Impaired Emotional Clarity and Psychopathology: A Transdiagnostic Deficit with Symptom-Specific Pathways through Emotion Regulation

Abstract

Deficits in emotional clarity, or difficulties identifying which emotions one feels, are increasingly associated with multiple forms of psychopathology. We addressed two fundamental, unresolved issues regarding the transdiagnostic nature of this dysfunction. First, we examined the relationship of deficits in emotional clarity to seven symptom types, accounting for possible confounding effects of overlapping symptoms. We found that deficits in emotional clarity were associated with symptoms of depression, social anxiety, borderline personality, binge eating, and alcohol use, but not anxious arousal or restrictive eating. Second, we tested whether deficits in emotional clarity would relate to psychopathology by way of impaired emotion regulation. Notably, the relationship between deficits in emotional clarity and each symptom type was mediated by a distinct, disorderspecific pattern of emotion regulation deficits. Findings suggest that deficits in emotional clarity can be conceptualized as a transdiagnostic process with diverging mechanisms involving emotion regulation difficulties that vary from disorder to disorder. We discuss these findings within a contextual approach to delineating transdiagnostic processes.

Full text

Journal of Social and Clinical Psychology, Vol. 33, No. 4, 2014, pp. 319-342
319
© 2014 Guilford Publications, Inc.
The authors dedicate this paper to the memory of Susan Nolen-Hoeksema. The
authors would like to thank Katie Dixon-Gordon, John Dovidio, Kirsten Gilbert, Lori
Hilt, Brett Marroquin, Katie McLaughlin, Elizabeth Tepe, and Blair Wisco, for their
insightful comments on earlier versions of the manuscript.
Address correspondence to Vera Vine, M. S., M.Phil., Yale University, Department of
Psychology, P.O. Box 208205, New Haven, CT 06520; E-mail: vera.vine@yale.edu
IMPAIRED EMOTIONAL CLARITY
VINE AND ALDAO
IMPAIRED EMOTIONAL CLARITY
AND PSYCHOPATHOLOGY:
A TRANSDIAGNOSTIC DEFICIT WITH
SYMPTOM-SPECIFIC PATHWAYS
THROUGH EMOTION REGULATION
VERA VINE
Yale University
AMELIA ALDAO
Ohio State University
Decits in emotional clarity, or difculties identifying which emotions one feels,
are increasingly associated with multiple forms of psychopathology. We ad-
dressed two fundamental, unresolved issues regarding the transdiagnostic nature
of this dysfunction. First, we examined the relationship of decits in emotional
clarity to seven symptom types, accounting for possible confounding effects of
overlapping symptoms. We found that decits in emotional clarity were associ-
ated with symptoms of depression, social anxiety, borderline personality, binge
eating, and alcohol use, but not anxious arousal or restrictive eating. Second, we
tested whether decits in emotional clarity would relate to psychopathology by
way of impaired emotion regulation. Notably, the relationship between decits in
emotional clarity and each symptom type was mediated by a distinct, disorder-
specic pattern of emotion regulation decits. Findings suggest that decits in
emotional clarity can be conceptualized as a transdiagnostic process with diverg-
ing mechanisms involving emotion regulation difculties that vary from disorder
to disorder. We discuss these ndings within a contextual approach to delineating
transdiagnostic processes.

320 VINE AND ALDAO
In the last two decades, there has been a surge of interest in indi-
vidual differences in people’s ability to understand their emotions
(Gohm & Clore, 2002; Kashdan, Ferssizidis, Collins, & Muraven,
2010). This ability is often operationalized as emotional clarity, or
the subjective experience of knowing which emotions one feels
(Salovey, Mayer, Goldman, Turvey, & Palfai, 1995). Deficits in emo-
tional clarity appear to be present across various forms of psycho-
pathology (e.g., Harrison, Sullivan, Tchanturia, & Treasure, 2010;
Mennin, Holaway, Fresco, Moore, & Heimberg, 2007; Spokas, Lu-
terek, & Heimberg, 2009). It might therefore be useful to concep-
tualize this deficit a transdiagnostic factor, or a psychological pro-
cess present across multiple disorders (Harvey, Watkins, Mansell,
& Shafran, 2004; Kring & Sloan, 2009). Transdiagnostic models pro-
vide parsimonious explanations of comorbidity between disorders
(e.g., McLaughlin & Nolen-Hoeksema, 2011), which allows them
to inform psychosocial interventions targeting multiple presenting
problems simultaneously (Barlow et al., 2010). However, two fun-
damental questions concerning the transdiagnostic nature of defi-
cits in emotional clarity remain unresolved: (a) Are deficits in emo-
tional clarity truly implicated in each disorder, or are their effects
attributable to elevated comorbidity rates among various forms of
psychopathology? (b) What are the mechanisms by which deficits
in emotional clarity are associated with divergent forms of psy-
chopathology? Answering these questions will help us determine
whether deficits in emotional clarity are indeed transdiagnostic,
and whether they therefore represent a promising target for trans-
diagnostic interventions.
Approximately half of cases of a major mental disorder co-occur
with another disorder (Kessler, Chiu, Demler, & Walters, 2005). This
makes it possible that a given process might appear to be relevant
to a particular form of psychopathology, when in reality it is more
strongly associated with another, overlapping condition. For defi-
cits in emotional clarity to be genuinely transdiagnostic, their as-
sociations with multiple symptom types must remain significant
above and beyond the effects of overlapping conditions. To date,
most studies examining emotional clarity have considered one dis-
order at a time. For instance, separate studies have linked deficits
in emotional clarity to depression (e.g., Flynn & Rudolph, 2010),
anxiety disorders (e.g., Mennin et a., 2007), borderline personality
(e.g., Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006), eating dis-
orders (e.g., Gilboa-Schechtman, Avnon, Zubery, & Jeczmien, 2006),

IMPAIRED EMOTIONAL CLARITY 321
and alcohol abuse (e.g., Fox, Hong, & Sinha, 2008). The few studies
that did assess multiple symptom types reported the relationships
between symptoms and emotional clarity in a bivariate fashion,
without accounting for symptom overlap (e.g., Mennin, McLaugh-
lin, & Flanagan, 2009; Svaldi, Griepenstroh, Tuschen-Caffier, & Eh-
ring, 2012). For these reasons, it is not yet known whether deficits in
emotional clarity are truly transdiagnostic.
Nolen-Hoeksema and Watkins (2011) highlighted a second issue
facing transdiagnostic conceptualizations: the need to identify the
mechanisms linking a single underlying factor to dissimilar symp-
tom profiles. Aldao (2012) further emphasized the importance of
considering whether ostensibly transdiagnostic processes might
take different forms or serve different functions in the context of
different disorders. In other words, a transdiagnostic conceptual-
ization of deficits in emotional clarity must be able to explain the
mechanism by which this deficit could predict behavioral presenta-
tions as dissimilar as, for instance, an absence of pleasure, fear of
social interactions, excessive drinking, and under- or over-eating.
A plausible mechanism involves deficits in the ability to regu-
late emotions, or to modulate the valence, intensity, or duration of
emotions in the service of responding adaptively to the environ-
ment (Gross, 1998). Emotion regulation is increasingly viewed as a
transdiagnostic factor itself because of its implication in a variety
of mental disorders (Aldao, Nolen-Hoeksema, & Schweizer, 2010;
Kring & Sloan, 2009). Indeed, emotional clarity is so frequently
correlated with emotion regulation, that some theoretical models
view it as a subcomponent of emotion regulation (Gratz & Roemer,
2004; Mennin et al., 2007). Contemporary interventions for a wide
range of mental disorders conceptualize the ability to understand
emotions as a building block for adaptive emotion regulation and
consequently target deficits in this ability during early phases of
treatment, before addressing emotion regulation skills (Barlow
et al., 2010; Linehan, 1993; Mennin & Fresco, in press). Moreover,
emotion regulation has been shown to mediate the associations of
deficits in emotional clarity on depression symptoms (Flynn & Ru-
dolph, 2010), so it is possible that a similar process helps explain
symptoms of other disorders. Lastly, emotion regulation has been
conceptualized as consisting of a wide range of abilities (Gratz &
Roemer, 2004; Mennin et al., 2007), the form and function of which
vary from disorder to disorder (Aldao, 2012). The multifaceted na-
ture of emotion regulation means that this single construct could

322 VINE AND ALDAO
parsimoniously explain the diversity of clinical outcomes associ-
ated with deficits in emotional clarity, since different facets of emo-
tion regulation could mediate the effects of low emotional clarity on
different disorders.
In the present research, our first aim was to conduct a stringent
comparison of deficits in emotional clarity across multiple forms of
psychopathology by accounting for relationships among symptoms
in a sample of undergraduate students. We did this by regressing
emotional clarity scores on seven different symptom types (anhe-
donic depression, anxious arousal, social anxiety, borderline per-
sonality, binge eating, restrictive eating, and alcohol abuse), each
time controlling for the six other symptom types. Our second aim
was to test whether the relationships between deficits in emotional
clarity and psychopathology symptoms were statistically medi-
ated by specific facets of emotion regulation. We selected abilities
that have been delineated in Gratz and Roemer’s (2004) clinically-
focused model of emotion dysregulation: (a) allowing and accept-
ing emotional responses without trying to alter them; (b) accessing
and implementing effective emotion regulation strategies when dis-
tressed; (c) inhibiting context-inappropriate impulsive behavior in
the face of intense emotions; and (d) controlling attentional deploy-
ment in the service of goal-directed behavior (see also Derryberry &
Reed, 2002). We omitted the remaining facet from Gratz & Roemer’s
(2004) model, the tendency to attend to one’s emotions, because this
process theoretically precedes understanding emotions (Palmieri,
Boden, & Berenbaum, 2009), and so does not fit our framework as
a possible mechanism explaining downstream effects of emotional
clarity. We predicted that emotion regulation would mediate effects
of emotional clarity differentially in relation to different symptom
types. Given the scant literature on this topic, we developed no
specific hypotheses regarding the precise patterns of mediation by
emotion regulation facets.
METHOD
PARTICIPANTS
Participants were 211 undergraduate students (70.6% female) who
completed a survey for research credit online at a large Midwestern
university. The mean age of the sample was 18.7 (SD = 1.4, range 18

IMPAIRED EMOTIONAL CLARITY 323
to 32) and most of the participants (80.6%) self-identified as Cauca-
sian (4.7% identified as African American, 8.1% as Asian American,
3.3% as Hispanic/Latino, 0.5% as Native American, and 3.3% iden-
tified as other).
MEASURES
Emotional Clarity and Emotion Regulation. The Difficulties in Emo-
tion Regulation Scale (DERS; Gratz & Roemer, 2004) is a 36-item
measure assessing trait-level deficits in six domains related to cog-
nitive, behavioral, and emotional responses to negative emotional
arousal. Participants report how they react when they are upset and
rate their level of difficulty in each domain on a 5-point scale, with
higher numbers indicating greater difficulties. We used the Clarity
subscale to assess deficits emotional clarity. This subscale consists
of five items assessing difficulty achieving a sense of understand-
ing of one’s emotions when upset (e.g., I am confused about how
I feel). We used three other subscales to assess clinically relevant
aspects of emotion regulation. The Acceptance subscale consists of
six items assessing negative meta-reactions to one’s emotions (e.g.,
When I’m upset, I feel guilty for feeling that way). The Strategies
subscale consists of eight items capturing limited access to emotion
regulation strategies (e.g., When I’m upset, I believe there is nothing
I can do to make myself feel better). The Impulse subscale consists
of six items reflecting impulse control difficulties in the presence of
emotional arousal (e.g., When I’m upset, I have difficulty control-
ling my behaviors). Internal reliability in the present sample was
good to excellent (for Clarity α = .80, for Strategies α = .90, for Ac-
ceptance α = .91, and for Impulse α = .85).
To provide a more nuanced assessment of the ability to control at-
tentional deployment in goal-directed ways, also delineated in the
Gratz & Roemer (2004) model of emotion dysregulation, we used
the Attentional Control Scale (ACS; Derryberry & Reed, 2002). The
ACS consists of two subscales: attentional focusing, or the ability
to maintain attention on a goal-relevant task, e.g., “When I need to
concentrate and solve a problem, I have trouble focusing my atten-
tion” (reverse scored), and attentional shifting, the ability to dis-
engage attention from a goal-irrelevant stimulus or shift attention
flexibly among tasks, e.g., “When a distracting thought comes to
mind, it is easy for me to shift my attention away from it”. Higher

324 VINE AND ALDAO
scores reflect higher attentional control (Focusing α = .77; Shifting
α = .76).
Anxious Arousal and Anhedonic Depression Symptoms. The Mood
and Anxiety Symptoms Questionnaire Short Form (MASQ-SF; Wat-
son & Clark, 1991) is a 62-item measure assessing mood and anxi-
ety symptoms. The Anxious Arousal subscale (MASQ AA) consists
of 17 items that are specific to physiological symptoms of anxiety.
The Anhedonic Depression subscale (MASQ AD) contains 22 items
specific to aspects of depression that are not shared with anxiety
disorders. Items are rated on a 5-point scale with higher scores indi-
cating more symptoms. Per IRB guidelines, we did not include the
item assessing suicidal ideation. Internal reliability in the present
sample was good for MASQ AA (α = .88) and excellent for MASQ
AD (α = .94).
Social Anxiety Symptoms. To capture social anxiety symptoms
thoroughly, we standardized and averaged together scores from
two widely used measures. The Brief Fear of Negative Evaluation
(BFNE; Leary, 1983) is a 12-item self-report inventory that assesses
symptoms of social anxiety disorder, with an emphasis on anxiety
about evaluations by others. Some have suggested that the straight-
forward (i.e., nonreverse scored) items constitute a separate factor
with better convergent validity and excellent reliability (Rodebaugh
et al., 2004), so we used only the 8 straightforward items in the pres-
ent study (α = .93). The Social Interaction Anxiety Scale (SIAS; Mat-
tick & Clarke, 1998) is a 20-item measure assessing symptoms of
social anxiety disorder, with emphasis on anxiety experienced in
groups or dyads. As with the BFNE, recent work suggests that the
17 straightforward items have better convergent validity and excel-
lent internal reliability (α = .93; Rodebaugh, Woods, & Heimberg,
2007), so we used only the straightforward items (α = .95). The com-
posite social anxiety score had excellent internal reliability (α = .96).
Borderline Personality Symptoms. The McLean Screening Instru-
ment for Borderline Personality Disorder (MSI-BPD; Zanarini et
al., 2003) is a 10-item measure assessing symptoms of borderline
personality disorder. Items are rated in a yes/no format. The item
assessing for deliberate self-harm was not included per IRB require-

IMPAIRED EMOTIONAL CLARITY 325
ments. In this sample, internal reliability was good (Kuder Richard-
son 20 coefficient .78).
Eating Disorder Symptoms. We assessed two different presenta-
tions of disordered eating. The Binge Eating Scale (BES; Gormally,
Black, Daston, & Rardin, 1982) is a 16-item scale assessing behav-
ioral manifestations of binge eating and negative cognitive and
emotional reactions to a binge episode, which differentiates indi-
viduals with mild, moderate, and severe binge-eating tendencies.
Internal reliability in this sample was excellent (α = .90). The Eating
Disorders Attitude Test (EAT-26; Garner, Olmsted, Bohr, & Garfin-
kel, 1982) is a 26-item inventory that measures problematic eating
attitudes and behaviors, capturing symptoms of anorexia nervosa
and bulimia nervosa. Items are rated on a 6-point scale with higher
scores indicating more symptoms. Internal reliability in our sample
was good (α = .85).
Substance Use Symptoms. The Short Michigan Alcohol Screening
Test (SMAST; Selzer, Vinokur, & Rooijen, 1975) was developed as a
screening instrument to detect diagnosable alcohol dependence. It
consists of 13 yes/no questions about typical psychosocial difficul-
ties associated with excessive alcohol use. In nonclinical samples,
distributions are positively skewed (e.g., Selzer et al., 1975) and in-
ternal reliability is modest (e.g., .57, .62; Fleming & Barry, 1989). In
the present sample internal reliability, indicated by the Kuder Rich-
ardson 20 coefficient, was .63.
RESULTS
DESCRIPTIVE ANALYSES AND BIVARIATE CORRELATIONS
We transformed skewed scores (Table 1 contains raw values). Con-
sistent with prior research (e.g., Gratz & Roemer, 2004; Mennin et
al., 2007), deficits in emotional clarity were associated with deficits
in emotion regulation as well as with all seven symptoms of psy-
chopathology (ps < .05). Deficits in emotion regulation were also as-
sociated with symptoms, and symptom measures were moderately
correlated among themselves (ps < .05).

326 VINE AND ALDAO
TABLE 1. Zero-Order Correlations and Descriptives for Scales
M SD 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
1. DERS Clarity 11.83 4.04 -
2. DERS Acceptance 12.82 5.28 .60 -
3. DERS Strategies 16.80 6.77 .65 .72 -
4. DERS Impulse 11.51 4.55 .51 .62 .71 -
5. ACS Focusing 22.72 4.73 – .40 – .32 – .38 – .24 -
6. ACS Shifting 29.69 4.92 – .42 – .24 – .37 – .34 .60 -
7. MASQ-AA 27.64 8.96 .29 .31 .40 .38 – .13 – .14 -
8. MASQ-AD 50.72 15.64 .56 .45 .57 .47 –.30 – .44 .32 -
9. BFNE 37.25 10.13 .39 .48 .52 .31 – .37 – .27 .31 .38 -
10. SIAS 26.07 16.97 .50 .51 .61 .46 – .34 – .37 .43 .53 .58 -
11. MSI-BPD 2.32 2.34 .47 .44 .59 .46 – .31 – .22 .38 .51 .33 .42 -
12. BES 9.70 8.14 .52 .46 .52 .43 – .38 – .33 .36 .46 .47 .42 .47 -
13. EAT-26 8.69 8.67 .23 .42 .37 .28 – .25 – .04 .22 .18 .38 .32 .35 .47 -
14. SMAST 1.11 1.47 .21 .17 .19 .25 – .08 – .13 .16 .12 .10 .18 .11 .10 – .00
Note. DERS = Difculties in Emotion Regulation Scale; MASQ-AA = Anxious Arousal, Mood and Anxiety Symptom Questionnaire; MASQ-AD = Anhedonic Depression,
Mood and Anxiety Symptom Questionnaire; Composite SAD = composite of Brief Fear of Negative Evaluation Scale and Social Interaction Anxiety Scale; MSI-BPD =
McLean Screening Instrument for Borderline Personality Disorder; BES = Binge Eating Scale; EAT-26 = Eating Attitudes Test; SMAST = Short Michigan Alcohol Screening
Test. Coefcients greater than .13 signicant at p < .05; coefcients greater than .17 signicant at p < .01; coefcients greater than .22 signicant at p < .001

IMPAIRED EMOTIONAL CLARITY 327
IS EMOTIONAL CLARITY RELATED TO SYMPTOM TYPES
WHEN ACCOUNTING FOR SYMPTOM OVERLAP?
We examined the effects of deficits in emotional clarity on psycho-
pathology symptom scores, with and without controlling for over-
lapping symptom scores, using a series of hierarchical regression
analyses. We constructed seven models, each predicting one of the
types of psychopathology symptoms: anxious arousal (MASQ-AA),
anhedonic depression (MASQ-AD), composite social anxiety (SIAS,
BFNE), borderline personality (MSI-BPD), binge eating (BES), re-
strictive eating (EAT-26), and alcohol abuse (SMAST). Deficits in
emotional clarity (DERS Clarity) were entered as a predictor in the
first step of each model. In order to determine whether emotional
clarity was associated with each symptom type independently of
the relationships among symptoms, all symptom scores except for
the dependent variable were added as covariates in the second step
of the model.
Anxious Arousal (MASQ AA). In the first step, deficits in emotional
clarity significantly predicted symptoms of anxious arousal, β = .29,
t = 4.43, p < .001, and accounted for 8.1% of their variance, F(1,209)
= 19.63, p < .001. As Table 2 shows, with symptom covariates includ-
ed, the effect of difficulties in emotional clarity on anxious arousal
was no longer significant, β = -.04, t = -.54, p = .587.
Anhedonic Depression (MASQ AD). In the first step, deficits in
emotional clarity significantly predicted symptoms of anhedonic
depression, β = .56, t = 9.84, p < .001, and accounted for 31.3% of
their variance, F(1,209) = 96.73, p < .001. With symptom covariates
included, the effect of deficits in emotional clarity on anhedonic de-
pression remained significant, β = .31, t = 4.55, p < .001.
Composite Social Anxiety (BFNE, SIAS). In the first step, deficits
in emotional clarity significantly predicted social anxiety, β = .49,
t = 8.03, p < .001, and accounted for 23.6% of its variance, F(1,209)
= 64.45, p < .001. With symptom covariates included, the effect of
deficits in emotional clarity on composite social anxiety scores re-
mained significant, β = .16, t = 2.31, p < .023.
Borderline Personality (MSI-BPD). In the first step, deficits in emo-
tional clarity significantly borderline personality symptoms, β = .47,
t = 7.71, p < .001, and accounted for 21.8% of their variance, F(1,209)
= 59.51, p < .001. With symptom covariates included, the effect of

328 VINE AND ALDAO
deficits in emotional clarity on borderline symptoms remained sig-
nificant, β = .15, t = 2.11, p < .037.
Binge Eating (BES). In the first step, deficits in emotional clarity
significantly predicted binge eating symptoms, β = .52, t = 8.88, p
< .001, and accounted for 27.1% of their variance, F(1,209) = 78.87,
p < .001. With symptom covariates included, the effect of deficits in
emotional clarity on binge eating remained significant, β = .15, t =
2.11, p < .037.
Restrictive Eating (EAT-26). In the first step, deficits in emotional
clarity significantly predicted restrictive eating symptoms, β = .25, t
= 3.68, p < .001, and accounted for 5.7% of their variance, F(1,208) =
TABLE 2. Hierarchical Regression Analyses Predicting Psychopathology Symptom Scores
Using Difculties in Emotional Clarity and Overlapping Symptoms
Outcome Variable Step Predictor Entered β t p
MASQ AA 1 DERS Clarity .294 4.431 .000
2 DERS Clarity – .044 – .543 .588
MASQ AD .039 .496 .621
Composite SAD .318 4.020 .000
MSI-BPD .188 2.474 .014
BES .126 1.533 .127
EAT-26 – .033 – .460 .646
SMAST .071 1.131 .260
MASQ AD 1 DERS Clarity .564 9.838 .000
2 DERS Clarity .308 4.546 .000
MASQ AA .029 .481 .631
Composite SAD .201 2.875 .004
MSI-BPD .258 3.958 .000
BES .133 1.867 .063
EAT-26 – .143 – 2.297 .023
SMAST – .034 – .626 .532
Composite SAD 1 DERS Clarity .488 8.072 .000
2 DERS Clarity .160 2.311 .022
MASQ AA .234 4.038 .000
MASQ AD .195 2.875 .004
MSI-BPD .026 .397 .692
BES .128 1.815 .071
EAT-26 .215 3.571 .000
SMAST .080 1.495 .137

IMPAIRED EMOTIONAL CLARITY 329
TABLE 2. (continued)
MSI-BPD 1 DERS Clarity .472 7.711 .000
2 DERS Clarity .154 2.106 .036
MASQ AA .153 2.433 .016
MASQ AD .279 3.958 .000
Composite SAD .029 .397 .692
BES .113 1.514 .132
EAT-26 .167 2.585 .010
SMAST .004 .073 .942
BES 1 DERS Clarity .542 8.871 .000
2 DERS Clarity .250 3.715 .000
MASQ AA .091 1.531 .127
MASQ AD .127 1.867 .063
Composite SAD .126 1.815 .071
MSI-BPD .100 1.514 .132
EAT-26 .285 4.880 .000
SMAST – .016 – .309 .758
EAT-26 1 DERS Clarity .247 3.682 .000
2 DERS Clarity – .045 –.574 .567
MASQ AA –.032 – .467 .641
MASQ AD – .178 – .297 .023
Composite SAD .276 3.571 .000
MSI-BPD .192 2.585 .010
BES .370 4.880 .000
SMAST – .077 – 1.280 .202
SMAST 1 DERS Clarity .215 3.173 .002
2 DERS Clarity .192 2.114 .036
MASQ AA .088 1.115 .266
MASQ AD – .057 – .626 .532
Composite SAD .137 1.495 .137
MSI-BPD .006 .073 .942
BES – .029 – .309 .758
EAT-26 – .104 – .280 .202
Note. DERS Clarity = Clarity subscale, Difculties in Emotion Regulation Scale; MASQ-AA = Anxious
Arousal, Mood and Anxiety Symptom Questionnaire; MASQ-AD = Anhedonic Depression, Mood and
Anxiety Symptom Questionnaire; Composite SAD = composite of Brief Fear of Negative Evaluation
Scale and Social Interaction Anxiety Scale; MSI-BPD = McLean Screening Instrument for Borderline
Personality Disorder; BES = Binge Eating Scale; EAT-26 = Eating Attitudes Test; SMAST = Short Michigan
Alcohol Screening Test.

330 VINE AND ALDAO
13.56, p < .001. With symptom covariates included, the effect of defi-
cits in emotional clarity on restrictive eating scores was no longer
significant, β = -.05, t = .57, p = .566.
Problematic Alcohol Use (SMAST). In the first step, deficits in emo-
tional clarity significantly predicted problematic alcohol use, β =
.21, t = 3.12, p < .003, and accounted for 4.0% of its variance, F(1,209)
= 9.75, p < .003. With symptom covariates included, the effect of
deficits in emotional clarity on problematic alcohol use remained
significant, β = .19, t = 2.11, p < .037.
DOES EMOTION REGULATION MEDIATE THE RELATIONSHIP
BETWEEN EMOTIONAL CLARITY AND SYMPTOMS, AND ARE
MEDIATORS SYMPTOM-SPECIFIC?
In order to test for mediation by emotion regulation variables, we
used bootstrapping (Preacher & Hayes, 2008), which can estimate
the magnitudes of multiple indirect effects simultaneously based on
repeated samples drawn from the available data. We ran five medi-
ation models, one for each form of psychopathology uniquely pre-
dicted by deficits in emotional clarity in the regressions above (i.e.,
omitting anxious arousal and restrictive eating). In each model, we
used 2,000 bootstrap samples and tested as possible mediators at-
tentional focusing (ACS Focusing), attentional shifting (ACS Shift-
ing), non-acceptance of emotions (DERS Non-Acceptance), access
to effective strategies (DERS Strategies), and impulsive behavior
(DERS Impulse). We interpreted mediators as significant if the point
estimate of the indirect path was significantly different from zero, or
in other words, if the bias corrected and accelerated (Bca) 95% con-
fidence interval (CI) did not contain zero (Preacher & Hayes, 2008).
We interpreted total indirect effects (i.e., significant mediation by all
possible mediators as a set) as evidence of mediation by emotion
regulation in general across disorders. We examined specific indi-
rect effects (i.e., mediation by a single mediator, while accounting
for all the others) in order to compare divergent patterns in possible
emotion regulatory mechanisms across disorders. When multiple
mediators emerged as significant, we compared the magnitudes of
the indirect effects using the procedure outlined by Preacher and
Hayes (2008). To isolate the mediators operating for unique symp-
tom presentations, we controlled for overlapping symptoms in each

IMPAIRED EMOTIONAL CLARITY 331
model, selecting covariates based on whether they significantly
predicted the symptom in question in the regression model above
(Table 2). The five multiple mediation models appear in Figure 1.
Anhedonic Depression (MASQ AD). The multiple mediation model
accounted for 46.11% of variance in anhedonic depression symp-
toms, F(9, 200) = 20.87, p < .001. The total indirect effect through all
proposed mediators was significant, b = .0039, SE = .0015, [.0009,
.0068]. Examination of specific indirect effects revealed a significant
path through ACS Shifting, b = .0031, SE = .0011, [.0012, .0055], such
that participants reporting difficulties in emotional clarity reported
lower ability to shift attention, which in turn was associated with
more severe depression. All other indirect paths were not signifi-
cant.
Composite Social Anxiety (BFNE, SIAS). The multiple mediation
model accounted for 50.81% of variance in social anxiety, F(9,200) =
24.98, p < .001. The total indirect effect through all proposed media-
tors was significant, b = .0484, SE = .0114; [.0295, .0750]. The specific
indirect path through DERS Acceptance was significant, b = .0196,
SE = .0079, [.0077, .0403], such that participants with deficits in emo-
tional clarity tended to report difficulties accepting their emotions,
which in turn were associated with higher levels of social anxiety.
The indirect path through DERS Strategies was also significant, b =
.0259, SE = .0098, [.0086, .0472], such that participants with deficits
in emotional clarity reported difficulties gaining access to emotion
regulation strategies, which in turn were associated with higher lev-
els of social anxiety. The magnitudes of the indirect paths through
DERS Acceptance and DERS Strategies did not differ significantly
from each other, b = -.0063, SE = .0140, [-.0344, .0232]. All other indi-
rect paths were not significant.
Borderline Personality (MSI-BPD). The multiple mediation model
accounted for 42.49% of variance in borderline symptoms, F(9,200)
= 18.16, p < .001. The total indirect effect through all proposed medi-
ators was significant, b = .0082, SE = .0039, [.0006, .0161]. The specif-
ic indirect path through ACS Shifting was significant, b = -.0033, SE
= .0019, [-.0080, -.0005], such that participants with deficits in emo-
tional clarity tended to report lower ability to shift attention, which
in turn was associated with higher levels of borderline symptoms.
The indirect path through DERS Strategies was also significant, b
= .0103, SE = .0034, [.0049, .0181], such that participants reporting

332 VINE AND ALDAO
FIGURE 1. Parts A, B, C. Multiple mediation models predicting each
symptom type and controlling for overlapping symptoms suggested
by regression models. Unstandardized path coefficients and SEs are
shown beside each line. Significant indirect paths are boldfaced. †p <
.10; *p < .05; **p < .01; ***p < .001.

IMPAIRED EMOTIONAL CLARITY 333
FIGURE 1. Parts D, E. Multiple mediation models predicting each
symptom type and controlling for overlapping symptoms suggested
by regression models. Unstandardized path coefficients and SEs are
shown beside each line. Significant indirect paths are boldfaced.
†p < .10; *p < .05; **p < .01; ***p < .001.
deficits in emotional clarity tended to report difficulties gaining ac-
cess to emotion regulation strategies, which in turn were associated
with higher borderline symptoms. The magnitude of the indirect
path through DERS Strategies was significantly larger than that of
the path through ACS Shifting, b = .0136, SE = .0038, [.0066, .0220].
All other indirect paths were not significant.
Binge Eating (BES). The multiple mediation model accounted for
42.45% of variance in binge eating, F(7,202) = 23.02, p < .0001. The
total indirect effect through all proposed mediators was significant,
b = .0499, SE = .0178, [.0176, .0891]. No specific indirect paths were
significant.

334 VINE AND ALDAO
Problematic Alcohol Use (SMAST). The multiple mediation model
for the effect of deficits in emotional clarity accounted for 4.72% of
variance in problematic alcohol use, F(6, 204) = 2.74, p < .015. The
total indirect effect through all proposed mediators was not signifi-
cant, b = .0065, SE =.0057, [-.0046, .0176]. However, there was one
significant specific indirect path through DERS Impulse, b = .0090,
SE = .0046, [.0013, .0190], such that participants reporting deficits in
emotional clarity tended to report difficulty regulating impulsive
behavior, which in turn was associated with higher problematic al-
cohol use.1
DISCUSSION
Current transdiagnostic psychosocial interventions are based on
the premise that understanding emotions can facilitate their regula-
tion (Barlow et al., 2010; Linehan, 1993; Mennin & Fresco, in press),
a premise that, while compelling, has remained underexplored em-
pirically. The findings from the present study represent a first step
towards a transdiagnostic research program on deficits in emotional
clarity, which would expand the empirical basis of transdiagnostic
interventions and support further refinement of therapeutic tech-
niques targeting emotional clarity. Specifically, we addressed two
outstanding issues regarding the transdiagnostic nature of deficits
in emotional clarity: the problem of substantial symptom overlap,
and the challenge of simultaneously explaining common and dis-
tinct mechanisms linking a transdiagnostic factor to different forms
of psychopathology. The issue of symptom overlap was evident in
our bivariate correlations among symptoms (most rs .22 to .53; ps
< .05). When we controlled for overlapping symptoms in our mul-
tiple regression analyses, we found that deficits in emotional clarity
were independently related to five out of the seven symptom types:
anhedonic depression, social anxiety, borderline personality, binge
eating, and alcohol use. These findings pave the way for future in-
vestigations of the importance of understanding one’s emotions to
clinical phenomena because they suggest that deficits in emotional
1. To rule out a competing hypothesis, we ran a series of reverse mediations testing
whether emotional clarity mediated the effects of emotion regulation strategies on
symptoms. Only reverse mediations involving ACS Shifting were significant; reverse
mediations involving DERS Strategies, DERS Acceptance, and DERS Impulse were not
significant.

IMPAIRED EMOTIONAL CLARITY 335
clarity may have genuine transdiagnostic relevance to at least these
five symptom types. Regarding the second issue, we found that dif-
ficulties with emotion regulation mediate the relationship between
deficits in emotional clarity and multiple symptom profiles, but
that distinct facets of emotion regulation mediated these effects in
disorder-specific ways.
We did not find deficits in emotional clarity to be independent-
ly associated with either anxious arousal or restrictive eating. Of
course, because we estimated these relationships in a nonclinical
sample, it is possible that restriction of variance in the symptom
measures might have limited our ability to find significant asso-
ciations. Alternatively, deficits in emotional clarity may indeed be
less fundamental to anxious arousal and/or restrictive eating than
to other forms of psychopathology. Arguably, the emotional land-
scape of pure anxious arousal is relatively straightforward, domi-
nated largely by fear, leaving less room for individual differences
in emotional clarity to have an effect. Body dissatisfaction has been
associated with high, not low, emotional clarity, but only among
individuals who also tend to experience high negative affect and
attend to emotions (Manjrekar & Berenbaum, 2012). Thus, it is pos-
sible that the role of understanding emotions in relation to restric-
tive eating symptoms is more complex and subject to moderating
effects of other affective processes. It will be important for future
transdiagnostic investigations of emotional clarity to utilize large
clinical samples that will allow for a more sophisticated modeling
of relationships among symptoms.
Our mediation analyses shed light on the crucial next question
of how or why deficits in emotional clarity might matter for de-
pression, social anxiety, borderline personality, binge eating, and
substance use. As Figure 1 shows, deficits in emotional clarity were
associated with deficits in all of the emotion regulation abilities we
measured (i.e., all a paths were significant), and emotion regulation
significantly mediated the effects of deficits in emotional clarity
on symptoms of depression, social anxiety, borderline personality,
binge eating disorder, and alcohol use. Although our method pre-
cludes causal interpretations, these findings are consistent with a
small but burgeoning literature suggesting that the ability to un-
derstand one’s emotions may constitute a building block for the
adaptive regulation of affective states (Barrett, Gross, Christensen,
& Benvenuto, 2001; Gratz & Roemer, 2004; Mennin et al., 2007). Fur-
ther work, especially experimental work that could shed light on

336 VINE AND ALDAO
causality, is needed to determine more precisely how understand-
ing an emotion might help regulate emotion. One possibility is that
identifying one’s feelings clearly might provide information about
possible courses of action (Barrett et al., 2001; Baumeister, Vohs, De-
Wall, & Zhang, 2007), which may explain the relationship we ob-
served between emotional clarity and access to emotion regulation
strategies. It has been speculated that confusion about one’s feelings
might be taxing on self-regulatory and other cognitive resources
(Lischetzke & Eid, 2003; Salovey et al., 1995), which might explain
the relationship to impulsivity and attentional control. Finally, it has
been suggested that clearly identified emotions might feel less aver-
sive than unclear emotions (Vine, Aldao, & Nolen-Hoeksema, un-
der review), which might explain associations between emotional
clarity and ability to accept emotions.
As predicted, the specific patterns of mediation by facets of emo-
tion regulation varied across disorders. This effect appeared to be
driven by specificity in the relationships between emotion regula-
tion facets and symptom types. Whereas people reporting deficits
in emotional clarity also reported difficulties in all the emotion
regulation domains, only some of these regulatory difficulties were
associated with each form of psychopathology (i.e., not all b paths
were significant in each model; see Figure 1). This specificity of our
mediation findings shows how a single process, such as emotional
clarity, may be implicated simultaneously in multiple disorders, yet
relate to each disorder through different mechanisms (see Nolen-
Hoeksema & Watkins, 2011). It also supports the notion that a single
process, such as emotion regulation, can be transdiagnostic or dis-
order-specific depending on the level at which it is operationalized
and conceptualized (see Aldao, 2012).
Our specific mediation findings are in line with prior research
on affective dysfunction in each disorder. In the case of depres-
sion symptoms, we found that the effects of deficits in emotional
clarity were mediated by difficulties shifting attention away from
goal-irrelevant stimuli. This is consistent with work showing that
depressed individuals have difficulties disengaging attention from
negative material (see Joormann, 2010) and tend to perseverate on
negative thoughts (i.e., to ruminate; Nolen-Hoeksema, Wisco, &
Lyubomirsky, 2008). For social anxiety, the effects of deficits in emo-
tional clarity were mediated by acceptance of emotions and access
to emotion regulation strategies. The DERS operationalizes access
to strategies as the “belief that there is little that can be done to re-

IMPAIRED EMOTIONAL CLARITY 337
regulate emotions effectively, once an individual is upset” (Gratz &
Roemer, 2004, p. 47), or in other words, a helpless or passive stance
toward regulating emotions. Thus, our results for social anxiety are
consistent with meta-cognitive accounts of social anxiety as involv-
ing beliefs that emotions are wrong and uncontrollable (Spokas et
al., 2009; Tamir, John, Srivastava, & Gross, 2007). Our mediation
finding suggests that difficulties understanding emotions might
undergird such maladaptive beliefs in social anxiety.
Borderline personality disorder is frequently viewed as a quintes-
sential disorder of emotion dysregulation (Gratz et al., 2006; Line-
han, 1993). Our mediation results highlight the potential impor-
tance of two particular facets of emotion regulation: access to emo-
tion regulation strategies, and to a lesser degree, attention shifting
ability. The role of the DERS strategies subscale is consistent with
clinical observations suggesting that individuals with borderline
personality tend to view emotions as overwhelming and impos-
sible to regulate (Linehan, 1993). The mediation by deficits in at-
tentional shifting is consistent with research showing that people
with borderline personality tend to ruminate on negative, often
anger-provoking topics (Selby, Anestis, Bender, & Joiner, 2009). Our
mediation models suggest that deficits in emotional clarity might
underpin these regulatory dysfunctions and associated borderline
symptomatology.
Effects of emotional clarity on alcohol use symptoms were me-
diated by difficulty inhibiting impulsive behavior. Impulsivity is
a well-documented factor in substance use (e.g., Fox et al., 2008).
Our results suggest a conceptualization of this well-known deficit
as stemming in part from difficulties understanding emotions. This
finding is consistent with work by Kashdan and colleagues (2010)
showing that the tendency not to differentiate among discrete emo-
tion words predicted rates of binge drinking. Effects on binge eating
symptoms, while mediated by emotion regulation facets as a whole,
did not have specific indirect effects through any one facet, which
may reflect the heterogeneous functions of binge eating behavior
(Stice, Ziemba, Margolis, & Flick, 1996).
The present study had some limitations as well as strengths. Data
were obtained from a sample of unselected undergraduate students,
rather than a clinical population. This might explain the weak in-
ternal consistency of our measure of problematic alcohol use (see
Fleming & Barry, 1989), and may also have restricted the range
of the symptom measures. Replication in a clinical sample would

338 VINE AND ALDAO
confirm the relative importance of deficits in emotional clarity to
various disorders. Furthermore, findings were cross-sectional, so it
is not possible to draw causal interpretations of the relationships
observed. To partially address this limitation, we tested reverse me-
diations, in which we modeled emotion regulation abilities as inde-
pendent variables and deficits in emotional clarity as the mediator.
The fact that the majority of reverse mediations were nonsignificant
is consistent with the literature we reviewed suggesting that un-
derstanding emotions may facilitate regulating them (e.g., Barlow
et al., 2010; Linehan, 1993). The only reverse mediations that were
significant involved the ability to shift attention, which was linked
to anhedonic depression and borderline symptoms by way of defi-
cits in emotional clarity. More work is needed to determine whether
the relationship between emotion regulations strategies involving
inflexibility of attentional deployment may be related to deficits in
emotional clarity reciprocally.
Clinically, our findings support the practice of teaching patients
to identify their emotions as a stepping-stone toward effective emo-
tion regulation (e.g., Barlow et al., 2010; Linehan, 1993), and suggest
that this practice may be useful in treating a wide variety of distinct
clinical presentations. At the same time, the disorder-specificity
of our mediation findings suggests the conceptualization of these
deficits may vary across disorders. Individuals abusing alcohol, for
instance, might lack a sense of emotional clarity that could reduce
impulsive behavior, whereas individuals suffering from anhedonia
might be described as lacking emotional clarity that could help shift
attention away from distress. Thus, interventions may need to tai-
lor how they teach patients to move from recognizing to regulating
emotions, depending on the presenting problem.
In conclusion, in the present study we examined deficits in emo-
tional clarity from a transdiagnostic perspective, comparing its rele-
vance across multiple forms of psychopathology and revealing both
common and symptom-specific emotion regulatory mechanisms.
This investigation highlights multiple issues in transdiagnostic re-
search, such as the importance of accounting for overlapping symp-
tomatology, and the need to identify both common and distinct
mechanisms linking a single process to divergent clinical presenta-
tions. Our results suggest that deficits in emotional clarity may be
independently implicated in anhedonic depression, social anxiety,
borderline personality, binge eating, and problematic alcohol use,

IMPAIRED EMOTIONAL CLARITY 339
and yet relate to each disorder through different emotion regulation
mechanisms. Ultimately, this study lays the groundwork for future
research on the role of emotional clarity in emotion regulation and
psychopathology, which appears to be a transdiagnostic factor with
symptom-specific mechanisms.
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