Journal of Psychiatric Research 45 (2011) 603e611

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Journal of Psychiatric Research

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Clarifying the role of emotion dysregulation in the interpersonal-psychological

theory of suicidal behavior in an undergraduate sample
Michael D. Anestis a, b, *, Courtney L. Bagge b, Matthew T. Tull b, Thomas E. Joiner a
a
Florida State University, Jackson, MS 39216, United States
b
University of Mississippi Medical Center, United States

a r t i c l e i n f o a b s t r a c t

Article history: The interpersonal-psychological theory of suicidal behavior (IPTS; Joiner, 2005) has been subjected to
Received 13 August 2010 a number of rigorous investigations and has shown to be a promising lens through which to under-
Received in revised form stand suicide. One area thus far left unstudied with respect to the IPTS is emotion dysregulation. The
18 October 2010
bulk of the work examining the role of emotion dysregulation in suicidality has focused on suicidal
Accepted 19 October 2010
ideation rather than behavior, with a number of studies reporting that emotion dysregulation is
predictive of suicidal ideation (e.g., Lynch et al., 2004; Orbach et al., 2007). Studies examining suicide
Keywords:
attempts have produced more ambiguous results. One way to clarify the nature of this relationship is to
Suicide
Emotion regulation
consider the construct of emotion dysregulation through an examination of specific subcomponents. In
Interpersonal-psychological theory this study, we examined two specific components of emotion dysregulation e negative urgency and
distress tolerance e and their relationships to all three components of the IPTS, thereby providing
clarity for an otherwise poorly understood relationship. Results indicated that emotionally dysregu-
lated individuals e those with low distress tolerance and high negative urgency e exhibited higher
levels of suicidal desire, as indexed by perceived burdensomeness and thwarted belongingness. In
contrast, emotionally dysregulated individuals exhibited lower levels of the acquired capability for
suicide and physiological pain tolerance. As such, a complicated but theoretically cogent picture
emerged indicating that, although emotion dysregulation may drastically increase the likelihood of
suicidal desire, it simultaneously serves as a form protection against lethal self-harm.
Ó 2010 Elsevier Ltd. All rights reserved.

Suicide is a substantial public health concern, with more than
32,000 individuals dying by suicide annually within the United
States (Centers for Disease Control and Prevention, 2004). In recent
years, the interpersonal-psychological theory of suicidal behavior
(IPTS; Joiner, 2005) has been subjected to a number of rigorous
investigations and has shown to be a promising lens through which
to understand suicide and, as such, could serve as a strong foun-
dation upon which to base prevention and treatment efforts. The
hallmark feature of the IPTS is its distinction between those who
desire death by suicide and those who have the capability to enact
lethal self-harm. In other words, the theory posits that most indi-
viduals who wish to die by suicide are not actually able to engage in
a lethal attempt and the majority of individuals who are most
capable of engaging in a lethal attempt have no desire to do so.
Thus, severe risk for suicide completion involves heightened levels
of both desire and capability.
* Corresponding author. Florida State University, Jackson, MS 39216, United States.
E-mail address: anestis@psy.fsu.edu (M.D. Anestis).
According to the IPTS, the desire for suicide is characterized by
two specific cognitive distortions: thwarted belongingness and
perceived burdensomeness. Thwarted belongingness involves
a sense on the part of the individual that he or she lacks meaningful
connections to others, either because of a belief that nobody cares
or a sense that, although others care, they cannot relate to the
individual’s current situation (e.g., soldiers reintegrating into
civilian life post-combat deployment). Perceived burdensomeness
involves a sense on the part of an individual that he or she makes no
meaningful contributions to the world, serving instead as a liability
to others. Early empirical work examining these variables has
supported their utility in predicting suicidal desire, with multiple
studies demonstrating that the two-way interaction of perceived
burdensomeness and thwarted belongingness predicts a distinct
but highly related construct: suicidal ideation (Joiner et al., 2009;
Van Orden et al., 2008). Importantly, suicidal ideation and desire
are not considered to be identical, as, to our knowledge, the degree
to which an individual wishes to die by suicide has not been
empirically demonstrated to directly correspond to the frequency
with which that individual thinks about suicide.

0022-3956/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpsychires.2010.10.013
604 M.D. Anestis et al. / Journal of Psychiatric Research 45 (2011) 603e611
Constructs that conceptually overlap with perceived bur-
densomeness and thwarted belongingness have also been associ-
ated with increased risk for suicidal ideation. Depression, for
instance, has been shown in a number of studies to be associated
with suicidal ideation (e.g., Bostwick and Pankratz, 2000). The
diagnostic criteria for depression include a sense of diminished self-
worth, which parallels perceived burdensomeness. Additionally,
depression has been associated with increased social isolation (e.g.,
Coyne, 1976), which conceptually mirrors thwarted belongingness.
Similarly, hopelessness has been shown in a number of studies to be
associated with increased suicidal desire (e.g., Abramson et al.,
1989) and Van Orden et al. (2010) proposed that hopelessness
about one’s burdensomeness and belongingness might amplify the
impact of the latter two variables on the degree of suicidal desire.
Despite the overlap between depression, hopelessness, bur-
densomeness, and belongingness, the IPTS components have
demonstrated incremental validity in studies controlling for
depression and hopelessness in the prediction of suicidal ideation
(e.g., Joiner et al., 2009; Van Orden et al., 2008).
The third component of the IPTS e the acquired capability for
suicide e is what truly distinguishes the theory from other concep-
tualizations of suicidal behavior. Joiner (2005) argues that, in order to
enact lethal self-harm, an individual must acquire the capability to do
so through repeated exposure to painful and provocative experi-
ences. Such repeated exposures result in habituation to physiological
pain and a diminished fear of death, thereby enabling an individual to
follow through with the inherently frightening and painful experi-
ence of a suicide attempt with a high rate of lethality. In support of
this perspective, Nock and Prinstein (2005) reported that individuals
who engage in frequent non-suicidal self-injury (NSSI) report pain
analgesia during self-injury episodes. Orbach et al. (1996) reported
that individuals admitted to an emergency room due to a suicide
attempt exhibited a higher physiological pain tolerance than did
individuals admitted to the same emergency room due to accidental
injury, and Orbach et al. (1997) reported that individuals with two or
more past suicide attempts exhibit a higher pain tolerance than do
individuals with zero or one suicide attempt. Additionally, in a direct
measurement of the construct, Van Orden et al. (2008) reported that
the acquired capability for suicide predicted individuals’ past number
of suicide attempts.
In the most stringent test of the theory to date, Joiner et al.
(2009) reported that the three-way interaction of all three IPTS
components predicted clinician-rated suicide risk, with elevations
in all three variables conferring the greatest level of vulnerability,
consistent with the IPTS. Early research on the IPTS thus appears
compelling; however, empirical investigations of the IPTS would
benefit from considering the role of other factors that may influ-
ence motivation for suicide.
One area thus far left unstudied with respect to the IPTS is
emotion dysregulation. Gratz and Roemer (2004), through an
extensive review of the literature on emotion regulation, developed
a multi-dimensional conceptualization of emotion regulation based
on the idea that emotions are functional. According to this
conceptualization, emotion dysregulation is comprised of four
distinct, but related, facets: (1) lack of awareness, understanding,
and acceptance of emotional experiences, (2) lack of access to
adaptive means for altering the intensity and/or duration of an
affective experience, (3) an unwillingness to experience emotional
distress as part of pursuing goals and, (4) an inability to persist in
goal-directed behaviors when upset. Thus, this conceptualization
distinguishes emotion dysregulation from a temperamental
emotional vulnerability (e.g., being emotionally intense/reactive),
focusing instead on the ways in which individuals respond to and/
or relate to their emotions rather than the quality of the emotions
themselves.
A number of psychiatric diagnoses characterized by difficulties
regulating emotions are also characterized by highly elevated
suicide rates (e.g., borderline personality disorder; Paris and Zweig-
Frank, 2001). The bulk of the work examining the role of emotion
dysregulation in suicidality has focused on suicidal ideation rather
than behavior, with a number of studies reporting that emotion
dysregulation is predictive of suicidal ideation (e.g., Lynch et al.,
2004; Orbach et al., 2007).
Studies examining suicide attempts have produced more
ambiguous results. For instance, Selby et al. (2009) found that,
although suicide attempts were correlated with catastrophizing,
conceptualized as a cognitive component of emotion dysregulation
(Garnefski et al., 2001), they were not correlated with other
measures of emotion dysregulation (e.g., anger rumination, general
rumination, and brooding). Similarly, in a sample of depressed
children, Tamas et al. (2007) found that suicide attempters did not
exhibit lower levels of adaptive emotion regulation or greater levels
of maladaptive emotion regulation than did individuals with only
recurrent thoughts of death, individuals with only suicidal ideation,
or individuals with ideation and plans but no attempts. In contrast,
Zlotnick, Donaldson, Spirito, and Pearlstein (1997) examined
a sample of adolescent inpatient psychiatric patients and reported
that lifetime number of suicide attempts was significantly associ-
ated with emotion dysregulation; however, emotion dysregulation
did not predict whether a participant had been admitted to the
inpatient unit due to severe suicidal ideation or a suicide attempt.
These studies consistently demonstrated a robust relationship
between emotion dysregulation and suicidal desire, but the nature
of the relationship between emotion dysregulation and suicide
attempts was less clear.
One way to clarify the nature of this relationship is to consider the
construct of emotion dysregulation through an examination of
specific subcomponents. Two components of emotion dysregulation
frequently associated with a host of negative outcomes are distress
tolerance (defined as the capacity to experience, accept, and function
in the context of negative psychological states; Simons and Gaher,
2005) and negative urgency (defined as the degree to which an
individual exhibits a tendency to act rashly in the context of or in an
effort to reduce negative affective sensations; Cyders and Smith,
2007; Whiteside and Lynam, 2001). These variables overlap with
multiple facets of Gratz and Roemer’s model of emotion dysregula-
tion discussed above, such as emotional nonacceptance and an
unwillingness to experience negative emotions in the pursuit of goal-
directed behavior (see also Gratz et al., 2007). No research directly
examining negative urgency and distress tolerance and their rela-
tionships with suicidal behavior or ideation have been conducted to
our knowledge; however, research on distress tolerance and negative
urgency has yielded results indicating that these variables are
significantly correlated with outcomes previously demonstrated to
be salient predictors of suicide risk.
Individuals low in distress tolerance have been shown to exhibit
greater levels of a number of problematic outcomes, including NSSI,
binge eating and purging, and an inability to sustain abstinence
from substances (Anestis et al., 2009; Daughters et al., 2005; Nock
and Mendes, 2008). Similarly, high levels of negative urgency have
been linked to a number of problematic behavioral outcomes,
including aggression, marijuana use, alcohol use, substance use
disorders, binge eating and purging, and excessive reassurance
seeking (Anestis et al., 2007a, b; Fischer et al., 2003; Miller et al.,
2003; Lynam and Miller, 2004; Verdejo-Garcia et al., 2007). Given
the tendency for individuals with low distress tolerance or high
levels of negative urgency to engage in such harmful behaviors, it
remains plausible that those same individuals would be at an
increased risk of considering suicide as one potential method
through which to find relief from aversive affective experiences.
 M.D. Anestis et al. / Journal of Psychiatric Research 45 (2011) 603e611
An important distinction thus far left unexamined, however, is
the degree to which the increased vulnerability to suicidal desire
associated with high levels of emotion dysregulation is mirrored by
an increased capability for suicide. Consistent with the IPTS, it
would be expected that emotionally dysregulated individuals
would exhibit elevated levels of perceived burdensomeness and
thwarted belongingness. At the same time, however, the inability to
withstand discomfort inherent in emotion dysregulation variables
may actually serve as an obstacle to the acquisition of the capability
for suicide, which involves fearlessness towards physiological pain
and death. Along these lines, Anestis, Bender, Selby, Ribeiro, and
Joiner (in press) and Bender et al. (unpublished manuscript)
reported in undergraduate samples that high levels of self-reported
distress tolerance predicted higher levels of the acquired capability.
In other words, emotionally dysregulated individuals e those who
experience difficulties tolerating negative emotions e actually
exhibited lower levels of the acquired capability.
One way to understand this seemingly paradoxical association is
to consider the complicated relationship between impulsivity and
suicide. Although impulsive individuals are at a greater risk for
death by suicide (e.g., Dougherty et al., 2004), and are more likely to
engage in NSSI (e.g., Glenn and Klonsky, 2010), research has indi-
cated that suicide is generally not an impulsive action (Simon et al.,
2001; Witte et al., 2008). Building off this point, Baca-Garcia and
colleagues (2001, 2005) demonstrated that the degree to which
a suicide attempt was impulsive was inversely correlated to the
lethality of that attempt. Individuals who have difficulties with
regulating their emotions may be motivated to consider suicide as
a means for relief from aversive affective sensations, but unlikely to
enact such behaviors given less painful and/or frightening alter-
natives. In this sense, emotion dysregulation may serve as a buffer
against the acquired capability for suicide. Furthermore, because
negative affect is experienced as extremely aversive, such individ-
uals might require a greater degree of painful and provocative
experiences in order to develop levels of the acquired capability for
suicide comparable to those who are not as acutely impacted by
negative affective states.
To further clarify the nature of the relationship between various
forms of emotion dysregulation and components of the IPTS in an
undergraduate sample we designed a study in which undergrad-
uates filled out a series of questionnaires and took part in a physi-
ological pain tolerance task. We chose to focus on undergraduates
because suicide is the second leading cause of death in college
students (Centers for Disease Control and Prevention, 2009).
Data indicate that up to 1.3% of undergraduates attempt suicide
during college and up to 6.4% seriously consider lethal self-harm
(American College Health Association, 2009). Additionally, recent
studies indicate that commonly emphasized risk factors (e.g.,
frequency of suicidal ideation) are not optimal predictive tools for
suicidal behavior in undergraduates, thereby highlighting the need
for further research into alternative models of risk conceptualiza-
tion in this population (Wilcox et al., in press). In this study, two
forms of emotion dysregulation were considered: distress toler-
ance and negative urgency. We hypothesized that greater levels of
emotion dysregulation as demonstrated through higher levels of
negative urgency and lower levels of distress tolerance, would
predict elevations in the desire for death by suicide, as evidenced by
higher levels of thwarted belongingness and perceived bur-
densomeness. We further hypothesized that greater levels of
emotion dysregulation would predict lower levels of the acquired
capability for suicide and tolerance of physiological pain. Should
the data support these hypotheses, a somewhat complex but
theoretically and clinically important picture would emerge with
respect to the relationship between emotion dysregulation
and suicidality. Emotionally dysregulated individuals would be
605
shown to be vulnerable to suicidal thoughts, but would not have
acquired the capacity to enact lethal self-injury. This would suggest
that, although emotionally dysregulated individuals are at an
increased risk for death by suicide, this increased risk is not driven
by emotional dysregulation.
1. Method
1.1. Participants
The sample consisted of 283 undergraduates ranging in age from
18 to 39 (mean ¼ 19.34, standard deviation ¼ 2.10). 109 (38.5%) of the
participants were male, 166 (58.7%) were female, and 8 (2.8%)
declined to indicate sex. The ethnic composition of the sample was
68.6% (n ¼ 194) White, 13.1% (n ¼ 37) Hispanic or Latino, 12.0%
(n ¼ 34) African American, 2.8% Asian (n ¼ 8), and 3.5% (n ¼ 10) other.
In order to control for the impact of potential third variables on
our measure of pain tolerance, participants were required to be
right-handed, as left limbs have been shown to demonstrate greater
pain sensitivity than right limbs, regardless of hand preferences
(Murray and Hagan, 1973). Participants were asked to refrain from
consuming sugared foods and alcoholic beverages for at least 1 h
prior to participation (Mercer and Holder, 1997). Additionally,
participants were asked to refrain from consuming any analgesics
(e.g., aspirin, acetaminophen) or other pain suppressants for at least
8 h prior to participation.
1.1.1. Predictor variables
The Urgency, (lack of) Premediation, (lack of) Perseverance,
Sensation Seeking, and Positive Urgency Impulsive Behavior Scale
(UPPS-P; Cyders et al., 2007; Cyders and Smith, 2007) is a 59-item
self-response scale that features five subcategories. The Negative
Urgency subscale consists of twelve items measuring the degree to
which individuals act rashly in the face of negative affect (e.g., I often
make matters worse because I act without thinking when I am upset),
each of which uses a Likert type scale ranging from 1 “Agree
Strongly” to 4 “Disagree strongly.” Negative urgency items were
recoded for the sake of clarity, meaning that high scores on negative
urgency represented increased levels of rash action in response to
negative affect. Negative urgency served as a predictor in several
analyses and the coefficient alpha for this scale was .87. In support of
the construct validity of this scale, negative urgency has been shown
to correspond to measures of neuroticism (e.g., Whiteside and
Lynam, 2001), binge eating and purging, and tension reduction
alcohol consumption motives (Anestis et al., 2007a, b).
The Distress Tolerance Scale (DTS; Simons and Gaher, 2005) is
a 15-item self-report questionnaire examining the degree to which
individuals experience negative emotions as intolerable (e.g. I can’t
handle feeling distressed or upset.). Items utilize a Likert scale
ranging from 1 (Strongly Agree) to 5 (Strongly Disagree), with lower
scores indicating a tendency to experience psychological distress as
unacceptable. Scores on the DTS have been shown to be negatively
correlated with measures of negative affectivity and lability and
positively correlated with measures of positive affectivity (Simons
and Gaher, 2005). Additionally, scores have been shown to be
negatively correlated with measures of disorders characterized by
low distress tolerance, such as binge eating and purging (e.g.,
Anestis et al., 2007a, b), alcohol use, and marijuana use (Simons and
Gaher, 2005). Furthermore, the DTS has been shown to correlate in
the expected direction with measures of various components of
emotion dysregulation, including negative urgency, anxiety sensi-
tivity (Anestis et al., 2007a, b), discomfort intolerance (Kutz et al.,
2010), worry (Huang et al., 2009), and coping motives for mari-
juana use (Zvolensky et al., 2009). The DTS served as a predictor in
several analyses and the coefficient alpha for this measure was .90.
606 M.D. Anestis et al. / Journal of Psychiatric Research 45 (2011) 603e611
1.1.2. Covariates
The Painful and Provocative Events Scale (PPE; Gordon, Bender, &
Joiner, unpublished manuscript) is a 25-item scale designed to assess
the frequency with which an individual has been exposed to
a variety of painful/provocative experiences (e.g., Have you partici-
pated in contact sports? Have you been a victim of physical abuse?).
Experiences assessed on this scale are theorized to involve a degree
of physical pain and/or provocation, which the IPTS posits could
contribute to an individual’s capability for enacting lethal self-harm.
Some experiences involve pain and provocation experienced directly
by the participant, whereas others involve witnessing pain and/or
provocation in others. Items utilize a Likert scale (1 ¼ never;
2 ¼ once; 3 ¼ 2e3 times; 4 ¼ 4e20 times; 5 ¼ more than 20 times). In
support of the construct validity of the measure, scores on the PPE
have been shown to be positively correlated with scores on the
Impulsive Behaviors Scale (Rosotto et al., 1998) and with a measure
of the acquired capability for suicide (Van Orden et al., 2008). This
measure served as a covariate in several analyses and its coefficient
alpha was .66 (an expectedly moderate coefficient given that this is
a life events measure). This variable was included as a covariate due
to concerns that any relationship between emotion dysregulation
variables and either the acquired capability for suicide or pain
tolerance might be better explained by an increased use of behaviors
that might more directly account for shifts in these outcomes.
The Beck Depression Inventory e Second Edition (BDI-II; Beck
et al., 1998) is a 21-item self-report questionnaire used to assess
current symptoms and severity of depression. Items utilize a Likert
scale ranging from 0 to 3, with higher scores indicating greater
levels of depression. An example of a response that would be scored
zero is “I do not feel sad,” while an example of a response that
would be scored three is “I am so sad or unhappy that I can’t stand
it.” The BDI-II has been shown to be a reliable and valid measure of
depressive symptoms (Beck et al., 1998). Item 9 on the BDI-II asks
about suicidal ideation. Due to concerns of criterion contamination
with the outcome measures, this item was removed in all analyses.1
Internal consistency in the current sample was good, a ¼ .84.
The Beck Anxiety Inventory, (BAI; Beck et al., 1988) is a 21-item
self-report questionnaire. Each item uses a Likert Scale (0e3) to
measure the degree to which participants have experienced
particular symptoms of anxiety over the course of the past two
weeks. The measure shows strong test-retest reliability and
extensive information regarding the validity of the measure has
been published by the authors. The coefficient alpha for the BAI was
.92. The BAI and BDI-II were included as covariates in an effort to
ensure that any significant relationship between emotion dysre-
gulation variables and suicidal desire is not better explained by the
presence of psychopathological symptoms.
The sensation seeking, positive urgency, (lack of) premeditation,
and (lack of) perseverance subscales of the UPPS-P Impulsive
Behavior Scale also served as covariates. The sensation seeking
subscale is comprised of twelve items measuring the degree to
which individuals seek out activities that involve elements of risk
and thrill (e.g., I quite enjoy taking risks). Items were recoded such
that high scores on this subscale represented an increased tendency
to seek out risk and thrill. In support of the construct validity of this
scale, sensation seeking has been shown to correspond to measures
of excitement seeking (Whiteside and Lynam, 2001). Sensation
seeking was chosen as a covariate due to previous research indi-
cating that it is a significant predictor of the acquired capability for
suicide (Bender et al., unpublished manuscript). The positive
urgency subscale consists of 14 items measuring the degree to which
1
All analyses utilizing the BDI-II were re-run with item 9 included and the
results were unchanged.
individuals tend to act rashly in response to positive affective states
(e.g., When I am happy, I can’t seem to stop myself from doing things
that can have bad consequences). The (lack of) premeditation subscale
consists of 11 items measuring the degree to which individuals tend
to act without planning (e.g., I am not one of those people who blurt
out things without thinking). The (lack of) perseverance subscale
consists of 10 items measuring the degree to which individuals tend
to quit when they experience difficulty or boredom (e.g., I generally
like to see things through to the end). The respective alpha coefficients
for these scales were .86, .92, .85, and .80.
1.1.3. Outcome variables
A pressure algometer (Type II, Somedic Inc., Solletuna, Sweden)
was utilized to measure participants’ physical pain tolerance. Partic-
ipants were instructed in the application of the pressure algometer.
All trials were conducted on participants’ right hands, with pressure
from the algometer applied below the knuckle of the second digit.
Participants were instructed to say “pain” when they first felt pain
(threshold) and to say “stop” when the pain became too uncomfort-
able to continue (tolerance). The algometer was applied perpendic-
ularly to the skin and was lowered at a rate of approximately 5 N per
second until physical pain tolerance (PPT) was reached. Once the
participant indicated, through verbal report, that PPT had been
reached, the experimenter immediately retracted the algometer. The
digital display continued to show the value of pressure applied at the
moment the algometer was retracted and the weight of pressure
applied to the individual’s finger served as the index of pain tolerance
in these analyses. The results of five separate trials of pain tolerance
were averaged in order to ensure a more reliable measurement.
A reliability analyses was run, with each of the five trials for each
individual serving the role of an item on a self-report scale. The
coefficient alpha for the pressure algometer trials was .97.
The Acquired Capability for Suicide Scale (ACSS; Bender, Gordon,
Bresin, & Joiner, in press) is a 20-item self-report measure that
utilizes a 5-point Likert scale ranging from 0 (not at all like me) to 4
(very much like me). Items examine the degree to which participants
exhibit habituation to the fear of death (e.g. I am very much afraid to
die.[reversed]). Joiner’s (2005) interpersonal-psychological theory of
suicide posits that the capability to enact lethal self-harm develops
through repeated exposure to painful and provocative events and, as
such, elevations on this measure indicate that participants exhibit
a diminished sense of fear in response to thoughts of death or
potentially fatal experiences. Scores on the ACSS have been shown to
correspond with physiological pain tolerance (Bender et al.,
unpublished manuscript), self-reported history of painful and
provocative experiences, and lifetime number of suicide attempts
(Van Orden et al., 2008). Additionally, the scale is correlated with
Linehan, Goodstein, Nielsen, and Chile’s (1983) Fear of Suicide
subscale of the Reasons for Living Inventory in the expected direction
(r ¼ .48, p < .0001; Bender et al., unpublished manuscript) and with
a Beck Scale for Suicidal Ideation (BSS; Beck and Steer, 1991) item that
asks about an individual’s courage to kill oneself (r ¼ .79, p < .007;
Bender et al., unpublished manuscript). The coefficient alpha for this
measure was .84.
The Interpersonal Needs Questionnaire (INQ; Van Orden et al.,
2008) is a 25-item self-report scale designed to assess the two
components of suicidal desire as conceptualized by the IPTS:
thwarted belongingness and perceived burdensomeness. Items are
scored on a Likert scale with higher scores indicating greater risk.
Prior studies have provided support for the construct validity of this
scale. For instance, Van Orden et al. (2008) reported that the
perceived burdensomeness and thwarted belongingness subscales
interacted to predict suicidal ideation, with higher scores on both
subscales conferring the greatest level of risk, even when control-
ling for depression. Joiner et al. (2009) replicated this finding, when
 M.D. Anestis et al. / Journal of Psychiatric Research 45 (2011) 603e611 607

hopelessness included as an additional covariate. Additionally,
scores on the INQ were not significantly correlated with scores on
the ACSS in either study, thereby supporting the theory’s distinc-
tion between suicidal desire and the capability for suicide. For
a thorough review of the construct validity of perceived bur-
densomeness and thwarted belongingness, please see Van Orden
et al. (2010). The alpha coefficient for the perceived burdensome-
ness subscale in this sample was .85 and the alpha coefficient for
the thwarted belongingness subscale in this sample was .88.
2. Results
Means, standard deviations, minimums, maximums, and inter-
correlations for the variables utilized in these analyses can be found
in Table 1. Variable distributions were examined, and this exami-
nation revealed that one variable, pain tolerance, had sig-
nificantskew (1.246) and kurtosis (1.887). These scores underwent
a rank transformation that corrected for non-normality, resulting in
diminished skew (.0) and kurtosis (1.2). For ease of presentation, the
nontransformed means and standard deviations of the original
variables are displayed in tables and text. When referring to multi-
variate analysis, we present results of analyses (e.g., correlations,
betas) conducted after the transformation of the original variable.
To test whether the variables utilized in our analyses were
operating as expected, we examined the zero-order correlations
between suicidal ideation as measured by item 9 of the BDI-II and
the variables in our analyses theorized to correlate with suicidal
desire: negative urgency, distress tolerance, perceived bur-
densomeness, and thwarted belongingness. Results indicted that
distress tolerance (r ¼ .25, p < .001), perceived burdensomeness
(r ¼ .37, p < .001), and thwarted belongingness (r ¼ .30, p < .001)
significantly correlated with suicidal ideation in the expected
directions. Negative urgency, however, was not significantly
correlated with suicidal ideation (r ¼ .09, p ¼ .12). History of sui-
cidality included the following: 6.7% (n ¼ 19) of the sample
endorsed experiences of suicidal ideation within the past two
weeks; 2.8% (n ¼ 8) of the sample reported a previous suicide
attempt; and 63.3% (n ¼ 179) reported no past history of suicidal
behavior. Data on previous suicidal behavior were not available for
33.9% (n ¼ 96) of the sample, as such data were collected partway
through the study. Due to the low base rate of past suicidal behavior
in our sample, tests examining the relationship between pain
tolerance, the acquired capability, and lifetime number of suicide
attempts were not run; however, previous research has indicated
that these variables are significantly related to one another in the
expected direction (e.g., Van Orden et al., 2008).
In order to test our hypothesis that both negative urgency and
distress tolerance would predict perceived burdensomeness and
thwarted belongingness, controlling for depression symptoms,
anxiety symptoms, sensation seeking, positive urgency, (lack of)
premeditation, (lack of) perseverance, and sex, we constructed
a series of two hierarchical linear regression equations. In one of
the equations, perceived burdensomeness served as the outcome
variable and in the other equation, thwarted belongingness served
as the outcome variable. In Step 1 of each equation, the covariates
were entered. Negative urgency and distress tolerance were then
entered simultaneously in Step 2. Results indicated that lower
levels of distress tolerance significantly and uniquely predicted
increases in perceived burdensomeness (t ¼ 3.40, p < .001, semi-
partial correlation [sr] ¼ .17, effect size [f2] ¼ .05; see Table 2) and
thwarted belongingness (t ¼ 3.72, p < .001, sr ¼ .18, f2 ¼ .05; see
Table 3). Results also indicated that negative urgency did not
significantly predict perceived burdensomeness (t ¼ 1.10, p ¼ .27,
sr ¼ .05, f2 ¼ .004; see Table 2) or thwarted belongingness (t ¼ .64,
p ¼ .53, sr ¼ .03, f2 ¼ .002; see Table 3).
In order to test our hypothesis that both lower levels of distress
tolerance and elevations in negative urgency would predict the
acquired capability for suicide and physical pain tolerance,
controlling for painful and provocative events, sensation seeking,
positive urgency, (lack of) premeditation, (lack of) perseverance,
and sex, an additional series of two hierarchical linear regression
equations was constructed. In one of the equations, the acquired
capability for suicide served as the outcome variable and in the
other, physical pain tolerance served as the outcome variable. In
each equation, the covariates were entered in Step 1. Distress
tolerance and negative urgency were then simultaneously entered
in Step 2. Results indicated that distress tolerance did not signifi-
cantly predict the acquired capability for suicide (t ¼ .62, p ¼ .53,
sr ¼ .03, f2 ¼ .002; see Table 4) but did significantly predict pain
tolerance (t ¼ 2.10, p < .04, sr ¼ .12, f2 ¼ .03; see Table 5). Results

Table 1
Means, standard deviations, minimums, maximums, and intercorrelations for all variables utilized in the analyses.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1.NU 1
**
2.DT .48 1
3.PPE **.24 .02 1
4.SS .10 .10 **.35 1
5.PU **.67 **.40 **.28 **.16 1
6.Prem **.29 **.24 .06 *.14 **.30 1
7.Pers **.45 *.13 **.35 **.18 **.47 **.50 1
8.Sex .03 .06 **.36 .11 **.20 *.13 .05 1
9.BDI **.42 **.47 *.13 .06 **.32 **.27 *.15 .03 1
10.BAI **.26 **.33 .06 .03 **.17 *.12 .10 .01 **.43 1
11.Burden **.30 **.41 .11 **.23 **.34 **.34 **.34 **.18 **.45 **.25 1
12.Belong **.31 **.41 **.18 **.24 **.30 **.34 **.31 **.20 **.43 **.19 **.82 1
13.Ideation .09 **.25 .03 *.14 *.12 **.16 .07 .08 **.33 **.21 **.37 **.30 1
14.ACSS *.12 **.17 **.42 **.51 .03 *.13 .08 **.36 .08 .11 .08 .08 .04 1
15.Painþ .06 **.17 **.30 **.22 .05 .10 .05 **.26 .01 .09 .05 .01 .09 **.34 1
Mean 27.40 51.72 43.08 35.28 24.08 18.70 21.61 1.60 8.00 31.85 13.47 21.48 .07 50.77 450.93
SD 6.82 11.88 7.73 6.98 7.65 3.73 5.59 .49 6.94 9.39 7.35 11.59 .29 10.31 232.66
Minimum 12 19 27 14 13 12 11 1 0 21 8 10 0 35 77.80
Maximum 47 75 64 48 46 31 38 2 36 66 47 64 2 75 1012.90

N ranges from 256 to 283; þ ¼ mean and standard deviation represent unadjusted values for ease of interpretation. * ¼ significant at the p < .05 level; ** ¼ significant at the p <
.01 level; NU ¼ Negative Urgency; DT ¼ Distress Tolerance; PPE ¼ Painful and Provocative Events; SS ¼ Sensation Seeking; PU ¼ Positive Urgency; Prem ¼ (lack of)
Premeditation; Pers ¼ (lack of) Perseverance; BDI ¼ Beck Depression Inventory -2 (without item 9); BAI ¼ Beck Anxiety Inventory; Burden ¼ Perceived Burdensomeness;
Belong ¼ Thwarted Belongingness; Ideation ¼ Suicidal Ideation (item 9 of BDI-II); ACSS ¼ Acquired Capability for Suicide; Pain ¼ Pain Tolerance; SD ¼ Standard Deviation.
608 M.D. Anestis et al. / Journal of Psychiatric Research 45 (2011) 603e611

Table 2
Distress tolerance and negative urgency predicting perceived burdensomeness, controlling for sensation seeking, positive urgency, (lack of) premeditation, (lack of) perse-
verance, depression symptoms, anxiety symptoms, and sex.

R2 for set b SE t-value p-value Zero-order Part

1 .35 3.128 4.279 .000
Sensation seeking .233 .053 4.270 .000 .192 .213
Positive urgency .045 .055 .754 .452 .273 .038
Lack of premeditation .033 .113 .535 .593 .313 .027
Lack of perseverance .203 .080 3.167 .002 .257 .158
Depression .373 .059 6.371 .000 .485 .317
Anxiety .090 .040 1.643 .102 .280 .082
Sex .156 .721 3.019 .003 .157 .150
2 .38 3.870 5.528 .000
Sensation seeking .212 .053 3.943 .000 .192 .193
Positive urgency .025 .065 .352 .725 .273 .017
Lack of premeditation .017 .111 .273 .785 .313 .013
Lack of perseverance .239 .082 3.681 .000 .257 .180
Depression .325 .061 5.317 .000 .485 .260
Anxiety .066 .039 1.211 .227 .280 .059
Sex .144 .725 2.774 .006 .157 .136
Negative urgency .082 .074 1.104 .271 .267 .054
Distress tolerance .209 .035 3.398 .001 .416 .166

N ¼ 270; Dependent variable ¼ Perceived Burdensomeness.

also indicated that elevations in negative urgency significantly
predicted lower acquired capability for suicide scores (t ¼ 2.74,
p < .007, sr ¼ .13, f2 ¼ .07; see Table 4) but did not significantly
predict pain tolerance (t ¼ .53, p ¼ .58, sr ¼ .03, f2 ¼ .002; see Table
5). The statistically significant findings were in the hypothesized
direction which, importantly, is the opposite direction of the initial
set of findings regarding suicidal desire (also predicted).
3. Discussion
The relationship between emotion dysregulation and suicide is
frequently discussed, but research on this issue has thus far been
unable to clarify the precise nature of that relationship. The central
purpose of this study was to examine the relationship between two
emotion dysregulation-related variables e distress tolerance and
negative urgency e and the three components of the IPTS: thwar-
ted belongingness, perceived burdensomeness, and the acquired
capability for suicide. Utilizing a sample of undergraduates e
a population for whom suicide is a leading cause of death - we
anticipated that heightened levels of emotion dysregulation would
predict elevated levels of suicidal desire and yet predict lower levels
of the acquired capability for suicide and physiological pain toler-
ance. Results, in large part, supported our hypotheses.
Low levels of distress tolerance predicted increased levels of
thwarted belongingness, even when controlling for sex, sensation
seeking, positive urgency, (lack of) premeditation, (lack of) perse-
verance, and symptoms of depression and anxiety. Additionally,
low levels of distress tolerance predicted high levels of perceived
burdensomeness controlling for the same list of covariates. These
findings indicate that when individuals are frequently over-
whelmed by the experience of negative emotions, they are at
greater risk for developing suicidal desire. This finding was not
surprising, as past research has consistently linked emotion dys-
regulation with suicidal ideation and desire (e.g., Lynch et al., 2004;
Orbach et al., 2007). The non-significant relationships between
negative urgency and both perceived burdensomeness and
thwarted belongingness were surprising and seem to indicate that
the significant zero-order correlation (r ¼ .30 and .31 respectively)
between those variables may be largely accounted for by distress
tolerance. A series of post-hoc analyses in which each covariate was
individually removed from the regression equations revealed that it
was the presence of distress tolerance in the equation that rendered

Table 3
Distress tolerance and negative urgency predicting thwarted belongingness, controlling for sensation seeking, positive urgency, (lack of) premeditation, (lack of) perseverance,
depression symptoms, anxiety symptoms, and sex.

R2 for set b SE t-value p-value Zero-order Part

1 .34 5.046 4.618 .000
Sensation seeking .231 .086 4.181 .000 .207 .211
Positive urgency .004 .088 .071 .944 .229 .004
Lack of premeditation .081 .182 1.300 .195 .331 .065
Lack of perseverance .170 .130 2.616 .009 .227 .132
Depression .393 .095 6.624 .000 .468 .334
Anxiety .014 .064 .246 .806 .206 .012
Sex .183 1.163 3.499 .001 .183 .176
2 .37 6.190 5.843 .000
Sensation seeking .209 .084 3.860 .000 .207 .189
Positive urgency .093 .104 1.294 .197 .229 .063
Lack of premeditation .064 .178 1.049 .295 .331 .052
Lack of perseverance .185 .130 2.834 .005 .227 .139
Depression .314 .098 5.122 .000 .468 .251
Anxiety .022 .063 .399 690 .206 .020
Sex .191 1.160 3.661 .000 .183 .180
Negative urgency .048 .119 .635 .526 .287 .031
Distress tolerance .230 .056 3.724 .000 .424 .183

N ¼ 270; Dependent variable ¼ Thwarted Belongingness.

 M.D. Anestis et al. / Journal of Psychiatric Research 45 (2011) 603e611 609

Table 4
Distress Tolerance and negative urgency predicting acquired capability for suicide, controlling for sensation seeking, positive urgency, (lack of) premeditation, (lack of)
perseverance, painful and provocative events, and sex.

R2 for set b SE t-value p-value Zero-order Part

1 .42 5.250 6.517 .000
Sensation seeking .426 .079 8.085 .000 .517 .379
Positive urgency .147 .075 2.715 .007 .032 .127
Lack of premeditation .082 .161 1.431 .154 .135 .067
Lack of perseverance .003 .121 .042 .967 .082 .002
PPE .216 .076 3.798 .000 .422 .178
Sex .280 1.104 5.423 .000 .366 .255
2 .44 6.027 5.408 .000
Sensation seeking .414 .078 7.912 .000 .517 .366
Positive urgency .013 .094 .198 .843 .032 .009
Lack of premeditation .066 .160 1.151 .251 .135 .053
Lack of perseverance .022 .121 .342 .733 .082 .016
PPE .238 .076 4.209 .000 .422 .195
Sex .240 1.128 4.551 .000 .366 .210
Negative urgency .192 .107 2.740 .007 .124 .127
Distress tolerance .034 .048 .623 .534 .164 .029

N ¼ 270; Dependent variable ¼ Acquired Capability for Suicide Note: PPE ¼ Painful and Provocative Experiences Scale.

the negative urgency findings null. This is also notable in that it
seems to indicate that the action component of negative urgency is
less relevant to suicidal desire than the affective component, which
is also captured in the distress tolerance construct (indeed, the two
variables are highly correlated with one another). In this sense, the
subjective experience of and response to (e.g., nonacceptance)
distress may play a larger role in the development of suicidal desire
than the maladaptive behaviors that sometimes result from an
inability to tolerate such sensations. Additionally, the non-signifi-
cant correlation between negative urgency and suicidal ideation
might indicate that the motivation to reduce feelings of negative
affect might be representative of a more transient, momentary
sensation that leads to action and is not directly responsible for the
brooding involved in thoughts of suicide.
The more noteworthy findings, related to the acquired capability
for suicide and physiological pain tolerance, and the use of both
a self-report measure and a behavioral pain tolerance task repre-
sented a strength of this study. Results indicated that negative
urgency but not distress tolerance predicted the acquired capability
for suicide, whereas distress tolerance but not negative urgency
predicted physiological pain tolerance. It is important to remember
that the capability for suicide and desire for suicide are orthogonal
from one another (e.g., Van Orden et al., 2008) and as such, being
capable of suicide does not mean that an individual is, was, or ever
will be suicidal. Instead, this finding indicates that when individ-
uals evaluate the experience of negative affect as highly aversive
(and are thus unwilling to tolerate it), they are less able to tolerate
physical pain and when an individual tends to act rashly in an effort
to reduce aversive emotional experiences, they are less likely to be
able to enact lethal self-harm.
The significant finding for negative urgency in the prediction of
the acquired capability seems to indicate that the action compo-
nent of negative urgency is of greater importance in the develop-
ment of the acquired capability than is the subjective affective
experience component. In a non-clinical population in which
severely painful behaviors occur at a low base rate, individuals with
high levels of negative urgency may quickly engage in distracting
behaviors that prevent them from habituating to aversive affective
sensations while making no contribution to their ability to tolerate
physiological pain. The significant relationship between distress
tolerance and pain tolerance, on the other hand, seems to indicate
that a general ability to tolerate discomfort plays a stronger role in
the development of heightened pain tolerance. This is consistent
with recent research indicating that pain tolerance may, in fact, be
context dependent, with individuals with a history of NSSI (a
population previously found to exhibit high levels of emotion
dysregulation; Gratz and Roemer, 2008) exhibiting higher pain
tolerance in the presence of increased levels of interpersonally-
oriented negative affect (Gratz et al., in press).
As mentioned above, diagnoses characterized by emotion dys-
regulation (e.g., borderline personality disorder) are also associated
with elevated rates of suicide; however, our findings may indicate

Table 5
Distress tolerance and negative urgency predicting pain tolerance, controlling for sensation seeking, positive urgency, (lack of) premeditation, (lack of) perseverance, painful
and provocative events, and sex.

R2 for set b SE t-value p-value Zero-order Part

1 .18 46.605 .133 .894
Sensation Seeking .186 .722 2.770 .006 .219 .161
Positive Urgency e.212 .662 3.229 .001 .061 .187
Premeditation .167 1.419 2.388 .018 .086 .138
Perseverance e.057 1.087 .737 .462 .060 .043
PPE .233 .688 3.376 .001 .296 .196
Sex e.172 9.828 2.699 .007 .255 .156
2 .19 54.131 .963 .336
Sensation Seeking .170 .727 2.511 .013 .219 .145
Positive Urgency .174 .844 2.076 .039 .061 .120
Premeditation .187 1.425 2.651 .009 .086 .153
Perseverance .082 1.117 1.029 .305 .060 .059
PPE .225 .693 3.240 .001 .296 .187
Sex .176 10.044 2.717 .007 .255 .157
Negative Urgency .047 .961 .529 .597 .056 .031
Distress Tolerance .145 .423 2.104 .036 .166 .121

N ¼ 252; Dependent variable ¼ Pain Tolerance Note: PPE ¼ Painful and Provocative Experiences Scale.
610 M.D. Anestis et al. / Journal of Psychiatric Research 45 (2011) 603e611
that suicide in those populations cannot be explained solely by
emotion dysregulation. Lethal suicide attempts are inherently
frightening and painful events. In order to develop the capability of
engaging in such behavior, an individual must be able to tolerate
substantial discomfort and fear. Individuals with elevated levels of
negative urgency or low levels of distress tolerance might be
innately less capable of such actions and, as such, may need to
experience greater levels of pain and provocation than others over
the course of their lives in order to sufficiently habituate to the
sensations that would otherwise prevent them from engaging in
a lethal attempt.
In this sense, the use of an undergraduate sample diminished
our ability to fully address this question, as this sample included
low base rates of the types of severely dysregulated behaviors
potentially capable of impacting the relationship between emotion
dysregulation and suicide in that manner (e.g., NSSI, suicide
attempts). It remains a possibility that within clinical populations,
emotionally dysregulated individuals do, in fact, engage in enough
highly painful and provocative experiences to overcome their own
inherent buffer against the acquired capability. Furthermore, the
relationship between emotion dysregulation and suicidal ideation
may differ in clinical populations, thereby reducing the generaliz-
ability of our findings to such individuals. Future studies utilizing
a clinical sample would provide important insights on these points.
With that being said, the use of an undergraduate population also
enabled us to assess the nature of the relationships between these
variables in a manner with greater external validity while still
examining a population for whom suicide is a leading cause of
death. In other words, understanding how these variables relate to
one another in a sample more similar to the general population
than a clinical population ensures that the data do not simply
represent relationships as they appear within the context of
heightened levels of psychopathology.
This study involved a number of other limitations. The use of
a single time point precluded any understanding of directionality in
the relationships between variables. It remains possible that the
components of the IPTS influence individuals’ levels of emotion
dysregulation. Although we statistically controlled for symptoms of
depression and anxiety, the use of a non-clinical population also
precluded an examination of the degree to which the level of
psychopathology impacts the relationships explored in this study.
Future work that includes the use of structured diagnostic inter-
views would be highly valuable in clarifying that point. Also,
although participants were asked to abstain from utilizing
a number of substances that could theoretically impact pain
tolerance (e.g., analgesics), other substances (e.g., nicotine) were
not assessed for and could have potentially spuriously impacted
results. Finally, the use of self-report measures of distress tolerance
and negative urgency may have introduced bias into the responses
of participants. Future research utilizing behavioral measures of
these constructs will help ensure that method variance did not
spuriously influence our results.
Despite these limitations, the current study maintains important
scientific and clinical implications. Scientifically, our study marks
one of the initial explorations of the role of emotion in general and
emotion dysregulation specifically in suicidal behavior as concep-
tualized by the IPTS. In turn, clinically, a greater understanding of the
role of emotion dysregulation in specific components of suicidal
behavior can help to develop more precise interventions for
emotionally dysregulated suicidal individuals, as examinations of
specific components of suicide risk increases the likelihood that
clinicians can target the exact vulnerability of a particular patient.
Additionally, this study provided empirical evidence suggesting that
considering overarching terms such as emotion dysregulation and
suicide is an overly broad approach to understanding an important
clinical situation. Both emotion dysregulation and suicidality can be
broken down into meaningful components, which suggests a much
more complicated relationship.
Funding source
No funding sources were utilized for this project.
Contributors
Author M.A. designed the study and managed data analysis. All
authors took part in the interpretation of the results. Author M.A.
managed the literature search and wrote the initial draft of the
manuscript. All authors contributed to and have approved the final
draft.
Conflict of interest
The authors of this manuscript do not have any conflicts of
interest.
Acknowledgements
The authors greatly appreciate the work of Bruno Chiurliza,
Charlie Spillers, Ryan Clark-Gonzalez, Jimmy Powers, Dusty Hun-
saker, and Anthony Ferrari, who collected data during the course of
the study.
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