Psychology, Health & Medicine

ISSN: 1354-8506 (Print) 1465-3966 (Online) Journal homepage: https://www.tandfonline.com/loi/cphm20

Anxiety and depression aggravate impulsiveness:

the mediating and moderating role of cognitive
flexibility

Yongjuan Yu, Yongju Yu & Yigang Lin

To cite this article: Yongjuan Yu, Yongju Yu & Yigang Lin (2019): Anxiety and depression
aggravate impulsiveness: the mediating and moderating role of cognitive flexibility, Psychology,
Health & Medicine, DOI: 10.1080/13548506.2019.1601748

To link to this article: https://doi.org/10.1080/13548506.2019.1601748

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PSYCHOLOGY, HEALTH & MEDICINE
https://doi.org/10.1080/13548506.2019.1601748

Anxiety and depression aggravate impulsiveness: the

mediating and moderating role of cognitive flexibility
a b
Yongjuan Yu , Yongju Yu and Yigang Linb
a
School of Finance and Economics, Yangtze Normal University, Chongqing, China; bDepartment of
Sociology, Sichuan International Studies University, Chongqing, China

ABSTRACT ARTICLE HISTORY

Empirical research suggested that individuals with anxiety and/or Received 27 August 2018
depression exhibited action on the spur of the moment, with little Accepted 21 March 2019
consideration for the consequences of their actions. However, it KEYWORDS
remains unclear whether the precise mechanisms underlying the Anxiety; depression;
impacts of anxiety and depression on impulsivity. The present cognitive flexibility;
study examined how anxiety and depression influence impulsivity, attention impulsivity;
as well as the mediating and moderating role of cognitive flex- nonplanning impulsivity;
ibility. A sample of 477 Chinese university students was recruited. motor impulsivity
All participants finished self-report measures of anxiety, depres-
sion, impulsivity, and cognitive flexibility. No significant gender
difference was found in anxiety, depression, cognitive flexibility,
and three subscale scores of impulsivity. Greater scores of anxiety
and depression were associated with lower scores of cognitive
flexibility and higher levels of impulsivity. Depression and cogni-
tive flexibility could predict attention impulsivity and nonplanning
impulsivity, while anxiety and cognitive flexibility could predict
motor impulsivity. Cognitive flexibility served as a mediator in
the links of anxiety and three subscales of impulsivity.
Furthermore, cognitive flexibility moderated the impact of anxiety
on motor impulsivity.

Introduction
Impulsivity has been progressively drawn attention in recent psychology, cognitive
neuroscience, and clinic psychiatry. It has been defined as a predisposition toward
rapid, unplanned reactions to specific stimuli without consideration for the negative
outcomes (Moeller, Barratt, Dougherty, Schmitz, & Swann, 2001). Therefore, indivi-
duals with high impulsivity are often lack of careful consideration, exhibiting rapid,
unplanned reactions and inappropriate behaviors, ultimately leading to undesirable
consequences.
Impulsivity has a multidimensional structure. According to Barratt Impulsiveness
Scale-11 (BIS-11) developed by Patton, Stanford, and Barratt (1995), impulsivity has
been divided into three facets: 1) acting on the spur of the moment (motor activation),
2) making rapid cognitive decisions and having little tolerance for cognitive conflicts

CONTACT Yongju Yu [email protected] Department of Sociology, Sichuan International Studies

University, No. 33 Zhuangzhi Road, Lieshimu, Shapingba District, Chongqing 400031, China
© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 Y. YU ET AL.

not focusing on the task at hand (attention/cognition), and 3) not planning and
thinking carefully (lack of planning). Boschloo et al. (2013) divided it into four aspects,
including disinhibition, thrill/adventure seeking, experience seeking, and boredom
susceptibility.
Impulsivity has been recognized as a common feature to understand various clinical
disorders and problems (Hales, Yudofsky, & Gabbard, 2011), including psychiatric
disorders, substance misuse, disruptive behavioural disorders, gambling disorder
(Quilty, Mehra, Toneatto, & Bagby, 2010), and borderline personality disorder
(Bayard, Raffard, & Gely-Nargeot, 2011). It is also closely related to aggression, self-
injury, suicide attempts, domestic violence (Del Carlo et al., 2012) and risk-taking
behaviors (Black, Serowik, & Rosen, 2009). Therefore, focusing on the main variables
that affect impulsivity is becoming particularly important.
As the most common negative emotions for clinical and nonclinical populations,
anxiety and depression have been widely concerned by researchers. Moustafa et al.
reported that anxiety, followed by stress and depression, served as a strong predictor of
impulsivity in young-aged individuals (Moustafa, Tindle, Frydecka, & Misiak, 2017). In
a cross-sectional survey conducted among 210 university students (Sevincer, Ince,
Taymur, & Konuk, 2016), researchers noted that anxiety was significantly and positively
associated with attention and motor impulsivity, rather than nonplanning impulsivity,
while depression was found to be significantly and positively related to attention and
nonplanning impulsivity rather than motor impulsivity. Boschloo et al. (2013) demon-
strated that some aspects of impulsivity were more strongly related to anxiety, while
others were more strongly associated with depression. Therefore, previous studies
suggested that anxiety and depression may affect different aspects of impulsivity due
to their specific impairment characteristics in cognitive processing.
Although symptoms of anxiety and depression are often related to an individual’s
impulsive thoughts and actions, the underlying mechanisms are still unknown. The
emotion-cognition-behavior loop proposed by the cognitive-behavior school (Clark &
Fairburn, 1997) gives us a special perspective to understand how anxiety and depression
impact impulsivity. Increasing evidence suggested that both anxiety and depression may
lead to impaired cognitive function. For example, long term and extensive anxiety can
lead to deficits in cognitive flexibility and decision-making (Park & Moghaddam, 2017).
Clinical researchers have already found that people who had anxiety disorders have
difficulty shifting from a previously effective strategy to a currently valid strategy, and
are easily disturbed by the distractors (Lyche, Jonassen, Stiles, Ulleberg, & Landrø,
2010). According to Beck’s cognitive theory of depression, persons with depressive
symptoms are easily trapped in a ‘negative loop’, rigidly viewing themselves, the world,
and the future in a negative cognitive schema (Beck, 1967). Clinical research demon-
strated that people diagnosed with major depressive disorder exhibited cognitive inflex-
ibility with rigid and automatic thoughts (Deveney & Deldin, 2006). In a dynamic go/
no-task, researchers demonstrated that depressed individuals showed impaired cogni-
tive flexibility (Murphy et al., 1999). On the basis of these findings, we speculate that the
links between anxiety, depression, and impulsivity can be explained by cognitive
flexibility.
As a core aspect of executive functioning, cognitive flexibility has been defined as the
ability to freely shift cognitive sets to perceive or respond to external environment in
 PSYCHOLOGY, HEALTH & MEDICINE 3

a variety of way, including by thinking out multiple solutions to the problem, switching
freely between different categories of knowledge, and inhibiting the interferential
prepotent responses in order to achieve a specific goal (Johnco, Wuthrich, & Rapee,
2014; Rende, 2000). According to the finding by Dickman (1993), individuals with high
and low levels of impulsivity differed in their capability of shifting attention. A clinical
study on patients with obsessive-compulsive disorder revealed that cognitively inflexible
individuals exhibited more severe impulse symptoms (Chamberlain, Fineberg,
Blackwell, Robbins, & Sahakian, 2006).
Despite the importance of cognitive flexibility, knowledge is currently lacking with
respect to the vital role of cognitive flexibility in the relationships between anxiety,
depression, and impulsivity. This study therefore seeks to identify the relationship
between anxiety, depression, and specific dimensions of impulsivity, as well as the
role of cognitive flexibility. We hypothesized that (1) anxiety and depression would
be differently associated with three components of impulsivity. Further, we expected
that (2) the links between anxiety, depression, and impulsivity would be mediated by
cognitive flexibility; and (3) cognitive flexibility would also buffer the associations
between anxiety, depression, and impulsivity, such that anxiety and depression would
more positively predict impulsivity at lower than higher level of cognitive flexibility.

Method
Participants and procedures
This study was approved by the Ethics Committee of Yangtze Normal University. All
procedures were carried out in accordance with the Declaration of Helsinki. Selected by
random convenience, eligible 477 junior students were recruited from one university in
Chongqing, China. For the participants, inclusion criteria were as follows: (1) provided
written informed consent to take part in the present study; (2) no evidence of substance
abuse or dependence in the past 3 months; and (3) no mental and cognitive disorders or
brain injury.
Prior to the commencement of this study, we explained the purpose and contents to
all participants. They were told that their anonymity and confidentiality would be
maintained throughout. Then, they completed a separate response booklet with struc-
tured and self-reported questionnaires. Each Participant received a gift worth 10 RMB
for their time.

Study measures
Anxiety and depression
The Symptom Checklist-90 (SCL-90, Derogatis, Lipman, & Covi, 1973) is generally
used to assess a wide range of psychological problems and psychopathological symp-
toms. The Chinese version of the SCL-90 (Wang, 1984) is widely adopted with good
psychometric properties. The anxiety and depression subscales were used in this study.
The anxiety subscale comprises 10 items, and the depression one comprises 13 items. In
this study, the Cronbach’s coefficients of anxiety and depression were 0.90 and 0.92,
respectively.
4 Y. YU ET AL.

Cognitive flexibility
The 20-item cognitive flexibility inventory (CFI, Dennis & Vander Wal, 2010) is used to
measure the extent to which individuals can successfully challenge and replace mala-
daptive ideas with more balanced and adaptive thinking. Participants were asked to rate
the items on a 7-point Likert-type scale from 1 to 7. The CFI scale has been demon-
strated adequate reliability and validity among the Chinese sample (Wang, Yang, Xiao,
& Su, 2016). The Cronbach’s alpha for the total scale was 0.871 in our sample.

Impulsiveness
Chinese version of Barratt Impulsiveness Scale-11 (BIS-11; Patton et al., 1995) was
adopted to assess levels of participants’ impulsivity in present study. The BIS-11 is a 30-
item self-report measurement of impulsivity, which consists of three factors: attentional
impulsivity, motor impulsivity, and non-planning impulsivity. Consistent with original
version (BIS-11; Patton et al., 1995), participants rated the items on a 4-point Likert-
type scale. Chinese version of BIS-11 scale has been demonstrated adequate reliability
and validity (Li et al., 2011). In the current study, the Cronbach’s alpha for the scale and
subscales ranged from 0.803 to 0.911.

Data analysis
Gender differences were compared by using independent sample t-test. Pearson
Correlation analyses were conducted to describe the associations of study variables.
Structural equation modeling (SEM) was used to examine the impact of cognitive
flexibility in the relationships of anxiety, depression, and impulsivity. Hierarchical
multiple regression analyses were used to examine whether cognitive flexibility served
as a moderator between anxiety, depression, and impulsivity. If an interaction term is
statistically significant, this model might be regarded as a buffering model. P < 0.05
indicated statistically significant in this study. SPSS (version 20.0) and Amos (version
20.0) were used for data analyses.

Results
Preliminary analyses and gender differences analyses
The ages of the 477 participants ranged from 18 to 25 years (mean = 21.28, SD = 0.98).
Among them, 21.4% are male, 78.6% are female, 39.2% are the only child in their
family, and 60.8% are the kids with siblings. Table 1 shows the means, standard
deviations, and ranges of scores for main study variables, as well as analyses of gender
differences. The results indicated that males exhibited slightly higher levels of anxiety
and depression, and a slighter low level of cognitive flexibility compared to females, but
these differences were not statistically significant (Ps > 0.05). Besides that, the differ-
ences in attention impulsivity, motor impulsivity, and nonplanning impulsivity by
gender were not statistically significant.
 PSYCHOLOGY, HEALTH & MEDICINE 5

Table 1. Means, standard deviations, and comparisons of gender difference in the study variables.
Male Female
Variable Range Total mean score n = 102 n = 375 t P
Attention impulsivity 10–40 22.90 ± 4.06 22.90 ± 3.99 22.90 ± 4.09 −0.012 0.990
Motor impulsivity 10–40 21.46 ± 4.11 21.73 ± 4.68 21.38 ± 3.94 0.760 0.447
Nonplanning impulsivity 10–40 24.63 ± 3.96 24.54 ± 4.08 24.66 ± 3.93 −0.270 0.789
Anxiety 0–40 6.67 ± 6.65 7.82 ± 8.22 6.35 ± 6.14 1.682 0.095
Depression 0–52 9.49 ± 8.89 10.79 ± 10.85 9.14 ± 8.26 1.434 0.154
Cognitive flexibility 20–140 93.78 ± 14.33 91.87 ± 17.03 94.3 ± 13.48 −1.330 0.186
Note: Continuous variables were presented as mean ± standard deviation (SD). N = 477.

Associations of study variables

Correlation analyses were performed to examine possible associations among anxiety,
depression, cognitive flexibility, and impulsivity. As listed in Table 2, three subscales of
impulsivity (attention impulsivity, motor impulsivity, and nonplanning impulsivity)
were positively correlated with anxiety and depression, while negatively correlated
with cognitive flexibility (all Ps < 0.01). Additionally, both anxiety and depression
were negatively associated with cognitive flexibility (all Ps < 0.01).

Mediation analyses
To explore whether cognitive flexibility served as a mediator of the relationship between
anxiety, depression, and impulsivity, tests for mediation were conducted by AMOS 20.0.
Firstly, the pathway of anxiety and attention impulsivity was deleted from the model because
of its non-significant effect (b= 0.035, P = 0.917). After recalculation, the model was also found
unacceptable with chi-square of 8.766 (degrees of freedom (df) = 1, P = 0.003). The goodness-
of-fit indices of the mediation model were as follows: CFI = 0.993, TLI = 0.897, GFI = 0.994,
SRMR = 0.013, and RMSEA = 0.128. In this model, the direct effect of depression on cognitive
flexibility (b= 0.157, P = 0.518), the direct effect of depression to motor impulsivity (b= 0.039,
P = 0.167), as well as the pathway of anxiety and nonplanning impulsivity (b= 0.059, P = 0.086)
did not reach significance. Thus, these non-significant paths were deleted individually and the
adjusted model was recalculated accordingly. As illustrated in Figure 1, it explained 10.0% of
cognitive flexibility variance, 16.6% of motor impulsivity variance, 10.1% of nonplanning
impulsivity variance, and 16.5% of attention impulsivity variance. The excellent model fit was
obtained with a non-significant chi-square of 4.601 (df = 4, P = 0.331). The goodness-of-fit
indices of the mediation model were as follows: CFI = 0.999, TLI = 0.998, GFI = 0.997,
SRMR = 0.014, and RMSEA = 0.018.

Table 2. Correlations among the study variables.

Total score of Attention Motor Nonplanning
Variable impulsivity impulsivity impulsivity impulsivity Anxiety Depression
Attention impulsivity 0.824**
Motor impulsivity 0.755** 0.471**
Nonplanning impulsivity 0.722** 0.423** 0.255**
Anxiety 0.371** 0.286** 0.358** 0.208**
Depression 0.386** 0.297** 0.344** 0.246** 0.895**
Cognitive flexibility −0.397** −0.351** −0.301** −0.261** −0.316** −0.270**
Note: N = 477; **P < 0.01.
6 Y. YU ET AL.

Figure 1. Results of mediation path analysis showing the relationships between anxiety, depression,
and impulsivity having cognitive flexibility as a mediator with standardized estimates and square
multiple correlations. All paths in this figure reached statistical significance at P< 0.05.

In this model, the results indicated that anxiety had indirect positive impact on
attention impulsivity (b = 0.096), motor impulsivity (b = 0.067), and nonplanning
impulsivity (b = 0.067) via cognitive flexibility. Also, these data revealed a significant
direct effect of 0.291 on motor impulsivity. Besides that, depression had direct positive
effects on attention impulsivity and motor impulsivity (b = 0.207, b = 0.184, respec-
tively), rather than on motor impulsivity. Therefore, we demonstrated the first hypoth-
esis that anxiety and depression exert different impacts on impulsivity.
According to the previous literature (Cheong & MacKinnon, 2012; MacKinnon,
Lockwood, & Williams, 2004), Bootstrapping procedures via Amos 20.0 (k = 2,000)
were used to test for indirect effects. The mediation effect will reach a significant level
(P < 0.05) if 95% CI for the estimates of the mediation effect does not consist of zero.
Table 3 shows detailed results. It could be found that anxiety exerted significant indirect
effects on attention impulsivity, motor impulsivity, and nonplanning impulsivity
through cognitive flexibility. In other words, anxiety had direct and indirect impacts
via cognitive flexibility on motor impulsivity. Additionally, anxiety showed indirect
effects on attention impulsivity and nonplanning impulsivity via cognitive flexibility,
while depression exerted direct effects on attention impulsivity and nonplanning
impulsivity. Therefore, our hypothesis (2) in the present study was partially supported.

Moderation analyses
Moderation analyses were conducted according to the accepted guidelines (Baron &
Kenny, 1986). Multivariate, hierarchical linear regressions were conducted to examine
whether cognitive flexibility moderates the relationships between anxiety, depression,

Table 3. Bootstrapping indirect effects and 95% confidence intervals (CI) for the final mediational model.
95% CI
Model pathways Point estimates Lower Upper
Anxiety -> Cognitive flexibility -> Attention impulsivity 0.096 0.068 0.121
Anxiety -> Cognitive flexibility -> Motor impulsivity 0.067 0.041 0.094
Anxiety -> Cognitive flexibility -> nonplanning impulsivity 0.067 0.039 0.100
 PSYCHOLOGY, HEALTH & MEDICINE 7

and attention impulsivity. All continuous variables were centered. Covariates (age and
gender) were entered at the first step of regression models. Anxiety, depression, and
cognitive flexibility were entered in the model at the second step. Interaction terms of
anxiety × cognitive flexibility and depression × cognitive flexibility were both entered at
the last step. Table 4 shows the data of hierarchical regression. Consistent with the
findings based on mediating analyses, these results showed that depression and cogni-
tive flexibility, rather than anxiety, significantly predicted attention impulsivity.
However, the interaction (depression × cognitive flexibility) was not statistically sig-
nificant, suggesting that depression has the same effect on attention impulsiveness
regardless of the level of cognitive flexibility. Therefore, cognitive flexibility did not
buffer the relationships between anxiety and attention impulsivity, and between depres-
sion and attention impulsivity. Similar results were obtained for nonplanning impul-
sivity. Hierarchical linear regressions for motor impulsivity showed that there were
significant main effects of anxiety and cognitive flexibility. Besides that, the interaction
(anxiety × cognitive flexibility) significantly predicted motor impulsivity, suggesting
that cognitive flexibility moderated the link between anxiety and motor impulsivity. No
moderating role of cognitive flexibility was found in the association of depression and
motor impulsivity.
To test the impact of the anxiety × cognitive flexibility interaction on motor
impulsivity, simple slopes at 1SD above (>108.11) and below (<79.45) the mean
cognitive flexibility level were examined according to Holmbeck’s suggestion
(Holmbeck, 2002).

Table 4. The regression models for attention impulsivity, motor impulsivity, and nonplanning
impulsivity.
Nonplanning
Attention impulsivity Motor impulsivity impulsivity
B β B β B β
Step 1 Age 0.011 0.001 −0.344 −0.034 0.123 0.013
Gender 0.015 0.004 0.015 0.004 0.009 0.002
Step 2 Age 0.344 0.035 0.035 0.003 0.358 0.037
Gender −0.089 −0.021 −0.063 −0.015 −0.060 −0.015
Anxiety −0.004 −0.006 0.109* 0.177* −0.083 −0.139
Depression 0.103* 0.225* 0.059 0.128 0.139** 0.313**
Cognitive flexibility −0.084** −0.297** −0.061** −0.212** 0.062** −0.224**
Step 3 Age 0.306 0.031 −0.025 −0.002 0.361 0.037
Gender −0.078 −0.019 −0.044 −0.010 0.065 −0.016
Anxiety 0.176 0.288 0.875* 1.418* 0.931* −1.565*
Depression −0.320 −0.701 −0.643* −1.391* 0.219 0.492
Cognitive flexibility −0.106** −0.374** −0.074** −0.257** −0.099** −0.358**
Anxiety × cognitive −0.002 −0.247 −0.008* −1.148* 0.009* 1.388*
flexibility
Depression × cognitive 0.005 0.873 0.008* 1.430* −0.001 −0.163
flexibility
Step 1 F = 0.003; P = 0.997; F = 0.291; P = 0.747; F = 0.038; P = 0.963;
R12 = 0.001 R12 = 0.001 R12 = 0.000
Step 2 F = 19.214; P < 0.001; F = 19.410; P < 0.001; F = 11.296; P < 0.001;
R22 = 0.169 R22 = 0.171 R22 = 0.107
Step 3 F = 14.390; P < 0.001 F = 14.627; P < 0.001; F = 11.159; P < 0.001;
R32 = 0.177 R32 = 0.179 R32 = 0.143
ΔR2 (Step 3 – Step 2) 0.008 0.008 0.036
Note: N = 477, *P < 0.05, **P < 0.01. B = nonstandardized regression coefficient, β= standardized regression coefficient.
8 Y. YU ET AL.

Figure 2. Simple slopes of anxiety predicting motor impulsivity at high (+1 SD) and low (−1 SD)
levels of cognitive flexibility. Note: CF, cognitive flexibility.

When cognitive flexibility reported by university students was low, the relationship
between anxiety and motor impulsivity was stronger (β = 0.406, t = 3.608, P < 0.01) as
compared to the case when cognitive flexibility was high (β = 0.250, t = 2.255, P < 0.05).
As illustrated in Figure 2, the relationship between anxiety and motor impulsivity was
more significant for participants who had lower levels of cognitive flexibility compared
with those reporting higher levels of cognitive flexibility.

Discussion
Previous research has reported the strong relationships of anxiety and depression with
impulsivity (Fawcett, 2001; Moustafa et al., 2017; Swann, Steinberg, Lijffijt, & Moeller,
2008; Taylor et al., 2008). Nevertheless, few studies have examined their relationships
with an explicit attempt to tie them together, and further analyze the potential role of
cognitive flexibility. Our findings demonstrated that motor impulsivity was positively
predicted by anxiety, but not by depression. While attention impulsivity and nonplan-
ning impulsivity were positively predicted by depression, not by anxiety. Besides that,
cognitive flexibility mediated the relationship between anxiety and three subscales of
impulsivity. Furthermore, cognitive flexibility moderated the association of anxiety and
motor impulsivity.
In the current study, it was found that anxiety, depression, cognitive flexibility, and
impulsivity are strongly associated. In line with the original hypothesis, the results
indicated that anxiety and depression significantly and positively correlated with total
scores of impulsivity. The association between depression and impulsivity is in agree-
ment with the finding by Swann et al. (2008) that depression and impulsivity can be
inherently linked. These results also supported the notion that anxiety is related to
higher impulsivity, whether anxiety is considered as a disorder or as a symptom (Bellani
et al., 2012).
Based on the analyses of structural equation modeling and hierarchical linear
regression, we found that anxiety and depression were differentially related to three
aspects of impulsivity. First, motor impulsivity, which is the tendency to act on the spur
of the moment, was significantly predicted by anxiety. It is consistent with the pre-
viously proposed idea that reductions in anxiety would attenuate the expression of
 PSYCHOLOGY, HEALTH & MEDICINE 9

impulsive behavior, thereby diminishing associated negative outcomes (Taylor et al.,

2008). The possible explanation of this phenomenon may lie in the fact that elevated
vigilance and impaired cognitive efficiency associated with anxiety may lead to impul-
sive behaviors. Second, we found that attention impulsivity and nonplanning impulsiv-
ity, rather than motor impulsivity, were related strongly to depression. It adds
credibility to the viewpoint that depression is involved in making abrupt cognitive
decisions, having low tolerance for cognitive challenges, and lacking a sense of the
future (Swann et al., 2008). In addition, cognitively flexibility was significantly and
negatively associated with three subscales of impulsivity, which provides direct support
for the standpoint that cognitive inflexibility contributes to the development of impul-
sivity (Chamberlain et al., 2006). However, depression did not significantly predict
cognitive flexibility in this study. One explanation could be that the high correlation
between anxiety and depression in our sample may weaken the relationship between
depression and cognitive flexibility. This needs to be further explored in future studies.
Our present study revealed that cognitive flexibility mediated the relationship
between anxiety and motor impulsivity. This perhaps reflects the fact that anxiety
may be characterized by an inflexible style in the cognitive processing of information
(Lee & Orsillo, 2014), and diminish the risk behaviors in decision-making. However,
the association of depression and impulsivity was not mediated by cognitive flexibility.
The possible explanation is that the depression levels reported by university students
were rather low; thus, the result did not reach significance. Therefore, the conclusion
about the mediating role of cognitive flexibility needs further investigation in clinical
patients in future studies.
To the best of our knowledge, it is the first study to analyze the moderating effect of
cognitive flexibility in the associations between anxiety, depression, and impulsivity.
The moderation role of cognitive flexibility in the relationship between anxiety and
motor impulsivity was obtained. These data are in support of previous studies that
cognitive flexibility would enhance human performance by modulation of the anxiety
and stress (Han et al., 2011). Nevertheless, we did not find a moderating effect of
cognitive flexibility on the relations between depression and three subscales of impul-
sivity since depression could not significantly contribute to the explanation of cognitive
flexibility in this study. These findings may help to understand the associations of
anxiety, depression, cognitive flexibility, and impulsivity. Our results further demon-
strated the fact that cognitive flexibility serves as a protective factor for alleviating and
lessening the effect of anxiety on impulsive behaviors.
Of note, the findings of the present study need to be viewed in light of its limitations.
Firstly, this study only examined the effects of anxiety and depression on impulsivity,
without consideration of other negative emotions, such as fear, sadness, and anger.
Secondly, this investigation was conducted among university students. Our findings
need to be validated in clinical patients with anxiety and/or depression disorders.
Thirdly, all participants were recruited from one normal university, with more female
students than male students. The gender imbalance might affect the objectivity of the
results. Finally, self-report measurements were used in this study. Therefore, cognitive
neuroscience techniques and methods can be adopted for further verification to ensure
objectivity of the results.
10 Y. YU ET AL.

Nevertheless, this study showed that anxiety and depression are important risk
factors for the development of impulsivity. Anxiety and depression are differently
correlated to three components of impulsivity. In addition, cognitive flexibility can
serve as a mediator in the impact of anxiety on impulsivity. To be specific, anxiety
exerted significant indirect effects on attention impulsivity, motor impulsivity, and
nonplanning impulsivity via cognitive flexibility. Moreover, a more significant relation-
ship was found between anxiety and motor impulsivity for participants who had lower
levels of cognitive flexibility, compared with those reporting higher levels of cognitive
flexibility. Therefore, this study fills part of the existing knowledge gap.

Acknowledgments
The authors extend their deepest thanks to all the individuals who voluntarily participated in this
study.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This study was supported by the key Project of Science and Technology Research of Chongqing
Municipal Education Commission of China (No. KJZD-K201800901).

ORCID
Yongjuan Yu http://orcid.org/0000-0002-8416-2132
Yongju Yu http://orcid.org/0000-0002-0803-2520

References
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social
psychological research: Conceptual, strategic, and statistical considerations. Journal of
Personality and Social Psychology, 51, 1173–1182.
Bayard, S., Raffard, S., & Gely-Nargeot, M. C. (2011). Do facets of self-reported impulsivity
predict decision-making under ambiguity and risk? Evidence from a community sample.
Psychiatry Research, 190, 322–326.
Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Harper
& Row.
Bellani, M., Hatch, J. P., Nicoletti, M. A., Ertola, A. E., Zunta-Soares, G., Swann, A. C., . . .
Soares, J. C. (2012). Does anxiety increase impulsivity in patients with bipolar disorder or
major depressive disorder? Journal of Psychiatric Research, 46, 616–621.
Black, R. A., Serowik, K. I., & Rosen, M. I. (2009). Associations between impulsivity and high risk
sexual behaviors in dually diagnosed outpatients. The American Journal of Drug and Alcohol
Abuse, 35, 325–328.
Boschloo, L., Vogelzangs, N., van Den Brink, W., Smit, J. H., Beekman, A. T., & Penninx, B. W.
(2013). The role of negative emotionality and impulsivity in depressive/anxiety disorders and
alcohol dependence. Psychological Medicine, 43, 1241–1253.
 PSYCHOLOGY, HEALTH & MEDICINE 11

Chamberlain, S. R., Fineberg, N. A., Blackwell, A. D., Robbins, T. W., & Sahakian, B. J. (2006).
Motor inhibition and cognitive flexibility in obsessive-compulsive disorder and
trichotillomania. The American Journal of Psychiatry, 163, 1282–1284.
Cheong, J., & MacKinnon, D. P. (2012). Mediation/indirect effects in structural equation
modeling. In R. H. Hoyle (Ed.), Handbook of structural equation modeling (pp. 417–435).
New York: The Guilford Press.
Clark, D. M., & Fairburn, C. G. (1997). Science and practice of cognitive behaviour therapy.
Oxford: Oxford University Press.
Del Carlo, A., Benvenuti, M., Fornaro, M., Toni, C., Rizzato, S., Swann, A. C., . . . Perugi, G.
(2012). Different measures of impulsivity in patients with anxiety disorders: A case control
study. Psychiatry Research, 197, 231–236.
Dennis, J. P., & Vander Wal, J. S. (2010). The cognitive flexibility inventory: Instrument
development and estimates of reliability and validity. Cognitive Therapy & Research, 34,
241–253.
Derogatis, L. R., Lipman, R. S., & Covi, L. (1973). SCL-90: An outpatient psychiatric rating scale -
preliminary report. Psychopharmacology bulletin, 9, 13–28.
Deveney, C. M., & Deldin, P. J. (2006). A preliminary investigation of cognitive flexibility for
emotional information in major depressive disorder and non-psychiatric controls. Emotion, 6,
429–437.
Dickman, S. J. (1993). Impulsivity and information processing. In W. Mccown, M. Shure, &
J. Johnson (Eds.), The impulsive client: Theory, research, and treatment (pp. 151–184).
Washington DC: American Psychological Association.
Fawcett, J. (2001). Treating impulsivity and anxiety in the suicidal patient. Annals of the
New York Academy of Sciences, 932, 94–105.
Hales, R. E., Yudofsky, S. C., & Gabbard, G. O. (2011). Essentials of psychiatry (3rd ed.).
Arlington: American Psychiatric Publishing, Inc.
Han, D. H., Park, H. W., Kee, B. S., Na, C., Na, D. E., & Zaichkowsky, L. (2011). Performance
enhancement with low stress and anxiety modulated by cognitive flexibility. Psychiatry
Investigation, 8, 221–226.
Holmbeck, G. N. (2002). Post-hoc probing of significant moderational and mediational effects in
studies of pediatric populations. Journal of Pediatric Psychology, 27, 87–96.
Johnco, C., Wuthrich, V. M., & Rapee, R. M. (2014). Reliability and validity of two self-report
measures of cognitive flexibility. Psychological Assessment, 26, 1381–1387.
Lee, J. K., & Orsillo, S. M. (2014). Investigating cognitive flexibility as a potential mechanism of
mindfulness in generalized anxiety disorder. Journal of Behavior Therapy & Experimental
Psychiatry, 45, 208–216.
Li, X. Y., Phillips, M. R., Xu, D., Zhang, Y. L., Yang, S. J., Tong, Y. S., . . . Niu, Y. J. (2011).
Reliability and validity of an adapted Chinese version of Barratt impulsiveness scale. Chinese
Mental Health Journal, 25, 610–615.
Lyche, P., Jonassen, R., Stiles, T. C., Ulleberg, P., & Landrø, N. I. (2010). Cognitive control
functions in unipolar major depression with and without co-morbid anxiety disorder.
Frontiers in Psychiatry, 1:149. doi:10.3389/fpsyt.2010.00149
MacKinnon, D. P., Lockwood, C. M., & Williams, J. (2004). Confidence limits for the indirect
effect: Distribution of the product and resampling methods. Multivariate Behavioral Research,
39, 99–128.
Moeller, F. G., Barratt, E. S., Dougherty, D. M., Schmitz, J. M., & Swann, A. C. (2001). Psychiatric
aspects of impulsivity. The American Journal of Psychiatry, 158, 1783–1793.
Moustafa, A. A., Tindle, R., Frydecka, D., & Misiak, B. (2017). Impulsivity and its relationship
with anxiety, depression and stress. Comprehensive Psychiatry, 74, 173–179.
Murphy, F. C., Sahakian, B. J., Rubinsztein, J. S., Michael, A., Rogers, R. D., Robbins, T. W., &
Paykel, E. S. (1999). Emotional bias and inhibitory control processes in mania and depression.
Psychological Medicine, 29, 1307–1321.
Park, J., & Moghaddam, B. (2017). Impact of anxiety on prefrontal cortex encoding of cognitive
flexibility. Neuroscience, 345, 193–202.
12 Y. YU ET AL.

Patton, J. H., Stanford, M. S., & Barratt, E. S. (1995). Factor structure of the Barratt impulsiveness
scale. Journal of Clinical Psychology, 51, 768–774.
Quilty, L. C., Mehra, P., Toneatto, T., & Bagby, M. (2010). Impulsivity and pathological gambling
across depressive versus bipolar disorders. International Gambling Studies, 10, 81–90.
Rende, B. (2000). Cognitive flexibility: Theory, assessment, and treatment. Seminars in Speech &
Language, 21, 121–132.
Sevincer, G. M., Ince, E., Taymur, I., & Konuk, N. (2016). Night eating syndrome frequency in
university students: Association with impulsivity, depression, and anxiety. Bulletin of Clinical
Psychopharmacology, 26, 215–328.
Swann, A. C., Steinberg, J. L., Lijffijt, M., & Moeller, F. G. (2008). Impulsivity: Differential
relationship to depression and mania in bipolar disorder. Journal of Affective Disorders, 106,
241–248.
Taylor, C. T., Hirshfeld-Becker, D. R., Ostacher, M. J., Chow, C. W., Lebeau, R. T.,
Pollack, M. H., . . . Simon, N. M. (2008). Anxiety is associated with impulsivity in bipolar
disorder. Journal of Anxiety Disorders, 22, 868–876.
Wang, Y., Yang, Y., Xiao, W. T., & Su, Q. (2016). Validity and reliability of the Chinese version
of the Cognitive Flexibility Inventory in college students. Chinese Mental Health Journal, 30,
58–63.
Wang, Z. Y. (1984). Symptom Checklist (SCL-90). Shanghai Archives of Psychiatry, 2, 68–70.