1
Abstract
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Following stroke, individuals often experience reduced social participation, regardless of
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physical limitations. Impairments may also occur in a range of cognitive and emotional
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functions. Successful emotion regulation, which has been identified as important in
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psychological adaptation to chronic illness, is associated with better perceived psychological
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well-being and social functioning. However, there is little evidence about the effect of stroke
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on emotion regulation difficulties, and associated impact on important outcomes in recovery
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from stroke.
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Objectives
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The objectives were (1) to determine whether people who have had a stroke reported greater
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difficulties in emotion regulation than controls, and (2) to establish whether emotion
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regulation difficulties relate to social participation.
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Methods
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75 stroke and 40 healthy participants completed measures of emotion regulation (DERS),
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social participation (mFLP, WHOQoL-Bref) and activity limitations (mFLP). Stroke
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participants were seen at the acute stage (63 days post-stroke) for study 1 and 18 months
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post-stroke for study 2.
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Results
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In Study 1 acute-stage stroke patients had significant impairments on impulse control,
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awareness of emotions, and strategies for emotion regulation. There was also evidence that
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emotion regulation difficulties (impulse control, awareness and clarity about emotions) were
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associated with social participation in the stroke sample, even after controlling for potential
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confounders. In Study 2, there was evidence that, in the chronic-stage post stroke, difficulties
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with strategy and acceptance of emotions were associated with social participation
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restrictions. Whilst emotion regulation as a whole in the acute phase predicted social
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participation in the chronic phase of stroke, no one domain of emotion regulation was a
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significant predictor of social participation >1 year later.
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Discussion
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These results indicate that multiple aspects of emotion regulation are impaired following
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stroke, with implications for social participation and recovery.
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Practitioner points
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This research highlights the following important clinical implications
1) Following a stroke, emotion regulation can be immediately and persistently
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affected, with post stroke individuals experiencing greater difficulties with their
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emotion regulation than control participants.
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2) Emotion regulation can significantly predict important stroke outcomes including
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social participation and quality of life, over and above physical limitations and
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other post stroke confounders.
3) This study highlights the potential for developing a behaviour change intervention
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to address emotion regulation difficulties and thus ensuring individuals maximise
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their potential rehabilitation outcome.
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Cautions of the study for consideration
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1) Emotion regulation was a self report measure, and proxy measures would have
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been desirable.
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2) We are unable to establish if the post stroke individuals differed from the controls
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on their emotion regulation prior to stroke.
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Introduction
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Stroke is the leading cause of severe complex disability in the UK. Incidence of first
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time stroke is estimated at 87,000 per annum in the UK (National Office for Statistics, 2001).
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Advances in stroke treatment and rehabilitation have seen an increase in individuals surviving
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stroke, however this is associated with an increase in individuals returning home with some
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degree of residual impairment.
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Following stroke, individuals may experience changes in functional ability, mobility,
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and in their emotional functioning, with many reporting changes in emotional state.
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Impairments in all, or any, of these functions can result in individuals being less inclined or
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less able to participate in social events, activities and interpersonal relationships. Stroke
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survivors often experience a reduction in social participation, as observed in reduced
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engagement in leisure and social activities, which cannot be explained solely by activity
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limitations caused by physical impairments (Desrosiers, Rochette, Noreau, Bravo, He´bert, &
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Boutin, 2003), yet stroke survivors tend to think of their own recovery in terms of achieving
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social goals (Pajalic, Karlsson & Westergren, 2006). Feelings of social isolation and being
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unable to participate socially following stroke are often reported (Haun, Rittman, & Sberna,
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2008). Socially isolated people are at increased risk for recurrent strokes, myocardial
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infarction, and mortality compared with people who are more socially engaged (Robinson,
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Murata & Shimoda, 1999). Social isolation, inability to engage in work and reduced social
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support are also linked to increased risk of depression and slower recovery of functional
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status during stroke recovery (Ayerbe, Ayis, Rudd, Heuschmann & Wolfe, 2011). Whilst
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social functioning has been identified as a key determinant in patients’ perceived quality of
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life (Lynch, Butt , Heinemann, Victorson, Nowinski, Perez, Cella, 2008) the factors which
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influence social functioning, social networks and general social participation within the
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stroke population remain relatively unexplored. Gaining a greater understanding of these
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factors influencing social participation restrictions following stroke is an important issue.
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Emotions have been identified as important for successful social interaction and
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participation (Gross, 2002). Following stroke, negative mood states are commonly
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experienced (Bogousslavsky, 2002). The prevalence of anxiety and depression following
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stroke has been reported to be around 28% (Barker- Collo, 2007) and 33% (Hackett, Yapa,
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Parag & Anderson, 2005) respectively. Post stroke depression, anxiety and other emotional
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symptoms affect functional and social outcomes (Robinson et al, 1999). The role of emotion
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regulation in both its influence over negative mood (Ehring, Tuschen-Caffier, Schnulle,
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Fischer & Gross, 2010) and in successful social functioning (Kimhy, Vakhrusheva, Jobson-
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Ahmed, Tarrier, Malaspina & Gross, 2012) suggests that this may be an important area for
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exploration.
Emotion regulation is the ability to recognise and understand one’s own emotions, as
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well as modulate the extent of emotional arousal that is experienced. Successful emotion
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regulation allows monitoring and evaluation of emotions and highlights awareness and
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understanding of emotions as critical to this process (Gratz & Roemer, 2004). In particular
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Gratz and Roemer emphasise the functionality of emotion, and the importance of the
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individual accepting and valuing their emotional responses rather than controlling or
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modulating their emotional experiences and expression. The individuality of emotional
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response and the context in which the emotion is experienced has also been highlighted as
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important in understanding successful emotion regulation (Gratz and Roemer, 2004). The
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Difficulties in Emotion Regulation Scale (DERS, Gratz & Roemer, 2004) was developed to
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assess emotion dysregulation more comprehensively than existing measures, focusing on the
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conceptualisation of emotion regulation as an adaptive rather than control process. The
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DERS items were chosen to reflect difficulties within the following dimensions of emotion
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regulation: (a) awareness and understanding of emotions; (b) acceptance of emotions; (c) the
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ability to engage in goal-directed behaviour when experiencing negative emotions; and (d)
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access to emotion regulation strategies perceived as effective. The final dimension reflects
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an attempt to measure the flexible use of situation appropriate strategies to modulate
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emotional responses. The sub-domains of the DERS have been shown to provide clinically
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relevant and significant results, beyond the total DERS score (Gratz & Roemer, 2004). The
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DERS has provided empirical support for a multidimensional conceptualization of emotion
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regulation.
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Across many health conditions, successful emotion regulation has been associated
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with good health outcomes and satisfaction with social relationships (Van middendorp et al,
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2005; Lopes, Salovey, Beers & Cotes, 2005). Emotion regulation has also been shown to be
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a key predictor of self rated quality of life and social participation in individuals with
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multiple sclerosis (Phillips, Saldias, McCarrey, Scott, Henry, Summers, & Whyte, 2009).
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Difficulties in emotion regulation have been argued to result in anxiety and depression, with
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individuals who have difficulties in emotion regulation experiencing longer and more severe
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bouts of depression and anxiety (Aldoa, Nolen-Hoeksema & Schweizer, 2010). Weaknesses
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in specific aspects of emotion regulation may be particularly important within a clinical and
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rehabilitation setting, where the clarity of emotional awareness and ability to direct emotions
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towards a goal becomes critical. (Gratz & Roemer, 2004).
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In stroke, many factors contribute to restrictions in social participation, including
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physical activity limitations, cognitive impairment and negative mood. In addition to this, the
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underlying emotional regulation processes which influence an individual’s ability to continue
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to achieve their desired goals in the face of negative mood may influence social participation
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independently of these other post stroke factors.
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This research aims to examine the link between emotion regulation impairments and social
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engagement in stroke survivors.
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The current research aimed to determine:
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1) Whether emotion regulation ability was impaired in stroke survivors compared to
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healthy controls.
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2) Whether such impairments correlate with and predict social participation
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following stroke, independently of an individual’s activity limitations and other
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post stroke confounders. We investigated whether emotion regulation impairments
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change from the acute phase two months post-stroke (Study 1) to the chronic
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phase 18 months later (Study 2). This is an important issue as this is often a period
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of considerable recovery of cognitive and emotional functions (Patel, Coshall,
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Rudd & Wolfe, 2003).
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3) Whether specific impairments in emotion regulation in the acute phase of stroke
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predict quality of life and social participation 18 months later.
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Study 1: Emotion regulation and social participation in the acute phase of stroke.
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This study addresses the following hypotheses:
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1) Stroke patients will experience greater difficulties with emotion regulation compared
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to healthy controls.
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2) Emotion regulation difficulties in stroke patients will correlate with reduced social
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participation, independently of activity limitations, cognitive impairment, mood and
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years of education.
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Methods
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Participants
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Stroke. Participants were identified from Aberdeen Royal Infirmary, Woodend
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Hospital and the NHS Grampian Stroke Register between February 2008 and March 2009
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within 90 days of stroke. The following inclusion criteria were applied: 1) a confirmed
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diagnosis of stroke; 2) no pre-existing neurological condition, psychiatric condition or
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chronic drug/alcohol abuse; 3) no severe cognitive impairment (MMSE score <= 24). A total
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of 639 individuals were identified as potentially eligible, of whom 37 died and 78 had a
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diagnosis other than stroke. Of the 524 confirmed with a stroke diagnosis, 199 did not fulfil
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the inclusion criteria, leaving 326 eligible patients. All 325 stroke patients were approached,
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189 failed to respond to the invitation, 52 declined to participate and 84 consented to
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participate. 9 withdrew after consent, leaving 75 participants who completed the assessment
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(47 male; mean age 65.99 (SD 12.09) years old; mean time post stroke of 63 (SD 36) days at
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assessment 1).
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Controls. 40 healthy controls (27 males; mean age 70.70 (SD= 8.50)) were recruited through
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the School of Psychology Public Participation Panel, University of Aberdeen. The inclusion
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criteria were; no pre-existing neurological conditions, psychiatric condition or chronic
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drug/alcohol abuse; no severe visual and/or hearing impairment.
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All participants were of British nationality and white British ethnicity, with average years of
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education of 11.85 (SD 3.25) and 11.90 (SD 2.38) for stroke and control respectively.
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Procedure
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Eligible participants were identified consecutively from stroke units and clinics and invited to
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participate by letter from the lead clinician. If they wished to participate, they either posted
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their reply on the ward or in a freepost envelope. Participants could opt to be assessed on the
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ward, at home or at the University of Aberdeen. Consenting participants completed two
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assessment sessions, the first at 2-months and the second at 18-months post-stroke, each
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session lasting approximately 90 to 120 minutes. The following measures were administered
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at both time points. Other administered measures are reported in the published protocol
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(Scott, Phillips, Johnston, Whyte, & MacLeod, 2012).
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Measures
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Emotion regulation
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Emotion regulation was assessed using the Difficulties in Emotion Regulation Scale
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(DERS, Gratz, & Roemer, 2004), a 36-item self-report questionnaire assessing multiple
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aspects of emotion regulation. The scale provides a total score and six subscale scores
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measuring difficulties in emotion regulation, including: acceptance of emotions (‘‘When I’m
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upset, I become embarrassed for feeling that way’’), ability to engage in goal-directed
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behaviour (‘‘When I’m upset, I have difficulty getting things done’’), impulse control
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(‘‘When I’m upset, I feel out of control’’), awareness of emotions (‘‘I pay attention to how I
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feel’’), access to regulation strategies (‘‘When I’m upset, I believe that there is nothing I can
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do to make myself feel better’’), and clarity of emotions (‘‘I am confused about how I feel’’).
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Participants indicate how often each item applies to them on a 5-point Likert-type scale, with
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1 as almost never and 5 as almost always. Higher scores indicate greater difficulties in
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emotion regulation.
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Anxiety and Depression was assessed using the Hospital Anxiety and Depression Scale
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((HADS) Zigmond & Snaith, 1983) which measures anxiety and depression, minimising
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confounding with physical symptoms in stroke. The 14 item scale (7 measuring anxiety and 7
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depression) asks participants to think of how they have been feeling in the past 7 days and
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choose the appropriate response from a list of 4 answers.
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Social participation was assessed using three measures of participation;
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The Modified Functional Limitation Profile (mFLP) (Pollard & Johnson 2001) is a
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hierarchical measure of participation, with 136 items giving scores across 12 categories.
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Using discriminant content validation (DCV) methods, the categories established to assess
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participation are; mobility, household, recreation, social interaction and work. Participants
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are asked to think of themselves as they are today, due to their stroke, and read each
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statement in each category indicating whether each statement described them or not. When a
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statement described the participant this was scored and they moved on to the next category.
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Participants’ scores are the weight given to the selected item in each category and higher
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scores indicate greater participation restriction. A percentage score for the mFLP
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Participation domain is derived by multiplying the item weight of the selected item in the
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category by 100 and then divide by the maximum score of the category.
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The Lubben Social Network Scale (LSNS-18) (Lubben, 1988) uses 18 questions to evaluate
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the size and type of social network (family ties, friendship ties and neighbourly ties). The
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LSNS-18 assesses the size of the respondent’s active social network (i.e., relatives or friends
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seen or heard from ≥1 times/month), perceived support network (i.e., relatives or friends who
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could be called on for help), and perceived confidant network (i.e., relatives or friends to
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whom the respondent could talk about private matters). Participants choose which response is
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accurate for their circumstances for each question, providing a score in which higher scores
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are associated with larger social networks, higher levels of perceived support and confidants.
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The WHO-QoL BREF (The WHOQoL Group,1998) is a measure of multidimensional aspects
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of quality of life, separated into four domains; physical, psychological, social relationships
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and environmental. Using DCV methods, 80% of the WHO-QoL items have been
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demonstrated to tap some aspect of social participation (Pollard, Johnston & Dieppe, 2006)
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with 42% of those items purely measuring social participation. The percentage of items
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purely measuring participation are; 67% within the Social domain, 17% within the
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psychological domain and 88% within the environmental domain. The whole measure was
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administered and the three domains of Social, Psychological and Environmental used in
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analyses. The measure instructs participants as to the time frame that they must consider for
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each item and whether they are to think about ‘how much’, ‘how completely’, ‘how satisfied’
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or ‘how often’ they have felt that way. Responses are recorded accordingly, with higher
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domain and measure scores indiciating higher levels of perceived Quality of Life.
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Activity limitation
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Activity limitation was assessed using the categories from mFLP measuring activity
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limitation as established by DCV as discussed above i.e. ambulation, body care, alertness and
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communication. The mFLP activity limitation domain is scored in the same manner as the
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participation domain of the mFLP.
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Cognitive function screen
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A basic cognitive functioning screen was conducted using the Mini Mental State
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Examination (MMSE, Folstein, Folstein & McHugh, 1975). The short questionnaire, includes
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simple questions and tasks assessing orientation in time and place, registration, recall,
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attention and calculation, language, repetition and complex demands. The MMSE detects
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moderate cognitive difficulties in individuals with stroke at 1-month post-stroke and
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subsequent follow-up (Bour, Rasquin, Boreas, Limburg & Verhey, 2010). The recommended
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cut off of 24 allowing 96% specificity for dementia provided by Bour et al (2010) was used.
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Results
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Descriptive statistics are reported in Table 1. A MANOVA compared stroke versus
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healthy participants on cognitive function and emotion regulation measures. There was a
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statistically significant difference between groups, F (9,106)= 3.24, p<.01, Wilk's Λ = 0.789,
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partial η2 = .21. Further analyses for multiple comparison between groups, with post hoc
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corrections, revealed that stroke patients had significantly greater difficulties on DERS total
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score, F (9,106)= 5.22, p<.05, and specifically in three domains of emotion regulation;
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Impulse Control, F (9,106)= 5.49, p<.05, Awareness F (9,106)= 2.76, p<.05 and Strategy, F
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(9,106)= 5.04, p<.05 (Table 1).
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Insert table 1 here
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To address the hypothesis that emotion regulation difficulties in stroke patients would
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correlate with reduced social participation, independently of activity limitations and other
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post stroke confounders, regression analyses were conducted (see Table 2) on stroke
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participants’ data only, with all subscales of the domain entered in one step into the
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regression model. Results demonstrated that no individual aspects of emotion regulation
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explained variance in the mFLP measure of Social Participation. The regression models for
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all three WHO-QoL domains were significant. DERS Goals scores were associated with
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Psychological quality of life, while Impulse Control, Awareness and Clarity were
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significantly associated with social quality of life. DERS Clarity and Awareness were also
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significantly associated with the WHO-QoL Environment domain. Although DERS
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Awareness was also significantly associated with social network size, the regression model
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was not significant overall.
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Insert table 2
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As other aspects of functioning influencing social participation may be affected following
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stroke, hierarchical regressions were conducted controlling for cognitive impairment
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(MMSE), mood (HADS), activity limitations (mFLP) and years of education. A separate
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hierarchical regression analysis was carried out for each social participation measure for
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which there were significant predictors in the initial regressions reported in Table 2. For each
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hierarchical regression the covariates were entered in the first model, then the significant
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emotion regulation variables from Table 2 were entered in the second model.
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TheWHOQoL Psychological domain. (see Table 3). Model 1, including only the covariates,
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was not significant, F(4,71)=1.96, n.s. Adding DERS Goals to the model substantially
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increased the amount of variance explained in the QOL measure, resulting in a significant
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regression, F(5,70) = 5.13, p <.001), ∆R2 = .19, p <.001. For the WHOQoL Social domain.
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(see Table 4), Model 1 including only the covariates explained a significant proportion of
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variance, F(4,71)= 3.17, p<.05. but adding in the emotion regulation variables explained
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more variance, F(7,68)=6.77, p< .001, ∆R2 = .27, p <.001. Impulse, Awareness and Clarity
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scales from the DERS were all significant predictors of WHOQoL Social.
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Insert table 3 & 4 here
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For WHOQoL Environmental domain (see Table 5) the covariates only Model 1 did not
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explain significant variance, F(4,71)=1.75, n,s, but adding in the emotion regulation did,
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Model 2 F(6,69)=3.25, p< .01, ∆R2 = .14, p <.01. DERS Clarity was the only significant
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predictor in this model. Finally, for the Lubben Social Network scale (Table 6) the covariate
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Model 1 was not significant F(4,71)=1.07, n,s, and adding emotion regulation (Model 2)
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improved the fit, F(5,70)=2.73, p<.05; ∆R2 = .08, p <.01. Here DERS Awareness
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significantly predicted social network score.
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Insert table 5 & 6 here
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Discussion
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This study sought to establish if individuals with stroke experienced greater
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difficulties in emotion regulation than healthy controls, and whether such difficulties were
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associated with social participation restrictions. The results demonstrated that stroke
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participants showed significantly more difficulties in emotion regulation than healthy
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controls. Stroke participants overall reported more emotion regulation difficulties and
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specifically in three DERS domains; Awareness, Impulse, and Strategy. Following a stressful
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and potentially life altering event such as a stroke, after which emotional distress can occur,
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individuals may experience their emotions as overwhelming and find such a wall of emotions
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difficult to acknowledge (awareness), distract themselves from their negative emotions
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(strategy) and struggle to control their behaviour in the face of such overwhelming emotions
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(impulse). The particular emotion regulation difficulties identified appear to be reactive, as
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such the lack of significant association with nonacceptance of emotion at this stage could be
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hypothesised as occurring because individuals are simply not clear enough, and aware
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enough of their own emotions to be at the point of acceptance.
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This research sought to establish whether emotion regulation difficulties following
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stroke may impact on an individual’s social participation and social networks. Four domains
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of emotion regulation, Goals, Awareness, Impulse and Clarity were significantly associated
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with social participation and remained so when cognitive function, activity limitation, mood
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and years of education were controlled for using hierarchical regression.
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Awareness, which refers to recognising that feelings are valid and important and
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acknowledging upsetting emotions, was significantly associated with the WHOQoL Social
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domain and Lubben Social Network Scale. The WHOQoL Social is focused on satisfaction
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with personal relationships and friendships, whilst the Lubben Social Network Scale assesses
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quantity and quality of networks across family, friends and neighbours. The current findings
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suggest that awareness and acknowledgement of feelings may play an important in social
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networks and personal relationships or, such personal relationships may influence the
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acknowledgement of emotions. Impulse control was also significantly associated with
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WHOQoL Social, suggesting that when someone is being overwhelmed by their emotions,
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they gain less satisfaction from their personal relationships or vice versa. The DERS Goals
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domain was the only significant association with the WHOQoL psychological scale. Goals
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is concerned with an individual’s ability to focus on goals and objectives even though they
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may be experiencing negative emotions. Impairment in this domain of emotion regulation
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could reduce satisfaction with psychological functions such as the ability to concentrate or
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that these psychological functions may be needed in order to focus on goals. Clarity of
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emotion regulation was significantly associated with the environment domain of the
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WHOQoL, when controlling for other potential post stroke confounders. Clarity indicates
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whether someone can make sense of their feelings. Confusion over feelings may reduce or be
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reduced by overall satisfaction with social participation and opportunities to participate as
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measured by the environment domain of the WHOQoL.
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In the early phase of post stroke recovery, emotions can often be intense and
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overwhelming (Taylor, Todman, & Broomfield, 2011). Gaining a greater understanding as to
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how emotion regulation influences social participation at later stages in stroke recovery is of
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particular importance. Participation in social events becomes a bigger part of life as
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individuals are discharged from hospital and return to daily life. While Study 1 has shown
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associations between emotion regulation and social participation, stronger evidence of the
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impact of emotion regulation on social participation requires longitudinal data. Accordingly
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a second study was conducted inviting all participants in Study 1 to return, over a year later.
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It was of interest to explore whether emotions in the acute phase post stroke impacted on
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recovery in the longer term.
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Study 2: Emotion regulation and social participation 18 months post stroke
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This study addressed the link between emotion processing and social participation in the
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chronic phase of stroke and addressed two research questions.
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1) Do the same aspects of emotion regulation explain variance in social participation
in the later stages of post stroke recovery as in the early phase?
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2) Do emotion regulation difficulties in the early phase of post stroke recovery predict
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social participation restriction in the later phase?
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Methods
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Participants
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Of the 75 participants from Study 1, 3 died, 2 were medically unwell, 6 declined, 11
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failed to respond to invitation, and 5 could not be contacted. Therefore, 48 participants (28
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male) returned for the second assessment, with a mean age 67.63 (SD 12.92) years old and a
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mean time post stroke of 518 (SD 91) days.
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The same test battery was administered in Study 2 as in Study 1.
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Results.
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In order to ascertain whether the returning 48 participants differed significantly from
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the individuals who did not return for follow up assessment, a series of t-tests were
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conducted. The 48 continuing participants did not differ significantly from those who
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discontinued on any of the study variables at time 1(Table 7).
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Insert table 7 here
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To determine whether the continuing participants had changed significantly from initial
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assessment to follow up paired sample t-tests were conducted on measures of social
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participation, emotion regulation, activity limitation and cognition (table 8). Participants
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reported significantly less participation restriction and significantly improved mood at the
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second assessment, however significantly poorer perceived quality of participation in
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WHOQoL Psychological and Social domains.
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Insert table 8 here
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In order to identify which aspects of emotion regulation were associated concurrently with
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social participation at time 2, regression analyses were conducted (see Table 9). The results
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demonstrate that the emotion regulation domain of Nonacceptance was significantly
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associated with FLP Participation levels, β= .37, p <.05. Non-acceptance of emotions also
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predicted WHOQoL social functioning, β= .47, p <.05. Strategy was significantly associated
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with WHOQoL environment domain, β= .51, p < .05. There were no significant predictors of
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WHOQoL Psychological functioning or social network size.
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Insert table 9 here
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As in Study 1, hierarchical regressions were conducted controlling for MMSE, HADS,
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activity limitations (mFLP) and years of education, for each significant emotion regulation
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variable and social participation measure from the initial regression ( table 9). For FLP
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Participation (Table 10) Model 1 including only the covariates was highly significant,
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F=(4,44)= 14.09, p<.001, with activity limitation the most important predictor. There was no
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additional contribution to variance from the DERS Nonacceptance (Model 2), F=(5,43)=
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11.03, p<.001; ∆R2 = .08, p=ns. Table 11 reports the hierarchical regression for the
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WHOQoL social domain. Although MMSE was significant (t=2.24, p <.05), the covariates
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did not significantly predict the model (Model 1, F (4,44)= 2.10, p=n.s.), while adding in the
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DERS Nonacceptance scale improved the model F (5,43)= 3.49, p<.05; ∆R2 = .14, p <.01.
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Finally, model 1 was a significant predictor of the WHOQoL Environmental domain, (F
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(4,44)= 3.28, p=<.05), with activity limitation the main predictor (Table 12). Adding in the
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DERS strategy measure (Model 2) increased the amount of variance explained, F (5,43)=
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4.51, p<.01, ∆R2 = .12, p <.01, and activity limitations was no longer significant (t=-1.06, p=
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n.s).
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Insert table 10, 11 and 12 here
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In sum, different emotion regulation strategies were significant in explaining variance in the
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later stages of stroke than in the initial phase of stroke.
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To address the question of whether emotion regulation difficulties that were
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evident at time 1, predicted social participation restrictions at time 2, regression analyses
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were run with the four emotion regulation domains that were significantly associated with
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participation at time 1 (Awareness, Impulse, Goals and Clarity) and the five social
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participation variables from time 2.
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Time 1 emotion regulation variables did not significantly predict Time 2 FLP, Lubben or
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WHOQOL social and Environmental measures. Emotion regulation predicted the WHOQoL
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social measurement of social participation, F(6,42)=3.84, P<.01 (table 13), however no
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specific sub domain of emotion regulation was a significant predictor.
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Discussion
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The second study aimed to establish whether the difficulties in emotion regulation
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significant in the initial stages of stroke, remained significant at 18 months post-stroke. The
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results demonstrated that in study 2, whilst emotion regulation continued to be significantly
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associated with social participation, different emotion regulation strategies proved significant.
406
While in the acute phase (Study 1), awareness was associated with three of the four
18
407
significant domains of social participation, by the chronic phase of stroke, awareness was no
408
longer significantly associated with social participation (Study 2). Non-acceptance and
409
Strategy were the only domains of emotion regulation to remain as significant predictor of
410
social participation. This may be because in the acute phase of stroke individuals may be
411
emotionally overwhelmed by the experience of a stroke and social participation may be
412
influenced by the individuals’ reactions to these emotions. Anecdotally patients often report
413
such feelings, and consequently the intense emotions experienced as they try to cope with the
414
experience of the stroke may overwhelm their ability to modulate their emotions and
415
behaviour (strategy) and accept their emotions. However by 18 months post-stroke the
416
emotions are no longer so overwhelming and the strategies adopted to regulate the emotions
417
may be more important in determining participation with difficulties occurring when a person
418
cannot accept their emotions by this stage in their recovery and acknowledge that they can
419
find a way to make themselves feel better when they are upset. The particular emotion
420
regulation difficulties that were observed in study 1, may be viewed within the literature
421
surrounding Post-Traumatic Stress Disorder (PTSD). Emotion regulation difficulties occur in
422
PTSD, particularly in acceptance of emotions, impulse control and strategy (Ehring & Quack,
423
2010). This is of consideration as there is increased evidence to suggest that PTSD following
424
stroke can be as prevalent as 31% of cases (Norman, O’Donnell, Creamer, M & Barton,
425
2012) and have an impact on post stroke recovery by influencing adherence to treatment
426
(Edmondson, Horowitz, Goldfinger, Fei, & Kronish, 2013).
427
The second aim of study 2 was to establish whether the emotion regulation difficulties
428
from the acute phase predicted social participation restrictions in the chronic phase of stroke.
429
Although emotion regulation was significantly associated with social participation, no single
430
domain of emotion regulation was significant.
431
General Discussion
19
432
The results of these two studies establish that following stroke, there are impairments
433
of emotion regulation and that emotion regulation is associated with, and predicts later
434
participation in satisfying life situations. Different aspects of emotion regulation may be
435
important at different stages in recovery and we have explored how these aspects of emotion
436
regulation may function at the acute more reactive versus the later more strategy-driven
437
stages.
438
measurement, while recognising limitations of the current work.
In this discussion, we consider the implications for intervention, theory and
439
440
The association between emotion regulation and social participation requires more
441
detailed examination, as should this continue to establish itself as a key predictor of
442
engagement in social situations and interactions, there is the potential to intervene and
443
develop emotion regulation interventions to assist individuals with impairments.
444
Furthermore, given the close link between aspects of emotion regulation and mood, greater
445
exploration of this association would be important in future research in order to establish the
446
relationship between the two areas in recovery from stroke. Given the prevalence of post
447
stroke depression, if emotion regulation was identified as following a similar path, and indeed
448
predicted post stroke depression, then interventions to improve emotion regulation strategies
449
would be a favourable addition to the non-pharmaceutical treatment of post stroke
450
depression.
451
Emotion regulation interventions have been utilised in several other clinical
452
populations. Cameron & Jago (2008) reviewed two interventions; a self-regulation writing
453
technique for promoting adaptation to stressful experiences and an emotion regulation
454
intervention for women with breast cancer. The interventions were grounded in Leventhal’s
455
common sense model of self regulation and successfully reduced illness related distress. The
20
456
authors highlight the need to understand which emotion regulation strategies are influencing
457
coping and functioning in illness before intervening.
458
In a comprehensive review of the literature Webb, Gallo, Miles, Gollwitzer and
459
Sheeran (2012) explored emotion regulation from an action control perspective, and
460
suggested that difficulties in emotion regulation existed due to a gap between the desired
461
emotional control and the outcome. The intervention strategy reviewed was that of
462
implementation intentions. The review concluded that forming implementation intentions was
463
effective in modifiying emotional outcomes in line with the desire goal, concluding that
464
emotion regulation had been improved. Mindfulness has also been demonstrated to be
465
effective in improving mood and emotion regulation (Chiesa, Serretti, & Jakobson, 2013) and
466
indeed the neural basis for its success has also been highlighted (Holzel, Lazar, Gard,
467
Schuman-Olivier, Vago & Ott, 2013). Further, Gratz, Levy and Tull (2012) have
468
demonstrated support for the theoretical model of Emotion Regulation Group Therapy
469
(ERGT) in interventions and the mediating role of changes in emotion dysregulation across
470
two separate trials of this ERGT in individuals with borderline personality disorder and
471
deliberate self harm. Further exploration of such interventions would be of interest within the
472
stroke population.
473
In this study emotion regulation was assessed using the Difficulties in Emotion
474
Regulation Scale, a self-report questionnaire which was chosen to reflect difficulties in six
475
domains of emotion regulation. Self-report is the most common method used to assess
476
emotion regulation within a clinical group, and although the DERS is significantly associated
477
with behavioural and physiological measures of emotion regulation (Gratz, Rosenthal, Tull,
478
Lejuez and Gunderson, 2006), the general use of self report measures within this research is a
479
limitation. Nevertheless, the finding that different DERS scales may be important at
21
480
different stages in recovery from stroke further confirms the validity of the distinct
481
dimensions identified by factor analysis (Gratz and Roemer, 2004).
482
However, the different findings with different measures of participation further
483
emphasise the lack of an agreed definition of that construct that can facilitate the
484
development of valid measures. There is a need for theoretical elaboration of the construct so
485
that factors influencing participation can be integrated. The current work fits within the basic
486
framework of the International Classification of Functioning and Disability (ICF) and
487
indicates how a particular set of impairments might influence the several indices of
488
participation, and suggests that these impairments may impact participation restrictions
489
directly rather than by influencing activity limitations. However several authors have
490
commented on the need for further elaboration of the participation construct and for
491
clarification of the relationships between the constructs in a theoretical framework that can
492
integrate theory over the several disciplines that investigate participation. Psychological
493
theory has been successfully integrated with biomedical explanations of activity limitations
494
resulting in better prediction and understanding of why and when individuals experiencing
495
impairments may be limited (Johnston & Dixon, 2013). The current findings suggest that
496
models of self-regulation, such as Carver and Scheier’s Control Theory (1998), may indicate
497
how individuals faced with acquired impairments such as deficits in emotion regulation,
498
identify goals (such as managing emotions) compatible with their higher order values of
499
social participation in life situations and engage in self-regulatory strategies to achieve these
500
goals, with resulting impact on positive and negative emotions
501
It will also be important in future research to look in more detail at the potential role
502
of neural damage in emotion regulation difficulties. In particular, damage to brain networks
503
involving the frontal lobes and limbic system might contribute to many of the emotional
504
difficulties assessed in the current research. A study of a large group of brain damaged
22
505
participants who were well characterised in terms of lesion location could shed light on this
506
issue.
507
Emotion regulation in stroke has received little direct attention in the literature.
508
Compared to healthy controls, stroke survivors were significantly impaired in several
509
domains of emotion regulation. Further, emotion regulation variables significantly predicted
510
social participation following stroke independently of cognitive function, mood, education
511
and activity limitations in both the acute and chronic phases of stroke. These findings
512
highlight the importance of examining the links between emotion regulation and social
513
participation in stroke survivors.
514
23
515
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Table 1; Descriptive statistics for stroke and control participants.
Stroke
Control
Variables
Score (SD)
M (SD)
Age (mean)
66.22 (12.13)
70.70 (8.50)
MMSE (mean)
28.90 (1.62)
29.55 (.63)
DERS Nonacceptance
12.76 (6.32)
11.02 (4.17)
2.09
DERS Goals
10.63 (4.55)
9.97 (2.49)
0.97
DERS Impulse
9.42 (4.25)
7.77 (1.74)
5.49 *
DERS Awareness
16.04 (4.70)
14.80 (3.15)
2.76 *
DERS Strategy
14.27 (6.40)
11.97 (3.41)
5.04 *
DERS Clarity
8.92 (3.90)
8.45 (2.52)
0.64
72.07 (21.54)
64.76 (10.57)
5.22*
DERS Total
625
* p < .05 ** p < .01; DERS= Difficulties in Emotion Regulation Scale
626
627
628
629
29
F (9,106)
10.23 **
630
Table 2; Regressions between emotion regulation and social participation variables.
FLP
WHOQOL
WHOQOL WHOQOL
Participation Psychological Social
Restriction
(β values)
(β values)
Lubben
Environment
Social
(β values)
Network
(β values)
Scale
(β
values)
.11
.13
.04
.03
-.01
.03
-.44 *
-.08
.07
-.07
-.24
.13
-.36 *
-.15
.02
.24
-.05
-.27 *
-.26*
-.32 *
DERS Strategy
.34
.02
.21
.11
.03
DERS Clarity
-.13
-.20
-.30 *
-.34*
-.13
F(6,68)
1.39
3.37 *
6.17 *
2.80*
2.12
Total R2
.11
.24
.37
.22
.17
DERS
Nonacceptance
DERS Goals
DERS Impulse
DERS
Awareness
631
* p < .05
632
633
634
635
636
637
638
30
639
Table 3; Hierarchical regression predicting WHOQoL psychological scores from MMSE,
640
years of education, mood and activity limitation (Model 1) and in addition emotion
641
regulation (Model 2).
Model 1
Model 2
B
SE B
β
t
B
SE B
β
t
MMSE
-.19
1.41
-.01
-.13
-.62
1.26
-.05
-.49
Education
-.64
.67
-1.22
-.96
-.31
.60
-.06
-.52
HADS (Total)
-.54
.40
-.17
-1.34
-.08
.38
-.02
-.23
FLP Activity
-.06
.02
-.26
-2.15*
-.01
.02
-.06
-.57
-2.08
.52
-.51
-3.97***
Limitation
DERS Goals
F
1.96
5.13***
Adj R2
.06
.25
∆R2
642
* p < .05; ** p<.01; *** p<.001
643
31
.19***
644
Table 4; Hierarchical regression predicting WHOQoL Social scores from MMSE, years of
645
education, mood and activity limitation (Model 1) and in addition emotion regulation (Model
646
2).
Model 1
Model 2
B
SE B
β
t
B
SE B
β
t
MMSE
2.99
1.43
.26
2.08*
1.68
1.25
.14
1.33
Education
-1.17
.67
-.21
-1.73
-.94
.57
-.17
-1.65
HADS (Total)
-.26
.41
-.08
-.65
.20
.35
.06
.57
FLP Activity
-.05
.02
-.23
-2.01*
-.02
.02
-.09
-.91
DERS Impulse
-1.14
.50
-.26
-2.29*
DERS
-.97
.43
-.24
-2.23*
-1.30
.62
-.26
-2.08*
Limitation
Awareness
DERS Clarity
F
3.17*
6.77***
Adj R2
.12
.39
∆R2
647
* p < .05; ** p<.01; *** p<.001
648
32
.27***
649
650
Table 5; Hierarchical regression predicting WHOQoL Environmental scores from MMSE,
651
years of education, mood and activity limitation (Model 1) and in addition emotion
652
regulation (Model 2).
Model 1
Model 2
B
SE B
β
t
B
SE B
β
t
MMSE
2.44
1.29
.25
1.88
1.23
1.25
.12
.98
Education
-.34
.61
-.07
-.56
-.09
.57
-.02
-.17
HADS (Total)
.04
.37
.01
.12
.29
.35
.10
.81
FLP Activity
-.04
.02
-.21
-1.69
-.02
.02
-.13
-1.11
-.75
.57
-.22
-1.72
-1.21
.57
-.29
-2.11*
Limitation
DERS
Awareness
DERS Clarity
F
1.75
3.25**
Adj R2
.04
.18
∆R2
653
* p < .05; ** p<.01; *** p<.001
654
33
.14**
655
656
Table 6; Hierarchical regression predicting Lubben Social Netwrok scores from MMSE,
657
years of education, mood and activity limitation (Model 1) and in addition emotion
658
regulation (Model 2).
Model 1
Model 2
B
SE B
β
t
B
SE B
β
t
MMSE
1.79
1.24
.19
1.45
.96
1.19
.10
.80
Education
-.59
.591
-.13
-.99
-.36
.56
-.08
-.65
HADS (Total)
-.29
.37
.10
-.79
-.21
.35
-.07
-.61
FLP Activity
-.00
.02
-.04
-.34
.00
.02
.02
.19
-1.20
.40
-.37
-2.97**
Limitation
DERS
Awareness
F
1.07
2.73*
Adj R2
.04
.12
∆R2
659
* p < .05; ** p<.01;***p<.001
660
34
.08***
661
Table 7; Comparison of participants withdrawn and continued to participate in Study 2.
Age
n
M
SD
t
p
Withdrawn
28
63.96
13.10
.78
.66
Continued
48
66.35
11.90
Withdrawn
28
28.18
2.07
1.81
.07
Continued
48
28.90
1.37
Withdrawn
28
111.68
83.97
.63
.52
Continued
48
123.63
75.90
Withdrawn
28
159.09
122.61
.83
.40
Continued
48
182.72
116.44
Withdrawn
28
64.01
20.06
.27
.78
Continued
48
65.31
16.97
Withdrawn
28
63.25
16.99
1.41
.16
Continued
48
70.15
19.26
Withdrawn
28
69.60
14.56
.46
.64
Continued
48
71.58
16.92
Withdrawn
28
19.14
5.84
.39
.69
Continued
48
19.65
5.34
Withdrawn
28
11.28
2.89
.91
.36
Continued
48
12.02
3.61
Withdrawn
28
44.63
13.41
1.77
.08
Continued
48
51.68
16.13
MMSE
FLP Activity limitation
FLP Participation
Restriction
WHOQoL Psych
WHOQoL Social
WHOQoL Enviro
HADS total
Years of Education
LSNS
662
35
663
Table 8; Descriptive statistics time 1 to time 2 for stroke participants completing both
664
assessments.
Time 1
Time 2
Variables
Score (SD)
M (SD)
MMSE
28.90 (1.62)
28.96 (1.12)
-0.32
FLP AL
123.92
123.02
0.79
FLP Participation
181.02
117.13
4.71***
WHOQoL Psych
65.72 (16.76)
60.00 (14.82)
2.25*
WHOQoL Social
70.00 (19.77)
65.00 (20.68)
1.96*
WHOQoL Enviro
71.32 (17.36)
73.67 (15.15)
-.86
HADS
19.51
9.26
7.59***
LSNS
51.71
53.07
-.730
DERS Nonacceptance
12.50 (6.70)
12.18 (6.40)
.30
DERS Goals
9.75 (3.74)
10.04 (4.18)
-.47
DERS Impulse
8.59 (3.14)
9.25 (3.33)
-1.04
DERS Awareness
15.74 (4.54)
16.04 (5.10)
-.37
DERS Strategy
13.04 (4.78)
11.86 (4.14)
1.43
DERS Clarity
8.85 (3.87)
8.71 (2.94)
.25
t
Restriction
665
*p<.05; **p<.01; ***p<.001
666
667
668
669
670
671
672
673
674
36
675
676
677
678
Table 9; Study 2 regressions between emotion regulation and social participation variables.
FLP
WHOQoL
WHOQoL WHOQoL
Participation
Psychological
Social
Environment
Restriction
(β values)
(β values)
(β values)
(β values)
DERS
Nonacceptance
DERS Goals
.02
.47 *
.12
-.06
-.03
-.06
.30
.18
.20
.21
.11
-.06
-.15
-.28
.09
-.06
.06
.20
-.02
DERS Strategy
.06
-.39
-.52
-.51*
.10
DERS Clarity
.09
-.05
-.20
-.36
-.24
F (6,42)
2.58 *
1.30
2.90 *
5.71***
.73
Total R2
.30
.18
.33
.50
.11
DERS Impulse
DERS
Awareness
679
.37 *
Lubben
Social
Network
Scale
(β values)
* p <.05; p<.01; p<.001
680
37
681
682
Table 10; Study 2: Hierarchical regression predicting FLP Participation restriction scores
683
from MMSE, years of education, mood and activity limitation (Model 1) and in addition
684
emotion regulation (Model 2).
Model 1
Model 2
B
SE B
β
t
B
SE B
β
t
MMSE
-15.40
10.71
-.17
-1.44
-15.42
10.83
-.16
-1.42
Education
-5.46
2.97
-.20
-1.83
-5.39
3.01
-.20
-1.78
HADS (Total)
1.08
1.81
.07
.59
1.09
1.83
.07
.59
FLP Activity
.86
.15
.69
5.74***
.85
.16
.67
5.24***
.69
1.94
.04
.35
Limitation
DERS
Nonacceptance
F
14.09***
11.03***
Adj R2
.55
.54
∆R2
685
* p < .05; **p<01; ***p<001
686
38
.08
687
688
Table 11: Study 2 Hierarchical regression predicting WHOQoL Social scores from MMSE,
689
years of education, mood and activity limitation (Model 1) and in addition emotion
690
regulation (Model 2).
Model 1
Model 2
B
SE B
β
t
B
SE B
β
t
MMSE
7.27
3.23
.38
2.24*
7.35
2.98
.39
2.47*
Education
.350
1.05
.05
.33
.61
.98
.09
.62
HADS (Total)
-.14
.61
-.05
-.23
-.06
.56
-.02
-.11
FLP Activity
-.01
.05
-.07
-.36
-.06
.05
-.23
-1.31
8.69
3.16
.41
2.75**
Limitation
DERS
Nonacceptance
F
2.10
3.49*
Adj R2
.09
.23
∆R2
691
* p < .05; **p<01
692
39
.14**
693
Table 12; Study 2 Hierarchical regression predicting WHOQoL Environmental scores from
694
MMSE, years of education, mood and activity limitation (Model 1) and in addition emotion
695
regulation (Model 2).
Model 1
Model 2
B
SE B
β
t
B
SE B
β
t
MMSE
1.64
2.29
.12
.72
-.69
2.29
-.05
-.31
Education
1.46
.75
.32
1.95
1.11
.71
.24
1.57
HADS (Total)
-.07
.43
-.03
-.15
.02
.40
.01
.06
FLP Activity
-.07
.03
-.38
-2.18*
-.04
.03
-.19
-1.06
-12.74
4.75
-.46
-2.68*
Limitation
DERS Strategy
F
3.28*
4.51**
Adj R2
.19
.31
∆R2
696
* p < .05; **p<01
697
698
699
700
701
702
703
704
40
.12*
705
Table 13: Regression analysis between time 1 emotion regulation and time 2 social
706
participation.
FLP
WHOQOL
WHOQOL WHOQOL
Participation Psychological Social
Restriction
(β values)
(β values)
Lubben
Environment
Social
(β values)
Network
(β values)
Scale
(β values)
.27
-.25
-.04
-.02
.15
-.09
-.02
-.27
-.11
-.20
.13
-.08
-.12
-.02
-.33
-.21
-.19
-.32
-.28
.09
F(6,68)
.82
2.08
3.84*
1.16
2.01
Adj R2
.02
.09
.22
.02
.08
DERS Goals
DERS
Impulse
DERS
Awareness
DERS Clarity
707
41