New research looks at how symptoms and coping strategies go together.
By Grant H. Brenner
I found that with depression, one of the most important things you could realize is that you’re not alone. —Dwayne Johnson
Depression and anxiety are distinct from one another, while also overlapping. Depression can involve intrusive negative thoughts and pessimistic fears that overlap with worry and anxiety. Unremitting symptoms of anxiety and panic contribute to hopelessness and helplessness, leading one to feel trapped, without escape from emotional pain, increasing suicide risk. Depressive and anxiety disorders are common, account for a high level of distress and disability, and are widely recognized as being under-treated.
Emotion Regulation and Resilient Coping
Emotion regulation strategies are key, and coping can be either positive or negative. Positive and negative emotion regulation strategies cross different conditions, and are therefore called “transdiagnostic.” For example, we can use positive coping to deal with any clinical condition, whether it is depression, anxiety, diabetes, or any other issue. Coping goes beyond diagnosis as well, and relates to how we manage any stressor.
Adaptive coping is associated with greater resilience and a better long-term outlook. Adaptive coping includes taking a proactive approach to challenges, empowering oneself; relying on useful tools such as exercise, sleep hygiene, maintaining routines, and support systems; using positive psychology to reframe the situation; and avoiding ways of thinking that lead to nonconstructive behaviors. The capacity to intentionally use adaptive approaches varies, and may be severely impaired by the presence of more severe clinical conditions including anxiety and depression, as well as other factors such as external stressors and innate predisposition.
Repetitive Negative Thinking Versus Positive Appraisal
Researchers break emotion regulation strategies into two big buckets: “positive reappraisal” and “repetitive negative thinking”. As cited by Everaert and Joormann (2019), reviewed below, positive reappraisal is “defined as cognitively reframing the meaning of a distressing event in a less negative or more positive manner to minimize its emotional impact” while repetitive negative thinking “refers to a transdiagnostic process of excessive thinking about negative topics that is passive and/or difficult to control.”
We believe that greater use of positive reappraisal and reduced use of repetitive negative thinking is associated with better outcomes, and many therapeutic approaches seek to modify one or the other of these factors. For example, cognitive-behavioral therapy focuses on directly identifying and modifying patterns of thought and action, psychodynamic therapy looks at how past patterns can repeat in the present to provide greater choice through self-understanding and new experiences in therapeutic relationships, and psychiatric medication management aims to directly modify symptoms, to name some basic approaches. Research is incomplete regarding which aspects of depression and anxiety are affected by positive reappraisal versus repetitive negative thinking.
Analyzing Symptom Networks and Emotion Regulation Correlated with Depression and Anxiety
In order to better understand the transdiagnostic role of positive reappraisal and repetitive negative thinking, Everaert and Joorman use network analysis to look at how different symptoms cluster together and are impacted by different emotion-regulation strategies. Working with 468 participants, they administered a series of surveys including the Beck Depression Inventory, the Beck Anxiety Inventory, relevant parts of the Repetitive Thinking Questionnaire, and the reappraisal piece of the Cognitive Emotion Regulation Questionnaire. Their sample included participants without clinically significant symptoms, those with mild to moderate symptoms, and those with more severe difficulties, spanning the gamut from having no diagnosis to likely suffering from depressive and anxiety disorders.
They looked at how different symptoms of depression and anxiety clustered together into webs of inter-related symptoms. They correlated how those networks of symptoms related to different emotion regulation strategies. They studied how positive reappraisal and repetitive negative thinking did or did not go together when dealing with depression and anxiety.
They developed three maps: the emotion-regulation-depression-symptoms (ER-DEP) network; the emotion-regulation-anxiety-symptoms (ER-ANX) network; and the emotion regulation-depression and anxiety co-occurrence symptom (ER-COO) network. Rather than go by traditional diagnostic categories, to an extent arbitrary as they are based on older diagnostic systems, they analyzed the study data for internal patterns, rather than fitting the data to prior expectations.
Research Results: Anxiety, Depression and Emotion Regulation
For ER-DEP, they found that repetitive negative thinking connected with guilty feelings, changes in appetite, agitation, being self-critical, and feeling sad. Positive reappraisal, on the other hand, only was inversely related with pessimism. The greater the positive reappraisal, the lower the pessimism.
Repetitive negative thinking and positive reappraisal were not closely related. The key symptoms (most “central nodes in the network”) for emotion regulation in depression were worthlessness, loss of pleasure, self-dislike, negative thinking, loss of interest, and sadness, and they most strongly went along with repetitive negative thinking. Positive reappraisal did not have a strong impact on core symptoms of depression, overall.
For ER-ANX, repetitive negative thinking most strongly correlated with fear of losing control, fear of worst-case scenarios, inability to relax, and nervous feelings. Positive reappraisal was correlated with reduced worst-case scenario fears only. Positive reappraisal and repetitive negative thinking were not correlated with one another here. The core symptoms in the anxiety network were feeling unsteady or shaky, fear of the worst happening, feeling fear or terror, being short of breath, and feeling faint or lightheaded. Again, repetitive negative thinking had a much stronger contribution to anxiety symptoms than positive reappraisal protected against them.
Are Positive Reappraisal and Repetitive Negative Thinking Connected?
Highlighting the findings from the ER-DEP and ER-ANX analyses, the ER-COO found that repetitive negative thinking contributed much more strongly than positive reappraisal for most core symptoms. Repetitive negative thinking was the most strongly connected node in that network, whereas positive reappraisal was the weakest.
Repetitive negative thinking connected with many core symptoms of depression and anxiety, including guilty feelings, change in appetite, being self-critical, and fears of losing control, worst-case scenarios, and nervousness, respectively. Positive reappraisal was correlated with less pessimism, and weakly with reduced fear of worst-case scenarios.
Emotion Regulation in Everyday Life
These findings have important implications, though they require further study and replication. Counterintuitively, positive reappraisal appears to play a relatively small role, though not necessarily unimportant.
First, positive reappraisal is not associated with many of the core symptoms of depression and anxiety. While this research is correlational, and does not look at intervention or causality, it suggests that repetitive negative thinking may be a higher-value target for most of the core symptoms of anxiety and depression. Given the effort required to change emotion regulation strategies, focusing on reducing or stopping repetitive negative thinking may have more bang for the buck. However, positive appraisal may be an important target in specific cases.
While positive reappraisal did not correlate with a large number of symptoms, the ones it does correlate with are essential—reduced pessimism and a greater sense that good things can happen. Small but critical shifts in how we see things and what we believe is possible may snowball, making a massive difference in how things turn out.
For individuals seeking change, this and related research helps to identify not only which symptoms, when tackled, will most alleviate anxiety and depression, but also which emotion regulation strategy is most strongly correlated with relief of those symptoms, allowing for a more personalized therapeutic approach. Targeting core symptoms and setting concrete emotional regulation goals to reduce those symptoms is likely to yield the best results.
Efforts to change and get treatment can be effective, but caution and compassion are required. It can be easy to fail to empathize with people caught in the throes of depression and anxiety when we don’t understand what that perspective is really like. Mental illness often robs people of choice and perspective. Making active decisions to think differently, to see things differently, is often simply not possible—especially with more severe conditions.
Simple exercises such as imagining a stop sign or working through worst-case scenarios may help some stop negative thoughts or defuse terrible fears; for others it isn’t enough and may cause frustration when ineffective.
Likewise, cognitive-behavioral therapy may be very challenging in the face of helplessness and hopelessness, uncomfortable agitation and nervousness, and fatigue. Going to traditional therapy and making connections with the past may not change the present, though support and shared problem-solving efforts may identify areas where small constructive changes are possible, and can build up over time. Positive reappraisal in some cases is best used selectively, and sparingly.
When people close to those with depression and anxiety don’t understand the challenges or get what it is like to have no choice in how one sees oneself and reality, prescriptions to think positively or stop thinking negatively may go nowhere fast, leading to mutual frustration, injury, sometimes destroying relationships—ultimately a vicious cycle of dwindling support.
On the other hand, having loved ones and professionals who understand, who can help identify core areas where progress is possible at a pace which works, allows for a greater chance of sustainable recovery. Being able to partner together, get aligned, and share one another’s perspective is a game-changer.
Network analysis of positive appraisal, negative thoughts, depression and anxietySource: Everaert and Joorman, 2019