Relationship between anger, emotion regulation, interpersonal problems and depression in individuals with depressive symptoms in Saudi Arabia
Alrwailan, Khaled Ali
BACKGROUND: Depression is a mental health disorder (World Health Organization, 2013) with a chronic, recurrent course among adults (Fava, 2003). According to empirical studies and clinical observations, there are four key areas of depression in terms of symptoms, which are emotional, somatic, cognitive and interpersonal (Cheung & Power, 2012). Emotional symptoms, such as anger, are more dominant in individuals with depression (Blatt, 2004; cf. Cheung & Power, 2012). Previous literature (e.g., Besharat et al., 2013) has found a strong relationship between anger and depression in individuals suffering from depression. Moreover, individuals with symptoms of depression have been found to have interpersonal difficulties (i.e., being too aggressive, showing shyness and low assertiveness), which in turn undermine their relationships. Likewise, previous literature has highlighted a strong relationship between maladaptive emotion regulation strategies and depressive symptoms (Moriya & Takahashi, 2013). These strategies are dependent upon cultural contexts that shape the way individuals manage their emotions. Cultural orientations such as collectivism or individualism may impact on how individuals manage their emotions, especially negative emotions such as anger (Seo, 2011; Sivadas, Bruvold, & Nelson, 2008). Moreover, past studies (e.g., Chowdhury & Gupta, 2014) have documented that individuals with depressive symptoms may inhibit the overt expression of anger (by using suppression strategy), while they feel anger internally, indicating that there may be an interaction between experiencing and expressive suppression factors (i.e., the suppression of overt expression of anger), which in turn may be linked to depressive symptoms. Surprisingly, even though the negative consequences of dysregulation of anger as well as expressive suppression on depression have been well reported, the interactions between the anger expression-out (tendency to express a feeling of anger in aggressive behaviour, either physically or verbally, towards people or objects), expressive suppression and collectivist factors have not been explored in the literature. Moreover, there is no study, according to the author’s knowledge, which brings all these predictor variables together in one study to investigate them in individuals with symptoms of depression, especially in Saudi Arabia. Therefore, if we bring all these predictor variables together in one study, we could explain the contributors to depression better than if we were examining them in isolation. Therefore, the current study will consider the presence of interpersonal problems, such as being self- sacrificing and being too aggressive, as a key factor of depression in addition to the previously mentioned factors to provide a better explanation of depression than what is already available. OBJECTIVES: This research utilises cross sectional designs. It aims to examine how the interaction between expressive suppression (ES) and anger expression-out (AO) as well as the interaction between collectivism (HVC) and anger expression-out provides an enhanced understanding of depression compared to these predictors (ES, AO and HVC) in isolation. The present research has two hypotheses: it was hypothesised that (1) the interaction between high expressive suppression and low anger expression-out (AO × ES) as well as (2) the interaction between high collectivism and low anger expression-out (AO × HVC) would contribute to the variance in depression over and above what was predicted by expressive suppression, collectivism and anger expression-out variables in isolation. The interaction denotes the inhibition of overt expression of anger. That is, individuals with depressive symptoms may feel anger internally, but they may frequently make an effort to inhibit the expressive components of angry responses, which in turn may contribute to depressive symptoms. The purpose was to add to the current explanations of the Beck’s cognitive model of depression, which tends to focus more on the effects of negative schematic beliefs, which in turn may add to our understanding of depression. METHODS: Three-hundred-and-five adults (183 Male and 122 Female) with symptoms of depression were recruited from mental health hospitals in Saudi Arabia after formal approval from concerned authorities. The participants’ age ranged from 18 to 59 years, with a mean age of 34.4 years (SD = 8.5). Seven questionnaires were administered: The Beck Depression Inventory (BDI-II); The Dysfunctional Attitudes Scale (DAS-26); The State-Trait Anger Expression Inventory (STAXI-2); The Emotion Regulation Questionnaire (ERQ); The Brief Core Schema Scale (BCSS); The Horizontal and Vertical Individualism and Collectivism Scale (HVICS) and The Inventory of Interpersonal Problems (IIP-32). All questionnaires were translated into Arabic using the translation and back translation technique. Psychometric properties were examined, and revealed good reliability. Hierarchical multiple regression and simple slope analyses were used in order to analyse the data. RESULTS: The findings of the present research indicated that the variables of dysfunctional attitudes, negative core schema beliefs, interpersonal problems, trait anger, and interaction terms (AO × ES and AO × HVC) were significant predictors of the Beck Depression Inventory (BDI-II) total score. The present results provide support to the study’s hypotheses by showing that the interaction between anger expression-out and both expression suppression (AO × ES) and collectivism (AO × HVC) predicted depressive symptoms in the sample, and explained a greater amount of variance than negative cognitions. These results suggest that suppression of overt expression of anger plays an important role in depression in the Saudi context. The interpersonal component combined with the interaction terms explained more variance in depression over and above cognitive factors, indicating that the interpersonal component was very important in contributing to depressive symptoms. This result indicated that suppression of overt expression of anger was more relevant to interpersonal difficulties. The final model accounted for 62% of the variance in depression. DISCUSSION: The findings of this study suggest that dysregulation of anger, emotion regulation and interpersonal components play an important role in depression. That is, the interaction of behaviour, thoughts and emotions contributes to symptoms of depression. Moreover, the current results may potentially expand the current theoretical model of depression by considering interpersonal aspects, especially in relation to anger. Consequently, the proposed interactional model may contribute in developing potential intervention strategies relating to emotion regulation in individuals with symptoms of depression.