Using DERS to differentiate between alcoholism and so-called co-morbidities

Throughout our blogs thus far, we have proposed that alcoholism is a psychiatric disorder in it’s own right.

It may have “co-morbidities” such as generalized anxiety disorder (GAD) or post traumatic stress disoder (PTSD) and so on but these do not necessarily fully account for the manifestation of the specific difficulties we see in those with alcoholism, such as distress-based impulsivity, decision making making deficits which favour short term over long term considerations.

Also the maladaptive emotional regulation strategies we see in e.g. depression, which are shared in alcoholism, such as use of rumination, thought suppression or the catastrophising seen in OCD and in alcoholism, as well as the intolerance of uncertainty also seen in this condition and alcoholism may simply be due to an overlap in the pathomechanism that drive these conditions.

In other words, these different disorders may have similar impairment in similar brain regions or deficits in certain neurotransmitters or have hyperactive stress systems but that these slight discrepancies manifest in certain idiosynstratic behaviours, e.g. relapse to substance use as opposed to hoarding or cleaning or checking.

We feel there may be a danger in relegating manifest features of alcoholism to those of “co-morbidities” when these co-morbidities, if present at all, act on existing psychic structures, structures which we believe are often geneticaly inherited and influenced by, in many instances, by adverse childhoods.

In the addiction cycle , alcoholism becomes increasingly to look like anxiety as the result of increasingly hyperactive stress systems and emotional regulation becomes increasingly impaired giving rise  to maladaptive strategies such as the rumination seen in depression. The stimulus response of automatic drug approach behaviors under extreme emotional distress, at the endpoint of addiction,  is similar to that posited to occur in PTSD.

Just because alcoholism and addiction have similar manifest neuromechanisms and a certain commonality in manifest behaviours does not necessarily make the case for total relegation of these to that of co-morbidity.

How can researchers hope to differentiate between these conditions in the hope of more accurately investigating alcoholism and how can treatment providers more effectively treat these conditions by separating alcoholism from it’s co-morbidities, and treat each area individually as well as holistically.

The  Difficulties in Emotion Regulation Scale (DERS; 1) a comprehensive measure of difficulties in emotion regulation. It offers some hope for differentiating various disorders according to scores on this scale but also in paying attention to scores on subscales, e.g. alcoholics often score highly in the impulsivity sub- scale. This is crucial to effective treatment because research shows that relapse is often prompted by  difficulties in impulse control. In other words, distress provokes impulsive behaviour more perhaps than in depression.

DERS may have particular utility in understanding a client’s particular areas of treatment concern and in devising a treatment strategy to address this.

The DERS is a 36-item self-report measure that assesses individuals’ typical levels of emotion regulation difficulties in general, as well as across a number of specific dimensions of emotion regulation.

Individuals are asked to indicate how often the items apply to themselves, with responses ranging from 1 to 5, where 1 is “almost never (0-10%),” 2 is “sometimes (11-35%),” 3 is “about half the time (36-65%),” 4 is “most of the time (66-90%),” and 5 is “almost always (91-100%).” The DERS provides a total score (ranging from 36 to 180) that represents overall difficulties in emotion regulation, as well as six subscale scores: (a) nonacceptance of emotional responses (scores range from 6 to 30; e.g., “When I’m upset, I feel ashamed with myself for feeling that way.”); (b) difficulties engaging in goal-directed behaviors when distressed (scores range from 5 to 25; e.g., “When I’m upset, I have difficulty getting work done.”); (c) difficulties controlling impulsive behaviors when distressed (scores range from 6 to 30; e.g., When I’m upset, I lose control over my behaviors.”); (d) lack of emotional awareness (scores range from 6 to 30; e.g., “I pay attention to how I feel.” [reverse scored]); (e) limited access to emotion regulation strategies perceived as effective (scores range from 8 to 40; e.g., “When I’m upset, I know that I can find a way to eventually feel better.” [reverse scored]); and (f) lack of emotional clarity (scores range from 5 to 25; e.g., “I have difficulty making sense out of my feelings.”).

The DERS is scored so that the overall score, as well as all subscale scores, reflect greater difficulties in emotion regulation (2).


In terms of reliability, the overall DERS score as well as the subscale scores have been found to have high internal consistency within both clinical (3,4) and nonclinical populations (1, 5) . In addition, the DERS has demonstrated good test-retest reliability over a period of 4 to 8 weeks (ρI = .88; 1).

In support of the construct validity of this measure, scores on the DERS have been found to be significantly associated with a variety of behaviors thought to serve an emotion-regulating function, including deliberate self-harm (6,7 ), chronic worry (8,9) binge-eating (10), and cocaine-dependence (4).

Further, scores on the DERS have been found to be heightened among individuals with psychiatric disorders thought to be characterized by emotion regulation difficulties, including borderline personality disorder BPD (vs. non-PD outpatients; ) and  co-occurring BPD and substance dependence (vs. non-BPD substance users; 7).

Finally, the DERS demonstrates significant associations with a number of constructs thought to be related to emotion regulation difficulties, including positive associations with negative affect (12,5,9), depression and anxiety symptom severity (13,14,9), anxiety sensitivity (5, 14-16 ), and experiential avoidance (1, 17,18), and negative associations with emotional expression and processing (5).

The emotional nonacceptance subscale of the DERS has been found to predict performance on two behavioral  measures of the willingness to experience emotional distress (19 ), as well as a behavioral measure of the ability to engage in goal-directed behaviors when distressed (11)

Further, the DERS subscale of difficulties controlling impulsive behaviors when distressed has been found to be negatively associated with activation of the rostral anterior cingulate cortex (an area of the brain thought to be associated with inhibitory control) among cocaine dependent patients (20).

Finally, the DERS has been found to be sensitive to change over time (i.e., following short-term treatments). For example, Fox et al. (21) found significant improvements in emotional awareness and clarity over the course of inpatient treatment for alcohol dependent individuals. Finally, Fox et al. (21) found that inpatient treatment for cocaine dependent patients resulted in significant improvements in overall emotion dysregulation, as well as the particular dimensions of difficulties engaging in goal-directed behavior when distressed, limited access to emotion regulation strategies perceived as effective, and lack of emotional clarity

Of note, as the literature on the DERS continues to grow, there is emerging evidence of standard scores on the DERS within different clinical and nonclinical populations.

Specifically, evidence suggests that nonclinical samples of college students and community adults average 75-80 on the DERS ( 1,22, 9), whereas treatment-seeking substance users average 85-90 (2,3,21).

Interestingly “co-morbid” conditions scored higher – clinical GAD samples average 95-100 (13, 22), individuals with PTSD symptoms at a severity level consistent with a PTSD diagnosis average 100-105 (15,23), and borderline personality disorder outpatient samples average 125 (24,11),  which may suggest a potential use for the DERS in differentiating various emotional dysregulation disorders and showing that alcoholism can be shown to be a disorder in it’s own right, with different scoring in certain domains, and associated subscales, such as impulsive control compared to for example GAD. This has obvious effects on treatment especially in treatment follows specific evidence arising from scales such as DERS.

The DERS has been found to be related in expected ways with the other processes of change, evidencing significant positive associations with experiential avoidance and significant negative associations with mindfulness and self-compassion. The DERS has been found to be associated with various forms of psychopathology and maladaptive behaviors thought either to stem from emotion dysregulation or to serve an emotion-regulating or emotionally-avoidant function.

Finally, findings that the DERS is sensitive to change over time suggests that it may have utility in the assessment of mechanisms of change in treatment as well as instruct the specificity of these treatments.


1. 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, 41-54.

2. Gratz, K. L., & Tull, M. T. (in press). Emotion regulation as a mechanism of change in acceptance-and mindfulness-based treatments. In R. A. Baer (Ed.), Assessing mindfulness and acceptance: Illuminating the processes of change. Oakland, CA: New Harbinger Publications.

3. Gratz, K. L., Tull, M. T., Baruch, D. E., Bornovalova, M. A., & Lejuez, C. W. (2008). Factors associated with co-occurring borderline personality disorder among inner-city substance users: The roles of childhood maltreatment, negative affect intensity/reactivity, and emotion dysregulation. Comprehensive Psychiatry, 49, 603-615.

4. 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, 298-301.

5.  Johnson, K. A., Zvolensky, M. J., Marshall, E. C., Gonzalez, A., Abrams, K., & Vujanovic, A. (2008). Linkages between cigarette smoking outcome expectancies and negative emotional vulnerability. Addictive Behaviors, 33, 1416-1424.

6. Gratz, K. L., & Chapman, A. L. (2007). The role of emotional responding and childhood maltreatment in the development and maintenance of deliberate self-harm among male undergraduates. Psychology of Men and Masculinity, 8, 1-14

7. Gratz, K. L., & Roemer, L. (2008). The relationship between emotion dysregulation and deliberate self-harm among female undergraduate students at an urban commuter university. Cognitive Behaviour Therapy, 37, 14-25

8. Salters-Pedneault, K., Roemer, L., Tull, M. T., Rucker, L., & Mennin, D. S. (2006). Evidence of broad deficits in emotion regulation associated with chronic worry and generalized anxiety disorder. Cognitive Therapy and Research, 30, 469-480.

9. Vujanovic, A. A., Zvolensky, M. J., & Bernstein, A. (2008). The interactive effects of anxiety sensitivity and emotion dysregulation in predicting anxiety-related cognitive and affectivee symptoms. Cognitive Therapy and Research, 32, 803-817.

10. Whiteside, U., Chen, E., Neighbors, C., Hunter, D., Lo, T., & Larimer, M. (2007). Difficulties regulating emotions: Do binge eaters have fewer strategies to modulate and tolerate negative affect? Eating Behaviors, 8, 162-169

11. Gratz, K. L., Rosenthal, M. Z., Tull, M. T., Lejuez, C. W., & Gunderson, J. G. (2006). An experimental investigation of emotion dysregulation in borderline personality disorder. Journal of Abnormal Psychology, 115, 850-855.

12.  Cisler, J. M., Olatunji, B. O., & Lohr, J. M. (in press). Disgust sensitivity and emotion regulation potentiate the effect of disgust propensity on spider fear, blood-injection-injury fear, and contamination fear. Journal of Behavior Therapy and Experimental Psychiatry

13.  Roemer, L., Lee, J. K., Salters-Pedneault, K., Erisman, S. M., Orsillo, S. M., & Mennin, D. S. (in press). Mindfulness and emotion regulation difficulties in generalized anxiety disorder: Preliminary evidence for independent and overlapping contributions. Behavior Therapy.

14.  Tull, M. T., Stipelman, B. A., Salters-Pedneault, K., & Gratz, K. L. (2009). An examination of  recent non-clinical panic attacks, panic disorder, anxiety sensitivity, and emotion regulation difficulties in the prediction of generalized anxiety disorder in an analogue sample. Journal of Anxiety Disorders, 23, 275-282.

15.  McDermott, M. J., Tull, M. T., Gratz, K. L., Daughters, S. B., & Lejuez, C. W. (in press). The role of anxiety sensitivity and difficulties in emotion regulation in posttraumatic stress disorder among crack/cocaine dependent patients in residential substance abuse treatment. Journal of Anxiety Disorders

16.  Tull, M. T. (2006). Extending an anxiety sensitivity model of uncued panic attack frequency and symptom severity: The role of emotion dysregulation. Cognitive Therapy and Research, 30, 177-184.

17.  Tull, M. T., & Gratz, K. L. (2008). Further examination of the relationship between anxiety sensitivity and depression: The mediating role of experiential avoidance and difficulties engaging in goal-directed behavior when distressed. Journal of Anxiety Disorders, 22, 199-210.

18.  Tull, M. T., & Roemer, L. (2007). Emotion regulation difficulties associated with the experience of uncued panic attacks: Evidence of experiential avoidance, emotional nonacceptance, and decreased emotional clarity. Behavior Therapy, 38, 378-391.

19.  Gratz, K. L., Bornovalova, M. A., Delany-Brumsey, A., Nick, B., & Lejuez, C. W. (2007). A laboratory-based study of the relationship between childhood abuse and experiential avoidance among inner-city substance users: The role of emotional nonacceptance. Behavior Therapy, 38, 256-268.

20. Li, C. R., Huang, C., Yan, P., Bhagwagar, Z., Milivojevic, V., & Sinha, R. (2008). Neural correlates of impulse control during stop signal inhibition in cocaine-dependent men. Neuropsychopharmacology, 33, 1798-1806

21.  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, 298-301.

22. Salters-Pedneault, K., Roemer, L., Tull, M. T., Rucker, L., & Mennin, D. S. (2006). Evidence of broad deficits in emotion regulation associated with chronic worry and generalized anxiety disorder. Cognitive Therapy and Research, 30, 469-480.

23. Tull, M. T., Barrett, H. M., McMillan, E. S., & Roemer, L. (2007). A preliminary investigation of the relationship between emotion regulation difficulties and posttraumatic stress symptoms. Behavior Therapy, 38, 303-313.

24.  Gratz, K. L., & Gunderson, J. G. (2006). Preliminary data on an acceptance-based emotion regulation group intervention for deliberate self-harm among women with borderline personality disorder. Behavior Therapy, 37, 25-35.


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