Self-Awareness and Self-Relevant Thought in Emotion 381 about anticipated negative events typically because of the successes or failures of people increases their negative emotions. Thus, with whom they are associated. defensive pessimism may be a useful means of emotional self-r egulation for some people Although many theorists have assumed but not for others. that people desire positive feedback about themselves because they have a need to Evaluation of One’s maintain or enhance their self-esteem, self- Personal Characteristics enhancement may be more parsimoniously People’s self-relevant beliefs and evalua- viewed as a way to regulate emotion. People tions often evoke emotional responses and seek positive information about themselves, are also involved in emotion regulation. because being capable, attractive, socially Human infants develop a conception of skilled, or likable elicits positive emotions themselves slowly over the first 2 years of by increasing the perceived likelihood of life (Kagan, 1998) and characterize them- desired outcomes. Conversely, receiving neg- selves in increasingly complex and abstract ative self-relevant feedback typically indi- ways in a developmental progression that cates a lower likelihood of desired outcomes continues into late adolescence (Harter, and a greater likelihood of undesired ones. 2012). As their self-concepts develop, chil- dren begin to experience myriad emotions Sociometer theory carries this notion by thinking about their own characteris- a step further by suggesting that people’s tics and behavior. Once people develop the affective reactions to self-enhancing and capacity to label, characterize, and evaluate self-depreciating events serve an important themselves, they react emotionally to these interpersonal function by providing feed- self-representations, as well as to events and back about the degree to which they are information that validate or threaten them. valued and accepted by others (for a review, see Leary, 2006). Events that threaten a Self‑Evaluations and Emotion person’s positive self-image evoke negative People react negatively to events that threaten emotions, because they cast that person in their self-views and positively to events that an undesirable light in other people’s eyes, affirm them, even when such events have no thereby undermining his or her relation- real consequences for their well-being. Thus, ships with them (Leary, Tambor, Terdal, & by virtue of being self-aware, people become Downs, 1995). From this perspective, the emotionally invested in whether reality feelings that arise from positive and negative conforms to their desired self-views. Two self-relevant events are part of a monitoring kinds of symbolic satisfactions and threats system that keeps people apprised of their to people’s self-construals have received relational value and motivates behaviors to the most attention from researchers—self- help them avoid social rejection. enhancement and self-verification. Several perspectives suggest that people People prefer to evaluate themselves posi- want to maintain not only a positive view tively rather than negatively, and a great deal of themselves but also a stable and consis- of research has examined the ways in which tent self-view (Swann & Buhrmester, 2012). people try to maintain views of being good As a result, information suggesting that and effective individuals. Thus, events that people are not who or what they think they support a favorable view of oneself tend to are evokes negative feelings. Cognitive dis- evoke positive emotions, such as pride, hap- sonance theory was among the first per- piness, and satisfaction; events that contra- spectives to describe the emotional effects dict one’s favorable self-view, on the other of having inconsistent beliefs. Any pair of hand, are associated with negative emotions, contradictory beliefs can potentially induce such as anxiety, despondency, frustration, the unpleasant affective state of dissonance, shame, and rage (Baumeister, 1998). Because but inconsistent beliefs involving aspects of people’s identities include significant others oneself seem to be particularly unpleasant in their lives, people also feel good or bad (Aronson, 1968). Swann and his colleagues have specifi- cally examined people’s responses to events that verify or disconfirm their self-views (for a review, see Swann & Buhrmester, 2012). People tend to be troubled by information
382 PERSONALITY PROCESSES AND INDIVIDUAL DIFFERENCES that discredits their self-perceptions, pre- Theorists once assumed that comparing sumably because such information under- ourselves to those who are worse off than mines their certainty in their beliefs about we are (i.e., downward social comparison) themselves and lowers their sense of predict- generally leads to more positive emotions ability and control (Swann, Stein-Seroussi, than comparing ourselves to people who & Giesler, 1992). As a result, receiving are better off (upward social comparison). information that is inconsistent with one’s However, whether downward or upward self-concept is often troubling, even if it is comparisons lead to positive or negative favorable (Kwang & Swann, 2010). affect depends on how people interpret the Although self-verification and self- comparative information. When downward enhancement have often been pitted against comparisons make people feel better or one another as theoretical perspectives on more fortunate than others, they induce pos- motivated self-cognition, evidence shows itive emotions. In contrast, when downward that both processes occur, and research social comparisons raise the specter that one has begun to uncover the conditions under might also fare poorly (e.g., when a newly which each effect is obtained (Kwang, & diagnosed cancer patient compares him- or Swann, 2010). Importantly, the possibility herself to a patient in later stages of the ill- exists that both processes serve the goal of ness), they lead to negative emotions (Buunk promoting one’s social acceptance. That is, et al., 1990; Morrell et al., 2012). Similarly, people often increase their chances of social comparing oneself to outstanding role mod- acceptance by either portraying themselves els evokes positive affect if the superstar’s in positive ways or seeking to interact with accomplishments seem personally attain- people who see them as they see themselves. able but negative affect when they do not (Lockwood & Kunda, 1997). The effects of upward and downward social compari- Regulating Emotion son are quite complex and are also moder- by Managing Self‑Evaluations ated by variables such as self-e steem, mood, Because self-e valuations influence emotions, neuroticism, and optimism (Lyubomirsky people can regulate their emotions by man- & Ross, 1997). Nevertheless, people often aging how they perceive and evaluate them- choose and interpret social comparisons in selves. Two of the most widely researched ways that help them regulate their emotions. tactics for doing so involve social compari- son and attribution. Attributions Social Comparison In the same vein, people can regulate their People’s self-evaluations—a nd their emotions through their attributions for emotions—are affected by how they com- events that occur. People’s beliefs about pare to others, particularly in domains where why particular emotion-inducing events no objective standard for self-evaluation occurred in the first place (e.g., “Why was exists (e.g., judgments of physical attractive- I passed over for the promotion?”) and why ness or popularity). Therefore, people some- they reacted as they did to those events (e.g., times regulate their emotions through their “Why did I lose my temper?”) influence both choices of social comparison targets (Suls & their self-evaluations and their emotions. Wheeler, 2012). Although people sometimes Since Schachter and Singer’s (1962) initial use comparison targets that provide an demonstration that people’s interpretations accurate indication of their own attributes, of arousing events affect their emotional their selections more often appear designed experiences, research has shown that attri- to promote positive feelings (Buunk, Col- butions have a strong effect on emotion. The lins, Taylor, VanYperen, & Dakof, 1990; same event can evoke drastically different Morrell et al., 2012). At times, people seek emotions depending on the person’s attribu- downward comparisons to feel better about tions for it (Siemer, Mauss, & Gross, 2007), themselves by contrast; at other times, they and such attributions necessarily involve seek upward comparisons for inspiration or self-f ocused thought. hope. Weiner’s (1985) attribution theory of emotion most fully describes the relation-
Self-Awareness and Self-Relevant Thought in Emotion 383 ship between patterns of attributions and ficulties, including depression, anxiety, and specific emotions. From this perspective, frequent anger and guilt (Hilt, 2004). people’s emotional responses to positive and negative events depend on three aspects of In light of the link between people’s the attributions that they make—causal attributions and their emotions, interven- locus (whether the cause of the event was tions and psychotherapy techniques have internal or external to the individual), sta- been developed that focus on attributional bility (whether the cause is short-lived or reframing to ameliorate emotional distress. long-l asting), and controllability (whether Such approaches involve teaching people the cause is under the person’s control). For to identify and challenge their inaccurate example, if people attribute success to their causal attributions and to develop more own efforts (an internal, stable, and control- accurate, positive ones. For example, when lable cause), they experience positive self- people engage in excessive self-blame about agency emotions such as pride, satisfaction, negative events (i.e., unrealistically attribut- and confidence, whereas attributing that ing negative events to a stable internal fac- same success to other people (an external, tor), an approach known as attributional stable, uncontrollable cause) results in posi- retraining has been used with beneficial tive other-agency emotions such as gratitude, effects on depression, anxiety, and guilt. obligation, and appreciation toward those Attributional retraining involves reviewing who helped. And, if the success is attributed the negative event that led to the attribution, to impersonal circumstances (an external, searching for alternative explanations that unstable, and uncontrollable causes), people are at least equally plausible, and alleviating feel lucky and happily surprised (positive some or all of the person’s responsibility for situation-agency emotions). the negative outcome. Conversely, attribu- tional retraining can also involve fostering The attribution of agency has proven to internal attributions for positive outcomes be particularly important in distinguishing when appropriate, such as learning to attri- among negative emotions, such as anger bute one’s successes to effort and skill rather (other-agency), guilt (self-agency), and sor- than luck, in order to increase positive emo- row (circumstance-agency; Ellsworth & tions and self-efficacy (Hilt, 2004). Smith, 1988). Additionally, agency attribu- tions, regardless of their accuracy, influence Techniques to help clients reframe their people’s appraisals of their ability to deal attributions are often used within the con- with negative events and their consequences text of cognitive-behavioral therapy, which (Ellsworth & Scherer, 2003). The emotional makes it difficult to assess their effectiveness effects of attributions are also mediated as a unique mechanism for change. Even so, by people’s appraisals of the implications research generally supports the efficacy of of those attributions for their well-being attributional reframing for reducing emo- (David, Schnur, & Belloiu, 2002). tional distress (Hilt, 2004). For example, decreased negative attributions in couples Research on both student and clinical mediated increases in relationship satis- samples demonstrates that people who char- faction (Hrapczynski, Epstein, Werlinich, acteristically explain negative events in terms & LaTaillade, 2012), and a reduction in of internal, stable, and global causes (i.e., patients’ negative inferences lowered their a pessimistic explanatory style) are more depression and anxiety (DeFronzo Dobkin likely to develop symptoms of depression et al., 2007). In addition, an integral compo- (in particular, the subtype “hopeless depres- nent of treatment for panic disorder involves sion”) than those who tend to make exter- modifying patients’ attributions for their nal, unstable, and specific attributions for physiological symptoms of anxiety (e.g., negative outcomes (Abramson, Metalsky, & learning that they are not harmful) in order Alloy, 1989; Alloy et al., 2000). In addition, to reduce anxiety and the frequency of panic attributing positive events to unstable and attacks. specific sources is associated with depres- sion, albeit less strongly than attributions Attributional retraining has also been for negative events (Ahrens & Haaga, 1993). used successfully in nonclinical settings, In fact, negative attributional styles contrib- such as schools and the workplace, as both ute to a variety of common emotional dif- a method for preventing emotional distress and an intervention for emotional problems.
384 PERSONALITY PROCESSES AND INDIVIDUAL DIFFERENCES For instance, a study that focused on chang- Grunewald, & Kemeny, 2004), even if those ing employees’ negative attributional styles standards have been internalized and people resulted in significant increases in job sat- are no longer consciously aware of their ori- isfaction and subjective well-being (Proud- gin (Baldwin & Baccus, 2004). foot, Corr, Guest, & Dunn, 2009). Overall, research suggests that attributional refram- People’s perceptions of how others view ing can be an effective technique for improv- and evaluate them (often called reflected ing emotional outcomes in both clinical and appraisals) can elicit a variety of emotions. nonclinical populations. And, again, all of For example, people experience social anxi- these effects are mediated by people’s self- ety when they think that others will not relevant thoughts. form desired impressions of them, even if they know that they possess positive attri- Awareness of Other People’s butes. Research has shown that people who Perceptions and Evaluations score high in social anxiety tend to be highly A great deal of human emotion arises from self-focused and think about themselves people’s beliefs about how they are perceived negatively during social interactions. In fact, and evaluated by other people. Other peo- negative self-relevant imagery is causally ple’s judgments of us have important impli- involved in both trait social anxiety and the cations for our social, occupational, roman- experience of state social anxiety in people tic, financial, and other outcomes, so we who are not typically anxious (Makkar & understandably react differently when we Grisham, 2011). Similarly, people become are viewed favorably rather than unfavorably embarrassed when they believe that other by other people. Self-awareness is needed to people have formed undesired impressions infer other people’s thoughts, and some the- of them (Miller, 1996) and experience hurt orists have even proposed that the ability to feelings when they think that others do not reflect on one’s private experiences evolved sufficiently value them (Leary, Springer, to help people infer what others might be Negel, Ansell, & Evans, 1998). In each of thinking about them (Gallup, 1997). In fact, these cases, self-reflection is needed to infer in young children the ability to imagine what others might be thinking and to elicit other people’s perspectives emerges at about the emotional response. the same time as self-a wareness (Focquaert, Braeckman, & Platek, 2008). Guilt and shame also involve concerns about other people’s evaluations. Guilt Self‑Awareness and Social Emotions involves a negative evaluation of a specific Around this time, children also begin to behavior, whereas shame involves a nega- experience self-c onscious emotions—such as tive evaluation of oneself (Tangney & Tracy, embarrassment, pride, shame, and guilt—in 2012). People often feel guilty or ashamed response to the real or imagined evaluations simply from knowing that others regard of other people (Miller, 1996). This particu- their behavior or character unfavorably, lar subset of emotions is often labeled “self- even if they personally believe that they did conscious” because these emotions typically nothing wrong. Of course, people also expe- involve acute feelings of self-consciousness, rience positive emotions from imagining as people think a great deal about them- other people’s reactions to them. People may selves and what other people might be think- experience pride when they think that others ing about them (Tangney & Tracy, 2012). admire them, and joy when they think that Yet the central feature of these emotions is others love them deeply, even in the absence that they occur when people believe that of explicit indications of admiration or love. others have formed, or might form, particu- lar positive or negative impressions of them. Furthermore, people’s beliefs about how These emotions inherently involve reactions others expect them to feel also affect their to social-evaluative events or perceived vio- emotions. For example, when people feel lations of social standards (see Dickerson, sad but believe that others think they should be happy, they experience stronger negative emotions and lower subjective well-being. In fact, perceived social expectancies predict people’s subsequent emotions and well-being more consistently than—and independently of—their personal expectancies. Research
Self-Awareness and Self-Relevant Thought in Emotion 385 has shown this is the case because perceived self-aware, human beings live in an emo- social expectancies (e.g., to be happy) pro- tional world that differs greatly from that of mote negative self-evaluations in people other animals. Indeed, it is difficult to imag- when their emotions (e.g., sadness) violate ine what human subjective experience would these expectations (Bastian et al., 2012). be like without self-awareness and the inter- nal self-talk that underlies so much human Regulating Social Emotions emotion. Given the role of self-relevant thought in social emotions, another way that people Self-awareness was perhaps the pivotal can regulate their emotions is by managing psychological adaptation that put human their thoughts about what others might be beings on such a distinctly different path thinking about them. Such strategies fall than that of other animals. From the stand- into two broad categories. point of emotion, however, the capacity to think consciously about oneself is both First, people sometimes reduce undesired a blessing and a curse (Leary, 2004). Self- social emotions by reevaluating the impor- awareness and self-r elevant thought are ben- tance of other people’s impressions and eval- eficial in planning for the future in ways that uations of them. Although people tend to maximize gains and minimize losses, and react rather automatically to indications that the emotions that arise when people look others are judging them unfavorably, they forward and backward are often useful in may later decide that others’ judgments are informing judicious decisions and effective not actually important or consequential in behavior. Yet, as we have seen, people suf- a particular instance (Leary, 2006). Reduc- fer far more from temporal emotions such ing the motivation to make a desired impres- as anxiety and regret than is necessary for sion or the importance of being evaluated in successful self-r egulation. Similarly, people’s a particular way can attenuate or minimize ability to compare themselves to standards emotions such as social anxiety, embarrass- and evaluate themselves accordingly pro- ment, guilt, and hurt feelings. vides important input into their behavioral choices. But people are often distressed by Second, to the extent that unpleasant unfavorable self-evaluations even when they social emotions arise from believing that do not matter in a practical sense. Likewise, one is being viewed unfavorably, people can people could not interact successfully with reevaluate others’ likely evaluations of them. others without an ability to infer what oth- For example, people who frequently experi- ers are thinking about them, and the self- ence social anxiety can be taught that other conscious emotions that sometimes arise are people’s evaluations of them are usually not often beneficial in steering their behavior in as negative as they imagine. Similarly, peo- ways that are socially advantageous. How- ple whose feelings are easily hurt can learn ever, people are frequently more concerned that others’ seemingly hurtful actions— about others’ evaluations than they need to such as minor slights, snubs, and signs of be, resulting in unnecessary social anxiety, disinterest—are usually more benign than embarrassment, guilt, and shame that can they might first appear. sometimes interfere with effective behavior and self-r egulation. Conclusion Our focus in this chapter has been on the People obviously prefer to feel positive ways in which the human ability to self- emotions more than negative emotions, and reflect affects emotional experience and they can change how they feel by changing regulation. As we have seen, self-awareness how they think about themselves. As we have allows people to experience emotions by seen, people regulate their emotions in many comparing themselves to their personal stan- ways, including attenuating self-awareness, dards, thinking about themselves in the past predictive control, social comparison, and and future, assessing their personal charac- attributional reframing, among others. teristics, and thinking about how they are But even this hedonically desirable ability perceived by other people. By virtue of being has both good and bad effects. Minimiz- ing unwanted emotions certainly promotes subjective well-being, and managing one’s emotions often facilitates effective behavior
386 PERSONALITY PROCESSES AND INDIVIDUAL DIFFERENCES and better self-regulation. However, when ress and problems. In R. P. Abelson, E. Aron- unpleasant emotions serve an important son, W. J. McGuire, T. M. Newcomb, M. J. purpose in keeping people attuned to threats Rosenberg, & P. H. Tannenbaum (Eds.), The- to their well-being or motivating them to engage in needed behavioral change, the use ories of cognitive consistency: A sourcebook of self-talk to dampen such emotions might (pp. 5–27). Chicago: Rand McNally. be counterproductive. We hope that future Baldwin, M. W., & Baccus, J. R. (2004). Main- research will result in a better understand- taining a focus on the social goals underly- ing of the conditions under which regulating ing self-conscious emotions. Psychological emotions via self-relevant thought is benefi- Inquiry, 15, 139–144. cial rather than detrimental to people’s well- Bargh, J. A., Gollwitzer, P. M., & Lee-Chai, A. being. (2001). The automated will: Nonconscious activation and pursuit of behavioral goals. Note Journal of Personality and Social Psychology, 1. Although our focus is on the implications of 81, 1014–1027. self-awareness for emotion, we should note Bastian, B., Kuppens, P., Hornsey, M. J., Park, that affective experiences can also influence J., Koval, P., & Uchida, Y. (2012). Feeling bad the operation of self-related processes. For about being sad: The role of social expectan- example, emotions can affect people’s self- cies in amplifying negative mood. Emotion, perceptions, self-efficacy, and ability to self- 12, 69–80. regulate (DeSteno & Salovey, 1997; Leith & Baumeister, R. F. (1991). Escaping the self. New Baumeister, 1996). Emotional experiences York: Basic Books. also influence where people focus their atten- Baumeister, R. F. (1998). The self. In D. T. Gil- tion (Fredrickson & Branigan, 2005) and bert, S. T. Fiske, & G. Lindzey (Eds.), Hand- how they make decisions (Kugler, Connolly, book of social psychology (4th ed., Vol. 2, & Ordóñez, 2012). Thus, not only is self- pp. 680–740). Boston: McGraw-Hill. awareness intimately involved in the experi- Brown, C. M., & McConnell, A. R. (2011). ence and regulation of emotion, but emotions Discrepancy-based and anticipated emotions also reciprocally affect self-related attention in behavioral self-regulation. Emotion, 11, and thought. 1091–1095. Buunk, B. P., Collins, R. L., Taylor, S. E., VanY- References peren, N. W., & Dakof, G. A. (1990). The affective consequences of social comparison: Alloy, L. B., Abramson, L. Y., Hogan, M. E., Either direction has its ups and downs. Jour- Whitehouse, W. G., Rose, D. T., Robinson, nal of Personality and Social Psychology, 59, M. S., et al. (2000). The Temple–Wisconsin 1238–1249. Cognitive Vulnerability to Depression (CVD) Bryant, F. B., & Veroff, J. (2007). Savoring: A Project: Lifetime history of Axis I psychopa- new model of positive experience. Mahwah, thology in individuals at high and low cogni- NJ: Erlbaum. tive risk for depression. Journal of Abnormal Carver, C. S., Lawrence, J. W., & Scheier, M. F. Psychology, 109, 403–418. (1999). Self-d iscrepancies and affect: Incorpo- rating the role of fear selves. Personality and Abramson, L. Y., Metalsky, F. I., & Alloy, L. Social Psychology Bulletin, 25, 783–792. B. (1989). Hopelessness depression: A theory Carver, C. S., & Scheier, M. F. (1981). Atten- based subtype of depression. Psychological Review, 96, 358–372. tion and self-regulation: A control theory approach to human behavior. New York: Ahrens, A. H., & Haaga, D. A. F. (1993). The Springer-Verlag. specificity of attributional style and expec- David, D., Schnur, J., & Belloiu, A. (2002). tations to positive and negative affectivity, Another search for the “hot” cognitions: depression, and anxiety. Cognitive Therapy Appraisal, irrational beliefs, attributions, and and Research, 17, 83–98. their relation to emotion. Journal of Rational- Aronson, E. (1968). Dissonance theory: Prog- Emotive and Cognitive-Behavior Therapy, 20, 93–132. DeFronzo Dobkin, R., Allen, L. A., Alloy, L. B., Menza, M., Gara, M. A., & Panzarella, C.
Self-Awareness and Self-Relevant Thought in Emotion 387 (2007). Adaptive inferential feedback partner self-conception in primates. In J. G. Snodgrass training for depression: A pilot study. Cogni- & R. L. Thompson (Eds.), The self across psy- tive and Behavioral Practice, 14(4), 350–363. chology (pp. 78–82). New York: New York DeSteno, D. A., & Salovey, P. (1997). The effects Academy of Sciences. of mood on the structure of the self-concept. Golub, S. A., Gilbert, D. T., & Wilson, T. D. Cognition and Emotion, 11, 351–372. (2009). Anticipating one’s troubles: The costs Dickerson, S. S., Grunewald, T. L., & Kemeny, and benefits of negative expectations. Emo- M. E. (2004). When the social self is threat- tion, 9, 277–281. ened: Shame, physiology, and health. Journal Harter, S. (2012). The construction of the self: of Personality, 72, 1189–1216. A developmental perspective (2nd ed.). New Duval, S., & Wicklund, R. A. (1972). A theory of York: Guilford Press. objective self awareness. New York: Academic Hayes, S. C., Strosahl, K., & Wilson, K. G. Press. (1999). Acceptance and commitment therapy: Ellsworth, P. C., & Scherer, K. R. (2003). An experiential approach to behavior change. Appraisal processes in emotion. In R. J. David- New York: Guilford Press. son, K. R. Scherer, & H. H. Goldsmith (Eds.), Higgins, E. T. (1987). Self-d iscrepancy: A theory Handbook of affective sciences (pp. 575–595). relating self and affect. Psychological Review, New York: Oxford University Press. 94, 319–340. Ellsworth, P. C., & Smith, C. A. (1988a). From Hilt, L. M. (2004). Attribution retraining for appraisal to emotion: Differentiating among therapeutic change: Theory, practice, and unpleasant feelings. Motivation and Emotion, future directions. Imagination, Cognition and 12, 271–302. Personality, 23(4), 289–307. Emmons, R. A. (1986). Personal strivings: An Hrapczynski, K. M., Epstein, N. B., Werlinich, approach to personality and subjective well- C. A., & LaTaillade, J. J. (2012). Changes in being. Journal of Personality and Social Psy- negative attributions during couple therapy for chology, 51, 1058–1068. abusive behavior: Relations to changes in sat- Field, N. P., Joudy, R., & Hart, D. (2010). The isfaction and behavior. Journal of Marital and moderating effect of self-concept valence on Family Therapy, 38(1), 117–132. the relationship between self-focused atten- Jaynes, J. (1976). The origin of consciousness in tion and mood: An experience sampling the breakdown of the bicameral mind. Boston: study. Journal of Research in Personality, 44, Houghton-M ifflin. 70 –77. Joiner, T. E. (2001). Negative attributional style, Foa, E. B., Huppert, J. D., & Cahill, S. P. hopelessness depression and endogenous (2006). Emotional processing theory: An depression. Behaviour Therapy and Research, update. In B. O. Rothbaum (Ed.), Pathologi- 39, 139–149. Joormann, J., Siemer, M., & Gotlib, I. H. (2007). cal anxiety: Emotional processing in etiology Mood regulation in depression: Differential and treatment (pp. 3–24). New York: Guil- effects of distraction and recall of happy mem- ford Press. ories on sad mood. Journal of Abnormal Psy- Focquaert, F., Braeckman, J., & Platek, S. M. chology, 116, 484–490. (2008). An evolutionary cognitive neurosci- Kabat-Zinn, J. (2003). Mindfulness-b ased stress ence perspective on human self-awareness and reduction (MBSR). Constructivism in the theory of mind. Philosophical Psychology, 21, Human Sciences, 8, 73–107. 47– 68. Kagan, J. (1998). Is there a self in infancy? In Fredrickson, B. L., & Branigan, C. (2005). Posi- M. Ferrari & R. J. Sternberg (Eds.), Self- tive emotions broaden the scope of attention and thought–action repertoires. Cognition awareness: Its nature and development and Emotion, 19, 313–332. (pp. 137–147). New York: Guilford Press. Fromson, P. M. (2006). Self-discrepancies and Kross, E., & Ayduk, O. (2008). Facilitating negative affect: The moderating roles of pri- adaptive emotional analysis: Distinguishing vate and public self-consciousness. Social distanced-analysis of depressive experiences Behavior and Personality, 34, 333–350. from immersed-analysis and distraction. Per- Frijda, N. H. (1986). The emotions. London: sonality and Social Psychology Bulletin, 34, Cambridge University Press. 924–938. Gallup, G. G., Jr. (1997). On the rise and fall of Kugler, T., Connolly, T., & Ordóñez, L. D.
388 PERSONALITY PROCESSES AND INDIVIDUAL DIFFERENCES (2012). Emotion, decision, and risk: Betting Makkar, S. R., & Grisham, J. R. (2011). Social on gambles versus betting on people. Journal anxiety and the effects of negative self-imagery of Behavioral Decision Making, 25, 123–134. on emotion, cognition, and post-event pro- Kwang, T., & Swann, W. B. (2010). Do people cessing. Behaviour Research and Therapy, 49, embrace praise even when they feel unworthy?: 654 – 664. A review of critical tests of self-enhancement versus self-verification. Personality and Social Markus, H., & Nurius, P. (1986). Possible selves. Psychology Review, 14, 263–280. American Psychologist, 41, 954–969. Leary, M. R. (2004). The curse of the self: Self- Marshall, R. D., Bryant, R. A., Amsel, L., Suh, awareness, egotism, and the quality of human E., Cook, J. M., & Neria, Y. (2007). The life. New York: Oxford University Press. psychology of ongoing threat: Relative risk Leary, M. R. (2006). Sociometer theory and the appraisal, the September 11 attacks, and pursuit of relational value: Getting to the root terrorism-related fears. American Psycholo- of self-e steem. European Review of Social gist, 62, 304–316. Psychology, 16, 75–111. Leary, M. R., & Buttermore, N. E. (2003). Evo- Martin, L. (1999). I-D compensation the- lution of the human self: Tracing the natural ory: Some implications of trying to satisfy history of self-a wareness. Journal for the The- immediate-return needs in a delayed-return ory of Social Behaviour, 33, 365–404. culture. Psychological Inquiry, 10, 195–208. Leary, M. R., Estrada, M. J., & Allen, A. B. (2009). The analogue-I and the analogue-m e: Medvec, V. H., Madey, S. E., & Gilovich, T. The avatars of the self. Self and Identity, 8, (1995). When less is more: Counterfactual 147–161. thinking and satisfaction among Olympic Leary, M. R., Springer, C., Negel, L., Ansell, E., medalists. Journal of Personality and Social & Evans, K. (1998). The causes, phenomenol- Psychology, 69, 603–610. ogy, and consequences of hurt feelings. Jour- nal of Personality and Social Psychology, 74, Miller, R. S. (1996). Embarrassment: Poise and 1225–1237. peril in everyday life. New York: Guilford Press. Leary, M. R., Tambor, E. S., Terdal, S. K., & Downs, D. L. (1995). Self-esteem as an inter- Miranda, R., & Mennin, D. S. (2007). Cognitive personal monitor: The sociometer hypothesis. Therapy and Research, 31, 71–82. Journal of Personality and Social Psychology, Morrell, B., Jordens, C. C., Kerridge, I. H., Har- 68, 518–530. nett, P., Hobbs, K., & Mason, C. (2012). The Leith, K. P., & Baumeister, R. F. (1996). Why do perils of a vanishing cohort: A study of social bad moods increase self-d efeating behavior?: comparisons by women with advanced ovar- Emotion, risk-taking, and self-regulation. ian cancer. Psycho-Oncology, 21, 382–391. Journal of Personality and Social Psychology, Norem, J. K., & Illingworth, K. S. S. (1993). 71, 1250–1267. Strategy-dependent effects of reflecting on self Linehan, M. M. (1993). Cognitive behavioral and tasks: Some implications of optimism and treatment of borderline personality disorder. defensive pessimism. Journal of Personality New York: Guilford Press. and Social Psychology, 65, 822–835. Lockwood, P., & Kunda, Z. (1997). Superstars and me: Predicting the impact of role models Petrocelli, J. V., & Smith, E. R. (2005). Who I on the self. Journal of Personality and Social am, who we are, and why: Links between Psychology, 73, 91–103. emotions and causal attributions for self- and Lyubomirsky, S., & Ross, L. (1997). Hedonic group discrepancies. Personality and Social consequences of social comparison: A con- Psychology Bulletin, 31, 1628–1642. trast of happy and unhappy people. Journal of Personality and Social Psychology, 73, Phillips, A. G., & Silvia, P. J. (2005). Self- 1141–1157. awareness and the emotional consequences of Macrae, C. N., Bodenhausen, G. V., & Milne, self-discrepancies. Personality and Social Psy- A. B. (1998). Saying no to unwanted thoughts: chology Bulletin, 31, 703–713. Self-focus and the regulation of mental life. Phillips, A. G., & Silvia, P. J. (2010). Individual Journal of Personality and Social Psychology, differences in self-d iscrepancies and emotional 75, 578–589. experience: Do distinct discrepancies predict distinct emotions? Personality and Individual Differences, 49, 148–151. Phillips, A. G., Silvia, P. J., & Paradise, M. J. (2007). The undesired self and emotional experience: A latent variable analysis. Journal of Social and Clinical Psychology, 26, 1035– 1047.
Self-AÂ
Part VII Psychopathology
Chapter 24 Emotion Regulation in Anxiety Disorders Laura Campbell‑Sills Kristen K. Ellard David H. Barlow The relationship between emotion regula- of anxiety disorder symptoms. We contend tion (ER) and anxiety disorders has received that the use of specific ER strategies by anx- considerable attention since the publication ious individuals is best understood within of the first edition of this handbook. ER the broader context of the basic emotional features more prominently in conceptual processing that characterizes anxiety disor- accounts of anxiety disorders, and empiri- ders. The first section of the chapter there- cal investigations that focus on the intersec- fore reviews evidence supporting the view tion of ER and anxiety have increased dra- that ER in anxiety disorders derives in large matically. It is no longer justified to assert part from biological and psychological vul- that the role of emotion and ER is under- nerabilities that confer increased emotional recognized in conceptualizations and treat- reactivity, attentional biases toward threat ments for anxiety disorders. Nor is it nec- and other negative information, and global essary to rely on extrapolation of findings tendencies to experience emotions as aver- from healthy samples to posit relationships sive and to engage in avoidant processing between ER and anxiety disorders: In an and behavior. These features of anxiety dis- exciting development, we are now able to orders influence anxious individuals’ use of review behavioral and neurobiological lit- the specific ER strategies that constitute the eratures that elucidate the role of ER in the focus of the latter portion of the chapter. In development, phenomenology, and treat- discussing these strategies, we consider sev- ment of anxiety disorders. eral potential pathways to the ER difficulties reported by individuals with anxiety disor- This recent acceleration of research has ders, including overreliance on maladaptive generated an array of potentially important ER, less frequent use or compromised effec- observations regarding the relationship of tiveness of adaptive ER, and dysfunction of ER to anxiety disorders, which we aim to neural systems supporting ER. integrate in this chapter. One area of partic- ular interest is the use of specific ER strate- Defining Our Terms gies (e.g., suppression, cognitive reappraisal) Before we turn to our main topics, it will be by individuals with anxiety disorders: how useful to clarify the definitions of terms used frequently they use certain strategies, how throughout this chapter. Our definitions of successful they are at implementing them, and—most importantly—how this may relate to the development and maintenance 393
394 PSYCHOPATHOLOGY emotion and emotion regulation closely par- regions; and (2) maintenance of abilities to allel those articulated by Gross (this volume). pursue short- and long-term goals that are We consider emotions to be multimodal phe- important to the individual. Effective ER nomena that involve changes in subjective likely involves a combination of selecting experience, physiology, and action tenden- “good” strategies and being able to apply cies. Emotions occur in response to internal these methods flexibly depending on contex- or external stimuli that are meaningful to tual demands (e.g., Kashdan & Rottenberg, the organism’s survival, well-being, or other 2010). goals. In many situations, the subjective experience, physiological changes, or behav- A Conceptual Framework ioral tendencies associated with an emo- for Examining ER tion increase the chances of attaining a goal in Anxiety Disorders (e.g., sympathetic arousal and the impulse Consideration of the biological and psycho- to flee help achieve the goal of survival in logical factors that underlie anxiety disor- a life-threatening situation). However, by ders provides an important framework for definition, the emotions that characterize understanding ER in these disorders. Barlow anxiety disorders are excessive, often caus- (1988, 2002) proposed that anxiety disor- ing the individual both subjective distress (in ders emerge out of a “triple vulnerability,” the form of intense emotions, catastrophic wherein generalized biological vulnerabili- thoughts, and/or uncomfortable physical ties toward greater emotional reactivity, and sensations) and interference with adaptive a generalized psychological vulnerability functioning (e.g., when patterns of extreme arising from early developmental events that avoidance develop). engender a sense of the world as uncontrol- lable or unpredictable (hence, threatening), When using the term emotion regula- represent an etiological diathesis toward tion, we refer to processes that influence psychopathology. When combined with the occurrence, intensity, duration, and life stress and learned experiences (specific expression of emotion. These processes may vulnerabilities), symptoms associated with support up-regulation or down-regulation anxiety and related emotional disorders are of positive or negative emotions, and can likely to result. Specific diagnostic presenta- be placed on a continuum of automatic to tions (e.g., social anxiety disorder [SAD], effortful (Gross, this volume). While all panic disorder [PD]) are determined by learn- forms of ER are likely relevant to anxiety ing experiences that focus the diathesis on disorders, much of this chapter focuses on particular contexts (e.g., social evaluation, effortful down-regulation of negative emo- bodily sensations; Barlow, 2002; Suárez, tion. This choice is partly based on typical Bennett, Goldstein, & Barlow, 2009). In this anxiety disorder presentations, which are way, the DSM anxiety diagnoses represent largely characterized by excessive negative the endpoint of the convergence of the triple emotions such as fear and anxiety. It also vulnerabilities. However, at the core of each reflects the predominant focus of empiri- specific disorder lies a common tendency to cal work to date, because most research has experience intense emotions that are viewed focused on a limited number of effortful ER as threatening or unwanted, often prompt- strategies. ing efforts to diminish or avoid the aversive emotional experience (Barlow, 1988, 2002). Throughout the chapter we also refer to maladaptive and adaptive ER. By maladap- Various lines of research lend support tive we mean that an ER strategy is either to the different components of this model. unsuccessful in reducing the unwanted emo- Neurobiological findings are broadly con- tional response (as reflected by subjective sistent with the notion of a generalized bio- report, physiological arousal, behavioral logical vulnerability to increased emotional data, or brain imaging data) or associated reactivity in anxiety and related emotional with costs that likely outweigh any benefits disorders. Specific genetic polymorphisms of short-term reduction of acute emotion. have been associated with anxiety-related In contrast, “adaptive” strategies promote traits (e.g., Montag, Fiebach, Kirsch, & (1) decreased subjective distress, physiologi- cal arousal, maladaptive behavior, and/ or activation of emotion-generating brain
Emotion Regulation in Anxiety Disorders 395 Reuter, 2011) and shown to interact with reactivity, hypersensitivity to threat, and stressors to predict anxiety sensitivity (an tendencies to experience emotions as aver- established risk factor for PD; Stein, Schork, sive) likely have a considerable impact on & Gelernter, 2008) and onset of symptoms the ER of anxious individuals. These influ- of emotional disorders (e.g., Caspi et al., ences may occur at multiple points along 2003). Genetic findings have been linked to the temporal continuum of ER (see Gross, neural models of anxiety disorders, in that this volume), beginning at the earliest stages associations have been observed between when automatic processes related to atten- these polymorphisms and both activation tion and awareness are engaged. Attention of neural substrates of emotion generation and automatic responses to threat occur (e.g., Drabant et al., 2012; Munafo, Brown, within milliseconds and influence further & Hariri, 2008) and functional connectiv- information processing almost immediately ity between emotion-generating regions and (e.g., Garner, Mogg, & Bradley, 2006). As structures implicated in their inhibitory noted earlier, an extensive literature sug- control (Pezawas et al., 2005). Importantly, gests that attentional biases toward threat hyperactivation of limbic structures impli- and other negative information are key fea- cated in emotion generation (e.g., amygdala, tures of anxiety disorders (Beck & Clark, insula) coupled with reduced inhibitory cor- 1997; MacLeod et al., 1986; Olantunji & tical control of these structures has been Wolitzky-Taylor, 2009; Pineles & Mineka, found across anxiety disorders (e.g., Etkin 2005). Such biases in the early processing of & Wager, 2007; Shin & Liberzon, 2010). emotional stimuli may provoke a range of subsequent responses, including behavioral Empirical support for a generalized psy- efforts to dampen responding (e.g., gaze chological vulnerability to anxiety disorders aversion; Garner et al., 2006) and attempts is also evident. Anxious individuals con- to escape threatening information via cog- sistently display attentional biases toward nitive control (e.g., Leutgeb, Schäfer, & negative or threatening cues, as well as dif- Schienle, 2009; Paquette et al., 2003). ficulty disengaging from negative stimuli (Beck & Clark, 1997; MacLeod, Mathews, According to the “hypervigilance– & Tata, 1986; Olantunji & Wolitzky-T aylor, avoidance” model, the early attentional 2009; Pineles & Mineka, 2005). These cog- biases toward threat that characterize anxi- nitive biases toward negative information ety disorders are paradoxically followed have been shown to predict elevated anxi- by reduced processing of threat (e.g., via ety symptoms in response to stress (e.g., cognitive avoidance) and increased avoid- MacLeod & Hagan, 1992; van den Hout, ant responding. This model converges with Tenney, Huygens, Merckelbach, & Kindt, behavioral and neuroimaging findings (e.g., 1995). Additionally, traits reflecting dimin- Bishop, Duncan, Brett, & Lawrence, 2004; ished tolerance for distress, physical sensa- Koster, Crombez, Verschuere, Van Damme, tions, and other types of discomfort (e.g., & Wiersema, 2006; see Hofmann, Ellard, uncertainty) are associated with a range & Siegle, 2012, for a review), and with the of anxiety and mood disorders (Boswell, clinical consensus that cognitive and behav- Thompson-H olland, Farchione, & Barlow, ioral avoidance are integral to the psycho- 2013; Keough, Riccardi, Timpano, Mitch- pathology of anxiety disorders. Examples ell, & Schmidt, 2010; McEvoy & Mahoney, from clinical observation include avoid- 2012; Olatunji & Wolitzky-Taylor, 2009) ance of situational and interoceptive (i.e., and in some cases have been shown to pre- bodily sensation) cues in PD; avoidance of dict onset of anxiety disorders following eye contact and social interactions in SAD; stress (Schmidt, Lerew, & Jackson, 1999) or avoidance of contamination through wash- to mediate change in anxiety symptoms over ing, doubting thoughts through checking, or time (Dugas, Laugesen, & Bukowski, 2012). intrusive images through repetitive phrases in obsessive–compulsive disorder (OCD); Implications for Emotion Regulation avoidance of trauma reminders in posttrau- in Anxiety Disorders matic stress disorder (PTSD); and avoidance The underlying features of anxiety disorders of anxious arousal and uncertainty through described earlier (i.e., heightened emotional worry and reassurance seeking in general- ized anxiety disorder (GAD).
396 PSYCHOPATHOLOGY Tendencies toward cognitive and behav- anxiety disorders (Barlow, 1988; Brown, ioral avoidance likely have broad impacts on Barlow, & Liebowitz, 1994). Thus, findings anxious individuals’ ER. Available evidence related to emotion dysregulation in GAD suggests that engagement with emotion- may reflect processes found in anxiety dis- ally salient stimuli generally promotes more orders more generally. effective ER than avoidance or disengage- ment. For instance, a study that employed In support of this view, several analogous eye-tracking demonstrated that regardless of findings emerge when considering emotional the specific ER strategy used (cognitive reap- experience and ER across specific anxiety praisal or suppression), subjects who focused disorders. For instance, decreased emotional visual attention more on the emotionally clarity has been associated with symptoms salient aspects of a stimulus were more likely of GAD, PD, PTSD, and SAD (Baker, Hol- to regulate emotions successfully (Bebko, loway, Thomas, Thomas, & Owens, 2004; Franconeri, Ochsner, & Chiao, 2011). In McLaughlin et al., 2007; Tull & Roemer, addition, simply labeling emotions (which 2007; Weiss et al., 2012). Decreased accep- involves awareness and acknowledgment tance of emotions has been found in GAD, of emotions) has been shown to reduce dis- PD, and PTSD (McLaughlin et al., 2007; tress as effectively as “active” ER strategies Tull & Roemer, 2007; Weiss et al., 2012), such as cognitive reappraisal and distraction and in one study individuals with SAD were (Lieberman, Inagaki, Tabibnia, & Crockett, not clearly differentiated from individuals 2011). Anxious subjects’ tendencies to avoid with GAD on this variable (Mennin et al., deeper processing of emotional stimuli may 2009). Individuals with symptoms of PTSD preclude them from experiencing the ben- (e.g., Ehring & Quack, 2010; Weiss et al., efits of engagement-oriented responses to 2012), GAD (Mennin et al., 2005, 2009; emotional stimuli. Salters-Pedneault et al., 2006), and SAD (Mennin et al., 2009; Turk et al., 2005) also Relationship of Anxiety Disorders endorse difficulties with repairing negative to ER: General or Specific? mood and accessing effective ER strategies Thus far we have discussed anxiety as a when distressed (these dimensions of ER global trait, without distinguishing among were not assessed in available studies of PD). the anxiety disorders (cf. Barlow, Sauer- Zavala, Carl, Bullis, & Ellard, 2013). As Recent meta-analytic work also supports we move toward discussion of specific ER the view that maladaptive ER represents strategies, we will for the most part continue a transdiagnostic feature of anxiety and to refer to anxiety disorders collectively. We related emotional disorders. An analysis of should, however, note that there has been 114 studies suggested comparable relation- particular interest in the relationship of ships of ER strategies to anxiety and mood ER to GAD (e.g., McLaughlin, Mennin, & disorder symptoms, which tended to display Farach, 2007; Mennin, Heimberg, Turk, & stronger relationships to ER than did eat- Fresco, 2005; Mennin, McLaughlin, & Fla- ing and substance use disorder symptoms nagan, 2009; Salters-Pedneault, Roemer, (Aldao, Nolen-Hoeksema, & Schweizer, Tull, Rucker, & Mennin, 2006; Turk, Heim- 2010). Avoidance, rumination, and suppres- berg, Luterek, Mennin, & Fresco, 2005). The sion were positively related to anxiety and emotion dysregulation model of GAD posits depression, whereas problem solving and that this disorder results from a convergence cognitive reappraisal were negatively associ- of high levels of emotional reactivity and ated with both types of symptoms (though intensity, dysfunctional meta-emotion (e.g., the reappraisal–anxiety relationship was decreased clarity and understanding of emo- only marginally significant, it was similar tions), and maladaptive efforts to regulate in magnitude to the reappraisal–depression emotions (Mennin et al., 2005; Mennin & relationship). Another investigation found Fresco, this volume). GAD has been con- that a latent “cognitive ER” factor (defined ceptualized as the “basic” anxiety disorder by cognitive reappraisal, problem solving, given that its defining features (e.g., anxious suppression, and rumination) was signifi- apprehension) reflect processes that contrib- cantly associated with symptoms of three ute to the manifestation of symptoms in all classes of disorder: anxiety, mood, and eat- ing disorders (Aldao & Nolen-Hoeksema, 2010). The strongest association of the cog- nitive ER factor was with depressive symp-
Emotion Regulation in Anxiety Disorders 397 toms, followed by anxiety symptoms, then Suppression eating symptoms. Suppression is a response-Âf
398 PSYCHOPATHOLOGY beneficial under certain circumstances. For Acceptance example, suppression after exposure to Acceptance entails allowing oneself to traumatic scenes was shown to reduce both experience emotions without attempting to subjective distress during exposure and later alter or suppress them. Acceptance-based intrusions (Dunn, Billotti, Murphy, & Dal- interventions promote accepting attitudes gleish, 2009). It may not be the engagement toward emotions (e.g., emotions have a nat- of suppression per se, but the rigid or habit- ural trajectory and will dissipate if allowed ual use of this ER strategy, that is maladap- to run their course) and explicitly discour- tive (cf. Bonanno, Papa, Lalande, Westphal, age suppression. The concept of acceptance & Coifman, 2004). shares features with the concept of mind- fulness, which promotes nonjudgmental, Cognitive Reappraisal present-moment awareness of emotions and Cognitive reappraisal entails thinking about other internal experiences. Acceptance and stimuli in a way that diminishes the inten- mindfulness are intended to increase sub- sity of emotions. For example, while view- jects’ awareness of their emotions (including ing mourners at a funeral, a person using habitual impulses to suppress or avoid dis- cognitive reappraisal might think that the comfort), which may provide them greater deceased person is at peace and that the opportunity to respond to emotions adap- mourners will recover with time. This strat- tively (Roemer, Orsillo, & Salters-Pedneault, egy is conceptualized as an antecedent- 2008; Hill & Updegraff, 2012). focused strategy (i.e., one that is deployed before the full-scale emotional response has Experimental studies of healthy and anx- occurred; Gross, this volume). Use of cogni- ious samples have shown that instructions to tive reappraisal to manage negative emotions accept emotions are associated with reduc- is associated with a range of beneficial effects tions in subjective distress and behavioral in healthy subjects. These include reduced avoidance (Eifert & Heffner, 2003; Levitt et intensity of the subjective experience of emo- al., 2004; Wolgast et al., 2011). For exam- tion (Bebko et al., 2011; Gross, 1998; Hof- ple, studies employing carbon dioxide chal- mann, Heering, Sawyer, & Asnaani, 2009), lenges have shown that anxious subjects who reduced expressive behavior (Gross, 1998), accepted emotions reported less intense fear, attenuation of startle (Jackson, Malmstadt, fewer catastrophic thoughts, and greater Larson, & Davidson, 2000), enhanced para- willingness to complete another biological sympathetic tone (Aldao & Mennin, 2012), challenge when compared to subjects who reduced behavioral avoidance (Wolgast, either suppressed emotions or received no Lundh, & Viborg, 2011), and reduced amyg- instructions (Eifert & Heffner, 2003; Levitt dala activation (e.g., Goldin et al., 2008; et al., 2004). Another study of a mixed anxi- Ochsner, Bunge, Gross, & Gabrieli, 2002; ety and mood disorder sample showed that, Ochsner, Ray, et al., 2004). compared to suppression, engaging in accep- tance resulted in reduced heart rate during Several of these outcomes have not been emotion-provoking films and faster recovery measured in studies of cognitive reappraisal of subjective distress (Campbell-Sills et al., that included anxious subjects. However, the 2006a). most frequently reported benefit of cognitive reappraisal—r educed intensity of the subjec- Summary tive experience of emotion—has been dem- Results of experiments instructing subjects onstrated in individuals high in trait anxiety to use specific ER strategies support the view (Campbell-S ills et al., 2011) and in subjects that reappraisal and acceptance are generally diagnosed with anxiety disorders (Aldao & adaptive strategies, whereas suppression is Mennin, 2012; Ball, Ramsawh, Campbell- adaptive under a more restricted range of cir- Sills, Paulus, & Stein, 2012). Available evi- cumstances (and can often be maladaptive). dence suggests divergent effects of cognitive The available literature (though still limited) reappraisal on the physiological responses suggests that, like healthy subjects, individ- and brain function of anxious and nonanx- uals with anxiety disorders derive benefits ious individuals; these findings are discussed from cognitive reappraisal and acceptance in detail below (“Pathways to Ineffective ER (e.g., reduced subjective distress) and experi- in Anxiety Disorders”).
Emotion Regulation in Anxiety Disorders 399 ence detrimental effects of suppression (e.g., Gross & John, 2003). In contrast, habitual increased physiological arousal). use of suppression is related to lower levels of overall positive affect and well-being; Pathways to Ineffective ER higher levels of overall negative affect; in Anxiety Disorders poorer interpersonal functioning; and more Individuals with anxiety disorders report symptoms of anxiety, mood, and eating dis- wide-ranging difficulties related to emo- orders (Aldao & Nolen-H oeksema, 2010; tional experience and ER (Baker et al., 2004; Aldao et al., 2010; Gross & John, 2003). Ehring & Quack, 2010; McLaughlin et al., Though effects of habitual use of acceptance 2007; Mennin et al., 2005, 2009; Salters- have not been investigated, habitual mind- Pedneault et al., 2006; Tull & Roemer, fulness has been associated with lower lev- 2007; Turk et al., 2005; Weiss et al., 2012). els of daily anxiety and depression, reduced Consideration of the literature focused on emotional reactivity to laboratory stressors, specific ER strategies such as suppression, improved abilities to differentiate emotions, cognitive reappraisal, and acceptance raises decreased emotional lability, and fewer self- a number of possible explanations for these reported ER difficulties (Arch & Craske, ER difficulties. In this section, we consider 2010; Hill & Updegraff, 2012). the following potential pathways to ineffec- tive ER in anxiety disorders: When selecting strategies to regulate emo- 1. Strategy selection. Anxious individuals tional experiences, there is evidence that individuals with anxiety disorders rely more might select maladaptive strategies more on maladaptive strategies, such as suppres- often, or adaptive strategies less often, sion, and less on adaptive strategies, such than nonanxious individuals. as reappraisal and acceptance. For instance, 2. ER ability. Anxious individuals may be studies using both survey-based and experi- less competent in applying ER strategies. mental methods have found that individuals 3. Divergent effects of ER strategies. The with anxiety disorders utilize suppression same ER strategy, applied with a similar more than do nonanxious individuals (Baker level of competence, may have different et al., 2004; Campbell-Sills et al., 2006a; effects for individuals with and without Levitt et al., 2004; Ball et al., 2012). With anxiety disorders. regard to adaptive strategy use, subjects 4. Neurobiological differences. Function- with GAD have been found to endorse less ing of neural substrates supporting spe- frequent use of cognitive reappraisal (Ball et cific ER strategies may be compromised al., 2012) and acceptance (Salters-Pedneault in anxious individuals. et al., 2006). Children and adolescents diag- nosed with anxiety disorders also report Strategy Selection less frequent use of reappraisal in everyday Neurobiology, temperament, learning his- life than do nonanxious subjects (Carthy, tory, and other factors likely interact to Horesh, Apter, Edge, & Gross, 2010). determine individual differences in propensi- ties to use specific ER strategies (e.g., see, in A critical issue related to ER strategy this volume, John & Eng; Rothbart, Sheese, selection in anxiety disorders is the role of & Posner; and Thompson). Consistent with emotional intensity. Empirical work has now experimental results, questionnaire studies shown that for healthy controls, ER strategy suggest that habitual use of reappraisal to preference depends on situation intensity. manage emotions is associated with a range Engagement of reappraisal is preferred in of positive outcomes, including higher lev- lower intensity situations, whereas disen- els of overall positive affect and well-being, gagement/distraction is preferred in higher lower levels of overall negative affect, better intensity situations (Sheppes, Scheibe, Suri, interpersonal functioning, and fewer symp- & Gross, 2011). Due to differences in base- toms of anxiety and mood disorders (Aldao line emotional state, emotional reactivity, & Nolen-H oeksema, 2010; Aldao et al., and attentional biases, the same situation 2010; Eftekhari, Zoellner, & Vigil, 2009; may be significantly more intense for anx- ious than for nonanxious individuals. The more intense emotions elicited by the situa- tion may in turn create different conditions for selection of ER strategies; for instance, facilitating a disengagement-oriented strat-
400 PSYCHOPATHOLOGY egy (e.g., suppression) in a situation where Another factor relevant to ER strategy the lower intensity emotions of healthy selection is subjects’ “meta-experience” of individuals would prompt an engagement- emotion, which includes dimensions such oriented strategy (e.g., cognitive reappraisal). as attitudes toward emotions, understand- ing of emotions, emotional clarity, and A variety of other factors may contribute acceptability of emotions. As noted earlier, to the observed differences between anxious individuals with anxiety disorders exhibit and nonanxious subjects in the selection of higher levels of traits reflecting diminished ER strategies. With respect to reappraisal, tolerance for emotional distress and other an expanded awareness is necessary to allow types of discomfort, as well as decreased for the processing of alternative interpreta- clarity and acceptability of emotions. While tions. The narrowed attention fostered by studies directly examining the relationships attentional biases associated with anxiety between meta-experiences of emotion and disorders may preclude processing of alter- selection of ER strategies have been sparse, nate stimulus meanings, a necessary compo- one study using a mixed anxiety and mood nent of successful reappraisal. Similarly, the disorder sample showed that less accepting propensity toward hypervigilance followed attitudes toward current emotions mediated by avoidant processing may preclude engage- the relationship between negative emotion ment of mindfulness and acceptance, both intensity and spontaneous use of suppression of which require openness toward all experi- (Campbell-Sills et al., 2006a). Thus, more ence, including that which is uncomfortable. intense negative emotion prompted subjects By contrast, suppression and behavioral to engage in suppression only when the emo- avoidance naturally emanate from avoid- tions were experienced as less acceptable. ant processing, and may therefore be more This finding suggests that meta-experience readily recruited by individuals with anxiety of emotion may influence strategy selection disorders. in individuals with anxiety disorders. ER strategy selection also may relate to ER Ability individual differences in abilities to use Individual differences in abilities to imple- executive control to mitigate the impact of ment ER strategies undoubtedly exist emotional stimuli. Recent work suggests and may be relevant to the ER difficulties that individuals who habitually use cogni- reported by anxious subjects. However, tive reappraisal may have an enhanced abil- very few studies have evaluated the levels ity to use executive control in the service of competence that subjects have in apply- of regulating emotions (Cohen, Henik, & ing specific ER strategies. This research aim Moyal, 2012; Gyurak, Goodkind, Kramer, requires methods for assessing the quality Miller, & Levenson, 2012). By contrast, of the process by which individuals engage individuals with anxiety disorders may have in ER strategies. One exception is Carthy et compromised abilities in this regard. This al.’s (2010) analysis of cognitive reappraisal view is consistent with findings of neuro- abilities demonstrated by children with and imaging studies (discussed in more detail without anxiety disorders during a labora- below) that show reduced prefrontal cortex tory ER task. In this study, subjects recited (PFC) activation in individuals with anxi- their reappraisals out loud during the task ety disorders using reappraisal to regulate (which utilized negative images) and their emotions (Goldin, Manber-Ball, Werner, responses were coded as reappraisal suc- Heimberg, & Gross, 2009; Goldin, Manber, cesses or failures. While children with anxi- Hakimi, Canli, & Gross, 2009; Ball et al., ety disorders were able to reappraise the 2012; New et al., 2009), and the observa- majority of stimuli successfully (87%), they tion that nonclinical, anxiety-prone subjects demonstrated slightly but significantly lower require greater PFC resources than healthy reappraisal abilities than healthy controls controls to down-regulate negative emo- (93%). One other study reported on the pro- tions with reappraisal (Campbell-S ills et al., cess of training subjects to use reappraisal to 2011). Diminished abilities to recruit execu- down-regulate emotions elicited by negative tive control networks early in the processing images (Campbell-S ills et al., 2011). Anxious of emotional stimuli could also lead to over- and healthy control groups did not differ in reliance on suppression (a strategy deployed later in the temporal continuum of ER) to manage negative emotions.
Emotion Regulation in Anxiety Disorders 401 their need for extra training in reappraisal individuals. In this study, subjects with prior to performing the experimental task. GAD and healthy controls were assigned More work is needed to elucidate whether to cognitive reappraisal, acceptance, or there are important differences in abilities passive viewing conditions (Aldao & Men- of anxious and nonanxious individuals to nin, 2012). Their subjective experience and apply cognitive reappraisal and other ER heart rate variability (HRV) were measured strategies. while they viewed films that elicited anxi- ety, sadness, and disgust. HRV, an index Divergent Effects of ER Strategies of parasympathetic influence on the heart, Even when the same ER strategy is selected reflects the capacity of the autonomic ner- and applied with a similar level of compe- vous system to respond adaptively to chang- tence, its effects may vary for anxious and ing environmental conditions. HRV tends nonanxious individuals. In particular, the to decrease under conditions of threat and beneficial effects of adaptive strategies could to increase under conditions of flexible and be attenuated, or the negative effects of mal- adaptive regulation (Friedman, 2007). adaptive strategies could be amplified, lead- ing to greater ER difficulties in individuals Results revealed that subjects who used with anxiety disorders. cognitive reappraisal reported lower subjec- tive negative affect in response to the films Two studies suggest that the costs of sup- compared to subjects who used acceptance pression may be higher for anxious individu- or who engaged in passive viewing (which als. In one study, the effects of suppression did not differ). This pattern was consistent and no instructions were compared in sub- across the GAD and healthy control groups. jects high and low in trait negative affect With respect to physiological effects, sub- (a trait strongly associated with anxiety jects with GAD displayed significantly and mood disorders; Barlow, 2002; Brown lower HRV than healthy controls across & Barlow, 2009). Individuals with high all film types and regulation conditions. negative affect who engaged in suppression These findings were consistent with previ- showed a paradoxical increase in negative ous reports of low parasympathetic tone emotions when writing about a negative in GAD (Thayer, Friedman, & Borkovec, personal memory, whereas those with low 1996). Moreover, during recovery from anx- negative affect did not (Dalgleish, Yiend, iety- and disgust-provoking films, subjects Schweizer, & Dunn, 2009). Another study with GAD showed an HRV pattern that was found that instructions to suppress emo- opposite to that displayed by healthy con- tions were associated with increased subjec- trols. Healthy subjects who used reappraisal tive distress in subjects with elevated scores and acceptance showed higher HRV than on a measure of experiential avoidance (a those who had received no instructions, trait also associated with anxiety disorders; suggesting enhanced parasympathetic tone Feldner, Zvolensky, Eifert, & Spira, 2003). with adaptive ER. In contrast, subjects with The increased sympathetic arousal found GAD who used reappraisal and acceptance to accompany suppression may render this showed lower HRV than those who received strategy particularly ineffective for anxiety- no instructions. This pattern of parasym- prone individuals, who are sensitive to and pathetic response may indicate diminished often fear physical symptoms. efficacy of reappraisal and acceptance in GAD that is only observed at the physiologi- Research suggests that under controlled cal level. experimental conditions (i.e., when sub- jects are trained to reappraise standard- Aldao and Mennin’s (2012) HRV find- ized emotional stimuli), anxious subjects ings converge with those of another study of can achieve reductions in subjective distress reappraisal in healthy individuals classified that are comparable to those observed in as high or low on neuroticism, a personality healthy subjects (Campbell-Sills et al., 2011; trait strongly related to anxiety and mood Ball et al., 2012). However, another recent disorders (e.g., Brown, Chorpita, & Barlow, study suggests that even when the subjec- 1998; Barlow et al., 2013; Wilamowska et tive outcomes of cognitive reappraisal are al., 2010). In this study (Di Simplicio et al., equivalent, the physiological benefits of this 2012), “low neuroticism” subjects showed strategy may be compromised for anxious the expected pattern of higher HRV when regulating emotions (vs. maintaining emo-
402 PSYCHOPATHOLOGY tions), while “high neuroticism” subjects same training. However, the subjects with showed no significant difference in HRV GAD and PD displayed decreased dorsome- across the two conditions. These results sig- dial and dorsolateral PFC activation while nify low parasympathetic tone in the high implementing this strategy. Moreover, PFC neuroticism group, as well as reduced physi- activation during reappraisal was inversely ological benefits of cognitive reappraisal for related to anxiety severity (e.g., subjects with anxiety-prone individuals. the highest levels of anxiety severity dis- played the lowest levels of left dorsolateral Finally, a recent ecological study of anx- PFC activation), providing additional evi- ious and healthy children found differences dence of a significant relationship between in the efficacy of ER strategies that were anxiety and PFC function during ER. related to anxiety disorder status (Tan et al., 2012). This study assessed emotional reac- Functional abnormalities also were tions to negative events in the past hour, use observed when subjects with SAD were of ER strategies (distraction, reappraisal, instructed to use cognitive reappraisal to problem solving, acceptance, avoidance, and reduce emotions elicited by personally rel- rumination), and current emotional experi- evant statements (Goldin, Manber-Ball, ence. Interestingly, children with anxiety et al., 2009). In this study, potentiated disorders endorsed using the various ER responses in regions such as the medial PFC strategies with the same frequency as non- and amygdala delayed normal cognitive pro- anxious youth. Examination of strategy use cessing in the dorsolateral PFC, which only in relation to peak and current emotional occurred after a temporal lag relative to that intensity ratings revealed that some adaptive in healthy controls. One possible interpreta- strategies (e.g., reappraisal) were equally tion of this pattern is that anxious individu- effective in down-regulating subjective dis- als must overcome an initial increased aver- tress in children with and without anxiety sive response (reflected in medial PFC and disorders. However, the data suggested that amygdala hyperactivity) before implement- acceptance was only effective for decreasing ing reappraisal (reflected in delayed dorso- subjective distress in nonanxious children. lateral PFC processing). Neurobiological Differences Dysfunction of neural circuitry support- Another factor that may contribute to inef- ing cognitive reappraisal (and other forms of fective ER in anxiety disorders is dysfunc- ER) may be context dependent. In particu- tion of neural systems supporting ER. The lar, dysfunction may be exacerbated in the majority of research on this topic has focused presence of emotional cues that represent the on cognitive reappraisal, and these studies focus of the individual’s anxiety disorder. A have revealed several potentially important study of individuals with SAD found differ- neural correlates of anxious subjects’ use of ences in neural activation that were related this strategy. to stimulus type (Goldin, Manber, et al., 2009). When regulating responses to images One pattern that has now been observed depicting physical threat, no differences in participants diagnosed with several dis- emerged between subjects with SAD and tinct anxiety disorders (GAD, SAD, PD, healthy controls. However, when regulating and PTSD) is hypoactivation of PFC regions reactions to social threat, subjects with SAD implicated in “top-down” control of emo- displayed reduced activation in brain regions tions during reappraisal of emotional stim- implicated in cognitive control (dorsolat- uli (Ball et al., 2012; Goldin, Manber, et al., eral PFC, dorsal anterior cingulate cortex), 2009; Goldin, Manber-Ball, et al., 2009; visual attention (medial cuneus, posterior New et al., 2009). This suggests that less cingulate), attention (bilateral dorsal pari- robust engagement of PFC may contribute etal), and visual feature detection (bilateral to ER difficulties across anxiety disorders. fusiform, superior temporal gyrus). These One recent study (Ball et al., 2012) showed findings suggest that in SAD the coordina- that subjects with GAD and PD who were tion of cognitive control circuitry may be trained to use cognitive reappraisal achieved selectively compromised during the regula- similar reductions in subjective distress com- tion of social threat. pared to healthy controls who received the Few neuroimaging studies have exam- ined anxious subjects’ use of ER strategies
Emotion Regulation in Anxiety Disorders 403 other than reappraisal. An exception, a finding is intriguing given the consistent recent investigation of subjects with GAD, implication of dorsolateral PFC in down- compared the effects of acceptance, sup- regulation of negative emotions via cogni- pression, and worry on subjective and neu- tive reappraisal (e.g., Goldin et al., 2008; ral responses to personally relevant worry Ochsner et al., 2002; Ochsner, Ray, et al., statements (Ellard, 2012). Both acceptance 2004). The greater amygdala–dorsolateral and suppression were associated with less PFC coupling in GAD may represent a com- subjective distress and amygdala activation pensatory mechanism that functions as an than worry. However, engagement of PFC attempt to dampen emotional responding structures to meet these regulatory goals through cognitive control (cf. Borkovec, differed for the two conditions. Suppression Alcaine, & Behar, 2004). Such a compen- was associated with increased activation satory mechanism may in fact be counter- of insula and of right lateral PFC regions productive for anxious individuals given the implicated in working memory and the gen- observation that worry is associated with eration of inner speech, which suggested increased amygdala activation in subjects paradoxically greater engagement of brain with GAD (Ellard, 2012). regions implicated in somatic and linguistic representations of emotional stimuli. On the Finally, it should be noted that more other hand, acceptance was associated with complex and fine-grained analyses are reduced insula activation and greater left needed to further elucidate the neural bases dorsomedial PFC activation. The dorsome- of ER difficulties in anxiety disorders. A dial PFC has been implicated in representa- recent pathway mapping analysis identified tions of meta-states of self-awareness, such subcortical regions that mediated the rela- as making inferences about moment-to- tionship between PFC activation and reap- moment feelings (Ochsner, Knierim, et al., praisal success in healthy subjects (Wager, 2004), intentions for action (Lau, Rogers, Davidson, Hughes, Lindquist, & Ochsner, Haggard, & Passingham, 2004), and tacti- 2008). Two distinct pathways—o ne through cal response selection (Matsuzaka, Akiya- the amygdala (associated with reduced maa, Tanjib, & Mushiake, 2012). Addition- reappraisal success) and one through the ally, left lateralization of PFC activation has nucleus accumbens and ventral striatum been associated with approach motivation, (associated with greater reappraisal suc- whereas right lateralized activation has been cess)—were identified. This implies that associated with avoidance (Speilberg et al., successful reappraisal may involve both the 2011). Importantly, acceptance also engaged dampening of amygdala responses by the ventromedial PFC regions implicated in PFC and an increase in nucleus accumbens/ extinction learning, which may relate to ventral striatum activation, which may behavioral data suggesting greater willing- facilitate approach toward the emotion- ness to reengage with aversive stimuli fol- provoking stimulus. Extrapolating to the lowing acceptance (Eifert & Heffner, 2003; case of ER in anxiety disorders, these Levitt et al., 2004). results raise the possibility that dysfunction may extend beyond regions implicated in Studies of functional connectivity mea- cognition and emotion to include regions sured during resting states also contribute implicated in processing sensory informa- to our understanding of ER in anxiety dis- tion and choosing an adaptive behavioral orders. Deviations in functional connectiv- response. Specifically, ER difficulties across ity between subregions of the amygdala and anxiety disorders may be characterized by a broad network of somatosensory asso- not only deficits in cortical control of affec- ciation cortices, motor regions, memory tive responses but also a failure to bring regions, and regions associated with self- appropriate approach- and reward-related referential processing have been observed behaviors online (e.g., Etkin, Prater, Hoeft, in individuals with GAD (Etkin, Prater, Menon, & Schatzberg, 2010). These find- Schatzberg, Menon, & Greicius, 2009). ings also suggest that cortical control of Increased amygdala–dorsolateral PFC con- limbic responses represents only one aspect nectivity was also found in patients with of widespread processing necessary in order GAD, whereas no such functional connec- to achieve regulatory goals through reap- tivity was found in healthy controls. This praisal.
404 PSYCHOPATHOLOGY Summary Although the reviewed associations between The available evidence suggests that the ER strategies and anxiety disorders are com- problems with ER reported by individuals pelling, it is not possible to ascertain causal with anxiety disorders may be partly due to relationships due to the cross-sectional strategy selection, because anxious individu- nature of virtually all available studies. For als appear to select the maladaptive strategy instance, the findings that anxious subjects of suppression more frequently and adap- use suppression more than healthy controls tive strategies such as cognitive reappraisal could be explained by habitual suppression and acceptance less frequently. This may be being a risk factor for anxiety disorders. attributable to the more intense emotions However, it is also plausible that the intense experienced by anxiety-prone individuals or emotions that characterize anxiety disorders to their more negative meta-experiences of could overwhelm the subject to the extent emotions, both of which may favor avoid- that more cognitively demanding ER strate- ant and less cognitively demanding methods gies (e.g., reappraisal) are less available and for regulating emotions (e.g., suppression). suppression becomes the chosen strategy by Biases against use of reappraisal may relate default. to diminished abilities of anxious individu- als to use executive control to modulate emo- Fortunately, two recent longitudinal stud- tions, or to narrowed (i.e., threat-focused) ies provide data that permit discrimination attention that does not allow for process- between the “risk” and “epiphenomenon” ing of alternative appraisals. Overreliance hypotheses. The data so far suggest that use on suppression may be particularly costly of maladaptive ER conveys risk for psycho- for anxious individuals given evidence that pathology. In a prospective study of ado- they are more susceptible to paradoxical lescents, structural equation modeling was increases in distress when using suppression used to evaluate the relationship between to manage emotions. ER (a latent factor defined by indicators of emotional understanding, dysregulated More research is needed to determine expression of sadness and anger, and rumi- whether individuals with anxiety disorders native responses to distress) and symptoms are less competent in applying adaptive of anxiety, depression, aggression, and eat- strategies (e.g., cognitive reappraisal) once ing pathology (McLaughlin, Hatzenbuehler, they have been prompted to use them. Avail- Mennin, & Nolen-H oeksema, 2011). Ado- able evidence suggests that when trained to lescents were assessed at baseline and again use reappraisal, anxious and nonanxious seven months later. Analyses showed that subjects achieve similar reductions in subjec- after researchers controlled for baseline tive distress. However, reappraisal may be symptoms, poor ER at baseline predicted less effective in promoting enhanced para- increased symptoms of anxiety, aggression, sympathetic tone in anxious individuals. and eating pathology (but not depression) The growing neuroimaging literature on ER measured 7 months later. Importantly, psy- and anxiety disorders further suggests a fail- chopathology symptoms measured at base- ure to recruit PFC effectively and efficiently line did not predict worse ER at the follow- during cognitive reappraisal. Dysfunction u p. of neural substrates of ER likely constitutes another basis of the regulatory difficulties A large (N > 1,000), prospective, reported by individuals with anxiety disor- community-based study also investigated ders. the relationship between use of adaptive and maladaptive ER strategies and psychopa- Maladaptive ER: thology (Aldao & Nolen-Hoeksema, 2012). Risk Factor or Epiphenomenon Composite ER scores were used, such that of Anxiety Disorders? maladaptive ER reflected use of behavioral An important issue we have yet to address disengagement, denial, suppression, and the is the directionality of relationships “brooding” facet of rumination, and adap- between anxiety- and ER-related constructs. tive ER reflected use of positive reframing (similar to reappraisal) and acceptance. The overall index of psychopathology that was used included anxiety symptoms, depres- sive symptoms, and alcohol use. Regression
Emotion Regulation in Anxiety Disorders 405 analyses controlling for baseline symptoms Abela, & Ringo Ho, 2007). Highly neurotic showed that self-reported use of maladap- individuals with low levels of emotional tive strategies at baseline predicted global repair endorsed increased engagement in psychopathology 1 year later. The authors risky behaviors following increases in anxi- noted that the same results emerged when ety and depression symptoms. In contrast, only internalizing symptoms (depression highly neurotic individuals who endorsed and anxiety) were considered, though results high levels of emotional repair displayed pertaining to anxiety symptoms alone were decreased engagement in risky behaviors fol- not reported. Although measurement of anx- lowing increases in anxiety and depression. iety was not optimal in this study (composite These results suggest that adaptive ER may of a single clinician rating and questionnaire curtail emotional responses that could lead that mainly assesses autonomic arousal), the to clinical worsening or complications. results contribute to the evidence that use of maladaptive strategies is not simply an epi- Cross-sectional evidence also suggests phenomenon or consequence of anxiety dis- that adaptive ER strategies may have a pal- orders or other psychopathology. liative effect on anxiety disorder symptoms. For example, a study of male veterans with If overreliance on maladaptive ER strate- PTSD found that the combination of higher gies constitutes a risk factor for anxiety and levels of emotional clarity and more fre- related emotional disorders, it is plausible quent use of cognitive reappraisal was asso- that habitual use of adaptive strategies could ciated with lower overall PTSD severity and impart resilience to psychopathology. How- greater positive affect (Boden, Bonn-M iller, ever, the only available longitudinal data Kashdan, Alvarez, & Gross, 2012). Another do not support this hypothesis. In Aldao study showed that trauma-exposed under- and Nolen-Hoeksema’s (2012) longitudinal graduates with “probable PTSD” endorsed study, self-reported use of adaptive strategies greater difficulties related to ER such as (cognitive reappraisal and acceptance) at decreased emotional acceptance and diffi- baseline did not significantly predict psycho- culties engaging in goal-directed behavior, pathology symptoms 1 year later. Nor did controlling impulsive behavior, and access- the interaction of adaptive and maladaptive ing adaptive ER strategies when distressed. strategies at baseline predict psychopathol- In contrast, trauma-exposed subjects with- ogy at follow-u p. The lack of a significant out PTSD had fewer difficulties controlling longitudinal relationship between adaptive impulsive behaviors and greater access to ER and psychopathology converges with adaptive ER strategies when distressed (rela- cross-sectional research showing that mal- tive to both trauma-exposed subjects with adaptive strategies have stronger associations probable PTSD and those without trauma with symptoms of anxiety and mood disor- exposure; Weiss et al., 2012). Aldao and ders than adaptive strategies (e.g., Aldao & Nolen-Hoeksema (2012) also reported a Nolen-Hoeksema, 2010; Aldao et al., 2010; significant interaction effect of adaptive and Moore, Zoellner, & Mollenholt, 2008). For maladaptive ER strategies on psychopathol- example, a cross-sectional investigation of ogy symptoms at the baseline assessment of ER in trauma-exposed women found that their study. Level of adaptive strategy use expressive suppression was strongly posi- was negatively correlated with psychopa- tively associated with stress-related symp- thology for subjects endorsing high usage of toms, whereas cognitive reappraisal was maladaptive strategies, suggesting that adap- only weakly negatively associated with these tive ER mitigated the detrimental effects of symptoms (Moore et al., 2008). maladaptive ER. Despite these negative findings, it is still It is also possible that aspects of adap- possible that adaptive ER relates in impor- tive ER that have not yet been examined in tant ways to anxiety disorders and other longitudinal investigations are important to psychopathology. For example, one longi- resilience to psychopathology. Although fre- tudinal study of an undergraduate sample quent use of adaptive ER strategies was not reported divergent outcomes for individuals shown to predict psychopathology symp- high in neuroticism who endorsed low and toms (Aldao & Nolen-H oeksema, 2012), high levels of “emotional repair,” a construct frequent and competent use may do so. related to use of adaptive ER (Auerbach, Though cross-sectional, one community-
406 PSYCHOPATHOLOGY based study showed that cognitive reap- tection against later anxiety or related symp- praisal ability (measured as success in reduc- toms, preliminary research suggests that ing subjective and physiological indicators adaptive ER is associated with decreased of emotion on a standardized task) was severity of anxiety disorder symptoms and associated with lower levels of depressive may reduce clinical complications (which symptoms in women experiencing high lev- often result from maladaptive/avoidant ER). els of stress (Troy, Wilhelm, Shallcross, & Interventions designed to facilitate adaptive Mauss, 2010). ER also have shown promising results. More longitudinal research is needed to determine Finally, it is noteworthy that treatment- whether competent use of adaptive strategies related changes in ER are associated with protects individuals from developing anxi- reductions in anxiety disorder symptoms. ety and related emotional disorders when For example, a recent study showed that exposed to stressors or in the presence of changes in reappraisal self-efficacy mediated other risk factors for disorder. the effects of cognitive-behavioral therapy for SAD (Goldin et al., 2012). Initial efficacy Conclusions and Future Directions data from several treatments for anxiety dis- A dramatic increase in research over the last orders that directly target ER further sug- decade has led to important observations gest that facilitating adaptive ER can lead to regarding the relationship of ER to the etiol- resolution of anxiety disorder symptoms. In ogy, phenomenology, and treatment of anxi- addition to ER-focused treatments for spe- ety disorders. We have attempted to synthe- cific anxiety disorders (e.g., emotion regu- size these important data and to consider lation therapy for GAD: Mennin & Fresco, them within the broader context of basic this volume; acceptance-based behavior features of anxiety disorders that influence therapy for GAD: Roemer et al., 2008), ER. our group has developed and tested a uni- fied protocol for transdiagnostic treatment Individuals with anxiety disorders report of emotional disorders, designed to reduce wide-ranging difficulties related to emo- maladaptive emotional processing, promote tional experience and ER. We have posited increased engagement of adaptive ER, and that these difficulties emanate from underly- facilitate extinction of distressing reactions ing features of anxiety disorders that include to intense negative emotions (Barlow et al., heightened emotional reactivity, hypersen- 2011). Results of the initial randomized con- sitivity to threat, and increased tendencies trolled trial demonstrated that this interven- toward avoidant processing and behavior. tion led to significant reductions in anxiety These basic characteristics of anxiety dis- focused on emotional experience, anxiety orders may contribute to problematic ER sensitivity, and emotional avoidance strate- strategy selection, because the emotional gies (Ellard et al., 2011), while another study processing of anxious individuals appears showed large treatment effect sizes across to facilitate maladaptive strategies, such as disorders (Farchione et al., 2012). Empirical suppression, and impede adaptive strategies, support for the efficacy of the unified pro- such as cognitive reappraisal and accep- tocol and other ER-focused treatments for tance. ER-related difficulties also may be anxiety disorders reinforces the notion that exacerbated by differences in consequences ER is an important factor that may contrib- of ER strategies for anxious individuals ute to the onset and/or maintenance of anxi- (e.g., negative effects of suppression may be ety disorders. potentiated; physiological benefits of adap- tive strategies may be attenuated). Further- Summary more, mounting evidence of dysfunction of The results of two recent longitudinal inves- neural systems supporting adaptive ER sug- tigations suggest that maladaptive ER may gests that this may be a key factor underly- temporally precede and increase risk for ing the difficulties reported by individuals psychopathology, including anxiety disor- with anxiety disorders. ders, consistent with the etiological model to which we have referred in this chapter. While Despite the substantial expansion of inter- adaptive ER does not appear to confer pro- est and research related to ER and anxiety
Emotion Regulation in Anxiety Disorders 407 disorders, it is clear that much more empiri- Auerbach, R. P., Abela, J. R., & Ringo Ho, cal work is needed to refine our understand- M. H. (2007). Responding to symptoms of ing of the topics addressed in this chapter. depression and anxiety: Emotion regulation, Basic questions related to measurement of neuroticism, and engagement in risky behav- ER and construct validity remain impor- iors. Behaviour Research and Therapy, 45, tant areas for further study and, in general, 2182–2191. replication of many of the findings summa- rized in this chapter is needed. Although we Baker, R., Holloway, J., Thomas, P. W., Thomas, believe the evidence points to maladaptive S., & Owens, M. (2004). Emotional process- ER being a transdiagnostic feature of anxi- ing and panic. Behaviour Research and Ther- ety and related emotional disorders, more apy, 42, 1271–1287. empirical work is needed to confirm this view or, alternatively, to establish the speci- Ball, T. M., Ramsawh, H. J., Campbell-ÂS
408 PSYCHOPATHOLOGY predicts long-term adjustment. Psychological effects—for high reappraisers only? Emotion, Science, 15, 482–487. 12, 970–979. Borkovec, T. D., Alcaine, O., & Behar, E. (2004). Dalgleish, T., Yiend, J., Schweizer, S., & Dunn, Avoidance theory of worry and generalized B. D. (2009). Ironic effects of emotion sup- anxiety disorder. In R. G. Heimberg, C. L. pression when recounting distressing memo- Turk, & D. S. Mennin (Eds.), Generalized anx- ries. Emotion, 9, 744–749. iety disorder: Advances in research and prac- Di Simplicio, M., Costoloni, G., Western, D., tice (pp. 77–108). New York: Guilford Press. Hanson, B., Taggart, P., & Harmer, C. J. Boswell, J. F., Thompson-H olland, J., Farchione, (2012). Decreased heart rate variability dur- T. J., & Barlow, D. H. (2013). Intolerance of ing emotion regulation in subjects at risk for uncertainty: A common change factor in the psychopathology. Psychological Medicine, 42, treatment of emotional disorders. Journal of 1775–1783. Clinical Psychology, 69, 630–645. Drabant, E. M., Ramel, W., Edge, M. D., Hyde, Brown, T. A., & Barlow, D. H. (2009). A pro- L. W., Kuo, J. R., Goldin, P. R., et al. (2012). posal for a dimensional classification system Neural mechanisms underlying 5-HTTLPR- based on the shared features of the DSM-IV related sensitivity to acute stress. American anxiety and mood disorders: Implications Journal of Psychiatry, 169, 397–405. for assessment and treatment. Psychological Dugas, M. J., Laugesen, N., & Bukowski, W. M. Assessment, 21, 256–271. (2012). Intolerance of uncertainty, fear of anx- Brown, T. A., Barlow, D. H., & Liebowitz, M. iety, and adolescent worry. Journal of Abnor- (1994). The empirical basis of GAD. Ameri- mal Child Psychology, 40, 863–870. can Journal of Psychiatry, 151, 1272–1280. Dunn, B. D., Billotti, D., Murphy, V., & Dal- Brown, T. A., Chorpita, B. F., & Barlow, D. H. gleish, T. (2009). The consequences of effortful (1998). Structural relationships among dimen- emotion regulation when processing distress- sions of the DSM-IV anxiety and mood disor- ing material: A comparison of suppression and ders and dimensions of negative affect, posi- acceptance. Behaviour Research and Therapy, tive affect, and autonomic arousal. Journal of 47, 761–773. Abnormal Psychology, 107, 179–192. Eftekhari, A., Zoellner, L. A., & Vigil, S. A. Campbell-Sills, L., Barlow, D. H., Brown, T. A., (2009). Patterns of emotion regulation and & Hofmann, S. G. (2006a). Effects of suppres- psychopathology. Anxiety, Stress and Coping, sion and acceptance on emotional responses of 22, 571–586. individuals with anxiety and mood disorders. Ehring, T., & Quack, D. (2010). Emotion regula- Behaviour Research and Therapy, 44, 1251– tion difficulties in trauma survivors: The role 1263. of trauma type and PTSD symptom severity. Campbell-S ills, L., Barlow, D. H., Brown, T. A., Behavior Therapy, 41, 587–598. & Hofmann, S. G. (2006b). Acceptability and Eifert, G. H., & Heffner, M. (2003). The effects suppression of negative emotion in anxiety of acceptance versus control contexts on and mood disorders. Emotion, 6, 587–595. avoidance of panic-related symptoms. Journal Campbell-Sills, L., Simmons, A. N., Lovero, K. of Behavior Therapy and Experimental Psy- L., Rochlin, A. A., Paulus, M. P., & Stein, M. chiatry, 34, 293–312. B. (2011). Functioning of neural systems sup- Ellard, K. K. (2012). An examination of the neu- porting emotion regulation in anxiety-prone ral correlates of emotion acceptance versus individuals. NeuroImage, 54, 689–696. worry in generalized anxiety disorder. Unpub- Carthy, T., Horesh, N., Apter, A., Edge, M. D., lished doctoral dissertation, Boston Univer- & Gross, J. J. (2010). Emotional reactivity sity, Boston, MA. and cognitive regulation in anxious children. Ellard, K. K., Fairholme, C. P., Thompson- Behaviour Research and Therapy, 48, 384– Hollands, J., Carl, J. R., Farchione, T. J., & 393. Barlow, D. H. (2011, November). Early reduc- Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., tions in distress and anxiety related to emo- Craig, I. W., Harrington, H., et al. (2003). tional experiences in the Unified Protocol: Influence of life stress on depression: Modera- Effect on treatment response. Paper presented tion by a polymorphism in the 5-HTT gene. at the 45th annual meeting of the Associa- Science, 301, 386–389. tion for Behavioral and Cognitive Therapies, Cohen, N., Henik, A., & Moyal, N. (2012). Toronto, Canada. Executive control attenuates emotional Etkin, A., Prater, K. E., Hoeft, F., Menon, V.,
Emotion Regulation in Anxiety Disorders 409 & Schatzberg, A. F. (2010). Failure of anterior the effects of individual cognitive-b ehavioral cingulate activation and connectivity with the therapy for social anxiety disorder. Journal of amygdala during implicit regulation of emo- Consulting and Clinical Psychology, 80(6), tional processing in generalized anxiety dis- 1034–1040. order. American Journal of Psychiatry, 167, Gross, J. J. (1998). Antecedent- and response- 545–554. focused emotion regulation: Divergent con- Etkin, A., Prater, K. E., Schatzberg, A. F., Menon, sequences for experience, expression, and V., & Greicius, M. D. (2009). Disrupted amyg- physiology. Journal of Personality and Social dalar subregion functional connectivity and Psychology, 74, 224–237. evidence of a compensatory network in gen- Gross, J. J. (this volume, 2014). Emotion regula- eralized anxiety disorder. Archives of General tion: Conceptual and empirical foundations. Psychiatry, 66, 1361–1372. In J. J. Gross (Ed.), Handbook of emotion Etkin, A., & Wager, T. D. (2007). Functional regulation (2nd ed., pp. 3–20). New York: neuroimaging of anxiety: A meta-analysis of Guilford Press. emotional processing in PTSD, social anxiety Gross, J. J., & John, O. P. (2003). Individual dif- disorder, and specific phobia. American Jour- ferences in two emotion regulation processes: nal of Psychiatry, 164, 1476–1488. Implications for affect, relationships, and Farchione, T. J., Fairholme, C. P., Ellard, K. K., well-being. Journal of Personality and Social Boisseau, C. L., Thompson-H ollands, J., Carl, Psychology, 85, 348–362. J. R., et al. (2012). Unified protocol for trans- Gross, J. J., & Levenson, R. W. (1993). Emo- diagnostic treatment of emotional disorders: tional suppression: Physiology, self-report, A randomized controlled trial. Behavior Ther- and expressive behavior. Journal of Personal- apy, 43, 666–678. ity and Social Psychology, 64, 970–986. Feldner, M. T., Zvolensky, M. J., Eifert, G. H., & Gross, J. J., & Levenson, R. W. (1997). Hiding Spira, A. P. (2003). Emotional avoidance: An feelings: The acute effects of inhibiting nega- experimental test of individual differences and tive and positive emotion. Journal of Abnor- response suppression using biological chal- mal Psychology, 106, 95–103. lenge. Behaviour Research and Therapy, 41, Gyurak, A., Goodkind, M. S., Kramer, J. H., 403 – 411. Miller, B. L., & Levenson, R. W. (2012). Friedman, B. H. (2007). An autonomic Executive functions and the down-regulation flexibility–neurovisceral integration model and up-regulation of emotion. Cognition and of anxiety and cardiac vagal tone. Biological Emotion, 26, 103–118. Psychology, 74, 185–199. Hill, C. L., & Updegraff, J. A. (2012). Mindful- Garner, M., Mogg, K., & Bradley, B. P. (2006). ness and its relationship to emotional regula- Orienting and maintenance of gaze to facial tion. Emotion, 12, 81–90. expressions in social anxiety. Journal of Hofmann, S. G., Ellard, K. K., & Siegle, G. J. Abnormal Psychology, 115, 760–770. (2012). Neurobiological correlates of cog- Goldin, P. R., Manber, T., Hakimi, S., Canli, T., nitions in fear and anxiety: A cognitive– & Gross, J. J. (2009). Neural bases of social neurobiological information-p rocessing model. anxiety disorder: Emotional reactivity and Cognition and Emotion, 26, 282–299. cognitive regulation during social and physi- Hofmann, S. G., Heering, S., Sawyer, A. T., & cal threat. Archives of General Psychiatry, 66, Asnaani, A. (2009). How to handle anxiety: 170 –180. The effects of reappraisal, acceptance, and Goldin, P. R., Manber-Ball, T., Werner, K., suppression strategies on anxious arousal. Heimberg, R., & Gross, J. J. (2009). Neural Behaviour Research and Therapy, 47, 389– mechanisms of cognitive reappraisal of nega- 394. tive self-beliefs in social anxiety disorder. Bio- Jackson, D. C., Malmstadt, J. R., Larson, C. logical Psychiatry, 66, 1091–1099. L., & Davidson, R. J. (2000). Suppression Goldin, P. R., McRae, K., Ramel, W., & Gross, J. and enhancement of emotional responses to J. (2008). The neural bases of emotion regula- unpleasant pictures. Psychophysiology, 37, tion: Reappraisal and suppression of negative 515–522. emotion. Biological Psychiatry, 63, 577–586. John, O. P., & Eng, J. (this volume, 2014). Three Goldin, P. R., Ziv, M., Jazaieri, H., Werner, K., approaches to individual differences in affect Kraemer, H., Heimberg, R. G., et al. (2012). regulation: Conceptualization, measures, and Cognitive reappraisal self-efficacy mediates findings. In J. J. Gross (Ed.), Handbook of
410 PSYCHOPATHOLOGY emotion regulation (2nd ed., pp. 321–345). be sure, to be sure: Intolerance of uncertainty New York: Guilford Press. mediates symptoms of various anxiety disor- Joormann, J., & Siemer, M. (this volume, 2014). ders and depression. Behavior Therapy, 43, Emotion regulation in mood disorders. In J. J. 533–545. Gross (Ed.), Handbook of emotion regulation McLaughlin, K. A., Hatzenbuehler, M. L., Men- (2nd ed., pp. 413–427). New York: Guilford nin, D. S., & Nolen-H oeksema, S. (2011). Press. Emotion dysregulation and adolescent psy- Kashdan, T. B., & Rottenberg, J. (2010). Psy- chopathology: A prospective study. Behaviour chological flexibility as a fundamental aspect Research and Therapy, 49, 544–554. of health. Clinical Psychology Review, 30, McLaughlin, K. A., Mennin, D. S., & Farach, F. 865–878. J. (2007). The contributory role of worry in Keough, M. E., Riccardi, C. J., Timpano, K. R., emotion generation and dysregulation in gen- Mitchell, M. A., & Schmidt, N. B. (2010). eralized anxiety disorder. Behaviour Research Anxiety symptomatology: The association and Therapy, 45, 1735–1752. with distress tolerance and anxiety sensitivity. Mennin, D. S., & Fresco, D. M. (this volume, Behavior Therapy, 41, 567–574. 2014). Emotion regulation therapy. In J. J. Koster, E. H., Crombez, G., Verschuere, B., Gross (Ed.), Handbook of emotion regulation Van Damme, S., & Wiersema, J. R. (2006). (2nd ed., pp. 469–490). New York: Guilford Components of attentional bias to threat in Press. high trait anxiety: Facilitated engagement, Mennin, D. S., Heimberg, R. G., Turk, C. L., & impaired disengagement, and attentional Fresco, D. M. (2005). Preliminary evidence avoidance. Behaviour Research and Therapy, for an emotion dysregulation model of gener- 44, 1757–1771. alized anxiety disorder. Behaviour Research Lau, H. C., Rogers, R. D., Haggard, P., & Pass- and Therapy, 43, 1281–1310. ingham, R. E. (2004). Attention to intention. Mennin, D. S., McLaughlin, K. A., & Flanagan, Science, 303, 1208–1210. T. J. (2009). Emotion regulation deficits in Leutgeb, V., Schäfer, A., & Schienle, A. (2009). generalized anxiety disorder, social anxiety An event-related potential study on exposure disorder, and their co-occurrence. Journal of therapy for patients suffering from spider pho- Anxiety Disorders, 23, 866–871. bia. Biological Psychology, 82, 293–300. Montag, C., Fiebach, C. J., Kirsch, P., & Reuter, Levitt, J. T., Brown, T. A., Orsillo, S. M., & Bar- M. (2011). Interaction of 5-HTTLPR and a low, D. H. (2004). The effects of acceptance variation on the oxytocin receptor gene influ- versus suppression of emotion on subjective ences negative emotionality. Biological Psy- and psychophysiological response to carbon chiatry, 69, 601–603. dioxide challenge in patients with panic disor- Moore, S. A., Zoellner, L. A., & Mollenholt, N. der. Behavior Therapy, 35, 747–766. (2008). Are expressive suppression and cogni- Lieberman, M. D., Inagaki, T. K., Tabibnia, G., & tive reappraisal associated with stress-related Crockett, M. J. (2011). Subjective responses to symptoms? Behaviour Research and Therapy, emotional stimuli during labeling, reappraisal, 46, 993–1000. and distraction. Emotion, 11, 468–480. Munafo, M. R., Brown, S. M., & Hariri, A. R. MacLeod, C., & Hagan, R. (1992). Individual (2008). Serotonin transporter (5-HTTLPR) differences in the selective processing of threat- genotype and amygdala activation: A meta- ening information, and emotional responses to analysis. Biological Psychiatry, 63, 852–857. a stressful life event. Behaviour Research and New, A. S., Fan, J., Murrough, J. W., Liu, X., Therapy, 30, 151–161. Liebman, R. E., Guise, K. G., et al. (2009). A MacLeod, C., Mathews, A., & Tata, P. (1986). functional magnetic resonance imaging study Attentional bias in emotional disorders. Jour- of deliberate emotion regulation in resilience nal of Abnormal Psychology, 95, 15–20. and posttraumatic stress disorder. Biological Matsuzaka, Y., Akiyama, T., Tanji, J., & Mush- Psychiatry, 66, 656–664. iake, H. (2012). Neuronal activity in the pri- Ochsner, K. N., Bunge, S. A., Gross, J. J., & mate dorsomedial prefrontal cortex contrib- Gabrieli, J. D. (2002). Rethinking feelings: utes to strategic selection of response tactics. An FMRI study of the cognitive regulation of Proceedings of the National Academy of Sci- emotion. Journal of Cognitive Neuroscience, ences, 109, 4633–4638. 14, 1215–1229. McEvoy, P. M., & Mahoney, A. E. (2012). To Ochsner, K. N., Knierim, K., Ludlow, D. H.,
Emotion Regulation in Anxiety Disorders 411 Hanelin, J., Ramachandran, T., Glover, G., Sheppes, G., Scheibe, S., Suri, G., & Gross, J. J. & Mackey, S. C. (2004). Reflecting upon feel- (2011). Emotion regulation choice. Psycholog- ings: An fMRI study of neural systems sup- ical Science, 22, 1391–1396. porting the attribution of emotion to self or other. Journal of Cognitive Neuroscience, 16, Shin, L. M., & Liberzon, I. (2010). The neuro- 1746–1772. circuitry of fear, stress, and anxiety disorders. Ochsner, K. N., Ray, R. D., Cooper, J. C., Rob- Neuropsychopharmacology, 35, 169–191. ertson, E. R., Chopra, S., Gabrieli, J. D., et al. (2004). For better or for worse: Neural sys- Speilberg, J. M., Miller, G. A., Engels, A. S., Her- tems supporting the cognitive down- and up- rington, J. D., Sutton, B. P., Banich, M. T., et regulation of negative emotion. NeuroImage, al. (2011). Trait approach and avoidance moti- 23, 483–499. vation: Lateralized neural activity associated Olatunji, B. O., & Wolitzky-Taylor, K. B. (2009). with executive function. NeuroImage, 54, Anxiety sensitivity and the anxiety disorders: 661– 670. A meta-a nalytic review and synthesis. Psycho- logical Bulletin, 135, 974–999. Stein, M. B., Shorck, N. J., & Gelernter, J. (2008). Paquette, V., Lévesque, J., Mensour, B., Ler- Gene-by-environment (serotonin transporter oux, J. M., Beaudoin, G., Bourgouin, P., et al. and childhood maltreatment) interaction for (2003). “Change the mind and you change the anxiety sensitivity, an intermediate phenotype brain”: Effects of cognitive-b ehavioral therapy for anxiety disorders. Neuropsychopharma- on the neural corrleates of spider phobia. Neu- cology, 33, 312–319. roImage, 18, 401–409. Pezawas, L., Meyer-Lindenberg, A., Drab- Straube, T., Glauer, M., Dilger, S., Mentzel, H. J., ant, E. M., Verchinski, B. A., Munoz, K. E., & Miltner, W. H. (2006). Effects of cognitive- Kolachana, B. S., et al. (2005). 5-HTTLPR behavioral therapy on brain activation in spe- polymorphism impacts human cingulate– cific phobia. NeuroImage, 29, 125–135. amygdala interactions: A genetic susceptibility mechanism for depression. Nature Neurosci- Suárez, L. M., Bennett, S. M., Goldstein, C. ence, 8, 828–834. R., & Barlow, D. H. (2009). Understanding Pineles, S. L., & Mineka, S. (2005). Attentional anxiety disorders from a “triple vulnerabil- biases to internal and external sources of ity” framework. In M. M. Antony & M. B. potential threat in social anxiety. Journal of Stein (Eds.), Oxford handbook of anxiety and Abnormal Psychology, 114, 314–318. related disorders (pp. 153–172). New York: Roemer, L., Orsillo, S. M., & Salters-Pedneault, Oxford University Press. K. (2008). Efficacy of an acceptance-based behavior therapy for generalized anxiety dis- Tan, P. Z., Forbes, E. E., Dahl, R. E., Ryan, order: Evaluation in a randomized controlled N. D., Siegle, G. J., Ladouceur, C. D., et al. trial. Journal of Consulting and Clinical Psy- (2012). Emotional reactivity and regulation in chology, 76, 1083–1089. anxious and nonanxious youth: A cell-phone Rothbart, M. K., Sheese, B. E., & Posner, M. I. ecological momentary assessment study. Jour- (this volume, 2014). Temperament and emo- nal of Child Psychology and Psychiatry, 53, tion regulation. In J. J. Gross (Ed.), Handbook 197–206. of emotion regulation (2nd ed., pp. 305–320). New York: Guilford Press. Thayer, J. F., Friedman, B. H., & Borkovec, T. Salters-Pedneault, K., Roemer, L., Tull, M. T., D. (1996). Autonomic characteristics of gener- Rucker, L., & Mennin, D. S. (2006). Evidence alized anxiety disorder and worry. Biological of broad deficits in emotion regulation associ- Psychiatry, 39, 255–266. ated with chronic worry and generalized anxi- ety disorder. Cognitive Therapy and Research, Thompson, R. A. (this volume, 2014). Socializa- 30, 469–480. tion of emotion and emotion regulation in the Schmidt, N. B., Lerew, D. R., & Jackson, R. J. family. In J. J. Gross (Ed.), Handbook of emo- (1999). Prospective evaluation of anxiety sen- tion regulation (2nd ed., pp. 173–186). New sitivity in the pathogenesis of panic: Replica- York: Guilford Press. tion and extension. Journal of Abnormal Psy- chology, 108, 532–537. Tolin, D. F., Abramowitz, J. S., Brigidi, B. D., & Foa, E. B. (2003). Intolerance of uncertainty in obsessive–compulsive disorder. Journal of Anxiety Disorders, 17, 233–242. Troy, A. S., Wilhelm, F. H., Shallcross, A. J., & Mauss, I. B. (2010). Seeing the silver lining: Cognitive reappraisal ability moderates the relationship between stress and depressive symptoms. Emotion, 10, 783–795. Tull, M. T., & Roemer, L. (2007). Emotion regu-
412 PSYCHOPATHOLOGY lation difficulties associated with the experi- successful emotion regulation. Neuron, 59, ence of uncued panic attacks: Evidence of 1037–1050. experiential avoidance, emotional nonaccep- Weiss, N. H., Tull, M. T., Davis, L. T., Dehon, tance, and decreased emotional clarity. Behav- E. E., Fulton, J. J., & Gratz, K. L. (2012). ior Therapy, 38, 378–391. Examining the association between emotion Turk, C. L., Heimberg, R. G., Luterek, J. A., regulation difficulties and probable posttrau- Mennin, D. S., & Fresco, D. M. (2005). Emo- matic stress disorder within a sample of Afri- tion dysregulation in generalized anxiety dis- can Americans. Cognitive Behavior Therapy, order: A comparison with social anxiety dis- 41, 5–14. order. Cognitive Therapy and Research, 29, Wilamowska, Z. A., Thompson-Hollands, J., 89–106. Fairholme, C. P., Ellard, K. K., Farchione, T. van den Hout, M., Tenney, N., Huygens, K., J., & Barlow, D. H. (2010). Conceptual back- Merckelbach, H., & Kindt, M. (1995). ground, development, and preliminary data Responding to subliminal threat cues is related from the unified protocol for transdiagnostic to trait anxiety and emotional vulnerability: A treatment of emotional disorders. Depression successful replication of Macleod and Hagan and Anxiety, 27, 882–890. (1992). Behaviour Research and Therapy, 33, Wolgast, M., Lundh, L. G., & Viborg, G. (2011). 451– 454. Cognitive reappraisal and acceptance: An Wager, T. D., Davidson, M. L., Hughes, B. L., experimental comparison of two emotion Lindquist, M. A., & Ochsner, K. N. (2008). regulation strategies. Behaviour Research and Prefrontal-subcortical pathways mediating Therapy, 49, 858–866.
Chapter 25 Emotion Regulation in Mood Disorders Jutta Joormann Matthias Siemer Imagine receiving a negative evaluation at overestimation of the ability to complete work, having an argument with your part- the project in a timely manner, whereas an ner, discovering you have forgotten to pay a inability to savor a success and the use of bill and have incurred a late fee; and imagine strategies that down-regulate the ensuing experiencing all of this on a gray, rainy, win- positive mood may interfere with the moti- ter day. Situations like these, which have the vation to start the next project. Therefore, potential to induce lasting negative affect, both difficulties in the regulation of positive are part of everyday life. Perhaps not sur- and negative affect have been implicated in prisingly, researchers have found that peo- mood disorders. ple generally do not endure negative affect passively; rather, they actively use strategies Mood disorders are among the most to try to regulate their negative moods and prevalent of all psychiatric disorders, with emotions. It is important to note, however, major depressive disorder (MDD) affecting that there is a wide range of individual dif- almost 20% of Americans at some point in ferences in the ability to regulate affect: their lives (Kessler & Wang, 2009). Given Whereas some individuals can successfully the high prevalence and the substantial per- regulate their negative affect, others cannot, sonal and societal costs of mood disorders, and still others may respond to their emo- efforts to identify risk factors and underly- tions in ways that further exacerbate their ing mechanisms, as well as effective inter- negative affect. Importantly, it is becoming vention strategies, are particularly pressing. increasingly clear that these individual dif- As implied by the label, the hallmark fea- ferences in the regulation of negative moods ture of mood disorders is disordered affect. and emotions play a significant role in the MDD is defined by sustained negative affect onset and maintenance of mood disorders. and difficulties experiencing positive affect. Less frequently discussed is the regulation Bipolar disorder (BD) is characterized by of positive moods and emotions and of dif- episodes of depressed but also elevated and/ ficulties that may stem from an inability to or irritable mood. Despite the fact that dis- respond effectively to positive affect. Exces- ordered affect is the central feature of mood sive bathing in the glory of initial posi- disorders, theories of the onset, mainte- tive feedback, for example, may lead to an nance, and recurrence of these disorders have traditionally focused on cognition and 413
414 PSYCHOPATHOLOGY behavior but not as much on affect. Indeed, differ from their nondisordered counterparts cognitive-behavioral interventions have in emotion regulation. proven successful in treating these disorders by focusing on the modification of maladap- At least two different but related aspects tive cognitions and behaviors (Beck, Rush, of emotion regulation are crucial in this con- Shaw, & Emery, 1979). Despite these suc- text. First, it is possible that people who are cesses, many researchers have pointed out prone to experience affective disorders and that there is room for improvement in our their nondisordered counterparts differ in theoretical models and in our treatment the selection of specific emotion regulation approaches. Specifically, a closer look at strategies because of wrong expectations the concept of emotion regulation and at about the usefulness of a strategy in a given mechanisms that allow us to understand situation, or because of acquired preferences individual differences in the important abil- for the selection of ineffective or maladap- ity to regulate affective states may help us tive strategies. Indeed, numerous studies better understand vulnerability to affective show that depression is associated with a disorders and thereby improve our treatment tendency to ruminate when experiencing approaches. negative affect, and that the use of this strat- egy is perceived as helpful in coping with Indeed, models of both depression and BD negative events even though it in fact inter- have emphasized the role of emotion regu- feres with recovery (Papageorgiou & Wells, lation. It has been proposed, for example, 2001). In addition, it is possible that affec- that individuals who experience episodes of tive disorders are characterized by a more depression do not differ from their nonde- limited repertoire of strategies that may pressed counterparts in the degree to which interfere with the flexible use of multiple they become sad but instead are character- strategies that fit the situation at hand. This ized by an inability to repair or regulate their flexibility has been proposed as particularly emotions, resulting in longer episodes of adaptive (Kashdan & Rottenberg, 2010). It sadness and depressed mood for depression- is also possible, however, that depression- prone individuals (Teasdale, 1988; Nolen- related difficulties in emotion regulation are Hoeksema, Wisco, & Lyubomirsky, 2008). due not to strategy selection but to prob- In depression, preferential use of maladap- lems implementing adaptive strategies such tive strategies, such as rumination, as well as reappraisal. Of course, these two aspects as difficulties using adaptive strategies, such of emotion regulation in affective disorders as reappraisal, may explain why negative may be related. Difficulties implementing an emotions in response to life events quickly adaptive strategy, for example, may result in spiral into sustained negative mood (e.g., preferential selection of maladaptive strate- Nolen-Hoeksema et al., 2008). In BD, we gies. find similar difficulties regulating negative affect. In addition, maladaptive responding In this chapter, we review studies examin- to positive affect and events may explain ing the first aspect of emotion regulation in how elevated mood leads into a manic affective disorders by summarizing research episode (Gruber, 2011; Johnson, 2005). on the use of different emotion regulation Indeed, Gruber (2011) points out that “BD strategies, then examine evidence for the sec- involves a tendency to increase or amplify ond, that people with affective disorders have positive emotions” (p. 219). Likewise, John- difficulties implementing adaptive strategies. son (2005) has described how increases in We also examine underlying mechanisms of positive affect after an initial success and emotion dysregulation in affective disorders individual differences in responding to posi- by focusing on basic cognitive processes that tive mood are related to the development of may help or hinder emotion regulation and mania. Even though these predictions seem discuss how these may be affected by mood plausible, however, empirical evidence is still disorders. Our discussion focuses on studies largely missing, particularly when it comes that have used clinically diagnosed samples, to BD. A first goal of this chapter is there- but we also review studies with analogue fore to summarize empirical findings that samples if they are particularly informative support the proposition that people who are or if clinical studies are missing. diagnosed with affective disorders do indeed Emotion regulation is defined here as strategic and automatic processes that influ-
Emotion Regulation in Mood Disorders 415 ence the occurrence, magnitude, duration, to work over further. Many of us mull over and expression of an emotional response important matters in this way, digesting (see Gross, this volume). The focus of most them a little at a time. But in depression, studies on emotion regulation is the down- rumination frequently features negative, regulation of negative affect. This aspect of self-deprecating statements and pessimistic emotion regulation is also the primary focus ideas about the world and the future. of this chapter when it comes to MDD. How- ever, we also discuss how depression may be Depressive rumination has been shown associated with problems savoring positive in numerous studies to exacerbate and pro- affect and that a risk factor for BD is rumi- long depressed mood (see review by Nolen- nation on positive events (e.g., in response Hoeksema et al., 2008). It may seem coun- to successful goal achievement), which may terintuitive to think that someone would result in a failure to down-regulate positive use rumination as an emotion regulation affect that may then spiral into a full-blown strategy given that numerous studies show manic episode (Johnson, 2005). that it increases negative affect. However, it is a frequently used response when peo- Strategy Selection ple experience negative affect or encoun- in Mood Disorders ter a negative event, and studies show that Recent research suggests that it is overly depressed individuals perceive many benefits simplistic to differentiate adaptive from mal- of rumination, such as feelings of increased adaptive strategies. Indeed, the adaptiveness self-awareness and understanding (Papa- of a particular strategy will likely depend on georgiou & Wells, 2001). Lyubomirksy the context in which it is used, as well as and Nolen-H oeksema (1993), for example, the flexibility of its use (Bonnano, Papa, Lal- reported that rumination in dysphoric par- ande, Westphal, & Coifman, 2004). Still, ticipants (i.e., participants with subclini- previous research has identified specific cal levels of depressive symptoms usually strategies that are more likely to incur addi- assessed via self-report) was associated with tional costs (e.g., increase in cognitive load an enhanced sense of insightfulness. Empiri- or physiological arousal) and that seem less cal evidence has shown that people who tend likely to regulate affect effectively (Gross & to engage in rumination when distressed are John, 2003). Emotion regulation is a broad more likely to develop depressive disorders concept that comprises a number of different and tend to experience more prolonged peri- processes, and it is beyond the scope of this ods of depression (e.g., Nolen-H oeksema, chapter to provide an exhaustive review of 2000). Indeed, considerable evidence has the literature. We therefore focus on strat- linked higher trait rumination with the egies that have consistently been linked to onset and maintenance of depression (see mood disorders and have been the focus of Nolen-Hoeksema et al., 2008, for a review). empirical studies on depression and/or BD. Nolen-Hoeksema (2000), for example, examined a sample of approximately 1,300 Rumination adults randomly selected from the com- A particularly detrimental response to nega- munity. Among nondepressed individuals, tive affect that has been associated with rumination scores at first assessment pre- various emotional disorders is rumination, dicted the onset of new major depressive epi- which is bringing an idea back to mind sodes over the following year. Researchers over and over again. Originally the word have also examined the effects of an experi- referred to the way cows and certain other mental induction of rumination on people’s animals eat, storing partially digested food mood and behaviors. Rumination in these in a stomach called a rumen, bringing that studies is usually contrasted with distrac- food up later to chew over more thoroughly. tion, another emotion regulation strategy Even in the original Latin, however, it took that we discuss later. In general, compared on a vivid figurative meaning, describing the with distraction, rumination leads to sus- practice of bringing an idea back to mind tained negative mood, increases in negative cognitions and overgeneral autobiographical memory, and decreases in effective problem solving in depressed participants (e.g., Wat- kins & Moulds, 2005).
416 PSYCHOPATHOLOGY Although much less studied, individuals a rumination induction in response to the recall of a positive autobiographical memory with BD have also been shown to ruminate and reported no group differences in self- about negative emotion. In fact, some studies reported affect or physiological responding. indicate that people with BD ruminate even more than people with unipolar depression It seems interesting that whereas positive (Kim, Yu, Lee, & Kim, 2012). However, BD rumination is associated with negative out- is associated with not only increased depres- comes in BD, depressed participants may sive rumination but also rumination about have difficulties savoring positive events. positive emotion. Indeed, positive rumina- Thus, although rumination on negative tion, defined as dwelling on the content, content clearly seems present and maladap- consequences, and causes of positive feelings tive in both MDD and BD, the maladap- (Feldman, Joormann, & Johnson, 2008), tive response may be rumination on posi- has been identified as an important risk tive content in BD, whereas lack of savoring factor for BD. Gruber (2011), for example, may be the maladaptive response in MDD. proposes that positive rumination may inter- Raes, Smets, Nelis, and Schoofs (2012), for fere with the processing of relevant external example, found in two nonclinical student information that could help terminate the samples that a self-reported dampening emotional state. Compared to control par- response to positive affect predicted depres- ticipants, college students diagnosed with sive symptoms in 3- and 5-month follow-up BD or MDD endorsed heightened rumina- assessments. tion in response to negative affect, but only those with BD endorsed elevated rumina- Reappraisal tion in response to positive affect (Johnson, In his fascinating book on depression, McKenzie, & McMurrich, 2008). Moreover, Andrew Solomon (2001) writes about one within BD, ruminative responses to negative of his depressive episodes, “I started to fear, affect were explained by depressive symp- every time my dog left the room, that it was toms. Gruber, Eidelman, Johnson, Smith, because he was not interested in me” (p. 86). and Harvey (2011) also examined rumina- The tendency to interpret emotion-eliciting tion about positive and negative emotions: situations in a negative way is a defining Compared to the control group, the BD feature of depressive disorders. Altering group endorsed greater trait rumination for these interpretations is obviously a power- positive as well as negative emotions. Inter- ful way to regulate affect and a main com- estingly, participants with BD in this sample ponent of cognitive therapy for depression. were not at the time experiencing episodes Reappraisal involves changing a situation’s of depression or mania, which suggests that meaning to alter one’s emotional response to elevated rumination is not just a correlate of the situation (Gross, 1998; Gross & John, the depressive or manic state. Importantly, 2003). Reappraisal has been studied exten- trait rumination about negative and posi- sively in nonclinical populations and has tive emotion was associated with greater been shown to reduce negative affect (John lifetime depression frequency, whereas trait & Gross, 2004; Urry, 2009). In addition, rumination about positive emotion was reappraisal does not entail the social and associated with greater lifetime mania fre- cognitive costs associated with rumination quency. Similarly, Alloy et al. (2009) found and other less adaptive strategies (Richards that trait rumination about positive emotion & Gross, 2000). Furthermore, it is associ- was associated with greater lifetime mania ated with reduced physiological activation in frequency in their BD group. Although few response to negative emotion (Ray, McRae, rumination inductions have been used in the Ochsner, & Gross, 2010; Urry, 2009). BD literature, researchers found heightened positive emotion in a ruminative compared Not surprisingly, studies in clinical and with reflective (i.e., third-person perspec- nonclinical samples have tied less frequent tive) induction in participants with BD com- habitual use of reappraisal to greater depres- pared with healthy controls (Gruber, Har- sion severity (Garnefski & Kraaij, 2006; vey, & Johnson, 2009). In contrast, Gruber Joormann & Gotlib, 2010). It should be et al. (2011) exposed their participants with noted, however, that most of these studies interepisode BD and control participants to have used a cross-sectional design, which
Emotion Regulation in Mood Disorders 417 makes it difficult to examine whether egy. Suppression is conceptualized as an decreased reappraisal use is a symptom of emotion regulation strategy by which an depression or indeed a risk factor. Garnef- individual attempts to inhibit the effects of ski, Legerstee, Kraaij, van den Kommer, and external cues on internal (e.g., physiological) Teerds (2002), for example, found reduced and external (e.g., emotional expression) use of reappraisal in a clinical sample diag- states. The inhibition of emotion expression nosed with depression and anxiety. Few is frequently referred to as expressive sup- researchers have examined the habitual use pression. Research on emotion suppression of reappraisal in BD. One exception is Gru- indicates that habitual use of this strategy ber, Harvey, and Gross (2012), who exam- is largely ineffective in reducing negative ined the spontaneous use of reappraisal emotions. Findings indicate that expressive in BD in response to emotional film clips. suppression, for example, is associated with They found that individuals with BD were increased depression symptoms (Joormann more likely than control individuals to use & Gotlib, 2010). Moreover, emotion sup- reappraisal in response to not only positive pression is associated with increased use of and negative but also neutral film clips. The rumination (Liverant, Kamholz, Sloan, & authors interpreted this result as showing Brown, 2011) and decreased inhibitory con- that BD is associated with more regulation trol (Joormann & Gotlib, 2010). However, effort. one study indicates that providing instruc- tions on the use of expressive suppression in It is important to note that habitual reap- response to negative stimuli may be effica- praisal is not beneficial in all contexts. Some cious in reducing acute emotional respond- studies have found habitual use of reappraisal ing among depressed participants (Liverant, to be unrelated to symptoms or correlated Brown, Barlow, & Roemer, 2008). Though with poorer outcomes. Nezlek and Kuppens virtually no studies have examined the use (2008), for example, who examined daily of emotion suppression in individuals with measures of affect and emotion regulation, BD, one recent study found that, compared found that daily use of reappraisal to upreg- to healthy controls, interepisode partici- ulate positive emotions was associated with pants with BD demonstrate increased use increases in positive affect and self-esteem, of spontaneous expressive suppression in whereas no relation was found between the response to both positive and negative mood use of reappraisal to down-regulate nega- inductions (Gruber et al., 2012). In a clini- tive affect and the experience of negative cal sample that included depressed and anx- affect. In addition, in a recent meta-analysis, ious participants, Campbell-Sills, Barlow, Aldao, Nolen-Hoeksema, and Schweizer Brown, and Hofmann (2006) examined (2010) reported that whereas greater reap- emotion suppression, using a mood induc- praisal use is related to lower depression tion film and the assessment of spontane- and anxiety symptoms, reappraisal is more ous use of emotion regulation strategies. inconsistently related to symptoms than They reported that clinical participants used other strategies (rumination, suppression). more suppression, and that suppression was In a follow-up study, Aldao and Nolen- related to higher levels of negative affect. Hoeksema (2012) found that the degree to which reappraisal is adaptive depends on Use of Multiple Strategies the frequency of maladaptive strategy use; Few studies have examined the use of more reappraisal was related to lower depression than one strategy in psychopathology. A symptoms but only for individuals who fre- noteworthy exception is the aforementioned quently use maladaptive strategies (rumina- meta-a nalysis by Aldao et al. (2010), which tion, suppression, etc.). The authors argued examined the relation between the habit- that reappraisal serves as a compensatory ual use of six emotion regulation strate- strategy to counteract the problems that gies (rumination, reappraisal, suppression, come with greater maladaptive strategy use. acceptance, problem solving, avoidance) and four groups of symptoms of psychopathol- Suppression ogy (depression, anxiety, substance-related Suppression has long been regarded as a disorders, and eating disorders) in studies particularly maladaptive regulation strat-
418 PSYCHOPATHOLOGY that used clinical or normative samples. they reported that formerly depressed par- They obtained a large effect size for the ticipants used more rumination but did not association of depression with rumination differ from never-depressed participants in and avoidance, a medium to large effect size reported use of reappraisal or suppression. for problem solving and suppression, and In addition, the formerly depressed group small effect sizes for acceptance and reap- reported more emotion nonacceptance. praisal. The authors summarized their find- Interestingly, even though the groups did ings by pointing out that, overall, adaptive not differ on habitual use of suppression, emotion regulation strategies (reappraisal, the formerly depressed group reported more acceptance) showed a weaker association spontaneous use of suppression in response with psychopathology than maladaptive to a negative film clip. No group differences strategies. In a follow-u p study using a com- were found in reappraisal use in response munity sample, Aldao et al. (2010) further to the film clip. The authors interpret this found an interaction between the use of finding to suggest that depression may not adaptive and maladaptive strategies cross- be associated with suppression of all emo- sectionally. High use of adaptive strategies tional experiences but rather with the spe- was associated with lower psychopathol- cific suppression of sadness. Further studies ogy only in participants who also reported are needed to examine this possibility more high levels of use of maladaptive strategies. closely. The authors further reported that the use of adaptive strategies did not predict psychopa- Few studies have examined the use of thology in a follow-u p assessment, whereas multiple strategies in BD. Green et al. (2011) the use of maladaptive strategies signifi- showed that the BD group reported more cantly predicted psychopathology 6 months frequent use of rumination and less frequent later. use of reappraisal in response to negative life events compared to unaffected relatives, but Studies that use clinical samples and this study did not examine responses to posi- examine the use of a range of different tive events. Abnormal response styles to neg- emotion regulation strategies are particu- ative mood have previously been observed larly informative. D’Avanzato, Joormann, in students with hypomanic traits (Thomas Siemer, and Gotlib (2013), for example, & Bentall, 2002) and in patients with BD compared habitual use of emotion regula- (Thomas, Knowles, Tsai, & Bentall, 2007). tion strategies in control participants and Thomas and Bentall (2002) found that hypo- in samples of participants diagnosed with manic traits were associated with not only depression or social anxiety disorder. These rumination but also increased distraction authors reported that depressed participants and risk taking. Thomas et al. (2007) found were more likely to ruminate and less likely that patients with mania reported high levels to use reappraisal than control participants, of risk taking and active coping (distraction whereas participants with social anxiety dis- and problem solving), whereas patients with order reported more expressive suppression remitted BD reported high levels of rumina- compared to the two other groups. In addi- tion. Clearly more research is needed on the tion, whereas elevated rumination was also interplay of emotion regulation strategies in found in previously depressed participants this disorder. who were not currently depressed, healthy controls and the previously depressed group Summary of Strategy Selection did not differ on use of reappraisal or expres- In summary, the results clearly show that sive suppression. Interestingly, only use of depression is characterized by increased use reappraisal and rumination were related to of rumination and less use of reappraisal. symptom severity across all samples; expres- There is some indication that rumination sive suppression use was unrelated to depres- use may be a stable feature of depression sive or anxiety symptoms. risk even outside of acute episodes of the disorder, whereas reduced use of reappraisal These results are in line with a recent is observed only in people who are currently study by Ehring, Tuschen-Caffier, Schnülle, depressed (see D’Avanzato et al., 2013; Fischer, and Gross (2010) that compared Ehring et al., 2010). This finding suggests formerly depressed to never-d epressed par- ticipants. Like D’Avanzato et al. (2013),
Emotion Regulation in Mood Disorders 419 that rumination may be a risk factor for not clear what underlies the preference and not only the recurrence but also the onset of dispositional use of specific emotion regu- depression, whereas changes in reappraisal lation strategies in affective disorders. It is use may be an epiphenomenon of experienc- likely that difficulties implementing certain ing a depressive episode. Results for expres- strategies also shape the selection of emo- sive suppression and other forms of suppres- tion regulation strategies. In the second part sion are less clear-cut, as are findings for the of this chapter, we therefore examine the use of acceptance in depression. implementation of emotion regulation strat- egies in mood disorders and try to identify It is interesting to note that, in contrast cognitive processes that may underlie diffi- to MDD, BD seems to be characterized by culties in emotion regulation. problems regulating negative and positive affect, and many studies now suggest an Implementation important role for positive rumination in the of Adaptive Strategies onset of manic episodes. Indeed, it is possi- Whereas the majority of studies discussed in ble that acute mood state plays an important the previous section used self-r eport to exam- role here, with patients with BD in a depres- ine the frequency of use of different emotion sive episode resembling patients with MDD regulation strategies, other studies have in their use of rumination and reduced use focused on whether affective disorders are of reappraisal. At the same time, positive characterized by less effective implementa- rumination when experiencing hypomania tion of adaptive strategies. These researchers may play a critical role in the onset of manic typically instruct participants to use a strat- episodes (Johnson, 2005). Other studies egy such as reappraisal during an emotion- have shown that participants with BD delib- eliciting event, then assess affect, as well as erately choose self-calming strategies during psychophysiological indicators of arousal, early phases of hypomania to try to prevent before and after the use of the strategy. the emergence of manic symptoms (Lam & Wong, 1997). The use of other emotion Distraction regulation strategies in BD, however, has Perhaps the best studied adaptive strategy either not been studied or studies have led to in depression is distraction. Distraction is inconclusive results. It should be noted that frequently used as a control condition in BD is also characterized by irritable affect, rumination studies, and many studies have yet no studies have examined the relation of shown that distraction seems to regulate this aspect of the disorder to emotion regula- affect effectively in depressed participants tion. (see Nolen-Hoeksema et al., 2008, for a review). Whereas depressed participants It is further important to note that most instructed to ruminate show increased nega- studies reviewed here examine individuals tive affect and recall of negative memories, who are currently in episode. It is not clear, those instructed to distract do not differ therefore, whether the use of maladaptive from the control group on these measures. strategies precedes the onset of the disor- For example, in a study that examined the der or is merely another symptom of being recall of positive memories in depression, depressed or manic. Gaining more insight currently and formerly depressed partici- into whether the use of emotion regulation pants did not differ from control partici- strategies is a vulnerability factor will be pants in their affect recovery after a nega- important for intervention and prevention tive mood induction that was followed by programs. In addition, we should note that a distraction induction (Joormann, Siemer the majority of studies of habitual strategy & Gotlib, 2007). Thus, studies suggest use are cross-sectional and have relied on that depressed participants are able to use self-report only. This is problematic, because distraction to regulate negative affect effec- it is not clear to what extent people can accu- tively. Research on the use of distraction in rately report on their use of strategies, and BD is currently nonexistent. the self-r eport of emotion regulation may be affected by current mood state. More stud- ies that examine strategy use in response to a mood manipulation (e.g., Ehring et al. 2010) are clearly needed. Importantly, it is
420 PSYCHOPATHOLOGY ness of reappraisal. Reappraisal, initiated Reappraisal once an emotional response is underway Only a handful of studies has examined the (often referred to as online reappraisal), effectiveness of reappraisal in affective dis- appears to be more difficult to implement orders, and results are much more mixed. and more cognitively taxing than anticipa- Indeed, to our knowledge, no study thus tory reappraisal or other strategies, such as far has examined whether current MDD is distraction, implemented at early processing associated with less effective reappraisal use. stages of an emotional episode (Sheppes & Troy, Wilhelm, Shallcross and Mauss (2010) Meiran, 2007; Sheppes, Catran, & Meiran, recruited a nonclinical sample of individu- 2009; Urry, 2009). Online reappraisal may als who had recently experienced a stressful be particularly important to examine in life event and found that elevated depression MDD. Given the persistent negative affect symptoms were related to less effective reap- characterizing this disorder, individuals with praisal in response to an emotion-eliciting depression are likely to need to implement film clip. Similarly, McRae, Jacobs, Ray, emotion regulation strategies in response to John, and Gross (2012) reported that indi- an existing emotional state of relatively high viduals with lower well-being (composite of intensity. If implemented online, reappraisal lower positive affect, higher negative affect, probably requires levels of cognitive control and lower life satisfaction) exhibited reduced that may not be available to people with effectiveness of reappraisal in response to affective disorders. This may explain the negative emotional pictures, and that per- mixed findings on the effectiveness of reap- formance on this task was related to reduced praisal in mood disorders. We discuss this habitual use of reappraisal. Thus, this study point in more detail later, when we examine suggests a relation between the effectiveness cognitive processes that underlie effective of strategies and habitual strategies use as emotion regulation. proposed earlier. In contrast, Ehring et al. (2010) reported that even though formerly Mood‑Incongruent Recall depressed participants were less likely to Other studies have examined the recall of endorse the use of reappraisal on self-report, mood-incongruent material in depression they did not differ from the control group (Joormann et al., 2007). In these studies, in their ability to use reappraisal effectively participants did not receive explicit instruc- when explicitly instructed to do so. Indeed, tions to regulate affect. Instead, they were these authors summarized their results informed that the project examined memory by saying that formerly depressed partici- processes and were asked to recall mood- pants choose ineffective strategies but can incongruent memories (i.e., recall of a posi- use more functional ones if so instructed. tive autobiographical memory) immediately Given that no studies have examined reap- following a negative mood induction. Recall praisal effectiveness in current depression, of mood-incongruent memories was com- however, it is unclear whether this result is pared to a distraction condition. The results specific to a previously depressed sample or showed that not only dysphoric but also would generalize to current depression. Very currently depressed and formerly depressed few studies have looked at the effectiveness participants compared to controls did not of different emotion regulation strategies experience a recovery of their negative affect in BD. A noteworthy exception is the pre- when recalling mood-incongruent memories viously mentioned study by Gruber et al. (see also Werner-S eidler & Moulds, 2012). (2012), who found that participants with Distraction, however, repaired negative BD reported more effort when using reap- affect in all groups. These results suggest praisal and suppression but also less success. that depression is associated with an inabil- It should be noted, however, that effort and ity to focus on positive material to offset success were assessed using two self-report negative affect, which may be an important items; these results therefore clearly require automatic mood repair mechanism. The replication using alternative operationaliza- results are well aligned with the aforemen- tions of these constructs. tioned finding that depression is associated with reduced savoring after experiencing Flexibility of use and the timing over the positive events. course of an emotional response are key variables that may influence the effective-
Emotion Regulation in Mood Disorders 421 Summary of€Strategy€Implementation Cognitive Processes and€Difficulties In summary, the studies presented so far in€Emotion€Regulation suggest that affective disorders are associ- Cognitive€Biases ated with more frequent use of maladap- Individual differences in cognitive processes tive strategies, as well as difficulties imple- such as attention, memory, and interpre- menting adaptive strategies. Specifically, tation may affect the attention toward even though distraction seemed to work emotion-Âe
422 PSYCHOPATHOLOGY to inflexible, automatic, and unconscious 2010; Goeleven, De Raedt, Baert, & Koster, appraisals that make it difficult to regulate 2006). These findings suggest that depres- emotions by using deliberate reappraisal of sion involves difficulties keeping irrelevant the situation (Siemer & Reisenzein, 2007). emotional information from entering WM. Whereas some studies have failed to find Other studies suggest that depression is also attentional biases in depression, others associated with difficulties removing previ- suggest that stimulus exposure duration is ously relevant negative material from WM critical (e.g., Mogg, Bradley, Williams, & (Joormann & Gotlib, 2008). Difficulties Mathews, 1993). Specifically, biases have inhibiting the processing of negative mate- been found when stimuli are presented for rial that was, but is no longer, relevant might longer durations (see Mathews & MacLeod, explain why people respond to negative 2005, for a review). Recent studies therefore mood states and negative life events with suggest that depressed individuals do not recurring, uncontrollable, and unintentional direct their attention to negative informa- negative thoughts. tion more frequently than do control partic- ipants, but once it captures their attention, It is likely that deficits in cognitive con- they exhibit difficulties disengaging from it trol not only affect people’s ability to disen- (e.g., Joormann & Gotlib, 2007). Difficul- gage attention from irrelevant material but ties disengaging from negative material may also make it difficult for them intentionally result in maintenance of attention on mood- to forget unwanted material. Investigators congruent information, which may eventu- have consistently documented such memory ally lead to recurrent ruminative thoughts. biases in depression. Deficits in inhibition have been tested in directed forgetting tasks, Cognitive Control in which participants are instructed to for- In addition to cognitive biases, depression- get previously studied material at some point related deficits in cognitive control may during the experiment. Later, however, affect emotion regulation (see Figure 25.1). recall is tested, of both material that was to Negative mood is generally associated with be remembered and material that was to be the activation of mood-congruent represen- forgotten. Using emotional material, Power, tations in working memory (Siemer, 2005). Dalgleish, Claudio, Tata, and Kentish (2000) The ability to control the contents of work- reported that depressed participants showed ing memory (WM) might therefore play an less forgetting of negative material. Using important role in recovery from negative a similar task with depressed participants, affect. WM is a limited-capacity system Joormann, Hertel, LeMoult, and Gotlib that reflects the focus of attention and the (2009) replicated these difficulties in the temporary activation of representations intentional forgetting of negative material. that are the content of awareness. Cognitive A subset of participants, however, was pro- inhibition is part of executive control pro- vided a strategy to improve suppression by cesses that select and update WM content using thought substitutes. In this condition (Hasher, Zacks, & May, 1999). Deficits in depressed participants were able to inhibit cognitive inhibition may make it difficult to and forget negative words. This finding has discard mood-congruent content from WM, intriguing implications for interventions. keeping attention focused on the emotion- eliciting aspects and the initial appraisals of Deficits in disengaging attention from the event. The effectiveness of distraction negative material and difficulties controlling and reappraisal may directly depend on the the content of WM may affect emotion regu- ability to inhibit mood-congruent content in lation in various ways. An inability to appro- WM, and difficulties with inhibition may priately expel mood-congruent items from result in rumination. WM as they become irrelevant may result in rumination. Deficits in cognitive control In a series of studies using a negative may also lead to difficulties attending to and priming task, dysphoric participants, clini- processing new information, thereby hin- cally depressed participants, and partici- dering the use of more adaptive strategies. pants with a history of depressive episodes Effective reappraisal, for example, depends exhibited reduced inhibition of negative but on a person’s ability to override (automatic) not positive material (Joormann & Gotlib, interpretation biases that lead to unwanted appraisals of the emotion-eliciting cues. Replacing automatic appraisals with alter-
Emotion Regulation in Mood Disorders 423 native evaluations of the situation requires so more work is needed to clarify further the cognitive control. Finally, deficits in cogni- role of suppression–avoidance and accep- tive control can make it difficult to access tance in both disorders, as well as the role mood-incongruent material. People fre- of reappraisal in BD. Given methodological quently recruit pleasant memories to repair issues associated with the use of self-report sad mood. Difficulties inhibiting salient but in research on emotion regulation, future irrelevant thoughts could therefore reduce studies should include additional measures the use of more effective emotion regulation such as experience sampling or experimental strategies and/or render these strategies less manipulations of mood to understand strat- effective. Few studies so far have investigated egy selection better in affective disorders. the association between inhibition and the use and effectiveness of emotion regulation Fewer studies have examined difficulties strategies such as reappraisal and distrac- in the implementation of adaptive strate- tion. Numerous findings, however, support gies. Initial findings suggest that whereas the proposition that inhibition deficits are depressed participants can use distraction related to the use of increased rumination. effectively, reappraisal is more challenging. For example, Joormann (2006) reported a Importantly, studies suggest that depression correlation between rumination and defi- is associated with difficulties using positive cits in cognitive inhibition, as assessed by material to offset negative affect. Whereas negative priming, and Joormann and Gotlib some studies suggest that these difficulties (2008) found a correlation between rumi- in strategy implementation do not just char- nation and the ability to remove irrelevant acterize currently depressed participants, negative material from WM. Finally, Joor- more research is needed on the question of mann and Gotlib (2010) reported that an whether we find similar deficits prior to the inability to inhibit the processing of negative first episode of the disorder, and whether material was related to an increased likeli- these difficulties predict future episodes of hood of rumination and a decreased likeli- depression or mania. Specifically, longitudi- hood of using reappraisal, in both healthy nal studies in high-risk samples are needed and depressed participants. to answer the important question of whether these difficulties in emotion regulation are Summary and Future Directions indeed a risk factor for the onset of the dis- Given that sustained affective states are the order or simply an epiphenomenon of mood hallmark feature of mood disorders, basic disorders. research on the regulation of mood states and emotions provides important informa- We further examined cognitive processes tion for an improved understanding of risk that may underlie difficulties in emotion factors for the development and mainte- regulation. Biased processing in depres- nance of MDD and BD. Research on emo- sion may affect the initial appraisal of an tion regulation may thereby contribute to emotion-eliciting event, as well as the abil- the development of improved prevention and ity to reappraise. Cognitive control defi- intervention efforts. Our review of the litera- cits may affect response-focused strategies ture provides evidence of the importance of such as distraction and online reappraisal both aspects of emotion regulation presented (see Figure 25.1). Whereas both strategies at the beginning of this chapter: individual require cognitive control, online reappraisal differences in the habitual use of specific is frequently seen as the more effortful strat- emotion regulation strategies and disorder- egy, which may explain why distraction related difficulties in the implementation works but reappraisal may fail in depressed of adaptive strategies. Specifically, MDD is participants. Importantly, recent work by associated with frequent use of rumination Sheppes, Scheibe, Suri, and Gross (2011) has and less use of reappraisal. BD is also related shown that reappraisal becomes more dif- to increased rumination use, although, inter- ficult when affect is intense, and that non- estingly, in response to positive and negative disordered participants prefer distraction events. Results for other emotion regulation over reappraisal when dealing with intense strategies were either missing or inconsistent, emotions. As discussed, mood disorders are associated with deficits in cognitive con- trol, and emotion regulation in these disor- ders frequently requires modifying intense affective states. Indeed, Sheppes and Gross
424 PSYCHOPATHOLOGY (2011) have pointed out that engaging emo- and cognitive control training seem particu- tion regulation strategies at a later point in larly promising. Most of these studies have the emotion episode typically results in the involved anxiety disorders, but at least two regulation of more intense affect. Mood dis- recent articles provide encouraging data to orders probably involve many attempts at indicate that training to modify attention regulation of high-intensity affect at later biases may also apply to depression (Wells & points in time, because they frequently Beevers, 2010; Baert, Koster, & De Raedt, require the regulation of global moods with 2011). Other studies have focused on modi- unclear or unknown antecedents. It is there- fying memory and interpretation biases, but fore not surprising that reappraisal is diffi- these trainings have not yet been tested with cult to implement in mood disorders. Future depressed participants (Raes, Williams, & research should focus more on identifying Hermans, 2009). Of special importance is differences between emotion and mood reg- a recent study that showed improvement in ulation, and on implications of these differ- cognitive control after training in executive ences for affective disorders. control. Specifically, cognitive control train- ing yielded transferable gains to improve Most studies on emotion regulation have control over affective stimuli (Schweizer, focused on the down-regulation of negative Hampshire, & Dalgleish, 2011). A similar affect, but our review of the literature shows training showed effects on thought control that the processing of mood-congruent over intrusive memories (Bomyea & Amir, material and the regulation of positive affect 2011). These findings are exciting and repre- may also play an important role in mood sent first steps toward a more comprehensive disorders, specifically in BD. Difficulties model of how cognitive factors facilitate or savoring positive events and recalling posi- hinder emotion regulation, thereby affect- tive material when feeling sad, however, ing individuals’ vulnerability to experience may also play a role in MDD. Therefore, the depressive episodes. down-regulation of negative affect seems a very narrow focus, and studies in BD and At this point, however, a lot of questions depression should pay more attention to the remain unanswered. Why do people diag- regulation of positive affect. In addition, at nosed with affective disorders prefer certain numerous points during the chapter, we have emotion regulation strategies, and are they recommended flexibility in the use of emo- aware of these preferences? How do people tion regulation strategies as an important learn to use these strategies, and how can we topic for future studies. Very few studies help them unlearn them? Are individual dif- examining affective disorders have assessed ferences in attention, interpretation, mem- more than one strategy, and it is currently ory, and cognitive control indeed related to not known whether the primary problem the selection and effectiveness of regulation in emotion regulation in these disorders is strategies? Does modifying cognitive biases inflexibility or of habitual use of a specific and cognitive control affect emotional strategy, or difficulties implementing a strat- responding, stress reactivity, and emotion egy. regulation? Are the outlined associations among depression, cognitive processes, and Finally, there are some important treat- emotion regulation specific to depressive ment implications of research on emotion disorders or a feature of psychopathology in regulation in mood disorders. Cognitive- general? These and other questions should behavioral therapy has focused on the iden- be the main focus of future studies in this tification and modification of maladaptive exciting area of research. A deeper under- cognitions, and recent additions to this standing of the ways that cognitive pro- intervention have started to focus more sys- cesses help and hinder emotion regulation tematically on training reappraisal skills and may allow us to better address some of the preventing emotional avoidance (Campbell- difficulties depressed individuals encounter Sills & Barlow, 2007). If inflexibility is in developing new and more flexible ways a problem, it may be helpful to develop a of thinking, a central goal of cognitive ther- broader repertoire of strategies and to iden- apy. Understanding the relation of cognitive tify habitual emotion regulation strategies. processes and emotion regulation may also Given the earlier discussion of cognitive help us understand how we can get these processes that underlie emotion regulation, new ways of thinking to “stick” and lead to recent studies on cognitive bias modification
Emotion Regulation in Mood Disorders 425 permanent changes in emotional response, regulation and vulnerability to depression: facilitating the use of these new skills in the Spontaneous versus instructed use of emotion face of stress. suppression and reappraisal. Emotion, 10(4), 563–572. References Feldman, G. C., Joormann, J., & Johnson, S. L. (2008). Responses to positive affect: A self- Aldao, A., & Nolen-H oeksema, S. (2012). When report measure of rumination and dampen- are adaptive strategies most predictive of psy- ing. Cognitive Therapy and Research, 32(4), chopathology? Journal of Abnormal Psychol- 507–525. ogy, 121(1), 276–281. Garnefski, N., & Kraaij, V. (2006). Cogni- tive Emotion Regulation Questionnaire— Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. development of a short 18-item version (2010). Emotion-regulation strategies across (CERQ-short). Personality and Individual psychopathology: A meta-analytic review. Differences, 41(6), 1045–1053. Clinical Psychology Review, 30(2), 217–237. Garnefski, N., Legerstee, J., Kraaij, V., van den Kommer, T., & Teerds, J. (2002). Cognitive Alloy, L. B., Abramson, L. Y., Flynn, M., Liu, coping strategies and symptoms of depres- R. T., Grant, D. A., Jager-Hyman, S., et al. sion and anxiety: A comparison between ado- (2009). Self-focused cognitive styles and bipo- lescents and adults. Journal of Adolescence, lar spectrum disorders: Concurrent and pro- 25(6), 603–611. spective associations. International Journal of Goeleven, E., De Raedt, R., Baert, S., & Koster, Cognitive Therapy, 2(4), 354–372. E. H. W. (2006). Deficient inhibition of emo- tional information in depression. Journal of Baert, S., Koster, E. H. W., & De Raedt, R. Affective Disorders, 93(1–3), 149–157. (2011). Modification of information process- Green, M. J., Lino, B. J., Hwang, E. J., Sparks, ing biases in emotional disorders: Clinically A., James, C., & Mitchell, P. B. (2011). Cogni- relevant developments in experimental psy- tive regulation of emotion in bipolar I disorder chopathology. International Journal of Cog- and unaffected biological relatives. Acta Psy- nitive Therapy, 4(2), 208–222. chiatrica Scandinavica, 124(4), 307–316. Gross, J. J. (1998). Antecedent- and response- Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, focused emotion regulation: Divergent con- G. (1979). Cognitive therapy of depression: A sequences for experience, expression, and treatment manual. New York: Guilford Press. physiology. Journal of Personality and Social Psychology, 74, 224–237. Bomyea, J., & Amir, N. (2011). The effect of Gross, J. J. (this volume, 2014). Emotion regula- an executive functioning training program tion: Conceptual and empirical foundations. on working memory capacity and intrusive In J. J. Gross (Ed.), Handbook of emotion thoughts. Cognitive Therapy and Research, regulation (2nd ed., pp. 3–20). New York: 35(6), 529–535. Guilford Press. Gross, J. J., & John, O. P. (2003). Individual dif- Bonanno, G. A., Papa, A., Lalande, K., West- ferences in two emotion regulation processes: phal, M., & Coifman, K. (2004). The impor- Implications for affect, relationships, and tance of being flexible. Psychological Science, well-being. Journal of Personality and Social 15, 482–487. Psychology, 85(2), 348–362. Gruber, J. (2011). Can feeling too good be bad?: Campbell-Sills, L., & Barlow, D. H. (2007). Positive emotion persistence (PEP) in bipolar Incorporating emotion regulation into con- disorder. Current Directions in Psychological ceptualizations and treatments of anxiety and Science, 20(4), 217–221. mood disorders. In J. J. Gross (Ed.), Hand- Gruber, J., Eidelman, P., Johnson, S. L., Smith, book of emotion regulation (pp. 542–559). B., & Harvey, A. G. (2011). Hooked on a feel- New York: Guilford Press. ing: Rumination about positive and negative emotion in inter-episode bipolar disorder. Campbell-S ills, L., Barlow, D. H., Brown, T. A., Journal of Abnormal Psychology, 120(4), & Hofmann, S. G. (2006). Acceptability and 956–961. suppression of negative emotion in anxiety Gruber, J., Harvey, A. G., & Gross, J. J. (2012). and mood disorders. Emotion, 6(4), 587–595. When trying is not enough: Emotion regula- D’Avanzato, C., Joormann, J., Siemer, M., & Gotlib, I. H. (2013). Emotion regulation in depression and anxiety: Examining diagnos- tic specificity and stability. Cognitive Therapy and Research. [E-publication prior to print] Ehring, T., Tuschen-Caffier, B., Schnülle, J., Fischer, S., & Gross, J. J. (2010). Emotion
426 PSYCHOPATHOLOGY tion and the effort–success gap in bipolar dis- lib, I. H. (2009). Training forgetting of nega- order. Emotion, 12(5), 997–1003. tive material in depression. Journal of Abnor- Gruber, J., Harvey, A. G., & Johnson, S. L. mal Psychology, 118(1), 34–43. (2009). Reflective and ruminative process- Joormann, J., Siemer, M., & Gotlib, I. H. (2007). ing of positive emotional memories in bipo- Mood regulation in depression: Differential lar disorder and healthy controls. Behaviour effects of distraction and recall of happy mem- Research and Therapy, 47(8), 697–704. ories on sad mood. Journal of Abnormal Psy- Hallion, L. S., & Ruscio, A. M. (2011). A meta- chology, 116(3), 484–490. analysis of the effect of cognitive bias modifi- Kashdan, T. B., & Rottenberg, J. (2010). Psy- cation on anxiety and depression. Psychologi- chological flexibility as a fundamental aspect cal Bulletin, 137(6), 940–958. of health. Clinical Psychology Review, 30(4), Hasher, L., Zacks, R. T., & May, C. P. (1999). 467– 480. Inhibitory control, circadian arousal, and age. Kessler, R. C., & Wang, P. S. (2009). Epidemi- In D. Gopher & A. Koriat (Eds.), Attention ology of depression. In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression and performance XVII: Cognitive regulation (2nd ed., pp. 5–22). New York: Guilford Press. Kim, S., Yu, B. H., Lee, D. S., & Kim, J.-H. of performance: Interaction of theory and (2012). Ruminative response in clinical application (pp. 653–675). Cambridge, MA: patients with major depressive disorder, bipo- MIT Press. lar disorder, and anxiety disorders. Journal of John, O. P., & Gross, J. J. (2004). Healthy and Affective Disorders, 136(1–2), e77–e81. unhealthy emotion regulation: Personality Lam, D., & Wong, G. (1997). Prodromes, cop- processes, individual differences, and life span ing strategies, insight and social functioning development. Journal of Personality, 72(6), in bipolar affective disorders. Psychological 1301–1333. Medicine, 27(5), 1091–1100. Johnson, S. L. (2005). Mania and dysregulation Lawson, C., MacLeod, C., & Hammond, G. in goal pursuit: A review. Clinical Psychology (2002). Interpretation revealed in the blink Review, 25(2), 241–262. of an eye: Depressive bias in the resolution of Johnson, S. L., McKenzie, G., & McMurrich, S. ambiguity. Journal of Abnormal Psychology, (2008). Ruminative responses to negative and 111(2), 321–328. positive affect among students diagnosed with Liverant, G. I., Brown, T. A., Barlow, D. H., bipolar disorder and major depressive disor- & Roemer, L. (2008). Emotion regulation in der. Cognitive Therapy and Research, 32(5), unipolar depression: The effects of acceptance 702–713. and suppression of subjective emotional expe- Joormann, J. (2006). Differential effects of rumi- rience on the intensity and duration of sadness nation and dysphoria on the inhibition of and negative affect. Behaviour Research and irrelevant emotional material: Evidence from a Therapy, 46(11), 1201–1209. negative priming task. Cognitive Therapy and Liverant, G. I., Kamholz, B. W., Sloan, D. M., Research, 30(2), 149–160. & Brown, T. A. (2011). Rumination in clini- Joormann, J. (2010). Cognitive inhibition and cal depression: A type of emotional suppres- emotion regulation in depression. Current sion? Cognitive Therapy and Research, 35(3), Directions in Psychological Science, 19(3), 253–265. 161–166. Lyubomirsky, S., & Nolen-H oeksema, S. (1993). Joormann, J., & Gotlib, I. H. (2007). Selective Self-perpetuating properties of dysphoric attention to emotional faces following recov- rumination. Journal of Personality and Social ery from depression. Journal of Abnormal Psychology, 65(2), 339–349. Psychology, 116(1), 80–85. Mathews, A., & MacLeod, C. (2005). Cognitive Joormann, J., & Gotlib, I. H. (2008). Updating vulnerability to emotional disorders. Annual the contents of working memory in depres- Review of Clinical Psychology, 1(1), 167–195. sion: Interference from irrelevant negative McRae, K., Jacobs, S. E., Ray, R. D., John, O. material. Journal of Abnormal Psychology, P., & Gross, J. J. (2012). Individual differences 117(1), 182–192. in reappraisal ability: Links to reappraisal Joormann, J., & Gotlib, I. H. (2010). Emotion frequency, well-being, and cognitive control. regulation in depression: Relation to cognitive Journal of Research in Personality, 46(1), 2–7. inhibition. Cognition and Emotion, 24(2), Mogg, K., Bradley, B. P., Williams, R., & 281–298. Joormann, J., Hertel, P. T., LeMoult, J., & Got-
Emotion Regulation in Mood Disorders 427 Mathews, A. (1993). Subliminal process- self-c ontrol effort. International Journal of ing of emotional information in anxiety and Psychophysiology, 71(2), 91–96. depression. Journal of Abnormal Psychology, Sheppes, G., & Gross, J. J. (2011). Is timing 102(2), 304–311. everything? Temporal considerations in emo- Nezlek, J. B., & Kuppens, P. (2008). Regulating tion regulation. Personality and Social Psy- positive and negative emotions in daily life. chology Review, 15(4), 319–331. Journal of Personality, 76(3), 561–579. Sheppes, G., & Meiran, N. (2007). Better late Nolen-H oeksema, S. (2000). Further evidence than never?: On the dynamics of online regu- for the role of psychosocial factors in depres- lation of sadness using distraction and cogni- sion chronicity. Clinical Psychology: Science tive reappraisal. Personality and Social Psy- and Practice, 7(2), 224–227. chology Bulletin, 33(11), 1518–1532. Nolen-Hoeksema, S., Wisco, B. E., & Lyu- Sheppes, G., Scheibe, S., Suri, G., & Gross, J. J. bomirsky, S. (2008). Rethinking rumination. (2011). Emotion-regulation choice. Psycholog- Perspectives on Psychological Science, 3(5), ical Science, 22(11), 1391–1396. 400 – 424. Siemer, M. (2005). Mood-congruent cognitions Papageorgiou, C., & Wells, A. (2001). Positive constitute mood experience. Emotion, 5(3), beliefs about depressive rumination: Devel- 296–308. opment and preliminary validation of a self- Siemer, M., & Reisenzein, R. (2007). The pro- report scale. Behavior Therapy, 32(1), 13–26. cess of emotion inference. Emotion, 7, 1–20. Power, M. J., Dalgleish, T., Claudio, V., Tata, P., Solomon, A. (2001). The noonday demon. New & Kentish, J. (2000). The directed forgetting York: Scribner. task: Application to emotionally valent mate- Teasdale, J. D. (1988). Cognitive vulnerability rial. Journal of Affective Disorders, 57(1–3), to persistent depression. Cognition and Emo- 147–157. tion, 2(3), 247–274. Raes, F., Smets, J., Nelis, S., & Schoofs, H. Thomas, J., & Bentall, R. P. (2002). Hypomanic (2012). Dampening of positive affect prospec- traits and response styles to depression. Brit- tively predicts depressive symptoms in non- ish Journal of Clinical Psychology, 41(3), clinical samples. Cognition and Emotion, 309–313. 26(1), 75–82. Thomas, J., Knowles, R., Tai, S., & Bentall, R. P. Raes, F., Williams, J. M. G., & Hermans, D. (2007). Response styles to depressed mood in (2009). Reducing cognitive vulnerability to bipolar affective disorder. Journal of Affective depression: A preliminary investigation of Disorders, 100(1–3), 249–252. MEmory Specificity Training (MEST) in inpa- Troy, A. S., Wilhelm, F. H., Shallcross, A. J., & tients with depressive symptomatology. Jour- Mauss, I. B. (2010). Seeing the silver lining: Cognitive reappraisal ability moderates the nal of Behavior Therapy and Experimental relationship between stress and depressive Psychiatry, 40(1), 24–38. symptoms. Emotion, 10(6), 783–795. Ray, R. D., McRae, K., Ochsner, K. N., & Gross, Urry, H. L. (2009). Using reappraisal to regu- J. J. (2010). Cognitive reappraisal of negative late unpleasant emotional episodes: Goals and affect: Converging evidence from EMG and timing matter. Emotion, 9(6), 782–797. self-report. Emotion, 10(4), 587–592. Watkins, E., & Moulds, M. (2005). Distinct Richards, J. M., & Gross, J. J. (2000). Emotion modes of ruminative self-focus: Impact of regulation and memory: The cognitive costs of abstract versus concrete rumination on prob- keeping one’s cool. Journal of Personality and lem solving in depression. Emotion, 5(3), Social Psychology, 79(3), 410–424. 319–328. Schweizer, S., Hampshire, A., & Dalgleish, Wells, T. T., & Beevers, C. G. (2010). Biased T. (2011). Extending brain-training to the attention and dysphoria: Manipulating selec- affective domain: Increasing cognitive and tive attention reduces subsequent depressive affective executive control through emotional symptoms. Cognition and Emotion, 24(4), working memory training. PLoS ONE, 6(9), 719–728. e24372. Werner-Seidler, A., & Moulds, M. L. (2012). Sheppes, G., Catran, E., & Meiran, N. (2009). Mood repair and processing mode in depres- Reappraisal (but not distraction) is going to sion. Emotion, 12(3), 470–478. make you sweat: Physiological evidence for
Chapter 26 Emotion Regulation in Substance Use Disorders Hedy Kober Have you ever had coffee or tea? A glass of drug cravings, as well as further drug use. wine? Smoked even a single cigarette? Virtu- As such, loss of regulatory control is a key ally all adults report consuming psychoac- feature of SUDs. The addition of drug crav- tive drugs1 at some point in their lives, sug- ing (strong desire for drugs) as a diagnostic gesting that casual drug use is quite common criterion for SUDs in DSM-5 emerged from (Substance Abuse and Mental Health Ser- a wealth of accumulated research over the vices Administration [SAMHSA], 2011). On last decade directly linking craving to drug the other end of the drug use spectrum, sub- use and relapse (return to drug use follow- stance use disorders (SUDs; or addictions) ing abstinence; e.g., Shiffman et al., 2013; are complex illnesses, encompassing a host see later sections for additional discussion). of severe negative physical, economic, and This suggests that craving is also a key fea- social consequences, and contributing to ture in SUDs, and that regulation of craving worldwide disability. With a lifetime preva- is a specific form of emotion regulation that lence of 35.3% in the general population, can directly reduce drug use. individuals with SUDs constitute a relatively small proportion of casual drug users, yet This chapter focuses on the crucial and they also represent the most prevalent and complex role of emotion regulation in SUDs costly of psychiatric disorders (National (see Figure 26.1 for a schematic summary). Institute of Mental Health [NIMH], 2007; In the first section, I discuss the role of acute SAMHSA, 2011). drug intoxication as a means of emotion regulation, arguing specifically that people Defined as “a problematic pattern of drug use drugs in part to regulate their current use, leading to clinically significant impair- emotional state. This may include increasing ment or distress” (American Psychiatric positive affect, ameliorating a preexisting Association, 2013, p. 481), SUDs are both negative state, or decreasing craving. In the personally and socially devastating in that next section, I explore the role of emotion they are often chronic and can severely impair dysregulation in SUDs, both as a possible even basic life functioning. In the fifth edi- cause for and a possible consequence of drug tion of the Diagnostic and Statistical Man- use. In this section, I make several specific ual of Mental Disorders (DSM-5), SUDs are arguments. First, I argue that emotion dys- characterized by the presence of symptoms regulation in childhood and adolescence may including tolerance, withdrawal, continued be an early risk factor and/or distal causal use despite wishes to stop, continued use factor in the later development of SUDs. Sec- despite known negative consequences, and ond, I argue that an inability to effectively importantly, a loss of regulatory control over regulate emotions in specific moments may 428
Emotion Regulation in Substance Use Disorders 429 A. Before SUD B. With SUD PFC Drugs PFC Drugs Regulation Emotion Negative Appetitive Negative Appetitive (high, craving) (craving) FIGURE 26.1. A simplified model of emotion regulation in SUDs. Panel A: Before SUDs. Prefrontal cortex (PFC) and drugs can both serve to regulate emotion. It is thought that PFC implements regula- tion over negative emotion and craving (indicated by downward blunted arrows). In turn, unregulated negative emotion and craving are associated with increased drug use (upward arrows). Here I propose that drugs can be seen as a form of emotion regulation as well (indicated by downward blunted arrows), increasing feelings of high, and decreasing negative emotion and craving. In this context, deficient emo- tion regulation or PFC control may serve as risk factors for SUDs. Panel B: After development of SUDs. Chronic drug use affects PFC (indicated by blunted arrow), diminishing its ability to regulate negative emotion, as well as drug craving (dashed downward blunted arrows). In turn, unregulated negative emotion and craving further lead to increased drug use (upward arrows). Drug use itself continues to regulate both negative emotion and drug craving (though perhaps less effectively). This results in a vicious cycle of reduced PFC-based emotion regulation, negative affect, craving, and increased drug use. Therefore, treatments for SUDs often focus on enhancing emotion regulation skills, especially regulation of craving, which has been linked to reduced drug use. be a proximal causal factor for instances of cal profiles of individual drugs differ, and drug use in individuals who are already suf- these differences have both theoretical and fering from SUDs. Third, I posit that SUDs neurobiological implications (e.g., Badiani, are marked by deficits in regulation of a spe- Belin, Epstein, Calu, & Shaham, 2011), cific appetitive state, namely, drug craving, many drugs are ultimately described as which is at the core of these disorders. I then euphoric, increasing positive emotion (Jaffe review evidence that suggests differences in & Jaffe, 1989). In human laboratory experi- the structure and function of the prefrontal ments, self-administration of drugs, includ- cortex (PFC) may be the neural mechanisms ing alcohol, methamphetamine, cocaine, underlying emotion dysregulation in SUDs. and marijuana, significantly increase feel- This section further highlights that although ings of “high” and “good drug effects” (e.g., some PFC abnormalities may precede drug Hart, Ward, Haney, Foltin, & Fischman, use, the long-term effect of chronic drug use 2001; see Figure 26.1A). Consistently, it is on PFC may further impair emotion regula- has been proposed that these positive effects tion in SUDs. In this way, drug use may lead of drugs lead to positive reinforcement and to further emotion dysregulation. The chap- increase the likelihood of future drug use ter concludes with a section on treatments (Kober, Turza, & Hart, 2009). Further- for SUDs, many of which focus on increas- more, drug users often develop positive ing emotion regulation skills geared specifi- expectancies regarding drug use (e.g., “If I cally toward regulation of craving as means drink, I will feel good”) that are associated of reducing substance use. with increased drug use and increased risk of developing SUDs (e.g., Jones, Corbin, & Drug Use as Emotion Regulation Fromme, 2001). Drugs can regulate emotion by pharmaco- logically altering one’s current state. For In addition to increasing positive emo- example, although the exact pharmacologi- tion, various drugs are known to alleviate negative emotional states, including anxi- ety (e.g., alcohol, and anxiolytic medication such as Valium and Xanax), sadness and
430 PSYCHOPATHOLOGY depression (e.g., stimulants such as cocaine treatment for such comorbid disorders fre- and amphetamines), and pain (e.g., heroin, quently reduces drug use (Nunes & Levin, morphine, and other synthetic prescrip- 2004). Second, and similarly, those with tion opiates such as Vicodin). Consistently, chronic pain are far more likely to develop it has been proposed that these negativity- SUDs relative to the general, pain-free pop- reducing effects of drugs lead to negative ulation, especially to pain-reducing drugs reinforcement, thus increasing the likeli- such as opiates (Morasco et al., 2011). hood of future drug use (Koob & Le Moal, 2008). This idea was initially popularized Third, even normal-range trait levels of by the “self-m edication hypothesis” pro- negative affect are related to drug use. For posed by Khantzian (1985), which has two example, trait depression and neuroticism main components: (1) Unpleasant affective correlate negatively with time to relapse states predispose individuals to drug use, in cigarette smokers (Gilbert, Crauthers, and (2) the choice of drug is not random; Mooney, McClernon, & Jensen, 1999), rather, it is the nature of the drug’s effects while trait levels of anger and anxiety corre- in ameliorating the preexisting negative late with craving to drink in alcoholics (Litt, state that renders a particular drug more Cooney, & Morse, 2000). Fourth, negative or less reinforcing. In other words, those affective states are known triggers for crav- with a particular predisposition to negative ing in the context of both casual and prob- affect states are more likely to develop an lematic substance use (e.g., Shiffman, Paty, SUD for a drug that reverses those particu- Gnys, Kassel, & Hickcox, 1996). This phe- lar affective states. To illustrate, Khantzian nomenon ranges from the common epithet suggested that individuals with strong rage “I had such a hard day, I need a beer or a and aggression use opiate drugs to regu- stiff drink” to instances of relapse to drug late these emotions. In contrast, individu- use after experiencing a strong life stressor als with preexisting depression and melan- (e.g., death in family). Indeed, it has been choly develop cocaine use disorders due to well documented that both naturally occur- cocaine’s ability to relieve these symptoms. ring and experimentally induced negative The self-m edication hypothesis is consistent affect and stress increase drug craving, drug with patients’ reports that “they got hooked use, and relapse (e.g., Sinha & Li, 2007). not because they had taken the drug, but because they were not normal before in such Finally, drug use also serves to regulate a way that the drugs were . . . not the prob- the experience of craving, which is one of lem but a solution” (Le Moal, 2009, p. 542). the most common motivators for drug use It is further consistent with the observation (Childress et al., 1993; Shiffman et al., that the expectancy that drugs will allevi- 2013). That is, individuals with SUDs use ate negative affect (e.g., “Drinking will calm drugs to temporarily alleviate their experi- me down”) is associated with increased drug ence of craving, thus generating a vicious use and increased risk for SUDs (Jones et al., cycle of increasing craving and use. Taken 2001). together, the evidence reviewed in this sec- tion suggests that drug taking can be a form Although the self-m edication hypothesis of emotion regulation. Specifically, the acute has been challenged, several lines of evidence effects of drugs may regulate preexisting support the hypothesis that drug use serves emotions in both casual and problem drug to regulate negative emotion. First, SUDs users, including increasing positive emotion, frequently co-occur with a number of other decreasing negative emotion, and decreas- psychiatric disorders, especially mood and ing craving for drugs themselves (see Figure anxiety disorders. Moreover, preexisting 26.1A). psychiatric diagnoses increase the likelihood of an individual to subsequently develop an Emotion (dys)Regulation Is a Causal SUD (e.g., Kessler et al., 2005). This suggests Factor in SUDs that individuals who already experience dif- Although many people casually use drugs ficult emotions are more likely to seek and and alcohol, only a small percentage develop use drugs, and to develop problematic habits SUDs, highlighting the need to identify risk of drug use that presumably ameliorate their and causal factors for the initiation, develop- affective symptoms. A related point is that
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
- 499
- 500
- 501
- 502
- 503
- 504
- 505
- 506
- 507
- 508
- 509
- 510
- 511
- 512
- 513
- 514
- 515
- 516
- 517
- 518
- 519
- 520
- 521
- 522
- 523
- 524
- 525
- 526
- 527
- 528
- 529
- 530
- 531
- 532
- 533
- 534
- 535
- 536
- 537
- 538
- 539
- 540
- 541
- 542
- 543
- 544
- 545
- 546
- 547
- 548
- 549
- 550
- 551
- 552
- 553
- 554
- 555
- 556
- 557
- 558
- 559
- 560
- 561
- 562
- 563
- 564
- 565
- 566
- 567
- 568
- 569
- 570
- 571
- 572
- 573
- 574
- 575
- 576
- 577
- 578
- 579
- 580
- 581
- 582
- 583
- 584
- 585
- 586
- 587
- 588
- 589
- 590
- 591
- 592
- 593
- 594
- 595
- 596
- 597
- 598
- 599
- 600
- 601
- 602
- 603
- 604
- 605
- 606
- 607
- 608
- 609
- 610
- 611
- 612
- 613
- 614
- 615
- 616
- 617
- 618
- 619
- 620
- 621
- 622
- 623
- 624
- 625
- 626
- 627
- 628
- 629
- 630
- 631
- 632
- 633
- 634
- 635
- 636
- 637
- 638
- 639
- 640
- 641
- 642
- 643
- 644
- 645
- 646
- 647
- 648
- 649
- 650
- 651
- 652
- 653
- 654
- 655
- 656
- 657
- 658
- 659
- 660
- 661
- 662
- 663
- 664
- 665
- 666
- 667
- 668
- 669
- 670
- 671
- 672
- 673
- 674
- 675
- 676
- 677
- 678
- 679
- 680
- 681
- 682
- 683
- 684
- 685
- 686
- 687
- 688
- 689
- 1 - 50
- 51 - 100
- 101 - 150
- 151 - 200
- 201 - 250
- 251 - 300
- 301 - 350
- 351 - 400
- 401 - 450
- 451 - 500
- 501 - 550
- 551 - 600
- 601 - 650
- 651 - 689
Pages:
