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Mancinelli E, Cottu M, Salcuni S. Validation of the Difficulties in Emotion Regulation Scale-Short Form in a sample of Italian adolescents. J Clin Psychol 2024. [PMID: 38970816 DOI: 10.1002/jclp.23732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/09/2024] [Accepted: 06/26/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVE The primary objective of the present study is to validate the Difficulty in Emotion Regulation Scale-Short Form (DERS-SF) in a sample of Italian adolescents. Additionally, we aim to evaluate its factorial structure by examining the contribution of each subscale (i.e., Nonacceptance, Clarity, Awareness, Goals, Impulse, Strategy) on the general factor using bi-factor models by replicating a past study. METHOD The sample comprises N = 704 adolescents aged 11-17 years (M = 13.38, SD = 1.37; 53.12% females). To establish external validity, correlation and path analyses were conducted between the DERS-SF sub-scales, the total score, and measures of internalizing and externalizing symptoms, as well as Problematic Smartphone Use (PSU). Measurement invariance was tested comparing males versus females and pre-adolescents and adolescents. RESULTS Overall, results supported the multidimensional nature of the DERS-SF, confirming its original six-factor structure. However, bi-factor models analysis revealed that the Awareness subscale should be excluded when calculating the total score. Furthermore, findings indicated that the Strategy subscale variance is largely accounted for by the general factor rather than the specific subscale. In terms of external validity, significant positive associations between the DERS-SF sub-scales, the total score, and PSU, internalizing and externalizing symptoms were observed. Measurement invariance was supported. CONCLUSIONS Altogether, findings support the validity of the DERS-SF among Italian Adolescents and provide insights relevant to the understanding of the multifaceted facets of emotion regulation, emphasizing its relevance as a transdiagnostic process.
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Affiliation(s)
- Elisa Mancinelli
- Department of Developmental and Socialization Psychology, University of Padova, Padova, Italy
- Digital Health Lab, Centre for Digital Health and Wellbeing, Fondazione Bruno Kessler, Trento, Italy
| | - Manuela Cottu
- Department of Developmental and Socialization Psychology, University of Padova, Padova, Italy
| | - Silvia Salcuni
- Department of Developmental and Socialization Psychology, University of Padova, Padova, Italy
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Aspeqvist E, Andersson H, Korhonen L, Dahlström Ö, Zetterqvist M. Measurement and stratification of nonsuicidal self-injury in adolescents. BMC Psychiatry 2024; 24:107. [PMID: 38326791 PMCID: PMC10848387 DOI: 10.1186/s12888-024-05535-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/18/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Nonsuicidal self-injury (NSSI) is highly prevalent in adolescents. In survey and interview studies assessing NSSI, methods of assessment have been shown to influence prevalence estimates. However, knowledge of which groups of adolescents that are identified with different measurement methods is lacking, and the characteristics of identified groups are yet to be investigated. Further, only a handful of studies have been carried out using exploratory methods to identify subgroups among adolescents with NSSI. METHODS The performance of two prevalence measures (single-item vs. behavioral checklist) in the same cross-sectional community sample (n = 266, age M = 14.21, 58.3% female) of adolescents was compared regarding prevalence estimates and also characterization of the identified groups with lifetime NSSI prevalence. A cluster analysis was carried out in the same sample. Identified clusters were compared to the two groups defined using the prevalence measures. RESULTS A total of 118 (44.4%) participants acknowledged having engaged in NSSI at least once. Of these, a group of 55 (20.7%) adolescents confirmed NSSI on a single item and 63 (23.7%) adolescents confirmed NSSI only on a behavioral checklist, while denying NSSI on the single item. Groups differed significantly, with the single-item group being more severely affected and having higher mean scores on difficulties in emotion regulation, self-criticism, number of methods, higher frequency of NSSI, higher rates of suicidal ideation and suicidal behavior and lower mean score on health-related quality of life. All cases with higher severity were not identified by the single-item question. Cluster analysis identified three clusters, two of which fit well with the groups identified by single-item and behavioral checklist measures. CONCLUSIONS When investigating NSSI prevalence in adolescents, findings are influenced by the researchers' choice of measures. The present study provides some directions toward what kind of influence to expect given the type of measure used, both with regards to the size of the identified group and its composition. Implications for future research as well as clinical and preventive work are discussed.
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Affiliation(s)
- Erik Aspeqvist
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Hedvig Andersson
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Laura Korhonen
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Child and Adolescent Psychiatry, Region Östergötland, Linköping, Sweden
- Barnafrid, Swedish National Center on Violence Against Children, Linköping University, Linköping, Sweden
| | - Örjan Dahlström
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
- Athletics Research Center, Linköping University, Linköping, Sweden
| | - Maria Zetterqvist
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Child and Adolescent Psychiatry, Region Östergötland, Linköping, Sweden
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Espirito-Santo H, Paraíso L, Andrade D, Daniel F, Grasina A, Lemos L, Simões-Cunha L, Bjureberg J. Emotion dysregulation in older people: validity and reliability of an 8-item version of the Difficulties in Emotion Regulation Scale. Aging Ment Health 2024; 28:360-368. [PMID: 37771115 DOI: 10.1080/13607863.2023.2260329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/11/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVES The abbreviated 16-item version of the Difficulties with Emotion Regulation Scale (DERS-16) is widely used to assess individuals' perceived challenges in regulating their emotions, a central aspect of psychological symptoms commonly experienced in old age. However, its psychometric properties have yet to be tested in this population. Furthermore, a shorter version of the DERS-16 could further minimize the assessment burden on older individuals. Thus, we aimed to test the DERS-16's psychometric performance and determine if any items were redundant to develop a psychometrically sound shorter version. METHODS We enrolled 302 Portuguese older adults (Mage = 75.22; SD = 8.99 years) in a cross-sectional study. RESULTS Exploratory factor analyses indicated a one-factor structure and a four-factor solution with eight items (69.3%-81.9% of the variance observed). The four-factor-8-item solution presented an interpretable structure and demonstrated good reliability values (> 0.70) and construct validity with the Twenty-Item Toronto Alexithymia Scale, Eight-Item Geriatric Depression Scale, and Geriatric Anxiety Inventory (r = 0.66, 0.40, 0.52; p < 0.001). CONCLUSION The robust psychometric properties of DERS-8 make it a valuable tool for clinical and longitudinal studies, facilitating targeted interventions in older adults and allowing for precise emotion dysregulation screening.
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Affiliation(s)
- Helena Espirito-Santo
- Miguel Torga Higher Education Institute (ISMT), Coimbra, Portugal
- Center for Research in Neuropsychology and Cognitive and Behavioral Intervention (CINEICC), Coimbra University, Coimbra, Portugal
| | - Luís Paraíso
- Miguel Torga Higher Education Institute (ISMT), Coimbra, Portugal
| | - Diogo Andrade
- Miguel Torga Higher Education Institute (ISMT), Coimbra, Portugal
| | - Fernanda Daniel
- Miguel Torga Higher Education Institute (ISMT), Coimbra, Portugal
- Center for Research in Neuropsychology and Cognitive and Behavioral Intervention (CINEICC), Coimbra University, Coimbra, Portugal
| | | | - Laura Lemos
- Miguel Torga Higher Education Institute (ISMT), Coimbra, Portugal
| | - Luís Simões-Cunha
- Miguel Torga Higher Education Institute (ISMT), Coimbra, Portugal
- Research and Development Center of the Military University Institute, Miguel Torga Higher Education Institute (ISMT), Lisboa, Portugal
| | - Johan Bjureberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
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Rosharudin NA, Muhammad NA, Mohd Daud TI, Hoesni SM, Yusoff SR, Razman MOI, Mohd Ali M, Khairuddin KF, Mohd Kari DNP. Psychometric properties of the Malay version of the difficulties in Emotion Regulation Scale-18 in Malaysian adolescents. PLoS One 2023; 18:e0289551. [PMID: 37639447 PMCID: PMC10461853 DOI: 10.1371/journal.pone.0289551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 07/20/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE The Difficulties in Emotion Regulation Scale-18 (DERS-18) is an instrument used to measure deficits in emotion regulation. However, the instrument has not been adapted to Malaysians and has never been validated in the Malay language. This study aimed to examine the psychometric properties of the Malay version of DERS-18. METHOD The DERS-18 underwent forward-backward translation and assessment of face and content validity. Both Malay version of the DERS-18 and DASS-21 were completed by 701 adolescents (44.4% boys) aged 13 and 14 years old. To assess its dependability, a floor and ceiling effect evaluation and Cronbach's analysis were both performed. A series of confirmatory factor analyses (CFA), bivariate correlation, and regression were performed to evaluate the construct and criterion validity, respectively. RESULTS The Malay version of DERS-18, after excluding "Awareness", indicated excellent reliability (Cronbach's α = 0.93), and acceptable internal consistency for each subscale (range of α from 0.63 to 0.82). Floor or ceiling effects were observed at item level and subscale level, but not at total level. CFA results revealed that the Malay version of the DERS-18 bifactor model (excluding "Awareness") portrayed the best construct validity (χ2/df = 2.673, RMSEA = 0.049, CFI = 0.977, TLI = 0.968) compared to a single factor, a correlated factor, and a higher-order factor model. The DERS-18 subscales (except "Awareness") and DERS-18 total scores were significantly correlated with stress, anxiety, and depression in a positive direction (r ranged from 0.62 to 0.64, p < 0.01). The general factor of the DERS-18 and its specific factors ("Clarity", "Goals", and "Non-Acceptance") significantly predicted the symptoms of stress, anxiety, and depression (R2 ranged from 0.44 to 0.46, p < 0.001). CONCLUSION The Malay version of the DERS-18, excluding "Awareness", possessed good reliability, construct validity, and criterion validity to assess emotion dysregulation among Malaysian adolescents.
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Affiliation(s)
- Nur Afrina Rosharudin
- Centre for Research in Psychology and Human Well-Being, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| | - Noor Azimah Muhammad
- Department of Family Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Tuti Iryani Mohd Daud
- Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Suzana Mohd Hoesni
- Centre for Research in Psychology and Human Well-Being, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| | - Siti Rashidah Yusoff
- Centre for Research in Psychology and Human Well-Being, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| | - Mohamad Omar Ihsan Razman
- Centre for Research in Psychology and Human Well-Being, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| | - Manisah Mohd Ali
- Centre for Research in Education and Community Wellbeing, Faculty of Education, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| | - Khairul Farhah Khairuddin
- Centre for Research in Education and Community Wellbeing, Faculty of Education, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| | - Dharatun Nissa Puad Mohd Kari
- Department of Counselor Education and Counseling Psychology, Faculty of Educational Studies, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
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Visted E, Solbakken OA, Mæland S, Fadnes LT, Bjerrum LB, Nordhus IH, Flo-Groeneboom E. Validation of a brief version of the Difficulties in Emotion Regulation Scale (DERS-16) with an older Norwegian population. Eur J Ageing 2023; 20:26. [PMID: 37347324 DOI: 10.1007/s10433-023-00775-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 06/23/2023] Open
Abstract
Emotion regulation is proposed to have a salient role in optimal aging. However, currently used measures of emotion regulation have not been validated for older adults. Therefore, we evaluated the psychometric properties of the Difficulties in Emotion Regulation Scale-short form (DERS-16) in a large Norwegian sample consisting of individuals between 70 and 95 years (n = 2525). Tests of internal consistency, reliability, assessment of intra-domain correlations, and confirmatory factor analyses were performed. Construct validity was further investigated by assessing concurrent associations between DERS-16 and well-established measures of psychological disorders, psychological health, and well-being (five-item version of Geriatric Depression Scale, Geriatric Anxiety Inventory-short form, and OECD guidelines on measuring subjective well-being). All subscales derived from the instrument showed adequate internal consistency. Furthermore, we obtained a theoretically consistent factor structure, in which a bifactor model combining a general emotion regulation factor and five additional domain-specific facet-factors had superior model fit. As expected, difficulties in emotion regulation correlated positively with symptoms of depression and anxiety, and negatively with psychological health and well-being. Associations were generally of moderate strength. We can thus conclude that the DERS-16 demonstrates excellent psychometric properties when used in samples with older adults and may safely be employed in studies of emotion regulation difficulties in the older segment of our population.
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Affiliation(s)
- Endre Visted
- Department of Clinical Psychology, University of Bergen, Årstadveien 17, 5009, Bergen, Norway.
| | - O A Solbakken
- Department of Psychology, University of Oslo, P.O Box 1094, Blindern, 0317, Oslo, Norway
| | - S Mæland
- Department of Global Public Health and Primary Care, University of Bergen, P.O Box 7804, 5020, Bergen, Norway
| | - L T Fadnes
- Department of Global Public Health and Primary Care, University of Bergen, P.O Box 7804, 5020, Bergen, Norway
- Bergen Addiction Research, Department of Addiction Medicine, Haukeland University Hospital, 5021, Bergen, Norway
| | - L B Bjerrum
- Department of Clinical Psychology, University of Bergen, Årstadveien 17, 5009, Bergen, Norway
| | - I H Nordhus
- Department of Clinical Psychology, University of Bergen, Årstadveien 17, 5009, Bergen, Norway
| | - E Flo-Groeneboom
- Department of Clinical Psychology, University of Bergen, Årstadveien 17, 5009, Bergen, Norway
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Yeh YJ, Chen JH, Tsai W, Kimel S. Examining the Factor Structure and Measurement Invariance of the Difficulties in Emotion Regulation Scale Across Taiwanese and American University Students. JOURNAL OF PSYCHOEDUCATIONAL ASSESSMENT 2022. [DOI: 10.1177/07342829221113654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Difficulties in Emotion Regulation Scale (DERS) is a widely used measure of emotion dysregulation. However, limited research has examined its factor structure and measurement invariance in cross-national samples. The present study tested competing measurement models and the measurement invariance of the DERS in university student samples from the United States ( n = 324) and Taiwan ( n = 399). Results indicated that the bifactor model with the Awareness subscale items removed demonstrated the best fit. The results of model-based indices provided evidence for the general emotion dysregulation factor of the DERS. Cross-national measurement invariance testing found partial strong invariance. These findings indicate that DERS would best be used as a measure of general emotion dysregulation among college students in the United States and Taiwan. These findings emphasize that future work is needed to examine cross-national differences in the construct and assessment of emotion dysregulation.
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Affiliation(s)
- Yun-Jy Yeh
- Department of Psychology, Soochow University, Taipei, Taiwan
| | - Jyun-Hong Chen
- Department of Psychology, National Cheng-Kung University, Tainan, Taiwan
| | - William Tsai
- Department of Applied Psychology, New York University, New York, NY, USA
| | - Sasha Kimel
- Department of Psychology, California State University San Marcos, San Marcos, CA, USA
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Petersson S, Årestedt K, Birgegård A. Evaluation of the Affect School as supplementary treatment of Swedish women with eating disorders: a randomized clinical trial. J Eat Disord 2022; 10:76. [PMID: 35637512 PMCID: PMC9153112 DOI: 10.1186/s40337-022-00596-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/23/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Despite solid research there remains a large group of patients with eating disorders who do not recover. Emotion dysregulation has been shown to be a feature in the different eating disorders. A manualized group intervention developed in Sweden, the Affect School, aims to enhance emotional awareness and the ability to perceive and express emotions. AIM This study aimed to test the hypothesis that participation in the Affect School as a complement to ordinary eating disorder treatment would enhance awareness and regulation of emotions and reduce alexithymia and cognitive eating disorder symptoms in a sample of patients with eating disorders at a Swedish specialized outpatient clinic. METHOD Forty patients with various eating disorders were randomized to either participation in the Affect School as a supplement to treatment as usual (TAU), or to a TAU control group. Participants were assessed with the Eating Disorder Examination Questionnaire, the Deficits in Emotion Regulation Scale-36, and the Toronto Alexithymia Scale-20 at start, end of intervention, and at the 6- and 12-month follow-ups. RESULTS No significant differences were observed post-treatment but Affect School participants had improved significantly more than controls on eating disorder cognitions and behaviours and emotion dysregulation at the 6- and 12-month follow-ups and had significantly less alexithymia at the 6-month follow-up. CONCLUSION Difficulties with emotion recognition and/or regulation can complicate fulfilment of personal needs and obstruct communication and relationships with others. The present study indicates that adding Affect School group sessions to regular treatment enhances emotional awareness and emotion regulation and decreases eating disorder symptoms and alexithymia. Patients with eating disorder diagnoses have described problems with emotional management, for example: lower emotional awareness and difficulties in using adaptive emotional regulatory strategies compared to people without eating disorders. It has been suggested that interventions aiming at enhancing emotional awareness and acceptance would be beneficial in treatment. In the present study we explored whether adding the Affect School to regular treatment would enhance awareness and regulation of emotions and decrease eating disorder symptoms. Forty women with an eating disorder were randomly allocated to either an additional participation in a group treatment for 8 weeks or usual treatment only. The treatment contained education on different affects such as joy, fear, interest, shame, anger, disgust, and worry. The education was followed by discussions on own experiences. Participants filled in self-assessment forms that measured eating disorder symptoms, emotional recognition, and emotion regulation before the start and at the end of the group treatment, and after 6 and 12 months respectively. The results when comparing the two groups suggested that the Affect School could be an effective additional treatment. Participants in the Affect School improved their scorings but the change took time and did not show until at the 6- and 12 months follow-ups.
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Affiliation(s)
- Suzanne Petersson
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden.
- Department of Rehabilitation, Kalmar Regional Council, Hus 13, plan 7, Länssjukhuset, 391 85, Kalmar, Sweden.
| | - Kristofer Årestedt
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
- Department of Research, Region Kalmar County, Kalmar, Sweden
| | - Andreas Birgegård
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
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Suicidal Behaviour Among Nigerian Undergraduates: Associations with Gambling Disorder and Emotional Dysregulation. HEALTH SCOPE 2022. [DOI: 10.5812/jhealthscope-121797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: There is a high prevalence of suicidal behavior among Nigerian youths. However, the connections between suicidal behavior and precipitating factors, such as gambling disorder and emotional dysregulation (ED) in this population, are not well researched. Objectives: The present study examined the associations between gambling disorder, ED, and suicidal behavior in Nigerian university undergraduate students. Methods: This study was carried out during October 2020 - April 2021 on 1338 undergraduates with a mean ± SD age of 19.84 ± 3.22 years selected using random and purposive sampling for the universities and participants respectively. Participants responded to the Attitudes Towards Gambling Scale, Difficulties in Emotion Regulation Scale, and Redeemer's University Suicidality Scale. Descriptive statistics (simple percentages) and inferential statistics (Pearson’s correlation and regression analysis) were used for data analysis. Results: The Pearson's correlation revealed that suicidal behaviour had significant positive correlations with the nonacceptance of emotional responses or distress (r = 0.22, P = 0), difficulties engaging in goal-directed behaviours (r = 0.21, P = 0), difficulties in impulse control (r = 0.27, P = 0), the lack of emotional awareness (r = 0.14, P = 0), limited access to emotional regulation strategies (r = 0.33, P = 0), the lack of emotional clarity (r = 0.32, P = 0), and difficulties in emotional regulation (r = 0.4, P = 0). Problematic gambling (PG) independently predicted suicidal behavior, while PG and ED dimensions jointly predicted suicidal behavior. The ED dimensions contributed 15% incrementally to the prediction of suicidal behavior and beyond the 2% variance accounted for PG in undergraduates. Conclusions: Our results showed positive links between PG, ED, and suicidal behavior among Nigerian undergraduates. It suggests that the combination of PG and ED increases the severity of suicidal behavior among students.
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Ozeren GS. The correlation between emotion regulation and attachment styles in undergraduates. Perspect Psychiatr Care 2022; 58:482-490. [PMID: 34223633 DOI: 10.1111/ppc.12902] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/02/2021] [Accepted: 06/14/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE This study defines the emotion regulation difficulties experienced by undergraduate students and their attachment styles and determines the relationship between them. DESIGN AND METHODS In this study, 586 undergraduates participated by filling in the difficulties in the emotion regulation scale and the relationship styles questionnaire. We used a descriptive correlational study design to analyze these data. FINDINGS Difficulties in emotion regulation were negatively correlated with secure attachment and positively correlated with insecure attachment. PRACTICE IMPLICATIONS Psychiatric nurse educators can organize emotion regulation groups and create a module that teaches attachment styles and their correlation, available to students from all departments.
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Affiliation(s)
- Gul Sultan Ozeren
- Department of Nursing, Faculty of Health Sciences, Sinop University, Sinop, Turkey
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Family Functioning and Risky Behaviors Among Female Adolescents: Mediating Role of Emotion Dysregulation and Decision-Making Styles. CURRENT PSYCHOLOGY 2022. [DOI: 10.1007/s12144-022-02799-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Forsén Mantilla E, Clinton D, Monell E, Levallius J, Birgegård A. Impulsivity and compulsivity as parallel mediators of emotion dysregulation in eating-related addictive-like behaviors, alcohol use, and compulsive exercise. Brain Behav 2022; 12:e2458. [PMID: 34928542 PMCID: PMC8785615 DOI: 10.1002/brb3.2458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Transdiagnostically relevant psychological traits associated with psychiatric disorders are increasingly being researched, notably in substance use and addictive behaviors. We investigated whether emotion dysregulation mediated by impulsivity and/or compulsivity could explain variance in binge eating, food addiction, self-starvation, and compulsive exercise, as well as alcohol use (addictive-like behaviors relevant to the obesity and eating disorder fields). METHOD A general population sample of adults (N = 500, mean age = 32.5 years), females (n = 376) and males (n = 124), completed the Difficulties in Emotion Regulation Scale-16, the Trait Rash Impulsivity Scale, the Obsessive-Compulsive Inventory-Revised, the Eating Disorders Examination Questionnaire, the Self-Starvation Scale, the Exercise Dependence Scale, the Yale Food Addiction Scale, and the Alcohol Use Disorders Identification Test online. Besides gender comparisons and intercorrelations between measures, we used predefined multiple mediation models with emotion dysregulation as independent variable, impulsivity and compulsivity as parallel mediators, to investigate whether these factors contributed explanatory power to each addictive-like behavior as outcome, also using age and body mass index as covariates. RESULTS Females scored higher than males on emotion dysregulation and the eating-related addictive-like behaviors food addiction, self-starvation, and binge eating. Intercorrelations between measures showed that emotion dysregulation and compulsivity were associated with all outcome variables, impulsivity with all except compulsive exercise, and the eating-related behaviors intercorrelated strongly. Mediation models showed full or partial mediation of emotion dysregulation for all behaviors, especially via compulsivity, suggesting a behavior-specific pattern. Mediation models were not affected by age or gender. DISCUSSION Addictive-like behaviors seemed to be maintained by trait levels of emotion dysregulation, albeit channeled via trait levels of compulsivity and/or impulsivity. The role of emotion dysregulation may help us to understand why addictive-like behaviors can be difficult to change in both clinical and nonclinical groups, and may be informative for treatment-planning in patients where these behaviors are present. Our findings support adopting a more dimensional approach to psychiatric classification by focusing psychological facets such as those studied.
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Affiliation(s)
- Emma Forsén Mantilla
- Department of Medical Epidemiology and Biostatistics, Karolinska institutet, Stockholm, Sweden
| | - David Clinton
- Department of Medical Epidemiology and Biostatistics, Karolinska institutet, Stockholm, Sweden
| | - Elin Monell
- Department of Medical Epidemiology and Biostatistics, Karolinska institutet, Stockholm, Sweden
| | - Johanna Levallius
- Department of Medical Epidemiology and Biostatistics, Karolinska institutet, Stockholm, Sweden
| | - Andreas Birgegård
- Department of Medical Epidemiology and Biostatistics, Karolinska institutet, Stockholm, Sweden
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Monell E, Birgegård A, Nordgren L, Hesser H, Bjureberg J. Factor structure and clinical correlates of the original and 16-item version of the Difficulties In Emotion Regulation Scale in adolescent girls with eating disorders. J Clin Psychol 2021; 78:1201-1219. [PMID: 34855219 DOI: 10.1002/jclp.23286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 10/18/2021] [Accepted: 11/12/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The Difficulties in Emotion Regulation Scale (DERS) is increasingly used in adolescents. This study is the first to examine the factor structure, measurement, and structural invariance across age, reliability, and validity of the original 36-item and 16-item version of the DERS in adolescents with eating disorders. METHODS Several models were examined using confirmatory factor analysis. Measurement and structural invariance were studied across age groups, and Omega, Omega Hierarchical, and criterion validity were examined. RESULTS A bifactor model, with five subscales, showed acceptable fit in both DERS versions. Measurement and structural invariance held across age. The general factor had high reliability and accounted for a large proportion of variance in eating pathology and emotional symptoms. CONCLUSION The Awareness subscale had a negative effect on fit in DERS, but both DERS versions were reliable and valid measures in both younger and older adolescents with eating disorders when using only five subscales.
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Affiliation(s)
- Elin Monell
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Birgegård
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Line Nordgren
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
| | - Hugo Hesser
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden.,School of Law, Psychology and Social Work, Center for Health and Medical Psychology, Örebro University, Örebro, Sweden
| | - Johan Bjureberg
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.,Department of Psychology, Stanford University, Stanford, California, USA
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13
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Wigham S, McKinnon I, Reid K, Milton D, Lingam R, Rodgers J. Questionnaires used in complex trauma intervention evaluations and consideration of their utility for autistic adults with mild intellectual disability: A systematic review. RESEARCH IN DEVELOPMENTAL DISABILITIES 2021; 117:104039. [PMID: 34314952 DOI: 10.1016/j.ridd.2021.104039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 06/16/2021] [Accepted: 07/13/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Research suggests some trauma symptoms e.g. avoidance are difficult to recognise in autistic people with intellectual disability while arousal/emotional and interpersonal difficulties may be useful signals. This review aims to (i) identify questionnaires used in general population complex trauma interventions to measure emotional and interpersonal difficulty and (ii) evaluate their psychometric properties to inform selection of a potential measure/s for use and/or adaptation for autistic people with mild intellectual disability and trauma related mental health conditions. METHODS Stage 1: we searched Medline, Cinahl, Embase and PsycInfo for general population and clinical complex trauma intervention studies. Stage 2: we used a search filter in Embase to identify psychometric evaluations of relevant questionnaires used in Stage 1 studies and assessed these with the COnsensus based Standards for the selection of health based Measurement Instruments (COSMIN) checklist. RESULTS five studies were identified in Stage 1 utilising three measures of emotion dysregulation and interpersonal difficulties. Thirty-three articles on their psychometric properties were identified in Stage 2. Strongest psychometric evidence was found for the Emotion Regulation Questionnaire (ERQ) and Difficulties in Emotion Regulation Scale (DERS). CONCLUSIONS Evaluating content validity/acceptability of the ERQ and DERS for autistic people with mild intellectual disability and trauma-related mental health conditions are useful next steps.
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Affiliation(s)
- Sarah Wigham
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, NE1 4LP, United Kingdom.
| | - Iain McKinnon
- Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, United Kingdom; Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Wolfson Research Centre, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, United Kingdom
| | - Keith Reid
- Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, United Kingdom; Northumbria University Health and Life Sciences, United Kingdom
| | - Damian Milton
- Tizard Centre, Department of Social Policy, Sociology and Social Research, University of Kent, Canterbury, United Kingdom
| | - Ravi Lingam
- Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, United Kingdom
| | - Jacqui Rodgers
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, NE1 4LP, United Kingdom
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14
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Puttevils L, Vanderhasselt MA, Horczak P, Vervaet M. Differences in the use of emotion regulation strategies between anorexia and bulimia nervosa: A systematic review and meta-analysis. Compr Psychiatry 2021; 109:152262. [PMID: 34265598 DOI: 10.1016/j.comppsych.2021.152262] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/08/2021] [Accepted: 07/05/2021] [Indexed: 02/09/2023] Open
Abstract
OBJECTIVE Research has identified abnormal emotion regulation (ER) as an underlying mechanism in the onset and maintenance of eating disorders. Yet, it still remains unclear whether different forms of ER, adaptive and maladaptive strategies, are similar across categories of eating disorders. METHOD A systematic review and meta-analysis were carried out to look at ER differences between anorexia nervosa (AN) and bulimia nervosa (BN), two common eating disorder pathologies with different eating patterns. RESULTS 41 studies were included in the meta-analysis. The results revealed no differences in the use of maladaptive ER strategies between individuals with AN and BN, however patients with AN tend to use less adaptive ER strategies as compared to patients with BN. CONCLUSIONS Making less use of adaptive strategies in AN might be due to low body weight and high levels of alexithymia which define AN. In order to improve treatment outcome in individuals suffering from AN, these findings suggest to focus more on improving the use of adaptive ER strategies.
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Affiliation(s)
- Louise Puttevils
- Department of Head and Skin, Ghent University, Belgium; Ghent Experimental Psychiatry (GHEP) lab, Belgium.
| | - Marie-Anne Vanderhasselt
- Department of Head and Skin, Ghent University, Belgium; Ghent Experimental Psychiatry (GHEP) lab, Belgium; Department of Experimental-Clinical and Health Psychology, Ghent University, Belgium
| | - Paula Horczak
- Department of Head and Skin, Ghent University, Belgium; Ghent Experimental Psychiatry (GHEP) lab, Belgium
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15
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Zhao Y, Wu K, Wang Y, Zhao G, Zhang E. Construct validity of brief difficulties in emotion regulation scale and its revised version: evidence for a general factor. CURRENT PSYCHOLOGY 2021. [DOI: 10.1007/s12144-021-02056-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Sörman K, Garke MÅ, Isacsson NH, Jangard S, Bjureberg J, Hellner C, Sinha R, Jayaram-Lindström N. Measures of emotion regulation: Convergence and psychometric properties of the difficulties in emotion regulation scale and emotion regulation questionnaire. J Clin Psychol 2021; 78:201-217. [PMID: 34217149 DOI: 10.1002/jclp.23206] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 04/23/2021] [Accepted: 06/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Investigating unique and shared aspects of measures of emotion regulation (ER) advances our understanding of ER as a multidimensional construct. This study aimed to investigate psychometric properties of three ER-measures: Difficulties in Emotion Regulation Scale (DERS-36), the abbreviated version DERS-16, and Emotion Regulation Questionnaire (ERQ). METHODS In a community sample (N = 843; 56% females) we investigated their internal consistency, factor structure, convergence, and association with symptoms of depression, anxiety, stress and substance abuse. RESULTS The proposed factor structures of the DERS-16 and the ERQ demonstrated an adequate fit. There were moderate correlations between the two DERS versions (36 and 16) and ERQ subscales Reappraisal and Suppression. Total scores of DERS-36 and DERS-16 demonstrated preferential associations with depression and anxiety. Corresponding associations between ERQ subscales and psychiatric symptoms were weak. CONCLUSION The results indicate that DERS-16 could be useful as an alternative, easily administered measure of ER difficulties.
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Affiliation(s)
- Karolina Sörman
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Stockholm, Sweden
| | - Maria Å Garke
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Stockholm, Sweden
| | - Nils H Isacsson
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Stockholm, Sweden
| | - Simon Jangard
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Stockholm, Sweden.,Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Johan Bjureberg
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Stockholm, Sweden
| | - Clara Hellner
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Stockholm, Sweden
| | - Rajita Sinha
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Nitya Jayaram-Lindström
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Stockholm, Sweden
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17
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McVey AJ, Schiltz HK, Coffman M, Antezana L, Magnus B. A Preliminary Psychometric Analysis of the Difficulties with Emotion Regulation Scale (DERS) Among Autistic Adolescents and Adults: Factor Structure, Reliability, and Validity. J Autism Dev Disord 2021; 52:1169-1188. [PMID: 33886035 DOI: 10.1007/s10803-021-05018-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 12/01/2022]
Abstract
Emotion dysregulation is common among autistic people, yet few measures have received psychometric evaluation in this population. We examined the factor structure, reliability, and validity of a commonly-used measure of emotion dysregulation, the Difficulties with Emotion Regulation Scale (DERS), in a sample of 156 autistic adolescents and adults. Data were drawn from the NIH National Database for Autism Research (NDAR) and an author's existing dataset. Results demonstrated that the factor structure generally conformed to the original 6-factor model, with modifications. Reliability analyses revealed good-to-excellent internal consistencies. Validity analyses indicated that the DERS was positively associated with measures of anxiety, depression, and alexithymia. Our findings provide preliminary evidence for the utility of the DERS in a small autistic sample, with minor modifications.
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Affiliation(s)
- Alana J McVey
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada. .,Department of Psychology, Marquette University, Milwaukee, WI, USA.
| | | | - Marika Coffman
- Duke Center for Autism and Brain Development, Duke University, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA.,Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Ligia Antezana
- Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Brooke Magnus
- Department of Psychology, Marquette University, Milwaukee, WI, USA.,Department of Psychology and Neuroscience, Boston College, Chestnut Hill, MA, USA
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18
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Examining the Structure of Difficulties in Emotion Regulation Scale with Chinese Population: A Bifactor Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084208. [PMID: 33921118 PMCID: PMC8071479 DOI: 10.3390/ijerph18084208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 11/17/2022]
Abstract
The Difficulties in Emotion Regulation Scale (DERS), as one of the most frequently employed measures of emotion regulation (ER), has increasingly been used in numerous researches and applications. However, the structures derived from previous factor-analytic studies have a high degree of inconsistency. In the current study, both the traditional factor analysis method and novel (bifactor) modeling approaches were employed to examine the most optimal measurement structure of the DERS in a sample of 1036 Chinese participants. After a series of comparisons, the findings indicated that the bifactor model, with a general ER factor and four distinct subdimensions, was the most optimal structure for the DERS. Based on the study’s findings, the discussion was focused mainly on the future directions and the implications of this bifactor model. The impact and limitations of the study were also discussed, and several suggestions for future research were provided at the end of the paper.
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19
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Rania M, Monell E, Sjölander A, Bulik CM. Emotion dysregulation and suicidality in eating disorders. Int J Eat Disord 2021; 54:313-325. [PMID: 33205495 PMCID: PMC7984062 DOI: 10.1002/eat.23410] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Suicidality in eating disorders (EDs) is high, and identification of therapeutically targetable traits associated with past, current, and future suicidality is of considerable clinical importance. We examined overall and ED subtype-specific associations among suicidal ideation, suicide attempts, and general and specific aspects of emotion dysregulation in a large sample of individuals with ED, at presentation for treatment and 1-year follow-up. METHOD Using registry data from 2,406 patients, scores on the Difficulties in Emotion Dysregulation Scale (DERS) at initial registration were examined as predictors of recent suicidal ideation and self-report lifetime suicide attempts. Associations were examined in the full sample and in each ED subtype. In 406 patients, initial DERS scores were examined as predictors of suicidality at 1-year follow-up. RESULTS Overall DERS was associated with suicidal ideation and suicide attempts, even when adjusting for ED psychopathology and current depression. Perceived lack of emotion regulation strategies showed unique associations with suicidal ideation and suicide attempts, both in the full sample and in most ED subtypes. Initial DERS was also associated with follow-up suicidal ideation and suicide attempts, although this association did not remain when adjusting for past suicidality. DISCUSSION Results suggest that emotion dysregulation may be a potential mechanism contributing to suicidality in EDs, beyond the effects of ED psychopathology and current depression. Although the prevalence of suicidality differs across ED subtypes, emotion dysregulation may represent a risk trait for future suicidality that applies transdiagnostically. Results support addressing emotion dysregulation in treatment in order to reduce suicidality.
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Affiliation(s)
- Marianna Rania
- Department of Health SciencesUniversity Magna Graecia of CatanzaroCatanzaroItaly
- Center for Clinical Research and Treatment of Eating DisordersMater Domini University HospitalCatanzaroItaly
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Elin Monell
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
- Centre for Psychiatry Research, Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Stockholm Health Care ServicesRegion StockholmStockholmSweden
| | - Arvid Sjölander
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Cynthia M. Bulik
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
- Department of PsychiatryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Department of NutritionUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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20
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Monell E, Clinton D, Birgegård A. Self-directed behaviors differentially explain associations between emotion dysregulation and eating disorder psychopathology in patients with or without objective binge-eating. J Eat Disord 2020; 8:17. [PMID: 32377341 PMCID: PMC7193412 DOI: 10.1186/s40337-020-00294-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 04/02/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Emotion dysregulation and negative self-directed behaviors are key characteristics of eating disorders (EDs), but their interaction in relation to ED psychopathology is insufficiently explored, and empirically robust and clinically relevant models are needed. METHODS This study examined whether the association between emotion dysregulation and ED psychopathology was mediated by different negative self-directed behaviors in 999 ED patients divided into two sub-samples based on absence or presence of objective binge-eating episodes (OBE). Several simple and extended mediation models were examined using the Difficulties in Emotion Regulation Scale (DERS) as independent variable, the Structural Analysis of Social Behavior (SASB) as mediator, and the Eating Disorder Examination Questionnaire (EDE-Q) as dependent variable. RESULTS An associational pathway was found where higher emotion dysregulation was associated with more negative self-directed behaviors, which in turn was associated with higher ED psychopathology. Self-directed behaviors of importance differed between patient groups. In participants without OBE, lower self-love and higher self-attack were influential, whereas in participants with OBE, lower self-affirmation and higher self-blame were influential. CONCLUSIONS Self-directed behaviors may help to explain the association between emotion dysregulation and ED psychopathology. Our findings have both theoretical and clinical implications that are pathology-specific. Addressing specific self-directed behaviors could be an important way of helping patients deal with their emotions in relation to ED psychopathology.
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Affiliation(s)
- Elin Monell
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan 69, SE-11364 Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - David Clinton
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan 69, SE-11364 Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Institute for Eating Disorders, Oslo, Sweden
| | - Andreas Birgegård
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan 69, SE-11364 Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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