Schizophrenia Research 240 (2022) 135–142

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Schizophrenia Research
journal homepage: www.elsevier.com/locate/schres

Deconstructing emotion regulation in schizophrenia: The nature and

consequences of abnormalities in monitoring dynamics
Lisa A. Bartolomeo, Ian M. Raugh, Gregory P. Strauss *
Department of Psychology, University of Georgia, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Prior studies implicate abnormalities at the identification, selection, and implementation stages of Gross’
Schizophrenia extended process model of emotion regulation in schizophrenia. However, it is unclear whether monitoring
Emotion regulation dynamics (i.e., emotion regulation maintenance, switching, and stopping), another critical component of the
Ecological momentary assessment
model, are also abnormal or what predicts those abnormalities. The current study evaluated switching (i.e.,
switching to a different emotion regulation strategy because the initial strategy was not effective) and stopping
dynamics (i.e., terminating the implementation of an emotion regulation strategy) and their associated mech­
anisms using 6 days of ecological momentary assessment in 47 outpatients with schizophrenia or schizoaffective
disorder (SZ) and 52 healthy controls (CN). Results indicated that individuals with SZ exhibited excessive
switching between emotion regulation strategies and delayed stopping compared to CN, self-efficacy moderated
group differences in stopping abnormalities, and switching and stopping abnormalities were associated with
different patterns of state-level positive and negative symptoms in SZ. Findings may inform psychosocial emotion
regulation therapies for SZ that could incorporate elements for monitoring dynamics and associated mechanisms.

1. Introduction According to Gross’ model, emotion regulation consists of three

Emotion regulation abnormalities are core to many forms of psy­
chopathology and associated with illness liability and poor psychosocial
functioning (Berking & Wupperman, 2012; Sheppes, Suri, & Gross,
2015). Mechanistic processes underlying emotion regulation abnor­
malities are therefore promising targets for prevention and intervention
(Berking et al., 2008; Mennin & Fresco, 2010); however, for such efforts
to be successful, it is necessary to clarify the nature of emotion regula­
tion abnormalities within different psychological disorders so that
treatments can be tailored accordingly. This is highly important for
schizophrenia (SZ), a debilitating illness characterized by multiple af­
fective disturbances, including processes related to emotion perception,
expression, experience, and regulation (Kring & Elis, 2013; Kring &
Moran, 2008; O'Driscoll, Laing, & Mason, 2014; Trémeau, 2006). Un­
fortunately, the link between emotion regulation and the development
and maintenance of psychotic symptoms is not well understood. Facil­
itating this understanding necessitates a more granular approach that
enables examination of multiple, distinct emotion regulation processes
operating in tandem, such as James Gross’ Extended Process Model
(Gross, 2015).
stages (identification, selection, and implementation) driven by valua­
tion systems that receive input of one’s current and desired emotional
states, contextual factors, and past experiences (Gross, 2015). Moni­
toring dynamics underlie these regulatory valuation systems, which are
responsible for tracking the effectiveness of emotion regulation strate­
gies and guiding the decision to maintain, switch, or stop implementing
a strategy. Prior evidence from laboratory and ecological momentary
assessment (EMA) studies indicates that schizophrenia is characterized
by abnormalities at each stage of emotion regulation, including: 1)
inefficient identification characterized by overvaluing the goal to
regulate at low levels of negative affect and undervaluing the goal to
regulate at high levels of negative affect (Raugh & Strauss, in press); 2) a
limited repertoire of emotion regulation strategies and a tendency to
select maladaptive strategies (Green, Hellemann, Horan, Lee, & Wynn,
2012; Horan, Hajcak, Wynn, & Green, 2013; Kee et al., 2009; Kimhy
et al., 2012; Livingstone, Harper, & Gillanders, 2009); and 3) impaired
implementation of numerous emotion regulation strategies, likely
resulting from dysfunctional cognitive and neural processes (e.g.,
aberrant emotion-attention interactions, low cognitive effort) (Bartolo­
meo, Culbreth, Ossenfort, & Strauss, 2020; Morris, Sparks, Mitchell,

* Corresponding author at: University of Georgia, Department of Psychology, 125 Baldwin St., Athens, GA 30602, USA.
E-mail address: gstrauss@uga.edu (G.P. Strauss).

https://doi.org/10.1016/j.schres.2021.12.043
Received 3 June 2021; Received in revised form 9 November 2021; Accepted 25 December 2021
Available online 10 January 2022
0920-9964/© 2022 Elsevier B.V. All rights reserved.
L.A. Bartolomeo et al. Schizophrenia Research 240 (2022) 135–142

Weickert, & Green, 2012; Ursu et al., 2011; van der Meer et al., 2014; participants denied lifetime neurological disorders and substance use
Visser, Esfahlani, Sayama, & Strauss, 2018). To our knowledge, no disorders within the last 6 months. Subjects provided written informed
studies have directly examined monitoring dynamics in SZ, which is consent for a protocol approved by the University of Georgia Institu­
important for understanding how interactions between identification, tional Review Board and were compensated $20 per hour for laboratory
selection, and implementation contribute to emotion regulation testing, $1 per EMA survey completed, and $80 for returning the phone
abnormalities. at the end of the study.
Sheppes et al. (2015) proposed potential sources of dysfunction Six participants (3 SZ and 3 CN) were excluded for not reaching a
within monitoring dynamics that may contribute to emotion dysregu­ priori EMA compliance standards (responding to < 20% of momentary
lation in psychopathology. Switching involves changing the current surveys), resulting in a final sample of 47 SZ and 52 CN. Groups did not
regulatory tactic to a different tactic that is more positively valued. At differ on age, sex, ethnicity, or parental education; however, SZ had
least two patterns of ineffective switching are possible, including a lower personal education (see Table 1). Mean adherence rates were 66%
failure to settle on one strategy (leading to repetitive switching), or a in SZ and 74% in CN (F(1, 96) = 3.51, p = .06).
failure to switch to a new strategy despite evidence that the current
strategy is ineffective. Stopping is defined as terminating an emotion 2.2. Procedures
regulation strategy or tactic when the desired emotional change has
occurred, or when repeated emotion regulation efforts have been un­ The study consisted of an initial laboratory session, six consecutive
successful and the goal to regulate is no longer positively valued. At least days of EMA, and a final post-EMA laboratory session.
two problems with stopping may also be present: terminating a strategy During the initial laboratory visit, participants provided informed
before it has an effect, or terminating too late, even when it is clear that a consent and completed a series of diagnostic and clinical symptom in­
strategy is ineffective. An EMA study by Visser et al. (2018) found that terviews, including the SCID-5 (First, 2015), Brief Negative Symptom
individuals with SZ reported using more emotion regulation strategies Scale (BNSS; Kirkpatrick et al., 2010), Positive and Negative Symptom
than controls at each daily survey prompt and reported exerting high Scale (PANSS; Kay, Fiszbein, & Opler, 1987), and Level of Function Scale
levels of emotion regulation effort even when negative emotion intensity (LOF; Hawk, Carpenter, & Strauss, 1975). All interviews were conducted
was absent. These findings provide indirect support for the hypothesis by either Dr. Strauss (a licensed clinical psychologist) or lab personnel
that abnormal emotion regulation monitoring dynamics occur in SZ and trained to reliability standards (inter-rater reliability of alpha > 0.80)
are characterized by a failure to settle and delayed stopping. who sought consultation with Dr. Strauss to establish consensus for di­
To directly assess the nature of emotion regulation monitoring dy­ agnoses. Participants were provided with a Blu Vivo 5R smartphone
namic abnormalities in SZ, the current study used EMA to examine running Android operating system 7.0 that was programmed with the
switching and stopping dynamics during emotion regulation (specif­ mEMA app from ilumivu to collect EMA data. Trained lab personnel
ically the down-regulation of negative emotion) in daily life. Based on instructed participants in the use of the phone and mobile app, including
prior EMA evidence (Visser et al., 2018), It was hypothesized that in­
dividuals with SZ would exhibit increased switching and delayed stop­ Table 1
ping relative to controls. In addition, the study aimed to identify Participant Demographic and Clinical Characteristics.
moderators of switching and stopping abnormalities by examining
SZ CN Test p-value
psychological processes that have been hypothesized to be involved with (n = 47) (n = 52) Statistic
monitoring dynamic abnormalities, including emotional awareness,
Age 39.53 38.94 F = 0.07 p = 0.80
emotion regulation self-efficacy, and emotion regulation effort (Sheppes
(12.31) (10.26)
et al., 2015). We hypothesized that increased rates of switching and Parental Education 14.05 (2.80) 13.59 (2.88) F = 0.59 p = 0.45
delayed stopping would be associated with reductions in all of these Participant 13.04 (2.25) 15.56 (2.81) F = 23.87 p < .001
processes in SZ. Lastly, associations between monitoring dynamic ab­ Education
% Female 66 69.2 χ2 = 0.12 p = 0.73
normalities and clinical symptoms were examined. Based on prior
% Race χ2 = 7.29 p = 0.20
studies (Badcock, Paulik, & Maybery, 2011; Henry, Rendell, Green, White 59.6 44.2
McDonald, & O'Donnell, 2008; Nittel et al., 2018), it was hypothesized Black 29.8 28.8
that increased rates of switching and delayed stopping would be asso­ Asian-American 0 5.8
ciated with more severe positive and negative symptoms measured via Latinx 4.3 11.5
Biracial 6.4 5.8
EMA.
Other 0 3.8
MCCB T-score 41.51 52.17 F = 18.40 p<
2. Material and methods (15.49) (10.05) 0.001
Symptom Ratings
PANSS Total 64.07
This study was preregistered using Open Science Framework – – –
(14.09)
(https://osf.io/yd9t3) and is a subset of a larger study (Raugh et al., PANSS Positive 17.61 (5.99) – – –
2021). PANSS 6.89 (2.85) – – –
Disorganized
2.1. Participants BNSS Total 15.74 – – –
(13.36)
BNSS Alogia 0.76 (1.95) – – –
Fifty individuals with DSM-5 (American Psychiatric Association, BNSS Anhedonia 4.33 (4.46) – – –
2013) diagnoses of schizophrenia or schizoaffective disorder (SZ) and 55 BNSS Asociality 2.83 (2.62) – – –
healthy controls (CN) participated in the study. SZ were recruited from BNSS Avolition 3.98 (3.37) – – –
BNSS Blunted 2.43 (3.59)
local community outpatient mental health centers, flyers, and electronic – – –
Affect
advertisements. Clinical diagnosis was determined via the Structured LOF Total 2.54 (0.88) – – –
Clinical Interview for DSM-5 (SCID-5; First, 2015). CN were recruited LOF Work 1.70 (1.55) – – –
from the local community using flyers and electronic advertisements. LOF Social 2.94 (1.25) – – –
CN had no current psychiatric diagnoses as established by the SCID-5, no Note. SZ = schizophrenia group; CN = control group; MCCB = MATRICS
current SZ-spectrum personality disorders as determined via the SCID- Cognitive Consensus Battery; PANSS = Positive and Negative Syndrome Scale;
PD (First, Williams, Benjamin, & Spitzer, 2015), no family history of BNSS = Brief Negative Symptom Scale; LOF = Level of Function Scale (mean
psychosis, and were not taking psychotropic medications. All LOF scores displayed). Values reflect Mean (SD) unless otherwise indicated.

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L.A. Bartolomeo et al.
a guided demonstration of survey notifications and completion of a
practice survey with an overview and explanation of the types of ques­
tions that would be asked. Additionally, participants were provided with
written instructions and encouraged to contact the researchers in the
event of any technical problems. Lab personnel conducted follow-up
calls on the subsequent day to ensure that the phone and app were
functioning properly and that there were no issues responding to
surveys.
Over six consecutive days, participants were prompted to respond to
eight momentary surveys per day that were quasi-randomly scheduled
within 90 min epochs between 9 AM and 9 PM. Momentary surveys were
scheduled between 18 min to 3 h apart from each other. Survey avail­
ability lasted 25 min: 10 min prior to and 15 min after receiving a
notification, which was signaled to the participant via a tone and vi­
bration emitted by the smartphone. Attempts to respond to the survey
after the 15-min window were not permitted, but participants were
allotted unlimited time to complete the questions. Surveys assessed the
following: 1) momentary emotion; 2) emotional events; 3) emotion
regulation, including switching (“Did you switch strategies because it
was not working?” with responses coded as Yes or No) and stopping
(“Are you still trying to change your emotions?” with responses coded as
Yes or No); 4) proposed moderators, including emotional awareness
(“How well can you describe the feelings that you are having right
now?”), emotion regulation self-efficacy (“How successful do you think
you will be at changing your emotions the next time you are in this
situation?”), and emotion regulation effort (“How much effort did you
use to try to change your emotions by ___?”; 5) current context; and 6)
momentary positive and negative symptoms. Survey questions and flow
are displayed in Supplemental Materials.
The final phase occurred one week after the initial laboratory visit, at
the end of the EMA phase. Participants returned the EMA equipment,
completed neuropsychological testing (Wechsler Test of Adult Reading
(Wechsler, 2001) and the MATRICS Consensus Cognitive Battery
(MCCB; Nuechterlein et al., 2008)), and other procedures not germane
to the current study.
2.3. Data analysis
SPSS Statistics 26.0 (IBM Corporation, 2019) and R (R Core Team,
2020) were used to conduct the statistical analyses. Only survey in­
stances where participants endorsed down-regulating negative emotion
were included in the analysis. To examine the nature of monitoring
dynamic abnormalities in SZ, separate multi-level binary logistic re­
gressions were conducted to determine whether the probability of
switching and stopping predicted diagnostic group (SZ, CN), with nested
levels of day and survey instance; however, when including day resulted
in singular fit, it was dropped from the model. Linear mixed modeling
(LMM) with an AR1 covariance structure was used to evaluate group
(SZ, CN) differences in stopping duration using a fixed model and
random slope design. Maximum likelihood estimation was employed to
account for missing data, and analyses were nested within day and
survey instance. Tests for moderation were pre-registered as additional
Group X Context (switching or stopping Yes or No) LMMs. However, it
was determined that hierarchical logistic regressions of Context
(switching or stopping) as an outcome of Group and Moderator (self-
efficacy, etc) were more appropriate for evaluating the hypothesized
moderation effects. Separate multi-level binary logistic regressions with
a diagonal covariance structure were also conducted to determine
whether emotional awareness, emotion regulation self-efficacy, and
emotion regulation effort moderated group differences in switching and
stopping rate. To assess the relationship between switching and stopping
abnormalities with EMA state measures of positive and negative symp­
toms, point-biserial correlations were used for associations with
switching/stopping frequency (dichotomous variables) and bivariate
correlations were used for associations with emotion regulation dura­
tion (continuous variable). Exploratory correlations were conducted to
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Schizophrenia Research 240 (2022) 135–142
examine the relationship between monitoring dynamic abnormalities
and clinical rating scales.
Additional exploratory analyses that were not preregistered were
conducted, including multi-level binary logistic regressions regarding
the effects of negative affect, social context (i.e., whether participants
reported being currently engaged in a social interaction), goal-directed
context (i.e., whether participants reported being currently engaged in
a goal-directed activity), and their interactions with Group on the
probability of switching and stopping.
3. Results
3.1. Processing dynamic abnormalities
Consistent with hypotheses, multilevel binary logistic regression
indicated that SZ had higher rates of switching and LMM indicated that
SZ demonstrated delayed stopping relative to CN (see Table 2). These
findings suggest that the nature of monitoring dynamic abnormalities in
SZ is characterized by more frequent switching between emotion regu­
lation strategies and delayed termination of emotion regulation
attempts.
3.2. Moderators of processing dynamic abnormalities
Group differences in switching frequency were not moderated by
emotional awareness, emotion regulation self-efficacy, or emotion
regulation effort (see Table 3).
With regard to moderators of stopping rate, there was a significant
Group X Emotion regulation self-efficacy interaction (see Table 3 and
Fig. 1). Results indicated that CN were more likely to stop regulation
than SZ at lower levels of self-efficacy but less likely to stop regulation
than SZ at higher levels of self-efficacy. The Group X Emotional
awareness and Emotion regulation effort interactions were nonsignifi­
cant, suggesting that neither variable moderated group differences in
stopping rate.
3.3. Associations with momentary symptoms
In SZ, reduced switching frequency was associated with more severe
avolition and asociality in the moment as measured via EMA. These
results suggest that negative symptoms are related to being less likely to
switch strategies. Correlations with positive symptoms were nonsignif­
icant (see Table 4).
Less time regulating was associated with more severe momentary
anhedonia, avolition, and asociality. In contrast, higher rates of
continuing to regulate were associated with more severe momentary
delusions (see Table 4). These findings indicate that negative symptoms
may be related to being less likely to persist in emotion regulation at­
tempts, whereas positive symptoms are associated with being more
likely to persist.
3.4. Exploratory analyses
Post-hoc exploratory correlations were conducted to examine the
association between monitoring dynamics and clinical measures in SZ,
including neurocognitive performance, clinically rated symptoms, and
functional outcome. Results indicated that lower switching rate was
associated with more severe total negative symptoms, anhedonia, and
blunted affect. All other correlations were nonsignificant (see Table S2
in Supplemental Materials).
Exploratory analyses that examined negative affect as a predictor of
group differences in switching were nonsignificant (B = 0.03, z = 1.79,
χ2 = 3.22, p = .072); further, the relationship between negative affect
and switching probability was not moderated by group (B = -0.02, z =
-1.19, χ2 = 1.42, p = .233). For stopping, there was a significant Group X
Negative affect interaction (B = -0.03, z = -2.01, χ2 = 4.04, p = .044),
L.A. Bartolomeo et al. Schizophrenia Research 240 (2022) 135–142

Table 2
Results of Multilevel Models Examining Whether Groups Differ in Switching and Stopping.
SZ CN Coefficient (SE) t p 95% CI
(n = 47) (n = 52) Lower, Upper

Frequency of switching 42.1% 20.80% 1.02 (0.46) 2.24 0.026 0.12, 1.93
Frequency of continuing to regulate 53.9% 34.0% 1.95 (0.40) 4.83 <0.001 1.16, 2.75
Stopping Duration 82.81 (60.93) 59.53 (49.18) 65.8 (6.16) 10.67 <0.001 53.4, 78.1

Note. Switching rate = percentage of surveys where participants endorsed switching. Stopping rate = percentage of surveys where participants reported they had
stopped regulating. SZ = schizophrenia group. CN = control group. Stopping duration = LMM, others regression. Values reflect mean (SD) unless otherwise indicated.

inefficient stopping dynamics, evidenced by patients being more likely

Table 3
to persist in emotion regulation at lower levels of negative affect but less
Results of Multilevel Models Examining Moderators of Switching and Stopping
likely to persist at higher levels of negative affect compared to CN. This
Rate.
extends prior laboratory-based research in healthy individuals indi­
Coefficient z p 95% CILower, cating that greater levels of negative affect were associated with greater
(SE) Upper
likelihood of switching (Murphy & Young, 2020) and that greater
Switching rate responsiveness to internal feedback predicted greater switching fre­
Emotional Awareness
quency (Birk & Bonanno, 2016).
Group 2.06 (1.29) 1.6 0.11 − 0.46, 4.59
Emotional Awareness 0.01 (0.02) 0.83 0.41 − 0.02, 0.04 Sheppes et al. (2015) proposed that a failure to settle could result
Group × Emotional − 0.01 (0.02) − 0.87 0.39 − 0.05, 0.02 from instability in thoughts and behavior, suggesting that disorganized
Awareness symptoms or cognitive impairment may contribute to switching ab­
Self-efficacy normalities in SZ. However, post-hoc exploratory correlations between
Group 0.97 (1.51) 0.64 0.52 − 1.99, 3.92
Self-efficacy 0 (0.02) 0.15 0.88 − 0.04, 0.04
switching rate and measures of disorganized symptoms and cognitive
Group × Self-efficacy 0 (0.02) 0.07 0.95 − 0.04, 0.05 performance did not support this hypothesis (see Table S2 in Supple­
Effort mental Materials). Regarding delayed stopping in SZ, one potential
Group 0.59 (1.72) 0.35 0.73 − 2.78, 3.97 explanation for this finding is impaired time perception. Individuals
Effort 0.01 (0.02) 0.63 0.53 − 0.03, 0.05
with SZ have been shown to overestimate elapsed time compared to
Group × Effort 0.01 (0.02) 0.26 0.80 − 0.04, 0.05
Stopping rate healthy controls, which has been attributed to generalized impairments
Emotional Awareness in memory and attention (Bonnot et al., 2011). To explore this possi­
Group 0.34 (0.89) 0.39 0.69 − 1.39, 2.09 bility, we conducted exploratory correlations between attention and
Emotional Awareness 0 (0.01) − 0.38 0.71 − 0.02, 0.02 memory subscores on the MCCB and rates of continuing to regulate and
Group × Emotional 0.01 (0.01) 0.84 0.40 − 0.01, 0.03
Awareness
emotion regulation duration in SZ. None of the correlations were sig­
Self-efficacy nificant, suggesting that delayed stopping was not associated with
Group − 2.32 (1.2) − 1.94 0.05 − 4.67, 0.02 attention or memory deficits in the current sample (see Table S2 in
Self-efficacy − 0.05 (0.02) − 3.46 < 0.001 − 0.09, − 0.02 Supplemental Materials). Nonetheless, abnormal time perception may
Group × Self-efficacy 0.05 (0.02) 2.86 0.004 0.02, 0.09
still reflect a general cognitive process contributing to longer self-reports
Effort
Group 1.07 (1.24) 0.86 0.39 − 1.36, 3.5 of the duration of continuing to regulate.
Effort 0.01 (0.01) 0.92 0.36 − 0.01, 0.04 According to Gross (2015), failure to settle and delayed stopping may
Group × Effort 0 (0.02) − 0.09 0.93 − 0.03, 0.03 be highly demanding on physiological and cognitive systems, thus
Note. Switching rate = percentage of surveys where participants endorsed taxing already limited resources in SZ. Consistent with this notion, past
switching. Stopping rate = percentage of surveys where participants reported research has shown that inability to discontinue an ineffective emotion
they had stopped regulating. regulation strategy and implement a new strategy is associated with
worse psychological outcomes, including increased depression, anxiety,
such the relationship between negative affect and the probability of and general distress (Kato, 2012). Thus, excessive switching and delayed
persisting in regulation attempts was stronger in CN (B = 0.05; 95% CI stopping in SZ may be meaningfully related to the maintenance and
[0.02 to 0.08]) than SZ (B = 0.02; 95% CI [0.001 to 0.04]) (see Fig. 2). exacerbation of psychiatric symptoms, possibly as a result of elevated
Specifically, SZ were significantly more likely to persist at lower levels of negative affect, chronic stress, and insufficient resources. Importantly,
negative affect but less likely to persist at higher levels of negative affect some emotion regulation strategies are more taxing and require more
compared to CN. The results of exploratory analyses examining group resources than others (Strauss et al., 2016). It is possible that individuals
differences in the relationship between contextual variables (i.e. social with SZ fail to select the most contextually appropriate strategies
and goal-directed activity) on switching and stopping probability yiel­ because they are less adept at identifying appropriate context for each
ded nonsignificant Group X Context interactions (p’s > 0.05), suggesting strategy and when it is most appropriate to use available resources.
that social and goal-directed activities did not influence group differ­ Inappropriate selection could compound switching and stopping ab­
ences in switching and stopping dynamics (see Table S3 Supplemental normalities, such that SZ may excessively switch between inappropriate
Materials). strategies and spend more time regulating, leading to further resource
depletion. Specific strategies that participants selected and switched
4. Discussion between were not examined in the current study, but are important
considerations for future studies examining abnormalities in emotion
The current study aimed to determine: 1) the nature of emotion regulation monitoring dynamics in SZ.
regulation processing dynamic abnormalities in SZ, 2) moderators of Regarding moderators of monitoring dynamics, emotion regulation
these abnormalities, and 3) whether abnormalities in monitoring dy­ self-efficacy moderated group differences in rates of continuing versus
namics are associated with state-level clinical symptoms. Consistent stopping regulation attempts. CN were more likely to continue regu­
with hypotheses, results indicated that the nature of emotion regulation lating at high levels of emotion regulation self-efficacy and more likely
monitoring dynamic abnormalities in SZ is characterized by a failure to to stop at lower levels. This pattern supports Sheppes et al.’s (2015)
settle and delayed stopping. Further, individuals with SZ demonstrated theory that individuals with low self-efficacy are more likely to stop

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L.A. Bartolomeo et al. Schizophrenia Research 240 (2022) 135–142

Fig. 1. Moderating Effect of Emotion Regulation Self-Efficacy on Probability of Stopping in Schizophrenia and Control Groups Note. CN = Control group; SZ = Schizophrenia
group. Statistics colored in black reflect between-group contrasts; statistics colored corresponding to the group (CN or SZ) are the linear effect in that group. Shaded
area reflects standard error. *** = p < .001, ** = p < .01, * = p < .05.

regulating prematurely, suggesting that self-efficacy is a normative

Table 4
process that guides stopping dynamics in psychiatrically healthy adults.
Correlations Between Monitoring Dynamics and Momentary Symptoms.
In contrast, momentary levels of self-efficacy did not influence stopping
Switching: Stopping: Frequency Stopping: Emotion dynamics in SZ. The lack of modulation of stopping rate based on self-
Frequency of of Continuing to Regulation
efficacy observed in SZ may reflect impaired insight into the effective­
Changing Strategies Regulate Duration
ness of regulation attempts. Poor insight may lead to inefficient stopping
Anhedonia 0.15 0.04 0.31**
− −
behaviors, such as failing to stop when efforts are ineffective or stopping
Avolition − 0.19* 0.03 − 0.21*
Asociality − 0.17* 0.02 − 0.30** prematurely even when efforts are efficacious and may benefit from
Delusions − 0.01 0.16* − 0.17 continued regulation.
The results of correlational analyses indicated that individual dif­
Note. Correlation results examining associations between monitoring dynamics
and symptoms in the moment in SZ. Values reflect Pearson correlation co­
ferences in positive and negative symptoms are associated with different
efficients. ** Denotes significance at the 0.01 level (2-tailed). * Denotes signif­ patterns of monitoring dynamic abnormalities in SZ. Down-regulating
icance at the 0.05 level (2-tailed). negative emotion when positive symptoms are present may require
more time, resulting in longer emotion regulation attempts. In contrast,
impaired motivation associated with negative symptoms may lessen the
likelihood of switching strategies and persisting in emotion regulation

Fig. 2. The Relationship Between Negative Affect and Probability of Persisting in Emotion Regulation in Schizophrenia and Control Groups. Note. CN = Control
group; SZ = Schizophrenia group. Statistics colored in black reflect between-group contrasts; statistics colored corresponding to the group (CN or SZ) are the linear
effect in that group. Shaded area reflects standard error. *** = p < .001, ** = p < .01, * = p < .05.

139
L.A. Bartolomeo et al.
attempts that require significant effort. Thus, different clinical profiles
within the SZ-spectrum may be differentially associated with specific
monitoring dynamic abnormalities.
Certain limitations should be considered. First, the current study
examined two monitoring dynamics: switching and stopping. An
important direction for future research will be to also examine the third
monitoring dynamic, maintenance. Maintenance occurs when a strategy
or tactic is effective at changing the emotional response and contextually
appropriate, leading to consistent action outputs of identification, se­
lection, and implementation stages across consecutive emotion regula­
tion cycles. Maintenance failures can arise from interference from other
active goals (Gross, 2015). To our knowledge, no study has empirically
examined emotion regulation maintenance in healthy or clinical pop­
ulations. EMA is a valuable tool for studying maintenance because it
allows researchers to examine the temporal sequence of emotion regu­
lation cycles, including what strategies are implemented and their
effectiveness over time. Novel analytic approaches may need to be
developed for this purpose. Second, the current sample consisted of
stable adult outpatients with chronic SZ. Thus, the results may not
extend transphasically (i.e., to individuals in earlier phases of illness) or
to inpatient populations. Third, it is unclear whether the observed ab­
normalities in switching and stopping dynamics are driven by psychosis
versus general psychopathology. For example, Sheppes et al. (2015)
proposed that manic states in bipolar disorder may be associated with
excessive switching, suggesting a failure to settle could occur in both SZ
and bipolar disorder. It is important for future studies to examine these
processes in other clinical populations in order to determine what is
unique or specific to SZ.
Despite these limitations, the present study yielded several important
findings that advance the field’s knowledge of emotion regulation ab­
normalities in SZ and potential targets for intervention. Pending repli­
cation and further study, our results indicate that the nature of
processing dynamic abnormalities in SZ is characterized by excessive
switching and delayed stopping. To target these abnormalities, experi­
ential exposures may be helpful for enhancing contextual learning and
expanding the behavioral repertoire of adaptive responding. Exposures
provide the opportunity to practice emotion regulation skills, such as
maintaining strategies (to target excessive switching), changing regu­
latory goals, and accepting or tolerating emotions (to target delayed
stopping). Exposures are a component of Emotion Regulation Therapy
(ERT), an intervention that incorporates principles from CBT, experi­
ential therapy, and DBT (Mennin, 2004; Renna, Quintero, Fresco, &
Mennin, 2017). The goals of ERT coincide with the three stages of
emotion regulation in Gross’ extended process model, such that patients
develop skills to overcome difficulties at the identification, selection,
and implementation stages, as well as problems with monitoring dy­
namics. Although ERT has not been examined in individuals with SZ,
there is evidence supporting its efficacy in other clinical populations,
including patients with major depressive disorder and generalized
anxiety disorder (Mennin, 2004; Mennin, Fresco, Ritter, & Heimberg,
2015).
In order to optimize a psychosocial intervention like ERT for use in
psychotic populations, there is a need for additional research on the
processes that moderate emotion regulation difficulties. The current
findings indicated that self-efficacy moderated stopping abnormalities
in SZ, which may stem from deficient insight. To target poor insight into
emotion regulation effectiveness, patients may benefit from psycho­
education about emotions/emotion regulation to better understand
their emotions and goals. It will be important for future studies to not
only replicate and identify new moderators of identification, selection,
implementation, and monitoring dynamics, but also to explore how
moderators interact across emotion regulation stages and cycles.
Different approaches may also be needed to target emotion regulation
processes associated with positive versus negative symptoms. For
example, patients with high positive symptoms may benefit from a
skills-based approach where they learn how to select contextually
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Schizophrenia Research 240 (2022) 135–142
appropriate strategies and determine when it is appropriate to stop
regulating, whereas individuals with high negative symptoms may
benefit from treatment targeting defeatist attitudes, which may
contribute to being less likely to switch strategies and persist in emotion
regulation attempts (Grant, Huh, Perivoliotis, Stolar, & Beck, 2012).
These skills may lessen switching frequency and time spent regulating,
which in turn may conserve cognitive and physiological resources. A
deeper understanding of these processes may inform novel targets for
intervention and the development of personalized treatment approaches
that target difficulties at a specific stage or moderator.
5. Conclusions
Individuals with SZ demonstrated abnormal monitoring dynamics in
daily life compared to CN, including a failure to settle and delayed
stopping. Emotion regulation self-efficacy moderated group differences
in stopping dynamics, evidenced by individuals with SZ endorsing
greater self-efficacy when continuing to regulate and lower self-efficacy
when they had stopped regulating, whereas the opposite was evident in
CN. In SZ, lower switching frequency and shorter regulation attempts
were associated with more severe negative symptoms, while greater
frequency of continuing to regulate was associated with more severe
positive symptoms. The current findings extend prior evidence for
impaired emotion regulation in SZ by identifying novel abnormalities in
monitoring dynamics that may have important implications for
intervention.
5.1. Twitter
#EMA study by Bartolomeo et al. finds that individuals with
#schizophrenia differ from healthy controls in key aspects of #emo­
tionregulation in daily life, including excessive switching between
strategies and prolonged emotion regulation attempts. In schizophrenia,
these abnormalities were associated with different patterns of positive
and negative symptoms, which may have important implications for
#intervention. Results also revealed that #self-efficacy moderated
group differences in rates of continuing versus stopping emotion regu­
lation attempts, which may reflect impaired insight in schizophrenia and
a key treatment target.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.schres.2021.12.043.
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Greg Strauss Greg Strauss, Ph.D. is an Assistant Professor at the

University of Georgia and director of the Clinical Affective
Neuroscience Laboratory and Georgia Psychiatric Risk Evalu­
ation Program (G-PREP). Dr. Strauss’ program of research ex­
amines the phenomenology, etiology, assessment, and
treatment of negative symptoms in schizophrenia and youth at
clinical high-risk for psychosis.

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