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Am J Drug Alcohol Abuse. 2011 January ; 37(1): 37–42. doi:10.3109/00952990.2010.535582.

Emotion Regulation and Substance Use Frequency in Women

with Substance Dependence and Borderline Personality
Disorder Receiving Dialectical Behavior Therapy

Seth R. Axelrod, PhD1, Francheska Perepletchikova, PhD1, Kevin Holtzman, PsyD2, and
Rajita Sinha, PhD1
1 Yale University, School of Medicine, New Haven, CT

2 The Dialectical and Cognitive Behavioral Therapy Center, LLC, New Haven, CT

Abstract
Background—Dialectical Behavior Therapy (DBT) identifies emotion dysregulation as central
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to the dangerous impulsivity of borderline personality disorder (BPD) including substance use
disorders, and DBT targets improved emotion regulation as a primary mechanism of change.
However, improved emotion regulation with DBT and associations between such improvement
and behavioral outcomes such as substance use has not been previously reported.
Objective—Thus, the goal of this study was to assess for improvement in emotion regulation and
to examine the relationship between improvements in the emotion regulation and substance use
problems following DBT treatment.
Method—Emotion regulation as assessed by the Difficulties in Emotion Regulation Scale,
depressed mood as assessed by the Beck Depression Inventory, and their associations with
substance use frequency were investigated in 27 women with substance dependence and BPD
receiving 20 weeks of DBT in an academic community outpatient substance abuse treatment
program.
Results—indicated improved emotion regulation, improved mood, and decreased substance use
frequency. Further, emotion regulation improvement, but not improved mood, explained the
variance of decreased substance use frequency.
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Conclusions—This is the first study to demonstrate improved emotion regulation in BPD

patients treated with DBT and to show that improved emotion regulation can account for increased
behavioral control in BPD patients.
Significance and Future Research—Emotion regulation assessment is recommended for
future studies to further clarify the etiology and maintenance of disorders associated with
emotional dyregulation such as BPD and substance dependence, and to further explore emotion
regulation as a potential mechanism of change for clinical interventions.

Keywords
Emotion Regulation; Substance Dependence; Borderline Personality Disorder; Dialectical
Behavior Therapy

Please address correspondence and reprint requests to Seth Axelrod, Ph.D., Assistant Professor, Department of Psychiatry, Yale
University School of Medicine, 425 George Street, New Haven, CT 06511, [email protected].
This manuscript was presented in part at the 9th annual meeting of the International Society for the Improvement and Teaching of
Dialectical Behavior Therapy, New Orleans, LA, November 18, 2004.
 Axelrod et al. Page 2

Emotional regulation includes processes for amplifying, attenuating, or maintaining

affective responses. The capacity to regulate emotion has been identified as central to mental
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health, determining one’s capacity for working, relating to others, and enjoyment (1), and.
chronic difficulties in emotion regulation have been specifically implicated as the central
underlying pathology of the BPD (2). Specifically, interpersonal problems, impulsive
behaviors, and other BPD symptoms (e.g., suicidality, self-harm, identity disturbance) have
been considered to be byproducts of an inability to control emotional responses (2,3,4).

Individuals with BPD are more emotionally unstable than individuals without BPD (5), have
more intense responses to emotionally negative events and slower return to baseline (6),
have more trait negative affect (7). Further, individuals with BPD tend to experience and
recall more emotions with negative valence as compared with neutral or positive emotions
(8,9,10,11). Yet, they do not exhibit an increased sensitivity to emotional stimuli (11,12,13),
indicating that even when emotional responses are in the normative range, emotional control
is still compromised. The formulation that deficient affective regulation underlies BPD
pathology is also supported by abnormalities observed in the neurocircuitry involved with
emotion regulation in BPD patients including electrophysiology (e.g., 11,14), structural
imaging (e.g., 15), and functional imaging (e.g., 16; for a review of neuroimaging studies of
BPD see 17). Various neuroanatomical and neurophysiological abnormalities have been
reported in individuals with BPD, including reduced hippocampal, amygdala and frontal
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lobe volumes, as well as diminished serotonergic function (see 3 for review).

The disordered emotional regulation in BPD may be related to disrupted attention processes
and impaired executive functioning. Individuals with BPD exhibit a tendency to attend to
dominant stimuli and ignore nondominant but task relevant cues, and hyperfocus on cues
associated with negative affective valence (18). Thus, contextual and often nonemotional
cues are largely underutilized or ignored in BPD, while most attention is diverted to more
salient and often more negative emotional stimuli. Further, individuals with BPD display
deficits on tasks that require controlled or effortful information processing, as well as
abstraction ability and cognitive flexibility that tap executive functioning (19). Therefore,
the processes of attention and executive functioning are targeted by cognitive-behavioral
interventions, such as Dialectical Behavior Therapy (DBT), to increase the self-regulatory
processes in these individuals.

DBT, is an empirically supported treatment for BPD (2,20) and cormorbid BPD and
Substance Use Disorders (21–26). DBT conceptualizes the dangerous impulsivity exhibited
by BPD patients (e.g., deliberate self-harm and substance use) as maladaptive emotion
regulation strategies. DBT purports to increase control of such behaviors via improved
emotion regulation (2,27). However, no prior published research has directly assessed
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improved emotion regulation with DBT, or shown that positive outcome is mediated by
increased emotion regulation capacity. To begin to address this gap, we assessed emotion
regulation in an open trial of DBT with treatment-seeking women with substance
dependence and BPD. Substance use serves to avoid or decrease emotional distress (28).
Difficulties of emotion regulation have been documented in individuals with substance use
disorders including cocaine (29) and alcohol (30), and individuals comorbid for BPD.
Further, patients with substance use disorders have been shown to have greater emotion
regulation difficulties than those with BPD alone (31). We investigated the following
questions: 1) is DBT associated with improved emotion regulation?; and, 2) can improved
emotion regulation account for decreased substance use during treatment?

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Method
Subjects
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Participants included 27 women who were consecutively admitted into a primary substance
use clinic and that met DSM-IV criteria for BPD and substance dependence. This public-
funded clinic serves only low socioeconomic status individuals who either have no
insurance or are on a public insurance coverage, and does not admit patients with major
mental illnesses such as those that are actively psychotic with a schizophrenia,
schizoaffective, or bipolar disorder, or those that are actively suicidal (patients were not
excluded for past suicidality) or those who do not speak English. There were no other
specific exclusion criteria for this study. Participants were 92% Caucasian and 8% Hispanic
with an average age of 38.0 (range 27–51); 62% were never married and 38% were divorced
(none were currently married). All had at least high school education and 31% had some
college education. They met DSM-IV current criteria for an average of 1.7 substance
dependence diagnoses (88% alcohol, 44% cocaine, 25% opiates, and 6% marijuana). They
had an average of 2.4 Axis I disorders, with 81% comorbidity for depressive disorders, 69%
for anxiety disorders (50% for PTSD), and 6% for bipolar disorder. Eighty-eight percent
were prescribed antidepressants, 31% were prescribed mood stabilizers (anticonvulsants),
and 12% were not prescribed psychotropic medications. Patients diagnosed with opiate
dependence were started on an opiate antagonist (naltrexone) at study entry.
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Procedures
Participants were newly admitted outpatients at a specialized, publicly-funded community
substance abuse facility affiliated with Yale University. Licensed and certified academic
psychiatrists conducted the admission assessments including psychiatric diagnoses that were
determined by reviewing DSM-IV criteria for specific Axis I and Axis II BPD disorders and
documenting symptom counts to determine BPD and substance abuse diagnoses. Those
diagnosed with comorbid DSM-IV substance dependence and BPD upon intake assessment
were assigned to DBT treatment, and once committed to treatment, were approached for
study participation. Study participation did not involve any manipulation of standard
treatment of this facility; therefore, this study received expedited approval from the Yale
Human Investigation Committee. All participants provided informed consent prior to study
participation. Self-report measures (described below) were administered at the beginning
(T1), middle (T2), and end (T3) of treatment.

DBT Program—This program was established as part of a statewide DBT training

initiative for the Connecticut Department of Mental Health and Addiction Services
(DMHAS) conducted by Dr. Marsha Linehan and colleagues, following the “train-the-
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trainer” model (32). A DMHAS DBT trainer (RS) attended the consultation meetings and
supervised the one doctoral level and three masters level clinicians for treatment adherence
(2,33). Treatment consisted of 20 weeks of weekly, hour-long individual therapy, weekly
90-minute skills group, as needed telephone skills coaching, and a weekly hour-long
consultation group for the therapists. The relatively brief length of treatment was based on
practical constraints of the substance abuse facility. Substance use was the prioritized
quality-of-life-interfering-behavior (2), following the treatment targets of life-threatening
and treatment-interfering behaviors. Treatment non-completion was defined as patients
missing four consecutive individual or skills group sessions (2).

Measures
Beck Depression Inventory (BDI; 34) was used to measure depression. The BDI is a well-
validated and frequently used 21-item self-report scale designed to measure severity of

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depressive symptomatology with scores significantly associated with clinical measures of

depression.
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Difficulties in Emotion Regulation Scale (DERS; 35) includes 36 self-report items endorsed
on a five-point scale ranging from “almost never; 0–10%” to “almost always 91–100%” and
assess six dimensions of emotion dysregulation including 1) nonacceptance of one’s
negative emotions (NONACCEPTANCE; e.g., “When I’m upset, I feel ashamed at myself
for feeling that way”); 2) difficulties accomplishing goals when experiencing negative
emotions (GOALS; e.g., “When I’m upset, I have difficulty focusing on other things”); 3)
difficulties remaining in control of one’s behavior when experiencing negative emotions
(IMPULSE; e.g., “I experience my emotions as overwhelming and out of control”); 4) lack
of emotional awareness (AWARENESS; e.g., “I pay attention to how I feel” reverse-
scored); 5) low self-efficacy for regulating negative emotions (STRATEGIES, e.g., “When
I’m upset, I believe that wallowing in it is all I can do”); and 6) difficulty identifying and
understanding emotions (CLARITY; e.g., “I have difficulty making sense out of my
feelings”). In a large college sample the DERS and its subscales demonstrated high internal
consistency with Total DERS α = .93 and all subscales α > .80, significant correlations with
other measures of emotion regulation, and significant correlations with self-reported history
of self-harm and intimate partner abuse (35). In addition, the scales showed adequate to high
four-to-eight week test-retest reliability in a small subsample, with intraclass coefficients of
ρI = .88 for Total DERS and ρI = .57 to .80 for the six subscales (35).
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Substance Use Frequency for the 30 days preceding treatment and for the last 30 days of
treatment was compiled from clinician completed documentation on substance use forms
that were part of the standard practice of the clinical setting, and included data on weekly
patient self-report, ongoing clinician assessment, collateral information when available, and
weekly urine toxicology screenings and alcohol breathalyzer tests. The data was collected by
the clinician and we recorded/transcribed it. Participants self-reported positive drug use in
one fifth of the assessments on average, and had positive urine toxicology reports in one
quarter of the assessments on average. It is noted that the substances monitored by the urine
toxicology screenings (i.e., 4-panel or 8-panel) were selected based on clinical assessment of
need and were therefore not consistent across all participants. Also, any missed urine
toxicology screenings due to patient absences or administrative error were excluded. On the
basis of these data, clinicians rated substance use frequency according to the following four
categories: 0 = none, 1 = 1 to 3 times per month, 2 = 1 to 3 times per week, and 3 = more
than three times per week. The contribution of urine toxicology and self-report assessments
to coded frequency was approximately equal, with a slightly greater contribution of urine
toxicology at baseline and slightly greater contribution of self-report at discharge;
discrepancies between these sources were always rated in the positive direction. All use of
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alcohol and substances of abuse were incorporated whether or not a given substance was the
primary substance of abuse for that patient.

Results
Participants attended an average of 14.9 therapy sessions and 14.0 skills sessions, with
55.6% completing treatment. Participants who did and did not complete treatment did not
differ on primary drug of choice [χ2(df 2) = .96; p = .62] or baseline frequency of drug use
[t(df 21)= 1.17; p = .26], BDI [t(df 25)= 1.33; p = .20], or DERS [t(df 22)= 0.11; p = .91].
The BDI and DERS for the three time points approximated normal distributions
(Kolmogorav Smirnov Z = .49 to .68; p = .75 to .97). One-way repeated measures ANOVAs
using the SAS Proc Mixed procedure to account for missing data were conducted to assess
change in BDI scores and DERS scores over treatment time (T1, T2, T3).

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We utilized Holm-Bonferroni corrections to adjust the alpha level downward to prevent

chance capitalization in multiple comparisons. Holm-Bonferroni sequential approach allows
for increasing power while controlling Type I error (36). BDI scores decreased significantly
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across time period, including a significant reduction in scores from the beginning to the
middle of treatment, F(2,35) = 31.55, p < .001; T1: 25.07(9.77) > T2: 15.29(9.34) = T3:
14.50, (8.45). DERS data was available for 24 participants (three participants did not
complete DERS at baseline due to an administration error), and DERS Total scores also
decreased significantly across time, including a reduction at mid-treatment and again at
treatment end, F(2,32) = 16.44, p < .001; at each assessment period [T1: 118.00 (18.47) >
T2: 108.00 (22.23) > T3: 94.80(17.89)]. For exploratory purposes we examined changes in
DERS subscales as well (see Table 1).

Of the twenty-four participants who completed the DERS, 39.1% had weekly substance use
in 30 days prior to the start of treatment, while only 8.6% were found to have weekly
substance use in the 30 days prior to the end of treatment, indicating a significant reduction
in use χ2(1) = 8.944, p = .003 (one subject was not included due to missing substance use
data).

To examine the contribution of improved emotion regulation on the reduction in substance

use, one-way repeated measures ANOVAs were calculated first for change in substance use
over time from the beginning to end of treatment, and then with change in DERS emotion
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regulation from beginning to end of treatment entered as a covariate. Results indicated

significant change in substance use form pre- to post-intervention, F(1, 21) = 6,731, p = .
017. Significant interactions were observed with frequency of substance use and emotion
regulation, F(1, 21) = 8.202, p = .009, with changes in substance use losing significance
when controlling for improvement in emotion regulation F(1, 21) = .112, ns. No significant
interaction was observed for reduced frequency of substance use and improvement in BDI,
F(1, 21) = 2.664, ns.

Discussion
This study demonstrated measurable improvement in emotion regulation in women with
substance dependence and BPD that received DBT treatment. Improved emotion regulation
appeared to be distinct from, and to continue beyond, improved mood. When entered as a
covariate, improved emotion regulation accounted for decreased frequency of substance use,
suggesting that developing effective emotion regulation skills may have allowed study
participants to cease other less effective emotion regulation behaviors. This interpretation is
consistent with the DBT model that understands emotion dysregulation to mediate the
maladaptive behaviors of BPD in the face of life stressors (2;27). These results extend the
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findings of previous research showing both improved emotion regulation and decreased
dangerous impulsivity (i.e., self-harm) with participation in DBT-informed interventions
(37,38), by specifically showing an association between the improved emotion regulation
and decreased dangerous impulsivity (i.e., substance use).

Given that the present results linking improved emotion regulation and decreased substance
use are correlational, it is not possible to make conclusive interpretations of causality. For
example, the results could alternatively be interpreted as indicating that those who were able
to reduce their substance use were then more proficient at developing emotion regulation
skills—perhaps comparable to the hindering role of PRN benzodiazepines observed in
cognitive behavioral treatments for panic disorder with agoraphobia (39). Or, it is possible
that the observed associations were caused by some interaction of the variables, or by some
third unspecified process. However, it is noteworthy that decreased substance use was

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specifically associated with improved emotion regulation, and not with improved mood
(depression), supporting the specificity of this result.
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With respect to the dimensions of emotion regulation that were observed to improve in the
exploratory analyses, during the first half of treatment patients reported increased
confidence in their ability to regulate negative emotions. By the end of treatment, this
confidence improved further, and patients also reported increased ability to attend to,
identify, and understand their emotions, and to remain in control when experiencing
negative emotions.

Only 55.6% of participants completed treatment as defined by DBT protocol attendance

requirements (2), and this finding speaks to the challenges involved with engaging patients
with comorbid BPD and substance use disorders into treatment (40,41). When treatment
attrition occurred, it generally included the patients “falling out” of contact, and therefore
the reasons for leaving treatment were generally not available. While there is some
indication that DBT is more successful than standard treatments at engaging patients with
substance use disorders (21), the present study’s retention rate is consistent with past studies
reporting retention between 52% and 64% (21,22,26). Linehan and colleagues have
addressed the challenges of treatment retention with patients that are comorbid for BPD and
substance use disorders by developing a variety of “attachment strategies” such as
procedures for finding “lost” patients (26). Although some of these attachment strategies
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were utilized in the present investigation, such as using telephone contact break cycles of
avoidance following patient absences; many of the more intense attachment strategies
described by Linehan and colleagues were not utilized, such as conducting therapy in
patients’ natural environments or responding to patient absences with token gifts
symbolizing the therapists’ pining. It is also noted that whereas Linehan and colleagues
included the prescription of drug agonist medication as part of the DBT-SUD treatment for
opiate users, the present study prescribed an opiate blocker, and this less reinforcing
medication may have also contributed to treatment attrition observed.

A primary limitation of the study is that there was not a control treatment condition. This
limits our ability to attribute emotion regulation improvement specifically to DBT treatment.
For example, preliminary results from a recent randomized controlled treatment of DBT
applied to substance dependence did not find improved emotion regulation to be specific to
the DBT treatment condition (26). Significantly, patients received concurrent
psychopharmacological treatment, which could have contributed to the observed
improvements in emotional distress and reduced substance use; however, it is noted that
with the exception of Nalrexone, the medications prescribed do not typically have large
effects on substance use outcome, and psychotropic medications would not be expected to
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increase efficacy for attending to, accepting, and modulating emotions, as assessed in the
DERS. An additional limitation is that the treatment provided was of shorter duration than
most previous DBT studies, and based on the pattern of findings observed it is unclear if the
full treatment effect was realized. It is noted, however, that there have been several studies
of comprehensive DBT of shorter duration than one year, such as a 12- to 16-week
adaptation for adolescents by Miller, Rathus, Linehan at collagues (42,43) and two 26-week
randomized controlled trials (44,45).

Other limitations include the exclusion of men, the under representation of minorities, and
the use of clinical interviews for BPD and substance use diagnoses. The study also did not
include no systematic assessment of DBT adherence, and therefore problems of adherence
cannot be ruled out for contributing to treatment attrition. Further, assessments of substance
use included participants' self-report and clinician assessments, all subject to potential bias.
Although the substance use frequency variable was a composite that included biological

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data, this data was collected as part of standard clinical care as opposed to standardized
research outcome measures. On the other hand, the present study has the benefit of
exemplifying the application of DBT in a standard community substance use clinic setting.
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Nonetheless, this is the first study to show improved emotion regulation in BPD patients
receiving DBT and to show that such improvement mediates improvement in an impulsive,
maladaptive behavior (substance abuse). On the basis of these findings emotion regulation
assessment is recommended for future studies of the etiology and maintenance of psychiatric
disorders associated with emotion dyregulation, such as BPD and substance dependence, as
well as to further explore the potential role of emotion regulation as a mechanism of change
for clinical intervention.

Acknowledgments
This research was supported in part by the following NIH grants: P50-DA0941 (Bruce J. Rounsaville, M.D.), P50-
DA16556 (RS), and T-32-MH062994 (Morris Bell, PhD), and by the Department of Mental Health and Addiction
Services (DMHAS) of the State of Connecticut. We thank the clinical and research staff of the Substance Abuse
Treatment Unit at the Connecticut Mental Health Center for their contribution to this research. We are also grateful
to Drs. Steve Southwick and Bruce Rounsaville for their helpful comments on an earlier version of this manuscript.

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Table 1
DERS at Baseline, Mid-treatment, and End of Treatment

Baseline Midtreatment Treatment end

Scale Mean (SD) Mean (SD) Mean(SD) F(2,32) Comparisons
Axelrod et al.

NONACCEPTANCE 17.50 (6.35) 16.58 (6.26) 14.87 (3.76) 3.10

GOALS 17.75 (4.10) 17.47 (4.41) 16.00 (3.91) 2.28
IMPULSE 19.21 (5.10) 17.53 (5.00) 16.00 (4.19) 5.36** T1 > T3

AWARENESS 19.92 (3.73) 18.42 (4.60) 14.93 (3.33) 10.68*** T1 = T2 > T3

STRATEGIES 27.58 (6.79) 25.53 (7.11) 21.20 (6.18) 16.91*** T1 > T2 > T3

CLARITY 15.75 (2.11) 14.95 (3.06) 12.00 (3.02) 11.48*** T1 = T2 > T3

DERS TOTAL 118.00 (18.47) 108.00 (22.23) 94.80 (17.89) 16.44*** T1 > T2 > T3

Notes: n = 24 at baseline; n = 19 at midtreatment; n = 15 at treatment end.

*
p < .05;
**
p < .01;
***
p < .001.

Differences are calculated as one-way repeated measures ANOVAs using the SAS Proc Mixed procedure to account for missing data. T1 = Baseline; T2 = Midtreatment; T3 = End of Treatment.

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