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. Author manuscript; available in PMC: 2023 Jan 1.
Published in final edited form as: Death Stud. 2021 Sep 6;46(10):2477–2484. doi: 10.1080/07481187.2021.1972366

Emotion regulation deficits across the spectrum of self-harm

Rebekah Clapham 1, Amy Brausch 1
PMCID: PMC9554899  NIHMSID: NIHMS1839398  PMID: 34486924

Abstract

Suicide and non-suicidal self-injury (NSSI) are prevalent in emerging adulthood and one possible commonality is emotion regulation deficits. Participants (N = 708) completed multiple self-report measures that assessed emotion regulation deficits, depression, past-year NSSI frequency, past-year suicide attempts, and recent suicide ideation severity. Controlling for depression, linear regression analyses found that the only significant association was between greater deficits in emotion regulation strategies and greater recent NSSI frequency and suicide ideation intensity. These results suggest some commonality in emotion regulation deficits across NSSI and suicide ideation. Prevention and intervention efforts should teach emotion regulation strategies to lower self-harm risk.

Suicide is a major public health concern worldwide, with close to 800,000 people dying by suicide each year (WHO, 2020). In the United States, suicide ranks as the 10th leading cause of death for all ages, and the second leading cause of death for ages 10–34 (Hedegaard et al., 2018). Non-suicidal self-injury (NSSI), defined as the direct, deliberate destruction of body tissue without suicidal intent (Nock & Favazza, 2009), and suicide thoughts occur in especially high rates amongst high school and college students (Brausch & Woods, 2019; Muehlenkamp et al., 2013). Studying the full spectrum of self-harm behavior is essential since both NSSI and suicide ideation are associated with risk of future suicide attempts (Nock et al., 2006). One possible commonality amongst NSSI, suicide thoughts, and suicide behavior is emotion regulation (ER). Deficits in emotion regulation are common in NSSI, but less understood in the context of suicide ideation and attempts (Anestis et al., 2013; Chen & Chun, 2019; Pisani et al., 2013). Examining how specific ER deficits associate with each self-harm behavior will improve our understanding of these relationships, as well as refining prevention and intervention efforts.

Emotion regulation (ER) refers to the process of how we influence, express and experience our emotions (Gross, 1998). While coping can be defined as the processes we use to respond to stressors, ER more broadly refers to responses to both stressful and nonstressful circumstances; thus, coping can be a type of ER (Gross, 2015; Kopp, 1989). ER naturally serves as a protective factor against maladaptive thoughts, feelings, and behaviors; it is the absence of ER, or ER deficits, that lie at the root of most emotional disorders (Bullis et al., 2019). Past research demonstrates that there are strong associations between general ER deficits and self-harm outcomes, even after accounting for depressive symptoms (Rajappa et al., 2012; Slee et al., 2008; Wolff et al, 2019). To better understand ER deficits, they have been broadly conceptualized across six dimensions: lack of awareness of emotions (Awareness); lack of clarity about emotions being experienced (Clarity); non-acceptance of emotional distress (Non-acceptance); acting impulsively in response to negative emotions (Impulse); inability to pursue goals when emotionally distressed (Goals); and perceived lack of access to effective regulatory strategies for distress (Strategies) (Gratz & Roemer, 2004). Many past studies have examined total ER deficits in relation to self-harm behaviors (e.g., Hemming et al., 2019; Wolff et al., 2019), but examining relations with specific deficits may reveal commonalities and/or differences across the self-harm spectrum. Additionally, it is critical to understand how ER deficits fit within the context of recent NSSI and suicidal thoughts and behaviors in order to tailor prevention and early intervention efforts to improve effectiveness.

Past research has suggested that ER deficits may have different relationships with the varying types of self-harm. Specifically, in relation to NSSI, the Experiential Avoidance model (EAM) suggests that individuals engage in NSSI when they experience strong, negative emotions, and have poor ER skills (Chapman et al., 2006). This model has been supported by studies that found associations between multiple subscales of the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) and NSSI (e.g., Chen & Chun, 2019). In contrast, other studies have only found the lack of access to ER strategies subscale to associate with NSSI (Perez et al., 2012). Wolff and colleagues (2019) conducted a meta-analysis of emotion regulation and NSSI and found that there were consistent associations between lack of regulation strategies, non-acceptance of emotional response, and difficulties with impulse control and goal-directed behavior with NSSI history, while there were less strong associations between NSSI and lack of emotional awareness and clarity. The majority of the studies (37/48) assessed lifetime NSSI and only half of studies accounted for NSSI frequency. A handful of studies (n = 5) assessed recent NSSI (within at least the past 12 months) in community samples; small to medium effect sizes (OR = 1.68) were found for the relationship between greater ER deficits and more recent NSSI compared to lifetime NSSI. While these findings consistently link ER deficits to NSSI, most studies have used the total scale from the DERS, and the few studies to examine individual subscales show mixed results. These limitations, plus the lack of data on recent NSSI in lower-risk samples, highlight the need for further research to clarify relationships between NSSI and each ER deficit.

In addition to strong ties to NSSI, ER deficits are linked to suicide ideation after controlling for depression (Rajappa et al., 2012), although this relationship is less clear. Greater ER deficits are associated with more severe suicide ideation in some studies (Muehlenkamp et al., 2013; Rajappa et al., 2012; Weinberg & Klonsky, 2009), while other studies report only moderate associations (Anestis et al., 2013). Less is known about relationships between specific ER deficits and suicide ideation. A recent meta-analysis by Hemming and colleagues (Hemming et al. 2019) found a strong association between alexithymia (difficulty identifying and describing feelings) and suicide ideation. However, this meta-analysis only included studies that assessed ER deficits through measures for alexithymia; consequently, the meta-analysis excludes a large body of work that assesses other aspects of ER. Other studies that have examined suicide ideation in relation to the multidimensional aspects of ER report varied results. Some studies found that lacking access to ER strategies is specifically tied to suicide ideation (Rajappa et al., 2012), while others found low emotional clarity is strongly associated with suicide ideation (Neacsiu et al., 2018). Additionally, 85% of the studies included in the meta-analysis (Hemming et al., 2019) utilized clinical samples, which limits understanding of how multiple aspects of ER may be tied to current suicide ideation in lower-risk young adults. Identifying relevant ER deficits that strongly associate with suicide ideation in this population will inform prevention and early intervention programs.

Hemming and colleagues (2019) also found a consistent link between ER deficits and suicide attempts, yet this association was weaker than the association they found with suicide ideation. However, as with NSSI and suicide ideation, past researchers have found ER deficits to be linked to suicide attempts beyond depression, suggesting a strong link between the two (Neacsiu et al., 2018). Further in line with suicide ideation, past research ties lack of emotional clarity and effective strategies directly to suicide risk (Pisani et al., 2013). However, individuals with suicide attempt history tend to report more difficulties with general regulation of emotion when compared to individuals with suicide ideation. Additionally, past researchers found impulsivity to be predictive of suicide attempts but not suicide ideation (Neacsiu et al., 2018). Thus, it is possible that individuals with suicide attempt history may have different, and potentially more significant, relationships with multiple dimensions of ER deficits than those with suicide ideation, yet the specifics of these individual relationships are unclear. However, these studies were limited in that they either assessed lifetime history of suicide attempts (Neacsiu et al., 2018), or only used two subscales of the DERS to assess ER deficits (Pisani et al., 2013).

While past research has demonstrated general associations between ER deficits and NSSI, suicide attempts, and suicide ideation (Hemming et al., 2019; Neacsiu et al., 2018; Wolff et al., 2019), there remain gaps in the literature. Specifically, few studies examine the full spectrum of recent self-harm in a non-clinical sample (Hemming et al., 2019; Wolff et al., 2019). Additionally, a significant number of existing studies examining ER deficits and NSSI do not account for frequency of NSSI (Wolff et al., 2019). Lastly, there are mixed findings on the associations between specific ER deficits and suicide thoughts and behaviors (Brausch & Woods, 2019; Pisani et al., 2013; Rajappa et al., 2012). Understanding how specific ER deficits relate to suicide attempts and self-harming thoughts and behaviors may help predict and prevent future self-harm (Ribeiro et al., 2016).

The current study sought to expand on past research by assessing the relationships between dimensions of ER deficits and recent NSSI, suicide ideation, and suicide attempt history (Hemming et al., 2019; Neacsiu et al., 2018; Wolff et al., 2019). We predicted that more overall difficulty with ER would be associated with more frequent past-year NSSI engagement, greater likelihood of past-year suicide attempts, and more intense current suicide ideation. Another goal was to examine if certain ER deficits would be differently associated with NSSI, suicide ideation, and suicide attempts. We predicted that deficits in the strategies, non-acceptance, impulse, and goals dimensions of ER would be most strongly associated with past-year NSSI, and deficits in the awareness, strategies, and clarity aspects of ER would be most strongly associated with past-year suicide attempts and recent suicide ideation.

Method

Participants

Participants were 708 undergraduate students recruited from a public university in the south-central United States. We recruited them through the university’s psychology on-line study board, which required them to be 18 or older and fluent in English. The mean age of the sample was 21.25 (SD = 8.79) with a range of 19 to 54 years. Most were women (76.5%), heterosexual (84.3%), and white (82.2%); 11.4% identified as Black/African American, 4.3% as multi-ethnic, 4.9% as Asian, and 1% as other.

Procedure

Students seeking course credit in psychology courses could choose to participate in a study titled “College Student Health and Mental Health.” The research protocol was through a secure survey platform (Qualtrics; Millisecond Software, 2015). Participants who provided informed consent proceeded to complete a series of measures. If participants indicated a recent suicide attempt or ideation, a pop-up window appeared with information about national and local crisis services. They had to acknowledge that they had read the information before proceeding with the study. Upon completion of the survey, participants received a list of mental health resources as part of the debriefing process. Participants received course credit as compensation for study participation. The study received approval from the University’s Institutional Review Board. Confidentiality was maintained using identification numbers in place of participant names.

Measures

Emotion regulation

The Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) is 36 questions about multiple aspects of ER difficulties. The measure yields a total score and 6 subscale scores: non-acceptance of emotional response, lack of emotional awareness, difficulties engaging in goal directed behavior, impulse control difficulties, limited access to ER strategies, and lack of emotional clarity. Responses are on a 5-point scale from almost never (1) to almost always (5); 11 items are reverse scored. Items are summed for subscale and total scores and higher scores indicate greater difficulties with regulating emotion. This scale has been found to be psychometrically sound and a valid tool for assessing ER difficulties (Victor & Klonsky, 2016). Internal consistency for the total score (α = 0.96) and individual subscales (αs = 0.81–0.91) in the current sample were good.

NSSI frequency

The Inventory of Statements about Self-Injury (ISAS; Klonsky, & Glenn, 2009) assesses past-year and lifetime frequency of NSSI across multiple methods such as cutting, biting, and burning. Total frequency of past-year NSSI was obtained by summing frequencies across all NSSI methods. This scale has been found to be psychometrically sound and a valid tool for an assessment of self-injury (Glenn & Klonsky, 2011).

Suicide ideation and depressive symptoms

To assess suicide ideation, item 9 from the Beck Depression Inventory (BDI; Beck et al., 1961) was used. The response options range from 0 to 3, ranging from I don’t have any thoughts of killing myself (0) to I would kill myself if I had the chance (3). Several studies have used this item to assess suicide ideation (e.g., Hintikka et al., 2004; Kaltiala-Heino et al., 1999; Loas et al., 2016). The full BDI is 21 items and assesses current depressive symptoms. Item 9 was not included in the total score, and the remaining 20 items were summed. The BDI has been found to be psychometrically sound and a valid tool for an assessment of depression (Beck et al., 1996). Internal consistency for the 21-item scale in the current sample was good, α = 0.95; for the 20-item scale α = 0.93.

Suicide attempts

Past-year suicide attempts were assessed with one item and coded into a dichotomous variable (no = 0, yes = 1).

Data management/analytic plan

All variables had normal distributions except for the past-year NSSI frequency (skew = 12.24, kurtosis = 172.26), for which we used a log10 transformation, which improved the distribution (skew = 0.131, kurtosis = −0.655). To control for Type 1 error, we adjusted the p-value to <.01. No multicollinearity was present.

Results

Over 17% (n = 123) of participants reported engaging in NSSI in their lifetime, and 7.9% (n = 56) reported NSSI within the last 12 months (46% of those with lifetime NSSI reported past-year NSSI). The most common NSSI method was cutting (75%), and 83% of these participants reported engaging in cutting multiple times in their lives. Raw lifetime NSSI frequency ranged from 1–674, with a mean of 73 (SD = 136.56) and a median of 20. In the overall sample, 29 participants (4%) reported at least one past-year suicide attempt. Almost 22% reported any recent suicide thoughts; 18.4% reported low intent and 3.5% reported intent to kill themselves. The mean score from the BDI was 10.25, 67.8% were in the non-depressed range (<13), 15.4% were in the mildly dysphoric range (13–19), and 16.8% were in the dysphoric range (≥20); these values align with normative data from college samples (Whisman & Richardson, 2015). See Table 1 for means, standard deviations, and correlations between all study variables.

Table 1.

Descriptives and correlations between depression, DERS subscales, and self-harm outcomes.

Mean (SD) 1 2 3 4 5 6 7 8 9 10
1. Awareness 15.98 (5.38) 1 .15** .17** >.01 .19** .50** .10** .22** .07 .30**
2. Impulse 12.55 (5.27) 1 .58** .52** .73** .46** .06 .28** .13** .46**
3. Non-acceptance 14.10 (6.35) 1 .52** .71** .51** .08* .30** .14** .49 **
4. Goals 14.95 (5.03) 1 .66** .30** .03 .24** .08** .37**
5. Strategies 18.39 (7.62) 1 .52** .13** .44 ** .18** .60**
6. Clarity 12.44 (4.35) 1 .13** .30** .12** .50**
7. NSSI Frequency  4.14 (33.11) 1 .36** .27** .31**
8. Suicide Ideation   0.27 (0.57) 1 .39** .59**
9. Suicide Attempts 4% 1 .24**
10. Depression 10.25 (10.04) 1
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*

p < .05,

**

p < .01.

ANOVAs tested for differences on all study variables by gender. Women had significantly higher scores for NSSI frequency, depression symptoms, and four of the six ER subscales (no differences for the awareness and impulse subscales). There was no gender difference for suicide ideation or past-year suicide attempts. We included gender and depression as co-variates in all subsequent analyses.

To see if greater ER deficits would associate with greater past-year NSSI frequency, we used a linear regression. The overall model was significant, F(8, 700) = 13.58, p < .001), and accounted for 13.4% of the variance. After controlling for depression and gender, the only significant association was between the strategies subscale of the DERS and NSSI (β = 0.009, t = 2.85, p = .004).

To see if greater ER deficits would associate with recent suicide ideation, we used another linear regression. The overall model was significant, F(8, 700) = 52.43, p <.001, and accounted for 36.7% of the variance. After controlling for depression and gender, the strategies subscale of the DERS was again the only subscale significantly associated with suicide ideation (β = 0.021, t = 5.03, p < .001).

To see if greater ER deficits would associate with greater likelihood of past-year suicide attempts, we used a third linear regression. The overall model was not significant, χ2(6) = 6.34, p = .39 (see Table 2).

Table 2.

Linear and logistic regression results for emotion regulation deficits predicting self-harm outcomes.

Outcome: past-year NSSI
DERS subscales   β   t p
Awareness   .005   1.947   0.05
Non-acceptance −.002   −.709   0.48
Goals −.002   −.716   0.47
Impulse −.007 −1.91   0.05
Strategies   .009   2.853   0.004*
Clarity −.001   −.304   0.76
Outcome: suicide ideation   β   t p
Awareness   .005   1.431   0.15
Non-acceptance −.006 −1.521   0.13
Goals −.008 −1.761   0.08
Impulse −.009 −1.98   0.05
Strategies   .021   5.029 <0.001*
Clarity −.004   −.729   0.47
Outcome: past-year suicide attempt   B   OR p
Awareness −.001   0.99   0.99
Non-acceptance −.005   0.99   0.92
Goals −.130   0.88   0.05
Impulse   .026   1.03   0.62
Strategies   .097   1.10   0.05
Clarity −.023   0.98   0.71
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Note. DERS subscales are from the difficulties with emotion regulation scale.

*

Adjusted p-value for significance is p < .01.

Discussion

The current study provides evidence for the different associations between individual ER deficits with recent NSSI and suicide thoughts and behaviors. Overall, study results support the possibility of unique associations between aspects of emotion regulation deficits with more frequent NSSI engagement, as well as more intense suicide ideation among college students. Recent suicide ideation and past-year NSSI were only significantly associated with lack of access to ER strategies. Depression accounted for much of the variance in the associations between ER deficits and both past-year NSSI and current suicide ideation, but lack of ER strategies contributed unique variance above and beyond the effects of depression, and thus seems to be a consistent and persistent ER deficit linked to NSSI and suicide ideation. There were no significant associations between the ER deficits subscales and past-year suicide attempts. Overall, these findings demonstrate connections between self-harming thoughts and behaviors and ER deficits, which aligns with past studies (Hemming et al., 2019; Wolff et al., 2019). Significant associations between ER deficits and recent self-harm in the current study augments existing literature on these relationships with lifetime self-harm, suggesting a potential long-term, persistent relationship between ER deficits and self-harm. Thus, without development of ER skills, individuals may be at heightened risk for self-harm thoughts and behaviors when they experience distress.

The unique association between deficits in ER strategies and increased past-year NSSI engagement suggests that lack of access to emotion regulation strategies may contribute to individuals utilizing NSSI behaviors as a continuous coping substitute. People who self-harm often use intentional self-injury as a means to regulate emotions by decreasing negative affect and increasing positive affect when access to ER strategies are slim or unavailable (Hamza & Willoughby, 2015). The results of the current study replicate past findings that show a strong association between lack of ER strategies and NSSI (Wolff et al., 2019), and add to the literature by demonstrating this association with recent NSSI frequency. Furthermore, the current study extends on prior studies by showing that ER strategies associate with NSSI frequency above and beyond the effects of depression. However, prior research suggests that NSSI is also associated with other ER deficits related to awareness, goals, clarity, non-acceptance, and impulse control, after accounting for depression (Rajappa et al., 2012; Slee et al., 2008; Wolff et al., 2019). It is possible that ER strategies are more reliant on other ER skills being sufficient, such as acceptance and impulse control. For example, it may be harder to implement self-regulation skills if one cannot resist initial impulse actions, or accept that they are feeling upset. It is also possible that these specific ER deficits may be linked to NSSI by increasing depression symptoms. The relationships amongst these subscales should be further examined in future research.

Lack of access to ER strategies was also uniquely associated with suicide ideation above and beyond depressive symptoms. Prior research has found that suicide may be viewed as the salient solution to one’s problems when other strategies are lacking (O’Connor & Kirtley, 2018). In addition, past researchers found that endorsement of fewer adaptive strategies for negative emotions and more maladaptive responses were strongly associated with suicide ideation (Hemming et al., 2019). However, similarly to NSSI, past research has found more links between ER deficits and suicide ideation, including lack of emotional clarity and acceptance of emotions (Neacsiu et al., 2018). The current study expands on the link between ER deficits and suicide ideation by highlighting the unique and relevant role of lacking access to ER strategies in the severity of current suicide ideation in a non-clinical sample. This finding suggests that in order to reduce on-going thoughts of suicide, intervention and prevention plans should focus specifically on helping individuals develop a strong skillset of ER strategies. Dialectical Behavior Therapy (DBT; Linehan, 2014) is one existing evidence-based treatment that includes modules on building distress tolerance and emotion regulation skills, and other suicide-focused treatments such as Brief Cognitive-Behavioral Therapy for Suicide Prevention (BCBT; Bryan & Rudd, 2018) and the Collaborative Assessment and Management of Suicidality (CAMS; Jobes, 2016) incorporate a focus on building alternative coping skills.

The lack of relationship between any of the ER deficits with past-year suicide attempt status was not surprising considering the relatively small number of individuals with past-year suicide attempts (n = 29). However, these findings are inconsistent with past research. Previous studies have demonstrated that those who are more at risk for suicide have trouble finding ways to cope with their emotions and that individuals who attempt suicide multiple times have more trouble with affect regulation than people who attempt suicide only once (Klonsky & Muehlenkamp, 2008). Prior research has also found a strong link between the emotional clarity and impulsivity subscales with suicide attempts after controlling for depression (Neacsiu et al., 2018). Additionally, deficits in strategies may indicate a lack of problem-solving abilities. When individuals do not know what else to do in the midst of distress and have no strategies, suicide attempt may be more likely (Pisani et al., 2013). Hemming et al. (2019) found a moderate association between lifetime suicide attempts and difficulties in identifying and describing feelings, which are similar to the lack of emotional awareness and clarity subscales from the DERS. However, the current study assessed past-year suicide attempts, while the majority of previous studies have assessed lifetime; thus, it could be that ER deficits are not as relevant to recent attempts. It is also possible that the current study had too low of a base rate of suicide attempts and power to detect relationships with ER deficits.

These differences in findings could also be explained by the fact that previous studies investigating this topic have used clinical samples with greater severity (e.g., those diagnosed with mood disorders, history of self-harm, or past suicide attempts), while this study used an undergraduate community sample. While this study used a cross-sectional design, previous studies have looked at the longitudinal relationships between ER deficits, NSSI, and suicide ideation and attempts and found more associations than the current study, suggesting that clinical samples represent greater severity in both ER deficits, and self-harm thoughts and behaviors (Glenn & Klonsky, 2011). The current study shows that some ER deficits are emerging as highly relevant to suicide ideation and NSSI even in a low-risk sample and may be key targets for prevention and early intervention efforts.

There are some study limitations that are necessary to address. First, the sample was primarily white, female, heterosexual, and homogenous in age. Although this sample may be representative of certain college populations, results are not generalizable to more diverse groups. The lack of diversity in terms of race/ethnic and sexual orientation is problematic because it further contributes to the underrepresentation of these groups among suicide and self-NSSI research (Boehmer, 2002; Rockett et al., 2010). Further, because past studies found these groups are at heightened risk of suicide and NSSI (Bostwick et al., 2014), it is important that future research includes these populations in studies that could highlight potential suicide prevention or intervention strategies. In addition, the base rates for NSSI, suicide ideation, and suicide attempts were low, which limited the range of clinical severity in the sample. Therefore, this study requires replication with a more diverse and clinical sample. Additionally, only a single item assessed suicide ideation and attempts, and only one model and measure assessed ER; future research should consider implementing multiple measures and multi-method assessment of ER and self-harm behaviors. The study utilized only self-report measures which could have influenced the results through response bias and memory issues. Further, past-year suicide attempts and NSSI were assessed retrospectively, while emotion dysregulation and suicide ideation were assessed currently; this difference in measurement precludes causal or directional interpretations of the findings. The cross-sectional design of the study also limits knowledge on the development of the relationships between ER deficits and self-harm outcomes. It is important that future research use longitudinal designs with measures consistent in time-frame to investigate directional and reciprocal relationships between ER deficits, NSSI, and suicide outcomes.

The current results provide evidence about associations between specific ER deficits across the spectrum of self-harm. Because there were not significant associations between all ER deficits and recent ideation, NSSI, and suicide attempts, this study suggests that relationships between ER deficits and recent self-harm thoughts and behaviors are complex and require further study. It may be that different ER skills serve different functions and therefore have different relationships with suicide and NSSI; thus, these relationships should be examined separately. The commonality of a lack of access to ER strategies relating to past-year NSSI and current suicide ideation suggests that intervention and prevention plans should focus on teaching people a myriad of ER skills. Prevention and intervention measures should include psychoeducation and practice of multiple ER strategies. Longitudinal studies may further demonstrate that focusing on ER skills early on will have protective effects for the development and continuation of suicide ideation and self-harm behavior.

Funding

This work was supported by the National Institute of Mental Health under Award Number [R15MH113045-1] and by the National Institute of General Medical Sciences under Award Number [P20GM103436].

Footnotes

Disclosure statement

The authors have no conflicts of interest to report.

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