Restricted accessResearch articleFirst published online 2026-3
Emotion Dysregulation in Adults with Acquired Brain Injury: Conceptualization of Emotion Dysregulation,Validation of the French DERS-16 Scale and its Utility in Clinical Practice
Emotional consequences are a major area of interest in the field of acquired brain injury (ABI), yet less studied than the other consequences of ABI, despite particularly deleterious consequences on quality of life.
Objectives and methods
This study assessed the relevance of the French version of Difficulties in Emotion Regulation Scale-16 and developed a model of emotional dysregulation in ABI through four studies.
Results
Study 1 confirmed the unidimensional structure and internal consistency (Cronbach's α = 0.95) of DERS-16 in non-clinical controls. Study 2 established a cutoff of 33.5 for pathological emotional dysregulation and found significantly higher DERS-16 scores in ABI participants compared to non-clinical controls but lower than in borderline personality disorder (BPD) participants (p < 0.001). Study 3 demonstrated consistency between clinical assessments and DERS-16 results, characterizing emotional dysregulation in ABI. Study 4 showed DERS-16 sensitivity to changes (mean DERS-16 difference of 1.21 [0.42; 2.00] per month, p = 0.003).
Conclusions
DERS-16 is a valuable scale for screening and monitoring emotional dysregulation in ABI, highlighting the importance of addressing emotional difficulties in rehabilitation programs. The proposed model highlights organic, cognitive, psychological, environmental, vulnerability factors and general population factors contributing to emotional dysregulation in ABI.
AlwayY.GouldK. R.JohnstonL.McKenzieD.PonsfordJ. (2016). A prospective examination of Axis I psychiatric disorders in the first 5 years following moderate to severe traumatic brain injury. Psychological Medicine, 46(6), 1331–1341. https://doi.org/10.1017/S0033291715002986
2.
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787
3.
ArundineA.BradburyC. L.DupuisK.DawsonD. R.RuttanL. A.GreenR. E. A. (2012). Cognitive behavior therapy after acquired brain injury: Maintenance of therapeutic benefits at 6 months posttreatment. The Journal of Head Trauma Rehabilitation, 27(2), 104–112. https://doi.org/10.1097/HTR.0b013e3182125591
4.
AshworthF.EvansJ. J.McLeodH. (2017). Third wave cognitive and behavioural therapies: Compassion focused therapy, acceptance and commitment therapy and positive psychotherapy. In Neuropsychological rehabilitation: The international handbook (pp. 327–339). Routledge/Taylor & Francis Group.
5.
BemmounaD.LagzouliA.WeinerL. (2023). The biosocial correlates and predictors of emotion dysregulation in autistic adults compared to borderline personality disorder and nonclinical controls. Molecular Autism, 14, 47. https://doi.org/10.1186/s13229-023-00580-3
6.
BickartK. C.OlsenA.DennisE. L.BabikianT.HoffmanA. N.SnyderA.SheridanC. A.FischerJ. T.GizaC. C.ChoeM. C.AsarnowR. F. (2022). Frontoamygdala hyperconnectivity predicts affective dysregulation in adolescent moderate-severe TBI. Frontiers in Rehabilitation Sciences, 3, 1064215. https://doi.org/10.3389/fresc.2022.1064215
7.
BjurebergJ.LjótssonB.TullM. T.HedmanE.SahlinH.LundhL.-G.BjärehedJ.DiLilloD.Messman-MooreT.GumpertC. H.GratzK. L. (2016). Development and validation of a brief version of the difficulties in emotion regulation scale: The DERS-16. Journal of Psychopathology and Behavioral Assessment, 38(2), 284–296. https://doi.org/10.1007/s10862-015-9514-x
8.
BolgerN.DeLongisA. (n.d.). Effects of daily stress on negative mood. 11.
9.
BoscoF. M.GabbatoreI.AngeleriR.ZettinM.ParolaA. (2018). Do executive function and theory of mind predict pragmatic abilities following traumatic brain injury? An analysis of sincere, deceitful and ironic communicative acts. Journal of Communication Disorders, 75, 102–117. https://doi.org/10.1016/j.jcomdis.2018.05.002
10.
BradburyC. L.ChristensenB. K.LauM. A.RuttanL. A.ArundineA. L.GreenR. E. (2008). The efficacy of cognitive behavior therapy in the treatment of emotional distress after acquired brain injury. Archives of Physical Medicine and Rehabilitation, 89(12, Supplement), S61–S68. https://doi.org/10.1016/j.apmr.2008.08.210
11.
BroomfieldN. M.QuinnT. J.Abdul-RahimA. H.WaltersM. R.EvansJ. J. (2014). Depression and anxiety symptoms post-stroke/TIA: Prevalence and associations in cross-sectional data from a regional stroke registry. BMC Neurology, 14, 198. https://doi.org/10.1186/s12883-014-0198-8
12.
BrownJ. F. (2019). Improving accessibility to dialectical behaviour therapy for individuals with cognitive challenges. In The Oxford handbook of dialectical behaviour therapy (pp. 769–795). Oxford University Press.
13.
BusnerJ.TargumS. D. (2007). The clinical global impressions scale. Psychiatry (Edgmont), 4(7), 28–37.
14.
CalkinsS. D. (1994). Origins and outcomes of individual differences in emotion regulation. Monographs of the Society for Research in Child Development, 59(2/3), 53–72. https://doi.org/10.2307/1166138
15.
CantorJ.AshmanT.Dams-O’ConnorK.DijkersM. P.GordonW.SpielmanL.TsaousidesT.AllenH.NguyenM.OswaldJ. (2014). Evaluation of the short-term executive plus intervention for executive dysfunction after traumatic brain injury: A randomized controlled trial with minimization. Archives of Physical Medicine and Rehabilitation, 95(1), 1. https://doi.org/10.1016/j.apmr.2013.08.005
16.
CasselA.McDonaldS.KellyM.TogherL. (2019). Learning from the minds of others: A review of social cognition treatments and their relevance to traumatic brain injury. Neuropsychological Rehabilitation, 29(1), 22–55. https://doi.org/10.1080/09602011.2016.1257435
17.
CiobanuT.BrodardF.AntoniettiJ.-P.GenoudP. A.BrandnerC. (2021, December 21). Screening negative affectivity in young adults: Validation and psychometric evaluation of the French version of the Depression Anxiety Stress Scales. - PsycNET.APA PsycNET. https://doi.org/10.1037/cbs0000110
18.
CôtéG.GosselinP.DagenaisI. (2013). Évaluation multidimensionnelle de la régulation des émotions: Propriétés psychométriques d’une version francophone du Difficulties in Emotion Regulation Scale. [Psychometric properties of a French version of the Difficulties in Emotion Regulation Scale.]. Journal de Thérapie Comportementale et Cognitive, 23(2), 63–72. https://doi.org/10.1016/j.jtcc.2013.01.005
19.
Dan-GlauserE. S.SchererK. R. (2013). The difficulties in emotion regulation scale (DERS): Factor structure and consistency of a French translation. Swiss Journal of Psychology, 72(1), 5–11. https://doi.org/10.1024/1421-0185/a000093
DixonM. L.ThiruchselvamR.ToddR.ChristoffK. (2017). Emotion and the prefrontal cortex: An integrative review. Psychological Bulletin, 143(10), 1033–1081. https://doi.org/10.1037/bul0000096
22.
EtkinA.BüchelC.GrossJ. J. (2015). The neural bases of emotion regulation. Nature Reviews. Neuroscience, 16(11), 693–700. https://doi.org/10.1038/nrn4044
GratzK. L.RoemerL. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. https://doi.org/10.1023/B:JOBA.0000007455.08539.94
26.
GrimaN.PonsfordJ.RajaratnamS. M.MansfieldD.PaseM. P. (2016). Sleep disturbances in traumatic brain injury: A meta-analysis. Journal of Clinical Sleep Medicine, 12(03), 419–428. https://doi.org/10.5664/jcsm.5598
27.
HackettM. L.PicklesK. (2014). Part I: Frequency of depression after stroke: An updated systematic review and meta-analysis of observational studies. International Journal of Stroke: Official Journal of the International Stroke Society, 9(8), 1017–1025. https://doi.org/10.1111/ijs.12357
28.
HayesS. C.StrosahlK.WilsonK. G. (2003). Acceptance and commitment therapy: An experiential approach to behavior change (Paperback ed). Guilford Press.
29.
HeibergG.PedersenS. G.FriborgO.NielsenJ. F.HolmH. S.Steinbüchel vonN.ArntzenC.AnkeA. (2018). Can the health related quality of life measure QOLIBRI- overall scale (OS) be of use after stroke? A validation study. BMC Neurology, 18(1), 98. https://doi.org/10.1186/s12883-018-1101-9
30.
HenryJ. D.CrawfordJ. R. (2005). The short-form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large non-clinical sample. The British Journal of Clinical Psychology, 44(Pt 2), 227–239. https://doi.org/10.1348/014466505X29657
JohnsonR. A.AlbrightD. L.MarzolfJ. R.BibboJ. L.YaglomH. D.CrowderS. M.CarlisleG. K.WillardA.RussellC. L.GrindlerK.OsterlindS.WassmanM.HarmsN. (2018). Effects of therapeutic horseback riding on post-traumatic stress disorder in military veterans. Military Medical Research, 5(1), 3. https://doi.org/10.1186/s40779-018-0149-6
33.
KatsifarakiM.WoodR. L. (2014). The impact of alexithymia on burnout amongst relatives of people who suffer from traumatic brain injury. Brain Injury, 28(11), 1389–1395. https://doi.org/10.3109/02699052.2014.919538
34.
KuppelinM.GoetschA.ChoiselR.Isner-HorobetiM.-E.GoetschT.Krasny-PaciniA. (2024). An exploratory study of dialectical behaviour therapy for emotional dysregulation and challenging behaviours after acquired brain injury. NeuroRehabilitation, 55(1), 77–94. https://doi.org/10.3233/NRE-230383
35.
KuppelinM.GoetschT.LaugelM.ElbelM.Isner-HorobetiM.-E.Krasny-PaciniA. (2026). Adding dialectical behaviour therapy to multidisciplinary rehabilitation does not change quality of life but can improve emotional regulation and personal goals attainment after acquired brain injury [Manuscript submitted]. Disability And Rehabilitation Journal.
36.
LarsenR. J. (n.d.). Affect Intensity and Reactions to Daily Life Events. 12.
37.
LinehanM. (2017). Manuel d’entraînement aux compétences TCD. Médecine & Hygiène, RMS édition.
38.
LinehanM. M. (1993). Cognitive-behavioral treatment of borderline personality disorder (pp. xvii, 558). Guilford Press.
39.
LinehanM. M. (2014). DBT Skills Training Manual, Second Edition(Second Edition, Available separately: DBT Skills Training Handouts and Worksheets, Second). The Guilford Press.
40.
LinehanM. M. (2015a). DBT® Skills Training Manual (2nd ed.). Guilford Press.
41.
LinehanM. M. (2015b). DBT® skills training manual, 2nd ed (pp. xxiv, 504). Guilford Press.
42.
MaX.TamirM.MiyamotoY. (2018). A socio-cultural instrumental approach to emotion regulation: Culture and the regulation of positive emotions. Emotion (Washington, D.C.), 18(1), 138–152. https://doi.org/10.1037/emo0000315
43.
MakM.MoulaertV. R. M.PijlsR. W.VerbuntJ. A. (2016). Measuring outcome after cardiac arrest: Construct validity of Cerebral Performance Category. Resuscitation, 100, 6–10. https://doi.org/10.1016/j.resuscitation.2015.12.005
44.
MartinR. E.OchsnerK. N. (2016). The neuroscience of emotion regulation development: Implications for education. Current Opinion in Behavioral Sciences, 10, 142–148. https://doi.org/10.1016/j.cobeha.2016.06.006
45.
MayM.MildersM.DowneyB.WhyteM.HigginsV.WojcikZ.AminS.O’RourkeS. (2017). Social behavior and impairments in social cognition following traumatic brain injury. Journal of the International Neuropsychological Society: JINS, 23(5), 400–411. https://doi.org/10.1017/S1355617717000182
46.
McDonaldS.FisherA.FlanaganS.HonanC. A. (2017). Impaired perception of sincerity after severe traumatic brain injury. Journal of Neuropsychology, 11(2), 291–304. https://doi.org/10.1111/jnp.12086
47.
MooreG. A. (2010). Parent conflict predicts Infants’ vagal regulation in social interaction. Development and Psychopathology, 22(1), 23–33. https://doi.org/10.1017/S095457940999023X
48.
NeumannD. (2017). Treatments for emotional issues after traumatic brain injury. The Journal of Head Trauma Rehabilitation, 32(5), 283–285. https://doi.org/10.1097/HTR.0000000000000337
49.
NeumannD.HammondF. M.SanderA. M.BognerJ.BushnikT.FinnJ. A.ChungJ. S.KlyceD. W.SevignyM.KetchumJ. M. (2024). A longitudinal investigation of alexithymia as a predictor of empathy, emotional functioning, resilience, and life satisfaction two years after brain injury. Archives of Physical Medicine and Rehabilitation, 105(8), 1529–1535. https://doi.org/10.1016/j.apmr.2024.04.008
50.
NeumannD.MalecJ. F.HammondF. M. (2017). Reductions in alexithymia and emotion dysregulation after training emotional self-awareness following traumatic brain injury: A phase I trial. Journal of Head Trauma Rehabilitation, 32(5), 286–295. https://doi.org/10.1097/HTR.0000000000000277
51.
Nolen-HoeksemaS. (n.d.). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. 8.
52.
OsbornA. J.MathiasJ. L.Fairweather-SchmidtA. K. (2014). Depression following adult, non-penetrating traumatic brain injury: A meta-analysis examining methodological variables and sample characteristics. Neuroscience and Biobehavioral Reviews, 47, 1–15. https://doi.org/10.1016/j.neubiorev.2014.07.007
53.
OsbornA. J.MathiasJ. L.Fairweather-SchmidtA. K. (2016). Prevalence of anxiety following adult traumatic brain injury: A meta-analysis comparing measures, samples and postinjury intervals. Neuropsychology, 30(2), 247–261. https://doi.org/10.1037/neu0000221
54.
OwnsworthT.GraceyF. (2017). Cognitive behavioural therapy for people with brain injury. In Neuropsychological rehabilitation: The international handbook (pp. 313–326). Routledge/Taylor & Francis Group.
55.
OwnsworthT.LittleT.TurnerB.HawkesA.ShumD. (2008). Assessing emotional status following acquired brain injury: The clinical potential of the depression, anxiety and stress scales. Brain Injury, 22(11), 858–869. https://doi.org/10.1080/02699050802446697
56.
PeppingN.WeinbornM.PestellC. F.PreeceD. A.MalkaniM.MooreS.GrossJ. J.BecerraR. (2024). Improving emotion regulation ability after brain injury: A systematic review of targeted interventions. Neuropsychological Rehabilitation, 35(0), 1283–1323. https://doi.org/10.1080/09602011.2024.2398029
57.
RizviS. L.RitschelL. A. (2014). Mastering the art of chain analysis in dialectical behavior therapy. Cognitive and Behavioral Practice, 21(3), 335–349. https://doi.org/10.1016/j.cbpra.2013.09.002
58.
RosenbergH.DethierM.KesselsR. P. C.WestbrookR. F.McDonaldS. (2015). Emotion perception after moderate-severe traumatic brain injury: The valence effect and the role of working memory, processing speed, and nonverbal reasoning. Neuropsychology, 29(4), 509–521. https://doi.org/10.1037/neu0000171
59.
RosenbergH.McDonaldS.RosenbergJ.Frederick WestbrookR. (2018). Amused, flirting or simply baffled? Is recognition of all emotions affected by traumatic brain injury?Journal of Neuropsychology, 12(2), 145–164. https://doi.org/10.1111/jnp.12109
60.
RoulinP.MarmisseL.KuppelinM.AttiasC.KleinS.Isner-HorobetiM.-E.VassiliadouH. D.Krasny-PaciniA. (2025). Vécu émotionnel de patients victimes de lésion cérébrale acquise après apprentissage de régulation émotionnelle: Une étude qualitative. Glossa, 143, 83–116. https://doi.org/10.61989/b153ar62
61.
RoyC.LeclercA.OdintsovI.Isner-HorobetiM.-E.KuppelinM.Krasny-PaciniA. (2026). Emotional experience of patients with acquired brain injury: A qualitative study [Manuscript submitted]. Brain Impairement.
62.
Sajeda RamasawmyHicksR.GillesP.-Y. (2010). Développement d’une échelle de dépression et d’anxiété pour la population mauricienne: La DASS-21. https://doi.org/10.13140/2.1.4186.8802
63.
ShearinE. N.LinehanM. M. (1994). Dialectical behavior therapy for borderline personality disorder: Theoretical and empirical foundations. Acta Psychiatrica Scandinavica, 89(s379), 61–68. https://doi.org/10.1111/j.1600-0447.1994.tb05820.x
64.
SheeseB. E.VoelkerP.PosnerM. I.RothbartM. K. (2009). Genetic variation influences on the early development of reactive emotions and their regulation by attention. Cognitive Neuropsychiatry, 14(4–5), 332–355. https://doi.org/10.1080/13546800902844064
65.
ShieldsC.OwnsworthT.O’DonovanA.FlemingJ. (2016). A transdiagnostic investigation of emotional distress after traumatic brain injury. Neuropsychological Rehabilitation, 26(3), 410–445. https://doi.org/10.1080/09602011.2015.1037772
66.
ThompsonR. A.CalkinsS. D. (1996). The double-edged sword: Emotional regulation for children at risk. Development and Psychopathology, 8(1), 163–182. https://doi.org/10.1017/S0954579400007021
67.
ThompsonS. C.Sobolew-ShubinA.GalbraithM. E.SchwankovskyL.CruzenD. (1993). Maintaining perceptions of control: Finding perceived control in low-control circumstances. Journal of Personality and Social Psychology, 64(2), 293–304. https://doi.org/10.1037/0022-3514.64.2.293
68.
TrappN. T.BrussJ. E.ManzelK.GrafmanJ.TranelD.BoesA. D. (2023). Large-scale lesion symptom mapping of depression identifies brain regions for risk and resilience. Brain: A Journal of Neurology, 146(4), 1672–1685. https://doi.org/10.1093/brain/awac361
69.
TsaousidesT.SpielmanL.KajankovaM.GuettaG.GordonW.Dams-O'ConnorK. (2017). Improving emotion regulation following web-based group intervention for individuals with traumatic brain injury. The Journal of Head Trauma Rehabilitation, 32(5), 354–365. https://doi.org/10.1097/HTR.0000000000000345
70.
van der HornH. J.LiemburgE. J.AlemanA.SpikmanJ. M.van der NaaltJ. (2016). Brain networks subserving emotion regulation and adaptation after mild traumatic brain injury. Journal of Neurotrauma, 33(1), 1–9. https://doi.org/10.1089/neu.2015.3905
71.
VitoloE.DianoM.GirominiL.ZennaroA. (2022). Markers of emotion regulation processes: A neuroimaging and behavioral study of reappraising abilities. Biological Psychology, 171, 108349. https://doi.org/10.1016/j.biopsycho.2022.108349
72.
von SteinbuechelN.RichterS.MorawetzC.RiemsmaR. (2005). Assessment of subjective health and health-related quality of life in persons with acquired or degenerative brain injury. Current Opinion in Neurology, 18(6), 681–691. https://doi.org/10.1097/01.wco.0000194140.56429.75
73.
Von SteinbüchelN.WilsonL.GibbonsH.HawthorneG.HöferS.SchmidtS.BullingerM.MaasA.NeugebauerE.PowellJ.von WildK.ZitnayG.BakxW.ChristensenA.-L.KoskinenS.SarajuuriJ.FormisanoR.SasseN.TruelleJ.-L., & QOLIBRI Task Force. (2010). Quality of life after brain injury (QOLIBRI): Scale development and metric properties. Journal of Neurotrauma, 27(7), 1167–1185. https://doi.org/10.1089/neu.2009.1076
74.
WeisC. N.WebbE. K.de Roon-CassiniT. A.LarsonC. L. (2022). Emotion dysregulation following trauma: Shared neurocircuitry of traumatic brain injury and trauma-related psychiatric disorders. Biological Psychiatry, 91(5), 470–477. https://doi.org/10.1016/j.biopsych.2021.07.023
75.
WiartL.LuautéJ.StefanA.PlantierD.HamonetJ. (2016). Non pharmacological treatments for psychological and behavioural disorders following traumatic brain injury (TBI). A systematic literature review and expert opinion leading to recommendations. Annals of Physical and Rehabilitation Medicine, 59(1), 31–41. https://doi.org/10.1016/j.rehab.2015.12.001
76.
WongG. K. C.LamS. W.NgaiK.WongA.MokV.PoonW. S. (2014). Quality of life after brain injury (QOLIBRI) overall scale for patients after aneurysmal subarachnoid hemorrhage. Journal of Clinical Neuroscience, 21(6), 954–956. https://doi.org/10.1016/j.jocn.2013.09.010
77.
WoodR. L.DoughtyC. (2013). Alexithymia and avoidance coping following traumatic brain injury. The Journal of Head Trauma Rehabilitation, 28(2), 98–105. https://doi.org/10.1097/HTR.0b013e3182426029
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