Mindfulness-Oriented Expressive Painting for Emotional Dysregulation: A 52-Week Multilevel Mechanistic Longitudinal Trial Integrating Psychological, Physiological, and Neural Indicators

Emotional dysregulation is a transdiagnostic factor underlying various psychological disorders. This study examined the efficacy of Mindfulness-Oriented Expressive Painting (MOEP) and tested a novel Integrative Multilevel Emotion Regulation Model (IMERM).

A 52-week randomized controlled trial was conducted with 195 adults (aged 18–55, DERS ≥ 80) allocated to MOEP intervention (n = 65), active control (n = 65), or waitlist control (n = 65). The 16-week intervention comprised weekly 90-min group sessions and 30-min online practice, followed by 36-week follow-up. Assessments included psychological instruments, physiological indicators (HRV, cortisol, IL-6), and neuroimaging measures (fMRI).

The MOEP group demonstrated significant improvements with large effect sizes: emotion dysregulation (d = 1.72), trait mindfulness (d = 1.41), rumination (d = 1.28), and cognitive reappraisal (d = 1.24). Physiological outcomes showed enhanced HRV, reduced cortisol (24.2%), and decreased inflammatory markers. Neuroimaging revealed strengthened prefrontal-amygdala connectivity (77.8% increase) and reduced default mode network activity. Gains were maintained at 52-week follow-up. Multilevel structural equation modeling provided initial support for the IMERM framework.

MOEP produced significant, sustained improvements through coordinated psychological, physiological, and neural changes, with effect sizes exceeding standard mindfulness interventions. The findings support integrating expressive arts with contemplative practices for emotion regulation difficulties.

This study is not preregistered.