Emotion dysregulation and non-suicidal self-injury: A systematic review and meta-analysis

Abstract

Background: Over the past several years there has been considerable interest in the relation between emotion dysregulation and non-suicidal self-injury (NSSI), particularly given that rates of NSSI have been increasing and NSSI is a critical risk factor for suicidal behavior. To date, however, no synthesis of empirical findings exists.

Methods: The present study presents a comprehensive meta-analytic review of the literature on the association between NSSI and emotion dysregulation. A total of 48 publications, including 49 independent samples, were included in this analysis.

Results: Overall, a significant association was found between emotion dysregulation and NSSI (pooled OR = 3.03 [95% CI = 2.56-3.59]). This association was reduced but remained significant (OR = 2.40 [95% CI = 2.01-2.86]) after adjustment for publication bias. Emotion dysregulation subscales most strongly associated with NSSI included limited access to regulation strategies, non-acceptance of emotional responses, impulse control difficulties, and difficulties engaging goal-directed behavior. Lack of emotional awareness/clarity and cognitive aspects of dysregulation yielded weaker, yet significant, positive associations with NSSI.

Conclusions: Findings support the notion that greater emotion dysregulation is associated with higher risk for NSSI among individuals across settings, regardless of age or sex. Furthermore, findings reveal facets of dysregulation that may have unique implications for NSSI. This meta-analysis highlights the importance of better understanding emotion dysregulation as a treatment target for preventing NSSI.

Keywords: Miscellaneous; Suicide.

Conflict of interest statement

Conflict of interest statement: The authors have no real or potential conflicts of interest to declare.

Copyright © 2019 Elsevier Masson SAS. All rights reserved.

Figures

Figure 1.

PRISMA flow chart of literature search

Figure 2.

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall emotion regulation and non-suicidal self-injury 2b. Difficulties in Emotion Regulation – Lack of Emotional Awareness scale and non-suicidal self-injury 2c. Difficulties in Emotion Regulation – Lack of Emotional Clarity scale and non-suicidal self-injury 2d. Difficulties in Emotion Regulation – Difficulties Engaging in Goal-Directed Behavior scale and non-suicidal self-injury 2e. Difficulties in Emotion Regulation – Impulse Control Difficulties scale and non-suicidal self-injury 2f. Difficulties in Emotion Regulation – Non-acceptance of Emotional Responses scale and non-suicidal self-injury 2g. Difficulties in Emotion Regulation – Limited Access to Emotion Regulation Strategies scale and non-suicidal self-injury 2h. Emotion Regulation Questionnaire – Cognitive Reappraisal scale and non-suicidal self-injury 2i. Emotion Regulation Questionnaire – Expressive Suppression scale and non-suicidal self-injury

Figure 2.

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall emotion regulation and non-suicidal self-injury 2b. Difficulties in Emotion Regulation – Lack of Emotional Awareness scale and non-suicidal self-injury 2c. Difficulties in Emotion Regulation – Lack of Emotional Clarity scale and non-suicidal self-injury 2d. Difficulties in Emotion Regulation – Difficulties Engaging in Goal-Directed Behavior scale and non-suicidal self-injury 2e. Difficulties in Emotion Regulation – Impulse Control Difficulties scale and non-suicidal self-injury 2f. Difficulties in Emotion Regulation – Non-acceptance of Emotional Responses scale and non-suicidal self-injury 2g. Difficulties in Emotion Regulation – Limited Access to Emotion Regulation Strategies scale and non-suicidal self-injury 2h. Emotion Regulation Questionnaire – Cognitive Reappraisal scale and non-suicidal self-injury 2i. Emotion Regulation Questionnaire – Expressive Suppression scale and non-suicidal self-injury

Figure 2.

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall emotion regulation and non-suicidal self-injury 2b. Difficulties in Emotion Regulation – Lack of Emotional Awareness scale and non-suicidal self-injury 2c. Difficulties in Emotion Regulation – Lack of Emotional Clarity scale and non-suicidal self-injury 2d. Difficulties in Emotion Regulation – Difficulties Engaging in Goal-Directed Behavior scale and non-suicidal self-injury 2e. Difficulties in Emotion Regulation – Impulse Control Difficulties scale and non-suicidal self-injury 2f. Difficulties in Emotion Regulation – Non-acceptance of Emotional Responses scale and non-suicidal self-injury 2g. Difficulties in Emotion Regulation – Limited Access to Emotion Regulation Strategies scale and non-suicidal self-injury 2h. Emotion Regulation Questionnaire – Cognitive Reappraisal scale and non-suicidal self-injury 2i. Emotion Regulation Questionnaire – Expressive Suppression scale and non-suicidal self-injury

Figure 2.

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall emotion regulation and non-suicidal self-injury 2b. Difficulties in Emotion Regulation – Lack of Emotional Awareness scale and non-suicidal self-injury 2c. Difficulties in Emotion Regulation – Lack of Emotional Clarity scale and non-suicidal self-injury 2d. Difficulties in Emotion Regulation – Difficulties Engaging in Goal-Directed Behavior scale and non-suicidal self-injury 2e. Difficulties in Emotion Regulation – Impulse Control Difficulties scale and non-suicidal self-injury 2f. Difficulties in Emotion Regulation – Non-acceptance of Emotional Responses scale and non-suicidal self-injury 2g. Difficulties in Emotion Regulation – Limited Access to Emotion Regulation Strategies scale and non-suicidal self-injury 2h. Emotion Regulation Questionnaire – Cognitive Reappraisal scale and non-suicidal self-injury 2i. Emotion Regulation Questionnaire – Expressive Suppression scale and non-suicidal self-injury

Figure 2.

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall emotion regulation and non-suicidal self-injury 2b. Difficulties in Emotion Regulation – Lack of Emotional Awareness scale and non-suicidal self-injury 2c. Difficulties in Emotion Regulation – Lack of Emotional Clarity scale and non-suicidal self-injury 2d. Difficulties in Emotion Regulation – Difficulties Engaging in Goal-Directed Behavior scale and non-suicidal self-injury 2e. Difficulties in Emotion Regulation – Impulse Control Difficulties scale and non-suicidal self-injury 2f. Difficulties in Emotion Regulation – Non-acceptance of Emotional Responses scale and non-suicidal self-injury 2g. Difficulties in Emotion Regulation – Limited Access to Emotion Regulation Strategies scale and non-suicidal self-injury 2h. Emotion Regulation Questionnaire – Cognitive Reappraisal scale and non-suicidal self-injury 2i. Emotion Regulation Questionnaire – Expressive Suppression scale and non-suicidal self-injury

Figure 2.

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall emotion regulation and non-suicidal self-injury 2b. Difficulties in Emotion Regulation – Lack of Emotional Awareness scale and non-suicidal self-injury 2c. Difficulties in Emotion Regulation – Lack of Emotional Clarity scale and non-suicidal self-injury 2d. Difficulties in Emotion Regulation – Difficulties Engaging in Goal-Directed Behavior scale and non-suicidal self-injury 2e. Difficulties in Emotion Regulation – Impulse Control Difficulties scale and non-suicidal self-injury 2f. Difficulties in Emotion Regulation – Non-acceptance of Emotional Responses scale and non-suicidal self-injury 2g. Difficulties in Emotion Regulation – Limited Access to Emotion Regulation Strategies scale and non-suicidal self-injury 2h. Emotion Regulation Questionnaire – Cognitive Reappraisal scale and non-suicidal self-injury 2i. Emotion Regulation Questionnaire – Expressive Suppression scale and non-suicidal self-injury

Figure 2.

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall emotion regulation and non-suicidal self-injury 2b. Difficulties in Emotion Regulation – Lack of Emotional Awareness scale and non-suicidal self-injury 2c. Difficulties in Emotion Regulation – Lack of Emotional Clarity scale and non-suicidal self-injury 2d. Difficulties in Emotion Regulation – Difficulties Engaging in Goal-Directed Behavior scale and non-suicidal self-injury 2e. Difficulties in Emotion Regulation – Impulse Control Difficulties scale and non-suicidal self-injury 2f. Difficulties in Emotion Regulation – Non-acceptance of Emotional Responses scale and non-suicidal self-injury 2g. Difficulties in Emotion Regulation – Limited Access to Emotion Regulation Strategies scale and non-suicidal self-injury 2h. Emotion Regulation Questionnaire – Cognitive Reappraisal scale and non-suicidal self-injury 2i. Emotion Regulation Questionnaire – Expressive Suppression scale and non-suicidal self-injury

Figure 2.

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall emotion regulation and non-suicidal self-injury 2b. Difficulties in Emotion Regulation – Lack of Emotional Awareness scale and non-suicidal self-injury 2c. Difficulties in Emotion Regulation – Lack of Emotional Clarity scale and non-suicidal self-injury 2d. Difficulties in Emotion Regulation – Difficulties Engaging in Goal-Directed Behavior scale and non-suicidal self-injury 2e. Difficulties in Emotion Regulation – Impulse Control Difficulties scale and non-suicidal self-injury 2f. Difficulties in Emotion Regulation – Non-acceptance of Emotional Responses scale and non-suicidal self-injury 2g. Difficulties in Emotion Regulation – Limited Access to Emotion Regulation Strategies scale and non-suicidal self-injury 2h. Emotion Regulation Questionnaire – Cognitive Reappraisal scale and non-suicidal self-injury 2i. Emotion Regulation Questionnaire – Expressive Suppression scale and non-suicidal self-injury

Figure 2.

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall emotion regulation and non-suicidal self-injury 2b. Difficulties in Emotion Regulation – Lack of Emotional Awareness scale and non-suicidal self-injury 2c. Difficulties in Emotion Regulation – Lack of Emotional Clarity scale and non-suicidal self-injury 2d. Difficulties in Emotion Regulation – Difficulties Engaging in Goal-Directed Behavior scale and non-suicidal self-injury 2e. Difficulties in Emotion Regulation – Impulse Control Difficulties scale and non-suicidal self-injury 2f. Difficulties in Emotion Regulation – Non-acceptance of Emotional Responses scale and non-suicidal self-injury 2g. Difficulties in Emotion Regulation – Limited Access to Emotion Regulation Strategies scale and non-suicidal self-injury 2h. Emotion Regulation Questionnaire – Cognitive Reappraisal scale and non-suicidal self-injury 2i. Emotion Regulation Questionnaire – Expressive Suppression scale and non-suicidal self-injury