ORIGINAL ARTICLE
Predicting Symptoms of Depression From Social Anhedonia and Emotion Regulation Brennan D. Atherton, BS,* Robert M. Nevels, PhD, MSCP,† and Michael T. Moore, PhD* Abstract: The literature examining social anhedonia, emotion regulation, and symptoms of depression in psychiatric inpatients has been limited. However, some studies have shown that difficulties in emotion regulation and social anhedonia were independently associated with depression. The current study attempted to examine the effects of these two potential predictors of unipolar depressed mood. Fifty-nine (73% female) psychiatric inpatients were given the measures of emotion regulation, symptoms of anxiety and depression, and social anhedonia. Results showed that difficulties in emotion regulation, specifically dysfunctional emotion regulation strategies and emotional clarity, served as significant predictors of depressive symptoms above and beyond contributions from social anhedonia. These results highlight the importance of attending to emotion regulation in the study and treatment of depression in inpatient samples. Key Words: Emotion regulation, social anhedonia, depression (J Nerv Ment Dis 2015;203: 170–174)
D
epression is a very serious and common mental disorder. In a recent nationwide epidemiological survey, major depressive disorder (MDD) had the highest lifetime and 12-month prevalence rates (16% and 17%, respectively) of 14 major psychiatric disorders (Kessler et al., 2003). In the year 2000 alone, $26.1 billion was spent on medical care for the treatment for depression, $5.4 billion was spent in suiciderelated mortality costs, and $51.5 billion was lost because of lost productivity (Greenberg et al., 2003). Average costs per day for inpatients with depression are approximately $870, with an average length of stay of 8.4 days (Stensland et al., 2012). One symptom that has frequently been investigated in inpatients with MDD, and that will be a focus of the current investigation, is social anhedonia (SA).
Social Anhedonia The importance of the interpersonal context to depression is widely recognized. Research related to stress generation (e.g., Hammen, 1991) has highlighted how depressed individuals can produce stress in their personal relationships through excessive reassurance seeking (see Starr and Davila, 2008, for a review), among other mechanisms. SA is defined as the experience of reduced pleasure from interpersonal interactions and subsequent reduced desire for social affiliation (Germine et al., 2011). SA represents a particular subtype of the more general class of anhedonic experience that is a central criterion for MDD (American Psychiatric Association, 2013). In addition, SA represents social disinterest, and not shyness, introversion, or anxiety in social situations (Silvia and Kwapil, 2011). Rey et al. (2009) examined SA in a sample of university undergraduates. They found that individuals who self-reported more SA also *Department of Psychology, Jackson State University, Jackson; and †Private Practice, Ridgeland, MS. Dr Moore is now at Adelphi University, Gordon F. Derner Institute of Advanced Psychological Studies, Garden City, NY. Send reprint requests to Michael T. Moore, PhD, Adelphi University, 1 South Avenue, Gordon F. Derner Institute of Advanced Psychological Studies, Blodgett Hall, 2nd Floor, Garden City, NY 11530. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20303–0170 DOI: 10.1097/NMD.0000000000000262
170
www.jonmd.com
reported more symptoms of depression. Blanchard et al. (2001) studied MDD and schizophrenia in an inpatient sample. Results indicated that SA is a state, not trait, marker of depression, whereas SA was found to be a stable trait in individuals diagnosed with schizophrenia. Despite the status of anhedonia as a central symptom of MDD and the importance of social functioning in depression, SA has been infrequently studied in the context of inpatient hospitalization. In comparison, emotion regulation has been much more frequently studied in samples with depression.
Difficulties in Emotion Regulation Difficulties in emotion regulation have been shown to be a risk factor for various forms of psychopathology, including depression (Gross and Munoz, 1995). Gross (1998) defines emotion regulation as the process by which individuals influence their emotions. He also states that it refers to how individuals experience, as well as express, their emotions. Gross and Munoz (1995) define emotion regulation as either regulating something via emotions or regulating emotions themselves. Gratz and Roemer (2004) have defined emotion regulation as the awareness, acceptance, and understanding of emotions as well as the ability to control impulsivity and to strive toward goals while experiencing negative emotions. Lastly, Gratz and Roemer state that emotion regulation involves the ability to use appropriate strategies to modulate emotional responses to meet goals and certain situational demands. Although the above definitions share many features, they are by no means mutually exclusive; the operationalization of emotion regulation used in the current paper corresponds most closely to that of Gratz and Roemer. Recent research linking deficits in emotion regulation to depression in a sample of female university students has found that depressed students demonstrate less emotional acceptance, awareness, and clarity of their emotions than their nondepressed peers do (Svaldi et al., 2012); depressed students also showed higher levels of negative emotions, selfcriticism, and emotional suppression. The individuals diagnosed with MDD differed from those diagnosed with anorexia or bulimia nervosa, borderline personality disorder, and binge eating disorder with regard to the use of positive thoughts to regulate emotions, with depressed participants demonstrating less positive thoughts than the other groups. Ehring et al. (2008) found, in currently nondepressed university students, that past depression was related to higher levels of selfperceived emotion regulation difficulties, more use of emotion regulation strategies that are dysfunctional, and difficulty keeping things in perspective. They also found that those with a history of depression had difficulties in emotional acceptance and clarity when compared with those without such a history. Not all of the research examining emotion regulation and depression has been done in undergraduate samples, however. Garnefski and Kraaij (2006) found that a sample of psychiatric outpatients scored significantly higher than did adolescents, adults, and older adults without psychiatric problems with regard to self-blame, rumination, and catastrophizing emotion regulation strategies—which all led to depressive symptoms. They found that accepting and resigning oneself to a situation, self-blame, and blaming others led to depressive symptoms. In addition, a lack of positive refocusing and positive reappraisal was found to lead to depressive symptoms. Marquart et al. (2009) found that
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015
ER, SA, & Depression
depressed psychiatric inpatients reported weak expectations regarding their ability to regulate their negative moods. In addition, depression severity was closely related to male patients' expectations regarding their ability to control negative moods through affect regulation, behavioral activation, cognitive restructuring, and social involvement. Suicide risk was significantly related to expectations regarding the ability to control negative moods. Wineman (2009) found similar results for adolescent female inpatients, in that depression and suicidality were both related to emotion dysregulation. In another study, Fehlinger et al. (2013) found that high competencies in regulating emotions significantly predicted depression. More specifically, access to emotion regulation strategies was the most important predictor of the severity of depressive symptoms, whereas the realization of goal-directed behavior, identification, acceptance, and expression of emotions were not significant predictors.
a high school diploma. None of the aforementioned demographic variables had significant associations with symptoms of depression, with the exception of level of education. As a result, this variable was included as a covariate in the analysis which follows below. Diagnostic information is, unfortunately, unavailable because of the added time and expense of diagnostic interviewing. However, the mean score for the sample on the Depression subscale of the Depression Anxiety Stress Scale (DASS-D) (Lovibond and Lovibond, 1995) was indicative of severe depression (mean [SD], 24.5, [14.65]) and comparable with other studies that have used inpatient (e.g., Ronk et al., 2013) and outpatient (Antony et al., 1998; Brown et al., 1997) samples diagnosed with a unipolar mood disorder. In addition, 66% of the sample listed a symptom(s) of a mood disorder as a presenting complaint upon admission.
The Current Study
Measures
The current study investigated the interplay between SA and emotion regulation and compared the ability of both variables to predict symptoms of depression in an inpatient sample. Although SA has been frequently studied in inpatient samples with psychosis, its association with depression is less well known in this context. The associations between emotion regulation and depression have been more frequently examined, but primarily using outpatient or student samples. It is reasonable to expect the relationships between SA, emotion regulation, and symptoms of depression to differ between inpatient and outpatient samples, and generalization, without justification, from the latter to the former is problematic. For instance, the link between SA and depression should be stronger in inpatients, given the link both variables have with impairments in social skills (Blanchard et al., 1998; Segrin, 2000), which are more impaired in depressed inpatients (Dalley et al., 1994; Edison and Adams, 1992; Segrin, 1992). Similarly, the link between emotion dysregulation and depression should be stronger in inpatients to the extent that attempted suicide, a highly dysfunctional attempt at emotional avoidance (Chapman et al., 2006), is a common impetus for inpatient hospitalization. Our hypothesis is that both SA and aspects of emotion regulation will be associated with symptoms of depression. We make no predictions about the relative strength of these associations, and any inferences related to this point should be viewed as purely exploratory.
The DASS-21 (Lovibond and Lovibond, 1995) is a 21-item selfreport questionnaire designed to differentiate between the core symptoms of depression, anxiety, and stress. It is a shortened version of the original 42-item version (Lovibond and Lovibond, 1993). Items are measured on a 4-point Likert-type scale, with higher scores indicating increasing amount of depression, anxiety, and stress. The DASS has demonstrated excellent internal consistency overall (α = 0.93) as well as for the depression (α = 0.88), anxiety (α = 0.82), and stress (α = 0.90) scales (Henry and Crawford, 2005). In the current sample, only the depression subscale was used, which demonstrated a comparably excellent degree of internal consistency (α = 0.94). Henry and Crawford (2005) found that the DASS had adequate construct validity, as evidenced by its good convergent validity with the Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983) and the Personal Disturbance scale (Bedford and Foulds, 1978). The Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, 2004) is a 36-item, self-report measure that provides a comprehensive assessment of overall emotion regulation difficulties using six specific dimensions: nonacceptance of negative emotions (nonacceptance), difficulties engaging in goal-directed behaviors when experiencing negative emotions (goals), difficulties controlling impulsive behaviors when experiencing negative emotions (impulse), limited access to effective emotion regulation strategies (strategies), lack of emotional awareness (awareness), and lack of emotional clarity (clarity). Participants rate the extent to which each item applies to him/her using a 5-point Likert scale, where higher scores indicate increasing difficulties in emotion regulation. Gratz and Roemer (2004) found good test-retest reliability for the DERS (ρI = 0.88) over a period of 4 to 8 weeks as well as good internal consistency (α = 0.93) for the total scale and alphas ranging from 0.80 to 0.89 for the subscale scores. In the current sample, internal consistency values (α) ranged from good to excellent: nonacceptance, 0.87; goals, 0.83; impulse, 0.87; awareness, 0.78; strategies, 0.90; and clarity, 0.80. The Revised Social Anhedonia Scale (RSAS; Eckblad et al., 1982) is a 40-item true-false measure designed to assess SA. It has shown an acceptable level of test-retest reliability over 8 to 12 weeks in a student sample (r = 0.81; Winterstein et al., 2010). The RSAS demonstrated good internal consistency between these two sample points, with alphas ranging from 0.83 to 0.85 (Winterstein et al., 2010). Bailey et al. (1993) found that the RSAS was found to be significantly correlated with both depression (r = 0.43) and anxiety (r = 0.41). In the current sample, an unacceptably low degree of internal consistency was found using all 40 items of the instrument (α = 0.60). Sixteen items that demonstrated the lowest item-total correlations were removed (items 8, 9, 11, 15, 16, 18, 19, 20, 24, 25, 27, 28, 31, 32, 33, and 36), and the resulting 24-item scale was associated with an acceptable level degree of internal consistency (α = 0.79). This adapted scale was used in the analyses reported below.
METHODS Participants and Procedure Participants (n = 59) were recruited from an inpatient unit at a university medical center in the southern United States and were seen there between September 2010 and June 2011. Inclusion criteria were younger than 65 years and the absence of a psychotic episode at the time of intake. The mean (SD) age of the sample was 36.33 (11.99) years (range, 18–62 years), and the sample was predominantly female (72.88%). With regard to marital status, 34% identified as never married, 27% reported being divorced, 24% were married, 7% were separated, 5% were widowed, and 3% of participants did not identify their marital status. In terms of race, the sample was predominantly white (59%), but other racial and ethnic groups were represented (27% identified as African American, 10% identified as multiracial, and 4% identified as Native American). With regard to ethnicity (which was asked as a separate question from race), 2% self-identified as Hispanic/ Latino. The sample was generally of low socioeconomic status, as indicated by degree of employment, income, and level of education. Most of the sample were unemployed (75%; only 12% had full-time work) and 51% reported making less than $10,000 per year. With regard to the highest level of education, 34% reported attending some college, 27% reported attending some high school, and 22% reported receiving © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.jonmd.com
171
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015
Atherton et al.
RESULTS See Table 1 for a listing of zero-order bivariate correlations between all measured variables. A linear regression with the six DERS scales and RSAS as predictors of the Depression subscale of the DASS21 accounted for significant variance in this criterion, R2 = 0.71, F(7, 41) = 14.30, p < 0.001. In addition, when the RSAS was entered in step 1, the DERS subscales predicted significant variance above and beyond this variable, ΔR2 = 0.43, ΔF(6, 41) = 10.13, p < 0.001. The RSAS served as a significant predictor when it was entered alone in step 1, β = 0.53, t(41) = 4.26, p < 0.001, Cohen's f 2 = 0.39, but not when the DERS subscales were added in step 2, β = 0.08, t(41) = 0.82, p = 0.42, f 2 = 0.02. DERS–strategies, β = 0.52, t(41) = 2.39, p = 0.02, f 2 = 0.14, served as a significant predictor in step 2, whereas DERS– clarity was a significant predictor at a trend level, β = 0.28, t(41) = 1.90, p = 0.065, f 2 = 0.09. The former predictor conformed to the convention of Cohen (1992) for a medium effect and the latter for a small-to-medium effect. DERS–nonacceptance, β = 0.09, t(41) = 0.60, p = 0.55, f 2 = 0.01, DERS–goals, β = 0.04, t(41) = 0.33, p = 0.75, f 2 < 0.01, DERS–impulse, β = −0.08, t(41) = −0.54, p = 0.60, f 2 = 0.001, and DERS–awareness, β = 0.02, t(41) = 0.16, p = 0.88, f 2 < 0.01, did not significantly predict DASS-D scores and corresponded to a small effect, or less.
DISCUSSION Our hypothesis, that SA would be associated with depressive symptoms in psychiatric inpatients, was supported. This result is consistent with previous research linking the two concepts in both inpatient (Blanchard et al., 2001) and undergraduate (Rey et al., 2009) samples. The hypothesis suggesting that emotion dysregulation would be associated with increasing depressive symptoms was also supported. This was consistent with previous research finding a link between difficulties in emotion regulation and depression (Ehring et al., 2008; Fehlinger et al., 2013; Garnefski and Kraaij, 2006; Marquart et al., 2009; Svaldi et al., 2012; Wineman, 2009). Although depression was correlated with all of the DERS scales, only difficulties in emotion regulation strategies and difficulties with emotional clarity served as significant predictors, consistent with previous research. Moriya and Takahashi (2013) found that lack of emotional clarity and limited access to emotion regulation strategies fully mediated the relationship between interpersonal stress and depression in undergraduate students, whereas the other DERS subscales did not. Ehring et al. (2008) found similar results: past depression was related to less effective emotion regulation strategies,
higher difficulty in emotional acceptance, and dysfunction in emotional clarity in an undergraduate sample. The current study demonstrated that dysfunctional emotion regulation strategies and dysfunctional emotional clarity are also predictive of depressive symptoms in an inpatient population.
Clinical Implications SA has been most frequently studied in the context of schizophrenia and, when it has been studied in the context of depression, has only been studied in an undergraduate sample (Rey et al., 2009). The current investigation emphasizes the importance of SA in interactions with depressed clients in an inpatient milieu. The exact relationship between SA and symptoms of depression, however, has yet to be identified. Is SA just another symptom of depression? Is it related to impairments in social skills? If so, how? Difficulties in emotion regulation strategies were found to significantly predict depressive symptoms in the current study, over and above variance accounted for by SA. These findings fit into the larger body of research relating the use of specific emotion regulation strategies and symptoms of depression. Broadly, this research has found that the use of cognitive reappraisal, when compared with emotional suppression or rumination, is less common in those with depression (Gross and John, 2003; Joorman and Gotlib, 2010). There have been few studies examining the effects of emotional clarity and its impact on depressive symptoms and the literature has been mixed in its support of this link. For example, Fisher et al. (2010) found that use of emotional clarity was associated with decreased symptoms of anxiety but did not impact symptoms of depression. Salguero et al. (2013) found that emotional attention was associated with emotional clarity, and emotional clarity was associated with emotional repair. Emotional repair was associated with lower depressive symptoms due to the association between emotional repair and decreased rumination. However, increasing emotional attention was also positively related to rumination, which was associated with depressed mood. Strange et al. (2013) found that emotional clarity buffered against the effects of depressive symptoms, such as dysfunctional attitudes, self-criticism, and neediness. Recently, emotion regulation has moved to the forefront in thinking related to the treatment of both anxiety and depression. Emotion Regulation Therapy (ERT; Mennin, 2006) focuses on emotion regulation difficulties, such as heightened intensity of emotions, a poor understanding of emotions, negative reactivity to emotional state, and maladaptive emotional management; this therapy was initially developed to combat the symptoms of generalized anxiety disorder (GAD;
TABLE 1. Correlational Analysis Between DASS-D, RSAS, and DERS Subscales DASS-D
RSAS
Nonacceptance
Goals
Impulse
Awareness
Strategies
Clarity
–
0.53*** –
0.61*** 0.42*** –
0.50*** 0.28* 0.60*** –
0.60*** 0.36** 0.64*** 0.63*** –
0.37** 0.28* 0.02 0.08 0.37** –
0.82*** 0.52*** 0.73*** 0.65*** 0.78*** 0.40** –
0.75*** 0.53*** 0.48*** 0.35** 0.57*** 0.51*** 0.77*** –
DASS-D RSAS Nonacceptance Goals Impulse Awareness Strategies Clarity
Nonacceptance = DERS, Nonacceptance, Subscale; Goals = DERS, Goals Subscale; Impulse = DERS, Impulse Subscale; Awareness = DERS, Awareness Subscale; Strategies = DERS, Strategies Subscale; Clarity = DERS, Clarity Subscale. *p < 0.05 (two tailed). **p < 0.01 (two tailed). ***p < 0.001 (two tailed).
172
www.jonmd.com
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015
Mennin, 2006). However, ERT theory has been found to be relevant to individuals with MDD. Mennin et al. (2007) found that negative reactivity to emotions and a poor understanding of emotions were significantly related to MDD. However, heightened intensity of emotions and maladaptive management of emotions were found to be more significantly related to symptoms of GAD. Initial evidence for ERT has been promising in the treatment of GAD (see Mennin and Fresco, 2013), and future trials may show ERT to be efficacious in the treatment of MDD as well. Berking et al. (2013) examined the efficacy of a form of cognitive-behavioral therapy emphasizing emotion regulation training (CBT-ERT) in an inpatient sample. The emotion regulation component of this therapy included muscle relaxation, deep breathing, acceptance of emotions, self-support, identifying causes of one's emotions, and emotion modification. Results showed a greater reduction in symptoms of depression in depressed inpatients when they were given CBT-ERT, as opposed to general CBT. Patients also demonstrated greater reductions in negative affect, as well as a greater sense of well-being. Kumar et al. (2008), using exposure-based cognitive therapy (Hayes et al., 2007), was effective in combating depression. More specifically, the mindfulness component of this particular therapy was found to decrease depressive maladaptive emotion regulation strategies, such as rumination and avoidance. In total, the available evidence demonstrates that improvements in emotion regulation can positively benefit the treatment of acute unipolar mood disturbance, although which specific components of emotion regulation are most beneficial remains a largely open question.
Limitations and Future Directions Limitations of the current study include the largely female inpatient sample, which limits generalizability to men. In addition, although the results from the DASS-21 are indicative of a severely depressed sample that is consistent with others diagnosed with MDD and/or dysthymia, the lack of structured interview data means that we cannot comment on the diagnostic status or possible comorbidities present in the sample with any certainty. We found the RSAS to possess inadequate internal consistency in our sample of depressed clients in inpatient treatment. This necessitated a revision of the measure, which, although it resulted in a more coherent item set, bears an uncertain relationship with the RSAS. Although a full psychometric evaluation of the RSAS is beyond the scope of the current article, future work should identify the psychometric properties of the RSAS in a larger sample of depressed, treatment-seeking individuals.
CONCLUSIONS SA demonstrated a significant relationship with symptoms of depression, but only when emotion regulation was not included in the model. Because dysfunctional strategies and clarity were the only aspects of emotion regulation to specifically predict depressive symptomatology, they should be studied more extensively as potential tools to alleviate depressive symptoms in inpatient populations. Therapies that focus on these aspects of emotion regulation could prove to be the most useful in treating this prevalent and costly mental health concern.
ER, SA, & Depression
Bailey B, West KY, Widiger TA, Freiman K (1993) The convergent and discriminant validity of the Chapman Scales. J Pers Assess. 61:121–135. Bedford A, Foulds G (1978) Delusions-Symptoms-States Inventory state of anxiety and depression. Windsor, UK: NFER-Nelson. Berking M, Ebert D, Cuijpers P, Hoffman SG (2013) Emotion regulation skills training enhances the efficacy of inpatient cognitive behavioral therapy for major depressive disorder: A randomized controlled trial. Psychother Psychosom. 82:234–245. Blanchard JJ, Horan WP, Brown SA (2001) Diagnostic differences in social anhedonia: A longitudinal study of schizophrenia and major depressive disorder. J Abnorm Psychol. 110:363–371. Blanchard JJ, Mueser KT, Bellack AS (1998) Anhedonia, positive and negative affect, and social functioning in schizophrenia. Schizophr Bull. 24:413–424. Brown TA, Chorpita BF, Korotitsch W, Barlow DH (1997) Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behav Res Ther. 35:79–89. Chapman AL, Gratz KL, Brown MZ (2006) Solving the puzzle of deliberate selfharm: The experiential avoidance model. Behav Res Ther. 44:371–394. Cohen J (1992) A power primer. Psychol Bull. 112:155–159. Dalley MB, Bolocofsky DN, Karlin NJ (1994) Teacher-ratings and self-ratings of social competency in adolescents with low- and high-depressive symptoms. J Abnorm Child Psychol. 22:477–485. Eckblad ML, Chapman LJ, Chapman JP, Mishlove M (1982) The Revised Social Anhedonia Scale. Unpublished test. Edison JD, Adams HE (1992) Depression, self-focus, and social interaction. J Psychopathol Behav. 14:1–19. Ehring T, Fischer S, Schnülle J, Bösterling A, Tuschen-Caffier B (2008) Characteristics of emotion regulation in recovered depressed versus never depressed individuals. Pers Individual Differences. 44:1574–1584. Fehlinger T, Stumpenhorst M, Stenzel N, Rief W (2013) Emotion regulation is the essential skill for improving depressive symptoms. J Affect Disord. 144:116–122. Fisher J, Sass SM, Heller W, Silton RL, Edgar JC, Stewart JL, Miller GA (2010) Time course of processing emotional stimuli as a function of perceived emotional intelligence, anxiety, and depression. Emotion. 10:486–497. Garnefski N, Kraaij V (2006) Relationships between cognitive emotion regulation strategies and depressive symptoms: A comparative study of five specific samples. Pers Individual Differences. 40:1659–1669. Germine LT, Garrido L, Bruce L, Hooker L (2011) Social anhedonia is associated with neural abnormalities during face emotion processing. Neuroimage. 58:935–945. Gratz KL, Roemer L (2004) Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. J Psychopathol Behav. 26:41–54. Greenberg PE, Kessler RC, Birnbaum HG, Leong SA, Lowe SW, Berglund PA, CoreyLile PK (2003) The economic burden of depression in the United States: How did it change between 1990 and 2000? J Clin Psychiatry. 64:1465–1475. Gross JJ (1998) The emerging field of emotion regulation: An integrative review. Rev Gen Psychol. 2:271–299. Gross JJ, John OP (2003) Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. J Pers Soc Psychol. 85:348–362. Gross JJ, Munoz RF (1995) Emotion regulation and mental health. Clin Psychol. 2:151–164.
DISCLOSURES The authors declare no conflict of interest. REFERENCES American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Publishing. Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP (1998) Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales (DASS) in clinical groups and a community sample. Psychol Assess. 10:176–181.
Hammen C (1991) Generation of stress in the course of unipolar depression. J Abnorm Psychol. 100:555–561. Hayes AM, Feldman GC, Beevers CG, Laurenceau JP, Cardaciotto L, Smith JL (2007) Discontinuities and cognitive changes in an exposure-based cognitive therapy for depression. J Consult Clin Psychol. 75:409–421. Henry JD, Crawford JR (2005) The short-form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large nonclinical sample. Br J Clin Psychol. 44:227–239. Joorman J, Gotlib IH (2010) Emotion regulation in depression: Relation to cognitive inhibition. Cogn Emot. 24:281–298.
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.jonmd.com
173
Atherton et al.
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015
Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS (2003) The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R). JAMA. 289:3095–3105. Kumar S, Feldman G, Hayes A (2008) Changes in mindfulness and emotion regulation in an exposure-based cognitive therapy for depression. Cogn Ther Res. 32:734–744. Lovibond SH, Lovibond PF (1993) Manual for the Depression Anxiety Stress Scales (DASS). Psychology Foundation Monograph. Sydney, Australia: Psychology Foundation. Available from the Psychology Foundation, Room 1005 Matthews Building, University of New South Wales, NSW 2052, Australia. Lovibond SH, Lovibond PF (1995) Manual for the Depression Anxiety Stress Scales (2nd ed). Sydney, Australia: Psychology Foundation. Available from The Psychology Foundation, Room 1005 Mathews Building, University of New South Wales, NSW 2052, Australia. Marquart AL, Overholser JC, Peak NJ (2009) Mood regulation beliefs in depressed psychiatric inpatients: Examining affect, behavior, cognitive, and social strategies. Int J Psychiatr Clin. 13:265–272. Mennin DS (2006) Emotion Regulation Therapy: An integrative approach to treatment-resistant anxiety disorders. J Contemp Psychother. 36:95–105. Mennin DS, Fresco DM (2013) Emotion Regulation Therapy. In Gross JJ (Ed), Handbook of Emotion Regulation (2nd ed). New York: Guilford Press. Mennin DS, Holaway RM, Fresco DM, Moore MT, Heimberg RG (2007) Delineating components of emotion and its dysregulation in anxiety and mood psychopathology. Behav Ther. 38:284–302. Moriya J, Takahashi Y (2013) Depression and interpersonal stress: The mediating role of emotion regulation. Motiv Emotion. 37:600–608.
Salguero JM, Extremera N, Fernández-Berrocal P (2013) A meta-mood model of rumination and depression: Preliminary test in a non-clinical sample. Scand J Psychol. 54:166–172. Segrin C (1992) Specifying the nature of social skill deficits associated with depression. Hum Commun Res. 19:89–123. Segrin C (2000) Social skills deficits associated with depression. Clin Psychol Rev. 20:379–403. Silvia PJ, Kwapil TR (2011) Aberrant asociality: How individual differences in social anhedonia illuminate the need to belong. J Pers. 79:1013–1030. Starr LR, Davila J (2008) Excessive reassurance seeking, depression, and interpersonal rejection: A meta-analytic review. J Abnorm Psychol. 117:762–775. Stensland M, Watson PR, Grazier KL (2012) An examination of costs, charges, and payments for inpatient psychiatric treatment in community hospitals. Psychiatr Serv. 63:666–671. Strange JP, Boccia AS, Shapero BG, Molz AR, Flynn M, Matt LM, Abramson LY, Alloy LB (2013) Emotion regulation characteristics and cognitive vulnerabilities interact to predict depressive symptoms in individuals at risk for bipolar disorder: A prospective behavioural high-risk study. Cogn Emot. 27:63–84. Svaldi J, Griepenstroh J, Tuschen-Caffier B, Ehring T (2012) Emotion regulation deficits in eating disorders: A marker of eating pathology or general psychopathology? Psychiatry Res. 197:103–111. Wineman PA (2009) The efficacy of a dialectical behavior therapy-based journal-writing group with inpatient adolescent females: Improving emotion regulation, depressive symptoms and suicidal ideation. Diss Abstr Int Sect B. 70:3817.
Rey G, Jouvent R, Dubal S (2009) Schizotypy, depression, and anxiety in physical and social anhedonia. J Clin Psychol. 65:695–708.
Winterstein BP, Willse JT, Kwapil TR, Silvia PJ (2010) Assessment of score dependability of the Wisconsin schizotypy scales using generalizability analysis. J Psychopathol Behav Assess. 32:575–585.
Ronk FR, Korman JR, Hooke GR, Paige AC (2013) Assessing clinical significance of treatment outcomes using the DASS-21. Psychol Assess. 25:1103–1110.
Zigmond AS, Snaith RP (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 67:361–370.
174
www.jonmd.com
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Predicting Symptoms of Depression From Social Anhedonia and Emotion Regulation Brennan D. Atherton, BS,* Robert M. Nevels, PhD, MSCP,† and Michael T. Moore, PhD* Abstract: The literature examining social anhedonia, emotion regulation, and symptoms of depression in psychiatric inpatients has been limited. However, some studies have shown that difficulties in emotion regulation and social anhedonia were independently associated with depression. The current study attempted to examine the effects of these two potential predictors of unipolar depressed mood. Fifty-nine (73% female) psychiatric inpatients were given the measures of emotion regulation, symptoms of anxiety and depression, and social anhedonia. Results showed that difficulties in emotion regulation, specifically dysfunctional emotion regulation strategies and emotional clarity, served as significant predictors of depressive symptoms above and beyond contributions from social anhedonia. These results highlight the importance of attending to emotion regulation in the study and treatment of depression in inpatient samples. Key Words: Emotion regulation, social anhedonia, depression (J Nerv Ment Dis 2015;203: 170–174)
D
epression is a very serious and common mental disorder. In a recent nationwide epidemiological survey, major depressive disorder (MDD) had the highest lifetime and 12-month prevalence rates (16% and 17%, respectively) of 14 major psychiatric disorders (Kessler et al., 2003). In the year 2000 alone, $26.1 billion was spent on medical care for the treatment for depression, $5.4 billion was spent in suiciderelated mortality costs, and $51.5 billion was lost because of lost productivity (Greenberg et al., 2003). Average costs per day for inpatients with depression are approximately $870, with an average length of stay of 8.4 days (Stensland et al., 2012). One symptom that has frequently been investigated in inpatients with MDD, and that will be a focus of the current investigation, is social anhedonia (SA).
Social Anhedonia The importance of the interpersonal context to depression is widely recognized. Research related to stress generation (e.g., Hammen, 1991) has highlighted how depressed individuals can produce stress in their personal relationships through excessive reassurance seeking (see Starr and Davila, 2008, for a review), among other mechanisms. SA is defined as the experience of reduced pleasure from interpersonal interactions and subsequent reduced desire for social affiliation (Germine et al., 2011). SA represents a particular subtype of the more general class of anhedonic experience that is a central criterion for MDD (American Psychiatric Association, 2013). In addition, SA represents social disinterest, and not shyness, introversion, or anxiety in social situations (Silvia and Kwapil, 2011). Rey et al. (2009) examined SA in a sample of university undergraduates. They found that individuals who self-reported more SA also *Department of Psychology, Jackson State University, Jackson; and †Private Practice, Ridgeland, MS. Dr Moore is now at Adelphi University, Gordon F. Derner Institute of Advanced Psychological Studies, Garden City, NY. Send reprint requests to Michael T. Moore, PhD, Adelphi University, 1 South Avenue, Gordon F. Derner Institute of Advanced Psychological Studies, Blodgett Hall, 2nd Floor, Garden City, NY 11530. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20303–0170 DOI: 10.1097/NMD.0000000000000262
170
www.jonmd.com
reported more symptoms of depression. Blanchard et al. (2001) studied MDD and schizophrenia in an inpatient sample. Results indicated that SA is a state, not trait, marker of depression, whereas SA was found to be a stable trait in individuals diagnosed with schizophrenia. Despite the status of anhedonia as a central symptom of MDD and the importance of social functioning in depression, SA has been infrequently studied in the context of inpatient hospitalization. In comparison, emotion regulation has been much more frequently studied in samples with depression.
Difficulties in Emotion Regulation Difficulties in emotion regulation have been shown to be a risk factor for various forms of psychopathology, including depression (Gross and Munoz, 1995). Gross (1998) defines emotion regulation as the process by which individuals influence their emotions. He also states that it refers to how individuals experience, as well as express, their emotions. Gross and Munoz (1995) define emotion regulation as either regulating something via emotions or regulating emotions themselves. Gratz and Roemer (2004) have defined emotion regulation as the awareness, acceptance, and understanding of emotions as well as the ability to control impulsivity and to strive toward goals while experiencing negative emotions. Lastly, Gratz and Roemer state that emotion regulation involves the ability to use appropriate strategies to modulate emotional responses to meet goals and certain situational demands. Although the above definitions share many features, they are by no means mutually exclusive; the operationalization of emotion regulation used in the current paper corresponds most closely to that of Gratz and Roemer. Recent research linking deficits in emotion regulation to depression in a sample of female university students has found that depressed students demonstrate less emotional acceptance, awareness, and clarity of their emotions than their nondepressed peers do (Svaldi et al., 2012); depressed students also showed higher levels of negative emotions, selfcriticism, and emotional suppression. The individuals diagnosed with MDD differed from those diagnosed with anorexia or bulimia nervosa, borderline personality disorder, and binge eating disorder with regard to the use of positive thoughts to regulate emotions, with depressed participants demonstrating less positive thoughts than the other groups. Ehring et al. (2008) found, in currently nondepressed university students, that past depression was related to higher levels of selfperceived emotion regulation difficulties, more use of emotion regulation strategies that are dysfunctional, and difficulty keeping things in perspective. They also found that those with a history of depression had difficulties in emotional acceptance and clarity when compared with those without such a history. Not all of the research examining emotion regulation and depression has been done in undergraduate samples, however. Garnefski and Kraaij (2006) found that a sample of psychiatric outpatients scored significantly higher than did adolescents, adults, and older adults without psychiatric problems with regard to self-blame, rumination, and catastrophizing emotion regulation strategies—which all led to depressive symptoms. They found that accepting and resigning oneself to a situation, self-blame, and blaming others led to depressive symptoms. In addition, a lack of positive refocusing and positive reappraisal was found to lead to depressive symptoms. Marquart et al. (2009) found that
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015
ER, SA, & Depression
depressed psychiatric inpatients reported weak expectations regarding their ability to regulate their negative moods. In addition, depression severity was closely related to male patients' expectations regarding their ability to control negative moods through affect regulation, behavioral activation, cognitive restructuring, and social involvement. Suicide risk was significantly related to expectations regarding the ability to control negative moods. Wineman (2009) found similar results for adolescent female inpatients, in that depression and suicidality were both related to emotion dysregulation. In another study, Fehlinger et al. (2013) found that high competencies in regulating emotions significantly predicted depression. More specifically, access to emotion regulation strategies was the most important predictor of the severity of depressive symptoms, whereas the realization of goal-directed behavior, identification, acceptance, and expression of emotions were not significant predictors.
a high school diploma. None of the aforementioned demographic variables had significant associations with symptoms of depression, with the exception of level of education. As a result, this variable was included as a covariate in the analysis which follows below. Diagnostic information is, unfortunately, unavailable because of the added time and expense of diagnostic interviewing. However, the mean score for the sample on the Depression subscale of the Depression Anxiety Stress Scale (DASS-D) (Lovibond and Lovibond, 1995) was indicative of severe depression (mean [SD], 24.5, [14.65]) and comparable with other studies that have used inpatient (e.g., Ronk et al., 2013) and outpatient (Antony et al., 1998; Brown et al., 1997) samples diagnosed with a unipolar mood disorder. In addition, 66% of the sample listed a symptom(s) of a mood disorder as a presenting complaint upon admission.
The Current Study
Measures
The current study investigated the interplay between SA and emotion regulation and compared the ability of both variables to predict symptoms of depression in an inpatient sample. Although SA has been frequently studied in inpatient samples with psychosis, its association with depression is less well known in this context. The associations between emotion regulation and depression have been more frequently examined, but primarily using outpatient or student samples. It is reasonable to expect the relationships between SA, emotion regulation, and symptoms of depression to differ between inpatient and outpatient samples, and generalization, without justification, from the latter to the former is problematic. For instance, the link between SA and depression should be stronger in inpatients, given the link both variables have with impairments in social skills (Blanchard et al., 1998; Segrin, 2000), which are more impaired in depressed inpatients (Dalley et al., 1994; Edison and Adams, 1992; Segrin, 1992). Similarly, the link between emotion dysregulation and depression should be stronger in inpatients to the extent that attempted suicide, a highly dysfunctional attempt at emotional avoidance (Chapman et al., 2006), is a common impetus for inpatient hospitalization. Our hypothesis is that both SA and aspects of emotion regulation will be associated with symptoms of depression. We make no predictions about the relative strength of these associations, and any inferences related to this point should be viewed as purely exploratory.
The DASS-21 (Lovibond and Lovibond, 1995) is a 21-item selfreport questionnaire designed to differentiate between the core symptoms of depression, anxiety, and stress. It is a shortened version of the original 42-item version (Lovibond and Lovibond, 1993). Items are measured on a 4-point Likert-type scale, with higher scores indicating increasing amount of depression, anxiety, and stress. The DASS has demonstrated excellent internal consistency overall (α = 0.93) as well as for the depression (α = 0.88), anxiety (α = 0.82), and stress (α = 0.90) scales (Henry and Crawford, 2005). In the current sample, only the depression subscale was used, which demonstrated a comparably excellent degree of internal consistency (α = 0.94). Henry and Crawford (2005) found that the DASS had adequate construct validity, as evidenced by its good convergent validity with the Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983) and the Personal Disturbance scale (Bedford and Foulds, 1978). The Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, 2004) is a 36-item, self-report measure that provides a comprehensive assessment of overall emotion regulation difficulties using six specific dimensions: nonacceptance of negative emotions (nonacceptance), difficulties engaging in goal-directed behaviors when experiencing negative emotions (goals), difficulties controlling impulsive behaviors when experiencing negative emotions (impulse), limited access to effective emotion regulation strategies (strategies), lack of emotional awareness (awareness), and lack of emotional clarity (clarity). Participants rate the extent to which each item applies to him/her using a 5-point Likert scale, where higher scores indicate increasing difficulties in emotion regulation. Gratz and Roemer (2004) found good test-retest reliability for the DERS (ρI = 0.88) over a period of 4 to 8 weeks as well as good internal consistency (α = 0.93) for the total scale and alphas ranging from 0.80 to 0.89 for the subscale scores. In the current sample, internal consistency values (α) ranged from good to excellent: nonacceptance, 0.87; goals, 0.83; impulse, 0.87; awareness, 0.78; strategies, 0.90; and clarity, 0.80. The Revised Social Anhedonia Scale (RSAS; Eckblad et al., 1982) is a 40-item true-false measure designed to assess SA. It has shown an acceptable level of test-retest reliability over 8 to 12 weeks in a student sample (r = 0.81; Winterstein et al., 2010). The RSAS demonstrated good internal consistency between these two sample points, with alphas ranging from 0.83 to 0.85 (Winterstein et al., 2010). Bailey et al. (1993) found that the RSAS was found to be significantly correlated with both depression (r = 0.43) and anxiety (r = 0.41). In the current sample, an unacceptably low degree of internal consistency was found using all 40 items of the instrument (α = 0.60). Sixteen items that demonstrated the lowest item-total correlations were removed (items 8, 9, 11, 15, 16, 18, 19, 20, 24, 25, 27, 28, 31, 32, 33, and 36), and the resulting 24-item scale was associated with an acceptable level degree of internal consistency (α = 0.79). This adapted scale was used in the analyses reported below.
METHODS Participants and Procedure Participants (n = 59) were recruited from an inpatient unit at a university medical center in the southern United States and were seen there between September 2010 and June 2011. Inclusion criteria were younger than 65 years and the absence of a psychotic episode at the time of intake. The mean (SD) age of the sample was 36.33 (11.99) years (range, 18–62 years), and the sample was predominantly female (72.88%). With regard to marital status, 34% identified as never married, 27% reported being divorced, 24% were married, 7% were separated, 5% were widowed, and 3% of participants did not identify their marital status. In terms of race, the sample was predominantly white (59%), but other racial and ethnic groups were represented (27% identified as African American, 10% identified as multiracial, and 4% identified as Native American). With regard to ethnicity (which was asked as a separate question from race), 2% self-identified as Hispanic/ Latino. The sample was generally of low socioeconomic status, as indicated by degree of employment, income, and level of education. Most of the sample were unemployed (75%; only 12% had full-time work) and 51% reported making less than $10,000 per year. With regard to the highest level of education, 34% reported attending some college, 27% reported attending some high school, and 22% reported receiving © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.jonmd.com
171
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015
Atherton et al.
RESULTS See Table 1 for a listing of zero-order bivariate correlations between all measured variables. A linear regression with the six DERS scales and RSAS as predictors of the Depression subscale of the DASS21 accounted for significant variance in this criterion, R2 = 0.71, F(7, 41) = 14.30, p < 0.001. In addition, when the RSAS was entered in step 1, the DERS subscales predicted significant variance above and beyond this variable, ΔR2 = 0.43, ΔF(6, 41) = 10.13, p < 0.001. The RSAS served as a significant predictor when it was entered alone in step 1, β = 0.53, t(41) = 4.26, p < 0.001, Cohen's f 2 = 0.39, but not when the DERS subscales were added in step 2, β = 0.08, t(41) = 0.82, p = 0.42, f 2 = 0.02. DERS–strategies, β = 0.52, t(41) = 2.39, p = 0.02, f 2 = 0.14, served as a significant predictor in step 2, whereas DERS– clarity was a significant predictor at a trend level, β = 0.28, t(41) = 1.90, p = 0.065, f 2 = 0.09. The former predictor conformed to the convention of Cohen (1992) for a medium effect and the latter for a small-to-medium effect. DERS–nonacceptance, β = 0.09, t(41) = 0.60, p = 0.55, f 2 = 0.01, DERS–goals, β = 0.04, t(41) = 0.33, p = 0.75, f 2 < 0.01, DERS–impulse, β = −0.08, t(41) = −0.54, p = 0.60, f 2 = 0.001, and DERS–awareness, β = 0.02, t(41) = 0.16, p = 0.88, f 2 < 0.01, did not significantly predict DASS-D scores and corresponded to a small effect, or less.
DISCUSSION Our hypothesis, that SA would be associated with depressive symptoms in psychiatric inpatients, was supported. This result is consistent with previous research linking the two concepts in both inpatient (Blanchard et al., 2001) and undergraduate (Rey et al., 2009) samples. The hypothesis suggesting that emotion dysregulation would be associated with increasing depressive symptoms was also supported. This was consistent with previous research finding a link between difficulties in emotion regulation and depression (Ehring et al., 2008; Fehlinger et al., 2013; Garnefski and Kraaij, 2006; Marquart et al., 2009; Svaldi et al., 2012; Wineman, 2009). Although depression was correlated with all of the DERS scales, only difficulties in emotion regulation strategies and difficulties with emotional clarity served as significant predictors, consistent with previous research. Moriya and Takahashi (2013) found that lack of emotional clarity and limited access to emotion regulation strategies fully mediated the relationship between interpersonal stress and depression in undergraduate students, whereas the other DERS subscales did not. Ehring et al. (2008) found similar results: past depression was related to less effective emotion regulation strategies,
higher difficulty in emotional acceptance, and dysfunction in emotional clarity in an undergraduate sample. The current study demonstrated that dysfunctional emotion regulation strategies and dysfunctional emotional clarity are also predictive of depressive symptoms in an inpatient population.
Clinical Implications SA has been most frequently studied in the context of schizophrenia and, when it has been studied in the context of depression, has only been studied in an undergraduate sample (Rey et al., 2009). The current investigation emphasizes the importance of SA in interactions with depressed clients in an inpatient milieu. The exact relationship between SA and symptoms of depression, however, has yet to be identified. Is SA just another symptom of depression? Is it related to impairments in social skills? If so, how? Difficulties in emotion regulation strategies were found to significantly predict depressive symptoms in the current study, over and above variance accounted for by SA. These findings fit into the larger body of research relating the use of specific emotion regulation strategies and symptoms of depression. Broadly, this research has found that the use of cognitive reappraisal, when compared with emotional suppression or rumination, is less common in those with depression (Gross and John, 2003; Joorman and Gotlib, 2010). There have been few studies examining the effects of emotional clarity and its impact on depressive symptoms and the literature has been mixed in its support of this link. For example, Fisher et al. (2010) found that use of emotional clarity was associated with decreased symptoms of anxiety but did not impact symptoms of depression. Salguero et al. (2013) found that emotional attention was associated with emotional clarity, and emotional clarity was associated with emotional repair. Emotional repair was associated with lower depressive symptoms due to the association between emotional repair and decreased rumination. However, increasing emotional attention was also positively related to rumination, which was associated with depressed mood. Strange et al. (2013) found that emotional clarity buffered against the effects of depressive symptoms, such as dysfunctional attitudes, self-criticism, and neediness. Recently, emotion regulation has moved to the forefront in thinking related to the treatment of both anxiety and depression. Emotion Regulation Therapy (ERT; Mennin, 2006) focuses on emotion regulation difficulties, such as heightened intensity of emotions, a poor understanding of emotions, negative reactivity to emotional state, and maladaptive emotional management; this therapy was initially developed to combat the symptoms of generalized anxiety disorder (GAD;
TABLE 1. Correlational Analysis Between DASS-D, RSAS, and DERS Subscales DASS-D
RSAS
Nonacceptance
Goals
Impulse
Awareness
Strategies
Clarity
–
0.53*** –
0.61*** 0.42*** –
0.50*** 0.28* 0.60*** –
0.60*** 0.36** 0.64*** 0.63*** –
0.37** 0.28* 0.02 0.08 0.37** –
0.82*** 0.52*** 0.73*** 0.65*** 0.78*** 0.40** –
0.75*** 0.53*** 0.48*** 0.35** 0.57*** 0.51*** 0.77*** –
DASS-D RSAS Nonacceptance Goals Impulse Awareness Strategies Clarity
Nonacceptance = DERS, Nonacceptance, Subscale; Goals = DERS, Goals Subscale; Impulse = DERS, Impulse Subscale; Awareness = DERS, Awareness Subscale; Strategies = DERS, Strategies Subscale; Clarity = DERS, Clarity Subscale. *p < 0.05 (two tailed). **p < 0.01 (two tailed). ***p < 0.001 (two tailed).
172
www.jonmd.com
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015
Mennin, 2006). However, ERT theory has been found to be relevant to individuals with MDD. Mennin et al. (2007) found that negative reactivity to emotions and a poor understanding of emotions were significantly related to MDD. However, heightened intensity of emotions and maladaptive management of emotions were found to be more significantly related to symptoms of GAD. Initial evidence for ERT has been promising in the treatment of GAD (see Mennin and Fresco, 2013), and future trials may show ERT to be efficacious in the treatment of MDD as well. Berking et al. (2013) examined the efficacy of a form of cognitive-behavioral therapy emphasizing emotion regulation training (CBT-ERT) in an inpatient sample. The emotion regulation component of this therapy included muscle relaxation, deep breathing, acceptance of emotions, self-support, identifying causes of one's emotions, and emotion modification. Results showed a greater reduction in symptoms of depression in depressed inpatients when they were given CBT-ERT, as opposed to general CBT. Patients also demonstrated greater reductions in negative affect, as well as a greater sense of well-being. Kumar et al. (2008), using exposure-based cognitive therapy (Hayes et al., 2007), was effective in combating depression. More specifically, the mindfulness component of this particular therapy was found to decrease depressive maladaptive emotion regulation strategies, such as rumination and avoidance. In total, the available evidence demonstrates that improvements in emotion regulation can positively benefit the treatment of acute unipolar mood disturbance, although which specific components of emotion regulation are most beneficial remains a largely open question.
Limitations and Future Directions Limitations of the current study include the largely female inpatient sample, which limits generalizability to men. In addition, although the results from the DASS-21 are indicative of a severely depressed sample that is consistent with others diagnosed with MDD and/or dysthymia, the lack of structured interview data means that we cannot comment on the diagnostic status or possible comorbidities present in the sample with any certainty. We found the RSAS to possess inadequate internal consistency in our sample of depressed clients in inpatient treatment. This necessitated a revision of the measure, which, although it resulted in a more coherent item set, bears an uncertain relationship with the RSAS. Although a full psychometric evaluation of the RSAS is beyond the scope of the current article, future work should identify the psychometric properties of the RSAS in a larger sample of depressed, treatment-seeking individuals.
CONCLUSIONS SA demonstrated a significant relationship with symptoms of depression, but only when emotion regulation was not included in the model. Because dysfunctional strategies and clarity were the only aspects of emotion regulation to specifically predict depressive symptomatology, they should be studied more extensively as potential tools to alleviate depressive symptoms in inpatient populations. Therapies that focus on these aspects of emotion regulation could prove to be the most useful in treating this prevalent and costly mental health concern.
ER, SA, & Depression
Bailey B, West KY, Widiger TA, Freiman K (1993) The convergent and discriminant validity of the Chapman Scales. J Pers Assess. 61:121–135. Bedford A, Foulds G (1978) Delusions-Symptoms-States Inventory state of anxiety and depression. Windsor, UK: NFER-Nelson. Berking M, Ebert D, Cuijpers P, Hoffman SG (2013) Emotion regulation skills training enhances the efficacy of inpatient cognitive behavioral therapy for major depressive disorder: A randomized controlled trial. Psychother Psychosom. 82:234–245. Blanchard JJ, Horan WP, Brown SA (2001) Diagnostic differences in social anhedonia: A longitudinal study of schizophrenia and major depressive disorder. J Abnorm Psychol. 110:363–371. Blanchard JJ, Mueser KT, Bellack AS (1998) Anhedonia, positive and negative affect, and social functioning in schizophrenia. Schizophr Bull. 24:413–424. Brown TA, Chorpita BF, Korotitsch W, Barlow DH (1997) Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behav Res Ther. 35:79–89. Chapman AL, Gratz KL, Brown MZ (2006) Solving the puzzle of deliberate selfharm: The experiential avoidance model. Behav Res Ther. 44:371–394. Cohen J (1992) A power primer. Psychol Bull. 112:155–159. Dalley MB, Bolocofsky DN, Karlin NJ (1994) Teacher-ratings and self-ratings of social competency in adolescents with low- and high-depressive symptoms. J Abnorm Child Psychol. 22:477–485. Eckblad ML, Chapman LJ, Chapman JP, Mishlove M (1982) The Revised Social Anhedonia Scale. Unpublished test. Edison JD, Adams HE (1992) Depression, self-focus, and social interaction. J Psychopathol Behav. 14:1–19. Ehring T, Fischer S, Schnülle J, Bösterling A, Tuschen-Caffier B (2008) Characteristics of emotion regulation in recovered depressed versus never depressed individuals. Pers Individual Differences. 44:1574–1584. Fehlinger T, Stumpenhorst M, Stenzel N, Rief W (2013) Emotion regulation is the essential skill for improving depressive symptoms. J Affect Disord. 144:116–122. Fisher J, Sass SM, Heller W, Silton RL, Edgar JC, Stewart JL, Miller GA (2010) Time course of processing emotional stimuli as a function of perceived emotional intelligence, anxiety, and depression. Emotion. 10:486–497. Garnefski N, Kraaij V (2006) Relationships between cognitive emotion regulation strategies and depressive symptoms: A comparative study of five specific samples. Pers Individual Differences. 40:1659–1669. Germine LT, Garrido L, Bruce L, Hooker L (2011) Social anhedonia is associated with neural abnormalities during face emotion processing. Neuroimage. 58:935–945. Gratz KL, Roemer L (2004) Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. J Psychopathol Behav. 26:41–54. Greenberg PE, Kessler RC, Birnbaum HG, Leong SA, Lowe SW, Berglund PA, CoreyLile PK (2003) The economic burden of depression in the United States: How did it change between 1990 and 2000? J Clin Psychiatry. 64:1465–1475. Gross JJ (1998) The emerging field of emotion regulation: An integrative review. Rev Gen Psychol. 2:271–299. Gross JJ, John OP (2003) Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. J Pers Soc Psychol. 85:348–362. Gross JJ, Munoz RF (1995) Emotion regulation and mental health. Clin Psychol. 2:151–164.
DISCLOSURES The authors declare no conflict of interest. REFERENCES American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Publishing. Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP (1998) Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales (DASS) in clinical groups and a community sample. Psychol Assess. 10:176–181.
Hammen C (1991) Generation of stress in the course of unipolar depression. J Abnorm Psychol. 100:555–561. Hayes AM, Feldman GC, Beevers CG, Laurenceau JP, Cardaciotto L, Smith JL (2007) Discontinuities and cognitive changes in an exposure-based cognitive therapy for depression. J Consult Clin Psychol. 75:409–421. Henry JD, Crawford JR (2005) The short-form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large nonclinical sample. Br J Clin Psychol. 44:227–239. Joorman J, Gotlib IH (2010) Emotion regulation in depression: Relation to cognitive inhibition. Cogn Emot. 24:281–298.
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.jonmd.com
173
Atherton et al.
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015
Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS (2003) The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R). JAMA. 289:3095–3105. Kumar S, Feldman G, Hayes A (2008) Changes in mindfulness and emotion regulation in an exposure-based cognitive therapy for depression. Cogn Ther Res. 32:734–744. Lovibond SH, Lovibond PF (1993) Manual for the Depression Anxiety Stress Scales (DASS). Psychology Foundation Monograph. Sydney, Australia: Psychology Foundation. Available from the Psychology Foundation, Room 1005 Matthews Building, University of New South Wales, NSW 2052, Australia. Lovibond SH, Lovibond PF (1995) Manual for the Depression Anxiety Stress Scales (2nd ed). Sydney, Australia: Psychology Foundation. Available from The Psychology Foundation, Room 1005 Mathews Building, University of New South Wales, NSW 2052, Australia. Marquart AL, Overholser JC, Peak NJ (2009) Mood regulation beliefs in depressed psychiatric inpatients: Examining affect, behavior, cognitive, and social strategies. Int J Psychiatr Clin. 13:265–272. Mennin DS (2006) Emotion Regulation Therapy: An integrative approach to treatment-resistant anxiety disorders. J Contemp Psychother. 36:95–105. Mennin DS, Fresco DM (2013) Emotion Regulation Therapy. In Gross JJ (Ed), Handbook of Emotion Regulation (2nd ed). New York: Guilford Press. Mennin DS, Holaway RM, Fresco DM, Moore MT, Heimberg RG (2007) Delineating components of emotion and its dysregulation in anxiety and mood psychopathology. Behav Ther. 38:284–302. Moriya J, Takahashi Y (2013) Depression and interpersonal stress: The mediating role of emotion regulation. Motiv Emotion. 37:600–608.
Salguero JM, Extremera N, Fernández-Berrocal P (2013) A meta-mood model of rumination and depression: Preliminary test in a non-clinical sample. Scand J Psychol. 54:166–172. Segrin C (1992) Specifying the nature of social skill deficits associated with depression. Hum Commun Res. 19:89–123. Segrin C (2000) Social skills deficits associated with depression. Clin Psychol Rev. 20:379–403. Silvia PJ, Kwapil TR (2011) Aberrant asociality: How individual differences in social anhedonia illuminate the need to belong. J Pers. 79:1013–1030. Starr LR, Davila J (2008) Excessive reassurance seeking, depression, and interpersonal rejection: A meta-analytic review. J Abnorm Psychol. 117:762–775. Stensland M, Watson PR, Grazier KL (2012) An examination of costs, charges, and payments for inpatient psychiatric treatment in community hospitals. Psychiatr Serv. 63:666–671. Strange JP, Boccia AS, Shapero BG, Molz AR, Flynn M, Matt LM, Abramson LY, Alloy LB (2013) Emotion regulation characteristics and cognitive vulnerabilities interact to predict depressive symptoms in individuals at risk for bipolar disorder: A prospective behavioural high-risk study. Cogn Emot. 27:63–84. Svaldi J, Griepenstroh J, Tuschen-Caffier B, Ehring T (2012) Emotion regulation deficits in eating disorders: A marker of eating pathology or general psychopathology? Psychiatry Res. 197:103–111. Wineman PA (2009) The efficacy of a dialectical behavior therapy-based journal-writing group with inpatient adolescent females: Improving emotion regulation, depressive symptoms and suicidal ideation. Diss Abstr Int Sect B. 70:3817.
Rey G, Jouvent R, Dubal S (2009) Schizotypy, depression, and anxiety in physical and social anhedonia. J Clin Psychol. 65:695–708.
Winterstein BP, Willse JT, Kwapil TR, Silvia PJ (2010) Assessment of score dependability of the Wisconsin schizotypy scales using generalizability analysis. J Psychopathol Behav Assess. 32:575–585.
Ronk FR, Korman JR, Hooke GR, Paige AC (2013) Assessing clinical significance of treatment outcomes using the DASS-21. Psychol Assess. 25:1103–1110.
Zigmond AS, Snaith RP (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 67:361–370.
174
www.jonmd.com
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
