Psychiatr Q DOI 10.1007/s11126-017-9499-6 R E V I E W A RT I C L E

Reconsidering Emotion Dysregulation Alessandra D’Agostino 1 & Serena Covanti 1 & Mario Rossi Monti 1 & Vladan Starcevic 2

# Springer Science+Business Media New York 2017

Abstract This article aims to review the concept of emotion dysregulation, focusing on issues related to its definition, meanings and role in psychiatric disorders. Articles on emotion dysregulation published until May 2016 were identified through electronic database searches. Although there is no agreement about the definition of emotion dysregulation, the following five overlapping, not mutually exclusive dimensions of emotion dysregulation were identified: decreased emotional awareness, inadequate emotional reactivity, intense experience and expression of emotions, emotional rigidity and cognitive reappraisal difficulty. These dimensions characterise a number of psychiatric disorders in various proportions, with borderline personality disorder and eating disorders seemingly more affected than other conditions. The present review contributes to the literature by identifying the key components of emotion dysregulation and by showing how these permeate various forms of psychopathology. It also makes suggestions for improving research endeavours. Better understanding of the various dimensions of emotion dysregulation will have implications for clinical practice. Future research needs to address emotion dysregulation in all its multifaceted complexity so that it becomes clearer what the concept encompasses. Keywords Emotion dysregulation . Emotion regulation . Emotion . Psychopathology . Borderline personality disorder

* Alessandra D’Agostino [email protected]

1

Department of Humanistic Studies - Centre for Research, Training and Intervention in Clinical Psychology, University of Urbino, Urbino, Italy

2

Sydney Medical School - Nepean, Discipline of Psychiatry, University of Sydney, Sydney, NSW, Australia

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Introduction Over the past decade, increasing attention has been paid to emotion dysregulation. This has resulted in the growth of the literature on this phenomenon from a few essays to entire volumes. The reasons for such interest relate to the evidence of a strong relationship between emotion regulation difficulties and a number of clinical conditions. In fact, current models of psychopathology have incorporated emotion dysregulation as a key component in a range of psychiatric symptoms and disorders [1], and this is probably why emotion dysregulation has been called the Bhallmark of psychopathology^ [2]. This paper aims to provide a review of emotion dysregulation and to clarify its conceptual core and role in different psychiatric disorders. Potential implications for clinical practice will be also discussed.

Emotion Regulation and Emotion Dysregulation: Conceptual and Assessment Issues Emotions are complex psychological states involving three components: a subjective experience, a physiological response and a behavioural or expressive response [3]. Development of normal emotion regulation leads to successful adaptations to the demands of environmental constraints. In fact, the term Bemotion regulation^ is used to refer to Bthe range of activities that allow an individual to respond to the ongoing demands of experience with the range of emotions in a manner that is socially tolerable and sufficiently flexible to permit spontaneous reactions as well as the ability to delay spontaneous reactions as needed^ [4] (p. 76). Emotion regulation is likely to involve a set of processes or systems (e.g., attentional, cognitive, behavioural, social, biological) that act to modulate, manage or organize emotions in order to help individuals meet the demands of the environment and achieve their goals [5]. To further emphasize the relationship between emotion regulation and the environment, recent research has increasingly focused on the intersubjective nature of emotion regulation. Indeed, a substantial body of research suggests that a proper study of emotion regulation requires a consideration of both intrapersonal and relational views on emotion [6]. From this perspective, emotions are conceptualized as Bresponsive^ to social events, Bregulated^ by social constraints (relating to norms and values) and Bsocially constituted^, as they both determine social relationships and are defined by them [7]. The above considerations imply that emotion regulation is a dynamic and reciprocal interaction [8] involving a flexible use of a wide variety of emotion-regulation strategies (such as active problem-solving, cognitive reappraisal, self-soothing, emotional acceptance and awareness, information-seeking and support-seeking). This allows individuals to adjust their goals and behaviours to those of others, creating a cycle of mutual influence. In contrast, emotion dysregulation denotes a rigid and maladaptive use of emotion regulation strategies or inability to choose the most appropriate strategy for achieving goals [5]. Avoidance, rumination, denial, emotion suppression, aggression and venting are examples of these maladaptive emotion regulation strategies [9]. Emotion dysregulation has recently become a very popular term in the psychiatric and clinical psychology literature and it has been used to describe the characteristics of various mental disorders and considered a Btransdiagnostic process^ [10]. However, many issues make this concept controversial. The first problem pertains to terminology. BEmotion dysregulation^ and Bproblems in emotion regulation^ have been usually used interchangeably, but Cicchetti and colleagues [11] warn that the two terms imply different meanings. According to these authors, Bemotion dysregulation^ involves an inappropriate or maladaptive application of

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emotion regulation strategies that are still available for appropriate use, while Bproblems in emotion regulation^ reflect an absence of these strategies. This distinction – as Cicchetti and colleagues add – is important especially for treatment, so that different interventions could be planned based on the presence, absence or maladaptive use of emotion regulation strategies. But the greatest problem here is that there is still a lack of adequate tools to examine whether emotion regulation strategies are deficient, employed during inopportune moments or completely absent. Moreover, definitions of emotion dysregulation seem to be lacking. One of the few attempts to exhaustively define emotional dysregulation was made by Gratz and Roemer [12] who described it as a multidimensional construct involving: a) lack of awareness, understanding and acceptance of emotions; b) lack of access to adaptive strategies for modulating the intensity and/or duration of emotional responses; c) unwillingness to experience emotional distress whilst pursuing desired goals; and d) inability to engage in goal-directed behaviours when experiencing distress. Similarly, Cole and Hall [13] conceptualized emotion dysregulation as comprising the following characteristics: a) ineffectiveness of regulatory attempts; b) interference of emotions with appropriate behaviours; c) emotions expressed or experienced as out of context; and d) emotional variations occurring either too abruptly or too slowly. Recently, Ebner-Priemer and colleagues [14] presented a theoretical model of emotion dysregulation (BThe DynAffect Model^), combining insights from basic affective science and the biosocial theory of borderline personality disorder (BPD) [15]. This model, developed specifically for BPD, also seems to be applicable to other forms of psychopathology characterized by the same emotional dysfunction. According to Ebner-Priemer and colleagues [14], emotion dysregulation refers to three fundamental processes: a) negative affective homebase (that is, one’s affective baseline state); b) high levels of affective variability (that is, the total sum of the changes around the affective homebase in response to internal or external events); and c) low levels of attractor strength or return to baseline (that is, the deficient regulatory processes that pull core affect back to its homebase). Another problem related to the concept of emotion dysregulation is a lack of appropriate tools to assess this psychopathological phenomenon. Currently, there are no direct measures of emotion dysregulation, and instruments for the assessment of emotion regulation are the only ones that exist. These measures include the Generalized Expectancies for Negative Mood Regulation Scale (NMR-S; [16]), the Emotion Regulation Questionnaire (ERQ; [17]), the Difficulties in Emotion Regulation Scale (DERS; [12]), the Cognitive Emotion Regulation Questionnaire (CERQ; [18]), the Affective Style Questionnaire (ASQ; [19]) and the Emotion Regulation of Others and Self (EROS; [20]). Psychophysiological measures (such as corrugator electromyography, eye blink startle magnitude, electroencephalogram and cardiac vagal tone) can be used to assess emotion regulation and, indirectly, emotion dysregulation. However, this approach is used less often. The greatest advantage of psychophysiological measures is that they can serve as objective indicators of emotional processes, especially in children; their main limitations are the cost of data collection and lack of specificity of physiological responding for emotional processes [21]. Beyond the specific problems inherent to various assessment methods, the main issue is that most studies have investigated emotion dysregulation using a single method, adopting a unidimensional perspective derived from self-report measures. This approach overlooks the complexity of emotion dysregulation and fails to account for various psychopathological mechanisms. There are compelling reasons to use multiple methods in the assessment of emotion dysregulation [22]. Indeed, it has been suggested that future research should rely on 22

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multi-trait, multi-method analysis strategies with multi-informant data to ensure validity and control for potential confounders [23].

Methods A narrative review of literature on emotion dysregulation was carried out by examining the relevant articles published in English between January 2003 and May 2016. A search of the databases PubMed, PsycINFO, Science Direct, Medline, EMBASE and Google Scholar was performed to identify the relevant articles. Search terms included Bemotion dysregulation^, Bemotion regulation^ and Bemotion^. All articles were inspected to ascertain whether they were appropriate for inclusion in the review. The exclusion criteria were a failure to address emotion dysregulation as the main topic and failure to define emotion dysregulation. Articles published before 2003 were included if they were considered an important contribution to the literature on emotion dysregulation. This was based on the number of citations that these articles received or their provision of the foundation for the subsequent research.

Results The search identified 244 articles (empirical studies, theoretical papers and review articles), which were retrieved and examined. Of these, 103 were included in the review and 141 were excluded on the basis of the aforementioned criteria. In addition, 20 landmark articles published before 2003 were included.

Dimensions of Emotion Dysregulation In the articles included in the present review, there was no agreement on the conceptual core of emotion dysregulation and different authors came up with different meanings of the term. We have identified the following five overlapping, not mutually exclusive dimensions of emotion dysregulation: decreased emotional awareness, inadequate emotional reactivity, intense experience and expression of emotions, emotional rigidity and cognitive reappraisal difficulty. These dimensions will be examined in the text that follows, along with their role in various DSM-5 [24] psychiatric disorders (see Table 1).

Decreased Emotional Awareness Decreased emotional awareness has been suggested as one of the main dimensions of emotion dysregulation. Emotional awareness refers to the ability to identify and label internal emotional experience [25]. It is often referred to in the literature as Bemotional clarity^ [26], the opposite of Balexithymia^ [27]. Emotional awareness is distinct from emotional expression in that awareness does not necessarily involve an outward display, but rather implies an internal recognition of the present emotion [28]. Several theoretical models suggest that emotional awareness increases throughout life, becoming more sophisticated and differentiated as long as individuals acquire more cognitive resources [29]. Both emotion regulation and dysregulation seem to be closely linked to emotional awareness [30]. Some studies emphasise that successful emotion regulation is dependent on one’s

+ +

Social anxiety disorder Generalized anxiety disorder

+ (Excessive emotional reactivity)

+ (Heightened control of emotions) + (Excessive emotional reactivity) + (Excessive emotional reactivity or heightened control of emotions) + (Excessive emotional reactivity)

+ (Excessive emotional reactivity) + (Heightened control of emotions)

+ (Excessive emotional reactivity) + (Excessive emotional reactivity)

+ (Excessive emotional reactivity) + (Excessive emotional reactivity)

Inadequate emotional reactivity

+ = Presence of this dimension of emotion dysregulation in the particular disorder

Borderline personality disorder

Schizotypal personality disorders

Oppositional defiant disorder

+

+

Bulimia nervosa

Sleep disorders

+

Anorexia nervosa

Posttraumatic stress disorder

Obsessive-compulsive disorder

+

+

Decreased emotional awareness

Depressive disorders

Bipolar disorder

Schizophrenia

Attention-deficit/hyperactivity disorder

Autism spectrum disorder

ED dimensions DSM-5 disorders

+ (Primarily negative emotions)

+ (Primarily negative emotions)

+ (Both negative and positive emotions) + (Both negative and positive emotions) + (Primarily negative emotions)

+ (Primarily positive emotions)

+ (Primarily negative emotions)

Intense experience and expression of emotions

Table 1 Presence of various dimensions of emotion dysregulation (ED) in DSM-5 disorders

+ (Restricted emotional range)

+ (Context-inappropriate emotional response)

+ (Restricted emotional range, context-inappropriate emotional response)

Emotional rigidity

+

+

+

Cognitive reappraisal difficulty

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ability to identify specific emotions [31]. Additionally, strong associations were found between facets of emotional awareness and various forms of psychopathology [32]. Examples of decreased emotional awareness can be found in a range of psychiatric disorders, such as attention deficit/hyperactivity disorder (ADHD), anxiety and depressive disorders, eating disorders and BPD (Table 1).

Attention-Deficit/Hyperactivity Disorder In a recent study, Shaw et al. [33] reported that emotion dysregulation was prevalent in ADHD throughout the lifespan and that it was a major contributor to impairment. The authors suggested that emotion dysregulation in ADHD might be related to deficits in recognition of emotional stimuli and/or allocation of attention to them. Anxiety and Depressive Disorders Research suggests that low emotional awareness is associated with depressive and anxiety symptoms, especially in young people [34]. In fact, children and adolescents who have difficulties identifying, describing and expressing their emotions may feel more overwhelmed by their emotional experiences, thus reporting increased levels of negative affect [35]. Lower emotional awareness may prevent individuals with depression and anxiety (especially generalized anxiety disorder [GAD] and social anxiety disorder) from accessing information that would enable them to cope with negative emotion and arousal [36]. Eating Disorders Sim and Zeman [37] found that low emotional awareness, negative emotion and non-constructive coping with negative emotion partially mediated the relationship between body dissatisfaction and bulimic behaviours in patients with bulimia nervosa. Similarly, Racine and Wildes [38], using a multidimensional measure of emotion regulation in a clinical sample of individuals with anorexia nervosa, found that low emotional awareness significantly predicted the severity of eating disorder cognitions and that this association was independent of depression and anxiety. Borderline Personality Disorder Low emotional awareness seems to be a cardinal feature of BPD [39]. Although borderline patients report intense emotions, they have difficulty differentiating between their own emotional experiences [15, 40, 41], as well as emotional experiences of others [40]. Furthermore, they have a tendency to report more non-specific emotions than healthy controls [41] and tension instead of specific emotions [42]. Borderline patients also exhibited greater difficulty in deciphering ambiguous responding from others [40].

Inadequate Emotional Reactivity Inadequate emotional reactivity is another aspect of emotion dysregulation. It can be defined as a tendency of the individual to react in an inappropriate manner to intense and overwhelming emotions [43]. Emotional reactivity is one’s initial, unmodulated response to an emotionprovoking event, whereas emotion-coping strategies (e.g., interpretation of the arousal, use of distraction and support seeking) modify this response [44]. Some studies have shown that intense emotional reactions do not arise only from too little control exerted over emotional experiences, but also from too much control [45, 46]. Thus, a prolonged inhibition of negative emotional experiences may not only worsen functioning and fail to provide a relief from them [47], but may also intensify these experiences [48].

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This aspect of emotion dysregulation has been studied in many psychiatric disorders, including autism spectrum disorder (ASD), ADHD, major depressive disorder, bipolar disorder, GAD, obsessive-compulsive disorder (OCD), eating disorders, sleep disorders and BPD (Table 1).

Autism Spectrum Disorder Clinicians have long emphasized that maladaptive emotional responses, as a manifestation of emotion dysregulation, play a fundamental role in ASD [49]. These responses may take the form of a mood or behavioural disturbance, such as self-injury, outbursts of anger, screaming, aggression and grabbing, throwing or breaking objects [50–52]. Attention-Deficit/Hyperactivity Disorder A recent research [53] demonstrates that young adolescents with ADHD exhibit emotion dysregulation in the form of behavioural dyscontrol (e.g., aggression and rule-breaking); this tends to occur in the context of strong emotions, and return to the emotional baseline is slow. Also, according to Macklem [54], some adolescents with ADHD exhibit prominent oppositional behaviours in response to their own anger and hostility. Major Depressive Disorder One study of depressed adolescents has shown that they report a greater intensity and variability of emotions and that they are more likely to use inappropriate strategies to regulate negative emotions [55]. In particular, depressed adolescents cope with their negative emotions by behaving aggressively [54]. Levels of depression have also been correlated with a more frequent use of maladaptive cognitive emotion regulation strategies and a relatively infrequent use of functional cognitive strategies [18, 46, 56, 57]. Bipolar Disorder M’Bailara and colleagues [58] showed that euthymic bipolar patients experienced stronger emotions and exhibited greater emotional reactivity than control subjects. Furthermore, these patients mostly displayed emotional hyper-reactivity in neutral situations, which may account for their vulnerability to minor stressful events in everyday life. Generalized Anxiety Disorder GAD has been conceptualized as Ba syndrome involving heightened intensity of subjective emotional experience, poor understanding of emotion, negative reactivity to emotional experience, and the use of maladaptive emotion management strategies^ [59] (pp. 89–90). Turk and colleagues [59] have suggested that emotional reactions of people with GAD occur more easily, more quickly and more intensely than those of other individuals (i.e., they exhibit a heightened emotional reactivity). Similarly, Mennin et al. [60] have shown that individuals with GAD reported greater intensity of emotional experience, a greater tendency to express negative emotions and a greater negative reactivity than control subjects. Andreescu and colleagues [61] have recently suggested that individuals with GAD tend to show strong emotional responses because of their exaggerated propensity to perceive threat. Obsessive-Compulsive Disorder Campbell-Sills and Barlow [62] have observed that OCD is strongly associated with efforts to control emotions, suggesting that suppression of emotions often results in the exacerbation and maintenance of the same unwanted emotions. Eating Disorders Overton [63] showed that the maladaptive emotional experience may be different for patients with bulimia nervosa and for those with anorexia nervosa. The former

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tend to become overwhelmed by intense emotions, displaying insufficient self-control in response to them (emotional under-regulation), while the latter respond to unpleasant emotional states by over-controlling them (emotional over-regulation).

Sleep Disorders Harvey and colleagues [64] have proposed a theoretical framework for the role of emotion in insomnia. According to these authors, there may be two pathways for daytime emotion to contribute to night-time insomnia. The first originates from emotional suppression during the day; if individuals excessively suppress their emotions during the day, a rebound in emotion may occur at night, which fuels insomnia. The second pathway may involve a heightened emotional reactivity during the day, which makes it difficult to deactivate emotionally and subsequently fall asleep. Oppositional Defiant Disorder Children with oppositional defiant disorder show problems with emotion regulation and self-control [65]. Their negative emotional reactions may be so extreme that they are not able to appropriately manage them [54]. Borderline Personality Disorder The emotional cascade model of BPD [66] proposes that maladaptive behaviours tend to occur in the context of amplified emotional responses to even minute emotional stimuli. Carpenter and Trull [67] indicate that people with BPD are unable to tolerate everyday distress and that they are prone to using maladaptive strategies (e.g., rumination, thought suppression, experiential avoidance, impulsive behaviours) to manage distress and overwhelming negative emotions. According to Linehan [15], borderline individuals have a low threshold for emotional reaction, they react quickly and their emotional reactions tend to be extreme and to last long. Thus, BPD is characterised not only by various intense negative emotions (e.g., fear, anger, anxiety, depression, guilt, shame), but also by a difficulty controlling them [68]. Moreover, Selby and Joiner [69] underline that another aspect of emotional reactivity in individuals with BPD relates to their propensity to experience betrayal, suggesting that, whenever the threat of betrayal is activated and there is a sense of inability to manage it, individuals with BPD react with intense and uncontrollable negative emotions.

Intense Experience And Expression Of Emotions Higher levels of negative emotions have generally been associated with adjustment problems and psychopathology [9] and negative emotions have generally played a more important role in psychopathology than positive emotions [70, 71]. Emotion regulation is sometimes equated with the control of negative emotions, implying that intense or inappropriate expression of negative emotion is a sign of emotion dysregulation. However, recent literature highlights a role also played by an intense expression of positive emotions and specific domains of positive emotion dysregulation (i.e., non-acceptance and/or avoidance of positive emotional states) in some disorders [63, 72–74]. Intense experience and expression of emotions have been reported in ADHD, bipolar disorder, sleep disorders, eating disorders, oppositional defiant disorder and BPD.

Attention-Deficit/Hyperactivity Disorder A recent review of ADHD [75] suggests that emotion dysregulation in this condition involves a failure to inhibit negative emotions, which

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leads to emotionally driven, impulsive behaviour (i.e., emotional impulsivity). In addition, clinical observation and studies emphasize intense expression of negative emotions by children and adolescents with ADHD as a key feature of their emotion dysregulation [4].

Bipolar Disorder Studies provide evidence that positive emotions may be problematic for people with bipolar disorder even when they are not experiencing mania. Gruber [76] studied people whose bipolar disorder was in remission and found that they experienced more positive emotions than people who never had this diagnosis; positive emotions were expressed in an inappropriate context, which could lead to various negative outcomes. Furthermore, individuals with bipolar disorder were shown to exhibit difficulties regulating both positive and negative emotions [72]. Sleep Disorders Poor sleep quality has been correlated with high levels of negative emotions and low levels of positive emotions in both clinical and non-clinical samples [77]. Other studies have found that intense negative emotions may interfere with sleep; this was reported for sadness [78], regret, shame, guilt [79] and loneliness [80]. Eating Disorders Studies have demonstrated that individuals with eating disorders often experience high levels of negative emotion that are perceived as difficult to tolerate [81]. However, other research reported that patients with eating disorders experienced both negative and positive emotions more intensely than individuals in the control group [63]. In particular, Selby and colleagues [73] noted that Bthe potential for combined and high levels of both positive and negative emotion dysregulation in anorexia may result in a perfect storm of motivation for weight-loss activity, thereby leading to weight loss well beyond what is healthy or attainable for most people^ (p. 526). Oppositional Defiant Disorder Children with oppositional defiant disorder express more hostility and negativity in interpersonal situations compared to children without the disorder [82] and they experience more anger and irritability than their peers [54]. Borderline Personality Disorder Studies suggest that negative emotion is strongly associated with BPD and that individuals with BPD appear to generally experience more negative emotion than individuals without this diagnosis [83, 84]. The experience of negative emotion in BPD is characterised by intensity, instability over time and abruptness. The latter is likely a result of the heightened emotional reactivity to environmental stimuli, including emotions of others and cues that are subtle or that seem innocuous to individuals without BPD [67].

Emotional Rigidity A body of research suggests that emotional rigidity is a key aspect of emotion dysregulation [85–89]. In contrast, emotional flexibility or adaptability is crucial for successful adaptation to one’s environment and life events, as reflected by an appropriate use of various emotions. There are two manifestations of emotional rigidity. The first is a domination of a particular emotion, with a diminished ability to experience any other emotion (restricted emotional range); the second is context-inappropriate emotional response [90].

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a) Restricted Emotional Range The range of emotions refers to a variety of emotions that a person is able to experience and express. A full emotional range denotes an appropriate display of various context-dependent emotions (Bemodiversity^, according to Quoidbachet al. [91]) and it is a sign of a successful adaptation. As already noted, restricted emotional range is characterised by a maladaptive experience and expression of a single emotion, with a difficulty Bswitching^ to another emotion. A restricted emotional range characterises schizophrenia and schizotypal personality disorder.

Schizophrenia It has been observed that the range of emotions is often restricted in schizophrenia [92]. Individuals with schizophrenia may have a Breduced^ affect, Blimited range^ of affect or, in extreme cases, a Bblunted^ or Bflat^ affect, that is, a severe reduction of emotional expressiveness [93]. Schizotypal Personality Disorder A restricted emotional range has been considered to characterise individuals with schizoid and schizotypal personality disorders. However, people referred to as Bschizoid^ may actually fall into two different groups: an Baffectconstricted group^, which might be better subsumed under schizotypal personality disorder, and a Bseclusive^ group, which might be better subsumed under avoidant personality disorder [94]. b) Context-Inappropriate Emotional Response Emotional experiences are intimately linked with the specific context in which they occur. Consequently, a better understanding of emotions also requires an understanding of the context, and ascertaining the appropriateness of emotional responses has to take into account the corresponding context. Context-inappropriate emotional responses occur in various ways. First, emotional expression is inappropriate if it violates the local social or cultural norms, with emotional response then being perceived as inconsiderate or offensive [13]. Secondly, emotional expression may be completely unexpected and unusual for the context and thus considered deviant. Finally, there may be a lack of emotional response to situations that usually elicit emotional responses. These context-inappropriate emotional responses may characterise schizophrenia and posttraumatic stress disorder (PTSD).

Schizophrenia Context-inappropriate emotional responses (Binappropriate affect^) in schizophrenia have been associated with difficulties in social interaction and poorer social outcome [95–97]. Posttraumatic Stress Disorder According to Davidson’s [98] hypothesis, individuals with PTSD do not display Babnormal emotion^, but exhibit normal emotion in inappropriate contexts. For example, intense fear experienced by many PTSD patients is probably adaptive in the context of the original trauma, facilitating escape from a threatening situation, whereas it becomes inappropriate in a variety of innocuous contexts. In addition, individuals with PTSD may exhibit emotional numbness, i.e., they can be emotionally unresponsive to situations that usually elicit emotional responses in others [13].

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Cognitive Reappraisal Difficulty Another aspect of emotion dysregulation is a difficulty with cognitive reappraisal, that is, problems with re-evaluating emotions and attributing relevant meanings to them if the situation calls for it [99]. Cognitive-emotional interactions are extremely important because they modulate emotional responses [100]. Accordingly, cognitive capacities allow people to re-examine their emotional responses, which contributes to better adaptation [101]. Cognitive reappraisal pertains to the changes in meaning that alter emotional response [100]. Ray and colleagues [102] assume that this reappraisal should simultaneously alter experiential, behavioural and physiological aspects of the emotional response. According to Gross [103], reappraisal of an event or its consequences may reduce the intensity of an emotional experience rather than inhibit emotional expression. Considering this role of cognitive reappraisal, its habitual use has been shown to be an adaptive emotion regulation strategy [104]. Cognitive reappraisal has also been associated with better mental health [17] and lower levels of psychopathology [104, 105]. Conversely, difficulties with cognitive reappraisal have been associated with more psychopathology, and they seem to be present in many psychiatric disorders [17]. Difficulties with cognitive reappraisal have an important role in psychiatric disorders such as ASD, PTSD and BPD.

Autism Spectrum Disorder Samson et al. [106] have reported that a less frequent use of cognitive reappraisal in ASD is associated with increased negative emotion experience, which is in turn related to more prominent maladaptive behaviours. Posttraumatic Stress Disorder Ehlers and Clark [107] proposed that emotional reactions in chronic PTSD were primarily dependent on cognitive appraisals of both the traumatic event and subsequent symptoms. Indeed, negative appraisals of a traumatic event and symptoms, inability to reappraise a traumatic event and its consequences and perceived permanent negative changes in personality and life aspirations differentiate those with and without chronic PTSD [108–110]. In addition, Boden and colleagues [111] reported that individuals with PTSD under-utilized relatively effective emotion regulation strategies such as cognitive reappraisal. Borderline Personality Disorder In people with BPD, emotional arousal or mood tends to have a pervasive negative effect on various cognitive processes, which in turn may activate or reactivate negative emotional states [15]. A recent research [112] provides evidence for difficulties in cognitive reappraisal of aversive stimuli and negative emotions in female borderline patients.

Discussion The impact of emotion dysregulation on mental and physical health has been the focus of much recent research. Emotion dysregulation is considered a common characteristic of a number of clinical conditions, and growing evidence suggests that emotion regulation difficulties characterize many clinically relevant behaviours and symptoms. Despite this, a more detailed analysis of emotion dysregulation faces a number of obstacles.

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First, there are terminological issues. Emotion dysregulation is sometimes equated with Bemotion sensitivity^ or Baffective instability^, and no agreed-upon definition of the conceptual core of emotion dysregulation exists. In particular, there is no agreement between authors who consider emotion dysregulation as a higher-order factor cutting across multiple psychiatric disorders [113] and those who suggest that specific psychiatric disorders are associated with certain types of emotion dysregulation [1]. With respect to this, the priority is not to determine which of these theoretical positions may be correct, but to integrate them in order to capture the multifaceted complexity of the construct. Second, there are several psychopathological dimensions that constitute emotion dysregulation, but only a few studies have analysed them simultaneously. Most researchers have investigated only one dimension. In other cases, emotion dysregulation was studied without specifying which of its dimensions was the focus of investigation or without clearly defining the term, making it difficult to Bput different studies into context, as they work from different starting points, employ different methods, obtain different outcomes, and yet all purport to study emotion dysregulation^ [67] (p. 341). Third, there is no conceptual consistency even within the same dimension of emotion dysregulation. For example, some studies addressing intense experience and expression of emotions only focused on the negative emotions, whereas others also investigated positive emotions. With regards to inadequate emotional reactivity, some research only examined excessive reactivity and lack of control over emotions, whereas other studies only focused on heightened control of emotions. These inconsistencies and different approaches have made our understanding of emotion dysregulation rather fragmented. Fourth, the situational and cultural contexts in which emotions are unfolding are often neglected. Most research tools for assessing emotion dysregulation have been developed within the western cultural context, which is likely to have influenced the conclusions as to whether many emotion regulation strategies are adaptive or maladaptive [114]. Although it has been demonstrated that emotions must be viewed as complex transactions with the environment [115] and that emotion dysregulation itself relates to social interaction and arises in an Bintersubjective matrix^ [116, 117], most research into emotion dysregulation to date has used an intrapersonal approach, studying isolated individuals. This approach increases the risk of drawing erroneous conclusions. Other research has relied on external stimuli and/or environments, such as listening to short stories or seeing films that induce angry, joyful or neutral emotional responses [118–120]. Fifth, the available tools for measuring emotion dysregulation are clearly inadequate. In fact, they present numerous problems: a) they measure the construct in absentia (as a lack of emotion regulation); b) each tool addresses a certain aspect or dimension of emotion dysregulation, without measuring the whole construct; c) most instruments are self-report measures and the extent to which individuals can accurately report on their emotions varies and is questionable in many cases. These problems have limited the clinical usefulness of the concept of emotion dysregulation and raised questions about the corresponding research findings. Although increasing evidence suggests that emotion dysregulation is relevant for various forms of psychopathology [104, 121, 122], its specific role in the development and maintenance of various disorders has not been empirically tested yet. There is also a question of the direction of causality, i.e., whether

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some forms of emotion dysregulation play a key role in the development of certain mental disorders or represent their consequence. This is largely due to the fact that most research has used cross-sectional design.

Future Directions Future research is expected to clarify the concept of emotion dysregulation by determining its components and boundaries, also taking into account the contextual aspects. A precondition for this is the development and use of the novel instruments for comprehensive assessment of emotion dysregulation. Studying the developmental origin of emotion dysregulation will contribute to a better understanding of the underlying mechanisms and their role in psychopathology. Furthermore, it will be crucial to ascertain whether some dimensions of emotion dysregulation are relatively specific for certain psychiatric disorders and whether others are truly Btransdiagnostic^ and characterise various forms of psychopathology. This research agenda calls for different approaches, in addition to the need for longitudinal, prospective studies. Thus, a wide variety of individual emotional responses requires a detailed study of single cases and greater consideration of the differences between individual experiences. Also, emotion dysregulation should be studied in individuals with psychiatric disorders because most of our current knowledge comes from research that has examined emotion regulation processes in healthy participants [123]. Such studies should examine and compare both individuals with disorders that appear to be crucially characterised by emotion dysregulation (e.g., BPD) and those with conditions in which emotion dysregulation does not seem to play a central role (e.g., OCD). Different manifestations of emotion dysregulation and different roles that it plays in different disorders will also require more nuanced therapeutic approaches to individuals with these conditions.

Conclusion This review contributes to the literature by identifying the key components of emotion dysregulation and by showing how these permeate various forms of psychopathology, although BPD and eating disorders appear to be more characterised by emotion dysregulation than other disorders (Table 1). The review also highlights a discrepancy between the widespread use of the term Bemotion dysregulation^ and inadequate conceptual status of this construct. Future research should address emotion dysregulation not as an end-state [104] but as a dynamic process incorporating multiple dimensions that should be understood in their interaction and development over time [67]. In the meantime, emotion dysregulation may remain a meaningless Bpasse-partout^ concept for the contemporary clinic, a container mistaken for the content, a key that claims to open too many doors. Such use of emotion dysregulation should be precluded by the terminological and conceptual rigor and greater clarity in the realm of the psychopathology of emotions promoted by this article.

Psychiatr Q Compliance with Ethical Standards Ethical Responsibilities The manuscript is original and has not been published elsewhere nor is it currently under consideration for publication elsewhere. Conflict of Interest The authors declare that they have no conflict of interest. Funding None.

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Alessandra D’Agostino is PhD candidate in Clinical Psychology at the University of Urbino, Italy and Head of Borderline & Body Lab, Centre for Research, Training and Intervention in Clinical Psychology, University of Urbino, Italy.

Psychiatr Q Serena Covanti is graduate student in Clinical Psychology at the University of Urbino and research collaborator at the Borderline & Body Lab, Centre for Research, Training and Intervention in Clinical Psychology, University of Urbino, Italy. Mario Rossi Monti is Full Professor of Clinical Psychology at the University of Urbino and Scientific Responsible of the Centre for Research, Training and Intervention in Clinical Psychology, University of Urbino, Italy. Vladan Starcevic is Associate Professor at Sydney Medical School, Consultant Psychiatrist and Head of the Academic Department of Psychiatry at Nepean Hospital, Australia. He is also a Visiting Professor at the University of Belgrade and University of Novi Sad.