Académique Documents
Professionnel Documents
Culture Documents
discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/221763565
CITATIONS
READS
106
3,648
2 authors:
Matthias Berking
Peggilee Wupperman
SEE PROFILE
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
View project
REVIEW
URRENT
C
OPINION
Purpose of review
In recent years, deficits in emotion regulation have been studied as a putative maintaining factor and
promising treatment target in a broad range of mental disorders. This article aims to provide an integrative
review of the latest theoretical and empirical developments in this rapidly growing field of research.
Recent findings
Deficits in emotion regulation appear to be relevant to the development, maintenance, and treatment of
various forms of psychopathology. Increasing evidence demonstrates that deficits in the ability to adaptively
cope with challenging emotions are related to depression, borderline personality disorder, substance-use
disorders, eating disorders, somatoform disorders, and a variety of other psychopathological symptoms.
Unfortunately, studies differ with regard to the conceptualization and assessment of emotion regulation,
thus limiting the ability to compare findings across studies. Future research should systematically work to
use comparable methods in order to clarify the following: which individuals have; what kinds of emotion
regulation difficulties with; which types of emotions; and what interventions are most effective in alleviating
these difficulties.
Summary
Despite some yet to be resolved challenges, the concept of emotion regulation has a broad and significant
heuristic value for research in mental health.
Keywords
emotion regulation, mental disorders, psychopathology, review, skills
INTRODUCTION
Emotion regulation refers to extrinsic and intrinsic
processes responsible for monitoring, evaluating,
and modifying emotional reactions, especially their
intensive and temporal features, to accomplish
ones goals [1]. After years as a major research topic
in developmental psychology and borderline
personality disorder (BPD), the concept of emotion
regulation has recently become popular in general
mental-health and psychotherapy research. At this
point, not a month passes without at least one peerreviewed publication on emotion regulation in the
context of depression, anxiety, substance-related
disorders, eating disorders, and so on. However,
despite its popularity, the concept struggles to attain
viability as a scientific construct due to various
unmet challenges involving definition, assessment,
and clinical implications. Such problems have been
discussed (although not solved) in the context of
developmental psychology [1,2], but not yet in
relation to the specific needs of research with a
clinical focus. Therefore, the aim of this article is
www.co-psychiatry.com
a
Department of Clinical Psychology and Psychotherapy, Philipps-University, Marburg, Germany, bJohn Jay College, City University of New York,
New York and cYale School of Medicine, New Haven, Connecticut, USA
KEY POINTS
&
&
Depression
Depression is widely conceptualized as a consequence of dysfunctional emotion regulation
[1517]. Consistently, depressed individuals report
difficulties, first, identifying emotions [18,19];
Anxiety disorders
Emotion regulation deficits are involved in a variety
of anxiety disorders [33 ]. Such deficits can result in
ineffective coping with conditioned fear responses,
leading the fear reaction to seem (even more) aversive and uncontrollable thus reconditioning the
reaction and increasing the likelihood of avoidance
behaviors that may become chronic. Consistently,
when compared with nonanxious controls, individuals with generalized anxiety disorder report poorer
understanding of emotions, greater negative reactivity to emotions, and less ability to self-soothe
after experiencing negative emotions [34,35] (see
reference [36] for conflicting findings on the ability
to identify and describe emotions). In individuals
with posttraumatic stress disorder (PTSD), symptom
severity and impairment are both associated with
lack of emotional clarity, lack of emotional acceptance, difficulty engaging in goal-directed behavior
when upset, and an overall limited ability to engage
in emotion regulation strategies [37,38]. Emotion
regulation difficulties also mediate the association
between PTSD symptom severity and substance abuse in patients with histories of chronic abuse [39],
and enhancement of emotion regulation skills in
the first phase of PTSD treatment increases the
effectiveness of the second (exposure-based) phase
[40].
&
Substance-related disorder
One of the most prominent clinical factors in alcohol and drug use is difficulty coping with negative
affect [41], to the extent that substance misuse is
widely conceptualized as an effort to regulate or
avoid negative emotions [20 ,41,42,43 ]. For
example, epidemiological and treatmentoutcome
studies show that negative affect predicts
&&
www.co-psychiatry.com
&
129
Behavioural medicine
Eating disorders
Increasing evidence suggests that eating disorder
symptoms (binging, purging, and/or restricting)
serve as dysfunctional attempts to regulate or suppress negative emotions [5558]. For example, negative mood predicts binging and purging in bulimia
nervosa [57,59,60], as well as binge episodes in
binge eating disorder (BED) [6163]. Compared with
controls, women with bulimia nervosa, BED, and
anorexia nervosa report greater difficulties with
emotional awareness [64,65,66 ], greater tendency
to avoid emotions, and less ability to accept and
manage emotions [67]. In a sample of adolescent
girls, low awareness of emotions and dysfunctional
styles of coping with emotions partially mediated the
relationship between body dissatisfaction and bulimia nervosa symptoms [68]. In college students with
BED, the frequency of binge episodes was predicted
by total score of the Difficulties in Emotion Regulation Scale (DERS) [69], as well as every one of the
subscales [70]. Finally, women with anorexia nervosa
report significantly more difficulties in all subscales
of the DERS than do nonpsychiatric controls [71].
&
Somatoform disorders
Emotion regulation has long been thought to play a
central role in the development of somatoform
symptoms. In the 1970s, Nemiah and Sifneos [72]
introduced the concept of alexithymia (difficulty
identifying and describing emotions): individuals
unable to detect, name, and express emotions would
likely have difficulties using cognitive resources to
regulate emotions and, thus, have an increased
likelihood of misrepresenting bodily sensations
accompanying emotions [73]. In the ensuing decades, numerous empirical studies have provided substantial evidence that somatoform disorders are
associated with deficits in the abilities to consciously experience and tolerate emotions, correctly
identify emotions, and accurately link emotions to
body sensations [74,75,76 ,7780].
&
130
www.co-psychiatry.com
RELEVANT CHALLENGES
In order to enhance the viability of emotion regulation as a scientific construct, the following challenges must be addressed in clinically focused
research.
Definition-related challenges
Perhaps the primary concern regarding emotion
regulation as a scientific construct is that everything
seems to be emotion regulation these days. Whether
it is worry, catastrophizing, rumination, suppression of emotional expression, and so on various
concepts formerly investigated as relevant phenomena on their own are currently being subsumed
under the concept of emotion regulation
[81 ,82,83]. However, such a loosely defined conceptualization runs the risk of losing meaning and,
thus, heuristic value. Therefore, a critical assessment
is needed to specify what actually constitutes
emotion regulation. Of note is that emotion regulation is traditionally defined in terms of function,
not content. Every process can be described as
emotion regulation if driven by (explicit or implicit)
intentions, goals, and/or efforts to redirect and
modify the flow of emotions [84]. In contrast, concepts such as worry, catastrophizing, and rumination are largely components of affective states such
as anxiety and dysphoric mood [2]. Their function is
not to regulate these states, but instead to assess the
seriousness of perceived threat or find a way out of
aversive and uncontrollable situations. Therefore,
these processes are often more consistent with
a self-regulation perspective, as opposed to an
emotion regulation perspective.
With regard to the suppression of the emotional
expression, it is of note that at least in clinical
populations such attempts are usually driven by
the intention to avoid negative evaluation by others
(and/or by oneself for feeling out of control and/or
displaying emotions in front of others). Given that
emotions can exist without being expressed and
that one does not necessarily strive to regulate
emotional experience when suppressing emotional
expression, we propose that this process should not
be considered an emotion regulation strategy per se.
Future research should work to distinguish more
clearly between the suppression of emotion (potentially an emotion regulation strategy) and the suppression of the expression of emotion (unlikely an
emotion regulation strategy).
&
Assessment-related challenges
One of the most relevant challenges remains the
development of instruments and procedures that
validly and reliably assess emotion regulation.
Volume 25 Number 2 March 2012
&
www.co-psychiatry.com
131
Behavioural medicine
(a) Patient
Type of disorder
Awareness/clarity
Stress
Severity of disorder
Understanding
Anxiety
Chronicity of disorder
Acceptance/tolerance
Self-compassion
Fear
Level of comorbidity
Symptom severity
Social support
Situation selection
Situation improvement
Anger
(d) Interventions
Implicit vs. explicit
skills training
Focus on one/few vs.
broad range of skills
Focus on one/few vs.
broad range of emotions
Cognitive techniques
Sadness
Behavioral techniques
Attention deployment
Shame
Experiential techniques
Strengths/resources
Reappraisal
Guilt
Mindfulness-based
techniques
etc.
etc.
etc.
etc.
Personality traits
(1) Risk
factor
(3) Symptom/consequence
(4) Treatment
target
(5) Mechanism
of change
Time
FIGURE 1. Areas for future research on emotion regulation in the mental-health field. ER, emotion regulation.
strongly associated with subsequent treatment outcome. Then, implicit or explicit strategies to
promote these changes need to be developed and
evaluated in randomized clinical trials. If shown to
be effective, these strategies should then be detailed
to the extent that they could be used alone or
incorporated into existing evidence-based treatments [91]. Thereby, psychotherapy research would
move away from evaluating only broad categories of
psychotherapeutic interventions (which often seem
to overlap on specific levels [92]) and would
instead also include a focus on specific interventions
for specific problems.
CONCLUSION
Although emotion regulation has become a popular
scientific concept, the quest for conceptual clarity,
valid assessment, and accurate conclusions about
implications has only begun. Thus, without claiming to offer solutions for all the challenges associated with this concept, we have provided a brief
overview of relevant findings and offered a few
caveats for consideration in future research. At this
point, available data indicate that emotion regulation is associated with various forms of psychopathology and might be considered a putative
transdiagnostic factor relevant for the development,
maintenance, and treatment of several mental disorders. Future research should include more stringent methods of investigating causal relationships
and work to clarify the following: which patients or
132
www.co-psychiatry.com
Conflicts of interest
There are no conflicts of interest.
www.co-psychiatry.com
133
Behavioural medicine
45. Gamble SA, Conner KR, Talbot NL, et al. Effects of pretreatment and
posttreatment depressive symptoms on alcohol consumption following treatment in project MATCH. J Stud Alcohol Drugs 2010; 71:7177.
46. Hodgins DC, El-Guebaly N, Armstrong S. Prospective and retrospective
reports of mood states before relapse to substance use. J Consult Clin
Psych 1995; 63:400407.
47. Swendsen JD, Tennen H, Carney MA, et al. Mood and alcohol consumption:
an experience sampling test of the self-medication hypothesis. J Abnorm
Psychol 2000; 109:198204.
48. Willinger U, Lenzinger E, Hornik K, et al. Anxiety as a predictor of relapse
in detoxified alcohol-dependent clients. Alcohol Alcohol 2002; 37:609
612.
49. Cooney NL, Litt MD, Morse PA, et al. Alcohol cue reactivity, negative-mood
reactivity, and relapse in treated alcoholic men. J Abnorm Psychol 1997;
106:243250.
50. Birch CD, Stewart SH, Wall A, et al. Mood-induced increases in alcohol
expectancy strength in internally motivated drinkers. Psychol Addict Behav
2004; 18:231238.
51. Sinha R, Fox HC, Hong KA, et al. Enhanced negative emotion and alcohol
craving, and altered physiological responses following stress and cue exposure in alcohol dependent individuals. Neuropsychopharmacology 2009;
34:11981208.
52. Brown RA, Evans DM, Miller IW, et al. Cognitive-behavioral treatment for
depression in alcoholism. J Consult Clin Psych 1997; 65:715726.
53. Watt M, Stewart S, Birch C, Bernier D. Brief CBT for high anxiety sensitivity
decreases drinking problems, relief alcohol outcome expectancies, and
conformity drinking motives: evidence from a randomized controlled trial. J
Ment Health 2006; 15:683695.
54. Fox HC, Axelrod SR, Paliwal PP, et al. Difficulties in emotion regulation and
impulse control during cocaine abstinence. Drug Alcohol Depend 2007;
89:298301.
55. Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating
disorders: a transdiagnostic theory and treatment. Behav Res Ther 2003;
41:509528.
56. Penas-Lledo E, Vaz Leal FJ, Waller G. Excessive exercise in anorexia nervosa
and bulimia nervosa: relation to eating characteristics and general psychopathology. Int J Eat Disorder 2002; 31:370375.
57. Smyth JM, Wonderlich SA, Heron KE, et al. Daily and momentary mood and
stress are associated with binge eating and vomiting in bulimia nervosa
patients in the natural environment. J Consult Clin Psych 2007; 75:629638.
58. Wild B, Eichler M, Feiler S, et al. Dynamic analysis of electronic diary data of
obese patients with and without binge eating disorder. Psychother Psychosom 2007; 76:250252.
59. Crosby RD, Wonderlich SA, Engel SG, et al. Daily mood patterns and
bulimic behaviors in the natural environment. Behav Res Ther 2009;
47:181188.
60. Smyth JM, Wonderlich SA, Sliwinski MJ, et al. Ecological momentary assessment of affect, stress, and bingepurge behaviors: day of week and time of day
effects in the natural environment. Int J Eat Disorder 2009; 42:429436.
61. Chua JL, Touyz S, Hill AJ. Negative mood-induced overeating in obese binge
eaters: an experimental study. Int J Obes Relat Metab Disord 2004; 28:606
610.
62. Hilbert A, Tuschen-Caffier B. Maintenance of binge eating through negative
mood: a naturalistic comparison of binge eating disorder and bulimia nervosa.
Int J Eat Disorder 2007; 40:521530.
63. Stein RI, Kenardy J, Wiseman CV, et al. Whats driving the binge in binge
eating disorder: a prospective examination of precursors and consequences?
Int J Eat Disorder 2007; 40:195203.
64. Bydlowski S, Corcos M, Jeammet P, et al. Emotion-processing deficits in
eating disorders. Int J Eat Disorder 2005; 37:321329.
65. Carano A, De Berardis D, Gambi F, et al. Alexithymia and body image in adult
outpatients with binge eating disorder. Int J Eat Disorder 2006; 39:332
340.
66. Svaldi J, Caffier D, Tuschen-Caffier B. Emotion suppression but not reapprai&
sal increases desire to binge in women with binge eating disorder. Psychother
Psychosom 2010; 79:188190.
This article uses an experimental design to clarify the causal impact of putative
emotion regulation strategies on core symptoms of BED.
67. Corstorphine E, Mountford V, Tomlinson S, et al. Distress tolerance in the
eating disorders. Eat Behav 2007; 8:9197.
68. Sim L, Zeman J. Emotion regulation factors as mediators between body
dissatisfaction and bulimic symptoms in early adolescent girls. J Early Adolesc
2005; 25:478496.
134
www.co-psychiatry.com