Impulsive behaviors as an emotion regulation strategy: Examining associations between PTSD, emotion dysregulation, and impulsive behaviors among substance dependent inpatients

Abstract

Recent investigations have demonstrated that posttraumatic stress disorder (PTSD) is associated with a range of impulsive behaviors (e.g., risky sexual behavior and antisocial behavior). The purpose of the present study was to extend extant research by exploring whether emotion dysregulation explains the association between PTSD and impulsive behaviors. Participants were an ethnically diverse sample of 206 substance use disorder (SUD) patients in residential substance abuse treatment. Results demonstrated an association between PTSD and impulsive behaviors, with SUD patients with PTSD reporting significantly more impulsive behaviors than SUD patients without PTSD (in general and when controlling for relevant covariates). Further, emotion dysregulation was found to fully mediate the relationship between PTSD and impulsive behaviors. Results highlight the relevance of emotion dysregulation to impulsive behaviors and suggest that treatments targeting emotion dysregulation may be useful in reducing impulsive behaviors among SUD patients with PTSD.

Introduction

Posttraumatic stress disorder (PTSD) is an anxiety disorder characterized by the development and persistence of re-experiencing, avoidant, and hyperarousal symptoms following direct or indirect exposure to a potentially traumatic event (Blake et al., 1990). PTSD is a serious clinical concern, associated with considerable functional impairment (Kessler & Frank, 1997) and high rates of co-occurring psychiatric disorders (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Furthermore, individuals with posttraumatic stress disorder (PTSD) have been found to be at-risk for a wide range of impulsive behaviors, including substance misuse (Brady et al., 2004, Jakupcak et al., 2010, Kessler et al., 1995, Ouimette et al., 2005), antisocial behaviors (Booth-Kewley et al., 2010, Resnick et al., 1989), interpersonal aggression (Galovski and Lyons, 2004, Monson et al., 2010, Orcutt et al., 2003), binge eating and purging (Gleaves et al., 1998, Holzer et al., 2008), deliberate self-harm (Cloitre et al., 2002, Sacks et al., 2008), and risky sexual behavior (Rosenberg et al., 2001). Despite evidence for elevated rates of impulsive behaviors within PTSD, however, few studies have examined the factors that may underlie the association between PTSD and impulsive behaviors.

One mechanism worth examining in this regard is emotion dysregulation. As defined here, 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) 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 & Roemer, 2004). Theoretical and empirical literature highlights the role of emotion dysregulation in PTSD (Cloitre et al., 2002, Ehring and Quack, 2010, McDermott et al., 2009, Tull et al., 2007, Weiss et al., in press). Specifically, PTSD has been found to be positively associated with overall emotion dysregulation and the specific dimensions of lack of emotional acceptance, difficulties engaging in goal-directed behaviors and controlling impulsive behaviors when upset, limited access to emotion regulation strategies, and lack of emotional clarity (Ehring and Quack, 2010, Tull et al., 2007). Furthermore, research provides evidence of heightened emotion dysregulation among individuals with (vs. without) PTSD, both in general and among substance use disorder (SUD) patients in particular. For example, emotion dysregulation was found to reliably distinguish between cocaine-dependent patients with and without a probable PTSD diagnosis (above and beyond both anxiety symptom severity and anxiety sensitivity; McDermott et al., 2009).

A small but growing body of research also provides support for the role of emotion dysregulation in a variety of impulsive behaviors. For example, Leith and Baumeister (1996) found that impulsive behavior is more likely to occur following the experience of negative moods characterized by high levels of arousal (which may be more difficult to regulate; Mennin, Heimberg, Turk, & Fresco, 2005). Similarly, emotion dysregulation has been found to be heightened among SUD patients with (vs. without) a history of deliberate self-harm (DSH; Gratz & Tull, 2010a), as well as to distinguish women with frequent DSH from those without a history of DSH (above and beyond several other well-established risk factors for DSH; Gratz & Roemer, 2008). Likewise, Whiteside et al. (2007) found that emotion dysregulation accounted for a significant amount of the variance in binge eating (above and beyond gender, food restriction, and over-evaluation of weight and shape). Finally, Messman-Moore, Walsh, and DiLillo (2010) demonstrated that emotion dysregulation was significantly positively associated with past 6-month risky sexual behavior within a nonclinical sample of college women.

Although the aforementioned findings provide support for a relationship between emotion dysregulation and both PTSD and impulsive behaviors, additional research is needed to explore whether emotion dysregulation underlies the association between PTSD and impulsive behavior. Consequently, the goal of the present study was to extend extant research by examining associations between PTSD, emotion dysregulation, and impulsive behaviors, as well as the mediating role of emotion dysregulation in the relationship between PTSD and past engagement in impulsive behaviors. In examining these associations, one population that may be especially important to study is patients with SUDs, given evidence of (a) heightened rates of PTSD among SUD patients (compared to non-substance users; Brady et al., 2004); (b) high levels of impulsive behaviors among SUD patients with co-occurring PTSD (Hoff et al., 1997, Najavits et al., 2007, Ouimette et al., 1999, Parrott et al., 2003); and (c) elevated levels of emotion dysregulation among SUD patients (Fox et al., 2007, Fox et al., 2008, McDermott et al., 2009).

Consistent with past research (Ehring and Quack, 2010, McDermott et al., 2009, Tull et al., 2007), we hypothesized that SUD patients with (vs. without) PTSD would report higher levels of both emotion dysregulation and impulsive behaviors. Furthermore, we predicted that emotion dysregulation would be significantly positively associated with impulsive behaviors. Finally, given literature suggesting that emotion dysregulation may underlie a variety of impulsive behaviors (see, e.g., Gratz and Roemer, 2008, Safer et al., 2009; for a review, see Gratz & Tull, 2010b), we hypothesized that emotion dysregulation would mediate the relationship between PTSD and impulsive behaviors.