Psychotherapy Brown Bag

Emotions and suicide: The link is not as straight forward as we might think

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:

1. 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).
2. 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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If you would like to learn more about this or other topics discussed on PBB, we recommend that you consult with our online store for scientifically-based psychological resources.

Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University

Emotion dysregulation and suicide

by Michael D. Anestis, M.S.

I have a small window here at the end of my work week to put together a quick post, so I wanted to spend a little time talking with PBB readers about a study I just published with Thomas Joiner (Anestis & Joiner, in press) in the Journal of Affective Disorders.  The study took a new look at the interpersonal-psychological theory of suicidal behavior (IPTS), taking emotion dysregulation in general (and negative urgency in particular) into consideration.

Click on the IPTS link above for a more thorough description of the theory, but here is a quick summary of what the theory says:

• We must differentiate between the desire for death by suicide and the capability for death by suicide
• Few who desire have the capability and few with the capability have the desire.
• The desire is comprised of two variables: thwarted belongingness and perceived burdensomeness.  The former refers to a distorted belief of an individual that he or she has no meaningful connections to others and the latter refers to a distorted belief of an individual that he or she makes no meaningful contributions to the world.
• The acquired capability for suicide is comprised of a diminished fear of death and a heightened tolerance for physical pain.  This is developed through repeated exposure to painful and/or provocative events.

All of these points have been supported through extensive research and many of those studies have been written about previously on PBB (click here to access all PBB articles that discuss suicide).  Despite all of this great research on the IPTS, there are a number of important areas for which we simply do not yet have data.  Dr.Joiner and I addressed a couple of those in this study:

• What role might emotion dysregulation have in suicide risk?
• Does the IPTS work the same for everyone?

The way we approached this was by gathering data from 492 patients at an outpatient community mental health clinic on a number of variables relevant to this topic.  For emotion dysregulation, we looked at negative urgency, which is defined as the tendency to act rashly in an effort to diminish negative emotions (click here for a more thorough description of this idea).  We hypothesized that the three-way interaction of the IPTS components (perceived burdensomeness, thwarted belongingness, and the acquired capability for suicide) would predict participants' lifetime number of suicide attempts, even when controlling for sex and depression severity.  In other words, we believed that individuals with high levels of all three of those variables would have a greater number of lifetime suicide attempts and that effect would not be better accounted for by being male or female or being depressed.  This, in fact, turned out to be the case.

Going a step further, we made our own heads spin and hypothesized that the four-way interaction of the IPTS components and negative urgency would also predict lifetime number of suicide attempts.  In other words, we anticipated that individuals who not only had high levels of thwarted belongingness, perceived burdensomeness, and the acquired capability, but also high levels of negative urgency, would have the greatest number of lifetime suicide attempts. Again, the data supported our hypothesis.  Four-way interactions are not something you typically see, as they are highly complicated and a bit confusing, but think of it this way:  we understand from multiple studies now that when individuals have elevations on all three IPTS components, they're likely to be at greater risk for suicide and, as we showed here, are likely to have a more extensive history of suicidal behavior.  The question though is, do elevations on those variables have the exact same level of impact for everyone or are there some people for whom this is a bigger deal?  This is like stress and depression.  Anyone who becomes stressed is more vulnerable to becoming depressed, but folks with a genetic vulnerability to mood disorders might be more likely to become depressed in response to stress than would somebody without that vulnerability.  In this case, we're saying that anyone with elevations on the IPTS components is likely to have a more extensive history of suicide attempts, but folks with high levels of negative urgency are at particular risk in that scenario.

Why might this be?  There are a bunch of potential answers here.  The first might simply be that these folks are also more likely to have Cluster B personality disorders like borderline personality disorder.  Another might be that a lifetime of struggling to manage negative emotions leaves these individuals more likely to consider harmful methods for regulating how they feel because, faced with this problem over and over throughout the years leaves them ready to accept highly imperfect options in frequent moments of desperation.  As it turns out, I have some new data that leaves me thinking the answer is something else entirely; however, while the initial paper discussing those results is under review at a journal, I have to hold off on discussing them in order to avoid shooting my own legs out from under me.

All this being said, I will be discussing these results at the Association for Behavioral and Cognitive Therapies conference in San Francisco this November on a panel with PBB contributors Tracy Witte, Kim Van Orden, and Kelly Cukrowicz, so if you plan on attending the conference, I'll look forward to hearing your thoughts.

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If you would like to learn more about this or other topics discussed on PBB, please consult our online store for scientifically-based psychological resources.

Mike Anestis is a resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University

Sexual trauma and bulimia nervosa: Possible mechanisms of action and new data - June 2009 Psychotherapy Brown Bag featured article

by Sarah Fischer, Ph.D.

Whenever I read about a consistent association between two types of psychopathology, such as bulimia nervosa (BN) and substance abuse, for example, I always wonder “Why?”  The ‘Why’ question is what really drives my interest in research on eating disorders and co-occurring conditions. Sexual trauma is one experience that is fairly consistently linked to eating disorder symptoms. Thus, I am delighted to have this opportunity to write about possible mechanisms of action linking trauma experiences to the development of eating disorder symptoms, and to share some new data testing these hypotheses.  First, I would like to share some hypotheses developed with a colleague, Erin Hartzell, about how childhood abuse may lead to later symptoms of bulimia nervosa. Next, I would like to share a hypothesis and some new data about how later sexual trauma experiences may affect BN symptom development.

Childhood Abuse and BN Symptom Development

Child abuse, most often sexual, is considered a non-specific risk factor for eating disorder symptoms.  It is considered a risk factor because there are elevated rates of child abuse in eating disordered samples, yet non-specific because those rates are similar to rates of child maltreatment in other samples of women with psychopathology (Thompson & Wonderlich, 2004;  Jacobi, Hayward, & de Zwaan, 2004).  A recent meta- analysis on this topic found that women who had been sexually abused had higher rates of eating disorder symptoms than those who had not, and that individuals with BN had higher rates of sexual abuse than those without BN (Smolak& Murnen, 2002). More recent data in a sample of women who had been sexually victimized as adults or children indicate that women with trauma histories had higher rates of eating disorder symptoms than did controls (Holzer, Uppala, Wonderlich, Crosby, & Simonich, 2008).  Researchers have only recently begun to describe specific models linking sexual or physical abuse to later eating disordered symptoms, rather than examining rates of co-occurrence of the two conditions (Thompson & Wonderlich, 2004). For example, some data indicate that Post Traumatic Stress Disorder symptoms mediate the link between childhood sexual abuse (CSA) and later eating disorder symptoms (Holzer et al., 2008). In other words, in this sample, the relationship between CSA and later eating disorder symptoms was explained statistically by PTSD, such that the reason that relationship existed was because those who experienced CSA developed PTSD, which in turn influenced the development of eating disorder symptoms.  Thus, the time appears ripe for specific mechanisms of action linking trauma to the development of eating disorder symptoms to be articulated and tested, as the field begins to move beyond descriptive data collection.

In contrast to CSA, emotional or psychological abuse is one form of child maltreatment that has received relatively little attention; however, it is also found in elevated rates in samples of women with obesity and eating disorder symptoms ( Grilo, Masheb, Brody, Toth, Burke-Martindale, & Rothschild, 2005; Grilo & Masheb, 2001). CSA does not likely occur in a vacuum; in families in which children are sexually or physically abused, the victims are also likely to be emotionally abused and neglected. Therefore, it seems likely that the overlooked factor of co-occurring emotional abuse may have a significant contribution to the development of psychopathology, including BN symptoms. In fact, most studies that examine CSA do not present data on emotional abuse.

The consequences of growing up in an emotionally abusive environment have several potential links to future eating disordered behavior, which can be incorporated into existing models of the development of BN symptoms. Bruch (1973) was the first to identify poor interoceptive awareness as a possible risk factor for disordered eating behavior, and to link this deficit to childhood environments.  She described poor interoceptive awareness as being associated with difficulties in recognizing hunger and satiety cues, resulting from an environment in which a child's needs are not sufficiently met. In this type of environment, skills to recognize and manage physiological signals are not taught. Poor interoceptive awareness is also associated with difficulties in correct emotion recognition and identification (van Strien & Ouwens, 2007; Garner, 1991) and emotional eating (Larsen, van Strien, Eisinga, & Engels, 2006). For example, individuals who have difficulty distinguishing emotions and physical sensations may perceive themselves as hungry when they are feeling anxiety or arousal. A number of studies have linked alexithymia (poor emotion identification) and interoceptive awareness to eating disorders (Mitchell & Mazzeo, 2004). One prospective study demonstrated that poor interoceptive awareness predicts the onset of disordered eating in girls (Leon, Fulkerson, Perry, & Early-Zald, 1995).

Emotional abuse may lead to BN symptoms by a second mechanism, which can be incorporated in the cognitive behavioral model of the development of eating disorders.  Individuals who are emotionally abused are often devalued, criticized, and belittled from a young age. This devaluation is likely to be integrated into the self concept of the victim of emotional abuse, resulting in the person believing that they are unlovable, or weak, or worthless. This low self esteem could lead to weight and shape concerns, and attempts to modify one's appearance through dieting. This cycle, of course, is the start of Fairburn’s Cognitive Behavioral model of the development of BN. While a discussion of dieting and the influence of dieting on BN symptoms is beyond the scope of this article, it does appear that severe caloric restriction, such as attempting to undereat as opposed to reduction of overeating (Herman, van Strien, & Polivy, 2008), cutting out food groups, and following food rules, leads to restraint that is almost impossible to sustain. This leaves one susceptible to breaking food rules and 'black and white thinking' about those rules, which causes individuals to overeat after a prolonged period of restraint.  The low self esteem that is hypothesized to lead to attempts to modify weight and shape through diet is one mechanism by which emotional abuse can influence later BN symptoms.

Finally, emotional abuse can lead to the development of BN symptoms by deficits in adaptive emotion regulation skills. Heatherton and Baumeister (1991) suggest that the function of binge eating is to distract from an abstract stimulus (negative thoughts about self; painful emotions) with a concrete stimulus (food). Several studies have been conducted with the use of EMA technology, and all consistently find that increases in negative affect precede binge eating behavior (Stein, Kenardy, Wiseman, Dounchis, Arnow, & Wilfley, 2007; Engelberg, Steiger, Gauvin, & Wonderlich, 2007; Smyth, et al., 2007).  Moreover, binge eating behavior may be negatively reinforced via this pathway because it acts to decrease or block negative affect, at least in the short term, by relieving the experience of painful emotions (Arnow, Kennedy, & Agras, 1992; Heatherton & Baumeister, 1991; Polivy & Herman, 1993; Whiteside, Chen, Neighbors, Hunter, Lo, & Larimer, 2007). Linehan’s (1993) conceptualization of Borderline Personality Disorder and the role of the invalidating environment provides theoretical support for the relationship between early abuse and disorders of emotion dysregulation.  While the role of the invalidating environment has not explicitly been described or studied in relation to later BN symptoms, we believe that this model provides a framework for describing one mechanism by which emotional abuse may lead to eating disorders. Only one study to date has attempted to examine the relationship of the invalidating environment and eating disordered behavior. In this study, women with eating disordered symptoms endorsed self report items indicating that their family environments had several features of the invalidating environment described by Linehan (Mountford, Corphostine, Tomlinson, & Waller, 2007).

Deficits in emotion identification and labeling, a consequence of the invalidating environment and emotional abuse, often then lead to deficits in emotion regulation skills. If one is not provided with modeling of healthy emotion regulation strategies, such as in an abusive home, then one may turn to immediately reinforcing, maladaptive strategies to alleviate distress or distract oneself from negative emotion.  As described previously, several studies have already linked BN symptoms to negative emotional antecedents and poor distress tolerance skills. We hypothesize that poor distress tolerance skills mediate the link between the experience of emotional abuse and later binge eating.  In short, emotional abuse leads to the development of poor emotion regulation skills, and these maladaptive skills lead to binge eating.

Testing These Models

So, where does sexual trauma fit in here? As previously stated, it is unlikely that CSA occurs without concurrent emotional abuse. Therefore, my colleagues and I hypothesize that it is actually the emotional abuse that co-occurs with CSA that leads to deficits in self esteem, interoceptive awareness, and especially emotion regulation skills, which mediate the link between child abuse and later ED symptoms. We had the opportunity to test one of these hypotheses in a large sample of undergraduate women (N = 1302).  Using a statistical technique known as structural equation modeling (SEM), we tested a mediational hypothesis.  Specifically, we first hypothesized that emotional abuse would contribute the most variance to BN symptoms when three types of childhood abuse were simultaneously modeled: emotional, sexual, and physical (Hartzell & Fischer, manuscript submitted for publication). Second, we hypothesized that deficits in emotion regulation skills would mediate the relationship between childhood abuse and BN symptoms. Overall, results indicated that the model fit the data well (CFI = .99, RMSEA = .03) and supported our hypotheses. However, we were surprised about one finding. When all three types of childhood abuse were simultaneously modeled, only emotional abuse had a significant direct effect on multiple eating disorder symptoms (restriction, binge eating, and weight and shape concerns). Sexual abuse, in fact, did not have a significant direct relationship to any of the ED symptoms in our sample. With regards to the mediation, all three types of abuse had significant, positive associations with deficits in emotion regulations skills, which in turn had significant positive associations with all ED symptoms modeled (Hartzell & Fischer, manuscript submitted). (Sobel tests of the significance of the mediation indicated that the indirect effects of emotional abuse through emotion dysregulation were significant, but not those of sexual abuse).

Adult Sexual Trauma and BN Symptoms

I would like to now turn to a discussion of some hypotheses of how personality can interact with trauma experiences to influence BN symptoms. Of course, genetic influences on temperament and personality are in place from birth, and are also constantly influenced by environmental events. Therefore, childhood trauma experiences may also influence personality development. For example, Borderline Personality Disorder symptoms in individuals with BN may be uniquely associated with childhood sexual abuse experiences (Dohm et al., 2002).

This aside, individuals often experience sexual trauma in adulthood as well as childhood.  The first few years of college may be a particularly high risk time for sexual trauma in young adult women. Therefore, I am interested in examining the interacting effects of personality and new trauma experiences on the development of BN. Cross sectional research has indicated that negative urgency, the tendency to act rashly in response to negative affect or distress, is positively associated with binge eating symptoms (Fischer & Smith, 2008; Fischer, et al., 2004; Anestis, et al., 2007). However, this trait is also positively associated with alcohol abuse (Whiteside & Lynam, 2003; Fischer & Smith, 2008; Miller, Flory, Lynam, & Leukefeld, 2003) risky sexual behavior (Miller, et al., 2003 ) and pathological gambling (Fischer & Smith, 2008). Theoretical models of personality risk for pathology hypothesize that personality traits are genetically heritable factors that increase vulnerability to several types of psychopathology.  However, environmental events may actually cause an individual to cross the 'liability threshold' into pathology (Bulik, Sullivan, & Kendler, 2003). Thus, genetic trait by environment interactions may be linked to bulimia nervosa and other eating disorders (Bulik, et al., 2003). 

My current research is testing hypotheses based on the idea that one such gene -environment transaction may exist between negative urgency and sexual trauma. Our hypothesis is that individuals with high levels of negative urgency, who act rashly or impulsively when distressed,  may not provide themselves with the opportunity to learn longer term, more adaptive strategies to cope with negative affect. They thus tend to turn to maladaptive emotion regulation strategies, such as binge eating, purging, and substance abuse. I hypothesize that individual differences in negative urgency may interact with the experience of sexual assault to influence the development of or increase in eating disorder symptoms. I had the opportunity to collect data to test this hypothesis in a longitudinal study of women across their first year of college (N = 550), a high risk time for the development of BN symptoms (Fischer, Stojek, & Collins, manuscript in preparation). My colleagues and I collected data on eating disorder symptoms, impulsivity related personality constructs, and sexual assault at three different time points across the year. Thus, we were able to capture pre-existing sexual assault, new occurrences of sexual assault, pre-existing BN symptoms, and the emergence or increase of BN symptoms over the year.

At time 1, we found that pre-existing sexual assault and negative urgency had unique direct positive effects on BN symptoms. We then controlled for the presence of BN symptoms at time 1, and tested the interaction effect of time 1 levels of negative urgency and new occurrences of sexual assault at both time 2 and time 3.  At both time points, the interaction effect was significant (Fischer, et al., manuscript in preparation). Thus, women who had been sexually assaulted in the interim between time 1 and time 2, and time 2 and time 3, and had high levels of negative urgency, experienced increases in BN symptoms at time 2 and time 3.  My colleagues and I are very excited about this data, as it is one of the only prospective studies demonstrating both the influence of sexual assault on the development of symptoms and testing a hypothesized mechanism of action.

Linking Adult Experiences and Symptoms, Childhood Abuse, and Personality

Of course, both childhood and adult experiences can interact to influence personality, interact with personality, and influence BN symptoms. The effect of an emotionally labile temperament may be mitigated when an individual grows up in an environment that puts forth effort to teach adaptive emotion regulation skills. However, when such an individual is placed in an emotionally abusive environment in which they are not taught adaptive emotion regulation tools, the result may be psychopathology such as bulimia nervosa. Of course, this interaction could lead to any of the pathways previously outlined. For example, high negative urgency individuals in an abusive environment may be more likely to develop weight and shape concerns as a result of low self esteem, or may be more likely to experience deficits in interoceptive awareness because of their tendency to quickly block negative emotions. Poor distress tolerance may be both a mediator and a moderator of emotional abuse to later binge eating. Sexual abuse experiences can also influence neurotransmitter and personality development itself. For example, the neurotransmitter that is hypothesized to play a key role in the development of eating disordered behavior is serotonin, or 5HT (Steiger, 2004). This neurotransmitter has been associated with satiety and disordered eating, but also with personality traits associated with BN, such as affective instability and impulsivity (Lesch, Bengel, Heils, et al., 1996; Steiger, Richardson, & Joober, 2007). Steiger and colleagues found increased levels of psychopathology in bulimic women who both had been abused and were a carrier of an allele that regulates serotonin reuptake (Steiger, et al., 2007). This indicated that a gene by environment interaction was present; that individuals who had a genetic vulnerability to personality instability had greater psychopathology when they had experienced abuse.  This is supportive of the notion that personality may interact with environmental events to influence the development of psychopathology. Overall, there are many avenues to be explored in this area of research, and it is an exciting time to study these transactions.

If you are interested in learning more about these topics, we recommend that you browse our newly redesigned online store.  Products are listed by category (e.g., eating disorders, ADHD) and are geared for both professionals and non-professionals.

Sarah Fischer is an assistant professor in the psychology department at the University of Georgia.

Not all emotions are created equal: The difference between positive and negative urgency

by Michael D. Anestis, M.S.

In preparation for Sarah Fischer's June 1 featured PBB article, I wanted to provide another look at two of the variables included in the UPPS-P Impulsive Behavior Scale.  If you read our prior article on the UPPS-P, you'll recall that the measure breaks the idea of "impulsivity" into five distinct subscales:

• Positive urgency
• Negative urgency
• Sensation seeking
• (lack of) Perseverance
• (lack of) Premeditation

Today's article takes a closer look at positive and negative urgency in an effort to illustrate how important it is to differentiate between specific forms of impulsivity.

Both positive and negative urgency refer to a tendency on the part of an individual to behave rashly in response to emotions.  In other words, these variables do not simply reflect a general tendency not to think before acting, regardless of context.  Individuals with high levels of positive urgency tend to lose control over their behavior when they feel exhilarated or happy, whereas individuals with high levels of negative urgency tend to lose control over their behavior when experiencing sadness, anger, fear, or other negative emotions.  An easy way to think about this would be to compare high levels of positive or negative urgency to a faulty brake pedal.  When individuals experience intense emotions, it is as though they are driving a car at a dangerously fast speed.  For individuals with elevated levels of positive or negative urgency, the brake pedal either does not work or is simply highly ineffective, thus making them less able to stop themselves from going off the road.  The problem is thus not an overly sensitive gas pedal - the actual experience of negative or positive emotions is not necessarily any more intense than for individuals low in positive and negative urgency - but rather a failure to inhibit behavior that they would be unlikely to engage in if not for their vulnerability to their particular emotional state.

For individuals high in positive urgency, under-controlled behaviors are often used in an effort to prolong or intensify positive emotions.  For individuals high in negative urgency, on the other hand, under-controlled behaviors are often used in an effort to escape negative emotions.  An important distinction should be made here, as it further clarifies the importance of considering these variables separately rather than simply talking about a broader term like "impulsivity" or even simply lumping urgency into a single category.  The drive to increase or prolong positive emotions is not the same as the drive to reduce negative emotions.  As it turns out, positive and negative emotions are not simply on opposite ends of a single continuum.  Instead, they are each their own, unique continuum.  Depression gives us a good way to consider this point.  There are two primary symptoms of depression, at least one of which must be present for an individual to qualify for a DSM-IV-TR diagnosis of depression: depressed mood and anhedonia.  Anhedonia refers to an inability to experience pleasure or joy, even in response to things that previously induced such feelings.  So, an individual can be diagnosed with depression even in the absence of depressed mood as long as they are experiencing severely reduced positive affect.  The depression diagnosis thus does a good job of pointing out that "not being able to feel good" is not the same thing as "feeling bad" and "being able to feel good" does not mean "not feeling bad."  Bringing this point back to the central focus of this article, positive and negative urgency are not simply different ways of saying that we all want to feel better.  One is saying that an individual can not tolerate feeling badly whereas the other one is saying that an individual essentially becomes intoxicated in response to feeling good.  An individual can certainly exhibit high levels of both of these variables simultaneously, but this does not make them the same thing.

To further clarify the importance of distinguishing between these two variables - and other aspects of impulsivity as well - rather than simply lumping them together into a single, broader category, I would like to call attention to some of the empirical research that has been conducted on this matter.  This research is summarized extremely well in an article by Melissa Cyders and Greg Smith (2008) published in the prestigious journal Psychological Bulletin.  In a section of their paper detailing the differences between positive and negative urgency, Cyders and Smith first point out that, while positive and negative urgency are distinct from one another, they are significantly correlated and predict some of the same behaviors, including problematic drinking and gambling.  The vast majority of the research, however, highlights the differences between the two variables. Even in a behavior such as problematic gambling, for which both positive and negative urgency are significant predictors, there are important distinctions.  Whereas negative urgency only predicts the degree to which an individual currently engages in problematic gambling, positive urgency has been shown to predict increases in problematic gambling over the course of a year in college freshmen (Cyders et al., 2007).  Similarly, only positive urgency prospectively predicted illegal drug use and risky sexual behavior during the first year of college (Zapolski, Cyders, Rainer, & Smith, 2007).  Additionally, whereas several studies have indicated that negative urgency predicts bulimic symptoms such as binge eating and purging (Anestis, Selby, Fink, & Joiner, 2007; Anestis, Selby, & Joiner, 2007; Fischer, Anderson, & Smith, 2004; Fischer, Smith, & Anderson, 2003), positive urgency is not related to bulimic behaviors (Cyders et al., 2007).

Perhaps the greatest evidence for the importance of distinguishing between these two variables came from a pair of straight forward, but highly important findings: negative but not positive urgency predicts the use of maladaptive behaviors in response to negative emotions (Cyders et al., 2007) whereas positive but not negative urgency predicts the use of maladaptive behaviors in response to positive emotions (Cyders & Smith, 2007, 2008).  In other words, individuals with high levels of negative urgency are not at an increased risk for losing control of their behaviors when feeling good and individuals with high levels of positive urgency are not at an increased risk for losing control of their behaviors when they feel bad.  Each type of urgency is specific to positive or negative emotions.

I realize that, when we talk about individual difference variables such as positive and negative urgency, the article can start to feel highly scientific and esoteric and become difficult to relate to, but we at Psychotherapy Brown Bag feel strongly that it is pivotal to find a way to bridge this gap and to explain these topics in a way that appeals to a broader audience less inclined to spend their days reading empirical studies in psychological journals (we realize not everyone gets the same nerdy pleasure from this as we do).  To do so, I ask that you think about this topic in a fairly straight forward way.  Consider the last time you were upset and felt tempted to do something you would have later regretted.  Did you feel part of you that resisted that impulse - that asked you to consider the repercussions of that behavior and come up with an alternative response?  What about the last time you felt extremely excited and were having a great time.  Did you feel tempted to do something to sustain that feeling or prolong the evening that, in all likelihood, would have caused you problems later on?  If so and you resisted, what kept you from taking that risky leap?  For individuals with high levels of positive or negative urgency, that innate stopping mechanism is ether absent or weak, and resisting strong impulses in the face of particular emotions is extremely difficult.  It's not that these individuals are out of control all of the time or do not care about consequences.  It is simply that, in the context of particular feelings, they become vulnerable to using problematic behaviors that accomplish a short term goal (e.g., reducing negative emotions) at great long term expense.

Importantly, by measuring variables like positive and negative urgency, we can learn to what degree individuals are vulnerable to using particular behaviors in certain contexts and work to develop skills to counteract these vulnerabilities before they become a problem.  Research into individual difference variables thus serves a potentially invaluable purpose: identifying and subsequently reducing risk before unbearable costs are created.  Considering positive and negative urgency rather than simply thinking about "impulsivity" is thus useful in the same way thinking about sadness or anger is more useful than simply saying you feel "bad."  We learn more about what is really going on, what might happen next, and what can be done to prevent harm.

There is a lot more research out there on the UPPS-P, some of it already published and some of it ongoing at the moment.  We will cover many of those studies in future articles.  In the meantime, we eagerly await the PBB contribution of Sarah Fischer, whose work has driven much of the research on the UPPS-P - a quick look at how many times she has been cited in our UPPS-P articles will attest to this fact - for further clarification of the utility of this and other related topics.

If you would like to learn more about these topics, we encourage you to browse our online store, which features a variety of products based on empirical research.  Some of these products are aimed at professionals (e.g., treatment manuals) whereas others are aimed at a broader audience seeking to obtain accurate information on topics related to mental health.  Additionally, please feel free to contact us with questions regarding suggested readings.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

The UPPS-P impulsive behavior scale: Bringing specificity to a broad topic

by Michael D. Anestis, M.S.

As I begin the final section of my Abnormal Psychology class each semester, I often ask my students a fairly simple sounding question:

What is impulsivity?

Generally speaking, I receive some well thought-out responses that center on the idea of acting without thinking.  After complimenting my students' responses, which are invariably strong, I ask a follow-up question:

                          What are some examples of impulsive behaviors?

Here's where things get tricky.  Typical answers include substance use, self-injury, sky diving, gambling, physical aggression, yelling, shopping, extreme sports, and binge eating.  That list is quite broad, I point out, and my students nod in agreement, as we all recognize two basic facts: these behaviors are not all the same and not every individual utilizes a behavior for the same reason.  For example, while some individuals drink alcohol for social reasons, others drink to cope with negative emotions.  Although drinking for social reasons can be problematic, those who drink to reduce negative emotions have, by far, the worst outcome (Cooper, 1992).  So, we all know impulsivity when we see it, but it appears that defining it might be somewhat complicated.

The vague nature of the above list of behaviors is a prime example of the problems inherent in the concept of impulsivity.  In fact, Lynam and Miller (2004) concluded that impulsivity is defined differently across so many different studies that it nearly impossible to provide a single, universally accepted definition.  Gray (1970) defined impulsivity as an individual's sensitivity to and tendency to act upon reward cues.  In other words, the degree to which an individual notices potentially rewarding stimuli and acts in a way to attain them determines the degree to which he is impulsive.  The highly influential concepts of the Behavioral Activation System (BAS) and Behavioral Inhibition System (BIS) were formed on the basis of this definition. 

Eysenck and Eysenck (1977) decided that impulsivity was slightly broader than Gray's conceptualization and defined it instead as a combination of taking risks, making swift decisions, and forsaking planning.  This definition did not specify that individuals were highly sensitive to rewards, but rather focused on a behavioral tendency to act without considering consequences.

In another influential definition of impulsivity, Patton, Stanford, and Barratt (1995) indicated that the construct is comprised of three components: lack of planning, lack of focus on the task at hand, and the tendency to act without delay.  This definition is fairly consistent with that of Eysenck and Eysenck (1977), but includes consideration of a difficulty in focusing on the current task.

Each of these definitions has been utilized in highly influential research and has helped us to better understand maladaptive behavioral patterns.  The problem, however, is that these definitions still do not address the problems my students and I come across each semester when we look at our list of impulsive behaviors.  For one thing, none of these definitions makes any mention of emotions as a component of impulsivity despite mountains of research indicating that affect plays a pivotal role in dysregulated behavior.  Such weaknesses were the motivation for the creation of the UPPS Impulsive Behavior Scale (Whiteside & Lynam, 2001), which has since been revised and is now referred to as the UPPS-P Impulsive Behavior Scale (Cyders, Smith, Spillane, Fischer, Annus, & Peterson, 2007).  The UPPS-P breaks the concept of impulsivity into five distinct subscales:

Positive Urgency
The tendency to act rashly when experiencing positive emotions.

Negative Urgency
The tendency to act rashly when experiencing negative emotions.

Sensation Seeking
The tendency to seek out activities involving an element of risk or thrill.

(lack of) Premeditation
The tendency to act without deliberation

(lack of) Perseverance
The tendency to give up when activities become difficult or boring

So why was it important to create this new assessment tool and to parse the construct of impulsivity into so many different components?  Quite simply, because each of these subscales predicts different behavioral outcomes.  In other words, by determining whether an individual exhibits high levels of one of these variables, we can have a better sense of her vulnerabilities to particular behaviors and mental illnesses.  In this sense, the UPPS-P has similar utility to the functional model of non-suicidal self-injury, which was discussed in an earlier PBB post.

Sarah Fischer, one of the most influential researchers on this topic, will be providing an upcoming PBB featured article and we intend to write in depth on these variables in the coming weeks, but I want to provide a brief overview of the research on the UPPS-P in order to clarify the importance of thinking about a broad topic such as impulsivity in a more specific manner. 

Negative urgency, the most heavily researched of these variables, has been shown to predict a variety of problematic outcomes. In particular, high levels of negative urgency have been shown to predict elevations in aggression, drinking alcohol to reduce negative affect, compulsive buying behaviors, hostile attribution style, substance use disorders, and early marijuana use in men (Billieux, Rochat, My Lien Rebetez, & Van der Linden, 2008; Fischer, Anderson, & Smith, 2004; Fischer, Smith, & Anderson, 2003; Lynam & Miller, 2004; Miller, Flory, Lynam, & Leukefeld, 2003; Verdejo-Garcia, Bechara, Recknor, & Perez-Garcia, 2007).  Fischer and Smith (2008) found that negative urgency interacts with expectancies, such that high levels of negative urgency in combination with the expectation that a behavior will reduce negative emotions is highly predictive of the likelihood of using that behavior.  The authors demonstrated this in a variety of dysregulated behaviors, including binge eating, problematic drinking, and gambling.  Additionally, Anestis, Selby, and Joiner (2007) found that increases in levels of negative urgency predicted increases in drinking to reduce negative emotions, binge eating, and excessive reassurance seeking over a six-week period.  Anestis, Selby, Fink, & Joiner (2007) found that negative urgency interacts with distress tolerance such that high levels of negative urgency and low levels of distress tolerance resulted in the greatest level of binge eating behaviors.

So what do all these findings tell us?  Individuals with high levels of negative urgency are likely to engage in a variety of problematic behaviors when they are upset.  Their use of such behaviors is driven in large part by their emotional experiences, indicating that such individuals are in need of training in emotion regulation skills.  If negative urgency is, in fact, driving a behavior, it is thus imperative for a clinician to identify this fact, as the drive to reduce negative affect is often predictive of the worst outcome in behaviors such as alcohol consumption (Cooper, 1992).

What about the other scales?  Although there is not as much research on the other scales as of yet, there is enough to demonstrate that, while they are all related to the broad idea of impulsivity, they are also quite distinct from one another.  Sensation seeking, for instance, does not predict a similar list of behaviors.  In fact, whereas negative urgency is negatively correlated with distress tolerance, sensation seeking is positively correlated with distress tolerance.  In other words, individuals high in negative urgency typically can not tolerate much negative emotion whereas individuals high in sensation seeking are typically capable of tolerating significant negative emotional experiences.  Additionally, whereas negative urgency is not significantly correlated with the acquired capability for suicide, sensation seeking is positively correlated with the acquired capability (Bender, Anestis, Anestis, & Joiner, 2009).  Because individuals high in sensation seeking tend to engage in thrilling, dangerous behaviors, they habituate to fear and physiological pain and, over time, become capable of enacting lethal self-harm.  Remember, the desire for suicide and the capability for suicide are distinct from one another, but this finding nonetheless is important as it means that, if an individual high in sensation seeking desires suicide, they are much more likely to utilize a lethal attempt method than is an individual low in sensation seeking.

Using a term like "impulsive" to describe an individual's behavior thus misses the point.  Impulsivity can mean many different things and the precise meaning plays a significant role in determining the nature of the behavior.  Understanding the mechanism driving behaviors is thus important for a variety of reasons.  First, as I began to demonstrate above and will demonstrate further in future posts, different mechanisms predict different outcomes.  Secondly, if two individuals engage in the same behavior for different reasons (e.g., gambling to distract from negative emotions versus gambling to sustain positive emotions), they are likely to respond differently to treatment.  The UPPS-P is a fairly new scale, but research on this topic is drawing a lot of attention and producing compelling results.  As new findings are published, we will be sure to discuss them on PBB.

I would love to hear from readers regarding their thoughts on this scale.  Do you think there are types of impulsivity not mentioned in the subscales?  Do you think the subscales overlap too heavily?  Do you think it matters whether an individual utilizes a behavior to reduce negative emotions or for some other reason?  How do you think this scale can be used by therapists to help drive treatment?

If you would like to read more about the behaviors mentioned above, we recommend the following products, all of which are available through our online store:

• Understanding Nonsuicidal Self-Injury: Origins, Assessment, and Treatment

• Freedom from Selfharm: Overcoming Self-Injury with Skills from DBT and Other Treatments

• Cognitive-Behavioral Treatment of Borderline Personality Disorder

• Skills Training Manual for Treating Borderline Personality Disorder

• Crave: Why You Binge Eat and How to Stop

• Overcoming Binge Eating

• Handbook of Emotion Regulation

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.