Melbourne School of Psychological Sciences - Theses
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ItemChildhood maltreatment and structural neuroanatomy as risk factors for adolescent onset depression( 2012)This thesis concerns three broad subjects – childhood maltreatment, structural neuroanatomical features in early adolescence, and depressive symptoms in mid-adolescence – with the aim of examining predictive relationships between them. The core focus of the thesis was on investigating relationships between the volumes of key brain structures implicated in emotion regulation, and adolescent onset depression. The measurement of brain structures in a psychiatrically healthy sample of children aged 11-12 years, and the use of these measurements to predict onset of depressive symptoms 2-3 years later, allowed for contribution to theoretical debate about the timing of structural alterations previously associated with depression – specifically, whether observed alterations formed risk factors for depression, or whether they were outcomes of disease-related processes. The evidence of premorbid structural alterations demonstrated by this thesis suggests that there are vulnerability biomarkers for depression, and may assist in better understanding the mechanisms of depressive illness as well as identifying individuals at risk. The secondary focus of the thesis was on retrospectively examining relationships between maltreatment in childhood and structural neuroanatomical features in adolescence, with the aim of identifying effects of childhood adverse experience on brain development. Previous studies have largely utilised adult populations with maltreatment-related psychiatric illness, and therefore have not been able to conclude whether structural alterations following childhood maltreatment only occur in those individuals who later develop psychopathology, or whether these changes occur before the onset of any psychopathology. This thesis investigated whether structural changes were associated with childhood maltreatment in a healthy sample of young adolescents, allowing the separation of early experiential effects from later psychopathological processes. This research also explored whether the volumes of selected brain structures mediated relationships between childhood maltreatment and adolescent onset depression, however no such relationships were detected. As this was an exploratory measure secondary to the key themes of the thesis, and interpretations were constrained by issues of sample size, it is not dealt with in detail. The most robust aspect of this research design was the examination of neurostructural risk factors for depression, and this formed the central content of the thesis. There is also a large extant body of research and literature on depression and brain development, from which to gain a strong theoretical grounding on the role of each brain structure examined in terms of the cognitive and affective processes it is thought to subserve. For this reason, material on the epidemiology and neurobiological models of depression form the first three chapters. An exploration of the emerging body of literature on the relationships between childhood maltreatment and brain development is contained subsequently. Chapter 1 provides an introduction to the epidemiology and selected etiological influences on adolescent depression. Chapter 2 gives an overview of the current understanding of brain development in adolescence, and describes some of the key theoretical models linking brain development to adolescent onset depression. Key structures highlighted in these models were selected for investigation within this thesis, and detailed examination of the evidence and resultant hypotheses for each of five selected structures’ relationships with depression is contained in Chapter 3. The focus then turns to childhood maltreatment as a second major contributor to adolescent onset depression; Chapter 4 summarises research on the prevalence and types of childhood maltreatment and the relationships between childhood maltreatment and adverse outcomes including the development of depression. Chapter 5 reviews literature from the emerging field of developmental traumatology, drawing inferences from the body of work examining neuroendocrinological sequelae of childhood maltreatment and bringing together preliminary findings from a range of sources to form hypotheses regarding potential relationships between childhood maltreatment and the brain structures discussed in previous chapters. Chapter 6 gives detail on the design and methodology of the thesis, and Chapter 7 explains the data analysis used and reports on the results. Interpretation of findings, discussion of strengths and limitations of the research, and implications for future work are contained in Chapter 8.
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ItemPerceptual asymmetries in navigation( 2012)Unilateral spatial neglect is a neuropsychological disorder characterised by a chronic asymmetry in attentional resources in favour of the right side of space. Neglect usually arises following damage to the right parietal lobe, and impacts upon patients’ capacity to effectively complete visuospatial tasks, such as navigation. Neurologically intact humans also exhibit asymmetries in their attentional resources, albeit to a lesser degree than neglect patients. These normal attentional asymmetries have historically been indexed on visuo-perceptual tasks, such as line bisection, but a small body of research has examined whether they also induce behavioural asymmetries on ecologically valid tasks, such as navigation. This research examined the nature and mechanisms of navigation biases in neurologically intact individuals, who steered vehicles through an extrapersonal aperture. Results confirmed the presence of a rightward navigation bias, though this was contingent upon the width of the aperture. Results also showed a clear tendency for participants to preferentially look toward the right side of an aperture during a navigation task. It is argued that asymmetries in navigation are primarily driven by a rightward attentional bias invoked by the extrapersonal nature of the aperture. An overestimation of the left side of personal (body) space, which extends to encompass vehicles, may also contribute to navigation biases, if participants deviate rightward to accommodate their “wider” left side. The existence of a rightward attentional bias for perceptual processing of extrapersonal space has wide-ranging implications, which include domains such as road safety and advertising.
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ItemAnorexia nervosa: controversy regarding diagnostic criteria and evidence for control-related cognitive and metacognitive mechanisms maintaining the disorder( 2012)Background: The study was divided into three sections. (i) The utility of current controversial physical diagnostic criteria for Anorexia Nervosa (AN), specifically, the weight threshold and amenorrhea. A literature review revealed no clinically relevant differences signified by the physical criteria; however, existing studies had not assessed the cognitive diagnostic criteria for AN and had excluded individuals on oral contraception. (ii) Perfectionism, self-esteem, control-related cognitions, and dysfunctional metacognitions have been proposed to maintain AN, yet empirical evidence is limited, nor have existing studies controlled for the potentially confounding effects of low weight, depression, and anxiety. (iii) The lack of efficacy in treating AN may reflect our limited understanding of the mechanisms underlying its maintenance and treatment, highlighting the need for model testing. Fairburn, Shafran, and Cooper (1999) proposed a cognitive model constructed on the individual’s need for control; however, empirical evidence for the model is limited. A potentially useful addition to a maintenance model is the untested higher level of cognition, metacognition and its dysfunctionality in AN. Research Aims: (i) Test for differences between subgroups of AN patients signified by each physical criterion, and by oral contraceptive use, on clinically relevant factors including cognitive AN diagnostic criteria, AN maintenance factors, and general psychopathology. (ii) Assess differences between AN and dieting and non-dieting comparison groups in perfectionism, self-esteem, control-related cognitions, and metacognitions, whilst controlling for effects of low weight, depression, and anxiety. (iii) Test two control-centred maintenance models, Model A (cognitive level) and Model B (metacognitive level), in predicting the outcome variable, drive for thinness, in AN and non-eating disordered comparison groups. Method: Participants were 110 female AN patients and 132 non-eating disordered females (66 dieting, 66 non-dieting) from the community, aged 18 to 45 years. Information was collected through self-report measures. (i) ANOVAs and t-tests were used for group comparisons. (ii) MANOVAs, MANCOVAs and ANCOVAs were used for group comparisons, with body mass index, depression, and anxiety as covariates. (iii) Path analyses were used to test Model A and Model B. Results: (i) Measures were remarkably similar for all AN subgroups (p >.05), with few statistically significant differences. (ii) Variables were rated as significantly more severe in the AN group compared with the comparison groups (Bonferroni-adjusted p <.006). Differences were of clinical significance, still present after controlling for low weight, depression, and anxiety. (iii) In the AN group only, overall fit of Models A and B were excellent, with key predicted pathways confirmed (p <. 05). Conclusion: Findings have implications for DSM-V development, confirming that the weight and amenorrhea criteria do not signify clinically relevant differences and should be applied with caution when used. Perfectionism, self-esteem, and control-related cognitions and metacognitions distinguished AN from the non-eating disordered comparison sample. Preliminary empirical evidence supported the two control-related maintenance models of drive for thinness in AN, one at the cognitive level as proposed in Fairburn et al.’s (1999) cognitive theory of AN, and the other a novel metacognitive model, both including perfectionism and self-esteem. Control-related cognitive and metacognitive variables are thus potential targets of AN treatment.
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ItemExperiences of ovarian cancer in older women( 2012)The aim of this study was to explore the lived experience of older women with ovarian cancer. It aimed to illuminate how women make sense of an ovarian cancer diagnosis in older age by a) investigating the psychosocial challenges of living with ovarian cancer and b) investigating inner strength factors which have helped or hindered a sense of well-being or resilience for these women. Ovarian cancer is predominantly a disease of older women, and the incidence of ovarian cancer is rising due to the ageing population. The limited primary research that has been conducted focusing on the psychosocial impact of ovarian cancer has highlighted the multi-dimensional nature of women’s experiences of living with cancer. The majority of the current literature includes women of all ages. Older cancer survivors are seldom the focus of research and have been considered the ‘silent population’, as little research has given voice to their experiences. Yet it is important to understand their experiences to identify how older cancer survivors access their various sources of strength to enable them to attain well-being, despite the losses and changes they confront This study used in-depth unstructured interviews to gives voice to the lived experience of nine older women (65+ years) with ovarian cancer. A qualitative, Interpretative Phenomenological Analysis (IPA) research approach enabled the exploration of the women’s’ experiences from a phenomenological perspective, through presenting the 18 essential themes in their experiences. Using the Model of Inner Strength (Roux, Dingley, Lewis & Grubbs, 2004) framework the key findings extended the current thinking about older women’s experiences of ovarian cancer and indicated that the women draw on the dimensions of inner strength, insight, engagement, participation and connectedness, to make ‘sense’ of their experiences and to balance the negative and positive psychosocial effects of the diagnosis, treatment and treatment side effects. The women’s perception of inner strength enabled them to adapt and compensate in order to optimally function and participate in all aspects of life (physical, emotional, social and spiritual). The women’s attitude was to see possibilities in their lives and to fully engage and participate in social, creative and physical activates. The Model of Inner Strength proposes women’s inner strength is impacted by cancer treatment, physical changes with ageing, challenges to quality of life and symptom clusters of distress. Along with these factors for older women with ovarian cancer, cancer symptoms, ageism, concurrent distress, concurrent medical conditions and end of life concerns were also found to be important. Although, the Model of Inner Strength provides a framework for understanding the experiences of cancer in older, the findings suggests a purely IPA study would allow the cultural, social, and individual factors to be further illuminated.
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ItemThe impact of psychopathy on the forensic, treatment, and social outcomes of community mental health clients with a schizophrenia spectrum disorder and criminal offending history( 2012)The number of community-treated individuals with a schizophrenia spectrum disorder (SSD) and criminal offending history is increasing therefore responding to their needs is an important goal for community mental health clinicians. In order to do so, an understanding of the forensic, treatment, and social outcomes of these individuals, and the factors that contribute to those outcomes is vital. Psychopathy has been identified as a potential contributor to adverse outcomes in individuals with a SSD, however, studies to date have focused on forensic and general psychiatric inpatients as the population of interest and offending as the outcome of interest, thus providing no insight into the range of forensic, treatment, and social outcomes experienced by community mental health clients with a SSD and criminal offending history, and the impact that psychopathy has on these outcomes. The principal aim of this study therefore was to investigate the contribution of psychopathy to the forensic, treatment, and social outcomes of community mental health clients with a SSD and criminal offending history. Participants were 80 clients of a community mental health service with a SSD and criminal offending history, and 80 clients of the same service with a SSD but no criminal offending history, matched on age, sex, and primary psychiatric diagnosis. Psychopathy was measured using the Hare Psychopathy Checklist – Screening Version. There were two phases of data collection: Forensic, treatment, and social outcomes were assessed at a baseline date (for the cross-sectional part of the study) and annually for 3 years post-baseline (for the repeated-measures part of the study). Outcome data were obtained from clients’ medical records. Clients with a criminal offending history more closely matched the prototypical psychopath, and had significantly higher levels of the affective/interpersonal and behavioural/social deviance features of psychopathy than clients with no history of offending. The cross-sectional results revealed that clients with a history of offending had a number of significantly poorer forensic, treatment, and social outcomes compared to clients with no history of offending. The affective/interpersonal component of psychopathy was a unique and significant predictor of all outcomes examined. The repeated-measures results revealed that, over the 3-year follow-up period, there was a significant decrease in the number of community treatment orders applied and revoked, and the number of changes in living arrangement for the two groups combined. The affective/interpersonal component of psychopathy did not predict the rate of change in these outcomes. The repeated-measures part of the study also revealed that the time between the baseline date and the first crime was significantly shorter for clients with a criminal offending history than clients with no offending history. The affective/interpersonal component of psychopathy was a unique and significant predictor of both the time to first crime and first psychiatric hospitalisation after the baseline date. It was concluded that individuals with a SSD and offending history who live and receive treatment in the community have higher psychopathy levels and poorer outcomes than community treated individuals with a SSD and no offending history, and that the affective/interpersonal component of psychopathy is a unique and significant predictor of those adverse outcomes. The findings have important implications for the assessment, treatment, and management of community mental health clients with a SSD and offending history.
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ItemThe nature and mechanisms of subjective perceptions and their role in postnatal distress( 2012)Introduction: Existing models of biological and psychosocial risk factors for the development of postnatal distress have been criticized for not taking into account the subjective perception women have about their motherhood experience. When studied the role of subjective experiences was evaluated qualitatively. Using methods of Appraisal Theory and dream research as two distinctive quantitative approaches, this study explored the nature and mechanisms underlying the subjective experiences of expectant and new mothers, and its contribution to mood in the context of sleep. As a universal experience in this group, sleep disruption facilitates the study of the interaction between objective and subjective components. Methods: During the third trimester of pregnancy (Time-1), 122 healthy, low-risk women completed questionnaires on mood, appraisal, and sleep. Among them, 96 completed the same questionnaires within 7 to 15 days after childbirth (Time-2), and 101 at 10-12 weeks postpartum (Time-3). A subsample of 25 women provided additional objective sleep measures by wearing actigraphs for 7 continuous days at every assessment time to conduct Study 1 (Sleep Study), whereas data from the general sample (i.e. 122 women) were used to conduct Study 2 (Appraisal Study). A different subsample of 20 participants provided dream reports for 7 days at Time-1 and Time-3 for Study 3 (Dreams Study). Dream content was coded using the Hall and Van de Castle Coding System for Dreams. Results: In Study 1, low postnatal mood was associated with poor subjective – but not objective – sleep at the three assessments. At Time-2, however, less nocturnal objective sleep was also significantly associated with increased maternal distress. In Study 2, at all three assessment times high levels of distress were consistently associated with a low perceived ability to cope practically (PFCP) and emotionally (EFCP) with pregnancy and early motherhood. Additional Multiple Regression Analyses showed EFCP and negative expectations about the future (i.e. low Future Expectancy) to predict distress in subsequent assessments. Likewise, subjective reports of poor sleep quality and high sleep-related daytime dysfunction were significantly associated with low EFCP, PFCP and low Future Expectancy. In Study 3, the comparison of dream content against norms for a female population revealed a similar pattern of content for ante and postnatal dreams, which were characterized by a large percentage of family members, children, and baby characters; and a low percentage of friends. In addition, friendly interactions were more common than aggressive ones, sexual interactions were significantly lower, and the percentage of familiar settings was significantly smaller. Finally, antenatal – but not postnatal- dreams had significantly more references to the pregnant belly. Conclusion: The findings of Study 1 supported the discrepancy between objective and subjective observations and suggested that the conscious awareness of disrupted sleep and sleep-related daytime dysfunction makes a larger contribution to postnatal mood than actual sleep quantity and quality in a group of healthy women. Study 2 highlighted EFCP, PFCP, and Future Expectancy as the most significant appraisals involved in both distress and subjective sleep, thus contributing to a better understanding of the cognitive mechanisms involved in the subjective perception of these phenomena. Finally, Study 3 provided a description of the nature of the subjective experiences that may influence the appraisal of objective circumstances as well as description of the psychological processes that prepare pregnant women for a successful transition to motherhood.
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ItemEvaluation of a continuum model of psychotic symptoms: evidence from neuroanatomical, neuropsychological and clinical correlates( 2012)The fully dimensional model of psychosis posits that schizotypal personality traits in psychologically healthy people lie on a continuum with the psychotic symptoms experienced by people with a psychotic illness. Therefore, it was anticipated that psychotic and psychotic-like symptoms would show similar correlates for both individuals with a psychotic illness and psychologically healthy individuals. The validity of this notion was evaluated across three studies, which examined relationships between positive symptom traits and a range of neuroanatomical, neuropsychological and psychological variables. Case participants involved in the three studies had a diagnosis of schizophrenia or schizoaffective disorder, and control participants were psychologically healthy. In Study 1, comprehensive phenomenological information was acquired from cases (n = 20 and controls (n = 30) regarding the nature and frequency of positive symptom traits. Significant differences were identified between groups in terms of how they responded to and appraised their own positive psychotic and psychotic-like experiences. Four of these responses (immersion, external and impersonal attributions, and lack of social understanding) were also associated with the frequency and severity of positive psychotic and psychotic-like experiences across all participants’ lifetimes. Study 2 examined both between-group differences and within-group relationships in relation to neurocognitive functioning. Cases (n = 167) had significantly lower mean scores than controls (n = 222) on measures of Full Scale IQ, immediate memory, visual construction, language, attention, delayed memory and working memory. Participants’ scores on a measure of working memory were negatively associated with the frequency and severity of positive psychotic and psychotic-like experiences across their lifetimes. In Study 3, diffusion weighted MRI was used to assess whether groups differed according to structural brain connectivity, and whether connectivity was related to the frequency and severity of psychotic and psychotic-like experiences. One measure of white matter connectivity (fractional anisotropy) was significantly lower for cases (n = 93) as compared to controls (n = 80) across diffuse areas of the brain. For control participants, fractional anisotropy measurements in the corpus callosum and inferior frontal and temporal areas were negatively associated with the frequency and severity of positive psychotic and psychotic-like experiences across participants’ lifetimes. The findings of the three studies identified similar relationships for both cases and controls between positive symptom traits and a range of neuroanatomical, neuropsychological and psychological variables. These were taken to broadly support a fully dimensional model of schizotypy and psychosis.
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ItemExponential random graph models for affiliation networks( 2012)Exponential random graph models (ERGMs) model network global structures using network configurations representing local social processes assuming certain levels of dependencies between network ties. There is an extensive literature on ERGMs since its introduction (known as p* models) in the early 80s (Holland and Leinhardt [1981], Frank and Strauss [1986], Wasserman and Pattison [1996]). With the recent development of ERGM specifications (Snijders et al. [2006], Robins et al. [2007, 2009]) and techniques for model simulations and maximum likelihood estimation (Snijders [2002], Handcock et al. [2008], Koskinen [2008], Caimo and Friel [2011]), ERGMs have been applied to statistical analysis of social network data in a variety of contexts (e.g. Goodreau et al. [2009], Lusher and Robins [2009], Gondal [2011],Daraganova et al. [2012]). Affiliation networks represent a mutually constitutive relationship between two distinct sets of entities (Breiger [1974]). Affiliation networks also serve as meso-level networks in multilevel network contexts (e.g. Hedström et al. [2000], Lazega et al. [2008], Brass et al. [2004]). This thesis is devoted to the methodological development to extend the current ERGM framework to the cases of analysing affiliation networks and multilevel networks. There are several studies under the topic of the thesis. First of all, we review the current ERGM specifications for one- and two-mode networks, and extend the current two-mode model specifications (Wang et al. [2009]) based on a hierarchy of dependence assumptions introduced by Pattison et al. [2009] who provide guidance for future ERGM specification development. Secondly, conditional models and models with exogenous nodal attribute effects, also known as social selection models (SSMs), are proposed as extensions of Robins et al. [2001] to the cases of bipartite networks. Thirdly, snowball sampling strategies on large bipartite networks and various conditional estimation strategies as extensions to Pattison et al. [2011] are investigated using simulation studies. Fourthly, a general data structure is proposed for multilevel networks combining the features of both one- and two-mode networks, as well as their interactions. We offer ERGMs as a new approach for analysing multilevel networks. Based on the hierarchy of dependence assumptions (Pattison et al. [2009]) and the current ERGM specifications for both one- and two-mode networks, a set of model specifications are proposed for the analysis of multilevel network structures. Furthermore, SSMs for multilevel networks are proposed involving the interactions between nodal attributes and network structural effects across levels. Finally, we discuss the use of the proposed multilevel ERGMs as a general approach for capturing network heterogeneity. Features of the proposed models and modelling strategies are demonstrated using modelling examples on empirical data sets, which include model estimations and goodness of fit (GOF) tests. Software packages BPNet and MPNet for the simulation and estimation of the proposed model specifications are implemented as extensions to PNet (Wang et al. [2009]). Compared with the existing techniques and model specifications, the proposed models may be more feasible in model convergence while providing better GOF. They also offer more detailed and accurate descriptions of the underlying network processes.
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ItemEmotional self-awareness and depressive symptoms: an investigation of an early intervention mobile phone self-monitoring program for adolescents( 2012)Up to 30% of adolescents experience depressive symptoms before 18 years of age and are at risk of developing severe recurrent depression. There is, however, a lack of appropriate treatments available for these young people. Self-monitoring is often used in therapy to increase awareness about mood and distress, and is likely to decrease depressive symptoms. Furthermore, self-monitoring has potential as an early intervention tool for young people at risk of depression, particularly when mobile phones are used as a medium. Using both qualitative and quantitative methods, this thesis investigates the concept of emotional self-awareness (ESA) and its mediating role in the relationship between self-monitoring and depressive symptoms. To this end, several studies were conducted. First, a systematic literature review examining the benefits of ESA was conducted. A review of 50 publications found five common themes throughout the literature regarding ESA: (a) becoming aware of an emotional experience; (b) the ability to define and distinguish specific feelings; (c) identifying the contextual factors surrounding emotions; (d) communication of emotional knowledge; and (e) analysing emotional events to make decisions. Second, a post-hoc qualitative study examined secondary school students’ general feedback about ESA after self-monitoring. Spontaneous feedback from 20% of participants reported at least one ESA theme after completion of the self-monitoring program. Third, following from the post-hoc study, in-depth qualitative interviews were conducted with 37 young people after self-monitoring, specifically targeting ESA. This study provided rich descriptive detail about the themes of ESA from young people’s perspectives. Fourth, a preliminary measure of ESA was developed and tested with 22 young people with subclinical depressive symptoms, recruited from two general practitioners in a rural setting. This small-scale mixed-methods study combined an in-depth qualitative interview and a quantitative measure of ESA. Young people with high scores on the ESA measure had a different qualitative experience than those with low scores. Last, a randomised controlled trial examined the effects of self-monitoring on depressive symptoms when mediated by ESA. Young people with mild or more depressive symptoms were recruited from primary care settings and randomised into an intervention group (n = 68) or an attention-comparison group (n = 46). Mediation analysis demonstrated that self-monitoring significantly increased ESA in the intervention group when compared with the comparison group and that an increase in ESA significantly decreased depressive symptoms. Furthermore, there was a medium size of indirect effect (κ2 = 0.44) for depressive symptoms per week indirectly through ESA when compared with the comparison group. In summary, a useful model of ESA was developed in this thesis and tested across the studies suggesting that self-monitoring can increase ESA, which in turn, decreases depressive symptoms. Mobile phones are well suited to early intervention programs, providing an alternative to watchful waiting. Mobile phone self-monitoring programs should be considered as a first-step low-cost early intervention for young people who are at-risk of mental health problems. Self-monitoring has the advantages of helping young people increase their ESA while gaining more information about their mental health symptoms, which can also direct them to suitable interventions.
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ItemEmotional reactivity and emotional and social perception following surgical excision within the prefrontal cortex( 2012)The present thesis investigated emotional reactivity and emotional and social perception in patients with discrete, surgically circumscribed lesions to the prefrontal cortex. The aim was to better understand the mechanisms underlying the profound impairments in emotion, behaviour and social functioning in patients with lesions to the ventromedial PFC. Participants were 27 patients between 1 and 12 months post-neurosurgery, divided into groups based on Brodmann areas resected, determined by MRI. Patients had lesions to the anterior cingulate (ACC, n=4), orbital (n=7), dorsolateral (DL, n=11), or ventromedial (VM, n= 5) PFC. Ventromedial lesions were defined as including both orbital and ACC resection. The control group comprised 26 extra-cerebral neurosurgery patients. A pilot study standardised a new set of film stimuli for the elicitation of discrete emotions. Three experiments investigated emotional reactivity, emotional and social perception, and self-and observer-ratings of emotional and social dysfunction, respectively. Experiment 1 presented participants with the film clips standardised in the pilot study. Self-reported emotion, electrocardiogram, skin conductance, frontal electroencephalogram (EEG), facial and vocal expression were measured. Results indicated the orbital group displayed less intense facial expressions, and had lower heart rate and less sympathetic cardiac activity during the emotional films compared to the control group. The ventromedial group had more sympathetic cardiac activity. An analysis of EEG alpha asymmetry failed to support hemispheric theories of emotional valence asymmetry. Experiment 2 involved a forced-choice computerised facial morphing task, a questionnaire that assessed theory of mind (ToM) and empathy, and a new task that measured perception of emotion in still facial and vocal expressions, and music from films. VM patients were impaired at identifying morphed facial expressions, and were impaired on the ToM scale. VM patients also rated the still faces, prosody and music items as more intensely emotional compared to controls both for congruent ratings, e.g. positive ratings of positive items, and incongruent ratings, e.g. negative ratings of positive items. Experiment 3 included a measure of subjective emotional change since neurosurgery, on which the orbital group gave significantly higher ratings. Two observer-rated measures, the Emotional and Social Dysfunction Questionnaire and the Iowa Rating Scales of Personality Change failed to reveal many significant differences for the VM group, which was speculated be due to the poorer prognosis of this group. A new dual inhibition model of emotional reactivity following VM lesions was developed. It argues that the orbital PFC is crucial for representing the reward value of stimuli, and the mPFC for the cognitive aspects of emotion processing, including self-referential processing, understanding the thoughts of others, and attention toward emotional stimuli. Each area is involved in the perception of salient emotional stimuli, via different mechanisms, and both inhibit the amygdala, which serves to signal potentially salient emotional stimuli. When either the orbital PFC or ACC is damaged, the other area can still detect emotional salience and inhibit the amygdala. However, when both areas are damaged, as in VM lesions, there is disinhibition of the amygdala, coupled with impaired perception of emotion, therefore severe disturbances to emotional and social functioning.