Emotion dysregulation across levels of substance use
Introduction
Research on emotion regulation, i.e., extrinsic and intrinsic processes and abilities involved in monitoring, evaluating, and modulating emotional experiences in the pursuit of goal-directed behavior (see Gratz and Roemer, 2004; Gross, 2015; Thompson, 1994), has grown exponentially during the past two decades. The use of putatively adaptive emotion regulation strategies, as well as greater emotion regulation abilities (e.g., emotional clarity and acceptance), are considered to be of utmost importance for individuals’ short- and long-term well-being and general functioning (Barrett et al., 2001; John and Gross, 2004). Conversely, emotion dysregulation, or the use of maladaptive emotion regulation strategies or deficits in emotion regulation abilities (e.g., difficulties controlling impulsive behavior when experiencing emotional distress; Gratz and Roemer, 2004), are implicated in the etiology and maintenance of a number of psychiatric disorders (Aldao et al., 2010). Indeed, emotion dysregulation has been proposed to be a transdiagnostic mechanism underlying diverse forms of psychopathology (Berking and Wupperman, 2012). For example, empirical evidence suggests that emotion dysregulation is of importance to several psychiatric disorders, including anxiety disorders (Cisler et al., 2010), mood disorders (Joormann and Stanton, 2016), and borderline personality disorder (Axelrod et al., 2011; Gratz et al., 2016).
An understanding of the relevance of emotion dysregulation to substance use disorders (SUDs) is emerging, and several theoretical frameworks highlight the relevance of emotion dysregulation as a process which contributes to SUDs and moderates the effect of psychosocial stressors. For example, the affective processing model of negative reinforcement in addiction (Baker et al., 2004) suggests that substance use is driven by attempts to avoid or escape emotional states perceived as aversive. Although this model does not address the specific role of emotion dysregulation in substance use per se, it does suggest that individuals who do not have access to other strategies for tolerating or managing negative emotional states may develop a reliance on substance use as a method for obtaining quick relief from aversive internal states. Likewise, Brady and Sinha's (2005) stress-based model of addiction emphasizes the role of substance use and abuse in promoting dysregulation in the biological stress system, with concomitant disruptive effects on emotional reactivity, impulse control, and greater drug craving. These factors, in turn, are then proposed to maintain the negative cycle of substance use (Brady and Sinha, 2005; Sinha, 2001; Wemm and Sinha, 2019).
In addition to these theoretical models supporting the potential relevance of emotion dysregulation to SUDs, research has examined the relationship between emotion dysregulation and substance use demonstrating that emotion dysregulation is indeed associated with a variety of substance use outcomes (Berking et al., 2011; Bradizza et al., 2018; Sloan et al., 2017; Weiss et al., 2015). For example, studies have reported that emotion dysregulation is positively correlated with both alcohol dependence and marijuana use (Bonn-Miller et al., 2008; Petit et al., 2015). Likewise, the observed association between increased negative affect and concomitant decreased positive affect with alcohol cravings has been attributed to difficulties in the regulation of such affect (Khosravani et al., 2017). Researchers also report a link between periods of abstinence and emotion dysregulation in the context of alcohol and cocaine use, showing that difficulties controlling impulsive behavior in the context of emotional distress in particular can persist over at least four weeks into abstinence (Fox et al., 2008, 2007).
Although theoretical and empirical literature supports the relevance of emotion dysregulation to substance use in general and SUDs in particular, there are some limitations to extant research. First, studies tend to examine emotion dysregulation in the context of individuals with a specific SUD diagnosis. Less is known about associations of emotion dysregulation to a wider range of substance use frequency (i.e., on a spectrum of no use to frequent use; (Hyman, 2010). Second, although the relation between emotion dysregulation and SUDs has been examined in a variety of different populations (e.g., community, outpatient, inpatient), researchers have yet to examine differences in emotion dysregulation across these samples that demonstrate varying levels of substance use severity. Finally, the interplay of emotion dysregulation and psychiatric symptoms (e.g., anxiety, depression) and how they may affect substance use is rarely considered, despite considerable evidence that emotion dysregulation is associated with many psychiatric disorders that frequently co-occur with substance use (Chan et al., 2008). Among individuals with more psychiatric symptoms, emotion dysregulation may be particularly likely to contribute to more severe substance use patterns. For example, the heightened emotional distress associated with a greater number of psychiatric symptoms, combined with elevated levels of emotion dysregulation, may contribute to greater difficulty resisting urges for substance use or an increased reliance on substances to escape emotional distress. Although studies have yet to fully explore this hypothesis, there is evidence that individuals with alcohol use disorder and at least two comorbid anxiety and mood disorders seem to experience both more emotion dysregulation and heavier drinking, when compared to those without or with one comorbid disorder (Bradizza et al., 2018). However, more research is needed to understand if heightened psychiatric symptoms in this case actually moderates the association between emotion dysregulation and substance use.
Thus, the present study aimed to extend current research on the relation of emotion dysregulation to SUDs by examining levels of emotion dysregulation across different levels of substance use frequency and severity (across community and clinical samples), as well as the moderating role of co-occurring psychiatric symptoms. We investigated (i) if emotion dysregulation is positively associated with greater substance use frequency and severity, irrespective of the SUDs present, (ii) if there are relations between specific emotion dysregulation facets (e.g., emotional nonacceptance, difficulties engaging in goal-directed behavior when distressed, difficulties controlling impulsive behaviors when distressed, limited access to effective emotion regulation strategies, lack of emotional clarity, and lack of emotional awareness) and substance use frequency and severity, and (iii) if psychiatric symptoms influence the relation between emotion dysregulation and substance use frequency. Although we expected that higher levels of emotion dysregulation would correspond to more frequent and severe substance use, we did not make specific predictions regarding relations between specific facets of emotion dysregulation and substance use frequency and severity given the absence of existing research in this area. These analyses were considered exploratory. Finally, we predicted that the relation between emotion dysregulation and substance use frequency would be stronger among individuals with higher reported levels of psychiatric symptoms.
Section snippets
Participants
The current study made use of cross-sectional data from three separate studies conducted in the United States. Sample One was a community-based sample (n = 843, 56% female), with ages ranging from 18 to 64 (M = 30.07, SD = 9.36). Participants were recruited for research participation in a study on emotions and health, with advertisements posted in social media, flyers and newspapers in the Greater New Haven, CT, area. Samples Two and Three consisted of patients at two state-run residential SUD
Participant demographics and descriptive statistics
Results indicated a significant difference in sex composition across subgroups, χ 2 (2) = 17.34, p < .001 (see Table 1). Specifically, the Community sample without substance misuse had a significantly higher percentage of females than the SUD residential treatment group. Likewise, the ANOVA (comparing the Community without substance misuse group to the other two subgroups, as well as the Community with substance misuse group to the SUD residential treatment group) revealed a significant
Discussion
The purpose of the current study was to investigate how emotion dysregulation (and its different facets) varies across different levels of substance use severity and frequency, as well as to examine the role of psychiatric symptoms in the relation of emotion dysregulation to substance use outcomes. Results indicate that overall emotion dysregulation was positively associated with substance use frequency, whereas facets of emotion dysregulation was differentially associated with substance use
Funding
This research was funded by National Institutes of Health grants UL1-DE019586 and PL1-DA024859 (PI: RS), National Institute on Drug Abuse of the National Institutes of Health grants R21 DA022383 and R21 DA030587 (PI: MTT), and by grants provided by the Stockholm County Council 20170512, Stiftelsen Söderström-Königska Sjukhemmet SLS-750801 and The Swedish Society of Medicine SLS-780001 (PI: NJL).The use of the data in the current study was approved by the Yale University School of Medicine (Yale
Declaration of Competing Interest
The authors declare no conflicts of interest.
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Maria Å. Garke, Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Norra Stationsgatan 69, 113 64 Stockholm.