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/lp/springer-journals/an-analysis-of-the-pattern-of-adaptive-emotion-regulation-associated-4oBZ0dDFPg
- Publisher
- Springer Journals
- Copyright
- Copyright © The Author(s) 2020
- ISSN
- 0147-5916
- eISSN
- 1573-2819
- DOI
- 10.1007/s10608-020-10173-6
- Publisher site
- See Article on Publisher Site
Abstract
Background Research on emotion regulation and paranoid ideation has mostly focused on isolated regulation strategies and has remained largely inconclusive. According to the emotion regulation model by Berking and Whitley (in: Affect Regula- tion Training, Springer, New York 2014) successful modification or acceptance/tolerance of emotions requires an adequate comprehension (awareness, clarity, understanding) of emotions and adequate self-support. Method Building on this model, we investigated whether comprehension and self-support strengthen the negative associa- tion between modification and acceptance/tolerance and paranoid ideation. In study 1, we examined the hypotheses cross- sectionally based on questionnaire data from a combined sample (N = 125) consisting of people with a psychotic disorder, people at risk of developing psychosis, and healthy controls. In study 2, we examined the same hypotheses longitudinally by employing the experience sampling method in people with clinically relevant psychopathology below diagnostic threshold (N = 138). Results In study 1, the association between modification and paranoid ideation was not moderated by comprehension or self-support. However, comprehension and self-support moderated the association between acceptance/tolerance and para- noid ideation. In study 2, the interaction effect between comprehension and acceptance/tolerance on paranoid ideation was confirmed. Conclusion The results indicate that comprehending and accepting/tolerating emotions could be protective against paranoid ideation. Keywords Delusions · Schizophrenia · Coping · Interactions of emotion regulation strategies · ESM In an influential model of psychosis, Garety et al. ( 2001) method (ESM) in samples with different levels of symptom postulated that negative affect has a crucial influence on severity (Ben-Zeev et al. 2011; Krkovic et al. 2018, 2020; the interpretation of internal and external experiences and Thewissen et al. 2011; Thiery et al. 2014). Moreover, an thereby significantly contributes to paranoid ideation. In experimental manipulation of negative affect was shown to support of this model, elevated levels of negative affect be associated with increases in paranoid ideation in the gen- have been found to predict paranoid ideation in longitudinal eral population (Lincoln et al. 2010a, b) and negative affect studies (Fowler et al. 2012; Freeman et al. 2012; Lincoln mediated the impact of a social stressor on paranoid ideation et al. 2017a) and in studies based on the experience sampling in patients with a psychotic disorder (Freeman et al. 2015). In the face of this evidence for negative affect as a predictor of paranoid ideation, it stands to reason that difficulties in Electronic supplementary material The online version of this the regulation of negative affect play an important role in the article (https ://doi.org/10.1007/s1060 8-020-10173 -6) contains formation of paranoid ideation. supplementary material, which is available to authorized users. Emotion regulation has been defined as a process com- * Martin F. Wittkamp prising the monitoring, appraisal and modification of the martin.wittkamp@uni-hamburg.de quality, intensity, and duration of affective states (Thomp- son 1994). It has further been conceptualised as a set of Clinical Psychology and Psychotherapy, Institute of Psychology, Faculty of Psychology and Movement regulation strategies. These strategies are often subdivided Sciences, Universität Hamburg, Von-Melle-Park 5, into those considered maladaptive, such as suppression 20146 Hamburg, Germany Vol:.(1234567890) 1 3 Cognitive Therapy and Research (2021) 45:468–479 469 (Campbell-Sills et al. 2006) and rumination (Nolen-Hoek- in handling an emotion. The model further discriminates sema et al. 2008), and those considered adaptive, such as between (5) a modificatory pathway, which includes modi- cognitive reappraisal (John and Gross 2004) and acceptance fication strategies, such as cognitive reappraisal, positive (Flaxman et al. 2010). The assumption behind this subdivi- refocusing and social sharing and (6) a non-modificatory sion is that maladaptive strategies will be positively, and pathway, which includes non-modificatory strategies, such adaptive strategies will be negatively associated with psy- as acceptance and tolerance. Awareness, clarity, and under- chopathology (Aldao 2012). Associations with psychopa- standing of an emotion (1–3, which we will subsume as thology, however, have only been robustly shown for the comprehension) and compassionate self-support (4, which putatively maladaptive strategies, whereas findings on the we will shorten to self-support in the following) are stipu- association between adaptive strategies and overall psycho- lated to impact on the emotion regulation process indirectly pathology are heterogeneous (Aldao et al. 2010). A similar by facilitating modification (5) and acceptance/tolerance pattern of findings is evident in studies investigating emo- (6; Berking and Whitley 2014). In support of this assump- tion regulation strategies in psychosis (for a meta-analytic tion, a cross-sectional study demonstrated the interaction of review see Ludwig et al. 2019). Although studies report clarity and cognitive reappraisal to be negatively associated a positive association between maladaptive strategies and with PTSD symptoms (Boden et al. 2012) and an experi- positive psychotic symptoms overall, there is rather high het- mental study showed a moderating effect of self-support on erogeneity in findings for adaptive strategies with only some the effect of cognitive reappraisal on depressive symptoms studies reporting a significant negative association between (Diedrich et al. 2016). Thus, taking these interactions into cognitive reappraisal and positive psychotic symptoms and account might also inform our understanding of the nature most studies reporting no significant association (Ludwig of emotion regulation difficulties that drive psychotic symp- et al. 2019). This pattern of findings does not accord with toms, such as paranoid ideation. the effective reduction of psychotic symptoms by means of This study aims to identify adaptive emotion regulation clinical interventions that focus on conveying adaptive strat- patterns that are negatively associated with and may be egies, such as cognitive reappraisal and acceptance/tolerance protective against paranoid ideation. We expect to find that (Cramer et al. 2016; Eichner and Berna 2016; Louise et al. comprehension and self-support will strengthen the negative 2018; Opoka et al. 2018). To resolve this paradox, it is nec- association between paranoid ideation and modification (H1) essary to improve our understanding of the conditions under and between paranoid ideation and acceptance/tolerance which the use of putatively adaptive strategies can unfold (H2). To ascertain the robustness of findings, the hypoth- their positive effect on paranoid ideation. eses were tested using data from two studies that focused One way to do this is by taking a wider perspective on on different levels of symptom severity and used different the process of emotion regulation. In most of the existing designs. Study 1 used a sample of people with psychotic questionnaire studies, researchers have focused on isolated, disorders, a sample of participants with high risk to develop putatively adaptive emotion regulation strategies and espe- a psychotic disorder and healthy controls, while study 2 used cially on cognitive reappraisal (Ludwig et al. 2019) without a sample of people with clinically relevant psychopathology taking into account possible interactions with other strate- below diagnostic threshold. Study 1 used a cross-sectional gies. This approach may be too narrow, because evidence design, while study 2 used a longitudinal design with ESM. from experimental and ESM studies suggests that individu- Data from study 1 stems from of a larger project on emotion als use various emotion regulation strategies simultaneously regulation in psychotic disorders (LI 1298/7-1). Study 2 uses to deal with emotions (for a review, see Ford et al. 2019). baseline data from a project testing the effect of an emotion Beyond that, adaptive combinations of regulatory strategies regulation training (Wittkamp and Lincoln 2020). have been found to outperform both single strategy use and sequences of ineffective multiple strategies (Aldao et al. 2015; Bonanno and Burton 2013; Heiy and Cheavens 2014). Study 1 Thus, taking combinations of strategies into account rather than focusing on isolated strategies is more likely to help us Recruitment, Procedure, and Design of the Original identify the nature of emotion regulation relevant to mental Project health and well-being. A model of emotion regulation that takes this type of The original study included participants with psychotic approach by focussing on the ee ff ctive interplay of strategies disorders, anxiety disorders, those at risk of psychosis and is the adaptive coping with emotions model (ACE) put for- healthy controls who were recruited via in- and outpatient ward by Berking and Whitley (2014). This model includes clinics in Hamburg, advertisements in local newspapers, (1) awareness, (2) clarity, (3) understanding the cause of blackboards, and online platforms. Inclusion criteria were an emotion, and (4) providing compassionate self-support sufficient German language skills, an age between 18 and 1 3 470 Cognitive Therapy and Research (2021) 45:468–479 65 years, IQ > 85, no current suicidality, no neurological symptom subscale of the Positive and Negative Syndrome disorders or dementia, no diagnosis of a bipolar disorder or Scale (PANSS; Kay et al. 1987). AR fulfilled at least one substance dependence and the ability to provide informed of three criteria for prodromal syndromes as defined in consent. Participants completed questionnaires and neu- the Structured Interview for Prodromal Syndromes (SIPS; ropsychological tests and partook in a social exclusion par- Miller et al. 2003) and did not fulfil criteria for PD. HC adigm and an emotion regulation paradigm on 2 separate did not fulfil criteria for any present or past Axis I disorder days. The details of recruitment, selection criteria and study according to M.I.N.I., had no first-degree relative with a procedure have been published elsewhere (Lincoln et al. psychotic disorder, were not taking any psychopharmaco- 2017b) along with the data related to the social exclusion logical medication, and did not fulfil AR criteria. Sample paradigm. The project was approved by the Ethics Commit- characteristics for the combined sample and subgroups are tee of the German Psychological Society. presented in Table 1. Measures Used for this Study Method Adaptive emotion regulation strategies were assessed with Participants the German version of the Emotion Regulation Skills Ques- tionnaire – Emotion Specific (ERSQ-ES; Ebert et al. 2013). In this study, we utilized data from the participants with The scale contains 12 items rated on a five-point Likert scale psychotic disorders (PD, n = 60), those at risk of psychosis (0 = “not at all” to 4 = “always”), where the use of emotion (AR, n = 25) and the healthy controls (HC, n = 40) who had regulation strategies is rated specific to emotions. To prevent provided baseline questionnaire data on emotion regulation potentially biased self-reports due to memory deficits that and paranoid ideation. PD fulfilled criteria for a psychotic are typically found in the PD and AR subgroups (Brewer disorder according to the Mini International Neuropsychi- et al. 2005; Leavitt and Goldberg 2009), we used an inter- atric Interview (M.I.N.I.; Sheehan et al. 1998) at the time view format. Participants were asked to recall a situation in of assessment or during the last 2 years. Alternatively, if which they experienced a particular negative emotion (anxi- the last psychotic episode was longer than 2 years ago, PD ety, anger, sadness, and shame) and were then instructed needed to have experienced at least two psychotic episodes to rate to which extent they applied each of the regulatory in total and presently report either at least two symptoms strategies. The ERSQ-ES in its original structure with nine with mild severity (cut-off ≥ 3) or at least one symptom with emotion-specific subscales was reported to have good valid- moderate severity (cut-off ≥ 4) on the positive or negative ity and reliability (Ebert et al. 2013). In our analyses we Table 1 Sample characteristics, means and standard deviations of emotion regulation strategies and paranoid ideation and comparisons between subgroups in study 1 Variable Study 1 Study 2 Psychosis group At risk group Healthy con- Combined sam- Statistics for univariate Com- Games Howell Subthreshold (n = 60) (n = 25) trols (n = 40) ple (n = 125) parisons (F, χ ) Post Hoc Tests sample (n = 138) Age 40.15 (11.66) 34.72 (14.05) 40.03 (10.78) 39.02 (12.00) F(2, 122) = 2.04; n.s n.s 36.33 (12.12) 2 e Gender (%female) 63% 72% 68% 66% χ = 0.63, df = 2; n.s n.s 75% a b c d e Education in years 16.26 (4.09) 16.48 (7.68) 18.32 (4.08) 16.98 (5.00) F(2, 112) = 2.06; n.s n.s 17.07 (4.80) Comprehension 3.18 (0.63) 2.97 (0.65) 3.43 (0.44) 3.22 (0.60) F(2, 122) = 5.1; p < 0.01 HC > AR (p < 0.01) 2.26 (0.77) Self-Support 2.58 (0.84) 2.11 (0.85) 2.97 (0.84) 2.62 (0.89) F(2, 122) = 7.8; p < 0.01 HC > PD,AR (p < 0.001) 2.17 (0.95) Modification 1.82 (0.73) 1.48 (0.74) 2.45 (0.62) 1.95 (0.78) F(2, 122) = 16.96; p < 0.001 HC > AR (p < 0.001) 1.77 (0.93) Acc/Tol 2.36 (0.81) 2.12 (0.70) 2.96 (0.56) 2.51 (0.79) F(2, 122) = 12.77; p < 0.001 HC > PD,AR (p < 0.001) 2.34 (0.81) Paranoid Ideation 2.23 (1.04) 2.19 (0.76) 1.08 (0.12) 1.853 (0.96) F(2, 122) = 27.55; p < 0.001 HC < PD,AR (p < 0.001) 2.00 (1.59) Comprehension, Self-Support, Modification, Acceptance/Tolerance were measured with the Emotion Regulation Skills Questionnaire – Emotion Specific. Paranoid ideation was measured with the Paranoia Checklist 18 item version (study 1) and 3 item version (study 2) Acc/Tol acceptance/tolerance, HC healthy controls, PD psychosis group, AR at risk group n = 5 missing cases n = 3 missing cases n = 2 missing cases n = 10 missing cases n = 21 missing cases 1 3 Cognitive Therapy and Research (2021) 45:468–479 471 focused on the following subscales: comprehension, self- paranoid ideation than AR and PD. AR and PD did not dif- support, modification, and acceptance/tolerance. Compre- fer in this regard. hension was calculated as the mean score of awareness, clar- ity and understanding and showed good internal consistency Regression Analysis for the Association of Emotion (Cronbach’s alpha = 0.86). Self-support, modification, and Regulation Strategies and Paranoid Ideation acceptance/tolerance also had acceptable internal consisten- cies across emotions (all Cronbach’s alphas > 0.70). Thus, Hypothesis 1: As shown in Table 2, modification was nega- we used the average score across emotions for each subscale. tively associated with paranoid ideation, but this association Paranoid ideation was assessed with a German version of was not moderated by comprehension or self-support. the frequency scale of the Paranoia Checklist (PCL-18; Free- man et al. 2005). The PCL-18 consists of 18 items that are Hypothesis 2: There were significant interaction effects of self-rated on a v fi e-point Likert scale (1 = “rarely”, 2 = “once acceptance/tolerance and comprehension as well as accept- a month”, 3 = “once a week”, 4 = “several times a week”, ance/tolerance and self-support on paranoid ideation (see 5 = “at least once a day”). In this study we used the mean Table 2). As can be seen in Fig. 1a, paranoid ideation was scores (range 1–5). The German version of the PCL-18 has lower for individuals who were high in acceptance/toler- shown excellent internal consistency and good convergent ance who also had high comprehension of their emotions as validity in clinical and non-clinical samples (Lincoln et al. well, in comparison to those who were high in acceptance/ 2010a, b). In this study, Cronbach’s alpha of the total scale tolerance but low in comprehension. Statistically, this was was 0.96. significant at t (124) = 3.64, p < 0.001, d = 0.33. More pre- cisely, the interaction accounted for an approximate 1-point Statistical Analyses difference in the mean rating of the frequency of paranoid ideation that varied from 1 (rarely) to 5 (at least once a day). Statistical analyses were conducted in SPSS (version 25) and Paranoid ideation was comparably low for individuals who were performed on the combined sample to represent differ - were low in both acceptance/tolerance and comprehension, ent levels of paranoid ideation severity along the continuum compared to individuals who scored high on both strate- of psychosis (see Table 1) and thereby to increase variance gies. Figure 1b shows that the paranoid ideation score was in paranoid ideation and test-power. As paranoid ideation lower for individuals who had low acceptance/tolerance but was not normally distributed (skewness = 2.08, SE = 0.44, scored high on self-support than for those who were high in and kurtosis = 4.56, SE = 0.088), we applied bootstrapping both acceptance/tolerance and self-support; t (124) = 3.49, based on 1000 samples. A multiple regression analysis with p < 0.001, d = 0.31. Finally, participants who had low accept- forced entry was conducted with paranoid ideation as the ance/tolerance but high self-support had lower paranoid dependent variable and four strategies of emotion regula- ideation than individuals who scored low on both strate- tion (comprehension, self-support, modification, and accept- gies; t (124) = 3.86, p < 0.001, d = 0.35. This difference was ance/tolerance) along with their interactions as independent illustrated by a 1-point mean difference in the mean rating of variables. Independent variables were centred around their the frequency of paranoid ideation that varied from 1 (rarely) grand mean. The interaction graphs were created based on to 5 (at least once a day). predicted mean values calculated with the PROCESS macro (Hayes 2017). We found the missing data in the emotion Additional Analyses regulation assessments (0.6%) to be missing completely at random according to Little’s MCAR test, χ (409) = 454.07, Due to a relatively high proportion of female participants p = 0.061. We therefore used the expectation maximization in our sample, we conducted a reanalysis controlling for algorithm (Dempster et al. 1977) for imputation. gender (see Table A1 in the Online Appendix). In this analysis, modification was no longer directly associated with paranoid ideation. Results To assure the robustness of our findings using the imputed data, we further repeated the calculations con- Descriptive Statistics straining the analysis to complete cases. There were no differences between imputed and complete case results Table 1 provides an overview of descriptive statistics of (see Table A2 in the Online Appendix). emotion regulation and paranoid ideation in each sub- group and the combined sample and statistical comparisons between subgroups. HC had significantly lower levels of 1 3 472 Cognitive Therapy and Research (2021) 45:468–479 Table 2 Study 1: multiple a Variable B SE95% CI p regression analysis for emotion regulation strategies Modification − 0.35 0.15 [− 0.67, − 0.05] 0.028 as independent variables and Acceptance/tolerance 0.06 0.16 [− 0.22, 0.38] 0.677 paranoid ideation as dependent Self-support − 0.11 0.14 [− 0.44, 0.13] 0.407 variable Comprehension − 0.08 0.21 [− 0.45, 0.36] 0.724 Modification × self-support − 0.07 0.22 [− 0.47, 0.46] 0.746 Modification × comprehension 0.21 0.39 [− 0.75, 0.87] 0.623 Acceptance/tolerance × self-support 0.48 0.20 [0.01, 0.82] 0.019 Acceptance/tolerance × comprehension − 0.76 0.32 [− 1.30, − 0.04] 0.019 CI confidence interval R = 0.20 Confidence interval per bootstrap with 1.000 samples b. Acceptance/Tolerance ×Self-Support a. Acceptance/Tolerance ×Comprehension 2.80 2.80 2.60 2.60 Comprehension Self-Support 2.40 2.40 Low Low 2.20 2.20 Middle Middle 2.00 2.00 1.80 1.80 High High 1.60 1.60 1.40 1.40 1.20 1.20 1.00 1.00 0.80 0.80 Acceptance/Tolerance Acceptance/Tolerance Low Middle High Low Middle High Fig. 1 Interaction effects between acceptance/tolerance and com- acceptance/tolerance and moderators (ERSQ-ES) at one SD below, prehension (a) and acceptance/tolerance and self-support (b). Pre- above and at the mean. Error bars indicate the standard error of the dicted level of paranoid ideation (PCL-18) for combinations of predicted mean. Lines only serve for better readability Specific inclusion criteria were symptom frequency and Study 2 distress deviating from the norm in any of the three sub- domains of the Community Assessment of Psychic Expe- Recruitment, Procedure, and Design of the Original riences (CAPE; Stefanis et al. 2002: frequency ≥ 31 and Project distress ≥ 24 for positive psychotic symptoms, frequency ≥ 31 and distress ≥ 26 for negative psychotic symptoms, Participants were recruited via online platforms, newslet- or frequency ≥ 17 and distress ≥ 18 for depressive symp- ters, leaflets, and posters in public spaces in Hamburg, toms) or in the anxiety or phobic subdomain of the Brief Germany. Inclusion criteria were sufficient German lan- Symptom Inventory (BSI; Franke and Derogatis 2000: guage skills, an age between 18 and 65 years and the pres- anxiety symptoms ≥ 0.68 or phobic symptoms ≥ 0.39). ence of clinically relevant, subthreshold psychopathology Exclusion criteria were current psychological treatment in at least one symptom domain (positive psychotic, nega- and the diagnosis of a current Axis I or Axis II disorder tive psychotic symptoms, depressive, anxiety or phobic (specific phobia was not an exclusion criterion due to symptoms) indicative of an increased risk to develop a its high prevalence and relatively minor distress; Comer psychotic disorder (for theoretical reviews on the transdi- et al. 2011) as diagnosed with the Structured Clinical agnostic expression of risk to develop psychotic disorders, see Fusar-Poli et al. 2014; Van Os and Reininghaus 2016). 1 3 Paranoid Ideation Paranoid Ideation Cognitive Therapy and Research (2021) 45:468–479 473 Interview for DSM-IV (SCID; German version: Wittchen Measures Used in the ESM et al. 1997). The study was a two-armed, randomized-controlled The negative emotions anxiety, sadness, anger, shame, trial comparing an 8-week emotion regulation group insecurity, and loneliness were each rated in their intensity training to self-help bibliotherapy. Participants were on an 11-point self-report Likert scale (0 = “not at all” to pre-screened for eligibility via online-questionnaires 10 = “very strong”). The scale demonstrated good internal and followed-up by a face-to-face assessment includ- consistency between individuals (Cronbach’s alpha = 0.84) ing diagnoses assessment. Before being allocated to the so we used the mean score of all negative emotions as a intervention or the control group participants underwent coefficient of negative emotions. a baseline assessment that included a socio-demographic Adaptive emotion regulation strategies were assessed with assessment, clinical questionnaires, and a 1-week ESM the German version of the ERSQ-ES (Ebert et al. 2013) that assessment of negative emotions, emotion regulation, and we adapted for the ESM. At each notification, participants paranoid ideation. In this study, we used the ESM data on reported the use of regulatory strategies on a five-point Lik - negative emotions, emotion regulation, and paranoid idea- ert scale (0 = “does not apply at all” to 4 = “fully applies”) tion from the combined intervention and control group. specific to the emotion that they had rated as most intensive A detailed description of the procedure and data on the (anxiety, sadness, anger, shame, insecurity, or loneliness). efficacy of the intervention will be published elsewhere The 12 items used in the original form of the ERSQ-ES were (Wittkamp and Lincoln 2020). The study was approved by slightly adapted to ensure that they referred to the emotion the local Ethics Committee of the University of Hamburg. experienced and the regulation strategy applied before the notification (e.g., modification: In the situation just before the beep, I was able to influence my anxiety). Comprehen- sion was calculated as the mean value of awareness, clarity, Method understanding and demonstrated excellent internal consist- ency between individuals (Cronbach’s alpha = 0.90). Self- Participants support, modification, and acceptance/tolerance, in our sample, also showed good internal consistency between indi- The final sample consisted of N = 138 par ticipants. Sam- viduals and across emotions (all Cronbach’s alphas > 0.88). ple characteristics are presented in Table 1. After the Thus, we used the individual subscales averaged across baseline ESM assessment but before baseline question- emotions. naires, 21 participants dropped out from the study, result- Paranoid ideation was assessed with the German, three- ing in missing data for age, gender, and years of education item version of the PCL (PCL-3; Schlier et al. 2016). The for these participants. included items (“I need to be on my guard against others”, “People try to upset me”, and “Strangers and friends look at ESM me critically”) have been shown to be valid and change-sen- sitive (Schlier et al. 2016). Items were rated on an 11-point The ESM was administered via movisens XS Version 1.5.0 Likert scale (0 = “not at all”, 10 = “very much”). Due to non- (movisens GmbH, Karlsruhe, Germany) on participants’ pri- normality of the data, the scale was dichotomized to pres- vate smartphones or on the study-smartphones. Participants ence (= 1) or absence (= 0) of paranoid ideation. were provided with a detailed explanation and examples of items along with an instruction sheet. Within the ESM Statistical Analyses assessment, over a period of six consecutive days, five times per day between 9 am and 10 pm, participants were notified Statistical analyses were run with IBM SPSS Statistics with signal contingent, random time sampling (Wheeler and (version 25). To account for the hierarchical data struc- Reis 1991) with minimum time gaps of 1.5 h in between ture, we conducted time-lagged multilevel binomial pro- notifications. At each notification, participants were first bit regression analyses with random intercept and random asked to rate the intensity of each of a pre-defined list of slopes. Independent variables (comprehension, self-sup- negative emotions experienced just before the notification, port, modification, and acceptance/tolerance) were cen - then to select the negative emotion with the highest inten- tered around the person mean. To allow for chronological sity just before the notification and to indicate the emotion inferences regarding the association between emotion reg- regulation strategies they had used for that negative emotion. ulation and paranoid ideation, we used measurements of This was followed by a brief assessment of paranoid ideation emotion regulation at a given time-point (t) to predict par- experienced just before the notification. anoid ideation at the following measurement point (t + 1). To ensure that emotions that required regulation were 1 3 474 Cognitive Therapy and Research (2021) 45:468–479 present, solely measurements with negative emotions > 0 Emotion Regulation Strategies at t as Predictors at t were included. Overnight lags were excluded. To test of Paranoid Ideation at t + 1 While Controlling whether emotion regulation at t had an impact on paranoid for Paranoid Ideation and Negative Emotions at t ideation at t + 1 beyond the effect of preceding negative emotions and paranoid ideation, we controlled for negative Results from the regression analysis can be seen in Table 3. emotions and paranoid ideation at t. For the interaction Modification at t significantly predicted paranoid ideation at graph, we used mean values calculated based on predicted t + 1. There was no significant relationship between accept- probabilities for paranoid ideation, which were defined by ance/tolerance at t and paranoid ideation at t + 1. combinations of comprehension and acceptance/tolerance each at three different levels: < 1 SD below (= low), > 1 Hypothesis 1: There were no significant interaction effects, SD above (= high) and between > 1 SD below and > 1 SD neither between modification and comprehension at t nor above (= middle) its mean (see Fig. 2). between modification and self-support at t on paranoid idea- tion at t + 1. Hypothesis 2: The interaction of acceptance/tolerance and Results comprehension at t predicted a decreased likelihood to expe- rience paranoid ideation at t + 1. As can be seen in Fig. 2a, Descriptive Statistics the predicted probability for paranoid ideation at t + 1 was lower when comprehension was moderate or high at t and Three participants were excluded from the analyses due acceptance/tolerance was high at t than it was when accept- to insufficient compliance with the ESM (> 90% missing ance/tolerance was high and comprehension was low; t data). After exclusion of these cases, the average compli- (85) = 2.08, p < 0.05., d = 0.44. Specifically, the chances of ance rate was 78.47% (range: 10–100%). This corresponds experiencing paranoid ideation at t + 1 were decreased by to compliance rates found in other ESM studies (Silvia 13% when comprehension was moderate or high at t. There et al. 2013). Paranoid ideation was present on 48% of was no significant effect of interaction between acceptance/ measurement points and negative emotions were present tolerance at t and self-support at t on paranoid ideation at (intensity > 0) on 80% of the measurement points. t + 1 (see Fig. 2b). a. Acceptance/Tolerance ×Comprehension b. Acceptance/Tolerance ×Self-Support 0.65 0.65 Comprehension Self-Support 0.6 0.6 Low Low 0.55 0.55 Middle Middle 0.5 0.5 High High 0.45 0.45 0.4 0.4 0.35 0.35 Acceptance/Tolerance Acceptance/Tolerance Low Middle High Low Middle High Fig. 2 Interaction effects between acceptance/tolerance and com- ES) < 1 SD below (= low), > 1 SD above (= high) and between > 1 prehension (a) that was significant, and acceptance/tolerance and SD below and > 1 SD above (= middle) the mean value of compre- self-support (b) that was not significant. Predicted probability of hension, self-support, or acceptance/tolerance as measured at t. Error paranoid ideation (PCL-3) at t + 1 for measures with combinations bars represent standard errors of the mean. Lines only serve for bet- of acceptance/tolerance and comprehension or self-support (ERSQ- ter readability 1 3 Predicted Probability Paranoid Ideation Predicted Probability Parnaoid Ideation Cognitive Therapy and Research (2021) 45:468–479 475 Additional Analyses et al. 2012; Diedrich et al. 2016; Kalokerinos et al. 2019). However, these previous studies have mostly tested mod- To ascertain the robustness of our findings we did a rea- erating effects specifically for cognitive reappraisal rather nalysis excluding four participants with less than 70% data than for modification in general, which might explain the available in the ESM. The main findings did not differ from diverging findings. Another explanation for not detecting those found in our original analysis in which we took we moderating effects in both studies is that the nature of the took the less conservative approach by excluding partici- association might be more complex than a mere moderation. pants with less than 90% data available (see Table A3 in the Interestingly, Berking et al. (2012) found an indirect effect Online Appendix). between comprehension, self-support, and psychopathology via modification. Thus, it is conceivable that comprehension and self-support constitute prerequisites for the application Discussion of modification. Taken together, cross-sectionally as well as longitudinally modification seems to be protective against In the present study we investigated links between the inter- paranoid ideation. However, the underlying mechanisms play of adaptive emotion regulation strategies and paranoid remain to be disentangled in future research. ideation. Acceptance/Tolerance as a Predictor Modification as a Predictor of Paranoid Ideation of Paranoid Ideation and the Moderating Eec ff t and Moderating Eec ff ts of Comprehension of Comprehension and Self‑support Our expectation that the association between acceptance/tol- We predicted that an adequate comprehension and self- erance and paranoid ideation would be moderated by com- support would strengthen the negative association between prehension was confirmed. In study 1 , we found that par- modification and paranoid ideation. However, in study 1, ticipants with a strong ability to accept and tolerate, along there was a direct association between modification and par - with a better understanding of their emotions, reported con- anoid ideation that was not moderated by comprehension or siderably less paranoid ideation than those who were high self-support. In study 2, modification predicted subsequent in acceptance and tolerance but reported low understand- paranoid ideation and this effect was also not moderated ing of their emotions. The finding from study 2 confirmed by comprehension or self-support. Hence, although modi- this pattern by showing that when participants adequately fication and paranoid ideation were negatively associated accepted and understood their emotions, the likelihood of in both studies, this association was independent of other experiencing subsequent paranoid ideation was lower than emotion regulation strategies. This is surprising, given the when participants accepted their emotion without adequately ACE model’s assumption that comprehension of emotions understanding it. This is in line with what we had expected and self-support lead to a more focused and targeted attempt based on the ACE model. These observations further cor- to modify emotions (Berking and Whitley 2014) that has roborate previous experimental research finding participants been partially confirmed in previous research (e.g. Boden with lower baseline levels of comprehension, acceptance, Table 3 Study 2: binary Variable B SE 95% CI p multilevel probit regression analysis with emotion regulation Modification 0.12 0.05 [0.03, 0.20] 0.012 strategies at t as independent Acceptance/tolerance − 0.03 0.05 [− 0.12, 0.07] 0.588 variables and paranoid ideation Self-support 0.03 0.04 [− 0.04, 0.11] 0.387 at t + 1 as dependent variable Comprehension − 0.08 0.04 [− 0.16, − 0.01] 0.036 Modification × self-support − 0.08 0.06 [− 0.18, 0.04] 0.187 Modification × comprehension − 0.05 0.06 [− 0.17, 0.07] 0.433 Acceptance/tolerance × self-support 0.00 0.05 [− 0.09, 0.10] 0.946 Acceptance/tolerance × comprehension − 0.12 0.06 [− 0.23, − 0.01] 0.037 Negative emotions 0.08 0.04 [0.01, 0.16] 0.033 Paranoid ideation 0.16 0.09 [− 0.00, 0.33] 0.056 Only cases were included with negative emotions > 0 at t. Negative emotions and paranoid ideation at t were included as control variables CI confidence interval 1 3 476 Cognitive Therapy and Research (2021) 45:468–479 and tolerance to be more likely to respond to a stressor of strategies that address factors associated with an emo- with an increase of paranoid ideation (Lincoln et al. 2015). tion, such as an underlying problem (cf. problem-solving). Extending this finding, both of our studies showed that high Detailed information about an emotion might not be nec- acceptance without an adequate understanding of emotions essary for some of these strategies (e.g. problem-solving) was associated with increased paranoid ideation. This sug- to work. In contrast, acceptance refers to a willingness to gests that acceptance is only adaptive when it is applied in stay in contact with the emotion itself (Campbell-Sills et al. combination with an adequate understanding of the respec- 2006). Thus, it seems plausible that acceptance might be tive emotion. crucially facilitated when an emotion is well-defined and understood in contrast to a situation, in which the emotional Acceptance/Tolerance as a Predictor of Paranoid state is diffuse. Possibly, the attempt to accept a diffuse emo- Ideation and the Moderating Eec ff t of Self‑support tional state results in a form of passive resignation (cf. Gar- nefski and Kraaij 2006). This could also help to explain our In study 1, we found self-support to moderate the association finding that acceptance in combination with an insufficient between acceptance/tolerance and paranoid ideation. Specif- understanding leads to high levels of paranoid ideation. ically, paranoid ideation was low when self-support was high and acceptance/tolerance was low. In study 2, self-support Limitations did not moderate the association between acceptance/toler- ance and paranoid ideation. Thus, the present results do not The present findings should be interpreted in the light of corroborate the theoretical assumptions from the ACE model some limitations. First, in both studies, self-support was concerning self-support (Berking and Whitley 2014). How- measured with only one item. Nevertheless, a validation ever, findings from study 1 are in line with an experimental study showed that the applied self-support assessment with study by Diedrich et al. (2014) demonstrating that in direct the ERSQ-ES had good psychometric properties (Ebert et al. comparison, acceptance and self-support were equally effec- 2013), which was also confirmed by acceptable to good tive at down-regulating emotions. Our findings complement internal consistencies found in study 1 and study 2. Second, this study by indicating that self-support might be adaptive in study 2, we had to dichotomize paranoid ideation due to when applied as an alternative regulatory strategy by those non-normality of the distribution and thereby relevant infor- individuals who do not accept their emotions. This inference mation may have been lost (Schlier et al. 2016). Third, PD from study 1 might further help to explain our unexpected and AR in study 1 included high percentages of female par- finding that paranoid ideation was relatively low when ticipants as compared to most at risk and psychosis samples acceptance/tolerance and comprehension were low. Specifi- (for a review, see Ochoa et al. 2012). This might limit the cally, we might speculate that self-support compensated for generalizability of our findings because gender differences a lack of acceptance and thereby lowered levels of paranoid have been found for emotion regulation (Nolen-Hoeksema ideation. In sum, contrary to what we expected, rather than 2012), which might affect the associations between regu - strengthening the negative association between acceptance latory strategies and paranoid ideation we examined here. and tolerance with paranoid ideation, self-support seemed Indeed, a reanalysis controlling for gender indicated that the to serve as an alternative strategy associated with decreased direct association between modification and paranoid idea- paranoid ideation for those participants who did not accept tion could be specific to females, whereas adaptive patterns their emotions. However, this finding was not confirmed lon- of acceptance and self-support or comprehension seem to gitudinally and therefore needs to be reexamined in future hold, irrespective of gender. Finally, severe difficulties in research. awareness and clarity, which have been found in samples of patients with psychosis and those at risk of developing psy- General Discussion chosis (Kimhy et al. 2012; Van Rijn et al. 2011), might have biased self-reports of discrete negative emotions in study 2. Interestingly, our findings were different for modification Future studies could account for this by using an alternative and acceptance. We found a direct negative effect of modi- classification of emotion, such as valence and arousal (Wil- fication on paranoid ideation, irrespective of how well an helm and Schoebi 2007). emotion was understood. For acceptance we found that it only negatively influenced paranoid ideation provided that Implications for Future Research and Clinical an emotion was well understood. A closer examination of Practice the constructs of modification and acceptance could help to explain these diverging findings. Modification describes the Despite these limitations our findings corroborate the theo- ability to adaptively change emotions (Berking and Whitley retical assumption that it is important to consider the inter- 2014). In this broad definition, modification includes a range play of adaptive emotion regulation strategies in order to 1 3 Cognitive Therapy and Research (2021) 45:468–479 477 Foundation, grant number DFG Li 1298/7-1. Research in study 2 did understand better what is driving psychopathology (Aldao not receive any specific grant from fundieng agiencies in the public, and Nolen-Hoeksema 2013; Berking and Whitley 2014; commercial, or not-for-profit-sectors. Ford et al. 2019). Specifically, our results suggest that accepting emotions can prevent subsequent paranoid idea- Data Availability Datasets described in this paper are available from tion but only if emotions have been well comprehended. the corresponding author on request. Our findings also suggest that self-support could be protec- tive against paranoid ideation for those individuals who do Compliance with Ethical Standards not accept their emotions. Future research needs to clarify Conflict of Interest Martin F. Wittkamp, Katarina Krkovic and Tania whether these adaptive patterns of emotion regulation are M. Lincoln declare that they have no conflict of interest. transdiagnositic or specific to paranoid ideation. Further - more, it needs to be examined whether other adaptive emo- Ethical Approval This research was performed in line with the princi- tion regulation patterns that are related to other psychopa- ples of the Declaration of Helsinki. Approval for study 1 was granted by the Ethics Committee of the German Psychological Society and thology, such as PTSD or depressive sypmtoms (Boden et al. approval for study 2 was granted by the Ethics Committee of the Uni- 2012; Diedrich et al. 2016), are also associated with para- versity of Hamburg. noid ideation. It must be noted that this study along with the previous research investigates only one-directionally how Informed Consent Informed consent was obtained from all individual participants included in both studies. emotion regulation strategies predict paranoid ideation. It is plausible however, that strategies emerge as a reaction to Animal Rights No animal studies were carried out by the authors for a present symptom and the accompanying negative emo- this article. tion in an effort to reduce it. This could be an interesting question for future studies. Comprehension as a moderator Open Access This article is licensed under a Creative Commons Attri- is of special importance, given previous findings that peo- bution 4.0 International License, which permits use, sharing, adapta- ple with a psychotic disorder and those at risk have lower tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, levels of comprehension than healthy controls (Kimhy et al. provide a link to the Creative Commons licence, and indicate if changes 2012, 2016; Van Rijn et al. 2011). Our findings also have were made. The images or other third party material in this article are to be interpreted in the light of the theoretical assumption included in the article’s Creative Commons licence, unless indicated that negative emotion merely represents one of many fac- otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not tors that are assumed to precede paranoid ideation in cogni- permitted by statutory regulation or exceeds the permitted use, you will tive models (Garety et al. 2001). Hence, it is not surprising need to obtain permission directly from the copyright holder. To view a that the associations we found were rather small. However, copy of this licence, visit http://creativ ecommons .or g/licenses/b y/4.0/. applying adaptive regulation patterns nevertheless accounted for clinically meaningful change in frequency of paranoid ideation and can further be well addressed in clinical inter- ventions. Specifically, it could be promising to convey skills References to become aware of, label and understand emotions to enable an adaptive and focused acceptance and tolerance. Finally, Aldao, A. (2012). Emotion regulation strategies as transdiagnostic pro- cesses: A closer look at the invariance of their form and function. our findings suggest that individuals experiencing paranoid Revista de Psicopatologia y Psicologia Clinica, 17(3), 261–277. ideation could benefit from interventions that focus on effec- https ://doi.org/10.5944/rppc.vol.17.num.3.2012.11843 tive combinations of regulation strategies, such as the Affect Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion- Regulation Training (Berking and Whitley 2014). regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30(2), 217–237. https ://doi. org/10.1016/j.cpr.2009.11.004 Acknowledgements We thank Johanna Sundag and Leonie Ascone Aldao, A., & Nolen-Hoeksema, S. (2013). One versus many: Capturing Michelis for organizing the collection of data used for study 1. Fur- the use of multiple emotion regulation strategies in response to an thermore, we thank the students who conducted the data collection. emotion-eliciting stimulus. Cognition & Emotion, 27(4), 753–760. https ://doi.org/10.1080/02699 931.2012.73999 8 Author Contributions Tania Lincoln and Martin Wittkamp contributed Aldao, A., Sheppes, G., & Gross, J. J. (2015). Emotion regulation flex- to the study conception and design. Material preparation and prepara- ibility. Cognitive Therapy and Research, 39(3), 263–278. https :// tion of data collection were performed by Tania Lincoln and Martin doi.org/10.1007/s1060 8-014-9662-4 Wittkamp. Data analyses were performed by Katarina Krkovic and Ben-Zeev, D., Ellington, K., Swendsen, J., & Granholm, E. (2011). Martin Wittkamp. The first draft of the manuscript was written by Examining a cognitive model of persecutory ideation in the daily Martin Wittkamp and all authors contributed to the manuscript. 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