Changes in Negative Affect Following Pain (vs. Nonpainful) Stimulation in Individuals With and Without a History of ...

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Personality Disorders: Theory, Research, and
Treatment
Changes in Negative Affect Following Pain (vs.
Nonpainful) Stimulation in Individuals With and Without
a History of Nonsuicidal Self-Injury
Konrad Bresin and Kathryn H. Gordon
Online First Publication, October 10, 2011. doi: 10.1037/a0025736
CITATION
Bresin, K., & Gordon, K. H. (2011, October 10). Changes in Negative Affect Following Pain
(vs. Nonpainful) Stimulation in Individuals With and Without a History of Nonsuicidal
Self-Injury.
Personality Disorders: Theory, Research, and Treatment
. Advance online
publication. doi: 10.1037/a0025736
Personality Disorders: Theory, Research, and Treatment
© 2011 American Psychological Association
2011, Vol.
●●
, No.
●
, 000–000
1949-2715/11/$12.00 DOI: 10.1037/a0025736
Changes in Negative Affect Following Pain (vs. Nonpainful)
Stimulation in Individuals With and Without a History of
Nonsuicidal Self-Injury
Konrad Bresin and Kathryn H. Gordon
North Dakota State University
Theoretical models of nonsuicidal self-injury (NSSI; i.e., purposeful destruction of
body tissue without suicidal intent) suggest that individuals engage in NSSI in order to
regulate negative affect (NA). One limitation of the current research is that most studies
using pain as a proxy of NSSI have failed to include a nonpainful stimuli control group.
This study attempted to address this limitation by comparing the emotional response to
painful (vs. nonpainful) heat stimulation in individuals with a history of NSSI (vs. no
history of NSSI) following a negative mood induction. It was predicted that among
individuals with a history of NSSI, pain would lead to larger reductions in NA than
warm stimulation. Furthermore, it was predicted that this reduction would be larger
than that of controls regardless of condition. The hypotheses received partial support,
such that pain led to greater reductions in negative affect for individuals with a history
of NSSI, but not compared to controls. Future research directions are discussed.
Keywords:
nonsuicidal self-injury, NSSI, self-harm, pain, negative affect
Nonsuicidal self-injury (NSSI) is defined as
self-inflicted damage to one’s own body tissue
that is performed in the absence of suicidal
intent (Nock, 2009). NSSI is a behavior that is
difficult to understand because it lies in oppo-
sition to the common principle of approach/
maximize pleasure and avoid/minimize pain
(Freud, 1929; Gray, 1982; Kahneman & Tver-
sky, 1979). In spite of this, individuals report
that they often engage in NSSI to reduce nega-
tive affect (NA; Nock & Prinstein, 2004). Em-
pirical work supports this prediction in that
NSSI proxies lead to reduced NA (e.g., Franklin
et al., 2010). Still, there are gaps in the current
literature. For example, currently it is unclear if
painful stimulation is necessary to regulate
emotion or whether any tactile stimulation is
adequate. The primary aim of this study was to
compare individuals with a recent history of
NSSI (i.e., within the last year) to individuals
with no NSSI history on their emotional re-
sponse to a painful (vs. nonpainful) heat stim-
ulation following a mood induction.
Nonsuicidal Self-injury as Affect Regulation
Nock and Prinstein (2004) proposed that one
possible function of NSSI is to reduce NA. Sub-
sequent theory has expanded upon this prediction
(e.g., Chapman, Gratz, Brown, 2006; Nock, 2009;
Selby & Joiner, 2009). For example, the experi-
ential avoidance model (EAM) proposes that in-
dividuals who have intense reactions to emotional
stimuli and difficulty regulating emotions may
desire to escape from aversive experiences (e.g.,
NA) via NSSI (Chapman et al., 2006). One pos-
sible mechanism proposed by the EAM is distrac-
tion. However, based on this model, it is unclear
why individuals would choose NSSI over other
methods of distraction (e.g., watching TV). Build-
ing on the EAM, Selby and Joiner’s emotional
cascade theory (2009) suggests that this is because
among emotionally dysregulated individuals, less
intense methods of distraction (e.g., a cold
shower) are unsuccessful in regulating intense
emotions, and only strong sensations (e.g., physi-
cal pain) are able to distract from high NA states.
Konrad Bresin and Kathryn H. Gordon, Department of
Psychology, North Dakota State University.
Konrad Bresin is now at the University of Illinois Urba-
na-Champaign. This research was supported, in part, by a
grant from ND EPSCoR to Kathryn H. Gordon (NSF Grant
EPS-081442).
Correspondence concerning this article should be addressed
to Konrad Bresin, Psychology Department, University of Illi-
nois Urbana-Champaign, 603 East Daniel St., Champaign, IL
61820. E-mail: Konrad.Bresin@gmail.com
1
2
BRESIN AND GORDON
Pain as Affect Regulation
Both groups showed deactivation in the
amygdala during pain and nonpainful heat
stimuli following negative slides, though this
effect was larger for individuals with BPD
than controls. These results may suggest that
any sensory stimulation, not just painful stim-
ulation, may be effective in reducing NA. In
the current context, the major limitation of
this study is that it was conducted on individ-
uals with BPD, not self-injurers per se.
Though NSSI is one possible symptom of
BPD, it is possible to meet criteria for BPD
without engaging in NSSI (American Psychi-
atric Association, 2000). It is feasible that the
relationship between pain and emotion may
differ for those who engage in NSSI but do
not necessarily meet criteria for BPD.
A growing body of research has found sup-
port for affect regulation models in that proxies
of NSSI can decrease the experience of NA.
One series of studies found a reduction in NA
and heart rate following an imagined NSSI in-
cident in individuals with a history of NSSI
(e.g., Haines, Williams, Brain, & Wilson,
1995). The major limitation of these studies is
that it is unclear if these results would replicate
with the inclusion of the physical sensations
experienced during actual NSSI. Other studies
using undergraduate samples without a history
of NSSI suggest that the experience of pain may
decrease NA. For example, Bresin, Gordon,
Bender, Gordon, and Joiner (2010) measured
NA before and after the experience of pain in
two samples of college undergraduates. Results
showed that NA decreased following the expe-
rience of pain. One major limitation of this
study is that there was no manipulation of emo-
tion prior to the exposure to physical pain. It is
possible that at high levels of NA, pain may
exacerbate NA. Also, this study included indi-
viduals without a history of NSSI, which poten-
tially limits generalizability of the results to
self-injuring populations.
These limitations were addressed in a study
by Franklin et al. (2010). In this study, affective
modulation of the startle reflex was measured
during anticipation of a stressful speech and
after a cold pressor task. The results showed
that, regardless of NSSI history, participants
displayed a reduction in the startle reflex after
exposure to the cold pressor task, indicating that
the experience of pain may reduce NA. One
limitation of this study is the lack of a control
condition that consisted of nonpainful tactile
stimulation. Based on this study, it is unclear
whether an intense experience, such as pain, is
necessary for decreasing NA (as predicted by
Selby & Joiner, 2009) or if any tactile stimula-
tion would also decrease NA.
Niedtfeld et al. (2010) attempted to address
this limitation by including painful and non-
painful stimulation. In this study, a group of
individuals with borderline personality disorder
(BPD; 80% with a history of NSSI) and healthy
controls were exposed to emotion-eliciting
slides before being exposed to either painful
stimuli or warm nonpainful stimuli. Amygdala
activity was recorded using functional MRI.
Current Study
The current study attempts to address limita-
tions of previous research. Individuals with a
history of NSSI in the last year and without a
history of NSSI were recruited. Participants
completed a mood induction where they wrote
about a time when they were not living up to an
important personal attribute (e.g., being intelli-
gent). Following the mood induction, partici-
pants were either exposed to painful heat stim-
ulation or nonpainful heat stimulation (based on
participant ratings; detailed below). Finally,
participants gave self-report levels of affect at
three times during the study (Time 1: before any
mood induction; Time 2: following the mood
induction; Time 3: following the painful/
nonpainful induction). Based on previous the-
ory and research (Niedtfeld et al., 2010; Selby
& Joiner, 2009), we predicted that for individ-
uals with a history of NSSI, pain would lead to
a larger reduction in NA than warm stimulation.
Furthermore, we predicted that the NSSI group
that experienced painful stimulation would have
a reduction in NA larger than that of the control
group regardless of condition.
Method
Participants
Undergraduates (1,612) were screened using
the Deliberate Self-Harm Inventory (DSHI;
Gratz, 2001) for participation in this study. Of
these, 136 participants (8%) indicated that they
CHANGES IN AFFECT FOLLOWING PAIN
3
had engaged in NSSI in the past 12 months, 251
participants (15%) indicated engaging in NSSI
more than 12 months ago, and the remaining
participants (76%) reported no history of NSSI.
For the NSSI group, 59 participants (34 fe-
male) were recruited. The average time since
the last NSSI episode was 5.52 months
(
SD
email about study participation. The time frame
was chosen to be consistent with previous stud-
ies (e.g., Gratz et al., 2011). Participants who
reported no history of NSSI were contacted
about participation in the study for the control
group.
Pain stimuli.
All heat stimuli were pro-
duced by a Medoc Thermal Sensory Analyzer, a
computerized device for the quantitative assess-
ment of heat- and cold-induced pain. All stimuli
were presented to the left volar forearm. Partic-
ipants were exposed to pain stimuli twice during
the session. At the beginning of the experiment,
participants were exposed to and rated a series
of temperatures (40 °C, 43 °C, 45 °C, 48 °C, 50
°C). On each trial, the thermode began at 35 °C.
The temperature level increased at a rate of 4 °C
per second until the target temperature was
reached. Once the target temperature was
reached, the thermode maintained the tempera-
ture for seven seconds.
Following each trial, participants made a ver-
bal rating of stimulus intensity on a scale rang-
ing from 0 (
no heat sensation
) to 100 (
intoler-
able heat pain
) with 50 (
heat pain threshold
)as
a midpoint (Tran, Wang, Tandon, Hernandez-
Garcia, & Casey, 2010). The order of the tem-
peratures was held constant. In order to prevent
habituation, there was a 30-second time block
between trials (Tran et al., 2010). If the partic-
ipant felt they could not withstand a tempera-
ture, they were instructed to click a mouse but-
ton which decreased the temperature at a rate
of 10 °C per second until the adaptation tem-
perature was reached.
Following the mood induction, participants
were exposed to the temperature they previ-
ously rated nearest to 20 (nonpainful stimula-
tion) or the temperature they rated nearest to 60
(painful stimulation) based on random assign-
ment (cf. Niedtfeld et al., 2010). No tempera-
tures were used if the participant did not previ-
ously complete the entire seven second trial.
Procedures were the same as earlier in the
study.
Mood induction.
As stimuli for the mood
induction, participants completed the computer-
ized selves interview (Shah & Higgins, 2001).
First, participants listed four “attributes of the
person you would ideally like to be” and four
“attributes of the person you feel you should
be.” After providing all eight attributes, partic-
ipants rated each attribute on how far they were
4.48). The most common methods in-
cluded: cutting (50%), scratching (41%) and
burning (29%). Participants reported an average
of 3.28 methods (
SD
1.84). The median num-
ber of NSSI incidents was 15 (range
1–1000).
For the non-NSSI group, 56 (31 Females) par-
ticipants without a history of NSSI were re-
cruited. Across groups, the sample was 96%
Caucasian and the mean age was 19.48 years
(
SD
2.53).
Procedure
Upon arrival to the laboratory, participants
provided consent. Then, participants rated the
intensity of a series of warm temperature stim-
uli. Next, participants completed a preinduction
measure of affect (i.e., Time 1 NA). Then, par-
ticipants completed the mood induction and a
Time 2 NA assessment. Immediately following
the mood induction, participants were randomly
assigned to be exposed to either a nonpainful
stimulation or a painful stimulation (based on
their prior ratings) and subsequently reported
their affect (i.e., Time 3 NA). Finally, partici-
pants were thanked for their time and excused.
Participants were compensated with course
credit or 10 dollars. All procedures were ap-
proved by the university’s Institutional Review
Board.
Materials
Screening measure.
All potential partici-
pants completed the DSHI (Gratz, 2001) on a
secure website prior to participating in the
study. The DSHI is a 17-item questionnaire that
assesses the lifetime history of a variety of NSSI
methods. First, participants indicated if they had
ever intentionally injured areas of their body
without suicidal intent using a specific method
(e.g., cutting). If they responded “yes”, they
answered follow-up questions (e.g., when was
the last time that it happened?). Participants
who indicated they had engaged in any form of
NSSI within the last 12 months were sent an
4
BRESIN AND GORDON
from possessing it (Far), and how important it
was for them to possess (Important) on a 7-point
Likert scale (1
the nonpainful condition rated the intensity of
the stimuli at
the second exposure lower
extremely
). A
score was calculated to decipher the attribute
each participant rated most important and cur-
rently furthest from (i.e., Far
not at all
,7
(
M
13.82) than participants in
the painful condition (
M
24.12,
SD
20.91)
and this difference was significant,
F
(1,
111) 83.72,
p
56.63,
SD
2
Important).
Then, participants were asked to “choose a
specific time in your life in which you were
supposed to act with or be
attribute
and were
not” to write about. Participants were encour-
aged to pick a situation that caused great stress
and made them “upset, mad, nervous, sad, or
fearful.” After choosing a situation, participants
rated the situation on a scale to 1 (
not stressful
at all
)to10(
the most stress I have experi-
enced
). Finally, participants were given 10 min-
utes to describe the situation they chose in detail
including: where they were, who was there,
what they were doing, and the body sensations
they experienced (cf. Miller et al., 1987). Par-
ticipants were asked to try to generate the same
sensations and feelings that they felt in the
situation while they were writing. Pilot data in a
sample of 20 undergraduates showed a large
effect size for this mood induction (
d
.001, partial
.45. The
average
temperatures were 41.74 °C
2.07) for the
nonpainful and painful conditions, respectively.
Groups did not significantly differ in the stress
rating of their event for the mood induction,
t
(112)
(
SD
2.18) and 47.77 °C (
SD
.18. Across groups,
the average rating was 6.83 out of 10
(
SD
.87,
p
.38,
d
1.70).
For the mood induction, there was not a sig-
nificant main effect of group,
F
(1, 112)
1.53,
2
p
.01. There was a signifi-
cant main effect of time,
F
(1, 112)
.21, partial
234.35,
2
.51. The main effect of
time indicated that the mood induction was suc-
cessful in significantly increasing NA across
groups. It is interesting that there was a signif-
icant
p
.001, partial
group-by-time
interaction,
F
(1,
2
112)
.04. Contrary
to previous research (Nock & Mendes, 2008),
individuals without a history of NSSI had a
significantly larger increase in NA following
the mood induction,
t
(112)
9.61,
p
.01, partial
.88).
Dependent Measure
.58. Groups did not significantly differ at
Time 1,
t
(112)
3.10,
p
.01,
d
NA was measured with the Positive and Neg-
ative Affective Schedule (PANAS; Watson,
Clark, & Tellegen, 1988). In order to limit in-
terruption of affect assessments, we used five
items (upset, hostile, ashamed, nervous, afraid;
Thompson, 2007). Participants rated each item
on a 5-point Likert scale (1
.29, but at
Time 2, the non-NSSI group had significantly
higher NA,
t
(112)
1.61,
p
.11,
d
2.81,
p
.01
d
.51 (see
Table 1 for means).
extremely
) with the instructions of “rate each
item to the extent you feel at this moment.”
Participants completed the PANAS three times
during the study: Time 1 (before mood induc-
tion), Time 2 (following the mood induction),
and Time 3 (following the painful/non painful
induction). Internal consistencies ranged from
.76–.79.
not at all
,5
Primary Analysis
To test the primary hypothesis, NA scores
were submitted to a group (NSSI vs. non-NSSI)
by condition (painful stimulation vs. nonpainful
stimulation) by time (Time 2 vs. Time 3) mixed
model ANOVA, with group and condition as
between-subjects factors and time as a within-
subject factor. The main effect of group and
condition, and the group-by-condition and the
time-by-condition interactions were not signifi-
cant (all
p
’s
Results
.05). There was a significant
main effect of time,
F
(1, 109)
287.11,
p
Manipulation Check
2
.001, partial
.55, indicating regardless of
group and condition, NA decreased over time.
There was a time-by-group interaction,
F
(1,
109)
Inconsistent with previous research (Russ et
al., 1992), there was no effect of NSSI group on
intensity ratings of heat stimuli and group did
not interact with condition during the first ex-
posure (
p
’s
2
.02. How-
ever, this interaction was further moderated by
condition,
F
(1, 109)
4.91,
p
.05, partial
.30). As expected, participants in
5.90,
p
.05, partial
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