Emotion Dysregulation and Coping Drinking Motives in College Women Terri L. Messman-Moore, PhD; Rose Marie Ward, PhD

Objectives: To examine emotion dysregulation as a predictor of coping drinking motives, alcohol consumption, and alcohol-related problems among college women. Methods: In the cross-sectional study, 424 college women completed confidential surveys assessing the variables of interest. Results: Structural equation models suggest an indirect relationship between emotion dysregulation and alcohol variables. Emotion dysregulation predicted drinking coping motives, and drinking motives predicted

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ates of heavy episodic drinking among young women are on the rise. In the past 25 years in the United States, the proportion of women aged 18-20 reporting heavy episodic drinking shifted from 1 in 5 to almost 1 in 3, and among those aged 21-23, rates nearly doubled from 20.3% in 1979 to 38.6% in 2006.1 The increase in heavy drinking among emerging adult women is particularly disturbing given its association with numerous negative consequences including physical injury2 and increased risk for sexual victimization.3 Furthermore, when both level of alcohol consumption and BAC (blood alcohol concentration) are considered, sex differences in negative consequences are more pronounced, with female college students at greater risk for negative consequences associated with symptoms of dependence including tolerance and an inability to limit drinking, as well as risk of personal harm such as blacking out, passing out, and injury.4 As rates of dangerous drinking patterns continue to rise among college women, it is important to identify factors motivating such use to intervene effectively. Previous studies suggest that young women tend to use alcohol (or drugs) to improve mood, reduce tension, cope with problems, or in-

Terri L. Messman-Moore, O’Toole Family Professor, Director of Clinical Training, Department of Psychology, Miami University, Oxford, OH. Rose Marie Ward, Associate Professor, Miami University, Department of Kinesiology and Health, Oxford, OH. Correspondence; Dr Messman-Moore; [email protected]

Am J Health Behav.™ 2014;38(4):553-559

both alcohol-related problems and heavy drinking. Conclusions: In college women, interventions which target emotion dysregulation may indirectly reduce alcohol consumption and alcohol-related problems via a decrease in coping drinking motives. Implications for future research will be discussed. Key words: coping drinking motives; emotion dysregulation; alcohol problems; college women Am J Health Behav. 2014;38(4):553-559 DOI: http://dx.doi.org/10.5993/AJHB.38.4.8

crease confidence, whereas young men tend to use alcohol or drugs for sensation seeking or to enhance their social status. 5-9 Young women appear to drink more than young men in the context of negative emotional states, such as when they are depressed or concerned about personal or academic problems,5 and are more likely to initiate heavy episodic drinking to escape or alleviate distress.8 The tendency to use alcohol to dampen negative affect or to cope may lead to alcohol-related problems for college women. For example, coping drinking motives explain more variance in negative alcohol-related outcomes for college women than for college men.10,11 Given that young women have a greater tendency to drink in the context of negative affect,9 it is critical to examine factors that may influence drinking to cope and subsequent problematic drinking patterns among them. Drinking to Cope with Negative Affect Compared to enhancement or social drinking motives, coping drinking motives are associated with more problematic outcomes.12 Individuals who endorse coping motives drink alone more often and have significantly more drinking problems.13,14 Furthermore, drinking to cope has direct effects on drinking problems even after controlling for level of alcohol consumption, unlike enhancement motives.7,14 College students who drink to cope have higher levels of alcohol consumption (eg, frequency of alcohol use and heavy episodic drinking), dependence symptoms, and experience more negative alcohol-related consequences.11,15,16

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Emotion Dysregulation and Coping Drinking Motives in College Women The central role of coping motives in alcohol-related problems is well-documented, although less is known about factors that influence such motives. There is a link between negative affect and coping drinking motives among college students,17 suggesting alcohol use can reduce tension and may function to regulate emotion.18 Impaired emotion regulation has been suggested as a mechanism underlying coping drinking motives, although it is rarely assessed explicitly. Instead, researchers infer that deficits in emotion regulation exist among individuals who report using alcohol to cope or reduce tension.19,20 Among college students, coping drinking motives explain the relationship between social anxiety and negative alcohol-related consequences,21 suggesting an emotion regulation function. Moreover among college students who experience social anxiety, women appear to drink to cope more frequently than do men.9 However, although an individual may report using alcohol to “cope,” “feel better,” or “reduce stress,” it does not necessarily mean that person has problems with emotion regulation. Emotion Regulation There is increasing evidence that problems with emotion regulation underlie numerous psychological disorders,22 including alcohol dependence.23 Emotion regulation is a multi-faceted construct, aspects of which may shift across contexts although emotion regulation is often assessed as a static factor that tends to be stable within individuals.22 Emotion regulation involves emotional awareness, clarity, and acceptance, as well as effective emotional expression and adaptive goaldriven behavior.24 Adaptive emotion regulation involves the flexible use of skills to modulate both positive and negative emotional experience, rather than controlling or eliminating unwanted emotions; thus, emotion regulation emphasizes one’s ability to inhibit inappropriate or impulsive behaviors, and behave in accordance with desired goals when experiencing negative emotions.24 In general, most self-report measures tend to assess emotion dysregulation as a trait22 given that emotion dysregulation remains stable for significant periods of time in the absence of intervention.25 Deficits in any single or multiple aspects of emotion regulation may result in maladaptive coping strategies to address negative affect. Despite the widely supported assumption that alcohol is used to regulate negative affect,13 and despite the widely-studied role of coping-related drinking motives in alcohol use, alcohol-related problems, and alcohol-related diagnoses, there are few studies available that specifically assess difficulties in emotion regulation as predictors of coping drinking motives and alcohol-related problems. Among college students, difficulties in emotion regulation are associated with higher levels of alcohol-related problems and higher levels of coping drinking motives, but not with levels of recent heavy drinking.26 Aspects of

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emotion dysregulation, such as experiential avoidance27 or negative mood regulation expectancies,18 have been linked to coping drinking motives; however, a more comprehensive and specific assessment of emotion regulation appears warranted. No studies are yet available that examine whether emotion regulation may influence coping drinking motives among college women, or how such factors impact college women’s alcohol use and alcoholrelated problems. Study Aims and Hypotheses The current study seeks to examine the link between emotion dysregulation and coping drinking motives, and to determine whether emotion dysregulation is indirectly related to alcohol-related problems and heavy drinking in college women via its association with coping drinking motives. In particular, it is hypothesized that emotion dysregulation will be associated with alcohol-related problems, and that this relationship will be mediated by coping motives. Given the paucity of research supporting a link between emotion dysregulation and drinking behavior (rather than alcohol dependence or alcohol-related problems), the relationship between emotion dysregulation and drinking behavior will be explored. However, coping drinking motives are hypothesized to predict drinking behavior as well as alcohol-related problems. METHODS Participants The sample of 424 college women was distributed across the 4 years of education (Freshmen N = 88, 19.4%; Sophomores N = 101, 22.3%; Juniors N = 100, 22.1%; Seniors N = 124, 27.4%). The average age of the participants was 19.78 (SD = 1.30). The sample was primarily Caucasian (N = 371, 81.9%), non-sorority members (N = 308, 68.0%), unmarried (N = 408, 90.1%), with highly educated fathers (college education and beyond, N = 312, 73.6%) and highly educated mothers (college education and beyond, N = 286, 67.5%), and was predominantly upper-middle class, with 46.2% (N = 196) of participants reporting a family income greater than $100,000. Procedure Participants were recruited from a mid-sized Midwestern university via the student newspaper and flyers on campus. All data were collected in group sessions in large classrooms staffed by one of the authors and 3-5 female research assistants. After completion of informed consent, participants were given a packet containing copies of the measures marked with a code number to maintain participant confidentiality. After returning the packet, participants were debriefed and paid $25. Measures Emotion dysregulation. The Difficulties in Emotion Regulation Scale24 (DERS) was used to

Messman-Moore & Ward assess emotion dysregulation. The DERS has 36 items on 6 subscales, with higher scores indicating greater emotional dysregulation. All items are scored on a 5-point Likert scale from 1 = “Almost never” to 5 = “Almost always” indicating how often the participant experienced the statement. The first subscale, Awareness (6 items), assesses a lack of emotional awareness indicated by the inability to attend to emotions (eg, “I am attentive to my feelings.” Reverse coded.). The second subscale, Clarity (5 items), indicates a lack of emotional clarity and assesses personal understanding of emotions (eg, “I have difficulty making sense out of my feelings.”). The third subscale, Nonacceptance (6 items), assesses the failure to accept feeling distressed (eg, “When I’m upset, I feel guilty for feeling that way.”). The fourth subscale, Impulse (6 items), assesses problems in the ability to control behaviors when experiencing negative affect (eg, “When I’m upset, I lose control over my behaviors.”). The fifth subscale, Strategies (8 items), reflects limited access to effective emotion regulation strategies to deal with negative emotions (eg, “When I’m upset, I believe that I’ll end up feeling very depressed.”). The sixth subscale, Goals (5 items), assesses difficulties accomplishing tasks when experiencing a negative emotion (eg, “When I’m upset, I have difficulty concentrating”). Internal consistencies for the 6 scales ranged from .91 (Nonacceptance and Goals) to .78 (Clarity) in the current sample. Coping drinking motives. The 5-item coping subscale of the Drinking Motives Questionnaire– Revised7 (DMQ-R) was used to assess drinking to cope (eg, “To forget your worries”). Participants indicated how often they drank due to coping motives using a 5-point Likert scale (1 = “Almost never/never” to 5 = “Almost always/always”). Higher scores indicated that they more often used alcohol to cope. The internal consistency for the coping motives scale was .86 in the current sample. Alcohol use and alcohol-related problems. Alcohol consumption was assessed using measures consistent with national studies of college student alcohol use (eg, CAS28). Participants were asked if they had ever consumed alcohol, how old they were the first time they consumed alcohol, their highest number of drinks consumed in a single drinking occasion in the last 30 days, and number of times in the last month that they had consumed 4 or more drinks in a row on one occasion. In addition, the first 3 items of the Alcohol Use Disorders Identification Test (AUDIT29) were utilized to form a latent construct of alcohol consumption: (1) How often do you have a drinking containing alcohol? (2) How many drinks containing alcohol do you have on a typical day when you are drinking? and (3) How often do you have 6 or more drinks on one occasion? These questions, also referred to as the AUDIT-C, show high levels of sensitivity and specificity in screening for alcohol dependence, any alcohol use disorder (AUD), and risky drinking.30 In the current sample, internal consistency reliability

was .80. Alcohol-related problems were assessed with the 23-item Rutgers Alcohol Problem Index (RAPI31). Participants indicated how many times in the past 3 years certain behaviors occurred due to their alcohol consumption (eg, “Not able to do your homework or study for a test”). Using a 5-point Likert scale from 0 = “Never” to 4 = “More than 10 times,” the scale is scored by summing the 23 items resulting in total scores which range from 0 to 69. Higher levels mean more problematic drinking tendencies. In the current sample, the internal consistency for the RAPI was .90.

Am J Health Behav.™ 2014;38(4):553-559

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RESULTS Preliminary Analyses The primary study variables and demographics were examined to determine if patterns of missing data existed. Only 5 to 9 participants had missing data for each of the variables. Patterns were not observed across the analyses suggesting that the data were missing at random. Descriptive Statistics Most individuals (87.6%, N = 397) indicated that they had previously consumed an alcoholic beverage. On average, their first drink occurred at 16.03 years old (SD = 2.01, range 6 to 21). During the last 30 days, their peak-drinking occasion was on average 5.67 standard drinks (SD = 4.30, range 0 to 30). The majority of participants (68.2%) reported heavy episodic drinking (consuming 4 or more drinks on at least one occasion) in the last month; 14.6% (N = 62) engaged in heavy episodic drinking once, 19.1% (N = 81) 2-3 times, 20.8% (N = 88) 4-6 times, and 13.7% (N = 58) 7 or more times. A significant minority, 29.8% (N = 135), denied heavy episodic drinking in the past month. Means, standard deviations, and correlations for study variables are in Table 1. Emotion dysregulation was positively associated with coping drinking motives, and coping drinking motives were positively associated with alcohol consumption and alcohol-related problems. All aspects of emotion dysregulation were positively associated with coping drinking motives, although aspects of emotion dysregulation were inconsistently related to alcohol-related problems and alcohol consumption. Difficulties in attaining goals and impulsive behavior difficulties when distressed were associated with higher levels of alcohol-related problems, whereas emotional nonacceptance and lack of emotion regulation strategies were not related to alcohol-related problems. Structural Equation Models The relationships between the constructs were assessed within a structural equation modeling framework using Mplus version 7.1132 and maximum likelihood estimation. The proposed models were based upon theoretical predictions and examined using the following criteria: (1) theoretical salience; (2) microfit indices (parameter estimates

http://dx.doi.org/10.5993/AJHB.38.4.8

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Emotion Dysregulation and Coping Drinking Motives in College Women

Table 1 Zero-order Correlations and Descriptive Statistics for Study Variables 1. 1. Nonacceptance

2.

3.

4.

5.

6.

7.

--

2. Goals

.32***

--

3. Impulse

.44***

.49***

--

4. Strategies

.56***

.55**

.70***

--

5. Coping motives

.17***

.25***

.25***

.31***

--

6. Alc-rel problems

-.03

.19***

.16**

.08

.52***

--

7. Alc Consumption

-.11*

.08

.06

.04

.42***

.62***

--

Mean

12.23

15.96

10.60

15.69

2.05

12.56

4.88

SD

5.75

5.00

4.29

6.44

.92

11.54

2.78

*p < .05; **p < .01; ***p < .001 Note. Difficulties in Emotion Regulation Scale subscales included Emotional Nonacceptance (Nonacceptance), Difficulties Attaining Goals (Goals), engaging in impulsive behavior when distressed (Impulse), and lack of emotion regulation strategies (Strategies); Alc-rel = Alcohol-related problems assessed with the Rutgers Alcohol Problem Index; Alcohol consumption was assessed with the first 3 items of the Alcohol Use Disorders Identification Test.

and residuals); (3) global fit statistics (CFI, TLI, chi-square, RMSEA); and (4) parsimony. To meet standards of theoretical salience, the model must be predicted from documented theory and previous research. For RMSEA, a fit of less than .05 will be taken to indicate a well-fitting model.33 For global fit indices, a non-significant chi-square indicates that the data do not significantly differ from the hypotheses represented by the model; for CFI and TLI, fit indices of above .90 (preferably above .95) will be the criteria utilized to indicate a well-fitting model (CFI34; TLI34). Requiring parsimony will lead to the retention of a model with the fewest parameters that still meets the other criteria. Measurement models of emotion dysregulation. Given the relative paucity of information on the factor structure of the DERS in college women, a series of exploratory factor analyses were performed. The primary model consisted of the 6 subscales loading on one latent structure (ie, a measure of global emotion regulation). The initial model fit the data, χ2(N = 424, 9) = 81.54, CFI = .91, TLI = .85, RMSEA = .14. Upon examination of the model, 2 subscales, Awareness and Clarity, did not perform well (loading .33 and .44 on the latent factor respectively). The second model tested a 2-factor hierarchical structure of the DERS. On the first factor Nonacceptance, Goals, Impulsive, and Strategies were grouped together whereas Awareness and Clarity were grouped on a separate factor. The second model fit the data well, χ2(N = 424, 8) = 27.10, CFI = .98, TLI = .96, RMSEA = .08. To examine a more parsimonious model, the final exploratory model examined the fit of a

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model trimming Awareness and Clarity. The third model fit the data well, χ2(N = 424, 2) = 1.40, CFI > .99, TLI > .99, RMSEA < .001. Due to the superior fit of the modified model, all subsequent models utilized the modified version of the DERS (trimming Awareness and Clarity). The current findings suggest that emotional awareness and clarity are not key components of the emotion dysregulation construct, at least among female college students. Two other studies35,36 have raised similar concerns about the awareness subscale of the DERS, noting that its lower association with the DERS total scale raises questions about its connection to the larger construct of emotion dysregulation. Hypothesized model. The primary goal was to consider theoretically-relevant and empiricallyidentified constructs to develop the proposed model that predicted alcohol-related problems and alcohol consumption. On the basis of the zero-order correlations (presented in Table 1) and theory, a model assessing the direct and indirect effects of emotion dysregulation on alcohol consumption and alcohol-related problems, via coping drinking motives, was proposed. The model (Figure 1) with the trimmed emotion dysregulation latent construct significantly predicted coping drinking motives. Coping drinking motives subsequently predicted alcohol problems and alcohol consumption; model fit statistics: χ2(N = 424, 23) = 110.46, CFI = .95, TLI = .92, RMSEA =.10, SRMR = .05. The mediation effects were evaluated in a singlestep model.37 For example, if the product (a*b) of the coefficients of a path between DERS and drinking to cope (a) and the path between drinking to

Messman-Moore & Ward

Figure 1 Difficulties in Emotion Regulation Predicting Coping to Drink, Drinking Problems, and Alcohol Consumption Rutgers Alcohol Problem Index

Nonacceptance of Emotional Responses Difficulties in Goal Directed Behavior Impulse Control Difficulties

-.05

.64*** .61**** .77***

Difficulties in Emotion Regulation

.89***

.51*** .46***

Coping Motives

.29***

How often do you have a drink containing alcohol?

.53*** -.18***

.78***

Limited Acces s to Emotion Regulation Strategies

Alcohol Consumption

.84***

How many drinks containing alcohol do you have on a typical day when you are drinking?

.93*** How often do you have six or more drinkings on one occasion?

***p

Emotion dysregulation and coping drinking motives in college women.

To examine emotion dysregulation as a predictor of coping drinking motives, alcohol consumption, and alcohol-related problems among college women...
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