Emotional Regulation Through Mindfulness: Links to Health Behavior and the Role of Distressed (Type D) Personality

Abstract

Emotional (dys) regulation is central to many forms of psychopathology and psychosomatic diseases. Little is known about the factors underlying individual differences in emotion regulation. It is plausible that both genetic (including stable personality factors) and environmental/socio-cultural influences determine one’s emotion regulation. Type D (“distressed”) personality, the combination of negative affectivity and social inhibition, has been associated with adverse health outcomes. Type D individuals have the tendency to experience negative emotions across time and situations but inhibit the expression of emotions and behavior because of fear of rejection or disapproval, which has proved to be unhealthy in the long term. Mindfulness as a form of emotion regulation is, in many ways, distant to the framing of emotion regulation in conventional scientific literature. With the growing evidence that mindfulness training can help people moderate distressing emotions and enhance positive affect, there is a need to clarify the mechanisms through which these effects occur, as well as their impact on health behaviors. Recent research outcomes indicate that mindfulness stress reduction training may not only affect psychological states, but also psychological trait characteristics, which in turn are relevant for one’s health.Considering that health behaviors reflect a person's health beliefs, could mindful living actually be a continuous health promoter? This paper intends to offer an extended literature review on emotional regulation and mindfulness, focusing on the role of ‘distressed’ personality in a more general health promotion and behavioral change framework.

Full text

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Emotional Regulation Through Mindfulness: Links to Health
Behavior and the Role of Distressed (Type D) Personality
Regulação emocional através do Mindfulness: Ligações com
comportamentos de saúde e o papel da Personalidade (Tipo D)
Ricardo João Teixeira1,2, Artemisa Rocha Dores1, João Francisco Barreto1, Ivan Nyklíček3
1 School of Allied Health Sciences, Technical-Scientific Area of Human and Social Sciences, Institute Polytechnic of Porto, Portugal
2Clínica Médico-Psiquiátrica da Ordem, Porto, Portugal
3Center of Research on Psychology in Somatic Disease (CoRPS), Department of Medical and Clinical Psychology, Tilburg
University, The Netherlands
Corresponding author: Teixeira, R.J.; Psychology Department Coordinator at Clínica Médico-Psiquiátrica da Ordem, RuaGonçalo
Cristóvão, 347, 2º, sl. 202, 4000-270, Porto, Portugal; Tel: +351 223 321 527; Email address: ricardojft@gmail.com

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Abstract
Emotional (dys) regulation is central to many forms of psychopathology and psychosomatic diseases. Little is
known about the factors underlying individual differences in emotion regulation. It is plausible that both genetic
(including stable personality factors) and environmental/socio-cultural influences determine one’s emotion
regulation. Type D (“distressed”) personality, the combination of negative affectivity and social inhibition, has
been associated with adverse health outcomes. Type D individuals have the tendency to experience negative
emotions across time and situations but inhibit the expression of emotions and behavior because of fear of
rejection or disapproval, which has proved to be unhealthy in the long term. Mindfulness as a form of emotion
regulation is, in many ways, distant to the framing of emotion regulation in conventional scientific literature.
With the growing evidence that mindfulness training can help people moderate distressing emotions and
enhance positive affect, there is a need to clarify the mechanisms through which these effects occur, as well as
their impact on health behaviors. Recent research outcomes indicate that mindfulness stress reduction training
may not only affect psychological states, but also psychological trait characteristics, which in turn are relevant
for one’s health.Considering that health behaviors reflect a person's health beliefs, could mindful living actually
be a continuous health promoter? This paper intends to offer an extended literature review on emotional
regulation and mindfulness, focusing on the role of ‘distressed’ personality in a more general health promotion
and behavioral change framework.
Keywords: emotion regulation, mindfulness, health behavior, type D personality.
Resumo
A (des) regulação emocional é prevalente em muitas formas de psicopatologia e doenças psicossomáticas.
Pouco se sabe sobre os fatores subjacentes às diferenças individuais na regulação das emoções. É plausível que
tanto a genética (incluindo fatores estáveis da personalidade) como fatores ambientais/socioculturais,
determinem a própria regulação das emoções. A personalidade tipo D, correspondente à combinação de
afetividade negativa e inibição social, tem sido associada a resultados adversos para a saúde. Indivíduos tipo D
têm uma tendência para vivenciar emoções negativas ao longo do tempo e situações, mas inibindo a expressão
de emoções e comportamentos devido ao medo da rejeição ou desaprovação, o que se provou como sendo
prejudicial a longo prazo. O mindfulness como uma forma de regulação emocional é, em muitos aspectos,
distante do enquadramento da regulação emocional na literatura científica convencional. Com a crescente
evidência de que o treino em mindfulness pode ajudar pessoas a moderarem as emoções angustiantes assim
como a melhorarem o afeto positivo, existe uma necessidade de esclarecer os mecanismos pelos quais estes
efeitos ocorrem, bem como o seu impacto sobre os comportamentos de saúde. Resultados de investigações
recentes indicam que o treino de redução de stress baseado nomindfulness pode não só afetar estados
psicológicos, mas também características/traços psicológicos, que por sua vez são relevantes para a saúde.
Considerando que os comportamentos de saúde refletem as crenças de saúde de uma pessoa, será que viver em
plena consciência (de forma mindful) pode, na verdade, ser um promotor contínuo da saúde? Este trabalho
pretende oferecer uma extensa revisão da literatura sobre a regulação emocional e mindfulness, focando o papel
da personalidade tipo D num quadro de mudança comportamental e de promoção geral da saúde.
Palavras-Chave: regulação emocional, mindfulness, comportamentos de saúde, personalidade tipo D.

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Introduction
Emotions and Emotional (Dys)
Regulation
Contemporary emotion theories
highlight the importance of emotions in
reading behavioral, motor, and
physiological responses, in facilitating
decision making, in improving memory for
important events, and in negotiating
interpersonal interactions (Gross &
Thompson, 2007). In a functionalist
approach, they can be adaptive responses
to the problems and opportunities that
people face (Levenson, 1994). However,
emotions aren’t always helpful. They can
hurt us as well as help us (Parrott, 1993).
They are not adaptive when they are of the
wrong type, when they come at the wrong
time, or when they occur at the wrong
intensity level. At times such as these, it
may be useful to try to regulate our
emotions (Werner & Gross, 2010).
Emotion regulation refers to the
process of modulating one or more aspects
of an emotional experience or response
(Campos & Sternberg, 1981; Gross, 1998).
An adaptive emotion regulation is assumed
to be intrinsic to mental health and
adaptive functioning generally (Gross &
Munoz, 1995). The construct is assumed to
refer to both subjective experience and
emotion-related behavioral responses
(Feldman-Barrett & Gross, 2001; Mauss,
Evers, Wilhelm, & Gross, 2006), and
concomitant changes in physiological,
behavioral, and cognitive processes
(Bridges, Denham, & Ganiban, 2004). It
also refers to bottom-up (e.g. perceptual)
processes such as appraisal, and top-down
(e.g. cognitive) processes like working
memory and volitional control of
attention(Chiesa, Serretti, & Jakobsen,
2013). Emotion regulation also has an
interpersonal element, extending to
processes such as social interaction. For
instance, strategies appear transferable
between people, for instance between

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mother and child (Cole, Martin, & Dennis,
2004).
Within the scope of this paper, only
the concept of ‘emotion regulation’ was
considered, considering that under the
broader term of ‘affect regulation’ we can
also find other regulatory processes, such
as ‘mood regulation’ and ‘self-
regulation’(Jimenez, Niles, & Park, 2010).
Briefly, emotion regulation corresponds to
efforts to alter short-lived emotions as they
arise while mood regulation refers to
efforts to alter emotional experience of
longer duration and more diffused quality
(Gross, 1998). In turn, self-regulation
refers to efforts to reduce discrepancies
between one’s current state or self-schema
and a desired state by relying on feedback
to alter thoughts, feelings and behavior
(Baumeister & Heatherton, 1996; Carver
& Scheier, 1996).
In recent years, scholars in the
emerging field of emotion regulation have
taken up the issue of how emotions may be
altered or influenced. Typically, their
focus has been on individuals and on
interpersonal relations (Gross, 2007). This
approach is grounded in previous work on
psychological defenses (Freud, 1959),
stress and coping (Lazarus, 1966),
attachment (Bowlby, 1969), and self-
regulation (Mischel, Shoda, & Rodriguez,
1989). At the individual level, emotion
regulation refers to processes that are
engaged when individuals try to influence
the type or amount of emotion they (or
others) experience, when they (or others)
have them, and how they (or others)
experience and express these emotions
(Gross, 1998). Emotion regulation may be
automatic or controlled, conscious or
unconscious, and may have its effects at
one or more points in the emotion
generative process. Emotion regulation
may change the degree to which emotion
response components cohere as the
emotion unfolds, such as when large
changes in emotion experience and
physiological responding occur in the

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absence of facial behavior (Gross &
Thompson, 2007).
Generally, it is well established
that adaptive emotion regulation strategies
(e.g., acceptance, problem solving,
reappraisal) show weaker associations with
psychopathology than maladaptive
strategies (e.g., avoidance, self-criticism,
hiding expression, suppression of
experience, worry, rumination) (Aldao &
Nolen-Hoeksema, 2012). Numerous
psychological disorders, including
psychosomatic diseases, are associated
with affective instability and emotion
dysregulation (Koenigsberg et al., 2010;
Phillips, Drevets, Rauch, & Lane, 2003;
Subic-Wrana, 2011; Werner & Gross,
2010). For example, there is an emerging
consensus linking emotional dysregulation
especially with depression and anxiety
disorders (Aldao, Nolen-Hoeksema, &
Schweizer, 2010). Increasingly, many
other disorders are also being
conceptualized and investigated from an
emotion regulation perspective(Rottenberg
& Gross, 2007). Aldao and Nolen-
Hoeksema(2012) showed that a flexible
implementation of adaptive strategies,
such as acceptance and problem solving, in
line with contextual demands, is associated
with better mental health.Maladaptive
emotion regulation strategies (such as
avoidance)can promote greater distraction,
suppression of thoughts or emotions, or
social inhibition. It is also associated with
increased distress (Mennin, Holaway,
Fresco, Moore, & Heimberg, 2007; Moore,
Zoellner, & Mollenholt, 2008). As
mentioned, in general terms, maladaptive
emotion regulation may arouse a
psychological disorder, promoting
higherdepression and anxiety,an issue that
will be explored below.
Emotions and Type D Personality
Little is known about the factors
underlying individual differences in
emotion regulation. It is plausible that both
genetic (including stable personality

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factors) and environmental/socio-cultural
influences determine one’s emotion
regulation (Maas, Laan, & Vingerhoets,
2011). According to Denollet(2005),
maladaptive emotion regulation is present
in individuals with Type D personality.
This type of personality (also known as
‘distressed personality’), associated with
adverse health outcomes, describes
individuals who simultaneously experience
high levels of negative affectivity and
social inhibition (Denollet, 2005). They
also show an altered activation pattern in
brain areas important for emotion
perception (Kret, Sinke, & de Gelder,
2011).
Type D individuals are therefore
characterized byhaving atendency to
experience negative emotions across time
and situations, paired with the inhibition of
the expression of emotions and behavior
(in social interactions) because of fear of
rejection or disapproval. Although first
Type D has been deemed as simply
another measure of negative affect
(Lesperance & Frasure-Smith, 1996), it is
more than that as it also includes a way in
which people deal with this negative affect
(Denollet et al., 2006).This propensity has
proved to be unhealthy in the long term.
Strong evidence from a number of patient
groups (Aquarius, Denollet, Hamming, &
De Vries, 2005; Denollet, 2005; Schiffer et
al., 2005) indicates that Type D is
associated with increased psychological
distress, including symptoms of depression
and social alienation (Denollet, Sys, &
Brutsaert, 1995; Pedersen, Van Domburg,
Theuns, Jordaens, & Erdman, 2004), anger
(Denollet & Brutsaert, 1998), anxiety
(Pedersen, Van Domburg, et al., 2004),
vital exhaustion (Pedersen & Middel,
2001), poorer quality of life (Al-Ruzzeh et
al., 2005; Schiffer et al., 2005), and
adverse clinical outcomes, including an
elevated risk of rehospitalization,
reinfarction, and mortality in cardiac
patients (Denollet & Brutsaert, 1998;
Denollet et al., 1996; Denollet, Vaes, &

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Brutsaert, 2000; Pedersen, Lemos, et al.,
2004).
According to Messerli-Bürgyand
colleagues (2012), maladaptive emotion
regulation and Type D personality, share
similarities. The authors found a strong
association between the two constructs,
and showed that depressed mood and
stress perception predictedhaving Type D
personality independently. These data
support Denolletand colleagues (1995)
formulation of a generally higher stress
perception in Type D personality, specially
perceived distress in social interactions.
Literature supports that these individuals
tend to suppress the expression of
emotions in social interactions. This
suppression of threatening information and
a tendency to keep unpleasant experiences
out of one’s mind may come at a cost. This
might result in general emotional arousal,
higher irritability and physiological hyper-
reactivity to emotional stressors (Denollet,
1991). This may have adverse health
consequences, up to an elevated risk of
cardiac infarction and other cardiac events
(Denollet, Gidron, Vrints, & Conraads,
2010). These consequences resemble those
of maladaptive emotion regulation
(Messerli-Bürgy et al., 2012), because it
includes strategies to avoid, distort and
escape from reality, as well as to over-
control emotions. These processes are
deemed to be inefficient and maladaptive
coping strategies. Experimental research
has shown that overcontrol or suppression
of emotions in general results in increased
physiological stress responses (Gross &
Levenson, 1997; Levenson, 1994;
Richards & Gross, 2000).
Although Type D has mainly been
studied in cardiovascular patients,
evidence is now emerging that Type D is
also a vulnerability factor for decreased
physical and mental health, and poor self-
management in a wide variety of non-
cardiovascular patient populations (Mols
& Denollet, 2010a; Mols & Denollet,
2010b). Even though the Type D construct
has been criticized as not providing an

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obvious opportunity for treatment
strategies (Lesperance & Frasure-Smith,
1996) - due to the fact that personality is
generally considered to be stable across
time and situations – Type D is associated
with health-related behaviors, which may
provide a clear target for interventions, as
health behaviors are potentially modifiable
(Williams et al., 2008).
Emotions, Type D, and Health Behavior
The study of emotions and health
has undergone significant development in
the last decades. Research was initially
concerned with the influence of
physiological reactions to outside aversive
events (Selye, 1951), and subsequently
with the influence of experienced negative
emotions on the body’s ability to fight
infections (Cohen & Wills, 1985). More
recently, Leventhal and Patrick-Miller
(2000) have argued that emotions can be
indicators of health. Such relationships
usually assume a direct pathway between
health and emotions. However, it is also
plausible to envision indirect influences
between emotions and health; for example,
those in which emotions influence health
behaviors, which in turn might influence
health states. Traditional health behavior
theories, such as the health belief model or
the theory of planned behavior (Ajzen,
1985), have not been concerned with the
influence of emotional states on health
behavior. Such theories stand in contrast to
a self-regulation perspective, as elaborated
in the parallel-processing model
(Leventhal, 1970) or the cognitive-social
health information processing framework
(Miller, Shoda, & Hurley, 1996). In both
of these latter approaches, emotional states
are given equal weight to the cognitive
processing of a health threat. Still, the
specific roles of emotions in health
cognitions and health behavior have not as
yet been well described, compared to the
body of literature concerning the influence
of health-related beliefs and illness
representations on behavior (Lau &

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Hartman, 1983; Meyer, Leventhal, &
Gutmann, 1985). Within the scope of the
present paper, only the possible roles that
emotions may play in health behaviors will
be addressed.
There are severalstudies providing
evidence that emotionally distressed
individuals are more likely to engage in
maladaptive health behaviors, such as
smoking, not practicing exercise, or having
an unhealthy diet (Slaven-Lee, Padden,
Andrews, & Fitzpatrick, 2011).Thus, these
behaviors could represent one important
mediator of the relationship between
emotion, emotion regulation, Type D
(distressed) personality and ill
health(Williams et al., 2008). For example,
Pedersen and colleagues (2004) found a
relationship between Type D status and
smoking in their study with coronary heart
disease patients. Type D individuals were
more likely to smoke compared with non-
Type-D individuals (37% vs. 29%). In
addition, it is known that socially inhibited
individuals are less likely to engage in
health-promoting behavior(Kirkcaldy,
Shephard, & Siefen, 2002). Williamsand
colleagues (2008) examined the
associations between Type D and health-
related behaviors in a healthy sample, and
found that Type D individuals show poorer
health behaviors (e.g., eating a balanced
diet, practicing regular exercise, getting
regular medical checkups). Mommersteeg,
Kupper, and Denollet (2010) investigated
the associations between Type D, self-
reported metabolic syndrome, and health
behaviors (including smoking, alcohol use,
exercise and dietary habits) in a healthy
community sample. Broadly, the authors
found that Type D was associated with
metabolic syndrome and less healthy
behaviors. In a more specific study,
Borkoles, Polman, and Levy (2010)
examined the association between Type D
and exerciseprevalence among men. They
found that Type D individualswere more
sedentary and less active.With cardiac
patients, recent studies demonstrated that
Type Dindividuals were less likely to

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adhere to theirmedication (Williams,
O'Connor, Grubb, & O'Carroll, 2011a),
and that they possessed a less favorable
profile of illness beliefs (Williams,
O'Connor, Grubb, & O'Carroll, 2011b).
These latter results shed some light on why
Type D individuals engage in less health-
promoting behaviors.
Establishing a clearer relationship
between Type D personality and health
behavior is fundamental, since it could
explain a possible mechanism between
Type D and illnesses, but it also suggests
that Type D is a risk factor for poor health
in general (Gilmour & Williams, 2011;
Williams et al., 2008).Considering the
high prevalence of Type D personality in
the general population (about 20-25%)
(Denollet, 2005), and the associated health
risks (e.g., a significant predictor of death
in cardiac patients), it is highly important
to explore possibilities for psychological
interventions and behavior change.
Mindfulness as an Emotion Regulation
Strategy
The concept of mindfulness has
enticed various domains, such as basic
emotion research, clinical science, and
neurosciences (Goldin & Gross, 2010).
Mindfulness is commonly defined as a
kind of awareness that emerges through
paying attention on purpose, in the present
moment, and non-judgmentally to the
unfolding of experience moment to
moment (Kabat-Zinn, 2003). Bishop and
colleagues (2004) proposed a more
operational definition for researchers that
emphasizes the regulation of attention and
one’s orientation to experience. In a
parsimonious attempt, Feldman, Hayes,
Kumar, Greeson, and Laurenceau (2007)
report that common to these definitions are
four components: 1) the ability to regulate
attention, 2) an orientation to present or
immediate experience, 3) awareness of
experience, and 4) an attitude of
acceptance or nonjudgment towards
experience.

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Assuch, mindfulness is disputed
whether it is or is not a form of emotional
regulation, because mindfulness is, in
many ways, distant to the framing of
emotion regulation in conventional
scientific literature. In fact, the act of
watching one’s experience including
emotions with equanimity rather than
attempting to alter or control it is central to
mindfulness (Nyklíček, 2011; Shapiro,
Carlson, Astin, & Freedman, 2006).
Literature suggests that a fundamental
benefit of mindfulness training is that it
promotes the ability to disengage from
emotionally provocative material, freeing
individuals to refocus their attention on
other aspects of experience (Corcoran,
Farb, Anderson, & Segal, 2011).
Nevertheless, mindfulness is increasingly
being conceptualized in terms of its
regulatory capacity (Baer, 2003; Shapiro et
al., 2006), as mindfulness does decrease
negative emotions, such as feelings of
anxiety and depression (Fjorback, Arendt,
Ornbol, Fink, & Walach, 2011; Hofmann,
Sawyer, Witt, & Oh, 2010). In addition,
emotion regulation, along with
nonattachment and rumination, was found
to mediate the effects of mindfulness on
decreasing psychological distress (Coffey
& Hartman, 2008).
There are many apparent
connections between mindfulness and
emotion regulation. However, awareness
of and attention for emotions, as assessed
in emotion regulation scales,is often not
related with reduced clinical problems or
increased well-being, possibly because
emotional awareness associated with
critical judgment, lack of clarity, or
difficulties regulating is in fact detrimental
(Lischetzke & Eid, 2003). This suggests
that it may be the quality of emotional
awareness that is clinically relevant,
particularly the mindfulness-related
accepting/compassionate awareness
(Bishop et al., 2004). Hayes and Feldman
(2004) describe the ways that mindfulness
practice may enhance emotion regulation
abilities, by decreasing both

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overengagement (e.g., rumination and
entanglement) and underengagement (e.g.,
avoidance) with emotions and facilitating
healthy, adaptive engagement that
promotes clarity and functional use of
emotional responses. Correlational
research supports an association between
mindfulness and reduced emotion
regulation difficulties (Baer, Smith,
Hopkins, Krietemeyer, & Toney, 2006;
Hayes & Feldman, 2004). Thus, it is
conceivable that aspects of mindfulness
and emotion regulation difficulties account
for shared variance inpsychological
symptom severity (Roemer et al., 2009).
Recent studies indeed show a
significant relationship between self-
reported mindfulness and fewer difficulties
in emotion regulation strategies (Feldman
et al., 2007; Hill & Updegraff, 2012;
Roemer et al., 2009). Mindfulness
meditation practice has been shown to
facilitate attentional self-regulation and
emotional regulation (Kabat-Zinn, 1994).
Recognizing the benefits of mindfulness,
different intervention formats has emerged
(Shonin, Van Gordon, & Griffiths, 2013).
However, the most studied interventionis
the Mindfulness-Based Stress Reduction
(MBSR), a structured group program of
mindfulness training developed by Kabat-
Zinn (1990). There is also an increasing
interest in mindfulness-based practices in
the context of clinical interventions for
anxiety and depression disorders, as well
as other clinical problems (Allen,
Chambers, & Knight, 2006; Carmody,
2009).
Goldin and Gross (2010) suggested
that an emotion regulation framework
(Gross, 2007) may help clarify the
processes that underlie MBSR, which may
be distinct from those implicated in other
more traditional modalities such as
cognitive-behavioral therapy. Although the
MBSR does not include any explicit
instruction for changing the nature of
thinking, or emotional reactivity, it has
been shown to diminish the habitual
tendency to emotionally react to and

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ruminateabout transitory thoughts and
physical sensations (Ramel, Goldin,
Carmona, & McQuaid, 2004; Teasdale et
al., 2000), reducestress, depression, and
anxiety symptoms (Chiesa & Serretti,
2009; Evans et al., 2008; Segal, Williams,
& Teasdale, 2002)(seeFjorback et
al.(Fjorback et al., 2011) for a recent
systematic), modify distorted patterns of
self-view (Goldin, Ramel, & Gross, 2009),
and enhance behavioral self-regulation
(Lykins & Baer, 2009).
Chambers, Gullone, and Allen
(2009), in a review argue that MBSR may
reduce symptoms of stress, anxiety, and
depression by modifying emotion
regulation abilities. However, it is not yet
clear which specific abilities may be
enhanced by MBSR (Nyklíček, 2011).
This is because emotion regulation refers
to a variety of strategies that can be
implemented at different points during the
emotion-generative process to influence
which emotions arise, when and how long
they occur, and how these emotions are
experienced and expressed(Gross, 2007).
Considering Gross’s (1998) model of
emotion regulation, there are five families
of emotion regulation strategies, including
situation selection, situation modification,
attentional deployment, cognitive change,
and response modulation. There is
evidence that MBSR and long-term
mindfulness meditation practice may
especially directly influence attentional
deployment (Goldin et al., 2009; Jha,
Krompinger, & Baime, 2007; Ramel et al.,
2004; Slagter, Lutz, Greischar,
Nieuwenhuis, & Davidson, 2009).
Although Lutz, Slagter, Dunne, and
Davidson (2008) proposed that such
mindfulness training might improve the
capacity to disengage from aversive
emotional stimuli, thus enabling greater
emotional flexibility, the putative effects
of mindfulness on emotional reactivity and
attentional deployment require more
empirical research.

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Perspective on the Role of Mindfulness
on Health Behaviors in Type D
Individuals
With growing evidence that
mindfulness training can help people
moderate distressing emotions and
enhance positive affect, there is a need to
clarify the mechanisms through which
these effects occur, as well as their
potential impact on health behaviors
(Keng, Smoski, & Robins, 2011; Roberts
& Danoff-Burg, 2011; Salmoirago-
Blotcher, Hunsinger, Morgan, Fischer, &
Carmody, 2013). It is important to
understand the relations among
mindfulness, stress, and health, since it
could contribute to the development of
strategies to help preventing and treat
somehealth problems.
Some research explored potential
links between health-related behaviors
(e.g., cigarette smoking, binge eating, lack
of physical activity, risky sexual behavior)
and mindfulness (Roberts & Danoff-Burg,
2011). The capacity for emotion regulation
through mindfulnessmay be central to
making and sustaining behavioral change,
and programs that support this capacity
represent an opportunity to improve
behavioral outcomes (Williams & Thayer,
2009). As mentioned, mindfulness
programs, including the MBSR (Kabat-
Zinn, 1990), have been shown to enhance
emotion regulation (Chambers et al., 2009;
Goldin & Gross, 2010). Zvolensky,
Solomon, and McLeish (2006),
investigated the association ofmindfulness-
based attention with both emotional
complaints and perceived health status and
functioning in a community sample.
Results showed that greater levels of
mindfulness-based attention were
associated with lower depressive
symptoms and with perceptions of a better
physical and psychological functioning.
However, the possible direct effects of
mindfulness training on health-related
behaviors still receiveonly limited
attention. Some large survey-based studies
have shown that higher mindfulness is

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associated with increased physical activity,
better sleep quality (Andersen et al., 2013;
Carmody et al., 2011; Roberts & Danoff-
Burg, 2011; Salmoirago-Blotcher et al.,
2013), and healthier dietary habits
(Carmody et al., 2012; Gilbert & Waltz,
2010; Salmoirago-Blotcher et al., 2013).
In turn, some pilot studies of mindfulness
interventions for smoking cessation have
shown promising results on point
prevalence abstinence rate (Brewer et al.,
2011; Davis, Fleming, Bonus, & Baker,
2007), while mindfulness-based programs
exist for unhealthy eating habits, especially
as seen in eating disorders, such as binge
eating disorder (Butryn et al., 2013;
Kristeller & Hallett, 1999).
Because of the increased mortality
risk in major depression and Type D
cardiac patients and the limited influence
of cognitive behavioral therapy on this risk
(Berkman et al., 2003), further
investigations on the effect of emotion-
regulation-focused approaches in cardiac
patients with specific psychological
difficulties like Type D personality seem
warranted. So far, Type D personality was
not found to be influenced, but coping
strategies of Type Ds have been shown to
be modified (Martin et al., 2010).
However, mindfulness is believed to
produce fundamental changes in
dimensions such as self-awareness, self-
expression, and tolerance to negative
emotional experience, with an important
impact on a person’s appraisal and belief
systems (Feldman et al., 2007)and, more
generally, in cognitive-affective
integration. This may be associated with
changes in scores on personality tests
which are relevant to health. Recent
research outcomes indicate that MBSR
attenuates characteristics of Type D
personality, which was statistically
mediated by increased mindfulness
(Nyklicek, van Beugen, & Denollet, 2012).
The effects were found on both Type D
characteristics, namely negative affectivity
and social inhibition, and the effects were
maintained even when changes in state

EMOTIONAL REGULATION THROUGH MINDFULNESS 297
REVIEW
negative affect were controlled. The
mediating effect by mindfulness suggests
that mindfulness may indeed be the
mechanism by which the intervention
exerts its effects. Besides the general
mechanism of mindfulness and its putative
effects on emotion regulation, the decrease
in social inhibition is of additional interest
and importance. Participants in MBSR
groups are taught, in a non-judgmental
way, that it is perfectly alright to think,
feel, and behave the way they do, probably
decreasing feelings of discomfort when
expressing oneself in social situations. As
part of the Type D construct, social
inhibition has been shown to be associated
with a larger cancer incidence (Denollet,
1998) and an array of poorer
cardiovascular outcomes (Denollet et al.,
2000). Inhibition in general has been
linked to greater health symptomatology
(Consedine, Magai, Cohen, & Gillespie,
2002).
As previously referred, there is a
higher prevalence of health risks among
Type D individuals. Thus, it is imperative
to perform more studies on mindfulness-
based and other psychological
interventions for patients with this profile.
It is conceivable that when Type D
characteristics decrease, this may be
accompanied with enhanced emotion
regulation and subsequently also more
adaptive general health behaviors. To date,
this has not been investigated.
Conclusion
In this paper, associations were
discussed between emotion regulation,
mindfulness, and health-related behaviors.
In addition, the role of distressed
personality (Type D) in these associations
was reflected upon. It was shown that (i)
emotions and emotion regulation play an
important role in health, at least partially
viahealth-related behaviors, (ii) Type D
personality is associated with negative
emotions, poor emotion regulation
strategies, and poor health behaviors,
while (iii) mindfulness seems to decrease

EMOTIONAL REGULATION THROUGH MINDFULNESS 298
REVIEW
negative emotions, enhance positive
moodand adaptive emotion regulation.
Therefore, it is conceivable that
mindfulness may also have favorable
effects on health-related behavior.
As discussed, research on this topic
is still rather scarce. However, especially
correlational studies suggest that a positive
association between mindfulness and
healthy behaviors may exist and recently
the application of mindfulness-based
interventions to change unhealthy,
especially addictive, behaviors is
expanding rapidly. Well conducted
randomized controlled trials including a
sufficient number of participants are
needed to properly address the issue if
mindfulness is an effective method to
change health-related behaviors.
Finally, as discussed, mindfulness
has even been claimed to potentially even
change a person’s fundamental belief
system, and, hence, personality
characteristics. After the first randomized
controlled study on the effects of
mindfulness-based intervention on Type D
characteristics, which has showed
promising favorable results, future studies
are needed to replicate and expend these
more directly to health. Only a very
limited number of controlled trials has
examined the effects of mindfulness-based
interventions on physical health, showing
beneficial effects, such as blood pressure
reduction (Campbell, Labelle, Bacon,
Faris, & Carlson, 2012; Nyklíček,
Mommersteeg, Van Beugen, Ramakers, &
Van Boxtel, in press), and enhanced
immune function in HIV-infected men
(Creswell, Myers, Cole, & Irwin, 2009).
Several next steps may be
envisioned regarding future research in the
field of mindfulness, emotion regulation,
personality, and health-related behavior.
First, prospective cohort studies in people
at risk for health problems due to
unhealthy behaviors are recommended.
Obesity seems to be an example of a field
which may benefit from such studies,
especially as obesity-related health

EMOTIONAL REGULATION THROUGH MINDFULNESS 299
REVIEW
problems are rising dramatically and
unhealthy diet and low levels of physical
exercise are major cause of obesity. An
example of such a study may be a
prospective study following a cohort of
individuals at risk for obesity (e.g., based
on history of obesity in their family or
recent weight development), and
measuring repeatedly emotions, emotion
regulation styles, mindfulness, Type D
personality, eating and exercise habits, and
body mass index (or hip-to-waist-ratio).
Advances statistics such as mixed models
or structural equation modeling may be
used to unravel the development of
associations over time. Furthermore,
rigorous randomized controlled trials are
needed examining the effects of
mindfulness-based interventions on (Type
D) personality, health behaviors, and
physical health indices. Not only
intermediate physiological function, such
as glycemic control and blood pressure,
but eventually also medical outcomes,
such as the development of diabetes
mellitus or cardiovascular disease may be
examined. In such studies, change in
emotion regulation and health habits may
be examined as mediating mechanisms
potentially leading to better health.
If found to be effective, as may be
expected based on both theoretical
considerations and previous empirical
results, mindfulness may be an important
factor not only for mental, but also for
physical health.
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How to cite this Article: Teixeira, J. R., Dores, R. A., Barreto, F. J., & Nyklíček,, I. (2015). Emotional Regulation Through Mindfulness: Links to Health Behavior
and the Role of Distressed (Type D) Personality. International Journal of Psychology and Neuroscience, 1 (1), 282-316.
Received: 24/Oct/2014; Revised: 02/Dec/2014; Accepted: 01/Jun/2015; Published online: 17/Jun/2015 ISBN in atribuition