Elsevier

Journal of Affective Disorders

Volume 277, 1 December 2020, Pages 1-4
Journal of Affective Disorders

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Expressive suppression of emotion is a moderator of anxiety in a unified protocol for transdiagnostic treatment of anxiety and depressive disorders: A secondary analysis

https://doi.org/10.1016/j.jad.2020.07.132Get rights and content

Highlights

  • Pre-treatment high ES of emotion reduces the efficacy of not only CBT but also UP.

  • UP is effective for improving anxiety symptoms in patients with high ES.

  • Interventions intended to improve ES may improve the efficacy of UP.

  • An optimal degree of ES, rather than simply high or low ES, should be considered.

  • Cultural differences should be considered for optimal degrees of ES.

Abstract

Background

Expressive suppression (ES) of emotion is considered a moderator that reduces the efficacy of cognitive behavioural therapy (CBT); however, whether and how ES moderates the efficacy of the unified protocol for transdiagnostic treatment of emotional disorders (UP), a version of CBT targeting aversive/avoidant responses to emotions, including ES, remain unclear. We investigated whether and how emotion regulation, especially ES, moderates UP efficacy for anxiety symptoms in patients with anxiety and depressive disorders.

Methods

We conducted a secondary analysis of data from a previous trial. Seventeen patients with anxiety and/or depressive disorders were included. Changes (slope estimates) in the Structured Interview Guide for the Hamilton Anxiety Rating Scale from pre-treatment to post-treatment were measured using a latent growth curve model with empirical Bayesian estimation. Pre-treatment ES, cognitive reappraisal, and depressive symptoms were used as slope factor predictors.

Results

Only pre-treatment ES significantly predicted the slope in the latent growth curve model (estimate value = 0.45; standard deviation = 0.21; 95% credible interval = 0.03–0.87, one-tailed p-value = 0.004), and an inverse correlation between pre-treatment ES levels and improvement magnitude of anxiety symptoms was demonstrated.

Limitations

Because the data were obtained from a single-arm trial, this study did not have controls, and most participants received pharmacotherapy in addition to UP. Therefore, generalisability of the present findings might be compromised.

Conclusions

Low ES before UP was an effective predictor of greater improvement in anxiety symptoms after UP. The findings suggest that interventions intended to improve ES may improve UP efficacy.

Introduction

Anxiety and depressive disorders are the two most prevalent categories of mental disorders worldwide (Vos et al., 2015). Cognitive behavioural therapy (CBT) is the first-line treatment for these conditions (Arch and Craske, 2009). However, a systematic review of meta-analyses has indicated that CBT does not lead to complete remission in 54% of patients with general anxiety disorders, in 50–62% with obsessive-compulsive disorder, and in 23% with panic disorder (Hofmann et al., 2012). To improve the efficacy of CBT for anxiety, it is important to clarify the mechanism of action of CBT (Insel, 2009). This could be achieved by identifying the moderators that predict responses to CBT and/or mediators of CBT that improve with treatment and thus contribute to reducing anxiety symptoms.

Anxiety and depressive disorders are considered consequences of impaired emotion regulation (Dryman and Heimberg, 2018), which has been identified as an important mechanism underlying the effects of CBT in anxiety disorders (Berking et al., 2013). Because emotion regulation consists of a variety of specific skills, it is necessary to verify which skills have a significant impact on CBT effects (Berking et al., 2013); notably, cognitive reappraisal (CR) and expressive suppression (ES) have been considered significant ones. CR affects the subjective evaluation of emotion-eliciting situations or problems and is considered an adaptive strategy and a mediator of CBT because it improves with CBT and contributes to subsequent reduction of anxiety symptoms (Gross and John, 2003; Hu et al., 2014). In contrast, ES suppresses the outward expression of emotions and is considered a maladaptive strategy associated with anxiety symptoms (Gross and John, 2003; Dryman and Heimberg, 2018). ES is considered a moderator because high ES might be detrimental to treatment outcomes of CBT (Scherer et al., 2015). Therefore, it is important to determine how to treat patients with high ES to enhance the efficacy of CBT.

Patients with high ES might benefit from the unified protocol for transdiagnostic treatment of emotional disorders (UP), which is a version of CBT frequently used for patients with anxiety and depressive disorders. The UP might be effective especially for patients with high ES because it targets aversive/avoidant responses to emotions through five modules: increasing mindful emotion awareness, promoting cognitive flexibility, countering emotional behaviours, and understanding and confronting physical sensations and emotion exposure (Barlow et al., 2011). However, patients with high ES might only have smaller benefits from the UP because it is performed according to a treatment procedure similar to that employed for generic CBT (Scherer et al., 2015). Therefore, it remains unclear whether UP is effective for patients with high ES. Accordingly, this exploratory study aimed to investigate whether and how emotion regulation, especially ES, moderates the efficacy of UP for anxiety symptoms in patients with anxiety and depressive disorders. To this end, we conducted a secondary analysis of the data of a previous clinical trial on the UP (Ito et al., 2016).

Section snippets

Participants and study design

In this study, we conducted a secondary analysis of the data of a single-arm trial to assess the feasibility of the UP in anxiety and depressive disorders. Details of the original trial have been described elsewhere (Ito et al., 2016). A total of 17 patients who visited the National Center of Neurology and Psychiatry in Japan (10 women and 7 men; mean age = 35.18 years; standard deviation [SD] = 10.80 years) participated in this study. All participants were primarily diagnosed with anxiety or

Convergence determination and suitability of empirical Bayesian estimates

All parameters achieved a PSR factor of ≤ 1.01, and the posterior predictive p-value was 0.59. When an uninformative prior was used, however, the posterior predictive p-value was 0.32. These results suggested that the estimated values had greater validity when the maximum likelihood estimates were used as the prior parameters in this study.

Estimation results from the LGCM

The mean slope estimate was −11.81 (SD = 1.90; 95% credible interval [CI] = −15.53 to −8.05; one-tailed p-value < 0.001) (Table 1). This result showed that

Discussion

The aim of this exploratory study was to investigate whether and how emotion regulation, especially ES, moderates the efficacy of UP for anxiety symptoms in patients with anxiety and depressive disorders. Our study showed that a low level of ES before UP predicted a greater improvement of anxiety symptoms after UP, as demonstrated in a previous study investigating generic CBT (Scherer et al., 2015). Additionally, pre-treatment CR did not predict the extent of improvement in anxiety symptoms by

Declaration of Competing Interest

The authors declare that they have no conflicts of interest.

Acknowledgements

The authors would like to thank the study participants.

Funding

This study was supported by a National Center of Neurology and Psychiatry (NCNP) Intramural Research Grant (244, 273, 302) for Neurological and Psychiatric Disorders, a Grant-in-Aid for Young Scientists (A) (25705018) and Grant-in-Aid for challenging Exploratory Research (26590171) awarded to MI from the Japan Society for the Promotion of Science, and AMED under Grant Number JP20dk0307084.

References (21)

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