Elsevier

Psychiatry Research

Volume 260, February 2018, Pages 379-383
Psychiatry Research

The role of emotion dysregulation: A longitudinal investigation of the interpersonal theory of suicide

https://doi.org/10.1016/j.psychres.2017.11.075Get rights and content

Highlights

  • Emotion dysregulation operates as both a protective and risk factor for suicide.

  • Emotion dysregulation predicted higher levels of desire for suicide over time.

  • It also predicted more NSSI which then led to higher capability for suicide.

  • But emotion dysregulation directly predicted lower capability for suicide over time.

Abstract

Emotion dysregulation is considered to be transdiagnostic in nature, given its association with a variety of problem behaviors. Of concern, emotion dysregulation also may be associated with key components of the Interpersonal Theory of Suicide (ITS), namely suicidal desire and acquired capability for suicide (ACS; heightened fearlessness toward death and pain tolerance). ITS suggests that experiencing suicidal desire in conjunction with ACS leads to greater risk for suicide attempts. The present 4-wave longitudinal study tested bidirectional associations among emotion dysregulation, NSSI, ACS, and suicidal desire. Emotion dysregulation was associated with both desire and capability for suicide over time. Specifically, emotion dysregulation was associated with (1) higher levels of suicidal desire, (2) higher levels of NSSI, which in turn predicted higher ACS, and (3) lower ACS, suggesting that individuals with emotion dysregulation may find thoughts of death and pain more aversive. Thus, there are two separate paths for how emotion regulation leads to ACS, one path in which emotion dysregulation indirectly leads to ACS through NSSI, and one path in which emotion dysregulation protects against the development of ACS (note that higher levels of ACS alone are not sufficient to lead to a suicide attempt – suicidal desire also is required).

Introduction

The ability to manage and regulate emotions has critical implications for psychosocial development. Emotion regulation has been conceptualized as a capacity for evaluating and modifying one's emotional reactions in order to achieve a desired goal (Thompson, 1994). Importantly, poor emotion regulation (i.e., emotion dysregulation) has been linked to models of psychopathology (see Aldao et al., 2010 for a review). Indeed, emotion dysregulation is associated with a variety of problem behaviors including nonsuicidal self-injury (NSSI; the deliberate destruction or alteration of bodily tissue without suicidal intent; American Psychiatric Association, 2013), depression (Silk et al., 2003), and of critical concern- suicide attempts (Pisani et al., 2013). Given the transdiagnostic nature of emotion dysregulation, theoretical models outlining its path to more severe problem behaviors (i.e., suicide attempts) are crucial for aiding in preventative efforts.

One important theoretical model is Joiner's (2005) Interpersonal Theory of Suicide. According to Joiner's theory, in order to end one's own life, an individual must not only desire to end their life (i.e., suicidal desire, thought to be composed of perceived burdensomeness and thwarted belongingness; Van Orden et al., 2010), but also be able to overcome the basic self-preservation instinct (i.e., they must have acquired a capability for suicide; Van Orden et al., 2008). Acquired capability for suicide (ACS), defined as heightened fearlessness toward death and pain tolerance, is thought to develop over time through experiencing repeated painful and provocative events (PPE; e.g., abuse, being in the military, etc.; Van Orden et al., 2008). Although not the focus of the current study, recent research also has indicated that there may be a genetic component to acquired capability for suicide (Smith et al., 2012; see also Klonsky and May, 2015).

Emotion dysregulation may be an important component of the Interpersonal Theory of Suicide framework, given that it has been implicated as a risk factor for each of the main components of the theory, that is, both suicide desire and ACS. Indeed, cross-sectional research has indicated that higher levels of emotion dysregulation are associated with higher levels of suicidal desire (Anestis et al., 2011a). According to Anestis et al., when individuals are easily overwhelmed by negative emotions they may become more at risk for suicidal desire. Thus, emotion dysregulation may be an important risk factor associated with the desire to end life. Researchers also have found a link between emotion dysregulation and ACS (Bender et al., 2012), although research in this area is more limited.

Recently, researchers have suggested two separate paths from which emotion regulation may be associated with ACS. The first is an indirect path from emotion regulation to ACS through NSSI (Anestis et al., 2013, Law et al., 2015). For example, emotion dysregulation has been found to be cross-sectionally associated with more frequent engagement in NSSI (e.g., as a way to regulate emotions; Andover and Morris, 2014; Anestis et al., 2011b). In turn, higher levels of NSSI has been found to be a PPE associated with higher levels of ACS (Joiner et al., 2012), as indicated by both self-report measures (Franklin et al., 2011) and lab-based tasks (Hamza et al., 2014; St. Germain and Hooley, 2013). In addition, a recent longitudinal study found a unidirectional association between NSSI and ACS, such that NSSI predicted higher levels of ACS over time (Willoughby et al., 2015).

There also may be a direct path from emotion regulation to ACS, whereby poor emotion regulation may serve as a protective factor against developing an ACS (Law et al., 2015). Specifically, Bender et al. (2012) found that higher levels of distress tolerance (i.e., good emotion regulation) were cross-sectionally associated with higher levels of ACS. Indeed, individuals who are better able to tolerate aversive emotions may find thoughts of death and engagement in painful behaviors more manageable and therefore, may be more likely to engage in lethal self-harm (Bender et al., 2012, Anestis et al., 2012). These cross-sectional studies, however, cannot assess temporal order; thus the direction of effects over time (e.g., whether emotion dysregulation predicts ACS (or NSSI) over time, and/or whether ACS (or NSSI) predicts emotion dysregulation over time) is not known. Further, longitudinal work that simultaneously tests both the desire and capability components of Joiner (2005) theory is necessary in order to ascertain the nature of these associations over time.

The present four-wave longitudinal study represents the first critical test of the link between emotion regulation, suicidal desire, NSSI and ACS over time. On the basis of previous cross-sectional research, we hypothesized that individuals with more emotion dysregulation would report greater suicidal desire over time than individuals with better emotion regulation. We also hypothesized that individuals with more emotion dysregulation would report more frequent engagement in NSSI over time than individuals with better emotion regulation and in turn, that more frequent NSSI engagement will be associated with greater ACS over time. With regard to the direct path from emotion regulation and ACS, in light of previous cross-sectional research, we hypothesized that individuals with better emotion regulation would report greater ACS over time. Whether these effects would still be found in a longitudinal study that measures the key components of the theory simultaneously, however, is not clear. Finally, we also controlled for other potential “third variables”, such as sex, parental education, age, and depression.

Section snippets

Participants

The current sample (N = 782; 75.4% female) was drawn from a larger longitudinal study consisting of 1132 first-year undergraduate students (Mage = 19.11, SD = 1.05) from a mid-sized Canadian university who completed a survey about aspects of their life annually for 7 years. In total, 87.5% of the participants were born in Canada, and the most common ethnic backgrounds reported other than Canadian were British (19%), Italian (16.8%), French (9.5%) and German (9%), which is consistent with the

Preliminary analyses

Descriptive statistics for all study variables are listed in Table 1. A MANOVA testing sex differences among the four main study variables indicated that males, in comparison to females, had higher ACS across all four time points (ps < 0.001), greater suicidal desire across Times 2, 3 and 4 (p < 0.01; see Davidson et al., 2011 and Freedenthal et al., 2011 for similar findings using the INQ), and greater engagement in NSSI at Time 4 (p = 0.037). Females had greater emotion dysregulation at Time

Discussion

The present study extended previous cross-sectional research by longitudinally testing the role of emotion dysregulation in predicting the desire and capability components of Joiner's (2005) Interpersonal Theory of Suicide. Specifically, we tested the bidirectional associations among emotion dysregulation, NSSI, ACS and suicidal desire. Results revealed that emotion dysregulation may be an important predictor of both desire and capability for suicide. In terms of desire, emotion dysregulation

Conclusion

The present study helps to clarify the relationship between emotion dysregulation, NSSI, suicidal desire, and ACS. Importantly, this study offers three separate ways in which emotion dysregulation may be associated with an increased risk for suicide. First, emotion dysregulation was found to be associated with higher levels of suicidal desire. Second, emotion dysregulation predicted greater engagement in NSSI, which, over time, predicted higher levels of ACS. Finally, having good emotion

Acknowledgements

Funding for this longitudinal project was from Social Sciences and Humanities Research Council (SSHRC) (435-2014-1929) of Canada.

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