Today I came across a study soon to be published in Cognitive Therapy and Research that looks at the relationship between several variables we have discussed previously on PBB. 

Specifically, the authors - Kim Gratz and Matthew Tull of the University of Mississippi Medical Center - examined the role of emotion dysregulation in deliberate self-harm (also called non-suicidal self-injury) for individuals with substance use disorders (SUDs). 

In other words, the authors wanted to extend the impressive research that has linked difficulties regulating emotions to deliberate self-harm (DSH) in general (e.g., Linehan, 1993; Selby, Anestis, & Joiner, 2009) by looking at whether the same model applies to people with SUDs. 

For the purposes of this study, emotion dysregulation was defined as dysfunctional methods for responding to emotions (e.g., nonacceptance of emotions, difficulty controlling behavior when upset). 

You might remember from an earlier PBB article on Cooper's Drinking Motives Questionnaire, that research has also indicated that, for some individuals, consuming alcohol also serves as a method for regulating negative emotions and, as such, the authors were taking the logical next step of empirically testing an idea about which many people simply make assumptions.

Before explaining their study, the authors provided some compelling justification for investigating the matter. 

As it turns out, research has indicated that DSH is fairly prominent in individuals with SUDs (29-52%; Evren & Evren, 2005; Evren et al, 2006; Evren et al., 2008). 

To provide a bit of context for those numbers, Gratz and Tull (in press) went on to compare that to the rates of DSH in other at risk populations, including high school and college students (14-35%; Gratz, 2001; Muehlenkamp & Gutierrez, 2004; Ross & Heath, 2002) and individuals diagnosed with eating disorders (23-25%; Whitlock et al., 2006). 

Despite the substantial prevalence of DSH in SUD samples, very little research to date has examined the role of emotion regulation in DSH in these samples.  If you have read any of our articles discussing Nock and Prinstein's (2004) functional model of non-suicidal self-injury, you might recall that, while self-injurious for the purpose of reducing negative affect is the most common reason for the behavior, it is not the only reason, so actually testing this empirically in this particular demographic is vital.

Gratz and Tull (in press) noted one other important consideration before describing their specific study and results: even if individuals diagnosed with a SUD who engage in DSH demonstrate higher levels of emotion dysregulation than do individuals diagnosed with a SUD who do not engage in DSH, that relationship might be better accounted for by another variable. 

Specifically, they pointed to the possibility that these two behaviors might simply represent a shared vulnerability to particular diagnoses (e.g., borderline personality disorder, PTSD) or traumatic events (e.g., childhood abuse) or be a symptom of severe substance use.  As such, they noted that any data indicating higher levels of emotion dysregulation in individuals with SUDs who also self-injure would need to demonstrate that the relationship was significant above and beyond the effects of such variables.

Drinking and depressed

To address these questions, Gratz and Tull (in press) conducted a study that included 61 inpatients in a drug and alcohol treatment center (54% male).  The sample was comprised almost entirely of African American individuals (97%), most of whom reported low incomes (79% earning less than $10,000 annually) and unemployment (89%) and most of whom were single (75%). 

Participants ranged in age from 20 to 58 with an average age of 44.45.  Each participants was administered a structured diagnostic interview as well as a number of questionnaires assessing the variables of interest in the study.  30% of the participants reported a history of DSH, 49% met criteria for PTSD, 30% met criteria for borderline personality disorder, and 23% reported a history of childhood abuse.

So, what did they find?  First of all, as anticipated, individuals with a SUD who reported a history of DSH exhibited higher levels of emotion dysregulation than did individuals with a SUD who reported no history of DSH.  In other words, if a participant reported that he or she had a history of self-injury, they were also more likely to report experiencing frequent difficulties effectively managing their emotions. 

Taking this a step further, the authors also found that, even when they accounted for diagnoses of PTSD and borderline personality disorder, histories of childhood abuse, and the severity of substance use, the relationship between emotion dysregulation and DSH remained significant.  In other words, the link between difficulty effectively managing emotions and DSH in individuals with SUDs is not better accounted for by any of those factors. 

Finally, the authors also reported that participants who self-injured reported a tendency to not accept negative emotions, difficulties engaging in goal directed behavior while upset, and a lack of access to more effective means for regulating emotions.

The implications of these findings are substantial.  First of all, it demonstrates that self-injury in individuals with substance use disorders shares many characteristics with self-injury in other populations. 

Second, it indicates that emotions play a primary role in self-injurious behavior in this population.  Despite a common belief that DSH is an attempt to manipulate others or a behavior with no coherent rationale, there is substantial evidence that, far more often than not, when individuals engage in non-suicidal self-injury, they are attempting to decrease the intensity of their own negative emotions. 

In other words, this is a behavior that is designed to modify their own internal state, not an effort to get something out of somebody else or a completely random and meaningless action.  Of course, not everyone engages in these behaviors for this purpose; however, these data indicate that, in individuals who suffer from a substance use disorder, emotion regulation is a primary motivating force.

The authors noted several limitations to their study and I would love to see future work that includes longitudinal measurements and a direct examination of the function of specific DSH episodes, but this study provided highly valuable information and it gives us further evidence that when we know somebody who self-injures, more often than not, the behavior is about them and their suffering, not an attempt to manipulate us.


If you would like to learn more about deliberate self-harm, we recommend the following resource, which is also available through our online store for scientifically-based psychological resources:

    * Understanding Nonsuicidal Self-Injury: Origins, Assessment, and Treatment by Matthew Nock

    * Freedom from Selfharm: Overcoming Self-Injury with Skills from DBT and Other Treatments by Kim Gratz and Alexander Chapman

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

See original article for links.

[Photo: actor Angelina Jolie has talked about her self-cutting as a teen, and multiple uses of drugs and alcohol.]

addictive behavior, drug addiction, substance abuse, problem drug use, problem drinking, alcoholism