddeti ve biliş düzeyi iyileşebilir (35). Dinlenme kan basıncında azalma gözlemlenebilir (36). Romatoid artrit hastalarında yürüme hızı ve duygusal ağrıda iyileşme görülebilir (37). ...
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Writing can facilitate existential change by helping individuals to address existential issues within themselves. Writing can help the individual to recognize and revise dysfunctional thought patterns and find a new perspective about themselves and their life. Writing therapy can encourage self-analysis in existential crises and support the search for meaning and existential reframing. Writing can help in the self-healing process by reducing feelings of powerlessness as a result of trauma. Writing therapy can be used as a tool to manipulate and reshape traumatic events, enabling the transfer of emotional truths. In the Turkish literature, there are no studies on the use of writing therapy in applied and clinical psychology. Writing therapy is a form of therapy that uses the act of writing to address emotional, psychological and physical problems. Different techniques are used and can be done independently or with a therapist. It can provide emotional healing, mental growth and personal development. The aim of this study is to examine the potential applicability of writing therapy. In the study, the "document review-literature review" method was used as a data collection method. Writing therapy is an effective method for coping with mental disorders. It has positive effects on post-traumatic stress, anxiety, depression, obsessive-compulsive disorder, grief and loss, substance abuse, eating disorders, interpersonal relationship problems, communication skill problems and low self-esteem. The short-term effects of writing therapy can sometimes be feelings of discomfort or negative mood, but in the long term it can provide many mental and physical health benefits. Writing therapy represents an effective method of psychotherapy that can help individuals who have difficulty expressing their emotions and is an effective, feasible and affordable therapy option for a range of psychopathology issues in clinical psychology. However, more research is needed on how long-lasting the effects of writing therapy are. Özet: Yazma, bireyin kendi içindeki varoluşsal sorunları ele almasına yardımcı olarak, varoluşsal değişimi kolaylaştırabilir. Yazma, bireyin işlevsiz düşünce kalıplarını fark etmesine ve gözden geçirmesine, kendisi ve yaşamı hakkında yeni bir perspektif bulmasına yardımcı olabilir. Yazı terapisi, varoluşsal krizlerde bireyin öz analizini teşvik ederek anlam arayışını ve varoluşsal yeniden çerçevelemeyi destekleyebilir. Yazmak, travma sonucu oluşan güçsüzlük duygusunu azaltarak kendi kendini iyileştirme sürecinde yardımcı olabilir. Yazı terapisi, travmatik olayları manipüle etmek ve yeniden şekillendirmek için bir araç olarak kullanılarak, duygusal gerçekleri aktarmayı sağlar. Türkçe alan yazına bakıldığında uygulamalı ve klinik psikolojide yazı terapisinin kullanımı hakkında çalışmaya rastlanmamaktadır. Yazı terapisi, duygusal, psikolojik ve fiziksel sorunları ele almak için yazma eylemini kullanan bir terapi şeklidir. Farklı teknikler kullanılır ve bağımsız veya terapist eşliğinde yapılabilir. Duygusal iyileşme, zihinsel büyüme ve kişisel gelişim sağlayabilir. Bu çalışmanın amacı yazı terapisinin potansiyel uygulanabilirliğini incelemektir. Araştırmada veri toplama yolu olarak, "belge tarama-literatür tarama" yönteminden yararlanılmıştır. Yazı terapisi, ruhsal bozukluklarla baş etmek için etkili bir yöntemdir. Travma sonrası stres, anksiyete, depresyon, obsesif-kompulsif bozukluk, yas ve kayıp, madde bağımlılığı, yeme bozuklukları, kişilerarası ilişki sorunları, iletişim becerisi sorunları ve düşük öz saygı gibi durumlar üzerinde olumlu etkileri vardır. Yazı terapisinin kısa vadeli etkileri bazen rahatsızlık hissi veya olumsuz ruh hali olabilir, ancak uzun vadede birçok zihinsel ve fiziksel sağlık yararı sağlayabilir. Yazı terapisi, duygularını ifade etmekte güçlük çeken bireylere yardımcı olabilecek etkili bir psikoterapi yöntemini temsil etmekte ve klinik psikolojideki bir dizi psikopatoloji sorunu için etkili, uygulanabilir ve ekonomik bir terapi seçeneğidir. Bununla birlikte, yazı terapisinin etkilerinin ne kadar uzun süreli olduğu konusunda daha fazla araştırmaya ihtiyaç vardır.
... Expressive writing, requiring significant emotional and cognitive engagement, serves as a critical area of study. This type of writing, often reflective and personal, can induce physiological changes correlating with heart rate and emotion [27,28]. The typing patterns observed during such tasks offer a unique lens through which to view an individual's cognitive and emotional state, providing a practical method to assess productivity [29]. ...
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Cognitive Arousal, frequently elicited by environmental stressors that exceed personal coping resources, manifests in measurable physiological markers, notably in galvanic skin responses. This effect is prominent in cognitive tasks such as composition, where fluctuations in these biomarkers correlate with individual expressiveness. It is crucial to understand the nexus between cognitive arousal and expressiveness. However, there has not been a concrete study that investigates this inter-relation concurrently. Addressing this, we introduce an innovative methodology for simultaneous monitoring of these elements. Our strategy employs Bayesian analysis in a multi-state filtering format to dissect psychomotor performance (captured through typing speed), galvanic skin response or skin conductance (SC), and heart rate variability (HRV). This integrative analysis facilitates the quantification of expressive behavior and arousal states. At the core, we deploy a state-space model connecting one latent psychological arousal condition to neural activities impacting sweating (inferred through SC responses) and another latent state to expressive behavior during typing. These states are concurrently evaluated with model parameters using an expectation-maximization algorithms approach. Assessments using both computer-simulated data and experimental data substantiate the validity of our approach. Outcomes display distinguishable latent state patterns in expressive typing and arousal across different computer software used in office management, offering profound implications for Human-Computer Interaction (HCI) and productivity analysis. This research marks a significant advancement in decoding human productivity dynamics, with extensive repercussions for optimizing performance in telecommuting scenarios.
... The benefits of EW intervention have been investigated in three categories: psychological health, physical health, and general functioning. Studies examine physical health changes by assessing individuals' blood pressure, heart rate, and cortisol levels (21, 33,34). Psychological health changes were mainly studied in relation about the reduction of negative emotions such as depression and anxiety (18,22,(35)(36)(37)(38)(39)(40)(41). ...
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Introduction Expressive Writing (EW) is an intervention that focuses on individuals’ writing down their thoughts and feelings about trauma or stressful events. Meta-analyses on EW studies have confirmed that EW has a positive effect. However, the heterogeneity of studies is high, so many studies have investigated boundary conditions and moderators. One of these moderators is the cultural difference in emotional suppression. Since EW focuses on the expression of suppressed thoughts and emotions, its effect might be slightly different for people in Asian cultures who show a high tendency to suppress their emotions. This study attempted to confirm the effect size of the EW interventions in Korea and examine whether these studies have different effect size from those based on Western cultures. Method A total of 29 studies published in Korea until 2021 were analyzed. The effect size was calculated using the “dmetar,” “meta,” and “metafor” packages of the statistical program R 4.0.4. Results The results were as follows. First, the effect size of EW intervention was 0.16, and we found that studies in the Korean context showed no significant difference from studies based on western meta-analysis. Second, the moderating variables that influenced the EW intervention were the writing type, the number of sessions, the time per session, and the measurement time. Discussion The results of this study suggest that EW interventions benefit Koreans. And it is at least harmless and has a positive effect considering the efficiency and conciseness of interventions. Furthermore, the finding shows that EW interventions can be helpful even in the general population without apparent psychological problems. By considering moderators, we could structure more effective form of EW interventions for Koreans.
Article
Yazma, bireyin kendi içindeki varoluşsal sorunları ele almasına yardımcı olarak, varoluşsal değişimi kolaylaştırabilir. Yazma, bireyin işlevsiz düşünce kalıplarını fark etmesine ve gözden geçirmesine, kendisi ve yaşamı hakkında yeni bir perspektif bulmasına yardımcı olabilir. Yazı terapisi, varoluşsal krizlerde bireyin öz analizini teşvik ederek anlam arayışını ve varoluşsal yeniden çerçevelemeyi destekleyebilir. Yazmak, travma sonucu oluşan güçsüzlük duygusunu azaltarak kendi kendini iyileştirme sürecinde yardımcı olabilir. Yazı terapisi, travmatik olayları manipüle etmek ve yeniden şekillendirmek için bir araç olarak kullanılarak, duygusal gerçekleri aktarmayı sağlar. Türkçe alan yazına bakıldığında uygulamalı ve klinik psikolojide yazı terapisinin kullanımı hakkında çalışmaya rastlanmamaktadır. Yazı terapisi, duygusal, psikolojik ve fiziksel sorunları ele almak için yazma eylemini kullanan bir terapi şeklidir. Farklı teknikler kullanılır ve bağımsız veya terapist eşliğinde yapılabilir. Duygusal iyileşme, zihinsel büyüme ve kişisel gelişim sağlayabilir. Bu çalışmanın amacı yazı terapisinin potansiyel uygulanabilirliğini incelemektir. Araştırmada veri toplama yolu olarak, "belge tarama- literatür tarama" yönteminden yararlanılmıştır. Yazı terapisi, ruhsal bozukluklarla baş etmek için etkili bir yöntemdir. Travma sonrası stres, anksiyete, depresyon, obsesif-kompulsif bozukluk, yas ve kayıp, madde bağımlılığı, yeme bozuklukları, kişilerarası ilişki sorunları, iletişim becerisi sorunları ve düşük öz saygı gibi durumlar üzerinde olumlu etkileri vardır. Yazı terapisinin kısa vadeli etkileri bazen rahatsızlık hissi veya olumsuz ruh hali olabilir, ancak uzun vadede birçok zihinsel ve fiziksel sağlık yararı sağlayabilir. Yazı terapisi, duygularını ifade etmekte güçlük çeken bireylere yardımcı olabilecek etkili bir psikoterapi yöntemini temsil etmekte ve klinik psikolojideki bir dizi psikopatoloji sorunu için etkili, uygulanabilir ve ekonomik bir terapi seçeneğidir. Bununla birlikte, yazı terapisinin etkilerinin ne kadar uzun süreli olduğu konusunda daha fazla araştırmaya ihtiyaç vardır.
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Forty-two patients with metastatic renal cell carcinoma who were participating in a Phase II clinical trial were randomly assigned to an expressive writing (EW) or neutral writing (NW) group. Patients in the EW group wrote about their cancer, and patients in the NW group wrote about health behaviors. No statistically significant group differences were found in symptoms of distress, perceived stress, or mood disturbance, except for the Vigor subscale of the Profile of Mood States. However, patients in the EW group reported significantly less sleep disturbance, better sleep quality and sleep duration, and less daytime dysfunction compared with patients in the NW group. The results suggest that EW may have sleep-related health benefits in terminally ill cancer patients.
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The author investigated whether expressive writing enhances emotional adaptation to a stressful event (graduate entrance exams) by reducing event-related intrusive thoughts or by desensitizing people to such thoughts. Participants in the experimental group, who were instructed to write their deepest thoughts and feelings about the exam, exhibited a significant decline in depressive symptoms from 1 month (Time 1) to 3 days (Time 2) before the exam. Participants in the control group, who wrote about a trivial topic, maintained a relatively high level of depressive symptoms over this same period. Expressive writing did not affect the frequency of intrusive thoughts, but it moderated the impact of intrusive thoughts on depressive symptoms. Specifically, intrusive thoughts at Time 1 were positively related to depressive symptoms at Time 2 in the control group and were unrelated to symptoms in the expressive writing group.
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A research synthesis was conducted to examine the relationship between a written emotional expression task and subsequent health. This writing task was found to lead to significantly improved health outcomes in healthy participants. Health was enhanced in 4 outcome types—reported physical health, psychological well-being, physiological functioning, and general functioning—but health behaviors were not influenced. Writing also increased immediate (pre- to postwriting) distress, which was unrelated to health outcomes. The relation between written emotional expression and health was moderated by a number of variables, including the use of college students as participants, gender, duration of the manipulation, publication status of the study, and specific writing content instructions.
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Using a process model of emotion, a distinction between antecedent-focused and response-focused emotion regulation is proposed. To test this distinction, 120 participants were shown a disgusting film while their experiential, behavioral, and physiological responses were recorded. Participants were told to either (a) think about the film in such a way that they would feel nothing (reappraisal, a form of antecedent-focused emotion regulation), (b) behave in such a way that someone watching them would not know they were feeling anything (suppression, a form of response-focused emotion regulation), or (c) watch the film (a control condition). Compared with the control condition, both reappraisal and suppression were effective in reducing emotion-expressive behavior. However, reappraisal decreased disgust experience, whereas suppression increased sympathetic activation. These results suggest that these 2 emotion regulatory processes may have different adaptive consequences.
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A theory of inhibition and psychosomatic disease suggests that the failure to confide traumatic events is stressful and associated with long-term health problems. We investigated the short-term autonomic correlates of disclosing personal and traumatic experiences among two samples of healthy undergraduates. In Experiment 1, subjects talked into a tape recorder about extremely stressful events that had occurred in their lives, as well as what they planned to do following the experiment. Skin conductance, blood pressure, and heart rate were continuously measured. Based on judges' ratings of subjects' depth of disclosure, subjects were classified as high or low disclosers. Talking about traumatic events was associated with decreased behavioral inhibition, as measured by lower skin conductance levels among high disclosers. Disclosing traumatic material was also associated with increased cardiovascular activity. In Experiment 2, subjects both talked aloud and thought about a traumatic event and about plans for the day. Half of the subjects were alone in an experimental cubicle and talked into a tape recorder; the remaining subjects talked to a silent “confessor” who sat behind a curtain. Among high disclosers, both talking and thinking about traumatic events produced lower skin conductance levels than did thinking or talking about plans for the day. The presence of a confessor inhibited subjects' talking. Implications for understanding the nature of confession and the development of an inhibitory model for psychosomatic processes are discussed.
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According to previous work, failure to confide in others about traumatic events is associated with increased incidence of stress-related disease. The present study served as a preliminary investigation to learn if writing about traumatic events would influence long-term measures of health as well as short-term indicators of physiological arousal and reports of negative moods. In addition, we examined the aspects of writing about traumatic events (i.e., cognitive, affective, or both) that are most related to physiological and self-report variables. Forty-six healthy undergraduates wrote about either personally traumatic life events or trivial topics on 4 consecutive days. In addition to health center records, physiological measures and self-reported moods and physical symptoms were collected throughout the experiment. Overall, writing about both the emotions and facts surrounding a traumatic event was associated with relatively higher blood pressure and negative moods following the essays, but fewer health center visits in the 6 months following the experiment. Although the findings and underlying theory should be considered preliminary, they bear directly on issues surrounding catharsis, self-disclosure, and a general theory of psychosomatics based on behavioral inhibition.
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We tested the assumption that the act of inhibiting ongoing behavior requires physiological work. In a guilty knowledge test (GKT) paradigm, subjects were induced to attempt to deceive the experimenter on two separate occasions while electrodermal activity was measured. For 20 of the 30 subjects, overt behaviors (changes in eye movement and facial expression) were recorded during the second GKT. Results indicated that the incidence of behaviors decreased during their deceptive responses. This behavioral inhibition coincided with increases in skin conductance level. In addition to suggesting nonverbal correlates of deception, the results indicate that long-term behavioral inhibition may be a factor in psychosomatic disease.