Keywords
emotion regulation
psychoactive substances
substance use disorders
addictive behavior
addiction
relapse
systematic review
How to Cite
Abstract
Background. Substance use disorders (SUDs) represent one of the most significant challenges in contemporary clinical psychology and psychiatry. Accumulating evidence indicates that emotional dysregulation is a key psychological factor underlying the development, maintenance, and relapse of addictive behaviors. It is characterized by impairments in recognizing, accepting, regulating, and adaptively expressing emotional experiences. Despite the growing body of empirical research, findings remain fragmented and require systematic synthesis.
Objective. To systematically review and synthesize current evidence regarding the role of emotional dysregulation in the development, maintenance, and relapse of substance use disorders, as well as to identify the primary psychological mechanisms underlying this relationship.
Methods. A systematic literature review was conducted in accordance with the PRISMA guidelines. Empirical studies, systematic reviews, and meta-analyses published in peer-reviewed international journals in recent years were included. The literature search was performed using the Scopus, Web of Science, PubMed, and PsycINFO databases with combinations of keywords related to emotional dysregulation, addictive behavior, and substance use disorders. The selected studies were analyzed using a qualitative synthesis approach.
Results. The reviewed literature indicates that emotional dysregulation constitutes one of the core transdiagnostic mechanisms contributing to addictive behavior. Strong evidence demonstrates associations between deficits in emotion regulation, negative affectivity, impulsivity, impaired emotional awareness, maladaptive coping strategies, and an increased risk of substance use disorders. Psychoactive substances are frequently used as a means of temporarily alleviating negative emotional states, thereby reinforcing a cycle of negative reinforcement and increasing the likelihood of relapse. Furthermore, several studies demonstrate that psychotherapeutic interventions targeting emotion regulation skills contribute to lower relapse rates and improved treatment outcomes.
Conclusions. Emotional dysregulation is a fundamental psychological mechanism involved in the onset, maintenance, and chronic course of substance use disorders. Integrating contemporary emotion regulation models into prevention programs, psychological interventions, and psychotherapeutic treatment may substantially enhance therapeutic effectiveness, promote adaptive stress-coping strategies, and reduce relapse risk. Future research should further investigate the neuropsychological mechanisms of emotional dysregulation, its relationship with different classes of psychoactive substances, and the development of personalized psychotherapeutic interventions.
Keywords: emotional dysregulation; emotion regulation; psychoactive substances; substance use disorders; addictive behavior; addiction; relapse; systematic review.
References
Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30(2), 217–237. https://doi.org/10.1016/j.cpr.2009.11.004
Bakhshaie, J., Rogers, A. H., Kauffman, B. Y., Zvolensky, M. J., & Ditre, J. W. (2019). Emotion dysregulation as an explanatory factor in the relation between negative affectivity and non-medical use of opioids in a diverse young adult sample. Addictive Behaviors, 95, 11–16. https://doi.org/10.1016/j.addbeh.2019.03.007
Baker, T. B., Piper, M. E., McCarthy, D. E., Majeskie, M. R., & Fiore, M. C. (2004). Addiction motivation reformulated: An affective processing model of negative reinforcement. Psychological Review, 111(1), 33–51. https://doi.org/10.1037/0033-295X.111.1.33
Berking, M., Margraf, M., Ebert, D., Wupperman, P., Hofmann, S. G., & Junghanns, K. (2011). Deficits in emotion-regulation skills predict alcohol use during and after cognitive-behavioral therapy for alcohol dependence. Journal of Consulting and Clinical Psychology, 79(3), 307–318. https://doi.org/10.1037/a0023421
Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., Clifasefi, S., Garner, M., Douglass, A., Larimer, M. E., & Marlatt, A. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30(4), 295–305. https://doi.org/10.1080/08897070903250084
Bowen, S., Witkiewitz, K., Clifasefi, S. L., Grow, J., Chawla, N., Hsu, S. H., Carroll, H. A., Harrop, E., Collins, S. E., Lustyk, M. K., & Larimer, M. E. (2014). Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: A randomized clinical trial. JAMA Psychiatry, 71(5), 547–556. https://doi.org/10.1001/jamapsychiatry.2013.4546
Carbia, C., López-Caneda, E., Corral, M., & Cadaveira, F. (2018). A systematic review of neuropsychological studies involving young binge drinkers. Neuroscience & Biobehavioral Reviews, 90, 332–349. https://doi.org/10.1016/j.neubiorev.2018.04.013
Carbia, C., López-Caneda, E., Corral, M., & Cadaveira, F. (2021). A biological framework for emotional dysregulation in alcohol misuse: From gut to brain. Molecular Psychiatry, 26, 1098–1118. https://doi.org/10.1038/s41380-020-00970-6
Cavicchioli, M., Movalli, M., & Maffei, C. (2019). The therapeutic role of emotion regulation and coping strategies during a stand-alone DBT skills training program for alcohol use disorder and concurrent substance use disorders. Addictive Behaviors, 98, 106035. https://doi.org/10.1016/j.addbeh.2019.106035
Cheetham, A., Allen, N. B., Yücel, M., & Lubman, D. I. (2010). The role of affective dysregulation in drug addiction. Clinical Psychology Review, 30(6), 621–634. https://doi.org/10.1016/j.cpr.2010.04.005
Conklin, C. A., & Tiffany, S. T. (2002). Applying extinction research and theory to cue-exposure addiction treatments. Addiction, 97(2), 155–167. https://doi.org/10.1046/j.1360-0443.2002.00014.x
Cooperman, N. A., Hanley, A. W., Kline, A., Falkin, G. P., D’Agostino, C., Patton, M., & Garland, E. L. (2024). Telehealth Mindfulness-Oriented Recovery Enhancement versus usual care in individuals receiving methadone treatment for opioid use disorder and pain: A randomized clinical trial. JAMA Network Open, 7(1), e2352462. https://doi.org/10.1001/jamanetworkopen.2023.52462
Cooper, M. L., Frone, M. R., Russell, M., & Mudar, P. (1995). Drinking to regulate positive and negative emotions: A motivational model of alcohol use. Journal of Personality and Social Psychology, 69(5), 990–1005. https://doi.org/10.1037/0022-3514.69.5.990
Daughters, S. B., Lejuez, C. W., Kahler, C. W., Strong, D. R., & Brown, R. A. (2005). Psychological distress tolerance and duration of most recent abstinence attempt among residential treatment-seeking substance abusers. Psychology of Addictive Behaviors, 19(2), 208–211. https://doi.org/10.1037/0893-164X.19.2.208
Daughters, S. B., Reynolds, E. K., MacPherson, L., Kahler, C. W., Danielson, C. K., Zvolensky, M., & Lejuez, C. W. (2009). Distress tolerance and early adolescent externalizing and internalizing symptoms: The moderating role of gender and ethnicity. Behaviour Research and Therapy, 47(3), 198–205. https://doi.org/10.1016/j.brat.2008.12.001
Dragan, M. (2015). Difficulties in emotion regulation and problem drinking in young women: The mediating effect of metacognitions about alcohol use. Addictive Behaviors, 48, 30–35. https://doi.org/10.1016/j.addbeh.2015.04.008
Dvorak, R. D., Sargent, E. M., Kilwein, T. M., Stevenson, B. L., Kuvaas, N. J., & Williams, T. J. (2014). Alcohol use and alcohol-related consequences: Associations with emotion regulation difficulties. The American Journal of Drug and Alcohol Abuse, 40(2), 125–130. https://doi.org/10.3109/00952990.2013.877920
Fox, H. C., Axelrod, S. R., Paliwal, P., Sleeper, J., & Sinha, R. (2007). Difficulties in emotion regulation and impulse control during cocaine abstinence. Drug and Alcohol Dependence, 89(2–3), 298–301. https://doi.org/10.1016/j.drugalcdep.2006.12.026
Fox, H. C., Hong, K. A., & Sinha, R. (2008). Difficulties in emotion regulation and impulse control in recently abstinent alcoholics compared with social drinkers. Addictive Behaviors, 33(2), 388–394. https://doi.org/10.1016/j.addbeh.2007.10.002
Garke, M. Å., Isacsson, N. H., Sörman, K., Bjureberg, J., Hellner, C., Gratz, K. L., & Jayaram-Lindström, N. (2021). Emotion dysregulation across levels of substance use. Psychiatry Research, 296, 113662. https://doi.org/10.1016/j.psychres.2020.113662
Garland, E. L., Bell, S., Atchley, R., & Froeliger, B. (2018). Emotion dysregulation in addiction: Reappraisal deficits promote craving and emotional distress in opioid-misusing chronic pain patients. Journal of Behavioral Medicine, 41(6), 831–840. https://doi.org/10.1007/s10865-018-9946-8
Garland, E. L., Bryan, C. J., Priddy, S. E., Riquino, M. R., Froeliger, B., & Howard, M. O. (2019). Effects of Mindfulness-Oriented Recovery Enhancement versus social support on negative affective interference during inhibitory control among opioid-treated chronic pain patients: A pilot mechanistic study. Annals of Behavioral Medicine, 53(10), 865–876. https://doi.org/10.1093/abm/kay096
Garland, E. L., Froeliger, B., & Howard, M. O. (2014). Mindfulness training targets neurocognitive mechanisms of addiction at the attention–appraisal–emotion interface. Frontiers in Psychiatry, 4, Article 173. https://doi.org/10.3389/fpsyt.2013.00173
Garland, E. L., Hanley, A. W., Nakamura, Y., Barrett, J. W., Baker, A. K., Reese, S. E., Riquino, M. R., Froeliger, B., Donaldson, G. W., & Howard, M. O. (2022). Mindfulness-Oriented Recovery Enhancement remediates anhedonia in chronic opioid use by enhancing neurophysiological responses during savoring of natural rewards. Psychological Medicine, 52(16), 3762–3772. https://doi.org/10.1017/S0033291721003834
Gold, A. K., Stathopoulou, G., Otto, M. W., & Evins, A. E. (2019). Emotion regulation and motives for illicit drug use in opioid use disorder. Journal of Substance Abuse Treatment, 104, 29–35. https://doi.org/10.1016/j.jsat.2019.06.009
Gonzalez, V. M., Reynolds, B., & Skewes, M. C. (2011). Role of impulsivity in the relationship between depression and alcohol problems among emerging adult college drinkers. Experimental and Clinical Psychopharmacology, 19(4), 303–313. https://doi.org/10.1037/a0022720
Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. https://doi.org/10.1023/B:JOBA.0000007455.08539.94
Gross, J. J. (1998). The emerging field of emotion regulation: An integrative review. Review of General Psychology, 2(3), 271–299. https://doi.org/10.1037/1089-2680.2.3.271
Gross, J. J. (2015). Emotion regulation: Current status and future prospects. Psychological Inquiry, 26(1), 1–26. https://doi.org/10.1080/1047840X.2014.940781
Gross, J. J., & John, O. P. (2003). Individual differences in two emotion-regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85(2), 348–362. https://doi.org/10.1037/0022-3514.85.2.348
Heatherton, T. F., & Wagner, D. D. (2011). Cognitive neuroscience of self-regulation failure. Trends in Cognitive Sciences, 15(3), 132–139. https://doi.org/10.1016/j.tics.2010.12.005
Holzhauer, C. G., Wemm, S. E., & Wulfert, E. (2024). The role of emotion dysregulation in heightened alcohol craving following stress among women with alcohol use disorder and co-occurring emotional symptoms. Psychology of Addictive Behaviors. Advance online publication. https://doi.org/10.1037/adb0000991
Hudak, J., Hanley, A. W., Marchand, W. R., Nakamura, Y., Yabko, B., & Garland, E. L. (2021). The temporal dynamics of emotion dysregulation in opioid misuse: An autonomic and affective analysis. Drug and Alcohol Dependence, 221, 108609. https://doi.org/10.1016/j.drugalcdep.2021.108609
Jansen, J. M., van den Heuvel, O. A., van der Werf, Y. D., de Wit, S. J., Veltman, D. J., van den Brink, W., & Goudriaan, A. E. (2019). Emotion processing, reappraisal, and craving in alcohol dependence: A functional magnetic resonance imaging study. Frontiers in Psychiatry, 10, Article 227. https://doi.org/10.3389/fpsyt.2019.00227
Jakubczyk, A., Trucco, E. M., Kopera, M., Kobyliński, P., Suszek, H., Fudalej, S., Brower, K. J., & Wojnar, M. (2018). The association between impulsivity, emotion regulation, and symptoms of alcohol use disorder. Journal of Substance Abuse Treatment, 91, 49–56. https://doi.org/10.1016/j.jsat.2018.05.004
Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. American Journal of Psychiatry, 142(11), 1259–1264. https://doi.org/10.1176/ajp.142.11.1259
Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4(5), 231–244. https://doi.org/10.3109/10673229709030550
Koob, G. F. (2008). A role for brain stress systems in addiction. Neuron, 59(1), 11–34. https://doi.org/10.1016/j.neuron.2008.06.012
Koob, G. F. (2013). Negative reinforcement in drug addiction: The darkness within. Current Opinion in Neurobiology, 23(4), 559–563. https://doi.org/10.1016/j.conb.2013.03.011
Koob, G. F., & Le Moal, M. (2008). Addiction and the brain antireward system. Annual Review of Psychology, 59, 29–53. https://doi.org/10.1146/annurev.psych.59.103006.093548
Koob, G. F., & Volkow, N. D. (2010). Neurocircuitry of addiction. Neuropsychopharmacology, 35(1), 217–238. https://doi.org/10.1038/npp.2009.110
Koob, G. F., & Volkow, N. D. (2016). Neurobiology of addiction: A neurocircuitry analysis. The Lancet Psychiatry, 3(8), 760–773. https://doi.org/10.1016/S2215-0366(16)00104-8
Le Berre, A. P. (2019). Emotional processing and social cognition in alcohol use disorder. Neuropsychology, 33(6), 808–821. https://doi.org/10.1037/neu0000572
Le Moal, M., & Koob, G. F. (2007). Drug addiction: Pathways to the disease and pathophysiological perspectives. European Neuropsychopharmacology, 17(6–7), 377–393. https://doi.org/10.1016/j.euroneuro.2006.10.006
Leyro, T. M., Zvolensky, M. J., & Bernstein, A. (2010). Distress tolerance and psychopathological symptoms and disorders: A review of the empirical literature among adults. Psychological Bulletin, 136(4), 576–600. https://doi.org/10.1037/a0019712
Linehan, M. M., Schmidt, H., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K. A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addictions, 8(4), 279–292. https://doi.org/10.1080/105504999305686
Maffei, C., Cavicchioli, M., Movalli, M., Cavallaro, R., & Fossati, A. (2018). Dialectical Behavior Therapy Skills Training in alcohol dependence treatment: Findings based on an open trial. Substance Use & Misuse, 53(14), 2368–2385. https://doi.org/10.1080/10826084.2018.1480035
Marlatt, G. A., & George, W. H. (1984). Relapse prevention: Introduction and overview of the model. British Journal of Addiction, 79(3), 261–273. https://doi.org/10.1111/j.1360-0443.1984.tb03867.x
McHugh, R. K., Reynolds, E. K., Leyro, T. M., & Otto, M. W. (2013). An examination of the association of distress intolerance and emotion regulation with avoidance. Cognitive Therapy and Research, 37, 363–367. https://doi.org/10.1007/s10608-012-9463-6
Molina, G., Viola, M., Rogers, M., O’Malley, S., Gangopadhyay, P., & Mahon, C. (2023). A systematic review of psychological interventions for adult survivors of adverse childhood experiences with substance use disorders. Trauma, Violence, & Abuse, 24(5), 3325–3345. https://doi.org/10.1177/15248380221130358
Morawetz, C., Bode, S., Derntl, B., & Heekeren, H. R. (2017). The effect of strategies, goals, and stimulus material on the neural mechanisms of emotion regulation: A meta-analysis of fMRI studies. Neuroscience & Biobehavioral Reviews, 72, 111–128. https://doi.org/10.1016/j.neubiorev.2016.11.014
Petit, G., Luminet, O., Maurage, F., Tecco, J., Lechantre, S., Ferauge, M., Gross, J. J., & de Timary, P. (2015). Emotion regulation in alcohol dependence. Alcoholism: Clinical and Experimental Research, 39(12), 2471–2479. https://doi.org/10.1111/acer.12914
Price, C. J., Thompson, E. A., Crowell, S. E., & Pike, K. (2019). Longitudinal effects of interoceptive awareness training through Mindful Awareness in Body-Oriented Therapy as an adjunct to women’s substance use disorder treatment: A randomized controlled trial. Drug and Alcohol Dependence, 198, 140–149. https://doi.org/10.1016/j.drugalcdep.2019.02.012
Rakesh, D., Allen, N. B., & Whittle, S. (2020). Balancing act: Neural correlates of affect dysregulation in youth depression and substance use—A systematic review of functional neuroimaging studies. Developmental Cognitive Neuroscience, 42, 100775. https://doi.org/10.1016/j.dcn.2020.100775
Riquino, M. R., Priddy, S. E., Howard, M. O., & Garland, E. L. (2018). Emotion dysregulation as a transdiagnostic mechanism of opioid misuse and suicidality among chronic pain patients. Borderline Personality Disorder and Emotion Dysregulation, 5, Article 11. https://doi.org/10.1186/s40479-018-0086-8
Sinha, R. (2001). How does stress increase risk of drug abuse and relapse? Psychopharmacology, 158(4), 343–359. https://doi.org/10.1007/s002130100917
Sinha, R. (2008). Chronic stress, drug use, and vulnerability to addiction. Annals of the New York Academy of Sciences, 1141(1), 105–130. https://doi.org/10.1196/annals.1441.030
Sinha, R. (2009). Modeling stress and drug craving in the laboratory: Implications for addiction treatment development. Addiction Biology, 14(1), 84–98. https://doi.org/10.1111/j.1369-1600.2008.00134.x
Sinha, R. (2011). New findings on biological factors predicting addiction relapse vulnerability. Current Psychiatry Reports, 13(5), 398–405. https://doi.org/10.1007/s11920-011-0224-0
Sloan, E., Hall, K., Moulding, R., Bryce, S., Mildred, H., & Staiger, P. K. (2017). Emotion regulation as a transdiagnostic treatment construct across anxiety, depression, substance use, eating, and borderline personality disorders: A systematic review. Clinical Psychology Review, 57, 141–163. https://doi.org/10.1016/j.cpr.2017.09.002
Stellern, J., Xiao, K. B., Grennell, E., Sanches, M., Gowin, J. L., & Sloan, M. E. (2023). Emotion regulation in substance use disorders: A systematic review and meta-analysis. Addiction, 118(1), 30–47. https://doi.org/10.1111/add.16001
Tang, Y. Y., Tang, R., & Posner, M. I. (2016). Mindfulness meditation improves emotion regulation and reduces drug abuse. Drug and Alcohol Dependence, 163, S13–S18. https://doi.org/10.1016/j.drugalcdep.2015.11.041
Thorberg, F. A., Young, R. M., Sullivan, K. A., & Lyvers, M. (2009). Alexithymia and alcohol use disorders: A critical review. Addictive Behaviors, 34(3), 237–245. https://doi.org/10.1016/j.addbeh.2008.10.016
Tull, M. T., Bardeen, J. R., DiLillo, D., Messman-Moore, T., & Gratz, K. L. (2015). A prospective investigation of emotion dysregulation as a moderator of the relation between posttraumatic stress symptoms and substance use severity. Journal of Anxiety Disorders, 29, 52–60. https://doi.org/10.1016/j.janxdis.2014.11.003
Weiss, N. H., Kiefer, R., Goncharenko, S., Raudales, A. M., Forkus, S. R., Schick, M. R., & Contractor, A. A. (2022). Emotion regulation and substance use: A meta-analysis. Drug and Alcohol Dependence, 230, 109131. https://doi.org/10.1016/j.drugalcdep.2021.109131
Wilcox, C. E., Pommy, J. M., & Adinoff, B. (2016). Neural circuitry of impaired emotion regulation in substance use disorders. American Journal of Psychiatry, 173(4), 344–361. https://doi.org/10.1176/appi.ajp.2015.15060710
Witkiewitz, K., Bowen, S., Douglas, H., & Hsu, S. H. (2013). Mindfulness-based relapse prevention for substance craving. Addictive Behaviors, 38(2), 1563–1571. https://doi.org/10.1016/j.addbeh.2012.04.001
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