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Assessing Emotion Regulation in Social Anxiety Disorder: The Emotion

Regulation Interview

Article  in  Journal of Psychopathology and Behavioral Assessment · September 2011

DOI: 10.1007/s10862-011-9225-x

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J Psychopathol Behav Assess (2011) 33:346–354
DOI 10.1007/s10862-011-9225-x

Assessing Emotion Regulation in Social Anxiety Disorder:

The Emotion Regulation Interview
Kelly H. Werner & Philippe R. Goldin & Tali M. Ball &
Richard G. Heimberg & James J. Gross

Published online: 15 April 2011

# Springer Science+Business Media, LLC 2011

Abstract Social anxiety disorder (SAD) is thought to involve Social Anxiety Disorder (SAD) is the fourth most common
emotional hyper-reactivity and emotion dysregulation. How- psychiatric disorder, with a lifetime prevalence rate of
ever, the precise nature of the emotion dysregulation in SAD 12.1% (Kessler, et al. 2005). It is characterized by an
has not been well characterized. In the present study, the intense fear of social situations, and it often co-occurs with
Emotion Regulation Interview (ERI) was developed to other psychiatric disorders, such as generalized anxiety
quantify the frequency and self-efficacy of five emotion disorder, agoraphobia, major depression, and substance
regulation strategies specified by Gross’s (Review of General abuse (Schneier et al. 1992).
Psychology 2: 271–299, 1998) process model of emotion Cognitive models of social anxiety posit that emotion
regulation. Forty-eight individuals with SAD and 33 healthy hyper-reactivity and dysregulation are core features of SAD
controls (HCs) were interviewed about responses during (a) a (Hermann et al. 2004; Hofmann 2004). Motivated by these
laboratory speech task and (b) two recent social anxiety- models, research to date has focused on the role of
evoking situations. Individuals with SAD reported greater use cognitive appraisals in maintaining social anxiety. Howev-
of avoidance and expressive suppression than HCs, as well as er, the differential use of emotion regulation strategies has
lesser self-efficacy in implementing cognitive reappraisal and not been well characterized in SAD. This is a key limitation
expressive suppression. These regulation deficits were not because emerging clinical research suggests that emotion
accounted for by differences in emotional reactivity. These dysregulation may underlie many mood and anxiety
findings highlight specific emotion regulation deficits in disorders (Kring and Werner 2004), including SAD (Etkin
SAD, and support the idea that the Emotion Regulation and Wager 2007; Turk et al. 2005).
Interview may be usefully applied to other clinical disorders. Healthy individuals engage in emotion regulation (ER),
which refers to attempts to influence which emotions they
Keywords Emotion regulation . Emotional reactivity . have, when they have them, and how they experience and
Social anxiety disorder . Social phobia express these emotions (Gross 1998). Effective emotion
regulation can reduce emotional reactions to stressful,
anxiety-provoking situations. Conversely, difficulties with
K. H. Werner (*) : P. R. Goldin : J. J. Gross
Department of Psychology, Stanford University,
emotion regulation have been postulated as a core mech-
420 Jordan Hall, Room 430, anism of anxiety disorders (Campbell-Sills and Barlow
Stanford, CA 94305, USA 2007; Werner and Gross 2009), and accordingly, clinical
e-mail: [email protected] treatments focus on enhancing the use of emotion regula-
R. G. Heimberg
tion skills to modulate emotional reactivity (e.g., Hayes et
Department of Psychology, Temple University, al. 1999; Linehan 1993).
Philadelphia, PA, USA The process model of emotion regulation, proposed by
Gross (1998), provides a framework for delineating
T. M. Ball
Psychiatry Department, University of California San Diego,
different types of emotion regulation strategies. This model
9500 Gilman Drive, Mailcode 0855 La Jolla, identifies five types of emotion regulation strategies.
CA 92093-0855, USA Situation selection entails choosing whether or not to enter
J Psychopathol Behav Assess (2011) 33:346–354 347

a potentially emotion-eliciting situation. Specifically, it Furthermore, there is some indication that expressive
involves choosing to approach or avoid certain people, suppression may be problematic in SAD; Kashdan and
places, or activities. Situation modification involves mod- colleagues found that higher suppression recording in a
ifying something about the situation in order to enhance or daily diary study was correlated with fewer positive
diminish its emotional impact. Within the situation, experiences in individuals with SAD (Kashdan 2007).
attentional deployment refers to directing one’s attention Further research is needed to determine whether individuals
to a specific feature of the environment in order to change with SAD are over-using suppression in comparison to their
that situation’s emotional impact. Cognitive change healthy counterparts.
describes the active modification of the meaning or The goal of the present study was to examine emotion
importance of the situation, again with the goal of altering dysregulation in SAD. To achieve this goal, the Emotion
emotional responding. Once the emotional response has Regulation Interview (ERI) was developed. The ERI is a
been generated, response modulation involves increasing or structured interview that assesses emotion regulation
decreasing the expression of that emotion (e.g., suppression strategies specified in Gross’s process model of ER. The
of facial expression). Attempts to regulate one’s emotion current study hypothesized that compared to healthy
may involve multiple regulatory strategies, which may be controls, individuals with SAD would endorse greater
used in adaptive or maladaptive ways. frequency of use of situation selection, situation modifica-
Few studies have investigated emotion regulation in tion, attention deployment, and response modulation (sup-
individuals with SAD (Kashdan 2007; Turk et al. 2005), pression), but lesser use of cognitive change. It was further
and no study has used a theoretically derived framework in hypothesized that individuals with SAD would report less
order to investigate multiple emotion regulation strategies self-efficacy than controls when implementing emotion
within one research paradigm. The main finding from regulation strategies.
previous research regarding emotion regulation in SAD is
that, like other anxiety disorders, overt and subtle avoid-
ance of threatening situations maintains SAD (Wells and Methods
Papageorgiou 1998). Beyond that, little is known regarding
specific emotion regulation habits of people with SAD. Participants
Thus while excess fear and anxiety characterizes SAD, little
work has been done to systematically characterize the role Participants with generalized SAD and demographically-
of emotion regulation in maintaining these heightened matched healthy control (HC) participants were recruited
levels. using flyers, internet postings, presentations at community
Interestingly, although it is known that cognitive forums, and local radio programs. After the initial telephone
behavioral therapy is quite helpful for SAD (Heimberg screening of 243 persons for general psychopathology and
2002), there is little empirical research on the usage of medical conditions, 64 potential participants with SAD and
cognitive regulation in SAD. In one recent fMRI investi- 41 potential HCs were invited to the laboratory and
gation of emotion regulation in individuals with SAD, administered the Anxiety Disorders Interview Schedule
Goldin and colleagues found that, compared to healthy for DSM-IV, Lifetime version (ADIS-IV-L; Di Nardo et al.
controls, individuals were less likely to recruit cognitive 1994). The ADIS-IV-L was conducted by clinical psychol-
regulation brain networks when instructed in response to ogists (PG, KW) and a graduate student in psychology
social anxiety stimuli (Goldin et al. 2009). More evidence is (TB).
needed to determine whether people with SAD implement The inclusion criterion for the clinical group was a
cognitive regulation with less frequency than healthy principal diagnosis of generalized SAD, the more insidious
controls. It is also unclear whether people with SAD have and debilitating sub-type of SAD, defined as greater than
lower levels of perceived self-efficacy in using cognitive moderate anxiety/fear for five or more distinct social
regulation. situations, with or without GAD, agoraphobia, specific
Research has demonstrated a vigilance-avoidance re- phobia, or dysthymic disorder. Exclusion criteria included
sponse for people with SAD in response to social stimuli. (1) any other current DSM-IV Axis I disorders (besides
This response is thought to indicate inflexible avoidant GAD, Agoraphobia, Dysthymia, and Specific Phobia), (2)
responding with attention deployment within a few seconds lifetime history of schizophrenia spectrum or bipolar
of a social threat (Bögels and Mansell 2004). Here there is disorders, or (3) current psychotherapy or psychotropic
indication of a distraction response on a short time scale, medication use. Because participants were recruited as part
yet it is unclear whether people with SAD use more of a larger study, they additionally met criteria for fMRI
conscious and prolonged mental distraction techniques to scanning. Potential HCs met the above criteria and were
cope with social situations. also excluded for any lifetime DSM-IV Axis I disorder as
348 J Psychopathol Behav Assess (2011) 33:346–354

assessed by the ADIS-IV-L (Di Nardo et al. 1994). All internal and external validity. The ERI was given just after
participants provided informed consent in accordance an impromptu speech task. The speech was very anxiety
with the Stanford University Human Subjects Committee producing, particularly for the participants with SAD, and
guidelines. was very fresh in participants’ minds as they were
The final sample included 48 individuals with a primary answering ERI questions. In addition, participants were
Axis-I diagnosis of SAD and 33 HCs who did not differ in asked about two recent situations from their own lives to
age, gender, education, or ethnicity (Table 1). For individuals gain a more representative picture of the types of social
with a primary Axis-I diagnosis of SAD, current (non- situations and subsequent regulation strategies participants
primary) Axis I co-morbidity included ten with dysthymic were likely using in their everyday lives.
disorder, seven with generalized anxiety disorder (GAD), For the laboratory speech task, participants were asked
and three with specific phobia; eight also reported past major about their frequency of usage of attentional deployment,
depression and two past substance abuse now in full cognitive change, and expressive suppression. There was
remission. Twenty individuals with SAD reported past (i.e., little opportunity to employ situation selection and
ended more than 3 months prior) experience with psycho- situation modification during the speech task, therefore
therapy, and eight reported past psychotropic medication use. these emotion regulation strategies were not assessed
with respect to the laboratory speech task. For the two
The Emotion Regulation Interview (ERI) idiographic situations, participants were asked to identify
and report on specific situations in which they felt
The ERI is a structured clinical interview based on Gross’s anxiety of 60 or above on the Subjective Units of
(1998) process model of emotion regulation. Currently, Distress Scale (SUDS; Wolpe 1958) from 0 (calm) to 100
measures of emotion regulation rely solely on self-report (most anxiety felt in life). Examples of idiographic
and there are no interviews assessing a theoretically derived situations included speaking up on a conference call,
framework of emotion regulation strategies—the ERI fills interviewing for a job, and talking to a child’s teacher.
this gap in the literature. Participants were asked about the frequency of the five
Participants were asked how they regulated their emotion regulation strategies, and about the self-efficacy
emotions in three situations: during a two-minute video- of implementation of two of these strategies.
taped speech in the laboratory about a recent social anxiety- Participants were asked to estimate the frequency of use
evoking situation and during two idiographic social 0% (never; or not at all) to 100% (always) of each strategy
anxiety-evoking situations that occurred within the last during the speech and the idiographic situations and to
month. Our goal in using both a laboratory speech task and enumerate examples of strategies. The five ER strategies
idiographic recent real-life situations was to maximize (and their specific verbal probes) were: “What percent of
the time do you ______ to reduce your anxiety?” (1)
Situation Selection: avoid situations (2) Situation Modifi-
Table 1 Demographics for social anxiety disorder and healthy control cation: modify the situation (3) Attentional Deployment:
participants distract yourself (4) Cognitive Change: think about the
situation differently (5) Expressive Suppression: hide the
SAD Mean ± SD HC Mean ± SD
visible signs of your anxiety.
Age (years) 33±8.2 33±9.4 Participants were also asked to provide ratings of their
Gender
self-efficacy in employing cognitive change and expressive
Men 25 16
suppression strategies. Specifically, participants were asked
Women 23 17
to rate the self-efficacy (0 = not, 100 = completely) of their
cognitive change (“When you tried to change how you
Education (years) 16.4±1.5 17.2±1.6
were thinking in order to reduce your anxiety in this
Ethnicity
situation, how successful were you at reducing your
Caucasian 26 19
anxiety?”) and expressive suppression (“When you tried
Asian American 15 10
to hide your anxiety so that others couldn’t tell that you
Latino 4 3
were anxious in this situation, how successful were you at
African 1 0
appearing calm?”). The rationale for focusing on these was
Native American 1 1
that long-term use of cognitive change and expressive
Native Hawaiian 1 0
suppression have differential effects on well-being (Gross
SAD individuals with social anxiety disorder, HC healthy controls, SD and John 2003).
standard deviation The ERI was conducted by interviewers trained by a
*p<.05, **p<.01 clinical psychologist to assure reliability in the delivery
J Psychopathol Behav Assess (2011) 33:346–354 349

of the interview. Training included watching videotaped I’m in.”) and the suppression subscale has eight items (e.g.,
interviews and administration of the interview to other “When I am feeling negative emotions (e.g., anxiety,
research assistants, the psychologist, and a pilot partic- sadness), I make sure not to express them.”) Participants
ipant. Additionally, the psychologist sat in on the first rated their agreement or disagreement with each item on a
interviews with individuals to ensure that there were no scale from 1 (strongly disagree) to 7 (strongly agree). This
deviations from standard interview procedure and scale shows good reliability and convergent as well as
reviewed tapes of the initial three interviews. An discriminant validity (Gross and John 2003).
independent interviewer watched the video-tapes of the Emotion regulation self-efficacy was assessed using the
ERI and weighted Kappa agreement was .95 for Emotion Regulation Questionnaire—Self Efficacy (ERQ-
percentages recorded. SE; Goldin et al. 2009). Participants indicate how capable
they are of using reappraisal [suppression] when they really
Measures to Assess Convergent Validity of the ERI want to, using the same item set described immediately
above. Participants rated their agreement or disagreement
Convergent validity was established by correlating the ERI with each item on a scale from 1 (strongly disagree) to 7
subscales with questionnaires containing corresponding (strongly agree).
content. In particular, for situation selection, avoidance
was assessed; for attentional deployment, distraction was Procedure
assessed; for ERI suppression and reappraisal frequency,
suppression and reappraisal usage were assessed. For Participants who were eligible after the clinical diagnostic
perceived success at using suppression and reappraisal, interview returned on another day for a two-hour behavioral
suppression and reappraisal self-efficacy was assessed. assessment which included the laboratory speech task and
Avoidance was assessed using the self-report version of the ERI. At the diagnostic interview session, participants’
the Liebowitz Social Anxiety Scale (LSAS-SR) (Fresco, et social anxiety and avoidance were assessed using the
al. 2001; Rytwinski, et al. 2009), which is derived from the Liebowitz Social Anxiety Scale (LSAS; Liebowitz 1987)
clinician administered Liebowitz Social Anxiety Scale (SAD: M=81.9, SD=18.8; HC: M=15.2, SD=9.0). At the
(LSAS; Liebowitz 1987). There are two subscales, social second session, participants gave two two-minute speeches
fear and social avoidance with respect to 24 specific social standing right in front of a video-camera with a researcher
situations. These include 11 social interactions (e.g., going observing the speeches. Subjective Units of Distress
to a party) and 13 performance situations (e.g., giving a (SUDS) ratings were obtained before and after each speech
talk). The current study used the avoidance subscale, in (Wolpe 1958). After the speeches, the ERI was conducted
which participants rated avoidance ranging from 0 (Never and required approximately 30 min.
0%) to 3 (Usually 67–100%). The LSAS shows good A subset of the individuals with SAD returned 4 months
psychometric characteristics in both clinician administered after their initial assessment to complete a post wait-list
(Baker et al. 2002; Heimberg, et al. 1999; Weeks, et al. research assessment for a second time and reported on
2005) and self-report (Fresco, et al. 2001; Rytwinski, et al. similar idiographic situations for the ERI (N=14). These
2009) formats. participants were part of a larger treatment study but did not
Distraction was assessed using the Response Styles receive treatment between Time 1 and Time 2. Again
Questionnaire (RSQ; Nolen-Hoeksema and Morrow participants gave a two-minute speech and after the speech,
1991), which assesses participants’ tendencies to ruminate the ERI was conducted and lasted approximately 30 min.
in response to their symptoms of negative emotion. The
RSQ includes 22 items describing responses and can be Analyses
divided into an 11 item rumination subscale and an 11 item
distraction subscale. An example item from the distraction To assess test-retest reliability, ERI responses of SAD
subscale is “I think about how hard it is to concentrate” and participants were assessed over a 4 month interval and then
respondents rate on a scale from 1 (almost never) to 4 correlated. To assess convergent validity of the ERI,
(almost always). Previous studies have reported acceptable responses for both individuals with SAD and HC (n=81)
convergent and predictive validity for the RSQ (Nolen- were correlated with the measures described above. To
Hoeksema and Morrow 1991). examine group differences in emotion regulation frequency
Suppression and cognitive reappraisal were assessed and self-efficacy, ERI responses of HC and SAD partic-
using a modified version of the Emotion Regulation ipants were compared for each of the ERI subscales.
Questionnaire (ERQ; Gross and John 2003). The cognitive Because ERI responses for the two idiographic situations
reappraisal scale has eight items (e.g., “I control my were correlated, they were combined by averaging the two
emotions by changing the way I think about the situation sets of responses.
350 J Psychopathol Behav Assess (2011) 33:346–354

Results cognitive change (ps > .23). (See Fig. 1a). To examine
whether SAD and HC participants differed in emotion
Reliability and Validity of the ERI regulation frequency during the idiographic situations, t-
tests were performed which showed that compared to HCs,
Reliability of the ERI was assessed by examining correla- individuals with SAD reported greater use of situation
tions between baseline and post-waitlist ERI responses for selection, t(79)=7.23, p<.001; ηp2 =0.40; and expressive
participants with SAD (n=14). Results were as follows: suppression, t(79)=2.54, p=.013, ηp2 =0.08. There were no
situation selection frequency (r=.70, p=.003), situation differences for situation modification, attentional deploy-
modification frequency (r=.66, p=.009), attention deploy- ment, or cognitive change (ps > .13). (See Fig. 1b).
ment frequency (r=.62, p=.010), cognitive regulation
frequency (r =.73, p= .001), cognitive regulation self- Emotion Regulation Self-Efficacy
efficacy (r=.68, p=.001), suppression frequency (r=.77,
p<.001), and suppression self-efficacy (r=.69, p=.003). To examine whether SAD and HC participants differed in
With respect to convergent validity, as expected, ERI their emotion regulation self-efficacy during the speech
situation selection frequency was correlated with the LSAS task, t-tests were performed which showed that compared to
avoidance subscale (r=.55, p<.001), and ERI attention HCs, individuals with SAD reported feeling less self-
deployment frequency was correlated with the RSQ efficacy when implementing cognitive change, t(79)=
distraction subscale (r=.25, p=.014). Also consistent with 3.34, p = .001; ηp2 = 0.12 and expressive suppression,
expectations, ERI cognitive regulation frequency was t(79)=3.23, p=.002; ηp2 =0.12. (See Fig. 2a). To examine
correlated with the ERQ cognitive reappraisal subscale whether SAD and HC participants differed in their emotion
(r=.27, p=.009), and ERI cognitive regulation self-efficacy regulation during the idiographic situations t-tests were
was correlated with ERQ cognitive reappraisal self-efficacy performed which showed that, compared to HCs, individ-
(r=.30, p=.004). Similarly, ERI suppression frequency was uals with SAD reported less self-efficacy when implement-
correlated with the ERQ suppression subscale (r=.21, ing cognitive change, t(79)=27.89, p<.01, ηp2 =0.26, or
p=.046), and ERI suppression self-efficacy was correlated when implementing expressive suppression, t(79)=4.46,
with ERQ suppression self-efficacy (r=.21, p=.045). p=.04, ηp2 =0.05. (See Fig. 2b).

Emotion Regulation Frequency Secondary Analyses

To examine whether SAD and HC participants differed in Individuals with SAD reported significantly more social
emotion regulation frequency during the speech task, t-tests anxiety than HCs on the speech task and the two
were performed which showed that, compared to HCs, idiographic situations: speech task t(79)=9.83, p<.001;
individuals with SAD reported greater frequency of [SAD: M=55.52, SD=19.07; HC: M=15.8, SD=15.8];
expressive suppression, t(79)= 2.15, p =.04; ηp2 = 0.06. idiographic situations, t(79)=3.57, p = .001; [SAD: M=
There were no differences for attentional deployment or 72.0, SD=12.3; HC: M=61.9, SD=12.8]. To determine

Fig. 1 Emotion regulation strat- Regulation Frequency Regulation Frequency in

egy frequency for (a) speech in Speech Task Idiographic Situations
task and (b) idiographic situa- 80% 80%
tions (*p<.05) a b
70% 70%

60% * 60% * *
50% 50%

40% 40%

30% 30%

20% 20%

10% 10%

0% 0%
Attentional Cognitive Expressive Situation Situation Attentional Cognitive Expressive
Deployment Change Suppression Selection Modification Deployment Change Suppression

SAD HC
J Psychopathol Behav Assess (2011) 33:346–354 351

Regulation Self-efficacy Regulation Self-efficacy

in Speech Task in Idiographic Situations
80% 80%
a b
70% 70%
* *
60%
* 60%

50% 50%

40% * 40%

30% 30%

20% 20%

10% 10%

0% 0%
Cognitive Expressive Cognitive Expressive
Change Suppression Change Suppression

SAD HC

Fig. 2 Emotion regulation strategy self-efficacy for (a) speech task and (b) idiographic situations (*p<.05)

whether the emotion regulation findings were due to group an impoverished life in social and work domains (Furmark
differences in anxiety levels, the analyses described above 2002; Hofmann et al. 2004).
were repeated, this time using the SUDS rating as a We found that HCs and people with SAD reported using
covariate were conducted. The significant differences situation modification at similar frequencies in anxiety
between groups were unchanged. provoking situations. Many situation modification strate-
gies (e.g., safety behaviors) are maladaptive in that they
prohibit full exposure to the feared social situations thereby
Discussion preventing effective processing of the emotional informa-
tion (Clark 2001). Yet situation modification includes
Individuals with SAD endure excessive fear of social adaptive strategies as well, such as: speaking with a
situations, yet the role that emotion dysregulation plays in confident voice, infusing humor, engendering social sup-
this disorder is not fully understood. In this study, a port for nervousness or directing the situation. A difference
theoretically derived Emotion Regulation Interview was between groups was likely not seen for situation modifica-
developed in order to better understand emotion regulation tion as this category contained both adaptive and maladap-
in SAD. Specifically, different forms and facets of emotion tive strategies.
regulation during both idiographic and speech contexts Interestingly, the two groups also did not differ in their
were used. frequency of attention deployment (i.e., distraction). Much
of the research on attention and SAD to date is on a short
Emotion Regulation Frequency in SAD time-scale and has demonstrated an immediate attentional
avoidance response upon the detection of a social threat
The current study confirms the prominent place of situation (Bögels and Mansell 2004; Gilboa-Schechtman et al. 1999).
selection in SAD. For anxiety situations of similar intensity, The current study indicates that more active, conscious, and
the current study demonstrates that individuals with SAD prolonged distraction techniques (e.g., focusing on smart-
avoid more readily than HCs. Avoidance is a core feature of phone in a group conversation) may be comparable when
SAD and is included in the diagnostic criteria for the persons with SAD and HCs are faced with social threat.
disorder (Di Nardo et al. 1993), and our finding clarifies The current study also found that SAD and HC used
that a tendency to avoid persists even when controlling for cognitive reappraisal with similar frequency. Although
anxiety severity. Other researchers have also indicated the unexpected, this finding does correspond with some recent
central role avoidance plays in SAD (Asendorpf 1990; evidence. Researchers have found that both SAD and HC
Rapee 1995). Avoidance provides immediate relief from were able to use cognitive reappraisal to decrease negative
social anxiety, but its long-term consequences can lead to emotion in an fMRI study indicating some equivalence in
352 J Psychopathol Behav Assess (2011) 33:346–354

these two groups’ implementation abilities (Goldin, et al. Implications for Basic Research, Assessment,
2009). Furthermore, in studies of anxious children and and Treatment
adolescents it has been shown that reappraisal effectively
reduced negative emotion for both anxious and non-anxious To date, the study of emotion regulation has largely relied
children, and its efficacy did not differ between the two upon self-report assessments constrained to a limited range
groups (Carthy, Horesh, Apter, Edge et al. 2010; Carthy, of strategies that are not anchored to specific life events,
Horesh, Apter, and Gross 2010). such as the Emotion Regulation Questionnaire (Gross and
The present findings converge with prior theoretical John 2003), the Difficulties in Emotion Regulation Scale
(Mennin et al. 2002), experimental (Gross and John 2003), (DERS; Gratz and Roemer 2004), and the Negative Mood
and clinical (Campbell-Sills et al. 2006) investigations in Regulation Scale (NMR; Catanzaro and Mearns 1990).
suggesting that use of emotion suppression is elevated in The ERI quantifies frequency and self-efficacy of
anxiety disordered populations. For example, one study multiple, distinct emotion regulation strategies and thus
showed that individuals with SAD believe that emotional provides a more refined assessment and classification of
expression is inappropriate and must be controlled, and this real-life emotion regulation strategies. In conducting these
belief partially mediated the association between SAD and interviews, we found that participants occasionally offered
expressive suppression (Spokas et al. 2009). In a laboratory responses that did not match the emotion regulation
emotion induction, participants with mixed anxiety disor- category under investigation. Given the interview format,
ders endorsed more expressive suppression (Campbell-Sills in these cases, the interviewer was able to offer prototypical
and Barlow 2007), indicating the importance of over-use of examples of the category in question and the participants
expressive suppression in this clinical context. were better able to determine whether they used that
particular category or not. Because there is no such
Emotion Regulation Self-Efficacy in SAD opportunity for clarification when completing question-
naires, this represents a clear advantage for the ERI
Individuals with SAD had lower self-efficacy when using approach to assess ER strategies.
cognitive change and expressive suppression than HCs. Using the ERI, it was observed that individuals with
This may be due to a deficit in the efficacy of these SAD use overlapping yet differentiable constellations of
strategies or to the perception that the strategies were not adaptive and maladaptive emotion regulation strategies. For
successful (or both). There is evidence that, when cued, instance, to cope with a work meeting, one person with
individuals with SAD are able to implement cognitive SAD may favor mental avoidance (attentional deployment)
change strategies and thereby decrease their negative whereas another will over-prepare (situation modification).
emotional experience (Goldin, et al. 2009). This suggests Another may clench his jaw, shoulders, and hands in
that, although emotion regulation ability may be intact, the attempt to hide his anxiety (expressive suppression). Using
perception of one’s actual emotion regulation efficacy may tools such as the ERI to understand which combination of
be distorted in SAD. strategies individual clients favor may be useful for
In gaining a fuller understanding of emotion regulation in clinicians to identify specific therapeutic techniques that
SAD, it is important to consider the broader context in which directly target dysfunctional strategies such as mindfulness
emotion regulation abilities lie. The current study focuses on for those who inflexibly rely on attentional deployment or
emotion regulation, a sub-category of the broader construct of acceptance for those who over-use expressive suppression.
emotional competence. Emotional competence refers to how Additionally, this interview is not limited to use with
effectively people deal with emotions and emotionally SAD. It could potentially be modified for use with different
charged problems (Ciarrochi et al. 2003; Saarni 1999) and emotions (other negative or even positive emotions),
its two main components include: 1) the ability to identify psychological disorders (e.g., substance abuse, eating
one’s own emotions, and 2) the ability to manage one’s disorders, depression), and developmental stages (e.g.,
emotions. In the current study, our focus was on emotion children, adolescents, the elderly). Such extensions would
management. It is also important to note that individuals with provide a clearer understanding of emotion regulation in
SAD may be lacking in their ability to be aware of and healthy and clinical samples and inform our understanding
identify their emotions. One study showed that people with and treatment of emotional disorders.
SAD are less able to pay attention to their emotions, and
have more difficulty describing their emotions than controls Limitations and Future Directions
(Turk et al. 2005). Therefore the emotion difficulties
experienced by individuals with SAD may include deficits Although this study assessed each of the five major types of
in awareness of their own emotional states, as well as in the emotion regulation strategies postulated by Gross, in the
ability to regulate emotions. future it will be important to make even more specific
J Psychopathol Behav Assess (2011) 33:346–354 353

distinctions among emotion regulation strategies. For The participant exclusion criteria were dictated by a
example, it is possible that HCs use situation modification larger study, and although they were appropriate for our
just as frequently as people with SAD, but people with data collection purposes, excluding these individuals may
SAD use more safety behaviors (Clark and McManus limit the generalizability of the current findings. Future
2002). Future research should investigate subcategories of research may benefit by including a broader range of
situation modification, attentional deployment and cogni- individuals, including individuals with other Axis I and
tive change to see if there are more specific deficits in SAD Axis II disorders.
and to further examine the adaptive and maladaptive The current study was able to determine emotion
variants within each subcategory. regulation abnormalities over and above emotional reactiv-
The data gathered in the current study are based on ity differences. Future research should look more specifi-
participants’ own reports of their emotion regulatory cally at the links between reactivity and regulation. For
strategy usage. The degree to which individuals are instance, anecdotal reports from the interview indicated
conscious of attentional or cognitive shifts to regulate their higher anxiety may call for less effortful emotion regulation
emotions is unknown. This is a concern as one study strategies (situation selection or situation modification), and
showed that individuals with SAD are less aware of their lower anxiety situations may allow for more cognitively
emotions than healthy controls (Turk et al. 2005). The task demanding strategies such as cognitive change. This
of adequately assessing regulatory self-efficacy is a difficult suggests the possible utility of a graduated approach to
one; however, the ERI does an adequate job of addressing the teaching of emotion regulation skills, starting with less
this by requiring individuals to provide concrete, objective anxiety-evoking situations and moving to more anxiety-
examples of using the regulatory strategies. Trained provoking situations. Finally, future studies could look to
interviewers facilitating the session are then able to further see if a particular ER profile or response style predicts
clarify with individuals about the use of their strategies and treatment outcome and symptom severity.
the appropriate categories of the objective behaviors. Future
versions of the ERI could add self-efficacy measures for the
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