بررسی سهم افزایشی مشکلات تنظیم احساسات در جهت کاهش اضطراب سلامت فراتر از استراتژی های تنظیم احساسات خاص

Given the potential transdiagnostic importance of emotion dysregulation, as well as a lack of research examining emotion dysregulation in relation to health anxiety, the present study sought to examine associations among specific emotion regulation strategies (cognitive reappraisal and expressive suppression), emotion regulation difficulties, and health anxiety in a physically healthy sample of adults (N = 482). As hypothesized, results of a series of hierarchical multiple regression analyses showed that emotion regulation difficulties provided a significant incremental contribution, beyond the specific emotion regulation strategies, in predicting each of the three health anxiety variables. Among the six dimensions of emotion regulation difficulties, the dimension representing perceived access to effective emotion regulation strategies was the only emotion regulation difficulty dimension that predicted all three health anxiety variables beyond the effects of the specific emotion regulation strategies. Results indicate that emotion regulation difficulties, and particularly one's subjective appraisal of his/her ability to effectively regulate emotions, may be of importance to health anxiety. Clinical implications are discussed.

The field of emotion regulation continues to flourish, as studies consistently find robust associations between emotion dysregulation and maladaptive psychological outcomes. For example, emotion dysregulation has been implicated in posttraumatic stress symptomatology (Bardeen et al., 2013a and Ehring and Quack, 2010), anxiety disorders (Cisler, Olatunji, Feldner, & Forsyth, 2010), alcohol dependence (Berking et al., 2011), depression (Tull, Stipleman, Salters-Pedneault, & Gratz, 2009), borderline personality disorder (Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006), and a host of other maladaptive outcomes (see Aldao, Nolen-Hoeksema, & Schweizer, 2010 for a review). Although there is a wealth of research showing associations between emotion dysregulation and maladaptive psychological outcomes, to date, there is lack of consensus regarding what exactly is meant by the term “emotion regulation;” a number of theoretical models and measures purport to capture this polysemus construct. Among the various accounts of emotion regulation, two conceptual models have garnered the bulk of empirical focus (Gratz and Roemer, 2004 and Gross, 1998). Gratz and Roemer (2004) provided one of the most comprehensive conceptualizations of emotion regulation to date, proposing that effective emotion regulation involves identification and understanding of emotions, acceptance of emotions, perceived access to effective emotion regulation strategies, and the ability to continue to purse goal-directed behavior and inhibit impulsive behaviors when experiencing negative emotions. Based on this model, Gratz and Roemer (2004) developed the Difficulties in Emotion Regulation Scale (DERS), which is made up of the six dimensions of emotion regulation difficulties mentioned above. The DERS was intended to measure Gratz and Roemer's (2004) conceptualization of emotion dysregulation in its entirety; and thus, may be described as a global measure of emotion regulation difficulties. The focus of the DERS on emotion regulation difficulties in all of the domains of emotion regulation proposed by Gratz and Roemer (2004) is important because, as noted by Gratz and Roemer (2004), it is not uncommon for measures of emotion regulation to focus on specific emotion regulation strategies as they relate to maladaptive outcomes. However, this practice suggests that specific strategies are either adaptive or maladaptive independent of context, rather than suggesting that almost all strategies can be adaptive depending on their flexible use within a given context (e.g., Bonanno et al., 2004 and Cheng, 2001). For this reason, Gratz and Roemer (2004) included items on the DERS that assess for the subjective appraisal of one's ability to effectively regulate emotions (as represented by the Limited Access to Emotion Regulation Strategies subscale); thus accounting for the context-dependent nature of adaptive emotion regulation strategy use. A second conceptual model of emotion regulation which has received considerable attention in the extant literature is Gross's (1998) process model of emotion regulation. As defined by Gross, “emotion regulation refers to the process by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions” (p. 275; emphasis in original). Gross's process model asserts that there are five points in the emotion generative process at which emotions can be regulated. These points, or stages, include situation selection, situation modification, attentional deployment, cognitive change, and response modulation ( Gross & Thompson, 2007). These stages are further categorized as being either antecedent- (the first four stages) or response-focused (the final stage). Antecedent-focused strategies occur before emotion response tendencies are fully activated and response-focused strategies occur after response tendencies are already underway (i.e., behavior has already been altered by the emotional experience; Gross & Thompson, 2007). Although several specific emotion regulation strategies have been examined in the extant literature, in the context of Gross's (1998) model, the cognitive change strategy of cognitive reappraisal and the response modulation strategy of expressive suppression have received an overwhelming amount of attention as they relate to maladaptive psychological outcomes (see Aldao et al., 2010). In fact, Gross and John (2003) developed the Emotion Regulation Questionnaire (ERQ) to allow for the assessment of these two specific emotion regulation strategies. Cognitive reappraisal occurs relatively early in the emotion generative processes and refers to efforts to change the interpretation of an emotion-eliciting event in order to alter its emotional impact. In contrast, expressive suppression occurs relatively late in the emotion generative process and refers to inhibiting emotion-expressive behavior (John & Gross, 2004). Although Gross and Thompson (2007) explicitly note that they make no assumptions about whether specific strategies are adaptive or maladaptive, cognitive reappraisal has typically been identified as an adaptive emotion regulation strategy and expressive suppression as a maladaptive emotion regulation strategy (see John & Gross, 2004). There is conceptual and empirical evidence to suggest that Gratz and Roemer's (2004) DERS and Gross and John's (2003) ERQ assess distinct facets of emotion regulation. For example, Gratz and Roemer (2004) described the “DERS as a measure of difficulties in emotion regulation” (p. 52), with the DERS assessing such difficulties along the six dimensions outlined above. Gross and John (2003) described the ERQ as assessing emotion regulation strategies, noting that “both reappraisal and suppression are strategies that allow individuals to modify their emotions” (p. 352; emphasis added). These differing descriptions of the measures by the scale developers are notable, as Gratz and Roemer (2004) developed the DERS, in large part, to extend the assessment of emotion dysregulation beyond assessing for specific emotion regulation strategies. More precisely, and as noted above, Gratz and Roemer (2004) asserted that subjective appraisal of one's ability to effectively regulate emotions is particularly important when considering the role emotion dysregulation in psychopathology. Although Gratz and Roemer (2004) suggest that the six dimensions of emotion regulation difficulties assessed by the DERS may affect emotional responding and experience, none of the six dimensions constitute strategies in and of themselves (e.g., DERS Strategies assesses one's perception of their ability to regulate their emotions, DERS-Clarity assesses one's ability to understand and identify their emotions). Coupled with these conceptual differences across the two measures, the magnitude of intercorrelations among the scales of the DERS and ERQ further support the above noted position that the two measures assess distinct facets of emotion dysregulation. For example, Ehring and Quack (2010) found that the cognitive reappraisal (rs ranging from −.25 to −.50) and expressive suppression (rs ranging from .28 to .46) scales of the ERQ shared small to moderate correlations with the scales of the DERS. The conceptual and empirical distinctiveness of the DERS and ERQ strongly support the position that these two measures assess unique aspects of emotion dysregulation. Following from the descriptions used by the respective scale developers, we refer to the DERS as assessing the construct of emotion regulation difficulties and the ERQ as assessing the construct of emotion regulation strategies for the remainder of this manuscript. As described, evidence to date suggests the transdiagnostic importance of emotion dysregulation, especially in relation to anxiety pathology (Cisler et al., 2010). Despite its potential transdiagnostic status, we know of only two studies to examine emotion dysregulation, as operationalized using one of the major conceptualizations of emotion dysregulation outlined above, in the context of health anxiety (Fergus and Valentiner, 2010 and Görgen et al., 2014). Health anxiety has been defined as “the wide range of worry that people can have about their health” (Asmundson & Taylor, 2005, p. 5). It has been suggested that health anxiety results from misinterpretations of body sensations (e.g., rapid heartbeat) and/or symptoms (e.g., sore throat) as a sign of a medical problem (Abramowitz and Braddock, 2008 and Taylor and Asmundson, 2004). Taxometric studies support conceptualizing health anxiety as a dimensional construct, such that individuals differ quantitatively rather than qualitatively in their health anxiety (Ferguson, 2009 and Longley et al., 2010). Given evidence in support of the dimensionality of health anxiety it is important for researchers to use the full range of available scores when assessing health anxiety. This methodological approach maximizes statistical power and minimizes information loss. Both Fergus and Valentiner (2010) and Görgen et al. (2014) asserted that emotion dysregulation is important to health anxiety. For example, Fergus and Valentiner (2010) noted that emotion dysregulation might lead individuals to incorrectly ascribe body sensations and/or symptoms as a medical condition when under stressful conditions as a result of an inability to identify and understand their emotional experience. Görgen et al. (2014) similarly noted that emotion dysregulation may result in an inability to adequately terminate negative emotional states, thereby leading to elevated emotional arousal and ultimately health anxiety due to the misinterpretation of the meaning of their emotional arousal. In the context of Gross's (1998) conceptualization of emotion dysregulation, both groups of researchers found that expressive suppression was generally more relevant to health anxiety than was cognitive reappraisal. Although these are promising findings linking emotion dysregulation to health anxiety, the studies completed by Fergus and Valentiner (2010) and Görgen et al. (2014) both had a key limitation in that they only assessed for the use of specific emotion regulation strategies in the form of cognitive reappraisal and expressive suppression. As explained by Gratz and Roemer (2004), context and flexibility of use may be particularly important in determining the degree to which the use of specific emotion regulation strategies results in maladaptive psychological outcomes. For example, the suppression of emotion may be extremely adaptive when playing poker, but rigidly applied across contexts, may result in a number of psychological problems, including health anxiety (Fergus and Valentiner, 2010 and Görgen et al., 2014). Although the use of specific emotion regulation strategies is important, it seems clear that the construct of emotion dysregulation, in its entirety, must account not only for specific strategies, but also for other processes which impact emotional responding (e.g., identification and understanding of emotions). Thus, the use of a more global measure of emotion regulation difficulties, such as the DERS, may offer advantages over more limited examinations of specific emotion regulation strategies (i.e., cognitive reappraisal, expressive suppression; ERQ) and shed further light on the emotion dysregulation-health anxiety association. Following this rationale, and based on the general lack of research in this area, the present study had four primary aims. First, we sought to examine associations among specific emotion regulation strategies, a global measure of emotion regulation difficulties, as well as each of the dimensions of emotion regulation difficulties, and health anxiety. At the bivariate level, we expected expressive suppression, as well as a global measure of emotion regulation difficulties and each dimension of emotion regulation difficulties, to significantly positively correlate with health anxiety. We further expected that cognitive reappraisal would significantly negatively correlate with health anxiety. Second, we sought to examine the incremental contribution of a global measure of emotion regulation difficulties, beyond the two specific emotion regulation strategies, in predicting health anxiety. We predicted that a global measure of emotion regulation difficulties would provide significant unique variance in predicting health anxiety after accounting for cognitive reappraisal and expressive suppression. Third, exploratory analyses were used to examine the specific dimensions of emotion regulation difficulties that are particularly relevant to health anxiety. Finally, these predictions were based on conceptualizing health anxiety as a unidimensional construct; however, health anxiety appears best conceptualized as a multidimensional construct (e.g., Asmundson et al., 2008). As such, we completed additional exploratory analyses to examine relations among specific emotion regulation strategies, a global measure of emotion regulation difficulties and each dimension of emotion regulation difficulties, and two health anxiety dimensions identified by Asmundson et al. (2008; i.e., health worry and somatic symptoms/bodily preoccupation). Additionally, because evidence suggests that failing to account for the shared variance of negative affect in associations between health-related and psychological constructs may obscure relations between these variables of interest (Watson & Pennebaker, 1989), negative affect was controlled for in all multivariate analyses.

Descriptive statistics and bivariate correlations among the study variables are presented in Table 1. As shown, skew and kurtosis statistics were within a conventional range (−1 to 1; George and Mallery, 2003 and Morgan et al., 2001) for all of the study variables. To examine the variability in observed health anxiety scores, we compared the observed group mean on the WI total to the mean score obtained by a reference sample (i.e., Fergus, 2013) who completed the same measure.2 Scores greater than 1.5 SD above the mean of the reference sample were used to illustrate the variability in observed health anxiety scores (following Carter & Wu, 2010). On the WI Total, a substantial percent of participants in the present sample (i.e., 14.73%) displayed scores greater than 1.5 SD above the mean of the reference sample (i.e., z-score > 1.5). As such, a sizable number of participants endorsed experiencing a relatively severe amount of health anxiety in the present study. Table 1. Zero-order correlations, means, and standard deviations for study variables. Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 1. WI Total – 2. WI Health Worry .93*** – 3. WI Somatic Preoccupation .93*** .74*** – 4. ERQ-Cognitive Reappraisal −.21*** −.17*** −.22*** – 5. ERQ-Emotion Suppression .19*** .17*** .17*** .02 – 6. DERS-Total .46*** .44*** .43*** −.41*** .32*** – 7. DERS-Nonacceptance .37*** .33*** .35*** −.23*** .33*** .81*** – 8. DERS-Goals .39*** .40*** .33*** −.24*** .13*** .76*** .52*** – 9. DERS-Impulse .42*** .39*** .39*** −.35*** .09 .78*** .51*** .62*** – 10. DERS-Strategies .49*** .46*** .45*** −.37*** .23*** .88*** .68*** .71*** .69*** – 11. DERS-Clarity .27*** .25*** .25*** −.32*** .30*** .71*** .50*** .35*** .45*** .48*** – 12. DERS-Awareness .06 .04 .08 −.33*** .39*** .48*** .27*** .10* .20*** .18*** .59*** – 13. PANAS-NA .51*** .46*** .48*** −.26*** .18*** .61*** .49*** .48*** .51*** .61*** .43*** .13** – M 14.0 7.8 6.2 29.9 15.7 83.8 13.9 14.2 11.8 18.8 10.1 15.0 20.0 SD 5.8 3.1 3.2 6.9 5.5 25.6 6.4 5.3 5.2 8.1 3.9 5.1 8.8 Minimum 6 3 3 6 4 36 6 5 6 8 5 6 10 Maximum 30 15 15 42 28 158 30 25 30 40 25 30 48 Skew .64 .37 .84 −.75 −.12 .32 .66 .22 1.00 .66 .81 .28 .89 Kurtosis −.26 −.45 −.23 .58 −.64 −.41 −.51 −.86 .59 −.34 .27 −.34 .22 Note. N = 482. WI = Whitley Index; ERQ = Emotion Regulation Questionnaire; DERS = Difficulties in Emotion Regulation; PANAS-NA = Positive and Negative Affect Schedule – Negative Affect Scale. * p < .05. ** p < .01. *** p < .001. Table options An examination of bivariate correlations showed that the three dimensions of health anxiety (WI Total, WI Health Worry, WI Somatic Preoccupation) were significantly positively associated with expressive suppression, global emotion regulation difficulties (DERS-T), and all but one of the six dimensions of emotion regulation difficulties (ps < .001; see Table 1). The Awareness dimension of the DERS was not significantly associated with any of the dimensions of health anxiety. As hypothesized, cognitive reappraisal was significantly negatively correlated with WI Total, WI Health Worry, and WI Somatic Preoccupation (ps < .001). As seen in Table 2, and as hypothesized, global emotion regulation difficulties (DERS-T) provided a significant incremental contribution, beyond the specific emotion regulation strategies, in predicting WI Total, WI Health Worry, and WI Somatic Preoccupation (ps < .001, ΔR2s < .001). As such, three exploratory follow-up regressions were conducted to examine the incremental contribution of each of the six dimensions of emotion regulation difficulties assessed by the DERS. As seen in Table 3, addition of the six dimensions of emotion regulation difficulties in the second step of each model provided a significant incremental contribution, beyond the specific emotion regulation strategies, in predicting WI Total, WI Health Worry, and WI Somatic Preoccupation (ΔR2s < .001). DERS-Strategies was the only DERS dimension that was significantly positively associated with all three dimensions of health anxiety (ps < .05). However, DERS-Impulse was significantly positively associated with both WI Total and WI Somatic Preoccupation (ps < .01), DERS-Goals was significantly positively associated with WI Health Worry (p < .05), and DERS-Awareness was significantly negatively associated with WI Health Worry (p < .05). None of the other dimensions of emotion regulation difficulties were significantly associated with WI Total, WI Health Worry, or WI Somatic Preoccupation. Table 2. Primary regression analyses. Predictor Whitley-Index Total Whitley-Index Health Worry Whitley-Index Somatic Symptoms/Body Preoccupation F(3,478) ΔR2 Step 1 β Step 2 β F(3,478) ΔR2 Step 1 β Step 2 β F(3,478) ΔR2 Step 1 β Step 2 β Step 1 60.10*** .27*** 46.40*** .23*** 53.60*** .25*** ERQ-CR −.09* −.03 −.06 .00 −.11** −.06 ERQ-ES .10** .05 .10* .04 .10* .06 PANAS-NA .46*** .46*** .43*** .31*** .44*** .35*** Predictor Whitley-Index Total Whitley-Index Health Worry Whitley-Index Somatic Symptoms/Body Preoccupation F(1,478) ΔR2 Step 1 β Step 2 β F(1,478) ΔR2 Step 1 β Step 2 β F(1,478) ΔR2 Step 1 β Step 2 β Step 2 50.54*** .02*** 40.41*** .03*** 43.35*** .02*** DERS-T .22*** .23*** .17** Note. N = 482. ERQ = Emotion Regulation Questionnaire (CR = Cognitive Reappraisal; ES = Emotion Suppression); DERS = Difficulties in Emotion Regulation (T = total scale score); PANAS-NA = Positive and Negative Affect Schedule – Negative Affect Scale. * p < .05. ** p < .01. *** p < .001. Table options Table 3. Exploratory regression analyses. Predictor Whitley-Index Total Whitley-Index Health Worry Whitley-Index Somatic Symptoms/Body Preoccupation F(3,478) ΔR2 Step 1 β Step 2 β F(3,478) ΔR2 Step 1 β Step 2 β F(3,478) ΔR2 Step 1 β Step 2 β Step 1 60.10*** .27*** 46.40*** .23*** 53.60*** .25*** ERQ-CR −.09* −.06 −.06 −.03 −.11** −.08 ERQ-EA .10** .12** .10* .12* .10* .10* PANAS-NA .46*** .31*** .43*** .26*** .44*** .31*** Predictor Whitley-Index Total Whitley-Index Health Worry Whitley-Index Somatic Symptoms/Body Preoccupation F(9,478) ΔR2 Step 1 β Step 2 β F(9,478) ΔR2 Step 1 β Step 2 β F(9,478) ΔR2 Step 1 β Step 2 β Step 2 25.19*** .05*** 21.07*** .06*** 21.10*** .04*** DERS-N .01 −.03 .04 DERS-G .04 .12* −.03 DERS-I .11* .09 .12* DERS-S .16* .15* .15* DERS-C −.01 .02 −.04 DERS-A −.09 −.11* −.06 Note. N = 482. ERQ = Emotion Regulation Questionnaire (CR = Cognitive Reappraisal; ES = Emotion Suppression); DERS = Difficulties in Emotion Regulation (N = Nonacceptance, G = Goals, I = Impulse, S = Strategies, C = Clarity, A = Awareness); PANAS-NA = Positive and Negative Affect Schedule – Negative Affect Scale. * p < .05. ** p < .01. *** p < .001. Table options Interestingly, a third variable (a suppressor) appeared to increase the strength of association between DERS-Awareness and WI Health Worry, as evidenced by a change from the non-significant positive bivariate association between these variables to a significant negative association in regression analysis. To identify the suppressor variable, a series of partial correlations was conducted in which each of the predictor variables from the second set of regression analyses was controlled for, one at a time, while examining the correlation between DERS-Awareness and WI Health Worry. DERS-Clarity was identified as the suppressor variable, as it was the only control variable which changed the correlation between DERS-Awareness and WI Health Worry from nonsignificant and positive to significant and negative (r = −.14, p < .01).