Emotion Regulation Flexibility in Adolescents: A Systematic Review from Conceptualization to Methodology.

Considerable attention has been devoted to the concept of flexible emotion regulation, which de-emphasizes the importance of any specific regulatory strategy in favor of the flexible deployment of strategies in response to specific situational challenges. The bulk of research in this area has been conducted on adult samples. Research on emotion regulation flexibility (ERF) in youth has been documented in only a limited number of studies and using various definitions. This systematic review aims to gather and summarize different conceptualizations and methodological approaches of adolescent ERF. We incorporate these findings into a general framework to understand ERF and its role in adolescents' emotional, behavioral and social functioning. Adhering to the PRISMA guidelines, 11 studies were included in the review. While ERF has been defined in various and inconsistent ways, the included studies utilized conceptualizations from two overarching domains: the regulation of expressed emotion and the repertoire of emotion regulation strategies. Promising approaches and future directions will be highlighted.

Trajectories of moral injury and their associations with posttraumatic stress symptoms among recently discharged israeli veterans.

BACKGROUND: While it is already known that potentially morally injurious events (PMIEs) have a deleterious effect on veterans, little is known about the changes in PMIEs subjective appraisals over time, as well as its contribution to changes in psychiatric symptoms. In the current study, we longitudinally assessed subjective appraisals of PMIEs experienced during combat military service and their associations with posttraumatic stress symptoms (PTSS) among recently discharged combat veterans. METHOD: Participants were 374 veterans who participated in a one-year longitudinal study with three measurement points: T1-one month before discharge from army service, and then again six months and twelve months following discharge (T2 and T3, respectively). RESULTS: Latent Growth Mixture Modeling (LGMM) indicated heterogenic patterns of changes in PMIEs across measurements. The 'resilient' (low and stable PMIEs) trajectory best represented PMIE, followed by 'recovery' and 'chronic' fluctuating trajectories. Moreover, the 'resilient' PMIEs trajectory was found to be consistently associated with lower PTSS scores compared to 'chronic' or 'worsening' trajectories. CONCLUSIONS: Our findings are the first to identify longitudinal trajectories of PMIEs subjective appraisals and to provide evidence of their association with PTSS, which might serve as potential assessment and intervention targets among recently discharged traumatized veterans.

The three axioms of resilience.

This article summarizes the growing literature on resilience in the face of aversive and potentially traumatic events (PTEs) in three basic axioms: (a) resilience is a common outcome, 2) there are no "key" traits to resilience (resilience is not a type), and (c) resilient outcomes occur through flexible self-regulation. The first axiom highlights the limitation of a traditional, binary view of trauma in terms of the presence-absence of posttraumatic stress disorder, emphasizing instead the heterogeneity of trauma outcomes. Four prototypical trajectories are reviewed: chronic symptoms; delayed symptoms; recovery; and the most common trajectory, resilience. The second axiom reviews the paradoxical inability of known correlates of resilience to adequately predict resilient outcomes. Resilience is instead described as a multifaceted phenomenon with no singular set of key traits, as various factors contribute to resilient outcomes in complex ways. The third axiom provides an explanation of how resilience can emerge from this complex array by introducing the concept of flexible self-regulation. The flexibility mindset is described as providing the motivation for flexible responding. The flexibility sequence is described as explaining the mechanisms underlying flexibility in terms of three serial stages: context sensitivity, strategy repertoire, and feedback adjustment. The final section briefly considers clinical implications.

Prospective trajectories of depression predict mortality in cancer patients.

An ever-growing body of empirical evidence has demonstrated the relationship between depression and cancer. The objective of this study was to examine whether depression trajectories predict mortality risk above and beyond demographics and other general health-related factors. Participants (n = 2,345) were a part of the Health and Retirement Study. The sample consisted of patients who were assessed once before their cancer diagnosis and thrice after. Depressive symptoms and general health-related factors were based on self-reports. Mortality risk was determined based on whether the patient was alive or not at respective time points. Latent Growth Mixture Modeling was performed to map trajectories of depression, assess differences in trajectories based on demographics and general health-related factors, and predict mortality risk. Four trajectories of depression symptoms emerged: resilient (69.7%), emerging (13.5%), recovery (9.5%), and chronic (7.2%). Overall, females, fewer years of education, higher functional impairment at baseline, and high mortality risk characterized the emerging, recovery, and chronic trajectories. In comparison to the resilient trajectory, mortality risk was highest for the emerging trajectory and accounted for more than half of the deaths recorded for the participants in emerging trajectory. Mortality risk was also significantly elevated, although to a lesser degree, for the recovery and chronic trajectories. The data highlights clinically relevant information about the depression-cancer association that can have useful implications towards cancer treatment, recovery, and public health.

Does cognitive load influence expressive flexibility? Comparing civilian and veteran populations.

Expressive flexibility (EF) is a component of emotion regulation flexibility repertoire that constitutes the ability to enhance or suppress the expression of emotion in accordance with a given situational context. Previous research has associated EF with healthy adjustment to adversity. This association has also been observed in combat veterans with elevated post-traumatic stress. EF and other elements of regulatory flexibility are believed to rely on functions of cognitive control, such as working memory. However, previous research has yet to investigate this link. Accordingly, we examined performance in veterans (N = 42) and non-veterans (N = 75) on an EF Task with and without the inclusion of a numerical cognitive load task. Results indicate an interaction between cognitive load and expressive condition. Specifically, suppression abilities were weaker in cognitive load conditions. These findings did not vary in veteran and non-veteran samples. These results add to a growing body of work indicating a relationship between cognitive control and regulatory flexibility, and suggest similar mechanisms between veteran and non-veteran populations.

Emotion regulation flexibility and psychosis: A longitudinal study disentangling components of flexibility in psychosis-proneness.

OBJECTIVES: Flexibility in self-regulation has emerged as an important component of mental health. Previous findings found that deficits in two components of regulatory flexibility were linked cross-sectionally to psychosis-proneness. We aimed to replicate and extend these findings longitudinally. METHODS: We measured psychosis-proneness and components of emotion regulation flexibility (i.e. context sensitivity, repertoire and feedback) at two time points with three months in between. RESULTS: Two flexibility components predicted psychotic-like experiences. The ability to detect the absence of contextual cues was implicated in both positive and negative dimensions but through opposite pathways. Expressive suppression ability-a subcomponent of repertoire-predicted positive symptoms. None of the flexibility components predicted distress related to the symptoms. CONCLUSIONS: The current study provides further evidence on the implication of emotion regulation flexibility in the longer-term maintenance of psychotic-like experiences. Future studies can advance this work further by evaluating possible bidirectional relationships between psychotic-like experiences and deficits in emotion regulation flexibility.

Resilience and Disaster: Flexible Adaptation in the Face of Uncertain Threat.

Disasters cause sweeping damage, hardship, and loss of life. In this article, we first consider the dominant psychological approach to disasters and its narrow focus on psychopathology (e.g., posttraumatic stress disorder). We then review research on a broader approach that has identified heterogeneous, highly replicable trajectories of outcome, the most common being stable mental health or resilience. We review trajectory research for different types of disasters, including the COVID-19 pandemic. Next, we consider correlates of the resilience trajectory and note their paradoxically limited ability to predict future resilient outcomes. Research using machine learning algorithms improved prediction but has not yet illuminated the mechanism behind resilient adaptation. To that end, we propose a more direct psychological explanation for resilience based on research on the motivational and mechanistic components of regulatory flexibility. Finally, we consider how future research might leverage new computational approaches to better capture regulatory flexibility in real time.

Grief trajectories after loss in pregnancy and during the neonatal period.

Distinguishing patterns of grief over time in parents with a loss in pregnancy or during the neonatal period is important for identification of parents with severe grief symptoms, who may need additional support. Our aim was to describe grief in this population and to examine variations by type of loss in a large prospective cohort. We used questionnaire data from the Danish longitudinal cohort, Life After the Loss, which contains information on parents with a loss in pregnancy (from 14 weeks) or during the neonatal period. Parents completed the Prolonged Grief-13 scale at 1, 7, and 13 months after their loss. We applied Latent Growth Mixture Modelling to identify prolonged grief trajectories and used multinomial regression models to assess factors associated with class membership. Three distinct trajectories were identified in 676 parents: resilience (73.1%), recovery (16.9%), and chronic (10%). The distribution varied by type of loss, and the chronic group were overrepresented by parents with stillbirths (16.2%) and neonatal deaths (16.1%) in contrast to parents with spontaneous abortions (8.2%) and termination of pregnancy due to fetal anomalies (6.2%). Furthermore, not having a living child or being a woman was associated with following the chronic trajectory. These results underline that, while most bereaved parents are resilient, 10% experience consistently high levels of grief symptoms during the first year after the loss. Information on type of loss, gender, and whether the parent has living children are meaningful indicators of grief class membership.

Heterogeneous trajectories of depression and resilience following limb amputation.

OBJECTIVE: To identify longitudinal trajectories of depression in the first 6 months following limb loss and to explore baseline predictors of trajectories, including pain and demographic factors. A secondary aim was to evaluate whether trajectories of depression were associated with elevated symptoms of posttraumatic stress (PTS) at 6 months. DESIGN: Secondary longitudinal data analysis of an inception cohort study of persons with new-onset limb loss. Participants completed assessments at three intervals (initial, 3 months, and 6 months). SETTING: Hospitalized care, acute rehabilitation, ambulatory care, and community. PARTICIPANTS: Participants were recruited from consecutive cases of amputation surgery in a metropolitan hospital system over a period of 4 years (2002-2007). The final sample (n = 203) was predominantly White (79.3%) and male (78.8%) with an average age of 49.4 years (standard deviation [SD] = 14.6). MAIN OUTCOME MEASURE(S): Depression was assessed via the Patient Health Questionnaire-9 (PHQ-9); posttraumatic stress symptoms were measured via the PTSD checklist- Civilian Version (PCL-C). RESULTS: Four trajectories of depression were identified via Latent Growth Mixture Modeling: Resilience (73.2%), Chronic Depression (11.2%), Emerging Depression (8.9%), and Recovery (6.7%). Average pain intensity significantly predicted trajectory membership. Membership in the Chronic Depression class predicted elevated 6-month PTS compared to all other classes; membership in the Resilience class predicted lower PTS than in the Chronic and Emerging Depression classes but did not differentiate from the Recovery trajectory. CONCLUSIONS: Findings reveal that the course of depression post-amputation is heterogenous, with varying profiles of symptom development, maintenance, and remission. A majority of individuals were classified as Resilient, whereas a substantial minority of individuals developed clinically significant depression between 3 and 6 months (Emerging Depression), suggesting that early screening during acute care may be insufficient. We detected a significant prospective relation between depression trajectories and distal PTS, advancing the potential clinical utility of trajectory modeling as a risk surveillance tool.

Depressive and anxiety symptom trajectories in Polish adolescents during the COVID-19 pandemic and the outbreak of war in Ukraine: uncovering the role of family relations.

INTRODUCTION: The aim of the study was to investigate longitudinal trajectories of change in anxiety and depression symptoms in Polish adolescents during the second year of the COVID-19 pandemic and after the outbreak of the war in Ukraine. Additionally, we aimed to identify risk/protective factors and outcomes associated with these trajectories. METHOD: We collected data in three waves between November 2021 and May 2022. Adolescents (N = 281 in the first wave) completed the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, the Filial Responsibility Scale for Youth, and questions related to the COVID-19 pandemic and war in Ukraine. RESULTS: We identified three trajectories of depressive symptoms: resilient with low, stable symptoms (71% of participants), chronically elevated symptoms (11%), and acute symptoms followed by recovery (18%). We distinguished two trajectories of anxiety symptoms: resilient (75%) and chronic (25%). Non-resilient trajectories were predicted by higher levels of familial unfairness (perceived lack of equality and reciprocity in the family), relationship difficulties at school and at home, older age, and poor socioeconomic status. Chronic depressive and anxiety symptoms were associated with higher war-related concerns. DISCUSSION: These findings can inform preventive and therapeutic interventions for at-risk adolescents to reduce negative long-term outcomes of social crises.

Identifying multilevel predictors of trajectories of psychopathology and resilience among juvenile offenders: A machine learning approach.

Mental ill health is more common among juvenile offenders relative to adolescents in general. Little is known about individual differences in their long-term psychological adaptation and its predictors from multiple aspects of their life. This study aims to identify heterogeneous trajectories of probable psychiatric conditions and their predictors. Participants included 574 juvenile offenders who were first convicted for serious crimes and without detention history. The participants were assessed at 11 timepoints over seven years (2000-2010). Growth mixture modeling revealed the same three trajectories for both probable anxiety and probable depression: stable low trajectory (75.96%; 75.78%), stable high trajectory (15.16%; 10.98%), and recovery (8.89%, 13.24%). Least absolute shrinkage and selection operator (LASSO) logistic regression identified three multilevel predictors for memberships of different trajectories. Risk factors against stable low trajectory lay within personal (e.g., neuroticism), relationship (e.g., parental hostility), and contextual levels (e.g., chaotic neighborhood). Resilience factors for stable low trajectory included strong work orientation and low education level of father. Recovery was predicted by Black race, self-identity, high education level of father, and nonincarcerated sentencing. Our findings suggest that both psychopathology and psychological resilience could be predicted by multiple personal, relationship, and contextual factors in the social ecology of juvenile offenders.

Everyday life experiences for evaluating post-traumatic stress disorder symptoms.

Background: Previous research has highlighted the importance of regularizing daily routines for maintaining mental health. Little is known about whether and how regularity of daily routines is associated with reduced post-traumatic stress disorder (PTSD) symptoms.Objective: We aimed to examine the associations between regularity of daily routines and PTSD symptoms in two studies (N = 796).Method: In Study 1, prospective data were analysed with the latent change score model to investigate the association between sustainment of regular daily routines and change in PTSD symptoms over time amid massive civil unrest in Hong Kong in 2019. Study 2 used vignette as a quasi-experimental method to assess the ability of maintaining regular daily routines in face of a major stressor, and tested its associations with PTSD symptoms.Results: In Study 1, increased regularity of diverse daily routines was inversely associated with increased PTSD symptoms amid the civil unrest in Hong Kong (ß = -.427 to -.224, 95% confidence intervals [-.543 to -.359, -.310 to -.090], p values < .01). In Study 2, a greater ability to maintain regular daily routines during stress was associated with lower levels of PTSD symptoms (ß = -.285 to -.096, 95% confidence intervals [-.379 to -.189, -.190 to -.003], p values < .05).Conclusions: Our findings suggest the benefit of considering diverse everyday activities in evaluating PTSD symptoms in both clinical and subclinical populations. Interventions with the direct focus on the role of daily living could promote psychological resilience during and after potentially traumatic events.

Increased regularity of routines (hygiene, healthy eating, sleep, duties at home, exercising, leisure and social activities, work/study involvement) was related to less increase in PTSD symptoms amid widespread civil unrest.The ability to maintain regular routines during stress was inversely associated with PTSD symptoms.Research and interventions with the direct focus on the role of daily living could promote psychological resilience during and after potentially traumatic events.

Physical activity may buffer against depression and promote resilience after major life stressors.

As many individuals experience potentially traumatic or stressful life events, understanding factors that are likely to promote resilience is imperative. Given the demonstrated efficacy of exercise for depression treatment, we examined if exercise buffers against the risk of developing psychiatric symptoms following life stressors. 1405 participants (61% female) from a longitudinal panel cohort experienced disability onset (43%), bereavement (26%), heart attack (20%), divorce (11%), and job loss (3%). They reported time spent exercising and depressive symptoms (Center for Epidemiologic Studies Depression scale) across three time points collected in two-year intervals: T0 (pre-stressor), T1 (acutely post-stressor), and T2 (post-stressor). Participants were classified in previously identified heterogeneous depression trajectories pre- to post-life stressor: resilient (69%), emerging (11.5%), chronic (10%), and improving (9.5%). Multinomial logistic regression found that more T0 exercise predicted likelihood of classification in resilient versus other groups (all p<.02). Controlling for covariates, only the higher likelihood of classification in resilient versus improving remained (p=.03). Follow-up repeated measures general linear model (GLM) assessed whether trajectory was associated with exercise at each time, controlling for covariates. GLM indicated significant within-subjects effects for time (p=.016, partial η2=.003) and time*trajectory (p=.020, partial η2=.005) on exercise and significant between-subjects effects of trajectory (p<.001, partial η2=.016) and all covariates. The resilient group showed consistent high exercise levels. The improving group had consistent moderate exercise. The emerging and chronic groups were associated with lower exercise post-stressor. Pre-stressor exercise may buffer against depression and ongoing exercise may be associated with lower depression levels following a major life stressor.

Modular segregation drives causality of the dynamic oscillatory network responses during threat processing.

Physiological responses to threat and stress stimuli entrain synchronized neural oscillations among cerebral networks. Network architecture and adaptation may play a critical role in achieving optimal physiological responses, while alteration can lead to mental dysfunction. We reconstructed cortical and sub-cortical source time series from high-density electroencephalography, which were then fed into community architecture analysis. Dynamic alterations were evaluated in terms of flexibility, clustering coefficient and global and local efficiency, as parameters of community allegiance. Transcranial magnetic stimulation was applied over the dorsomedial prefrontal cortex during the time window relevant for physiological threat processing and effective connectivity was computed to test the causality of network dynamics. A theta band-driven community re-organization was evident in key anatomical regions conforming the central executive, salience network and default mode networks during instructed threat processing. Increased network flexibility entrained the physiological responses to threat processing. The effective connectivity analysis showed that information flow differed between theta and alpha bands and were modulated by transcranial magnetic stimulation in salience and default mode networks during threat processing. Theta oscillations drive dynamic community network re-organization during threat processing. Nodal community switches may modulate the directionality of information flow and determine physiological responses relevant to mental health.

The interrelations between psychological outcome trajectories and resource changes amid large-scale disasters: A growth mixture modeling analysis.

Currently little is known about the interrelations between changes in psychiatric symptoms and changes in resources (personal, social, financial) amid large-scale disasters. This study investigated trajectories of psychiatric symptoms and their relationships with different patterns of changes in personal, social, and financial resources between 2020 and 2022 amid the COVID-19 pandemic. A population-representative sample (N = 1333) was recruited to complete self-report instruments at the pandemic's acute phase (February-July 2020, T1), and again at 1-year (March-August 2021, T2) and 1.5-year (September 2021-February 2022, T3) follow-ups. Respondents reported depressive and anxiety symptoms, self-efficacy, perceived social support, and financial capacity. Growth mixture modeling (GMM) identified four trajectories of depressive and anxiety symptoms: resilience (72.39-74.19%), recovery (8.40-11.93%), delayed distress (7.20-7.35%), and chronic distress (8.33-10.20%). Four patterns were demonstrated in resource changes: persistent high resources (40.89-47.64%), resource gain (12.08-15.60%), resource loss (6.30-10.43%), and persistent low resources (28.73-36.61%). Loss and gain in financial resources characterized chronic distress and resilience, respectively. Loss in personal resources characterized delayed distress, whereas loss or no gain in social resources was related to chronic/delayed distress. Respondents in resilience were also more likely to have persistent high resources while those with delayed/chronic distress were more likely to have persistent low resources. These results provide an initial evidence base for advancing current understanding on trajectories of resilience and psychopathology in the context of resource changes during and after large-scale disasters.

The Flexible Regulation of Emotional Expression Scale for Youth (FREE-Y): Adaptation and Validation Across a Varied Sample of Children and Adolescents.

Flexible self-regulation has been shown to be an adaptive ability. This study adapted and validated the adult Flexible Regulation of Emotional Expression (FREE) Scale for use with youth (FREE-Y) in community and maltreatment samples. The FREE-Y measures the ability to flexibly enhance and suppress emotion expression across an array of hypothetical social scenarios. Participants (N = 654, 8-19 years) were included from three studies. Confirmatory factor analysis (CFA) confirmed a theoretically appropriate higher order factor structure. Using multiple-group CFAs, measurement invariance was achieved across maltreatment status, age, and gender. Reliabilities were adequate and construct validity was demonstrated through associations with measures of emotion regulation, psychopathology, IQ, and executive functioning. Group comparisons indicated lower Suppression and Flexibility scores for maltreated versus comparison participants. Findings suggest that the FREE-Y is a valid measure of expressive regulation ability in youth that can be applied across a range of populations.

Looking back and moving forward: dimensions of coping flexibility divergently predict long-term bereavement outcomes.

BACKGROUND AND OBJECTIVES: Bereavement is a serious public health concern. Some people suffer prolonged and debilitating functional impairment after the death of a loved one. Evidence suggests that flexibility in coping approaches predicts resilience after stressful life events, but its long-term effects after the unique experience of bereavement are unknown. Which strategies of coping flexibility predict better-or worse-adjustment over time for bereaved people and at what times? DESIGN AND METHODS: The present study used path analyses to investigate longitudinal effects of forward-focus and loss-focus coping strategies on symptoms of persistent complex bereavement disorder (PCBD), depression, and posttraumatic stress disorder in a spousally bereaved adult sample (N = 248) at three time-points after the loss (∼3 months, ∼14 months, and ∼25 months). RESULTS: Forward-focus coping demonstrated adaptive utility overall, with sooner effects on PCBD than on depression. By contrast, loss-focus coping demonstrated a delayed-onset, maladaptive pattern. CONCLUSIONS: The findings contribute to the coping flexibility literature by suggesting that the adaptiveness or maladaptiveness of different coping strategies may depend on the context that requires coping. In particular, forward-focus coping may be substantially more advantageous than loss-focus coping in the context of bereavement. Implications, limitations, and future research directions are discussed.

Understanding posttraumatic stress trajectories in adolescent females: A strength-based machine learning approach examining risk and protective factors including online behaviors.

Heterogeneity in the course of posttraumatic stress symptoms (PTSS) following a major life trauma such as childhood sexual abuse (CSA) can be attributed to numerous contextual factors, psychosocial risk, and family/peer support. The present study investigates a comprehensive set of baseline psychosocial risk and protective factors including online behaviors predicting empirically derived PTSS trajectories over time. Females aged 12-16 years (N = 440); 156 with substantiated CSA; 284 matched comparisons with various self-reported potentially traumatic events (PTEs) were assessed at baseline and then annually for 2 subsequent years. Latent growth mixture modeling (LGMM) was used to derive PTSS trajectories, and least absolute shrinkage and selection operator (LASSO) logistic regression was used to investigate psychosocial predictors including online behaviors of trajectories. LGMM revealed four PTSS trajectories: resilient (52.1%), emerging (9.3%), recovering (19.3%), and chronic (19.4%). Of the 23 predictors considered, nine were retained in the LASSO model discriminating resilient versus chronic trajectories including the absence of CSA and other PTEs, low incidences of exposure to sexual content online, minority ethnicity status, and the presence of additional psychosocial protective factors. Results provide insights into possible intervention targets to promote resilience in adolescence following PTEs.

Components of emotion regulation flexibility and psychosis: The association between psychosis-proneness and context sensitivity.

OBJECTIVES: Emotion regulation flexibility has been conceptualized as a multi-componential construct involving context sensitivity, repertoire and feedback responsiveness. Psychosis research has yet to incorporate these new developments in the study of emotion regulation. Thus, we sought to advance even further the knowledge on emotion regulation in psychosis by adopting the emotion regulation flexibility approach as proposed by Bonanno and Burton (Perspectives on Psychological Science, 2013, 8, 591). METHOD: In total, 401 participants completed 4 scales assessing the multi-components of emotion regulation flexibility and psychosis-proneness. RESULTS: Our results indicated that Context Sensitivity (i.e., Cue Absence) and Feedback Responsiveness (i.e., Evaluation) were associated with psychosis-proneness. Cue absence was specifically associated with the positive dimension, while both Cue Absence and Enhancement ability were associated with the negative dimension. CONCLUSIONS: Overall, our results suggest that emotional context insensitivity is the most relevant component of regulatory flexibility in the case of psychosis-proneness. Thus, the disruption in this first step of flexible emotion regulation might be already present in those prone to psychosis. Difficulties in decoding appropriately the contextual cues might further disrupt the other steps of emotion regulation contributing to the psychotic (-like) experiences. This study needs replication in clinical and non-clinical samples.