Emotion Regulation Regulates More Than Emotion: Associations of Momentary Emotion Regulation With Diurnal Cortisol in Current and Past Depression and Anxiety

Abstract

Maladaptive emotion regulation and dysregulated hypothalamic-pituitary-adrenal (HPA) axis functioning are characteristic of depression and anxiety. However, little research examines whether and how emotion regulation affects HPA axis functioning. We utilized an experience sampling methodology to examine associations between three emotion regulation strategies (problem solving, disengagement, and emotional expression/support seeking) and diurnal cortisol rhythms and reactivity in everyday life. Participants were young adults with current, past, or no history of internalizing disorders (depression or anxiety; N = 182). Across participants, problem solving was associated with an elevated cortisol awakening response (CAR), whereas disengagement was associated with a steeper cortisol slope. Only for individuals with internalizing disorders was momentary problem solving and emotional expression/support seeking associated with higher cortisol reactivity and emotional expression/support seeking associated with a flatter diurnal slope and blunted CAR. Results provide insight into associations between emotion regulation and day-to-day HPA axis functioning.

Full text

Emotion Regulation Regulates More than Emotion: Associations
of Momentary Emotion Regulation with Diurnal Cortisol in
Current and Past Depression and Anxiety
Kirsten Gilbert1, Susan Mineka2, Richard E. Zinbarg2, Michelle G. Craske3,4, and Emma K.
Adam5,6
1Department of Psychiatry, Washington University in St. Louis
2Department of Psychology, Northwestern University
3Department of Psychology, University of California Los Angeles
4Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles
5School of Education and Social Policy, Northwestern University
6Cells to Society Center, Institute of Policy Research, Northwestern University
Abstract
Maladaptive emotion regulation and dysregulated hypothalamic-pituitary-adrenal (HPA) axis
functioning are characteristic of depression and anxiety. However, little research examines whether
and how emotion regulation affects HPA axis functioning. We utilized an experience sampling
methodology to examine associations between three emotion regulation strategies (problem
solving, disengagement, and emotional expression/support seeking) and diurnal cortisol rhythms
and reactivity in everyday life. Participants were young adults with current, past, or no history of
internalizing disorders (depression or anxiety;
N
= 182). Across participants, problem solving was
associated with an elevated cortisol awakening response (CAR) while disengagement was
associated with a steeper cortisol slope. Only for individuals with internalizing disorders was
momentary problem solving and emotional expression/support seeking associated with higher
cortisol reactivity and emotional expression/support seeking associated with a flatter diurnal slope
and blunted CAR. Results provide insight into associations between emotion regulation and day-
to-day HPA-axis functioning.
Keywords
cortisol; emotion regulation; diurnal; depression; anxiety
*Corresponding Author: Kirsten Gilbert, Department of Psychiatry, Washington University, 4444 Forest Park Avenue, Suite 2100, St.
Louis, MO 63108, Phone: (312) 286-0918, gilbertk@wustl.edu.
R.Z, M.C., S.M. and E.K.A. developed the study concept and contributed to the study design. Testing and data collection were
performed by R.Z., M.C., S.M. and E.K.A. K.G. performed the data analysis and interpretation under the supervision of E.K.A. K.G.
drafted the paper, and E.K.A. and R.Z provided critical revisions. All authors approved the final version of the paper for submission.
HHS Public Access
Author manuscript
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Published in final edited form as:
Clin Psychol Sci
. 2017 January 1; 5(1): 37–51. doi:10.1177/2167702616654437.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

In the presence of an emotional response, emotion regulation is often employed as a way to
modulate that response. Difficulties with regulating emotions, or maladaptive types of
emotion regulation, have repeatedly been associated with the onset and maintenance of
internalizing disorders such as depression and anxiety (e.g., Aldao, Nolen-Hoeksema, &
Schweizer, 2010; Kring & Sloan, 2009). Although much is known of how emotion
regulation regulates emotions, less is known about how emotion regulation exerts its effects
on biological stress processes, particularly hypothalamic-pituitary-adrenal (HPA) axis
functioning in the context of everyday life. HPA axis dysregulation is consistently
demonstrated in major depression (for review see Cowen, 2010; Thase, 2009) and emerging
evidence implicates HPA dysregulation in anxiety disorders (e.g., Adam et al., 2014;
Yehuda, 2001). It is not yet understood, however, whether or how maladaptive emotion
regulation that is characteristic of internalizing disorders is associated with HPA axis
functioning. The current study aimed to assess the effects of naturalistic emotion regulation
use on momentary cortisol responding and diurnal cortisol rhythms in both healthy and
clinical samples with current and past internalizing disorders.
The HPA axis plays a central role in the body's response to stress and cortisol is the primary
hormone released from the HPA axis (Kirschbaum & Hellhammer, 1989). Cortisol increases
in response to acute stressors and also follows a circadian or diurnal rhythm. Upon
wakening, normative levels of cortisol are elevated and increase 50-70% to peak during the
first 30 to 40 minutes after waking. This post-awakening surge in cortisol is also known as
the cortisol awakening response (CAR). After this peak, cortisol quickly declines over the
next couple of hours and continues to gradually decline until the nadir is reached at about
midnight, resulting in a negative diurnal cortisol slope from waking to bedtime (Adam &
Kumari, 2009; Pruessner et al., 1997).
Disturbances in diurnal HPA axis functioning have repeatedly been implicated in major
depressive disorder. Individuals with depression demonstrate elevated cortisol throughout
the day and a flatter diurnal cortisol slope (Cowen, 2010; Doane et al., 2013; Knorr, Vinberg,
Kessing, & Wetterslev, 2010). Moreover, elevated morning cortisol and an elevated CAR
prospectively predict the onset of depression (Adam et al., 2010; Harris et al., 2000). Mixed
results are reported for current depression though as some work indicates a blunted CAR
(Huber, Issa, Schik, & Wolf, 2006) while other findings indicate an elevated CAR (Dienes,
Hazel, & Hammen, 2013). Although less work has examined the role of HPA axis
dysregulation in anxiety disorders, in the presence of depression, anxiety is independently
associated with a flatter diurnal cortisol slope (Doane et al., 2013). Anxiety disorders are
also associated with HPA axis underactivity (Yehuda, 2001) and an elevated CAR predicts
the onset of anxiety disorders (Adam et al., 2014). We know that HPA axis alterations are
characteristic across depression and anxiety, yet we know little about the factors that
contribute to these HPA axis alterations. Gaining insight in these factors may provide a
better understanding of how this biological functioning goes awry and potentially how these
alterations may link aberrant emotion regulation to internalizing disorders.
Individual emotion regulation strategies are often referred to as adaptive or maladaptive
depending on outcomes. Adaptive emotion regulation has repeatedly been linked with
positive mental health outcomes (John & Gross, 2004) while maladaptive emotion regulation
Gilbert et al. Page 2
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

has consistently been associated with psychopathology (e.g., Aldao et al., 2010; Gross &
Jazaieri, 2014; Kring & Sloan, 2009). Problem solving is an approach-focused strategy
typically linked with adaptive outcomes and positive psychological health (Zeidner &
Saklofske, 1996). Problem solving focuses on changing the stressor itself and a lack of
problem solving is strongly associated with both depression and anxiety (Aldao et al., 2010)
while training in problem-solving is a major component of cognitive behavioral therapies
(e.g., Beck, Rush, Shaw, & Emery, 1979). A lack of problem-solving may also create gaps in
ways to deal with stressors and subsequently lead to more opportunities for maladaptive
emotion regulation (Aldao et al., 2010). A second form of regulation, namely
disengagement, involves disengaging from and avoiding emotional stimuli. Disengagement
has typically been conceptualized as maladaptive as it has repeatedly been associated with
depression and worse mental health (Aldwin & Revenson, 1987; Rohde, Lewinsohn, Tilson,
& Seeley, 1990). In fact, avoidance and suppression—two forms of disengagement from
emotional stimuli (Borkovec, Alcaine, & Behar, 2004; Gross & Levenson, 1997) have
demonstrated in a meta-analysis to be highly implicated in internalizing disorders (Aldao et
al., 2010). A third type of regulation emphasizes engaging with an emotional experience
internally or externally by allowing oneself to experience the emotion and process it with
others (e.g., emotional expression and emotional processing; Endler & Parker, 1990;
Stanton, Kirk, Cameron, & Danoff-Burg, 2000). The (mal)adaptiveness of emotional
expression shows less conclusive evidence. In some cases it is associated with increased
depression and decreased life satisfaction (Stanton et al., 2000) while others speculate that
experiencing and expressing emotions (rather than suppressing or avoiding them) is adaptive
(e.g., Gross & Levenson, 1997; Smyth & Pennebaker, 1990; Thompson, 1994). Moreover,
multiple therapies (e.g, mindfulness and acceptance based approaches) emphasize training in
emotional experiencing and expression (e.g., Hayes, Wilson, Gifford, Follette, & Strosahl,
1996; Segal, Williams, & Teasdale, 2002).
We know that various emotion regulatory strategies are associated with adaptive and
maladaptive outcomes, including psychopathology, yet we know little of the underlying
biological processes, especially those implicated in stress responding (i.e., HPA axis
functioning), that might be associated with these outcomes. With regards to problem solving,
some work finds no statistically significant association with cortisol (M. A. Hoyt et al.,
2014; Koh, Choe, Song, & Lee, 2006; O'Donnell, Badrick, Kumari, & Steptoe, 2008).
Conversely, problem-solving has been associated with lower levels of average daily cortisol
output (M. A. Hoyt et al., 2014; O'Donnell et al., 2008) and treatments aimed to increase
problem solving (i.e., cognitive behavioral therapy) show longer-term effects by buffering
cortisol reactivity (Gaab et al., 2003). However, a similar approach-related emotion
regulation strategy, reappraisal, has been associated with increased momentary cortisol
response (Lam, Dickerson, Zoccola, & Zaldivar, 2009) and individuals who reappraised a
stressor had greater peak cortisol responding to the stressor (Denson, Creswell, Terides, &
Blundell, 2014). Although problem-focused engagement has been linked with lower cortisol
levels in the longer term, there is some indication that in the moment, approaching a stressor
is associated with increased cortisol responding.
Disengagement with emotional stimuli shows more consistent results, indicating overall
maladaptive profiles of cortisol responding. Disengagement is associated with a slower
Gilbert et al. Page 3
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

cortisol decline following a stressor (Nicolson, 1992), flatter cortisol slopes in cancer
survivors (M. A. Hoyt et al., 2014) and higher cortisol responding to an acute stress of knee
surgery (Rosenberger, Ickovics, Epel, D'Entremont, & Jokl, 2004). However, it should be
noted that some researchers find that emotional disengagement shows no statistically
significant association with cortisol output, CAR or diurnal slope (O'Donnell et al., 2008).
Research examining emotional expression in relation to cortisol demonstrates that on the one
hand, expressing emotions and seeking support is associated with greater cortisol responding
in men dealing with relationship stress (Gunlicks-Stoessel & Powers, 2009). On the other
hand, emotional expression has been associated with lower cortisol output levels over the
course of the day in healthy older adults (O'Donnell et al., 2008). Emotional expression and
seeking support have also both been repeatedly shown to be statistically unrelated to various
cortisol indices, including slope, CAR, and reactivity (M. A. Hoyt et al., 2014; Master et al.,
2009; O'Donnell et al., 2008).
Present Study
It appears HPA axis functioning and emotion regulation are associated with each other,
however it appears the findings are quite disparate. One reason may be that many of the
above studies examined trait self-report measures or standardized lab measurements of
emotion regulation. Recent work emphasizes the importance of examining emotion
regulation outside the lab in order to provide a more ecologically valid assessment that better
captures daily life and decreases self-report biases (Myin-Germeys et al., 2009). Moreover,
the above studies often only examined the influence of
one
strategy on cortisol responding.
In fact, when O'Donnell and colleagues (2008) examined multiple regulation strategies
together, emotional expression no longer remained significantly associated with cortisol, as
problem-solving appeared to account for cortisol findings. It is now understood that multiple
regulation strategies are employed in the context of lab procedures (Aldao & Nolen-
Hoeksema, 2012) and daily life (Heiy & Cheavens, 2014). Thus, the present study aimed to
address these issues by examining the association of multiple emotion regulation strategies
in day-to-day life with diurnal cortisol responding. Furthermore, we wanted to examine how
these processes might differ in individuals with current internalizing disorders, individuals
with a history of internalizing disorders, and individuals with no history of internalizing
disorders. By examining the influence of momentary emotion regulation on cortisol
responding, we hope to gain insight into how emotion regulatory responses may be
associated with cortisol responding in internalizing disorders of depression and anxiety.
Methods
Participants
Participants included emerging adults (age range 21-23 years old) originally recruited from
two large public high schools in suburban Chicago and suburban Los Angeles for a
longitudinal investigation of risk for mood and anxiety disorders (Youth Emotion Project;
see Zinbarg et al., 2010). The Youth Emotion Project (YEP) was approved by the two
respective locations' institutional review boards. Over 1900 juniors in high school were
screened for neuroticism using the Eysenck Personality Questionnaire-Revised (EPQ-R-N;
Gilbert et al. Page 4
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Eysenck & Eysenck, 1975) and given that neuroticism is a risk factor for mood and anxiety
disorders (Kendler, Kuhn, & Prescott, 2004), individuals scoring in the top third on this
measure were oversampled (59%). This was done to increase the proportion of students in
the sample at high risk for onset of mood and anxiety disorders. The full study sample
included 627 individuals who consented to the longitudinal study and completed the baseline
assessment. Approximately 6 months later, 491 youth were randomly selected and invited to
participate in a follow-up diary study and cortisol assessment, and 344 completed the first
diary and cortisol assessment. The current analyses used data from the fourth follow-up
dairy and cortisol assessment, approximately 6 years after their individual baseline (this is
when emotion regulation items were added to the protocol). Insufficient cortisol data to
compute cortisol indices and insufficient dairy data due to attrition in the study at this fourth
follow-up assessment resulted in a final sample of 182 youth (134 Female, 74%), average
age of 22.78 (SD = 0.79) and with a racial/ethnic distribution of 54% Caucasian, 7% African
American, 13% Hispanic, 6% Asian, 21% Multiracial/other. Higher sampling of females is
due in part to the oversampling of high neuroticism (see Zinbarg et al., 2010) given that, on
average, females score higher on this personality trait (Costa, Terracciano, & McCrae, 2001)
and also are at greater risk for unipolar mood disorders and anxiety disorders (e.g., Craske,
2003; Nolen-Hoeksema & Hilt, 2008).
Procedure
Participants were interviewed at baseline for lifetime Axis I psychopathology using the
Structured Clinical Interview for DSM-IV-TR Axis I Disorders (First, Spitzer, Gibbon, &
Williams, 2002) to diagnose current and past mood and anxiety disorders. Participants also
self-reported basic demographic data including age, gender, race/ethnicity, and employment,
and socioeconomic status was coded using the Hollingshead system (Hollingshead, 1975).
Participants were then interviewed yearly for the next 6 years to assess development of any
mood or anxiety disorders since baseline. At approximately the 6-year point, participants
were invited to participate in the fourth follow-up cortisol assessment. Using ecological
momentary assessment, participants completed diary and salivary cortisol samples six times
a day for three consecutive weekdays during the school year. We asked participants to avoid
important days such as during exams, birthdays or vacations. Participants received a study
packet including a programmed digital wristwatch, three diary books, straws and 18 vials
and labels for saliva sampling. Individuals received $60 for their participation in the fourth
cortisol follow-up. Participants who completed all four waves received a $30 bonus.
Cortisol assessment
The cortisol collection procedure has been described in detail previously (e.g., Adam et al.,
2010). Cortisol was assessed via passive drool six times over the course of three weekdays:
upon awakening (S1), 40 minutes after waking (S2), three semi-random times throughout
the day using a programed watch beep (approximately 3h post-waking (S3), mid-afternoon
8hrs post-waking (S4), and mid-evening (12hrs post-waking (S5)) and immediately before
bedtime (S6). For scheduled samples participants were asked not to eat, drink, or brush their
teeth 30 minutes prior to sampling. Participants were instructed to label and refrigerate
completed samples until samples were returned to the lab. At this point samples were stored
at -20°C at the lab until they were shipped to Trier, Germany where they were assayed in
Gilbert et al. Page 5
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

duplicate using a time-resolved immunoassay with flourometric detection (DELFIA)
(Dressendörfer, Kirschbaum, Rohde, Stahl, & Strasburger, 1992). Intra-assay variation
ranged between 4.0% and 6.7% and inter-assay variation was 7.1% to 9.0%. Raw cortisol
data were transformed with a natural logarithmic transform to correct a positive skew prior
to use in analyses.
Momentary stressors and emotion regulation
Prior to completing each saliva sample, participants completed a short (5 min) diary report
regarding their location, activities, and the most stressful situation or event they encountered
in the past hour. Participants were then asked to describe the stressful event in a free
response (93% of samples included descriptive stressor information) and these were coded
as one the following: performance related (y/n) (e.g., academic, work, study participation,
extracurricular, schedule), interpersonal (y/n) (e.g., peer, friend, family, romantic), self (y/n)
(e.g., mental state, identity, well-being, future plans, past actions), sleep (y/n) (e.g., waking
up, tired, alarm, groggy), daily hassles (y/n) (e.g., household issues, lost item, waiting for
someone, errands), other (y/n), (e.g., money, general or unspecified, world events), and no
stress (y/n) (e.g., not stressed, relaxing, n/a). Participants also provided the perceived
severity of stress elicited by each reported stressor by rating how stressful each event was
from 0 (
not at all
) to 3 (
a lot
). Participants were then asked how much their response to the
stressor included a series of coping and emotion regulation strategies from 0 (
not at all
) to 3
(
a lot
). Questions queried about included eight items, seven modified from the daily coping
inventory (Stone & Neale, 1984) and one from the Brief-COPE (Carver, 1997). Data were
factor analyzed using principal axis factoring with an oblimin rotation of the items averaged
across moments for each person.
Factor analyses revealed three distinct emotion regulation factors: problem solving
(“
thinking of a solution or gathering information
” and “
doing something to solve the
situation
” α = 0.90); expressing emotion and seeking support (“
expressing my feelings to
reduce tension
” and “
seeking emotional support from others
” α = 0.81) and disengagement
(“
giving up trying to deal with it
,” “
accepting it, there is nothing to be done
” and “
distracting
myself with thoughts or activities
” α = 0.71). An item assessing relaxation (“
doing
something to relax
”) did not load on any factors and so was omitted from analysis. These
same factors were obtained at the momentary (Level 1), day (Level 2) and average (Level 3)
levels. Both expressing emotions/support seeking and disengagement factors were mildly
positively skewed and the square root transformation was used for all analyses. Momentary
use (L1), average daily use (L2), and average use (L3) of emotion regulation over the course
of the three days were used in analyses.
Diagnostic assessment
The Structured Clinical Interview for DSM-IV (SCID; First et al., 2002) was administered to
assess lifetime psychiatric diagnoses. Interviewers were extensively trained and supervised,
included graduate students or BA level research assistants, and all diagnoses were finalized
by consensus meetings (see Zinbarg et al., 2010). Inter-rater reliability was assessed for a
subset of interviews (approximately 10%) and Kappa values assessing aggregated disorders
were on average 0.82. The current study focused on internalizing disorders, including major
Gilbert et al. Page 6
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

depressive disorder (MDD), (but not dysthymia, minor depressive disorder or depressive
disorder NOS) and anxiety disorders, including specific phobia, generalized anxiety
disorder, social phobia, panic disorder with or without agoraphobia, obsessive compulsive
disorder, and post-traumatic stress disorder. Participants were classified as having a past
internalizing disorder and/or having a current disorder at the time of the cortisol and emotion
regulation momentary assessment.
Demographic, health, and stressor covariates
Demographic variables were included as covariates, including age, gender, and ethnicity.
Ethnicity was first included as dichotomous race variables with each ethnicity (e.g.,
Caucasian as the excluded group compared individually with African American, Hispanic,
Asian, Other), however because the number of variables saturated the models and ethnicity
did not appear to influence outcomes, race was dichotomized as Caucasian (0) versus
Minority (1) status. Health behaviors were reported in the diary booklet at each time point a
saliva sample was taken. We focused on variables previously shown to influence HPA axis
functioning (Adam & Kumari, 2009), including time of waking, hours of sleep, recent sleep,
eating, alcohol intake, caffeine intake, subjective pain, and medication use. Time of waking
and hours of sleep were continuous, the other health behavior variables were dichotomous.
Health behavior covariates were only retained in final models if they showed significant
associations with the cortisol outcome. We also examined qualities of the stressful situations
as covariates (perceived severity of stress dichotomized as high/low and the dichotomized
types of stressor experienced). Lastly, given the sample was recruited based on neuroticism
and neuroticism has been shown to influence emotion regulation tendencies (John & Gross,
2007), we also used neuroticism, as measured by a composite variable described in detail in
Zinbarg (2010), as a covariate. The Cronbach's alpha for the neuroticism composite was
0.81.
Data Analytic Plan
Descriptive statistics and bivariate correlations were examined between key dependent and
independent variables. The main analysis tested associations among emotion regulation,
cortisol, and diagnoses of current and past internalizing disorders using three-level
hierarchical linear modeling that is able to account for the nesting of moments within days
and days within persons (Byrk & Raudenbush, 1992). We used the software HLM
7.01(Raudenbush, Byrk, Cheong, Congdon, & du Toit, 2011). In these growth models, level
of cortisol for each person at each moment was the outcome variable and cortisol was
regressed on time of day variables as well as moment-level predictors (Level 1), day-level
predictors (Level 2) and stable person-level predictors (Level 3).
Models—We analyzed two hierarchical linear models. In the first model (Model 1) we
analyzed the basal cortisol rhythm within each individual by including, at Level 1, a time
variable indicating how long since waking the sample was given (growth parameter
indicating slope over course of day), a time since waking squared variable to capture the
quadratic curvilinear change in cortisol over the course of the day, and a dummy variable
representing the CAR (cortisol value at 40 min post-wake). In this model (Model 1), the
intercept π0ij, represented each person's average cortisol level at wake-up, π1ij reflected the
Gilbert et al. Page 7
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

CAR, and π2ij and π3ij reflected the average linear and quadratic slope across the day from
the waking sample to the bedtime sample, excluding the CAR. We then added demographic
(age, gender, and race) covariates at Level 3 and momentary health behavior covariates at
Level 1 to assess whether these variables influenced cortisol outcomes. The only variables
that influenced cortisol measures were Level 1 sleep and exercise and Level 3 age, gender
and ethnicity, thus only these variables were included in all final models, in addition to the
neuroticism covariate at Level 3. Adding Level 1 stressor quality variables, neither the
severity of stress nor type of stressor showed significant associations with the cortisol
outcome and thus were not retained in the final models.1 Of note, the sleep stressor type was
highly correlated with the above mentioned recent sleep health covariate and thus was
unable to be modeled. We then added the three emotion regulation factors at all levels to
assess the effects on cortisol outcomes: momentary emotion regulation (Level 1), average
use of emotion regulation across the day (day-level; Level 2) predicting Level 1 coefficients
for the Level 1 waking cortisol (intercept), CAR, slope and quadratic slope, and average
emotion regulation use across the three diary days of sampling (average use; Level 3)
predicting the Level 1 waking cortisol, CAR, slope, and quadratic slope.
In the second model (Model 2), all of Model 1 predictors were identical and we added
dichotomous variables assessing past and current internalizing disorders (depression and
anxiety disorders) at Level 3 predicting Level 1 coefficients for waking cortisol, the CAR,
and cortisol slope, and Level 1 and Level 2 coefficients for the impact of momentary
emotion regulation on cortisol. Level 3 internalizing disorder variables were also tested as
modifiers of the effects of day-level (Level 2) emotion regulation on cortisol outcomes.
Results
Descriptive Statistics
In the analytic sample of 182 participants, 92 (50.5%) had no current or past diagnosis of
internalizing disorders, 19 (10.4%) participants had current diagnosis of an internalizing
disorder and 71 (30.0%) had a past diagnosis of an internalizing disorder. Of those 19
participants with current internalizing disorders, 3 (16%) were experiencing a current major
depressive episode and 16 (84%) met criteria for a current anxiety disorder. For those 71
participants with past internalizing disorders, 62 (78%) had a past major depressive episode,
45 (56%) had a history of anxiety disorders, and 27 (34%) experienced both a history of
major depression and an anxiety disorder. There were 10 participants (5%) who met for both
a current and a past internalizing disorder. These participants were included in both groups
in order to examine the independent influences of having current and past pathology. See
Table 1 for descriptive statistics by diagnostic group and within the full sample. There were
no differences on age, gender, ethnicity, or socioeconomic status (
p's
> .05) between the
diagnostic groups
p's
> .05. Not surprisingly, the diagnostic groups differed on neuroticism,
F(2,179) = 17.16,
p
< .001, with the current and past internalizing groups showing higher
1Although the ‘no stress’ category did not show significant associations with momentary cortisol, we ran our final Model 1 and Model
2 covarying for this variable to consider whether a lack of stress reported influenced the relationship between emotion regulation and
cortisol responding. Results were parallel when including this covariate and a lack of stress experienced demonstrated no significant
association with cortisol outcomes.
Gilbert et al. Page 8
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

neuroticism than the group with no internalizing disorders; the current and past internalizing
groups did not significantly differ from each other. There were also no differences by age or
individual ethnicities on average emotion regulation use of any of the three strategies across
the days of cortisol sampling. However, it should be noted that when minority ethnicities
were combined to create a dichotomous Caucasian vs. Minority ethnicity variable,
Caucasians demonstrated reliably greater use of disengagement
t
(180)= 2.05,
p
= .04 but no
significant differences emerged for the other two regulation strategies. Lastly, females
engaged in significantly more expressing emotion and seeking support
t
(180) = 2.72,
p
= .
007 and problem solving
t
(180) = 2.07,
p
= .04 compared with males. The sexes did not
differ reliably on disengagement. Moreover, there were no differences by internalizing group
on average emotion regulation use for any of the three strategies.
For daily stressor qualities, the groups differed on the severity of perceived stress reported,
F
(2, 2913) = 18.42
p
< .001 with all three groups significantly differing from each other:
individuals with current internalizing disorders reported significantly higher stress severity,
followed by individuals with past internalizing disorders, followed by those with no
internalizing disorders (
p
's, < .003). For type of stressor reported, the only omnibus group
difference was on whether no stress was reported,
F
(2,2913) = 11.30,
p
< .001. Bonferroni
post-hoc tests revealed that individuals with a history of internalizing disorders reported
significantly fewer instances when they experienced no stress compared with both
individuals with current internalizing disorders (
p
= .001) and individuals no internalizing
disorders (
p
< .001).
Given the significant group difference in perceived stress severity we wanted to examine
whether this was specific to some types of stressors versus others (e.g., interpersonal stress
severity). To examine this, we multiplied the stress severity rating by each stressor category
to assess group differences in the degree to which each stressor category was reported to be
stressful. We found a significant effect for severity of performance stress,
F
(2,2905) = 3.20,
p
= .04, however Bonferroni post-hoc tests revealed no significant group differences. We
also found a significant difference for severity of interpersonal stress,
F
(2,2909) = 7.95,
p
< .
001, and Bonferroni post-hoc tests revealed that current internalizing disorders (
M
= 0.26
SD
= .073) reported interpersonal stress to be significantly more stressful compared with
those with a history of internalizing disorders (
M
= 0.17
SD
= 0.58) and no internalizing
disorders (
M
= 0.13
SD
= 0.47); the latter two groups did not differ significantly from each
other.
Intercorrelations among independent variables and cortisol
As seen in Table 2, lower waking cortisol was associated with significantly greater
likelihood of having a current internalizing disorder (
r
= -0.22,
p
= .002) whereas an elevated
CAR was significantly associated with past internalizing disorders (
r
= 0.15,
p
= 0.04) and
being Caucasian (
r
= -0.15,
p
= 0.04). Current (
r
= 0.19,
p
= 0.01) and past (
r
= 0.15,
p
=
0.04) internalizing disorders were reliably associated with a flatter slope. All three regulation
strategies were significantly associated with each other (
p
's < .0001) indicating that
participants often employed multiple strategies at each time point. Interestingly, increased
use of expressing emotion and seeking support (
r
= 0.19,
p
= 0.01) and disengagement (
r
=
Gilbert et al. Page 9
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

0.22,
p
< 0.001) were both significantly associated with neuroticism while problem solving
showed no reliable association. Similar to findings above, males used significantly less
expressing emotions and support seeking (
r
= -0.20,
p
= 0.01) and problem solving (
r
=
-0.15,
p
= 0.04) and Caucasians used significantly more disengagement compared with all
other ethnic categories (
r
= -0.15,
p
= 0.04).
Multilevel models of emotion regulation, cortisol, covariates and psychopathology
Cortisol diurnal rhythm—Model 1 illustrates the diurnal rhythm of cortisol with the
intercept representing average wake-up cortisol at π0 = -1.44, indicating a waking cortisol
level of .24 μg/dl and a significant and positive CAR, π1 = 0.50,
p
= .001, indicating
individuals experienced a 64.8%2 increase in cortisol on average from the first to the second
(40 minutes later) sample (see Table 3). The time since waking slope variable demonstrated
a significant negative slope across the day, π2 = -0.17,
p
= .001, demonstrating a 15.6%
decrease per hour on average at the time of waking as well as a significant positive quadratic
slope, π3 = 0.003,
p
= .001.
Multivariate associations between cortisol and emotion regulation—Model 1
indicated that across all participants, higher average use of disengagement was significantly
associated with about 23% higher waking cortisol and on average and about 7% steeper
slopes (see Table 3 for results). For problem solving, higher average problem solving was
significantly associated with, on average, about 15% greater CAR. Expressing emotion and
seeking support was not related to diurnal or momentary cortisol in Model 1.
Multivariate associations between cortisol, emotion regulation and
psychopathology—Model 2 added associations between current and past history of
internalizing disorders and all cortisol indices. All main effects of emotion regulation on
diurnal cortisol from Model 1 remained3 (see Table 3 for results). With regards to the
influence of psychopathology on cortisol responding, individuals with current internalizing
disorders exhibited 29% lower waking cortisol compared to individuals without current
internalizing disorders. Moreover, on days when these individuals engaged in more
expressing emotions and support seeking, they also experienced even lower waking cortisol
—approximately 63% lower waking cortisol compared with individuals without current
internalizing disorders. Related, on days when expressing emotions and seeking support,
individuals with current internalizing disorders demonstrated approximately a 13% flatter
slope than individuals without current internalizing disorders. On days when engaging in
more expressing emotions and seeking support (Level 2), individuals with a history of
internalizing disorders (but not current internalizing disorders) demonstrated a 48% smaller
CAR. Individual differences in momentary effects of emotional regulation on cortisol
responding occurred for both expressing emotions/seeking support and problem solving.
Specifically, individuals with a history of internalizing disorders had about 7% higher
cortisol levels when engaging in momentary emotion expression and support seeking
compared with individuals without past internalizing disorders while individuals with
2The dependent variable (cortisol) has been log transformed, thus we can interpret the coefficients as percentage change per unit
change in the dependent variable using the calculation of
B
%change = exp(
B
raw)-1.
3The association of average problem solving with a higher CAR dropped to p = .050.
Gilbert et al. Page 10
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

current internalizing disorders demonstrated about 12% higher cortisol responding when
engaging in momentary problem solving compared with individuals without current
internalizing disorders.
As a follow up, we also completed identical Model 2 analyses replacing dichotomous (y/n)
ratings of experiencing current or past internalizing disorders with dimensional current and
most severe past clinical severity rating (CSR) scores for internalizing disorders. CSR
ratings were coded for all participants during the diagnostic interview and ranged from 0 to
8 with ≥ 4 denoting clinical significance. Results from this Model 2a were identical to those
reported using dichotomous ratings, with these noted exceptions: a higher current CSR
rating was no longer associated with lower waking cortisol, a higher current CSR rating was
no longer associated with higher momentary cortisol when problem solving, nor was a
higher past CSR rating associated with higher momentary cortisol when expressing
emotions or seeking support. As was found in Model 1, average levels of problem solving
were still associated with a higher CAR (this finding dropped to
p
= .050 in the original
Model 2).
Exploratory Influence of Stressor Qualities—Although different stressor types or
stressor severity did not appear to significantly influence cortisol responding when entered
individually into the model (see Descriptive Statistics Results section), there were group
differences on the interaction between perceived stress severity and interpersonal stress type
(severity × interpersonal stressor), indicating that those with internalizing disorders
experienced their interpersonal stress to be more severe. Given that interpersonal stress
demonstrates strong associations with cortisol responding (e.g., Dickerson & Kemeny, 2004;
Kirschbaum, Pirke, & Hellhammer, 1993) we wanted to further explore how this type of
stressor in particular might influence the relationship between emotion regulation and
cortisol. To do this, we first tested whether the severity of interpersonal stress variable
influenced cortisol responding when only Level 1 diurnal cortisol modeling variables (CAR,
slope, quadratic slope) were included, and it was in fact associated with elevated cortisol
(γ400 = 0.07, SE = 0.03, p = .01). Next, we entered this variable into a model that again
included the cortisol modeling variables at Level 1, Level 3 covariates (age, sex,
neuroticism, ethnicity) modeled onto L1 cortisol variables, and with added Level 2 and
Level 3 emotion regulation, Level 3 covariates, and Level 3 current or past internalizing
disorders modeled only onto this Level 1 interaction term. The average influence of the
interpersonal stress severity variable on momentary cortisol was no longer significant, (γ600
= -0.02, SE = 0.03, p = .56) and none of the day (Level 2) or average (Level 3) emotion
regulation variables or current or past internalizing disorders interacted with interpersonal
stress severity to influence cortisol responding (
all
p's > .05). The only significant interactive
associations with cortisol were among the covariates: females experienced 18% higher
cortisol when experiencing a interpersonal stressor (γ606 = -0.21, SE = 0.06, p < .001) while
individuals higher in neuroticism experienced 9% higher cortisol when experiencing an
interpersonal stressor (γ600 = 0.10, SE = 0.04, p = .02). Lastly, we also completed identical
Model 1 and Model 2 analyses covarying for the interpersonal stress severity rating (within
the subset of the sample that completed descriptions of their stressor) with demographic and
emotion regulation variables again modeled onto this variable. Results were parallel to
Gilbert et al. Page 11
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

original findings and the interpersonal stress severity rating similarly was not associated
with cortisol responding in Model 1 (Intercept γ900 = -0.02, SE = 0.03, p = .61) or Model 2
(Intercept γ900 = -0.02, SE = 0.03, p = .56), except for the interaction with sex. Thus, it
appears that although interpersonal stress severity appears to play a role in cortisol
responding, this association is no longer significant when emotion regulation and covariates
are entered into the model, possibly indicating that emotion regulation is detracting from or
decreasing associations between momentary interpersonal stress and cortisol outcomes.
Discussion
Results of the current study demonstrate the importance of assessing purported adaptive and
maladaptive emotion regulation strategies with diurnal cortisol and also shed light on how
the use of emotion regulation is differentially associated with diurnal cortisol in individuals
currently experiencing internalizing disorders, those with a history of internalizing disorders,
and individuals without any history of internalizing disorders. We found that across all
participants, average tendencies to problem solve were associated with an elevated CAR
while average use of disengagement was associated with a steeper slope and higher waking
cortisol. We also found that expressing emotions and seeking support was especially
implicated in divergent diurnal cortisol rhythms in individuals with internalizing disorders.
Lastly, the only associations between momentary emotion regulation and cortisol responding
were in individuals with internalizing disorders: those experiencing current internalizing
disorders demonstrated elevated cortisol when engaging in momentary problem solving
while those with past internalizing disorders demonstrated elevated cortisol when engaging
in momentary emotion expression and support seeking. Moreover, all results replicated
(except for momentary cortisol responding) when utilizing dimensional assessments of
depression and anxiety. Together these findings illustrate the importance of studying the
nuances of
when
(e.g., being able to flexibly utilize strategies depending on context) and
for
whom
, (e.g., with or without internalizing disorders) emotion regulation may be associated
with differential HPA axis functioning.
Without taking into consideration the role of psychopathology, the tendency to engage in
more problem solving over the course of the three days was associated with an elevated
CAR across participants. On first pass, this finding appears somewhat counterintuitive as
problem-solving is associated with adaptive outcomes and lower psychopathology (Aldao et
al., 2010; Zeidner & Saklofske, 1996) while an elevated CAR is associated with onset of
depression (Adam et al., 2010) and anxiety (Adam et al., 2014). However, the CAR itself has
been hypothesized to be an adaptive response to the environment such that it provides a
“boost” in energetic resources to help take on the upcoming demands of the day (Adam,
Hawkley, Kudielka, & Cacioppo, 2006). The current findings support the boost hypothesis
such that those individuals who tended to engage in more problem solving over the course of
the three days also appeared to display a corresponding elevated CAR. This increase in
biological resources may be associated with actively engaging with and tackling daily
stressors head on in the short term of the three-day study. This is similar to recent work
demonstrating that a higher CAR on specific days is associated with better cognitive and
executive performance that day (Law, Evans, Thron, Hucklebridge, & Clow, 2015).
However, in the current study we are unable to draw causal conclusions, so it may be that
Gilbert et al. Page 12
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

actively approaching and engaging with stressors is associated with a subsequent increase in
the CAR. Either interpretation, our findings indicate that approaching and engaging with the
stressors via the use of problem solving is associated with increased cortisol responding in
the short term of three days (i.e., the “
when”
). It has been hypothesized that it is a
repeated
elevated CAR over time that contributes to maladaptive outcomes as over time it leads to
changes in glucocorticoid receptors via an allostatic load mechanism (McEwen, 1998).
Interestingly, individuals with current internalizing disorders experienced elevated cortisol
responding when engaging in momentary problem solving, although this finding did not
replicate when utilizing dimensional assessments, so findings should be interpreted with
caution. Other research indicates that cognitive reappraisal (a similar approach-focused
regulatory strategy) is associated with higher peak cortisol reactivity, hypothesized to be due
to the novelty of the instructed regulation paradigm requiring more effortful control during
the stressor (Denson et al., 2014). Although speculative, the current findings may similarly
indicate that for individuals who are currently depressed or anxious, problem-solving may
require more cognitive effort, and thus higher momentary cortisol, while engaging in
problem solving. Conversely, problem solving may be more automatic for those individuals
who are not currently depressed or anxious, and thus fewer biological resources are
necessary.
Interestingly, those individuals with internalizing disorders demonstrated divergent cortisol
outcomes especially when engaging in another emotion regulatory strategy, expressing
emotions and seeking support. Replicating previous work (Adam et al., 2010; Knorr et al.,
2010), current findings indicated that individuals with internalizing disorders demonstrated
lower waking cortisol. Moreover, on days when these individuals engaged in expressing
emotions and support seeking, they exhibited even lower cortisol at waking. Lower waking
cortisol predicts greater fatigue and lower perceived energy over the course of the day
(Adam et al., 2006). This lower perceived energy and fewer coping resources may be
associated with more emotional expression and support seeking that day as a way to
counteract a perceived fatigued state. Related, individuals with current internalizing
disorders exhibited flatter diurnal slopes on days when engaging in more emotional
expression and support seeking. The lower waking cortisol and flatter slopes in individuals
with current internalizing disorders might be associated with less preparatory biological
mobilization, which might lead to (or be due to) less active and approach-focused (i.e.,
problem solving and reappraisal) regulation. Additionally, on days when experiencing a
lower CAR, individuals with a history of internalizing disorders engaged in more expressing
emotions and seeking support. This lower CAR may indicate a lack of a “boost,” of
energetic resources (Adam, Hawkley, Kudielka & Cacioppo, 2006), which then may be
associated with more passive and automatic emotion regulation (i.e., emotional expression
and support seeking) rather than adaptive, approach-focused problem-solving strategies.
Lastly, individuals with a history of depression experienced elevated momentary cortisol
when engaging in emotional expression and support seeking, although this finding did not
replicate in analyses using dimensional measures of pathology.
It should be noted that the above findings only emerged for individuals with current or past
internalizing disorders, indicating that expressing emotions and seeking support may operate
Gilbert et al. Page 13
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

differently in these individuals compared with individuals without psychopathology. These
findings may clarify previous discrepant findings on this type of emotion regulation by
shedding light on how the use of this strategy may vary across individuals (i.e., the “
for
whom
”). Emotional expression and support seeking on the one hand demonstrates
maladaptive relationships with mental health and on the other hand is purported to be an
adaptive way to deal with stress (e.g., Segal, Williams, & Teasdale, 2002; Stanton et al.,
2000). Although speculative, individuals without internalizing disorders may utilize
emotional expression and seeking support by effectively leaning on social supports and
allowing themselves to experience their emotions mindfully while individuals with
internalizing disorders may be using a superficially similar strategy, but in fact may be
engaging in something more akin to passively co-ruminating with others or excessively
seeking support or reassurance. Co-rumination, or excessively discussing problems while
focusing on negative emotions, has been associated with increased depressive and anxiety
symptoms (Rose, Carlson, & Waller, 2007) while excessive reassurance is associated with
depression (Joiner & Metalsky, 2001) and anxiety (Joiner, Katz, & Lew, 1999). These
different types of emotional expression and support seeking may be associated with
divergent cortisol patterns evidenced among those with and without internalizing disorders
in the current data.
Lastly, the only association between disengagement and cortisol responding was somewhat
perplexing: average use of disengagement was associated with steeper cortisol slopes across
all participants. Steeper slopes have been linked with adaptive outcomes (e.g., Adam, 2012)
while flatter slopes are indicated in disorders such as depression and chronic fatigue (Doane
et al., 2013; Nater et al., 2008). Disengagement is often purported to be maladaptive (e.g.,
Borkovec et al., 2004; Rohde et al., 1990), however some research indicates that in the
short
term
, distraction and disengaging from stressors may be adaptive as a way to gain distance
from ones' emotions prior to attempting to solve them (Nolen-Hoeksema, Wisco, &
Lyubomirsky, 2008). It appears in the current sample disengagement is associated with a
purportedly more adaptive cortisol profile. However, we are unable to disentangle the
temporal precedence concerning whether flatter slopes contribute to higher use of
disengagement, whether disengagement contributes to a flatter diurnal slope, or whether a
third unknown variable contributes to this association.
One hypothesized third variable could be the type of stressor or the severity of perceived
stress experienced. However, in the current sample, we surprisingly saw no significant
influence of the severity of perceived stress or the type of stressor experienced in relation to
the associations between cortisol and emotion regulation. We did find that by itself in the
model, the severity of perceived momentary
interpersonal
stress was significantly associated
with elevated momentary cortisol, but this was no longer significant once momentary
emotion regulation strategies were accounted for. Thus, the impact of emotion regulation
strategies on cortisol did not appear to strongly depend on stressor type or severity, and
indeed, may reduce the impact of interpersonal stress severity on momentary cortisol. Future
work would greatly benefit from further exploring the interactive roles between stressor
type, emotion regulation use and cortisol patterns.
Gilbert et al. Page 14
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Taken together, the current findings provide potential clinical implications for teaching
flexibility
of emotion regulation use to individuals experiencing internalizing disorders.
First, findings indicated that problem solving was associated with an elevated CAR across
all individuals and increased cortisol mobilization in the moment for individuals with current
internalizing disorders. These elevations in cortisol responding may indicate that problem
solving may be adaptive, but only to a certain extent. Thus, emphasizing
flexibility
in using
emotion regulation strategies, rather than always turning to approach-focused problem-
solving, may be warranted. Further, findings surrounding the strategy of expressing
emotions and seeking support shed light on how an emotion regulation strategy is associated
with differential cortisol patterns once an individual has experienced an internalizing
disorder. Findings will need to be replicated and future work would benefit from elucidating
how and why expressing emotions and seeking support operates differently in individuals
with internalizing disorders. Gaining a better understanding of what contributes to these
associations may help these individuals flexibly utilize this strategy as part of their emotion
regulatory repertoire.
Findings from the current study should be interpreted within a few limitations. First, our
groups of current and past internalizing disorders included individuals with both major
depressive disorder and a variety of anxiety disorders. Due to small sample sizes within each
diagnostic category, we were unable to test the independent effects of emotion regulation
and diurnal cortisol within depression and anxiety. Moreover, even when combining
depression and anxiety into one category of internalizing disorders, only 19 (10%) of
participants met criteria for a current internalizing disorder. Thus, our results (especially
concerning current internalizing disorders) should be interpreted with caution. Future
research would benefit from utilizing larger sample sizes experiencing current pathology to
disentangle how various emotion regulation strategies may be associated with cortisol
dysregulation across different forms of psychopathology. Second, we didn't use objective
compliance monitoring of cortisol samples, which has been found to influence cortisol
estimates (Kudielka, Broderick, & Kirschbaum, 2003). Third, we did not assess whether the
emotion regulation strategies used in response to daily stressors were subjectively reported
as effective. Without knowing whether or not emotion regulatory efforts were successful, we
are unable to determine whether associations of emotion regulation strategies and cortisol
responding are truly adaptive or maladaptive. Fourth, given that this study was part of a
larger project and was assessed as part of a six year follow up, selection bias could be
occurring and might be influencing findings. We are unable to determine how participants
who dropped out of the study might have differed on cortisol indices, psychopathology, or
emotion regulation measures, and future research may wish to examine research naïve
individuals who have not previously undergone multiple clinical assessments and previously
participated in momentary assessment protocols.
The current study was unable to assess causal relations between HPA axis functioning and
emotion regulation and a pressing unknown in the field is 1) how emotion regulation
causally influences HPA axis functioning and vice versa and 2) how these transactions
contribute to the initial onset of psychopathology. This first point is ripe for future research
and could be examined with increased intensity of salivary cortisol and emotion regulatory
sampling to examine a more precise temporal relationship between emotion regulation and
Gilbert et al. Page 15
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

cortisol. For instance, rather than including six daily cortisol/emotion regulation
assessments, hourly assessments from waking to bedtime would allow for time series
analyses to be employed. This would utilize ecologically valid assessments to provide
insight into how emotion regulation strategies may be associated with subsequent rises or
drops in cortisol responding at a later time point in the day (or conversely increases in
cortisol in response to stress may predict the use of specific forms of emotion regulation at a
later point in the day). Recent research has used a similar protocol assessing emotion and
cortisol and found that increases in momentary cortisol are associated with increases in alert,
active, and relaxed self-reports one hour later (L. T. Hoyt, Zeiders, Ehrlich, & Adam, in
press). Understanding how HPA axis functioning may influence later use of emotion
regulation (or vice versa) may provide one pathway by which emotion regulation leads to
psychopathology through a biological mechanism.
Addressing the second above point, the current study was unable to draw causal conclusions
due to it's cross-sectional nature and thus it is unknown whether divergent HPA-emotion
regulation patterns are a cause or consequence of internalizing disorders. An area ripe for
future research would be to assess how trajectories of diurnal cortisol patterns and emotion
regulatory use change longitudinally prior to the onset of psychopathology. With repeated
momentary assessment protocols (e.g., a 3 day assessment every 6 months for 2 years in a
high-risk sample) growth curve modeling could provide a better understanding of the bi-
directional and causal nature of cortisol and emotion regulatory relationships. Furthermore,
in conjunction with clinical assessments, assessing trajectories of cortisol-emotion
regulation relationships may help shed light on how their interactive effects relate to the
onset of psychopathology.
References
Adam, EK. Emotion-cortisol transactions occur over multiple time scales in development: Implications
for research on emotion and the development of emotional disorders. In: Dennis, TA.Buss, KA.,
Hastings, PD., editors. Physiological Measures of Emotion from a Developmental Perspective: State
of the Science Monographs of the Society for Research in Child Development. Vol. 77. 2012. p.
17-22.
Adam EK, Doane LD, Zinbarg RE, Mineka S, Craske MG, Griffith JW. Prospective prediction of
major depressive disorder from cortisol awakening responses in adolescence.
Psychoneuroendocrinology. 2010; 35(6):921–931. DOI: 10.1016/j.psyneuen.2009.12.007 [PubMed:
20079576]
Adam EK, Hawkley LC, Kudielka BM, Cacioppo JT. Day-to-day dynamics of experience-cortisol
associations in a population-based sample of older adults. Proceedings of the National Academy of
Sciences. 2006; 103(45):17058–17063. DOI: 10.1073/pnas.0605053103
Adam EK, Kumari M. Assessing salivary cortisol in large-scale, epidemiological research.
Psychoneuroendocrinology. 2009; 34(10):1423–1436. DOI: 10.1016/j.psyneuen.2009.06.011
[PubMed: 19647372]
Adam EK, Vrshek-Schallhorn S, Kendall AD, Mineka S, Zinbarg RE, Craske MG. Prospective
associations between the cortisol awakening response and first onsets of anxiety disorders over a
six-year follow-up – 2013 Curt Richter Award Winner. Psychoneuroendocrinology. 2014; 44:47–59.
DOI: 10.1016/j.psyneuen.2014.02.014 [PubMed: 24767619]
Aldao A, Nolen-Hoeksema S. One versus many: Capturing the use of multiple emotion regulation
strategies in response to an emotion-eliciting stimulus. Cognition and Emotion. 2012; 27(4):753–
760. DOI: 10.1080/02699931.2012.739998 [PubMed: 23130665]
Gilbert et al. Page 16
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: A
meta-analytic review. Clinical Psychology Review. 2010; 30:217–237. DOI: 10.1016/j.cpr.
2009.11.004 [PubMed: 20015584]
Aldwin CM, Revenson TA. Does coping help? A reexamination of the relation between coping and
mental health. Journal of Personality and Social Psychology. 1987; 53(2):337–348. DOI:
10.1037/0022-3514.53.2.337 [PubMed: 3625471]
Beck, A., Rush, AJ., Shaw, BF., Emery, G. Cognitive Therapy of Depression. New York: The Guilford
Press; 1979.
Borkovec, TD., Alcaine, OM., Behar, E. Generalized anxiety disorder: Advances in research and
practice. New York, NY: Guilford Press; US; 2004. Avoidance theory of worry and generalized
anxiety disorder; p. 77-108.
Byrk, AS., Raudenbush, SW. Hierarchical linear models. Newbury Park, CA: Sage; 1992.
Carver CS. You want to measure coping but your protocol's too long: Consider the brief cope.
International Journal of Behavioral Medicine. 1997; 4(1):92–100. DOI: 10.1207/
s15327558ijbm0401_6 [PubMed: 16250744]
Costa PT, Terracciano A, McCrae RR. Gender differences in personality traits across cultures: Robust
and surprising findings. Journal of Personality and Social Psychology. 2001; 81(2):322–331. DOI:
10.1037/0022-3514.81.2.322 [PubMed: 11519935]
Cowen PJ. Not fade away: the HPA axis and depression. Psychological Medicine. 2010; 40(01):1–4.
DOI: 10.1017/S0033291709005558 [PubMed: 19335939]
Craske, MG. Origins of phobias and anxiety disorders: Why more women than men?. Oxford, UK:
Elsevier; 2003.
Denson TF, Creswell JD, Terides MD, Blundell K. Cognitive reappraisal increases neuroendocrine
reactivity to acute social stress and physical pain. Psychoneuroendocrinology. 2014; 49:69–78.
DOI: 10.1016/j.psyneuen.2014.07.003 [PubMed: 25063879]
Dickerson SS, Kemeny ME. Acute stressors and cortisolr esponses: A theoretical integration and
synthesis of laboratory research. Psychological Bulletin. 2004; 13(3):355–391. DOI:
10.1037/0033-2909.130.3.355
Dienes KA, Hazel NA, Hammen CL. Cortisol secretion in depressed, and at-risk adults.
Psychoneuroendocrinology. 2013; 38(6):927–940. DOI: 10.1016/j.psyneuen.2012.09.019
[PubMed: 23122890]
Doane LD, Mineka S, Zinbarg RE, Craske M, Griffith JW, Adam EK. Are flatter diurnal cortisol
rhythms associated with major depression and anxiety disorders in late adolescence? The role of
life stress and daily negative emotion. Development and Psychopathology. 2013; 25(03):629–642.
DOI: 10.1017/s0954579413000060 [PubMed: 23880381]
Dressendörfer RA, Kirschbaum C, Rohde W, Stahl F, Strasburger CJ. Synthesis of a cortisol-biotin
conjugate and evaluation as a tracer in an immunoassay for salivary cortisol measurement. The
Journal of Steroid Biochemistry and Molecular Biology. 1992; 43(7):683–692. DOI:
10.1016/0960-0760(92)90294-S [PubMed: 1472460]
Endler NS, Parker JD. Multidimensional assessment of coping: A critical evaluation. Journal of
Personality and Social Psychology. 1990; 58(5):844–854. DOI: 10.1037/0022-3514.58.5.844
[PubMed: 2348372]
Eysenck, HJ., Eysenck, SBJ. Manual of the Esyenck Personality Questionnaire (adult and junior).
London: Hodder & Stoughton; 1975.
First, MB., Spitzer, RL., Gibbon, M., Williams, JBW. Structured Clinicial Interview for DSM-IV-TR
Axis 1 Disorders, research version, non-patient edition (SCID-I/NP). New York: New York State
Psychiatric Institude, Biometrics Research; 2002.
Gaab J, Blättler N, Menzi T, Pabst B, Stoyer S, Ehlert U. Randomized controlled evaluation of the
effects of cognitive–behavioral stress management on cortisol responses to acute stress in healthy
subjects. Psychoneuroendocrinology. 2003; 28(6):767–779. DOI: 10.1016/
S0306-4530(02)00069-0 [PubMed: 12812863]
Gross JJ, Jazaieri H. Emotion, emotion regulation, and psychopathology: An affective science
perspective. Clinical Psychological Science. 2014; 2(4):387–401. DOI:
10.1177/2167702614536164
Gilbert et al. Page 17
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Gross JJ, Levenson RW. Hiding feelings: The acute effects of inhibiting negative and positive emotion.
Journal of Abnormal Psychology. 1997; 106(1):95–103. DOI: 10.1037/0021-843X.106.1.95
[PubMed: 9103721]
Gunlicks-Stoessel ML, Powers SI. Romantic partners' coping strategies and patterns of cortisol
reactivity and recovery in response to relationship conflict. Journal of Social and Clinical
Psychology. 2009; 28(5):630–649. DOI: 10.1521/jscp.2009.28.5.630 [PubMed: 22563141]
Harris TO, Borsanyi S, Messari S, Stanford K, Brown GW, Cleary SE, et al. Herbert J. Morning
cortisol as a risk factor for subsequent major depressive disorder in adult women. The British
Journal of Psychiatry. 2000; 177(6):505–510. DOI: 10.1192/bjp.177.6.505 [PubMed: 11102324]
Hayes SC, Wilson KG, Gifford EV, Follette VM, Strosahl K. Experimental avoidance and behavioral
disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting &
Clinical Psychology. 1996; 64(6):1152–1168. DOI: 10.1037/0022-006X.64.6.1152 [PubMed:
8991302]
Heiy JE, Cheavens JS. Back to basics: A naturalistic assessment of the experience and regulation of
emotion. Emotion. 2014; 14(5):878–891. DOI: 10.1037/a0037231 [PubMed: 24999913]
Hollingshead, A. Four Factor Index of Social Status. New Haven, CT: Yale University; 1975.
Hoyt LT, Zeiders K, Ehrlich KB, Adam EK. Positive upshots of cortisol in everyday life. Emotion. in
press. XX, XXX-XXX.
Hoyt MA, Marin-Chollom AM, Bower JE, Thomas KS, Irwin MR, Stanton AL. Approach and
avoidance coping: Diurnal cortisol rhythm in prostate cancer survivors.
Psychoneuroendocrinology. 2014; 49:182–186. DOI: 10.1016/j.psyneuen.2014.07.007 [PubMed:
25108161]
Huber TJ, Issa K, Schik G, Wolf OT. The cortisol awakening response is blunted in psychotherapy
inpatients suffering from depression. Psychoneuroendocrinology. 2006; 31(7):900–904. DOI:
10.1016/j.psyneuen.2006.03.005 [PubMed: 16707227]
John OP, Gross JJ. Healthy and unhealthy emotion regulation: Personality processes, individual
differences, and life span development. Journal of Personality. 2004; 72(6):1301–1333. DOI:
10.1111/j.1467-6494.2004.00298.x [PubMed: 15509284]
John OP, Gross JJ. Individual differences in emotion regulation. Handbook of emotion regulation.
2007:351–372.
Joiner TE, Katz J, Lew A. Harbingers of depressotypic reassurance seeking: Negative life events,
increased anxiety, and decreased self-esteem. Personality and Social Psychology Bulletin. 1999;
25(5):632–639. DOI: 10.1177/0146167299025005008
Joiner TE, Metalsky GI. Excessive reassurance seeking: Delineating a risk factor involved in the
development of depressive symptoms. Psychological Science. 2001; 12(5):371–378. DOI:
10.1111/1467-9280.00369 [PubMed: 11554669]
Kendler KS, Kuhn J, Prescott CA. The interrelationship of neuroticism, sex, and stressful life events in
the prediction of episodes of major depression. American Journal of Psychiatry. 2004; 161(4):631–
636. DOI: 10.1176/appi.ajp.161.4.631 [PubMed: 15056508]
Kirschbaum C, Hellhammer DH. Salivary Cortisol in Psychobiological Research: An overview.
Neuropsychobiology. 1989; 22(3):150–169. DOI: 10.1159/000118611 [PubMed: 2485862]
Kirschbaum C, Pirke KM, Hellhammer DH. The ‘Trier Social Stress Test’ – A Tool for Investigating
Psychobiological Stress Responses in a Laboratory Setting. Neuropsychobiology. 1993; 28(1-2):
76–81. [PubMed: 8255414]
Knorr U, Vinberg M, Kessing LV, Wetterslev J. Salivary cortisol in depressed patients versus control
persons: A systematic review and meta-analysis. Psychoneuroendocrinology. 2010; 35(9):1275–
1286. DOI: 10.1016/j.psyneuen.2010.04.001 [PubMed: 20447770]
Koh KB, Choe E, Song JE, Lee EH. Effect of coping on endocrinoimmune functions in different stress
situations. Psychiatry Research. 2006; 143(2-3):223–234. DOI: 10.1016/j.psychres.2005.04.008
[PubMed: 16831469]
Kring, AM., Sloan, DS., editors. Emotion Regulation and Psychopathology. New York, NY: Guilford
Press; 2009.
Gilbert et al. Page 18
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Kudielka BM, Broderick JE, Kirschbaum C. Compliance with saliva sampling protocols: Electronic
monitoring reveals invalid cortisol daytime profiles in noncompliant subjects. Psychosomatic
Medicine. 2003; 65:313–319. [PubMed: 12652000]
Lam S, Dickerson SS, Zoccola PM, Zaldivar F. Emotion regulation and cortisol reactivity to a social-
evaluative speech task. Psychoneuroendocrinology. 2009; 34(9):1355–1362. DOI: 10.1016/
j.psyneuen.2009.04.006 [PubMed: 19464808]
Law R, Evans P, Thron L, Hucklebridge F, Clow A. The cortisol awakening response predicts same
morning executive function: Results from a 50-day case study. Stress. 2015; 18(6):616–621. DOI:
10.3109/10253890.2015.1076789 [PubMed: 26382884]
Master SL, Amodio DM, Stanton AL, Yee CM, Hilmert CJ, Taylor SE. Neurobiological correlates of
coping through emotional approach. Brain, Behavior, and Immunity. 2009; 23(1):27–35. DOI:
10.1016/j.bbi.2008.04.007
McEwen BS. Stress, adaptation, and disease: Allostasis and allostatic load. Annals of the New York
Academy of Sciences. 1998; 840(1):33–44. DOI: 10.1111/j.1749-6632.1998.tb09546.x [PubMed:
9629234]
Myin-Germeys I, Oorschot M, Collip D, Lataster J, Delespaul P, van Os J. Experience sampling
research in psychopathology: Opening the black box of daily life. Psychological Medicine. 2009;
39(09):1533.doi: 10.1017/s0033291708004947 [PubMed: 19215626]
Nater UM, Youngblood LS, Jones JF, Unger ER, Miller AH, Reeves WC, Heim C. Alterations in
diurnal salivary cortisol rhythm in a population-based sample of cases with chronic fatigue
syndrome. Psychosomatic Medicine. 2008; 70(3):298–305. DOI: 10.1097/PSY.
0b013e3181651025 [PubMed: 18378875]
Nicolson, NA. Stress, coping and cortisol dynamics in daily life. In: de Vries, M., editor. The
Experience of Psychopathology: Investigating Mental Disorders in their Natural settings. New
York: Cambridge University Press; 1992. p. 219-232.
Nolen-Hoeksema, S., Hilt, LM. Gender differences in depression. In: Gotlib, IH., Hammen, C., editors.
Handbook of Depression. Vol. 2. New York: Guilford Press; 2008. p. 386-404.
Nolen-Hoeksema S, Wisco B, Lyubomirsky S. Rethinking rumination. Perspectives on Psychological
Science. 2008; 3:400–424. DOI: 10.1111/j.1745-6924.2008.00088.x [PubMed: 26158958]
O'Donnell K, Badrick E, Kumari M, Steptoe A. Psychological coping styles and cortisol over the day
in healthy older adults. Psychoneuroendocrinology. 2008; 33(5):601–611. DOI: 10.1016/
j.psyneuen.2008.01.015 [PubMed: 18329182]
Pruessner JC, Wolf OT, Hellhammer DH, Buske-Kirschbaum A, von Auer K, Jobst S, et al.
Kirschbaum C. Free cortisol levels after awakening: A reliable biological marker for the
assessment of ddrenocortical activity. Life Sciences. 1997; 61(26):2539–2549. DOI: 10.1016/
S0024-3205(97)01008-4 [PubMed: 9416776]
Raudenbush, SW., Byrk, AS., Cheong, YK., Congdon, RT., du Toit, M. HLM 7 for Windows. Skokie,
IL: Scientific Software International, Inc; 2011.
Rohde P, Lewinsohn PM, Tilson M, Seeley JR. Dimensionality of coping and its relation to depression.
Journal of Personality and Social Psychology. 1990; 58(3):499–511. DOI:
10.1037/0022-3514.58.3.499 [PubMed: 2324939]
Rose AJ, Carlson W, Waller EM. Prospective associations of co-rumination with friendship and
emotional adjustment: Considering the socioemotional trade-offs of co-rumination. Developmental
Psychology. 2007; 43(4):1019–1031. DOI: 10.1037/0012-1649.43.4.1019 [PubMed: 17605532]
Rosenberger PH, Ickovics JR, Epel ES, D'Entremont D, Jokl P. Physical recovery in arthroscopic knee
surgery: Unique contributions of coping behaviors to clinical outcomes and stress reactivity.
Psychology & Health. 2004; 19(3):307–320. DOI: 10.1080/0887044042000193460
Segal, ZV., Williams, J., Teasdale, JD. Mindfulness-based cognitive therapy for depression. New York:
The Guilford Press; 2002.
Smyth, JM., Pennebaker, JW. Sharing one's story: Translating emotional experiences into words as a
coping tool. In: Snyder, CR., editor. Coping: The Psychology of what works. New York: Oxford
University Pres; 1990. p. 70-89.
Gilbert et al. Page 19
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Stanton AL, Kirk SB, Cameron CL, Danoff-Burg S. Coping through emotional approach: Scale
construction and validation. Journal of Personality and Social Psychology. 2000; 78(6):1150–1169.
DOI: 10.1037/0022-3514.78.6.1150 [PubMed: 10870915]
Stone AA, Neale JM. New measure of daily coping: Development and preliminary results. Journal of
Personality and Social Psychology. 1984; 46(4):892–906. DOI: 10.1037/0022-3514.46.4.892
Thase, ME. Neurobiological aspects of depression. In: Gotlib, IH., Hammen, CL., editors. Handbook
of depression. 2nd. New York: Guilford; 2009. p. 187-217.
Thompson RA. Emotion regulation: A theme in search of a definition. Monographs of the Society for
Research in Child Development. 1994; 59:25–52. DOI: 10.1111/j.1540-5834.1994.tb01276.x
[PubMed: 7984164]
Yehuda R. Current status of cortisol findings in PTSD. Psychiatric Clin North Am. 2001; 25:341–368.
Zeidner, M., Saklofske, D. Adaptive and maladaptive coping. In: Zeidner, M., Endler, NS., editors.
Handbook of coping: Theory, research applications. New York: Wiley; 1996. p. 503-531.
Zinbarg RE, Mineka S, Craske MG, Griffith JW, Sutton J, Rose RD, et al. Waters AM. The
Northwestern-UCLA Youth Emotion Project: Associations of cognitive vulnerabilities,
neuroticism and gender with past diagnoses of emotional disorders in adolescents. Behaviour
Research and Therapy. 2010; 48(5):347–358. DOI: 10.1016/j.brat.2009.12.008 [PubMed:
20070951]
Gilbert et al. Page 20
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Gilbert et al. Page 21
Table 1
Demographic/Descriptive Statistics (N = 182)
Variable Full Sample (n = 182) No Internalizing
Disorders (n=92) Current Internalizing
Disorders (n = 19) Past Internalizing
Disorders (n = 71)
Age 22.78 (0.79) 22.66 (0.55) 22.78 (0.75) 22.93 (1.02)
Gender (
% Female)
134 (74%) 66 (71%) 12 (63%) 56 (80%)
Ethnicity
African American 12 (7%) 8 (9%) 2 (11%) 2 (3%)
Hispanic 24 (13%) 11 (12%) 1 (5%) 12 (17%)
Asian 10 (5%) 5 (5%) 1 (5%) 4 (6%)
Caucasian 98 (54%) 50 (54%) 10 (53%) 38 (54%)
Other 38 (21%) 19 (20%) 5 (26%) 14 (20%)
Socioeconomic status 49.26 (12.35) 48.69 (12.33) 50.83 (11.08) 49.56 (12.83)
Problem Solve 1.37 (0.66) 1.30 (0.67) 1.38 (0.54) 1.47 (0.66)
Express/Seek Support 0.41 (0.43) 0.39 (0.41) 0.33 (0.25) 0.46 (0.48)
Disengagement 0.75 (0.44) 0.71 (0.41) 0.75 (0.42) 0.80 (0.47)
Neuroticism 56.39 (10.17) 52.73 (9.77)
*
58.83 (7.87) 60.58 (9.51)
Daily Stressor Qualities
Severity of stressor 1.18 (0.49) 1.08 (0.89)
⋀
1.41 (1.01) 1.21 (0.90)
Performance (%) 782 (27%) 377 (26%) 81 (26%) 373 (27%)
Interpersonal (%) 320 (11%) 140 (10%) 43 (14%) 155 (11%)
Self (%) 172 (6%) 80 (5%) 16 (5%) 83 (6%)
Sleep (%) 367 (12%) 185 (13%) 30 (10%) 173 (13%)
Daily hassles (%) 751 (26%) 367 (26%) 73 (24%) 365 (27%)
Other (%) 112 (4%) 54 (4%) 9 (3%) 52 (4%)
No stress (%) 410 (14%) 232 (16%)
a
56 (18%) 159 (12%)
Note
: Mean(SD) unless otherwise noted as N(%). Socioeconomic status (SES) measured by Hollingshead system. Other ethnicity included Pacific
Islander, Native American, multiracial or if participants indicated ‘other’. Daily stress rated as ‘other’ included money, general or unspecified stress
or other.
*p
< .05; current & past internalizing > no internalizing.
⋀p
< .05; current internalizing > past internalizing > no internalizing
ap
< .05; current & no internalizing > past internalizing
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.

Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Gilbert et al. Page 22
Table 2
Intercorrelations of independent variables, covariates and cortisol (N = 182)
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1. Waking cortisol 1.0
2. CAR -.39
**
1.0
3. Cortisol slope -.70
**
.36
**
1.0
4. Express/seek support factor .03 -.72 -.72 1.0
5. Problem solving factor -.03 .12 .26 .39
**
1.0
6. Disengagement factor .10 -.74 -.21 .51
**
.34
**
1.0
7. Neuroticism -.03 .15 .14 .19
**
.14 .22
**
1.0
8. Past internalizing disorder -.13 .15
*
.15
*
.02 .11 .06 .41
**
1.0
9. Current internalizing disorder -.22
**
-.00 .19
*
-.05 .00 -.00 .08 .06 1.0
10. Sleep -.02 .11 -.13 -.01 .13 .03 .03 .03 -.13 1.0
11. Exercise .07 -.07 -.07 .05 -.11 .01 .07 .12 -.04 -.11
*
1.0
12. Age -.01 .09 .02 .00 -.07 .04 .08 .19
*
.02 -.06 .08 1.0
13. Gender (Male = 1) -.14 -.14 .09 -.20
**
-.15
*
.01 -.14 -.08 .08 -.07 -.08 .02 1.0
14. Ethnicity (Minority = 1) .12 -.15
*
-.07 .11 .03 -.15
*
-.00 -.04 .01 -.15
*
.02 -.00 -.08 1.0
*Note:
Emotion regulation factors are averaged across individuals (Level 3), CAR = Cortisol awakening response, sleep and exercise measured at the moment (Level 1), ethnicity measured as Caucasian vs.
Minority status.
*p
< .05
** p
< .01.
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.

Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Gilbert et al. Page 23
Table 3
Cortisol predicted by emotion regulation and psychopathology (N = 182)
Model 1 Model 2
Variable Coefficient SE p-value Coefficient SE p-value
Level 1 intercept: Wake-up cortisol level π0
Level 1 Intercept γ000 -1.44
**
0.04 <.001 -1.44
**
0.04 <.001
Level 2 Day disengagement β03 0.04 0.09 .67 0.03 0.09 .75
Level 2 Day express emotion/seek support β01 0.07 0.10 .49 0.03 0.11 .81
Current internalizing γ015 -- -- -- -1.00
*
0.42 .02
Past internalizing γ016 -- -- -- 0.23 0.17 .18
Level 2 Problem solve β02 0.07 0.06 .24 0.10 0.07 .16
Average Disengagement γ001 0.20
*
0.09 .03 0.20
*
.09 .02
Average Express emotion/seek support γ002 -0.09 0.12 .46 -0.13 0.11 .25
Average Problem solve γ003 -0.07 0.06 .27 -0.05 0.06 .35
Current internalizing γ008 -- -- -- -0.34
**
0.12 .004
Past internalizing γ009 -- -- -- -0.11 0.07 .13
Cortisol awakening response π1
Level 1 Intercept γ100 0.50
**
0.04 <.001 0.49
**
0.04 <.001
Level 2 Day disengagement β13 -0.12 0.11 .28 -.011 0.11 .30
Level 2 Day express emotion/seek support β11 -0.05 0.11 .66 0.04 0.11 .72
Current internalizing γ115 -- -- -- 0.53 0.41 .20
Past internalizing γ116 -- -- -- -0.66
**
0.25 .009
Level 2 problem solve β12 0.00 0.09 .99 -0.03 0.08 .76
Average disengagement γ101 -0.16 0.10 .10 -0.15 0.09 .10
Average express emotion/seek support γ102 -0.17 0.13 .20 -0.15 0.13 .25
Average problem solve γ103 0.14
*
0.06 .03 0.13
⋀
0.06 .05
Time since waking (Slope) π2
Level 1 Intercept γ200 -0.17
**
.01 <.001 -0.17
**
0.01 <.001
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.

Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Gilbert et al. Page 24
Model 1 Model 2
Variable Coefficient SE p-value Coefficient SE p-value
Level 2 Day disengagement β23 0.00 0.03 .96 -0.00 0.03 .96
Level 2 Day express emotion/seek support β21 0.00 0.03 .94 0.01 0.03 .78
Current internalizing γ215 -- -- -- 0.12
**
0.04 .007
Past internalizing γ216 -- -- -- -0.02 0.03 .38
Level 2 Day problem solve β22 -0.03 0.02 .07 -0.04 0.03 .06
Average disengagement γ201 -0.08
*
0.03 .01 -0.08
**
0.03 .009
Average express emotion/seek support γ202 0.00 0.04 .95 0.01 0.04 .90
Average problem solve γ203 0.04 0.02 .06 0.04 0.02 .08
Momentary disengagement intercept γ600 0.01 0.01 .36 0.01 0.01 .41
Momentary express emotion/seek support intercept γ400 -0.00 0.02 .87 -0.00 0.01 .86
Current internalizing γ405 -- -- -- 0.03 0.05 .56
Past internalizing γ406 -- -- -- 0.07
*
0.03 .03
Momentary problem solve intercept γ500 0.03 0.02 .09 0.03 0.02 .10
Current internalizing γ505 -- -- -- 0.12
*
0.04 .03
Past internalizing γ506 -- -- -- -0.02 0.03 .57
Note:
Internalizing= major depressive disorder and anxiety, Model 1 and 2 also controlling for sleep and exercise at Level 1, wake-time at Level 2, and age, gender, ethnicity, and neuroticism at Level 3,
only significant results presented for internalizing disorders (above model was run and findings were similar to original models).
⋀p
= .050
*p
< .05
** p
< .01.
Clin Psychol Sci
. Author manuscript; available in PMC 2018 January 01.