Emotional Regulation Following Acquired Brain Injury: Associations With Executive Functioning in Daily Life and Symptoms of Anxiety and Depression

BRIEF RESEARCH REPORT

published: 10 September 2020

doi: 10.3389/fneur.2020.01011

Frontiers in Neurology | www.frontiersin.org 1 September 2020 | Volume 11 | Article 1011

Edited by:

Nicola Smania,

University of Verona, Italy

Reviewed by:

Alessandro Giustini,

Istituto di Riabilitazione Santo

Stefano, Italy

Toshiyuki Fujiwara,

Juntendo University, Japan

*Correspondence:

Jan Stubberud

[email protected]

Specialty section:

This article was submitted to

Neurorehabilitation,

a section of the journal

Frontiers in Neurology

Received: 18 May 2020

Accepted: 31 July 2020

Published: 10 September 2020

Citation:

Stubberud J, Løvstad M, Solbakk A-K,

Schanke A-K and Tornås S (2020 )

Emotional Regulation Following

Acquired Brain Injury: Associations

With Executive Functioning in Daily

Life and Symptoms of Anxiety and

Depression. Front. Neurol. 11:1011.

doi: 10.3389/fneur.2020.01011

Emotional Regulation Following

Acquired Brain Injury: Associations

With Executive Functioning in Daily

Life and Symptoms of Anxiety and

Depression

Jan Stubberud

1,2,3

, Marianne Løvstad

1,3

, Anne-Kristin Solbakk

1,4,5,6

Anne-Kristine Schanke

1,3

and Sveinung Tornås

Department of Psychology, University of Oslo, Oslo, Norway,

Department of Research, Lovisenberg D iaconal Ho spital,

Oslo, Norway,

Department of Research, Sunnaas Rehabilitation H os pital, Nesodden, Norway,

RITMO Centre for

Interdisciplinary Studies in Rhythm, Time and Motion, University of Oslo, Oslo, Norway,

Department of Neurosurgery, Oslo

University Hospital, Olso, Norway,

Department of Neuropsychology, Helgeland H os pital, Mosjøen, Norway

Objective: To examine whether a questionnaire measuring emotional regulation

after acquired brain injury adds clinical information beyond what can be obtained

with a comprehensive executive function questionnaire and an anxiety and

depression measure.

Method: Seventy adult persons (age 19–66 years, M

age

= 43, SD

age

= 13) with

acquired brain injury in the chronic phase and executive function complaints. All were

recruited to participate in a randomized controlled trial (NCT02692352) evaluating the

effects of cognitive rehabilitat ion. Traumatic brain injury was the dominant cause of injury

(64%), and mean time since injury was 8 years. Emotional regulation was assessed with

the Brain Injury Trust Regulation of Emotions Questionnaire (BREQ). Executive function

was assessed with the Behavior Rating Inventory of Executive Function Adult Version

(BRIEF-A). The Hopkins Symptom Checklist 25 (HCSL-25) was employed to measure

anxiety and depression symptoms.

Results: Overall, signiﬁcant correlations were found between reports of emotional

regulation (BREQ) and executive function in daily life (BRIEF-A). Furthermore, our analyses

revealed a signiﬁcant relationship between self-reported scores of emotional regulation

(BREQ) and symptoms of anxiety and depression (HSCL-25).

Conclusion: The signiﬁcant associations between the BREQ and most of the other

clinical mea sures indicate that, for patients with acquired brain injury, the BREQ does

not add substantial information beyond what can be assessed with the BRIEF-A and

the HSCL-25.

Keywords: brain injury, emotional regulation, executive function, psychological distress, assessment

Stubberud et al. Emotional Regulation in Brain Injury

INTRODUCTION

Diﬃculties in emotional regulation are among the most common

and debilitating consequences of acquired brain injury (ABI),

such as traumatic brain injury (TBI) and cerebrovascular

accidents (CVA), with potential deleterious eﬀects in all life

domains [e.g., (

1–4)]. Indeed, impaired emotional regulation

can lead to compromised social functioning, decreased leisure

activity, increased risk of suicide, and loss of employment/failure

to return to work (3, 5–7). Despite its clinica l signiﬁcance,

relatively little research has systematically addressed emotional

regulation in individuals with ABI. Likely contributing to the

lack of research in this area is the absence of instruments

that adequately assess the complexity of this construct among

adults with ABI. Accurate evaluation of the nature of deﬁcits in

emotional regulation is, however, imperative in the process of

developing suitable and realist ic rehabilitation and therapeutic

intervention plans after ABI.

Emotional regulation relates to the capacity to ﬂexibly

modulate and control subjective experience and expression of

emotions (

8, 9), and th e reduction of emotional arousal (10). In

ABI, there may be impairments in self-monitoring and control,

in addition to the ability to diﬀerentiate emotions, that a re

revealed through various symptoms of emotional dysre gulation,

including disinhibited emotion/behavior, and reduced emotional

awareness and expression (

8, 11). Further, emotional regulation

is an important aspect of executive functioning (EF) (12,

13), broadly described as inter-related top-down processes

promoting the control and regulation of cognition, behavior,

and emotion (14). In contrast to the view that brain injury

is directly responsible for emotional dysregulation, it can also

represent secondary reactions to the consequences of ABI

(15). Importantly, the experience of cognitive deﬁcits after ABI

has been described as having a “disordered” mind (16), a

situation that can be emotionally experienced as a disorganized

inner state. Adding layers of complexity, pre- and comorbid

emotional problems may also inﬂuence symptom presentation

after ABI. Nevertheless, the reactions to the psychosocial

and cognitive changes associated with having an ABI makes

it challenging to conceptualize and measure problems with

emotional regulation (

17).

Most measures addressing emotional functioning were

not speciﬁcally developed for ABI and often focus on the

phenomenology of depressive or anxiety states, rather than

the actual capacity to regulate emotion. Thus, Cattran et al.

(8) developed a questionnaire to measure emotional regulation

after ABI, the Brain Injury Rehabilitation Trust Regulation of

Emotions Questionnaire (BREQ). To our knowledge, only two

feasibility studies (

18, 19), the original study by Cattran et al.

(8) and a cognitive rehabilitation study (20), have employed t he

BREQ in the ﬁeld of ABI. Also, the original study by Cattran

et al. is the only one providing BREQ data from relatives of

ABI individuals (i.e., informants) (8). Hence, there are a modest

number of empirical studies involving the BREQ. In addition,

no studies have examined its relat ionship with a comprehensive

EF questionnaire, such as the Behavior Rating Inventory of

Executive Function Adult Version (BRIEF-A; 21). Cattran

et al. (8), however, examined the association of BREQ with

the Dysexecutive Questionnaire [DEX; (21)] and demonstrated

strong correlations. Still, the DEX only contains 20 items, and

few of these address emotional functioning. In summary, the

multitude of problems related to reduced emotional regulation

after ABI, along with the lack of relevant measurement tools

that are necessary when diﬀerential diagnoses are considered,

highlight the importance of generating more knowledge about

the clinical properties of the BREQ (emotional regulation),

including establishing its association to various EF domains and

symptoms of anxiety and depression.

The present article reports on a subset of baseline data from

Tornås et al.’s (

20) randomized controlled trial (RCT; n = 70),

where the eﬃcacy of Goal Management Training (GMT) was

examined in patients with ABI.

The main goal of the current study was to examine the

relationship between the BREQ and (a) a questionnaire measure

of EF i n daily life (BRIEF-A) and (b) symptoms of anxiety and

depression, as measured by the Hopkins Symptom Checklist 25

[HSCL-25; (

22)], in persons with ABI in the chronic phase. Based

on the sparse extant literature, it was expe ct ed that:

1. Both self- and informant reports of BREQ and BRIEF-A [i.e.,

Global Executive Composite (GEC), Behavioral Regulation

Index (BRI), and Emotional Control subscale] would be

signiﬁcantly correlated (hypothesis 1).

2. Intercorrelations between BREQ and HSCL-25 would occur

(hypothesis 2).

METHOD

This study reports baseline data from a large single-center

RCT (

20). All participants provided written informed consent.

The study was approved by t h e Regional Committee for

Medical Research Ethics (2012/1436, South-Eastern Norway) and

conducted in accordance with the Helsinki De c larati on. Clinical

Trial Registration No.: NCT02692352.

Participants

An information letter was sent to 178 former patients (aged

18–67 years) at Sunnaas Rehabilitation Hospital (SRH) with a

veriﬁed ABI and self-reported executive diﬃculties in daily life,

at least 6 months post-injury. Any neurodegenerative disorder,

ongoing substance abuse, major psychiatric diseases, and/or

severe cognitive deﬁcits were exclusion criteria.

Informed consent was ret urned from 90 persons who

underwent a comprehensive screening interview by phone.

Fourteen declined participation and 6 did not meet inclusion

criteria. Thus, the ﬁnal sample totaled n = 70 (age 19–66 yea rs,

age

= 42.9, SD

age

= 13), with 69 participants returning th e

questionnaires used in the present study. Fifty-eight participants

(83%) had previously received subacute rehabilitation at SRH.

Traumatic brain injury was the dominant cause of injury (64.3%),

and a slight majority were males (52.9%). All participants were

Caucasian. Mean time since injury was 8 years (SD = 112.4

months), ranging from 10 to 575 months. The mean length

of education was 13.4 years (SD = 2.4) (Tables 1, 2). About

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Stubberud et al. Emotional Regulation in Brain Injury

TABLE 1 | Demographic, cognitive, and brain injury characteristics of

the participants.

Total (n = 70)

Age, mean ± SD 42.89 (12.96)

Gender, M = men 38 M (54.3)

Education, years ± SD 13.4 (2.43)

WASI 104.31 (12.65)

Tower Test 10.37 (2.82)

Months since injury ± SD 97.47 (112.44)

Injury etiology n (%)

TBI 45 (64.3)

Stroke 15 (21.5)

Tumor 6 (8.6)

Anoxic 2 (2.9)

Other 2 (2.9)

Vocational status n (%)

Work (full time) 6 (8.8)

Work (part time) 7 (10)

Voc. Rehab 25 (35.7)

Sick leave 3 (4.3)

Student 6 (8.6)

Disability pension 23 (32.9)

In a relationship n (%) 44 (63)

Percentage totals may not add to 100% due to rounding. Sign, Signiﬁcance; Voc. rehab,

Vocational rehabilitation; WASI, Wechsler Abbreviated Scale of Intelligence. Scaled scores

on the WASI and Tower Test.

one third (32.9%) of the sample received disability pension, and

the rest were either in vocational rehabilitation, working (part-

or full-time), students, or on sick leave. All participants were

independent in ADL.

For 56 of the participants, magnetic resonance imaging (MRI)

was obtained in the study period using a 3 Tesla scanner

(Achieva 3.0T, Philips Medica l System, Best, The Netherlands)

at the Intervention Center at Oslo University Hospital. Previous

MRI/computed tomography scans were collected from other

hospitals for ﬁve participants. For various reasons, scanning

could not be performed for nine participants. The frontal lobe

was the most aﬀected cortical location, followed by temporal- and

parietal lobe injury. Finally , about 50% of the sample had signs of

cortical atrophy (Table 2 ).

All participants were asked to give consent for the two

questionnaires to be sent to an informant that knew them very

well. Two of the participants declined, and four informants

did not return t h e questionnaires. Therefore, 64 informants (all

Caucasian) were included, with 57 and 56 informants completing

the BREQ and the BRIEF-A, respectively. More than half of

the informants (53.1%) were spouses/partners living with the

participants, about one third (31.3%) were parents, and the

remaining informants were siblings (12.5%), adult children

(3.1%), or close friends (7.8%).

Measures

In the main study (

20), various neuropsychological tests and

questionnaires were administered to the participants. For

TABLE 2 | Radiological description of the brain injuries.

CT/MRI veriﬁed ABI at onset n (%)

Yes 36 (97.3)

1 (2.7)

MRI veriﬁed lesion at baseline n (%)

Yes

23 (62.2)

No 8 (21.6)

Missing

6 (16.2)

Injury localization n (%)

Right hemisphere 7 (18.9)

Left hemisphere 9 (24.3)

Bilateral 5 (13.5)

Frontal 11 (29.7)

Parietal 4 (10.8)

Temporal 7 (18.9)

Occipital 0

Cerebellum 2 (5.4)

Subcortical nuclei

1 (2.7)

Subcortical white matter 13 (35.1)

Cortical atrophy n (%) 35 (50)

Veriﬁed by neurological and neuropsychological evaluation.

MR/CT scans were

collected from other hospitals for ﬁve participants due to practical or medical reasons; the

images were interpreted by the same radiologist. All 5 scans were performed between

2011 and 2013.

MRI was not possible to conduct due to practical reasons for four

participants, medical reasons for four, and one participant refused to undergo repeated

scanning.

Striatum, basal ganglia and/or thalamus. MRI, Magnetic Resonance Imaging.

the current supplementary study, th e Wechsler Abbreviated

Scale of Intelligence [WASI; (

23)] and the Tower Test (24)

were included to characterize the cognitive functioning

[i.e., general intellectual capacity (IQ) and EF] in the

sample. Daily life EF was assessed with the BRIEF-A (25),

emotional regulation was measured with the BREQ (8), and

symptoms of anxiety and depression were assessed with the

HSCL-25 (22).

The Brain Injury Rehabilitation Trust Regulation of

Emotions Questionnaire

The BREQ is a 32-item standardized questionnaire that

aims at assessing changes and disturbances in emotional

regulation following ABI, yielding a total sum score.

Patients and a signiﬁcant other are asked to rate each item’s

frequency of occurrence on a 4-point Likert scale from

1 (never) to 4 (always). The measure has demonstrated

good concurrent validity (r = 0.64–0.82) and to be

distinguishable from measures of cognitive ability and tests of

aﬀect (

8).

The Behavior Rating Inventory of Executive Function

Adult Version

The BRIEF-A is a 75-item standardized questionnaire of

an adult’s EF or self-regulation in his or her everyday

environment. Based on 9 sub-scales, it yields a GEC score

as well as two Composite Index scores: the BRI and the

Metacognition Index (MCI). The Emotional Control scale

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Stubberud et al. Emotional Regulation in Brain Injury

TABLE 3 | Correlations between the BREQ and the BRIEF-A and HSCL-25.

BREQ-S BREQ-I

BRIEF-S-GEC 0.55

0.44

BRIEF-S-BRI 0.77

0.46

BRIEF-S-MCI 0.21 0.32

BRIEF-I-GEC 0.30 0.71

BRIEF-I-BRI 0.51

0.84

BRIEF-I-MCI 0.12 0.55

BRIEF-S-EMO 0.74

0.48

BRIEF-I-EMO 0.54

0.81

HSCL-25 Total 0.52

0.29

BREQ, BIRT (Brain Injury Rehabilitation Trust) Regulation of Emotions Questionnaire;

BREQ-S, self-rated version of the BREQ; BREQ-I, informant-rated version of the

BREQ; HSCL-25, Hopkins Symptom Checklist 25; BRIEF-A, Behavior Rating Inventory

of Executive Function Adult Version; BRIEF-S/I, BRIEF self/informant version; EMO,

Emotional control; GEC, Global Executive Composite; BRI, Behavioral Regulation Index;

MCI, Metacognition Index.

Correlation is signiﬁcant at the 0.001 level (two-tailed).

measures t he impact of EF problems on emotional expression

and assesses the ability to modulate or control emotional

responses. Patients and a signiﬁcant other are asked to rate

each item’s frequency of occurrence on a 3-point Likert scale

from 1 (never) to 3 (often) (

25). The BRIEF-A’s reliability is

high; Cronbach’s a lpha of BRI and MI has been found to

be 0.94 and 0.96, respectively (26). The BRIEF-A informant

form was administered to the same signiﬁcant other informant

as the BREQ.

Hopkins Symptom Checklist 25 (HSCL-25)

The HSCL-25 is a 25-point self-report inventory of depressive

and anxiety symptoms (22). It includes a 15-item depressive

symptoms scale and a 10-item anxiety symptoms scale. Items

are scored on a Likert scale ranging from 0 (not at all) to

4 (very much). Finally, the HSCL-25 has satisfactory validity

and reliability as an instrument of anxiety and depression

symptoms (22).

Statistical Analyses

Data analyses were conducted using SPSS version 25.0 for

Windows. Frequency distributions, means, and standard

deviations (SD) were calculated for the demographic, medical,

and cognitive variables. Relationships between measures

were examined with Pearson product-moment correlation

coeﬃcients (two-tailed test). For BRIEF-A, the GEC, BRI,

MCI, and Emotional Control subscale in both self- and

informant reports were selected as variables, while the

total scores were employed for BREQ and HSCL-25. In

determining the strength of the relationships, Cohen’s (

27)

guidelines were employed: r = 0.10–0.29 (small), r = 0.30–0.49

(medium), and r > 0.50 (large). A conservative alpha-level

of 0.01 was applied in order to take multiple comparisons

into account.

RESULTS

Descriptive Data on General Intellectual

Capacity (IQ), Executive Functioning, and

Questionnaires

The ABI group had general intellectual capacity (IQ) and

EF test performance within the normal range, relative to

the stand a rdizati on samples (Table 1). The BREQ-self mean

score was 55.7 (SD = 14.4), while the BREQ-informant mean

score was 52.5 (SD = 13.1). To our knowledge, there are no

recommendations available regarding a clinical cut-oﬀ score

on the BREQ, nor any published data from healthy controls.

However, with the rating “always” (4), “often” (3), “sometimes”

(2), or “never” (1), we decided to use an item mean of ≥ 2.5

with total score ≥ 80 as cut-oﬀ score. Hence, when adding up

how many got a total score ≥ 80, 10% (n = 7) self-reported ≥

80, and 3% (n = 2) of the informants reported a score ≥ 80

in the patients. Moreover, two of the BRIEF-A (group average)

scores were equal to or above recommended clinical cut-oﬀ (≥

T = 65), i.e., GEC-self (M = 64.7, SD = 9.7) and MCI-self (M

= 65.3, SD = 9.8). On an individual level, a score equal to or

above recommended clinical cut-oﬀ was self-reported for 52% (n

= 36) on the GEC, 38% on the BRI (n = 26), 54% (n = 37) on the

MCI, and 41% (n = 28) on the Emotional Control scale. For the

informants, a clinical score was reported for 25% (n = 14) on the

GEC, 18% (n = 10) on the BRI, 38% (n = 21) on the MCI, and

13% (n = 9) on the Emotional Control scale. However, all BRIEF-

A-informant group scores were below cut-oﬀ (T ≤ 65). Wh ile the

group average on the HSCL-25 (M = 22.4, SD = 15.3) was below

the recommended clinical cut-oﬀ (HSCL-25 total < 25), 35% (n

=24) reported symptoms of anxiety and depression above clinical

cut-oﬀ (

28).

Relations Between BREQ and Brief-A (Self-

and Informant Reports)

All correlations between BREQ-self and BRIEF-A (GEC and BRI)

scores were large and positive, including GEC-self, r (67) = 0.55,

p < 0.001, BRI-self, r (67) = 0.77, p < 0.001, Emotional Control-

self r (67) = 0.74, p < 0.001, in addition to BRI-informant, r (54)

= 0.51, p < 0.001 and Emotional Control-informant, r (54) =

0.54, p < 0.001 (Table 3). Additionally, all correlations between

BREQ-informant and BRIEF-A (GEC and BRI) scores were

positive, including GEC-self, r (55) = 0.4 4, p < 0.001 (medium),

BRI-self, r (55) = 0.46, p < 0.001 (medium), Emotional Control-

self, r (55) = 0.48, p < 0.001 (medium), GEC-informant, r (54) =

0.71, p < 0.001 (large), BRI-informant, r (54) = 0.84, p < 0.001

(large), and Emotional Control-informant, r (54) = 0.81, p <

0.001 (large) (Table 3). Finally, for the MCI only the informant

reports of BREQ and BRIEF-A reached signiﬁcance, r (54) = 0.55,

p < 0.001 (large) (Table 3).

Relations Between BREQ (Self- and

Informant Reports) and HSCL-25

There was a positive signiﬁcant correlation between BREQ-self

scores and anxiety and depression scores (HSCL-25), r (61) =

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Stubberud et al. Emotional Regulation in Brain Injury

0.52, p < 0.001 (large). However, the correlation between BREQ-

informant and patient-rated HSCL-25 scores did not reach

statistical signiﬁcance, r (49) = 0.29, p = 0.03 (Table 3).

Post-hoc Analyses

In order to allow comparison of results, one sample t-tests

were conducted to determine if t here were signiﬁcant diﬀerences

between the BREQ reports in our study and the BREQ reports

from Cattran et al.’s study (age 18–61 years, M = 36, SD = 12)

(

8). There was no diﬀerence between the mean BREQ-self score

from our ABI sample (M = 55.7, SD = 14.4) and the mean BREQ-

self score from the ABI cohort studied by Cattran et al. (n = 72,

M = 58.23, SD = 20.01), t (68 ) = 1.31, p = 0.196. However, the

mean BREQ-informant score from our sample (M = 52.5, SD

= 13.1) was signiﬁcantly lower than the mean BREQ-informant

score from Cattran et al.’s study (M = 63.26, SD = 19.54), t (56)

= 6, p < 0.001 .

DISCUSSION

The main aim of the present study was to examine the

relationship between self- and informant perceived emotional

regulation and daily life EF, and emotional regulation and

symptoms of anxiety and depression, in persons with ABI.

Overall, several ﬁndings supported our hypotheses.

Reported Emotional Regulation and

Executive Function in Daily Life

Consistent with the ﬁrst hypothesis, both self- and informant

reports of perceived emotional regulation and d aily life EF

were signiﬁcantly correlated. For both BREQ versions, the

strongest associations were observed with the BRI in the

BRIEF-A. As this index is composed of scales designed to

measure the ability to maintain appropriate regulatory control of

behavior and emotional responses (i.e., Inhibit, Shift, Emotional

Control, and Self-Monitor), it is more closely related to the

domain of emotional regulation than the BRIEF-A MCI (

8, 11,

25). Of note, an association between the BRIEF-A Emotional

Control subscale and the BREQ was also found. A relationship

between BREQ and MCI informant-report was also detected.

The division between the BRI and MCI is mainly theoretical,

and some of the abilities reﬂected in the MCI (i.e., Initiate,

Working Memory, Plan/Organize, Task Monitor, Organization

of Materials) may also overlap with aspects of emotional

regulation. Clearly, the constructs of emotional regulation and

EF are closely connected (13), as the measures are intended

to assess everyday manifestations of emotional dysregulation

and executive dysfunction, respectiv ely. The BRIEF-A includes

behavioral and emotional aspects, such as appropriate inhibition

of thoughts and actions, ﬂexibility in shifting problem-solving

set, modulation of emotional response, and monitoring of one’s

activities, that are very important for emotional regulation

(8, 9). The ﬁndings in the present study are in accordance

with previous research (

8), showing a strong relationship

between BREQ and measures of EF. It is possible that the

BREQ represents a valuable contribution to the assessment

of emotional regulation in the ABI-population, but it is still

uncertain what additional information it adds beyond the BRIEF-

A. Due to an often observed discrepancy between objective

and subjective measures of cognition, with a generally poor

relationship between questionnaires and performance-based

neuropsychological tests (

29), one mig ht consider employing

multiple EF measures in future studies. Furthermore, as there

are no published studies that can inform on recommendations

regarding a clinical cut-oﬀ score on the BREQ, nor any published

BREQ data from healthy controls, it is diﬃcult to know if

our sample experienced emotional dysregulation in the clinical

range, based on the BREQ. Nevertheless, only 10% of the

participants self-reported, and 7% of the informants reported a

total score at or above what we suggest as the clinical cutoﬀ

(≥80). This ﬁnding is somewhat in contrast to the Emotional

Control (BRIEF-A) scores, where 41% self-reported and 13% of

the informants reported scores in the clinical range. Although

conjectural, our post-hoc analyses revealed t hat the informants

in the present study reported signiﬁcantly less problems with

emotional regulation in the patients compared to the ABI sa mple

in C attra n et al.’s study (

8). The ABI-participants in the latter

study (8) were, however, slightly younger and with a lower IQ

relative to our sample. It is important to consider that several

factors might contribute to bias, and diﬀerences, in patient

and informant ratings (e.g., cognitive deﬁcits, severe emotional

regulation dysfunction, self-awareness, social desirability bias,

informant’s burden, abuse, stress level, and/or personality) (30–

33), suggesting t hat information should be gathered from

multiple sources. Finally, the majority of the participants chose

a spouse/partner as an informant, and the remaining informants

were parents, siblings, friends, or adult children. Due to the

variability of the informants and their relationship with the

patients, potential diﬀerences between spouse/partner reporting

and the reporting of the other informants were examined. In

our post-hoc analyses, no signiﬁcant diﬀerences were, however,

detected between spouse/partner reporting and t h e reporting of

the other informants.

Perceived Emotional Regulation and

Symptoms of Anxiety and Depression

With regard to the second hypothesis, a statistically signiﬁcant

relationship between scores of emotional regulation (self-

reported) and symptoms of anxiety and depression was detected.

Although emotional regulation has been given relatively little

attention in the ﬁeld of ABI, it is among the most studied

phenomena in contemporary psychology, having generated a

robust body of evidence linking it to psychopathology (

34),

in addition to being recognized as a core function supporting

psychological well-being (35). In our study, both the self- and

informant-rated BREQ versions produced moderate to high

correlations with t he HSCL-25, which may suggest either that

the BREQ also measures a degree of anxiety and depression, or

that psychological distress is prevalent among those suﬀering

from emotional dysregulation. These ﬁndings are, however, in

accordance with Cattran et al. (

8) where moderate to h igh

correlations between the BREQ a nd the Anxiety subscale of the

Irritability, Depression, and Anxiety Scale were observed.

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Stubberud et al. Emotional Regulation in Brain Injury

Study Limitations

Clearly, studies with larger sample sizes are needed to

more deﬁnitively examine the relationships between the

questionnaires. The current sample was likely not representative

of the entire population of individuals with ABI, as the RCT

included participants who self-reported executive deﬁcits, and

were motivated for a cognitive rehabilitation intervention for

dysexecutive symptoms. Thus, they potentially represent a group

with high symptom awareness. In this regard, symptom validity

measures, in addition to awareness questionnaires (self- and

informant reports), should be considered for future studies.

Importantly, since we included participants ranging from 10

months to 48 years post-injury, they were at diﬀerent stages in

their recovery processes, and thus had diﬀerent functional status.

Further, as about one third of the sample was on a disability

pension, a majority in a relationship, and only 7% of informants

reported emotion regulation dysfunction, this likely reﬂects a

less severely injured segment of the ABI population (

36, 37).

Finally, a more detailed description of potentially complicating

premorbid or comorbid factors, information about treatments

received in the acute or subacute period, and symptom debut is

recommended for future studies.

CONCLUSION

This is the ﬁrst study to examine the relationship between BREQ

and a comprehensive EF questionnaire. Reports of emotional

regulation and perceived EF in daily life were found to correlate

in a sample of ABI participants. Furthermore, a relationship

between scores of emotional regulation and symptoms of anxiety

and depression was also detected. These ﬁndings indicate that,

for patients with ABI, the BREQ does not add substantial

information beyond what can be assessed with t he BRIEF-A and

the HSCL-25. Considering the covariation between the measures,

and the lack of published norms for the BREQ, a preliminary

recommendation is that it is premature to employ the BREQ as a

standard measure for assessing emotional regulation in ABI.

DATA AVAILABILITY STATEMENT

The raw data supporting the conclusions of this article will be

made available by the authors, without undue reservation.

ETHICS STATEMENT

The studies involving human participants were reviewed and

approved by Regional Committee for Medical Research Eth ic s,

South-Eastern Norway. The patients/participants provided their

written informed consent to participat e in this study.

AUTHOR CONTRIBUTIONS

JS, ML, A-KSo, A-KS c , a nd ST contributed to the design and

implementation of the research and to the analysis of the results.

JS wrote the paper with input from all authors. All authors

contributed to the article and approved the submitted version.

FUNDING

This study was funded by the Norwegian ExtraFoundation

for Health and Rehabilitation through EXTRA funds (grant

number 2011/2/0204).

ACKNOWLEDGMENTS

The authors thank t h e participants and t h e staﬀ at t he Cognitive

Rehabilitation Unit Sunnaas Rehabilitation Hospital.

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Conﬂict of Interest: The authors declare that the research was conducted in the

absence of any commercial or ﬁnancial relationships that could be construed as a

potential conﬂict of interest.

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provided the original author(s) and the copyright owner(s) are credited and that the

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