The Role of Cognitive Deficits in Emotional Dysregulation: a Study on a Simple of Patients from Psychiatric Rehabilitation Communities.

BACKGROUND: Emotional dysregulation is a common feature across various psychiatric disorders, including personality disorders, mood disorders, substance use disorders, and schizophrenia. It manifests through difficulties in emotion modulation, which can lead to impulsive behaviors, exaggerated emotional reactions, and poor management of negative emotions. Cognitive deficits, particularly those related to executive functions such as inhibition, working memory, and cognitive flexibility, play a crucial role in this process, contributing to a higher vulnerability to emotional dysregulation. This paper focuses on the role cognitive deficits may have in emotional dysregulation. The sample will include both psychiatric patients and offenders undergoing therapeutic rehabilitation in community settings. METHOD: In our observational study, fifty-nine psychiatric inpatients (total mean age: 45.3910.93), distributed by age, gender, and legal provision (offenders and non-offenders) were recruited in several psychiatric rehabilitation centers located in South Italy. We used Aberrant Salience Inventory (ASI), Barrat Impulsiveness Scale Version 11 (BIS-11), Historical-Clinical-Risk Management-20, Version 3 (HCR-20V3), Brief Psychiatric Research Symptoms (BPRS), Verbal fluency tests (VFT) Estimated IQ Short Intelligence Test (T.I.B.), World Health Organization Disability Assessment Schedule 2.0. (WHODAS 2.0). RESULTS: The results highlighted higher impulsivity levels in offenders associated with higher scores on the cognitive performance scales. CONCLUSION: Cognitive deficits are a significant contributor to emotional dysregulation in psychiatric patients, particularly in offender psychiatric patients.

Cognitive Impairment and Emotional Dysregulation in Offenders.

This study aimed to evaluate the correlation between cognitive function and emotional dysregulation in patients suffering from psychiatric disorders hosted in rehabilitation facilities, but within this sample, there are also perpetrators of violence who are not residents in facilities but are followed in clinics for crimes related to family violence. All patients were administered the rating scale to investigate general impulsivity, perform psychopathological evaluation, evaluate aberrant salience, and conduct a general cognitive assessment.

Feeling the distance: The relationship between emotion regulation and spatial ability in childhood.

Research has shown experimentally that if children are taught to use language to create distance (socially, physically, and temporarily) when they revisit a potentially traumatic experience they reduce the intensity of their emotions. Building on this, this study was carried out to explore whether children with better spatial skills are better at such downregulation because of their very aptitude in understanding the concept of distance. Using data from a general-population birth cohort in the UK, the study examined the bidirectional association between emotional dysregulation and spatial ability among children aged 5 and 7 years. The findings reveal a significant reciprocal relationship even after adjusting for family, contextual, and individual confounders including verbal ability: spatial skills at age 5 years were inversely related to emotional dysregulation at age 7 years, and conversely, greater emotional dysregulation at age 5 years was associated with poorer spatial ability at age 7 years. The two paths were equally strong and there was no evidence of differences between them on the basis of sex. Our results suggest that enhancing spatial abilities could be a potential avenue for supporting emotion regulation in middle childhood.

The implication of alexithymia in personality disorders: a systematic review.

BACKGROUND: Alexithymia, characterized by difficulty identifying and expressing emotions, is often associated with various psychiatric disorders, including personality disorders (PDs). This study aimed to explore the relationship between alexithymia and PD, focusing on their common origins and implications for treatment. METHODS: A systematic review was conducted following PRISMA guidelines using databases such as MEDLINE (PubMed), Scopus, and Web of Science. The inclusion criteria were studies assessing adults with DSM-5-diagnosed personality disorders using validated alexithymia scales. The Newcastle‒Ottawa Scale was used to assess the quality of the included studies. RESULTS: From an initial yield of 2434 citations, 20 peer-reviewed articles met the inclusion criteria. The findings indicate a significant association between alexithymia and personality disorders, particularly within Clusters B and C. Patients with these disorders exhibited higher levels of alexithymia, which correlated with increased emotional dysregulation and interpersonal difficulties. The review also highlighted the comorbidity burden of conditions such as psychosomatic disorders, eating disorders, depression, anxiety, suicidal behavior, and substance use disorders. CONCLUSIONS: These findings underscore the need for integrating alexithymia-focused assessments into clinical practice to enhance therapeutic approaches, allowing for more personalized and effective interventions. Addressing the emotional processing challenges in patients with personality disorders could significantly improve patient outcomes. Future research should prioritize establishing clinical guidelines and conducting longitudinal studies to explore the relationship between alexithymia and specific personality disorder subtypes, ensuring the practical translation of these findings into clinical practice.

Characterization of neural networks involved in transdiagnostic emotion dysregulation from a pilot randomized controlled trial of a neurostimulation-enhanced behavioral intervention.

BACKGROUND: Emotional dysregulation is a serious and impairing mental health problem. We examined functional activity and connectivity of neural networks involved in emotional dysregulation at baseline and following a pilot neurostimulation-enhanced cognitive restructuring intervention in a transdiagnostic clinical adult sample. METHODS: Neuroimaging data were analyzed from adults who scored 89 or higher on the Difficulties with Emotion Regulation (DERS) scale and had at least one DSM-5 diagnosis. These participants were part of a pilot randomized, double-blind, placebo-controlled trial combining a single therapeutic session of cognitive restructuring with active or sham transcranial magnetic stimulation over the dorsolateral prefrontal cortex. During the study, participants engaged in an emotional regulation task using personalized autobiographical stressors while undergoing functional magnetic resonance imaging (fMRI) before and after the pilot intervention. The fMRI task required participants to either experience the emotions associated with the memories or apply cognitive restructuring strategies to reduce their distress. RESULTS: Whole-brain fMRI results during regulation at baseline revealed increased activation in the dorsal frontoparietal network but decreased activation in the supplementary motor area, cingulate cortex, insula, and ventrolateral prefrontal cortex (vlPFC). Emotion dysregulation was associated with greater vmPFC and amygdala activation and functional connectivity between these regions. The strength of functional connectivity between the dlPFC and other frontal regions was also a marker of emotional dysregulation. Preliminary findings from a subset of participants who completed the follow-up fMRI scan showed that active neurostimulation improved behavioral indices of emotion regulation more than sham stimulation. A whole-brain generalized psychophysiological interaction analysis indicated that active neurostimulation selectively increased occipital cortex connectivity with both the insula and the dlPFC. Region-of-interest functional connectivity analyses showed that active neurostimulation selectively increased dlPFC connectivity with the insula and orbitofrontal cortex (OFC). CONCLUSION: Insufficient neural specificity during the emotion regulation process and over-involvement of frontal regions may be a marker of emotional dysregulation across disorders. OFC, vlPFC, insula activity, and connectivity are associated with improved emotion regulation in transdiagnostic adults. In this pilot study, active neurostimulation led to neural changes in the emotion regulation network after a single session; however, the intervention findings are preliminary, given the small sample size. These functional network properties can inform future neuroscience-driven interventions and larger-scale studies.

The Impact of Negative Emotional Dysregulation on the Outcome of Bariatric Surgery in Patients with Severe Obesity: An Observational One-Year Follow-Up Study.

Background: Psychiatric symptoms are highly prevalent in patients with severe obesity, often representing pivotal factors in the development and progression of this condition. This study examines the association between negative emotional dysregulation (NED) and weight loss following bariatric surgery. Methods: Ninety-nine patients were consecutively enrolled at the Obesity Center of the Pisa University Hospital between March 2019 and February 2021, during a routine psychiatric evaluation before bariatric surgery. Psychopathological dimensions were assessed using the Mini-International Neuropsychiatric Interview (MINI), the Reactivity, Intensity, Polarity, and Stability questionnaire in its 40-item version (RIPoSt-40), the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) and the Barratt Impulsiveness Scale (BIS-11). Based on a RIPoSt-40 cut-off score of 70, subjects were divided into two groups: with (NED+) and without (NED-) NED. Results: NED+ subjects had a higher rate of psychiatric comorbidities and eating disorders than NED- patients. Of the total sample, 76 underwent bariatric surgery, and 65 of them were re-evaluated one-year after surgery. Among them, 10 of 28 NED+ subjects (37.5%) had inadequate weight loss one year after surgery compared to 5 of 37 NED- subjects (13.5%) (p = 0.035, OR 3.55, 95%, C.I. 1.05-12.03). Conclusions: Our results suggest a significant association between NED and inadequate weight loss at one-year post surgery.

Difficulties among Teachers' Emotional Regulation: Analysis for the Development of Student Well-Being in Chilean Schools.

INTRODUCTION: Emotional regulation, a process that involves detecting and evaluating physiological signals in response to stressful events, is a crucial aspect of preparing students for school and ensuring teachers' effectiveness, stress management, and job satisfaction. METHOD: This research, which adopted a quantitative approach, used a non-experimental comparative and cross-sectional design with a non-probabilistic sample by convenience. The study involved the participation of n = 1321 teachers (n = 125 preschool education; n = 645 primary education; n = 417 secondary education; n = 134 higher education). RESULTS: The results revealed significant differences in the total scores of emotional regulation difficulty between teachers at the higher education level and primary and secondary school teachers, with the latter group showing higher levels of difficulty. DISCUSSION: The findings suggest that the impact of emotional regulation difficulties affects professional performance, highlighting the importance of interventions aimed at improving teachers' self-efficacy, resilience, and emotion regulation to reduce emotional exhaustion. CONCLUSION: From a practical point of view, our findings underline the importance of integrating emotional regulation training into pre-service teacher education and continuous teacher professional development programs. This could improve relational dynamics between students and teachers, fostering an environment conducive to teaching and learning processes.

Emotional Regulation Challenges in Chilean Teachers: An Analysis of the Measurement Invariance of the DERS-E and the Influence of Gender and Age.

The study investigates the emotional dysregulation in teachers of the Chilean school system, focusing on gender and age similarities and differences. The sample included 1059 teachers from various regions of Chile, of whom 80.3% were female and 19.7% were male. Participants completed the Spanish version of the Difficulties in Emotional Regulation Scale (DERS-E). A confirmatory factor analysis was carried out to evaluate the structure of the theoretical model, along with the convergent, discriminant, and internal consistency of the instrument. Additionally, a measurement invariance analysis was performed to identify possible differences between demographic groups, which is crucial to ensure that comparisons between these groups are valid and unbiased. The results indicated that the theoretical model presents a good fit to the data and confirms the validity and reliability of the DERS-E. Scalar invariance was achieved among the analyzed groups. We found significant differences in emotional dysregulation between men and women, which also varied by teacher age. The importance of understanding the specific needs of teachers in terms of their emotional regulation is discussed and the urgency of implementing training programs that improve their emotional skills, fostering a positive and effective learning environment, is highlighted.

Emotional Dysregulation in Emerging Adult ADHD: A Key Consideration in Explaining and Classifying Impairment and Co-Occurring Internalizing Problems.

OBJECTIVE: The current study sought to clarify and harness the incremental validity of emotional dysregulation and unawareness (EDU) in emerging adulthood, beyond ADHD symptoms and with respect to concurrent classification of impairment and co-occurring problems, using machine learning techniques. METHOD: Participants were 1,539 college students (Mage = 19.5, 69% female) with self-reported ADHD diagnoses from a multisite study who completed questionnaires assessing ADHD symptoms, EDU, and co-occurring problems. RESULTS: Random forest analyses suggested EDU dimensions significantly improved model performance (ps < .001) in classifying participants with impairment and internalizing problems versus those without, with the resulting ADHD + EDU classification model demonstrating acceptable to excellent performance (except in classification of Work Impairment) in a distinct sample. Variable importance analyses suggested inattention sum scores and the Limited Access to Emotional Regulation Strategies EDU dimension as the most important features for facilitating model classification. CONCLUSION: Results provided support for EDU as a key deficit in those with ADHD that, when present, helps explain ADHD's co-occurrence with impairment and internalizing problems. Continued application of machine learning techniques may facilitate actuarial classification of ADHD-related outcomes while also incorporating multiple measures.

Emotional dysregulation in relation to substance use and behavioral addictions: Findings from five separate meta-analyses.

Background/objective: Emotional dysregulation (ED) is a transdiagnostic variable underlying various psychiatric disorders, including addictive behaviors (ABs). This meta-analysis examines the relationship between ED and ABs (alcohol, tobacco, cannabis, gambling, and gaming), and indicators of AB engagement (frequency, quantity/time of use, severity, and problems). Method: Searches were conducted in PubMed, Scopus, WoS, and PsycINFO. Five separate meta-analysis were run using random-effects models. Moderators (age, sex, continental region, and sample type; community vs. clinical), and publication bias were evaluated. Results: A total of 189 studies (N = 78,733; 51.29 % women) were identified. ED was significantly related to all ABs. Problems and severity indicators exhibited the largest effects (r's .118-.372, all p <.023). There were larger effect sizes for cannabis problems (r = .372), cannabis severity (r = .280), gaming severity (r = .280), gambling severity (r = .245), gambling problems (r = .131), alcohol problems (r = .237), alcohol severity (r = .204), and severity of nicotine dependence (r = .118). Lack of impulse control exhibited some of the largest effects in relation to ABs. Clinical samples of cannabis users vs. community-based exhibited larger magnitude of associations. Conclusions: Interventions targeting ABs should address lack of strategies and impulsive behaviors as an emotion regulation strategy specifically, as it is a common risk factor for ABs.

Reactivity of Emotions in Adolescents - Caregivers' Tool (React): Development and Validation of a Novel Parent-Rated Measure for Assessing Emotional Dysregulation in Youth.

Objective: Emotional Dysregulation (ED) is characterized by the inability to manage emotions effectively, leading to maladaptive behaviors, and often co-occurs with psychiatric conditions carrying significant long-term consequences. Early diagnosis of ED is thus essential for targeted interventions. To address this need, we developed and validated the "Reactivity of Emotions in Adolescents: Caregivers' Tool" (REACT), a novel parent-rated questionnaire designed to assess ED in adolescents. Method: The present study involved two samples, one drawn from the general population (n = 89 healthy controls from local schools) and the other composed of clinical patients (n = 76 adolescents with different psychiatric and/or neurodevelopmental conditions). Patients' diagnoses were confirmed through the clinical interview K-SADS-PL to explore the presence of any psychopathological conditions. Participants from both groups completed the RIPoSt-Y questionnaire, providing a measure of ED, while their parents filled out the ARI, measuring affective reactivity in youth. Confirmatory and exploratory factor analyses were performed to refine the questionnaire's internal structure. Results: The final REACT questionnaire consists of 55 items distributed across three subscales, namely Negative Emotionality, Irritability, and Excitability. Psychometric evaluation showed that these subscales demonstrated excellent internal consistency and strong construct validity, with clinical patients scoring higher on all subscales compared to healthy controls. The REACT questionnaire showed also high convergent validity by exhibiting significant positive correlations with established measures of ED. Conclusions: This novel tool represents a valuable improvement in the assessment of ED in adolescence as it may facilitate tailored interventions to provide emotional well-being and long-term outcomes.

Non-Suicidal Self-Injury in Eating and Feeding Disorder Patients: Characteristics and Clinical Implications in a Group of Referred Female Adolescents.

BACKGROUND: Non-suicidal self-injury (NSSI) and Feeding or Eating Disorders (FEDs) often coexist during adolescence with reciprocal influences on their clinical picture. The present study aimed to identify differences and similarities in the clinical presentation of young patients with both conditions compared to those with the two non-comorbid disorders. METHODS: We consecutively recruited forty-five female patients aged between 11 and 18 at our third-level hospital and subdivided them into three groups (NSSI: n = 15; FED: n = 15; NSSI + FED: n = 15). Patients underwent a full clinical assessment. RESULTS: Based on our results, the NSSI + FED group was characterized by higher rates of binging/purging behaviors, greater prevalence of Cyclothymic Disorder, and a more severe clinical presentation compared to the non-comorbid groups. Moreover, higher levels of suicidal ideation were found in the NSSI + FED group. Pharmacological treatment patterns also differed, with SSRI being prescribed more frequently to NSSI + FED patients while mood stabilizers were prescribed more frequently to NSSI ones. A Principal Component Analysis identified four main dimensions: "Body Image" impairment was more pronounced in NSSI + FED patients, indicating negative attitudes towards their own body; "Metacognition" deficits were higher in NSSI than FED. CONCLUSIONS: The present study underscores distinctive clinical features in patients with comorbid NSSI and FED, emphasizing the urgent need for tailored intervention strategies focusing on specific symptom domains.

A model linking emotional dysregulation in neurodivergent people to the proprioceptive impact of joint hypermobility.

Emotional feelings are putatively ascribed to central representation of bodily states in the context of expectation and uncertainty in both internal state and external world. Neurodivergent people are more likely to experience co-occurring mental health challenges, although mechanistic insights underpinning this association are scarce. We therefore undertook a study to test whether imprecise processing of proprioceptive error signals may underlie the connection between neurodivergence and emotional dysregulation. In a cohort of people with complex chronic conditions, including chronic pain/fatigue, and complex trauma, and in a comparison group, we assessed presence of neurodivergence, variant connective tissue manifested through joint hypermobility, and emotional dysregulation. We present a data-informed conceptual model showing that variant connective tissue determines whether proprioceptive surprise is linked with emotional dysregulation in neurodivergent individuals. We suggest that future research in this area may have important clinical implications for the interaction of mental and physical wellbeing in neurodivergent people. This article is part of the theme issue 'Sensing and feeling: an integrative approach to sensory processing and emotional experience'.

Metacognition as a transdiagnostic factor across eating disorders: a latent profile analysis study.

Background: Metacognition is a crucial aspect of understanding and attributing mental states, playing a key role in the psychopathology of eating disorders (EDs). This study aims to explore the diverse clinical profiles of metacognition among patients with EDs using latent profile analysis (LPA). Method: A total of 395 patients with a DSM-5 diagnosis of ED (116 AN-R, 30 AN/BP, 100 BN, 149 BED) participated in this study. They completed self-report measures assessing metacognition, eating psychopathology, depression, emotional dysregulation, personality traits, and childhood adversities. LPA and Welch ANOVAs were conducted to identify profiles based on metacognition scores and examine psychological differences between them. Logistic regression models were employed to explore associations between personal characteristics and different profiles. Results: A 3-class solution had a good fit to the data, revealing profiles of high functioning (HF), intermediate functioning (IF), and low functioning (LF) based on levels of metacognitive impairments. Participants in the IF group were older and had a higher BMI than those in the HF and LF groups. Individuals with BN were largely categorized into HF and LF profiles, whereas participants with BED were mainly included in the IF profile. Participants in the LF group reported an impaired psychological profile, with high levels of depression, emotional dysregulation, childhood adversity, and personality dysfunction. Multinomial logistic regression analyses showed significant associations between metacognitive profiles and emotional and neglect abuse, emotion dysregulation, and detachment. Conclusion: This exploratory study unveils distinct metacognitive profiles in EDs, providing a foundation for future research and targeted interventions. In this light, metacognitive interpersonal therapy could be a valid and effective treatment for EDs, as suggested by the initial promising results for these patients.

Effectiveness of Acceptance and Commitment Therapy on Psychotic Severity Among Inpatients With Primary Psychoses: A Randomized Controlled Trial.

This study investigated the effectiveness of acceptance and commitment therapy (ACT) compared to treatment as usual in managing psychotic symptoms, emotional dysregulation, recovery and psychological flexibility in inpatients with primary psychoses. The Primary outcome assessed the positive and negative syndrome scale, while the secondary outcomes were to assess difficulties in the emotion regulation scale, recovery assessment scale and acceptance and action questionnaire. An open-label, two-arm parallel randomized controlled trial was conducted. Participants diagnosed with primary psychoses were randomly assigned to either the ACT (n = 33) or treatment-as-usual (n = 32) group. The intervention included six structured sessions of ACT. ACT significantly reduced psychotic symptoms from 128 to 104 (Z = 5.01) compared to treatment as usual from 130 to 117 (Z = 4.88). Emotional regulation improved significantly in the ACT group from 73 to 55 (Z = 4.835) compared to treatment as usual from 73 to 70 (Z = 2.406). Recovery increased in the ACT group from 50 to 88 (Z = 5.01) compared to treatment as usual from 51 to 61 (Z = 4.93). Psychological flexibility improved in the ACT group from 33 to 25 (Z = 4.98) compared to treatment as usual from 33 to 31 (Z = 4.75). Between-group differences after intervention were significant for psychotic symptoms, emotional regulation, recovery and psychological flexibility (Z = 2.356, 4.652, 3.881 and 4.453, respectively). Accordingly, the current study demonstrates the effectiveness of ACT in reducing psychotic symptoms and improving emotional regulation, recovery and psychological flexibility in patients with primary psychoses. Integrating ACT into standard care protocols can enhance treatment outcomes, offering a comprehensive approach to managing complex mental health conditions. Trial Registration: ClinicalTrials.gov identifier: NCT06160869.

Excite, or Take Flight? Exploring the Relationship between Difficulties with Emotion Regulation, Outcome Expectancies, and Problem Gambling.

Emotional dysregulation is a transdiagnostic process associated with a range of addictive behaviours including problem gambling, with emerging research indicating that emotionally oriented reasons for gambling (i.e., excitement, escape) are associated with problem gambling. However, the relationships between difficulties with emotion regulation, reasons for gambling, and problem gambling, are unclear. The current study tested whether the association between difficulties with emotion regulation and problem gambling could be explained by escape and excitement gambling outcome expectancies. A total of 187 regular gamblers recruited via social media (50.3% male, 48.7% female) completed measures of difficulties with emotion regulation, gambling outcome expectancies, and problem gambling severity (Mage = 41.07, SD = 15.8). Analyses revealed that escape outcome expectancies partially mediated the relationship between difficulties with emotion regulation and problem gambling severity. However, the mediating effect of excitement on this relationship was not significant. The findings suggest that individuals with greater emotional regulation difficulties may engage in problem gambling to help manage aversive emotional states. The study's findings illustrate the importance of considering emotional dysregulation and outcome expectancies in problem gambling treatment planning and public health strategies.

Evaluation of dialectical behavior therapy for adolescents in routine clinical practice: a pre-post study.

BACKGROUND: Self-harm and suicidal ideation are prevalent among adolescents, cause physical and psychosocial disability, and have potentially life-threatening consequences. Dialectical behavioral therapy for Adolescents (DBT-A) is an evidence-based intervention for reducing self-harm. However, few studies have investigated the effectiveness of DBT-A when delivered in routine clinical practice. METHODS: A follow-up cohort study, based on data from a quality assessment register of DBT-A in child and adolescent mental health services including seven outpatient clinics. Inclusion criteria were ongoing or a history of self-harming behavior the last 6 months; current suicidal behavior; at least 3 criteria of DSM-IV Borderline personality disorder (BPD), or at least the self-destruction criterion of DSM-IV BPD, in addition to minimum 2 subthreshold criteria; and fluency in Norwegian. Participants received 20 weeks of DBT-A consisting of multifamily skills training groups and individual therapy sessions. Outcomes from 41 participants included frequency of self-harm, suicide attempts and hospitalizations caused by self-harm or suicide attempts, assessed pre-, during, and post-treatment by self-report and reviews of the patient's medical records. Suicidal ideation, urge to self-harm and perceived feelings of happiness and sadness were assessed by the patients' diary cards at week 1, 5, 10, 15 and 20 of the treatment program. RESULTS: Participants attended an average of 17.9 (SD = 4.7) individual sessions, 14.7 (SD = 3.4) group-based skills training sessions and 4.6 (SD = 4.1) brief intersession telephone consultations. Moderate to large within-group effect sizes (ES) were found in self-harm from pre-treatment to 1-5 weeks (d = 0.64), 6-10 weeks (d = 0.84), 11-15 weeks (d = 0.99), 16-20 weeks (d = 1.26) and post-treatment (d = 1.68). Nine participants were admitted to hospitalization during DBT-A, whereas five had attempted suicide, but no suicides were completed. No statistically significant changes were found in suicidal ideation, urge to self-harm or perceived feelings of happiness or sadness from pre to post treatment. CONCLUSION: The findings of the current study are promising as the participants reported considerably reduced self-harm behavior after DBT-A treatment in a child and adolescent mental health outpatient setting.

Mentalization, emotional dysregulation and attachment to alternative attachment figures in retrospectively defined earned secure adults.

BACKGROUND: Researchers have tried to identify mechanisms through which an individual overcomes negative life experiences, proposing earning security as one of them. Retrospectively defined earned secures are recognized as individuals exhibiting secure attachments to their parents while evaluating the quality of their childhood care as low. This study aimed to examine attachment, mentalization, and emotional dysregulation in this group. We hypothesized that earned secures will report better mentalizing, lower emotion dysregulation, and more secure attachment to figures other than parents than insecure individuals. PARTICIPANTS AND PROCEDURE: female adult sample (N = 272) completed the Experiences in Close Relationships-Relationship Structures questionnaire, Parental Bonding Instrument, Difficulties in Emotion Regulation Scale, and Mental State Task. The time devoted to psychotherapy and demographics were also controlled as contextual variables. RESULTS: We identified an 'earned secure' group (14% of the sample), exhibiting secure attachment to mothers in adulthood despite reported inadequate care during childhood, along with the continuously secure, insecure, and 'lost secure' groups. People from the earned secure and secure groups reported better emotional regulation and some aspects of mentalization than those in the insecure and lost secure groups. They equally frequently reported the presence of an adult other than parents who were important to them in childhood, but the attachment to them was more secure. We did not find evidence of differences between the groups in the duration of psychotherapy. CONCLUSIONS: Secure attachment to alternative attachment figures, along with some mentalization and emotional regulation aspects, may be considered significant factors for earning security.