Health-related quality of life among adolescents with eating disorders

Objective

Health-related quality of life (HRQoL) is an emerging area of research in eating disorders (EDs) that has not been examined in adolescents in detail. The aim of the current study is to investigate HRQoL in an adolescent ED sample, examining the impact of ED symptoms on HRQoL.

Methods

Sixty-seven treatment-seeking adolescents (57 females) with anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder not otherwise specified (EDNOS) completed self-report measures of HRQoL and ED symptoms.

Results

Participants reported poorer HRQoL in mental health domains than in physical health domains. Disordered attitudes, binge eating, and compensatory behaviors were associated with poorer mental health HRQoL, and body dissatisfaction was associated with poorer physical health HRQoL.

Conclusion

The current study assessed HRQoL among adolescents with EDs, finding several consistencies with the literature on adults with EDs. Future research should compare adolescents and adults with EDs on HRQoL.     

Suicidal behavior in adolescents and adults with bulimia nervosa

Background

Recent evidence suggests increased risk for mortality in bulimia nervosa (BN). However, little is yet known about suicidal behavior in BN.

Aims

To examine frequency and correlates of suicidal ideation and attempts in adolescents and adults with BN in two population-based samples.

Method

A total of 10,123 adolescents and 2980 adults in two nationally representative surveys of mental disorder were queried regarding eating disorder symptoms and suicidal ideation and attempts.

Results

Less than 1 percent (0.9%) of adolescents and 1.0% of adults met the criteria for BN. Suicidal ideation was more common among adolescents with BN (53.0%) compared with those with binge eating disorder (BED) (34.4%), other psychopathology (21.3%) or no psychopathology (3.8%). Similar trends emerged for the association between BN and self-reported suicidal plans or attempts. Among adults, suicidality was more common in BN than in the no psychopathology group, but not significantly different from the anorexia nervosa (AN), BED, or other psychopathology subgroups.

Conclusion

There is a high risk of suicidal ideation and behavior among those with BN. These results underscore the importance of addressing suicide risk in adolescents and adults with eating disorder symptoms.     

Predicting post-traumatic stress disorder in veterans: Interaction of traumatic load with COMT gene variation

Background

Because post-traumatic stress disorder (PTSD) by definition can occur only after exposure to a traumatic event, military veterans who are at high risk for trauma exposure are a particularly relevant population for studying the interaction of trauma with genetic factors that may predispose for the disorder. A number of studies have implicated specific genes as possible risk factors in developing PTSD, including the catechol-O-methyltransferase gene (COMT).

Methods

Data from Iraq War veterans (n = 236) were used to examine the interaction between COMT and traumatic experiences in predicting later development of PTSD symptoms. Subjects were assessed for exposure to traumatic events both before and during deployment.

Results

The interaction between trauma load and COMT was a significant predictor of PTSD symptoms. Those with the heterozygous genotype (Val/Met) showed fewer symptoms associated with trauma exposure compared to those with either homozygous genotype. This interaction remained significant after controlling for other risk factors for PTSD, including personality dimensions of Internalizing and Externalizing.

Conclusions

COMT genotype affects risk for development of PTSD symptoms following exposure to trauma.     

Longitudinal relationships of insomnia,nightmares, and PTSD severity in recent combat veterans

Objective

This observational, longitudinal study of veterans with recent combat exposure describes the prevalence, severity and associations of posttraumatic stress disorder (PTSD), insomnia, and nightmares over time.

Methods

Eighty recent combat veterans recruited from Veterans Health Administration primary care settings met inclusion criteria including hazardous alcohol use and at least subthreshold PTSD. Insomnia status and nightmare status were assigned based on the Insomnia Severity Index total score and the PTSD Checklist nightmare item, respectively. Participants were re-assessed six months following their baseline assessment. Analyses of variance compared insomnia and nightmare groups on PTSD, depression, and alcohol use severity. Analyses of covariance (controlling for baseline differences) examined whether insomnia and/or nightmares were associated with the clinical course of PTSD. Persistence of conditions was also examined.

Results

At baseline, 74% presented with insomnia and 61% endorsed distressing nightmares. Insomnia was associated with significantly higher PTSD and depression severity at both baseline and six months. The presence of nightmares was associated with significantly higher PTSD severity at both time points and with depression severity at baseline only. Despite decreases in PTSD and depression severity, insomnia severity was relatively unchanged after six months. The prevalence and severity of nightmare complaints diminished modestly over time.

Conclusion

Among this sample of recent combat veterans, insomnia and nightmares were each strongly associated with the severity of both PTSD and depressive symptoms. Over time, insomnia in particular did not appear to resolve spontaneously and was associated with ongoing PTSD. Addressing insomnia early, therefore, may be a strategy to alter the course of PTSD.     

Overgeneral memory in asylum seekers and refugees

Background and objectives

Studies in western samples have shown that post-traumatic stress disorder (PTSD) and depression are associated with overgeneral autobiographical memory retrieval. This study assesses whether this association extends to asylum seekers and refugees from diverse cultural backgrounds. We discuss implications for those providing testimony of their experiences when seeking asylum.

Method

38 asylum seekers and refugees were recruited through clinics and community groups. Clinical interviews assessed PTSD and depression and participants completed a test of autobiographical memory specificity.

Results

When accounting for omissions, participants with PTSD and depression recalled a lower proportion of specific memories. Those with PTSD also failed more frequently to report any memory.

Limitations

The sample did not permit separate evaluation of the effects of PTSD and depression on specificity.

Conclusions

Lower memory specificity observed in people experiencing PTSD and depression in western populations extends to asylum seekers and refugees from diverse cultural backgrounds. This study adds to the literature suggesting that being recognised as a refugee fleeing persecution is more difficult for those with post-traumatic symptoms and depression.     

Mental health consequences of intimate partner violence in Vhembe district,South Africa

Objective

The aim of this study was to assess the contributions of different forms of intimate partner violence (physical violence, sexual violence, psychological abuse, and stalking) on symptoms of posttraumatic stress disorder (PTSD) and depression.

Methods

In all 268 women (18 years and older) consecutively receiving a protection order in the Vhembe district in South Africa were assessed by an external interviewer. Hierarchical regressions tested the unique effects of different types of intimate partner violence on PTSD and depression.

Results

In terms of PTSD symptom severity, more than half (51.9%) of the sample reported severe PTSD and 66.4% reported severe depression symptoms. Two types of intimate partner violence (physical and sexual) were significantly associated with PTSD symptoms, while only psychological violence was moderately correlated with depression symptoms. Physical abuse contributed to the prediction of PTSD and psychological abuse to depression.

Conclusions

A significant number of women with protection orders suffer from PTSD and depression. The results confirm a relationship between severity of intimate partner violence and mental health problems (PTSD and depression). Assessment of intimate partner violence should incorporate the multiple dimensions that have been identified as contributing to poor mental health.     

Understanding catastrophic worry in eating disorders: process and content characteristics

Background and objectives

The majority of people with eating disorders (ED) experience high levels of comorbid anxiety and depression, yet the maintenance processes of these in ED remain largely unknown. Worry, a defining cognitive feature and important maintenance factor of anxiety, has not been well-studied amongst people with ED. This is the first study to explore both the process and content characteristics of catastrophic worry in ED.

Methods

Twenty-nine patients with anorexia nervosa (AN), 15 patients with bulimia nervosa (BN) and 37 healthy controls (HC) completed measures assessing anxiety, depression, worry and eating disorder pathology. Catastrophic worry was assessed using the Catastrophizing Interview and catastrophic worry content was explored using qualitative Thematic Analysis.

Results

Compared to HCs, ED groups had higher levels of anxiety, depression and worry and they generated a greater number of catastrophic worry steps. Worry was further found associated with depressive symptomatology in those with ED. Worry content for the ED groups included ED themes, but also themes reflecting broader inter and intrapersonal concerns.

Limitations

The degree to which worry is driven by depressive versus anxious symptomatology remains unclear. The current study does not include an anxious or depressed control group, and results should be considered in the light of relatively small samples sizes.

Conclusion

Findings indicate that interventions that target worry processes may be a useful adjunct to treatment for those ED patients with clinical worry levels.     

Genotype-controlled analysis of serum dopamine β-hydroxylase activity in civilian post-traumatic stress disorder

Background

Norepinephrine (NE) plays a central role in post-traumatic stress disorder (PTSD). Dopamine β-hydroxylase (DβH) converts dopamine (DA) to NE and its activity varies widely across individuals. Mustapic et al. (2007) reported a PTSD-associated deficit in serum DβH activity in a genotype-controlled analysis of combat veterans. We tested whether such a deficit would occur in a sample of civilians.

Methods

The severity of current adult PTSD symptoms and current DSM-IV diagnosis of PTSD were determined by the PTSD Symptom Scale (PSS). Adulthood trauma exposure was assessed using the Traumatic Experience Inventory (TEI). Serum DβH activity (sDβH) was assayed by HPLC with electrochemical detection and genotypes were determined using the Taqman® platform.

Results

Two hundred and twenty seven African American (AA) subjects were enrolled in this study, with a mean age (± SD) of 42.9 (± 12.9) years. We found a strong association between rs1611115 genotype and sDβH (p < 0.0001). After controlling for adulthood trauma exposure, there were no significant differences of sDβH between subjects who met a PTSD diagnosis and those who did not (p > 0.05) in any genotype group. No significant correlations were found between sDβH and PTSD severity, but sDβH significantly associated with the status of comorbid depression based on the cutoff of HAMD (p = 0.014) in subjects with PTSD.

Conclusions

We have replicated in this sample the prior finding that DBH rs1611115 genotype strongly associates with sDβH. No associations between sDβH and PTSD diagnosis or symptom severity were found in this civilian sample.     

Comorbid atypical depression in borderline personality disorder is common and correlated with anxiety-related psychopathology

Background

The core features of borderline personality disorder (BPD) are affective instability, unstable relationships and identity disturbance. Axis I comorbidities are frequent, in particular affective disorders. The concept of atypical depression is complex and often underestimated. The purpose of the study was to investigate the comorbidity of atypical depression in borderline patients regarding anxiety-related psychopathology and interpersonal problems.

Methods

Sixty patients with BPD were assessed with the Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID I, SCID II) as well as the Atypical Depression Diagnostic Scale (ADDS). Additionally, patients completed a questionnaire (SCL-90-R, BDI, STAI, STAXI, IIP-C).

Results

Forty-five BPD patients (81.8%) had a comorbid affective disorder of which 15 (27.3%) were diagnosed with an atypical depression.In comparison to patients with major depressive disorder or no comorbid depression, patients with atypical depression showed significant higher scores in psychopathological symptoms regarding anxiety and global severity as well as interpersonal problems.

Conclusions

The presence of atypical depression in borderline patients is correlated with psychopathology, anxiety, and interpersonal problems and seems to be of clinical importance for personalized treatment decisions.     

Association of trauma exposure with psychiatric morbidity in military veterans who have served since September 11, 2001

Objective

This study examined the association of lifetime traumatic stress with psychiatric diagnostic status and symptom severity in veterans serving in the US military after 9/11/01.

Method

Data from 356 US military veterans were analyzed. Measures included a standardized clinical interview measure of psychiatric disorders, and paper-and-pencil assessments of trauma history, demographic variables, intellectual functioning, posttraumatic stress disorder (PTSD) symptoms, depression, alcohol misuse, and global distress.

Results

Ninety-four percent of respondents reported at least one traumatic stressor meeting DSM-IV criterion A for PTSD (i.e., life threatening event to which the person responded with fear, helplessness or horror), with a mean of four criterion A traumas. Seventy-one percent reported serving in a war-zone, with 50% reporting occurrence of an event meeting criterion A. The rate of current psychiatric disorder in this sample was: 30% PTSD, 20% major depressive disorder, 6% substance abuse or dependence and 10% for the presence of other Axis I psychiatric disorders. After accounting for demographic covariates and combat exposure, childhood physical assault and accident/disasters were most consistently associated with increased likelihood of PTSD. However, PTSD with no comorbid major depressive disorder or substance use disorder was predicted only by combat exposure and adult physical assault. Medical/unexpected-death trauma and adult physical assault were most consistently associated with more severe symptomatology.

Conclusions

Particular categories of trauma were differentially associated with the risk of psychiatric diagnosis and current symptom severity. These findings underscore the importance of conducting thorough assessment of multiple trauma exposures when evaluating recently post-deployed veterans.     

Self-image and suicide in a Swedish national eating disorders clinical register

Objective

Using a prospective design, to examine the relation between self-image (assessed using the Structural Analysis of Social Behavior) and suicide attempts/completions in women with anorexia nervosa-restricting type (ANR), anorexia nervosa-binge/purge type (ANBP), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified (EDNOS); and to assess whether these self-image variables add unique predictive value to suicide when considering other baseline predictors.

Method

Women (N = 2269) aged 12 to 45 (M = 22.1) presenting to specialist eating disorders clinics in Sweden between 2005 and 2009 were identified through the Stepwise Eating Disorders Quality Register. Data on age, body mass index, eating disorder severity (Eating Disorder Examination-Questionnaire scores), psychiatric comorbidity, global assessment of functioning, and self-image were abstracted from Stepwise and included as baseline predictors or covariates. Suicide information (prior attempt and attempt/completion after Stepwise registration) was obtained from the National Patient Register and Cause of Death Register.

Results

Prevalence of detected suicide attempts/completions over the study period was 9.2%. Negative self-image variables were associated with prior suicide attempts in ANR and EDNOS and later suicide attempts/completions in women with BN. In a stepwise Cox proportional hazards model, only low self-affirmation predicted time to suicide attempts/completions in women with BN when accounting for age and prior suicide attempt.

Conclusion

Assessing self-image might assist with identifying women with BN at elevated risk for suicide.     

An examination of weight bias among treatment-seeking obese patients with and without binge eating disorder

Objective

The objective was to compare weight-bias attitudes among treatment-seeking obese patients with and without binge eating disorder (BED vs. NBO) and to explore racial and sex differences and correlates of weight-bias attitudes.

Method

Participants included 221 obese patients (169 female, 52 male) seeking treatment for weight and eating, recruited through primary care settings; of these, 168 patients met BED criteria. Patients completed semi-structured interviews and psychometrically established self-report measures of attitudes about obesity, eating pathology and depression.

Results

Main effects for group (BED vs. NBO) and race (White vs. African American) were significant. Patients with BED had significantly higher levels of negative attitudes towards obesity than NBO patients, while African American patients had significantly lower levels of weight bias than did White patients. Greater negative attitudes towards obesity were significantly correlated with higher levels of depression and eating pathology for all patients.

Conclusions

Endorsement of negative weight bias was related to binge eating status, race, disordered eating, and depression. Primary care providers should be aware of weight biases among their patients.     

Subtypes in bulimia nervosa: the role of eating disorder symptomatology,negative affect,and interpersonal functioning

Background

The aim of the study was to investigate whether patients with bulimia nervosa (BN) could be subdivided into clinically meaningful groups reflecting the complex patterns of eating disorder symptoms and personality characteristics that face the clinician.

Methods

Seventy patients diagnosed with BN using the Eating Disorder Examination were assessed with measures of negative affect, attachment patterns, and interpersonal problems. An exploratory hierarchical cluster analysis was performed.

Results

The study found two main subtypes differing primarily in terms of symptom severity and level of negative affect, but these subtypes were further subdivided into four clinically relevant subtypes: A dietary restraint/negative affect/high symptomatic group, an emotionally overcontrolled group, a low dietary restraint/emotionally underregulated group, and a high functioning/securely attached group.

Conclusions

The study indicates that cluster-analytic studies, including a broad range of instruments measuring eating disorder symptoms as well as negative affect, relational patterns, and other personality characteristics, may contribute to an integration of previously suggested models of subtypes in BN.     

A five-item screening version of the Eating Disorder Inventory (EDI-3)

Objective

The Eating Disorder Inventory (EDI) is used worldwide in research and treatment of eating disorders (EDs). Using the latest version (EDI-3: 91 items), we extracted the best screening items for a diagnosis of anorexia (AN) and bulimia (BN) nervosa.

Method

A patient sample of 561 women was recruited from an ED treatment centre in Denmark, and a comparison group of 878 women was randomly selected from the general population. An ED diagnosis was determined according to the Eating Disorder Examination Interview, yielding 84 AN and 202 BN patients.

Results

Only two EDI items (Cronbach's α = .79) were needed to achieve a superior screening capability of BN (sensitivity = .94, specificity = .94). An adequate screening of AN was possible by using three items (α = .71; sensitivity = .91, specificity = .86).

Discussion

The present study provides an even more economical and reliable screening of AN and BN compared with existing screening instruments. Implications for DSM-5 are also discussed.     

Comparing weight gain in the year prior to treatment for overweight and obese patients with and without binge eating disorder in primary care

Objective

To examine weight change trajectories among overweight and obese patients with binge eating disorder (BED) versus without (NBO) during the year prior to seeking treatment.

Methods

Participants were 97 (75 women, 22 men) overweight and obese patients recruited for the same weight-loss treatment in primary care; 26 (27%) met DSM-5 BED criteria. Participants were assessed with the Eating Disorder Examination and completed self-report questionnaires about their weight histories and the Beck Depression Inventory-II.

Results

Participants' self-reported current weight and measured current weight were significantly correlated and did not statistically differ. Reported weight changes during the year prior to seeking treatment differed significantly by group: BED patients gained an average of 18.3 lb (8.2 kg) whereas NBO patients gained an average of 1.5 lb (0.7 kg). Among BED patients, but not NBO, weight change during the prior year was positively correlated with greater eating-disorder psychopathology, binge-eating frequency, frequency of overeating at lunch and dinner, and depression scores. For the overall group, BED status and binge-eating frequency each made independent significant contributions to predicting weight change in the past year.

Conclusion

Findings suggest BED patients are gaining considerably more weight during the year prior to treatment than NBO patients. BED treatment may interrupt a steep weight gain trajectory and prevent further weight gain for BED patients suggesting need for early intervention. Primary care physicians should screen for BED when overweight and obese patients present with rapid weight gain.     

Childhood maltreatment is associated with depression but not with hypochondriasis in later life

Objective

Previous studies demonstrated that a history of childhood trauma is linked to mental disorders in adulthood, particularly to depression. Adverse childhood experiences are also considered to contribute to the risk of hypochondriasis, but the results of previous studies have not been conclusive with respect to the strength and specificity of this association. Therefore, we compared the association of adverse childhood experiences with both hypochondriasis and depression.

Methods

Fifty-eight patients with hypochondriasis, 52 patients with depression, and 52 healthy control participants completed the Childhood Trauma Questionnaire (CTQ) which assesses 5 varieties of abuse and neglect. A clinical interview (SCID-I) was used to establish DSM-IV diagnoses. Associations between childhood maltreatment, hypochondriasis and depression were estimated by means of analyses of variance and multiple linear regression analyses.

Results

In comparison to hypochondriacal and healthy participants, patients with a current depressive disorder reported more emotional abuse as well as more emotional and physical neglect during childhood. Patients with hypochondriasis reported more emotional neglect than healthy individuals. However, when predicting the CTQ trauma types by diagnostic category adjusting for sex and comorbid DSM-IV diagnoses, emotional abuse, emotional neglect, physical abuse, physical neglect, as well as the CTQ total score were significantly associated with depression, but none of the CTQ scores was significantly related to hypochondriasis.

Conclusions

The findings suggest a robust association of childhood maltreatment with depression but not with hypochondriasis. This result does not support etiological models of hypochondriasis which rely on childhood maltreatment as a risk factor for the development of this disorder.     

Behavioral health mediators of the link between posttraumatic stress disorder and dyslipidemia

Objectives

Posttraumatic stress disorder (PTSD) has been linked to dyslipidemia, which is a major risk factor for coronary artery disease. Although this link is thought to reflect response to heightened stress, behavioral health risks, including smoking, alcohol dependence, and poor sleep quality, may mediate the relationship between PTSD and dyslipidemia.

Methods

To test this hypothesis, serum lipid levels were collected from 220 young adults (18–39 years old), 103 of whom were diagnosed with PTSD.

Results

PTSD and associated depressive symptoms were negatively related to high-density lipoprotein cholesterol (HDL-C), p = .04, and positively related to triglyceride (TG) levels, p = .04. Both associations were mediated by cigarette consumption and poor sleep quality, the latter of which accounted for 83% and 93% of the effect of PTSD and depression on HDL-C and TG, respectively.

Conclusions

These results complement recent findings highlighting the prominence of health behaviors in linking PTSD with cardiovascular risk.     

Trauma-related psychiatric comorbidity of somatization disorder among women in eastern Turkey

Objective

This study sought to determine the trauma-related psychiatric comorbidity of somatization disorder among women who applied to an outpatient psychiatric unit of a general hospital in eastern Turkey.

Methods

Forty women with somatization disorder and 40 non-clinical controls recruited from the same geographic region participated in the study. Somatization disorder and posttraumatic stress disorder (PTSD) sections of the Structured Clinical Interview for DSM-IV (including its criterion A traumatic events checklist), Dissociative Disorders Interview Schedule, Dissociative Experiences Scale (Taxon), Hamilton Depression Rating Scale, and Childhood Abuse and Neglect Questionnaire were administered to all participants.

Results

A significant proportion of the women with somatization disorder had the concurrent diagnoses of major depression, PTSD, dissociative disorder, and borderline personality disorder. Women with somatization disorder reported traumatic experiences of childhood and/or adulthood more frequently than the comparison group. A significant proportion of these patients reported possession and/or paranormal experiences. Binary logistic regression analysis demonstrated that current major depression, being married, total number of traumatic events in adulthood, and reports of possession and/or paranormal experiences were independent risk factors for somatization disorder diagnosis.

Conclusions

Among women with endemically high exposition to traumatic stress, multiple somatic complaints were in a significant relationship with major depressive disorder and lifelong cumulative traumatization. While accompanying experiences of possession and paranormal phenomena may lead to seeking help by paramedical healers, the challenge of differential diagnosis may also limit effective service to this group of somatizing women with traumatic antecedents and related psychiatric comorbidities.     

A personality classification system for eating disorders: a longitudinal study

Background

Studies of eating disorders (EDs) suggest that empirically derived personality subtypes may explain heterogeneity in ED samples that is not captured by the current diagnostic system. Longitudinal outcomes for personality subtypes have not been examined.

Method

In this study, personality pathology was assessed by clinical interview in 213 individuals with anorexia nervosa and bulimia nervosa at baseline. Interview data on EDs, comorbid diagnoses, global functioning, and treatment utilization were collected at baseline and at 6-month follow-up intervals over a median of 9 years.

Results

Q-factor analysis of the participants based on personality items produced a 5-prototype system, including high-functioning, behaviorally dysregulated, emotionally dysregulated, avoidant-insecure, and obsessional-sensitive types. Dimensional prototype scores were associated with baseline functioning and longitudinal outcome. Avoidant-Insecure scores showed consistent associations with poor functioning and outcome, including failure to show ED improvement, poor global functioning after 5 years, and high treatment utilization after 5 years. Behavioral dysregulation was associated with poor baseline functioning but did not show strong associations with ED or global outcome when histories of major depression and substance use disorder were covaried. Emotional dysregulation and obsessional-sensitivity were not associated with negative outcomes. High-functioning prototype scores were consistently associated with positive outcomes.

Conclusions

Longitudinal results support the importance of personality subtypes to ED classification.     

Emotion regulation,physiological arousal and PTSD symptoms in trauma-exposed individuals

Objectives

Retrospective studies suggest a link between PTSD and difficulty regulating negative emotions. This study investigated the relationship between PTSD symptoms and the ability to regulate negative emotions in real-time using a computerised task to assess emotion regulation.

Method

Trauma-exposed ambulance workers (N = 45) completed self-report measures of trauma exposure, PTSD symptoms and depression. Participants then completed a computer task requiring them to enhance, decrease or maintain their negative emotions in response to unpleasant images. Skin conductance responses (SCR) were recorded and participants also made ratings of emotion intensity. Immediately after the computer task, participants were asked to describe the strategies they had used to regulate their negative emotions during the task and recorded spontaneous intrusions for the unpleasant images they had seen throughout the following week.

Results

PTSD symptoms were associated with difficulty regulating (specifically, enhancing) negative emotions, greater use of response modulation (i.e., suppression) and less use of cognitive change (i.e., reappraisal) strategies to down-regulate their negative emotions during the task. More intrusions developed in participants who had greater reductions in physiological arousal whilst decreasing their negative emotions.

Limitations

PTSD was measured by self-report rather than by a clinician administered interview. The results suggest a relationship between emotion regulation ability and PTSD symptoms rather than emotion regulation and PTSD.

Conclusions

Difficulty regulating negative emotions may be a feature of trauma-exposed individuals with PTSD symptoms, which may be linked to the types of strategies they employ to regulate negative emotions.