Michael D. Anestis

Understanding the relationship between emotional and behavioral dysregulation: Emotional cascades

Recent research suggests that many dysregulated behaviors, such as binge-eating and non-suicidal self-injury, often occur during times of emotional distress. These behaviors also appear to decrease negative affect. Why is it, however, that individuals engage in these behaviors to reduce emotional distress rather than taking a shower or talking to a friend? This study proposes the role of emotional cascades, an emotional phenomenon that occurs when an individual intensely ruminates on negative affect, thus increasing the magnitude of that negative affect to the point that an individual engages in a dysregulated behavior in order to distract from that rumination. The purpose of these studies was to examine the relationship between rumination and dysregulated behaviors, and in doing so determine if there is some support for the emotional cascade model of behavioral dysregulation. Using two different studies we were able to demonstrate that rumination is associated with some dysregulated behaviors, both cross-sectionally using structural equation modeling, and temporally using a two time-point method.

Clarifying the role of emotion dysregulation in the interpersonal-psychological theory of suicidal behavior in an undergraduate sample

The interpersonal-psychological theory of suicidal behavior (IPTS; Joiner, 2005) has been subjected to a number of rigorous investigations and has shown to be a promising lens through which to understand suicide. One area thus far left unstudied with respect to the IPTS is emotion dysregulation. The bulk of the work examining the role of emotion dysregulation in suicidality has focused on suicidal ideation rather than behavior, with a number of studies reporting that emotion dysregulation is predictive of suicidal ideation (e.g., Lynch et al., 2004; Orbach et al., 2007). Studies examining suicide attempts have produced more ambiguous results. One way to clarify the nature of this relationship is to consider the construct of emotion dysregulation through an examination of specific subcomponents. In this study, we examined two specific components of emotion dysregulation - negative urgency and distress tolerance - and their relationships to all three components of the IPTS, thereby providing clarity for an otherwise poorly understood relationship. Results indicated that emotionally dysregulated individuals - those with low distress tolerance and high negative urgency - exhibited higher levels of suicidal desire, as indexed by perceived burdensomeness and thwarted belongingness. In contrast, emotionally dysregulated individuals exhibited lower levels of the acquired capability for suicide and physiological pain tolerance. As such, a complicated but theoretically cogent picture emerged indicating that, although emotion dysregulation may drastically increase the likelihood of suicidal desire, it simultaneously serves as a form protection against lethal self-harm.

An exploration of the emotional cascade model in borderline personality disorder.

The emotional cascade model proposes that the emotional and behavioral dysregulation of individuals with borderline personality disorder (BPD) may be fundamentally linked through emotional cascades, vicious cycles of intense rumination and negative affect that may induce aversive emotional states. In order to reduce this aversive emotion, dysregulated behaviors such as non-suicidal self-injury may then be used as distractions from intense rumination. This study explored emotional cascades in a sample enriched with participants meeting diagnostic criteria for BPD. The first part of the study explored a structural equation model that examined the mediational effects of emotional cascades on the relationship between BPD symptoms and dysregulated behavior and found evidence for full mediation, even after controlling for symptoms of depression and other Cluster B disorders. The second part of the study examined the effects of a rumination induction conducted with the intention of eliciting emotional cascades in those diagnosed with BPD. The results demonstrated that individuals with BPD experienced greater reactivity and intensity of negative affect, but not of positive affect, following the procedure-even when controlling for current depressive symptoms. Future directions and clinical implications for the emotional cascade model are discussed.

Overcoming the fear of lethal injury: Evaluating suicidal behavior in the military through the lens of the Interpersonal-Psychological Theory of Suicide

Suicide rates have been increasing in military personnel since the start of Operation Enduring Freedom and Operation Iraqi Freedom, and it is vital that efforts be made to advance suicide risk assessment techniques and treatment for members of the military who may be experiencing suicidal symptoms. One potential way to advance the understanding of suicide in the military is through the use of the Interpersonal-Psychological Theory of Suicide. This theory proposes that three necessary factors are needed to complete suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide. This review analyzes the various ways that military service may influence suicidal behavior and integrates these findings into an overall framework with relevant practical implications. Findings suggest that although there are many important factors in military suicide, the acquired capability may be the most impacted by military experience because combat exposure and training may cause habituation to fear of painful experiences, including suicide. Future research directions, ways to enhance risk assessment, and treatment implications are also discussed.

Examining the role of emotion in suicidality: Negative urgency as an amplifier of the relationship between components of the interpersonal–psychological theory of suicidal behavior and lifetime number of suicide attempts

Joiners (2005) interpersonal-psychological theory of suicidal behavior posits that an individual must exhibit elevations on three variables--perceived burdensomeness, thwarted belongingness, and the acquired capability for suicide--in order to enact lethal self-harm. Thus far, however, no research has examined the role of emotion in this process or whether the interaction of these three variables is more problematic for certain populations than for others. We sought to address these voids by examining the role of negative urgency as an amplifier of the relationship between the components of the theory and lifetime number of suicide attempts. Results indicated that the four-way interaction of negative urgency and the three components of the theory predicted lifetime number of suicide attempts, controlling for depression symptoms and sex. Additionally, the three-way interaction of the theory components significantly predicted lifetime number of suicide attempts in the full sample. Furthermore, for individuals with negative urgency scores at or above the median, the three-way interaction of the theory components significantly predicted lifetime number of suicide attempts whereas, for individuals with negative urgency scores below the median, the interaction was non-significant. These findings indicate that, although elevations on the three components of the theory may be dangerous for anyone, this is particularly true for individuals exhibiting high levels of negative urgency, as they might be more likely to quickly develop suicidal ideation and resort to painful self-harming behaviors while experiencing negative affective states.

Impulsive Behaviors as an Emotion Regulation Strategy: Examining Associations between PTSD, Emotion Dysregulation, and Impulsive Behaviors among Substance Dependent Inpatients

Recent investigations have demonstrated that posttraumatic stress disorder (PTSD) is associated with a range of impulsive behaviors (e.g., risky sexual behavior and antisocial behavior). The purpose of the present study was to extend extant research by exploring whether emotion dysregulation explains the association between PTSD and impulsive behaviors. Participants were an ethnically diverse sample of 206 substance use disorder (SUD) patients in residential substance abuse treatment. Results demonstrated an association between PTSD and impulsive behaviors, with SUD patients with PTSD reporting significantly more impulsive behaviors than SUD patients without PTSD (in general and when controlling for relevant covariates). Further, emotion dysregulation was found to fully mediate the relationship between PTSD and impulsive behaviors. Results highlight the relevance of emotion dysregulation to impulsive behaviors and suggest that treatments targeting emotion dysregulation may be useful in reducing impulsive behaviors among SUD patients with PTSD.

The relative and unique contributions of emotion dysregulation and impulsivity to posttraumatic stress disorder among substance dependent inpatients.

BACKGROUND Despite elevated rates of posttraumatic stress disorder (PTSD) among substance use disorder (SUD) patients, as well as the clinical relevance of this co-occurrence, few studies have examined psychological factors associated with a PTSD-SUD diagnosis. Two factors worth investigating are emotion dysregulation and impulsivity, both of which are associated with PTSD and SUDs. Therefore, this study examined associations between PTSD and facets of emotion dysregulation and impulsivity within a sample of trauma-exposed SUD inpatients. METHODS Participants were an ethnically diverse sample of 205 SUD patients in residential substance abuse treatment. Patients were administered diagnostic interviews and completed a series of questionnaires. RESULTS Patients with PTSD (n=58) reported significantly higher levels of negative urgency (i.e., the tendency to engage in impulsive behaviors when experiencing negative affect) and lower sensation seeking, as well as higher levels of emotion dysregulation and the specific dimensions of lack of emotional acceptance, difficulties engaging in goal-directed behavior when upset, difficulties controlling impulsive behaviors when distressed, limited access to effective emotion regulation strategies, and lack of emotional clarity. Further, overall emotion dysregulation emerged as a significant predictor of PTSD status, accounting for unique variance in PTSD status above and beyond facets of impulsivity (as well as other relevant covariates). CONCLUSIONS Results suggest that emotion dysregulation may contribute to the development, maintenance, and/or exacerbation of PTSD and highlight the potential clinical utility of targeting emotion dysregulation among SUD patients with PTSD.

A comparison of retrospective self-report versus ecological momentary assessment measures of affective lability in the examination of its relationship with bulimic symptomatology

Affective lability has been linked to several maladaptive behaviors (Anestis et al., 2009; Coccaro, 1991). Methodology for measuring affective lability varies and includes retrospective self-report and ecological momentary assessment (EMA). In this study, we sought to test these methodologies by examining which better predicted binge eating episodes and general eating disorder symptoms in a sample (n = 131) of women diagnosed with bulimia nervosa (BN). We hypothesized that, while the two forms of measurement would be correlated with one another and predict binge eating episodes, EMA affective lability would be the stronger predictor. Results supported several hypotheses. Specifically, both EMA affective lability and retrospective self-report affective lability significantly predicted global eating disorder symptoms, even when controlling for depression, age, body mass index, and level of education, EMA affective lability exhibited a significantly stronger correlation with binge eating episodes than did retrospective self-report affective lability, and EMA affective lability predicted number of binge eating episodes on any given day controlling for the same list of covariates. Limitations include the use of a clinical sample that may limit the generalizability of our findings. Findings highlight the importance of affect in such behavior.

Exercise caution: over-exercise is associated with suicidality among individuals with disordered eating.

We conducted four studies to examine the relationship between over-exercise and suicidality. Study 1 investigated whether over-exercise predicted suicidal behavior after controlling for other eating disorder behaviors in a patient sample of 204 women (144 with Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) Bulimia Nervosa [BN]). Study 2 tested the prospective association between over-exercise and acquired capability for suicide (ACS) in a sample of 171 college students followed for 3-4 weeks. Study 3 investigated whether pain insensitivity accounted for the relationship between over-exercise and ACS in a new sample of 467 college students. Study 4 tested whether ACS accounted for the relationship between over-exercise and suicidal behavior in a sample of 512 college students. In Study 1, after controlling for key covariates, over-exercise was the only disordered eating variable that maintained a significant relationship with suicidal behavior. In Study 2, Time 1 over-exercise was the only disordered eating behavior that was associated with Time 2 ACS. In Study 3, pain insensitivity accounted for the relationship between over-exercise and ACS. In Study 4, ACS accounted for the relationship between over-exercise and suicidal behavior. Over-exercise appears to be associated with suicidal behavior, an association accounted for by pain insensitivity and the acquired capability for suicide; notably, this association was found across a series of four studies with different populations.

Affective lability and impulsivity in a clinical sample of women with bulimia nervosa: the role of affect in severely dysregulated behavior

OBJECTIVE The primary aim of this study was to examine the role of affective lability in maladaptive behaviors in a sample of women who meet DSM criteria for current bulimia nervosa (BN). METHOD Participants were administered a semistructured diagnostic interview (SCID-P) and only those who currently met criteria for BN (N = 134) were included in the analyses. All other data were collected through the use of self-report questionnaires. RESULTS Affective lability significantly predicted the Impulsive Behavior Scale score (sr = 0.21, t = 2.64, p < .009, f(2) = 0.06) and excessive reassurance seeking (sr = 0.21, t = 2.74, p < .007, f(2) = 0.06), even when controlling for age, depressive symptoms, state and trait anxiety, and general impulsivity. DISCUSSION The degree to which individuals with BN experience labile emotions is associated with several indicators of dysregulated behavior such that higher levels of affective lability predict a more severely dysregulated behavioral profile.