Emotion Dysregulation and Psychosis Spectrum Disorders

Psychosis spectrum disorders (PSDs) are complex, highly heritable psychiatric conditions with high economic and societal costs. PSDs have historically been conceptualized as neurocognitive disorders in which psychotic episodes and impairments in social and emotional functioning are attributed to deficits in neurocognition. Although cognitive pathways play an important role in the etiology and presentation of PSDs, recent research suggests that interrelations between cognition and emotion are highly relevant. Moreover, aberrant emotion regulation likely plays a significant role in the presentation of PSDs. Emotion dysregulation (ED) may underlie and exacerbate both negative and positive symptoms in PSDs, such as blunted affect, avolition, disorganized speech and behavior, poor social cognition, and delusions and hallucinations. Advances in measurement of emotion dysregulation—including self-reports, behavioral paradigms, neuroimaging paradigms, and neurophysiological assessment—have informed etiological models of emotion dysregulation in PSDs. This chapter reviews research on emotion regulation and dysregulation in PSDs. Notably, more severe presentations of emotion symptoms and greater emotion regulation impairments are associated with worse outcomes in PSDs. It may therefore be the case that focusing on ED as an early risk factor and intervention target could improve outcomes and prevention approaches for psychotic disorders.

Emotion Generation, Regulation, and Dysregulation as Multilevel Transdiagnostic Constructs

Emotion generation, regulation, and dysregulation are complex constructs that are challenging to define and measure. This chapter reviews prevailing definitions and theories of these constructs and examines the literature across multiple levels of analysis. It adopts a developmental perspective, which guides interpretation of the literature and helps clarify discrepant points of view. The extent to which emotion generation and regulation are separable represents a significant controversy in the field. When viewed as cognitive constructs, it is virtually impossible to disentangle emotion generation and regulation. However, at the biological level, there are important differences in neural structures involved in bottom-up emotion generation processes versus those associated with top-down regulation of emotions. From a developmental perspective, emotions and emotion dysregulation emerge early in life, whereas emotion regulation strategies develop more gradually as a function of maturation and socialization. Future research should continue to reconcile different perspectives on emotion generation, regulation, and dysregulation.

Future Directions in Research and Treatment of Emotion Dysregulation

This chapter discusses themes that emerged while editing the Oxford Handbook of Emotion Dysregulation and outlines directions for future research. Although the term emotion dysregulation has at times been used amorphously in the literature, most authors now define the phenomenon as experiences and expressions of emotion that interfere with situationally appropriate, goal-directed behavior. Situational embedding of emotion dysregulation is important given very different expectations of appropriate emotional expression across contexts and cultures. Despite emerging consensus regarding emotion dysregulation as a construct, several challenges lie ahead. Major tasks for the field are to (1) abandon implicit notions of emotion dysregulation in favor of formally operationalized definitions, such as that provided earlier; (2) maintain a clear distinction between emotion dysregulation versus mood dysregulation; (3) map transdiagnostic features of emotion dysregulation across functional domains of behavior such as those instantiated in the Research Domain Criteria matrix and, where appropriate, syndromes in the Diagnostic and Statistical Manual of Mental Disorders; (4) further develop prevention and treatment programs that systematically target emotion dysregulation across development; and (5) extend emotion dysregulation research to stigmatized groups in an effort to identify mechanisms of mental health disparities. Chapters in this volume address these issues and advance the science of emotion dysregulation in new and exciting ways.

Assessment of Emotion Dysregulation Using Ecological Momentary Assessment

As emotion is a dynamic construct, ecological momentary assessment (EMA) methods, which gather data at multiple time points in individuals’ real-world environments, in the moment, are particularly well suited to measure emotion dysregulation and related constructs. EMA methods can identify contextual events that prompt or follow an emotional response. This chapter provides an overview of traditional methods of studying emotion dysregulation and how EMA can be used to capture emotion dysregulation in daily life, both within and independent of psychiatric diagnoses. It reviews the literature on emotion dysregulation and related constructs within specific diagnoses (e.g., depression, bipolar disorder, borderline personality disorder, and eating disorders) and behaviors (e.g., suicide, nonsuicidal self-injury, and alcohol use). Finally, it discusses future directions in EMA research, as well as its implications for psychological treatment.

Functionalist and Constructionist Perspectives on Emotion Dysregulation

Two theoretical perspectives—functionalism and constructionism—predominate modern research on emotion. This introductory chapter describes these perspectives and offers points of convergence and divergence. It pays special attention to common misconceptions about functionalism and to strengths and limitations of each perspective. Functionalism, which draws in part from phylogenetic accounts of emotion and motivation, is limited by difficulties drawing inferences about human emotion from animal research, even though animal research is conducted using very precise methods of high spatial and temporal resolution. In contrast, constructionism is limited by difficulties falsifying its core propositions given reliance on research using functional magnetic resonance imaging, which has poor temporal resolution. These limitations notwithstanding, both functionalism and constructionism have much to offer current interpretations of and future research on emotion dysregulation. Thus, pitting the perspectives against one other is counterproductive.

Emotion Dysregulation and Externalizing Spectrum Disorders

As described in the literature for many years, a sizable number of children with hyperactive-impulsive and combined subtypes/presentations of attention-deficit/hyperactivity disorder (ADHD)—especially males—progress to more serious externalizing syndromes across development. Such outcomes include oppositional defiant disorder, conduct problems, delinquency, substance use disorders, and in some cases antisocial personality disorder, incarceration, and recidivism. This chapter summarizes a developmental model that emphasizes different contributions of trait impulsivity, a highly heritable, subcortically mediated vulnerability, versus emotion dysregulation, a highly socialized, cortically mediated vulnerability, to externalizing progression. According to this perspective, trait impulsivity confers vulnerability to all externalizing disorders, but this vulnerability is unlikely to progress beyond ADHD in protective environments. In contrast, for children who are reared under conditions of adversity—including poverty, family violence, deviant peer influences, and neighborhood violence/criminality—neurodevelopment of prefrontal cortex structure and function is compromised, resulting in failures to achieve age-expected gains in emotion regulation and other forms of executive control. For these children, subcortical vulnerabilities to trait impulsivity are amplified by deficient cortical modulation, which facilitates progression along the externalizing spectrum.

Emotion Dysregulation and Aging

This chapter presents an overview of literature relevant to understanding relations between aging and emotion dysregulation. Although a number of studies suggest that aging leads to shifts in emotion regulation and emotional well-being, the extent to which aging affects emotion dysregulation is less clear. To clarify the effects of aging on emotion dysregulation, this chapter begins by examining shifts in effectiveness of emotion regulation that occur with age, considering pertinent theories, and then expands on these findings by examining more specifically how context appropriateness of emotions, consequences of emotions on behavior, duration of emotions, and etiology and presentation of psychopathology are altered by aging processes. Finally, this chapter concludes by identifying gaps in the literature and recommendations for future empirical endeavors to advance our current understanding of effects of aging on emotion dysregulation.

Dialectical Behavior Therapy and Treatment of Emotion Dysregulation

Developed to treat highly suicidal patients and often associated with the treatment of borderline personality disorder (BPD), dialectical behavior therapy (DBT) has evolved into a transdiagnostic treatment addressing emotion dysregulation. DBT is an emotion-focused, comprehensive cognitive-behavioral treatment including individual therapy, group skills training, between-session skills coaching (phone coaching), and a therapist consultation team. Several elements of DBT address emotion dysregulation directly or indirectly, including emotion regulation skills, distress tolerance strategies to dampen physiological arousal and curb impulses to engage in problematic behaviors, and individual therapy interventions to reduce emotion dysregulation. Growing evidence suggests that DBT may address behavioral, cognitive, physiological, and neurobiological aspects of emotion dysregulation. Future directions should include increasing multimethod research on the effects of DBT on emotion dysregulation, streamlining treatment, making DBT more efficient and targeted, and conceptualizing DBT’s place within the spectrum of other emotion-focused transdiagnostic treatments.

Emotion Dysregulation and Borderline Personality Disorder

Emotion dysregulation has been theorized to either directly or indirectly drive many of the symptoms associated with borderline personality disorder. In this chapter, several current controversies in this body of work are reviewed. The chapter presents the role of emotion dysregulation in theories of the development and maintenance of borderline personality disorder. Further, it reviews the state of research on emotional responding in borderline personality disorder, focusing on any evidence of emotional sensitivity, reactivity, and time course. Building on this review, the chapter summarizes recent advances in the study of difficulties in emotion regulation capacities and strategies in the context of this disorder. In addition, it outlines the links between emotion dysregulation and other problems in borderline personality disorder. Finally, this chapter highlights the limitations and future directions in this line of work.

Self-Report Assessment of Emotion Dysregulation

Self-report assessments remain among the most widely used measures for most psychological constructs, due to their feasibility, ease of administration, low cost, and wide availability. Self-report measures of emotion dysregulation are no exception. This chapter reviews two predominant conceptualizations of emotion dysregulation (one of which focuses on dysregulated emotional responses per se and another that focuses on maladaptive ways of responding to emotions), as well as the empirical support for extant self-report measures of emotion dysregulation consistent with both conceptualizations. Based on this review, the chapter concludes that both emotional responses themselves and an individual’s responses to those emotions may evidence dysregulation and inform our understanding of normal and abnormal development. Finally, future directions for research in this area are discussed, including the need for studies examining the clinical utility of targeting responses to emotions versus emotional experience per se in psychological interventions.