The Relationship Between Trait Impulsivity, Negative Affective States, and Urge for Nonsuicidal Self-Injury: a Daily Diary Study

Psychiatry Research ] (]]]]) ]]]–]]]

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Psychiatry Research

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The relationship between trait impulsivity, negative affective states, and urge for nonsuicidal self-injury: A daily diary study

Konrad Bresin a,n, Darren L. Carter b, Kathryn H. Gordon b a Psychology Department, University of Illinois Urbana-Champaign, 603 East Daniel Street, Champaign, IL 61920, USA b North Dakota State University, USA article info abstract

Article history: Theories of nonsuicidal self-injury (NSSI) and impulsivity suggest that individuals with high levels of Received 23 August 2011 negative urgency (e.g., those with a propensity to act rashly while experiencing negative affect) should Received in revised form experience the urge to engage in NSSI during negative affect states. However, previous research has not 28 May 2012 directly tested these predictions. This study used a daily diary methodology in a sample of individuals Accepted 20 September 2012 who engaged in NSSI in the last year. Participants completed self-report measures of trait impulsivity and subsequently made daily ratings of negative affect, sadness, guilt, and urge to engage in NSSI for 14 Keywords: days. Our results indicated that for individuals high in negative urgency, daily sadness, but not guilt NSSI or general negative affect, was a positive predictor of urge to engage in NSSI. Meanwhile, for those low Self-injury in negative urgency, sadness was unrelated to NSSI urge. Implications for theories of NSSI and Self-harm treatment are discussed. Impulsivity & Negative urgency 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Support for the affect regulation function of NSSI comes from multiple lines of research. Retrospective recall studies suggest Nonsuicidal self-injury (NSSI) is the intentional destruction that feelings such as tension, sadness, and anger towards the self of body tissue without suicidal intent (Nock, 2009). One theory as precede NSSI (Kamphuis et al., 2007; Klonsky, 2009). However, to why people engage in NSSI is that the behavior functions as a these studies are subject to recall bias. Laboratory studies suggest maladaptive strategy for coping with intense negative affect (NA; that proxies for NSSI (imagery scripts, pain) led to a reduction in Chapman et al., 2006). Theories of impulsivity suggest that certain NA (Haines et al., 1995; Franklin et al., 2010). Still, there may be individuals may be more likely to engage in rash actions (e.g., important differences between the experience of laboratory pain NSSI) while experiencing intense affect (Cyders and Smith, 2008). and actual NSSI. Consistent with this, previous research has found evidence of To reduce the impact of these limitations, some researchers increased levels of trait impulsivity in individuals with a history have used ecological momentary assessment (EMA), which con- of NSSI (Glenn and Klonsky, 2010). However, to date, these sists of repeated assessments in the participant’s natural environ- studies have been cross-sectional and have not tested the trait ment. This method allows for assessment of affect in the moment by state interactions proposed by theory. To address limitations of (Shiffman et al., 2008). Moreover, researchers can measure the current research, we conducted a daily diary study to test the changes in NA in relation to actual NSSI urges and incidents. hypothesis that negative urgency and state affect would interact Using EMA in a sample of adolescents, Nock et al. (2009) found to predict daily NSSI outcomes. that feelings such as anger towards the self and others predicted engagement in NSSI. Muehlenkamp et al. (2009) found a significant increase in NA in the hours leading up to NSSI, but no 1.1. The affect regulation function of nonsuicidal self-injury significant change in NA following the incident. Finally, Armey et al. (2011) found a significant quadratic slope for both NA and One of the many proposed functions of NSSI is to reduce NA guilt (but not hostility) around NSSI incidents, meaning that (Nock and Prinstein, 2004). More specifically, it has been pro- in the hours leading up to engagement in NSSI, participants posed that the urge to engage in NSSI may occur during high NA experienced an increase in NA and guilt and following NSSI these states, and following the actual act of NSSI, NA states may be feelings decreased. Taken together, these results indicate that momentarily reduced (Chapman et al., 2006; Nock, 2009). increased momentary NA may increase the likelihood of NSSI. One limitation of the current literature is that studies have n Corresponding author. not tested the interaction between trait and state predictors pro- E-mail address: [email protected] (K. Bresin). posed by theoretical models (e.g., Chapman et al., 2006). Another

Please cite this article as: Bresin, K., et al., The relationship between trait impulsivity, negative affective states, and urge for nonsuicidal self-injury: A daily diary study. Psychiatry Research (2012), http://dx.doi.org/10.1016/j.psychres.2012.09.033 2 K. Bresin et al. / Psychiatry Research ] (]]]]) ]]]–]]] limitation is many studies have focused on NA in general. NA is and sadness. Guilt was chosen for theoretical reasons, based on the composed of other lower order factors including: sadness, guilt, fear, self-punishment hypothesis, which suggests that NSSI is a form of and hostility (Watson and Clark, 1994). As the results of Armey et al. punishment meant to alleviate anger towards the self (Chapman (2011) indicate, particular NA states may have a stronger relation- et al., 2006; Schoenleber and Berenbaum, 2012). Also, as reviewed ship to NSSI than others. Finally, current research has largely focused above, Armey et al. (2011) found that guilt, but not hostility, on actual NSSI engagement. It seems probable that there would also significantly increased leading up to NSSI. Sadness was chosen be clinical utility in examining urges to engage NSSI as they may because individuals retrospectively report experiencing sadness, provide an opportunity for intervention prior to NSSI. depression, and loneliness prior to NSSI (Kamphuis et al., 2007; Klonsky, 2009). Furthermore, sadness is a form of deactivated 1.2. Nonsuicidal self-injury and impulsivity displeasure, which differs from other types of NA, which are activated displeasure (Yik, et al., 2011). Therefore, sadness provided Impulsivity is an individual difference that has been proposed an interesting contrast in terms of arousal (or activation) at as theoretically important for NSSI (Chapman et al., 2006). negative valence. We chose not to measure daily fear because, to However, the relationship between impulsivity and NSSI in our knowledge, previous research has not indicated a relationship research has been inconsistent. Studies using behavioral mea- between fear and NSSI (Kamphuis et al., 2007; Klonsky, 2009). We sures of impulsivity (e.g., the continuous performance task) have chose not to measure daily hostility due to the theoretical argument found no significant differences between individuals with and that anger directed toward the self should be related to NSSI, while without a history of NSSI (Glenn and Klonsky, 2010; Janis and anger in general should be related to other-directed aggression Nock, 2009). On the other hand, studies have found that indivi- (Schoenleber and Berenbaum, 2012). Furthermore, Armey et al. duals with a history of NSSI report higher levels of self-reported (2011) did not find an increase in hostility in relation to NSSI impulsivity (Glenn and Klonsky, 2010; Herpertz, et al., 1997). One incidents. Our prediction in all three types of affect measured was possible explanation for these divergent results is that individuals that negative urgency would interact with state NA to predict NSSI who engage in NSSI only perceive themselves to be more urge, such that at high levels of negative urgency, higher levels impulsive. Still, the results of a recent meta-analysis indicate that of state NA would be related to an increased NSSI urge. the relationship between self-report and behavioral measures of impulsivity is small (Cyders and Coskunpinar, 2011). Further- more, each may explain unique variance in psychopathology 2. Method (Bornovalova et al., 2008). An alternative explanation is that individuals who engage in NSSI are only more impulsive beha- 2.1. Participants viorally while experiencing intense NA. Psychometric work has indicated that self-report impulsivity We screened 1612 college undergraduates using the Deliberate is a multi-faceted construct consisting of five factors (Whiteside Self-Harm Inventory (DSHI; see below; Gratz, 2001) for participa- and Lynam, 2001; Cyders et al., 2007). Of these factors, negative tion in this study. Eight percent of participants indicated that they urgency, or the tendency to engage in risky behavior during had engaged in NSSI in the past 12 months, 15% indicated periods of NA, appears most likely to be related to NSSI. For engaging in NSSI more than 12 months ago. To ensure the clinical instance, Glenn and Klonsky (2010) found that college under- relevance of the sample, we recruited individuals with at least graduates with a history of NSSI reported higher levels of negative one NSSI incident in the last year (e.g., Glenn and Klonsky, 2010; urgency than those with no history of NSSI. Similarly, Snorrason Nock and Banaji, 2007). et al. (2011) found that when controlling for the other impulsivity We recruited 67 participants (38 female) for the study via factors, negative urgency was a significant predictor of patholo- e-mail. The mean age was 19.58 years (S.D.¼2.94). The median gical skin picking, a possible form of NSSI. However, these studies frequency of lifetime NSSI incidents was 15 (range¼1–1000). The are limited in that they are cross-sectional and do not examine participants used a mean number of 3.12 methods of NSSI the interaction with state affect predicted by NSSI models. (S.D.¼1.94). Table 1 displays the prevalence of specific NSSI methods. The average time since the last NSSI incident was six 1.3. Current study months (S.D.¼4.8).

Theories of NSSI propose that the urge to engage in NSSI is likely 2.2. Assessment measures to occur for certain individuals in negative affective states (e.g., Chapman et al., 2006). Similarly, models of impulsivity predict that 2.2.1. Screening individuals high in negative urgency will have a propensity to act Potential participants completed the DSHI (Gratz, 2001)ona rashly when experiencing intense levels of NA (Cyders and Smith, secure website. The DSHI is a 17-item questionnaire that assesses 2008). In spite of the parallel hypotheses of these theories, no the lifetime history of deliberate self-injury without the suicidal previous study to our knowledge has tested these interactive predictions. Therefore, we conducted a daily diary study to test Table 1 these predictions in a sample of participants with a history of NSSI Frequency of nonsuicidal self-injury methods. in the last year. Participants completed self-report measures of trait Method Frequency Percent impulsivity and subsequently made daily ratings of affect, NSSI, and NSSI engagement for 14 days. As mentioned below, the frequency Cutting 33 50.77 of NSSI engagement was too low to be used in analyses. Hence, Burning 20 30.77 Carved words into skin 20 30.77 we focus our predictions on NSSI urge. Carved pictures into skin 19 29.23 We examined three different types of NA. We focused on a Severe scratching 27 41.54 subset of NA types to reduce participant burden in our daily diary Self-biting 5 7.69 protocol. To be most consistent with theories of NSSI and negative Sticking sharp object into skin 14 21.54 Head banging 16 24.62 urgency (Chapman et al., 2006; Cyders and Smith, 2008), we ﬁrst Self-punching 18 27.69 tested if negative urgency moderated the effect between general NA and NSSI urge. We also explored two speciﬁc types of NA: guilt Note. N¼67.

Please cite this article as: Bresin, K., et al., The relationship between trait impulsivity, negative affective states, and urge for nonsuicidal self-injury: A daily diary study. Psychiatry Research (2012), http://dx.doi.org/10.1016/j.psychres.2012.09.033 K. Bresin et al. / Psychiatry Research ] (]]]]) ]]]–]]] 3 intent (i.e., NSSI). First, participants were asked if they had ever To examine the interaction between trait negative urgency and engaged in specific methods of NSSI (e.g., cutting, burning, severe state affect, we used generalized linear mixed modeling (Littell scratching, etc.). If participants indicated they had engaged in a et al., 2006), which allows for days to be nested within partici- specific NSSI method, they were asked a series of follow-up pants. All models were run using the PROC NLMIXED procedure in questions including, ‘‘When was the last time you did this?’’. As SAS 9.2 (SAS Institute, 2008). We ran three separate models. First, mentioned above, we contacted participants that met our study we examined the interaction between negative urgency and daily inclusion criteria. negative affect. To do this, negative urgency (grand mean centered; Enders and Tofighi, 2008) was entered as the Level 2.2.2. Impulsivity 2 predictor and daily NA (centered within-subject) was entered Negative urgency was assessed using the urgency subscale of as the Level 1 predictor, along with the cross-level interaction. the Urgency, (lack of) Premeditation, (lack of) Perseverance, In the other two models, we focused on specific types of NA. Sensation Seeking, and Positive Urgency behavior scale (UPPS-P; In these models, the Level 2 predictor was again negative urgency, Lynam et al., 2006). The urgency subscale contains 12 items (e.g., while daily negative affect and daily guilt (sadness) were the ‘‘When I am upset I often act without thinking’’). Participants Level 1 predictors. Finally, of most theoretical importance, the rated items on a 4-point Likert scale (1¼disagree strongly, negative urgency by daily guilt (sadness) cross-level interaction 4¼agree strongly). The mean (averaged across items) for the was used in the prediction of NSSI urge. All tests were two-tailed. current sample was 2.59 (S.D. ¼0.62; a¼0.90). For the first model, there was a significant effect of negative urgency (g¼1.51, t¼2.04, p¼0.04, OR¼4.52) and daily negative 2.2.3. Affect affect (g¼2.08, t¼5.69, po0.001, OR¼8.00). However, contrary We assessed daily affect using subscales of the Positive and to our prediction the interaction was not significant (g¼0.71, Negative Affect Schedule Expanded Form (PANAS-X; Watson and t¼1.16, p¼0.24, OR¼2.03). With guilt as the type of affect, there Clark, 1994). Specifically, we assessed NA (10 items, sample item: was a marginally significant effect of negative urgency (g¼1.37, ‘‘distressed’’, a across items¼0.86), guilt (6 items, sample item: t¼1.73, p¼0.08, OR¼3.93), and a significant effect of daily NA ‘‘angry at self’’, a¼0.92), and sadness (5 items, sample item: (g¼1.68, t¼3.35, p¼0.01, OR¼5.36). The effect of daily guilt ‘‘lonely’’, a¼0.90). Though not reported here, we also collected (g¼0.45, t¼1.34, p¼0.18, OR¼1.56) was not significant. Similar measures of positive affect and self-assurance. Participants rated to daily NA, the cross-level interaction was not significant items on a 5-point Likert scale (1¼very slightly or not at all, (g¼0.32, t¼0.74, p¼0.46, OR¼1.37). 5¼extremely) as to how they ‘‘generally felt today.’’ For sadness, the effect of negative urgency was not significant (g¼1.21, t¼1.58, p¼0.11, OR¼3.42). However, there were sig- 2.2.4. NSSI urge nificant effects for daily NA (g¼1.42, t¼3.30, p¼0.01, OR¼4.22) We assessed urge to engage in NSSI using a single item based and daily sadness (g¼0.84, t¼2.98, p¼0.04, OR¼2.33). Moreover, on Nock et al. (2009). Participants rated how strong their urge the interaction between negative urgency and daily sadness was was to harm themselves without wanting to die on that day using significant (g¼0.84, t¼1.91, p¼0.03, OR¼2.33). a 5-point Likert scale (0¼not present,4¼very severe). This vari- To follow up this significant interaction, we plotted estimated able was not normally distributed (skew¼5.04, kurtosis¼26.61). means for individuals high (þ1 S.D.) and low (1 S.D.) in Therefore, we created a dichotomous variable such that 0¼no negative urgency for days high (þ1 S.D. for the sample) and NSSI urge and 1¼some NSSI urge for that day. We also measured low (1 S.D. for the sample) in sadness. We also ran simple whether or not participants had engaged in NSSI that day. Over slopes tests to see if daily sadness predicted the probability of the study period, there were only nine incidents of NSSI, which NSSI urge for individuals high (þ1 S.D.) and low (1 S.D.) in was too low of a frequency to be used in analyses. negative urgency (Preacher et al., 2006). As shown in Fig. 1, for individuals high in negative urgency, daily sadness was a sig- 2.3. Procedures nificant predictor of NSSI urge (g¼1.37, t¼3.71, p o0.001, OR¼3.93). In contrast, for individuals low in negative urgency, All procedures were approved by the university’s Institutional daily sadness was not significantly related to NSSI urge (g¼0.32, Review Board. After providing informed consent, participants com- t¼0.77, p¼0.44, OR¼1.37). Since daily sadness was centered pleted the impulsivity assessment and received instructions for the within-subject, this indicates that for individuals with high levels daily diary portion of the study. The daily portion consisted of a total of negative urgency, higher levels of daily sadness for that person of 14 days of ratings that began the Monday after the impulsivity increase the probability of having an urge to engage in NSSI. Per assessment. Participants received an email at approximately 7 p.m. request from an anonymous reviewer, we examined the interac- each evening which allowed them to access the daily survey on a tion between negative urgency and each NA item on the PANAS, secure website. Participants had until 9 a.m. the following morning in 10 separate analyses. The interaction was only significant in for to complete the questions. Participants were given course credit for two items, upset and afraid. For upset, the interaction was similar compensation. To encourage compliance, participants were given to that of daily sadness (i.e., more urge for NSSI on higher upset additional credit for completing at least 11 days. Participants days, for high urgent people). The pattern was the opposite for completed an average of 11.06 days (S.D.¼2.63) of ratings. afraid (i.e., less NSSI urge on high fear days, for high urgent people).

3. Results 4. Discussion Six participants did not complete ratings on any days and were not used in the analyses. Participants not included in the analysis The primary goal of this study was to test the interaction between did not signiﬁcantly differ from those included in the analysis on trait negative urgency and daily NA (both general and speciﬁc) in the negative urgency, t (65)¼1.56, p¼0.12. The remaining partici- prediction of urge to engage in NSSI. We predicted that high levels of pants reported 613 data points. On average, participants reported NA would be related to the increased probability of urge to engage in the urge to engage in NSSI on 1.20 days (S.D.¼2.02). In total, there NSSI, but more so for those high in negative urgency. This prediction were 74 reports of some urge to engage in NSSI. was supported for daily sadness, but not daily NA or guilt. These

individuals with a history of NSSI might perform more impul- 0.14 High Negative Urgency (+1 SD) sively on behavioral tasks while experiencing sadness, as opposed 0.12 to other affective states. Future research on the role of behavioral Low Negative Urgency ( -1 SD) impulsivity in NSSI could beneﬁt from designing studies which 0.1 examine behavioral measures of impulsivity in the context of 0.08 affective states (e.g., priming manipulations; Bresin et al., 2012).

0.06 4.3. Implications for assessment and treatment of nonsuicidal 0.04 self-injury Probability of NSSI Urge Probability 0.02 Clinically, our results may suggest that the assessment of 0 negative urgency is important when assessing risk for future Low Sad Day (-1 SD) High Sad Day (+1 SD) NSSI, as it is connected to a precursor to NSSI (urges to engage in NSSI). Also, clinicians may ask clients to be particularly vigilant Fig. 1. Probability of nonsuicidal self-injury urge as a function of negative urgency and daily sadness. of sad emotional states (e.g., via self-monitoring) as these states appear to be associated with greater risk for NSSI urges. In terms of treatment, individuals who engage in NSSI who are high in results may have interesting theoretical and clinical implications negative urgency may benefit from treatment approaches for the relationships between NSSI and impulsivity. designed to decrease sadness. For example, the emotion regulation module of Dialectical Behavior Therapy (Linehan, 1993) 4.1. Implications for nonsuicidal self-injury as affect regulation encourages clients to act opposite to their feelings (e.g., watch a funny movie as opposed to a sad movie when feeling sad). This The results of this study are compatible with some aspects type of intervention could decrease momentary sadness and thus of the affect regulation function of NSSI (e.g., Chapman et al., 2006). potentially reduce the urge to engage in NSSI for individuals high The significant main effect of daily NA and sadness indicates that the in negative urgency. urge to engage in NSSI is higher on days where individuals experience higher negative emotion, which is in line with previous research that suggests NSSI is likely to occur during periods of high 4.4. Limitations and strengths NA (Muehlenkamp et al., 2009; Nock et al., 2009). Further, our results extend previous research by showing specific NA states Our results should be considered in light of this study’s (sadness) may be more related to NSSI urge among certain indivi- limitations. The outcome measure in our study was the urge to duals (those high in negative urgency). engage in NSSI rather than actual NSSI engagement. Thought this It is interesting that daily sadness, but not guilt or NA, was may be a limitation, precursors of maladaptive behaviors have related to NSSI urge for those high in negative urgency. Because been the focus of research in other areas of psychopathology and sadness represents a lower arousal form of NA, one possible thus may also be useful within the area of NSSI as well. For interpretation of the results is that feelings of deactivated dis- example, urges and cravings for substance use (Berkman et al., pleasure are a risk for the urge and engagement in NSSI. Another 2011; Ferriter and Ray, 2011) are often targets of treatments interpretation is that sadness may be related to the urge to aimed at reduction of actual substance use behavior (Florsheim engage in NSSI, but not the act itself. In fact, Nock et al. (2009) et al., 2008; Loeber et al., 2006). An additional limitation is our found that sadness negatively predicted engaging in NSSI. Due reliance on impulsivity assessed through self-report. Future to the fact that sadness is a deactivated emotion, when individuals studies may benefit from the inclusion of behavioral impulsivity high in negative urgency experience sadness they may feel the urge measures as well. Another limitation is that our sample was to engage in NSSI, but lack the drive or motivation to actually do so. college undergraduates. In spite of the fact that we recruited On the other hand, it may be that when individuals high in negative individuals who engaged in NSSI in the last year, it is likely that urgency experience high arousal NA states they may move from the range of psychopathology was lower in this sample than a feeling to behavior very quickly, essentially bypassing urge. Hence, purely clinical sample. Finally, due to the daily nature of our arousal may differentiate urge and behavior. It may also be that design, daily affect and NSSI urge are confounded by day. There- another personality trait, such as lack of premeditation may play a fore, the temporal order of affect and NSSI urge is difficult to infer role in making the transition from urge to behavior (e.g., Glenn and from this study. Future research may address these limitations by Klonsky, 2010). Unfortunately, due to the low rate of NSSI during the recruiting samples with a higher base rate of NSSI and using study period, we were not able to test these predictions in this multiple affect and behavior assessments within a single day study. Future research investigating these hypotheses may serve to reveal the temporal order of the emotional state and NSSI to further clarify the relationship between different types of NA and relationship. NSSI urges and behaviors. In spite of these limitations, this study is to date the strongest test of trait by state NSSI models. Since negative urgency was 4.2. Implications for research on impulsivity and nonsuicidal measured before NSSI urge, our design is an improvement over self-injury cross-sectional designs. In addition, by assessing affect over a short time period (i.e., 1 day), we decreased the extent of retro- Our results may help explain the inconsistent relationship spective bias inherent in some previous studies with longer recall between impulsivity and NSSI across behavioral and self-report periods (e.g., Klonsky, 2009). This study expanded upon previous measures (Glenn and Klonsky, 2010; Janis and Nock, 2009). Given EMA NSSI studies (e.g., Muehlenkamp et al., 2009; Nock et al., that negative urgency appears to be the impulsivity trait asso- 2009) by examining trait by state interactions. Finally, this study ciated with NSSI, it appears import to take into account the measured affect and NSSI urge in the participant’s natural moderating role of affect when considering the relationship environment which should lead to higher external validity than between NSSI and impulsivity. Our results may imply that studies taking place solely in a laboratory.

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