324 and differentiation MDD and AN linked to MDD sample had increased s and attenuation elevated difficulties in difficulties in attenuating and ation of emotions experience and differentiation modulating emotions of emotions eappraisal, Possibility that expressive ppression, Higher comorbidity linked reluctance, emotional awareness, to higher youth reported expression, emotional eluctance, negative affect, expressive awareness are linked to nhibition, positive reluctance, emotional depression, but lack of ative affect expression, emotional depression-only group makes awareness; Parent this difficult to determine her blame, report: inhibition of sadness catastrophizing, Internalizing: self- Catastrophizing blame and rumination; o perspective, Externalizing: positive ocusing, positive refocusing; Cognitive ER strategies explained more of acceptance, and the variance for internalizing than externalizing symptoms ren’s Anger Management Scale = CAMS, Children’s Emotion Management Scale = CEMS, = CSMS, Cognitions Checklist = CCL, Cognitive Emotion Regulation Questionnaire = CERQ, Emotion Regulation Questionnaire = ERQ, Emotion Regulation Questionnaire for Children ale = GRS, modified Differential Emotions Scale = mDES, Positive and Negative Affect e Bear Suppression Inventory = WBSI iety Inventory = BAI, Beck Depression Inventory = BDI, The Binge-Eating Scale = BES, The Brief Test = chEAT, Clinical Global Impression-Severity = CGI-S, Child Symptom Inventory = CSI, ders Examination-Q uestionnaire (EDE-Q), Global Assessment of Functioning = GAF; DSM-IV Axis f Depressive Symptomatology, IDS-C , Liebowitz Social Anxiety Scale = LSAS, Lifetime Interference nd Anxiety Symptom Questionnaire = MASQ, Mood and Anxiety Symptom Questionnaire-Short ent Scale = OASIS, Quick Inventory of Depressive Symptomology = QIDS, Revised Children’s re = RPEQ-aggressor version, The Short Michigan Alcohol Screening Test = SMAST-G, The Social view Schedule–C hild Version, Child and Parent report forms = ADIS-IV-C /P, Diagnostic Interview stic Interview = IDI, Structured Clinical Interview for DSM Disorders = SCID-I etic Resonance Imaging = fMRI, Respiratory Sinus Arrhythmia = RSA, The Zephyr[TM]
42 424 Transdiagnostic Approaches to Emotion Regulation pondering]). Participants completed a battery of emotion regulation questionnaires and symptom measures in one sitting. As expected, adaptive strategies were negatively correlated with anxiety/ depression and eating disorder symptoms, and maladaptive strategies were positively correlated with symptoms. A structural equation model also revealed that rumination (brooding, ponder- ing) and suppression had positive loadings, and reappraisal had a negative loading, on the single latent factor of cognitive emotion regulation. Problem solving did not load onto the latent fac- tor of cognitive emotion regulation. Model loadings suggested that adaptive strategies evidenced weaker relationships with distress than maladaptive strategies. One key finding revealed that rumination, suppression, and reappraisal were significantly related to all three types of psychopa- thology: anhedonic depression, anxious arousal, and eating disorder symptoms. Overall, a latent factor of cognitive emotion regulation was significantly associated with symptoms of all three disorders, providing evidence for a role for cognitive emotion regulation strategies across anxiety, depression, and eating pathology. Conklin et al. (2015) examined the relationship between adaptive and maladaptive emo- tion regulation strategies in 81 adults with comorbid anxiety and alcohol use disorders. Data were used from a clinical trial in which participants were randomized to one of four cognitive behavioral conditions: Unified Protocol for Transdiagnostic Treatment of Emotional Disorders or progressive muscle relaxation, and both conditions combined with either venlafaxine, or pill placebo. A different set of adaptive strategies were assessed using a revised BRIEF COPE measure (Carver, 1997) to capture active coping, planning, use of emotional support, use of instrumental support, positive reframing, acceptance, religion, sharing emotions (e.g., venting), and humor. Maladaptive strategies included denial, self-b lame, behavioral disinhibition, and substance use. Change in adaptive and maladaptive strategies before and after treatment was the primary inter- est. The key results showed that the change in use of maladaptive strategies was positively related to symptom severity at pre-and post-treatment. Decreases in the use of maladaptive strategies were significantly related to a decrease in symptom severity across treatment. Use of adaptive strategies was associated with lower symptom severity only for individuals with a higher use of maladaptive strategies at pre-treatment. These findings helped to demonstrate an association between emotion regulation strategies and the severity of psychopathology at repeated points in treatment and provided supporting data to establish emotion regulation as potential mediators of treatment outcomes. However, they did not examine differential relations between emotion regulation and either disorder class or differential change in disorder status. Thus, we have limited data to draw conclusions about the relative importance (commonality, distinctiveness) for these emotion regulation strategies across anxiety and alcohol use. Desrosiers, Vine, Klemanski, and Nolen-Hoeksema (2013) sought to provide further specific- ity on which cognitive emotion regulation strategies mediate associations between mindfulness and distress. Reappraisal, nonacceptance, rumination, and worry were examined in relation to depression and anxiety. Participants included a clinical sample of 187 adults, ages 18–7 1, seek- ing treatment at a mood and anxiety disorders clinic. Simple mediation model analyses revealed that rumination significantly mediated associations between mindfulness and both anxiety and depression, whereas multiple mediation analyses reveal that rumination showed specificity to depression symptoms. That is, lesser use of mindfulness was associated with greater depression, but this relation was mediated to the extent that individuals ruminated. While this finding sug- gests that rumination operates as a transdiagnostic mechanism across depression and anxiety, reappraisal was found to mediate only depression symptoms and worry was found to mediate only anxiety symptoms. The authors provide several plausible explanations for these differences. While rumination and worry both involve repetitive thinking, worry typically involves over-e ngagement about future negative outcomes, which is more closely associated with anxiety symptoms, and
524 Cross-sectional research with adults 425 rumination typically involves over-engagement with both present and past outcomes, which is associated with both anxiety and depressive symptoms. Reappraisal’s specificity to depressive symptoms might be related to the benefits of mindfulness, which can help individuals to adopt a nonjudgmental stance and potentially disengage from their repetitive thinking. Rumination and worry were examined with negative automatic thoughts in a study assessing differences between euthymic bipolar I disorder (BP; n = 21), insomnia (INS; n = 19), and non- clinical comparisons (NC; n = 20) (Gruber, Eidelman, & Harvey, 2008). While BP and INS par- ticipants reported significantly more rumination and worry than NC participants, BP and INS participants did not differ from one another in rumination and worry. The study also found that the BP group reported significantly more negative automatic thoughts than the NC group; how- ever, BP and INS groups again did not differ from one another in negative automatic thoughts. In follow-up analysis, rumination and worry were no longer elevated in BP and INS compared to NC after controlling for anxiety and depressive symptoms (Gruber et al., 2008). These results highlight important methodological and conceptual issues when studying transdiagnostic pro- cesses. Controlling for anxiety and depression may be important to adjust for any spurious effects of general distress or symptom severity when comparing a mechanism across disorders. At the same time, removing the effects of general distress may also be removing important explanatory processes that may explain commonalities across disorders. We simply may not have the measures that can adequately parse out the variance that is associated with unique transdiagnostic processes from general distress. Based on these studies (Aldao & Nolen-Hoeksema, 2010; Desrosiers et al., 2013), there is evi- dence that some cognitive emotion regulation strategies might operate transdiagnostically, while others might operate more uniquely to certain disorders. In particular, rumination might be a transdiagnostic mechanism across depression and anxiety, whereas worry might relate more closely to anxiety. The relationship between reappraisal and pathology may be more mixed. While Aldao and Nolen-H oeksema (2010) found that reappraisal was significantly related to anxiety and depression, Desrosiers et al. (2013) found that reappraisal was significantly related to depres- sion only. Another interesting finding discovered through latent class analysis was that the con- struct of cognitive emotion regulation may be more strongly influenced by maladaptive cognitive strategies than adaptive cognitive strategies. Adaptive strategies also appear to be helpful because they decrease the use of maladaptive strategies more than because they are positive in-and-of themselves. Another way to examine emotion regulation difficulties across disorders is to investigate the central facets of emotion regulation rather than certain constructs (e.g., rumination, worry). Using the Difficulties in Emotion Regulation Scale (DERS), Brockmeyer et al. (2012) exam- ined difficulties 1) experiencing and differentiating emotions (i.e., non-acceptance of emotional responses, lack of emotional awareness, and lack of emotional clarity) and 2) attenuating and modulating emotions (i.e., difficulties in engaging in goal-directed behavior, impulse control dif- ficulties, and limited access to effective emotion regulation strategies) in women diagnosed with major depression (MDD) or anorexia nervosa (AN), or considered healthy controls (N = 140). Overall, individuals with both MDD and AN reported greater difficulty regarding the experience and differentiation of emotions compared to healthy controls. However, difficulties in attenuating and modulating emotions was significantly higher only in individuals with MDD, and there was no significant difference between the AN or NC groups (Brockmeyer et al., 2012). These results provide examples of both disorder-s pecific and transdiagnostic emotion regulation processes. Research has also focused on how specific facets of emotion regulation mediate the relation- ship between broader emotion regulation processes and psychopathology. Vine and Aldao (2014) examined whether deficits in the broad construct of emotional clarity would correlate with
624 426 Transdiagnostic Approaches to Emotion Regulation psychopathology (i.e., symptoms of anhedonic depression, social anxiety, borderline personality, binge eating, restrictive eating, anxious arousal, and substance abuse) by way of impaired emotion regulation. Participants were 211 undergraduate students who completed the DERS and multiple self-r╉eport symptom measures. Multiple regression analyses revealed that deficits in emotional clarity were significantly related to five symptom types: anhedonic depression (β = .56), social anxiety (β = .49), borderline personality (β = .47), binge eating (β = .52), and alcohol use (β = .21); however, deficits were not significantly related to restrictive eating and anxious arousal. These results show that deficits in emotional clarity were more closely related to anhedonic depres- sion and borderline personality disorder symptoms. Multiple mediation model analyses revealed that there were several emotion regulation pathways that significantly related to the aforemen- tioned symptoms. Individuals with anhedonic depression experienced a significantly lower abil- ity to shift attention (Attentional Control Scale Shifting), which was associated with depression severity. Individuals with social anxiety showed significant difficulties with acceptance (DERS Acceptance) and access to strategies (DERS Strategies). Individuals with borderline personality symptoms showed that the specific indirect pathways through shifting and strategies were sig- nificant, with the effect of the “strategies” pathway being significantly larger than the “shifting” pathway (e.g., deficits in emotional clarity shift attention borderline personality symptoms). That is, individuals who demonstrated deficits in emotional clarity also reported lower ability to shift attention, which in turn was associated with higher levels of borderline symptoms. No specific indirect pathways were significant for individuals with binge eating symptoms. There was one significant specific indirect pathway through impulse (DERS Impulse) for participants with problematic alcohol use, which showed that individuals with deficits in emotional clarity tended to report difficulty regulating impulsive behavior. These findings show that a single emo- tion regulation process, such as emotional clarity, may predict multiple types of pathology in a transdiagnostic fashion. However, these relationships appear to be mediated by different emotion regulation mechanisms, depending on the type of pathology. Cross-âs•‰ ectional research with youth Evidence of disorder-s╉pecific and transdiagnostic emotion regulation processes has also been found in cross-âs•‰ ectional research with youth (see Table 20.1). Queen and Ehrenreich-M╉ ay (2014) examined affect and emotion regulation strategies (cognitive reappraisal, emotional suppression, emotional awareness, expressive reluctance, emotional inhibition) as a function of comorbidity in adolescents (12–1╉ 8-ây•‰ ears-o╉ ld). The study compared 44 youth with diagnosed comorbid anxiety and depressive disorders with 32 youth with diagnosed anxiety and no comorbid depressive disor- der. Parents and youth were assessed using a combination of semi-s╉ tructured interviews and self-╉ report questionnaires. Results found that youth with comorbidity were rated as having a higher Clinical Severity Rating for emotional disorders and higher Lifetime interference measures based on a semi-s╉tructured interview. They did not, however, have higher Clinical Global Impression (CGI) ratings overall. Youth self-âr•‰ eport found individuals with comorbidity reported higher levels of negative affect, expressive reluctance, and emotional suppression, in addition to poorer emo- tional awareness and lower positive affect. Parents reported that youth had higher inhibition of sadness, but did not report differences between inhibition of worry or anger between the two groups. Youth with comorbid anxiety and depression appear to demonstrate greater impairment and greater emotion regulation difficulties. While these results do not directly implicate common or unique processes, they do suggest that depression may convey greater risk for unique emotion regulation difficulties, specifically in awareness and experience of emotions. However, without a depression only group, it is unclear if the presence of depression alone that is linked to higher
724 Cross-sectional research with youth 427 dysregulation, or if it is something unique about the combination of anxiety and depression that is of key importance. Further examination of expressive reluctance, emotional expression, and emotional awareness may play an important role in the development or maintenance of comorbid anxiety and depression. In addition to emotion regulation strategies involving awareness and recognition of different emotions, cognitive emotion regulation strategies have also been thought to influence disor- der trajectories, and may be particularly important in youth given the vast changes to cognitive capacity that occur between childhood and adolescence. Garnefski, Vivian Kraaij, and Marije van Etten (2005), for example, compared a number of cognitive emotion regulation components (i.e., self and other blame, rumination, catastrophizing, putting into perspective, positive refocusing, positive reappraisal, acceptance, and planning) among 271 12-to-1 8-y ear-o ld teens who demon- strated internalizing symptoms, externalizing symptoms, comorbid internalizing, and external- izing symptoms, or no significant symptoms. It was hypothesized that self-blame, rumination, catastrophizing, and lack of positive reappraisal would be most highly associated with internal- izing and externalizing symptoms. Regression analyses were completed to determine the relation- ship between these cognitive strategies and internalizing problems (while controlling for gender, age and number of externalizing symptoms), and between cognitive strategies and externaliz- ing problems (while controlling for gender, age and number of internalizing symptoms). Results showed that adolescents with internalizing problems (either alone or appearing with externaliz- ing symptoms) reported significantly higher levels of self-b lame and rumination than those with externalizing problems alone or the healthy controls. No differences were found between inter- nalizing and externalizing youth with regard to catastrophizing. Adolescents with externalizing problems were more likely to report positive refocusing. With the exception of catastrophizing, there was no overlap between the specific cognitive emotion regulation strategies that predicted internalizing and externalizing problems, and cognitive emotion regulation strategies were able to explain more of the variance of internalizing problems than of externalizing problems. This sug- gests that cognitive emotion regulation strategies in general may play a larger role in contributing to internalizing problems than to externalizing problems, and that these mechanisms may play a key role in distinguishing between the two symptom profiles. The results of these adult and youth cross-s ectional studies highlight some of the ways in which emotion regulation strategies can be conceptualized and how they might operate uniquely or transdiagnostically across psychopathology. Emotion regulation mechanisms can be further classified based on their hypothesized function, such as cognitive strategies (e.g., rumination, worry, reappraisal), and adaptive or maladaptive strategies (e.g., Aldao & Nolen-H oeksema, 2010; Desrosiers et al., 2013). Certain emotion regulation strategies have also been examined as mediating variables (Vine & Aldao, 2014). One interesting takeaway from the adult studies seems to be the greater link of maladaptive emotion regulation strategies to pathology than adaptive emotion regulation strategies. These initial findings suggest that future research, and potentially clinical work, should focus more on how the reduction of maladaptive strategies, rather than the increase of adaptive strategies, relates to the development and maintenance of pathology over time. Additionally, as it stands, the above studies suggest that cognitive emotion regulation strate- gies may play an influential role in distinguishing between disorders within a youth population. Overall, the strengths of these studies include examining an array of emotion regulation strategies in both clinical and nonclinical populations, the use of multi-m ethod assessments (diagnostic and semi-s tructured interviews, such as the ADIS, SCID), and mixed methods (e.g., multiple media- tion models, measurement, and structural models). Unfortunately, there is a paucity of cross-sectional studies looking at emotion regulation across disorders in youth, and additional research could help to further clarify specific emotion
824 428 Transdiagnostic Approaches to Emotion Regulation regulation strategies that may differentiate between or underlie multiple different disorders in children and adolescents. With further assessment, this information may be beneficial in inform- ing which mechanisms can be targeted to produce the most effective change in youth with dif- ferent disorder profiles. It is important to note that while cross-s╉ ectional research can help detect possible links between strategies and symptomatology, the design limits examination of how the relationship between emotion regulation strategies and psychopathology might evolve over time. Additionally, despite some use of multimodal assessment, there is heavy reliance on self-r╉eport measures in the majority of cross-s╉ ectional studies, which lends itself to shared variance concerns and does not provide any directions for specific behavioral or physiological indicators of emotion regulation strategies or symptomology. Within both the adult and youth studies, recruitment of nonclinical (e.g., undergraduate students, community youth) samples, which restricts the range of psychopathology and might weaken the relationship to emotion regulation strategies. Overall, however, these cross-âs•‰ ectional studies provide a foundation for future studies, especially prospec- tive and experimental studies, which are needed to assess if these processes contribute to the etiology or maintenance of disorders. Biomarker and fMRI Studies Psychophysiogical and advanced imaging research provide exciting directions for understanding emotion regulation across disorders and diverse problem sets (Table 20.2). Gruber, Mennin, Fields, Purcell, and Murray (2015) looked at mean levels of intra-i╉ndividual changes in high-f╉requency heart rate variability (HRV-âH•‰ F), which has been associated with dysfunctional experiencing of positive emotions. Participants included 18–6╉0-ây•‰ears-âo•‰ ld adults, 21 of whom met criteria for bipolar disorder, 17 of whom met criteria for MDD, and 28 healthy controls. Additional mea- sures assessed mood symptoms, global functioning, and state and trait positive affectivity. Results found no group differences in mean HRV-âH•‰ F between bipolar disorders I, MDD, and controls. However, there was greater HRV-âH•‰ F instability in individuals with bipolar but this instability was not associated with dimensional measures of positive affect. The results support previous find- ings that bipolar disorders are linked to higher perceived variability in positive emotions, which is subsequently linked to increased depressive symptoms. The authors concluded that the study highlights the potential for research to move beyond laboratory and questionnaire based studies, and emphasized the importance of assessment over time. More recently, Burklund, Craske, Taylor, and Lieberman (2015) conducted a functional mag- netic resonance imaging (fMRI) study, which included participants with Social Phobia (SP) with- out comorbidity (n = 30), with comorbid depression (n = 18), with comorbid anxiety (n = 19), and healthy controls (n = 15). Participants were scanned while completing an emotion regula- tion task that involved affect labeling (e.g., labeling photographs of emotional facial expressions). fMRI data analyses revealed that individuals with pure SP and all comorbidity types showed an upregulation of amygdala activity compared to healthy controls during affect labeling, suggesting altered emotion regulation capacity in SP. Further, individuals with comorbid depression showed significant upregulation, or increased amygdala activity, compared to the other groups. This high- lights the significant impact of comorbidity within disorders and the importance of considering the role of comorbidity when examining emotion regulation processes across disorders. Burklund et al. (2015) also found that SP individuals with comorbid anxiety and depression had greater right ventral lateral prefrontal cortex (RVLPFC) activity, or amygdala reactivity, compared to SP individuals without comorbidity. These results highlight the role of comorbid symptoms when examining emotion regulation processes even when controlling for a single primary disorder (i.e., SP as in this study). These findings suggest that the individual’s difficulty with downregulating
924 Biomarker and fMRI Studies 429 Table 20.2 Adult fMRI and biomarker studies Citation Sample ER and ER Processes found Processes Characteristics Physiological components to be universal found to Measures (all that were be disorder assessed) Mean HRV-HF specific consistent across HRV-H F Gruber et al. N = 66; Ages ER physiological High groups instability (2015) 18–6 0, with measure: The Frequency seen in BD (n = 21), Zephyr[TM] heart rate Greater right individuals MDD (n = 17), BioHarness[TM] variability ventral lateral with BD healthy controls device (measures (HRB-H F) prefrontal cortex (n = 28) of parasympathetic (RVLPFC) activity, Individuals nervous system or amygdala with activity) ER self- reactivity in SP comorbid report: mDES (trait individuals with depression and state PA) comorbid anxiety showed and depression greater Burklund N = 82; Ages ER physiological Upregulation upregulation et al. (2015) of amygdala Less activation compared to 18–45, with measure: fMRI activity in PFC in both other groups GAD and PD SP (n = 30), SP labeling and participants None and comorbid reactivity task depression (n = 18), SP with comorbid anxiety (n = 19), and healthy controls (n = 15) Manber Ball n = 64: Adults ER physiological Reappraisal et al. (2013) of emotional with GAD (n measure: fMRI responses, maintenance = 23), panic (activation in of emotional responses disorder (n = prefrontal cortex 18), and healthy (PFC) during controls (n = emotion regulation) 23) neural emotion responses to negative stimuli likely relates to deficits in emotion regulation capac- ity. It is difficult to isolate the unique contributions of depression and anxiety disorders other than SP here, but findings suggest that greater pathology contributes to greater amygdala upregulation, which reflects greater emotion regulation dysregulation. It would take extra steps to determine the magnitude and type of effects each disorder contributes to amygdala dysfunction. Ball, Ramsawh, Campbell-Sills, Paulus, and Stein (2013) conducted an fMRI study including participants with primary diagnoses of generalized anxiety disorder (GAD; n = 23), panic disor- der (PD; n = 18), and healthy controls (HCs; n = 23). Participants completed self-r eport measures and were scanned while completing a task that required them to reappraise or maintain their emotional responses to negative images. The study was designed to test the hypothesis that GAD and PD would evidence hypo-activation in the prefrontal cortex (PFC) during emotion regu- lation attempts. Analyses of self-report measures revealed individuals with GAD reported the least reappraisal use in daily life. Reappraisal use was inversely associated with anxiety severity and functional impairment. fMRI data analyses showed that HCs had greater activation during both reappraisal and maintenance in brain areas important for emotion regulation (i.e., dorsolat- eral and dorsomedial PFC), whereas GAD and PD participants showed less activation in these
034 430 Transdiagnostic Approaches to Emotion Regulation areas, even as activation levels did not differ in the two clinical groups. Furthermore, those with the least PFC activation reported the greatest anxiety severity and impairment. These results pro- vide cross-m╉ ethod evidence that cognitive reappraisal and maintenance of emotional response might have transdiagnostic properties across GAD and PD. Although in nascent stages, heart rate and fMRI studies provide emerging evidence for physio- logical and neural functions of emotion regulation processes. Gruber et al. (2015) demonstrated that inconsistency in heart rate variability may be specifically linked to bipolar disorder, compared to MDD or healthy controls, and additional studies suggest that some forms of neural reactiv- ity is consistent across more severe symptoms of pathology. Burklund et al. (2015) found that participants with comorbid anxiety and depression exhibited increased amygdala reactivity com- pared to SP individuals without comorbidity (indicative of greater fear reactivity), and Ball et al. (2013) found that individuals with GAD and PD exhibited less reactivity in prefrontal cortex areas important for emotional regulation. These results provide evidence of several neural transdiag- nostic mechanisms across anxiety and depression. Burklund et al. (2015) also found that there are unique characteristics for individuals with comorbid depression, as they exhibited increased amygdala activity compared to individuals with comorbid anxiety. Unfortunately, we could not identify any youth-âb•‰ ased studies that investigated biomarkers of emotion regulation processes across multiple disorders. The more invasive assessment procedures used in this research may make investigators cautious about using child and adolescent samples; investigators and human subjects review boards may also expect a greater foundational evidence base before including a youth population. As it stands, limited research exists to inform the field on developmental dif- ferences of biological markers of emotion regulation. In summary, these studies underscore the importance of expanding research to include physiological and neurological measures of emotion regulation in order to gain greater specificity regarding potential transdiagnostic or disorder spe- cific strategies across pathology. Longitudinal designs Cross-s╉ ectional studies can highlight important links between emotion regulation strategies and disorders, but they do little to explain the development of regulation processes over time or their reciprocal relations with socio-e╉ motional distress. Longitudinal studies help explain how particu- lar processes contribute to or maintain particular symptoms over time and clarify convergent and divergent developmental trajectories (see Table 20.3). McLaughlin, Hatzenbuehler, Mennin, and Nolen-H╉ oeksema (2011) conducted a longitudinal assessment of the reciprocal relationship between psychopathology and emotion regulation skills. Participants included 1065 sixth to eighth graders who completed self-r╉ eport measures in school at baseline and after seven months. Emotional understanding, adaptive expression of negative, and cognitive emotion management strategies were targeted as emotion regulation processes. Results demonstrated that all types of emotion regulation were inter-âr•‰elated and were positively associ- ated with all four types of symptomology (anxiety, anger, eating pathology, depression), which were also inter-r╉elated. Interestingly, analyses found that a one factor model best fit the data, such that emotional understanding, dysregulated expression of sadness and anger, and ruminative responses were better combined into one factor of emotion dysregulation rather than examined as separate constructs. Using the single factor model, results showed that emotion dysregulation at Time 1 predicted Time 2 anxiety, anger, and eating pathology, but not depression. However, Time 1 anxiety, anger, eating pathology, and depression did not predict emotion regulation at Time 2. A number of interesting implications result. Unlike other studies that appear to find distinctions between different elements of emotion regulation as they relate to different disorders, this study
Table 20.3 Child longitudinal Citation Sample Characteristics ER Measures ER com were as McLaughlin et al. N = 1065; Ages 11–1 4 ER self-r eport: CAMS, CRSQ- (2011) with anxiety, depression, Rumination, CSMS, EESC Emotion agression, and eating -A ssessment at T1 and T2 expressi pathology (7 months later) sadness emotion strategi Vasilev et al. (2009) N = 212; Ages 8–1 2 with ER physiological RSA, no conduct disorder (n = 30), measure: RSA ER self- of emot Pang & Beauchaine depression (n = 28), report: DERS -Assessment at difficult (2013) comorbid conduct and 3 time points (each one year directed depression (n = 80), control apart) control group (n = 69) emotion access t N = 159; Ages 8–12 with ER physiological emotion conduct disorder (n = 30), measures: RSA -Assessment depression (n = 28), at 3 time points (each one RSA comorbid conduct and year apart) depression (n = 80), control group (n = 69)
134 mponents (all that Processes found to be Processes found to be ssessed) universal disorder specific T1 ER did not predict nal understanding, Four ER components best depression at T2 ion of anger and fit into a single emotion s, and cognitive dysregulation factor. T1 ER Access to ER strategies, n management ratings predicted T2 anxiety, impulse control, and ies (rumination) aggression, and eating acceptance of emotional pathology response were most linked onacceptance to reactivity tional response, Higher DERS linked to greater teis engaging in goal emotional withdrawal (as T1 comorbid depression d behaviors, impulse indicated by RSA) in response and conduct disorder difficulties, lack of to sadness induction at Time predicted lower baseline nal awarenes, limited 1, but increased response at RSA, over and above the to ER strategies, lack of Time 3. Lower DERS scores main effects. Comorbid nal clarity linked to stable reactivity depression and conduct across all three time points disorder samples had highest RSA reactivity TI higher levels of depression and conduct disorder linked to lower baseline RSA. Depression and conduct disorder samples demonstrated elevated emotional reactivity in response to sadness induction at each of the time points
234 432 Transdiagnostic Approaches to Emotion Regulation suggests that one broad construct actually fit the data more accurately. This may be due, in part, to the four particular inter-related elements of emotion regulation examined in this study; how- ever, other ER constructs may not fit as well into a single factor. Dysregulation in emotion man- agement also predicted subsequent symptomology at a later time point, but the reverse relation was not found. Although a formal cross-panel analysis was not performed to rule out additional confounding covariates, these results provide initial support for a prospective role of emotion regulation strategies in promoting anxiety, anger, and eating pathology. Further research in why depression was not predicted by earlier emotion regulation dysregulation is warranted. Hoping to examine the relationship between self-r eported emotion regulation and physiologi- cal indices over time, Vasilev, Crowell, Beauchaine, Mead, and Gatzke-K opp (2009) conducted a three-year study with 212 eight to 12 year olds who were categorized in one of four groups: non-clinical controls, conduct problems, depressive problems, or comorbid conduct and depres- sive problems. Physiological assessment of emotion regulation consisted of measuring respira- tory sinus arrhythmia (RSA), which captures changes in heart rate, and has been shown to be related to symptoms of depression, anxiety, self-injury, and disruptive behavior (Beauchaine et al., 2007; Crowell et al., 2005; Shannon, Beauchaine, Brenner, & Neuhaus, 2007; Silk, Steinberg, & Morris, 2003). At each of the three time points, examiners assessed baseline and change in RSA during a sadness induction task. The study aimed to link RSA at each assessment point to year three self-reported difficulties in emotion regulation, assessed by the self-reported DERS (i.e., non-acceptance of emotional response, difficulties engaging in goal directed behaviors, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity). It is normative for individuals to demonstrate increasing baseline levels of RSA during adolescence, and results from this study found that increasing baseline levels of RSA at each of the time points was associated with greater emotional awareness at year three. In comparison, individuals with relatively stable baseline RSA at each time demonstrated greater emotion regulation difficulties at year three. Regarding change in RSA rate following the sadness induction task, those who scored higher on the DERS tended to have greater emotional with- drawal (as indicated by RSA) in response to sadness induction at Time 1, but increased response at Time 3. Those who scored low on the DERS demonstrated relatively stable reactivity across all three time points. Authors suggested that low baseline RSA may actually be associated in increased instability in emotional reaction in response to triggers. Additional analysis found that access to emotion regulation strategies, impulse control, and acceptance of emotional response were most linked to reactivity. In related work, Pang and Beauchaine (2013) looked at baseline RSA and changes in RSA across the different disorder groups. At Time 1, higher levels of depression and conduct disorder were linked to lower RSA at baseline, indicating increased emotional withdrawal. The interaction of depression and conduct disorder also predicted lower baseline RSA, over and above the main effects. Individuals with depression and conduct disorder also demonstrated greater emotional reactivity in response to sadness induction at each of the time points, though individuals with comorbid depression and conducted disorder displayed the highest levels of reactivity. None of the disorder profiles were linked to trajectory changes in baseline RSA or RSA reactivity over time. Collectively, these studies demonstrate the ability of researchers to begin exploring how emo- tion regulation can impact change over time. The first study provides support for the notion that poor ER plays a temporal role in the development of symptomology, such that emotion regula- tion dysregulation precedes distress. Longitudinal studies using physiological markers of distress have found a link between RSA and specific self-reported emotion regulation strategies, such as emotional awareness and acceptance, impulse control, and access to emotion regulation strate- gies. The studies demonstrated that while both depression and conduct disorder were linked to
34 Summary of cross-sectional and longitudinal research 433 greater difficulties, comorbidity was associated with even higher levels of deficit. It appears that individuals who demonstrated developmentally normative rates of RSA over adolescence may actually respond most appropriately to emotional cues. In contrast, individuals with blunted base- line levels of RSA demonstrate difficulty with emotion regulation when presented with triggers. Interestingly, all of these studies have been conducted with youth. Summary of cross-s╉ ectional and longitudinal research This review of cross-âs•‰ectional, biomarker, advanced imaging, and longitudinal studies across youth and adult populations has highlighted several key themes in investigating emotion regula- tion as a transdiagnostic process. Currently, as demonstrated by the studies reviewed in this chap- ter, emotion regulation can be characterized by an array of different constructs (e.g., cognitive, adaptive, maladaptive) and specific emotion regulation strategies (i.e., rumination, emotional understanding, emotional expression). Further, each of these different constructs and strategies can be defined and measured in different ways depending on the particular self-r╉eport assess- ments used by each research team. While this allows for increased breadth in studying emotion regulation, it also poses a challenge for the field in that it becomes difficult to compare and syn- thesize results across studies and to conclusively highlight the most influential strategies. Despite these limitations, within the research that currently exists, it appears that cognitive emotion regu- lation strategies show promise as a transdiagnostic mechanism. Approximately 35% (n = 5) of reviewed studies found evidence for some cognitive emotion regulation strategies (e.g., worry, rumination) to operate transdiagnostically across disorders, 35% (n = 5) found evidence for emo- tional response strategies (e.g., emotional clarity, emotional expression), and 21% (n = 4) found evidence for transdiagnostic physiological reactivity mechanisms. The methodological and design features reviewed within these studies highlight a number of important considerations for the field to take into account in future research. Cross-s╉ectional research has been an efficient method to provide insights into which mechanisms merit additional examination. As noted, the importance of these findings will likely increase as the field further clarifies which strategies to examine and how to examine them. One positive step demonstrated in this review is the use of biological and physiological markers of emotion regulation and their link to self-âr•‰eport measures. Not only might this help demonstrate validity of self-âr•‰eport measures, but adds an important objective component to examining emotion regulation strategies across disorders. As a number of these studies show, research utilizing physiological and neurological assessment offers a unique and cutting-âe•‰ dge approach to this area of research. This, in addition to longitudinal design, can help explain the nuances of how particular emotion regulation strategies and emotion regulation as a whole can influence the trajectory of different disorders over time. Thus far, there is support for the impact of early emotion regulation difficulties in contributing to the development of pathology rather than the other way around. These findings have potentially important implications for the most effective and efficient ways to both prevent and treat different disorders. Self-âr•‰eport was a primary assessment used in all studies (e.g., Ruminative Response Scale). Approximately 64% used multimodal assessments, with 35% (n = 5) using clinical inter- views (e.g., SCID-I╉ V) and 28% (n = 4) using physiological assessments combined with self-âr•‰ eport. Clinical trials research To evaluate the evidence for transdiagnostic mechanisms represented in treatment research, a literature search was conducted using PsycINFO, PubMed and Google Scholar with the key- words “transdiagnostic AND (treatment OR intervention) AND (emotion regulation OR emo- tional regulation)”. Studies that involved interventions with a component of emotion regulation
43 434 Transdiagnostic Approaches to Emotion Regulation and used samples with comorbidities or multiple disorders were included. The literature search resulted in 14 articles, ten of which reported results from open trials or randomized controlled trials (RCTs) and four reported small n case studies. Effect sizes were (i.e., Cohen’s d) calculated at post-ât•‰reatment and follow-u╉ p to evaluate the effects of transdiagnostic treatments on diagnostic status, emotion-r╉ elated measures such as positive and negative affect, and anxiety and depressive symptoms (Table 4) A Cohen’s d value of 0.20 indicates a small effect size, 0.50 a medium effect size and 0.80 or greater a large effect size. Unified protocol Twelve of the studies focused on the Unified Protocol (UP) for treating emotional disorders. Originally developed by Barlow, Allen, and Choate (2004), the UP protocol integrates cognitive behavior therapy (CBT) and emotion regulation principles (Wilamowska et al., 2010). It con- sists of five core principles that include: (1) Increasing present-âf•‰ocused awareness of emotions, (2) increasing cognitive flexibility, (3) identifying and preventing emotional avoidance and mal- adaptive emotion-âd•‰ riven behaviors, (4) increasing awareness and tolerance of emotion-âr•‰elated physiological sensations, (5) exposing to bodily and environmental triggers of emotional experi- ences (Farchione et al., 2012). The aim of UP is to treat the symptoms of anxiety and mood dis- orders through tolerance of emotions and modifying maladaptive emotion regulation strategies (Wilamowska et al., 2010). A summary of these studies is presented in Table 20.4. The effects of UP have been studied mostly as an individual treatment for adults with a principal anxiety or uni- polar depressive disorder (above 18 years old; Bullis, Fortune, Farchione, & Barlow, 2014; Ellard, Fairholme, Boisseau, Farchione, & Barlow, 2010; Farchione et al., 2012). There are also studies using participants with chronic pain (Allen, Tsao, Seidman, Ehrenreich-M╉ ay, & Zeltzer, 2012), Bipolar Disorder, and Borderline Personality Disorder (Ellard, Deckersbach, Sylvia, Nierenberg, & Barlow, 2012; Sauer-Z╉ avala, Bentley, & Wilner, 2015). The UP has been applied to children (seven to 12 years old; Bilek & Ehrenreich-M╉ ay, 2012), adolescents (12–â1•‰ 7 years old; Trosper, Buzzella, Bennett, & Ehrenreich, 2009; Ehrenreich, Goldstein, Wright, & Barlow, 2009; Queen, Barlow, & Ehrenreich-M╉ ay, 2014) and adults (Bullis et al., 2015; Ornelas Maia, Braga, Nunes, Nardi, & Silva, 2013) in group format. Unified protocol as an individual intervention for adults The UP was first pilot tested by Ellard, Fairholme, Boisseau, Farchione, and Barlow (2010). This study examined the extent to which participants learned and used emotion regulation skills during treatment. The protocol included 15 treatment sessions. The efficacy of the treat- ment was tested through independent evaluator-r╉ated and self-âr•‰eported improvements in participants’ anxiety, and depressive symptoms, and functional impairment. Although emo- tion regulation was not directly measured, levels of participants’ positive and negative affect were assessed, which were seen as a consequence of emotion regulation (Barlow et al., 2004). Eighteen participants with multiple disorders completed an average of 13 treatment sessions. Results showed significant improvement in clinical severity ratings (CSR) for their princi- pal diagnosis, self-r╉eported anxiety and depressive symptoms, negative affect and functional impairment. Fifty-s╉ ix percent of participants were classified as in the normal range of negative affect at post-t╉reatment. The study defined a responder as ≥ 30% change on at least two outcomes of principal diagnosis (i.e., CSR, functional impairment, diagnosis specific measure) and high end-âs•‰ tate functioning as a loss of the principal diagnosis (i.e., CSR ≤ 3) and within the normal range of at least one of the functional impairment or diagnosis measures. Based on these criteria, 56% of the participants
Table 20.4 Clinical Trials Research Citation Sample Characteristics and Assessments ER compon Design that were Pain interview, Children’s Somatization Allen et al Case study: N = 2, 14–17 years Inventory (CSI), Emotion Expression Lack of em (2012) old, chronic pain with comorbid Scale for Children (EESC), Faces Pain awareness anxiety and depression. Scale-Revised (FPS-R), Functional to express Bilek & Assessment at posttreatment Disability Inventory (FDI), RCADS emotion Ehrenreich-May and 3 month follow-up (2012) ADIS-IV-C /P, Screen for Child Anxiety N/A Open trial, intent-to-t reat Related Emotional Disorders-C hild and (ITT): N = 22, 7–12 years old Parent Reports (SCARED), Children’s (M = 9.79 years), anxiety Depression Inventory-Child and disorder and comorbid Parent Reports (CDI), parent and child depressive disorder. Within satisfaction with treatment group comparison at posttreatment and 3 month follow-up Bullis et al. Open trial: N = 15, 20–52 years ADIS-IV-L, BDI-II, BAI, PANAS, PSWQ, Positive an (2014) old (M = 32.27 years), anxiety SIAS, WSAS, OCI-R, Albany Panic and affect disorders (M = 2.47 diagnoses; Phobia Questionnaire (APPQ) Bullis et al. 7 with comorbid depressive Total exper (2015) disorder). Within group ADIS-IV-L, Overall Anxiety Severity avoidance, comparison of treatment and Impairment Scale (OASIS), Overall avoidance, completers at posttreatment and Depression Severity and Impairment distress ave 18 month follow-up Scale (ODSIS), Multidimensional procrastina Experiential Avoidance Questionnaire distraction Open trial: N = 11, 20–69 years (MEAQ), WSAS, Quality of Life suppressio old (M = 44.55 years), anxiety Enjoyment and Satisfaction repression disorders (M = 1.27 diagnoses, Questionnaire (Q-LES-Q ) distress en n = 8 with comorbidity). Within group comparison at posttreatment
534 nents (all Treatment Effect size (Cohen’s d) assessed) UP for the Treatment Pre-posttreatment Pre-follow-up motion of Emotional s, reluctance Disorders in Youth N/A N/A with Pain (UP-YP) negative Emotion Detectives Within-group ESs: N/A Treatment Protocol Principal diagnosis Within-group ESs: nd negative Individual UP severity = 1.38 Principal diagnosis Total severity of depression and riential Group UP severity = 1.98 , Behavioral anxiety = 1.07 Self-r eport anxiety = 0.96 , Parent-r eport anxiety = 0.49 Self-r eport ersion, Self-r eport anxiety = 0.47 ation, Parent-report depression = 0.54 depression = 0.38 n and Self-report depression Positive affect = 0.41 on, Negative affect = 0.31 (ITT) = 0.34 N/A and denial, Self-r eport depression ndurance (completers) = 0.65 Within-group ESs: Principal diagnosis severity = 1.74 Self-r eport anxiety = 1.72 Self-r eport depression = 1.19 Positive affect = 0.39 Negative affect = 1.00 Within-g roup ESs: Self-r eport anxiety = 1.36 Self-report depression = 0.66 Total experiential avoidance = 1.12 (continued)
Table 20.4 Continued Citation Sample Characteristics and Assessments ER compon Design that were Ehrenreich, Open trial: N = 12, 12–17 years ADIS-IV-C /P, Revised Child Anxiety and Emotion re Buzzella et al. old, anxiety (42%) or comorbid Depression Scale (RCADS), Children’s sadness, an (2009) anxiety and depressive Emotion Management Scales (CEMS) worry disorder (58%). Assessment at Ehrenreich et al. posttreatment, 3 and 6 month Anxiety Disorders Interview Schedule N/A (2009) follow-up for DSM-IV Child and Parent Versions (ADIS-IV-C/P) N/A Ellard et al. Multiple baseline design: N = 3, (2012) 12–16 years old, principal MINI, Hamilton Depression Rating Positive an diagnosis of anxiety or Scale, Montgomery Asberg Depression affect Ellard et al. mood disorder. 2–8 week Rating Scale (MADRS), Young Mania (2010) baseline phase. Assessment at Rating Scale (YMRS), Clinical Global posttreatment and 6 month Impression Severity and Improvement follow-up (CGI-S, CGI-I), BDI-II, BAI Clinical replication series: N = 3, Clinician assessed Anxiety Disorders 23–6 2 years old, bipolar disorder Interview Schedule for DSM-IV Lifetime with comorbid anxiety disorder. version (ADIS-IV-L), Beck Depression Assessment at posttreatment Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), Positive and Negative Open trial #1: N = 18, 18– Affect Scale (PANAS), Obsessive- 54 years old (M = 30 years), Compulsive Inventory-Revised (OCI-R), anxiety or major depressive Panic Disorder Severity Scale (PDSS- disorder (M = 1.94 diagnoses). SR), Penn State Worry Questionnaire Within group comparison at (PSWQ), Social Interaction Anxiety posttreatment Inventory (SIAS), Work and Social Adjustment Scale (WSAS)
634 nents (all Treatment Effect size (Cohen’s d) assessed) Pre-posttreatment Pre-follow-up egulation of UP-Y None reported None reported nger and UP-Y N/A N/A Individual UP N/A N/A nd negative Individual UP Within-group ESs: N/A Principal diagnosis severity = 1.20 Self-report anxiety = 0.60 Self-r eport depression = 0.50 Positive affect = 0.30 Negative affect = 0.53
Open trial #2: N = 15, 18– ADIS-IV-L, clinician rated structured 44 years old (M = 29.73 years), interview guides for the Hamilton principal anxiety disorder Anxiety and Depression Rating Scales (M = 2.2 diagnoses). Within (SIGH-A , SIGH-D), BDI-II, BAI, PANAS, group comparison at Yale-B rown Obsessive Compulsive posttreatment and 6 month Scale (Y-B OCS), PDSS-SR, PSWQ, SIAS, follow-u p WSAS Farchione et al. Randomized controlled ADIS-IV-L, SIGH-A , SIGH-D , BDI-II, BAI, Positive an (2012) trial: N = 37, anxiety disorders PANAS, Y-B OCS, PDSS-SR, PSWQ, affect (M = 2.16 diagnoses; 12 with SIAS, WSAS comorbid depressive disorder) Between group comparison of treatment group (n = 26, 19– 52 years old, M = 29.38 years) with 16 week waitlist control group (n = 11, 19-43 years old, M = 30.64 years) at posttreatment N = 35, treatment initiators. Within group comparison at posttreatment and 6 month follow-u p
734 Individual UP Winthin-g roup ESs: Within-group ESs: Principal diagnosis Principal diagnosis nd negative Individual UP severity = 1.84 severity = 2.13 Self-report anxiety = 0.62 Self-r eport anxiety = 0.64 Self-r eport depression = 0.43 Self-r eport Positive affect = 0.53 Negative affect = 0.75 depression = 0.65 Positive affect = 0.27 Between-group ESs: Negative affect = 0.78 Principal diagnosis N/A severity = 2.27 Self-r eport anxiety = 0.43 Self-report depression = 0.87 Positive affect = 0.87 Negative affect = 0.42 Within-g roup ESs: Within-g roup ESs: Principal Principal diagnosis diagnosis severity = 2.12 severity = 1.55 Self-report anxiety = 1.04 Self-r eport anxiety = 1.18 Self-r eport Self-r eport depression = 1.05 depression = 0.94 Positive affect = 0.53 Positive affect = 0.57 Negative affect = 0.84 Negative affect = 0.85 (continued)
Table 20.4 Continued Citation Sample Characteristics and Assessments ER compon Design that were Mennin et al. Open trial, ITT: N = 21 ADIS-IV-L, modified CGI, PSWQ, Emotional (2015) (M = 35.25 years), generalized BDI-II, Mood and Anxiety Symptom decenterin anxiety disorder (GAD) with Questionnaire-Short Form (MASQ), nonaccept comorbid major depressive State-Trait Anxiety Inventory (STAI), negative em disorder (MDD; n = 11). Sheehan Disability Scale (SDS), Quality difficulty in Within group comparison at of Life Inventory (QOLI), Negative situations w posttreatment, 3 and 9 month Intensity scale from Affect Intensity pursuing g follow-u p Measure (AIM), Decentering subscale directed be from Experiences Questionnaire, DERS, controlling Emotion Regulation Questionnaire lack of reg (ERQ), Five Facet Mindfulness strategies, Questionnaire (FFMQ) with emoti awareness clarity, reap trait mindf Neacsiu et al. Randomized controlled DERS, DBT Skills subscale of DBT Ways Nonaccept (2014) trial, ITT: N = 44, high on of Coping Checklist (DBT-W CCL), negative em emotion disorder, at least Patient Health Questionnaire-9 difficulty in one anxiety or depressive (PHQ-9 ), OASIS, Brief Treatment situations w disorder (DBT-ST: M = 2.68; History Interview (B-THI), Addiction pursuing g ASG: M = 2.59). Between Severity Index Self-Report Form (ASI- directed be group comparison of treatment SR), Credibility and Expectancy of controlling group (M = 32.27 years old) Improvement Scales (CEIS) lack of reg with 16 sessions, 120 min, strategies, Activities-B ased Support Group with emoti (ASG, M = 38.82 years old) at awareness posttreatment and 2 month clarity follow-up
834 nents (all Treatment Effect size (Cohen’s d) assessed) Emotion Regulation Pre-p osttreatment Pre-follow-up intensity, Therapy (ERT) ng, Within-g roup ESs: Within-g roup ESs: tance of GAD severity = 3.60 GAD severity_3 m = 3.55 MDD severity = 0.54 GAD severity_9m = 3.60 motions, Self-r eport worry = MDD severity_3m = 0.65 n emotional Self-report depression = 1.28 MDD severity_9 m = 0.80 with Emotional intensity = 0.55 Self-report worry_3 m = 1.48 goal- Decentering = 1.18 Self-report worry_9m = 1.77 ehaviors, Emotion regulation = 0.71 Self-r eport depression_ g impulses, Reappraisal = 1.26 gulation 3m = 1.22 Trait mindfulness = 0.62 Self-report depression_ problems ional 9m = 1.41 s, emotional Emotional intensity_ ppraisal, fulness 3m = 0.25 Emotional intensity_ 9m = 0.64 Decentering_3 m = 1.01 Decentering_9m = 1.35 Emotion regulation_ 3m = 0.72 Emotion regulation_ 9m = 0.99 Reappraisal_3m = 1.35 Reappraisal_9m = 1.06 Trait mindfulness_3m = 0.32 Trait mindfulness_9 m = 0.76 tance of Dialectical Behavior Between-g roup Ess: Between-group ESs: motions, Therapy- Skills Self-report anxiety = 0.86 Self-report anxiety = 0.70 n emotional Training group Self-report depression = 0.39 Self-report with (DBT-ST) Emotion regulation = 0.99 goal- depression = 0.39 ehaviors, DBT skills = 0.75 Emotion regulation = 0.63 g impulses, gulation DBT skills = 0.27 problems ional s, emotional
Ornelas et al. Open trial: N = 16, 18-58 years Mini International Psychiatric Nil (2013) old (M = 35.63 years), unipolar Interview (MINI 5.0), BDI, BAI, World Nil mood disorder comorbid Health Organisation Quality of Life Queen et al. with anxiety. Within group (WHOQOL-BREF), ARIZONA scale of (2014) comparison at posttreatment sexual function Piecewise latent growth curve ADIS-IV-C/P, RCADS, Revised Child modelling: N = 59, 12-17 years Anxiety and Depression Scale—Parent old (M = 15.42 years), ≥ 8 Version sessions in previous open trial or RCT, anxiety (79.9%), unipolar depressive (15.3%) disorder or both (5.1%). Test trajectories of anxiety and depressive symptoms over the course of the UP-Y (data from an open trial or an RCT were analysed). Within group comparison at posttreatment, 3 and 6 month follow-up Sauer-Z avala Clinical replication series: N = 5, Diagnostic Interview for Personality Nonaccept et al. (2015) borderline personality disorder Disorders-4 th Edition (DIPD-IV), negative em with comorbid anxiety and ADIS-IV, The Zanarini Rating Scale difficulty in mood disorders. Assessment at for Borderline Personality Disorder situations w posttreatment (ZAN-B PD), Depression, Anxiety and pursuing g Stress Scales, Difficulties in Emotion directed be Regulation Scale (DERS) controlling lack of reg strategies, with emoti awareness clarity
934 Group UP Within-g roup ESs: N/A Individual UP-Y Self-report anxiety = 0.95 Self-report depression = 1.34 tance of Individual UP Within-group ESs: Within-g roup ESs: motions, Self-r eport anxiety = 0.81 Self-report anxiety_ n emotional Self-report depression = 0.65 with Parent-report anxiety = 0.48 3m = 1.29 goal- Parent-r eport depression = 0.63 Self-r eport anxiety_ ehaviors, g impulses, N/A 6m = 1.34 gulation Self-report depression_ problems ional 3m = 0.97 s, emotional Self-r eport depression_ 6m = 0.80 Parent-report anxiety_ 3m = 1.11 Parent-r eport anxiety_ 6m = 1.07 Parent-r eport depression_ 3m = 0.87 Parent-report depression_ 6m = 0.60 N/A
04 440 Transdiagnostic Approaches to Emotion Regulation were identified as treatment responders based on their principal diagnosis and 71% based on their comorbid diagnoses. Thirty-three percent of participants gained high end-s tate functioning based on their principal diagnosis and 50% based on their comorbid diagnosis. However, the authors considered the effects as “modest,” given that 67% of the sample remained at the clinical level at post-treatment. To enhance the UP, the protocol was extended to 18 ses- sions and this was further tested in 15 participants with a principal diagnosis of anxiety disor- der in a second pilot trial (Ellard et al., 2010). Participants had at least two comorbid anxiety or depressive disorders and they attended an average of 17 sessions of the treatment. There were significant improvements in clinical severity ratings of principal diagnosis, self-reported anxiety symptoms, negative affect and functional impairment. However, self-reported depressive symp- toms and positive affect did not show significant changes. The percentage of responders increased to 71% compared to the first pilot trial (56%) based on their principal diagnosis and 64% based on their comorbid diagnoses. Similarly, based on both principal and comorbid diagnoses, high end- state functioning increased from 32% and 50% in the first pilot trial to 60% and 64%, respectively. A higher proportion of participants were classified as within the normal range of negative affect (67%). At six-m onth follow-u p, only clinical severity ratings of principal diagnosis, negative affect and functional impairment showed significant improvements. Eleven participants (73%) showed further gains in responder status and high end-s tate functioning based on their principal diagnosis while only 50% showed improvements based on their comorbid diagnosis. However, the results from these two trials were preliminary, given the small sample size and absence of a control group. Subsequently, Farchione et al. (2012) conducted an RCT to investigate the efficacy of the UP and its effects at six-m onth follow-u p. The study involved 37 participants with a principal diagnosis of anxiety disorders and at least two comorbid diagnoses. Twelve of these participants had comor- bid depressive disorders. The UP used in this study was different from Ellard et al. (2010), which included motivational techniques to assess for readiness for change and engagement in treatment, additional optional emotion-focused exposure exercises, and treatment review and relapse pre- vention (see details in Barlow et al., 2011). Participants received a maximum of 18 sessions of treatment. The study used the same assessment measures as Ellard et al. (2010). Compared to the waitlist control, participants in the UP group demonstrated significantly greater improvement in self-reported and independent evaluator-rated anxiety and depressive symptoms, positive and negative affect, and functional impairment. Between groups, effect sizes ranged from 0.42 to 2.27 (Table 20.4). Responders were defined as either ≥ 30% change or ≤ 3 in clinical severity rating of principal diagnosis plus ≥ 30% change in at least diagnosis-specific or functional impairment measures. The definition of high end state functioning was the same as Ellard et al. (2010). None of the participants in the waitlist control were identified as responders or at high end state func- tioning. In contrast, 59% participants in the UP group were identified as responders and 50% of them at high end-state functioning. The study also analyzed results of the treatment initiator sample which included waitlist control participants who completed treatment after the waitlist period (n = 35; average of 15.26 sessions completed). Within group effect sizes of clinical severity ratings of principal diagnosis, anxiety and depressive symptoms, positive and negative affect and functional impairment ranged from moderate to large (Table 20.4). Forty five percent of the treat- ment initiators no longer met criteria of any clinical diagnoses at post-treatment and 64% at six month follow-up. Similarly, the proportion of the participants who were identified as responders (59%) and at high end state functioning (52%) at post-treatment based on principal diagnosis increased to 71% and 64% at follow-up. Regarding comorbid diagnoses, there was an increase in the percentage of participants who were identified as responders and at high end state functioning at follow-up compared to post-treatment, from 38% to 62%, and 41% to 72%, respectively. It was highlighted that 67% of participants with comorbid depressive disorders no longer met criteria
14 Summary of cross-sectional and longitudinal research 441 for any clinical diagnoses, and were identified as responders and at high end state functioning at post-t╉reatment and this increased to 89% at follow-u╉ p. These results demonstrated the efficacy of UP on anxiety and depressive disorders, with further symptom improvements at six month fol- low-âu•‰ p. The authors suggested that the effects of the UP on positive and negative affect were likely achieved through improving individuals’ reactions toward negative emotions and their engage- ments in positive emotional experiences. However, there were limitations including small sample size and the lack of reliability and fidelity checks. Furthermore, given that the comparison group was not an active treatment, conclusions on the processes of the UP in relation to therapeutic effects cannot be drawn. A follow-âu•‰ p study by Bullis, Fortune, Farchione, and Barlow (2014) aimed to explore the out- comes of participants in the Farchione et al. (2012) study at 18 months after treatment (i.e., long-╉ term follow-u╉ p; n = 15). The results showed a significant improvement in clinical severity ratings of principal diagnosis, number of clinical diagnoses, and clinician-r╉ ated and self-r╉ eport functional impairment at long-ât•‰erm follow-âu•‰ p in 15 treatment completers with anxiety disorders. Although 53% of participants did not meet criteria for any clinical diagnosis at long term follow-âu•‰ p, there was no evidence of further improvements from six months to 18-âm•‰ onth follow-u╉ p. Participants who were identified as responders and at high end state functioning at six months maintained their functioning at 18-âm•‰ onth follow-u╉ p. While there was an increase in participants’ depressive symptoms, negative affect and clinician-r╉ ated functional impairment from 6 months to long-t╉ erm follow-âu•‰ p, the average scores in these domains remained at the normal to mild range. The results suggest that gains in treatment were maintained up to 18 month follow-u╉ p. However, the small sample made it impossible to generalize the results to other diagnoses and populations. To sum up, the three studies reviewed above revealed that UP focuses primarily on increasing emotional awareness and changing maladaptive emotion regulation strategies. Although emotion regulation was not directly measured in these studies, there is evidence that targeting emotion regulation in adults could lead to improvements in anxiety and depressive symptoms, and nega- tive or positive affect concurrently. Unified protocol as a group intervention for adults While the UP has been delivered as an individual therapy, Ornelas Maia, Braga, Nunes, Nardi, and Silva (2013) aimed to evaluate a group treatment based on UP for 16 participants with moderate to severe unipolar mood disorder with comorbid anxiety. The treatment covered the five core principles of UP over 12 two-h╉ our sessions. The MINI International Neuropsychiatric Interview was used to identify the diagnoses and self-r╉ eported anxiety and depressive symptoms were mea- sured. There were significant improvements in self-âr•‰ eported anxiety and depressive symptoms at post-t╉reatment with large within-âg•‰ roup effect sizes. This study provided evidence for the feasi- bility of UP as a group intervention for adults, which allows the opportunity for social learning among participants. However, similar to previous studies, this study was an open trial with a small sample size and did not measure treatment adherence and emotion regulation. Similarly, the researchers who developed UP also pilot tested the UP as a group format in an open trial with 11 participants to examine whether results from studies on UP as an individual intervention could be replicated (Bullis et al., 2015). The majority of the participants had a prin- cipal anxiety diagnosis with only one with a dysthymia diagnosis. However, eight of the 11 par- ticipants had a comorbid disorder including other anxiety and mood disorders, attention deficit hyperactivity disorder, and alcohol abuse. The UP was delivered in a group of five to six partici- pants over 12 two-h╉ our sessions. Participants in the group treatment completed an average of ten treatment sessions and were assessed at pre-,╉ mid-╉and post-t╉reatment. Although there was no clear description about measurements for emotion regulation, a multi-d╉ imensional experiential
24 442 Transdiagnostic Approaches to Emotion Regulation avoidance questionnaire (MEAQ: Gamez, Chmielewski, Kotov, Ruggero, & Watson, 2011) was administered to assess the tendency to avoid negative internal experiences. This measure consisted of six subscales including behavioral avoidance, distress aversion, procrastination, distraction and suppression, repression and denial, and distress endurance. In addition, anxiety, depression, func- tional impairment, and satisfaction and enjoyment in daily living were also measured. Results showed that the UP demonstrated a strong effect on anxiety (d = 1.36) and experi- ential avoidance (d = 1.12) and a moderate effect on depressive symptoms (d = 0.66). UP was mostly rated as “very” or “extremely” acceptable and participants were satisfied. The group format provided opportunities for participants to increase their confidence in practicing skills, through involvement in other participants’ exposure and small group exercises. Although the efficacy of UP was demonstrated in a group intervention, the authors noted difficulties in training and moni- toring the understanding of treatment concepts in the group setting, especially with participants who require extensive direction. Moreover, the small sample size, reliance on self-âr•‰eport meas- ures, and lack of control group and follow-u╉ p failed to ascertain the causal inferences or modera- tors of treatment efficacy. Therefore, it was suggested to improve the treatment by devoting more time to homework review, limiting to one objective per session, including brief individual meet- ings with participants, and using the group intervention as a step towards intensive treatment. In sum, the group format of the UP protocol shows promising results. Specifically, Bullis et al. (2015) measured multiple dimensions of experiential avoidance in a study of adults with multiple disorders. Group UP showed large effects on six domains of emotion regulation as well as anxi- ety and depressive symptoms. Future research should include control conditions and long-t╉erm follow-u╉ p to consolidate the efficacy of UP on emotion regulation as a group intervention for adults with emotional disorders. Unified protocol for adolescents Concurrent to the development and testing of the UP with adults, the UP was also adapted for adolescents aged 12–â1•‰ 7 years old with anxiety or unipolar depressive disorders. In addition to the modifications of developmentally appropriate language and examples in the 13 session treat- ment, reviews with the parent at the end of every session and dedicated parent sessions in session one and six were included. Ehrenreich, Goldstein, Wright and Barlow (2009) used a multiple baseline design of two to eight weeks to pilot test the effects of the UP for adolescents on clinical severity ratings of anxiety and mood symptoms in multiple diagnoses for three individual cases. There were sustained improvements across disorders from pre-t╉reatment to six month follow-âu•‰ p. Participants found the emotion exposures to be the most helpful component of the treatment and parents were receptive to being included in treatment. However, due to the small sample size (n = 3) and the primary focus on anxiety disorders, the effect of UP on emotional disorder symp- toms in a heterogeneous sample of adolescents needs to be further investigated. To enhance participants’ motivation, Ehrenreich and colleagues further modified the treatment protocol by including goal-âo•‰ riented discussions and decisional balance, and extended the num- ber of sessions to 16 with three additional parent sessions that focused greatly on individual-╉ specific emotion exposure and regulation skills (Ehrenreich, Goldstein, Wright, & Barlow, 2009). The preliminary feasibility and effects of this UP-âY•‰ outh (UP-Y╉ ) protocol were investigated in an open trial reported in Trosper et al.(2009). Participants included 12 adolescents with a principal anxiety disorder or a comorbid anxiety and depressive disorder. Both the adolescent and their parent reported on changes in anxiety and depressive symptoms and emotion regulation skills for anger, sadness and worry at post-t╉reatment, three and six month follow-u╉ p. There was a signifi- cant improvement in adolescent clinical severity ratings and self-âr•‰ eported anxiety and depressive symptoms at post treatment and both follow-âu•‰ p time points. Adolescents reported a significant
34 Summary of cross-sectional and longitudinal research 443 improvement in worry, sadness, and overall emotion dysregulation, as well as coping with anger at post-t╉ reatment. At three month follow-u╉ p, there was significant improvements in overall emotion coping and dysregulation of sadness. However, there was generally no significant difference in emotion dysregulation and coping between three and six months. These results showed that UP-╉ Y is effective in improving emotion regulation and coping with emotions in adolescents. Similar to Ehrenreich et al. (2009), the sample was small (n = 12) and did not include participants with a principal depressive disorder. Moreover, emotion regulation was not specifically measured. Although anxiety and depression share similar vulnerabilities, studies have demonstrated that anxiety and depression are also distinct from each other (Anderson & Hope, 2008). As such, to compare the trajectory of the changes in self and parent reported anxiety and depressive symp- toms in adolescents up to six months following UP-âY•‰ treatment, Queen, Barlow, and Ehrenreich-╉ May (2014) analyzed the results of 59 adolescents who completed at least eight sessions of UP-âY•‰ from a total sample of 67 participants in either an open trial or an RCT. Emotion regulation was not examined in the analysis. Participants were 12–1╉ 7 year old adolescents with an anxiety disor- der (79.9%), unipolar depressive disorder (15.3%) or co-âp•‰ rincipal anxiety and depressive disor- ders (5.1%). Twenty-ât•‰hree participants (38.98%) were assigned a secondary comorbid depressive disorder. The UP was flexibly conducted between eight to 21 sessions with optional parenting skills training, motivational interviewing and safety planning depending on the needs of the indi- vidual participant. By the end of treatment, mean scores of self and parent-âr•‰ eported anxiety and depressive symptoms fell into the normal range. Symptom trajectories showed that self-âr•‰ eported anxiety symptoms decreased significantly by 4.76 units every eight weeks during treatment and 1.48 units every eight weeks during three to six month follow-u╉ p period. The rate of change of self-r╉eported anxiety symptoms during treatment was significantly associated with the rate of change during the follow-âu•‰ p period. Although self-r╉eported depressive symptoms significantly decreased during treatment at a similar rate of change as self-r╉eported anxiety symptoms, there were no significant reductions at follow-u╉ p. The rate of change of self-r╉ eported depressive symp- toms during treatment was not significantly related with the rate of change during the follow-âu•‰ p period. Parent-âr•‰ eported anxiety and depressive symptoms also demonstrated significant improve- ment during treatment. However, similar to the adolescents’ self-r╉eported depressive symptoms, both parent-r╉eported anxiety and depressive symptoms revealed no significant reduction from post treatment to three to six month follow-âu•‰ p. Participants and parents who reported greater severity in both anxiety and depressive symptoms at baseline demonstrated a greater rate of improvement of symptoms during treatment but only self-r╉eported anxiety symptoms showed a reduction in rate of improvement at follow-u╉ p. The preliminary evidence from this study needs to be further replicated with a larger sample with a diverse population in order to obtain trajectories of improvement in symptoms. Unified protocol for children Subsequently, UP was also developed into a group-âb•‰ ased intervention for younger children aged seven to 12 years old. Bilek, and Ehrenreich-M╉ ay (2012) aimed to examine the effect of Emotion Detectives Treatment Protocol on self and parent-r╉ eported symptoms of the principal anxiety disorder and the anxiety and depressive symptom severity ratings, given that research had shown that co-âm•‰ orbid depressive symptoms was associated with poorer treatment out- comes in youths with anxiety disorders. Twenty-ât•‰ wo children with a principal anxiety disorder, of which seven had comorbid depressive disorder, participated in an open trial of the 15 ses- sion Emotion Detectives Treatment Protocol. Although half of the participants were identi- fied to have “elevated depressive symptoms” based on self or parent report, participants with a principal depressive disorder were excluded. At each session, parents underwent group-b╉ ased
4 444 Transdiagnostic Approaches to Emotion Regulation parent training after individual reviews with their child at the beginning of the session. It was hypothesized that participants would show improvement in severity of their principal diagnosis regardless of the severity of their depressive symptoms at pre-ât•‰reatment. Seventy-ât•‰hree percent of the sample was identified as treatment completers who completed 11 or more sessions. At post-t╉reatment, 77.8% and 80% of the participants no longer met criteria for an anxiety and a depressive disorder, respectively. There was a significant improvement in clinical severity rat- ings of both principal diagnosis and the total scores of the clinical severity ratings of anxi- ety and depressive disorders, self-âr•‰eported anxiety symptoms and parent-r╉eported depressive symptoms. Effect sizes ranged from 0.47 to 1.38. A significant improvement in self-r╉eported depressive symptoms was only seen in the treatment completers. Both self-╉and parent-âr•‰ eported depressive symptoms at baseline did not significantly predict change in clinical severity ratings of principal diagnosis at post-t╉reatment. Satisfaction of the child (M = 5.5 on an eight point Likert Scale) and the parent with the treatment were high (M = 7.7). The Emotion Detectives Treatment Protocol was shown to be efficacious and feasible in children with a diagnosis of a principal anxiety disorder who also had comorbid depressive symptoms. However, analysis was not conducted to determine effects on those with or without comorbid depression. The sample was ethnically diverse, but the study was limited by the small sample size, lack of control group, and lack of control for Type I errors. The small sample also did not allow for group and therapist effects to be analyzed. More studies are required to test the efficacy of the Emotion Detectives Treatment Protocol with other emotional disorders. In sum, there is only limited research of UP with child and adolescent samples. In the three stud- ies reviewed above, emotion regulation was not directly assessed despite the fact that UP retained its focus on emotions and dysregulation of emotions and coping. Nevertheless, the improvements in both anxiety and depressive symptoms based on self-╉and parent-r╉eports provided beneficial, albeit only preliminary, evidence for the UP as a transdiagnostic approach for emotion regulation across emotion disorders. Unified protocol for other principal disorders Ellard, Deckersbach, Sylvia, Nierenberg, and Barlow (2012) explored the effects of the UP for the commonly comorbid bipolar disorders with anxiety disorders by evaluating a series of 3 clinical cases. Two of the cases who received 15 sessions of UP were rated as mildly ill and very much improved by clinician-r╉ ated severity and improvement measures at post-t╉reatment. Self-r╉ eported symptoms of depression, mania and anxiety were in the normal to borderline range. Emotion regulation was not measured. Participants identified that the helpful components of the treatment were present-âf•‰ocused awareness skills and learning how to alter maladaptive responses. However, as the authors pointed out, given the nature of the study design, it was impossible to determine the long-t╉erm effects of the treatment. In addition, given that all three participants requested con- tinued care to consolidate their learned skills, it was difficult to determine the optimum number of treatment sessions for this population. Therefore, more longitudinal and RCTs are needed to further investigate the short-╉and long-ât•‰erm efficacy, potential moderators, and mediators of UP for comorbid bipolar and anxiety disorders. Similar to bipolar disorders, anxiety and depressive disorders are also highly comorbid with chronic pain in children. Taking into account the role of emotion dysregulation in exacerbating responses to and severity of chronic pain, Allen, Tsao, Seidman, Ehrenreich-M╉ ay, and Zeltzer (2012) developed the UP in Youth with Pain (UP-Y╉ P) to address the lack of research that targets comorbid emotional disorders with pain in adolescents with chronic pain. The UP-âY•‰ P is an adap- tation of the United Protocol for the Treatment of Emotional Disorders in Youth (Ehrenreich et al., 2008), with inclusion of psychoeducation for pain and discomfort, and awareness of emotions and
54 Summary of cross-sectional and longitudinal research 445 exposure exercises. Although similar in length (i.e., eight to 21 sessions) as the UP-Y, the 50- minute sessions were conducted within six months and were flexible to be fortnightly delivered sessions at the end of the treatment. Results of the treatment protocol were presented in two cases with emotion awareness and expression of negative emotions measured. In one case, there was a decline in functional impairment, anxiety symptoms, somatization, and an increase in emotional awareness and expression while the level of pain remained stable. There were further gains at three month follow-up and pain was at its lowest level. However, in the other case, no change was seen in depressive symptoms and there were increases in somatization, pain and functional impair- ment despite an increase in emotion regulation scores. Although results suggest that the emphasis of increasing awareness of both physical and emotional symptoms in the UP-Y P may contribute to its effectiveness, future study is warranted to consolidate the findings. Given that neuroticism (i.e., the tendency to experience negative emotions uncontrollably) has been proposed as one common underlying trait in borderline personality disorder (BPD), anxiety and depressive disorders, Sauer-Z avala, Bentley, and Wilner (2015) used the UP as a relatively brief treatment to target neuroticism in participants with less severe symptoms of BPD. Using the same UP protocol as Farchione et al. (2012), this study evaluated symptom levels and emotion regulation skills in five BPD patients with comorbid anxiety and depressive disorder. Effect sizes were reported as standardized mean gain (ESsg). Results showed the improvements in BPD symptoms (ESsg = 1.06) and emotion regulation skills (ESsg = 1.29) were large in magnitude while moderate in anxiety (ESsg =.51) and depressive symptoms (ESsg =.70). Although the UP showed promise in treating BPD with comorbid emotional disorders, the heterogeneity in BPD made it difficult for the protocol to be appropriate for everyone. Therefore, the authors suggested that more studies with a larger sample size and including other personality traits are required to further investigate the moderators and efficacy of the UP for managing BPD. In sum, given that these studies have included measures related to emotion regulation, they provided further sup- port for the potential of UP to improve symptoms and skills in emotion regulation in multiple disorders. Taken together, our review reveals that the UP has been used to treat a variety of emotion- related disorders, with a majority focusing on principal anxiety and depressive disorders and their comorbidities. Overall, the UP protocol demonstrated promising effects on anxiety and depres- sive symptoms in adults, children and adolescents, either in an individual or a group treatment format. These results suggest the potential of the UP as a transdiagnostic approach that targets emotion regulation across emotion disorders, which in turn leads to improvements in anxiety and depressive symptoms, and negative or positive affect in these disorders. However, the reli- ability of the results of these studies on the UP is limited by small sample size and few comparison conditions. It should also be noted that in some studies, especially those conducted in children and adolescents, the majority of the participants had a principle diagnosis of an anxiety disorder but not a depressive disorder. The exclusion of individuals with Major Depressive Disorder (e.g., Bilek & Ehrenreich-May, 2012) and a relatively small number of participants with comorbid anxi- ety and depression symptoms require future research to include participants with a diversity of diagnoses. This will allow a more solid conclusion for the effects of the UP as a transdiagnostic approach. In addition, only three of the studies directly measured changes in emotion regula- tion in their samples (Allen et al., 2012; Ehrenreich et al., 2009; Sauer-Zavala et al., 2015). Future research including a controlled design with larger samples, assessments of emotion regulation, and participants with different types of emotional disorders are warranted. Furthermore, longer duration of follow-up, as well as more detailed analysis of outcomes, and investigating potential moderators and mediators would increase the validity of UP as a transdiagnostic treatment tar- geting emotion regulation.
64 446 Transdiagnostic Approaches to Emotion Regulation Using dialectical behavior therapy skills training Another intervention that was developed specifically to improve emotional regulation across multiple disorders is Dialectical Behavior Therapy Skills Training (DBT-âS•‰T). Dialectical Behavior Therapy was originally developed by Linehan (1993) for suicide and borderline per- sonality disorder (BPD). It proposed that dysfunctional behaviors are due to poorly regulated emotions or are maladaptive approaches to emotion regulation. Neacsiu, Eberle, Kramer, Wiesmann, and Linehan (2014) modified this approach to teach skills that help individuals to be less susceptible to emotions, manage situations that trigger emotions, control attention toward or away from emotional stimuli, interpret emotional cues, manage biological, experien- tial, and action changes, and process emotions. The four skill modules included in the DBT-S╉ T are mindfulness (e.g., non-âj•‰udgmental observation of the present moment), emotion regula- tion (e.g., strategies to change emotions or the tendency to respond emotionally), interpersonal effectiveness (e.g., assertiveness and self-r╉ espect), and distress tolerance (e.g., control impulses and accept difficulties). Neacsiu et al. (2014) examined the effects of the DBT-S╉ T in reducing anxiety, depression and emotion dysregulation in a sample of non-âB•‰ PD adults with difficulties with emotion regulation. Forty-âf•‰our adults with anxiety or depressive disorders who reported high emotion dysregula- tion participated in this study. This RCT compared the 16-âs•‰ ession DBT-S╉ T in a two-h╉ our weekly group therapy to a 16-âs•‰ession activities-âb•‰ ased support group (ASG) of the same duration. All participants attended an average of 13.66 sessions and were assessed at pre-t╉ reatment, two months into treatment, post-ât•‰ reatment, and two-m╉ onth follow-âu•‰ p on self-âr•‰ eported anxiety and depressive symptoms, use of coping skills, and specific emotion regulation skills. Results showed that both groups experienced significant decreases in emotion dysregulation over time but the DBT-S╉ T group demonstrated significantly greater and faster decrease compared to the ASG at post-ât•‰reatment (d = 1.86). However, at two month follow-u╉ p, there was a trend towards loss of gains in DBT-âS•‰ T group while the ASG group showed continued improvement. A similar pattern at follow-u╉ p was observed for the change in anxiety and depressive symptoms. There was a signifi- cantly faster improvement in anxiety symptoms in participants in the DBT-S╉ T group compared to the ASG group at the end of treatment (d = 1.37). On the other hand, both groups showed significant and equal magnitude of improvement in depressive symptoms at the end of treatment (d = 0.73). The use of DBT skills mediated the relationship between groups and improvement in 62.31% of variance in emotion regulation, 47.63% of variance in anxiety and 42.5% of variance in depressive symptoms. Participants in the DBT-âS•‰ T group significantly increased their use of regulation strate- gies and goal-d╉ irected behaviors (16%) compared to those in the ASG (3.5%), which was maintained at follow-âu•‰ p. Moreover, they were more likely to attribute symptom improvement to the interven- tion (M = 53.33%) than the ASG group (M = 26.88%). Participants in the DBT-S╉ T group were also more confident to recommend it to a friend (M = 6.58) than the ASG group (M = 4.06). Overall, DBT-âS•‰ T was superior to ASG in improving anxiety, emotion dysregulation and use of DBT skills. However, with no difference in the improvement in depressive symptoms, DBT-S╉ T as a transdiagnostic intervention needs further investigation. The study was limited by the use of dif- ferent therapists, small sample and more participants with dysthymia in the ASG group. Further research is required to improve dropout rates, noncompliance to protocol, to explore the loss of gains in the DBT-âS•‰ T at follow-âu•‰ p, and to replicate these initial findings. Emotion Regulation Therapy Mennin, Fresco, Ritter, and Heimberg (2015) argued that dysfunction in distress disorders such as generalized anxiety disorder (GAD) can be understood through three mechanisms. These are
74 Summary and conclusion 447 motivational mechanisms (i.e., the functional and directional properties of an emotional response tendency), regulatory mechanisms (i.e., controlling emotional responses using a variety of elabora- tive systems); and contextual learning consequences (i.e., promoting broad and flexible behavioral strategies). Emotion Regulation Therapy, which integrates principles of CBT with experiential therapy, targets deficits in these mechanisms that maintain GAD. Given that GAD with comorbid major depressive disorder (MDD) is associated with severe functional impairments compared to GAD or MDD alone, Mennin et al. (2015) conducted the first study to test the efficacy of Emotion Regulation Therapy for GAD with comorbid depressive symptoms. Emotion Regulation Therapy focuses on increasing awareness of properties of emotion response tendencies, developing less and more elaborate emotion regulation strategies and exposure to different contexts, which allow participants to develop a variety of flexible behaviors. Participants were 21 adults with principal diagnosis of GAD, among which 11 had comorbid MDD. The treatment protocol consisted of 20 weekly sessions with each session lasting for 60 minutes, except for Sessions 11–1╉ 6, which lasted 90 minutes for participants to practice exposure exercises. In the first half of the treatment pro- gram, participants were taught emotion regulation strategies to respond “counteractively” rather than “reactively”. In the second half of the treatment, they were encouraged to become more “pro- active” in using regulation skills through in-s╉ ession and out-s╉ ession exposure exercises. Results revealed significant improvements in clinical severity ratings of GAD and MDD, self-╉ reported worry and depressive symptoms, and quality of life at post-ât•‰reatment, three and nine months follow-âu•‰ p. This study also assessed for emotional intensity, decentering, emotion reg- ulation skills, reappraisal and trait mindfulness associated with the model of emotion regula- tion therapy, all of which improved significantly at post-t╉reatment and nine months follow-u╉ p. At three months follow-âu•‰ p, only changes in emotion regulation skills, decentering and reappraisal were significant. High end-âs•‰tate functioning was defined as falling in the normal range on four of six measures of GAD and three of four MDD measures. At post-t╉reatment, 66.7% and 45.5% achieved high end-âs•‰ tate functioning on GAD and MDD, respectively with the proportion increas- ing to 75% in GAD and 70% in MDD at three months follow-âu•‰ p. At nine months follow-âu•‰ p, 85% of the sample were at high end-âs•‰ tate functioning on GAD and 80% on MDD. This study provided preliminary evidence for the efficacy of Emotion Regulation Therapy for GAD participants with significant depressive symptoms. In addition to improvement in severity of anxiety and depres- sive symptoms, Emotion Regulation Therapy showed large effects on different aspects of emotion regulation. Despite these findings, ERT requires refinement to differentiate the intervention from other interventions with similar components. Future research should include larger RCTs and objective assessments of symptoms to determine the mechanisms targeted. Notably, this interven- tion has not yet been used with children and adolescents. Summary and conclusion Evidence that establishes emotion regulatory processes as important transdiagnostic etiological, maintenance, and treatment mechanisms is promising. Evidence from cross-s╉ ectional and longi- tudinal designs provide the most support for cognitive emotion regulation strategies (e.g., rumi- nation, reappraisal, worry, catastrophizing) as critical mechanisms across disorders, with more recent support for emotional response strategies (e.g., emotional clarity, emotional expression). Neuro-b╉ iological research has also identified important roles for amygdala functioning across disorders. In the treatment literature, several interventions that target emotional functioning as part of their treatment strategies demonstrate benefits for participants in primary and secondary presenting problems. However, most trials do not specifically report outcomes for specific emo- tion regulation processes, other than positive and negative affect. Emerging research on DBT and
84 448 Transdiagnostic Approaches to Emotion Regulation ERT appear to provide good examples of treatment evaluations that actively assess and report outcomes in emotion regulation—e╉ ach has shown positive short-╉and long-ât•‰erm benefits of treat- ment on improving individuals’ ability to regulate distress. This appears consistent across multiple presenting problems. Our review highlights the nascent stage of investigating emotion regulation processes across disorders and problem s╉ets and with children and adolescents. Research designs, assessment tools, and analytic approaches differ considerably across studies, making comparisons difficult. It is recommended that future emotion regulation research make concerted efforts to recruit multi-╉ problem samples, as comparisons can aid a more refined understanding of specific and common regulation deficits and strengths. This review has identified several model approaches, but it has also revealed multiple areas for future growth. Greater use of prospective designs, utilizing multi-╉ domain and multi-s╉ ource assessment, would improve experimental, longitudinal, and treatment research. References Achenbach, T. (2005). Advancing assessment of children and adolescents: Commentary on evidence-b╉ ased assessment of child and adolescent disorders. Journal of Clinical Child and Adolescent Psychology, 34, 541–‰5â• 47. doi: 10.1207/âs•‰ 15374424jccp3403_‰•9â Aldao, A., & Nolen-H╉ oeksema, S. (2010). Specificity of cognitive emotion regulation strategies: A transdiagnostic examination. Behaviour Research and Therapy, 48(10), 974–╉983. doi:10.1016/âj•‰ .brat.2010.06.0 02 Aldao, A., & Nolen-‰H•â oeksema, S. (2012). When are adaptive strategies most predictive of psychopathology? Journal of Abnormal Psychology, 121(1), 276–‰2•â 81. http://•â‰dx.doi.org/•â1‰ 0.1037/‰•â a0023598 Allen, L. B., Tsao, J. C. I., Seidman, L. C., Ehrenreich-M╉ ay, J., & Zeltzer, L. K. (2012). A unified, transdiagnostic treatment for adolescents with chronic pain and comorbid anxiety and depression. Cognitive and Behavioral Practice, 19, 56–6•â‰ 7. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th ed. (DSM-5╉ ). Arlington, VA: American Psychiatric Association. doi: 10.1176/âa•‰ ppi.books.9780890425596 Anderson, E.R., & Hope, D.A. (2008). A review of the tripartite model for understanding the link between anxiety and depression in youth. Clinical Psychology Review, 28, 275–2╉ 87. doi: 10.1016/╉ j.cpr.2007.05.004 Angold, A., Costello, E. J., & Erkanli, A. (1999). Comorbidity. Journal of Child Psychology and Psychiatry, 40, 57–â8•‰ 7. Retrieved from http://‰•âeds.b.ebscohost.com/╉ Ball, T. M., Ramsawh, H. J., Campbell-•S≠ills, L., Paulus, M. P., & Stein, M. B. (2013). Prefrontal dysfunction during emotion regulation in generalized anxiety and panic disorders. Psychological Medicine, 43(07), 1475–╉1486. doi:10.1017/•â‰S0033291712002383 Barlow, D., Allen, L., & Choate, M. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35, 205–‰â2• 30. doi: 10.1016/•S≠0005-‰7â• 894(04)80036-•4‰â Barlow, D. H., Ellard, K. K., Fairholme, C. P., Farchione, T. J., Boisseau, C. L., Allen, L. B., & Ehrenreich-╉ May, J. (2011). The unified protocol for transdiagnostic treatment of emotional disorders: Client workbook. New York: Oxford University Press. Beauchaine, T. P., Gatzke-K╉ opp, L. M., & Mead, H. K. (2007). Polyvagal theory and developmental psychopathology: Emotion dysregulation and conduct problems from preschool to adolescence. Biological Psychology, 74, 174–≕184. doi: 10.1016/âj‰• .biopsycho.2005.08.008 Bilek, E. L., & Ehrenreich-‰â•May, J. (2012). An open trial investigation of a transdiagnostic group treatment for children with anxiety and depressive symptoms. Behavior Therapy, 43, 887–8╉ 97. Brockmeyer, T., Bents, H., Holtforth, M. G., Pfeiffer, N., Herzog, W., & Friederich, H. C. (2012). Specific emotion regulation impairments in major depression and anorexia nervosa. Psychiatry Research, 200(2), 550–â5•‰ 53. doi: 10.1016/j╉.psychres.2012.07.009
94 Summary and conclusion 449 Bullis, J. R., Fortune, M. R., Farchione, T. J., & Barlow, D. H. (2014). A preliminary investigation of the long-term outcome of the unified protocol for transdiagnostic treatment of emotional disorders. Comprehensive Psychiatry, 55, 1920–1 927. http://d x.doi.org/10.1016/j .comppsych.2014.07.016 Bullis, J. R., Sauer-Zavala, S., Bentley, K. H., Thompson-H ollands, J., Carl, J. R., & Barlow, D. H. (2015). The unified protocol for transdiagnostic treatment of emotional disorders: Preliminary exploration of effectiveness for group delivery. Behavior Modification, 39(2), 295–3 21. doi: 10.1177/0145445514553094 Burklund, L. J., Craske, M. G., Taylor, S. E., & Lieberman, M. D. (2015). Altered emotion regulation capacity in social phobia as a function of comorbidity. Social Cognitive and Affective Neuroscience, 10(2), 199–208. doi:10.1093/scan/n su058 Campbell-Sills, L., & Barlow, D. H. (2007). Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 542–559). New York: Guilford Press. Carver, C. S. (1997). You want to measure coping but your protocol’s too long: Consider the Brief COPE. International Journal of Behavioral Medicine, 4, 92–100. Chorpita, B. F., & Daleiden, E. L. (2009). Mapping evidence-b ased treatments for children and adolescents: application of the distillation and matching model to 615 treatments from 322 randomized trials. Journal of Consulting and Clinical Psychology, 77(3), 566–579. doi: 10.1037/a0014565 Conklin, L. R., Cassiello-Robbins, C., Brake, C. A., Sauer-Zavala, S., Farchione, T. J., Ciraulo, D. A., & Barlow, D. H. (2015). Relationships among adaptive and maladaptive emotion regulation strategies and psychopathology during the treatment of comorbid anxiety and alcohol use disorders. Behaviour Research and Therapy, 73, 124–130. doi: 10.1016/j.brat.2015.08.001 Crowell, S. E., Beauchaine, T. P., McCauley, E., Smith, C. J., Stevens, A. L., & Sylvers, P. (2005). Psychological, autonomic, and serotonergic correlates of parasuicide among adolescent girls. Development and Psychopathology, 17(4), 1105–1 127. doi: 10.1017/S0954579405050522 Desrosiers, A., Vine, V., Klemanski, D. H., & Nolen‐Hoeksema, S. (2013). Mindfulness and emotion regulation in depression and anxiety: common and distinct mechanisms of action. Depression and Anxiety, 30(7), 654–6 61. doi: 10.1002/d a.22124 Ehrenreich, J. T., Buzzella, B. A., Trosper, S. E., Bennett, S. M., Wright, L. R., & Barlow, D. H. (2008). The Unified Protocol for treatment of emotional disorders in adolescents. Unpublished manuscript, Boston University. Ehrenreich, J. T., Goldstein, C. R., Wright, L. R., & Barlow, D. H. (2009). Development of a unified protocol for the treatment of emotional disorders in youth. Child & Family Behavior Therapy, 31(1), 20–3 7. doi: 10.1080/07317100802701228 Ehrenreich-M ay, J. & Chu, B. C. (2013). Overview of transdiagnostic mechanisms and treatments for youth psychopathology. In J. Ehrenreich-M ay & B. C. Chu (Eds.), Transdiagnostic treatments for children and adolescents: Principles and practice (pp. 3–14). New York: Guilford Press. Ellard, K.K., Deckersbach, T., Sylvia, L.G., Nierenberg, A.A., & Barlow, D.H. (2012). Transdiagnostic treatment of bipolar disorder and comorbid anxiety with the unified protocol: A clinical replication series. Behavior Modification, 36(4), 482–5 08. doi: 10.1177/0 145445512451272 Ellard, K. K., Fairholme, C. P., Boisseau, C. L., Farchione, T. J., & Barlow, D. H. (2010). Unified protocol for the transdiagnostic treatment of emotional disorders: Protocol development and initial outcome data. Cognitive and Behavioral Practice, 17, 88–101. Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour Research and Therapy, 41, 509–528. doi: 10.1016/S 0005-7 967(02)00088-8 Farchione, T. J., Fairholme, C. P., Ellard, K. K., Bossieau, C. L., Thompson-Hollands, J., Carl, J. R., … Barlow, D. H. (2012). Unified protocol for transdiagnostic treatment of emotional disorders: A randomized controlled trial. Behavior Therapy, 43, 666–678. Gamez, W., Chmielewski, M., Kotov, R., Ruggero, C., & Watson, D. (2011). Development of a measure of experiential avoidance: The Multidimensional Experiential Avoidance Questionnaire. Psychological Assessment, 23, 692–7 13. doi: 10.1037/a0023242
054 450 Transdiagnostic Approaches to Emotion Regulation Garber, J., & Weersing, V. R. (2010). Comorbidity of anxiety and depression in youth: Implications for treatment and prevention. Clinical Psychology: Science and Practice, 17, 293–3 06. doi: 10.1111/ j.1468-2850.2010.01221.x Garnefski, N., Kraaij, V., & van Etten, M. (2005). Specificity of relations between adolescents’ cognitive emotion regulation strategies and Internalizing and Externalizing psychopathology. Journal of Adolescence, 28(5), 619–631. doi: 10.1016/j.adolescence.2004.12.009 Gross, J. J. (1998). The emerging field of emotion regulation: an integrative review. Review of General Psychology, 2(3), 271. Gruber, J., Eidelman, P., & Harvey, A. G. (2008). Transdiagnostic emotion regulation processes in bipolar disorder and insomnia. Behaviour Research and Therapy, 46(9), 1096–1100. doi:10.1016/ j.brat.2008.05.004 Gruber, J., Mennin, D. S., Fields, A., Purcell, A., Murray, G. (2015). Heart rate variability as a potential indicator of positive valence system disturbance: A proof of concept investigation. International Journal of Psychophysiology, 98(2), 240–2 48. doi: 10.1016/j .ijpsycho.2015.08.005 Harvey, A. G., Watkins, E., Mansell, W., & Shafran, R. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. Oxford, UK: Oxford University Press. Insel, T. (2013, April 29). Transforming diagnosis. National Institute of Mental Health Director’s Blog. Retrieved from http://w ww.nimh.nih.gov/a bout/director/2 013/t ransforming-d iagnosis.shtml Kring, A. M., & Sloan, D. M. (Eds.). (2010). Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment. Guilford Press. Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Mansell, W., Harvey, A., Watkins, E., & Shafran, R. (2009). Conceptual foundations of the transdiagnostic approach to CBT. Journal of Cognitive Psychotherapy: An International Quarterly, 23, 6–19. doi: 10.1891/ 0889-8 391.23.1.6 McLaughlin, K. A., Hatzenbueler, M. L., Mennin, D. S., & Nolen-H oeksema, S. (2011). Emotion dysregulation and adolescent psychopathology: A prospective study. Behaviour Research and Therapy, 49(9), 544–5 54. doi: 10.1016/j .brat.2011.06.003 Mennin, D. S., Fresco, D. M., Ritter, M., & Heimberg, R. G. (2015). An open trial of emotion regulation therapy for generalized anxiety disorder and cooccurring depression. Depression and Anxiety, 32, 614– 623. doi: 10.1002/d a.22377 National Institute for Mental Health’s (2011, June). NIMH Research Domain Criteria (RDoC). Retrieved from http://w ww.nimh.nih.gov/research-priorities/rdoc/n imh-research-domain-c riteria-r doc.shtml Neacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., Linehan, M. M. (2014). Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: A pilot randomized controlled trial. Behaviour Research and Therapy, 59, 40–5 1. http:/dx.doi.org/10.1016/j.brat.2014.05.005 Nolen-H oeksema, S., & Watkins, E. R. (2011). A heuristic for developing transdiagnostic models of psychopathology explaining multifinality and divergent trajectories. Perspectives on Psychological Science, 6, 589–6 09. doi: 10.1177/1 745691611419672 Ornelas Maia, A. C., Braga, A. A., Nunes, C. A., Nardi, A. E., & Silva, A. C. (2013). Transdiagnostic treatment using a unified protocol: Application for patients with a range of comorbid mood and anxiety disorders. Trends in Psychiatry and Psychotherapy, 35(2), 134–140. Pang, K. C., Beauchaine, T. P. (2013). Longitudinal patterns of autonomic nervous system responding to emotion evocation among children with conduct problems and/or depression. Developmental Psychobiology, 55(7), 698–706. doi: 10.1002/d ev.21065 Queen, A. H., Barlow, D. H., & Ehrenreich-May, J. (2014). The trajectories of adolescent anxiety and depressive symptoms over the course of a transdiagnostic treatment. Journal of Anxiety Disorders, 28, 511–521. http://d x.doi.org/1 0.1016/j .janxdis.2014.05.007
154 Summary and conclusion 451 Queen, A. H., & Ehrenreich-May, J. (2014). Anxiety-disordered adolescents with and without a comorbid depressive disorder: Variations in clinical presentation and emotion regulation. Journal of Emotional and Behavioral Disorders, 22(3), 160–1 70. doi: 10.1177/1063426613478175 Sauer-Z avala, S., Bentley, K. H., & Wilner, J. G. (2015). Transdiagnostic treatment of borderline personality disorder and comorbid disorders: A clinical replication series. Journal of Personality Disorders, 29, 179–1 95. Shannon, K. E., Beauchaine, T. P., Brenner, S. L., Neuhaus, E., & Gatzke-K opp, L. (2007). Familial and temperamental predictors of resilience in children at risk for conduct disorder and depression. Development and Psychopathology, 19(3), 701–727. doi: 10.1017/S0954579407000351 Silk, J. S., Steinberg, L., & Morris, A. S. (2003). Adolescents’ emotion regulation in daily life: Links to depressive symptoms and problem behavior. Child Development, 74(6), 1869–1880. doi: 10.1046/ j.1467-8624.2003.00643 Taylor, S., & Clark, D. A. (2009). Transdiagnostic cognitive-behavioral treatments for mood and anxiety disorders: Introduction to the special issue. Journal of Cognitive Psychotherapy: An International Quarterly, 23, 3–5 . doi: 10.1891/0889-8 391.23.1.3 Trosper, S. E., Buzzella, B. A., Bennett, S. M., & Ehrenreich, J. T. (2009). Emotion regulation in youth with emotional disorders: Implications for a unified treatment approach. Clinical Child and Family Psychology Review, 12, 234–254. doi: 10.1007/s10567-0 09-0 043-6 Werner, K., & Gross, J. J. (2010). Emotion regulation and psychopathology: A conceptual framework. In Kring, A. M., & Sloan, D. M. (Eds.), Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment (pp. 13–3 7). New York, NY, US: Guilford Press. Wilamowska, Z. A., Thompson-H ollands, J., Fairholme, C. P., Ellard, K. K., Farchione, T. J., & Barlow, D. H. (2010). Conceptual background, development and preliminary data from the unified protocol for transdiagnostic treatment of emotional disorders. Depression and Anxiety, 27, 882–8 90. doi: 10.1002/ da.20735 Vasilev, C. A., Crowell, S. E., Beauchaine, T. P., Mead, H. K., & Gatzke-Kopp, L. M. (2009). Correspondence between physiological and self-report measures of emotion dysregulation: A longitudinal investigation of youth with and without psychopathology. Journal of Child Psychology and Psychiatry, 50(11), 1357–1364. doi:10.1111/j.1469-7610.2009.02172.x Vine, V., & Aldao, A. (2014). Impaired emotional clarity and psychopathology: A transdiagnostic deficit with symptom-specific pathways through emotion regulation. Journal of Social and Clinical Psychology, 33(4), 319–3 42. doi:10.1521/jscp.2014.33.4.319
254
Index A incarceration, parental 351 pharmacotherapy 293 abuse and neglect 305–2 0 proactive assessment 307 definition 305–6 conduct disorder 135–6 ecological model 307 development 137–8 emotion regulation 311–1 2 reactive deficits, adaptive outcomes of 317–18 abused/n eglected children and adolescents 314 deficits, expression of 314–1 5 conduct disorder 135–6 intervention, implications for 318–19 development 136–7 , 138 problems, development of 312–14 reactive vs. proactive 24 propagation and maintenance of outcomes 315–17 self-r egulation deficits 21–2 , 24 nonsuicidal self-injury 400 Fast Track PATHS 27 outcomes 310–11 socialization 63 emotion regulation deficits 317–18 traumatic stress exposure 376, 381 propagation and maintenance of 315–17 agoraphobia (AG) 156 prevalence 306 alcohol myopia therapy 217 risk factors 307–10 alcohol use/misuse abused/n eglected children and adolescents 316 academic achievement abusive parents 309 divorce, children of 333–4, 335, 336, 337, 340 affective lability 220 incarceration, parental 351, 355, 360 comorbidity optimism 341 anxiety disorders 424 traumatic stress exposure 376, 378 posttraumatic stress disorder 219–2 0 diagnosis 213 Acceptance and Commitment Therapy distress tolerance 219 nonsuicidal self-injury 408 dual-p rocess theory 221 Research Domain Criteria 98 emotion dysregulation 217–1 9 emotion regulation strategies 424 adaptive emotion responses 43 emotional clarity 426 adaptive information processing (AIP) model 386 emotional inertia 217 adulthood, transition from adolescence to impulsivity 25 intervention example 223 abuse and neglect 311, 316 mindfulness 220, 221 Attention Deficit Hyperactivity Disorder 120 prevalence 211, 212 depression 174 alexithymia 197 divorce, children of 334, 335 autism spectrum disorder 240 substance use disorders 213 nonsuicidal self-injury 400 Adverse Child Experiences (ACEs) study 353, 354, 366–7 alpha-a drenergic receptor-m ediated effects 47 affective disorders see anxiety disorders; depression alternative reinforcers 220, 224 affective lability 215 American Psychiatric Association (APA) abused/n eglected children and adolescents 314, 316 history of mental health/disorder 79 borderline personality disorder 267 see also Diagnostic and Statistical Manual of Mental substance use disorders 216–17, 218, 220, 224 Affective Lability Scales (ALS) 220 Disorders affective Posner paradigm 286, 287 amygdala age factors abuse and neglect 307–8 abused/n eglected children and adolescents 313 conduct disorder anxiety disorders 428–9 , 430 Attention Deficit Hyperactivity Disorder 118, 288 course 131 autism spectrum disorder 238, 239 onset 130, 131 borderline personality disorder 266 prevalence 131 depression 428–9 , 430 divorce, children of 338 labeling irritable emotion 295 eating disorders 196 major depressive disorder 289 incarceration, parental 360, 362, 366–7 measures of emotional reactivity 48, 50, 51, 52, 53 substance use disorders 211, 212, 213 narrow phenotype bipolar disorder 288, 289 aggression reappraisal abused/n eglected children and adolescents 314, 315 Attention Deficit Hyperactivity Disorder 119, detached vs. positive 53 vs. distraction 52 120, 121 vs. suppression 51 autism spectrum disorder 243 severe mood dysregulation 287, 288–9 borderline personality disorder 268 social phobia 428–9 conduct disorder 135–8 traumatic stress exposure 378 co-o ccurring externalizing and internalizing problems 33 cultural factors 63 impulsivity 26
45 454 Index anger for adults 434, 440–2 abused/neglected children and adolescents 314, 315 for children 443–4 autism spectrum disorder 242, 244 neuroticism 445 borderline personality disorder 267 aripiprazole 242, 293 conduct disorder 134–5 arousal levels cultural factors 67, 68–9, 70 Attention Deficit Hyperactivity Disorder 116 detection by abused/neglected children and cultural factors 68 adolescents 313, 318 atomoxetine 122 disruptive mood dysregulation disorder 283, 294 Attachment Family Drawing task 357 incarceration, parental 360, 361–2, 364 attachment styles 4 inhibition/maladaptive expression 10 borderline personality disorder 271 longitudinal research 430, 432 emotion regulation 312 rumination 402 incarceration, parental 356–8, 362, 366 severe mood dysregulation 289, 290, 294 insecure 4 Stop Signal Reaction Time Task (SSRT) outcomes 116 borderline personality disorder 268 incarceration, parental 351 Anger Control Training 292 psychopathology 10 anorexia nervosa (AN) 196–2 07 mentalization-b ased treatment for adolescents 271 attention case example 204–6 control of 133 central facets of emotion regulation 425 co-occurring externalizing and internalizing emotion regulation 196–8, 200 treatments 198–203 problems 32 internalizing problems 28, 31 Children’s Hospital at Westmead program 201–6 reappraisal vs. distraction 52 evidence-based 198–200 depression 175–6 , 426 antisocial behavior nonsuicidal self-i njury 403 abused/neglected children and adolescents 316 processes 117 incarceration, parental 351, 354, 355, 366 reactive aggression 136–7 anxiety disorders 154–6 5 severe mood dysregulation 285–7 abused/neglected children and adolescents 310, 311, 315 traumatic stress exposure 384 behavioral factors 159 Attention Deficit Hyperactivity Disorder (ADHD) 113–2 3 cognitive behavioral therapy 162–4 clinical implications 121 cognitive factors 158 comorbidity 115–16 comorbidity severe mood dysregulation 294 alcohol use disorder 424 development 119–20 anorexia nervosa 197, 200 diagnostic criteria 113 Attention Deficit Hyperactivity Disorder 115 differential diagnosis 282 autism spectrum disorder 241, 242, 243, 244 emotion dysregulation 118–19 bipolar disorder 444 executive dysfunctions 116–1 8 borderline personality disorder 445 gender differences 114 depression 426–7, 430, 440–4 impulsivity 25 nonsuicidal self-i njury 398 interventions 293 oppositional defiant disorder 282 neural mechanisms 117, 118, 286, 288 pain, chronic 444–5 pharmacotherapy 293 social phobia 428 prevalence 114 substance use disorders 213–14 psychosocial impairment 114–15 cultural factors 70 temperamental pathways to 21 diagnoses 154–6 transition from adolescence to adulthood 120 Dialectical Behavior Therapy Skills Training 446 treatment 121–2 divorce, children of 335, 336, 340 autism spectrum disorder (ASD) 235–5 3 effects 10–11 cognitive and behavioral influences 240–1 emotion regulation strategies 421–5 emotion regulation 237–4 4 Emotion Regulation Therapy 446–7 interventions 241–5 3 emotional clarity 426 irritability 293 etiology 156–7 parent management training 292 exposure therapy 97 pharmacotherapy 293 functional magnetic resonance imaging 428–30 prevalence 236 longitudinal research 430, 432 Secret Agency Society-Operation Regulation parental reactions 160–1 physiological factors 159–6 0 program 244–5 3 prevalence 9, 10 autobiographical memory (AM) 176–7, 181 rumination 402 autonomic nervous system (ANS) self-regulation deficits 21, 22 internalizing problems 27, 28, 30, 31 Attention Deficit Hyperactivity Disorder 117–1 8 severe mood dysregulation as predictor 282 sympathetic branch (SNS) transdiagnostic mechanisms 420, 425 traumatic stress exposure 378, 379, 381, 383, 387 activation measures 46–7 Unified Protocol 434–4 5 anxiety disorders 159, 160 for adolescents 442–3 traumatic stress exposure 380 traumatic stress exposure 379
54 avoidance strategies Index 455 abused/n eglected children and adolescents 317 anxiety disorders 158, 159, 160–1 Research Domain Criteria 98 borderline personality disorder 269 Unified Protocol 434, 445 nonsuicidal self-i njury 401 Bradley-L ang view of emotion 81–3 , 87–8 substance use disorders 214 Research Domain Criteria 90, 102 traumatic stress exposure 379, 381, 382, 384 brain development 7–8 , 259 brain regions Avoidant/R estrictive Food Intake Disorder effortful control processes 20 (ARFID) 196, 197 extended process model 87 fear conditioning 90–1 emotional clarity 426 process model 85, 90–1 treatments 199 reactive control processes 20 reappraisal 91 B see also neural mechanisms bulimia nervosa 196, 197, 206 battered child syndrome 305 treatments 198, 199, 206–7 behavioral activation (BA) 182–3, 184–5 behavioral inhibition C anxiety disorders 157, 161 callous unemotional (CU) traits Attention Deficit Hyperactivity Disorder 115, comorbid Attention Deficit Hyperactivity Disorder 115–16 116, 117 conduct disorder 131–2 , 134, 135–6 , 140 internalizing problems 29–30, 31 externalizing 25 behavioral therapy 121–2 incarceration, parental 360 beta-a drenergic receptor-mediated effects 47 between-subjects research 45 Cambridge Study in Delinquent Development 355, 364 binge eating disorder 196, 197, 206 catastrophizing 427 emotional clarity 426 chain analysis 407 treatments 199, 206–7 challenge appraisal 47 bioinformational model of emotion 82–3 Child Behaviour Checklist 119–2 0 biological and physiological aspects of emotion Children of Divorce Coping with Divorce 344 Children of Divorce Intervention Program (CODIP) 342 regulation 7–8 , 43–5 4 Children’s Emotion Management Scales 361, 362 adaptive emotion responses 43 cigarette use definition of emotion regulation 43 neural activation associations 48, 50 affective lability 220 outcome measures 45–8 hedonic capacity 220 process measures 48–51 impulsivity 25 reappraisal mindfulness 220 prevalence 211 detached vs. positive 53–4 clinical trials research, transdiagnostic mechanisms vs. distraction 52–3 vs. suppression 51–2 in 433–4 , 435–9 research methods 44–5 coaching, emotion 359 biomarker studies 428–30 cognitive analytic therapy (CAT) 270–1 biosocial theory 261–2 cognitive behavior therapy (CBT) biphasic model of emotion 82 bipolar disorder (BD) abused/n eglected children and adolescents 316, 318 abused/neglected children and adolescents 310 alcohol dependence 316 comorbid anxiety disorders 444 anorexia nervosa 199 heart rate variability 428, 430 anxiety disorders 162–4 narrow phenotype see narrow phenotype bipolar Attention Deficit Hyperactivity Disorder 122, 294 autism spectrum disorder 242, 243, 244 disorder rumination, worry, and negative automatic Secret Agent Society-Operation Regulation program 245, 250 thoughts 425 Unified Protocol 434, 444 borderline personality disorder 270 body posture 46 depression 174, 181–5 borderline personality disorder (BPD) 259–73 attachment-b ased theory 264 major depressive disorder 98 comorbid nonsuicidal self-injury 398, 400, 406, disruptive mood dysregulation disorder 291, 292 Feeling Thermometer 294 407, 408 nonsuicidal self-injury 405–6, 409 developmental theories 261–2 severe mood dysregulation 294 diagnosis 259–6 1 substance use disorders 223 dialectical behavior therapy 406, 407, 446 traumatic stress exposure 384–5 , 387–8 emotion dysregulation 261–4 Unified Protocol 434 emotional clarity 426 Cognitive Behavioral Intervention for Trauma in Schools empirical evidence 264–7 0 interventions 270–3 (CBITS) 385 neuroticism 445 Cognitive Emotion Regulation Questionnaire parasympathetic nervous system influence on the (CERQ) 268 heart 49 cognitive functioning 355 prevalence 261 cognitive reappraisal see reappraisal collectivism 64, 65, 66, 68, 71
654 456 Index community-based programs for children of divorce 343 delayed gratification 6–7 community risk factors, abuse and neglect 310 Attention Deficit Hyperactivity Disorder 120 comorbidity, and transdiagnostic approaches 420 development 8 conduct disorder (CD) 129–42 externalizing problems 23, 24 aggression 135–6 deliberate self-harm see nonsuicidal self-injury proactive 137–8 delinquency 26 reactive 136–7 depression 171–85 antisocial behavior trajectories 130 abused/n eglected children and adolescents 310, 311, with callous unemotional traits 131–2, 134, 135–6, 140 315, 316 classification 129 comorbidity adverse child experiences 354 comorbidity Attention Deficit Hyperactivity Disorder 115 depression 432–3 anorexia nervosa 197 co-occurring externalizing and internalizing anxiety disorders 426–7, 430, 440–4 Attention Deficit Hyperactivity Disorder 115, 116 problems 33 autism spectrum disorder 241, 243, 244 development of emotion regulation 132–3 borderline personality disorder 445 diagnosis 129, 130 depression 432–3 impulsivity 25 disruptive mood dysregulation disorder 282–3 longitudinal research 432–3 generalized anxiety disorder 447 parasympathetic nervous system effects on the nonsuicidal self-injury 398 oppositional defiant disorder 282 heart 49 pain, chronic 444–5 parent management training 291 social phobia 428 prevalence and course 130–2 substance use disorders 213–1 4 with severe anger dysregulation 134–5 cultural factors 70–1 temperament and emotionality 133 Dialectical Behavior Therapy Skills Training 446 temperamental pathways to 21 divorce, children of 335, 336, 340, 341 treatment 138–9 emotion regulation central facets 425 functional family therapy 140–1 difficulties 174–81 Incredible Years 141–2 strategies 421–5 Multisystemic Therapy 139–40 Emotion Regulation Therapy 447 conduct problems (CP) 130 emotional clarity 426 with callous unemotional traits 132, 134 genetic factors 10 conscience, development of 138 Research Domain Criteria 92, 97 context-s ensitive regulation 284–5 heart rate variability 428, 430 Cool Kids program 162 incarceration, parental 351 Cool Little Kids program 162, 163 interventions Coping Cat program 162, 164 cognitive behavioral therapy 181–5 Coping Power Program 138 evidence-based 181–3 Coping with Adolescent Stress program 182 longitudinal research 430, 432–3 Coping with Children’s Negative Emotions Scales 363 nature of 171–2 cortisol response to stress 379, 380, 381 prevalence 9, 172–3 measures 47–8 psychological theories of 174 court-c onnected programs for children of divorce 342 and reappraisal 6 covert externalizing 24 relapse rates 10 cross-c ultural psychology 61, 62, 64, 65–7, 71 Research Domain Criteria 92, 97, 98 cross-s ectional research 433–47 risk factors 173–4 with adults 421–6 , 427 rumination 402 biomarker and fMRI studies 428–3 0 self-regulation deficits 21, 22 with youth 426–8 co-occurring externalizing and internalizing cultural factors 60–71 abuse and neglect 310 problems 32, 33 Attention Deficit Hyperactivity Disorder 114 internalizing problems 27, 28, 29, 30, 31 cross-c ultural research 61, 62, 64, 65–7, 71 severe mood dysregulation as predictor 282 in emotion regulation 8 and suppression 6 externalizing problems 26 transdiagnostic mechanisms 420, 425 incarceration, parental 363, 364–5 traumatic stress exposure 378, 379, 381, 382 internalizing problems 30–1 interventions 385–6, 387 models of self and emotion regulation 64–5 Unified Protocol 434–4 5 Research Domain Criteria 91 for adolescents 442–3 scripts 67–9, 70 for adults 434, 440–1 , 442 self-control 33 for children 443–4 socialization 61–4, 67, 71 neuroticism 445 Cyberball task 265–6 developmental psychopathology model 262 Diagnostic and Statistical Manual of Mental D Disorders (DSM) decision making 177–9 anxiety disorders 154–5, 156 default mode network 289
754 Index 457 Attention Deficit Hyperactivity Disorder 113, 114 protective factors for adjustment to parental autism spectrum disorder 235 separation 341 borderline personality disorder 259–6 1 conduct disorder 129, 130, 131 risk factors for adjustment to parental separation 341 depression 171 dopamine receptors 97 disruptive mood dysregulation disorder 281, 282 drug abuse see substance use disorders history of mental health/disorder 80 dual-p rocess theory 221 nonsuicidal self-i njury 398 posttraumatic stress disorder 379, 389 E Research Domain Criteria 90, 91, 102 substance use disorders 211, 212 Early Adolescent Temperament Scale-R evised 360 transdiagnostic approaches 420 eating disorders 196–207 traumatic stress exposure 374–5 , 379, 389 Dialectical Behavior Therapy (DBT) 446 abused/n eglected children and adolescents 311 abused/n eglected children and adolescents 318 case example 204–6 borderline personality disorder 270, 406, 407 central facets of emotion regulation 425 emotion regulation 196–8, 200, 421–4 Research Domain Criteria 98 emotional clarity 426 eating disorders 200, 206–7 longitudinal research 430, 432 nonsuicidal self-i njury 406–7 , 408, 409 treatments 198–203 Dialectical Behavior Therapy Skills Training Children’s Hospital at Westmead program 201–3 (DBT-S T) 446 evidence-based 198–200 Difficulties in Emotion Regulation Scale (DERS) Ecological Momentary Assessment (EMA) borderline personality disorder 267–8, 269 methodology 267 substance use disorders 217, 219 educational attainment see academic achievement transdiagnostic approaches 425, 426, 432 effortful control 19–2 0, 34 dimensional models 420–1 disabilities 307, 308 biological measures 48–5 1 disappointment display rule paradigm 362–3 co-occurring externalizing and internalizing disruptive mood dysregulation disorder (DMDD) 281–96 diagnosis 281 problems 32 differential diagnosis 282–3 externalizing problems 23–4, 26 emotion (dys)regulation 283–91 internalizing problems 27, 28, 29, 30, 31 interventions 291–5 ego depletion effects 48 labeling irritable emotion 295 ego-r esiliency 31 parental contingencies for behavior, consistency in 295 electromyography 46 prevalence 282 emotion 3 severe mood dysregulation 281–2 as action preparation 81–3 distraction bioinformational model 82–3 nonsuicidal self-injury 408, 409 biphasic model 82 vs. reappraisal 52–3 in childhood and adolescence 4 substance use disorders 217 definitions 3, 263, 378 traumatic stress exposure 381 functions 3–4 , 132, 133 distress management perspectives 81–7 anorexia nervosa 201–2, 203 three-s ystems view 83, 84 Emotion Acceptance Behavior Therapy (EABT) 200 case example 204 emotion awareness 238, 249 Dialectical Behavior Therapy Skills Training 446 emotion coaching 359 emotion regulation strategies 424 Emotion Detectives Treatment Protocol nonsuicidal self-injury 401 anxiety disorders 163 distress thermometers 202 Unified Protocol 443–4 distress tolerance 215 emotion dysregulation see emotion regulation borderline personality disorder 267, 268 Emotion-F ocused Cognitive-B ehavioral Therapy substance use disorders 216, 218, 219, 224 Distress Tolerance Scale (DTS) 219 (ECBT) 162, 164, 165 divalproex emotion regulation (ER) 5–6 Attention Deficit Hyperactivity Disorder 293 disruptive mood dysregulation disorder 293 as action change 81–3 severe mood dysregulation 293 benefits 79 divorce, children of 331–4 6 in children and adolescents 9–11 effects 331 definitions 5, 43, 62, 237, 263–4 , 359, 378 emotion regulation 337 development 8–9, 132–3 and executive function 7 for at-risk children 337–8 extended process model (EPM) 85–8 as protective adjustment 340 impact of parental separation 332–6 Research Domain Criteria 98, 99–1 01 influential factors 338–40 function 6–7 interventions 341–4 group therapy 408, 409 mediating factors 336–7 influencing factors 7–8 prevalence 331–2 process model see process model of emotion regulation research methods 43–5 strategies 237 cross-sectional research 421, 427 as transdiagnostic mechanism 433 Emotion Regulation Checklist 360, 363
854 458 Index emotion regulation strategies 427 Emotion Regulation Therapy 446–7 incarceration, parental 360, 361–2 Emotion Regulation Training (ERT) 270 parasympathetic nervous system influence on the emotional abuse definition 306 heart 49 outcomes 311 traumatic stress exposure 376, 378, 382 prevalence 306 extinction learning 97–8 risk factors 308 exuberance see also abuse and neglect externalizing problems 26 emotional arousal internalizing problems 29 abused/n eglected children and adolescents 312, 314 eye movement desensitization and reprocessing incarceration, parental 358, 359 nonsuicidal self-i njury 400, 401 (EMDR) 386–7 Emotional Cascade Model eyetracking 46 borderline personality disorder 262, 269 nonsuicidal self-i njury 402, 403 F emotional clarity 425–6 emotional competence 137 face emotion labeling development 132, 133 disruptive mood dysregulation disorder 290, 293 emotional inertia 217 narrow phenotype bipolar disorder 288, 289 emotional inexpressivity 404 severe mood dysregulation 288–9 1 Emotional Processing Theory 98 emotional reactivity see emotionality facial action coding system (FACS) 46 emotional sensitivity 265–7 , 270 facial expressions, measures 46 emotionality 215 family factors abused/neglected children and adolescents 314 conduct disorder 135, 432 abuse and neglect 308–1 0 conscience development 138 divorce, children of 336, 339–4 0, 345 depression 432 family interventions nonsuicidal self-injury 402, 410 anorexia nervosa 198–2 00, 201, 202, 206 reactive aggression 136 substance use disorders 215–16, 219, 224 case example 204, 205–6 and temperament 133 Attention Deficit Hyperactivity Disorder 121 endophenotypes 97 borderline personality disorder 271–2 , 273 environmental factors divorce, children of 334 emotion regulation 7, 8 functional family therapy 140–1 psychopathology 9 mentalization-b ased treatment for escape strategies 158, 159, 160–1 ethnicity factors adolescents 271–2, 273 incarceration, parental 362–3 self-regulation deficits 27 substance use disorders 212 family relationships event-related potentials (ERPs) 48 anorexia nervosa 199, 204 executive function (EF) 7 Attention Deficit Hyperactivity Disorder 114 Attention Deficit Hyperactivity Disorder 115, borderline personality disorder 262 116–1 8, 119, 120 conduct disorder 131 depression 180–1 substance use disorders 224 development 8 Fast Track Promoting Alternative Thinking Strategies effortful control 19 externalizing problems 23–4 (PATHS) 27 internalizing problems 29 fear behaviors posttraumatic stress disorder 380 self-r egulation 26, 27 callous unemotional externalizing 25 substance use disorders 213 internalizing problems 30 experiential avoidance see avoidance strategies Research Domain Criteria 97–8 Experiential Avoidance Model of NSSI 401 fear conditioning 90 experimental research 44–5 Feeling Thermometer 294, 295 exposure therapy 97–8 fight-flight response 46 expressive behavior, measuring 46 focused breathing 387 expressive suppression see suppression Fragile Families and Child Well Being (FFCWB) extended process model (EPM) 85–8 Research Domain Criteria 98, 99–1 01 study 354, 355, 365 externalizing problems 21, 22–7 , 33–4 friendships see peer relationships abused/n eglected children and adolescents 311, 315, functional family therapy (FFT) 140–1 316, 317 functional magnetic resonance imaging (fMRI) comorbid Attention Deficit Hyperactivity Disorder 115 co-o ccurring internalizing problems 28, 32–3 studies 428–30 divorce, children of 332 Functional Model of NSSI 401–2, 403 interventions 342 G gender factors Attention Deficit Hyperactivity Disorder 114, 115 autism spectrum disorder 236 conduct disorder 131 depression prevalence 172 risk factors 173 development of emotional regulation 9 divorce, children of 338–9
954 Index 459 eating disorders 196 incidence 352 incarceration, parental 360, 362, 366 maternal vs. paternal 352–4 nonsuicidal self-injury 399 types of 352 proactive aggression 138 visitation 358–9 , 365–6 substance use disorders 212, 213, 220 incarceration-s pecific risk experiences (ISRE) 361, generalized anxiety disorder (GAD) 155–6 abused/neglected children and adolescents 310 363, 365 comorbidity Incredible Years (IY) 141 major depressive disorder 447 conduct disorder 141–2 oppositional defiant disorder 282 self-regulation 26 Emotion Regulation Therapy 446–7 independent model of the self 64–5 , 66–7 , functional magnetic resonance imaging 429–3 0 traumatic stress exposure 383 68–9 , 70 genetic factors individualism 64, 65, 66, 68, 71 conduct disorder 132, 142 inhibitory control depression 10, 173–4 Research Domain Criteria 92, 97 Attention Deficit Hyperactivity Disorder 116, 122 eating disorders 196 co-occurring externalizing and internalizing emotion regulation 7, 8 nonsuicidal self-injury 399, 402, 410 problems 32 psychopathology 10 internalizing problems 28–9 , 31 Research Domain Criteria 92, 97 insecure attachment 4 substance use disorders 224 borderline personality disorder 268 gratification, delayed see delayed gratification incarceration, parental 351 Grief and Trauma Intervention (GTI) 385–6 psychopathology 10 Gross-Ochsner view of emotion 81, 83–8 insomnia (INS) 425 Research Domain Criteria 90, 98, 99–101, 102 insula 48 guilt 360 intellectual development 4 intellectual disability (ID), and autism spectrum H disorder 235–7 happiness, cultural factors 66–7 , 68 interventions 244 heart, parasympathetic nervous system influence on intelligence, and reactive aggression 137 interdependent model of the self 64–5 , 66–7 , 68–9 , 70 the 49–5 1 internalizing problems 21, 27–32, 33–4 heart rate variability (HRV) abused/n eglected children and adolescents 311, 315, high-frequency (HF-HRV) 316, 317 parasympathetic nervous system influence on the comorbid Attention Deficit Hyperactivity Disorder 115 heart 49, 50 conduct disorder 130 transdiagnostic approaches 428 co-o ccurring externalizing problems 28, 32–3 divorce, children of 332 parasympathetic nervous system influence on the heart 49, 50 interventions 342 emotion regulation strategies 421–5 , 427 transdiagnostic approaches 428, 430 incarceration, parental 360, 361–2 , 366 traumatic stress exposure 380–1, 383 parasympathetic nervous system influence on the hedonic capacity 218, 220 Helping Young People Early (HYPE) program 270 heart 49 How I Feel questionnaire 361 traumatic stress exposure 376, 378, 382 International Classification of Diseases (ICD) I depression 171–2 history of mental health/disorder 80 illicit drug use Internet-b ased programs for children of divorce 344 emotion dysregulation 219 interpersonal therapy (IPT) 293–4 intervention example 223 INTOVIAN Tool 307 prevalence 211, 212 invalidating childhood experiences 400 see also substance use disorders Inventory of Parent and Peer Attachment Inventory impulsivity (IPPA) 357 abused/n eglected children and adolescents 315 irritability alcohol misuse 426 Attention Deficit Hyperactivity Disorder 115, 117, 118 abused/n eglected children and adolescents 314 self-regulation deficits 20, 21, 33 abusive parents 309 co-occurring externalizing and internalizing autism spectrum disorder 242 problems 32 borderline personality disorder 267 externalizing problems 22, 24, 25–6 disruptive mood dysregulation disorder 281 internalizing problems 29, 30, 31 differential diagnosis 282 incarceration, parental 351–6 7 emotion (dys)regulation 283 attachment 356–8 divorce, children of 335 context 352–6 etiopathological model 283–4 effects on children 354–6 generalized anxiety disorder 282 emotion processes 356–6 4 labeling 294–5 emotion regulation 359–64 major depressive disorder 282–3 oppositional defiant disorder 282 pharmacotherapy 293 severe mood dysregulation 282, 283, 294
064 460 Index depression 176–7 posttraumatic stress disorder 380 J working 116 mental health and disorder, history of 79–81 James, William 81, 82 mentalization based therapy (MBT) for adolescents (MBT-A) 271–3 K borderline personality disorder 271–3 for families (MBT-F) 271 Kids First 344 nonsuicidal self-injury 407–8, 409 Kids First Center 344 methylphenidate 122 Kids’ Turn program 343 mindfulness anorexia nervosa 201, 205 L Attention Deficit Hyperactivity Disorder 122 autism spectrum disorder 243 language development 132, 133 LAST Project 385 Secret Agent Society-Operation Regulation late positive potentials (LPPs) 48 program 245, 248, 249, 250 limbic-h ypothalamic-p ituitary-a drenal (LHPA) axis depression 424–5 autism spectrum disorder 240 Dialectical Behavior Therapy Skills Training 446 traumatic stress exposure 379, 381 emotion regulation strategies 424 Limited Prosocial Emotions (LPE) see callous nonsuicidal self-injury 408, 409 substance use disorders 214, 218, 220–1 unemotional (CU) traits training 122 lithium 293 traumatic stress exposure 387 longitudinal research designs 430–47 Mindfulness Attention Scale (MAAS) 220 substance use disorders 221 M MINI International Neuropsychiatric Interview 441 Monitoring the Future (MTF) survey 210–1 1 major depressive disorder (MDD) motivational interviewing 409 central facets of emotion regulation 425 Movie Task for the Assessment of Social Cognition 272 comorbidity multi-d imensional experiential avoidance questionnaire generalized anxiety disorder 447 oppositional defiant disorder 282 (MEAQ) 441–2 decision making 178 Multisystemic Therapy (MST) 139 diagnosis 171, 172 Emotion Regulation Therapy 447 conduct disorder 139–40 executive functioning 180 genetic factors 92, 97 N heart rate variability 428, 430 memory 177 narrow phenotype bipolar disorder (NP-BD) 282, neural mechanisms 289 283, 190 prevalence 172 Research Domain Criteria 92, 97, 98 attention-emotion interactions, dysregulated 286 risk factors 173, 174 context-sensitive regulation, decreased 284–5 traumatic stress exposure 378 interventions 292–3 Unified Protocol 445 social-emotional stimuli, misinterpretation of 288 National Institute for Mental Health (NIMG), Research Manual Assisted Cognitive-Behavioral Therapy (MACT) 405–6 Domain Criteria 80, 88, 90, 420–1 National Longitudinal Study of Youth 366 Manualized Cognitive-Behavioral Therapy 406 National Survey on Drug Use and Health marijuana use (NSDUH) 211, 212 distress tolerance 219 natural disaster exposure emotion dysregulation 219 intervention example 223 emotion regulation mechanisms 383 prevalence 211, 212 lifetime risk 375 mass trauma exposure see traumatic stress exposure posttraumatic stress disorder 376 maternal factors see also traumatic stress exposure abuse and neglect 308, 309, 313 negative automatic thoughts 425 anxiety disorders 161 negative divorce effect 334 Attention Deficit Hyperactivity Disorder 114 neglect cultural scripts 69 definition 306 divorce, children of 336, 339, 340, 341 emotion regulation problems, development of 313, incarceration 352–4 , 366 314, 315 attachment 356, 357, 358 nonsuicidal self-injury 400 emotion regulation 360, 361, 363 outcomes 311 psychopathology 10 prevalence 306 socialization 62, 63, 132–3 risk factors 308, 309–1 0 see also parental factors see also abuse and neglect Maudsley Model of Anorexia Nervosa Treatment for neural measures of emotional reactivity 48, 50 reappraisal 48, 50 Adults (MANTRA) 200 medication see pharmacotherapy detached vs. positive 53–4 meditation 243 vs. suppression 51–2 memory autobiographical (AM) 176–7 , 181
164 Index 461 neural mechanisms severe mood dysregulation 294 abuse and neglect 313–14 traumatic stress exposure 386, 387, 388 anxiety disorders 159–6 0 parental factors Attention Deficit Hyperactivity Disorder 117, 118, abuse and neglect 308–1 0 286, 288 autism spectrum disorder 238–9 emotion regulation problems, development of 312 borderline personality disorder 266 anxiety disorders 157, 160–1 conduct disorder 134 Attention Deficit Hyperactivity Disorder 114, 120 disruptive mood dysregulation disorder 290 borderline personality disorder 262 labeling irritable emotion 294–5 conduct disorder 131 major depressive disorder 289 cultural scripts 69 research methods 45 depression 173, 174 severe mood dysregulation 283, 285, 286–7 , 288–90, 294 development of emotional regulation 9 transdiagnostic approaches 428–30 disruptive mood dysregulation disorder 295 traumatic stress exposure 379–8 1 divorce see divorce, children of eating disorders 196, 200 neuroticism incarceration see incarceration, parental parasympathetic nervous system effects on the heart 49 posttraumatic stress disorder 384 Unified Protocol 445 poverty stressors 133 psychopathology 9, 10 New Beginnings Program (NBP) 343–4 self-r egulation 26–7 nonsuicidal self-injury (NSSI) 398–4 10 severe mood dysregulation 295 socialization 62, 63, 132–3 clinical guidance on management and treatment 408–9 substance use disorders 224 comorbid borderline personality disorder 268, 269, see also maternal factors; paternal factors Parenting through Change 344 270, 271 Parents and Children Making Connections—Highlighting Experiential Avoidance Model 401 extent of 399 Attention (PCMC-A ) program 26–7 Functional Model 401–2 , 403 parietal cortex 287 interventions 405–8 paternal factors nature of 399 theoretical perspectives 399–405 Attention Deficit Hyperactivity Disorder 114 nucleus accumbens 48 divorce, children of 334, 336–7 , 345 incarceration 352–4 , 355, 366 O attachment 357, 358 observational research 44 psychopathology 10 one-s ession treatment (OST) 162 see also parental factors online programs for children of divorce 344 peer relationships oppositional defiant disorder (ODD) abused/n eglected children and adolescents 317, 318 Attention Deficit Hyperactivity Disorder 114 comorbidity 282 divorce, children of 333–4, 335, 341 Attention Deficit Hyperactivity Disorder 115, 121 reactive aggression 136 traumatic stress exposure 378, 382 and conduct disorder, relationship between 130, 134 perseveration 241 differential diagnosis 282 personality development 4 parent management training 291 personality disorders 311 optimism 341 personality traits 341 orbitofrontal cortex 118 pharmacotherapy overanxious disorder see generalized anxiety disorder Attention Deficit Hyperactivity Disorder 121–2 over-g eneral memory (OGM) 176–7 , 181 autism spectrum disorder 242 disruptive mood dysregulation disorder 292–3 P phobias 156, 159 abused/n eglected children and adolescents 310 pain, chronic 434, 444–5 cognitive behavioral therapy 162 panic disorder (PD) 156 social see social anxiety physical abuse abused/neglected children and adolescents 310 definition 305 functional magnetic resonance imaging 429–30 emotion regulation problems, development of 314, 315 parasuicide see nonsuicidal self-injury nonsuicidal self-injury 400 parasympathetic nervous system (PNS) outcomes 311 influence on the heart 49–51 prevalence 306 measures 45 risk factors 307–8 , 310 traumatic stress exposure 380–1 see also abuse and neglect parent education/parent management training (PMT) physiological aspects see biological and physiological abuse and neglect 319 anxiety disorders 162, 163–4 aspects of emotion regulation Attention Deficit Hyperactivity Disorder 121, 294 posterior cingulate autism spectrum disorder 243–4, 292 conduct disorder 141–2 , 291 narrow phenotype bipolar disorder 289 disruptive mood dysregulation disorder 291–2, 295 severe mood dysregulation 287, 289 divorce 343–4, 345 Incredible Years 141–2 oppositional defiant disorder 291
264 462 Index posttraumatic stress disorder (PTSD) 375–6 , 378, 388–9 cultural factors 66, 67, 70 abused/neglected children and adolescents 311, 315–16 depression 180 behavioral mechanisms 382 detached 53–4 cognitive mechanisms 382 vs. distraction 52–3 emotion regulation mechanisms 379 divorce, children of 338, 340, 341 immediate posttraumatic stress reactions 379 executive function 7 interventions 384, 385–6, 387, 388 generalized anxiety disorder 429 neurobiological mechanisms 380, 381 internalizing disorders 29, 421–5 substance use disorders 218, 219–20, 224 neural measures 48, 50, 51–4 vulnerability and moderating factors 383–4 nonsuicidal self-injury 398, 403–5, 408–9, 410 parasympathetic nervous system influence on the posttraumatic stress symptoms (PTS) abused/neglected children and adolescents 316 heart 49 immediate 376–8, 379 and pathology, relationship between 425 interventions 386 positive 53–4 secondary 377, 378, 383 process model 85 poverty Research Domain Criteria 90, 91 abuse and neglect 309–10 strategies, variety among 53–4 conduct disorder 133 substance use disorders 214, 217 incarceration, parental 354 vs. suppression 51–2 sympathetic nervous system measures 46–7 prefrontal cortex (PFC) traumatic stress exposure 382 autism spectrum disorder 238 Reflective Functioning Questionnaire for Youth 272 generalized anxiety disorder 429–30 relaxation strategies panic disorder 429–3 0 autism spectrum disorder 244 social phobia 428–9 traumatic stress exposure 379, 380 Secret Agent Society-Operation Regulation program 248 pregenual anterior cingulate cortex (pgACC) 313 proactive externalizing 24–5 traumatic stress exposure 387 problem solving Research Domain Criteria (RDoC) 80–1 , 88–1 02, 420–1 internalizing disorders 421–4 conceptual scientific advancement 98–102 substance use disorders 214, 225 empirical scientific advancement 92–8 Problem-S olving Skills Training (PSST) 292, 405 perspectives of emotion 83 process model of emotion regulation 44, 84–5, 90–1 respiratory sinus arrhythmia (RSA) divorce, children of 340 borderline personality disorder 269 nonsuicidal self-i njury 402–3 conduct disorder 135, 432–3 traumatic stress exposure 378 depression 432–3 progressive muscle relaxation parasympathetic nervous system effects on the autism spectrum disorder 244 comorbid anxiety and alcohol use disorders 424 heart 49–50 Promoting Alternative Thinking Strategies (PATHS) traumatic stress exposure 380–1 restrictive eating curriculum 319 emotional clarity 426 psychoeducation see also Avoidant/R estrictive Food Intake Disorder risperidone 242, 293 anorexia nervosa 202, 203, 206 rumination 215 borderline personality disorder 272 autism spectrum disorder 243 traumatic stress exposure 385, 386 bipolar disorder and insomnia compared 425 psychopathology in children and adolescents 9–1 1 borderline personality disorder 262, 269 psychopathy 315, 316 depression 179, 80 psychosomatic complaints 336, 337 externalizing problems 33, 427 psychotherapy internalizing problems 29, 33, 421–5 , 427 anorexia nervosa 198, 199 nonsuicidal self-injury 398, 402, 403, 408, 410 Attention Deficit Hyperactivity Disorder 121 substance use disorders 217 autism spectrum disorder 243 as transdiagnostic mechanism 425 disruptive mood dysregulation disorder 291–2, 294 traumatic stress exposure 381 Q S Q methodology 346 sadness 67 sandcastles program 344 R schizophrenia 311 school-based interventions Radically-Open Dialectical Behavior Therapy (RO-D BT) 200 divorce, children of 342 teacher training reactive attachment disorder 311 reactive control 20 Attention Deficit Hyperactivity Disorder 121 Incredible Years 141 externalizing problems 22–3, 24 traumatic stress exposure 385–6 internalizing problems 27, 29–30, 31 Secret Agent Society-Operation Regulation (SAS-OR) reappraisal 5–6, 44 anxiety disorders 158 program 244–5 3 autism spectrum disorder 239 Seeking Safety 318 biological measures 45
364 Index 463 selective mutism (SM) 155 strange situation experiment 4 self-blame 33, 427 stress self-i njurious behavior see nonsuicidal self-injury Self Referent Encoding Task (SRET) 176 abuse and neglect 309, 310, 317 self-r egulation 18, 33–4 autism spectrum disorder 239 in caregivers 354 conceptual issues 18–2 0 cortisol response to 379, 380, 381 co-occurring problems 32–3 definition 18 measures 47–8 effortful control 19–2 0 depression 173, 174 externalizing problems 22–7 divorce, children of 339, 344 internalizing problems 27–32 incarceration, parental 354, 358–9 , 361 maladjustment 21–2 nonsuicidal self-i njury 400 reactive control 20 traumatic see traumatic stress exposure separation, parental see divorce, children of striatum 287 separation anxiety disorder (SAD) 155, 159, 160 Stroop task separation distress 28, 30 Attention Deficit Hyperactivity Disorder 118 severe mood dysregulation (SMD) 281–2, 296 emotion regulation 116 emotion (dys)regulation 283–91 substance use disorders (SUDs) 210–2 5 interventions 291–4 abused/n eglected children and adolescents 311, 316 labeling irritable emotion 295 abusive parents 309 parental contingencies for behavior, consistency in 295 comorbidity sexual abuse definition 305–6 borderline personality disorder 268 emotion regulation problems, development of 314, 315 nonsuicidal self-injury 398 nonsuicidal self-i njury 400 composite constructs and dual-p rocess theory 221–2 prevalence 306 diagnosis 212–13 risk factors 308 divorce, children of 343 see also abuse and neglect emotion regulation 213–21 shame attributes 215–1 6 borderline personality disorder 267 intervention example 222–3 incarceration, parental 360 strategies 213–1 4 traumatic stress exposure 385 emotional clarity 426 shyness 30 impulsivity 25 single parents 308 incarceration, parental 354, 355 Skills Training in Affect and Interpersonal prevalence 210–1 2 relapse rates 10 Regulation (STAIR)/P rolonged Exposure 318–1 9 traumatic stress exposure 378 smoking behavior see cigarette use suicidal behavior 399 Snaith-H amilton Pleasure Scale (SHAPS) 220 dialectical behavior therapy 407, 446 social anxiety 155, 160 Supportive Parenting for Anxious Childhood Emotions divorce, children of 340 (SPACE) program 163–4, 165 emotional clarity 426 suppression 5, 6 functional magnetic resonance imaging 428–9 self-r egulation deficits 22 abused/n eglected children and adolescents 317 Attention Deficit Hyperactivity Disorder 116 internalizing problems 29 cultural factors 8, 66, 67, 70 social cognitive neuroscience 83 divorce, children of 335, 338, 340 social development 4 executive function 7 social-emotional stimuli, misinterpretation of 287–90 internalizing disorders 29, 421–4 social factors 60–71 nonsuicidal self-injury 398, 403–5 , 408, 410 parasympathetic nervous system effects on the heart 49 abuse and neglect 310 process model 85 Attention Deficit Hyperactivity Disorder 114 vs. reappraisal 51–2 divorce, children of 333, 336 substance use disorders 214 social learning theory 309 traumatic stress exposure 379, 381 social phobia see social anxiety sympathetic nervous system (SNS) social relationships see peer relationships activation measures 46–7 social withdrawal 22 anxiety disorders 159, 160 socialization 61–4, 67, 71, 132–3 traumatic stress exposure 380 abused/neglected children and adolescents 312 systemic family therapy 198 anxiety disorders 161 Systems Training for Emotional Predictability and Problem cultural scripts 69 divorce, children of 339 Solving (STEPPS) 270 incarceration, parental 359, 363–4, 366, 367 soothability 215 T substance use disorders 216, 224 specific phobias (SP) 156, 159 teacher training abused/neglected children and adolescents 310 Attention Deficit Hyperactivity Disorder 121 cognitive behavioral therapy 162 Incredible Years 141 Stengel, Erwin 80 temperament and emotionality 133 substance use disorders 215–1 6
46 464 Index theory of mind 240–1 for adults thinking about reward in young people (TRY) group intervention 441–2 individual intervention 434–4 1 program 182–3 , 184–5 thought suppression see suppression bipolar disorder 444 threat appraisal/system for children 443–4 neuroticism 445 abused/n eglected children and adolescents 318 pain, chronic 444–5 biological aspects 47 Unified Protocol for the Treatment of Emotional Disorders disruptive mood dysregulation disorder 290 divorce, children of 340 in Youth (UP-Y ) 444 severe mood dysregulation 290 anxiety disorders 163, 165 three-s ystems view of emotion 83, 84 Unified Protocol for Transdiagnostic Treatment of Tools of the Mind intervention 26 transdiagnostic approaches 419–4 8 Emotional Disorders 424 biomarker and fMRI studies 428–3 0 Unified Protocol in Youth with Pain (UP-YP) 444–5 clinical trials 433–4 , 435–9 cross-s ectional research 433–47 V with adults 421–6 , 427 vagal tone 49 with youth 426–8 venlafaxine 424 dialectical behavior therapy skills training 446 ventral striatum 118 emotion regulation therapy 446–7 verbal intelligence 137 experimental, survey, and neurobiological designs 421 visual cortex 48 longitudinal designs 430–47 Unified Protocol 434–4 5 W transference-focused psychotherapy (TFP) 271 transition from adolescence to adulthood see adulthood, website-b ased programs for children of divorce 344 within-subjects research 45 transition from adolescence to working memory 116 Trauma Adaptive Recovery Group Education and World Health Organization Therapy 318 child abuse, definition 305 trauma-focused cognitive behavioral therapy history of mental health/disorder 79–8 0 International Classification of Diseases (ICD) (TF-C BT) 384–5 , 387–8 traumatic stress exposure 374–89 depression 171–2 history of mental health/disorder 80 interventions 384–8 worry outcomes 375–84 anxiety disorders 425 prevalence 375 bipolar disorder and insomnia compared 425 internalizing disorders 424–5 U Y Unified Protocol (UP) 434–4 5 for adolescents 442–3 Youth Risk Behavior Surveillance Study 211
Search
Read the Text Version
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- 57
- 58
- 59
- 60
- 61
- 62
- 63
- 64
- 65
- 66
- 67
- 68
- 69
- 70
- 71
- 72
- 73
- 74
- 75
- 76
- 77
- 78
- 79
- 80
- 81
- 82
- 83
- 84
- 85
- 86
- 87
- 88
- 89
- 90
- 91
- 92
- 93
- 94
- 95
- 96
- 97
- 98
- 99
- 100
- 101
- 102
- 103
- 104
- 105
- 106
- 107
- 108
- 109
- 110
- 111
- 112
- 113
- 114
- 115
- 116
- 117
- 118
- 119
- 120
- 121
- 122
- 123
- 124
- 125
- 126
- 127
- 128
- 129
- 130
- 131
- 132
- 133
- 134
- 135
- 136
- 137
- 138
- 139
- 140
- 141
- 142
- 143
- 144
- 145
- 146
- 147
- 148
- 149
- 150
- 151
- 152
- 153
- 154
- 155
- 156
- 157
- 158
- 159
- 160
- 161
- 162
- 163
- 164
- 165
- 166
- 167
- 168
- 169
- 170
- 171
- 172
- 173
- 174
- 175
- 176
- 177
- 178
- 179
- 180
- 181
- 182
- 183
- 184
- 185
- 186
- 187
- 188
- 189
- 190
- 191
- 192
- 193
- 194
- 195
- 196
- 197
- 198
- 199
- 200
- 201
- 202
- 203
- 204
- 205
- 206
- 207
- 208
- 209
- 210
- 211
- 212
- 213
- 214
- 215
- 216
- 217
- 218
- 219
- 220
- 221
- 222
- 223
- 224
- 225
- 226
- 227
- 228
- 229
- 230
- 231
- 232
- 233
- 234
- 235
- 236
- 237
- 238
- 239
- 240
- 241
- 242
- 243
- 244
- 245
- 246
- 247
- 248
- 249
- 250
- 251
- 252
- 253
- 254
- 255
- 256
- 257
- 258
- 259
- 260
- 261
- 262
- 263
- 264
- 265
- 266
- 267
- 268
- 269
- 270
- 271
- 272
- 273
- 274
- 275
- 276
- 277
- 278
- 279
- 280
- 281
- 282
- 283
- 284
- 285
- 286
- 287
- 288
- 289
- 290
- 291
- 292
- 293
- 294
- 295
- 296
- 297
- 298
- 299
- 300
- 301
- 302
- 303
- 304
- 305
- 306
- 307
- 308
- 309
- 310
- 311
- 312
- 313
- 314
- 315
- 316
- 317
- 318
- 319
- 320
- 321
- 322
- 323
- 324
- 325
- 326
- 327
- 328
- 329
- 330
- 331
- 332
- 333
- 334
- 335
- 336
- 337
- 338
- 339
- 340
- 341
- 342
- 343
- 344
- 345
- 346
- 347
- 348
- 349
- 350
- 351
- 352
- 353
- 354
- 355
- 356
- 357
- 358
- 359
- 360
- 361
- 362
- 363
- 364
- 365
- 366
- 367
- 368
- 369
- 370
- 371
- 372
- 373
- 374
- 375
- 376
- 377
- 378
- 379
- 380
- 381
- 382
- 383
- 384
- 385
- 386
- 387
- 388
- 389
- 390
- 391
- 392
- 393
- 394
- 395
- 396
- 397
- 398
- 399
- 400
- 401
- 402
- 403
- 404
- 405
- 406
- 407
- 408
- 409
- 410
- 411
- 412
- 413
- 414
- 415
- 416
- 417
- 418
- 419
- 420
- 421
- 422
- 423
- 424
- 425
- 426
- 427
- 428
- 429
- 430
- 431
- 432
- 433
- 434
- 435
- 436
- 437
- 438
- 439
- 440
- 441
- 442
- 443
- 444
- 445
- 446
- 447
- 448
- 449
- 450
- 451
- 452
- 453
- 454
- 455
- 456
- 457
- 458
- 459
- 460
- 461
- 462
- 463
- 464
- 465
- 466
- 467
- 468
- 469
- 470
- 471
- 472
- 473
- 474
- 475
- 476
- 477
- 478
- 479
- 480
- 481
- 482
- 483
- 484
- 485
- 486
- 487
- 488
- 489
- 490
- 491
- 492
- 493
- 494
- 495
- 496
- 497
- 498
- 1 - 50
- 51 - 100
- 101 - 150
- 151 - 200
- 201 - 250
- 251 - 300
- 301 - 350
- 351 - 400
- 401 - 450
- 451 - 498
Pages:
