, there is not agreement on the definition of emotion regulation , which has been inconsistently defined in the different studies . emotion regulation has rooted in analytical psychology , stress and coping strategies ( 1 ) . some concepts of emotion regulation emphasize the ability to control emotional experience and expression of negative emotions ( 2 , 3 ) . unlike other concepts , stress on the functional nature of emotions has suggested that adaptive emotion regulation involves the ability to control behaviors ( e.g. by engaging in goal - directed behaviors and or inhibiting impulsive behaviors ) rather than just controlling emotions in the face of negative emotions ( 4 , 5 ) . in fact , lack of the ability to experience and differentiate emotions and also spontaneous responses may be maladaptive similar to disability in reducing and regulating intense negative emotions ( 6 , 7 ) . previous research shows that difficulties in emotion regulation ( emotional dysregulations ) are key factors in developing many clinical behaviors and psychological problems ( 8) . furthermore , emotional dysregulation have been identified in numerous forms of psychopathology , ranging from affective disorders to personality disorders ( 6 ) such as generalized anxiety disorder ( gad ) ( 9 ) , depression ( 10 ) , anxiety ( 11 ) , borderline personality disorder ( 12 ) , social anxiety ( 13 ) , substance use ( 14 ) , and psychosomatic disorders ( e.g. functional gastrointestinal disorders ) ( 15 ) . study upon patients with functional gastrointestinal disorders ( fgid ) indicated that some factors involved in emotional dysregulation ( difficulties engaging in goal - directed behavior and lack of emotional awareness ) are predictors of decreased acceptance of pain ( 15 ) . experimental research has also shown that affect - based treatments and or interventions based on emotion regulation are effective in reduction severity of somatic symptoms besides emotions ( e.g. anxiety and depression ) ( 16 - 18 ) . furthermore , in the domains of emotion research and in the context of interventions for clinical problems , further attention has been paid to the concept of mindfulness and its practices . it is believed that the main cause of human distress is judging events as  good versus bad  ( 19 ) . also , it is assumed that mindfulness has a major impact on the release of individuals from their thoughts , habits and unhealthy behaviors ( 20 ) because it implies non - judgmental and nonreactive acceptance of emotional states ( 21 ) . hence , mindfulness increases self - regulated behavior related to improvement of well - being ( 20 ) . studies have shown that mindfulness negatively correlates with psychological symptoms of distress such as anxiety and depression , and positively with various forms of psychological well - being ( 22 , 23 ) . the useful effects of mindfulness - based interventions , such as mindfulness - based cognitive therapy ( mbct ) , especially mindfulness - based stress reduction ( mbsr ) , on human well - being have been confirmed in several studies ( 24 - 26 ) . mindfulness practices can enhance functional status , well - being , and reduce physical or psychological distresses ( 25 ) . ( 26 ) reported fewer symptoms of stress ; fewer somatic symptoms ( cardiopulmonary and gastrointestinal ) ; less emotional irritability , depression , and cognitive disturbance ; and fewer habitual patterns of stress , after mindfulness - based intervention in cancer outpatients . since both mindfulness and emotion regulation influence different aspects of well - being , these two constructs might be related to each other and some aspects of this relationship were demonstrated during some studies ( 19 , 21 ) . emotion regulation overlaps with mindfulness , in its emphasis on observing and describing emotions ( without necessarily acting on those emotions ) , and also participating in present moment activities ( i.e. engaging in goal - directed behavior when distressed ) ( 8) . the findings of the previous studies suggest that mindfulness can conduce to better emotional condition by reducing negative affectivity and various difficulties related to emotion ( 21 ) . it induces self - regulatory behaviors and increases experiences of positive emotional states ( 27 ) . because emotional disturbances are present in many patients with fgid ( as psychosomatic disorders ) , particularly in referral population , this study aimed to evaluate relationships of emotion regulation difficulties and mindfulness with psychological and digestive symptoms in those patients . although some aspects of the relationship between mindfulness and emotion regulation have already been investigated , some other aspects still need to be studied . for instance , the association between the factors involved in emotion regulation and mindfulness has not been investigated yet . hence , the main goal of the study was to examine the role of difficulties in emotion regulation and mindfulness in psychological and somatic symptoms of patients with fgid . in this cross - sectional study , 167 patients with fgid referred to the psychosomatic disorders clinic of isfahan were selected by census method , according to criteria of research . study criteria included willingness to participate in the study , age range of 18 - 70 years , lack of acute psychiatric disorders , and the diagnosis of fgid on the basis of rome iii criteria by gastroenterologists . to observe ethical considerations , the researcher assured to patients of the confidentiality of their information . in current study , demographic information included age , sex , marital status , and educational level . the difficulties in emotion regulation scale ( ders ) assesses difficulties in emotion regulation and can distinguish adaptive emotion regulation from emotional avoidance and expressive control . the scale is composed of 6 factors , including , non - acceptance of emotional responses ( non - acceptance ) , difficulties engaging in goal - directed behavior ( goal ) , impulse control difficulties ( impulse ) , lack of emotional awareness ( awareness ) , limited access to emotion regulation strategies ( strategy ) , and lack of emotional clarity ( clarity ) . ders has 36 items that are rated on a 5-point likert - type scale , ranging from 1 ( almost never ) to 5 ( almost always ) , and are recoded so that higher scores in every case indicate greater difficulties in emotion regulation . the scale has high internal consistency ; cronbach  = 0.93 for total ders and cronbach  > 0.80 for each factors ; also its test - retest equals 0.87 for total ders and ranges from 0.69 to 0.89 for all factors ( 28 ) . in an iranian healthy sample , internal consistency of the scale using cronbach  ranged from 0.66 to 0.88 for all factors ( 29 ) . with regard to validity , studies have suggested sufficient construct and predictive validity to the scale ( 28 ) . mindful attention awareness scale ( maas ) is a 15-item self - report measure of the present moment attention and awareness . items reflect in attention across several domains ( e.g. cognitive , emotional , physical , and general ) . each item rates over a 6-point likert - type scale , with 6 indicating  almost never  and 1 indicating  almost always . so , high scores reflect higher levels of present moment attention . it has been revealed a single - factor model for the scale , along with good internal consistency (  = 0.82 ) and temporal stability ( 27 ) . in this sample , the initial version of the depression , anxiety , and stress scale ( dass ) contained 42 phrases about negative emotional states . the scale measures the intensity of depression , anxiety , stress symptoms and can be used to assess treatment progression . subject rates intensity ( frequency ) of symptom presented in each phrase which he or she has experienced over the past week over a 4-point likert scale , ranging from 0 ( did not apply to me at all ) to 3 ( applied to me very much ) . cronbach  values have been reported for depression , anxiety , and stress as 0.91 , 0.81 , 0.89 , respectively ( 30 ) . the internal consistency reliability of short form of the 21-dass ( each of its subscales comprises 7 items ) was computed in an iranian sample and cronbach  values for depression , anxiety , and stress were 0.81 , 0.74 , 0.78 , respectively ( 31 ) . the gastrointestinal symptom rating scale ( gsrs ) is a disease - specific instrument of 15 items , with 5 subscales ( symptom clusters ) , including abdominal pain , reflux , diarrhea , constipation , and indigestion . the gsrs is rated on a 7-point likert - type scale , ranging from 1 ( no discomfort at all ) to 7 ( very severe discomfort ) . based on cronbach  , the internal consistency validities of total gsrs and its subscales have been reported as 0.62 , 0.61 , 0.83 , 0.80 , and 0.70 , respectively ( 32 ) . furthermore , in an iranian sample of patients with fgid , cronbach  values of the gsrs and the subscales of diarrhea , abdominal pain , constipation , indigestion were equivalent to 0.81 , 0.70 , 0.70 , 0.63 , 0.76 , respectively ( 33 ) . pearson correlation coefficient was used to test the relation between emotional dysregulation ( difficulties in emotion regulation ) , mindfulness and symptoms . the dependent variables were psychological and somatic symptoms and mindfulness ; the independent variables were emotional dysregulation and its factors and mindfulness . the spss version 15.0 ( spss inc . , in this cross - sectional study , 167 patients with fgid referred to the psychosomatic disorders clinic of isfahan were selected by census method , according to criteria of research . study criteria included willingness to participate in the study , age range of 18 - 70 years , lack of acute psychiatric disorders , and the diagnosis of fgid on the basis of rome iii criteria by gastroenterologists . to observe ethical considerations , the researcher assured to patients of the confidentiality of their information . in current study , demographic information included age , sex , marital status , and educational level . the difficulties in emotion regulation scale ( ders ) assesses difficulties in emotion regulation and can distinguish adaptive emotion regulation from emotional avoidance and expressive control . the scale is composed of 6 factors , including , non - acceptance of emotional responses ( non - acceptance ) , difficulties engaging in goal - directed behavior ( goal ) , impulse control difficulties ( impulse ) , lack of emotional awareness ( awareness ) , limited access to emotion regulation strategies ( strategy ) , and lack of emotional clarity ( clarity ) . ders has 36 items that are rated on a 5-point likert - type scale , ranging from 1 ( almost never ) to 5 ( almost always ) , and are recoded so that higher scores in every case indicate greater difficulties in emotion regulation . the scale has high internal consistency ; cronbach  = 0.93 for total ders and cronbach  > 0.80 for each factors ; also its test - retest equals 0.87 for total ders and ranges from 0.69 to 0.89 for all factors ( 28 ) . in an iranian healthy sample , internal consistency of the scale using cronbach  ranged from 0.66 to 0.88 for all factors ( 29 ) . with regard to validity , studies have suggested sufficient construct and predictive validity to the scale ( 28 ) . mindful attention awareness scale ( maas ) is a 15-item self - report measure of the present moment attention and awareness . items reflect in attention across several domains ( e.g. cognitive , emotional , physical , and general ) . each item rates over a 6-point likert - type scale , with 6 indicating  almost never  and 1 indicating  almost always . it has been revealed a single - factor model for the scale , along with good internal consistency (  = 0.82 ) and temporal stability ( 27 ) . in this sample , the initial version of the depression , anxiety , and stress scale ( dass ) contained 42 phrases about negative emotional states . the scale measures the intensity of depression , anxiety , stress symptoms and can be used to assess treatment progression . subject rates intensity ( frequency ) of symptom presented in each phrase which he or she has experienced over the past week over a 4-point likert scale , ranging from 0 ( did not apply to me at all ) to 3 ( applied to me very much ) . cronbach  values have been reported for depression , anxiety , and stress as 0.91 , 0.81 , 0.89 , respectively ( 30 ) . the internal consistency reliability of short form of the 21-dass ( each of its subscales comprises 7 items ) was computed in an iranian sample and cronbach  values for depression , anxiety , and stress were 0.81 , 0.74 , 0.78 , respectively ( 31 ) . the gastrointestinal symptom rating scale ( gsrs ) is a disease - specific instrument of 15 items , with 5 subscales ( symptom clusters ) , including abdominal pain , reflux , diarrhea , constipation , and indigestion . the gsrs is rated on a 7-point likert - type scale , ranging from 1 ( no discomfort at all ) to 7 ( very severe discomfort ) . based on cronbach  , the internal consistency validities of total gsrs and its subscales have been reported as 0.62 , 0.61 , 0.83 , 0.80 , and 0.70 , respectively ( 32 ) . furthermore , in an iranian sample of patients with fgid , cronbach  values of the gsrs and the subscales of diarrhea , abdominal pain , constipation , indigestion were equivalent to 0.81 , 0.70 , 0.70 , 0.63 , 0.76 , respectively ( 33 ) . in current study , demographic information included age , sex , marital status , and educational level . the difficulties in emotion regulation scale ( ders ) assesses difficulties in emotion regulation and can distinguish adaptive emotion regulation from emotional avoidance and expressive control . the scale is composed of 6 factors , including , non - acceptance of emotional responses ( non - acceptance ) , difficulties engaging in goal - directed behavior ( goal ) , impulse control difficulties ( impulse ) , lack of emotional awareness ( awareness ) , limited access to emotion regulation strategies ( strategy ) , and lack of emotional clarity ( clarity ) . ders has 36 items that are rated on a 5-point likert - type scale , ranging from 1 ( almost never ) to 5 ( almost always ) , and are recoded so that higher scores in every case indicate greater difficulties in emotion regulation . the scale has high internal consistency ; cronbach  = 0.93 for total ders and cronbach  > 0.80 for each factors ; also its test - retest equals 0.87 for total ders and ranges from 0.69 to 0.89 for all factors ( 28 ) . in an iranian healthy sample , internal consistency of the scale using cronbach  ranged from 0.66 to 0.88 for all factors ( 29 ) . with regard to validity , studies have suggested sufficient construct and predictive validity to the scale ( 28 ) . mindful attention awareness scale ( maas ) is a 15-item self - report measure of the present moment attention and awareness . items reflect in attention across several domains ( e.g. cognitive , emotional , physical , and general ) . each item rates over a 6-point likert - type scale , with 6 indicating  almost never  and 1 indicating  almost always . so , high scores reflect higher levels of present moment attention . it has been revealed a single - factor model for the scale , along with good internal consistency (  = 0.82 ) and temporal stability ( 27 ) . in this sample , the initial version of the depression , anxiety , and stress scale ( dass ) contained 42 phrases about negative emotional states . the scale measures the intensity of depression , anxiety , stress symptoms and can be used to assess treatment progression . subject rates intensity ( frequency ) of symptom presented in each phrase which he or she has experienced over the past week over a 4-point likert scale , ranging from 0 ( did not apply to me at all ) to 3 ( applied to me very much ) . cronbach  values have been reported for depression , anxiety , and stress as 0.91 , 0.81 , 0.89 , respectively ( 30 ) . the internal consistency reliability of short form of the 21-dass ( each of its subscales comprises 7 items ) was computed in an iranian sample and cronbach  values for depression , anxiety , and stress were 0.81 , 0.74 , 0.78 , respectively ( 31 ) . the gastrointestinal symptom rating scale ( gsrs ) is a disease - specific instrument of 15 items , with 5 subscales ( symptom clusters ) , including abdominal pain , reflux , diarrhea , constipation , and indigestion . the gsrs is rated on a 7-point likert - type scale , ranging from 1 ( no discomfort at all ) to 7 ( very severe discomfort ) . based on cronbach  , the internal consistency validities of total gsrs and its subscales have been reported as 0.62 , 0.61 , 0.83 , 0.80 , and 0.70 , respectively ( 32 ) . furthermore , in an iranian sample of patients with fgid , cronbach  values of the gsrs and the subscales of diarrhea , abdominal pain , constipation , indigestion were equivalent to 0.81 , 0.70 , 0.70 , 0.63 , 0.76 , respectively ( 33 ) . pearson correlation coefficient was used to test the relation between emotional dysregulation ( difficulties in emotion regulation ) , mindfulness and symptoms . the dependent variables were psychological and somatic symptoms and mindfulness ; the independent variables were emotional dysregulation and its factors and mindfulness . the spss version 15.0 ( spss inc . , in the study , 167 patients with fgid participated with the following characteristics : mean ( sd ) age of 33.81(10.56 ) years ; 135 ( 80.8% ) female ; 69 ( 41.6% ) graduated ; and 14 ( 74.3% ) married . the demographic information are presented in table 1 . descriptive statistics ( mean  sd ) and correlation coefficients between variables are presented in table 2 . difficulties in emotion regulation , on the whole and in parts , except  awareness  factor were significantly and positively correlated with severity of psychological symptoms . they also ( except awareness and clarity factors ) were significantly and positively correlated with severity of digestive symptoms . additionally , mindfulness was significantly and inversely correlated with both aspects of psychological and somatic symptoms . in addition , mindfulness was negatively correlated with difficulties in emotion regulation and its factors ( except awareness ) . abbreviations : a , anxiety ; d , depression ; ders , the difficulties in emotion regulation scale ; s , stress ; gsrs , gastrointestinal symptom rating scale ; maam , mindful attention awareness scale . 1 , maam ; 2 , total ders ; 3 , ders - non - accept ; 4 , ders - goal ; 5 , ders - impulse ; 6 , ders - awareness ; 7 , ders - strategy ; 8 , ders - clarity ; 9 , d ; 10 , a ; 11 , s ; 12 , gsrs . afterwards , to examine whether the factors of difficulties in emotion regulation ( ders ) and mindfulness ( maas ) predict independent variances in the severity of both aspects of symptoms , we performed stepwise multiple regression analyses . in the first step of regression , ders ( total and its factors ) were entered as the sole predictors of symptoms , and in the next step , mindfulness was entered . abbreviations : ders , the difficulties in emotion regulation scale ; maam , mindful attention awareness scale ; gsrs , gastrointestinal symptom rating scale . predictors : ders - goal , ders - impulse , maas ; dependent variable : gsrs . abbreviations : d , depression ; a , anxiety ; s , stress ; ders , the difficulties in emotion regulation scale ; maam , mindful attention awareness scale . dependent variable : a ; predictors : ders - strategy , ders - impulse , ders - non - accept , maas and age . dependent variable : s ; predictors : ders , d5 , maas and age . as it can be seen in table 3 , the results showed that only variables of goal and impulse remained as significantly independent predictors for somatic symptoms . mindfulness was not a significant predictor of symptoms with levels of ders controlled and did not significantly improve the model . whereas age was correlated with psychological symptoms ( especially anxiety and stress ) for controlling , it was entered in regression equations . the findings showed that in addition to total ders and some of its factors , mindfulness was also a predictor for depression , anxiety , and stress . it significantly improved the models , contributing an additional 3.3% , 1.8% , 2.8% of the variance for d , a , and s , consecutively ( table 4 ) . in general , results showed that difficulties in emotion regulation played the main role in prediction of the severity of psychological and somatic ( digestive ) symptoms and some factors acted as independent predictors ( e.g. impulse , strategy ) . we performed other stepwise multiple regression analyses to examine whether the factors of difficulties in emotion regulation predict independent variances for mindfulness . as it can be seen in table 5 , three factors of impulse , clarity , and non - accept acted as negatively significant predictors of mindfulness . dependent variable : maas ; predictors : ders - impulse , ders - clarity , ders - non - accept . determination of the role of difficulties in emotion regulation and mindfulness in psychological and somatic symptoms are important . according to gratz and tull ( 8) , the difficulties in clinical disorders and maladaptive behaviors would have important implications for the development of more targeted interventions . although the issue of difficulties in emotion regulation and mindfulness has been assessed in some psychiatric and medical disorders , this study was the first to examine the relationship between mindfulness and especially difficulties in emotion regulation with psychological and somatic ( digestive ) symptoms in fgid . as predicted , the findings of the study revealed positive significant associations between emotional dysregulation and most of its factors with psychological and somatic symptoms . regression analyses showed that some viewed variables can predict these symptoms ( i.e. the relationships remained when shared variance associated with other variables and also age was accounted ) . in other words , difficulties engaging in goal - directed behavior , difficulties in impulsive behaviors control , limited access to emotion regulation strategies , and non - acceptance of emotional responses were the most powerful factors in relation to symptoms . studies have shown that emotion regulation skills ( e.g. emotional acceptance , ability to engage in goal - directed behavior , adaptive strategies ) are associated with lower emotional problems ( 34 , 35 ) . as a note , in this study psychological and somatic symptoms were not correlated with the lack of awareness factor . it is contrary to some previous research that has been revealed awareness an important factor , which has positive or negative effect on emotion regulation process and some somatic symptoms ( 15 , 36 , 37 ) . ( 9 ) study that found all dimensions of emotion regulation difficulties ( with the exception of lack of emotional awareness ) were significantly elevated among individuals with gad . according to bardeen et al . ( 38 ) , ders awareness may sufficiently measure emotional awareness , but lack of emotional awareness is not necessarily associated with distress or attention to emotional states does not necessarily represent a healthy response or regulation of such states . also , our findings indicated that mindfulness were negatively correlated to both symptoms , however it was stronger for psychological symptoms . such results highlight the obvious benefits of mindfulness among patients and confirm the results of previous studies ( 20 , 22 , 23 ) . mindfulness interventions can alleviate the symptoms of physical and psychiatric disorders ( 26 , 39 ) . investigations have shown improvements in mental health measures , including psychological dimensions of quality of life , depression , anxiety , coping style and other affective dimensions of disability , and in some health parameters of physical well - being such as medical symptoms , sensory pain , and physical impairment ( 40 , 41 ) . in evaluating the relationship between difficulties in emotion regulation and mindfulness , the findings showed that desr total score and most of its factors were negatively correlated with mindfulness and this relationship remained for factors of non - accept , impulse , and clarity when controlling for variance shared with the others . ( 42 ) showed that mindfulness had significant relationships with emotion regulation on the whole and also with impulse control and goal attainment difficulties when distressed . when people experience negative emotions , they encounter problems in goal - oriented behavior ( such as loss of concentration or effective problem solving ) ( 43 ) . coffey et al . ( 44 ) identified clarity of internal experiences as a partial mediator of the relationship between mindfulness and negative affect regulation . however in their conceptual definitions , both mindfulness and emotion regulation difficulties included awareness and acceptance of emotional responses , but the findings showed that mindfulness was not significantly correlated with ders awareness . awareness of or attention to emotions as assessed in emotion regulation scales may not correspond to reduced clinical problems or increased well - being ( 45 , 46 ) . so , should this concept be valid , self - reported lack of awareness in ders alone may not be related to awareness of the present moment in mindfulness , because mindfulness includes awareness of emotional experiences with an attitude of acceptance and nonjudging ( 21 ) . thus , in processing the relationship between mindfulness and emotional dysregulation , that ingredient of acceptance of emotional responses may be more influential . the main limitations of this study were non - random sampling ( because of limited statistical population ) and reliance on self - report data which may be recall bias regarding the occurrence of symptoms . also , other social factors that may affect the relationship between variables have been overlooked . overall , the findings of the study indicate that the constructs of emotion regulation difficulties ( emotional dysregulation ) and mindfulness are related to both psychological and somatic symptoms in fgid , but some factors of dysregulation have more influential role in relation to increased symptoms as well as decreased mindfulness . patients with fgid may benefit from treatments that facilitate emotional experience , functional status , and ability to control impulsive behaviors . they can behave according to the goals when experiencing negative emotions ( i.e. emotion regulation skills ) . to reduce symptoms , treatments might further towards emotion regulation , and mindfulness practices can be utilized as one of the strategies or skills of emotion regulation . although more research is needed to uphold conclusions , the study can be a thoroughfare for future research in more examination of influential factors in poor emotion regulatory ability and their roles in developing psychological and somatic symptoms in physical disorders .
background : negative emotions are the best predictors for psychological and physical health.objectives:we aimed to investigate the role of difficulties in emotion regulation and mindfulness on psychological and somatic symptoms of patients with functional gastrointestinal disorders ( fgid).patients and methods : in this cross - sectional study , the studied sample was selected using census method . 
 a total of 167 patients with fgid completed a demographic questionnaire , difficulties in emotion regulation scale ( ders ) , mindful attention awareness scale ( maas ) , depression , anxiety and stress scale ( dass ) , and gastrointestinal symptom rating scale ( gsrs ) . to examine the relationship between studied variables , pearson correlation coefficients and multiple regression analyses were used.results:the findings of the study 
 indicate that difficulties in emotion regulation and mindfulness are significantly correlated to both increased psychological and somatic symptoms . 
 some factors of difficulties in emotion regulation positively predicted those symptoms . among these factors , 
 only lack of awareness was not significantly correlated with both symptoms as well as decreased mindfulness.conclusions:the findings suggest some potential targets to reduce symptoms . 
 patients with fgid may benefit from treatments that facilitate emotional experience , functional status , and ability to control impulsive behaviors and behave according to the goals when experiencing negative emotions .