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E-ISSN : 2733-4538
This study examined the effects of Emotion Regulation Therapy (ERT; Mennin & Fresco, 2009) in individuals with co-occurring generalized anxiety and depression symptoms. ERT is designed to treat emotion regulation difficulties as commonly seen in Generalized Anxiety Disorder (GAD) and Major Depressive Disorder (MDD) by sequentially focusing on motivation, regulation, and contextual learning mechanisms. We used a group version of ERT that consisted of 9 sessions with three stages: emotional and motivational awareness training, emotional regulation skills training, and experiential exposure. A total of 33 undergraduates with co-occurring symptoms of GAD and MDD were assigned to either the ERT or control group. Selfreport questionnaires for outcome variables (worry, general distress, anxiety, and depressive symptoms) and program-related process variables (awareness and emotional regulation strategies) were assessed at pre-, post- and 4-week-after treatment. Results showed that the ERT group, as compared to the control group, showed a significant symptom reduction in all outcome variables, and this effect was maintained at the follow-up period. Moreover, the ERT group showed significant changes in the process variables that were maintained until the follow-up, when compared with the control group. These results suggest that an intervention that systematically addresses emotion dysregulation may be effective for those with comorbid anxiety and depression. Based on these findings, implications and limitations of this study are discussed.
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, 27-45.
Behar, E., Alcaine, O., Zuellig, A. R., & Borkovec, T. D. (2003). Screening for generalized anxiety disorder using the Penn State Worry Questionnaire: A receiver operating characteristic analysis. Journal of Behavior Therapy and Experimental Psychiatry, 34, 25-43.
Boschen, M. J., & Oei, T. P. (2007). Discriminant validity of the MASQ in a clinical sample. Psychiatry Research, 150, 163-171.
Bruce, S. E., Yonkers, K. A., Otto, M. W., Eisen, J. L., Weisberg, R. B., Pagano, M., . . . Keller, M. B. (2005). Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: A 12-year prospective study. American Journal of Psychiatry, 162, 1179-1187.
Buckby, J. A., Yung, A. R., Cosgrave, E. M., & Killackey, E. J. (2007). Clinical utility of the Mood and Anxiety Symptom Questionnaire (MASQ) in a sample of young help-seekers. BMC Psychiatry, 7, 50. doi:10.1186/1471-244X-7-50
Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hofmann, S. G. (2006). Acceptability and suppression of negative emotion in anxiety and mood disorders. Emotion, 6, 587-595.
Cash, M., & Whittingham, K. (2010). What facets of mindfulness contribute to psychological well-being and depressive, anxious, and stress-related symptomatology? Mindfulness, 1, 177-182.
Cho, Y. (2007). Assessing emotion dysregulation: Psychometric properties of the Korean Version of the Difficulties in Emotion Regulation Scale. Korean Journal of Clinical Psychology, 26, 1015-1038.
Cho, Y. (2012). Effects of and mechanisms of changes in a group mindfulness-based emotion regulation intervention for improving psychological health: Mediating roles of emotion dysregulation and mindfulness. Korean Journal of Clinical Psychology, 31, 773-799.
Cho, Y., Noh, S., Jo, K., & Hong, S. (2014). The effect of mindfulness-based intervention on depression and anxiety symptoms: A meta-analysis. Korean Journal of Psychology: General, 33, 903-928.
Chon, K. K., Choi, S. C., & Yang, B. C. (2001). Integrated adaptation of CES-D in korea. The Korean Journal of Health Psychology, 6(1), 59-76.
Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric evidence and taxonomic implications. Journal of Abnormal Psychology, 100, 316-336.
Coffey, K. A., & Harman, M. (2008). Mechanisms of action in the inverse relationship between mindfulness and psychological distress. Complementary Health Practice Review, 13, 79-91.
Collimore, K. C., & Rector, N. A. (2014). Treatment of anxiety disorders with comorbid depression: A survey of expert CBT clinicians. Cognitive and Behavioral Practice, 21, 485-493.
Craigie, M. A., Rees, C. S., Marsh, A., & Nathan, P. (2008). Mindfulness-based cognitive therapy for generalized anxiety disorder:A preliminary evaluation. Behavioural and Cognitive Psychotherapy, 36, 553-568.
D’Avanzato, C., Joormann, J., Siemer, M., & Gotlib, I. H. (2013). Emotion regulation in depression and anxiety: Examining diagnostic specificity and stability of strategy use. Cognitive Therapy and Research, 37, 968-980.
Desrosiers, A., Klemanski, D. H., & Nolen-Hoeksema, S. (2013). Mapping mindfulness facets onto dimensions of anxiety and depression. Behavior Therapy, 44, 373-384.
Desrosiers, A., Vine, V., Curtiss, J., & Klemanski, D. H. (2014). Observing nonreactively: A conditional process model linking mindfulness facets, cognitive emotion regulation strategies, and depression and anxiety symptoms. Journal of Affective Disorders, 165, 31-37.
Eisner, L. R., Johnson, S. L., & Carver, C. S. (2009). Positive affect regulation in anxiety disorders. Journal of Anxiety Disorders, 23, 645-649.
Etkin, A., & Schatzberg, A. F. (2011). Common abnormalities and disorder-specific compensation during implicit regulation of emotional processing in generalized anxiety and major depressive disorders. American Journal of Psychiatry, 168, 968-978.
Evans, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., & Haglin, D. (2008). Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 22, 716-721.
Fava, M., Rush, A. J., Alpert, J. E., Balasubramani, G. K., Wisniewski, S. R., Carmin, C. N., . . . Trivedi, M. H. (2008). Difference in treatment outcome in outpatients with anxious versus nonanxious depression: A STAR*D report. American Journal of Psychiatry, 165, 352-351.
Fisak, B., & von Lehe, A. C. (2012). The relation between the five facets of mindfulness and worry in a non-clinical sample. Mindfulness, 3, 15-21.
Foroughi, A. A., Arani, A. M., Bakhtyari, M., Mohammadi, A., & Habibi, M. (2017). The efficacy of Emotion Regulation Therapy (ERT) in Generalized Anxiety Disorder (GAD): Symptom reduction and improving of emotion regulation and mindfulness skills: A case series. International Journal of Applied Behavioral Sciences, 3, 1-9.
Fresco, D. M., Mennin, D. S., Heimberg, R. G., & Ritter, M. (2013). Emotion Regulation Therapy for generalized anxiety disorder. Cognitive and Behavioral Practice, 20, 282-300.
Fresco, D. M., Mennin, D. S., Heimberg, R. G., & Turk, C. L. (2003). Using the Penn State Worry Questionnaire to identify individuals with generalized anxiety disorder: A receiver operating characteristic analysis. Journal of Behavior Therapy and Experimental Psychiatry, 34, 283-291.
Fresco, D. M., Moore, M. T., van Dulmen, M. H., Segal, Z. V., Ma, S. H., Teasdale, J. D., & Williams, J. M. G. (2007). Initial psychometric properties of the Experiences Questionnaire: Validation of a self-report measure of decentering. Behavior Therapy, 38, 234-246.
Fresco, D. M., Segal, Z. V., Buis, T., & Kennedy, S. (2007). Relationship of posttreatment decentering and cognitive reactivity to relapse in major depression. Journal of Consulting and Clinical Psychology, 75, 447-455.
Furman, D. J., Hamilton, J. P., & Gotlib, I. H. (2011). Frontostriatal functional connectivity in major depressive disorder. Biology of Mood & Anxiety Disorders, 1, 11. doi:10.1186/2045-5380-1-11
Garnefski, N., & Kraaij, V. (2006). Relationships between cognitive emotion regulation strategies and depressive symptoms: A comparative study of five specific samples. Personality and Individual Differences, 40, 1659-1669.
Giorgio, J. M., Sanflippo, J., Kleiman, E., Reilly, D., Bender, R. E., Wagner, C. A., . . . Alloy, L. B. (2010). An experiential avoidance conceptualization of depressive rumination: Three tests of the model. Behaviour Research and Therapy, 48, 1021-1031.
Goldstein-Piekarski, A. N., Williams, L. M., & Humphreys, K. (2016). A trans-diagnostic review of anxiety disorder comorbidity and the impact of multiple exclusion criteria on studying clinical outcomes in anxiety disorders. Translational Psychiatry, 6, e847. doi:10.1038/tp.2016.108
Gotlib, I. H., & Hamilton, J. P. (2008). Neuroimaging and depression:Current status and unresolved issues. Current Directions in Psychological Science, 17, 159-163.
Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26, 41-54.
Gross, J. J. (2014). Emotion regulation: Conceptual and empirical foundations. In J. J. Gross (Ed.). Handbook of emotion regulation (pp. 3-20). New York: The Guilford Press.
Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85, 348-362.
Ha, E. H., Oh, K. J., Song, D. H., & Kang, J, H. (2004). The effects of cognitive-behavioral group therapy for depression and anxiety disorders in adolescents: A preliminary study. Korean Journal of Clinical Psychology, 23, 263-279.
Hacker, T., Stone, P., & Macbeth, A. (2016). Acceptance and commitment therapy - Do we know enough? Cumulative and sequential meta-analyses of randomized controlled trials. Journal of Affective Disorders, 190, 551-565.
Hahn, D. W., Lee, C. H., & Chon, K. K. (1996). Korean adaptation of Spielberger’s STAI (K-STAI). The Korean Journal of Health Psychology, 1, 1-14.
Hanrahan, F. H., Field, A. P., Jones, F. W., & Davey, G. C. L. (2013). A meta-analysis of cognitive therapy for worry in generalized anxiety disorder. Clinical Psychology Review, 33, 120-132.
Hayes-Skelton, S. A., Calloway, A., Roemer, L., & Orsillo, S. M. (2015). Decentering as a potential common mechanism across two therapies for Generalized Anxiety Disorder. Journal of Consulting and Clinical Psychology, 83, 395-404.
Hong, J. H., & Shim, E. J. (2013). Emotional clarity and adolescent's mental health: The mediating role of emotion regulation deficits. Korean Journal of Psychology: General, 32, 195-212.
Jeon, M. A., & Kim, J. M. (2011). The effects of mindfulness-based cognitive therapy for emotion regulation in a patient group. Korean Journal of Clinical Psychology, 30, 113-135.
Johnstone, T., van Reekum, C. M., Urry, H. L., Kalin, N. H., & Davidson, R. J. (2007). Failure to regulate: Counterproductive recruitment of top-down prefrontal-subcortical circuitry in major depression. Journal of Neuroscience, 27, 8877-8884.
Kaufman, J., & Charney, D. (2000). Comorbidity of mood and anxiety disorders. Depression and Anxiety, 12, 69-76.
Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology, 3, 1-27.
Kendler, K. S., Prescott, C. A., Myers, J., & Neale, M. C. (2003). The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women. Archives of General Psychiatry, 60, 929-937.
Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617-627.
Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., . . . Hofmann, S. G. (2013). Mindfulness-based therapy: A comprehensive meta-analysis. Clinical Psychology Review, 33, 763-771.
Kim, B. N., Lim, Y. J., & Kwon, S. M. (2010). The role of decentering in the relationship between rumination and depressive symptoms. Korean Journal of Clinical Psychology, 29, 573-596.
Kim, H., & Park, K. (2014). The effects of process variables in Acceptance Commitment Therapy for women’s depression. Korean Journal of Clinical Psychology, 33, 429-458.
Kim, Y., & Ahn, D. (2015). Adolescents’s mindfulness: Its relationships with positive and negative psychological characteristics. Journal of the Korean Data Analysis Society, 17, 347-363.
Kim, J. W., & Min, B. B. (1998, June). Intolerance of Uncertainty and Problem Orientation in Worry. Paper presented at the annual conference of the Korean Psychological Association, Seoul, Korea.
Kumar, S. K., Feldman, G., & Hayes, A. (2008). Changes in mindfulness and emotion regulation in an exposure-based cognitive therapy for depression. Cognitive Therapy and Research, 32, 734-744.
Lee, C. M., & You, S. (2016). Emotional clarity, affect intensity, and distress tolerance on anxiety and depressive symptoms. Cognitive Behavior Therapy in Korea, 16, 123-140.
Lee, H., & Kim, K. H. (2014). Validation of the Korean version of the Mood and Anxiety Symptom Questionnaire (K-MASQ). Korean Journal of Clinical Psychology, 33, 395-411.
Lee, H., & Park, H. I. (2015). The effects of mindfulness-based therapy: A meta-analytic study. Korean Journal of Clinical Psychology, 34, 991-1038.
Lee, S., & Ahn, C. Y. (2012). The process variables of Acceptance-Commitment Group Therapy for anxiety and effect. The Korean Journal of Counseling and Psychotherapy, 24, 223-254.
Leventhal, A. M. (2008). Sadness, depression, and avoidance behavior. Behavior Modification, 32, 759-779.
Lewinsohn, P. M., & Clarke, G. N. (1999). Psychosocial treatments for adolescent depression. Clinical Psychology Review, 19, 329-342.
Linden, D. E. J. (2006). How psychotherapy changes the brain -The contribution of functional neuroimaging. Molecular Psychiatry, 11, 528-538.
Makovac, E., Meeten, F., Watson, D. R., Herman, A., Garfinkel, S. N., Critchley, H. D., & Ottaviani, C. (2016). Alterations in amygdala-prefrontal functional connectivity account for excessive worry and autonomic dysregulation in generalized anxiety disorder. Biological Psychiatry, 80, 786-795.
Mennin, D. S., & Fresco, D. M. (2009). Emotion regulation as an integrative framework for understanding and treating psychopathology. In A. M. Kring & D. M. Sloan (Eds.). Emotion regulation in psychopathology: A transdiagnostic approach to etiology and treatment (pp. 356-379). New York: The Guilford Press.
Mennin, D. S., & Fresco, D. M. (2014). Emotion Regulation Therapy. In J. J. Gross (Ed.). The Handbook of emotion regulation (pp. 469-487). New York: The Guilford Press.
Mennin, D. S., Fresco, D. M., Ritter, M., & Heimberg, R. G. (2015). An open trial of emotion regulation therapy for generalized anxiety disorder and co-occurring depression. Depression and Anxiety, 32, 614-623.
Mennin, D. S., Holaway, R. M., Fresco, D. M., Moore, M. T., & Heimberg, R. G. (2007). Delineating components of emotion and its dysregulation in anxiety and mood psychopathology. Behavior Therapy, 38, 284-302.
Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the penn state worry questionnaire. Behaviour Research and Therapy, 28, 487-495.
Mineka, S., Watson, D., & Clark, L. A. (1998). Comorbidity of anxiety and unipolar mood disorders. Annual Review of Psychology, 49, 377-412.
Ministry of Health and Welfare. (2011). The epidemiological survey of mental disorders in Korea. Seoul: Author.
Monk, C. S., Telzer, E. H., Mogg, K., Bradley, B. P., Mai, X., Louro, H. M. C., . . . Pine, D. S. (2008). Amygdala and ventrolateral prefrontal cortex activation to masked angry faces in children and adolescents with Generalized Anxiety Disorder. Archives of General Psychiatry, 65, 568-576.
Morrison, N. (2001). Group cognitive therapy: Treatment of choice or sub-optimal option? Behavioural and Cognitive Psychotherapy, 29, 311-332.
Newman, M. G., & Llera, S. J. (2011). A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry. Clinical Psychology Review, 31, 371-382.
Newman, M. G., Przeworski, A., Fisher, A. J., & Borkovec, T. D. (2010). Diagnostic comorbidity in adults with generalized anxiety disorder: Impact of comorbidity on psychotherapy outcome and impact of psychotherapy on comorbid diagnoses. Behavior Therapy, 41, 59-72.
Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives on Psychological Science, 3, 400-425.
Onur, E., Alkin, T., Sheridan, M. J., & Wise, T. N. (2013). Alexithymia and emotional intelligence in patients with panic disorder, generalized anxiety disorder and major depressive disorder. Psychiatric Quarterly, 84, 303-311.
Orsillo, S. M., Roemer, L., & Barlow, D. H. (2003). Integrating acceptance and mindfulness into existing cognitive-behavioral treatment for GAD: A case study. Cognitive and Behavioral Practice, 10, 222-230.
Pepping, C. A., O’Donovan, A., Zimmer-Gembeck, M. J., & Hanisch. M. (2014). Is emotion regulation the process underlying the relationship between low mindfulness and psychosocial distress? Australian Journal of Psychology, 66, 130-138.
Radolff, L. S. (1997). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401.
Renna, M. E., Quintero, J. M., Fresco, D. M., & Mennin, D. S. (2017). Emotion Regulation Therapy: A mechanism-targeted treatment for disorders of distress. Frontiers in Psychology, 8, 98. doi:10.3389/fpsyg.2017.00098
Rive, M. M., van Rooijen, G., Veltman, D. J., Phillips, M. L., Schenea, A. H., & Ruhea, H. G. (2013). Neural correlates of dysfunctional emotion regulation in major depressive disorder: A systematic review of neuroimaging studies. Neuroscience & Biobehavioral Reviews, 37, 2529-2553.
Ro, J., Kang, H., & Son, C. (2016). Effects of Acceptance and Commitment Therapy(ACT) on symptoms of worry, anxiety, tolerance of uncertainty, emotional regulation, and experiential avoidance in university students with excessive worry. The Korean Journal of Health Psychology, 21, 909-923.
Roemer, L., Lee, J. K., Salters-Pedneault, K., Erisman, S. M., Orsillo, S. M., & Mennin, D. S. (2009). Mindfulness and emotion regulation difficulties in generalized anxiety disorder: Preliminary evidence for independent and overlapping contributions. Behavior Therapy, 40, 142-154.
Salters-Pedneault, K., Roemer, L., Tull, M. T., Rucker, L., & Mennin, D. S. (2006). Evidence of broad deficits in emotion regulation associated with chronic worry and Generalized Anxiety Disorder. Cognitive Therapy and Research, 30, 469-480.
Schreiner, I., & Malcolm, J. P. (2008). The benefits of mindfulness meditation: Changes in emotional states of depression, anxiety, and stress. Behaviour Change, 25, 156-168.
Seo, W. J., & Cho, Y. (2012). The influences of emotion regulation difficulties, metacognition, and their dimensions on the severity of generalized anxiety symptoms. Cognitive Behavior Therapy in Korea, 12, 43-61.
Shin, A. Y., & Chae, J. H. (2011). Emotion regulation strategies in patients with depressive and anxiety disorders. Cognitive Behavior Therapy in Korea, 11(1), 41-52.
Shin, M. S., Kim, S. S., & Oh, K. J. (2006). Cognitive-behavioral therapy of psychiatric disorders for children and adolescents. Cognitive Behavior Therapy in Korea, 6, 145-161.
Son, J. M. (2005). Individual differences in two regulation strategies:Cognitive reappraiser vs. emotion suppressor. (Unpublished master’s thesis). Seoul National University, Seoul, Korea.
Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (Form Y). Palo Alto, CA : Consulting Psychologists Press.
Treanor, M., Erisman, S. M., Salters-Pedneault, K., Roemer, L., & Orsillo, S. M. (2011). Acceptance based behavioral therapy for GAD: Effects on outcomes from three theoretical models. Depression and Anxiety, 28, 127-136.
Watson, D. (2005). Rethinking the mood and anxiety disorders: A quantitative hierarchical model for DSM-V. Journal of Abnormal Psychology, 114, 522-536.
Watson, D., Weber, K., Assenheimer, J. S., Clark, L. A., Strauss, M. E., & McCormick, R. A. (1995). Testing a tripartite model: I. Evaluating the convergent and discriminant validity of anxiety and depression symptom scales. Journal of Abnormal Psychology, 104, 3-14.
Wolitzky-Taylor, K. B., Arch, J. J., Rosenfield, D., & Craske, M. G. (2012). Moderators and non-specific predictors of treatment outcome for anxiety disorders: A comparison of cognitive behavioral therapy to acceptance and commitment therapy. Journal of Consulting and Clinical Psychology, 80, 789-799.
Won, D., & Kim, K. H. (2006). Validation of the Korean version of Five-factor mindfulness questionnaire. The Korean Journal of Health Psychology, 11, 871-886.
Yalom, I. D. (1995). The theory and practice of group psychotherapy. New York: Basic Books.
Yang, K. E., & Park, K. H. (2014). The effects of intolerance for uncertainty and emotional dysregulation on worrying: Mediating effect of experiential avoidance. The Korean Journal of Health Psychology, 19, 187-201.
Zhou, Y., Cao, Z., Yang, M., Xi, X., Guo, Y., Fang, M., . . . Du, Y. (2017). Comorbid Generalized Anxiety Disorder and its association with quality of life in patients with Major Depressive Disorder. Scientific Reports, 7, 40511. doi:10.1038/srep40511
Zimmerman, M., & Chelminski, I. (2003). Generalized Anxiety Disorder in patients with Major Depression: Is DSM-IV’s hierarchy correct? American Journal of Psychiatry, 160, 504-512.