Suicide and Life-Threatening Behavior 46 (1) February 2016 © 2015 The American Association of Suicidology DOI: 10.1111/sltb.12172

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Emotion Dysregulation and Affective Intensity Mediate the Relationship Between Childhood Abuse and Suicide-Related Behaviors Among Women with Bulimia Nervosa KATHRYN H. GORDON, PHD, HEATHER SIMONICH, MS, STEPHEN A. WONDERLICH, PHD, SWATI DHANKIKAR, MD, ROSS D. CROSBY, PHD, LI CAO, MS, MUN YEE KWAN, MS, JAMES E. MITCHELL, MD, AND SCOTT G. ENGEL, PHD

Self-harm and suicide attempts occur at elevated rates among individuals with bulimia nervosa, particularly among those who have experienced childhood abuse. This study investigated the potential mediating roles of emotion dysregulation and affective intensity in the relationship between these variables in 125 women with bulimia nervosa. Analyses revealed that emotion dysregulation mediated the relationship between sexual and emotional abuse with both self-harm and suicide attempts. Negative affective intensity mediated the relationship between abuse and suicide attempts. The findings may advance the understanding of mechanisms underlying suicide-related behaviors in women with bulimia nervosa who experienced abuse and suggest potential clinical targets. Over the last two decades, there have been an increasing number of studies demonstrating an empirical association between a history of various forms of childhood abuse and eating disorders (Smolak & Murnen, 2002; Thompson & Wonderlich, 2004; Wonderlich, Brewerton, Jocic, Dansky, & Abbott, 1997). One of the most well-estab-

lished findings in this literature is that a history of childhood abuse increases the likelihood of a highly comorbid eating disorder presentation with evidence of combinations of significant mood disturbance, personality problems, substance abuse, and significant suicide-related behaviors (Wonderlich et al., 1997). Supporting this

KATHRYN H. GORDON, Department of Psychology, North Dakota State University, Fargo, ND and Neuropsychiatric Research Institute, Fargo, ND, USA; HEATHER SIMONICH, Neuropsychiatric Research Institute, Fargo, ND, USA; STEPHEN A. WONDERLICH, Neuropsychiatric Research Institute, Fargo, ND and Department of Clinical Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, ND, USA; SWATI DHANKIKAR, Department of Clinical Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, ND, USA; ROSS D. CROSBY, Neuropsychiatric Research Institute, Fargo, ND and Department of Clinical Neuroscience, University of North Dakota School of

Medicine and Health Sciences, Fargo, ND, USA; LI CAO, Neuropsychiatric Research Institute, Fargo, ND, USA; MUN YEE KWAN, Department of Psychology, North Dakota State University, Fargo, ND, USA; JAMES E. MITCHELL and SCOTT G. ENGEL, Neuropsychiatric Research Institute, Fargo, ND and Department of Clinical Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, ND, USA. Address correspondence to Kathryn H. Gordon, Department of Psychology, North Dakota State University, NDSU Department 2765, P.O. Box 6050, Fargo, ND 58108-6050; E-mail: [email protected]

80 conclusion are additional empirical data suggesting that individuals with eating disorders, in general, display unusually high rates of suicide-related behaviors and that this is associated with histories of childhood abuse (Bodell, Joiner, & Keel, 2013; Franko & Keel, 2006; Svirko & Hawton, 2007). One common conceptual explanation for the association between childhood trauma and various forms of psychopathology is that early traumatic experiences increase affective disturbances and emotion dysregulation in children (Briere, Hodges, & Godbout, 2010; Yates, 2004). For example, research has demonstrated that emotion dysregulation following childhood trauma is involved in the onset of substance use disorders (Dube, Anda, Felitti, Edwards, & Croft, 2002), posttraumatic stress disorder (e.g., Stevens et al., 2013), and borderline personality disorder (e.g., Gratz, Tull, Baruch, Bornovalova, & Lejuez, 2008). Also, there is increasing evidence that emotion dysregulation difficulties may play a significant role in the development of eating disorder symptomatology following trauma (Burns, Fischer, Jackson, & Harding, 2012; Wonderlich et al., 2007). Furthermore, there is mounting evidence suggesting that suicide-related behaviors follow childhood trauma and that this relationship may be mediated by emotion dysregulation (Lang & Sharma-Patel, 2011; Weierich & Nock, 2008). It is often assumed that suicide-related behaviors display a functional relationship with affective disturbance (e.g., intense negative emotions) and are both precipitated by and serve to reduce negative affect, thus helping the traumatized individual to regulate trauma-related emotional experiences (Muehlenkamp, Claes, Smits, Peat, & Vandereycken, 2011; Weierich & Nock, 2008). Indeed, it has been theorized that affective disturbances and emotion dysregulation are major driving forces behind suicide-related behaviors (Linehan, 1993), and empirical evidence confirms that they are associated with self-harm behaviors (Anestis et al., 2012; Muehlenkamp et al., 2009; Nock & Prinstein, 2005)

EMOTION DYSREGULATION

AND

SUICIDAL BEHAVIOR

and suicide attempts (e.g., Pisani et al., 2013; Rajappa, Gallagher, & Miranda, 2012). In summary, childhood abuse increases the risk for eating disorders (e.g., Thompson & Wonderlich, 2004; Wonderlich et al., 1997) and suicide-related behaviors (e.g., Brodsky & Stanley, 2008; Dube et al., 2001). In addition, trauma has been linked to elevated levels of negative affect (e.g., Karr et al., 2013) and emotion dysregulation (Lang & Sharma-Patel, 2011; Yates, 2004), which have also been associated with suicide-related behaviors (e.g., Nock & Prinstein, 2005; Rajappa et al., 2012). In light of evidence that childhood abuse leads to subsequent elevated levels of negative affect and emotion dysregulation, it is proposed that this, in turn, leads to suicide-related behaviors among individuals who have experienced childhood abuse. This mediational model has never been tested in a sample of individuals with bulimia nervosa (BN), a population of particular interest in light of its elevated risk for suicide-related behaviors (Bodell et al., 2013; Franko & Keel, 2006). Therefore, in the current study we tested a mediational model that posits that there is a significant relationship between various types of childhood abuse (sexual, emotional, and physical) and different forms of suicide-related behaviors (self-harm and suicide attempts) and that this relationship is mediated by emotion dysregulation and negative affective intensity among women with BN.

METHOD

Participants The total sample of participants included 125 women who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) criteria for BN. The majority of participants were single or never married (64.8%), Caucasian (96.8%), and had at least some college experience (81.6%). All women were at least 18 years

GORDON

ET AL.

of age (M = 24.87, SD = 7.24, range 18–55) and medically stable. The mean body mass index for the total sample was 23.70 (SD = 4.86). Participants were recruited through advertisements in eating disorder clinics, college campuses, and the general community. Measures Two assessment procedures were utilized for this study: diagnostic interviews and self-report measures. These measures were part of a larger project that involved ecological momentary assessment (EMA; see Smyth et al., 2007, for details on the larger study). The EMA assessments are not reported in the present article. Participants first completed a series of semistructured diagnostic interviews administered by doctoral level psychologists and then provided responses to questionnaires. Clinical Interviews. The Structured Clinical Interview for DSM-IV Axis I Disorders, Patient Edition (SCID-I/P; First, Spitzer, Gibbon, & Williams, 1995) has been widely utilized and is strongly endorsed as a psychometrically valid and reliable instrument. Structured clinical interviews were conducted for the assessment of BN and other comorbid psychiatric conditions. The Child Trauma Interview (CTI; Fink, Bernstein, Handelsman, Foote, & Lovejoy, 1995) is a structured interview that was used to assess physical, sexual, and emotional abuse. Trained raters evaluated the traumatic experiences reported by participants on 7-point scale in terms of both the frequency and severity of the trauma episode. The highest severity rating for each subject from any form of trauma provided the measure of trauma. The CTI has been found to exhibit convergent validity with measures of posttraumatic stress disorder (Fink et al., 1995). Interrater reliability ratings for the CTI for severity and frequency of abuse ranged from .92 to .99. The Diagnostic Interview for Borderlines-Revised (DIB-R; Zanarini, Frankenburg, & Vujanovic, 2002) is a semistructured

81 interview that provides a measure of the following core features of borderline personality disorder: affect intensity, cognitive disturbance, impulse action patterns, and interpersonal relationships. The DIB-R has exhibited sound psychometric properties (Zanarini, Gunderson, Frankenburg, & Chauncey, 1989). In the current study, intraclass correlation coefficients were calculated to assess interrater reliability based on 25 randomly selected cases and ranged from 0.75 on the cognition scale to 1.0 on the interpersonal scale and 0.98 for the total score. The affect intensity scale, which measures negative affect states including intense levels of depression, anger, anxiety and other dysphoric emotional states, was utilized as a mediational variable in the current study. Additionally, we used the impulse action patterns subscale as a measure of self-harm behavior (“I have found different ways to intentionally hurt myself”) and also used the suicide attempt item (“I have tried to commit suicide”) as a measure of suicide attempts. Self-Report Measures. The Dimensional Assessment of Personality Pathology–Basic Questionnaire (DAPP-BQ; Livesley & Jackson, 2009) is a 290-item self-report measure comprised of 18 scales which contribute to four higher level scales: emotion dysregulation, dissocial behavior, social avoidance, and compulsiveness. The emotion dysregulation scale was used in this study, and internal consistency of this measure was high (a = 0.98). Emotional dysregulation refers to emotional and relational indicators of dysregulated affect. Procedure Institutional review boards at the University of North Dakota and MeritCare Health System approved the protocol. Phone screenings were conducted to determine whether interested participants met preliminary DSM-IV diagnostic criteria for BN. A total of 154 individuals were invited to attend an informational meeting to learn more about the study. During this meet-

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ing, potential participants completed the informed consent documents and provided blood samples for the determination of medical stability (i.e., electrolyte screen). Two additional assessment meetings, which each lasted approximately 2 hours, were scheduled for participants to complete structured clinical interviews and selfreport measures.

RESULTS

Descriptives Please see Table 1 for descriptive statistics for all measures. Statistical Analyses Boot-strapped mediation analyses (Preacher & Hayes, 2008) were conducted

TABLE 1

Participant Demographics and Mean Scores on Key Measures

Age (years) BMI (kg/m2) Sexual abuse Physical abuse Emotional abuse Emotional dysregulation Affect intensity score

Mean

SD

Range

24.8 23.7 1.38 2.29 2.44 43.12

7.24 4.86 1.78 1.60 1.26 9.09

18.26–55.33 17.14–39.54 0–6 0–5 0–4 22.36–63.64

1.49

0.62

0–3

n Ethnicity (Caucasian) Marital status (single/never married) Education (college and higher degree) Self-harm (1 or more times in past 2 years) Suicide attempts (1 or more in past 2 years) Note: SD = standard deviation; BMI = body mass index..

%

121 96.8 81 64.8 102 81.6 28 22.8 16 12.8

AND

SUICIDAL BEHAVIOR

using each abuse type (sexual, physical, and emotional abuse from the CTI) as independent variables, emotional dysregulation from the DAPP and negative affect intensity from the DIB-R as the mediators, and self-harm and suicide attempts from the DIB-R as the dependent variables. A total of twelve mediation models were tested. For the analyses, we used INDIRECT macro developed for SPSS. This macro uses bootstrapping to test the indirect or mediated effects, which were estimated via bootstrap analysis using 1,000 randomly generated samples. Mediation was established if the 95% bias-corrected confidence interval for the indirect parameter estimate did not contain zero. All statistical analyses were conducted using SPSS 18.0 version. Self-Harm The DAPP emotion dysregulation scale mediated the relationship between sexual abuse and self-harm behavior (indirect effect = 0.017, 95% CI = 0.001–0.048) and also the relationship between emotional abuse and self-harm (indirect effect = 0.045, 95% CI = 0.001–0.01). The DIB-R affect intensity scale did not mediate effects for self-harm (Table 2). Suicide Attempts The DAPP emotion dysregulation scale mediated the relationship between sexual abuse and suicide attempts (indirect effect = 0.01, 95%CI = 0.0002–0.034) as well as the relationship between emotional abuse and suicide attempts (indirect effect = 0.022, 95% CI = 0.002–0.058). The DIB-R negative affective intensity scale mediated the relationship between suicide attempts (Table 2) and each of the childhood abuse types (sexual abuse indirect effect = 0.015, 95% CI = 0.004–0.037, physical abuse indirect effect = 0.018, 95% CI = 0.001–0.045, and emotional abuse indirect effect = 0.016, 95% CI = 0.003–0.042; see Table 3).

ET AL.

83

.039) .034) .057) .041) .047) .059)

0.017* (0.001, 0.048) (SE = .013) 0.013 (0.006, 0.049) (SE = .014) 0.046* (0.010, 0.100) (SE = .021) 0.004 (0.031, 0.030) (SE = .013) 0.007 (0.026, 0.041) (SE = .016) 0.010 (0.006, 0.050) (SE = .017)

DISCUSSION

Note: IV, independent variable; MV, mediating variable; DV, dependent variable; SE, standard error. *p < .05.

= = = = = = (SE (SE (SE (SE (SE (SE 0.034 0.017 0.035 0.047 0.017 0.001 0.022* (SE = .008) 0.023* (SE = .008) 0.024* (SE = .008) 0.037 (SE = .121) 0.062 (SE = .122) 0.076 (SE = .121) 0.77 (SE = .45) 0.584 (SE = .093) 1.896* (SE = .628) 0.100* (SE = .030) 0.120* (SE = .033) 0.128* (SE = .043) Sexual abuse Physical abuse Emotion abuse Sexual abuse Physical abuse Emotional abuse

Emotion dysregulation Emotion dysregulation Emotion dysregulation Negative affective intensity Negative affective intensity Negative affective intensity

Effect of MV on DV (b) Effect of IV on MV (a) MV IV

Summary of Mediation Results Using Self-Harm as the Dependent Variable

TABLE 2

Direct effect (c0 )

Indirect effect (a*b)

GORDON

In the current study we sought to test whether the relationships between different forms of childhood abuse (emotional, physical, and sexual) and suicide-related behaviors (self-harm and suicide attempts) were mediated by negative affective intensity and emotional dysregulation in a sample of women with BN. In the first set of analyses examining self-harm behavior, mediational analyses revealed that both childhood sexual abuse and emotional abuse were significantly linked to self-harm behaviors and that these relationships were mediated by emotional dysregulation but not affective intensity. We did not find a significant association between physical abuse and selfharm behaviors in the current sample, a finding which is consistent with some previous research (e.g., Glassman, Weierich, Hooley, Deliberto, & Nock, 2007) and contrary to other research (e.g., Bornovalova, Tull, Gratz, Levy, & Lejuez, 2011). The second set of mediational analyses examining suicide attempts showed that all three types of childhood abuse had significant associations with suicide attempts, which is in line with previous research (e.g., Joiner et al., 2007). The relationships between sexual abuse and emotional abuse with suicide attempts were mediated by both emotion dysregulation and negative affective intensity, while the relationship between physical abuse and suicide attempts was mediated only by negative affective intensity. With regard to theoretical implications, it appears that women with BN who have experienced childhood emotional or sexual abuse tend to have difficulties regulating their emotions and that this places them at greater risk for engaging in selfharm behaviors. This finding is compatible with leading theoretical models of selfharm, which propose that people often intentionally injure themselves in an effort to regulate their emotions (e.g., Chapman, Gratz, & Brown, 2006). These results have two main clinical implications. First, it is

0.010* (0.004, 0.040) (SE = .008) 0.008 (0.006, 0.004) (SE = .009) 0.022* (0.002, 0.058) (SE = .014) 0.015* (0.004, 0.037) (SE = .007) 0.018* (0.002, 0.045) (SE = .016) 0.016* (0.003, 0.043) (SE = .010) .025) .028) .034) .027) .030) .037) Note: IV, independent variable; MV, mediating variable; DV, dependent variable; SE, standard error. *p < .05.

= = = = = = (SE (SE (SE (SE (SE (SE 0.013* (SE = .005) 0.014* (SE = .005) 0.012* (SE = .005) 0.156* (SE = .077) 0.153 (SE = .078) 0.128 (SE = .075) Sexual abuse Physical abuse Emotional abuse Sexual abuse Physical abuse Emotional abuse

Emotion dysregulation Emotion dysregulation Emotion dysregulation Negative affective intensity Negative affective intensity Negative affective intensity

0.772 (SE = .454) 0.584 (SE = .093) 1.896* (SE = .628) 0.100* (SE = .030) 0.120* (SE = .033) 0.128* (SE = .043)

0.015 0.024 0.063 0.010 0.014 0.069

Indirect effect (a*b)

SUICIDAL BEHAVIOR

Effect of MV on DV (b)

Direct effect (c0 )

AND

Effect of IV on MV (a) MV IV

Summary of Mediation Results Using Suicide Attempts as the Dependent Variable

particularly important that individuals presenting with BN and a history of childhood sexual or emotional abuse are routinely assessed and monitored for self-harm behaviors, as they appear to be at elevated risk. Second, it is reasonable to assume that targeting affect dysregulation may reduce self-harm behaviors among individuals with BN. Coping methods in evidence-based treatments for BN, such as those utilized in integrative cognitive affect therapy (ICAT; Wonderlich et al., 2014) and cognitive behavioral therapy for BN-enhanced (CBTE; Fairburn, Cooper, & Shafran, 2003), may be particularly useful in decreasing emotion dysregulation and self-harm behaviors for individuals with BN. The second set of findings, focused on suicide attempts rather than self-harm behaviors, also has theoretical and clinical implications. All three types of childhood abuse had significant associations with suicide attempts among women with BN. Therefore, it is particularly important for clinicians to regularly monitor and assess suicide risk among clients with BN who have a history of childhood abuse. In three types of abuse, affect intensity was found to mediate the relationship between childhood trauma and suicide attempts. The results are consistent with the notion that individuals who experience childhood abuse are at greater risk for suicide attempts because they are more prone to intense negative affect. These aversive, intense affective states may lead to a desire for suicide, which may be viewed as an escape from unbearable emotional pain (Baumeister, 1990). In the cases of emotional and sexual abuse, emotion dysregulation was also found to mediate the relationships between childhood trauma and suicide attempts. This suggests that suicide attempts may result as both a consequence of emotion dysregulation and intense negative affect and that targeting both in therapy might lead to the most potent prevention of suicide attempts. In contrast, our results suggest that the key for individuals with BN who have a history of physical abuse may

EMOTION DYSREGULATION

TABLE 3

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ET AL.

be to decrease their intensely negative affect states and that emotion dysregulation is less relevant for this subgroup with regard to suicide attempts. Contemporary evidencebased treatments that focus on affective states (e.g., ICAT and CBT-E) may also have potential as effective interventions for reducing suicide attempts among individuals with BN, as they include healthy strategies for clients to reduce negative affective states, in addition to adaptive emotion regulation strategies (Table 3). Our results should be considered in light of the strengths and limitations of the study. With regard to limitations, the crosssectional design precluded conclusions about the temporal relationship between childhood abuse and suicide-related behaviors. Consistent with previous work (e.g., Yates, 2004), it was proposed that intense negative affect and emotion dysregulation frequently occur as a consequence of childhood trauma and that these, in turn, drive the use of suicide-related behaviors as maladaptive coping strategies. However, studies with longitudinal designs are needed to fully test the posited temporal relationships

85 between these variables. Furthermore, both self-harm and suicide attempt behaviors were assessed with one-item, dichotomous (i.e., yes/no) interview questions. While this allows for the inclusion of a broad range of suicide-related experiences, the severity and frequency of the behaviors exhibited by this sample is unknown. Finally, while women with BN are of particular interest because they have elevated rates of both childhood abuse and suicide-related behaviors (e.g., Franko & Keel, 2006; Svirko & Hawton, 2007), the results may not be generalizable to other groups of people. Strengths of the study include the use of psychometrically sound measures to assess all variables, the relatively large sample size of a highly relevant clinical sample, and the illumination of potential mechanisms for the link between childhood abuse and suicide-related behaviors. Future research should seek to build on our findings through the use of longitudinal designs, different types of samples (e.g., nonclinical, other types of psychiatric disorders, men), and more precise information about the nature of the suicide-related behaviors.

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