Exploring the Link Between Emotional and Behavioral Dysregulation: A Test of the Emotional Cascade Model

Examining the relationship between subtypes of rumination and non-suicidal self-injury: A meta-analytic review

INTRODUCTION

Non-suicidal self-injury (NSSI) is a highly prevalent maladaptive behavior, often used to cope with intense negative affect. Rumination is an emotion regulation strategy that leads to fixation on and exacerbation of (typically) negative affective states. However, studies examining the relationship between rumination and NSSI have yielded mixed results, showing high degrees of heterogeneity.

METHODS

The present study conducted meta-analyses (k = 50) of the association between overall rumination and NSSI, and independent meta-analyses for each of four subtypes of rumination (general, depressive, brooding, reflection rumination). Potential moderators that may influence the magnitude of these relationships were also examined.

RESULTS

A small-to-moderate positive association between rumination and NSSI was found independent of rumination subtype. Moderating effects included NSSI outcome measure and study design for overall rumination and general rumination, respectively. Race was found to moderate the relationships between both brooding and depressive rumination and NSSI, though in inverse directions. An analysis of effect heterogeneity across studies suggested that undetected moderators may be present.

CONCLUSION

Results of this study support the relationships between rumination subtypes and NSSI and identify factors that may impact these relationships. Continued research is needed to understand this association, particularly in more varied subtypes of rumination and cognitive-affective moderators.

Assessment and Disruption of Ruminative Episodes to Enhance Mobile Cognitive Behavioral Therapy Just-in-Time Adaptive Interventions in Clinical Depression: Pilot Randomized Controlled Trial

BACKGROUND

A just-in-time adaptive intervention (JITAI) is "designed to address the dynamically changing needs of individuals via the provision of the type or amount of support needed, at the right time when needed." If and how rumination-focused cognitive behavioral therapy (RFCBT), the gold standard, blocks emotional cascades underlying rumination is unclear. Furthermore, cognitive behavioral therapy has been successfully used as a mobile variant, but RFCBT has not been adapted for a mobile variant (mobile RFCBT [MRFCBT]) or for a JITAI variant.

OBJECTIVE

This study aimed to pilot-test a fully automated JITAI leveraging RFCBT and ways to identify and block cascading depressive rumination.

METHODS

Patients in therapy for clinical depression were recruited for a randomized controlled trial (RCT). After consenting to be part of the RCT, they were randomly assigned to either of the 2 mobile versions of the RFCBT conditions personalized to the individual's rumination timing patterns (JITAI-MRFCBT) or a no-treatment control condition through a double-blind procedure. Although the initial design was to have a 3-armed trial with 2 JITAI conditions (a JITAI and a narrative JITAI condition), we later opted to collapse those 2 conditions into 1 JITAI condition because of the low number of participants. All participants were recruited and participated through their smartphones, receiving 5 SMS text message reminders on each of the 35 days to self-report their rumination-related symptoms (eg, rumination episodes and duration). In the JITAI-MRFCBT condition, they also received treatment materials. The first 7 days provided a rumination baseline, and the last 7 days provided a postintervention rumination value. In total, 42% (25/59) of volunteers were eligible and provided their phone numbers, 20% (5/25) of whom never replied to the SMS text message reminding them to start the RCT. A total of 90% (18/20) of volunteers completed it (ie, finishing, as prespecified, 80% of the questionnaires and training tasks) and, therefore, were included in the analysis.

RESULTS

Using independent 2-tailed t tests with bootstrapping, results showed that participants in the JITAI-MRFCBT condition, compared with those in the control condition, reported a greater reduction in counts of rumination episodes (mean -25.28, SD 14.50 vs mean 1.44, SD 4.12, P<.001) and greater reduced average time (minutes) spent in rumination (mean -21.53, SD 17.6 vs mean 1.47, SD 1.5; P=.04). Results also suggest that, compared with those in the control group, those in treatment reduced ruminative carryover from one episode to the next.

CONCLUSIONS

The results suggest that JITAI-MRFCBT may reduce negative rumination by providing RFCBT just in time following rumination, thereby blocking the next rumination episode using the same trigger. This study supports a subsequent, full-scale JITAI and the importance of leveraging mobile smartphone technology with MRFCBT to curb depressive symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04554706; https://clinicaltrials.gov/ct2/show/NCT04554706.

Nonsuicidal self-injury and rumination: A meta-analysis

Trait rumination is the tendency to overthink and focus on negative emotions and events and is related to a number of psychological disorders and maladaptive behaviors including nonsuicidal self-injury (NSSI). The purpose of this study was to conduct a meta-analysis of the relationship between trait rumination and NSSI behaviors. Results from 60 samples showed small effect sizes between trait rumination and NSSI engagement, NSSI frequency, and the number of methods used to self-injure in cross-sectional samples. Results from 13 samples showed small effect sizes between trait rumination and NSSI engagement and NSSI frequency in longitudinal samples. Moderator analyses indicated that this relationship is similar whether the type of rumination is depressive or not and is generally consistent across different ages, genders, and ethnicities. These results help clarify the role of trait rumination as a risk factor for NSSI.

Examining the role of brooding, distress, and negative urgency in dysregulated behaviors: A cross-sectional study in treatment-seeking young people

OBJECTIVE

Dysregulated behaviors including substance use, disordered eating, and nonsuicidal self-injury (NSSI) have significant negative implications for individuals and health systems. It is therefore paramount to understand factors influencing behavioral dysregulation, to inform prevention and treatment approaches. The literature suggests that distress and rumination (brooding) prompt individuals to engage in behavioral dysregulation for distraction (Emotional Cascade Model), although these concepts have limited investigation in clinical, treatment-seeking samples, particularly alongside negative urgency. This cross-sectional study sought to examine the relationships of brooding, distress, and negative urgency with behavioral dysregulation, as well as the moderating effect of negative urgency between brooding and behavioral dysregulation, in treatment-seeking young people.

METHOD

A total of 385 treatment-seeking young people completed cross-sectional, self-report measures of distress, rumination, negative urgency, and engagement in dysregulated behaviors (NSSI, alcohol use, drug use, binge eating, and purging) over the past 1-3 months.

RESULTS

Structural equation modeling revealed that only negative urgency, and not brooding or distress, had a significant positive relationship with behavioral dysregulation. Negative urgency did not significantly moderate the relationship between brooding and behavioral dysregulation.

CONCLUSIONS

These findings reinforce the importance of considering negative urgency in the conceptualization, prevention, and treatment of behavioral dysregulation, and contribute to the knowledge of the relationship between brooding and various dysregulated behaviors within a treatment-seeking sample.

Emotion Dysregulation as a Mediator of the Relationship between Anxiety, Compulsive Exercise and Eating Disorder Symptoms in Adolescents

Anxiety has been suggested to be a key contributing factor for compulsive exercise, however, existing literature has demonstrated contradictory relationships between anxiety and compulsive exercise among adolescents. According to the Emotional Cascade Model (ECM), factors such as rumination and emotional suppression may mediate the association between affect and exercise. The current study therefore aimed to investigate whether rumination and emotional suppression mediate the relationship between anxiety and compulsive exercise in predicting ED symptoms in adolescents. Questionnaires assessing compulsive exercise, anxiety, depressive rumination, emotional suppression, and ED symptoms were completed by 212 adolescent males (Mage = 13.39, SD = 1.22) and 189 adolescent females (Mage = 13.64, SD = 1.29). The structural equation model showed indirect effects between anxiety and compulsive exercise through rumination and emotional suppression in males but not in females. Moreover, anxiety had an indirect effect on eating disorder symptoms through rumination, emotional suppression and compulsive exercise in both males and females. In line with ECM, the results suggest that rumination and emotional suppression may have a key role in the association between anxiety, compulsive exercise and eating disorder symptoms in adolescents. These findings suggest that compulsive exercise may be used as a dysfunctional coping mechanism to escape from a negative emotional cascade generated by the interaction of anxiety, rumination and emotional suppression. Future longitudinal studies to test the role of compulsive exercise as a dysfunctional behaviour in the ECM are needed.

The relationship between rumination and NSSI: A systematic review and meta-analysis

BACKGROUND

Rumination is a cognitive process that has been implicated in the onset and maintenance of a variety of psychological difficulties. The purpose of this review and meta-analysis was to examine the nature and strength of the relationship between rumination and non-suicidal self-injury (NSSI).

METHODS

The protocol for this review was pre-registered (CRD42019148186). A literature search of electronic databases PsycINFO, CINAHL, MEDLINE, and Web of Science was performed from the earliest date available to March 2020. Thirty-nine eligible papers were identified. An additional seven papers were identified from a search conducted in September 2021, resulting in a total of 46 papers. Separate meta-analyses were undertaken for NSSI frequency and NSSI history, with studies grouped by rumination type (depressive, transdiagnostic, anger, brooding, reflection, catastrophising, overall). Moderator analyses were also conducted along with a narrative synthesis of adjusted associations and longitudinal studies.

RESULTS

Rumination had a positive small association with NSSI frequency and a positive moderate association with NSSI history. The adjusted associations yielded mixed findings and most longitudinal research found rumination to be associated with prospective NSSI.

LIMITATIONS

Most included studies had a moderate risk of bias and used a student sample. A limitation of this review was that only English language papers were included.

CONCLUSIONS

Findings indicate that rumination is associated with NSSI, but more so the likelihood of engaging in NSSI overall than the frequency. Rumination-focused techniques for NSSI may therefore be of benefit. Further research is needed to understand this association, particularly with longitudinal studies that focus on state rumination rather than stable trait rumination.

PRACTITIONER POINTS

Rumination was found to have a small to moderate association with NSSI. Some individuals who engage in NSSI may benefit from psychological techniques that target rumination. Most of the studies included had a moderate risk of bias.

Toward a unifying theory of dysregulated behaviors

Dysregulated behaviors, defined as active behaviors that have short-term benefits but cause serious recurrent long-term distress or impairment to the individual and/or those around them, include behaviors such as suicidal and nonsuicidal self-injury, aggression, and substance use. These behaviors are common and costly to the individual, their friends and family, and society. Despite similar etiological models and interventions, dysregulated behaviors have largely been studied in isolation from one another. The goals of this paper were to a) define dysregulated behaviors as a coherent class of behaviors, b) review the prevalence and consequences of dysregulated behaviors, c) outline how dysregulated behaviors fit into current models of psychopathology, and d) describe the key questions to be addressed by future research in this area. It is argued that integrating across theories of discrete dysregulated behaviors can help provide aid in the development of etiological models, which in turn can improve prevention and intervention for dysregulated behaviors.

Understanding Dysregulated Behaviors and Compulsions: An Extension of the Emotional Cascade Model and the Mediating Role of Intrusive Thoughts

Objective: The Emotional Cascade Model (ECM) by Selby et al. (2008) proposes that people often engage in dysregulated behaviors to end extreme, aversive emotional states triggered by a self-perpetuating vicious cycle of (excessive) rumination, negative affect, and attempts to suppress negative thoughts.

Method: Besides replicating the ECM, we introduced intrusions as a mediator between rumination and behavioral dysregulation and tested this extended ECM for compulsions as part of obsessive–compulsive disorders. A structural equation modeling approach was used to test this in a sample of N = 414, randomly recruited from the general population.

Results: Intrusions were found to fully mediate the effect of rumination on a broad array of dysregulated behaviors and compulsions. This mediation endured when controlling for symptoms of depression.

Conclusion: These findings support the idea that rumination fuels intrusions, which in turn foster dysregulated behaviors. Therefore, addressing rumination as well as intrusions may improve psychotherapeutic interventions for mental disorders characterized by dysregulated behaviors and/or extreme aversive emotional states.

Borderline Personality Disorder Symptoms in College Students: The Complex Interplay between Alexithymia, Emotional Dysregulation and Rumination

Both Emotional Cascade Theory and Linehan’s Biosocial Theory suggest dysregulated behaviors associated with Borderline Personality Disorder (BPD) emerge, in part, because of cycles of rumination, poor emotional recognition and poor emotion regulation. In this study we examined relationships between rumination, alexithymia, and emotion regulation in predicting dysregulated behaviors associated with BPD (e.g. self-harm, substance use, aggression), and explored both indirect and moderating effects among these variables. The sample comprised 2261 college students who completed self-report measures of the aforementioned constructs. BPD symptoms, stress, family psychological illness, and alexithymia exerted direct effects on behaviors. Symptoms had an indirect effect on behaviors through rumination, alexithymia and emotional dysregulation. In addition, the relationship between symptoms and dysregulated behaviors was conditional on level of rumination and alexithymia. Implications for early identification and treatment of BPD and related behaviors in college settings are discussed.

Anger rumination and aggressive behaviour in borderline personality disorder

BACKGROUND

Emotional instability and dyscontrolled behaviours are central features in borderline personality disorder (BPD). Recently, some cognitive dysfunctional mechanisms, such as anger rumination, have been found to increase negative emotions and promote dyscontrolled behaviours. Even though rumination has consistently been linked to BPD traits in non-clinical samples, its relationship with problematic behaviour has yet to be established in a clinical population.

AIM

The purpose of the study was to explore the relationships between emotional dysregulation, anger rumination and aggression proneness in a clinical sample of patients with BPD.

METHODS

Enrolled patients with personality disorders (93 with BPD) completed a comprehensive assessment for personality disorder symptoms, anger rumination, emotional dysregulation and aggression proneness.

RESULTS

Anger rumination was found to significantly predict aggression proneness, over and above emotional dysregulation. Furthermore, both BPD diagnosis and anger rumination were significant predictors of aggression proneness.

CONCLUSION

Future research should examine whether clinical techniques aimed at reducing rumination are helpful for reducing aggressive and other dyscontrolled behaviours in treating patients with BPD.

Bidirectional-Compounding Effects of Rumination and Negative Emotion in Predicting Impulsive Behavior: Implications for Emotional Cascades

Influenced by chaos theory, the emotional cascade model proposes that rumination and negative emotion may promote each other in a self-amplifying cycle that increases over time. Accordingly, exponential-compounding effects may better describe the relationship between rumination and negative emotion when they occur in impulsive persons, and predict impulsive behavior. Forty-seven community and undergraduate participants who reported frequent engagement in impulsive behaviors monitored their ruminative thoughts and negative emotion multiple times daily for two weeks using digital recording devices. Hypotheses were tested using cross-lagged mixed model analyses. Findings indicated that rumination predicted subsequent elevations in rumination that lasted over extended periods of time. Rumination and negative emotion predicted increased levels of each other at subsequent assessments, and exponential functions for these associations were supported. Results also supported a synergistic effect between rumination and negative emotion, predicting larger elevations in subsequent rumination and negative emotion than when one variable alone was elevated. Finally, there were synergistic effects of rumination and negative emotion in predicting number of impulsive behaviors subsequently reported. These findings are consistent with the emotional cascade model in suggesting that momentary rumination and negative emotion progressively propagate and magnify each other over time in impulsive people, promoting impulsive behavior.