اختلال در نظم احساسات و آسیب شناسی روانی نوجوانان: یک مطالعه آینده نگر

Background Emotion regulation deficits have been consistently linked to psychopathology in cross-sectional studies. However, the direction of the relationship between emotion regulation and psychopathology is unclear. This study examined the longitudinal and reciprocal relationships between emotion regulation deficits and psychopathology in adolescents. Methods Emotion dysregulation and symptomatology (depression, anxiety, aggressive behavior, and eating pathology) were assessed in a large, diverse sample of adolescents (N = 1065) at two time points separated by seven months. Structural equation modeling was used to examine the longitudinal and reciprocal relationships between emotion dysregulation and symptoms of psychopathology. Results The three distinct emotion processes examined here (emotional understanding, dysregulated expression of sadness and anger, and ruminative responses to distress) formed a unitary latent emotion dysregulation factor. Emotion dysregulation predicted increases in anxiety symptoms, aggressive behavior, and eating pathology after controlling for baseline symptoms but did not predict depressive symptoms. In contrast, none of the four types of psychopathology predicted increases in emotion dysregulation after controlling for baseline emotion dysregulation. Conclusions Emotion dysregulation appears to be an important transdiagnostic factor that increases risk for a wide range of psychopathology outcomes in adolescence. These results suggest targets for preventive interventions during this developmental period of risk.

The adaptive management of emotions is critical for social functioning and psychological well-being (Aldao et al., 2010, Denham, 1998, Eisenberg et al., 2000 and Gross, 1998b). Thompson (1994) defined emotion regulation as: “the extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one’s goals” (p. 28). Individual differences in the ability to identify and understand one’s own emotions, the emotions of others, and the causes and consequences of different emotions, as well as in the types of strategies used to manage and regulate emotions, are evident by early childhood (Cummings, 1987, Denham, 1998 and Eisenberg et al., 1993). These differences in emotional understanding and in the acquisition of adaptive strategies for managing emotions have far-reaching implications for social functioning (Denham, 1986, Eisenberg et al., 1993, Eisenberg et al., 2000 and Saarni, 1999). Children and adolescents with better emotion regulation skills are more socially competent, have higher peer status and better quality relationships, and engage in higher levels of prosocial behavior than youth with poor emotion regulation skills (Denham, 1986, Denham et al., 2003, Denham et al., 1990, Eisenberg et al., 1993, Eisenberg et al., 1995, Hubbard and Coie, 1994, Rydell et al., 2003 and Spinard et al., 2006). Children’s emotion regulation skills also have been found to predict their social competence at later points in development (Denham et al., 2003, Rydell et al., 2003 and Spinard et al., 2006). Emotion regulation skills also have important implications for mental health (Gross & Muñoz, 1995). Accumulating evidence suggests that emotion regulation is related to the development and maintenance of youth psychopathology. Children with anxiety disorders have been found to have poorer emotional understanding and more difficulty managing negative emotions than non-anxious youth (Southam-Gerow and Kendall, 2000 and Suveg and Zeman, 2004). Adolescent depression also has been linked to reductions in the use and quality of strategies to manage negative emotions (Garber et al., 1995 and Silk et al., 2003). Engagement in rumination, an emotion regulation strategy involving passive self-focus on feelings of distress and on their causes and consequences (Nolen-Hoeksema & Morrow, 1991), has been associated consistently with adolescent depression both concurrently (Kuyken et al., 2006 and Ziegert and Kistner, 2002) and prospectively (Abela et al., 2002, Broderick and Korteland, 2004 and Burwell and Shirk, 2007). Poor emotional understanding and difficulty regulating negative emotions also have been documented among children who engage in high levels of aggressive behavior (Bohnert et al., 2003, Cole et al., 1994, Dearing et al., 2002, Eisenberg et al., 2000 and Shields and Cicchetti, 1998) and among adolescent females with eating pathology (Sim and Zeman, 2005 and Sim and Zeman, 2006). Adolescence represents a crucial developmental period in which to study the relationship between emotion regulation skills and psychopathology. A central task of adolescence is to learn to regulate affect in adaptive ways, increasingly without the aid of the adults who provide guidance in childhood (Steinberg and Avenevoli, 2000 and Steinberg et al., 2006). Changes in biological, cognitive, and social systems during adolescence present innumerable affectively-laden situations in which emotions must be successfully managed to ensure adaptive functioning (Larson and Richards, 1991 and Steinberg, 1987). For instance, increasing independent contact with peers introduces a myriad of challenges that require effective emotional response management (e.g., engagement in romantic relationships and sexual behavior, exposure to substance use). These numerous changes lead to increased perceptions of stress and daily hassles (Larson and Ham, 1993, Seidman et al., 1994 and Simmons and Blythe, 1987) as well as increases in the experience of negative affect and emotional instability, and a closer linking of stressful events to the emergence of negative affect (Larson and Ham, 1993, Larson and Lampman-Petraitis, 1989 and Larson et al., 2002). Adolescence also is characterized by high risk for the development of psychopathology (Andersen and Teicher, 2008, Hankin et al., 1998, Lewinsohn et al., 2000 and Twenge and Nolen-Hoeksema, 2002). Individuals who have not developed strategies to adaptively manage negative emotions arising from the many challenges of adolescence may be particularly at risk for adverse mental health outcomes (Silk et al., 2007 and Steinberg et al., 2006). Despite accumulating evidence suggesting that emotion dysregulation is associated with youth psychopathology, a number of important questions remain unanswered regarding the specific nature of this relationship. First, although poor emotion regulation has been documented among children and adolescents with a variety of diagnoses and associations between emotion regulation and symptoms of psychopathology have been observed in a number of studies, the vast majority of this research has been cross-sectional in nature, with some notable exceptions examining rumination specifically (Abela et al., 2002, Broderick and Korteland, 2004 and Burwell and Shirk, 2007) and problem behaviors in young children (Eisenberg, Guthrie et al., 2000). Thus, it remains unclear whether emotion dysregulation primarily represents a risk factor for the development of adolescent psychopathology or whether the onset of mental health problems renders adolescents less able to effectively manage their emotions. This distinction has important implications for targeting emotion regulation in treatment versus preventive interventions. If emotion regulation is a risk factor for future psychopathology, techniques targeting emotion regulation skills should be incorporated into both treatment and preventive interventions. Alternatively, if emotion regulation is primarily a consequence of psychopathology or a factor underlying disorder persistence, such techniques would most usefully be included into treatment rather than prevention. Second, there is a paucity of research on the extent to which emotion dysregulation represents a global risk factor for poor mental health outcomes versus a vulnerability to specific types of psychopathology. Poor emotion regulation has recently been posited to represent a transdiagnostic factor related to multiple types of psychopathology (Ehring and Watkins, 2008, Gross and John, 2003, Harvey et al., 2004, Kring and Sloan, 2010, Moses and Barlow, 2006 and Watkins, 2008). Significant cross-sectional associations have been documented between emotion dysregulation and symptoms of depression, anxiety, eating pathology, and substance abuse in transdiagnostic studies of adults and in a recent meta-analysis (Aldao and Nolen-Hoeksema, 2010 and Aldao et al., 2010). Prospective data are needed, however, to determine both the direction of effect in the relationship between emotion regulation deficits and psychopathology, and whether emotion dysregulation represent a vulnerability factor for the development of certain types of psychopathology, but not others. Finally, it is unknown whether different aspects of emotion functioning are best represented by a latent factor of emotion regulation or are better characterized as distinct processes in adolescence. Emotion regulation involves a number of component processes, each of which emerge at different points in development (Denham, 1998). Recent evidence from an adult sample indicated that poor understanding of emotions, negative cognitive reactivity to emotional experiences, and maladaptive emotion management (but not emotional intensity) loaded onto a higher-order factor of emotion dysregulation (Mennin, Holaway, Fresco, Moore, & Heimberg, 2007), but it is unknown whether these processes comprise a broad latent factor in adolescents. The current investigation aimed to address these gaps in the literature by examining the reciprocal relationships among poor emotion regulation skills and various forms of psychopathology in a sample of adolescents followed prospectively. We expected that adolescents who were better able to identify and understand their emotional experiences would also employ more effective strategies for managing their emotions. Specifically, we predicted that emotional understanding, adaptive expression of negative emotions, and cognitive emotion management strategies would best be represented by a higher-order construct of emotion regulation. We selected these specific aspects of emotion regulation in order to capture different stages in the emotion regulation process, each of which has relevance for psychopathology. Awareness and understanding of emotional experience represents an early stage of the emotion regulation process that requires attending to and differentiating interoceptive emotional cues. Emotional awareness has neural correlates that are distinct from emotion expression and regulation (Lane et al., 1998). It has been argued that emotional awareness is necessary to facilitate adaptive emotion regulation (Saarni, 1999), and poor awareness has been linked to a variety of poor mental health outcomes (Mennin et al., 2009, Novick-Kline et al., 2005, Southam-Gerow and Kendall, 2000 and Suveg and Zeman, 2004). Emotion expression conveys important information about one’s emotional experiences to others, and regulation of expression can directly influence the intensity of emotional experience (Gross, 1998a and Gross and John, 2003). Maladaptive or heightened expression of specific emotions—including anger, fear, and sadness—have been linked to internalizing and externalizing problems in adolescents (Keltner et al., 1995 and Zeman et al., 2002). Cognitive emotion regulation strategies—such as rumination—represent a relatively late stage in the emotion regulation process in which an individual engages in specific thoughts or behaviors in response to emotional experiences, often as an attempt to maintain or diminish those experiences. Rumination has been linked to adolescent psychopathology both concurrently and prospectively (Abela et al., 2002 and Burwell and Shirk, 2007). We anticipated that poor emotion regulation skills in each of these areas would predict subsequent increases in adolescent symptoms of depression, anxiety, aggressive behavior, and eating pathology but that baseline symptomatology would not predict changes in emotion regulation. Methods Participants The sample for this study was recruited from the total enrollment of two middle schools (Grades6–8) from a small urban community (population 71,538) in Connecticut. The parents of all eligible children (N = 1567) in the middle schools were asked to provide active consent for their children to participate. 22% of parents did not return consent forms and could not be reached to obtain consent, and 6% of parents declined to provide consent for their child to participate. The overall cooperation rate in the study at baseline was 72% (see Fig. 1). Of the participants who were present at the baseline assessment, 217(20.4%) did not participate at the Time 2 assessment. This school district population was highly transient; over the four-year period from 2000 to 2004, 22.7% of students had left the district ( Connecticut Department of Education, 2006). We conducted analyses using the sample of 1065 participants who were present at the baseline assessment, excluding participants who were present at Time 2 but not at Time 1. Study flow of participants in the study. Fig. 1.