Journal of Psychiatric Research 174 (2024) 263–274

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Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/jpsychires

Interventions targeting emotion regulation: A systematic umbrella review

Luigi F. Saccaro a, b, *, 1, Alexis Giff c, 1, Maurilio Menduni De Rossi d, e, Camille Piguet a, b
a
Psychiatry Department, Geneva University Hospital, Switzerland
b
Psychiatry Department, Faculty of Medicine, University of Geneva, Switzerland
c
Harvard Medical School, Boston, MA, USA
d
Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Piazza Martiri della Libertà 33, Pisa 56127, Italy
e
Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy

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

Keywords: Background: Emotion dysregulation (ED), the difficulty in modulating which emotions are felt, and when and
Psychotherapy how they are expressed or experienced, has been implicated in an array of psychological disorders. Despite
Borderline personality disorder potentially different manifestations depending on the disorder, this symptom is emerging as a transdiagnostic
Mindfulness
construct that can and should be targeted early, given the associations with various maladaptive behaviors as
Adolescents
Children
early as childhood and adolescence. As such, our goal was to investigate the psychotherapeutic interventions
Emotional dysregulation used to address ED and gauge their effectiveness, safety, and potential mechanisms across various populations.
Methods: This umbrella systematic review, pre-registered under PROSPERO (registration: CRD42023411452),
consolidates evidence from systematic reviews and meta-analyses on psychotherapeutic interventions targeting
ED, in accordance with PRISMA guidelines.
Results: Our synthesis of quantitative and qualitative evidence from 21 systematic reviews (including 11 meta-
analyses) points—with moderate overall risk of bias—to the effectiveness of Dialectical Behavior Therapy and
Cognitive Behavioral Therapy in reducing ED in a wide range of adult transdiagnostic psychiatric patients and
healthy participants. Similar results have emerged in other less extensively researched methods as well. How­
ever, results on adolescents and children are sparse, highlighting the need for additional research to tailor these
interventions to the unique challenges of ED in younger populations with diverse externalizing and internalizing
disorders.
Conclusions: These demonstrated transdiagnostic advantages of psychotherapy for ED underscore the potential
for specifically designed interventions that address this issue directly, particularly for high-risk individuals. In
these individuals, early interventions targeting transdiagnostic core dimensions may mitigate the emergence of
full-blown disorders. Future research on the mediating factors, the durability of intervention effects, and the
exploration of understudied interventions and populations may enhance prevention and treatment efficiency,
enhancing the quality of life for those affected by varied manifestations of ED.

1. Background pivotal role in the emergence and persistence of psychological disorders.

Its significance in mental health and prevalence across multiple psy­
Emotion regulation (ER) refers to our ability to influence emotions, chiatric disorders establish it as a transdiagnostic construct that
both from an expressive and experiential standpoint (McRae and Gross, healthcare providers can utilize to assess health and promote beneficial
2020). This process, motivated by various factors, may involve a host of behaviors in patients (Menefee et al., 2022; Sloan et al., 2017). A
modulatory strategies that ultimately affect how individuals feel and transdiagnostic construct refers to a psychological or behavioral factor
manage their emotions (Tamir et al., 2020). More specifically, ER that is relevant across different diagnostic categories, transcending
modifies an emotional response by selecting a goal that is subsequently traditional diagnostic boundaries (Mansell et al., 2009).
implemented through a particular strategy (Kreibig et al., 2022). In When emotional responses cease to be successfully regulated, we use
recent years, research across various domains has emphasized ER’s the term emotion dysregulation (ED). ED can manifest in various ways,

* Corresponding author. Psychiatry Department, Geneva University Hospital, Switzerland.

E-mail address: [email protected] (L.F. Saccaro).
1
These authors equally contributed.

https://doi.org/10.1016/j.jpsychires.2024.04.025
Received 30 September 2023; Received in revised form 12 March 2024; Accepted 15 April 2024
Available online 18 April 2024
0022-3956/© 2024 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
L.F. Saccaro et al. Journal of Psychiatric Research 174 (2024) 263–274

including heightened emotional reactivity, emotional lability, and For instance, ED is associated with behaviors including binge eating,
emotional avoidance. Although ambiguity remains in defining ER stra­ self-injury, suicidality, aggression, and risky or impulsive behaviors
tegies, common maladaptive ones include rumination, suppression, and including criminal activity (Esposito-Smythers et al., 2011; Hilt et al.,
avoidance (Sloan et al., 2017). In ED, regulatory attempts fail, leading 2011). Other factors such as adolescent stress, puberty, and peer context
emotions to affect appropriate behavior, be expressed in inappropriate may also exacerbate ED, highlighting the need for early and effective
contexts, and/or change at incorrect speeds (Thompson, 2019). Other treatment modalities.
important facets of ED include factors relating to emotional awareness, Psychotherapeutic, transdiagnostic interventions are promising for
impulse control, goal-directed cognition, acceptance, and access to early intervention due to their non-invasive nature, low risk, and suit­
effective ER strategies (Hallion et al., 2018). ability for treating ED. As the current treatment of choice for ED, psy­
ED may involve alterations in regions involved in ER, such as the chotherapy (Sloan et al., 2017) is well-suited for addressing the complex
amygdala, prefrontal cortex, and insula (Yu et al., 2021). From a processes underlying ED, as compared to pharmacological or neuro­
network perspective, it is possible that ED is related to disruption of the modulation approaches that are not yet as effective in targeting the
frontoparietal network (FPN), default mode network (DMN), the large-scale networks disruption underlying ED. A transdiagnostic
salience network (SN) (Pan et al., 2018), and the somatomotor network treatment is an intervention designed to address common underlying
(SMN) (Kropf et al., 2019). ED generally and in various disorders has factors or mechanisms across different disorders. In the case of ED,
also been associated with inflammatory markers, variations in neuro­ transdiagnostic treatments aim to target core ED processes rather than
transmitters like serotonin and dopamine, genetic and epigenetic fac­ focusing on specific diagnostic criteria. This approach recognizes that
tors, and environmental factors (Petruso et al., 2023; Kian et al., 2022; similar therapeutic strategies can be beneficial for individuals experi­
Thapar and Cooper, 2016; Gordovez and McMahon, 2020; Rowland and encing ED, regardless of the specific diagnostic label. Despite substantial
Marwaha, 2018; Winsper, 2018). evidence linking ER to psychopathology and its potential as a trans­
The manifestation of ED can vary depending on the disorder. How­ diagnostic factor, there is still a lack of standardized reporting and
ever, there is a growing body of evidence to suggest that ED is a crucial clinical evidence to appraise the efficacy of psychotherapeutic in­
underlying component of psychopathology across many conditions, terventions for ED as a transdiagnostic construct. While numerous sys­
highlighting the need for transdiagnostic treatments (Ruan et al., 2023; tematic reviews and meta-analyses of ER interventions in different
Sloan et al., 2017). Indeed, ED has been linked to a wide range of psy­ populations do exist, this gap still persists. As a result, we sought to
chiatric disorders, such as borderline personality disorder (BPD) and review the existing evidence on psychotherapeutic interventions tar­
other personality disorders, bipolar disorder (BD), ADHD, PTSD, geting ED and ER across a range of populations, diagnoses, and age
depression, anxiety, substance use disorders, eating disorders, and ad­ groups, including children, adolescents and adults. We also sought to
dictions (Beauchaine and Cicchetti, 2019; Fernandez et al., 2016; Pet­ understand the safety and potential mechanisms of action of these in­
ruso et al., 2023; Saccaro et al., 2023; Saccaro et al., 2021b; 2021c; Sloan terventions. The objective is to better understand the current state of the
et al., 2017; Melton et al., 2020; Sloan et al., 2017; Ekiz et al., 2023). In field, identify gaps in the literature, and determine the focus areas and
the context of ED, transdiagnostic constructs may include overarching directions for future clinical trials and research.
factors such as maladaptive emotion regulation strategies, deficits in
emotional awareness, or impaired impulse control (Sloan et al., 2017). 2. Materials & methods
These constructs are not limited to a specific psychiatric disorder but are
shared across various conditions characterized by ED (Mansell et al., 2.1. Search strategy, selection criteria, and screening
2009).
As a construct, ED is particularly salient due to the lack of validated This systematic review followed the Preferred Reporting Items for
transdiagnostic prevention and treatment interventions targeting spe­ Systematic Reviews and Meta-analyses (PRISMA) guidelines (Supple­
cifically ED, and its potential as a transdiagnostic vulnerability marker mentary Table 1) (Moher et al., 2009) and was pre-registered in the
to multiple disorders (Beauchaine and Cicchetti, 2019; Fernandez et al., PROSPERO database (registration number CRD42023411452).
2016). The value of transdiagnostic approaches is increasingly recog­ We used a two-step approach. First, we searched the Embase, Psy­
nized in psychiatry. The significant overlap across psychiatric disorders cNet, and PubMed (including MEDLINE, Bookshelf, and part of PMC) for
in symptomatology (Russo et al., 2014; Tamminga et al., 2013), genetics articles published until March 30, 2023. The search strategy included
(Pettersson et al., 2016), and high comorbidity (Kessler et al., 2011) intentionally broad terms such as: (intervention* OR clinical trial OR
suggests that traditional categorical classifications may not be the most randomized clinical trial) AND ((emotion* regulation) OR (emotion*
appropriate for psychiatric disorders (Kebets et al., 2019). The trans­ dysregulation)) AND (review OR metaanalysis OR meta-analysis). Next,
diagnostic and dimensional approach can therefore emphasize the we manually searched the reference lists of retrieved articles. Duplicate
importance of studying features that span various psychiatric diagnoses references were excluded. We screened the remaining articles by title
(Mansell et al., 2009; McGorry et al., 2018; van Os and Guloksuz, 2017), and abstract. The identified full texts were further inspected for eligi­
leading to an integrative rather than reductionistic framework. Given bility against a priori defined exclusion and inclusion criteria. As further
that ER skills are shaped during childhood and adolescence (Ruan et al., detailed in Table 1, we included original articles in English that met the
2023; Sanchis-Sanchis et al., 2020), and maturation of ER brain net­ following Participants, Interventions, Comparators, Outcomes, and
works continues until young adulthood (Casey et al., 2019), ED is Study design (PICOS) criteria. We included any kind of participants if
increasingly recognized as a transdiagnostic vulnerability marker for they received any intervention targeting specifically ER (Table 2). We
multiple psychiatric disorders, and particularly ED disorders (e.g. BD or defined ER and ED broadly, as described in the background, and
BPD) with shared characteristics and neurobiological bases (Petruso included reviews employing any clinical score directly assessing ER or
et al., 2023; Phillips, 2006; Saccaro et al., 2023; Saccaro et al., 2021b; ED (Table 3).
2021c; Sloan et al., 2017). For clarity and to avoid redundancy or bias, we excluded information
Consequently, ED constitutes a promising target for interventions in from overlapping studies or populations. When reviews or meta-
vulnerable populations at high-risk for psychiatric disorders. Adoles­ analyses included one or more overlapping articles or populations, we
cence and young adulthood are periods of particularly heightened prioritized meta-analyses, followed by the review with the highest
vulnerability to multiple psychiatric disorders (Kleinert and Horton, number of articles relevant to our research question. For multiple re­
2016; Lee et al., 2009; McGrath et al., 2023) and early interventions views with the same number of relevant articles, we prioritized the most
targeted at ED may help reduce the huge personal and socioeconomic recent. Comparisons were made between participants undergoing
burden with these psychiatric disorders (e.g. BPD, BD, or depression). intervention for ER vs participants not undergoing such an intervention,

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Table 1 Table 2
Search strategy according to the Population, Intervention, Comparison, Out­ Main intervention types and corresponding studies.
comes and Study Design (PICOS) model. Studies Intervention Description of Intervention
Parameter Inclusion criteria Exclusion criteria
Expósito-Campos et al., 2023, Cognitive therapy Interventions based on
Population Any population NA Helland et al., 2022, or CBT CBT. These are typically
Interventions Any psychological/ Reviews not including any Stoffers-Winterling et al., interventions structured, goal-oriented,
psychotherapeutic intervention study on such an 2012, Daros et al., 2021, and multi-session talk
targeting emotion regulation intervention Eadeh et al., 2021, Melton therapy interventions,
strategies, psychological or et al., 2020, Sloan et al., which aim to identify
neurobiological mechanisms, or 2017, Moltrecht et al., 2021 negative thought patterns
emotion dysregulation and help with cognitive
symptoms restructuring, coping, and
Comparison -Subjects undergoing Reviews not including any emotion regulation. They
intervention for emotion study on such a comparison can be delivered
regulation vs subjects not individually or in a group.
undergoing such an intervention Jones et al., 2023, Helland DBT Interventions based on
-Subjects before and after an et al., 2022, interventions DBT, developed for patients
intervention Stoffers-Winterling et al., with BPD. DBT aims to train
Outcomes Any outcome, such as clinical NA 2012, Daros et al., 2021, mindfulness, teach patients
scores or measures Eadeh et al., 2021, Melton to tolerate distress, and
Study design Metanalyses and systematic Observational study, case et al., 2020, Grohmann and help develop skills for
model reviews reports, case series, original Laws, 2021, Bankoff et al., effective emotion
articles, conference poster or 2012, Harvey et al., 2019, regulation and
abstracts, editorials, letters Sancho et al., 2018 interpersonal interactions.
to the editor, narrative It is also usually multi-
reviews, umbrella reviews, session and delivered on an
and book chapters individual or group basis.
Helland et al., 2022, Daros Mindfulness Interventions based on
et al., 2021, Eadeh et al., interventions mindfulness, including
or participants before and after an intervention. We included any 2021, Melton et al., 2020, mindfulness-based
Moltrecht et al., 2021, cognitive therapy (MBCT),
outcome directly related to ER or ED, such as clinical scores or measures.
Grohmann and Laws, 2021, which includes elements of
We included meta-analyses and systematic reviews, excluding all other Sloan et al., 2017, Xuan et al., CBT, and Mindfulness-
study designs (e.g. case reports, case series, original articles, conference 2020, Sancho et al., 2018, based stress reduction
poster or abstracts, editorials, letters to the editor, narrative reviews, Lamothe et al., 2016 (MBSR). These typically
umbrella reviews, and book chapters). Included reviews all reviewed at take the form of a several-
week class that might
least two non-overlapping relevant articles, aligning with the criteria include meditation and
mentioned above. The selection process was documented in the PRISMA movement practices such as
flow diagram (Fig. 1). Two independent researchers (AG, LFS) con­ mind-body scan, and help
ducted data screening. In cases of discrepancies, we held discussions participants learn to
recognize negative patterns
until reaching a unanimous agreement. Disagreements were resolved
and low mood episodes to
through the involvement of a senior reviewer (CP). respond skillfully. It can be
delivered on an individual
2.2. Data extraction or group basis.
Helland et al., 2022, Daros ACT Interventions based on
et al., 2021, Grohmann and interventions Acceptance and
Three independent researchers (AG, LFS, MM) conducted data Laws, 2021, Moltrecht et al., Commitment Therapy,
extraction. In cases of discrepancies, discussions were held until a 2021 which focuses on accepting
unanimous agreement was achieved. A senior reviewer (CP) resolved negative or unwanted
any disagreements. thoughts and emotions to
improve wellbeing. ACT
We extracted the following variables from each article when avail­ aims to develop a non-
able: authors and year of publication, type of clinical score to assess ER, judgmental and accepting
methodology and type of intervention, main statistical test used, attitude towards unwanted
outcome and significant qualitative or quantitative findings, number of experiences, increase
mindfulness, clarify values,
papers included and of participants, number of females, age, ethnicity,
cultivate cognitive defusion
methods, and results of quality assessment and risk of bias. We extracted and inspire action. It can be
the quality and risk of bias scores from each review to prioritize mea­ delivered on an individual
sures aligning closely with the original articles discussed. Therefore, we or group basis.
chose not to use the AMSTAR checklist as initially planned in the
PROSPERO protocol to maintain fidelity to the assessments in the re­
psychiatric disorders and manifest through different signs and symp­
views and comprehensively reflect their findings. If crucial information,
toms (e.g., anger, self-directed and other-directed violence, stress-
such as interventions or outcome measures, was missing, we contacted
coping, resilience, emotional eating style, conduct disorders, etc.), we
the corresponding author and excluded the study if no answer was
specifically focused on variables, interventions, and studies measuring
received within two months.
ER and ED as outcomes. We did not extract data for non-relevant mea­
We categorized the included studies into two tables, one for quali­
sures, variables, or interventions.
tative results (systematic reviews not including quantitative, meta-
analytic data synthesis, Table 4) and one for reviews including quanti­
3. Results
tative meta-analyses (Table 5). Supplementary Table 2 includes all
extracted data. “Qualitative” and “quantitative” refer simply to the
As Fig. 1 details, 1808 non-duplicate studies were identified through
methods of the reviews, not to the type of the original articles included
database and manual searching and screened by title and abstract. We
in the reviews.
excluded 1714 based on their abstract or title and another 73 after full
Given that ER and ED are broad concepts underlying various

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Table 3 The most common clinical scores assessing ER or ED as outcome

Main outcome measures used to assess changes in ER, ED, or related outcomes. measures were DERS (Difficulties in ER Scale, included in 17 reviews, i.
Studies Measure e. 81%), ERQ (ER questionnaire, in 6, i.e. 28%), CERQ (Cognitive ER
Questionnaire) and FFMQ (Five Facets Mindfulness Questionnaire),
Expósito-Campos et al., 2023, Jones et al., DERS (Difficulties in Emotion
2023, Ekiz et al., 2023, Helland et al., Regulation Scale) both in 4, i.e. 20%, of the included reviews.
2022, Stoffers-Winterling et al., 2012, Here, we briefly recapitulate other less-studied but promising in­
Daros et al., 2021, Eadeh et al., 2021, terventions examined in the included systematic reviews and meta-
Melton et al., 2020, Warner and Murphy, analyses.
2021, Grohmann and Laws, 2021, Sloan
et al., 2017, Osma et al., 2021, Xuan et al.,
ERGT, a group-based approach merging elements from DBT and
2020, Sancho et al., 2018, Sakiris and Acceptance and Commitment Therapy (ACT), represents a promising
Berle, 2019, Harvey et al., 2019 group intervention, improving ED in a meta-analysis on BPD adults
Helland et al., 2022, Eadeh et al., 2021, ERC (Emotion Regulation (Stoffers-Winterling et al., 2012) and in a systematic review on a
Moltrecht et al., 2021 Checklist)
transdiagnostic sample including BPD adults and adolescents (Sloan
Jones et al., 2023, Helland et al., 2022, Daros ERQ (Emotion Regulation
et al., 2021, Eadeh et al., 2021, Sakiris and Questionnaire) et al., 2017).
Berle, 2019, Osma et al., 2021 None of the included articles highlighted significant effects of
Helland et al., 2022, Daros et al., 2021, FFMQ (Five Facet Mindfulness Interpersonal therapy (IPT) specifically (Daros et al., 2021; Melton et al.,
Grohmann and Laws, 2021, Moltrecht Questionnaire), 2020; Stoffers-Winterling et al., 2012), and further research may be
et al., 2021, Lamothe et al., 2016
Helland et al., 2022, Daros et al., 2021, CERQ (Cognitive Emotion
needed.
Moltrecht et al., 2021, Eadeh et al., 2021 Regulation Questionnaire) The Unified Protocol (UP) for Emotional Disorders is a comprehen­
Daros et al., 2021, Moltrecht et al., 2021, RRS/RSQ (Ruminative Responses sive, transdiagnostic intervention designed to tackle ED across various
Expósito-Campos et al., 2023, Helland Scale/Rumination Style psychological conditions, aiming for extensive improvements in both
et al., 2022 Questionnaire)
positive and negative emotional states. While based on traditional CBT
Kunzler et al., 2022, Stoffers-Winterling DASS (Depression Anxiety Stress
et al., 2012, Sloan et al., 2017 Scale) principles, UP incorporates unique features such as a transdiagnostic
Expósito-Campos et al., 2023, BDI (Beck Depression Inventory) approach, flexible module sequencing, and a focus on ER and mindful­
Stoffers-Winterling et al., 2012, Sloan ness. The effectiveness of the UP was substantiated through a meta-
et al., 2017 analysis (Sakiris and Berle, 2019) and a systematic review (Osma
et al., 2021) of 12 non-overlapping articles on transdiagnostic samples of
text review. Consequently, the umbrella review’s final sample included patients. These works showed that UP bolstered beneficial ER strategies
21 reviews, which examined ER interventions across over 29,593 sub­ like heightened mindfulness-related awareness, embracing emotions,
jects from 541 relevant papers, averaging 26 articles per review. The and cognitive reappraisal, while diminishing counterproductive ER
populations studied included healthy participants and patients suffering methods, such as avoiding emotional experiences, suppressing emo­
from BD, BPD, anxiety and depressive disorders, PTSD, addiction dis­ tions, and struggling with the application of emotion-oriented skills.
orders, and eating disorders. 10 (48%) were systematic reviews (Bankoff In some instances, meta-analyses (Daros et al., 2021) summarized
et al., 2012; Ekiz et al., 2023; Expósito-Campos et al., 2023; Harvey the results of multiple different psychotherapeutic interventions. This
et al., 2019; Jones et al., 2023; Lamothe et al., 2016; Osma et al., 2021; complicates the disentanglement of specific intervention techniques, but
Sancho et al., 2018; Sloan et al., 2017; Warner and Murphy, 2021), 11 ultimately confirms that psychotherapy can effectively treat ED.
(52%) were also meta-analyses (Daros et al., 2021; Eadeh et al., 2021; Further details on main interventions and outcome measures are
Grohmann and Laws, 2021; Helland et al., 2022; Kunzler et al., 2022; reviewed in Tables 2-3
Melton et al., 2020; Moltrecht et al., 2021; Murray et al., 2022; Sakiris
and Berle, 2019; Stoffers-Winterling et al., 2012, p.; Xuan et al., 2020). 3.1. Quantitative findings
18 studies (85%) focused on adults, 13 (61%) also or only on ado­
lescents, and only one (0.04%) also on children. Detailed demographics Quantitative results on adults or mixed populations of adults and
of the participants that were assessed specifically for ER-related in­ adolescents showed that several interventions, predominantly CBT,
terventions and outcomes were not systematically reported. However, DBT, but also ACT and MBCT (Daros et al., 2021; Grohmann and Laws,
most of the reviews that did report such information (Ekiz et al., 2023; 2021; Moltrecht et al., 2021; Sloan et al., 2017), lead to improvements in
Harvey et al., 2019; Kunzler et al., 2022; Osma et al., 2021; Stoffers-­ ER outcomes (Grohmann and Laws, 2021; Sloan et al., 2017). The effect
Winterling et al., 2012; Xuan et al., 2020) included a majority of adults sizes were small to medium but consistently significant, ranging from
and female participants. Hedge’s g of ±0.28 to ±0.62, with positive increases in adaptive ER
While 5 reviews (21%) focused on healthy participants, the capacities (measured through scores such as CERQ) and reductions in ED
remaining 16 focused on patients suffering from a wide spectrum of scores (measured through scores such as DERS) (Daros et al., 2021;
psychiatric disorders. Among the disorders studied, the most frequently Eadeh et al., 2021; Grohmann and Laws, 2021; Kunzler et al., 2022;
explored were BPD, BD, and anxiety and depressive disorders (Ekiz Melton et al., 2020; Stoffers-Winterling et al., 2012; Xuan et al., 2020).
et al., 2023; Harvey et al., 2019; Jones et al., 2023; Moltrecht et al., These effects were consistent across multiple populations, including
2021; Osma et al., 2021; Sloan et al., 2017; Xuan et al., 2020). Other BD patients (Xuan et al., 2020), BPD patients (Stoffers-Winterling et al.,
high-incidence psychiatric disorders examined included ADHD, (com­ 2012), PTSD adult patients (Melton et al., 2020), other psychiatric pa­
plex) PTSD, Substance Use Disorder (SUD), Autism Spectrum Disorder, tients (Grohmann and Laws, 2021; Sakiris and Berle, 2019), as well as
and Eating Disorders (Eadeh et al., 2021; Grohmann and Laws, 2021; healthy participants (Daros et al., 2021; Kunzler et al., 2022).
Harvey et al., 2019; Melton et al., 2020; Moltrecht et al., 2021; Osma Concerning quantitative results exclusively on adolescents, two
et al., 2021; Sakiris and Berle, 2019; Sancho et al., 2018; Warner and meta-analyses including 63 studies on healthy participants (Helland
Murphy, 2021). et al., 2022) and adolescents with ADHD or anxiety and depressive
The three most common psychotherapeutic interventions studied disorders (Murray et al., 2022) found a small but significant effects on
were DBT, in 10 or 48%, including 343 original articles), CBT, included ED across all interventions examined, including CBT, DBT, MBCT,
in 8, i.e. 38% of the reviews included, comprising 428 original articles), acceptance and commitment therapy (ACT) (Helland et al., 2022), as
and Mindfulness-Based Cognitive Therapy (MBCT, in 7 or 33%, 353 well as ER-focused approaches (Murray et al., 2022), with a globally low
original articles). risk of bias.
A less explored yet promising intervention tailored for adolescents is

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Fig. 1. PRISMA 2009 Flow Diagram. Articles selection process.

the ER Individual Therapy for Adolescents (ERITA), aimed at height­ positive impact of various interventions on ED, ER, and related domains
ening emotional consciousness, employing strategies for ER, and man­ (Table 4).
aging impulses. Notably, this intervention displayed the potential to DBT and CBT emerge as the most studied interventions, showcasing
enhance ER and reduce ED, as demonstrated in two minor-scale original consistent effectiveness in improving ED and reducing maladaptive ER
studies involving adolescents dealing with non-suicidal self-injury strategies across different populations, including healthy participants
(Eadeh et al., 2021). (Expósito-Campos et al., 2023) and transdiagnostic samples of psychi­
Only one review also included children (age range: 6–24 years) atric patients affected by BPD (Moltrecht et al., 2021), BD (Jones et al.,
(Moltrecht et al., 2021), highlighting small to moderate effects sizes of 2023), anxiety and depressive disorders (Sloan et al., 2017), and eating
CBT, ER Therapy (ERT), and Family Behavioral Therapy (FBT) in disorders (Bankoff et al., 2012; Moltrecht et al., 2021).
enhancing adaptive ER strategies (Hedge’s g = 0.36) and in reducing ED Only one systematic review of 13 articles did not find evidence that
(Hedge’s g = − 0.46) in patients suffering from BPD, anxiety, and DBT improves ER in a mixed sample of psychiatric patients; however,
depression, with heterogeneous risk of bias (weak to strong). the authors of this study report a high risk of bias according to the
Further details on quantitative results are reviewed in Table 5. Cochrane Risk of Bias Tool (Harvey et al., 2019).
Mindfulness-based interventions, although less studied, were also
3.2. Qualitative findings associated with ER improvements (identifying and managing emotions)
in two reviews on patients suffering from BPD, anxiety, depression,
The qualitative insights gleaned from the 10 systematic reviews eating, or addiction disorders (Sancho et al., 2018; Sloan et al., 2017).
included in this umbrella review provide a comprehensive view of the Only one systematic review, comprising 8 original articles (Lamothe

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Table 4
Results from systematic reviews.
Study Main Intervention (s) Nr of Sample Main Clinical Scores/Measures Main Findings Main Population Type
relevant Size
Papers

Expósito-Campos CBT with affirmative 22 948 BDI, DERS-SF, RRS Heterogeneous trends towards Adult and adolescent
et al., 2023 TGNB-specific reductions in emotion transgender and non-binary
adaptations, regulation difficulties (non- individuals (TGNB) and non-
psychodynamic and conclusive results). TGNB individuals.
person-centered
psychotherapy
Jones et al., 2023 DBT 9 NG CALS-C, ALS, DERS, ERS, ERQ- DBT improves ED. Adult and adolescent patients
SE, ACS with bipolar disorders (BD).
Ekiz et al., 2023 STEPPS (Systems 20 1162 DERS, Emotional Intensity The intervention decreases in Adult and adolescent patients
Training for Emotional Continuum, Number of affective instability. with BPD and other PD.
Predictability and hospitalizations, Suicide Majority female.
Problem Solving)- group attempts, Suicidal behaviors,
treatment program for Number of crisis calls, Self-
BPD harm acts, Emergency
department visits
Melton et al., 2020 CBT, DBT, MBCT, and 104 NG DERS Interventions including mostly Adults exposed to traumatic
others CBT, as well as DBT, MBCT, events, some of which are
and IPT improved ED but patients with PTSD and CPTSD.
results did not reach statistical
significance.
Warner and DBT-ST (skills training) 9 NG DERS DBT-ST reduces ER difficulties Adult and adolescent patients
Murphy, 2021 (when participants received with SUD.
the intended dose of emotion
regulation training), both in
the immediate (d = 0.42) and
delayed (d = 0.39) conditions.
Sloan et al., 2017 CBT, MBCT, ERGT, EABT 67 4659 DERS, DSHI, ZAN-BPD, BDI, Psychotherapy reduced Adult and adolescent patients
HAMA, BEST, DASS maladaptive ER strategies and with BPD, anxiety, depression,
rumination; ERGT reduced ED. substance use, or an eating
disorder.
Lamothe et al., MBSR, IMT 8 572 SREIT, FMI, KIMS, FFMQ MBSR improved subscales Healthcare professionals.
2016 associated with emotions
identification.
Bankoff et al., DBT 3 NG Positive and Negative Affect DBT may reduce emotion Adult patients with eating
2012 Schedule, Negative Mood dysregulation symptoms, but disorders. Predominantly
Regulation Scale findings are mixed. Caucasian.
Osma et al., 2021 UP 5 254 DERS, ERQ Several studies showed ER Adult patients with other
improvement, with effect sizes medical conditions, including
ranging from d = 0.44 to d = Anxiety/Depressive symptoms,
1.40. GAD/SAD/MDD/PDD;
Irritable bowel syndrome,
infertility, HIV, and multiple
sclerosis. 75% female and
mostly Iranian.
Harvey et al., 2019 DBT 13 836 DERS DBT does not show consistent Adults and adolescents with
benefits relative to existing BPD, BD, BED, depressive
psychological treatments in disorders, or anxiety disorders.
improving ER difficulties. Subjects include inpatients,
outpatients, and high-school
students. Majority female.
Sancho et al., 2018 DBT, Mindful Awareness 4 266 DERS Mindfulness-based Adult patients with SUD and
in Body-oriented interventions reduce emotion behavioral addictions. 46.24%
Therapy, Mindfulness- dysregulation. female.
Based
Substance use Relapse
Prevention, Mindfulness
Training for Smokers

et al., 2016), investigated the effect of Mindfulness-Based Stress 3.3. Quality and risk of bias assessments
Reduction (MBSR) and interpersonal mindfulness training (IMT) based
on MBSR. This review highlighted promising results in enhancing Assessment of quality and risk of bias across the 21 included reviews
emotion identification in 572 healthy healthcare professionals. revealed a diverse landscape of methodological rigor.
No qualitative review focused exclusively on children or adolescents. A quantitative synthesis of risk-of-bias assessments across the re­
However, some of the systematic reviews did cover adolescents, views indicates an overall moderate average level of bias risk, graded on
including those with various disorders, such as BD, BPD, SUD, and a scale encompassing low, moderate, and high risk across the reviews
various anxiety and depressive disorders (Expósito-Campos et al., 2023; included. Various assessment tools were employed to gauge the quality
Jones et al., 2023; Ekiz et al., 2023; Warner and Murphy, 2021; Sloan of the articles included in the individual reviews, shedding light on the
et al., 2017; Harvey et al., 2019). strengths and limitations of the evidence base. The most frequently used
tool for quality assessment was the Cochrane risk of bias tool (in 10
articles, i.e. 48%). Six studies (28%) did not include systematic quality

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Table 5
Quantitative results from reviews including Meta-Analyses.
Study Main Intervention(s) Nr of Sample Main Clinical Scores/ Main Findings Main Population Type
relevant Size Measures
Papers

Helland et al., 2022 CBT, DBT, MBCT, ACT, 30 2389 DERS, EKF, ERQ, ERC, Interventions including goal- Eurasian adolescents.
Cognitive training, Group FFMQ, COPE, MERLC, setting and psychoeducation
therapy, and psychoeducation CERQ, RRS had significantly higher effects
on ER compared to
interventions without these
elements. Meta-analyses
showed an overall effect for all
included studies on emotion
regulation of Cohen’s d = 0.29
(95% CI 0.14–0.43, p <
00.001).
Kunzler et al., 2022 CBT, AIT, and unspecified 24 1879 DASS-21 Positive moderate effect sizes Adult nursing staff,
positive psychology were identified for 9 programs, majority female.
5 of which focused on teaching
ER strategies.
Murray et al., 2022 Cognitive Regulation 33 NG Youth-reported emotion ER approaches had consistent Early adolescents (aged
Approaches, Emotion regulation (e.g., positive effects (g = 0.20). 10–15) with anxiety,
Regulation Approaches, Parent management of anger or Slightly larger effects were seen depression, ADHD, and
Training, Physical Activity, and sadness, emotion for outcomes in the emotional other high-incidence
Working Memory dysregulation, coping), domain including psychiatric disorders
youth-reported emotional dysregulation and distress (g = with recognized ER
distress (e.g., anxiety or 0.24). difficulties. 48% female.
depression symptoms, stress,
other internalizing
symptoms)
Stoffers-Winterling CBT and subtypes, DBT, ERGT, 31 1870 DASS, DERS, BDI BPD symptom severity Adult patients with BPD.
et al., 2012 MBT interpersonal therapy decreased after DBT skills Majority female.
adapted for BPD (IPT-BPD), training (BPD severity: SMD
dynamic deconstructive − 0.66, P = 0.002; psychosocial
psychotherapy (DDP), STEPPS, functioning: SMD − 0.45, P =
psychoeducation, and others 0.002), ERGT (BPD severity:
mean difference − 8.49, P <
0.00001), manual-assisted
cognitive therapy (self-harm:
mean difference − 3.03, P =
0.03; suicide-related outcomes:
SMD − 0.96, P = 0.005) and
STEPPS (BPD severity: SMD
− 0.48, P = 0.002). ERGT
reduced total DERS scores and
impulsivity.
Daros et al., 2021 CBT, DBT, MBCT, ACT, ABBT, 88 11652 CERQ, COPE, DERS, ERQ, Psychological treatments Adolescents and young
ERT, IPT, MSBR. PST, etc FFMQ, RRS/RSQ produced small-to-medium adults (mean age
effect size decreases in ED (g = between 14 and 24.9).
0.54, p < 00.001), and small
effect size increases in
engagement ER skills (g = 0.26,
p < 00.001).
Eadeh et al., 2021 CBT, DBT, MBCT, ERITA, 41 NG ADS, CEMS, CERQ, DERS, Significant improvement in ER At-risk adolescents and
RELAX: Regulating Emotions EDI, ERC, MERLC, ERBS, was seen across all studies patients (age range:
Like An eXpert; CERTIFY: ERQ, ESCQ, EESC, CEMS (Hedge’s g = 0.28). 10–19) with
Cognitive Emotion Regulation externalizing and
Training Intended for Youth; internalizing disorders,
EASE: Emotional Awareness ASD, obesity, and youth
and Skills Enhancement; at risk for bipolar.
TARGET: Trauma Affect
Regulation: Guide for Education
and Therapy; ERI: Emotion
Regulation Intervention; EEP:
Emotion Education Program;
ERT: Emotion Regulation
Training
Grohmann and DBT, MBCT, ACT, mindfulness- 20 166 DERS, FFMQ MBIs significantly improved ER Adolescent and adult
Laws, 2021 based interventions for binge (g = − 0.58). patients with BED.
eating
Moltrecht et al., CBT, ACT, Emotion Regulation 21 2115 DERS, LPI, ERC, CISS, FFMQ, All included interventions Children, adolescents,
2021 Therapy(ERT); Mindfulness SPSI-R, ACS-PS, RRS, AFQ, improved ER, with effect sizes and adults with BPD,
(MF); Family Behavioural MAAS, IC-PS, Rumination ranging between g = 0.36 anxiety disorder, major
Therapy (FBT); Emotion items, CSCY-PS, PSQ, CRSQ, [0.14; 0.58] and g = 0.43[0.18; depression, substance
Regulation Program; Cognitive CERQ, CEMS 0.69]. abuse, eating disorders,
Therapy for PTSD. conduct disorders, or
ADHD.
(continued on next page)

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Table 5 (continued )
Study Main Intervention(s) Nr of Sample Main Clinical Scores/ Main Findings Main Population Type
relevant Size Measures
Papers

Sakiris and Berle, UP 7 789 DERS, ERQ, MEAQ, SMQ UP has a significant moderate Adult patients with at
2019 effect size both on reducing least one internalizing
maladaptive ER (6 studies) and disorder or comorbid
enhancing adaptive ER (3 internalizing disorders.
studies).
Xuan et al., 2020 MBCT 3 36 DERS, ERS, BRIEF MBCT improved ER with Adult patients with BD
modest significance (Z = 2.52, according to DSM-IV/
P = 0.01) and low ICD-9. 72% female.
heterogeneity (I2 = 35%).

and risk of bias summary assessments of all relevant articles but reported existing literature. While detailed descriptions of all psychotherapeutic
limitations (Bankoff et al., 2012; Eadeh et al., 2021; Expósito-Campos approaches are beyond the scope of this review and can be found in the
et al., 2023; Lamothe et al., 2016; Sancho et al., 2018; Xuan et al., 2020). corresponding references, it is noteworthy to mention that DBT, an
Of the 15 articles reporting risk of bias assessments, 9 (Jones et al., 2023; approach initially developed for BPD and subsequently tested in other
Helland et al., 2022; Kunzler et al., 2022; Murray et al., 2022; Stof­ disorders, emphasizes ER, distress tolerance, and interpersonal effec­
fers-Winterling et al., 2012; Daros et al., 2021; Melton et al., 2020; tiveness, with a duration spanning several months (Linehan, 1993). On
Grohmann and Laws, 2021; Harvey et al., 2019) used the Cochrane Risk the other hand, CBT is rooted in identifying and altering negative
of Bias Tool. Of the other 6 articles, 2 used the Quality Assessment Tool thought patterns and behaviors, exploring the relationship between
for Quantitative Studies of Effective Public Healthcare Panacea Project thoughts, feelings, and behaviors, and eventually changing maladaptive
(EPHPP) (Moltrecht et al., 2021; Sakiris and Berle, 2019); one article cognitive patterns contributing to emotional distress (Hofmann et al.,
used a tool made by five items from Barnicot et al. (2012) and five items 2012).
from EPHPP (Ekiz et al., 2023). Other tools, each used only by one Nevertheless, this umbrella review emphasizes the potential clinical
article, include the following: the Psychotherapy Outcome Study relevance of investigating other, less-explored ER interventions, such as
Methodology Rating Form (POMRF) (Sloan et al., 2017); The Study transdiagnostic interventions, ACT, mindfulness-based approaches, and
Quality Assessment Tools from the National Heart Lung and Blood group therapies, as we discuss in the following paragraphs.
Institute (NHBLI) (Osma et al., 2021); Consolidated Standards of As mentioned in the background, transdiagnostic frameworks sug­
Reporting Trials (CONSORT) (Warner and Murphy, 2021). 3 of the 15 gest that mental disorders are not isolated entities but rather stem from a
articles reported only an overall risk of bias score without detailing the set of core underlying dimensions (Mansell et al., 2009). By recognizing
specific or more common risks of bias among the included articles. In the these shared dimensions, a transdiagnostic approach shifts the focus
remaining 12 articles, the most common risk of bias item reported as from specific diagnoses to the underlying factors that contribute to
“high” was performance bias due to lack of blinding in 7 out of 12 various disorders, such as ED. From this viewpoint, it is interesting to
studies (Helland et al., 2022; Kunzler et al., 2022; Melton et al., 2020; note that the Unified Protocol for emotional disorders (UP) showed
Harvey et al., 2019; Warner and Murphy, 2021; Sakiris and Berle, 2019; promise in improving ED across various psychiatric conditions (Sakiris
Jones et al., 2023). The second most common risk of bias reported was and Berle, 2019; Osma et al., 2021).
attrition bias, with 6 out of 12 studies with incomplete outcome data due On the other hand, though less explored, mindfulness-based in­
to problems with study completion and dropouts (Ekiz et al., 2023; terventions also emerged as promising strategies. MBSR and MBCT
Kunzler et al., 2022; Stoffers-Winterling et al., 2012; Melton et al., 2020; demonstrated tangible improvements in identifying and regulating
Warner and Murphy, 2021; Harvey et al., 2019). The third most com­ emotions, for instance, among patients with BPD, anxiety, depression,
mon risk of bias was reporting bias in 3 out of 12 reviews (Kunzler et al., eating disorders, and addiction disorders. These interventions are
2022; Melton et al., 2020; Grohmann and Laws, 2021). Further details particularly relevant considering that mindfulness has been suggested to
are reviewed in Supplementary Table 2. be associated with a reduction in the pro-inflammatory status that is
associated with ED disorders and that inflammation may be especially
4. Discussion deleterious for ER processing neural circuits, which, indeed, are posi­
tively impacted by mindfulness (Bauer et al., 2019; Chou et al., 2022;
Our synthesis of quantitative and qualitative analyses highlights the Nusslock et al., 2019; Petruso et al., 2023; Saccaro et al., 2021b; 2021c).
efficacy of psychotherapeutic interventions in enhancing ER and Finally, group dynamics are a well-known crucial component of
reducing ED across a diverse spectrum of populations, including trans­ emotion processing, and group therapies have long been proposed as
diagnostic psychiatric patients and healthy individuals. Studies effective interventions for ED (Porat et al., 2020). Indeed, ERGT show­
involving adults are the most supported, while those with adolescents cased promising and statistically significant outcomes in ameliorating
are more limited, with only a small number of studies analyzing youth ED in BPD adults and adolescents (Stoffers-Winterling et al., 2012).
diagnosed with ADHD, anxiety and depressive disorders, and Non- These approaches may offer advantages over DBT, particularly treat­
Suicidal Self-lnjury (NSSI). Studies in children are even more limited, ment duration (several months for DBT compared to a few weeks for
though they align with these effects (Moltrecht et al., 2021). ERGT). The fact that this psychotherapeutic intervention, along with
Nearly all included studies, apart from one that highlighted a high others like CBT or DBT (Helland et al., 2022), has shown efficacy in
risk of bias (Harvey et al., 2019), revealed significant ER improvement improving ER even in adolescent populations, confirms its potential as
and reductions in maladaptive ER strategies or ED following most psy­ an early intervention in high-risk populations, such as transition-age
chotherapeutic interventions. This effectiveness was consistent across youths, as suggested in the background. However, most reviews
various treatment protocols, ER constructs examined, and targeted focused on adults, and further research on adolescents is needed.
populations, ages, or psychiatric disorders. The overall fair quality of the Ultimately, this umbrella review provides evidence supporting the
reviewed studies lends credibility to the synthesis of quantitative and efficacy of DBT and CBT, while also highlighting the potential of other
qualitative evidence, endorsing DBT and CBT as particularly impactful early clinical interventions in adults with ED disorders. Less sufficient
and well-studied interventions for enhancing ER, which is in line with but growing evidence exists in adolescent populations, with very limited

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evidence in children. These interventions have been shown to work in review, we recommend this as an avenue for future research. However,
populations ranging from healthy participants to patients affected by this limitation is partly amended by the wide range of psychiatric dis­
BD, BPD, anxiety and depressive disorders, PTSD, addiction disorders, orders that we studied in the included reviews and meta-analyses.
and eating disorders. Finally, the scarcity of results in adolescents and children emphasizes
the need for additional research to develop and analyze interventions
4.1. Strengths and limitations targeting ED, with a particular focus on high-risk psychiatrically
impaired youth.
This systematic umbrella review possesses several key strengths,
making a significant contribution to the field of interventions targeting 4.2. Conclusions, implications and future directions
ER. To begin with, it is the first comprehensive review of its kind,
signifying its novelty and the potential to shape future research di­ This umbrella review provides a comprehensive synthesis of in­
rections. Adherence to PRISMA guidelines adds to its methodological terventions targeting ER, offering insights into their effectiveness and
rigor, including, for instance, pre-registered methods, systematic implications for clinical practice and research from a quantitative and
searches across multiple databases, and blinded data review. The re­ qualitative viewpoint. The findings underscore the impact of a diverse
view’s robustness is underpinned by its meticulously designed search array of psychotherapeutic interventions on improved ER and reduced
criteria, ensuring high sensitivity through broad and general keywords ED across different populations and age groups. DBT and CBT stand out
and specificity, thanks to precise PICOS criteria. as the most well-studied and effective interventions for ED trans­
Quantitative synthesis of risk of bias assessments across the reviews diagnostically, demonstrating their efficacy across various diagnostic
offers a critical view of the existing evidence, highlighting the impor­ categories within the spectrum of ED-related disorders. However, other
tance of considering methodological quality when synthesizing and less-studied alternatives, such as ACT and mindfulness-based in­
interpreting the results of interventions targeting ED. Another note­ terventions, also exhibit promising results in enhancing adaptive ER
worthy strength lies in the review’s dual approach, combining qualita­ capacities and reducing ED. Additionally, the review highlights the
tive and quantitative insights. Qualitative insights gleaned from significance of ER as a transdiagnostic process, emphasizing the poten­
systematic reviews provide a nuanced perspective on the positive effects tial for interventions to concurrently impact multiple psychiatric dis­
of interventions. At the same time, quantitative analyses reinforce these orders (e.g. BD, BPD, anxiety and depressive disorders, PTSD, addiction
findings by recapitulating consistent and statistically significant effect disorders, and eating disorders, as discussed in Section 3). Of note, only
sizes. The extensive range of interventions and populations encom­ one review (Melton et al., 2020) addressed PTSD, identifying
passed in this review enhances its generalizability, rendering it a phase-based therapies targeting ED as most effective for reducing ED,
promising resource for clinicians and researchers who are seeking while trauma-focused therapies overall did not significantly reduce ED.
evidence-based guidance for transdiagnostic, early interventions in This highlights the need for additional research on ED-focused adapta­
psychiatric disorders presenting ED. Indeed, the clinical focus of the tions and interventions for specific disorders that do not typically target
review holds promise for rapidly translatable findings. ED.
Finally, the review offers value by shedding light on interventions These findings have several important implications. In addition to
that have not yet been extensively studied but are promising. Having affirming the value of well-established interventions like DBT and CBT
new potential interventions emerge is crucial given that not all pop­ in enhancing ER, our results open avenues for innovative and diverse
ulations may be suitable for or responsive to the most widely studied clinical applications of these and other, less well-characterized psycho­
interventions, like DBT or CBT. The recognition of various treatment therapeutic interventions for ED in different populations. Notably, a
alternatives aligns with the transdiagnostic nature of ED, potentially transdiagnostic approach has profound implications for addressing
yielding benefits for a broader range of patients. Indeed, transdiagnostic psychiatric comorbidities, particularly when treating individuals with
frameworks posit that core underlying dimensions, such as maladaptive multiple co-occurring mental health conditions, which is a common
ER strategies or deficits in emotional awareness, contribute to a spec­ clinical occurrence (Kessler et al., 2011). Since these conditions often
trum of ED-related disorders. By understanding how underlying sub­ share underlying mechanisms, interventions targeting these standard
processes are disrupted and how we can predict individual responses to dimensions can simultaneously impact multiple disorders. This syner­
specific approaches, clinicians can tailor interventions to address these gistic effect can lead to more comprehensive and effective outcomes. For
shared underlying factors, making them applicable across a diverse instance, when dealing with high-risk offspring of ED patients who may
range of diagnostic categories within the spectrum of ED-related be susceptible to a range of psychological disorders, a transdiagnostic
conditions. approach can intervene at an early stage to mitigate the risk factors that
However, despite these strengths, this umbrella review faces contribute to various disorders. This proactive approach reduces the
inherent limitations when aggregating diverse research. Heterogeneity likelihood of multiple conditions emerging later in life and can alleviate
in study designs, interventions, and outcome measures across the transdiagnostic prodromal symptoms (McGorry et al., 2018). These
included reviews introduces variability in the findings and restricts the findings may thus inform future clinical trials focusing on early in­
feasibility of quantitative umbrella meta-syntheses. This heterogeneity terventions for subjects at high risk for a spectrum of ED disorders.
underscores the complexity of ER interventions and highlights the A transdiagnostic approach may also provide a more unified and
challenge of drawing overarching conclusions. Addressing this chal­ streamlined intervention strategy. Rather than tailoring treatments for
lenge is pivotal for ensuring the robustness of the synthesized findings each disorder, a single treatment protocol can target the shared core
and further reinforcing the review’s credibility. dimensions. This may not only enhance treatment efficiency but also
Another limitation pertains to the scarcity of studies focusing on simplify clinical decision-making for practitioners dealing with complex
individuals experiencing multiple comorbid psychiatric disorders. Given cases of comorbidity. In the context of ED disorders, where comorbid­
the high prevalence of comorbidity in clinical settings, the absence of ities are common, a transdiagnostic approach can reduce the burden of
research investigating treatment efficacy for individuals with multiple administering multiple treatments for different conditions, making in­
disorders poses a limitation. The lack of outcome measures for co- terventions more manageable for both patients and healthcare providers
occurring disorders within the analyzed studies and small number of (Sloan et al., 2017).
pragmatic randomized control trials underscores the need for more From a research perspective, the review reveals the need for stan­
comprehensive investigations into the simultaneous reduction of dardized methodologies and outcome scores to address the observed
symptoms across various psychopathologies following ER interventions. heterogeneity in study designs and outcome measures. Future research
Since we did not examine the topic of comorbidities in depth in this could explore the durability of intervention effects over time, identify

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potential mediators and moderators of treatment outcomes, as well as Declaration of competing interest
the role of ED in the development of other psychiatric symptoms, and
delve into the mechanisms underlying specific interventions. The authors declare that they have no known competing financial
Additionally, ER interventions in the reviewed articles most often interests or personal relationships that could have appeared to influence
targeted patients with specific disorders like BPD, BD, and anxiety and the work reported in this paper.
depressive disorders, reflecting their associated ED symptoms and the
need for effective interventions. However, the overall diversity of psy­ Funding and acknowledgements
chiatric disorders studied in the included articles underscores the
transdiagnostic nature of ER and its relevance in various mental health This work was supported by the Swiss National Center of Compe­
contexts. This transdiagnostic perspective on ER suggests that these tence in Research (NCCR); “Synapsy: the Synaptic Basis of Mental Dis­
treatments might effectively address a broader spectrum of psychopa­ eases” financed by the Swiss National Science Foundation [Grant
thology. Thus, a pivotal direction for future research will be validating Number 51NF40- 158776], as well as a grant of the Swiss National
these interventions transdiagnostically, in heterogeneous real-world Science Foundation [Grant Number 32003B_156914] to CP. LFS was
patient samples, and across a wider range of psychiatric conditions, supported by two scholarships, by NCCR-Synapsy and by the Frutiger-
potentially comorbid among each other. Bickel foundation.
While the changes in ER reported in the reviewed articles were
mostly significant, the effect sizes were small to moderate. Hence, Abbreviations
additional evidence is needed on adjunctive transdiagnostic treatments
that specifically target ER, potentially contributing to further psycho­ ACS Affective control scale
pathology reduction. These treatments could be integrated into existing ACS-PS Adolescent coping scale-problem solving
therapy approaches alongside disorder-specific elements. For instance, a ACT Acceptance and commitment therapy
randomized controlled trial involving 432 inpatients with MDD found ADHD Attention-deficit/hyperactivity disorder
that supplementing routine CBT with a focused ER skills training not ADS Alcohol Dependence Scale
only led to a larger reduction in depressive symptoms but also enhanced AFQ Avoidance and Fusion Questionnaire
emotional well-being and specific ER skills relevant to mental health ALS Affective Lability Scale
(Berking et al., 2013). Similarly, a recent pilot study (Larsson et al., ASD Autism Spectrum Disorders
2020) explored the feasibility and efficacy of a short add-on group skills BAs Behavioral Addiction
training in ER for young adults with various eating disorders. The results BD Bipolar Disorder
indicated significant improvements in difficulties in ER, alexithymia, BDI Beck Depression Inventory
total eating disorder scores, and clinical impairment. Another recent BED Binge Eating Disorder
randomized controlled trial on internet-delivered 12-week ERITA as an BEST Behavioral and Emotional Screening Tool
adjunct to usual treatment showed that it effectively reduced self-injury BPD Borderline Personality Disorder
among a diverse group of adolescents (Bjureberg et al., 2023). Given the BRIEF Behavior Rating Inventory of Executive Function
increasing interest in mobile apps for mental health (Bae et al., 2023; CALS-C children’s affective lability scale
Saccaro et al., 2021), a recent systematic review focused on apps tar­ CEMS Children’s Emotion Management scale
geting ED in various mental health conditions, highlighting the potential CERQ Cognitive Emotion Regulation Questionnaire
benefits of app-enhanced psychotherapy in conjunction with ongoing CI confidence interval
psychological or psychotherapeutic treatment for ED, despite the need CISS Coping Inventory for Stressful Situation
for further research (Diano et al., 2023). These findings support the COPE Coping Orientation to Problems Experienced
ongoing development of adjunctive ER interventions (Berking et al., CPD Cutting Down Program
2013) or of modular psychotherapeutic approaches (Elsaesser et al., CRSQ Child Response Style Questionnaire
2022; Lucassen et al., 2015), with potential applications across condi­ CSCY-PS Coping Scale for Children and Youth
tions like substance use disorder, eating disorders, BD, and BPD (Berking DASS Depression Anxiety Stress Scale
et al., 2013). Nonetheless, additional investigation is necessary to DASS-21 Depression Anxiety Stress Scale – 21 Items
ascertain whether adjunctive ER interventions may enhance the efficacy DBT Dialectical Behavior therapy
of established evidence-based therapies. DBT-ST Dialectical Behavior Therapy Skills Training
Broadly speaking, the study of the transdiagnostic nature of ER opens DERS Difficulties in Emotion Regulation Scale
doors to a more comprehensive understanding of mental disorders. It DERS-SF Difficulties in Emotion Regulation Scale - Short Form
allows for the development of treatment strategies that target both co­ DGP Developmental Group Psychotherapy
morbid conditions and mental health risks concurrently. This approach DSHI Drug Use Screening Inventory
shows potential in enhancing prevention and treatment efficiency, EABT Emotion acceptance behavior therapy
advancing the field of ER interventions and ultimately promoting the ED Emotion dysregulation
well-being of individuals dealing with diverse ED manifestations. EDI Eating Disorder Inventory
EESC Emotional Eating Scale for Children
CRediT authorship contribution statement EKF Emotional Competence Questionnaire
ER Emotion regulation
Luigi F. Saccaro: Writing – review & editing, Writing – original ERBS Emotional Regulation and Behavioral Suppression
draft, Visualization, Methodology, Investigation, Funding acquisition, ERC Emotion Regulation Checklist
Formal analysis, Data curation, Conceptualization. Alexis Giff: Writing ERGT Emotion regulation group therapy
– review & editing, Writing – original draft, Visualization, Formal ERGT(G) emotion regulation group therapy based on the Gross model
analysis, Data curation. Maurilio Menduni De Rossi: Data curation. of ER
Camille Piguet: Writing – review & editing, Supervision, Software, ERITA Emotional Regulation Individual Therapy for Adolescents
Conceptualization, Funding acquisition, Methodology, Resources. ERQ-SE Emotion regulation questionnaire-self efficacy
ERS emotion reactivity scale
ESCQ Emotion Suppression and Coping Questionnaire
EST Emotional Schema Therapy

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