Cognitive Therapy and Research

, Volume 34, Issue 6, pp 544–553 | Cite as

The Relationship Between Emotion Dysregulation and Deliberate Self-Harm Among Inpatients with Substance Use Disorders

Original Article

Abstract

Despite the emphasis on the role of emotion dysregulation in deliberate self-harm (DSH), no studies have examined this association among patients with substance use disorders (SUD). This study examined if emotion dysregulation is heightened among SUD inpatients with (vs. without) DSH, and if the association between DSH and emotion dysregulation remains significant when controlling for their shared association with risk factors for both, including borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), childhood abuse, and substance use severity. Findings indicate heightened emotion dysregulation among SUD patients with (vs. without) DSH, and provide evidence of a unique association between emotion dysregulation and DSH when controlling for BPD, PTSD, childhood abuse, and substance use severity. Findings also highlight the particular relevance of three dimensions of emotion dysregulation to DSH among SUD patients: limited access to effective emotion regulation strategies, difficulties engaging in goal-directed behaviors when distressed, and emotional nonacceptance.

Keywords

Deliberate self-harm Self-injury Emotion regulation Emotional responding Substance use 

References

  1. Andover, M. S., Pepper, C. M., Ryabchenko, K. A., Orrico, E. G., & Gibb, B. E. (2005). Self-mutilation and symptoms of depression, anxiety, and borderline personality disorder. Suicide and Life-threatening Behavior, 35, 581–591.CrossRefPubMedGoogle Scholar
  2. Bernstein, E., Bernstein, J., Tassiopoulos, K., Valentine, A., Heeren, T., Levenson, S., et al. (2005). Racial and ethnic diversity among a heroin and cocaine using population: Treatment system utilization. Journal of Addictive Diseases, 24, 43–63.CrossRefPubMedGoogle Scholar
  3. Blake, D. D., Weathers, F. W., Nagy, L., Kaloupek, D. G., Klauminzer, G., Charney, D. S., et al. (1990). The clinician administered PTSD scale. Boston: National Center for PTSD- Behavioral Science Division.Google Scholar
  4. Bonn-Miller, M. O., Zvolensky, M. J., Bernstein, A., & Stickle, T. R. (2008). Marijuana coping motives interact with marijuana use frequency to predict anxious arousal, panic-related catastrophic thinking, and worry among current marijuana users. Depression and Anxiety, 25, 862–873.CrossRefPubMedGoogle Scholar
  5. Brady, K. T., Back, S. E., & Coffey, S. F. (2004). Substance abuse and posttraumatic stress disorder. Current Directions in Psychological Science, 13, 206–209.CrossRefGoogle Scholar
  6. Brems, C., Johnson, M. E., Neal, D., & Freemon, M. (2004). Childhood abuse history and substance use among men and women receiving detoxification services. American Journal of Drug and Alcohol Abuse, 30, 799–821.CrossRefPubMedGoogle Scholar
  7. Brown, M. Z., Comtois, K. A., & Linehan, M. M. (2002). Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. Journal of Abnormal Psychology, 111, 198–202.CrossRefPubMedGoogle Scholar
  8. Brown, P. J., Stout, R., & Mueller, T. (1996). Posttraumatic stress disorder and substance abuse relapse among women: A pilot study. Psychology of Addictive Behaviors, 10, 124–128.CrossRefGoogle Scholar
  9. Brown, S. A., Williams, K., & Collins, A. (2007). Past and recent deliberate self-harm: Emotion and coping strategy differences. Journal of Clinical Psychology, 63, 791–803.CrossRefPubMedGoogle Scholar
  10. Cartwright, W. S. (2008). Economic costs of drug abuse: Financial, cost of illness, and services. Journal of Substance Abuse Treatment, 34, 224–233.CrossRefPubMedGoogle Scholar
  11. Castellani, B., Wedgeworth, R., Wootton, E., & Rugle, L. (1997). A bi-directional theory of addiction: Examining coping and the factors related to substance relapse. Addictive Behaviors, 22, 139–144.CrossRefPubMedGoogle Scholar
  12. Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behaviour Research and Therapy, 44, 371–394.CrossRefPubMedGoogle Scholar
  13. Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70, 1067–1074.CrossRefPubMedGoogle Scholar
  14. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates.Google Scholar
  15. Cooper, M. L., Russell, M., Skinner, J. B., Frone, M. R., & Mudar, P. (1992). Stress and alcohol use: Moderating effects of gender, coping, and alcohol expectancies. Journal of Abnormal Psychology, 64, 139–152.CrossRefGoogle Scholar
  16. Dinwiddie, S. H., Reich, T., & Cloninger, C. R. (1992). Prediction of intravenous drug use. Comprehensive Psychiatry, 33, 173–179.CrossRefPubMedGoogle Scholar
  17. Evren, C., & Evren, B. (2005). Self-mutilation in substance-dependent patients and relationship with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality. Drug and Alcohol Dependence, 80, 15–22.CrossRefPubMedGoogle Scholar
  18. Evren, C., Kural, S., & Cakmak, D. (2006). Clinical correlates of self-mutilation in Turkish male substance-dependent inpatients. Psychopathology, 39, 248–254.CrossRefPubMedGoogle Scholar
  19. Evren, C., Sar, V., Evren, B., & Dalbudak, E. (2008). Self-mutilation among male patients with alcohol dependency: The role of dissociation. Comprehensive Psychiatry, 49, 489–495.CrossRefPubMedGoogle Scholar
  20. Favazza, A. R. (1998). The coming of age of self-mutilation. Journal of Nervous and Mental Disease, 186, 259–268.CrossRefPubMedGoogle Scholar
  21. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). Structured clinical interview for DSM-IV axis I disorders—patient edition (SCID-I/P, Version 2.0). New York, NY: New York State Psychiatric Institute.Google Scholar
  22. Fliege, H., Kocalevent, R., Walter, O. B., Beck, S., Gratz, K. L., Gutierrez, P., et al. (2006). Three assessment tools for deliberate self-harm and suicide behavior: Evaluation and psychopathological correlates. Journal of Psychosomatic Research, 61, 113–121.CrossRefPubMedGoogle Scholar
  23. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198.CrossRefPubMedGoogle Scholar
  24. Fox, H. C., Axelrod, S. R., Paliwal, P., Sleeper, J., & Sinha, R. (2007). Difficulties in emotion regulation and impulse control during cocaine abstinence. Drug and Alcohol Dependence, 89, 298–301.CrossRefPubMedGoogle Scholar
  25. Fox, H. C., Hong, K. A., & Sinha, R. (2008). Difficulties in emotion regulation and impulse control in recently abstinent alcoholics compared with social drinkers. Addictive Behaviors, 33, 388–394.CrossRefPubMedGoogle Scholar
  26. Gratz, K. L. (2001). Measurement of deliberate self-harm: Preliminary data on the deliberate self-harm inventory. Journal of Psychopathology and Behavioral Assessment, 23, 253–263.CrossRefGoogle Scholar
  27. Gratz, K. L. (2003). Risk factors for and functions of deliberate self-harm: An empirical and conceptual review. Clinical Psychology: Science and Practice, 10, 192–205.CrossRefGoogle Scholar
  28. Gratz, K. L. (2007). Targeting emotion dysregulation in the treatment of self-injury. Journal of Clinical Psychology: In Session, 63, 1091–1103.PubMedGoogle Scholar
  29. Gratz, K. L., & Chapman, A. L. (2007). The role of emotional responding and childhood maltreatment in the development and maintenance of deliberate self-harm among male undergraduates. Psychology of Men and Masculinity, 8, 1–14.CrossRefGoogle Scholar
  30. Gratz, K. L., & Roemer, L. (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, 41–55.CrossRefGoogle Scholar
  31. Gratz, K. L., & Roemer, L. (2008). The relationship between emotion dysregulation and deliberate self-harm among female undergraduate students at an urban commuter university. Cognitive Behaviour Therapy, 37, 14–25.CrossRefPubMedGoogle Scholar
  32. Gratz, K. L., Rosenthal, M. Z., Tull, M. T., Lejuez, C. W., & Gunderson, J. G. (2006). An experimental investigation of emotion dysregulation in borderline personality disorder. Journal of Abnormal Psychology, 115, 850–855.CrossRefPubMedGoogle Scholar
  33. Gratz, K. L., Tull, M. T., Baruch, D. E., Bornovalova, M. A., & Lejuez, C. W. (2008). Factors associated with co-occurring borderline personality disorder among inner-city substance users: The roles of childhood maltreatment, negative affect intensity/reactivity, and emotion dysregulation. Comprehensive Psychiatry, 49, 603–615.CrossRefPubMedGoogle Scholar
  34. Gratz, K. L., Tull, M. T., & Wagner, A. W. (2005). Applying DBT mindfulness skills to the treatment of clients with anxiety disorders. In L. Roemer & S. M. Orsillo (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualizations and treatment (pp. 147–161). New York: Springer.CrossRefGoogle Scholar
  35. Gray, M. J., Litz, B. T., Hsu, J. L., & Lombardo, T. W. (2004). Psychometrics properties of the life events checklist. Assessment, 11, 330–341.CrossRefPubMedGoogle Scholar
  36. Gunderson, J. G. (2001). Borderline personality disorder: A clinical guide. Washington, DC: American Psychiatric Association.Google Scholar
  37. Haines, J., & Williams, C. L. (1997). Coping and problem solving of self-mutilators. Journal of Clinical Psychology, 53, 177–186.CrossRefPubMedGoogle Scholar
  38. Harned, M. S., Najavits, L. M., & Weiss, R. D. (2006). Self-harm and suicidal behavior in women with comorbid PTSD and substance dependence. The American Journal on Addictions, 15, 392–395.CrossRefPubMedGoogle Scholar
  39. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York, NY: The Guilford Press.Google Scholar
  40. Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168.CrossRefPubMedGoogle Scholar
  41. Heath, N. L., Toste, J. R., Nedecheva, T., & Charlebois, A. (2008). An examination of nonsuicidal self-injury among college students. Journal of Mental Health Counseling, 30, 137–156.Google Scholar
  42. Jacobson, L. K., Southwick, S. M., & Kosten, T. R. (2001). Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. American Journal of Psychiatry, 158, 1184–1190.CrossRefGoogle Scholar
  43. Javaras, K. N., Pope, H. G., Lalonde, J. K., Nillni, Y. I., Bulik, C. M., McElroy, S. L., et al. (2008). Co-occurrence of binge eating disorder with psychiatric and medical disorders. Journal of Clinical Psychiatry, 69, 266–273.CrossRefPubMedGoogle Scholar
  44. Keppel, G., & Zedeck, S. (1989). Data analysis for research designs. New York, NY: W. H. Freeman and Company.Google Scholar
  45. King, A. C., & Canada, S. A. (2004). Client-related predictors of early treatment drop-out in a substance abuse clinic exclusively employing individual therapy. Journal of Substance Abuse Treatment, 26, 189–195.CrossRefPubMedGoogle Scholar
  46. Klonsky, E. D., Oltmanns, T. F., & Turkheimer, E. (2003). Deliberate self-harm in a nonclinical population: Prevalence and psychological correlates. American Journal of Psychiatry, 160, 1501–1508.CrossRefPubMedGoogle Scholar
  47. Langer, L. M., & Tubman, J. G. (1997). Risky sexual behavior among substance-abusing adolescents: Psychosocial and contextual factors. American Journal of Orthopsychiatry, 67, 315–322.CrossRefPubMedGoogle Scholar
  48. Leibenluft, E., Gardner, D., & Cowdry, R. (1987). The inner experience of the borderline self- mutilator. Journal of Personality Disorders, 1, 317–324.Google Scholar
  49. Lejuez, C. W., Bornovalova, M. A., Reynolds, E. K., Curtin, J. J., & Daughters, S. B. (2007). Risk factors in the relationship between gender and crack/cocaine. Experimental and Clinical Psychopharmacology, 15, 165–175.CrossRefPubMedGoogle Scholar
  50. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.Google Scholar
  51. Mack, J. (1975). Borderline states in psychiatry. New York: Grune & Stratton.Google Scholar
  52. Mino, A., Bousquet, A., & Broers, B. (1999). Substance abuse and drug-related death, suicidal ideation and suicide: A review. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 20, 28–35.CrossRefGoogle Scholar
  53. Muehlenkamp, J. J., & Gutierrez, P. M. (2004). An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide and Life-threatening Behavior, 34, 12–23.CrossRefPubMedGoogle Scholar
  54. Nelson, R. O. (1988). Relationships between assessment and treatment within a behavioral perspective. Journal of Psychopathology and Behavioral Assessment, 10, 155–170.CrossRefGoogle Scholar
  55. Nock, M. K., & Banaji, M. R. (2007). Assessment of self-injurious thoughts using a behavioral test. American Journal of Psychiatry, 164, 820–823.CrossRefPubMedGoogle Scholar
  56. Pattison, E. M., & Kahan, J. (1983). The deliberate self-harm syndrome. American Journal of Psychiatry, 140, 867–872.PubMedGoogle Scholar
  57. Perneger, T. V. (1998). What’s wrong with Bonferroni adjustments. British Medical Journal, 316, 1236–1238.PubMedGoogle Scholar
  58. Polk, E., & Liss, M. (2007). Psychological characteristics of self-injurious behavior. Personality and Individual Differences, 43, 567–577.CrossRefGoogle Scholar
  59. Ross, S., & Heath, N. (2002). A study of the frequency of self-mutilation in a community sample of adolescents. Journal of Youth and Adolescence, 31, 67–77.CrossRefGoogle Scholar
  60. Sacks, M. B., Flood, A. M., Dennis, M. F., Hertzberg, M. A., & Beckham, J. C. (2008). Self-mutilative behaviors in male veterans with posttraumatic stress disorder. Journal of Psychiatric Research, 42, 487–494.CrossRefPubMedGoogle Scholar
  61. Sankoh, A. J., Huque, M. F., & Dubey, S. D. (1997). Some comments on frequently used multiple endpoint adjustments methods in clinical trials. Statistics in Medicine, 16, 2529–2542.CrossRefPubMedGoogle Scholar
  62. Sansone, R. A., & Levitt, J. L. (2002). Self-harm behaviors among those with eating disorders: An overview. Eating Disorders, 10, 205–213.CrossRefPubMedGoogle Scholar
  63. Saunders, J. B., Aasland, O. G., Babor, T. F., De la Fuente, J. R., & Grant, M. (1993). Development of the alcohol use disorders identification test (AUDIT): Who collaborative project on early detection of persons with harmful alcohol consumption. Addiction, 88, 791–803.CrossRefPubMedGoogle Scholar
  64. Slee, N., Spinhoven, P., Garnefski, N., & Arensman, E. (2008). Emotion regulation as mediator of treatment outcome in therapy for deliberate self-harm. Clinical Psychology & Psychotherapy, 15, 205–216.CrossRefGoogle Scholar
  65. Soloff, P. H., Lis, J. A., Kelly, T., Cornelius, J., & Ulrich, R. (1994). Self-mutilation and suicidal behavior in borderline personality disorder. Journal of Personality Disorders, 8, 257–267.Google Scholar
  66. Tabachnick, B. G., & Fidell, L. S. (1996). Using multivariate statistics (3rd ed.). New York, NY: Harper Collins.Google Scholar
  67. Trull, T. J., Sher, K. J., Minks-Brown, C., Durbin, J., & Burr, R. (2000). Borderline personality disorder and substance use disorders: A review and integration. Clinical Psychology Review, 20, 235–253.CrossRefPubMedGoogle Scholar
  68. Tull, M. T., Barrett, H. M., McMillan, E. S., & Roemer, L. (2007). A preliminary investigation of the relationship between emotion regulation difficulties and posttraumatic stress symptoms. Behavior Therapy, 38, 303–313.CrossRefPubMedGoogle Scholar
  69. Tutzauer, F. (2003). On the sensible application of familywise alpha adjustment. Human Communication Research, 29, 455–463.CrossRefGoogle Scholar
  70. Verheul, R., van den Bosch, L. M. C., & Ball, S. A. (2009). Substance abuse. In J. M. Oldham, A. E. Skodol, & D. E. Bender (Eds.), Essentials of personality disorders (pp. 361–378). Washington, DC: American Psychiatric Publishing.Google Scholar
  71. Weathers, F. W., Keane, M. T., & Davidson, J. R. T. (2001). Clinician-administered PTSD scale: A review of the first ten years of research. Depression and Anxiety, 13, 132–156.CrossRefPubMedGoogle Scholar
  72. Whitlock, J., Eckenrode, J., & Silverman, D. (2006). Self-injurious behaviors in a college population. Pediatrics, 117, 1939–1948.CrossRefPubMedGoogle Scholar
  73. Zanarini, M. C., Frankenburg, F. R., Sickel, A. E., & Young, L. (1996). Diagnostic interview for DSM-IV personality disorders. Unpublished measure. Boston, MA: McLean Hospital.Google Scholar
  74. Zanarini, M. C., Skodol, A. E., Bender, D., Dolan, R., Sanislow, C. A., Morey, L. C., et al. (2000). The collaborative longitudinal personality disorders study II: Reliability of axis I and axis II diagnosis. Journal of Personality Disorders, 14, 291–299.PubMedGoogle Scholar
  75. Zlotnick, C., Mattia, J. I., & Zimmerman, M. (1999). Clinical correlates of self-mutilation in a sample of general psychiatric patients. Journal of Nervous and Mental Disease, 187, 296–301.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  1. 1.Department of Psychiatry and Human BehaviorUniversity of Mississippi Medical CenterJacksonUSA

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