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

https://doi.org/10.1016/j.drugalcdep.2012.07.017Get rights and content

Abstract

Background

Despite elevated rates of posttraumatic stress disorder (PTSD) among substance use disorder (SUD) patients, as well as the clinical relevance of this co-occurrence, few studies have examined psychological factors associated with a PTSD–SUD diagnosis. Two factors worth investigating are emotion dysregulation and impulsivity, both of which are associated with PTSD and SUDs. Therefore, this study examined associations between PTSD and facets of emotion dysregulation and impulsivity within a sample of trauma-exposed SUD inpatients.

Methods

Participants were an ethnically diverse sample of 205 SUD patients in residential substance abuse treatment. Patients were administered diagnostic interviews and completed a series of questionnaires.

Results

Patients with PTSD (n = 58) reported significantly higher levels of negative urgency (i.e., the tendency to engage in impulsive behaviors when experiencing negative affect) and lower sensation seeking, as well as higher levels of emotion dysregulation and the specific dimensions of lack of emotional acceptance, difficulties engaging in goal-directed behavior when upset, difficulties controlling impulsive behaviors when distressed, limited access to effective emotion regulation strategies, and lack of emotional clarity. Further, overall emotion dysregulation emerged as a significant predictor of PTSD status, accounting for unique variance in PTSD status above and beyond facets of impulsivity (as well as other relevant covariates).

Conclusions

Results suggest that emotion dysregulation may contribute to the development, maintenance, and/or exacerbation of PTSD and highlight the potential clinical utility of targeting emotion dysregulation among SUD patients with PTSD.

Introduction

Posttraumatic stress disorder (PTSD) is characterized by re-experiencing, avoidance, emotional numbing, and hyperarousal symptoms following exposure to a traumatic event (American Psychiatric Association, 2000). The lifetime prevalence of PTSD in the general population is 6.8% (Kessler et al., 2005); however, heightened lifetime (36–50%) and current (25–42%) prevalence rates of PTSD have been found among patients with a substance use disorder (SUD; Brady et al., 2004a). A PTSD–SUD diagnosis is associated with a range of negative clinical outcomes and maladaptive behaviors, including greater risk for SUD treatment dropout (Brady, 2001, Ford et al., 2007), quicker relapse following SUD treatment (Hien et al., 2000, Najavits et al., 2007), more severe substance use patterns within community (Cottler et al., 1992) and treatment-seeking (Najavits et al., 2007) samples, and higher rates of risky and self-destructive behaviors among patient (Najavits et al., 2007) and community (Plotzker et al., 2007) samples. Despite this, few studies have examined the psychological factors associated with a PTSD–SUD diagnosis. Two factors worth investigating are emotion dysregulation and impulsivity, both of which are associated with PTSD (e.g., Kotler et al., 2001, Tull et al., 2007) and heightened among SUD patient (Fox et al., 2007, Fox et al., 2008, Moeller and Dougherty, 2002, Patton et al., 1995) and community (Allen et al., 1998, Patton et al., 1995) samples.

Emotion dysregulation is a multi-faceted construct involving: (a) a lack of awareness, understanding, and acceptance of emotions; (b) the inability to control behaviors when experiencing emotional distress; (c) a lack of access to adaptive strategies for modulating the duration and/or intensity of aversive emotional experiences; and (d) an unwillingness to experience emotional distress as part of pursuing meaningful activities in life (Gratz and Roemer, 2004). Previous studies using non-clinical or community samples have found that PTSD symptom severity is associated with overall emotion dysregulation and the specific dimensions of lack of emotional acceptance, difficulties engaging in goal-directed behavior and controlling impulsive behavior when upset, limited access to emotion regulation strategies, and lack of emotional clarity (Ehring and Quack, 2010, Tull et al., 2007). Similar associations were observed among cocaine dependent patients in residential SUD treatment (McDermott et al., 2009).

Theoretical literature also highlights the role of emotion dysregulation in the development and maintenance of PTSD among individuals with a SUD. Consistent with negative reinforcement (Baker et al., 2004) and self-medication (Brady et al., 2004a) models of substance abuse, substances may be used to manage PTSD-related symptoms and associated distress following a traumatic event. The use of this particular maladaptive emotion regulation strategy may be more likely among individuals with a SUD. In addition to having familiarity with and access to substances, individuals with (vs. without) a SUD have been found to exhibit higher overall emotion dysregulation (Fox et al., 2007, Fox et al., 2008). Notably, however, although substance use may result in the immediate (short-term) reduction of PTSD-related symptoms and emotional distress, it is likely to have paradoxical consequences in the long-term, preventing exposure to corrective information and interfering with emotional processing (Foa and Kozak, 1986). Thus, using substances to regulate emotions will likely exacerbate PTSD symptoms and emotion dysregulation in the long-term, increasing motivations to use substances as an avoidant regulation strategy (Hayes et al., 1996).

Research also provides preliminary support for an association between impulsivity and PTSD. Although several definitions for impulsivity have been proposed (Cloninger et al., 1993, Eysenck and Eysenck, 1977), recent literature suggests that impulsivity is best defined as a multi-faceted construct consisting of four dimensions: (a) urgency (the tendency to act impulsively when experiencing negative affect); (b) (lack of) premeditation (failure to reflect on the consequences of an act before engaging in that act); (c) (lack of) perseverance (an inability to focus or follow through on difficult or boring tasks); and (d) sensation seeking (the tendency to enjoy and pursue activities that are exciting and an openness to trying new experiences; Whiteside and Lynam, 2001). Previous studies have demonstrated an association between some of these dimensions of impulsivity and PTSD (Aidman and Kollaras-Mitsinikos, 2006, Joseph et al., 1997, Kotler et al., 2001, Oquendo et al., 2005). For example, Kotler et al. (2001) reported that individuals with PTSD (vs. individuals with other anxiety disorders and matched controls) exhibited significantly higher scores on a measure of impulsivity (Impulsivity Control Scale; Plutchik and Van Praag, 1989) that assessed behaviors consistent with the impulsivity dimensions of (lack of) premeditation (i.e., spur of the moment behaviors) and (lack of) perseverance (i.e., lack of patience). Furthermore, Joseph et al. (1997) found that trauma-exposed individuals with heightened PTSD symptom severity (vs. those with lower levels of PTSD symptoms) exhibited greater impulsivity, as assessed by the impulsiveness subscale of the Eysenck Impulsiveness Questionnaire (Eysenck and Eysenck, 1978) which examines behaviors consistent with the impulsivity dimension of (lack of) premeditation.

Despite preliminary evidence for an association between PTSD and certain facets of impulsivity, studies examining the precise nature and direction of this association are limited. Consequently, it is not clear if impulsivity contributes to PTSD, PTSD leads to greater impulsivity, or both. For example, there is evidence that impulsivity may increase risk for traumatic exposure (Jang et al., 2003), contributing to the development (and, in the case of repeated traumatic exposure, exacerbation) of PTSD symptoms (as shown in Cottler et al., 1992). However, it also possible that particular symptoms of PTSD (e.g., hyperarousal and re-experiencing symptoms) may deplete self-regulatory resources (as discussed in Baumeister, 2003), limiting resources available to control impulsive behaviors. Indeed, evidence suggests that symptoms of hyperarousal (e.g., sleep difficulties, irritability) are positively associated with impulsivity (Medeiros et al., 2005, Stanford et al., 1995). Furthermore, several models of impulsivity posit (directly or indirectly) a relationship between impulsivity and arousal (Barratt and Patton, 1983, Eysenck and Eysenck, 1985), suggesting that the heightened physiological arousal observed among individuals with PTSD (e.g., Gerardi et al., 1994) may contribute to the impulsivity observed within this population (Joseph et al., 1997).

Although no studies have examined facets of impulsivity among individuals with co-occurring PTSD–SUD, literature suggests that impulsivity may be particularly elevated among individuals with a SUD and co-occurring PTSD. Theoretical literature highlights the likely bi-directional nature of the SUD-impulsivity relation, with substance abuse posited to be both a risk factor for and consequence of impulsivity (Hirschtritt et al., 2012). Moreover, research provides strong support for a robust association between facets of impulsivity and SUDs in general. For example, individuals with a SUD have been found to discount the value of delayed rewards (choosing smaller immediate rewards over larger delayed rewards; Madden et al., 1997) and fail to inhibit extraneous responding (Fillmore and Rush, 2002). Likewise, SUD patients have been found to exhibit significantly higher levels of several facets of impulsivity than non-SUD controls, including negative urgency, lack of premeditation, and lack of perseverance (Verdejo-García et al., 2007). Finally, Lejuez et al. (2007) found multiple aspects of impulsivity to be significantly positively correlated with cocaine dependence and past year cocaine use among SUD patients.

The goal of this study was to extend extant research by (a) examining differences in emotion dysregulation and impulsivity (assessed as multi-faceted constructs) between SUD patients with (vs. without) current PTSD, and (b) exploring the unique contributions of emotion dysregulation and impulsivity dimensions to PTSD within this population. Consistent with past findings of an association between PTSD and most of the impulsivity and emotion dysregulation dimensions examined here (e.g., Joseph et al., 1997, Kotler et al., 2001, McDermott et al., 2009), we hypothesized that SUD patients with (vs. without) current PTSD would report greater emotion dysregulation (overall and across all specific dimensions other than lack of emotional awareness) and higher levels of all four facets of impulsivity. Given the absence of research examining the unique contributions of impulsivity and emotion dysregulation to PTSD among SUD patients and the limited theoretical literature with regard to the convergence and divergence of the impulsivity and emotion dysregulation constructs (which are considered distinct yet overlapping constructs; Schreiber et al., 2012), no a priori hypotheses were made regarding the unique associations between emotion dysregulation and impulsivity dimensions and PTSD.

Section snippets

Participants

Participants were 205 SUD patients consecutively admitted to a residential SUD treatment facility in Mississippi. In terms of racial/ethnic background, 56% of participants self-identified as White, 36% as Black/African American, 4% as Native American, 2% as Latino/Latina, and 2% as “other.” Table 1 provides additional demographic characteristics of this sample.

Clinical interviews

The Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990) was used to assess for current PTSD. We chose to use the CAPS to assess

Preliminary analyses

According to the CAPS, 28% (n = 58) of participants met criteria for current PTSD. A series of independent sample t-tests and chi-square analyses were conducted to explore the impact of demographic factors and the severity of current psychopathology in general (i.e., number of co-occurring mood disorders, anxiety disorders [with the exception of PTSD], and SUDs) on PTSD status in order to identify potential covariates for the analysis examining the unique contributions of impulsivity and emotion

Discussion

Consistent with previous literature (Ehring and Quack, 2010, McDermott et al., 2009, Tull et al., 2007), findings demonstrated that SUD patients with (vs. without) PTSD reported greater overall emotion dysregulation and the specific dimensions of lack of emotional acceptance, difficulties engaging in goal-directed behavior and controlling impulsive behaviors when distressed, lack of access to effective emotion regulation strategies, and lack of emotional clarity. Results also extend extant

Role of funding source

This study was funded by R21 DA022383 of the National Institute on Drug Abuse of the National Institutes of Health, awarded to the second author (MTT). The NIDA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Contributors

Author NHW and MTT designed the study. NHW and MDA wrote the first draft of the manuscript and completed statistical analyses. MTT and KLG assisted in the completion of the final manuscript. All authors contributed to addressing reviewer comments. All authors contributed to and have approved the final manuscript.

Conflict of interest

The authors have no conflicts of interest to declare.

Acknowledgments

The authors would also like to thank Michael McDermott, Melissa Soenke, Rachel Brooks, and Sarah Anne Moore for their assistance with data collection.

References (65)

  • K.L. Jang et al.

    Exposure to traumatic events and experiences: aetiological relationships with personality function

    Psychiatry Res.

    (2003)
  • S. Joseph et al.

    Impulsivity and post-traumatic stress

    Pers. Individ. Dif.

    (1997)
  • M.J. McDermott et al.

    The role of anxiety sensitivity and difficulties in emotion regulation in posttraumatic stress disorder among crack/cocaine dependent patients in residential substance abuse treatment

    J. Anxiety Disord.

    (2009)
  • R. Plutchik et al.

    The measurement of suicidality, aggressivity and impulsivity

    Prog. Neuropsychopharmacol. Biol. Psychiatry

    (1989)
  • K. Salters-Pedneault et al.

    The role of avoidance of emotional material in the anxiety disorders

    Appl. Prev. Psychol.

    (2004)
  • L.R.N. Schreiber et al.

    Emotion regulation and impulsivity in young adults

    J. Psychiatr. Res.

    (2012)
  • M.S. Stanford et al.

    Irritability and impulsivity: relationship to self-reported impulsive aggression

    Pers. Individ. Dif.

    (1995)
  • S. Taylor et al.

    How does anxiety sensitivity vary across the anxiety disorders?

    J. Anxiety Disord.

    (1992)
  • M.T. Tull et al.

    A preliminary investigation of the relationship between emotion regulation difficulties and posttraumatic stress symptoms

    Behav. Ther.

    (2007)
  • A. Verdejo-García et al.

    Negative emotion-driven impulsivity predicts substance dependence problems

    Drug Alcohol Depend.

    (2007)
  • S.P. Whiteside et al.

    The Five Factor Model and impulsivity: using a structural model of personality to understand impulsivity

    Pers. Individ. Dif.

    (2001)
  • E. Aidman et al.

    Personality dispositions in the prediction of posttraumatic stress reactions

    Psychol. Rep.

    (2006)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders

    (2000)
  • T.B. Baker et al.

    Addiction motivation reformulated: an affective processing model of negative reinforcement

    Psychol. Rev.

    (2004)
  • E.S. Barratt et al.

    Impulsivity: cognitive, behavioral and psychophysiological correlate

  • R.F. Baumeister

    Ego depletion and self-regulation failure: a resource model of self-control

    Alcohol. Clin. Exp. Res.

    (2003)
  • D.D. Blake et al.

    The development of the clinician-administered PTSD scale

    J. Trauma Stress

    (1995)
  • D.D. Blake et al.

    The Clinician Administered PTSD Scale

    (1990)
  • K.T. Brady

    Comorbid posttraumatic stress disorder and substance use disorders

    Psychiatr. Ann.

    (2001)
  • K. Brady et al.

    Substance abuse and posttraumatic stress disorder

    Curr. Dir. Psychol. Sci.

    (2004)
  • K.T. Brady et al.

    Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: preliminary findings

    J. Subst. Abuse Treat.

    (2004)
  • M. Cloitre

    Sexual revictimization: risk factors and prevention

  • Cited by (177)

    View all citing articles on Scopus
    View full text