Dysregulation: Navigating Through Emotional Turmoil

As mental health professionals, we often find emotional dysregulation at the heart of our clients’ challenges.

The ups and downs of emotions leave many people with a sense of powerlessness and hopelessness.

Fortunately, in many cases, dysregulation can be improved over time with effective education, training, and practice.

Science-based tools and strategies can strengthen clients’ ability to regulate their nervous system and emotions and develop a greater sense of emotion regulation.

In this great read, we share these tools and strategies, discuss dysregulation and its impact on mental health, and reveal how to assess dysregulation.

Before you continue, we thought you might like to download our three Emotional Intelligence Exercises for free. These science-based exercises will enhance your ability to understand and work with your emotions and give you the tools to foster the emotional intelligence of your clients, students, or employees.

Dysregulation: A Definition

In recent years, emotional dysregulation has become an increasingly popular lens through which to understand a wide variety of mental health issues.

It is simply defined as “patterns of emotional experience or expression that interfere with goal-directed activity” (Thompson, 2019, p. 805).

More precisely, dysregulation causes a person’s functioning to significantly deviate from baseline (Bunford et al., 2015).

While everyone feels dysregulated at times, some individuals struggle to such a degree that it impacts their overall functioning.

Signs, Symptoms & Causes of Emotional Dysregulation

Maladaptive patterns of emotional experience and expression can manifest in different forms.

In some instances, individuals may experience intense emotions and emotional reactions, expressing them in a manner that may be disruptive or socially unacceptable (Paulus et al., 2021).

In other cases, individuals may react to dysregulation by avoiding emotions, suppressing them, or withdrawing.

Some examples and symptoms of emotional dysregulation include (Paulus et al., 2021):

• Mood swings
• Becoming easily frustrated or irritated
• Having difficulty managing emotions, particularly negative ones
• Impulsivity
• Self-harm
• Severe depression and/or anxiety
• Easily losing your temper
• Verbal outbursts, including crying, shouting, and yelling
• Physical outbursts, including aggression
• Mania or hypomania
• Difficulty maintaining relationships
• Difficulty managing stress
• Excessive substance use
• Dissociation
• Isolation and withdrawal
• Disordered eating
• Suicidal thoughts or attempts

Once again, not everyone struggling with dysregulation will demonstrate the same set of symptoms.

Likewise, emotional dysregulation can be caused by a multitude of factors (Paulus et al., 2021). It may not always be apparent what the underlying cause is for an individual.

Possible causes to consider include (Paulus et al., 2021):

• Genetic factors
• Early childhood trauma, including abuse, neglect, or life-altering experiences
• Chronic invalidation of emotions
• Poor modeling of emotion regulation by caregivers
• Traumatic brain injury
• Mental health disorders

We’ll discuss in more detail below some of the mental health disorders most commonly characterized by dysregulation.

Nervous System Dysregulation & Its Impact on Mental Health

Whether due to a traumatic brain injury or chronic childhood abuse, dysregulation and mental health issues often go hand in hand (Paulus et al., 2021).

When the nervous system becomes dysregulated, individuals may experience physiological symptoms such as muscle tension, emotional symptoms such as feeling overwhelmed, cognitive symptoms such as difficulty concentrating, sleep difficulties, and increased sensitivities to sensory stimuli (Elbers et al., 2018).

The connection between a dysregulated nervous system and emotions is often undeniable. Dysregulated emotions can cause us to act out or withdraw in ways that are more obvious to others.

Over time, a chronically dysregulated nervous system can cause lasting effects on a person’s emotional health, including patterns of emotional dysregulation that interfere with healthy functioning (Paulus et al., 2021).

In fact, recent research (Carmassi et al., 2022) suggests that emotional dysregulation is trans-diagnostic (present across multiple mental disorders), including for bipolar disorder, autism spectrum disorder, attention deficit hyperactivity disorder, post-traumatic stress disorder, personality disorders, schizophrenia spectrum disorders, fetal alcohol spectrum disorders, and disruptive mood dysregulation disorder.

In addition, we find emotional dysregulation present in:

• Oppositional defiant disorders (Reimherr et al., 2017)
• Borderline personality disorders (Carpenter & Trull, 2013; Kröger et al., 2011)
• Mood disorders (Aldao et al., 2010; Klassen et al., 2010)
• Anxiety disorders (Hofmann et al., 2012)
• Eating disorders (Merwin et al., 2013)
• Substance-related and addiction disorders (Bradley et al., 2011)

Emotional dysregulation is a critical component in many mental health issues. Let’s look at a few of these issues in more detail.

Emotional Dysregulation in ADHD

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is most often diagnosed in childhood, though rates of diagnosis in adulthood have increased in recent years.

A growing number of studies indicate emotional dysregulation as a central feature in ADHD, particularly in adult ADHD patients (Barkley & Murphy, 2006; Barkley & Fischer, 2010; Reimherr et al., 2010; Soler-Gutierrez et al., 2023).

One such study showed that 55% of adults with ADHD showed emotional dysregulation in greater severity than 95% of control subjects (Surman et al., 2013). It is estimated that between 37% and 40% of adults with ADHD struggle with emotional dysregulation (Hirsch et al., 2019).

Emotional dysregulation has also been researched in children and adolescents with ADHD, and a similarly close relationship has been demonstrated (Biederman et al., 2012; Sobanksi et al., 2010).

Patients with ADHD who also demonstrate emotional dysregulation have been found to be more impaired in daily life functioning than ADHD patients without dysregulation (Bunford et al., 2015; Bodalski et al., 2019; Barkley & Fischer, 2011; Bunford et al., 2020). These findings emphasize the importance of screening the emotional aspects when working with clients with ADHD.

5 Disorders Related to Mood Dysregulation

The following disorders are characterized by heightened difficulty regulating emotions:

1. Borderline personality disorder

Dysregulation is a core feature contributing to and characteristic of borderline personality disorder (BPD), a severe and complex disorder characterized by instability across many domains (Chapman, 2019).

In fact, much of the research and modern effective interventions (e.g., Dialectical Behavior Therapy or DBT) for dysregulation came from pioneering work with clients with BPD.

2. Post-traumatic stress disorder (PTSD) and complex PTSD

While research has established a strong relationship between trauma and emotional dysregulation, findings are inconclusive as to the exact nature of the relationship (Conti et al., 2023).

We know that individuals who experience trauma, particularly early in life, show symptoms of emotional dysregulation. However, research also points to increased vulnerability of developing PTSD in those who struggle with managing their emotions (Conti et al., 2023).

3. Bipolar disorder

Bipolar disorder is characterized by dysregulated mood, with alternating states of mania/hypomania and depression (Ayık et al., 2023).

Although it is accompanied by other symptoms, bipolar disorder is primarily defined and characterized by an inability to regulate one’s emotions. This pattern can lead to extreme mood states.

4. Disruptive mood dysregulation disorder

Disruptive mood dysregulation disorder is diagnosed in children who present with severe and chronic irritability, temper tantrums, and outbursts (verbal or physical) that are deemed developmentally inappropriate or disproportionate to the situation (Masi, 2015; Paulus et al., 2021).

5. Mood & anxiety disorders

Depression and anxiety disorders are dually characterized by sustained negative mood, a persistent reduction in positive affect, and symptoms of impaired emotion regulation.

Some researchers (e.g., Hofmann et al., 2012) have put forth a trans-diagnostic emotion dysregulation model of mood and anxiety disorders to capture what they propose is a core essence of these disorders.

9 Emotional Dysregulation Tests & Scales

A range of scales exist to measure emotional dysregulation, which is an important step in helping struggling clients.

One of the most commonly used assessment methods for adults is the Difficulties in Emotional Regulation Scale (DERS; Gratz & Roemer, 2004), a 36-item self-report questionnaire that covers six different domains:

1. Nonacceptance of emotional responses
2. Difficulty engaging in goal-directed behavior
3. Impulse control difficulties
4. Lack of emotional awareness
5. Limited access to emotion regulation strategies
6. Lack of emotional clarity

There is also a shorter 16-item version named DERS-16 (Bjureberg et al., 2016).

The 10-item Emotion Regulation Questionnaire (ERQ; Gross & John, 2003) is another widely used self-report questionnaire. It assesses how frequently people use cognitive reappraisal and expressive suppression to regulate their emotions. A shorter form, ERQ-S (Preece et al., 2023), with six items, has also been developed for use.

The Brief Emotion Dysregulation Scale (Wycoff et al., 2024) is a brief, 12-item transdiagnostic screening tool that assesses three areas: sensitivity, lability, and consequences.

The Emotion Regulation Inventory (Roth et al., 2009) measures three styles of emotion regulation that correspond to mental health indicators:

1. Integrative emotion regulation
   An autonomous style of dealing with negative emotions, with high levels of awareness and openness to understanding emotions It’s positively related to wellbeing and prosocial behavior (Benita et al., 2020).
2. Suppressive emotion regulation
   A more controlled approach to negative emotions includes avoiding or minimizing them. This style is related to increased risk for psychopathology (Brenning et al., 2022).
3. Dysregulated emotion regulation
   An impersonal and helpless style, with feelings of being easily overwhelmed by negative emotions, is also linked to increased risk for psychopathology (Brenning et al., 2022).

The Regulation of Emotions Questionnaire (REQ; Phillips & Power, 2007) is a self-report measure consisting of 19 examples of emotion regulation techniques, to which respondents endorse how much they use each one using a Likert scale.

The REQ has four scales (Phillips & Power, 2007):

1. Internal–dysfunction regulation strategies
2. Internal–functional regulation strategies
3. External–dysfunction strategies
4. External–functional strategies

The 21-item Emotion Reactivity Scale (Nock et al., 2008) was developed to measure how respondents experience emotion in general. It provides an overall emotional reactivity score.

An informant-report measure, the Emotion Regulation Checklist (Shields & Cicchetti, 1997), assesses emotion regulation in children using two subscales: the Lability/Negativity subscale (15 items) and the Emotion Regulation subscale (8 items).

And finally, the Affect Intensity and Reactivity Measure for Youth (Jones et al., 2009) is a 40-question measure assessing how strongly respondents experience positive and negative emotion using a Likert scale and simplified language appropriate for younger clients.

4 Strategies for Better Emotional Control

While the following list is by no means exhaustive, consider these four core strategies as foundational in gaining better control over emotions.

1. Emotional awareness: Understanding and labeling emotions

Managing emotions begins with improving awareness and understanding of emotions. Many people were never taught how to do this. For humans, language allows us to make sense of our experiences, including internal ones.

By learning to notice and label emotions and observing their effect, emotions are brought to the forefront of consciousness. This ensures control over emotions and how to direct them, rather than letting emotions drive behavior.

One practical tool to support this practice is the Emotion Wheel. This tool can be used in therapy, coaching, or alongside self-guided journaling as a way to improve your client’s ability to notice the subtle distinctions of emotions.

2. Decreasing emotional vulnerability: Taking care of your physical body

One often overlooked area when considering emotional dysregulation is the state of one’s physical body. A person who is tired, hungry, or sick is less adept at managing emotions.

To optimize resiliency, be sure to pay attention to nourishment, exercise, and regular sleep. In addition, avoiding mood-altering substances, including caffeine and alcohol, will help keep the body and mind healthy.

In dialectical behavior therapy, the PLEASE acronym is used to help clients remember to take care of their bodies:

PL – Treat physical illness
E – Eat healthily
A – Avoid mood-altering drugs
S – Sleep well
E – Exercise

3. Practice STOPP when dealing with intense emotions

A popular and useful strategy that is taught to individuals who struggle with controlling emotions is called STOPP (GetSelfHelp, n.d.). It helps clients take a mindful pause when in a current emotional state that may be overwhelming.

To be most effective, individuals should ideally practice this strategy during states of low emotional arousal so they develop the skills to implement when in the heat of the moment.
STOPP stands for:

• S – Stop!
  • Just pause for a moment.
• T – Take a breath
  • Notice your breathing as you breathe in and out.
• O – Observe
  • What thoughts are going through your mind right now?
  • Where is your focus of attention?
  • What are you reacting to?
  • What sensations do you notice in your body?
• P – Pull back – Put in some perspective
  • What’s the bigger picture?
  • Take a helicopter view.
  • What is another way of looking at this situation?
  • What would a trusted friend say to me right now?
  • Is this thought a fact or an opinion?
  • What is a more reasonable explanation?
  • How important is this? How important will it be in six months’ time?
• P – Practice what works – Proceed
  • What is the best thing to do right now? For me? For others? For the situation?
  • What can I do that fits with my values?
  • Do what will be effective and appropriate.

4. Implement trauma-informed strategies

Finally, for those healing from trauma, particularly complex PTSD, this video provides helpful methods designed to help regulate the nervous system, with attention on physiology.

Other mind–body practices, such as yoga, breathwork, and a variety of mindfulness-based therapies and exercises, are important elements to help individuals calm and regulate the nervous system throughout their trauma-healing journey.

6 Worksheets For Managing Dysregulation

To assist your clients in dealing with their emotions, there are a number of worksheets that we can suggest.

Practicing Radical Acceptance

The Practicing Radical Acceptance worksheet details the DBT skill of radical acceptance, which helps clients deal with intense negative emotions and experiences. The goal is to support clients in handling situations that they cannot control and regaining control of their emotional responses to those experiences.

Skills for Regulating Emotions

This worksheet draws from DBT skills including paying attention to positive events, fact checking, PLEASE, and opposite action. It summarizes and details these skills to help adults practice better regulation of their emotions.

Emotion Regulation Worksheet for Adults

This emotion regulation worksheet is structured to help adults analyze a situation that prompted certain emotions. It is designed to help them better recognize and understand their emotions and how their emotions impact behavior.

The Five Senses Worksheet

This simple exercise helps ground clients by using their senses to be mindful in the present moment. It is an easy-to-remember method that clients can use at any point of their day, particularly if they are feeling dysregulated.

Anger Exit and Re-Entry Routines

With this worksheet, couples deal with conflict and heightened emotions by walking through three steps toward more constructive communication.

Inside and Outside

The Inside and Outside Worksheet is meant to teach children how changing their thinking can help them deal with their emotions. It can also help parents or other caregivers understand what the child may be experiencing.

Helpful Resources From PositivePsychology.com

At PositivePsychology.com, we have many more resources that can equip you to help your client practice emotional awareness and increase emotional regulation. These skills will enable your client to better control and manage dysregulation.

For improved emotion regulation skills:

• 21 Emotion Regulation Worksheets & Strategies
• How to Help Clients Express Their Emotions: 6 Worksheets

Another helpful tool that we would like to suggest is the Emotional Intelligence Masterclass©. Geared toward professionals, this course contains six modules, including:

• Emotions
• Emotional intelligence
• Emotional awareness
• Beliefs about emotions
• Emotional knowledge
• Emotional expression

If you’re looking for more science-based ways to help others develop emotional intelligence, check out this collection of 17 validated EI tools for practitioners. Use them to help others understand and use their emotions to their advantage.

A Take-Home Message

Emotional dysregulation can be frustrating, disruptive, and debilitating.

It impacts work, family, relationships, and overall life satisfaction.

Whether due to a neurodevelopmental disorder, like ADHD, or a personality disorder, like BPD, dysregulation hinders people from operating from their healthiest baseline.

Many people struggle with dysregulation, but fortunately, we have an incredible array of tools at our disposal to support clients. If you’re not sure where to start, or you simply want to bolster the resources you currently have, be sure to check out the numerous worksheets and tools we’ve highlighted here.

With increasing attention on the importance of emotional dysregulation as a factor in so many mental health disorders that impact children, adolescents, and adults, the more equipped we can be, the more effective we’ll be.

And the more empowered our clients will become.

We hope you enjoyed reading this article. Don’t forget to download our three Emotional Intelligence Exercises for free.