Int.J. Behav. Med.

DOI 10.1007/s12529-014-9449-8

Healing Words: Using Affect Labeling to Reduce the Effects

of Unpleasant Cues on Symptom Reporting in IBS Patients
Elena Constantinou & Katleen Bogaerts &
Lukas Van Oudenhove & Jan Tack & Ilse Van Diest &
Omer Van den Bergh

# International Society of Behavioral Medicine 2014

Abstract
Purpose The present study aimed to induce elevated symptom reports through the presentation of unpleasant cues in
patients with irritable bowel syndrome (IBS) and examine
whether applying an emotion regulation technique (affect
labeling) can reduce symptom reporting in patients.
Methods Patients diagnosed with IBS (N=29) and healthy
controls (N=26) were presented with six picture series (three
pleasant, three unpleasant) under three within-subject conditions: merely viewing, emotional labeling, or content (nonemotional) labeling. Each picture viewing trial was followed
by affect ratings and a symptom checklist, consisting of general arousal and IBS-specific symptoms.
Results Viewing unpleasant pictures led to overall increased
symptom reports, both for arousal and gastrointestinal symptoms, in both groups. Labeling the pictures did not reduce
these effects significantly, although a trend toward less arousal
symptoms after unpleasant cues emerged in the patient group
only, especially during emotional labeling.
Conclusions Current findings indicate that the mere presentation of unpleasant cues can induce elevated symptom reports
in IBS patients. The results of the labeling manipulation
provide modest support for the effectiveness of emotion regulation strategies in reversing these effects of unpleasant cues
in patients suffering from functional syndromes. Methodological issues that may have confounded present results are
discussed.

E. Constantinou : K. Bogaerts : I. Van Diest : O. Van den Bergh (*)

Health Psychology, Faculty of Psychology and Educational Sciences,
University of Leuven, Tiensestraat 102, B-3000 Leuven, Belgium
e-mail: Omer.VandenBergh@ppw.kuleuven.be
L. Van Oudenhove : J. Tack
Translational Research Center for Gastrointenstinal Disorders,
University of Leuven, Leuven, Belgium

Keywords Emotion regulation . Affect labeling .

Symptom reporting . IBS patients

Introduction
Physical symptoms not adequately explained by organic dysfunction are common in primary and secondary care [13]. In
specialties like gastroenterology, gynecology, and neurology,
cases with unexplained symptomatology can exceed 50 % [3,
4]. Although specialty-specific functional syndromes have
been proposed, these different syndromes share many features
and are often considered to reflect common core mechanisms
[5].
One of the most prominent shared features is their relation
to emotional distress. Patients with functional syndromes
show high levels of comorbid depression and anxiety disorders [68], while experimentally induced negative affect has
been found to intensify the perception of physical symptoms
more in functional syndrome patients compared to controls or
patients with explained disease [911]. Although quite robust,
this link among negative affect and medically unexplained
symptoms remains poorly understood.
Among the functional syndromes, irritable bowel syndrome (IBS) in particular has been linked to mechanisms
related to emotional distress, like perceptual hypersensitivity
to visceral sensations [12, 13]. Specifically, IBS patients show
larger responses of the defensive system in anticipation of
visceral stimulation [14] and greater activations in brain areas
related to affective processing of internal sensations (thalamus, insular and anterior cingulate cortex (ACC) subregions
and amygdala) compared to healthy people [15]. Additionally,
patients exhibit reduced activations of prefrontal areas during
visceral stimulation, suggesting a deficit to downregulate these emotional responses [1517].

Int.J. Behav. Med.

Importantly, induced state negative affect (NA) (e.g., by

auditory stress) has been found to enhance the unpleasantness
of visceral stimulation more strongly in IBS patients than in
controls [10]. However, the role of such affective influences
on the experience of symptoms has not been sufficiently
explored. While IBS research has focused almost exclusively
on how stress alters the perception of actual visceral stimulation, research on non-clinical samples has shown that even
slight affective manipulations by means of a picture viewing
paradigm not involving experimentally induced physiological
stimulation can induce physical symptom reports especially in
high habitual symptom reporters in daily life. These studies
suggest that state NA can have top-down effects on symptom
perception by activating symptom schemata in memory in this
selected group [18, 19]. However, this paradigm demonstrating the role of state NA in the top-down mechanisms involved
in symptom perception has not yet been examined in patients.
In addition to its effects on the subjective experience of
visceral sensations, momentary distress during visceral stimulation has been found to result in more brain activations in
insula, ACC, and VLPFC and less activation in DLPFC for
IBS patients compared to controls [20]. This suggests that
under stressful conditions, IBS patients fail to recruit inhibitory mechanisms to regulate pain. These findings, along with
studies showing deficient emotion regulation in other functional syndromes [21] and theoretical views connecting chronic pain with reduced self-regulation [22], propose a reduced
ability for self and emotion regulation as an important mechanism influencing the relation between NA and unexplained
symptoms. They further advocate the possible benefits of
interventions targeting inhibitory control over emotional reactions in reducing symptomatology in functional syndrome
patients.
One way to activate inhibitory processes is the utilization
of emotion regulation techniques to downregulate affective
reactions. Such techniques have been linked with increased
activations in prefrontal and cingulate areas and parallel reductions in amygdala activation [23, 24]. Similar effects on
brain activity and self-reported affect have been reported for
implicit emotion regulation strategies, like affect labeling
[2527]. Merely assigning emotional labels to unpleasant
stimuli has been found to reduce negative affect in both nonclinical and patient samples [27, 28]. Although it is not yet
clear which aspect of affect labeling produces such regulatory
effects, it is assumed that labeling an emotion initiates a more
cognitive or semantic processing of the emotion which entails
the activation of prior conceptual knowledge about emotions
[29]. This process seems to disrupt or inhibit the more automatic components of emotion response, thus resulting in
incidental downregulation of emotion [30].
Patients with functional syndromes, who are less successful
in intentionally employing emotion regulation strategies [21],
could possibly benefit by an implicit strategy like affect

labeling. Supporting evidence comes from a study using a

non-clinical sample, which showed that labeling compared to
merely viewing unpleasant pictures reduced momentary
symptom reports, especially in people reporting frequent unexplained symptoms in daily life [31]. However, it is not
known whether such a brief intervention would have a similar
effect in patients.
Present Study
The present study aimed to examine (a) whether the mere
presentation of unpleasant pictures induces elevated symptom
reports in patients with IBS and (b) whether an implicit
emotion regulation strategy, namely affective labeling, can
inhibit these effects on symptom reports. To this end, a picture
viewing paradigm previously used to induce elevated symptom reports [18, 19] was combined with an affect labeling task
[31] and administered to IBS patients and healthy controls.
Specifically, participants viewed pleasant and unpleasant pictures under three within-subject conditions: (a) merely viewing the pictures, (b) choosing a non-emotional label for the
pictures (content labeling), and (c) choosing an emotional
label for the pictures (emotion labeling). Each picture viewing
condition was followed by a symptom checklist.
We expected that (a) IBS patients would report more
symptoms than controls, especially gastrointestinal ones, in
all conditions, (b) unpleasant pictures would result in increased symptom reports, especially in the patient group,
and (c) the two labeling conditions would reduce symptom
reports compared to merely viewing unpleasant pictures as
previously found [31], but this effect was expected to be more
pronounced in the patient group.

Methods
Participants
The sample consisted of IBS patients (N=29, 7 males, Mage =
37.55, SDage =12.46, range=1854) recruited from the general gastroenterology and neurogastroenterology outpatient
clinics of the University Hospital Gasthuisberg, Leuven. The
IBS diagnosis was made by gastroenterologists based on the
Rome III criteria for IBS [32] and after the exclusion of
organic dysfunctions as potential sources for patients symptoms. A healthy control group (N=26, 4 males, Mage =36.50,
SDage =12.65, range=1955) was recruited via local advertisements. The groups did not differ in age or gender
proportions.
Exclusion criteria for the control group were any selfreported current disease or chronic medical or mental disorder
or medication intake (except for oral contraceptives or

Int.J. Behav. Med.

occasional anti-allergic medication). For the patient group,

mental disorders and medication use were not an exclusion
criterion; 21 patients were taking medication (antireflux, antispasmodic, anti-inflammation, analgesics), 2 patients reported
minor physical problems, 4 patients other functional syndromes, and 3 psychological problems. Participants were also
excluded post hoc if they did not experience the expected
changes in pleasantness during the task, that is, pleasantness
ratings lower than average (<5 on a 19 scale) for at least one
of the negative trials and higher than neutral for at least one of
the positive trials (3 patients, 1 control). Participants received
monetary reimbursement for their participation. The study
was approved by the Medical Ethical Committee of UZ
Gasthuisberg.
Tasks
Modified Affect Labeling Task A modified affect labeling
task, consisting of six picture viewing trials (three pleasant/
three unpleasant), previously applied on a student sample
[31], was used. Pictures were selected from the International
Affective Picture System (IAPS; [33])1 based on ratings provided by students in other studies by our group and grouped
into six sets of 10 pictures, so that sets of similar pleasantness
did not differ on pleasantness or arousal ratings.2 Based on
norms by Mikels et al. [34], each pleasant set included five
pictures depicting excitement (e.g., skiing) and five depicting
contentment (e.g. cute babies), and each unpleasant set included five pictures depicting sadness (e.g., cemetery) and five
fear (e.g., gun).
During each trial, 10 IAPS pictures were presented in the
upper part of the screen for 6 s each (no inter-stimulus interval)
under three within-subject conditions: (a) view: merely watch
the pictures, (b) label emotion: select from two emotion words
presented below the picture (two out of: excited, content, sad,
afraid), the one most applicable to the depicted emotion and
(c) label content: select from two words presented below the
picture (two out of: object, animal, human, landscape), the
one most applicable to the content of the picture.
Each trial started with a word cue stating which task
participants had to perform, while at the end of each picture
1

Positive 1: 1463, 1920, 2550, 4574, 5201, 5260, 7330, 8030, 8080,
8185; positive 2: 1620, 2341, 5700, 5760, 5849, 7280, 8200, 8370, 8461,
8490; Positive 3: 1710, 2311, 2360, 5891, 7260, 8033, 8190, 8300, 8470,
8502; negative 1: 1114, 2095, 2520, 2692, 2900.1, 5971, 6315, 6821,
9181, 9611; negative 2: 1525, 6190, 6242, 9001, 9410, 9425, 9426, 9520,
9561, 9911; negative 3: 1932, 2800, 5972, 6300, 6370, 6800, 6838, 9041,
9140, 9421.
2
Positive pleasantness ratings (19): M1=7.50 SD1=0.36, M2=7.57
SD2=0.46, M3=7.55 SD3=0.60; positive arousal ratings (19): M1=
5.39 SD1=1.30, M2=5.09 SD2=1.27, M3=5.14 SD3=1.09; negative
pleasantness ratings (19): M1=2.72 SD1=0.79, M2=2.58 SD2=0.65,
M3=2.72 SD3=0.71; negative arousal ratings (19): M1=5.80 SD1=
0.77, M2=5.71 SD2=1.02, M3=5.77 SD3=0.75.

set, participants completed affect ratings and a symptom

checklist.
Measures
Affect Ratings After each picture, viewing trial participants
rated their affect using a computerized 9-point version of the
Self-Assessment Manikin (SAM; [35]). Three sets of nine
human figures depicting gradually increasing pleasantness,
arousal, and control were presented, and participants selected
the figures that represented their level of pleasantness, arousal,
and control during the trial.
Symptom Checklist A 14-item list of physical symptoms was
also completed after each trial. The checklist included a variety of symptoms (chest tightness, pounding of the heart,
headache, fatigue, not able to breathe deeply, rapid heartbeat,
dizziness, muscular pain, burning sensation in the eyes),
previously used in a similar picture viewing paradigm [18],
while gastrointestinal symptoms (abdominal or stomach
cramps, regurgitations, nausea, abdominal pain, abdominal
bloating) were added to examine the hypotheses of this study.
Participants rated the presence of each symptom on a 5-point
Likert scale (1=not at all, 5=very strong). Total scores (range
1470) were calculated and used in analyses.
Besides total scores, analyses were also conducted for
subsets of symptoms. Subsets were determined via principal
component analysis of the symptom checklist, using data from
a student sample (N=61, 7 males, Mage =18.90, SDage =1.25).
The principal component analysis resulted in two subsets of
symptoms3: (a) four symptoms related to cardiorespiratory
indicators of physiological arousal (chest tightness, pounding
of the heart, not able to breathe deeply and rapid heartbeat;
factor eigenvalue=3.15, Cronbachs =.75, total variance
explained=22.47 %) and (b) four pain-related/gastrointestinal
(GI) symptoms (headache, muscular pain, stomach/abdominal cramps, and stomach pain; factor eigenvalue=2.16,
Cronbachs =.70, total variance explained=15.45 %). This
structure was largely confirmed in the IBS patient group (N=
29), although for the patients, the second factor also included
the item bloated stomach. Despite its small size, the patient
group is considered more representative of the population of
interest; thus, the subsets computed for the analyses were one
with four arousal-related items and one with five pain/GIrelated items as suggested by the patient sample.

A parallel analysis procedure [36] was first conducted to determine the

number of reliable factors, which suggested a two-factor structure for the
checklist. A principal component analysis (PCA) with varimax rotation
and factor extraction constrained to two factors (KMO=.57; 2 (91)=
242.61, p<.001) confirmed the two-factor structure, which could explain
37.91 % of the variance. Items loading .60 or higher were retained for
each of the two factors.

Int.J. Behav. Med.

Group Characteristics

Design and Data Analyses

Habitual Symptom Reporting The Checklist for Symptoms in

Daily Life based on the checklist of Wientjes and Grossman
[37] was administered to assess participants level of habitual
symptom reporting. Participants reported how often they experienced 39 everyday symptoms from various modalities
(e.g., headache, back pain) over the past year on a 5-point
Likert scale (1=never, 5=very often). Total scores (ranging
from 39 to 195) were calculated.

A group (controls, patients)task (view, label content, label

emotion)affective cue (positive, negative) repeated measures ANOVA design was used. Analyses were conducted
on (a) the affect ratings (pleasantness, arousal, control) as a
manipulation check, (b) the total symptom score, and (c) the
scores for arousal- and pain/GI-related symptom subsets. Significant interactions and those related to a priori hypotheses
were followed up with separate simple effect ANOVAs. For
the manipulation checks, a significant main effect of affective
cue would denote successful manipulation of affect, while an
affective cuetask interaction would denote the expected
modulation of affect by labeling tasks. As for the main analyses, in order to examine our first hypothesis, i.e., whether
unpleasant pictures induced changes in symptom reports differentially in patients and controls without any intervention,
we examined the affective cuegroup interaction for the view
condition only with the criterion adjusted to .016
(Bonferroni adjustment). To examine our second hypothesis,
i.e., whether the two labeling tasks moderate the effects of
unpleasant pictures differentially for patients and controls, the
affective cuetask interaction was examined separately for
each group, regardless of the higher order three-way interaction ( adjusted to .025). Greenhouse-Geisser corrected pvalues and epsilon are reported when the sphericity assumption was violated. Analyses were conducted with
STATISTICA 11.0 (Statsoft, Inc., Tulsa, OK). The principal
component analysis procedures were run with SPSS 17.0.

Anxiety and Depression The Dutch version [38] of the Hospital Anxiety and Depression Scale (HADS; [39]) was used to
assess participants level of anxiety and/or depression. The
HADS consists of 14 questions, assessing anxiety and depressive feelings/symptoms over the past week on a 4-point Likert
scale. Separate scores for anxiety and depression were
calculated.
Procedure
Testing took place at the gastrointestinal unit of UZ
Gasthuisberg during the outpatient consultations. Patients diagnosed with IBS were invited by their doctors to participate
in a study examining the effects of emotions on IBS, whereas controls were invited to the clinic via email. Upon arrival to
the testing room, participants gave written informed consent
and completed a brief inventory assessing health status and
demographic information and the Checklist for Symptoms in
Daily Life.
Next, participants were introduced to the three tasks of the
modified affect labeling task. For the view task, participants
were instructed to merely view the pictures and allow natural
responses to the pictures, while for label emotion and label
content tasks, they were asked to choose among two given
labels, the one most relevant to the picture.
When participants had no further questions, the experimenter left the room and participants completed the six picture
viewing trials. Each trial consisted of (a) a 3-s presentation of
a word cue signaling what the task participants had to do (view,
label emotion, label content), (b) a 60-s picture viewing period,
and (c) a 1.5 min inter-trial period, during which participants
completed electronic affect ratings and the symptom checklist.
The trials were semi-counterbalanced with 12 orders created in such a way that each of the six trials was presented twice
at a certain order position, while each pleasant/unpleasant
picture set was presented four times for each task (view, label
emotion, label content). Affect 4.0 [40] was used for programming the experiment, while testing was done on a 13-inch
laptop computer.
At the end of the experiment, participants received a set of
questionnaires (including the HADS), which they had to
complete at home and send back.

Results
Descriptive Statistics
Table 1 presents means and SDs for each group on various
characteristics. The groups differed as expected on habitual
symptom reporting, anxiety and depression (Table 1). Within
the patient group, 18 people were on medication to manage
their IBS symptoms, one person was taking antidepressants
and one anxiolytics. One patient was receiving psychological
treatment for IBS and two for non-IBS-related reasons.
Manipulation Checks
Analyses showed that picture viewing elicited the expected
changes in perceived pleasantness, arousal, and control in
both groups, thus confirming the intended manipulation. Specifically, main effects of affective cue were observed for each
measure with positive trials (with pleasant pictures) resulting
in higher pleasantness (F(1,53)=389.18, p<.0001, partial
2 =.88), lower arousal (F(1,53) = 50.53, p <.001, partial

Int.J. Behav. Med.

Table 1 Group differences in self-reported variables
Measure

Age
BMI
CSD
HADS-anxiety
HADS-depression
HADS-total

Groupmean (SD)

arousal and control ratings, the effects of affective cue

were not significantly moderated by task (Fig. 1b, c).

t(df)

Controls

Patients

36.50 (12.65)
23.06 (3.41)
61.81 (10.73)
4.19 (2.56)
4.15 (1.40)
8.35 (3.78)

37.55 (12.46)
23.10 (4.09)
83.83 (15.81)
8.21 (3.68)
7.04 (3.24)
15.25 (6.36)

Main AnalysesHypotheses Testing

0.31 (53)
0.04 (53)
5.97 (53)***
4.51 (48)***
4.15 (48)***
4.71 (48)***

***p<.001
BMI body mass index, CSD checklist for symptoms in daily life, HADS
hospital anxiety and depression scale

2 = .49), and higher perceived control (F(1,52) = 43.58,

p<.001, partial 2 =.46) compared to negative trials (with
unpleasant pictures; see means in Table 2).
Furthermore, the two labeling conditions tended to
dampen these affective reactions, although the effect
was mainly observed for pleasantness ratings. Specifically, a significant affective cuetask interaction was
found for perceived pleasantness (F(2,106) = 18.16,
p < .001, partial 2 = .26). Follow-up analyses showed
that the two labeling conditions resulted in lower pleasantness compared to the view condition for positive
trials, F(2,106)=17.02, p<.001, partial 2 =.24, and content labeling resulted in less unpleasantness compared to
the view condition for negative trials, F(2,106)=4.28,
p<.05, partial 2 =.07 (Fig. 1a). This interaction was
highly significant for both groups (p< .0001). As for

Group Effect IBS patients reported overall more symptoms in

total and more pain/GI symptoms than controls (F(1,52)=
6.04, p<.05, partial 2 =.10 and F(1,52)=8.12, p<.01, partial
2 =.14, respectively). A main effect of group was not observed for arousal symptoms.
Affective Cue Effect As expected, overall more symptoms
were reported after negative than positive trials for the total
symptom score, F(1,52)=23.81, p<.001, partial 2 =.31, as
well as the arousal and pain/GI subsets (F(1,52)=25.47,
p<.001, partial 2 =.33 and F(1,52)=6.49, p<.05, partial
2 =.11, respectively). The affective cue effect was not moderated by group during the view condition for the total symptom score nor for pain/GI symptoms, although a nonsignificant trend emerged toward higher arousal symptom
reports in IBS patients than controls after merely viewing
negative compared to positive pictures, F(1,53) = 2.40,
p=.11, partial 2 =.05.
Labeling Effects For the total symptom scores, no task effect
or affective cuetask interaction was found for either group.
Similarly, no task effects were found for the pain/GI subset.
However, for the arousal symptoms, a trend for an affective
cuetaskgroup interaction was observed, F(2,104)=2.72,
=.74, p=.09, partial 2 =.05. Separate analyses per group
showed a trend toward an affective cuetask interaction for
IBS patients (F(2,56)=2.96, =.74, p=.08, partial 2 =.10).

Table 2 Means and SDs for all dependent variables of the affect labeling task
Measure

Group

Trial
Positive
View

Pleasantness (19)
Arousal (19)
Control (19)
Symptomstotal (1470)
Arousal symptoms (420)
Pain/GI symptoms (525)

Negative
Emotion label

Content Label

View

Emotion label

Content label

Patients
Controls
Patients
Controls

8.03 (1.09)
8.15 (0.83)
2.90 (2.14)
2.35 (1.50)

7.07 (1.36)
7.54 (1.30)
2.93 (1.73)
2.46 (1.24)

7.10 (1.59)
7.27 (1.15)
2.90 (2.04)
2.23 (1.42)

3.17 (1.44)
3.73 (1.56)
4.41 (2.01)
3.65 (1.65)

3.66 (1.90)
3.69 (1.38)
4.24 (1.79)
3.69 (1.95)

4.07 (1.58)
4.00 (1.57)
3.93 (1.71)
3.27 (1.82)

Patients
Controls
Patients
Controls
Patients
Controls
Patients
Controls

6.28 (2.48)
6.85 (2.33)
16.17 (2.73)
14.77 (1.14)
4.31 (0.93)
4.48 (0.87)
6.07 (1.58)
5.12 (0.44)

6.00 (2.55)
6.46 (2.18)
16.21 (3.04)
14.96 (1.43)
4.66 (1.37)
4.44 (0.82)
5.86 (1.51)
5.24 (0.52)

5.86 (2.57)
6.08 (2.48)
16.31 (3.53)
14.65 (1.16)
4.52 (1.64)
4.36 (0.76)
5.90 (1.57)
5.08 (0.40)

4.62 (2.34)
4.54 (2.56)
17.62 (3.44)
15.69 (2.09)
5.52 (1.98)
5.12 (1.30)
6.24 (1.66)
5.28 (0.74)

4.59 (2.61)
4.42 (2.37)
17.07 (2.81)
15.50 (1.63)
5.03 (1.24)
5.12 (1.64)
6.31 (1.98)
5.12 (0.33)

4.76 (2.18)
4.60 (2.36)
17.31 (3.14)
15.76 (2.11)
5.14 (1.62)
5.32 (1.97)
6.24 (1.86)
5.20 (0.50)

Int.J. Behav. Med.

Negave
Posive

9
7

6
5

4
3

Discussion

2
1
View

Content Label Emoon Label

Task

Negave
Posive

Arousal Rangs (1-9)

8
7
6
5

4
3
2
1
View

Content Label Emoon Label

Task

Negave
Posive

Control Rangs (1-9)

8
7

Previous literature suggests that unpleasant cues augment

symptom reporting, a bias that, according to data from a
non-clinical sample, is reduced when people regulate their
negative affect by verbally labeling these cues [31]. The
present study aimed to extend prior findings by examining
whether unpleasant cues increase momentary symptom reports in IBS patients and whether this can be reversed by
applying an implicit emotion regulation strategy. To this end,
patients diagnosed with IBS and healthy controls completed a
modified affect labeling task, which included viewing pleasant and unpleasant pictures under a merely viewing condition,
an emotion labeling, or a non-emotional labeling condition,
followed by a symptom checklist.
Affect ratings after each trial confirmed that the pictures
induced the expected affective reactions. Main analyses further showed that this affective manipulation modulated momentary symptom reports as unpleasant pictures led to overall
elevated symptom reports. Although the increase was rather
small, this effect is in line with findings from studies with
student populations [18, 19], and it indicates that mild unpleasant stimulation can influence the reporting of physical
symptoms in both non-clinical and patient samples. The current manipulation differs importantly from paradigms typically used in IBS research, as it does not use experimentally
induced physiological stimulation, e.g., by means of rectal
distensions [10]. Rather, it assesses affective influences on
self-reported symptoms with little actual physiological input

5
4

Negave
Posive

6.5

3
2
1
View

Content Label Emoon Label

Task
Fig. 1 Affective cuetask interaction for a pleasantness ratings (top panel),
b arousal ratings (middle panel), and c control ratings (bottom panel)

Arousal symptoms (4-20)

Pleasantness Rangs (1-9)

significantly more arousal symptoms than positive ones only

during the view condition (t(28)=4.03, p<.001), while the
difference between positive and negative trials tended to reduce
at the two labeling conditions (emotion labeling: t(28)=1.28,
p=.21, content labeling: t(28)=2.13, p=.04, Bonferroni adj.:
p<.025). This trend was not observed in controls (Fig. 2).

6.0

5.5
5.0

4.5
4.0

3.5
View

Content
Label
Controls

Follow-up analyses (paired-sample t tests for each task)

showed that for IBS patients, the negative trials led to

View

Label

Content
Label

Label

IBS paents

Fig. 2 Affective cuetask interaction for arousal-related symptoms in

patients and healthy controls

Int.J. Behav. Med.

and as such is highly relevant for patient groups experiencing

symptoms unrelated to detectable physiological dysfunction.
The fact that such a paradigm induced elevated symptom
reporting in IBS patients adds to prior findings emphasizing
the role of top-down schematic influences in the experience of
symptoms in this group [41].
Nevertheless, the effect of unpleasant cues on symptom
reports was not more pronounced in IBS patients, as initially
hypothesized. Only for arousal symptoms, there was a tendency for unpleasant cues to result in more symptoms
reporting for IBS patients compared to controls. This lack of
strong group differences on the effects of affective cues contradicts findings from non-clinical samples showing more
pronounced effects of unpleasant pictures for high habitual
symptom reporters scoring high for trait NA [18, 19], as well
as research showing more profound effects of induced NA in
the perception of visceral sensations in IBS patients [10, 20].
A possible explanation for this discrepancy may be the rather
mild affective manipulation used in our study. Most studies
with patients have used rather intense emotion or stress inducing stimuli (auditory stress), which may suggest that patients
are less susceptible to mild contextual cues. This implies that a
more intense manipulation of state NA is needed for its
differential effects on symptom reporting in a patient group
compared to healthy controls to emerge.
A second aim of this study was to examine whether affect
labeling can reduce the effects of unpleasant pictures on symptom reporting. Manipulation checks indicated that the two
labeling conditions dampened the affective reactions to the
pictures, confirming the emotion regulatory function of both
emotional and non-emotional labeling. However, labeling effects on affect ratings were not as pronounced as previously
found [31]. This may be due to the fact that unpleasant pictures
in this sample did not elicit very strong affective reactions. As a
result, there may have not been enough room for robust labeling effects to emerge. As for the effects of labeling on symptom
reports, current results provide only weak support for the
hypothesis that labeling reduces symptom reporting during
negative trials. The expected interaction between task and
affective cue was not found for total symptom scores, while,
when subsets of symptoms were explored, a tendency toward
the expected pattern of data was observed only for the arousalrelated symptoms. Specifically, both labeling conditions tended
to reduce affective influences on arousal symptoms, as hypothesized, but only for IBS patients. The fact that this effect was
more profound in patients is in line with our hypothesis that
patients, who are probably less able to spontaneously regulate
emotional reactions in an effective way [21, 42, 43], can benefit
more from emotion regulatory procedures. Even though the
effect was rather small, it provides initial experimental data that
can complement findings from clinical studies showing that
emotion regulation techniques focused on the verbalization of
affect, like expressive writing [44], and attentional control, like

mindfulness [4547], can reduce stress and symptom reports in

IBS patients.
However, it is important to note that affect labeling in our
study did not influence pain/GI symptom reports. Thus,
assigning labels to unpleasant stimuli attenuated slightly the
experience of symptoms related to emotional arousal but not
of symptoms that characterize the condition of IBS patients.
This may again be due to the mild affective manipulation and
the subsequent limited labeling effects. Stronger manipulations may be required for situational influences to be observed
on symptoms that are relevant and so pervasive into the lives
of IBS patients.
Besides the lack of a strong affective manipulation, other
limitations should be noted. The reported symptoms during
the experiment were rather low (at the lower end of the
symptom scale), which is expected as the paradigm did not
include the induction of physiological stimulation. However,
this resulted in small changes on symptom reporting between
conditions, which possibly reduced the strength of current
findings. Furthermore, current findings were based solely on
self-reports, which can be influenced by participant expectations and demand characteristics. Recording physiological
indices of emotional reactivity (e.g., heart rate, skin conductance) during picture viewing could confirm the intended
affective manipulations and eliminate the possibility of mere
reporting bias. Another issue is that the two groups differed in
various parameters of socioeconomic status as well as in
medication use (many IBS patients were using medication to
control their symptoms), factors that could have confounded
the results. Finally, the limited number of males in the sample
did not allow for examining gender differences in the task,
even though gender differences in symptom reporting in general have been systematically reported [48].
Further research using emotional stimuli that elicit stronger
emotional reactions, like film clips or imagery, could delineate
the trends seen in our study. Furthermore, IBS patients have
more localized and specified symptoms, compared to other
functional groups. Such specificity may be linked to less
negative affect, as has been shown in the context of anxiety
disorders [49]. Thus, future research should also examine the
effectiveness of emotion regulation strategies in other groups
of functional syndrome patients with more widespread symptomatology and possibly more overall emotional distress, like
CFS or fibromyalgia.
In conclusion, the present study replicated the augmenting
effects of unpleasant cues on symptom reporting in a functional syndrome patient sample and provides initial indications that emotion regulatory processes, like labeling emotional cues, can reduce to some extent the affective biases on
symptom perception, especially for functional syndrome patients. Further research is needed to explore the therapeutic
role of such emotion regulation strategies in functional
syndromes.

Int.J. Behav. Med.

Acknowledgments Authors would like to thank the physicians and
clinical trial coordinators at the gastrointestinal unit of the University
Hospital Gasthuisberg (Leuven, Belgium) for the recruitment of IBS
patients and Stphanie Vandeweyer for her assistance in data collection.
Compliance with Ethical Standards Each of the following authors,
Elena Constantinou, Katleen Bogaerts, Lukas Van Oudenhove, Jan Tack,
Ilse Van Diest, and Omer Van den Bergh, declares that s/he has no conflict
of interest, that all procedures performed in this study were in accordance
with the ethical standards of both the institutional and national research
committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards, and that informed consent was
obtained from all individual participants included in the study.

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