by Michael D. Anestis, M.S.
I always feel a little weird writing about my own work on PBB, but, in all honesty, the online portal to the library is down today and I have time to write a post, so my options are either this or nothing for the moment, so here we go!
A few months ago, I wrote about a study that Thomas Joiner and I have in press at Journal of Affective Disorders examining the relationship between negative urgency, the components of the interpersonal-psychological theory of suicidal behavior (IPTS; Joiner, 2005) and lifetime number of suicide attempts (click here to read that PBB post). In that paper, we found that individuals with high levels of all of the theory components (thwarted belongingness, perceived burdensomeness, acquired capability for suicide) as well as high levels of negative urgency reported the greatest number of past suicide attempts. This made intuitive sense to us, as it seems that folks who are highly motivated to diminish the strength of negative emotions regardless of the long term cost would, in fact, be more likely to desire suicide and to develop the capacity to enact lethal self-harm through their repeated use of painful and provocative emotion regulation strategies (e.g., non-suicidal self-injury [NSSI]).
Some recent data we have been collecting in other populations, however, left us wanting to look at this from another angle. Specifically, in another study we have in press at Archives of Suicide Research (Anestis, Bender, Selby, Ribeiro, & Joiner, in press), we found that high levels of distress tolerance predicted higher levels of the acquired capability for suicide. Now, for those of you unfamiliar with those variables, let me explain why this is a suprising and potentially important finding:
Folks with low levels of distress tolerance - who find the experiene of negative emotions to be highly aversive and overwhelming - have been shown in a number of studies to engage in a wide variety of painful and provocative behaviors (e.g., Nock & Mendes, 2008). Given that, you might expect these folks to have higher levels of the acquired capability for suicide, a component of the IPTS that involves habituation to physiological pain and the fear of death through repeated exposures to painful and provocative stimuli. Put more simply, folks with low distress tolerance often engage in behaviors like self-injury in an effort to reduce their negative emotions (emotion dysregulation). Overtime, by repeatedly engaging in these behaviors, the pain associated with them seems to decrease (e.g., Nock & Prinstein, 2005; Orbach et al., 1997). As such, for these folks, inflicting (potentially) lethal injury upon themselves becomes less physiologically and emotionally aversive. The thing is...the data from our study in Archives of Suicide Research seemed to indicate something very different. It was folks who COULD tolerate negative emotions who demonstrated elevations in the acquired capability.
Given that this finding was somewhat surprising, we wanted to see if it would be replicated in an independent sample, just to make sure that it was not a random error or simply reflective of the particular group of folks we examined in the earlier study. As a follow-up, I included relevant measures in my dissertation project and, during the two years we recruited for that study, we collected data that would help shine further light on this topic and ultimately became a paper we now have in press at Journal of Psychiatric Research (Anestis, Bagge, Tull, & Joiner, in press). Overall, we recruited just under 300 undergraduate participants and had them fill out a series of measures, take part in a structured interview, and complete both card sorting and physiological pain tolerance tasks. We had two main hypotheses:
- High levels of negative urgency and low levels of distress tolerance (e.g., greater levels of emotion dysregulation) would predict elevations in the components of the IPTS that represent the desire for suicide (thwarted belongingness and perceived burdensomeness).
- Low levels of negative urgency and high levels of distress tolerance (e.g., lower levels of emotion dysregulation) would predicted elevatiosn in the component of the IPTS that represents individuals' ability to engage in serious or lethal suicidal behavior (acquired capability for suicide).
The easiest way to summarize those hypotheses is that we expected individuals with greater difficulty regulating and tolerating their emotions to have a higher level of suicidal desire, but less capacity to act on such desire. The results were highly consistent with this idea.
Both negative urgency and distress tolerance were correlated with burdensomeness and belongingness in the expected direction (e.g., high negative urgency/low distress tolerance -> greater levels of suicidal desire). When we ran a series of hierarchical multiple regressions and controlled for sex, depression, and various components of impulsivity, distress tolerance, but not negative urgency significantly predicted burdensomeness and belongingness in the expected direction (negative urgency did as well if distress tolerance, which was highly correlated with it, was removed from the equation).
Similarly, both negtive urgency and distress tolerance were correlated with our two measures of the acquired capability (self-report and a physiolgical pain tolerance task) in the expected direction (e.g., low negative urgency/high distress tolerance -> greater levels of the acquired capability). We again ran a series of hierarchical multiple regressions and this time controlled for sex, painful and provocative events, and various components of impulsivity. In this case, negative urgency but not distress tolernace significantly predicted self-reported acquired capability and distress tolerance but not negative urgency significantly predicted physiological pain tolernace (and again, if you take significant predictor out, the non-significant predictor became significant).
So...what does all of that mean? Put simply, when folks find negative emotions highly aversive and are motivated to do whatever they can to immediately reduce the intensity of such emotions, they may be more likely than others to desire suicide, but less inherently capable than others to follow through on such desire. Suicidal behavior is an inately frightening and physically uncomfortable event. As such, people who have a difficult time tolerating and remaining in contact with emotional experiences may be less naturally capable of following through on a suicide attempt, choosing instead to opt for faster behaviors over which they may have more control with respect to the duration and intensity of the event (e.g., NSSI, binge eating).
As you consider these results, however, I want you to keep a couple things in mind:
First of all, these results do not indicate that emotion dysregulation makes it impossible or even less likely than an individual will die by suicide. Instead, they simply indicate that such individuals may need to engage in more painful and provocative experiences in order to acquired the capability for suicide than would an individual for whom intense emotional and physical sensations are less aversive. Given that emotionally dysregulated individuals are more likely to desire suicide, they may be more likely to engage in such behaviors anyway so, even though they have more to acquire with respect to the capacity to enact lethal self-harm, they still might be more likely to acquire it. The point, however, is that suicide would then not be due to their emotion dysregulation.
Secondly, these results do not mean that it is bad to tolerate distress and that clinicians should teach their clients to have low distress tolerance. Instead, they simply point out that, what is often an adaptive feature (high distress tolerance) can become a liability when an individual is motivated to engage in a problematic behavior (suicide attempt) that requires him or her to experience significant distress, potentially for a prolonged period of time, in order to accomplish their desired outcome.
I'm very excited about this line of research and have a number of other projects at various stages of development. In the meantime, I welcome your thoughts on these points and look forward to sharing more information with you as it becomes available to discuss.
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