Emotion regulation is defined as the ability to understand, differentiate, and accept emotional experiences while flexibly applying appropriate strategies to modulate emotions in a manner that facilitates meaningful, goal-directed behavior. In other words, it involves managing emotions effectively.
In contrast, emotional avoidance refers to an unwillingness to fully experience emotions, both positive and negative. It involves attempts to alter the form, frequency, or situational context of emotions to reduce distress, rather than accepting and learning from emotional experiences.
Clarifying the relation of these two constructs to anxiety can inform treatment targets for greater efficiency.
Bock, R. C., Baker, L. D., Kalantar, E. A., Berghoff, C. R., Stroman, J. C., Gratz, K. L., & Tull, M. T. (2024). Clarifying relations of emotion regulation, emotional avoidance and anxiety symptoms in a community-based treatment-seeking sample. Psychology and Psychotherapy: Theory, Research and Practice, 00, 1–12. https://doi.org/10.1111/papt.12523
Key Points
- Anxiety disorders are highly prevalent and disabling, yet many people do not benefit from existing treatments. Emotion regulation (ER) difficulties are associated with anxiety, but emotional avoidance (EA) may be a more specific treatment target.
- This study examined whether ER difficulties represent a proxy risk factor for the relation between EA and anxiety severity in a clinical sample.
- EA and ER difficulties were strongly positively correlated, and each accounted for unique variance in anxiety symptoms. However, when entered together into models, only EA was significantly associated with anxiety severity, suggesting ER difficulties may not directly contribute to anxiety independent of EA.
- Targeting EA specifically rather than ER difficulties broadly may increase the efficiency of anxiety interventions. However, limitations like reliance on cross-sectional self-report data mean findings should be replicated using more rigorous methods over time.
Rationale
Anxiety disorders, such as generalized anxiety, are highly prevalent globally, ranking within the top 10 leading causes of disability (Gunnarsson et al., 2021).
Although cognitive-behavioral therapies (CBTs) can effectively treat anxiety (Asnaani et al., 2020; van Dis et al., 2020), many patients drop out or do not improve (Bandelow et al., 2014; Taylor et al., 2012).
Identifying mechanisms that could enhance psychosocial anxiety treatments is needed to increase accessibility and outcomes.
Emotion regulation (ER) difficulties are robustly associated with anxiety disorder presence and symptoms (Allan et al., 2015; Mennin et al., 2005; Tull & Roemer, 2007; Tull et al., 2009). Treatments targeting ER processes help reduce anxiety (Asnaani et al., 2020).
However, some evidence suggests ER difficulties may be proxy variables for emotional avoidance (EA)—the unwillingness to experience emotions (Berking & Wupperman, 2012; Salters-Pedneault et al., 2004).
Clarifying whether EA more directly relates to anxiety could increase treatment specificity by revealing efficient intervention targets.
This study evaluated whether ER difficulties represent proxy risk factors for the EA-anxiety symptom severity relation within an anxiety disorders clinic sample, after accounting for anxiety sensitivity and medication use.
Method
This cross-sectional study used self-report assessments of community adults seeking anxiety treatment at intake to an outpatient U.S. anxiety clinic from 2010-2016.
Procedure
As part of routine intake, participants completed questionnaires assessing emotion regulation, emotional avoidance, anxiety sensitivity, anxiety symptoms, and medication use.
Sample
120 treatment-seeking adults participated (M age=39 years, 58.3% female, 74.2% White). Most had at least a high school education and median income approximating regional levels.
Measures
- Depression Anxiety Stress Scales-21 (DASS-21): Anxiety subscale measured anxiety symptom severity
- Anxiety Sensitivity Index-3 (ASI-3): Assessed fear of anxiety sensations
- Difficulties in Emotion Regulation Scale (DERS): Measured ER difficulties
- Emotional Avoidance Questionnaire (EAQ): Assessed avoidance of positive/negative emotions
Statistical Analysis
A 4-step hierarchical regression analysis evaluated whether:
1) ER difficulties associate with anxiety symptoms when accounting for covariates;
2) ER difficulties represent proxy risk factors for EA in predicting anxiety symptoms.
Results
As hypothesized, anxiety sensitivity, emotion regulation difficulties, and emotional avoidance all demonstrated significant positive associations with anxiety symptom severity (all ps < .001). Emotion regulation difficulties and emotional avoidance also positively correlated with each other (p < .001).
Initial regression models showed that emotion regulation difficulties explained unique variance in anxiety symptoms above covariates.
However, when emotional avoidance was added to these models, only emotional avoidance retained a significant independent association with anxiety symptoms.
Additional regression analyses entering emotional avoidance before emotion regulation difficulties supported emotional avoidance as the dominant correlate of anxiety symptom severity in this sample.
Overall, 66.7% of participants reported current use of anti-anxiety medications.
Insight
ER difficulties did not independently relate to anxiety when factoring in EA. This indicates EA is a more direct treatment target for anxiety relative to broad ER difficulties.
Targeting the unwillingness to experience emotions specifically could increase efficiency and outcomes of anxiety interventions.
Notably, this study extended limited research on ER, EA, and anxiety conducted primarily in nonclinical settings to a specialized anxiety clinic sample with high rates of anxiolytic medication usage.
Findings are consistent with evidence tying anxiety more directly to emotional unwillingness and avoidance than to ER broadly. Overall, outcomes propose EA-focused treatment elements may be both necessary and sufficient factors underlying effective anxiety symptom alleviation.
Future research must continue clarifying these mechanisms over time using rigorous methodology across clinical settings to inform targeted intervention optimization.
Strengths
This study had several strengths underscoring validity of the findings:
Utilized data from a specialized community-based anxiety clinic with treatment-seeking adults formally referred for anxiety concerns. This extends the literature focused largely on nonclinical groups. The sample provides clinically applicable insights, with 66.7% prescribed anxiolytic medications at intake.
Included validated assessments demonstrating good psychometric properties based on prior research. Using established self-report tools lends credibility.
Accounted for theoretically relevant covariates of anxiety symptoms and emotion regulation, including anxiety sensitivity and medication use. Controlling known confounds bolsters the interpretability of focal relations tested.
The first investigation differentiating unique vs. shared contributions of emotion regulation difficulties and emotional avoidance to anxiety severity. Addressing this novel question provides direction for enhancing treatment specificity.
Used rigorous statistical modeling capable of evaluating proxy risk factors when temporal precedence is ambiguous. Applying optimal analyses for the research aims strengthens conclusions.
Limitations
Despite enlightening findings, limitations warrant mention:
Sample lacked diagnostic interview confirmation of anxiety disorder presence/type. Unknown whether participants met clinical criteria despite referral for anxiety concerns. Generalizability is uncertain without diagnostic details.
Limited racial/ethnic diversity. Most participants identified as White, reducing the extendibility of patterns to minority groups. Replicating in more diverse samples is needed.
Self-selection biases possible with voluntary participation. Individuals choosing to enroll may possess attributes systematically influencing responses. This could skew results away from true population scores.
Sole reliance on self-report questionnaires. Subject to well-known limitations like inaccurate recall, demand characteristics, evaluation apprehension, and common method variance artificially inflating measured associations.
Cross-sectional design prevents determining temporal precedence between predictors and anxiety symptoms. Cannot confirm causal direction of reported effects without longitudinal tracking.
Findings derived from a single anxiety clinic. Replication across settings would establish generalizability of conclusions and rule out clinic-specific confounds.
Sample size provided acceptable but restricted statistical power. Larger cohorts could reveal smaller effects currently undetectable. Patterns should be re-tested in bigger groups.
Implications
Anxiety disorders contribute profoundly to global disability and economic burden, yet many patients show incomplete treatment response (Bandelow et al., 2014; Roy-Byrne et al., 2008; Taylor et al., 2012).
This study found emotional avoidance explained unique variance in anxiety symptom severity above emotion regulation difficulties within a clinical sample.
Outcomes extend literature concentrated largely on nonclinical groups to indicate targeting unwillingness to experience emotions directly could enhance outcomes for patients with anxiety disorders.
Emotional avoidance appears to be a more dominant correlate of anxiety relative to the broader process of emotion regulation.
This highlights the potential treatment utility of streamlining interventions to concentrate specifically on acceptance of and exposure to uncomfortable internal experiences. Doing so may hasten progress during brief therapy protocols.
Relatedly, findings imply existing evidence-based treatments addressing emotional avoidance explicitly, like acceptance and commitment therapy, could hold particular promise for ameliorating anxious distress efficiently (Twohig & Levin, 2017).
Anxiety symptom severity showed no unique association with emotion regulation difficulties when accounting for emotional avoidance.
This proposes interventions singularly concentrated on imparting broader emotion regulation skills in the absence of emotional acceptance components may fail to directly impact anxiety.
Such treatment elements could represent necessary but insufficient factors that are proxy variables for core processes truly underlying anxiety-related conditions.
Researchers should continue clarifying the contributions of avoidance-based emotion regulation processes to anxiety using prospective designs across clinical settings.
Related investigations must evaluate whether treatments directly targeting emotional avoidance yield enhanced outcomes compared to those focused on teaching multifaceted emotion regulation techniques.
Findings collectively underscore the critical importance of enhancing treatment precision for anxiety through isolating efficacious mechanisms.
References
Primary reference
Bock, R. C., Baker, L. D., Kalantar, E. A., Berghoff, C. R., Stroman, J. C., Gratz, K. L., & Tull, M. T. (2024). Clarifying relations of emotion regulation, emotional avoidance and anxiety symptoms in a community-based treatment-seeking sample. Psychology and Psychotherapy: Theory, Research and Practice, 00, 1–12. https://doi.org/10.1111/papt.12523
Other references
Allan, N. P., Norr, A. M., Macatee, R. J., Gajewska, A., & Schmidt, N. B. (2015). Interactive effects of anxiety sensitivity and emotion regulation on anxiety symptoms. Journal of Psychopathology and Behavioral Assessment, 37(4), 663–672. https://doi.org/10.1007/s10862-015-9484-z
Asnaani, A., Tyler, J., McCann, J., Brown, L., & Zang, Y. (2020). Anxiety sensitivity and emotion regulation as mechanisms of successful CBT outcome for anxiety-related disorders in a naturalistic treatment setting. Journal of Affective Disorders, 267, 86-95. https://doi.org/10.1016/j.jad.2020.01.160
Bandelow, B., Lichte, T., Rudolf, S., Wiltink, J., & Beutel, E. M. (2014). The diagnosis of and treatment recommendations for anxiety disorders. Deutsches Ärzteblatt International, 111(27–28), 473–480. https://doi.org/10.3238/arztebl.2014.0473
Berking, M., & Wupperman, P. (2012). Emotion regulation and mental health: Recent findings, current challenges, and future directions. Current Opinion in Psychiatry, 25(2), 128-134. https://doi.org/10.1097/YCO.0b013e3283503669
Gunnarsson, A. B., Hedberg, A. K., Håkansson, C., Hedin, K., & Wagman, P. (2021). Occupational performance problems in people with depression and anxiety. Scandinavian Journal of Occupational Therapy, 1-11, 148-158. https://doi.org/10.1080/11038128.2021.1882562
Mennin, D. S., Heimberg, R. G., Turk, C. L., & Fresco, D. M. (2005). Preliminary evidence for an emotion regulation deficit model of generalized anxiety disorder. Behaviour Research and Therapy, 43, 1281-1310. https://doi.org/10.1016/j.brat.2004.08.008
Roy-Byrne, P. P., Davidson, K. W., Kessler, R. C., Asmundson, G. J. G., Goodwin, R. D., Kubzansky, L., & Stein, M. B. (2008). Anxiety disorders and comorbid medical illness. General Hospital Psychiatry, 30, 208-225. https://doi.org/10.1016/j.genhosppsych.2007.12.006
Salters-Pedneault, K., Tull, M. T., & Roemer, L. (2004). The role of avoidance of emotional material in the anxiety disorders. Applied and Preventive Psychology, 11(2), 95-114. https://doi.org/10.1016/j.appsy.2004.09.001
Taylor, S., Abramowitz, J. S., & McKay, D. (2012). Non-adherence and non-response in the treatment of anxiety disorders. Journal of Anxiety Disorders, 26(5), 583-589. https://doi.org/10.1016/j.janxdis.2012.02.010
Tull, M. T., & Roemer, L. (2007). Emotion regulation difficulties associated with the experience of uncued panic attacks: Evidence of experiential avoidance, emotional nonacceptance, and decreased emotional clarity. Behavior Therapy, 38, 378-391. https://doi.org/10.1016/j.beth.2006.10.006
Tull, M. T., Stipelman, B., Salters-Pedneault, K., & Gratz, K. L. (2009). An examination of recent non-clinical panic attacks, panic disorder, anxiety sensitivity, and emotion regulation difficulties in the prediction of generalized anxiety disorder in an analogue sample. Journal of Anxiety Disorders, 23, 275-282. https://doi.org/10.1016/j.janxdis.2008.08.002
Twohig, M. P., & Levin, M. E. (2017). Acceptance and commitment therapy as a treatment for anxiety and depression: A review. Psychiatric Clinics, 40(4), 751–770. https://doi.org/10.1016/j.psc.2017.08.009
van Dis, E. A. M., van Veen, S. C., Hagenaars, M. A., Batelaan, N. M., Bockting, C. L. H., van den Heuvel, R. M., Cuijpers, P., & Engelhard, I. M. (2020). Long-term outcomes of cognitive behavioral therapy for anxiety-related disorders: A systematic review and meta-analysis. JAMA Psychiatry, 77(3), 265–273. https://doi.org/10.1001/jamapsychiatry.2019.3986
Keep Learning
Here are some suggested Socratic discussion questions about this paper for a college class:
- How might targeting emotional avoidance directly in psychosocial anxiety treatments increase efficiency and outcomes compared to addressing emotion regulation difficulties more broadly? What are the theoretical reasons and practical implications?
- If emotional avoidance is a more dominant correlate of anxious distress, why do many existing interventions concentrate substantially on teaching wide-ranging emotion regulation skills? How might treatment development change based on these findings?
- What next research steps are needed to clarify the relations found in this study? What limitations need to be addressed by future work to increase confidence in the conclusions?
- Could addressing emotional avoidance explicitly backfire or carry any risks? If so, how could those be prevented or mitigated?
- How could findings apply to childhood anxiety treatment versus adult treatment? Would implications differ across the lifespan?
