CanJPsychiatry 2014;59(11):569–575
In Review
Expanding and Clarifying the Role of Emotion Regulation in Nonsuicidal Self-Injury Margaret S Andover, PhD1; Blair W Morris, MA (PhD Candidate)2 1
Associate Professor, Department of Psychology, Fordham University, Bronx, New York. Correspondence: Department of Psychology, Fordham University, 441 East Fordham Road, Bronx, NY 10458; [email protected].
2
Doctoral Student, Department of Psychology, Fordham University, Bronx, New York.
Key Words: emotion dysregulation, deliberate selfharm, rumination, suppression, reappraisal Received and accepted August 2014.
Objective: Deficits in emotion regulation have been implicated in nonsuicidal self-injury (NSSI) by both theory and research. Research indicates that NSSI is commonly performed as an emotion regulation strategy, as it often decreases the experience of negative affect. People who engage in NSSI often report greater emotion dysregulation than those without an NSSI history. Further, interventions that have demonstrated effectiveness in reducing NSSI involve a focus on emotion regulation skills. Given the important role of emotion regulation in NSSI, research should continue to develop our understanding of this construct. Methods: We conducted a review of relevant research in emotion regulation and dysregulation and specific emotion regulation strategies in NSSI. Results: First, we provide an overview of current research on emotion regulation and dysregulation in NSSI. Second, we discuss the application of a specific emotion regulation model to NSSI research, and review research on NSSI supporting the use of this model. Conclusion: NSSI has been associated with an emotion regulation function and trait emotion dysregulation among people who self-injure. Relevant research provides initial support for the applicability of a specific model of emotion regulation to NSSI. We suggest directions for future research to continue to cultivate our understanding of emotion regulation in NSSI. WWW
Développer et clarifier le rôle de la régulation émotionnelle dans l’automutilation non suicidaire Objectif : Les déficits de régulation émotionnelle sont impliqués dans l’automutilation non suicidaire (AMNS) par la théorie et la recherche. La recherche indique que l’AMNS sert communément de stratégie de régulation émotionnelle, car elle diminue souvent l’expérience de l’affect négatif. Les personnes qui pratiquent l’AMNS déclarent souvent une plus grande dysrégulation émotionnelle que celles qui n’ont pas d’antécédents d’AMNS. En outre, les interventions qui ont démontré une efficacité à réduire l’AMNS mettent l’accent sur les compétences de régulation émotionnelle. Étant donné le rôle important de la régulation émotionnelle dans l’AMNS, la recherche devrait continuer à développer notre compréhension de ce construit. Méthodes : Nous avons mené une revue de la recherche pertinente sur la régulation et la dysrégulation émotionnelles, et sur les stratégies spécifiques de régulation émotionnelle dans l’AMNS. Résultats : Premièrement, nous présentons un aperçu de la recherche actuelle sur la régulation et la dysrégulation émotionnelle dans l’AMNS. Deuxièmement, nous discutons de l’application d’un modèle spécifique de régulation émotionnelle à la recherche sur l’AMNS, et menons une revue de la recherche sur l’AMNS qui soutient l’emploi de ce modèle. Conclusion : L’AMNS a été associée à une fonction de régulation émotionnelle et à un trait de dysrégulation émotionnelle chez les personnes qui s’automutilent. La recherche pertinente offre un soutien initial de l’applicabilité d’un modèle spécifique de régulation émotionnelle à l’AMNS. Nous suggérons des directions à la recherche future pour continuer de cultiver notre compréhension de la régulation émotionnelle dans l’AMNS.
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A
s awareness of the prevalence of NSSI and the risks associated with the behaviour have increased, interest in empirically supported treatments for NSSI has also increased. Empirical evidence has been strongest for interventions that have a specific focus on improving emotion regulation, such as DBT1 and emotion regulation group therapy,2,3 and emotion regulation has been implicated as an important treatment mechanism in these interventions (for example, Gratz,4 Gratz et al,5 and Slee et al6). In NSSI research more generally, our understanding of emotion regulation has focused predominantly on NSSI as a means of emotion regulation, and on trait emotion dysregulation among people who engage in NSSI. Much of this research has been guided by Linehan’s1 theory of emotion dysregulation in BPD, which focuses on emotional vulnerability and lack of emotion regulation skills. However, other models of emotion regulation may enhance and clarify our understanding of the difficulties experienced by people who engage in NSSI. The goal of this review is 3-fold. First, we will provide an overview of current research on emotion regulation and dysregulation in NSSI; for an in-depth review of these topics, please see Klonsky7 and Gratz.4 Second, we will discuss another model of emotion regulation8 that may provide a framework for building on existing work and for clarifying the process of, and deficits in, emotion regulation among self-injurers. We will then provide a review of NSSI research supporting the application of this model. Finally, we will suggest directions for future research to clarify and expand our understanding of emotion regulation in NSSI.
Empirical Support for Nonsuicidal SelfInjury as a Means of Emotion Regulation
The functions of NSSI have been a focus of considerable research and clinical interest. Although several functions have historically been proposed (for example, Klonsky7 and Suyemoto9), the function of emotion regulation has received the strongest empirical support (For a review, see Klonsky7). People who engage in NSSI often report that the behaviour is associated with reductions in negative emotions, such as tension, fear, and sadness (for example, Briere and Gil,10 Klonsky,11 Kumar et al,12 and Laye-Gindhu and Schonert-Reichl13), and studies using ecological momentary assessment, which reduces the potential for retrospective bias often found in survey research, have reported a decrease in negative affect following NSSI (for example, Armey et al14 and Nock et al15; however, also see Muehlenkamp et al16). Although primarily considered a means to reduce negative affect, those who engage in NSSI Abbreviations BPD
borderline personality disorder
DBT
dialectical behaviour therapy
DERS
Difficulties in Emotion Regulation Scale
NSSI
nonsuicidal self-injury
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Clinical Implications •
Research supports an emotion regulation function of NSSI and trait emotion dysregulation among people who engage in the behaviour.
•
Other models of emotion regulation, such as that of Gross (1998), may be used to supplement theories currently used in NSSI research to refine our understanding of the emotion regulation process and interventions for NSSI.
•
Research supports the applicability of Gross’ (1998) model to NSSI.
Limitations •
Further research is necessary to investigate the applicability of other models of emotion regulation to NSSI research.
•
Further research is necessary to determine the effectiveness of interventions focused on different stages of the emotion regulation process.
report that the behaviour also produces positive affect, and increased positive affect following NSSI is associated with greater lifetime frequency of the behaviour (for example, Armey et al,14 Jenkins and Schmitz,17 and Kemperman et al18; however, also see Muehlenkamp et al16). Nock and Prinstein19 proposed a behavioural model for the functions of NSSI in which the behaviour is maintained by automatic (intrapersonal) and social (interpersonal) reinforcement. This model has been empirically supported,19,20 and automatic functions for NSSI, especially automatic negative reinforcement, are significantly more likely to be reported than social functions.19 The finding of greater use of NSSI for automatic functions is consistent with an emotion regulation function, as NSSI is most often used to reduce undesired or to generate desired emotions. Psychophysiological research also supports an emotion regulation function of NSSI. Using guided imagery scripts of NSSI, Haines et al21 and Brain et al22 found that physiological arousal decreased during and after the description of NSSI among people with a history of the behaviour. Similarly, Welch et al23 noted decreases in arousal after the description of NSSI in the guided imagery script on 1 of 2 psychophysiological assessments among adults with a diagnosis of BPD. This pattern of decreasing physiological arousal is consistent with, and provides objective support for, an emotion regulation function. Laboratory studies suggest that pain is an important emotion regulation feature of NSSI. Several studies have demonstrated a decrease in negative affect following the administration of a painful stimulus (for example, Bresin and Gordon,24 Franklin et al,25 and Weinberg and Klonsky26), and increased positive affect has also been reported.27 In addition, emotion dysregulation is associated with decreased pain perception.28 The role of pain in emotion regulation may be more pronounced for some self-injurers, such as those who report no pain during NSSI29 or those with a lower subjective perception of pain.26 Pain may serve www.LaRCP.ca
Expanding and Clarifying the Role of Emotion Regulation in Nonsuicidal Self-Injury
to regulate negative emotions regardless of NSSI history, as people with and without the behaviour demonstrate reductions in negative affect after the administration of a painful stimulus.24,25 Together, research on the emotion regulation function of NSSI suggests that the behaviour is physiologically and psychologically maintained as an effective, although maladaptive, emotion regulation strategy.
Empirical Support for Emotion Dysregulation in Nonsuicidal Self-Injury
Research has investigated whether people who engage in NSSI experience global deficits in emotion regulation, or if emotion regulation is uniquely associated with NSSI function. In general, this research has focused on emotion dysregulation, or difficulties in the emotion generation and (or) regulation process.30 Nearly all studies of trait-level emotion dysregulation in NSSI have used the DERS,31 a self-report measure designed to assess nonacceptance of emotional responses, lack of emotional awareness, lack of emotional clarity, impulse control difficulties, difficulties engaging in goal-directed behaviour, and limited access to effective emotion regulation strategies.31 Subscale scores reflect each of these factors, but the DERS is often reported as a total score. The DERS has also been used to assess emotion dysregulation in other psychological disorders.32–35 Studies support increased trait emotional dysregulation among people who engage in NSSI. People with NSSI report greater levels of emotion dysregulation than those without an NSSI history in clinical and nonclinical samples.36–40 Increased self-reported emotion dysregulation is also associated with increased NSSI frequency.17,38,41Although emotion dysregulation and NSSI are both associated with BPD, Glenn and Klonsky42 found that among adolescent psychiatric patients, NSSI disorder, a disorder requiring future research in the 5th edition of the Diagnostic and Statistical Manual,43 was uniquely associated with emotion dysregulation over and above a BPD diagnosis. This suggests that the role of emotion dysregulation in NSSI is not simply accounted for by BPD characteristics. Specific dimensions of emotion dysregulation, as measured by subscales of the DERS, may differentiate people who engage in NSSI from those who do not,40,44,45 and DERS subscales may differentiate people who currently engage in NSSI from those with a past history of the behaviour.44 In addition, the limited access to emotion regulation strategies subscale of the DERS was uniquely associated with an emotion regulation function of the behaviour among adults,46 suggesting that NSSI may be used as a strategy to address a perceived deficit in emotion regulation skills. Difficulty tolerating distress, a construct related to emotion dysregulation, has also been investigated among people with NSSI. People with a history of NSSI have been shown to terminate a distressing task earlier than noninjurers,47 suggesting difficulty or unwillingness to experience emotional distress. Overall, research indicates a diffuse www.TheCJP.ca
pattern of emotion regulation difficulties among people with a history of NSSI. Studies have reliably found elevated emotion dysregulation among self-injurers using the DERS; however, a comprehensive understanding of specific aspects of the emotion regulation process is limited as the measure relies on self-perception of emotion regulation and overlaps considerably with emotional competency.31,48 Although the subscale of limited access to emotion regulation strategies has been associated with NSSI and appears germane to emotion regulation, it may measure perceived selfefficacy in emotion regulation, rather than effective use of strategies.48 Further research is necessary to investigate aspects of emotion regulation not assessed by the DERS, as well as to develop and incorporate objective measures of emotion regulation.
Theories of Emotion Regulation
The theory of emotion dysregulation most often applied to NSSI is Linehan’s biosocial theory of BPD.1 This comprehensive theory proposes that BPD is predominantly a dysfunction of the emotion regulation system; people engage in NSSI and suicidal behaviours to regulate emotional experiences. Emotion dysregulation in BPD consists of 2 components.1 First, people with BPD have increased emotional vulnerability, compared with those without the disorder, as they experience emotions more intensely, are more sensitive to negative and positive emotional stimuli, and experience a slow return to a baseline emotional state. Although beyond the scope of this review, this has been supported by research on NSSI.49 Second, people experience difficulty managing high levels of emotional arousal because they lack effective emotion regulation skills. Emotion regulation requires 2 skills: the ability to experience and label emotions, and the ability to reduce emotionally relevant stimuli that serve to reactivate negative or positive emotions or cause secondary emotional responses.1 Emotional vulnerability and deficits in emotion regulation are rooted in biological predispositions and exacerbated by environmental experiences. Emotion dysregulation is most pronounced with negative emotions, but people with BPD can also experience difficulty regulating positive emotions.1 Although Linehan’s model was developed for BPD, it has been influential in understanding NSSI and has guided much of the research on emotion dysregulation. However, as NSSI occurs outside the context of BPD,50,51 it may be useful to consider other models to enhance our current understanding of emotion regulation in NSSI. Gross’ model of emotion regulation8 has been applied to several psychological disorders, including BPD,52 and may be a useful supplement to refine and improve our understanding of emotion regulation in NSSI. According to Gross,8 emotion regulation is the process by which a person consciously or unconsciously influences the occurrence, experience, expression, duration, and magnitude of emotions. The processes involved in emotion regulation The Canadian Journal of Psychiatry, Vol 59, No 11, November 2014 W 571
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follow a sequence: situation, attention, appraisal, and response. The response process then provides feedback to the situation process, as a person’s emotional response may modify a particular situation or cause a new situation to develop.53 Five specific emotion regulation strategies have been associated with the 4 processes. Two strategies, situation selection and situation modification, are associated with the situation process. Situation selection involves taking action to make it more or less likely that one will be in a situation that will elicit positive or negative emotions, while situation modification involves directly modifying a situation with the specific goal of changing its emotional impact.8 The process of attention can be regulated through attentional deployment, where one directs attention within a given situation to impact emotional experiences. One example of attentional deployment is distraction, where an individual may influence the emotional impact of a situation by focusing attention on specific aspects within or outside the situation. Cognitive change is used to modify one’s appraisal of a situation to change emotional response; reappraisal is a common emotion regulation technique. Finally, emotional responses to a situation can be influenced by response modulation. In response modulation, strategies are used to change the behavioural, physiological, and psychological experiences of an emotion. These strategies may be adaptive, such as relaxation, or maladaptive, such as substance use. Importantly, NSSI has been identified as a response modulation strategy within the context of BPD.52 Although implications of emotion regulation often focus on improving the emotional experience by reducing negative emotions or increasing positive emotions, each process in Gross’ model can also be acted on so that negative emotional experiences are heightened or positive emotional experiences are reduced. The emotion regulation models developed by Gross8 and Linehan1 are quite compatible52 and potentially synergistic. The combination of emotional vulnerability and difficulties in emotion regulation skills1 are consistent with the concepts of emotion generation and regulation.54 In addition, although DBT primarily focuses on addressing emotion regulation after the emotion has been generated,30 the treatment is consistent with the processes and strategies outlined by Gross. For example, interpersonal effectiveness skills can be used in situation modification, as they may alter the experience of an interpersonal interaction. Similarly, mindfulness is a method of attentional deployment as it focuses on the control of attention toward aspects of the external or internal situational experience.30 Incorporating a broader model, such as that of Gross,8 into our existing model of emotion dysregulation in NSSI would promote an understanding that is simultaneously refined and comprehensive. Research on the emotion regulation function of NSSI is consistent with Gross’ model,8 as it supports NSSI as a response modulation strategy and suggests a deficit in the ability to regulate emotions in an adaptive manner. Although limited, NSSI research has supported the use of 572 W La Revue canadienne de psychiatrie, vol 59, no 11, novembre 2014
Gross’ model by implicating processes earlier in emotion regulation than emotional response. A thorough review is beyond the scope of this article, but we present an overview of research that suggests dysfunction earlier in the emotion regulation process consistent with this model. Rumination involves intense repetitive focus on emotional experiences, their causes and their consequences, and is associated with defective attentional deployment.8 A growing body of research supports an association between NSSI and rumination.55–58 However, the association between rumination and NSSI is likely complex, as recent research suggests that NSSI may be related to instability of rumination, rather than increased trait rumination, which is associated with depression.57 In addition, NSSI may be associated with specific rumination topics. Unstable rumination about the past, especially when experienced with unstable sadness, has been associated with increased NSSI frequency, while rumination about the future or emotional states may be protective against NSSI frequency.57 Research on rumination suggests that people with NSSI may experience deficits in attentional deployment, as well as other aspects of the attention process. This is supported by elevations on the difficulties in goal-directed behaviour subscale of the DERS, as this subscale may assess deficits in attentional deployment.48 Research has suggested a cognitive regulation function of NSSI in addition to an emotion regulation function, indicating an association between NSSI as a response modulation strategy and the attribution process. Adolescents who engage in NSSI report that the behaviour distracts them from unwanted thoughts.15 In addition, increased cognitive processing, specifically information processing, was found among people with an NSSI history following a painful stimulus, suggesting that NSSI may serve a cognitive regulation function.25 People with NSSI demonstrate poorer cognitive processing than noninjurers who are not elevated on emotion dysregulation,25 suggesting dysfunction at the appraisal process. Guerry and Prinstein59 reported that a negative attributional style was associated with NSSI frequency in a longitudinal study of adolescents, providing additional support for deficits in the appraisal process and associated regulation strategies. Research in several psychological disorders has focused on suppression, a response modulation strategy, and reappraisal, a cognitive change strategy (for example, Aldao et al60). Thought suppression, which specifically involves the suppression of unwanted thoughts rather than emotions, is associated with the presence and frequency of NSSI in adolescent and young adult samples,44,61,62 and poor cognitive reappraisal is associated with NSSI history.63 Thought suppression has also been shown to partially mediate the relation between emotion generation (specifically, emotional reactivity) and NSSI frequency.62 Suppression is associated with specific functions of NSSI, including automatic negative reinforcement,62 emotion regulation, and self-punishment46; however, the association www.LaRCP.ca
Expanding and Clarifying the Role of Emotion Regulation in Nonsuicidal Self-Injury
was decreased or nonexistent when investigating social reinforcement,62 interpersonal influence and communication, and feeling generation.46 However, cognitive reappraisal was not found to be associated with any reported NSSI function.46 Together, this research indicates specificity between suppression and emotion regulation functions of NSSI, suggesting that suppression may influence the emotional experience of people with NSSI. Few NSSI studies have assessed both suppression and reappraisal simultaneously, and use of these strategies has not yet been investigated in experimental research. However, self-report data suggest that suppression and reappraisal may be differentially associated with the onset, cessation, and maintenance of NSSI in adolescents during a 1-year period. Adolescents who began engaging in NSSI during the follow-up period reported significantly less cognitive reappraisal and more emotional suppression than those who did not engage in NSSI, while those who stopped engaging in NSSI during the follow-up period had greater cognitive reappraisal and less suppression than those who maintained NSSI.63 In addition, maintenance of NSSI during the 1-year period was significantly associated with poor cognitive reappraisal and increased suppression.63,64 Research on suppression in NSSI may appear to indicate that it is a maladaptive emotion regulation strategy. In fact, use of suppression has been associated with decreased positive— but not negative—emotional experiences, poorer memory, and increased activation of the sympathetic nervous system (for example, Gross53), as well as more difficulty in regulating negative emotions.46 However, global generalizations about the use of suppression should be cautioned against.53 For example, among female participants with BPD randomly assigned to engage in expressive suppression or emotional acceptance during a negative mood induction, those who engaged in suppression were less likely than those engaged in emotional acceptance to experience urges to selfinjure and -punish after the induction.65 This suggests that although suppression may appear less desirable than other emotion regulation strategies, such as reappraisal, it may have an adaptive function65 and may be more effective than other strategies in specific contexts. Together, these studies indicate that appropriate use of cognitive reappraisal and suppression may be important skills to target in NSSI treatment and prevention.
Conclusions and Future Directions
Research on the emotion regulation function of NSSI and trait emotion dysregulation among people who self-injure has been critical in understanding the behaviour, as well as in developing effective treatments, most of which currently focus on addressing deficits in emotion regulation. The field of NSSI may benefit from applying other models of emotion regulation, such as that of Gross,8 to NSSI research and current emotion dysregulation models. By focusing on a temporal process of emotion regulation that involves cognition and attention, in addition to efforts to change the emotional experience, such as proposed by Gross,8 we will www.TheCJP.ca
develop a broader understanding of emotion regulation, and clinicians may be able to intervene earlier in the emotion regulation process. Current research supports the application of Gross’ model to NSSI, as findings have indicated potential deficits at specific stages in the emotion regulation process. Future research should continue to explore the clinical utility of this model in NSSI, using objective assessments whenever possible (for example, Lewis et al66). In addition, research should determine how strategies at different stages in the emotion regulation process are used to change emotion, if at all. For example, a person may lack emotion regulation strategies, or he or she may engage in strategies that increase the likelihood of experiencing negative emotions.8 Understanding the specific emotion regulation processes involved will have a direct effect on successful intervention strategies. Research focused on the attention and attribution processes may be particularly important. These processes are associated with the cognitive control of emotion,67 implicated by the cognitive regulation function of NSSI. Research may expand into constructs associated with the emotion regulation process, such as decision making (for example, Greucci and Sanfey68), or may seek to refine our understanding of the unique contributions of the processes of emotion generation (that is, emotional vulnerability) and emotion regulation in NSSI (for example, Gross and Barrett54). In addition, as Gross’ model has been extensively applied to psychological disorders (for example, Aldao et al,60 Cisler et al,69 and Joormann and Siemer70), research consistent with this model will facilitate the investigation of emotion regulation as a mechanism underlying multiple disorders, consistent with the National Institute of Mental Health’s Research Domain Criteria goals (for example, Sanislow et al71). Future research may identify the specific emotion regulation mechanisms involved in current efficacious treatments for NSSI, as well as impact the development of new treatments—understanding the full range of emotion regulation may provide new avenues for intervention. For example, research on strategies associated with the attribution process suggests that therapies that focus on cognitive attributions and restructuring, such as cognitivebehavioural therapy, may be an effective intervention or prevention strategy.59,64 In addition, the application of other existing emotion regulation therapies to NSSI, such as emotion regulation therapy for generalized anxiety disorder,72 may be explored. NSSI has been associated with an emotion regulation function and trait emotion dysregulation among people who self-injure. The purpose of our paper was to propose the application and integration of a specific emotion regulation model to current research to enhance our understanding of NSSI and to suggest important targets for intervention. Relevant research provides initial support for the applicability of this model to NSSI. Supplementing research The Canadian Journal of Psychiatry, Vol 59, No 11, November 2014 W 573
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with other empirically supported emotion regulation models will allow for a simultaneously clearer and broader understanding of emotion regulation among people who engage in NSSI, as well as common mechanisms that underlie NSSI and related psychological disorders.
Acknowledgements
This research was supported in part by National Institute of Mental Health grant K23MH082824. The Canadian Psychiatric Association proudly supports the In Review by providing an honorarium to the authors.
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17. Jenkins AL, Schmitz MF. The roles of affect dysregulation and positive affect in non-suicidal self-injury. Arch Suicide Res. 2012;16(3):212–225. doi: 10.1080/13811118.2012.695270. 18. Kemperman I, Russ MJ, Clark WC, et al. Pain assessment in selfinjurious patients with borderline personality disorder using signal detection theory. Psychiatry Res. 1997;70(3):175–183. doi: 10.1521/ pedi.1997.11.2.146. 19. Nock MK, Prinstein MJ. A functional approach to the assessment of self-mutilative behavior. J Consult Clin Psychol. 2004;72(5):885–890. doi: 10.1037/0022–006X.72.5.88. 20. Nock MK, Prinstein MJ. Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol. 2005;114(1):140–146. doi: 10.1037/0021–843X.114.1.140. 21. Haines J, Williams CL, Brain KL, et al. The psychophysiology of self-mutilation. J Abnorm Psychol. 1995;104(3):471–489. doi: 10.1037/0021–843X.104.3.471. 22. Brain KL, Haines J, Williams CL. The psychophysiology of self-mutilation: evidence of tension reduction. Arch Suicide Res. 1998;4(3):227–242. doi: 10.1023/A:1009692507987. 23. Welch S, Linehan MM, Sylvers P, et al. Emotional responses to self-injury imagery among adults with borderline personality disorder. J Consult Clin Psychol. 2008;76(1):45–51. doi:10.1037/ 0022–006X.76.1.45. 24. Bresin K, Gordon KH. Changes in negative affect following pain (vs nonpainful) stimulation in individuals with and without a history of nonsuicidal self-injury. Personal Disord. 2013;4(1):62–66. Epub 2011 Oct 10. doi:10.1037/a0025736. 25. Franklin JC, Hessel ET, Aaron RV, et al. The functions of nonsuicidal self-injury: support for cognitive-affective regulation and opponent processes from a novel psychophysiological paradigm. J Abnorm Psychol. 2010;119(4);850–862. doi: 10.1037/a0020896. 26. Weinberg A, Klonsky ED. Measurement of emotion dysregulation in adolescents. Psychol Assess. 2009;21(4):616–621. doi: 10.1037/ a00016669. 27. Franklin JC, Lee KM, Hanna EK, et al. Feeling worse to feel better: pain-offset relief simultaneously stimulates positive affect and reduces negative affect. Psychol Sci. 2013;24(4):521–529. doi: 10.1177/0956797612458805. 28. Franklin JC, Aaron RV, Arthur MS, et al. Nonsuicidal self-injury and diminished pain perception: the role of emotion dysregulation. Compr Psychiatry. 2012;53(6):691–700. doi: 10.1016/ j.comppsych.2011.11.008. 29. Russ MJ, Roth SD, Lerman A, et al. Pain perception in self-injurious patients with borderline personality disorder. Biol Psychiatry. 1992;32(6):501–511. doi: 10.1016/0006–3223(92)90218-O. 30. Neacsiu AD, Bohus M, Linehan MM. Dialectical behavioral therapy: an intervention for emotion dysregulation. In: Gross JJ, editor. Handbook of emotion regulation. New York (NY): Guilford Press; 2014. p 491–507. 31. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. J Psychopathol Behav Assess. 2004;26(1):41–54. doi: 10.1023/ B:JOBA.0000007455.08539.94. 32. Fox HC, Hong KA, Sinha R. Difficulties in emotion regulation and impulse control in recently abstinent alcoholics compared with social drinkers. Addict Behav. 2008;33(2):388–394. doi: 10.1016/ j.addbeh.2007.10.002. 33. Fox H, Axelrod S, Paliwal P, et al. Difficulties in emotion regulation and impulse control during cocaine abstinence. Drug Alcohol Depend. 2007;89(2–3):298–301. doi: 10.1016/ j.drugalcdep.2006.12.026. 34. Harrison A, Sullivan S, Tchanturia K, et al. Emotional functioning in eating disorders: attentional bias, emotion recognition and emotion regulation. Psychol Med. 2010;40(11):1887–1897. doi: 10.1017/ S0033291710000036. 35. Whiteside U, Chen E, Neighbors C, et al. Difficulties regulating emotions: do binge eaters have fewer strategies to modulate and tolerate negative affect? Eat Behav. 2007;8(2):162–169. doi: 10.1016/j.eatbeh.2006.04.001. 36. Bedi R, Muller RT, Classen CC. Cumulative risk for deliberate selfharm among treatment-seeking women with histories of childhood abuse. Psychol Trauma. Epub 2013 Nov 25. doi: 10.1037/a0033897. www.LaRCP.ca
Expanding and Clarifying the Role of Emotion Regulation in Nonsuicidal Self-Injury 37. Gratz KL, Breetz A, Tull MT. The moderating role of borderline personality in the relationships between deliberate self‐harm and emotion‐related factors. Personal Ment Health. 2010;4(2):96–107. 38. Gratz KL, Chapman AL. The role of emotional responding and childhood maltreatment in the development and maintenance of deliberate self-harm among male undergraduates. Psychol Men Masc. 2007;8(1):1–14. doi: 10.1037/1524–9220.8.1.1. 39. Gratz KL, Roemer L. The relationship between emotion dysregulation and deliberate self-harm among female undergraduate students at an urban commuter university. Cogn Behav Ther. 2008;37(1):14–25. doi: 10.1080/16506070701819524. 40. Gratz KL, Tull MT. The relationship between emotion dysregulation and deliberate self-harm among inpatients with substance use disorders. Cogn Ther Res. 2010;34(6):544–553. doi: 10.1007/ s10608–009–9268–4. 41. Adrian M, Zeman J, Erdley C, et al. Emotional dysregulation and interpersonal difficulties as risk factors for nonsuicidal self-injury in adolescent girls. J Clin Child Adolesc Psychol. 2011;39(3):389–400. doi: 10.1007/s10802–010–94653. 42. Glenn CR, Klonsky ED. Nonsuicidal self-injury disorder: an empirical investigation in adolescent psychiatric patients. J Clin Child Adolesc Psychol. 2013;42(4):496–507. doi: 10.1080/ 15374416.2013.794699. 43. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. 5th ed. Arlington (VA): APA; 2013. 44. Anderson NL, Crowther JH. Using the experiential avoidance model of non-suicidal self-injury: understanding who stops and who continues. Arch Suicide Res. 2012;16(2):124–134. doi:10.1080/ 13811118.2012.667329. 45. Heath NL, Toste JR, Nedecheva T, et al. An examination of nonsuicidal self-injury among college students. J Ment Health Couns. 2008;30(2):137–156. doi: 10.1037/a0015732. 46. Turner BJ, Chapman AL, Layden BK. Intrapersonal and interpersonal function of nonsuicidal self-injury: associations with emotional and social functioning. Suicide Life Threat Behav. 2012;42(1):36–55. doi: 10.1111/j.1943–278X.2011.00069.x. 47. Nock MK, Mendes WB. Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers. J Consult Clin Psychol. 2008;76(1):28–38. 48. John OP, Eng J. Three approaches to individual differences in affect regulation: conceptualizations, measures, and findings. In: Gross JJ, editor. Handbook of emotion regulation. New York (NY): Guilford Press; 2014. p 321–345. 49. Glenn CR, Blumental TD, Klonsky ED, et al. Emotional reactivity in nonsuicidal self-injury: divergence between self-report and startle measures. Int J Psychophysiol. 2011;80(2):166–170. doi: 10.1016/ j.ijpsych0.2011.02.016. 50. Nock MK, Joiner TE, Gordon KH, et al. Non suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144(1):65–72. doi: 10.1016/ j.psychres.2006.05.010. 51. Andover MS, Pepper CM, Ryabchenko KA, et al. Self-mutilation and symptoms of depression, anxiety, and borderline personality disorder. Suicide Life Threat Behav. 2005;35(5):581–591. doi: 10.1521/suli.2005.35.5.581. 52. Jazaieri H, Urry HL, Gross JJ. Affective disturbance and psychopathology: an emotion regulation perspective. J Exp Psychopathol. 2013;4:584–599. doi: 10.5127/jep.030312. 53. Gross JJ. Emotion regulation: conceptual and empirical foundations. In: Gross JJ, editor. Handbook of emotion regulation. New York (NY): Guilford Press; 2014. p 3–20.
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54. Gross JJ, Barrett LF. Emotion generation and emotion regulation: one or two depends on your point of view. Emot Rev. 2011;3(1):8–16. doi: 10.1177/1754073910380974. 55. Hoff ER, Muehlenkamp JJ. Nonsuicidal self-injury in college students: the role of perfectionism and rumination. Suicide Life Threat Behav. 2009;39(6):576–587. doi: 10.1521/suli.2009.39.6.576. 56. Selby EA, Connell LD, Joiner TE. The pernicious blend of rumination and fearlessness in non-suicidal self-injury. Cogn Ther Res. 2010;34(5):421–428. doi: 10.1007/s10608–009–9260-z. 57. Selby EA, Franklin J, Carson-Wong A, et al. Emotional cascades and self-injury: investigating instability of rumination and negative emotion. J Clin Psychol. 2013;69(12):1213–1227. doi: 10.1002/ jclp.21966. 58. Zaki LF, Coifman KG, Rafaeli E, et al. Emotion differentiation as a protective factor against nonsuicidal self-injury in borderline personality disorder. Behav Ther. 2013;44(3):529–540. doi:10.1016/ j.beth.2013.04.008. 59. Guerry JD, Prinstein MJ. Longitudinal prediction of adolescent nonsuicidal self-injury: examination of a cognitive vulnerability–stress model. J Clin Child Adolesc Psychol. 2010;39(1):77–89. doi: 10.1080/15374410903401195. 60. Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: a meta-analytic review. Clin Psychol Rev. 2010;30(2):217–237. doi: 10.1016/j.cpr.2009.11.004. 61. Howe-Martin LS, Murrell AR, Guarnaccia CA. Repetitive nonsuicidal self-injury as experiential avoidance among a community sample of adolescents. J Clin Psychol. 2012;68(7):809–828. doi: 10.1002/jclp.21868. 62. Najmi S, Wegner DM, Nock MK. Thought suppression and self-injurious thoughts and behaviors. Behav Res Ther. 2007;45(8):1957–1965. doi: 10.1016/j.brat.2006.09.014. 63. Tatnell R, Kelada L, Hasking P, et al. Longitudinal analysis of adolescent NSSI: the role of intrapersonal and interpersonal factors. J Abnorm Child Psychol. 2014;42(6):885–896. doi: 10.1007/ s10802–013–9837–6. 64. Andrews T, Martin G, Hasking P, et al. Predictors of continuation and cessation in nonsuicidal self-injury. J Adolesc Health. 2013;53(1):40–46. doi: 10.1016/j.jadolhealth.2013.01.009. 65. Svaldi J, Dorn C, Matthies S, et al. Effects of suppression and acceptance of sadness on the urge for non-suicidal self-injury and self-punishment. Psychiatry Res. 2012;200(2–3):404–416. doi: 10.1016/j.psychres.2012.06.030. 66. Lewis AR, Zinbarg RE, Durbin CE. Advances, problems, and challenges in the study of emotion regulation: a commentary. J Psychopathol Behav Assess. 2010;32(1):83–91. doi: 10.1007/ s10862–009–9170–0. 67. Ochsner KN, Gross JJ. The cognitive control of emotion. Trends Cogn Sci. 2005;9(5):242–249. doi: 10.1016/j.tics.2005.03.010. 68. Greucci A, Sanfey AG. Emotion regulation and decision making. In: Gross JJ, editor. Handbook of emotion regulation. New York (NY): Guilford Press; 2014. p 140–153. 69. Cisler JM, Olatunji BO, Feldner MT, et al. Emotion regulation and anxiety disorders: an integrative review. J Psychopathol Behav Assess. 2010;32(1):68–82. doi: 10.1007/s10862–009–9161–1. 70. Joormann J, Siemer M. Emotion regulation in mood disorders. In: Gross JJ, editor. Handbook of emotion regulation. New York (NY): Guilford Press; 2014. p 413–427. 71. Sanislow CA, Pine DS, Quinn KJ, et al. Developing constructs for psychopathology research: research domain criteria. J Abnorm Psychol. 2010;119(4):631–639. doi: 10.1037/a0020909. 72. Mennin DS. Emotion regulation therapy: an integrative approach to treatment-resistant anxiety disorders. J Contemp Psychother. 2006;36(2):95–105. doi: 10.1007/s10879–006–9012–2.
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Expanding and Clarifying the Role of Emotion Regulation in Nonsuicidal Self-Injury Margaret S Andover, PhD1; Blair W Morris, MA (PhD Candidate)2 1
Associate Professor, Department of Psychology, Fordham University, Bronx, New York. Correspondence: Department of Psychology, Fordham University, 441 East Fordham Road, Bronx, NY 10458; [email protected].
2
Doctoral Student, Department of Psychology, Fordham University, Bronx, New York.
Key Words: emotion dysregulation, deliberate selfharm, rumination, suppression, reappraisal Received and accepted August 2014.
Objective: Deficits in emotion regulation have been implicated in nonsuicidal self-injury (NSSI) by both theory and research. Research indicates that NSSI is commonly performed as an emotion regulation strategy, as it often decreases the experience of negative affect. People who engage in NSSI often report greater emotion dysregulation than those without an NSSI history. Further, interventions that have demonstrated effectiveness in reducing NSSI involve a focus on emotion regulation skills. Given the important role of emotion regulation in NSSI, research should continue to develop our understanding of this construct. Methods: We conducted a review of relevant research in emotion regulation and dysregulation and specific emotion regulation strategies in NSSI. Results: First, we provide an overview of current research on emotion regulation and dysregulation in NSSI. Second, we discuss the application of a specific emotion regulation model to NSSI research, and review research on NSSI supporting the use of this model. Conclusion: NSSI has been associated with an emotion regulation function and trait emotion dysregulation among people who self-injure. Relevant research provides initial support for the applicability of a specific model of emotion regulation to NSSI. We suggest directions for future research to continue to cultivate our understanding of emotion regulation in NSSI. WWW
Développer et clarifier le rôle de la régulation émotionnelle dans l’automutilation non suicidaire Objectif : Les déficits de régulation émotionnelle sont impliqués dans l’automutilation non suicidaire (AMNS) par la théorie et la recherche. La recherche indique que l’AMNS sert communément de stratégie de régulation émotionnelle, car elle diminue souvent l’expérience de l’affect négatif. Les personnes qui pratiquent l’AMNS déclarent souvent une plus grande dysrégulation émotionnelle que celles qui n’ont pas d’antécédents d’AMNS. En outre, les interventions qui ont démontré une efficacité à réduire l’AMNS mettent l’accent sur les compétences de régulation émotionnelle. Étant donné le rôle important de la régulation émotionnelle dans l’AMNS, la recherche devrait continuer à développer notre compréhension de ce construit. Méthodes : Nous avons mené une revue de la recherche pertinente sur la régulation et la dysrégulation émotionnelles, et sur les stratégies spécifiques de régulation émotionnelle dans l’AMNS. Résultats : Premièrement, nous présentons un aperçu de la recherche actuelle sur la régulation et la dysrégulation émotionnelle dans l’AMNS. Deuxièmement, nous discutons de l’application d’un modèle spécifique de régulation émotionnelle à la recherche sur l’AMNS, et menons une revue de la recherche sur l’AMNS qui soutient l’emploi de ce modèle. Conclusion : L’AMNS a été associée à une fonction de régulation émotionnelle et à un trait de dysrégulation émotionnelle chez les personnes qui s’automutilent. La recherche pertinente offre un soutien initial de l’applicabilité d’un modèle spécifique de régulation émotionnelle à l’AMNS. Nous suggérons des directions à la recherche future pour continuer de cultiver notre compréhension de la régulation émotionnelle dans l’AMNS.
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In Review
A
s awareness of the prevalence of NSSI and the risks associated with the behaviour have increased, interest in empirically supported treatments for NSSI has also increased. Empirical evidence has been strongest for interventions that have a specific focus on improving emotion regulation, such as DBT1 and emotion regulation group therapy,2,3 and emotion regulation has been implicated as an important treatment mechanism in these interventions (for example, Gratz,4 Gratz et al,5 and Slee et al6). In NSSI research more generally, our understanding of emotion regulation has focused predominantly on NSSI as a means of emotion regulation, and on trait emotion dysregulation among people who engage in NSSI. Much of this research has been guided by Linehan’s1 theory of emotion dysregulation in BPD, which focuses on emotional vulnerability and lack of emotion regulation skills. However, other models of emotion regulation may enhance and clarify our understanding of the difficulties experienced by people who engage in NSSI. The goal of this review is 3-fold. First, we will provide an overview of current research on emotion regulation and dysregulation in NSSI; for an in-depth review of these topics, please see Klonsky7 and Gratz.4 Second, we will discuss another model of emotion regulation8 that may provide a framework for building on existing work and for clarifying the process of, and deficits in, emotion regulation among self-injurers. We will then provide a review of NSSI research supporting the application of this model. Finally, we will suggest directions for future research to clarify and expand our understanding of emotion regulation in NSSI.
Empirical Support for Nonsuicidal SelfInjury as a Means of Emotion Regulation
The functions of NSSI have been a focus of considerable research and clinical interest. Although several functions have historically been proposed (for example, Klonsky7 and Suyemoto9), the function of emotion regulation has received the strongest empirical support (For a review, see Klonsky7). People who engage in NSSI often report that the behaviour is associated with reductions in negative emotions, such as tension, fear, and sadness (for example, Briere and Gil,10 Klonsky,11 Kumar et al,12 and Laye-Gindhu and Schonert-Reichl13), and studies using ecological momentary assessment, which reduces the potential for retrospective bias often found in survey research, have reported a decrease in negative affect following NSSI (for example, Armey et al14 and Nock et al15; however, also see Muehlenkamp et al16). Although primarily considered a means to reduce negative affect, those who engage in NSSI Abbreviations BPD
borderline personality disorder
DBT
dialectical behaviour therapy
DERS
Difficulties in Emotion Regulation Scale
NSSI
nonsuicidal self-injury
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Clinical Implications •
Research supports an emotion regulation function of NSSI and trait emotion dysregulation among people who engage in the behaviour.
•
Other models of emotion regulation, such as that of Gross (1998), may be used to supplement theories currently used in NSSI research to refine our understanding of the emotion regulation process and interventions for NSSI.
•
Research supports the applicability of Gross’ (1998) model to NSSI.
Limitations •
Further research is necessary to investigate the applicability of other models of emotion regulation to NSSI research.
•
Further research is necessary to determine the effectiveness of interventions focused on different stages of the emotion regulation process.
report that the behaviour also produces positive affect, and increased positive affect following NSSI is associated with greater lifetime frequency of the behaviour (for example, Armey et al,14 Jenkins and Schmitz,17 and Kemperman et al18; however, also see Muehlenkamp et al16). Nock and Prinstein19 proposed a behavioural model for the functions of NSSI in which the behaviour is maintained by automatic (intrapersonal) and social (interpersonal) reinforcement. This model has been empirically supported,19,20 and automatic functions for NSSI, especially automatic negative reinforcement, are significantly more likely to be reported than social functions.19 The finding of greater use of NSSI for automatic functions is consistent with an emotion regulation function, as NSSI is most often used to reduce undesired or to generate desired emotions. Psychophysiological research also supports an emotion regulation function of NSSI. Using guided imagery scripts of NSSI, Haines et al21 and Brain et al22 found that physiological arousal decreased during and after the description of NSSI among people with a history of the behaviour. Similarly, Welch et al23 noted decreases in arousal after the description of NSSI in the guided imagery script on 1 of 2 psychophysiological assessments among adults with a diagnosis of BPD. This pattern of decreasing physiological arousal is consistent with, and provides objective support for, an emotion regulation function. Laboratory studies suggest that pain is an important emotion regulation feature of NSSI. Several studies have demonstrated a decrease in negative affect following the administration of a painful stimulus (for example, Bresin and Gordon,24 Franklin et al,25 and Weinberg and Klonsky26), and increased positive affect has also been reported.27 In addition, emotion dysregulation is associated with decreased pain perception.28 The role of pain in emotion regulation may be more pronounced for some self-injurers, such as those who report no pain during NSSI29 or those with a lower subjective perception of pain.26 Pain may serve www.LaRCP.ca
Expanding and Clarifying the Role of Emotion Regulation in Nonsuicidal Self-Injury
to regulate negative emotions regardless of NSSI history, as people with and without the behaviour demonstrate reductions in negative affect after the administration of a painful stimulus.24,25 Together, research on the emotion regulation function of NSSI suggests that the behaviour is physiologically and psychologically maintained as an effective, although maladaptive, emotion regulation strategy.
Empirical Support for Emotion Dysregulation in Nonsuicidal Self-Injury
Research has investigated whether people who engage in NSSI experience global deficits in emotion regulation, or if emotion regulation is uniquely associated with NSSI function. In general, this research has focused on emotion dysregulation, or difficulties in the emotion generation and (or) regulation process.30 Nearly all studies of trait-level emotion dysregulation in NSSI have used the DERS,31 a self-report measure designed to assess nonacceptance of emotional responses, lack of emotional awareness, lack of emotional clarity, impulse control difficulties, difficulties engaging in goal-directed behaviour, and limited access to effective emotion regulation strategies.31 Subscale scores reflect each of these factors, but the DERS is often reported as a total score. The DERS has also been used to assess emotion dysregulation in other psychological disorders.32–35 Studies support increased trait emotional dysregulation among people who engage in NSSI. People with NSSI report greater levels of emotion dysregulation than those without an NSSI history in clinical and nonclinical samples.36–40 Increased self-reported emotion dysregulation is also associated with increased NSSI frequency.17,38,41Although emotion dysregulation and NSSI are both associated with BPD, Glenn and Klonsky42 found that among adolescent psychiatric patients, NSSI disorder, a disorder requiring future research in the 5th edition of the Diagnostic and Statistical Manual,43 was uniquely associated with emotion dysregulation over and above a BPD diagnosis. This suggests that the role of emotion dysregulation in NSSI is not simply accounted for by BPD characteristics. Specific dimensions of emotion dysregulation, as measured by subscales of the DERS, may differentiate people who engage in NSSI from those who do not,40,44,45 and DERS subscales may differentiate people who currently engage in NSSI from those with a past history of the behaviour.44 In addition, the limited access to emotion regulation strategies subscale of the DERS was uniquely associated with an emotion regulation function of the behaviour among adults,46 suggesting that NSSI may be used as a strategy to address a perceived deficit in emotion regulation skills. Difficulty tolerating distress, a construct related to emotion dysregulation, has also been investigated among people with NSSI. People with a history of NSSI have been shown to terminate a distressing task earlier than noninjurers,47 suggesting difficulty or unwillingness to experience emotional distress. Overall, research indicates a diffuse www.TheCJP.ca
pattern of emotion regulation difficulties among people with a history of NSSI. Studies have reliably found elevated emotion dysregulation among self-injurers using the DERS; however, a comprehensive understanding of specific aspects of the emotion regulation process is limited as the measure relies on self-perception of emotion regulation and overlaps considerably with emotional competency.31,48 Although the subscale of limited access to emotion regulation strategies has been associated with NSSI and appears germane to emotion regulation, it may measure perceived selfefficacy in emotion regulation, rather than effective use of strategies.48 Further research is necessary to investigate aspects of emotion regulation not assessed by the DERS, as well as to develop and incorporate objective measures of emotion regulation.
Theories of Emotion Regulation
The theory of emotion dysregulation most often applied to NSSI is Linehan’s biosocial theory of BPD.1 This comprehensive theory proposes that BPD is predominantly a dysfunction of the emotion regulation system; people engage in NSSI and suicidal behaviours to regulate emotional experiences. Emotion dysregulation in BPD consists of 2 components.1 First, people with BPD have increased emotional vulnerability, compared with those without the disorder, as they experience emotions more intensely, are more sensitive to negative and positive emotional stimuli, and experience a slow return to a baseline emotional state. Although beyond the scope of this review, this has been supported by research on NSSI.49 Second, people experience difficulty managing high levels of emotional arousal because they lack effective emotion regulation skills. Emotion regulation requires 2 skills: the ability to experience and label emotions, and the ability to reduce emotionally relevant stimuli that serve to reactivate negative or positive emotions or cause secondary emotional responses.1 Emotional vulnerability and deficits in emotion regulation are rooted in biological predispositions and exacerbated by environmental experiences. Emotion dysregulation is most pronounced with negative emotions, but people with BPD can also experience difficulty regulating positive emotions.1 Although Linehan’s model was developed for BPD, it has been influential in understanding NSSI and has guided much of the research on emotion dysregulation. However, as NSSI occurs outside the context of BPD,50,51 it may be useful to consider other models to enhance our current understanding of emotion regulation in NSSI. Gross’ model of emotion regulation8 has been applied to several psychological disorders, including BPD,52 and may be a useful supplement to refine and improve our understanding of emotion regulation in NSSI. According to Gross,8 emotion regulation is the process by which a person consciously or unconsciously influences the occurrence, experience, expression, duration, and magnitude of emotions. The processes involved in emotion regulation The Canadian Journal of Psychiatry, Vol 59, No 11, November 2014 W 571
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follow a sequence: situation, attention, appraisal, and response. The response process then provides feedback to the situation process, as a person’s emotional response may modify a particular situation or cause a new situation to develop.53 Five specific emotion regulation strategies have been associated with the 4 processes. Two strategies, situation selection and situation modification, are associated with the situation process. Situation selection involves taking action to make it more or less likely that one will be in a situation that will elicit positive or negative emotions, while situation modification involves directly modifying a situation with the specific goal of changing its emotional impact.8 The process of attention can be regulated through attentional deployment, where one directs attention within a given situation to impact emotional experiences. One example of attentional deployment is distraction, where an individual may influence the emotional impact of a situation by focusing attention on specific aspects within or outside the situation. Cognitive change is used to modify one’s appraisal of a situation to change emotional response; reappraisal is a common emotion regulation technique. Finally, emotional responses to a situation can be influenced by response modulation. In response modulation, strategies are used to change the behavioural, physiological, and psychological experiences of an emotion. These strategies may be adaptive, such as relaxation, or maladaptive, such as substance use. Importantly, NSSI has been identified as a response modulation strategy within the context of BPD.52 Although implications of emotion regulation often focus on improving the emotional experience by reducing negative emotions or increasing positive emotions, each process in Gross’ model can also be acted on so that negative emotional experiences are heightened or positive emotional experiences are reduced. The emotion regulation models developed by Gross8 and Linehan1 are quite compatible52 and potentially synergistic. The combination of emotional vulnerability and difficulties in emotion regulation skills1 are consistent with the concepts of emotion generation and regulation.54 In addition, although DBT primarily focuses on addressing emotion regulation after the emotion has been generated,30 the treatment is consistent with the processes and strategies outlined by Gross. For example, interpersonal effectiveness skills can be used in situation modification, as they may alter the experience of an interpersonal interaction. Similarly, mindfulness is a method of attentional deployment as it focuses on the control of attention toward aspects of the external or internal situational experience.30 Incorporating a broader model, such as that of Gross,8 into our existing model of emotion dysregulation in NSSI would promote an understanding that is simultaneously refined and comprehensive. Research on the emotion regulation function of NSSI is consistent with Gross’ model,8 as it supports NSSI as a response modulation strategy and suggests a deficit in the ability to regulate emotions in an adaptive manner. Although limited, NSSI research has supported the use of 572 W La Revue canadienne de psychiatrie, vol 59, no 11, novembre 2014
Gross’ model by implicating processes earlier in emotion regulation than emotional response. A thorough review is beyond the scope of this article, but we present an overview of research that suggests dysfunction earlier in the emotion regulation process consistent with this model. Rumination involves intense repetitive focus on emotional experiences, their causes and their consequences, and is associated with defective attentional deployment.8 A growing body of research supports an association between NSSI and rumination.55–58 However, the association between rumination and NSSI is likely complex, as recent research suggests that NSSI may be related to instability of rumination, rather than increased trait rumination, which is associated with depression.57 In addition, NSSI may be associated with specific rumination topics. Unstable rumination about the past, especially when experienced with unstable sadness, has been associated with increased NSSI frequency, while rumination about the future or emotional states may be protective against NSSI frequency.57 Research on rumination suggests that people with NSSI may experience deficits in attentional deployment, as well as other aspects of the attention process. This is supported by elevations on the difficulties in goal-directed behaviour subscale of the DERS, as this subscale may assess deficits in attentional deployment.48 Research has suggested a cognitive regulation function of NSSI in addition to an emotion regulation function, indicating an association between NSSI as a response modulation strategy and the attribution process. Adolescents who engage in NSSI report that the behaviour distracts them from unwanted thoughts.15 In addition, increased cognitive processing, specifically information processing, was found among people with an NSSI history following a painful stimulus, suggesting that NSSI may serve a cognitive regulation function.25 People with NSSI demonstrate poorer cognitive processing than noninjurers who are not elevated on emotion dysregulation,25 suggesting dysfunction at the appraisal process. Guerry and Prinstein59 reported that a negative attributional style was associated with NSSI frequency in a longitudinal study of adolescents, providing additional support for deficits in the appraisal process and associated regulation strategies. Research in several psychological disorders has focused on suppression, a response modulation strategy, and reappraisal, a cognitive change strategy (for example, Aldao et al60). Thought suppression, which specifically involves the suppression of unwanted thoughts rather than emotions, is associated with the presence and frequency of NSSI in adolescent and young adult samples,44,61,62 and poor cognitive reappraisal is associated with NSSI history.63 Thought suppression has also been shown to partially mediate the relation between emotion generation (specifically, emotional reactivity) and NSSI frequency.62 Suppression is associated with specific functions of NSSI, including automatic negative reinforcement,62 emotion regulation, and self-punishment46; however, the association www.LaRCP.ca
Expanding and Clarifying the Role of Emotion Regulation in Nonsuicidal Self-Injury
was decreased or nonexistent when investigating social reinforcement,62 interpersonal influence and communication, and feeling generation.46 However, cognitive reappraisal was not found to be associated with any reported NSSI function.46 Together, this research indicates specificity between suppression and emotion regulation functions of NSSI, suggesting that suppression may influence the emotional experience of people with NSSI. Few NSSI studies have assessed both suppression and reappraisal simultaneously, and use of these strategies has not yet been investigated in experimental research. However, self-report data suggest that suppression and reappraisal may be differentially associated with the onset, cessation, and maintenance of NSSI in adolescents during a 1-year period. Adolescents who began engaging in NSSI during the follow-up period reported significantly less cognitive reappraisal and more emotional suppression than those who did not engage in NSSI, while those who stopped engaging in NSSI during the follow-up period had greater cognitive reappraisal and less suppression than those who maintained NSSI.63 In addition, maintenance of NSSI during the 1-year period was significantly associated with poor cognitive reappraisal and increased suppression.63,64 Research on suppression in NSSI may appear to indicate that it is a maladaptive emotion regulation strategy. In fact, use of suppression has been associated with decreased positive— but not negative—emotional experiences, poorer memory, and increased activation of the sympathetic nervous system (for example, Gross53), as well as more difficulty in regulating negative emotions.46 However, global generalizations about the use of suppression should be cautioned against.53 For example, among female participants with BPD randomly assigned to engage in expressive suppression or emotional acceptance during a negative mood induction, those who engaged in suppression were less likely than those engaged in emotional acceptance to experience urges to selfinjure and -punish after the induction.65 This suggests that although suppression may appear less desirable than other emotion regulation strategies, such as reappraisal, it may have an adaptive function65 and may be more effective than other strategies in specific contexts. Together, these studies indicate that appropriate use of cognitive reappraisal and suppression may be important skills to target in NSSI treatment and prevention.
Conclusions and Future Directions
Research on the emotion regulation function of NSSI and trait emotion dysregulation among people who self-injure has been critical in understanding the behaviour, as well as in developing effective treatments, most of which currently focus on addressing deficits in emotion regulation. The field of NSSI may benefit from applying other models of emotion regulation, such as that of Gross,8 to NSSI research and current emotion dysregulation models. By focusing on a temporal process of emotion regulation that involves cognition and attention, in addition to efforts to change the emotional experience, such as proposed by Gross,8 we will www.TheCJP.ca
develop a broader understanding of emotion regulation, and clinicians may be able to intervene earlier in the emotion regulation process. Current research supports the application of Gross’ model to NSSI, as findings have indicated potential deficits at specific stages in the emotion regulation process. Future research should continue to explore the clinical utility of this model in NSSI, using objective assessments whenever possible (for example, Lewis et al66). In addition, research should determine how strategies at different stages in the emotion regulation process are used to change emotion, if at all. For example, a person may lack emotion regulation strategies, or he or she may engage in strategies that increase the likelihood of experiencing negative emotions.8 Understanding the specific emotion regulation processes involved will have a direct effect on successful intervention strategies. Research focused on the attention and attribution processes may be particularly important. These processes are associated with the cognitive control of emotion,67 implicated by the cognitive regulation function of NSSI. Research may expand into constructs associated with the emotion regulation process, such as decision making (for example, Greucci and Sanfey68), or may seek to refine our understanding of the unique contributions of the processes of emotion generation (that is, emotional vulnerability) and emotion regulation in NSSI (for example, Gross and Barrett54). In addition, as Gross’ model has been extensively applied to psychological disorders (for example, Aldao et al,60 Cisler et al,69 and Joormann and Siemer70), research consistent with this model will facilitate the investigation of emotion regulation as a mechanism underlying multiple disorders, consistent with the National Institute of Mental Health’s Research Domain Criteria goals (for example, Sanislow et al71). Future research may identify the specific emotion regulation mechanisms involved in current efficacious treatments for NSSI, as well as impact the development of new treatments—understanding the full range of emotion regulation may provide new avenues for intervention. For example, research on strategies associated with the attribution process suggests that therapies that focus on cognitive attributions and restructuring, such as cognitivebehavioural therapy, may be an effective intervention or prevention strategy.59,64 In addition, the application of other existing emotion regulation therapies to NSSI, such as emotion regulation therapy for generalized anxiety disorder,72 may be explored. NSSI has been associated with an emotion regulation function and trait emotion dysregulation among people who self-injure. The purpose of our paper was to propose the application and integration of a specific emotion regulation model to current research to enhance our understanding of NSSI and to suggest important targets for intervention. Relevant research provides initial support for the applicability of this model to NSSI. Supplementing research The Canadian Journal of Psychiatry, Vol 59, No 11, November 2014 W 573
In Review
with other empirically supported emotion regulation models will allow for a simultaneously clearer and broader understanding of emotion regulation among people who engage in NSSI, as well as common mechanisms that underlie NSSI and related psychological disorders.
Acknowledgements
This research was supported in part by National Institute of Mental Health grant K23MH082824. The Canadian Psychiatric Association proudly supports the In Review by providing an honorarium to the authors.
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