Cognitive Therapy and Research

, Volume 42, Issue 6, pp 823–831 | Cite as

The Role of Anxiety Sensitivity in the Relationship Between Emotion Dysregulation and Internalizing Psychopathology Among Trauma-Exposed Inpatient Adolescents

  • Emma C. Woodward
  • Andres G. VianaEmail author
  • Elizabeth M. Raines
  • Abigail E. Hanna
  • Michael J. Zvolensky
Original Article


The present investigation examined the underlying role of anxiety sensitivity and its facets in the association between emotion dysregulation and three of the most prevalent and debilitating symptom classes among trauma-exposed psychiatric inpatient youth: posttraumatic stress disorder (PTSD), anxiety, and depression symptoms. Participants (N = 50; 52.0% female; Mage = 15.1 years, SD = .51, range 12–17 years) completed an assessment battery that included measures of emotion dysregulation anxiety sensitivity, PTSD, anxiety, and depression symptoms. Consistent with hypotheses, the global construct of anxiety sensitivity, as well as its mental incapacitation concerns and disease concerns facets, explained, in part, associations between emotion dysregulation and the three symptom classes. The study results provide novel and clinically meaningful findings regarding the potential mechanistic role of anxiety sensitivity in the relation of emotion dysregulation to PTSD and internalizing symptoms among trauma-exposed inpatient adolescents. As such, findings underscore the potential value of targeting anxiety sensitivity in general, and mental incapacitation and disease concerns specifically, as a means of reducing risk for internalizing psychopathology among trauma-exposed inpatient youth.


Anxiety sensitivity Emotion regulation Trauma Anxiety Depression Children 


Compliance with Ethical Standards

Conflict of Interest

Emma C. Woodward, Andres G. Viana, Elizabeth M. Raines, Abigail E. Hanna and Michael J. Zvolensky declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Animal Rights

No animal studies were carried out by the authors for this article.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. Albano, A., & Silverman, W. (1996). Anxiety disorders interview schedule for DSM-IV-child version: Clinical manual. San Antonio: Psychological Corporation.Google Scholar
  2. Carpenter, E. M., Frankel, F., Marina, M., Duan, N., & Smalley, S. L. (2004). Internet treatment delivery of parent-adolescent conflict training for families with an ADHD teen: A feasibility study. Child & Family Behavior Therapy, 26(3), 1–20.CrossRefGoogle Scholar
  3. Cisler, J. M., Olatunji, B. O., Feldner, M. T., & Forsyth, J. P. (2010). Emotion regulation and the anxiety disorders: An integrative review. Journal of Psychopathology and Behavioral Assessment, 32(1), 68–82.CrossRefGoogle Scholar
  4. Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70(5), 1067–1074. Scholar
  5. Cloitre, M., Miranda, R., Stovall-McClough, K. C., & Han, H. (2005). Beyond PTSD: Emotion regulation and interpersonal problems as predictors of functional impairment in survivors of childhood abuse. Behavior Therapy, 36(2), 119–124. Scholar
  6. Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child & Adolescent Psychiatry, 43(4), 393–402.CrossRefGoogle Scholar
  7. Cook, D. (2005). The role of maternal meta-emotion coaching in children’s self-regulation of negative emotion. 66, ProQuest Information & Learning, US.Google Scholar
  8. Ditlevsen, S., Christensen, U., Lynch, J., Damsgaard, M. T., & Keiding, N. (2005). The mediation proportion: A structural equation approach for estimating the proportion of exposure effect on outcome explained by an intermediate variable. Epidemiology, 16(1), 114–120.CrossRefGoogle Scholar
  9. Durlak, J. A., Weissberg, R. P., Dymnicki, A. B., Taylor, R. D., & Schellinger, K. B. (2011). The impact of enhancing students’ social and emotional learning: A meta-analysis of school-based universal interventions. Child Development, 82(1), 405–432. Scholar
  10. Feldner, M. T., Lewis, S. F., Leen-Feldner, E. W., Schnurr, P. P., & Zvolensky, M. J. (2006). Anxiety sensitivity as a moderator of the relation between trauma exposure frequency and posttraumatic stress symptomatology. Journal of Cognitive Psychotherapy, 20(2), 201–213.CrossRefGoogle Scholar
  11. Foa, E. B., Johnson, K. M., Feeny, N. C., & Treadwell, K. R. H. (2001). The child PTSD symptom scale: Preliminary examination of its psychometric properties. Journal of Clinical Child Psychology, 30(3), 376–384. Scholar
  12. Fox, H. C., Axelrod, S. R., Paliwal, P., Sleeper, J., & Sinha, R. (2007). Difficulties in emotion regulation and impulse control during cocaine abstinence. Drug and Alcohol Dependence, 89(2–3), 298–301. Scholar
  13. Friedberg, R., & Sindeman, S. (2011). CDI scores in pediatric psychiatric inpatients: A brief retrospective static group comparison. Depression Research and Treatment, 2011, 1–5.CrossRefGoogle Scholar
  14. Gardenswartz, C. A., & Craske, M. G. (2001). Prevention of panic disorder. Behavior Therapy, 32(4), 725–737. Scholar
  15. Garnefski, N., & Kraaij, V. (2006). Relationships between cognitive emotion regulation strategies and depressive symptoms: A comparative study of five specific samples. Personality and Individual Differences, 40(8), 1659–1669. Scholar
  16. Goenjian, A. K., Roussos, A., Steinberg, A. M., Sotiropoulou, C., Walling, D., Kakaki, M., & Karagianni, S. (2011). Longitudinal study of PTSD, depression, and quality of life among adolescents after the Parnitha earthquake. Journal of Affective Disorders, 133(3), 509–515. Scholar
  17. Gratz, K., & Roemer, L. (2004a). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. Scholar
  18. Gratz, K. L., & Roemer, L. (2004b). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. Scholar
  19. Gratz, K. L., Tull, M. T., Baruch, D. E., Bornovalova, M. A., & Lejuez, C. W. (2008). Factors associated with co-occurring borderline personality disorder among inner-city substance users: The roles of childhood maltreatment, negative affect intensity/reactivity, and emotion dysregulation. Comprehensive Psychiatry, 49(6), 603–615. Scholar
  20. Gus, L., Rose, J., & Gilbert, L. (2015). Emotion coaching: A universal strategy for supporting and promoting sustainable emotional and behavioural well-being. Educational and Child Psychology, 32(1), 31–41.Google Scholar
  21. Havens, J. F., Gudiño, O. G., Biggs, E. A., Diamond, U. N., Weis, J. R., & Cloitre, M. (2012). Identification of trauma exposure and PTSD in adolescent psychiatric inpatients: An exploratory study. Journal of Traumatic Stress, 25(2), 171–178.CrossRefGoogle Scholar
  22. Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling [White paper]. Retrieved from
  23. Johnson, K. A., Zvolensky, M. J., Marshall, E. C., Gonzalez, A., Abrams, K., & Vujanovic, A. A. (2008). Linkages between cigarette smoking outcome expectancies and negative emotional vulnerability. Addictive Behaviors, 33(11), 1416–1424. Scholar
  24. Joiner, T. E., Schmidt, N. B., Schmidt, K. L., Laurent, J., Catanzaro, S. J., Perez, M., & Pettit, J. W. (2002). Anxiety sensitivity as a specific and unique marker of anxious symptoms in youth psychiatric inpatients. Journal of Abnormal Child Psychology, 30(2), 167–175.CrossRefGoogle Scholar
  25. Judd, C. M., & Kenny, D. A. (2010). Data analysis in social psychology: Recent and recurring issues. In S. T. Fiske, D. T. Gilbert, G. Lindzey, S. T. Fiske, D. T. Gilbert & G. Lindzey (Eds.), Handbook of social psychology (Vol. 1, 5th ed., pp. 115–139). Hoboken: Wiley.Google Scholar
  26. Kashdan, T. B., Zvolensky, M. J., & McLeish, A. C. (2008). Anxiety sensitivity and affect regulatory strategies: Individual and interactive risk factors for anxiety-related symptoms. Journal of Anxiety Disorders, 22(3), 429–440. Scholar
  27. Keough, M. E., & Schmidt, N. B. (2012). Refinement of a brief anxiety sensitivity reduction intervention. Journal of Consulting and Clinical Psychology, 80(5), 766–772. Scholar
  28. Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26(5), 537–547. Scholar
  29. Koltek, M., Wilkes, T. C. R., & Atkinson, M. (1998). The prevalence of posttraumatic stress disorder in an adolescent inpatient unit. Canadian Journal of Psychiatry-Revue Canadienne De Psychiatrie, 43(1), 64–68.CrossRefGoogle Scholar
  30. Kovacs, M. (1985). The children’s depression, inventory (CDI). Psychopharmacology Bulletin, 21(4), 995–998. Retrieved from
  31. Kovacs, M. (1992). Children’s depression inventory. North Tonawanda: Multi-Health System.Google Scholar
  32. Lambert, S. F., McCreary, B. T., Preston, J. L., Schmidt, N. B., Joiner, T. E., & Ialongo, N. S. (2004). Anxiety sensitivity in African-American adolescents: Evidence of symptom specificity of anxiety sensitivity components. Journal of the American Academy of Child and Adolescent Psychiatry, 43(7), 887–895. Scholar
  33. Leen-Feldner, E. W., Feldner, M. T., Reardon, L. E., Babson, K. A., & Dixon, L. (2008). Anxiety sensitivity and posttraumatic stress among traumatic event-exposed youth. Behaviour Research and Therapy, 46(4), 548–556. Scholar
  34. Lipschitz, D. S., Winegar, R. K., Hartnick, E., Foote, B., & Southwick, S. M. (1999). Posttraumatic stress disorder in hospitalized adolescents: Psychiatric comorbidity and clinical correlates. Journal of the American Academy of Child and Adolescent Psychiatry, 38(4), 385–392. Scholar
  35. Matthey, S., & Petrovski, P. (2002). The children’s depression inventory: Error in cutoff scores for screening purposes. Psychological Assessment, 14(2), 146–149. Scholar
  36. McLaughlin, K. A., Hatzenbuehler, M. L., Mennin, D. S., & Nolen-Hoeksema, S. (2011). Emotion dysregulation and adolescent psychopathology: A prospective study. Behaviour Research and Therapy, 49(9), 544–554.CrossRefGoogle Scholar
  37. Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L. H., … Swendsen, J. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 980–989. Scholar
  38. Naragon-Gainey, K. (2010). Meta-analysis of the relations of anxiety sensitivity to the depressive and anxiety disorders. Psychological Bulletin, 136(1), 128–150. Scholar
  39. Neumann, A., van Lier, P. A. C., Gratz, K. L., & Koot, H. M. (2010). Multidimensional assessment of emotion regulation difficulties in adolescents using the Difficulties in Emotion Regulation Scale. Assessment, 17(1), 138–149.CrossRefGoogle Scholar
  40. Nixon, R. D. V., Meiser-Stedman, R., Dalgleish, T., Yule, W., Clark, D. M., Perrin, S., & Smith, P. (2013). The Child PTSD Symptom Scale: An update and replication of its psychometric properties. Psychological Assessment, 25(3), 1025–1031. Scholar
  41. Olatunji, B. O., & Wolitzky-Taylor, K. B. (2009). Anxiety sensitivity and the anxiety disorders: A meta-analytic review and synthesis. Psychological Bulletin, 135(6), 974–999. Scholar
  42. Pela, O. A., & Reynolds, C. R. (1982). Cross-cultural application of the Revised-Children’s Manifest Anxiety Scale: Normative and reliability data for Nigerian primary school children. Psychological Reports, 51(3 suppl), 1135–1138.CrossRefGoogle Scholar
  43. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40(3), 879–891.CrossRefGoogle Scholar
  44. Pynoos, R. S., Steinberg, A. M., & Piacentini, J. C. (1999). A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders. Biological Psychiatry, 46(11), 1542–1554.CrossRefGoogle Scholar
  45. Reiss, S. (1991). Expectancy model of fear, anxiety, and panic. Clinical Psychology Review, 11(2), 141–153. Scholar
  46. Reynolds, C. R., & Richmond, B. O. (1978). What I think and feel: A revised measure of children’s manifest anxiety. Journal of Abnormal Child Psychology, 6(2), 271–280.CrossRefGoogle Scholar
  47. Silk, J. S., Steinberg, L., & Morris, A. S. (2003). Adolescents’ emotion regulation in daily life: Links to depressive symptoms and problem behavior. Child Development, 74(6), 1869–1880.CrossRefGoogle Scholar
  48. Silverman, W. K., Fleisig, W., Rabian, B., & Peterson, R. A. (1991). Childhood anxiety sensitivity index. Journal of Clinical Child Psychology, 20(2), 162–168. Scholar
  49. Silverman, W. K., Ginsburg, G. S., & Goedhart, A. W. (1999). Factor structure of the childhood anxiety sensitivity index. Behaviour Research and Therapy, 37(9), 903–917.CrossRefGoogle Scholar
  50. Silverman, W. K., Goedhart, A. W., Barrett, P., & Turner, C. (2003). The facets of anxiety sensitivity represented in the Childhood Anxiety Sensitivity Index: Confirmatory analyses of factor models from past studies. Journal of Abnormal Psychology, 112(3), 364–374. Scholar
  51. Suliman, S., Mkabile, S. G., Fincham, D. S., Ahmed, R., Stein, D. J., & Seedat, S. (2009). Cumulative effect of multiple trauma on symptoms of posttraumatic stress disorder, anxiety, and depression in adolescents. Comprehensive Psychiatry, 50(2), 121–127.CrossRefGoogle Scholar
  52. Suveg, C., & Zeman, J. (2004). Emotion regulation in children with anxiety disorders. Journal of Clinical Child & Adolescent Psychology, 33(4), 750–759. Scholar
  53. Taylor, S., Koch, W. J., & Mcnally, R. J. (1992). How does anxiety sensitivity vary across the anxiety disorders. Journal of Anxiety Disorders, 6(3), 249–259. Scholar
  54. Tull, M. T., Stipelman, B. A., Salters-Pedneault, K., & Gratz, K. L. (2009). An examination of recent non-clinical panic attacks, panic disorder, anxiety sensitivity, and emotion regulation difficulties in the prediction of generalized anxiety disorder in an analogue sample. Journal of Anxiety Disorders, 23(2), 275–282.CrossRefGoogle Scholar
  55. Viana, A. G., Dixon, L. J., Berenz, E. C., & Espil, F. M. (2017a). Trauma and deliberate self-harm among inpatient adolescents: The moderating role of anxiety sensitivity. Psychological Trauma: Theory, Research, Practice, and Policy, 9(5), 509–517.CrossRefGoogle Scholar
  56. Viana, A. G., Hanna, A. E., Woodward, E. C., Raines, E. M., Paulus, D. J., Berenz, E. C., & Zvolensky, M. J. (2018a). Emotional clarity, anxiety sensitivity, and PTSD symptoms among trauma-exposed inpatient adolescents. Child Psychiatry & Human Development, 49, 146–154.CrossRefGoogle Scholar
  57. Viana, A. G., Paulus, D. J., Bakhshaie, J., Garza, M., Valdivieso, J., Ochoa-Perez, M., … Zvolensky, M. J. (2017b). Emotional nonacceptance within the context of traumatic event exposure: The explanatory role of anxiety sensitivity for traumatic stress symptoms and disability among Latinos in a primary care setting. General Hospital Psychiatry, 44, 30–37.CrossRefGoogle Scholar
  58. Viana, A. G., Woodward, E. C., Raines, E. M., Hanna, A. E., & Zvolensky, M. J. (2018b). The role of emotional clarity and distress tolerance in deliberate self-harm in a sample of trauma-exposed inpatient adolescents at risk for suicide. General Hospital Psychiatry, 50, 119–124.CrossRefGoogle Scholar
  59. Wald, J., & Taylor, S. (2008). Responses to interoceptive exposure in people with posttraumatic stress disorder (PTSD): A preliminary analysis of induced anxiety reactions and trauma memories and their relationship to anxiety sensitivity and PTSD symptom severity. Cognitive Behavioral Therapy, 37(2), 90–100. Scholar
  60. Weems, C. F., Costa, N. M., Watts, S. E., Taylor, L. K., & Cannon, M. F. (2007). Cognitive errors, anxiety sensitivity, and anxiety control beliefs: Their unique and specific associations with childhood anxiety symptoms. Behavior Modification, 31(2), 174–201.CrossRefGoogle Scholar
  61. Wen, Z., & Fan, X. (2015). Monotonicity of effect sizes: Questioning kappa-squared as mediation effect size measure. Psychological Methods, 20(2), 193.CrossRefGoogle Scholar
  62. Yap, M. B. H., Allen, N. B., & Sheeber, L. (2007). Using an emotion regulation framework to understand the role of temperament and family processes in risk for adolescent depressive disorders. Clinical Child and Family Psychology Review, 10(2), 180–196. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Emma C. Woodward
    • 1
  • Andres G. Viana
    • 1
    • 2
    • 5
    Email author
  • Elizabeth M. Raines
    • 1
  • Abigail E. Hanna
    • 1
  • Michael J. Zvolensky
    • 1
    • 3
    • 4
  1. 1.Department of PsychologyUniversity of HoustonHoustonUSA
  2. 2.Texas Institute of Measurement, Evaluation, and StatisticsUniversity of HoustonHoustonUSA
  3. 3.Department of Behavioral SciencesUniversity of Texas MD Anderson Cancer CenterHoustonUSA
  4. 4.University of Houston HEALTH InstituteHoustonUSA
  5. 5.Department of PsychologyUniversity of HoustonHoustonUSA

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