Emotion Regulation Notes

Regulating Emotions & Behaviour

Learning Objectives

  • Understand definitions and theories regarding emotion regulation.
  • Develop awareness of the transdiagnostic approach to youth mental health.
  • Explore the clinical associations of emotional dysregulation.
  • Identify management options for emotional and behavioral dysregulation.
  • Explore these concepts using a case study.

Definitions

  • Emotion: A complex psychological state involving physiological, behavioral, and cognitive changes.
    • Responses to events or situations.
    • Can significantly impact thoughts, feelings, and behaviors.
  • Affect: A broader term referring to any feeling or experience with a subjective quality.
    • Understood in terms of valence (positive, negative, or neutral) and arousal.
  • Cognition: Mental processes such as attention, perception, memory, thinking, and reasoning.

Circumplex Model of Affect

  • Horizontal axis: Valence dimension.
  • Vertical axis: Arousal dimension.

Key Differences

Emotions
  • Definition: Intense, short-lived reactions to specific stimuli, encompassing a range of responses such as joy, anger, fear, surprise, and more.
  • Characteristics: Brief and intense, triggered by internal or external events, and accompanied by physiological changes.
  • Example: Feeling elated after a success or experiencing fear during a thrilling movie.
Feelings
  • Definition: Subjective experiences that arise from emotions, influenced by personal interpretations, beliefs, and experiences.
  • Characteristics: Individual and subjective, shaped by personal perceptions, and can be more prolonged than emotions.
  • Example: Feeling warmth and affection toward a loved one or experiencing embarrassment after a mistake.
Moods
  • Definition: Sustained emotional states less intense than emotions, coloring our overall disposition over a more extended period.
  • Characteristics: More long-lasting, influencing our outlook and behavior, and influenced by various factors such as environment, health, and circumstances.
  • Example: Waking up feeling cheerful and optimistic, leading to a day filled with enthusiasm, or feeling persistently low and melancholic without a clear cause.

Emotions

  • Not fixed, pre-determined states.
  • Constructed by our mind, based on cognitive, physiological, and social factors.
  • Shaped by our interpretations, beliefs, past experiences, and early life.
  • Emotion is your brain helping to make meaning of your world.

Importance of Emotions

  • Communication: Emotions tell us things about the world and our place in it.
    • Function to communicate to others and influence others.
    • Similar to physical sensations (pain) communicating what your body is experiencing, emotions communicate what your brain/mind is experiencing.
  • Motivate behavior: Emotions cause us to respond; they motivate action.
    • Example: ANGER
      • Anger communicates about something important being threatened.
      • Motivates us to act (e.g., political rallies).
      • Influences others to respond to our needs.
      • Communicates that our expectations or needs are not being met.
      • Anger can be problematic:
        • When it is expressed in a non-adaptive way (e.g., violence, abuse, aggression).
        • When it is based on misinterpretations of others’ intent.

Transdiagnostic Approach to Youth Mental Health

  • Emotion dysregulation is a core transdiagnostic feature.
  • Clinical stages:
    • Stage 0: Asymptomatic
    • Stage 1a: Distress disorder
    • Stage 1b: Distress disorder and subthreshold specificity
    • Stage 2: First treated episode
    • Stage 3: Recurrence or persistence
    • Stage 4: Treatment resistance

Emotions

  • Emotions can be intolerably painful.
  • For some people, emotions feel incredibly problematic.
  • These people might wish to avoid emotional experiences altogether.
  • Clinical focus on understanding and regulating (managing) emotions.
  • Reminder that humans experience emotions for a reason.
  • Often, emotions are useful biological and instinctual responses.
  • Can lead to maladaptive, problem behavior.

Understanding Emotions

  • Identifying Emotions.

Factors Making Emotion Regulation Difficult

  • Genetics/Biological predisposition.
  • Lack of skill.
  • Reinforced emotional behavior.
  • Emotional overload.
  • Vulnerabilities (tired, hungry, trauma triggers).

Hand Model of the Brain

  • Prefrontal Cortex
  • Limbic System (Thumb)
  • Flip the Lid
  • Limbic System

Developmental Theories of Emotion Regulation

  • Genetics
  • Early life trauma
  • Mentalization: 'the ability to infer the mental states of others'
  • Increasing capacity to identify affect
  • Increased influence of peers
  • Co-regulation with caregiver (<3 yrs)
  • Stressors
  • Social deprivation
  • Parental mental illness, loss
  • Attachment theory
  • Erikson stages

Emotion Regulation in Young People

  • Self-Regulation:
    • The idea that we can manage our emotions and behavior even in changing situations.
    • This is difficult, even for adults, and it is something that people have to learn and practice as they grow and develop.
    • Expecting young children to always be able to "act right" when their brains are still developing is not reasonable – the emotional adult brain doesn’t develop until ~24 years old.
  • Co-Regulation:
    • The process where we are influenced by the feelings and actions of those around us.
    • Adults can support the development of self-regulation by modeling healthy self-regulation and meeting the child with warmth, responsive attention, structure, and practice.

Theory of Emotion Regulation

  • Identification
  • Selection
  • Implementation
    1. Identification of the emotion
      • Requires capacity to reflect or mentalize / theory of mind
      • Alexithymia
    2. Selection of strategy
      • e.g.: distraction, check the facts, opposition to emotion action
    3. Implementation of an emotion regulation strategy

Distraction

  • Helpful, especially in situations of high emotional distress.
  • Problematic if over-utilized.

Check the Facts: Thoughts Aren’t Facts (DBT)

  • Something happens.
  • You have thoughts about what has just happened.
  • You experience emotions based on your thoughts.
  • You respond to your thoughts and feelings with behaviors.
  • Alter the cognitions in order to change feelings and behavior.

Opposite to Emotion Action (DBT)

  • EMOTION -> BEHAVIOURAL URGE -> Engage in OPPOSITE ACTION
  • Anger -> Defend; Attack; Approach; Mobilizes you to get moving
    • Gently avoid the person rather than attack
    • Do something nice for that person
    • Imagine sympathy or empathy for the other person, rather than blame
  • Fear -> Run away; Escape; Avoid
    • Approach the situation
    • Stay in the situation
    • Do what you are afraid of, over and over…

Impacts of Emotion Dysregulation

  • Significant psychosocial, interpersonal, and functional impact.
  • May indicate a mental health disorder.
  • Risk factor for adult mental illness (and treatment resistance).
  • Increased rate of adverse outcomes → BEHAVIOUR
    • Risk-taking
    • Suicidal behavior
    • Substance use

Transdiagnostic Approach to Youth Mental Health

  • Emotion dysregulation is a core transdiagnostic feature

Case Study: Olivia, 14 yo

  • Referred from ED for follow up after episode of suicidal ideation. Her friend called an ambulance after Olivia told her friend about suicidal ideation via text.
  • In ED, reports very low mood, no energy, no appetite, no enjoyment in things, feels hopeless, not sleeping.
  • She still has suicidal ideation but agreed to safety plan to go home with parents.
  • Prior to your review, you see Olivia looking bright and reactive, on her phone talking to friends, laughing in the waiting room.
  • Olivia reports her friend overreacted as the reason for ED visit. SI fluctuates. There are no triggers or reasons for suicidal ideation.
  • Diagnosis of BPAD, ‘medications not working’
  • Uses lots of diagnostic terms, thinks she has ADHD, DID, OCD. Wants a new medication.

Collateral History

  • Parents report Olivia as ‘up and down’. Since hospital has been happy, seeing friends, but on her phone all night, goes to sleep late
  • Olivia was always a happy child, no issues until last summer holidays.
  • Had some conflict with friend, parents don’t know details. Very upset after that, but now has new friend group.
  • Intermittent episodes of extreme lows, anger, frustration, crying, expressing SI. Usually better in a few hours. Sometimes misses school.
  • Mum initially thought it was ‘just teen moodiness’. But then became worried it could be BPAD. Family Hx of BPAD in maternal grandfather.
  • Worried its biological, genetic.
  • Saw psychiatrist, tried different medications, didn’t work. Parents says that talking therapy doesn’t work for bipolar because it’s biological.

Management Approach

  • Assessment
    • Holistic, multidisciplinary, thorough, and longitudinal
    • Understand social, family context
    • Identify co-morbidities e.g. ADHD, ASD, anxiety
    • Neuropsychology, OT/ functional assessments
    • Identify sensory sensitivities, recommend strategies to reduce arousal
  • Therapy interventions
    • Psychological, OT, social worker
    • E.g. DBT-based approaches (primarily for emotional dysregulation)
      • Acceptance modules -> Mindfulness + distress tolerance
      • Change modules -> Emotional regulation + interpersonal effectiveness
  • Pharmacological
    • Paediatricians, C&A psychiatrists
    • Treating associated symptoms, co-morbid ADHD, anxiety
    • Mood stabilizers, anti-psychotics, anti-depressants may all be used, off-label
  • Follow up and monitoring to identify progress/transition

Management Approaches

  • Reducing family stressors & addressing social adversity
  • Early identification and intervention
  • Family support
  • Collaborative care with school, service providers
  • Family + individual approaches

Summary

  • Emotions help to communicate information and motivate behavior.
  • Emotion Regulation is not innate but develops throughout childhood, adolescence (and adulthood!).
  • Emotion dysregulation is associated with negative outcomes including increased risk-taking, suicidal ideation, substance use, interpersonal difficulties, and psychiatric illness.
  • Psychological management is key: various approaches based on age, including DBT (evidenced based in adolescence and adults).