Emotion regulation (ER) flexibility is highly relevant to psychosis-proneness as it influences how individuals adapt to and manage their emotional responses in varying contexts. Research suggests that deficits in ER flexibility components, particularly context sensitivity and emotional suppression, may contribute to the development and maintenance of psychotic-like experiences. Understanding this relationship can inform early intervention strategies and tailored treatments for individuals at risk of psychosis, potentially improving outcomes and quality of life.
Nardelli, C., Bonanno, G. A., Chen, S., & Bortolon, C. (2024). Emotion regulation flexibility and psychosis: A longitudinal study disentangling components of flexibility in psychosis‐proneness. British Journal of Clinical Psychology, 63(1), 54-72. https://doi.org/10.1111/bjc.12443
Key Points
- The study examined the relationship between emotion regulation (ER) flexibility and psychotic-like experiences (PLE) using both cross-sectional and longitudinal analyses.
- Context sensitivity, particularly the ability to detect the absence of contextual cues, predicted both positive and negative dimensions of PLE, but through opposite pathways.
- The ability to suppress emotional expression predicted positive symptoms of PLE.
- Flexibility components did not predict distress related to PLE symptoms.
- The research suggests a possible bidirectional relationship between PLE and deficits in ER flexibility, forming a potential vicious cycle.
- While informative, the study has limitations such as reliance on self-report measures and a relatively short follow-up period.
- Understanding the relationship between ER flexibility and PLE has implications for clinical interventions and early identification of psychosis risk.
Rationale
Previous research has established that emotional dysregulation is a central feature of psychosis, with implications for its onset and maintenance (Liu et al., 2020; Ludwig et al., 2019).
Recent studies have highlighted the importance of flexibility in emotion regulation (ER) in relation to psychosis (Bonanno & Burton, 2013).
A cross-sectional study by Bortolon et al. (2022) provided initial evidence of the relevance of ER flexibility in relation to psychosis-proneness.
However, longitudinal research was needed to better understand the causal relationships between ER flexibility components and psychotic-like experiences (PLE).
Additionally, investigating both the frequency and associated distress of PLE could provide insights into factors that differentiate subclinical experiences from clinical psychosis.
This study aimed to replicate and extend Bortolon et al.’s (2022) findings using both cross-sectional and longitudinal designs, examining how specific components of ER flexibility (context sensitivity, repertoire, and feedback) relate to PLE over time.
Method
The study employed a longitudinal online survey design with two measurement points separated by three months.
Procedure:
Participants completed questionnaires at two time-points (T1 and T2) through an online platform. At T1, they completed measures of ER flexibility components and psychosis-proneness. At T2, they completed only the psychosis-proneness measure again.
Sample:
The initial sample consisted of 303 English-speaking adults from the UK and US recruited through the Prolific platform. At T2, 249 participants completed the follow-up survey.
The mean age of participants was 43.94 years (SD = 14.96) at T1.
Measures:
- Context Sensitivity Index (CSI): Measured sensitivity to presence and absence of contextual cues.
- Flexible Regulation of Emotional Expression Scale (FREE): Assessed ability to enhance and suppress emotional expression.
- Coping Flexibility Scale (CFS): Measured ability to stop ineffective strategies and engage in alternatives.
- Community Assessment of Psychic Experience 42 (CAPE-42): Assessed lifetime prevalence of psychotic-like experiences.
Statistical measures:
The study used correlational analyses, linear regressions, and bootstrapping techniques to analyze the data. Regression diagnostics were performed to ensure the validity of the models.
Results
Hypothesis: Deficits in context sensitivity, repertoire, and feedback responsiveness at T1 would predict higher scores on psychosis-proneness (both frequency and distress) at T2.
Results:
- Context sensitivity (specifically cue absence) at T1 predicted positive symptoms at T2.
- Cue absence predicted negative symptoms at T2, but in the opposite direction.
- Suppression ability (a subcomponent of repertoire) predicted positive symptoms at T2.
- Flexibility components did not predict distress related to PLE.
Insight
The study provides evidence for the role of specific ER flexibility components in the development and maintenance of PLE.
The ability to detect the absence of contextual cues appears to have differential effects on positive and negative symptoms, suggesting a complex relationship between context sensitivity and psychosis-proneness.
The findings extend previous research by demonstrating longitudinal relationships and highlighting the importance of examining specific subcomponents of ER flexibility.
These results suggest that interventions targeting ER flexibility, particularly context sensitivity and emotional suppression abilities, may be beneficial in preventing or managing PLE.
Future research should explore potential bidirectional relationships between PLE and ER flexibility deficits, as well as investigate these relationships in clinical populations.
Strengths
- Longitudinal design allows for examination of predictive relationships
- Large sample size
- Use of validated measures for assessing ER flexibility and PLE
- Examination of both frequency and distress associated with PLE
- Consideration of subcomponents of ER flexibility
- Robust statistical analyses, including bootstrapping techniques
Limitations
- Reliance on self-report measures
- Relatively short follow-up period (3 months)
- Sample limited to English-speaking adults from the UK and US
- Inability to assess bidirectional relationships due to not measuring ER flexibility at T2
- Potential selection bias, as those who completed T2 were older and had lower CAPE scores on average
These limitations may affect the generalizability of the findings and the ability to draw strong causal conclusions. Future studies should consider using longer follow-up periods, multiple assessment points for all variables, and more diverse samples.
Clinical Implications
The findings have significant implications for understanding the development and maintenance of psychotic experiences.
They suggest that targeting specific ER flexibility components, particularly context sensitivity and emotional suppression abilities, may be beneficial in clinical interventions for individuals at risk of psychosis.
The differential associations between cue absence detection and positive vs. negative symptoms highlight the need for nuanced approaches in treatment.
For clinical practice, these results emphasize the importance of assessing and addressing ER flexibility skills in individuals with PLE. Interventions could focus on improving context sensitivity, particularly the ability to accurately detect the presence and absence of contextual cues. A
Additionally, helping individuals develop more adaptive emotional suppression abilities may be beneficial in managing positive symptoms.
The study also underscores the complexity of the relationship between ER and psychosis, suggesting that a one-size-fits-all approach to ER interventions may not be appropriate.
Clinicians should consider the specific symptom profile and ER deficits of each individual when designing interventions.
References
Primary reference
Nardelli, C., Bonanno, G. A., Chen, S., & Bortolon, C. (2024). Emotion regulation flexibility and psychosis: A longitudinal study disentangling components of flexibility in psychosis‐proneness. British Journal of Clinical Psychology, 63(1), 54-72. https://doi.org/10.1111/bjc.12443
Other references
Bonanno, G. A., & Burton, C. L. (2013). Regulatory flexibility: An individual differences perspective on coping and emotion regulation. Perspectives on Psychological Science, 8(6), 591-612.
Bortolon, C., Chen, S., & Bonanno, G. A. (2022). Components of emotion regulation flexibility and psychosis: The association between psychosis-proneness and context sensitivity. British Journal of Clinical Psychology, 62(1), 82-95.
Liu, J., Chan, T. C., Chong, S. A., Subramaniam, M., & Mahendran, R. (2020). Impact of emotion dysregulation and cognitive insight on psychotic and depressive symptoms during the early course of schizophrenia spectrum disorders. Early Intervention in Psychiatry, 14(6), 691-697.
Ludwig, L., Werner, D., & Lincoln, T. M. (2019). The relevance of cognitive emotion regulation to psychotic symptoms–a systematic review and meta-analysis. Clinical Psychology Review, 72, 101746.
Keep Learning
Socratic questions for a college class to discuss this paper:
- How might the relationship between context sensitivity and psychotic-like experiences differ in clinical versus non-clinical populations?
- What are some potential explanations for the opposite effects of cue absence detection on positive versus negative symptoms?
- How could the findings of this study inform early intervention strategies for individuals at risk of developing psychosis?
- What additional measures or methods could future studies employ to address the limitations of self-report and capture more objective aspects of emotion regulation flexibility?
- How might cultural factors influence the relationship between emotion regulation flexibility and psychotic-like experiences? How could future research address this?
- Given the potential bidirectional relationship between ER flexibility deficits and PLE, how might this create a “vicious cycle,” and what implications does this have for treatment approaches?
- How do the findings of this study relate to broader theories of emotion regulation and psychopathology? Are there other mental health conditions where similar patterns might be observed?
