Hindawi Publishing Corporation

Cardiovascular Psychiatry and Neurology

Volume 2014, Article ID 324374, 10 pages
http://dx.doi.org/10.1155/2014/324374

Review Article
Emotional Regulation and Depression:
A Potential Mediator between Heart and Mind

Angelo Compare,1,2 Cristina Zarbo,1 Edo Shonin,3

William Van Gordon,3 and Chiara Marconi1
1
Department of Human and Social Sciences, University of Bergamo, Piazza S. Agostino 2, 24124 Bergamo, Italy
2
Human Factors and Technologies in Healthcare Centre, University of Bergamo, Italy
3
Psychology Division, Nottingham Trent University, UK

Correspondence should be addressed to Angelo Compare; [email protected]

Received 22 September 2013; Revised 17 April 2014; Accepted 23 April 2014; Published 22 June 2014

Academic Editor: Janusz K. Rybakowski

Copyright © 2014 Angelo Compare et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

A narrative review of the major evidence concerning the relationship between emotional regulation and depression was conducted.
The literature demonstrates a mediating role of emotional regulation in the development of depression and physical illness.
Literature suggests in fact that the employment of adaptive emotional regulation strategies (e.g., reappraisal) causes a reduction of
stress-elicited emotions leading to physical disorders. Conversely, dysfunctional emotional regulation strategies and, in particular,
rumination and emotion suppression appear to be influential in the pathogenesis of depression and physiological disease. More
specifically, the evidence suggests that depression and rumination affect both cognitive (e.g., impaired ability to process negative
information) and neurobiological mechanisms (e.g., hypothalamic pituitary adrenal axis overactivation and higher rates of cortisol
production). Understanding the factors that govern the variety of health outcomes that different people experience following
exposure to stress has important implications for the development of effective emotion-regulation interventional approaches (e.g.,
mindfulness-based therapy, emotion-focused therapy, and emotion regulation therapy).

1. Introduction Whilst emotional regulation capacity has been proposed

as a mediator in the link between emotion and psychosomatic
Exposure to stress has generally been associated with a wide health, a review of the empirical and theoretical literature
range of negative outcomes, including decreased well-being that specifically reports on the mediating role of emotional
and increased incidence of psychological disorders such as regulation in the development of depression and subsequent
posttraumatic stress disorder, generalized anxiety disorder, additional somatic illness has not been undertaken to date.
and major depression [1, 2]. However, some individuals Thus, the purpose of this paper is to conduct a narrative
do not develop psychological disorders even when exposed review about the major evidence concerning the mediating
to high levels of stress. It appears, therefore, that when role of the emotional regulation in the link between depres-
faced with the same stressor, certain individuals demon- sion and physical illness. Key theories, methods of assess-
strate impaired functionality, while others show remarkable ment, clinical and neurobiological correlates, psychological
resilience. Stressful events typically elicit significant emo- and physiological mechanisms of action, and treatment
tional responses [3, 4]. Accordingly, emotional regulation approaches are discussed.
capacity has been proposed as a mediator of stress adjustment
[5, 6]. According to this model, exposure to stress leads
to the dysregulation of emotions, which in turn elicits 2. The Emotional Regulation
negative psychological and physiological health outcomes
(e.g., depression and stress-induced cardiomyopathy) (see Emotional regulation, also known as “emotional self-regula-
Figure 1). tion,” has been defined by Gross [7] as the set of cognitive
2 Cardiovascular Psychiatry and Neurology

Internal
Stress Emotions emotional
states

Cognitive
emotional
regulation Emotion- Cognitive Emotion-
related emotional related
physiological cognitions
processes regulation
Cognitive Cognitive
emotional emotional
regulation dysregulation
capacity

Emotion-
Adjustment to related
Physiological Psychological behaviors
stress and
resilience diseases diseases

Figure 1: The mediating role of emotional regulation in the Figure 2: Functioning aspects involved in cognitive emotion regu-
relationship between stress and emotions. lation.

processes that influence the type of emotional response, situation (real or imagined) emotionally relevant; (ii) atten-
as well as how individuals experience and express these tion directed towards the emotional situation; (iii) appraisal
emotions. Emotional regulation is a complex process that of situation, which means that situation should be evaluated
includes the initiation, the inhibition, or modulation of the and interpreted; and (iv) emotional response to situation
following aspects of emotion functioning [8] (see Figure 2): with changes in behavioral, experiential, and physiological
response systems. The modal model of emotion suggests
(1) internal emotional states (e.g., the subjective experi- moreover the existence of a feedback recursively and dynamic
ence of emotion); loop from the emotional response to the situation [14].
(2) emotion-related cognitions (e.g., reaction to thoughts According to the model of emotional regulation process,
about a situation); there are two overarching control strategies that modulate
(3) emotion-related physiological processes (e.g., auto- emotional experience (see Figure 3).
nomic arousal, hormonal reactions, etc.); (1) Antecedent-Focused Regulation. This regulation strat-
(4) emotion-related behaviors (e.g., facial expressions, egy occurs at an early stage in the modulation of
verbal responses, etc.). emotional response [15] and prior to the activation
of emotional and behavioral response systems [16].
The manner in which individuals are able to manage emo- Antecedent-focused regulation comprises the follow-
tional experience to conform adaptively to a given context ing types of emotion regulation strategies: (i) selecting
appears to be important to mental health [9]. Emotion the situation (e.g., approaching or avoiding people
regulation strategies, such as rumination, can also become or situations according to their anticipated emotional
maladaptive and significantly impair psychosocial function- impact), (ii) changing the situation (e.g., transforming
ing. Therefore, understanding when and why the regulation the environment to alter the emotional impact), (iii)
of emotions becomes harmful is of fundamental importance engaging attentional strategies (e.g., focusing atten-
[10]. This relates to the situational and individual factors that tion towards or away from situational circumstances
influence cognitive emotion regulation capacity including depending upon their emotional potency), and (iv)
trait and state levels of psychological, social, and somatic cognitive change (e.g., reinterpreting the situation to
health [11, 12]. alter its emotional significance).
A model of emotional regulation process, highlighting the
crucial role of emotion regulation strategies in determining (2) Response-Focused Regulation. This strategy is engaged
the relative health-benefit of different responses to emotions, at a later stage and is focused on modification of emo-
has been proposed by Gross et al. [13]. The process model of tional output [10]. In other words, response-focused
emotion regulation has been based upon the “modal model” regulation refers to modifications of the physiological
of emotion, suggesting that a person-situation transaction and observable signs of emotions after such emotions
that compels attention has particular meaning to an individ- have already become manifest [15]. Response-focused
ual and gives rise to a coordinated yet flexible multisystem regulation comprises the following types of regulatory
response to the ongoing person-situation transaction [14]. response: (i) suppression of emotion, (ii) inhibition
According to the modal model of emotion, emotions arise of emotion, (iii) emotion masking, and (iv) emotion
in a particular sequence that includes four key steps: (i) a intensification [16].
Cardiovascular Psychiatry and Neurology 3

[22]. The most psychometrically established and commonly

employed scales for evaluating emotional regulation are as
follows.
(1) The Mayer-Salovey-Caruso Emotional Intelligence Test
[23]. This scale asks respondents to evaluate the effec-
tiveness of a range of strategies to manage emotions
in different scenarios. Responses are compared with
those provided by expert researchers in the field.
(2) The Emotional Regulation Questionnaire [24]. The
emotional regulation questionnaire measures the
habitual use of expressive suppression and cognitive
revaluation. The scale includes items related to the
regulation of both positive and negative emotions
[24].
(3) The Emotion Expressivity Scale [25]. This 17-item
scale measures the expression and inhibition of emo-
tions. Emphasis is placed on the extent to which
respondents suppress their emotions during social
interaction [26].
Amygdala Ventral MPFC (4) Difficulties with Emotion Regulation Scale (DERS)
OFC Dorsal MPFC [27]. The DERS is a brief, 36-item self-report ques-
Figure 3: Amygdala-frontal circuit of emotion regulation. Pre-
tionnaire designed to assess multiple aspects of emo-
frontal cortex seems to be involved in the modulation of the amyg- tional dysregulation. Higher scores suggest greater
dala reactivity, a critical structure for the generation of negative emo- problems with emotion regulation.
tions. During reappraisal, enhanced activation in medial prefrontal (5) Emotional Reactivity Scale (ERS) [28]. Emotion reac-
cortex (MPFC) is associated with attenuation of amygdala activation tivity scale (ERS) is a 21-item self-report measure of
and with a reduction of negative affect intensity. Orbitofrontal cortex emotion sensitivity, intensity, and persistence.
(OFC) coordinates the interactions between these areas.

4. Emotional Regulation and Depression

Antecedent-focused regulation, such as reappraisal, employs The strategies people use to regulate their emotions, and in
cognitive reevaluation strategies in order to modify situations particular negative emotions, appear to be strongly linked
or reformulate their emotional significance [15]. In particular, to several psychopathologies, such as depression. Depression
reappraisal is a cognitively oriented strategy that allows us to is a highly prevalent emotion dysregulation disorder that
redefine emotional stimuli in unemotional terms or to think impairs social skills, quality of life, and capacity to label and
about a potential emotion situation in a different way to alter identify affective states. Referring to the DSM-V [29], the
the emotion’s impact. main criteria for a diagnosis of major depressive disorder
Conversely, response-focused regulation, such as sup- (MDD) are
pression, modulates emotional behavior via the inhibition of (i) the presence of depressed mood or a loss of interest or
emotion and external behavioral signals (e.g., facial expres- pleasure in daily activities for more than two weeks;
sion, verbal expressions, hand gestures, etc.). Response-
(ii) depressed mood that represents a change from the
focused regulation is a less adaptive strategy of regulating
person’s baseline;
emotions and is associated with greater sympathetic activa-
tion of the cardiovascular system [12, 17], as well as negative (iii) impairment in social, occupational, and educational
outcomes such as psychopathology, social dysfunction, and functions;
depression [18]. In fact, although literature has suggested that (iv) the presence of specific symptoms nearly every day
reappraisal and suppression are both successful in reducing concerning depressed or irritable mood, decreased
facial expression, only reappraisal has been shown to decrease interest or pleasure in most activities, significant
internally felt negative emotion [7, 12, 19, 20]. Individuals who weight change or change in appetite, change in sleep,
typically regulate their emotions through use of suppression change in activity, fatigue or loss of energy, feelings
report in fact less positive affect, more negative affect, less of worthlessness or excessive or inappropriate guilt,
social support, and more depression [21]. diminished concentration, and suicidality.
In the last decade, evidence implicating specific emotion reg-
3. Assessment of Emotional Regulation ulation strategies as risk factors for depression has emerged.
Findings from clinical and neuroimaging studies investi-
Measures of emotional regulation typically assess the degree gating the association between emotional regulation and
to which people are better able to manage their emotions depression are outlined below (see Table 1).
4 Cardiovascular Psychiatry and Neurology

Table 1: Emotional regulation and depression link in clinical and neuroimaging studies.

Emotional regulation and depression

Clinical studies Neuroimaging studies
Depressed patients show
Depressed patients show
(i) inappropriate or ineffective emotion regulation;
(i) dysfunctional stress responses;
(ii) difficulties in cognitive control;
(ii) decrease in mu-opioid receptor binding potential
(iii) difficulties in processing negative material (which leads to greater
in the left inferior temporal cortex;
rumination, less use of reappraisal strategies, and more use of
(iii) abnormal amygdala activation;
expressive suppression);
(iv) dysfunctional ventral prefrontal cortex activation.
(iv) negative self-report biases.

5. Clinical Studies affective responses to negative affect-eliciting stimuli associ-

ated with depression [41]. In fact, PFC activation is strongly
A number of clinical studies have shown that inappropriate influenced by emotional reactions through its functional
or ineffective emotion regulation is a critical component interaction with the amygdala and the striatal circuitry (areas
in the development and maintenance of depression and of the brain involved in emotion and reward processing) [42].
anxiety disorders [30–35]. Depression is also associated In Figure 3, we describe the amygdala-frontal circuit of
with impaired cognitive control such as difficulty in accept- emotion regulation. While the amygdala is a critical region
ing and processing negative material [36]. In turn, this to the generation, expression, and experience of negative
reduced ability to process negative material is associated emotions, some frontal cortical regions are thought to be
with increased rumination, impaired cognitive reappraisal, involved in the modulation of amygdala reactivity and the
and increased expressive suppression [36]. Clinical studies mediation of effective emotion regulation, with their top-
have also demonstrated that depressed patients are negatively down inhibitory effect on the amygdala. Moreover, stronger
biased in their recognition of emotion, which increases coupling exists between amygdala and these areas of the pre-
significantly according to diagnostic severity [37]. frontal cortex (PFC) during conscious emotion regulation,
like reappraisal: attenuation of amygdala activation is asso-
ciated with enhanced activation in ventromedial PFC and
dorsal medial PFC [43]. The medial PFC (MPFC) has been
6. Neurobiological and Neuroimaging Studies linked to the integration between emotion and cognition
of Circuit of Emotion Regulation and to the processes that underlie cognitive reappraisal. A
functional distinction has been posited between ventral and
Several neurobiological studies have focused on the link dorsal MPFC: ventral MPFC seems to be involved in appraisal
between emotional regulation and depression. Evidence for emotional salience of stimuli, while dorsal MPFC seems to
implicates dysfunctions in the brain serotonergic system be involved in regulation of appropriate behaviors following
in the pathophysiological mechanism of major depressive appraisal. Orbitofrontal cortex (OFC) works as an important
disorder (MDD). Knockout mice with targeted deletion of relay or coordination region for amygdala and MPFC interac-
genes involved in the mediation of serotonergic transmission tions. Greater functional connectivity between amygdala and
(i.e., removal of tryptophan hydroxylase 2 (Tph2 KO) which is OFC/dorsal MPFC during reappraisal is associated with less
a rate-limiting enzyme for serotonin (5-HT) synthesis) have intensity of negative affect.
demonstrated the important role played by the brain sero-
tonergic system in emotion dysregulation [38]. Endogenous
opioid neurotransmission that activates mu-opioid receptors 7. Rumination: A Maladaptive Emotional
has also been found to be involved in emotion regulatory Regulation Strategy
processes and is likewise implicated in the etiology of MDD
[39]. More specifically, negative mood is associated with sta- Depressed individuals experience a range of maladaptive
tistically significant decreases in mu-opioid receptor binding cognitions that may lead to underregulation. Rumination,
potential in the left inferior temporal cortex of patients with the most common maladaptive emotional regulation strategy
MDD [39]. in depressed individuals, can be defined as an emotional
Neuroimaging studies have positively correlated MDD process characterized by repetitive, unwanted, past-oriented
and ineffective emotion regulation with heightened amygdala negatively inclined thoughts [44, 45]. Rumination is generally
response [40]. Neuroimaging studies also demonstrate that considered to be maladaptive and has been implicated in the
the prefrontal cortex (PFC) is involved in mediating impor- exacerbation and maintenance of a variety of adverse mental
tant higher-order cognitive processes and that the level of health outcomes, including depression [46, 47]. Rumination
activation of the ventral prefrontal cortex reflects the degree is a process related to worry and refers to a cognitive
of emotional modulation and cognitive control on cognitively focus on real or imagined upcoming negative events [48].
demanding goal-directed tasks [41]. Dysfunction in this area Worry is a form of fear process and is associated with
of the brain has been hypothesized to explain the pathological anxiety, apprehension, and general tension [49]. Rumination
inability of the brain to regulate and suppress the heightened and worry are similar in that they are both characterized
Cardiovascular Psychiatry and Neurology 5

by repetitive negative thought [45]. For individuals who associated the inferior frontal gyrus (IFG) (Brodmann area
ruminate or who mentally rehearse past stressful events, the 45) with trait high levels of rumination [58]. The IFG asserts
physiological effects of stressors are often more enduring an important regulatory role in top-down control processes
[37] (e.g., continued reflection on a bygone argument may that lead to increases in subcortical activation [64]. Therefore,
cause stress hormones to continue to circulate in the body it is reasonable to assume that, by promoting ruminative
long after an argument has ended). The evidence implicates thinking, emotional suppression is likely to increase positive
impaired cognitive control as a crucial process underlying connectivity between subcortical limbic activation and the
ruminative thinking and suggests that it may be an important IFG.
vulnerability factor for depression [50].
The determinants of rumination are multifaceted. Indi-
vidual and situational differences may play a role in triggering 9. Emotional Regulation Role in the Link
and maintaining ruminative thought [51], and certain indi- between Depression and Illness
viduals are more prone to perseveration than others [44].
Literature has suggested that depression, through neurobio-
The evidence indicates that repeated psychosocial stress in
logical and behavioral processes, may affect physical health
early life has a significant impact on behavior and neural
and induce physical illness. In particular, depression has
functioning—both of which are risk factors for depression
been found to be the primary risk factor for cardiac diseases
[52]. Furthermore, it has been hypothesized that early-life
[65]. Depression has been in fact linked to (i) several
adversity may result in a reduced capacity for cognitive
biological mechanisms, such as inflammatory and immune
control in response to a repeated stressor, particularly in
processes, alterations in activating HPA, variability in heart
individuals who develop maladaptive emotional processing
rate, increased activity of the sympathoadrenal and pituitary-
strategies (i.e., trait rumination). In contrast, individuals who
adrenal axes, reduction in circulating endothelial progenitor
were exposed to early-life adversity but developed adaptive
cells, increase of cortisol and catecholamine levels, alteration
emotion processing skills (e.g., high levels of trait mindful-
of activities of autonomic nervous system, and oxidation
ness) typically exhibit enhanced capacity for cognitive control
processes [66–69] and (ii) several unhealthy lifestyles, such
during adulthood [52].
as increased consumption of tobacco, alcohol, and illicit
substances, reduced physical activity, overeating, and no
8. Physiological Mechanisms of Rumination medical adherence [68].
Due to the well-known and yet discussed existence
Rumination has been shown to induce prolonged activation
of dysfunctional emotional regulation in depression and
of the hypothalamic pituitary adrenal (HPA) axis, and, for
rumination, a mediating role of emotional regulation in
those who ruminate excessively or repeatedly, sustained ele-
the link between depression and somatic disease may be
vations in cortisol may incur deleterious health consequences
suggested. Emotional regulation may indirectly affect both
[51]. Examples are acute changes in the cardiovascular system
the etiology and the prognosis of a physical illness. According
and acceleration of atherosclerotic process [53]. The HPA
to inhibition theory, keeping emotions inside will lead to
axis is a slow-acting stress response system, whose activation
long-term health problems because it requires continuous
triggers a cascade of events which begins with the secretion
physiological work [70]. Several studies have in fact suggested
of corticotropin-releasing hormone by the hypothalamus and
that stronger mood regulation expectancies are associated
culminates in the release of glucocorticoids (i.e., cortisol)
with lower dysphoria and somatic symptoms in college
by the adrenal glands into the bloodstream [54]. The HPA
students and caregivers of chronic diseases [71, 72]. Several
axis is a major stress response system that is critical for
studies have shown that different styles of emotion regulation
survival and adaptation and may be particularly relevant
have different relationships with health [12, 73, 74]. In
in understanding the adverse effects that stressors have on
particular, alexithymia, emotional control, and ambivalence
somatic and psychological health. Subsequent and repeated
have been significantly related to more psychological, social,
recall of a stressor, which is symptomatic of both rumination
and physical distress in both healthy and chronically ill
and depression, could reactivate the stress response during
populations [75–77]. In contrast, emotional orientation and
otherwise nonstressful situations. In fact, evidence sug-
expression have shown beneficial effects and positive health
gests that perseverative cognition, such as rumination, may
consequences [78–81].
prolong cardiovascular-related physiological activation [55].
Although release of cortisol by the HPA in response to certain
stressors may be adaptive in the short term [56], prolonged 10. Psychological Treatments Focusing on
exposure to cortisol from exaggerated, extended, or repeated Emotional Regulation
activation of the HPA axis is likely to be maladaptive. Indeed,
a range of disorders, including cardiovascular disease, have Current neuroscientific evidence confirms that both emotion
been associated with persistent HPA axis activation [57]. and cognition are interacting yet distinct functions which
Furthermore, HPA overactivation and elevated basal cortisol communicate via bidirectional neural connections between
levels have been linked to avoidance, withdrawal, and nega- the neocortex and emotional centers [82]. These connections
tive emotions such as anxiety and depression [58–63]. allow emotion-related input to modulate cortical activity
Recent studies investigating how the neural correlates of and cognitive input from the cortex to modulate emotional
personality regulate emotion processing in the brain have processing. Understanding how cognitive and emotional
6 Cardiovascular Psychiatry and Neurology

systems interact has significant implications for emotion The main objective of emotion-focused therapy is to help
regulation interventions. For example, it has been suggested individuals modify internal affective states, the core beliefs
that intervening at the level of the emotional system itself is that underlie these states, and the behaviors that they elicit.
a more direct, efficient, and powerful way to override and Emphasis is placed on intervening before the emotion-
transform the maladaptive patterns that underlie unhealthy eliciting event takes place. This occurs via an increased
psychological, behavioral, and physiological stress responses ability to analyze and be aware of emotions which improves
[82]. a person’s ability to handle internal and external stressors.
The activation of positive emotions can play a critical Emotion-focused therapy has been widely used in interven-
role in breaking the stress cycle by effectively transforming tions aimed at the treatment of depression [16].
stress at its source [83]. Positive emotions have been linked to
improved health and increased longevity. They have also been
shown to beget increases in cognitive flexibility, creativity, 12. The Mindfulness-Based Cognitive Therapy
receptivity, innovative problem solving, and psychological
resilience in the face of adversity. Furthermore, positive emo- A further innovative interventional approach that has
tions influence interpersonal behavior and promote helpful- recently been deployed in clinical contexts is that of mindful-
ness, generosity, and cooperation [61–63]. In other words, ness training. Mindfulness derives from Buddhist meditation
positive emotions play a critical role in effective adaptation practice and is fundamentally concerned with developing and
to life’s challenges [84–86]. The literature also suggests that open and unbroken awareness of present moment cognitive-
emotional regulation strategies such as positive reappraisal effective and sensory experience. According to Compare et
and curtailed rumination exert a protective influence over al. [67], mindfulness effectuates a greater perceptual distance
relapse or exacerbated symptoms in patients with depression from distorted cognitive and affective processes and this
and anxiety disorders [87]. Above all, the most common meta-awareness facilitates the regulation (i.e., via the nonre-
therapies focusing on emotional regulation are presented. active observance) of habitual maladaptive responses. Via the
regulation of attention, mindfulness empowers participants
11. The Emotion-Focused Therapy to cultivate a new relationship with internal and external
experiences and in a way that does not encourage avoidance,
To be able to effectively regulate emotions, individuals overengagement, or elaboration [90].
need to be assessed and trained in evidence-based emotion During the last two decades, a credible evidence base has
management strategies. In a treatment protocol developed emerged supporting the utilization of mindfulness medita-
by Greenberg and known as emotion-focused therapy [88], tion as an emotion regulation strategy. Indeed, a mindfulness
individuals are taught to enhance their awareness of emotion approach known as mindfulness-based cognitive therapy
regulation strategies and of emotional processes more gen- (MBCT) is now advocated by the National Institute for
erally. Emotion-focused therapy is based on an awareness- Health and Clinical Excellence (NICE) and the American
enhancing strategy operationalized in an intervention known Psychiatric Association for the treatment of specific forms of
as process experiential therapy [89], which aims to help depression. Evidence has also shown that increases in levels
people develop emotional intelligence and effective emotion of dispositional mindfulness are significantly correlated with
regulation processes. Greenberg [88] proposes three key reductions in avoidance and rumination [91].
principles that underlie emotional change. Increased breath awareness (a fundamental component
of mindfulness meditation) has been shown to reduce
(1) Emotion Awareness. This relates to a greater awareness
autonomic and psychological arousal, and this increased
of emotional experiences and the information they
capacity to remain calm can help individuals to respond more
provide, as well as a greater understanding of the
adaptively to internal and external stressors [70]. Negative
behaviors that result from such emotions. Increased
thinking and ruminative thinking are often employed as mal-
emotional awareness promotes the creation of new
adaptive means of escaping from negative affective states such
meanings and helps people to develop new narratives
as guilt, depression, and anxiety [71]. The increased levels
to explain their experiences.
of self-awareness cultivated during mindfulness practice can
(2) Emotion Regulation. In order to reach a state of confer a greater capacity to label and therefore modulate
connection with their own emotional experience, it these affective states [71]. In other words, rather than avoiding
is necessary to increase people’s capacity for self- distressing feelings and thoughts by engaging in ruminative
calm (e.g., by regulating the heartbeat and breathing). thinking and/or maladaptive behaviors, mindfulness encour-
Reduced autonomic and psychological arousal allows ages people to objectify any dysfunctional cognitive and
people to derive insight and knowledge from their affective processes by seeing them as passing phenomena.
emotional processes and to learn how to handle Another important mechanism by which mindfulness
emergency signals and situations. is believed to modulate negative affective states is via the
(3) Changing Emotion with Emotion. A nonadaptive cultivation of self-compassion and compassion. Research has
affective state can be transformed into an adaptive shown that mindfulness leads to a greater awareness of the
one. This change is made possible by relaxation exer- individuals own suffering and psychological distress, and this
cises or through the deliberate induction of positive helps to instil a greater appreciation of the suffering of others
emotions [16]. [70, 72]. Accordingly, greater levels of self-compassion and
Cardiovascular Psychiatry and Neurology 7

compassion are thought to lead to improvements in pain and of amygdala reactivity towards emotion regulation, interre-
emotion tolerance due to individuals being able to assign gional connectivity between amygdala and prefrontal cortex
greater levels of perspective to their emotional and/or somatic in the context of affect regulation remains unknown. Further
pain (i.e., by appreciating that they are not the only person studies are needed to better explain the neural circuit con-
experiencing psychological/somatic distress) [72]. necting amygdala and PFC in emotion regulation.
Conversely, emotional dysregulation (e.g., rumination,
13. The Emotion Regulation Therapy (ERT) suppression, etc.) appears to be influential in the pathogenesis
of psychological disease, such as depression. More specifi-
The emotion regulation therapy (ERT) is a recent treat- cally, the evidence suggests that depression and rumination
ment for generalized anxiety disorder (GAD) that integrates affect both cognitive (e.g., difficulty in processing negative
components of cognitive-behavioral, acceptance, dialectical, information) and neurobiological mechanisms (e.g., HPA
mindfulness-based, experiential, and emotion-focused treat- axis overactivation and higher rates of cortisol production).
ments [92, 93]. The ERT is based on the emotion dysregu- Given the height link between depression, emotional
lation model of GAD that suggests that GAD subjects have regulation, and somatic diseases, future research and clin-
difficulties in the modulation of emotions, showing difficulty ical studies should focus on the specific role of emotional
in identifying, describing, and clarifying the motivational regulation in affecting both depression and somatic diseases
content of emotion. GAD subjects utilize in fact worry as a in order to highlight the specific mental and biological
maladaptive cognitive control strategy in order to reduce and processes that lead to illness. Understanding the factors that
control an aversive or uncertain emotional state. ERT aims, govern the variety of health outcomes that different people
then, to enhance knowledge, acceptance, utilization, and experience following exposure to stress will have important
management of emotions addressing cognitive, emotional, implications for the identification and ongoing validation
and contextual factors that may contribute to maladaptive of effective emotion-regulation interventional approaches
responses. (e.g., mindfulness-based therapy, emotion-focused therapy,
ERT program includes 20 sessions of 50–60 minutes, emotion regulation therapy, etc.).
divided in 16 weeks and four phases. The first phase focuses
on psychoeducation about GAD, functional patterns of worry
and emotions in various situations, and self-monitoring of Conflict of Interests
worry episodes. The second phase focuses on the develop- The authors declare that there is no conflict of interests
ment of somatic awareness and emotion regulation skills. The regarding the publication of this paper.
third phase focuses on the application of skills during expo-
sure to emotionally evocative themes. The fourth and final
phase focuses on terminating the therapeutic relationship, References
relapse prevention, and future goals [35]. [1] B. S. Dohrenwend and B. P. Dohrenwend, “Overview and
The main aim of ERT for GAD subjects is to learn prospects for research on stressful life events,” in Stressful Life
the ability to effectively increase or decrease attendance to Events: Their Nature and Effects, B. S. Dohrenwend and B. P.
emotional experience, tolerate distress, and adapt to social Dohrenwend, Eds., p. 313, Wiley, New York, NY, USA, 1974.
environment. In specific, ERT aims to teach GAD subjects [2] K. S. Kendler, L. M. Karkowski, and C. A. Prescott, “Causal
to: (i) identify, differentiate, and describe their emotions; (ii) relationship between stressful life events and the onset of major
increase both acceptance of affective experience and ability to depression,” The American Journal of Psychiatry, vol. 156, no. 6,
adaptively manage emotions; (iii) decrease use of emotional pp. 837–841, 1999.
avoidance strategies, such as worry; (iv) increase ability to [3] R. S. Lazarus, Stress and Emotion: A New Synthesis, Springer,
utilize emotional information in identifying needs, mak- New York, NY, USA, 1999.
ing decisions, guiding thinking, motivating behavior, and [4] I. G. Sarason, J. H. Johnson, and J. M. Siegel, “Assessing the
managing interpersonal relationships and other contextual impact of life changes: development of the life experiences
demands [35]. survey,” Journal of Consulting and Clinical Psychology, vol. 46,
no. 5, pp. 932–946, 1978.
[5] C. J. McCarthy, R. G. Lambert, and N. P. Moller, “Preventive
14. Conclusions resources and emotion regulation expectancies as mediators
between attachment and college students’ stress outcomes,”
Based on an extensive examination of the empirical and the-
International Journal of Stress Management, vol. 13, no. 1, pp. 1–
oretical literature related to emotional regulation, it appears 22, 2006.
that a strong association exists between emotional regulation
[6] D. Schwartz and L. J. Proctor, “Community violence exposure
and depression and that emotional regulation mediates the and children’s social adjustment in the school peer group: the
role between depression and further psychological and/or mediating roles of emotion regulation and social cognition,”
somatic illness. It is concluded that when adaptive emotional Journal of Consulting and Clinical Psychology, vol. 68, no. 4, pp.
regulation strategies (e.g., reappraisal) are employed, there 670–683, 2000.
is reduced likelihood of stress-elicited emotions leading to [7] J. J. Gross, “Antecedent- and response-focused emotion regu-
mental or physical disorders. lation: divergent consequences for experience, expression, and
Although there is some evidence that suggests the physiology,” Journal of Personality and Social Psychology, vol. 74,
involvement of frontal cortical regions in the modulation no. 1, pp. 224–237, 1998.
8 Cardiovascular Psychiatry and Neurology

[8] R. Siegler, How Children Develop, Exploring Child Develop [26] J. W. Burns, P. J. Quartana, and S. Bruehl, “Anger management
Student Media Tool Kit Scientific American Reader to Accompany style moderates effects of emotion suppression during initial
How Children Develop, Worth, New York, NY, USA, 2006. stress on pain and cardiovascular responses during subsequent
[9] J. J. Gross and R. F. Muñoz, “Emotion regulation and mental pain-induction,” Annals of Behavioral Medicine, vol. 34, no. 2,
health,” Clinical Psychology: Science and Practice, vol. 2, no. 2, pp. 154–165, 2007.
pp. 151–164, 1995. [27] K. L. Gratz and L. Roemer, “Multidimensional assessment
[10] S. A. Moore, L. A. Zoellner, and N. Mollenholt, “Are expressive of emotion regulation and dysregulation: development, factor
suppression and cognitive reappraisal associated with stress- structure, and initial validation of the difficulties in emotion
related symptoms?” Behaviour Research and Therapy, vol. 46, regulation scale,” Journal of Psychopathology & Behavioral
no. 9, pp. 993–1000, 2008. Assessment, vol. 26, no. 1, pp. 41–54, 2004.
[11] J. L. Abelson, I. Liberzon, E. A. Young, and S. Khan, “Cognitive [28] M. K. Nock, M. M. Wedig, E. B. Holmberg, and J. M. Hooley,
modulation of the endocrine stress response to a pharmacolog- “The emotion reactivity scale: development, evaluation, and
ical challenge in normal and panic disorder subjects,” Archives relation to self-injurious thoughts and behaviors,” Behavior
of General Psychiatry, vol. 62, no. 6, pp. 668–675, 2005. Therapy, vol. 39, no. 2, pp. 107–116, 2008.
[12] J. J. Gross, “Emotion regulation: affective, cognitive, and social [29] American Psychiatric Association, Diagnostic and Statistical
consequences,” Psychophysiology, vol. 39, no. 3, pp. 281–291, Manual of Mental Disorders, American Psychiatric Publishing,
2002. Arlington, Va, USA, 5th edition, 2013.
[13] J. J. Gross, “The emerging field of emotion regulation: an [30] D. H. Barlow, L. B. Allen, and M. L. Choate, “Toward a unified
integrative review,” Review of General Psychology, vol. 2, no. 3, treatment for emotional disorders,” Behavior Therapy, vol. 35,
pp. 271–299, 1998. no. 2, pp. 205–230, 2004.
[14] J. J. Gross and R. A. Thompson, “Emotion regulation: con- [31] L. Campbell-Sills, D. H. Barlow, T. A. Brown, and S. G.
ceptual foundations,” in Handbook of Emotion Regulation, J. J. Hofmann, “Acceptability and suppression of negative emotion
Gross, Ed., Guilford Press, New York, NY, USA, 2011. in anxiety and mood disorders,” Emotion, vol. 6, no. 4, pp. 587–
[15] P. R. Goldin, K. McRae, W. Ramel, and J. J. Gross, “The neural 595, 2006.
bases of emotion regulation: reappraisal and suppression of [32] L. Campbell-Sills, D. H. Barlow, T. A. Brown, and S. G.
negative emotion,” Biological Psychiatry, vol. 63, no. 6, pp. 577– Hofmann, “Effects of suppression and acceptance on emotional
586, 2008. responses of individuals with anxiety and mood disorders,”
[16] D. Villani, A. Grassi, and G. Riva, Tecnologie Emotive: Nuovi Behaviour Research and Therapy, vol. 44, no. 9, pp. 1251–1263,
Media per Migliorare la Qualità della Vita e Ridurre lo Stress, 2006.
LED, Milano, Italy, 2011. [33] T. B. Kashdan and M. F. Steger, “Expanding the topography of
[17] H. A. Demaree, B. J. Schmeichel, J. L. Robinson, J. Pu, D. social anxiety. An experience-sampling assessment of positive
E. Everhart, and G. G. Berntson, “Up- and down-regulating emotions, positive events, and emotion suppression,” Psycholog-
facial disgust: affective, vagal, sympathetic, and respiratory ical Science, vol. 17, no. 2, pp. 120–128, 2006.
consequences,” Biological Psychology, vol. 71, no. 1, pp. 90–99, [34] T. B. Kashdan, V. Barrios, J. P. Forsyth, and M. F. Steger, “Expe-
2006. riential avoidance as a generalized psychological vulnerability:
[18] A. A. Grandey, “Emotion regulation in the workplace: a new comparisons with coping and emotion regulation strategies,”
way to conceptualize emotional labor,” Journal of Occupational Behaviour Research and Therapy, vol. 44, no. 9, pp. 1301–1320,
Health Psychology, vol. 5, no. 1, pp. 95–110, 2000. 2006.
[19] J. J. Gross and R. W. Levenson, “Emotional suppression: physiol- [35] D. S. Mennin, “Emotion regulation therapy: an integrative
ogy, self-report, and expressive behavior,” Journal of Personality approach to treatment-resistant anxiety disorders,” Journal of
and Social Psychology, vol. 64, no. 6, pp. 970–986, 1993. Contemporary Psychotherapy, vol. 36, no. 2, pp. 95–105, 2006.
[20] J. J. Gross and R. W. Levenson, “Hiding feelings: the acute [36] J. Joormann and I. H. Gotlib, “Emotion regulation in depres-
effects of inhibiting negative and positive emotion,” Journal of sion: relation to cognitive inhibition,” Cognition and Emotion,
Abnormal Psychology, vol. 106, no. 1, pp. 95–103, 1997. vol. 24, no. 2, pp. 281–298, 2010.
[21] O. P. John and J. J. Gross, “Individual differences in emotion [37] M. Punkanen, T. Eerola, and J. Erkkilä, “Biased emotional
regulation,” in Handbook of Emotion Regulation, J.J. Gross, Ed., recognition in depression: perception of emotions in music by
Guilford Press, New York, NY, USA, 2007. depressed patients,” Journal of Affective Disorders, vol. 130, no.
[22] S. Côté, A. Gyurak, and R. W. Levenson, “The ability to regulate 1-2, pp. 118–126, 2011.
emotion is associated with greater well-being, income, and [38] N. Araragi and K. Lesch, “Serotonin (5-HT) in the regulation of
socioeconomic status,” Emotion, vol. 10, no. 6, pp. 923–933, 2010. depression-related emotionality: insight from 5-HT transporter
[23] J. D. Mayer, P. Salovey, and D. R. Caruso, Manual for the and tryptophan hydroxylase-2 knockout mouse models,” Cur-
MSCEIT (Mayer-Salovey-Caruso Emotional Intelligence Test), rent Drug Targets, vol. 14, no. 5, pp. 549–570, 2013.
Multi-Health Systems, Toronto, Canada, 2002. [39] S. E. Kennedy, R. A. Koeppe, E. A. Young, and J. Zubieta, “Dys-
[24] J. J. Gross and O. P. John, “Individual differences in two emotion regulation of endogenous opioid emotion regulation circuitry
regulation processes: implications for affect, relationships, and in major depression in women,” Archives of General Psychiatry,
well-being,” Journal of Personality and Social Psychology, vol. 85, vol. 63, no. 11, pp. 1199–1208, 2006.
no. 2, pp. 348–362, 2003. [40] G. Perlman, A. N. Simmons, J. Wu et al., “Amygdala response
[25] A. M. Kring, D. A. Smith, and J. M. Neale, “Individual and functional connectivity during emotion regulation: a study
differences in dispositional expressiveness: development and of 14 depressed adolescents,” Journal of Affective Disorders, vol.
validation of the Emotional Expressivity Scale,” Journal of 139, no. 1, pp. 75–84, 2012.
Personality and Social Psychology, vol. 66, no. 5, pp. 934–949, [41] Y. I. Sheline, D. M. Barcha, J. L. Price et al., “The default
1994. mode network and self-referential processes in depression,”
Cardiovascular Psychiatry and Neurology 9

Proceedings of the National Academy of Sciences of the United homeostasis,” Journal of the American Medical Association, vol.
States of America, vol. 106, no. 6, pp. 1942–1947, 2009. 267, no. 9, pp. 1244–1252, 1992.
[42] S. Aznar and A. B. Klein, “Regulating prefrontal cortex activa- [57] B. McEwen, T. Seeman, R. Davidson, K. Scherer, and H.
tion: an emerging role for the 5-HT2A serotonin receptor in Goldsmith, “Stress and affect: applicability to the concepts of
the modulation of emotion-based actions?” Molecular Neuro- allostasis and allostatic load,” in Handbook of Affective Sciences,
biology, vol. 48, no. 3, pp. 841–853, 2013. Oxford University Press, New York, NY, USA, 2003.
[43] S. J. Banks, K. T. Eddy, M. Angstadt, P. J. Nathan, and K. [58] K. A. Buss, R. J. Davidson, N. H. Kalin, and H. H. Goldsmith,
Luan Phan, “Amygdala-frontal connectivity during emotion “Context-specific freezing and associated physiological reactiv-
regulation,” Social Cognitive and Affective Neuroscience, vol. 2, ity as a dysregulated fear response,” Developmental Psychology,
no. 4, pp. 303–312, 2007. vol. 40, no. 4, pp. 583–594, 2004.
[44] J. M. Smith and L. B. Alloy, “A roadmap to rumination: a [59] C. K. Fortunato, A. E. Dribin, D. A. Granger, and K. A. Buss,
review of the definition, assessment, and conceptualization of “Salivary alpha-amylase and cortisol in toddlers: differential
this multifaceted construct,” Clinical Psychology Review, vol. 29, relations to affective behavior,” Developmental Psychobiology,
no. 2, pp. 116–128, 2009. vol. 50, no. 8, pp. 807–818, 2008.
[45] E. R. Watkins, “Constructive and unconstructive repetitive [60] M. R. Gunnar and D. M. Vazquez, “Stress neurobiology
thought,” Psychological Bulletin, vol. 134, no. 2, pp. 163–206, and developmental psychopathology,” in Developmental Psy-
2008. chopathology, D. Cicchetti and D. Cohen, Eds., Wiley, New York,
[46] S. Nolen-Hoeksema, J. Morrow, and B. L. Fredrickson, NY, USA, 2006.
“Response styles and the duration of episodes of depressed [61] M. R. Gunnar, S. Wewerka, K. Frenn, J. D. Long, and C.
mood,” Journal of Abnormal Psychology, vol. 102, no. 1, pp. 20– Griggs, “Developmental changes in hypothalamus-pituitary-
28, 1993. adrenal activity over the transition to adolescence: normative
[47] L. Rood, J. Roelofs, S. M. Bögels, S. Nolen-Hoeksema, and E. changes and associations with puberty,” Development and Psy-
Schouten, “The influence of emotion-focused rumination and chopathology, vol. 21, no. 1, pp. 69–85, 2009.
distraction on depressive symptoms in non-clinical youth: a
[62] N. H. Kalin, S. E. Shelton, M. Rickman, and R. J. Davidson,
meta-analytic review,” Clinical Psychology Review, vol. 29, no.
“Individual differences in freezing and cortisol in infant and
7, pp. 607–616, 2009.
mother rhesus monkeys,” Behavioral Neuroscience, vol. 112, no.
[48] T. D. Borkovec, W. J. Ray, and J. Stöber, “Worry: a cognitive 1, pp. 251–254, 1998.
phenomenon intimately linked to affective, physiological, and
[63] I. M. Goodyer, J. Herbert, A. Tamplin, and P. M. E. Altham,
interpersonal behavioral processes,” Cognitive Therapy and
“Recent life events, cortisol, dehydroepiandrosterone and the
Research, vol. 22, no. 6, pp. 561–576, 1998.
onset of major depression in high-risk adolescents,” The British
[49] T. D. Borkovec, E. Robinson, T. Pruzinsky, and J. A. DePree,
Journal of Psychiatry, vol. 177, pp. 499–504, 2000.
“Preliminary exploration of worry: some characteristics and
processes,” Behaviour Research and Therapy, vol. 21, no. 1, pp. [64] E. C. Fabiansson, T. F. Denson, M. L. Moulds, J. R. Grisham,
9–16, 1983. and M. M. Schira, “Don’t look back in anger: neural correlates
of reappraisal, analytical rumination, and angry rumination
[50] I. Demeyer, E. de Lissnyder, E. H. W. Koster, and R. de Raedt,
during recall of an anger-inducing autobiographical memory,”
“Rumination mediates the relationship between impaired
NeuroImage, vol. 59, no. 3, pp. 2974–2981, 2012.
cognitive control for emotional information and depressive
symptoms: a prospective study in remitted depressed adults,” [65] A. Compare, C. Zarbo, G. M. Manzoni et al., “Social support,
Behaviour Research and Therapy, vol. 50, no. 5, pp. 292–297, depression, and heart disease: a ten year literature review,”
2012. Frontiers in Psychology, vol. 4, article 384, 2013.
[51] P. M. Zoccola and S. S. Dickerson, “Assessing the relationship [66] A. Compare, E. Germani, R. Proietti, and D. Janeway, “Clinical
between rumination and cortisol: A review,” Journal of Psycho- psychology and cardiovascular disease: an up-to-date clini-
somatic Research, vol. 73, no. 1, pp. 1–9, 2012. cal practice review for assessment and treatment of anxiety
[52] L. Wang, N. Paul, S. J. Stanton, J. M. Greeson, and M. J. Smoski, and depression,” Clinical Practice and Epidemiology in Mental
“Loss of sustained activity in the ventromedial prefrontal cortex Health, vol. 7, pp. 148–156, 2011.
in response to repeated stress in individuals with early-life [67] A. Compare, R. Bigi, P. S. Orrego, R. Proietti, E. Grossi, and A.
emotional abuse: implications for depression vulnerability,” Steptoe, “Type D personality is associated with the development
Frontiers in Psychology, vol. 4, article 320, 2013. of stress cardiomyopathy following emotional triggers,” Annals
[53] D. J. Brotman, S. H. Golden, and I. S. Wittstein, “The cardiovas- of Behavioral Medicine, vol. 45, no. 3, pp. 299–307, 2013.
cular toll of stress,” The Lancet, vol. 370, no. 9592, pp. 1089–1100, [68] K. Maier, D. Chatkoff, and M. M. Burg, “Cardiopatia coronarica
2007. e depressione: prevalenza, prognosi, fisiopatologia e tratta-
[54] K. D. Rudolph, W. Troop-Gordon, and D. A. Granger, “Indi- mento,” in Mente e Cuore. Clinica Psicologica della Malattia
vidual differences in biological stress responses moderate the Cardiaca, E. Molinari, A. Compare, and G. Parati, Eds., pp. 93–
contribution of early peer victimization to subsequent depres- 107, Springer, Milano, Italy, 2007.
sive symptoms,” Psychopharmacology, vol. 214, no. 1, pp. 209– [69] C. B. Nemeroff and P. J. Goldschmidt-Clermont, “Heartache
219, 2011. and heartbreak-the link between depression and cardiovascular
[55] J. F. Brosschot, W. Gerin, and J. F. Thayer, “The perseverative disease,” Nature Reviews Cardiology, vol. 9, no. 9, pp. 526–539,
cognition hypothesis: a review of worry, prolonged stress- 2012.
related physiological activation, and health,” Journal of Psycho- [70] J. W. Pennebaker and H. C. Traue, “Inhibition and psychoso-
somatic Research, vol. 60, no. 2, pp. 113–124, 2006. matic processes,” in Emotion, Inhibition, and Health, H. C. Traue
[56] G. P. Chrousos and P. W. Gold, “The concepts of stress and and J. W. Pennebaker, Eds., Hogrefe Huber, Seattle, Wash, USA,
stress system disorders: overview of physical and behavioral 1993.
10 Cardiovascular Psychiatry and Neurology

[71] H. J. Brashares and S. J. Catanzaro, “Mood regulation expectan- [86] A. M. Isen, “Positive affect,” in Handbook of Cognition and
cies, coping responses, depression, and sense of burden in Emotion, T. Dalgleish and M. Power, Eds., John Wiley & Sons,
female caregivers of Alzheimer’s patients,” Journal of Nervous New York, NY, USA, 1999.
and Mental Disease, vol. 182, no. 8, pp. 437–442, 1994. [87] J. Min, J. J. Yu, C. Lee, and J. Chae, “Cognitive emotion
[72] I. Kirsch, J. Mearns, and S. J. Catanzaro, “Mood-regulation regulation strategies contributing to resilience in patients with
expectancies as determinants of dysphoria in college students,” depression and/or anxiety disorders,” Comprehensive Psychia-
Journal of Counseling Psychology, vol. 37, no. 3, pp. 306–312, try, vol. 54, no. 8, pp. 1190–1197, 2013.
1990. [88] L. Greenberg, Emotion-Focused Therapy, Coaching Client to
[73] J. J. Gross and O. P. John, “Mapping the domain of expressivity: Work through Their Feelings, APA, Washingtopn, DC, USA,
multimethod evidence for a hierarchical model,” Journal of 2002.
Personality and Social Psychology, vol. 74, no. 1, pp. 170–191, 1998. [89] L. S. Greenberg, L. N. Rice, and R. Elliot, Facilitating Emotional
[74] C. L. Gohm and G. L. Clore, “Four latent traits of emotional Change: The Moment-by-Moment Process, Guilford, New York,
experience and their involvement in well-being, coping, and NY, USA, 1993.
attributional style,” Cognition and Emotion, vol. 16, no. 4, pp. [90] S. R. Bishop, M. Lau, S. Shapiro et al., “Mindfulness: a proposed
495–518, 2002. operational definition,” Clinical Psychology: Science and Prac-
[75] L. Solano, M. Costa, L. Temoshok et al., “An emotionally tice, vol. 11, no. 3, pp. 230–241, 2004.
inexpressive (Type C) coping style influences HIV disease [91] S. Kumar, G. Feldman, and A. Hayes, “Changes in mindfulness
progression at six and twelve month follow-ups,” Psychology and and emotion regulation in an exposure-based cognitive therapy
Health, vol. 17, no. 5, pp. 641–655, 2002. for depression,” Cognitive Therapy and Research, vol. 32, no. 6,
[76] J. S. Tucker, D. K. Winkelman, J. N. Katz, and B. L. Bermas, pp. 734–744, 2008.
“Ambivalence over emotional expression and psychological [92] D. S. Mennin, R. G. Heimberg, C. L. Turk, and D. M. Fresco,
well-being among rheumatoid arthritis patients and their “Applying an emotion regulation framework to integrative
spouses,” Journal of Applied Social Psychology, vol. 29, no. 2, pp. approaches to generalized anxiety disorder,” Clinical Psychology:
271–290, 1999. Science and Practice, vol. 9, no. 1, pp. 85–90, 2002.
[77] R. Verissimo, R. Mota-Cardoso, and G. Taylor, “Relationships [93] D. S. Mennin, C. L. Turk, R. G. Heimberg, and C. N. Carmin,
between alexithymia, emotional control, and duality of life in “Focusing on the regulation of emotion: A new direction for
patients with inflammatory bowel disease,” Psychotherapy and conceptualizing and treating generalized anxiety disorder,” in
Psychosomatics, vol. 67, no. 2, pp. 75–80, 1998. Cognitive Therapy over the Lifespan: Evidence and Practice, M.
[78] A. L. Stanton, S. Danoff-Burg, C. L. Cameron et al., “Emo- A. Reinecke and D. A. Clark, Eds., pp. 60–89, Cambridge
tionally expressive coping predicts psychological and physical University Press, New York, NY, USA, 2004.
adjustment to breast cancer,” Journal of Consulting and Clinical
Psychology, vol. 68, no. 5, pp. 875–882, 2000.
[79] J. M. Smyth, “Written emotional expression: effect sizes, out-
come types, and moderating variables,” Journal of Consulting
and Clinical Psychology, vol. 66, no. 1, pp. 174–184, 1998.
[80] S. K. Lutgendorf and P. Ullrich, “Cognitive processing, disclo-
sure, and health: Psychological and physiological mechanisms,”
in The Writing Cure: How Expressive Writing Promotes Health
and Emotional Well-Being, S. J. Lepore and J. M. Smyth, Eds.,
American Psychological Association, Washington, DC, USA,
2002.
[81] J. W. Pennebaker, E. Zech, and B. Rimé, “Disclosing and sharing
emotion: Psychological, social, and health consequences,” in
Handbook of Bereavement Research: Consequences, Coping, and
Care, M. S. Stroebe, R. O. Hansson, W. Stroebe, and H. Schut,
Eds., American Psychological Association, Washington, DC,
USA, 2001.
[82] R. McCraty and D. Tomasino, “Coherence-building techniques
and heart rhythm coherence feedback: new tools for stress
reduction, disease prevention and rehabilitation,” in Clinical
Psychology and Heart Disease, E. Molinari, A. Compare, and G.
Parati, Eds., Springer, Milano, Italy, 2006.
[83] C. R. Snyder and S. J. Lopez, Handbook of Positive Psychology,
Oxford University Press, New York, NY, USA, 2002.
[84] B. L. Fredrickson, “The role of positive emotions in positive psy-
chology: the broaden-and-build theory of positive emotions,”
American Psychologist, vol. 56, no. 3, pp. 218–226, 2001.
[85] R. McCraty and D. Childre, “The grateful heart: the psychophys-
iology of appreciation,” in The Psychology of Gratitude, R. A.
Emmons and and M. E. McCullough, Eds., Oxford University
Press, New York, NY, USA, 2004.
Copyright of Cardiovascular Psychiatry & Neurology is the property of Hindawi Publishing
Corporation and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.