Year : 2018  |  Volume : 60  |  Issue : 3  |  Page : 307--311

Correlation of cognitive functions with emotional dysregulation in alcohol dependence: A preliminary study

Dushad Ram1, Manju George1, Basawanna Gowdappa2,  
1 Department of Psychiatry, JSS Medical College and Hospital, Mysore, Karnataka, India
2 Department of Medicine, JSS Medical College and Hospital, Mysore, Karnataka, India

Correspondence Address:
Dr. Dushad Ram
Department of Psychiatry, JSS Medical College and Hospital, MG Road, Mysore - 570 004, Karnataka


Context and Aims: Dysfunction of cognition and emotion is known in alcohol dependence; however, their relationship in alcohol dependence is unknown. Thus, this study aimed to know the level of emotional dysregulation and cognitive functions and their correlation in patients with alcohol dependence. Materials and Methods: In this hospital-based cross-sectional study, 120 patients with alcohol dependence were consecutively recruited and assessed with sociodemographic and clinical pro forma, Montreal Cognitive Assessment (MoCA), and Difficulty in Emotional Regulation Scale–Short Form (DERS-SF). Statistical Analysis: Descriptive statistical, Kruskal–Wallis H, and regression analysis. Results: Results revealed a mild level of cognitive impairment (mean MoCA score = 0 23.76) and high levels of emotional dysregulation (mean DERS-SF score = 0 26.90). On linear regression analysis (R2 = 0.266, df = 0 1, F = 0 42.782, P =0.000), the score on MoCA had statistically significant negative association with score on DERS-SF (P = 0.001). Conclusions: Cognitive impairment and emotional dysregulation are inversely related in patients with alcohol dependence. Improving the dysfunction may improve the outcome of alcohol dependence.

How to cite this article:
Ram D, George M, Gowdappa B. Correlation of cognitive functions with emotional dysregulation in alcohol dependence: A preliminary study.Indian J Psychiatry 2018;60:307-311

How to cite this URL:
Ram D, George M, Gowdappa B. Correlation of cognitive functions with emotional dysregulation in alcohol dependence: A preliminary study. Indian J Psychiatry [serial online] 2018 [cited 2020 Apr 7 ];60:307-311
Available from:

Full Text


Over the years, emotion and cognition have been the focus of research due to their etiological role in mental disorders and overall mental well-being. Emotional regulation is the process of mediating the type of emotional response, experience, and the expression of emotions.[1] Alcohol dependence has been associated with emotional dysfunction.[2] Different patterns of emotional dysregulation have been observed in different phases of alcohol dependence, i.e., abstinence is associated with more adaptive emotion regulation patterns and inefficient regulation drives to craving, relapse, and the maintenance of alcohol use.[2],[3],[4],[5] Despite being a core feature of alcohol dependence and a necessary component of optimal social functioning, there are only a few studies that address this issue in India. Tikka et al. found significantly higher anger expression with severe alcohol dependence.[6] George also reported a greater emotional dysregulation in severe alcohol dependence.[7] However, both the studies were constrained by small sample size.

Cognition refers to the mental processes by which external or internal input is transformed, reduced, elaborated, stored, recovered, and used.[8] Normal cognitive functioning is crucial to maintaining our day-to-day normal activity. Alcohol dependence is known to be associated with cognitive dysfunction.[9] Level of cognitive functions often predicts the functional outcome.[10] There are only a few studies conducted in India to examine cognitive function in alcohol use disorder. Bhat and Gambhir examined cognitive functions and observed a significant impairment in all parameters of cognition.[11] However, this study was limited to the military population. Kumar et al. also had a similar finding in early-onset alcohol dependence, depending on the demographic and clinical characteristics.[12] However, this study was constrained by small sample size.

Relationship between emotional regulation and cognitive functions appears to be reciprocal. Executive functions play an important role in emotion regulation, and cognitive dysfunction may lead to emotional dysregulation.[13],[14] In lower age, cognitive reappraisal of emotion and cognitive functions is positively correlated.[15] On the other hand, emotional stress can alter the cognitive networks that process information about perception, meaning, and action responses toward executing goals.[16] Inefficient responses of the cognitive control network (CCN) to emotional stimuli such as poor cognitive inhibition may perpetuate emotion dysregulation.[17],[18] Emotional dysregulation has been identified as a risk factor for cognitive impairment in adults.[19] Improving cognitive control over and persistence of emotional responses is often the target for cognitive-based psychotherapeutic approaches for the treatment of affective illnesses.[20]

Although there is evidence supporting the close relationship between emotion and cognition in mood disorders, there is a knowledge gap as to how emotional regulation and cognitive function are related in patients of alcohol dependence. With alcohol dependence being associated with emotional dysregulation and cognitive impairment, these variables may interact with and perpetuate the severity of each other. Interventions aimed to address either of them may contribute to the improved outcome of alcohol dependence. Being an independent determinant of the outcome of alcohol dependence, this preliminary study was carried out with the aim to know the level of emotional dysregulation and cognitive function and their correlation in patients with alcohol dependence. We hypothesized that levels of emotional dysregulation and cognitive function are inversely related.

 Materials and Methods

This hospital-based cross-sectional study was conducted at the Department of Psychiatry, JSS Medical College and Hospital, Mysore, Karnataka, India, over a period of 6 months after approval from JSS Ethics Committee. Participants were recruited among patients attending the outpatient department of psychiatry for follow-up after obtaining informed consent. All participants underwent detailed evaluation by qualified psychiatrist. Inclusion criteria included age between 45 and 60 years, a diagnosis of alcohol dependence as per the ICD-10-DCR criteria, duration of dependence pattern for a minimum of 5 years. Participants were excluded if they had comorbid psychiatric diagnosis, mental retardation, or dementia. The estimated sample size for this study was 112. Of 156 screened, 120 met the selection criteria and were assessed further by with the following assessment tools:

Sociodemographic and clinical pro forma – pro forma consisted of items such as age, gender, socioeconomic status (SES), level of education, religion, and family type.

Montreal Cognitive Assessment (MoCA) – this tool was developed by Nasreddine et al. in 2005 to detect cognitive impairment and is available in more than 46 languages and dialects.[21] The scale assesses memory, visuospatial abilities, executive functioning, attention–concentration and working memory, language, and orientation. MoCA is a brief cognitive tool that can be administered over a period of 10 min and has a high sensitivity and specificity for detecting cognitive impairment. It has been used in patients with alcohol use disorder and dementia as time efficient and resource-conscious way to assess cognitive impairment.[22],[23] MoCA score ranges between 0 and 30; a score of 26 or more is considered to be normal. MoCA has good concordance with the corresponding subscale of many standard neuropsychological measures.[24],[25] It has been used as an assessment tool in hospital setups among psychiatric patients.[26] This tool has been used in the Indian population.[27],[28],[29]

Difficulty in Emotional Regulation Scale–Short Form (DERS-SF) – this tool was initially developed by Gratz and Roemer in 2004, and 2 years later shorter DERS-SF was introduced by the same author to assess emotional dysregulation.[30],[31],[32] DERS-SF is an 18-item questionnaire that assesses emotional responses in six domains – nonacceptance, goals, impulse, awareness, strategies, and clarity of emotion. Each item has possible response of 1 (almost never) to 5 (almost always). Higher score indicates poor emotional regulation and vice versa. The Cronbach's alpha coefficients for the DERS-SF total scale and six subscales range from 0.78 to 0.91. Findings suggest that the DERS-SF has comparable concurrent validity to the original DERS.[18] This scale has been used among Indian patients with alcohol use disorder.[7],[33],[34]

Statistical analysis was performed using SPSS Vs 22 (Statistics for windows, Armonk, NY, IBM Corp). Descriptive statistical analysis was used for sociodemographic and clinical characteristics. Kruskal–Wallis H-test was used to know the group differences in the score of MoCA and DERS-SF with sociodemographic and clinical variables. Regression analysis was performed to find the association between cognitive functions and emotional dysregulation.


The study sample consisted of 120 males. Sixty-four percent belonged to the lower SES, 96.7% were Hindu, and 60% belonged to a joint family [Table 1]a. The mean age was 51 years and standard deviation was 4.65 years. Mean scores of MoCA and DERS-SF scale were 23.77 and 26.9, respectively [Table 1]b. None of the sociodemographic variables had a statistically significant group difference on the score of DERS-SF [Table 2]. However, educational status had a statistically significant group difference on the MoCA score (P = 0.03) [Table 3]. Age of the participants had a statistically significant negative correlation with the score of MoCA (P = 0.011) [Table 4]. On linear regression analysis (R2 = 0.266, df = 0 1, F = 0 42.782, P = 0.001), there was a statistically significant negative association between MoCA and DERS-SF score (P = 0.01) [Table 5].{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}


To the best of our knowledge, this study is the first that attempted to examine the levels and correlation of emotional dysregulation and cognitive functions in alcohol dependence. There has been a contrast view about the relationship between emotion and cognition. Beck proposes that cognition determines the emotion; while the Affect infusion model assumes the contrary.[35] In alcohol dependence, both emotion and cognition are impaired, and their relationship is unknown, and thus, this preliminary study was conducted. This relationship may have therapeutic and prognostic implications for alcohol dependence.

Demographic characteristics of this study were similar to other reports from tertiary care centers in India, reflecting socioeconomic aspects of the rural area; as the center, the study has been done caters mainly to the rural population.[36] Participants were in a vulnerable age (mean age: 51 years) to adverse consequences of persistent alcohol use, particularly in the domains of cognitive and emotional functions, and our observation of mild cognitive impairment and emotional dysregulation in this study appears to be in accordance.[6],[7],[11],[12] This is of concern as the other studies in general population did not report cognitive impairment in the fifth decade of life, thus undermining the need for screening cognitive dysfunction in patients with alcohol dependence.[37]

Consistent with the other reports, we observed high levels of emotional dysregulation. It is possible that the study sample had more patients with severe dependence, as it was conducted at a tertiary care center and patients with more severe form of dependence may come for treatment. Such pattern of alcohol use is associated more with inefficient emotional regulation skills (i.e., impaired ability to tolerate-negative emotions)/strategies (leading to craving and the maintenance of alcohol use) that predict relapse.[2],[3],[4],[5],[6],[7],[22]

People with a better educational status appear to have better cognitive functions in this study. This is in accordance with other studies.[12] Higher level of education appears to be not only protective of cognitive function but also seems to be associated with slower deterioration over a longitudinal course in patients with severe cognitive impairment such as dementia, suggestive of underlying cognitive reserve phenomena that are operating.[38],[39] Similarly, an inverse association of age with cognitive function in alcohol dependence has been reported, as observed in this study.[12] With aging, there is difficulty in the speed of information processing and transforming information to make decisions and difficulty in executive functioning that may be aggravated by alcohol dependence.[40]

An important finding of this study was the inverse relationship between the level of cognitive functions and emotional dysregulation. This finding was consistent with our hypothesis. Although cognitive impairment and emotional dysregulation have been studied in other psychiatric disorders, no study had examined the relationship of these variables in alcohol dependence.[41] Indirect evidence suggests that, in alcohol dependence, the cognitive function remains underutilized during emotional regulation strategies probably due to cognitive impairments induced by prolonged excessive alcohol drinking.[2],[42] Frontal lobe, limbic system, and cerebellum are the most susceptible to alcohol-induced neuronal effects.[43] These structures are involved in cognitive control processes managed by CCN.[44] Inefficient responses of the CCN to emotional stimuli perpetuate the emotion dysregulation.[17] Some areas in the amygdala are involved in both enhancing and impairing effects of emotion on cognition.[45],[46] Independent emotional dysfunction due to alcohol dependence would further impair cognitive functions such as impulsive actions and impaired decision making that would maintain alcohol use and this result in a vicious cycle.[47] It appears that impaired cognitive function and emotional dysregulation may reciprocally perpetuate dysfunction.

In view of the findings in this study, it can be concluded that patients with alcohol dependence experience cognitive impairment and emotional dysregulation are inversely related. Further longitudinal examination is needed to ascertain these findings with an appropriate control group. Early interventions in emotional or cognitive remediation may have both therapeutic and preventive implication in alcohol dependence. Finding of the study should be interpreted cautiously. The finding may not be generalized to the general population as the study population were hospital admitted participant. There were possible referral and selection bias, and there was no control group to compare. Further study is needed in addressing these limitations.


The authors would like to thank Yahosha, Shamaya, Hagai, Asther, Yasuas, Marias (Divine Retreat Center, Chalakudy, Kerala, India), Ashish, Akash, and Mini for their moral support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Gross JJ, Thompson RA. Emotion regulation: Conceptual foundations. In: Gross JJ, editor. Handbook of Emotion Regulation. New York: Guilford Press; 2007. p. 3-24.
2Petit G, Luminet O, Maurage F, Tecco J, Lechantre S, Ferauge M, et al. Emotion regulation in alcohol dependence. Alcohol Clin Exp Res 2015;39:2471-9.
3Marlatt GA. Taxonomy of high-risk situations for alcohol relapse: Evolution and development of a cognitive-behavioral model. Addiction 1996;91 Suppl:S37-49.
4Philippot P, Kornreich C, Blairy S. Nonverbal deficits and interpersonal regulation in alcoholics. In: Philippot P, Feldman RS, Coats EJ, editors. Nonverbal Behavior in Clinical Settings. Oxford, UK: Oxford University Press; 2003. p. 209-31.
5Dvorak RD, Sargent EM, Kilwein TM, Stevenson BL, Kuvaas NJ, Williams TJ, et al. Alcohol use and alcohol-related consequences: Associations with emotion regulation difficulties. Am J Drug Alcohol Abuse 2014;40:125-30.
6Tikka DL, Ram D, Dubey I, Tikka SK. Socio-emotional factors in alcohol dependence. Indian J Psychol Med 2014;36:153-7.
7George B. Efficacy of acceptance and mindful based relapse prevention program on emotion regulation difficulty among alcoholics in Kerala India. J Alcohol Drug Depend 2015;3:205.
8Neisser U. Cognition and Reality. San Francisco, CA: Freeman; 1976.
9Bernardin F, Maheut-Bosser A, Paille F. Cognitive impairments in alcohol-dependent subjects. Front Psychiatry 2014;5:78.
10Kathleen M, Golisz K, Toglia JP. Perception and Cognition. In: Neistadt ME, Elizabeth CB, editors. Willard and Spackman's Occupational Therapy. 9th ed. Baltimore: Lippincott Williams and Willkins; 1998. p. 260.
11Bhat PS, Gambhir J. Neurocognitive impairment in alcohol-dependence syndrome cases and its response to treatment. Med J Armed Forces India 2011;67:117-21.
12Kumar R, Kumar KJ, Benegal V, Roopesh BN. Cognitive deficits in early onset alcoholism. Int J Curr Med Pharm Res 2016;2:1137-42.
13Joormann J, Siemer M. Affective processing and emotion regulation in dysphoria and depression: Cognitive biases and deficits in cognitive control. Soc Personal Psychol Compass 2011;5:13-28.
14Holley SR, Ewing ST, Stiver JT, Bloch L. The relationship between emotion regulation, executive functioning, and aggressive behaviors. J Interpers Violence 2015. pii: 0886260515592619.
15Lantrip C, Isquith PK, Koven NS, Welsh K, Roth RM. Executive function and emotion regulation strategy use in adolescents. Appl Neuropsychol Child 2016;5:50-5.
16Foa EB, Kozak MJ. Emotional processing of fear: Exposure to corrective information. Psychol Bull 1986;99:20-35.
17Joormann J, Yoon K, Siemer M. Cognition and emotion regulation. In: Kring A, Sloan D editors. Emotion Regulation and Psychopathology: A Transdiagnostic Approach to Etiology and Treatment. New York: Guilford Press; 2010. p. 174-203.
18Alexopoulos GS, Kiosses DN, Heo M, Murphy CF, Shanmugham B, Gunning-Dixon F, et al. Executive dysfunction and the course of geriatric depression. Biol Psychiatry 2005;58:204-10.
19Ismail Z, Gatchel J, Bateman DR, Barcelos-Ferreira R, Chantillon M, Jaeger J, et al. Affective and emotional dysregulation as pre-dementia risk markers: Exploring the mild behavioral impairment symptoms of depression, anxiety, irritability, and euphoria. Int Psychogeriatr 2018;30:185-96.
20Berking M, Wupperman P. Emotion regulation and mental health: Recent findings, current challenges, and future directions. Curr Opin Psychiatry 2012;25:128-34.
21Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The montreal cognitive assessment, moCA: A brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005;53:695-9.
22Copersino ML, Fals-Stewart W, Fitzmaurice G, Schretlen DJ, Sokoloff J, Weiss RD, et al. Rapid cognitive screening of patients with substance use disorders. Exp Clin Psychopharmacol 2009;17:337-44.
23Ridley N, Batchelor J, Draper B, Demirkol A, Lintzeris N, Withall A, et al. Cognitive screening in substance users: Diagnostic accuracies of the mini-mental state examination, addenbrooke's cognitive examination-revised, and montreal cognitive assessment. J Clin Exp Neuropsychol 2018;40:107-22.
24Vogel SJ, Banks SJ, Cummings JL, Miller JB. Concordance of the montreal cognitive assessment with standard neuropsychological measures. Alzheimers Dement (Amst) 2015;1:289-94.
25Miller JB, Vogel S, Banks SJ, Miller JB. Factor analysis and construct validity of the Montreal Cognitive Assessment: Concordance with standard neuropsychological measures. Alzheimers Dement 2014;10:559-60.
26Gierus J, Mosiołek A, Koweszko T, Wnukiewicz P, Kozyra O, Szulc A, et al. The montreal cognitive assessment as a preliminary assessment tool in general psychiatry: Validity of moCA in psychiatric patients. Gen Hosp Psychiatry 2015;37:476-80.
27Kaur D, Kumar G, Singh AK. Quick screening of cognitive function in Indian multiple sclerosis patients using montreal cognitive assessment test-short version. Ann Indian Acad Neurol 2013;16:585-9.
28Krishnan S, Justus S, Meluveettil R, Menon RN, Sarma SP, Kishore A, et al. Validity of montreal cognitive assessment in non-English speaking patients with Parkinson's disease. Neurol India 2015;63:63-7.
29Nathami R, Amirthalingam P, Mukunthu N, Arunachalam G. Sensitivity of montreal cognitive assessment in comparison with mini mental status examination in testing cognitive status in epilepsy patients with phenytoin monotherapy. AJPCT 2015;3:237-44.
30Hobson J. The montreal cognitive assessment (MoCA). Occup Med 2015;65:764-5.
31Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav Assess 2004;26:41-54.
32Kaufman EA, Xia M, Fosco G, Yaptangco M, Skidmore CR, Crowell SE. The difficulties in emotion regulation scale short form (DERS-SF): Validation and replication in adolescent and adult samples. J Psychopathol Behav Assess 2016;38:443.
33Snow NL, Ward RM, Becker SP, Raval VV. Measurement invariance of the difficulties in emotion regulation scale in India and the United States. J Edu Dev Psychol 2013;3:147-57.
34Koul P, Shakher C. Orphanhood; in the context of mental health and difficulty in emotion regulation of children. Indian J Health Wellbeing 2014;5:927-30.
35Forgas JP. Mood and judgment: The affect infusion model (AIM). Psychol Bull 1995;117:39-66.
36Ram D. Whole blood thiamine levels and its relationship with severity of alcohol withdrawal and neurological soft signs in patients with alcohol use disorder. J Neuropsychiatry 2016;1:1-5.
37Das SK, Bose P, Biswas A, Dutt A, Banerjee TK, Hazra AM, et al. An epidemiologic study of mild cognitive impairment in Kolkata, India. Neurology 2007;68:2019-26.
38Berking M, Margraf M, Ebert D, Wupperman P, Hofmann SG, Junghanns K, et al. Deficits in emotion-regulation skills predict alcohol use during and after cognitive-behavioral therapy for alcohol dependence. J Consult Clin Psychol 2011;79:307-18.
39Vadikolias K, Tsiakiri-Vatamidis A, Tripsianis G, Tsivgoulis G, Ioannidis P, Serdari A, et al. Mild cognitive impairment: Effect of education on the verbal and nonverbal tasks performance decline. Brain Behav 2012;2:620-7.
40Murman DL. The impact of age on cognition. Semin Hear 2015;36:111-21.
41Anticevic A, Schleifer C, Youngsun TC. Emotional and cognitive dysregulation in schizophrenia and depression: Understanding common and distinct behavioral and neural mechanisms. Dialogues Clin Neurosci 2015;17:421-34.
42Pitel AL, Rivier J, Beaunieux H, Vabret F, Desgranges B, Eustache F, et al. Changes in the episodic memory and executive functions of abstinent and relapsed alcoholics over a 6-month period. Alcohol Clin Exp Res 2009;33:490-8.
43Moselhy HF, Georgiou G, Kahn A. Frontal lobe changes in alcoholism: A review of the literature. Alcohol Alcohol 2001;36:357-68.
44Niendam TA, Laird AR, Ray KL, Dean YM, Glahn DC, Carter CS, et al. Meta-analytic evidence for a superordinate cognitive control network subserving diverse executive functions. Cogn Affect Behav Neurosci 2012;12:241-68.
45Etkin A, Egner T, Kalisch R. Emotional processing in anterior cingulate and medial prefrontal cortex. Trends Cogn Sci 2011;15:85-93.
46Dolcos F, Wang L, Mather M. Current research and emerging directions in emotion-cognition interactions. Editorial paper for the frontiers research topic “the impact of emotion on cognition – Dissociating between enhancing and impairing effects” and the associated edited book. Front Integr Neurosci 2014;8:83.
47Murphy A, Taylor E, Elliott R. The detrimental effects of emotional process dysregulation on decision-making in substance dependence. Front Integr Neurosci 2012;6:101.