Journal of Affective Disorders 213 (2017) 4450

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Journal of Aective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

The relationship between childhood trauma and the severity of adulthood MARK
depression and anxiety symptoms in a clinical sample: The mediating role
of cognitive emotion regulation strategies

Hyu Jung Huha, Kyung Hee Kimb, Hee-Kyung Leeb, Jeong-Ho Chaec,
a
Stress Clinic, Health Promotion Center, Seoul St. Marys Hospital, The Catholic University of Korea, College of Medicine
b
Department of Psychology, The Catholic University of Korea
c
Department of Psychiatry, Seoul St. Marys Hospital, The Catholic University of Korea, College of Medicine

A R T I C L E I N F O A BS T RAC T

Keywords: Background: Childhood trauma is an important factor in adverse mental health outcomes, including
Emotion regulation depression and anxiety. The purpose of the present study was to evaluate a hypothesized model describing a
Childhood trauma pathway of childhood trauma and its inuence on psychiatric symptoms in patients with depressive disorder. In
Depression this model, childhood trauma was positively associated with current depression and anxiety symptoms, which
Anxiety
were mediated by a cognitive emotional regulation strategy.
Method: Patients with depressive disorder (n=585, 266 men, 316 women) completed the Beck Depression
Inventory (BDI), State-Trait Anxiety Inventory (STAI), Childhood Trauma Questionnaire (CTQ), and Cognitive
Emotion Regulation Questionnaire (CERQ). We divided the cognitive emotion regulation strategies into
adaptive and maladaptive strategies using a CERQ subscore. We employed structural equation modeling (SEM)
and simple/multiple mediation analyses.
Results: The indirect eect of maladaptive strategies was signicant in the relationship between overall
childhood trauma and depression/anxiety severity, whereas the mediation eect of adaptive strategies was
limited to depressive symptoms. With respect to specic types of trauma, maladaptive strategies mediated the
association between emotional abuse and current depression/anxiety, while the mediation eect of adaptive
strategies was limited to emotional neglect.
Limitations: This study's cross-sectional design does not allow establishment of causal relationships.
Childhood trauma recall bias may be possible.
Conclusions: These ndings support the hypothesized model in which childhood trauma is associated with
adulthood depression/anxiety symptoms in clinical samples, and mediated by emotion regulation strategies.
These results suggest that cognitive emotion dysregulation is an important factor aecting depression/anxiety
symptoms in patients with childhood trauma.

1. Introduction
A considerable body of evidence suggests that childhood trauma is
associated with the onset, symptom severity, and course of depression
and anxiety symptoms (Friis et al., 2002; Gibb et al., 2007; Kendler
et al., 1999). Despite the well-established relationship between child-
hood trauma and adulthood mental health problems, the specic
mechanism underlying early life trauma relationship to later psychia-
tric problems is still unclear.
The ability of emotion regulation is a possible mediator of the
relationship between childhood trauma and later depression and
anxiety symptoms. Although dierent researchers have used the term
emotion regulation in dierent ways (Gross and Thompson, 2007),
emotion regulation can be generally dened as the ability to respond
to the ongoing demands of experience with a range of emotion in a
manner that is socially tolerable and suciently exible to permit
spontaneous reactions as well as the ability to delay spontaneous
reactions as needed (Cole et al., 1994). Previous studies have
suggested that emotion regulation ability is developed in early life
within the context of interpersonal emotional exchanges between
caregiver and child (Feldman and Greenbaum, 1997). The quality of
caregiverchild emotional exchanges is an important factor in adult-

Corresponding author: Department of Psychiatry, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, 222 Seochodaero, Seocho-Gu, Seoul 137-
701, Republic of Korea, Tel.: +82 2 2258 6083; fax: +82 2 2258 3870.
E-mail address: alberto@catholic.ac.kr (J.-H. Chae).

http://dx.doi.org/10.1016/j.jad.2017.02.009
Received 1 August 2016; Received in revised form 30 January 2017; Accepted 6 February 2017
Available online 07 February 2017
0165-0327/ 2017 Elsevier B.V. All rights reserved.
H.J. Huh et al.
hood emotion regulation capacity (Cole et al., 2004).
It appears that childhood trauma disturbs development of the
ability to regulate emotions in a healthy manner. Childhood trauma,
especially repeated interpersonal trauma between caregiver and child,
interferes with the acquisition of appropriate emotion regulation skills
(Burns et al., 2010; Cicchetti and Rogosch, 2009). Several studies have
provided empirical evidence that childhood trauma can cause subse-
quent problems related to emotion regulation. One study described
sexually abused girls who had diculty understanding and regulating
their emotions (Shipman et al., 2000). They also expected less
emotional support from others and had more interpersonal problems
and more negative emotional states. Neglected children were shown to
be less able to understand negative emotion and to have fewer adaptive
emotion regulation skills. They expected caregivers to respond nega-
tively to their emotions, and attempted to suppress their emotions
(Shipman et al., 2005). These ndings show that dierent types of
childhood maltreatment can cause various patterns of decits or
diculties in understanding and regulating emotions. However, it is
still unclear how distinctive types of childhood trauma dierentially
inuence the development of emotion regulation ability.
Emotion dysregulation originating from childhood trauma can
contribute to the development, maintenance, and treatment of many
psychiatric disorders, including depression and anxiety (Berking and
Wupperman, 2012; Gross and Muoz, 1995; Kring and Werner, 2004).
Depressed individuals were found to have diculty identifying, tolerat-
ing, and adaptively regulating their negative emotions with respect to
stressful events. (Campbell-Sills et al., 2006; Ehring et al., 2008;
Gilbert et al., 2006; Honkalampi et al., 1999) Emotion regulation
decits in anxious individuals can lead to maladaptive coping with fear
related stimuli, increasing the possibility of chronic avoidance (Cisler
et al., 2010). Several prospective studies have revealed that emotion
dysregulation predicts later depression and anxiety symptom severity
(Berking and Wupperman, 2012). One study suggested that emotion
dysregulation predicted depression severity two years later. Other
research showed that positive expectations for the ability to manage
negative emotion were associated with reduced depression and anxiety
(Kassel et al., 2007; Kraaij et al., 2002).
A few studies have investigated emotion regulation as a mediator
between childhood trauma and subsequent mental health problems.
One study with a low-income African American sample provided
support for emotion regulation as a mediator between childhood
trauma and adult depression (Crow et al., 2014). In addition, several
other studies in children and adolescents showed the negative inuence
of childhood trauma on psychological adjustment was mediated by
emotion regulation decits (Choi and Oh, 2014; Kim and Cicchetti,
2010). These ndings support the role of emotion dysregulation as a
mediator between childhood trauma and adulthood depression/anxiety
symptoms. However, most participants in these previous studies were
adolescents or adults in a community.
To the best of our knowledge, only one recent study with clinical
sample provided evidence for the mediating role of emotion regulation
in the relationship between childhood trauma and later depression
(Hopnger et al., 2016). Although the study additionally explored
whether specic types of emotion regulation were important for
explaining the association between childhood trauma and current
depression, they did not consider factors such as comorbid anxiety
and possible dierential eects of various childhood traumas in
depressive disorders.
Thus, this study used structural equation modeling (SEM) to
characterize the relationships between cognitive emotion regulation
strategies, childhood trauma, adulthood depression, and comorbid
anxiety symptoms in a clinical sample diagnosed with depressive
disorder. Specically, cognitive emotion regulation strategy use was
examined as a mediator of the relationship between childhood trauma
and adult depression and anxiety symptoms. We hypothesized that
patients with childhood trauma would use more maladaptive and fewer
45
Journal of Affective Disorders 213 (2017) 4450
adaptive cognitive emotion regulation strategies. In addition, we
hypothesized that these tendencies would inuence current depressive
and comorbid anxiety symptoms. Further, we explored whether specic
types of childhood trauma had dierential eects on current depres-
sion/anxiety as mediated by cognitive emotion regulation strategies
and if specic strategies were signicantly important for the relation-
ship between childhood trauma and later depression/anxiety.
2. Methods
2.1. Participants
During the 36-month study period from August 2011 to July 2014,
patients who visited the Mood and Anxiety Disorders Unit at Seoul St.
Mary's Hospital, The Catholic University of Korea, and who met DSM-
IV diagnostic criteria for nonpsychotic depressive disorder as a
principal diagnosis were recruited consecutively. Diagnosis was deter-
mined by a psychiatrist using semi-structured diagnostic interviews
from the Mini-International Neuropsychiatric Interview (M.I.N.I)
(Sheehan et al., 1998). Eligibility criteria included being 1865 years
of age and literate in Korean. Exclusion criteria included a lifetime
diagnosis of psychotic disorder, bipolar disorder, mental retardation,
and any mental disorder due to a general medical condition. We also
excluded patients with a primary personality disorder diagnosis and
patients who were primarily treated with respect to this personality
disorder. A total of 622 outpatients who met inclusion criteria
consented to participate in this study. Analyses were restricted to
those who completed all study measures, thus the nal sample was
comprised of 585 patients. All subjects provided written informed
consent. Study procedure was approved by the Institutional Review
Board of the Ethics Committee of Seoul St. Mary's Hospital at the
Catholic University of Korea.
2.2. Measurements
2.2.1. Demographics and psychiatric symptoms
During semi-structured diagnostic interviews from the Mini-
International Neuropsychiatric Interview (M.I.N.I) patients were asked
about demographic information such as years of formal education,
marital status, and employment status.
Regarding psychiatric symptoms, we assessed participant depres-
sion and anxiety symptoms using Korean versions of the Beck
Depression Inventory (BDI) (Beck et al., 1961) and the State-Trait
Anxiety Inventory (STAI) (Spielberger and Luchene, 1970). The
Korean versions of the MINI (Yoo et al., 2006), the BDI (Lee et al.,
1995) and STAI (Hahn et al., 1996) have been well validated. In the
present study, BDI (Cronbach's =.916) and STAI (Cronbach's =.963)
scores showed good internal consistency.
2.2.2. Childhood trauma
Childhood abuse and neglect were assessed using the Childhood
Trauma Questionnaire (CTQ) (Bernstein and Fink, 1998), a 28-item
self-report inventory assessing ve types of trauma experienced by a
child or teenager: emotional, physical, and sexual abuse and emotional
and physical neglect. Items are rated on a 5-point frequency scale
(1=never true to 5=very often true) and summed to yield a total score
for each type of trauma, ranging from 5 to 25, with higher scores
indicating greater severity. The Korean version of the CTQ has also
been validated (Kim et al., 2011). In the present study, the CTQ total
score displayed good internal consistency (Cronbach's =.923).
Cronbach's for emotional abuse, emotional neglect, physical abuse,
physical neglect and sexual abuse were .875, .929, .888, .615 and .847,
respectively.
2.2.3. Cognitive emotion regulation strategies
The Cognitive Emotion Regulation Questionnaire (CERQ) was used
H.J. Huh et al. Journal of Affective Disorders 213 (2017) 4450

to evaluate cognitive emotion regulation strategies used to respond to Table 1

stressful events (Garnefski et al., 2001). The CERQ is a 36-item
questionnaire which uses a 5-point Likert scale to assess nine strategy
subscales. The nine strategy subscales are: self-blame, rumination,
catastrophizing, blaming others, acceptance, positive refocusing, refo-
cus on planning, positive reappraisal, and putting into perspective.
Generally, self-blame, rumination, catastrophizing, and blaming others
are regarded as maladaptive, whereas acceptance, positive refocusing,
refocus on planning, positive reappraisal, and putting into perspective
are regarded as adaptive (Aldao and Nolen-Hoeksema, 2010; Garnefski
et al., 2001). In the present study, the nine subscales were categorized
into adaptive and maladaptive strategies and scores for adaptive
(CERQ_A) and maladaptive strategies (CERQ_M) were summed from
the relevant subscales. The Korean version of the CERQ has been
validated (Ahn et al., 2013). CERQ total score demonstrated good
internal consistency (Cronbach's =.855) and the sub-scores for
CERQ_M (Cronbach's =.864) and CERQ_A (Cronbach's =.900)
cognitive emotion regulation strategies also displayed good internal
consistency.
2.3. Data analysis
Descriptive statistics and Pearson's correlation analysis were per-
formed to investigate the distributions of childhood traumatic experi-
ence, cognitive strategies, psychiatric symptoms of depression and
anxiety, and the relationships between these variables. We used item
parceling to create the observed variables. A two parceling approach
was applied to form the parcels. First, for unidimensional variables (i.e.
depression, anxiety), all items in each latent variable were separately
factor analyzed. Then, parcels were created by combining items based
on factor loading order. Second, for multidimensional variables (i.e.
childhood traumatic experience, cognitive strategies), using a domain-
representative approach, parcels were created by combining items from
dierent facets into item sets.
Descriptive statistics and measurement model t to the observed
variables were used to conrm whether the observed variables appro-
priately reected the latent constructs.
We tested the mediation model using structural equation modeling
(SEM). In the model, the independent variable was total CTQ score.
Dependent variables were BDI and STAI scores. CERQ_M and
CERQ_A sub-scores from the CERQ were mediating variables. Age,
gender and educational years were covariates. We used several good-
ness-of-t measures to evaluate how well the hypothesized model t
the observed data: 2, Tuker Lewis index (TLI), comparative t index
(CFI), and root mean square error of approximation (RMSEA).
Generally, a well-tting model is indicated when TLI or CFI is at least
.90 and the RMSEA is .06 or lower. Finally, we performed boot-
strapping to examine the signicance of the mediation eect.
Eighteen simple mediation analyses were performed to ask if
specic types of cognitive emotion regulation strategy signicantly
Demographic characteristics of participants.
Characteristic Mean (SD)/%
Age 36.94 (12.29)
Gender (Female) 54.3%
Educational year 14.05 (2.77)
Employment status (Unemployment) 28.8%
Marital status (Married/Cohabited) 57.1%
Depression (BDI) 24.31 (12.04)
Anxiety (STAI) 85.82 (10.94)
Childhood trauma (CTQ) 55.03 (16.62)
Maladaptive cognitive emotion regulation strategies 46.33 (11.20)
(CERQ_M)
Adaptive cognitive emotion regulation strategies (CERQ_A) 56.41 (14.01)
3. Results
3.1. Participant demographics and clinical characteristics
Participant demographics and clinical characteristics are summar-
ized in Table 1. Mean age was 36.94 ( 12.29) years, and 54.3%
(n=316) of the participants were female. Mean education years were
14.05 ( 2.77). 28.8% (n=159) of the participants were unemployed
and 57.1% (n=324) of the participants were married or cohabited.
Mean BDI score was 24.31 ( 12.04), indicating severe depression in
the study sample (Beck et al., 1961; Lee et al., 1995). Mean STAI score
was 85.82 ( 10.94), which is below the level for clinically signicant
state and trait anxiety (Hahn et al., 1996; Spielberger and Luchene,
1970). Mean CTQ score was 55.03 ( 16.62), indicating that partici-
pants reported moderate to severe childhood traumatic experiences
(Bernstein and Fink, 1998; Kim et al., 2011). Mean CERQ_M and
CERQ_A scores were 46.33 ( 11.20) and 56.41 ( 14.01), respec-
tively. The mean CERQ_M score (39.36 11.68) was higher and the
mean CERQ_A score (65 15.4) was lower than those of university
students in a comparable study (Lee, 2015). Specic diagnoses
included major depressive disorder (n=508), dysthymic disorder
(n=2) and depressive disorder not otherwise specied (n=75). Forty-
eight percent (n=284) of patients had comorbid anxiety disorders,
including panic disorder (n=69), obsessive compulsive (n=26), post-
traumatic stress (n=28), generalized anxiety (n=55), social anxiety
(n=17) and anxiety disorder not otherwise specied (n=89).
3.2. Overall childhood trauma, maladaptive/adaptive cognitive
emotion regulation and current depression/anxiety
The correlation matrix for all variables is provided in Table 2. None
of the variables were severely skewed or kurtotic. Childhood trauma
was positively correlated with use of maladaptive cognitive emotion
regulation strategies (r=.283, p < .01) and with depressive symptom
Table 2
Correlation among childhood trauma, cognitive emotion regulation strategies, depression
and anxiety.

explained the relationship between childhood trauma and current CTQ CERQ_M CERQ_A STAI BDI
depression/anxiety severity. For these analyses, the nine CERQ sub-
cores were entered as mediating variables, with CTQ total score as a 1. CTQ
predictive variable and BDI and STAI scores as outcome variables. In 2, CERQ_M .283**
3, CERQ_A .120** .024
addition, we performed multiple mediation analyses with CERQ_M 4. STAI .069 .354** .098*
and CERQ_A scores as mediating variables, the ve CTQ sub-scores 5. BDI .290** .566** .334** .211**
(emotional abuse, physical abuse, sexual abuse, emotional neglect and
physical neglect) as independent variables and BDI and STAI scores as Note. CTQ: Childhood trauma questionnaire (Childhood trauma), CERQ M: Maladaptive
dependent variables to ask if the eect of specic types of childhood subscales of cognitive emotion regulation questionnaire (Maladaptive cognitive emotion
regulation), CERQ A: Adaptive subscales of cognitive emotion regulation questionnaire
trauma were important for current depression/anxiety, and if they
(Adaptive cognitive emotion regulation), STAI: State-trait anxiety inventory (Anxiety),
were interactively mediated by adaptive or maladaptive cognitive BDI: Beck depression inventory (depression),
emotion regulation strategies. All analyses were performed using *
p < .05.
**
SPSS 22.0 and AMOS 18.0. p < .01.

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H.J. Huh et al. Journal of Affective Disorders 213 (2017) 4450

Maladaptive
cognitive emotion
Adaptive regulation
.045
cognitive emotion
regulation
.061 .641 ***

-.219 ***

.269 ***
.059 Anxiety

.054
-.332*** .609 ***

Childhood
trauma
.076*

Depression

Fig. 1. Mediation of relationship between childhood trauma and current anxiety and depressive symptoms through cognitive emotion regulation strategies, Path coecients were
standardized. Note, *p < .05, **p < .01, ***p < .001.

severity (r=.290, p < .01). Anxiety was not signicantly correlated with Table 3
childhood trauma. Childhood trauma was negatively correlated with The test of indirect effect in model of childhood trauma and depression/anxiety severity,
adaptive cognitive emotion regulation strategies (r=.120, p < .01). mediated by cognitive emotion regulation.

Maladaptive cognitive emotion regulation strategies were positively Path Estimate p-value 95% Bias-corrected
correlated with anxiety severity (r=.354, p < .01) and depressive CI
symptoms (r=.566, p < .01). Adaptive cognitive emotion regulation
strategies were negatively correlated with depressive symptom severity Lower Upper

(r=.334, p < .01), and positively correlated with anxiety symptoms Childhood trauma Maladaptive .170 P < .001 .109 .231
(r=.098, p < .05). emotion regulation Anxiety
Fig. 1 displays the model of the relationship between childhood severity
trauma and current depression/anxiety severity, as mediated by Childhood traumaMaladaptive .162 p < .001 .103 .221
emotion regulation
cognitive emotion regulation strategies. The t indices for the model
Depression severity
showed it was reasonable. The t indices for the model were Childhood trauma Adaptive .011 p=n.s .033 .011
2=584.907 (df=229, p < .001), CFI=.960, TLI=.948, and emotion regulation Anxiety
RMSEA=.052. severity
The path coecients, which represent latent variable relationships Childhood trauma Adaptive .016 p=n.s .050 .017
emotion regulation
for each model, were both signicant: the path from childhood trauma Depression severity
to maladaptive cognitive emotion regulation strategies (=.269, p
< .001) and the path from maladaptive cognitive emotion regulation Note. n.s.: not significant.
strategies to depression (=.609, p < .001) and anxiety (=.641, p
< .001). The direct path from childhood trauma to anxiety was not eect of childhood trauma on adulthood depression/anxiety severity.
signicant, suggesting that maladaptive cognitive emotion regulation There were signicant indirect eects of childhood trauma on anxiety
strategies fully mediated the relationship between childhood trauma severity through selected emotion regulation strategies including self-
and current anxiety symptoms. On the other hand, the direct path from blame, rumination, catastrophizing and blaming others. All types of
childhood trauma to depression was signicant (=.076, p < .05), cognitive emotion regulation strategies signicantly and partially
showing that maladaptive cognitive emotion regulation strategies mediated the relationship between childhood trauma and later depres-
partially mediated the association between childhood trauma and later sion.
depression severity.
Although the paths from adaptive cognitive emotion regulation 3.4. Specic types of childhood trauma
strategies to depression (=.332, p < .001) and anxiety (=.219, p
< .001) were both signicant, the path from childhood trauma to Table 5 summarizes multiple mediation results for maladaptive/
adaptive cognitive emotion regulation strategies was not signicant. adaptive cognitive emotion regulation strategies with respect to the
The bootstrapping index for an indirect eect (a x b) was not signicant eect of specic childhood trauma on adulthood depression/anxiety
when adaptive cognitive emotion regulation strategies were included as severity. A signicant mediation eect of maladaptive cognitive emo-
mediating variables. Therefore, the mediating eect of overall adaptive tion regulation strategies was observed for the relationship between
cognitive emotion regulation strategies on the relationship between childhood emotional abuse and current depression/anxiety severity.
childhood trauma and psychiatric symptoms was not signicant. On the other hand, the mediating eect of adaptive cognitive emotion
Table 3 summarizes bootstrapping results used to examine the regulation strategies was signicant for the association between emo-
signicance of model indirect eects. The indirect eect of childhood tional neglect and depression/anxiety.
trauma on depression and anxiety, mediated by maladaptive cognitive
emotion regulation strategies, was statistically signicant. 4. Discussion

3.3. Specic types of cognitive emotion regulation strategies Prior research has investigated the negative eects of childhood
trauma for many psychiatric problems and the relationship between
Table 4 summarizes results from the simple mediation analyses for early life trauma and emotion regulation ability. In this clinical study a
each nine cognitive emotion regulation strategies with respect to the mediation model was tested in which early life trauma was associated

47
H.J. Huh et al. Journal of Affective Disorders 213 (2017) 4450

Table 4
Mediation effect of specific types of cognitive emotion regulation in the relationship between childhood trauma and depression/anxiety severity (by simple mediation analysis).

Outcome: anxiety Outcome: depression

Mediating variable (M) Effect of childhood Effect of M on anxiety Direct effect Indirect effect Effect of M on depression Direct effect Indirect effect
trauma on M (a) severity (b) (c) (ab) severity (b) (c) (ab)

Self-blame .177*** .250*** .025 .044*** .353*** .235*** .062***

Rumination .206*** .293*** .009 .060*** .443*** .208*** .091***
Catastrophizing .262*** .289*** .291 .075*** .589*** .146*** .154***
Blaming others .159*** .177*** .042 .028** .216*** .262*** .034**
Acceptance .088* .177*** .054 .016+ .043 .296*** .003**
Positive refocusing .172*** .048 .079 .008 .322*** .242*** .055***
Refocus on planning .099* .077 .077 .007 .286*** .265*** .028***
Positive reappraisal .119** .046 .075 .005 .325*** .255*** .038**
Putting into perspective .127** .046 .076 .005 .263*** .261*** .033**

Note. CTQ: Childhood trauma, CERQ M: Maladaptive cognitive emotion regulation CERQ A: Adaptive cognitive emotion regulation, STAI: anxiety, BDI: depression, *p < .05, **p < .01,
***p < .001 (two-tailed probability), + p < .05 (one-tailed probability).

with depression and anxiety symptom severity as mediated by cognitive
emotion regulation ability.
Patients reporting greater childhood traumatic experiences had a
tendency to use more overall maladaptive cognitive emotion regulation
strategies, which mediated the relationship between early life traumatic
experience and current depression/anxiety symptoms. This suggests
that using maladaptive cognitive emotion regulation strategies is an
important possible mechanism underlying the negative eect of child-
hood trauma on depression/anxiety symptom severity in adulthood.
These ndings are in line with several previous studies which proposed
that emotion regulation is a mediator of childhood trauma's negative
eects (Kim and Cicchetti, 2010; Schwartz and Proctor, 2000), and
childhood trauma can lead to emotion dysregulation in later life
(Cloitre et al., 2009; Roth et al., 1997). Several theories which address
emotion regulation development, , including biosocial and attachment
theory, state that early traumatic experience, especially with a care-
giver, creates an environment which invalidates emotions (Reeves,
2008). In addition, traumatic experience with a caregiver leads to an
insecure attachment style in children. An invalidating environment and
insecure attachment can cause individuals to use maladaptive strate-
gies, such as repression or avoidance of negative emotions, in order to
survive (Batten et al., 2001). Maladaptive emotion regulation strategies
originating from childhood traumas or invalidating environments
cause vulnerability to psychological dysfunctions, such as depression
and anxiety, later in life (Krause et al., 2003; Reddy et al., 2006). From
the perspective of cognitive behavioral theory, maladaptive appraisal of
negative life events may be at the core of depression and anxiety (Beck,
1976). Maladaptive processing of stressful events can overwhelm
patients with negative emotions, thus contributing to clinically sig-
nicant depression and anxiety (Howatt, 2005).
By and large, the indirect eect of adaptive emotion regulation
strategies was weaker than maladaptive emotion regulation strategies.
Interestingly, acceptance which is generally regarded as adaptive was
positively associated with childhood trauma and anxiety severity. One
possible explanation for these ndings is that the consequences of
using a particular strategy may be moderated by individual clinical
symptom severity (Aldao and Nolen-Hoeksema, 2012). Clinical groups
may have diculty implementing adaptive strategies eectively and
thus may show weaker indirect eects of adaptive strategies that
mediate the relationship between childhood trauma and adult symp-
tom severity (Aldao and Nolen-Hoeksema, 2010). Further, emotion
regulation strategies which work adaptively for mentally healthy people
may produce maladaptive eects in clinical groups, leading to incon-
sistent adaptive strategy results (Liverant, 2008).

Table 5
Multiple mediation analysis of maladaptive and adaptive cognitive emotion regulation strategies in the relationship between specific types of childhood trauma and depression/anxiety
severity.

Path Estimate p-value 95% Bias-corrected CI

Lower Upper

Emotional abuse Maladaptive emotion regulation Anxiety severity .130 p < .01 .037 .230
Physical abuse Maladaptive emotion regulation Anxiety severity .004 n.s. .065 .068
Sexual abuse Maladaptive emotion regulation Anxiety severity .078 n.s. .022 .177
Emotional neglect Maladaptive emotion regulation Anxiety severity .028 n.s. .042 .100
Physical neglect Maladaptive emotion regulation Anxiety severity .051 n.s. .173 .029
Emotional abuse Maladaptive emotion regulation Depression severity .091 p < .05 .027 .166
Physical abuse Maladaptive emotion regulation Depression severity .003 n.s. .045 .048
Sexual abuse Maladaptive emotion regulation Depression severity .055 n.s. .015 .127
Emotional neglect Maladaptive emotion regulation Depression severity .019 n.s. .030 .068
Physical neglect Maladaptive emotion regulation Depression severity .036 n.s. .123 .019
Emotional abuse Adaptive emotion regulation Anxiety severity .005 n.s. .026 .036
Physical abuse Adaptive emotion regulation Anxiety severity .017 n.s. .043 .003
Sexual abuse Adaptive emotion regulation Anxiety severity .005 n.s. .027 .044
Emotional neglect Adaptive emotion regulation Anxiety severity .037 p < .01 .016 .070
Physical neglect Adaptive emotion regulation Anxiety severity .007 n.s. .023 .054
Emotional abuse Adaptive emotion regulation Depression severity .006 n.s. .032 .045
Physical abuse Adaptive emotion regulation Depression severity .021 n.s. .052 .005
Sexual abuse Adaptive emotion regulation Depression severity .006 n.s. .033 .053
Emotional neglect Adaptive emotion regulation Depression severity .04.2067 P < .01 .020 .081
Physical neglect Adaptive emotion regulation Depression severity .009 n.s. .030 .063

Note. n.s.: not significant

48
H.J. Huh et al.
Maladaptive cognitive emotion regulation strategy subscales fully
mediated the relationship between childhood trauma and anxiety. On
the other hand, all maladaptive and adaptive cognitive emotion
regulation strategy subscales partially mediated the relationship be-
tween childhood trauma and depressive symptoms. There is a large
need to investigate the role emotion regulation plays in psychiatric
disorders, as it is still unclear whether specic emotion regulation
strategies play dierent roles in dierent psychopathologies. A previous
study suggested that use of maladaptive cognitive emotion regulation
strategies was a general feature of depression and anxiety disorders
(DAvanzato et al., 2013). In addition, depressed patients reported
using adaptive strategies such as reappraisal less frequently than
patients with anxiety disorders. Our ndings with respect to the
mediating role of maladaptive and adaptive emotion regulation strate-
gies are in line with these previous ndings. One possible explanation
for these ndings is that depressive symptoms may interfere with
cognitive functions (e.g. executive function) which could result in
diculty using adaptive cognitive emotion regulation strategies
(Santorelli and Ready, 2015). A recent study reported the ability to
inhibit negative emotional stimuli was related to cognitive strategies
such as reappraisal (Joormann and Gotlib, 2010). Impaired executive
function specically related to depressive symptoms, but not anxiety
may contribute to diculty in adaptively coping with negative emo-
tions (Quinn and Joormann, 2015).
Multiple mediation analyses investigating adaptive and maladap-
tive cognitive emotion regulation strategy meditation between the ve
types of childhood trauma and current depression/anxiety showed
mediation eects were limited to the relationship between childhood
emotional trauma and current depression/anxiety. While maladaptive
strategies mediated the association between childhood emotional abuse
and current depression/anxiety, the mediation eect of adaptive
strategies was limited to childhood emotional neglect. Our ndings t
with previous results suggesting childhood emotional trauma plays a
more important role than other types of childhood trauma (Kuo et al.,
2015; van Veen et al., 2013). Furthermore, these ndings are also
consistent with several previous studies which showed maladaptive
emotion regulation was associated with emotional abuse, whereas
deciency in adaptive emotion regulation was related to emotional
neglect (DAvanzato et al., 2013; Mills et al., 2015; Shipman et al.,
2005). From the theoretical perspective of social learning, emotionally
neglected individuals may have had decient opportunities to learn
adaptive emotion regulation strategies through caregiver modeling,
which makes them vulnerable to depression/anxiety as adults (Morris
et al., 2007). On the other hand, emotional abuse during childhood
may contribute to the development of maladaptive emotion regulation
strategies through repetitive attempts to cope with an abusive environ-
ment (Mills et al., 2015).
Although this study focused on depression and anxiety symptoms,
many previous researchers reported that other psychiatric disorders
such as schizophrenia, borderline personality disorder and eating
disorders were related to childhood trauma (Fernando et al., 2014;
Isvoranu et al., 2016; Mandavia et al., 2016). Therefore, the ability to
regulate emotions may also mediate the relationship between child-
hood trauma and other psychiatric disorders.
5. Limitation
This study has several limitations. First, this was a cross-sectional
study which assessed measurements concurrently. To establish causal
relationships, future longitudinal studies following children experien-
cing early life trauma are necessary. Especially, prospective studies
which serially assess changes in emotion regulation ability and mental
health outcomes would be informative. Second, we could not apply a
standardized instrument for evaluating and excluding comorbid per-
sonality disorders. It might be possible that subjective impression of
investigators inuenced the exclusion process of patients with comor-
49
Journal of Affective Disorders 213 (2017) 4450
bid personality disorders, constituting a limitation of the present study.
Third, all variables, including childhood trauma, were assessed with
self-reports. It is possible that many patients have distorted mental
representations of their emotion regulation ability and memories of
trauma due to their depression or anxiety symptoms. Furthermore,
reliability of the childhood trauma questionnaire subscore for physical
neglect was limited in the present study. Similar results about internal
consistency of physical neglect subscore were also shown in several
previous studies (Paivio and Cramer, 2004; Scher et al., 2004;
Spinhoven et al., 2014). Therefore, interpretation of the related result
should be cautious. Forth, other factors related to childhood trauma,
such as the timing or length of the traumas and relationships with the
perpetrators, were not evaluated. Such factors might also inuence
current symptom severity. Fifth, although the concept of emotion
regulation is broad, encompassing more automatic and behavioral
processes, the present study focused on cognitive emotion regulation
strategies, a limited part of emotion regulation. Other types of
maladaptive emotion regulations such as avoidance or repression
might have important roles in the relationship between childhood
trauma and later depression/anxiety.
6. Conclusions
Despite its limitations, this study provides clinically useful evidence
from a large clinical sample for the mediating role of cognitive emotion
regulation between childhood trauma and current depression/anxiety
symptoms. Specically, these ndings support a model in which the
relationship between overall childhood trauma and adult depressive
and anxiety symptoms in clinical populations is mediated by maladap-
tive cognitive emotion regulation strategies. This suggests that cogni-
tive emotion dysregulation may be an important factor for patients who
experienced childhood trauma and currently present with depression
and comorbid anxiety symptoms.
Author disclosure
Contributors
All authors designed the study. Hyu Jung Huh managed the
literature searches, wrote the rst draft of the manuscript under the
supervision of Jeong-Ho Chae. Kyung Hee Kim and Hee Kyung Lee
participated in the statistical analysis. All authors contributed to and
have approved the nal manuscript.
Role of funding sources
This research was supported by a grant from the Korea Research
Foundation (2014R1A2A1A11050691). The Korea Research
Foundation did not play further role in study design; in the collection,
analysis, and interpretation of data; in writing of the manuscript; or in
the decision to submit the paper for publication.
Acknowledgments
This research was supported by a grant from the Korea Research
Foundation (2014R1A2A1A11050691).
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