The pursuit of death versus escape from negative affect: An examination of the nature of the relationship between emotion dysregulation and both suicidal behavior and non-suicidal self-injury

doi:10.1016/j.comppsych.2014.07.007

Comprehensive Psychiatry

Volume 55, Issue 8, November 2014, Pages 1820-1830

https://doi.org/10.1016/j.comppsych.2014.07.007 Get rights and content

Abstract

Across three studies, we tested a model in which the relationship between emotion dysregulation and suicidal behavior is accounted for by non-suicidal self-injury (NSSI). Whereas some models posit that suicide attempts serve as an escape from acute aversive states, our model proposes that NSSI accounts for the relationship between emotion dysregulation and suicide attempts. To test our model, we recruited two large nonclinical samples of adults and a clinical sample of adults seeking inpatient treatment for substance use disorders. To increase generalizability, we used four different measures of emotion dysregulation across the three studies: broad emotion regulation, distress tolerance, negative urgency, and grit (i.e., the persistent, passionate pursuit of long-term goals). Results were largely supportive of our hypothesized model, revealing significant indirect effects of emotion dysregulation on suicide attempts through NSSI in all three samples. Specifically, NSSI fully mediated the relationship between emotion dysregulation and suicide attempts in three of six analyses, and partially mediated this relation in the other three. Overall, findings are supportive of an emotion regulation model of NSSI and suggest that the relation between certain aspects of emotion dysregulation and suicide attempts may be indirect through NSSI.

Section snippets

Study 1

In study 1, we sought to conduct a preliminary test of our proposed model in an undergraduate sample. To assess the construct of emotion dysregulation, we included measures of both overall emotion dysregulation and the specific emotion dysregulation dimension of low distress tolerance, both of which have previously been found to be associated with both NSSI and suicidal behavior (e.g., [14], [19], [20], [21], [27]). As defined here, emotion dysregulation is conceptualized as maladaptive

Study 2

In study 2, we sought to extend the general findings from study 1 by examining two additional emotion dysregulation dimensions: negative urgency and grit. Negative urgency refers to the tendency to act impulsively in the face of negative affect [9], which has been conceptualized as one dimension of emotion dysregulation [7]. Research indicates that negative urgency is related to both NSSI [6], [34] and suicidal ideation and attempts [6], [35]. Grit is a personality trait involving the

Study 3

The primary goals of this study were to (1) extend the generalizability of the proposed model by examining these relations within a more severe clinical population and (2) link the findings from the first two samples by utilizing two of the four measures of emotion dysregulation dimensions: overall emotion dysregulation and negative urgency.

Exploratory analyses across studies

Notably, results of a series of exploratory analyses examining the mediating role of suicide attempts in the relation between emotion dysregulation and NSSI within all three samples provide further support for the specific model proposed here. These analyses speak to the relative utility of the proposed model vis-à-vis an alternative model in which suicide attempts explain the relation between emotion dysregulation and NSSI. Results of these analyses suggest that NSSI is more relevant to the

General discussion

The overarching goal of this manuscript was to test a model of emotion dysregulation in non-suicidal and suicidal self-injury in which the relationship between emotion dysregulation and suicide attempts is accounted for by NSSI. In contrast to escape theories of suicide (e.g., [3]), which posit that suicide attempts represent an attempt to escape from aversive affective states with little planning, our model posits that NSSI serves as a mechanism for escape from aversive affective states and

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Experiential avoidance has been positively associated with a recency of engagement in NSSI (i.e. engagement in self-injury in the last 12 months; Lin et al., 2017; Nielsen et al., 2017). An inability to tolerate distress has been associated with frequency of engagement in NSSI (Anestis et al., 2014; Slabbert et al., 2018). Likewise, alexithymia (an inability to describe or differentiate ones feelings; Nemiah and Sifneos, 1970) has been associated with both recency and frequency (Lin et al., 2017; Howe-Martin et al., 2012; Nielsen et al., 2017).
Emotion regulation, distress tolerance, experiential avoidance, and both positive and negative affect have all been linked to NSSI. These constructs are proposed to be distinct; however, they share conceptual similarities. For example, some people may regulate emotions by avoiding stressful situations, conflating emotion regulation and avoidance. We tested if constructs linked with NSSI (when studied in isolation), remain significant correlates of NSSI when considered alongside related constructs (with which they may share variance).
University students (n = 487, M = 21.36, SD = 2.48, 74% female, 40% with lived experience of self-injury) completed well-validated self-report measures of NSSI, difficulties with emotion regulation, distress tolerance, experiential avoidance, emotional reactivity, positive and negative affect, and alexithymia.
As predicted, emotion-related constructs were generally highly correlated. Additionally, with the exception of lack of emotional awareness, all constructs were significantly associated with NSSI in bivariate analyses. In multivariate analyses, associations were substantially attenuated. Positive affect, distress tolerance, and experiential avoidance were negatively associated with NSSI, and limited emotion regulation strategies was positively associated with NSSI. No other constructs were uniquely associated with NSSI and exploratory factor analyses indicated that all constructs loaded onto a single factor
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Findings raise the possibility that associations between some emotion-related constructs (e.g., alexithymia) and NSSI may reflect variance shared with other emotion-related constructs. If true, this will have important theoretical, clinical, and measurement implications for NSSI research.
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Despite research and theory linking emotion regulation (ER) difficulties to suicidal thoughts and behaviors, limited research has examined the relations of specific ER strategies to suicide risk outcomes, and almost no research has examined interpersonal ER strategies in particular. Thus, this study sought to examine associations of specific interpersonal (venting, reassurance-seeking) and intrapersonal (avoidance, acceptance) ER strategies to suicidal ideation and suicide attempt history.
A community sample of adults (N = 363) completed an online study, including measures of perceived burdensomeness, thwarted belongingness, past 3-month suicidal ideation, lifetime suicide attempts, and a scenario-based measure assessing the use of both interpersonal (venting, reassurance-seeking) and intrapersonal (avoidance, acceptance) ER strategies.
When controlling for theoretically-relevant clinical and demographic covariates (and all other ER strategies), greater venting was uniquely associated with greater perceived burdensomeness. Greater avoidance was uniquely associated with greater thwarted belongingness, greater perceived burdensomeness, and a lifetime history of suicide attempts.
Results highlight the relevance of two specific ER strategies (venting and avoidance) that warrant further examination as potential treatment targets aimed at mitigating suicide risk. Limitations include examining only a subset of potential interpersonal and intrapersonal ER strategies, as well as the sole use of self-report measures.
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: Suicide is a major public health issue. Psychological models and theories have suggested that difficulties regulating emotions may contribute to suicidal experiences. This systematic review aims to evaluate empirical research examining the relationship between emotion regulation and suicide ideation and behaviour in adults.
: Articles were required to include any measure of suicide ideation or attempt and the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) to assess emotion regulation. Peer reviewed, quantitative empirical papers, written in the English language were considered. All participants had to be aged 18 years or over. EMBASE, Medline and Psychinfo were searched for relevant articles. A quality assessment measured risk of bias. PRISMA guidelines were followed.
: Twenty-one papers were identified as eligible. Significant positive associations were reported between emotion dysregulation and suicide ideation and attempts. However, emotion dysregulation was often not predictive of ideation or attempts when controlling for other psychological variables.
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Direct and indirect associations between perception of childhood trauma and suicidal ideation through emotion dysregulation in males who use heroin
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Citation Excerpt :
Positive reappraisal as an CER strategy has been found to be associated with opioid craving (Garland et al., 2018) and be low in individuals using heroin than those not using heroin (Xin et al., 2014). Several studies have shown that total ERD and its dimensions are associated with suicidal behaviors such as suicidal ideation, deliberate self-harm, and suicide attempts in non-clinical and clinical samples (Ammerman, Kleiman, Uyeji, Knorr, & McCloskey, 2015; Anestis, Kleiman, Lavender, Tull, & Gratz, 2014; Ghorbani, Khosravani, Bastan, & Ardakani, 2017; Gratz & Tull, 2010; Kranzler, Fehling, Anestis, & Selby, 2016; Law, Khazem, & Anestis, 2015; Miranda, Tsypes, Gallagher, & Rajappa, 2013; Neacsiu, Fang, Rodriguez, & Rosenthal, 2018; Pisani et al., 2013; Pisetsky, Haynos, Lavender, Crow, & Peterson, 2017; Rajappa, Gallagher, & Miranda, 2012; Van Eck et al., 2015). Also, it has been found that positive reappraisal is inversely correlated with suicide attempts and/or suicidal ideation in non-clinical and clinical samples (Ghorbani et al., 2017; Mukherjee, Dogra, & Banerjee, 2014; Shani, Yelena, Reut, Adrian, & Sami, 2016; Svensson et al., 2014; Vasudeva & Singh, 2017).
Emotion dysregulation is considered as one of the factors related to suicide in individuals with childhood trauma (CT). However, no research has been performed on the role of emotion dysregulation in the relationship between perception of CT and suicidal ideation in individuals who use heroin. This study aimed to evaluate direct and indirect relationships between perception of CT and suicidal ideation through emotion regulation difficulties (ERD) and cognitive emotion regulation strategies (CERSs) in males with a DSM diagnosis of heroin dependence. In a cross-sectional design, 310 males with a DSM diagnosis of heroin dependence completed the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Difficulties in Emotion Regulation Scale (DERS), the Cognitive Emotion Regulation Questionnaire-Short version (CERQ-Short), the Obsessive-Compulsive Drug Use Scale-Form Heroin (OCDUS-Form Heroin), and the Depression Anxiety Stress Scales (DASS). The results revealed that perception of CT had no direct relation to suicidal ideation. Perception of CT was indirectly associated with suicidal ideation through some ERD dimensions [e.g., non-acceptance of emotional responses (Non-acceptance), limited access to emotion regulation strategies (Strategies), lack of emotional awareness (Awareness)] and the CERS of positive reappraisal. The findings suggest that high suicidal ideation may stem from a perception of CT and subsequently emotion dysregulation in individuals who use heroin. Also, the findings of this research may have implications for the prevention and treatment of suicidal ideation in individuals using heroin with a perception of CT. The results of the present study require further examination through longitudinal studies.

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The pursuit of death versus escape from negative affect: An examination of the nature of the relationship between emotion dysregulation and both suicidal behavior and non-suicidal self-injury

Abstract

Section snippets

Study 1

Study 2

Study 3

Exploratory analyses across studies

General discussion

Personal Individ Differ

Addict Behav

Behav Res Ther

Child Abuse Negl

Addict Behav

J Psychiatr Res

Compr Psychiatry

Behav Res Ther

J Affect Disord

Compr Psychiatry

Drug Alcohol Depend

Addict Behav

J Affect Disord

J Res Pers

[46] M.D. Anestis, S.M. Pennings, J.M. Lavender, M.T. Tull, K.L. Gratz, Low distress tolerance as an indirect risk factor for suicidal behavior: considering the explanatory role of non-suicidal self-injury, Compr Psychiatry 54, 2013, 996–1002.

Web-Based Injury Statistics Query and Reporting System (WISQARS)

Myths about suicide

Toward a clinical model of suicidal behavior in psychiatric patients

Am J Psychiatr

Why people die by suicide

Dialectical behavior therapy for borderline personality disorder

A multimethod analysis of impulsivity in nonsuicidal self-injury

Personal Disord

Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale

J Psychopathol Behav Assess

The Distress Tolerance Scale: Development and validation of a self-report measure

Motiv Emot