Drug and Alcohol Dependence 89 (2007) 298–301

Short communication

Difficulties in emotion regulation and impulse

control during cocaine abstinence
H.C. Fox ∗ , S.R. Axelrod, P. Paliwal, J. Sleeper, R. Sinha
Department of Psychiatry, Yale University School of Medicine, Substance Abuse Center,
Connecticut Mental Health Center, 34 Park Street, New Haven, CT 06519,
United States
Received 14 September 2006; received in revised form 13 November 2006; accepted 11 December 2006

Abstract
Rationale: Prior research has shown that cocaine dependence is associated with dysfunction of brain systems involved in emotions and motivational
states.
Objectives: To examine whether difficulties in emotion regulation are associated with early cocaine abstinence using the recently validated
Difficulties in Emotion Regulation Scale (DERS).
Method: Recently abstinent treatment-seeking cocaine patients (n = 60) completed the DERS during their first week of inpatient treatment and at
discharge (3–4 weeks later), and scores were compared with community controls (n = 50).
Results: Compared with controls, cocaine-dependent individuals reported difficulties relating to understanding emotions, managing emotions and
impulse control in the first week of abstinence. With continued abstinence, cocaine-dependent individuals showed continued difficulties only in
impulse control.
Conclusion: Cocaine-dependent individuals report emotion regulation difficulties, particularly during early abstinence. Additionally, protracted
distress-related impulse control problems suggest potential relapse vulnerability.
© 2007 Elsevier Ireland Ltd. All rights reserved.

Keywords: Cocaine; Emotion regulation; Impulse control; Abstinence; Distress

1. Introduction a stressful situation (Gross et al., 2006). Although such strate-

Human neuroimaging studies have indicated that cocaine
abuse is associated with structural (Liu et al., 1998) and func-
tional (Tucker et al., 2004) alterations in the anterior cingulate
and regions of the prefrontal cortex (Volkow et al., 1992, 1999),
with functional impairment in executive function during early
abstinence (Fein et al., 2002). Interactions between these regu-
latory control regions and emotion-related subcortical areas are
also implicated in a broad network of systems associated with
the experience and regulation of emotion (Ochsner and Gross,
2005).
“Emotion regulation” refers to the strategies used to influ-
ence, experience, and modulate emotions and may include
dynamics such as suppression and/or cognitive re-appraisal of
∗ Corresponding author. Tel.: +1 203 9747262; fax: +1 203 9747366.
E-mail address: helen.fox@yale.edu (H.C. Fox).
gies may be considered beneficial for an individual to focus
on long-term priorities, they are psychologically effortful and
under stressful situations a shift in attention may occur towards
more immediate, often pleasure-seeking goals (Baumeister et
al., 1994). Thus, immediate gratification seeking and procrasti-
nation occur in the context of efforts to emotionally self-regulate
(Tice et al., 2001).
This conflict in regulatory goals may have important impli-
cations for treatment outcome in cocaine patients. First,
impulse control represents one of the major behavioral ele-
ments of emotion regulation (Gratz and Roemer, 2004)
and has been identified in a large number of studies as
an important component of addictive processes (Evenden,
1999). Secondly, cocaine abstinence involves a distress state
marked by dysphoria, irritability, fatigue, anxiety and increased
stress (Kampman et al., 2001; Sinha, 2001). As such, a
failure to manage affect and impulses may well be exac-
erbated in cocaine-dependent individuals with drug-related

0376-8716/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.drugalcdep.2006.12.026
 H.C. Fox et al. / Drug and Alcohol Dependence 89 (2007) 298–301
neuron-adaptations in specific cortico-limbic neural cir-
cuitry.
Using a recently developed and validated measure of
emotion regulation, the Difficulties in Emotion Regulation
Scale (DERS), this study aims to examine emotion regulation
changes over time in newly abstinent treatment-seeking cocaine-
dependent individuals, compared with community-controlled
volunteers.
2. Method
2.1. Participants
Sixty treatment-seeking cocaine-dependent individuals (28F/32M) and 50
healthy volunteers (24F/26M) were recruited through local advertisements.
Cocaine patients met DSM-IV criteria for current cocaine dependence and
tested positive for cocaine in their urine toxicology screens upon entry into
a locked inpatient facility for 3–4 weeks of treatment and study participation.
Cocaine patients had no access to drugs/alcohol and limited access to visi-
tors. Exclusion criteria included dependence on substances other than cocaine,
alcohol, or nicotine. Controls with current or past diagnoses of any substance
dependence were also excluded. All participants were excluded if they required
psychiatric medications or were not in good health. The study was approved
by the Human Investigation Committee of the Yale University School of
Medicine.
2.2. Procedures
During the inpatient treatment phase, the baseline DERS assessment was
conducted between days 4 and 7 of week 1 of cocaine abstinence and between
weeks 3 and 4, prior to discharge. Breathalyzer and urine toxicology screens
Table 1
DERS subscales and sample items for the Difficulties in Emotion Regulation
Scale
Nonacceptance of emotional responses (Nonacceptance)
“When I’m upset, I feel ashamed at myself for feeling that way.”
“When I’m upset, I become angry with myself for feeling that way.”
Difficulties engaging in goal-directed behavior (Goals)
“When I’m upset, I have difficulty focusing on other things.”
“When I’m upset, I have difficulty getting work done.”
Impulse control difficulties (Impulse)
“When I’m upset I lose control over my behaviors.”
“I experience my emotions as overwhelming and out of control.”
Lack of emotional awareness (Awareness)
“I pay attention to how I feel.” (Reverse-scored)
“When I am upset, I take time to figure out what I’m really feeling.”
(Reverse-scored)
Limited access to emotion regulation strategies (Strategies)
“When I’m upset, I believe there is nothing I can do to make myself
feel better.”
“When I’m upset, I believe that wallowing in it is all I can do.”
Lack of emotional clarity (Clarity)
“I have difficulty making sense out of my feelings.”
“I have no idea how I am feeling.”
The Cronbach’s coefficient alpha for the cocaine-dependent participants at base-
line in the current study was .88 for Total DERS, .86 for Nonacceptance, .80 for
Goals, .78 for Impulse, .79 for Awareness, .85 for Strategy, and .72 for Clarity.
Adapted from Gratz and Roemer (2004).
299
were used to confirm drug/alcohol abstinence. Controls participated in face-
to-face appointments to complete both psychiatric interviews and the DERS at
baseline only.
2.3. Measures
2.3.1. Difficulties in Emotion Regulation Scale (Gratz and Roemer, 2004). The
DERS is a 36-item self-report measure developed to examine difficulties in the
ability to regulate emotions. Participants rate how often statements such as “I feel
at ease with my emotions” apply to them, 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%)”. Subscales assess six
dimensions of difficulties (subscales and sample items from each subscale are
in Table 1).
2.4. Design and statistical analyses
Independent t-tests or χ2 were used to assess group differences in drug use
and demographics. Any group differences in demographic characteristics were
included as co-variates in analyses of co-variance (ANCOVAs) which were used
to assess group differences on the DERS at baseline and discharge. Paired t-tests
were conducted to compare DERS differences at baseline and discharge within
the cocaine sample.
As emotion dysregulation is central to the pathophysiology of borderline
personality disorder (BPD; Linehan, 1993) and BPD is frequently co-morbid
with cocaine abuse (Kranzler et al., 1994), we also conducted the same analyses
excluding the subgroup of abstinent cocaine patients who met DSM-IV criteria
for BPD (n = 19/60).
3. Results
3.1. Participant characteristics
Cocaine patients and control participants differed signif-
icantly by age (37.2 ± 5.9 and 33.6 ± 10.0; p = .02), racial
status (66.7% and 46.0%; p = .001), and years of education
(12.3 ± 1.5 and 14.9 ± 2.6; p < .0001), with the cocaine patients
being somewhat older, higher proportion minority, and less
educated.
The cocaine group had significantly greater years of cocaine
use (9.5 ± 6.1 versus 1.0 ± 1.4; p = .03) and days of cocaine use
in the past month (18.9 ± 8.7% versus 0 ± 0%; p < .0001), as
well as greater years of alcohol use (11.6 ± 7.5 versus 9.0 ± 8.7;
p < .04) and days of alcohol use in the past month (9.6 ± 9.4 ver-
sus 4.8 ± 6.4; p < .02). In addition, a higher number of cocaine
abusers met lifetime criteria for DSM-IV anxiety diagnoses
including PTSD (28.3% versus 4.0%; p = .005); although groups
did not differ in mood disorder diagnoses (11.7% versus 8%;
p = .90).
3.2. Between group differences
After adjusting for age, race and years of education, cocaine
patients showed higher scores at baseline than controls on
the Total DERS score (85.8 ± 22.5 compared to 60.9 ± 15.0;
p < .01), but no differences at discharge (77.6 ± 20.7 compared
to 60.9 ± 15.0). At baseline, the groups were also significantly
different on Impulse, Awareness, Strategies and Clarity sub-
scales, with only Impulse and Awareness scores remaining
significantly different at discharge (see Fig. 1). The exclu-
sion of cocaine patients with BPD resulted in a similar pattern
300 H.C. Fox et al. / Drug and Alcohol Dependence 89 (2007) 298–301
Fig. 1. DERS subscales: means and S.E.M. for cocaine patients compared with
controls at baseline and discharge. Group differences at baseline—Awareness:
16.0 ± 5.0 compared to 12.0 ± 4.5; Clarity: 11.7 ± 3.8 compared to 8.3 ± 3.6;
Impulse: 13.5 ± 4.8 compared to 8.3 ± 2.4; Strategies: 18.1 ± 6.4 compared to
11.9 ± 3.1. Group differences at discharge—Awareness: 15.8 ± 4.8 compared to
12.0 ± 4.5; Impulse: 11.1 ± 3.7 compared to 8.3. Improvement between baseline
and discharge in cocaine patients—Clarity: from 11.7 ± 3.8 to 9.8 ± 3.6; Goals:
from 14.4 ± 4.6 to 12.6 ± 4.5; Strategies: 18.1 ± 6.4 compared to 16.0 ± 5.4.
All analyses were co-varied for group differences in age, race and years of
education.
with the exception of Clarity not being significantly different
between groups at baseline, and only the Impulse control sub-
scale remaining significantly different at discharge1 . No gender
differences were observed in these findings.
3.3. Within group differences
From baseline to discharge comparisons, cocaine abusers
reported significant improvement on the DERS Total score, the
Goals subscale, the Strategies subscale, and the Clarity sub-
scale. However, there were no differences between baseline and
discharge DERS scores in cocaine abusers on the Awareness,
Acceptance and Impulse control subscales (see Fig. 1).
4. Discussion
This is the first study to assess emotion regulation difficul-
ties in cocaine-dependent individuals during early abstinence.
Reported difficulties concerning emotional clarity and aware-
ness compared with controls at admission suggest that cocaine
abusers were less able to acknowledge and/or have a clear
understanding of their emotions. Clarity and awareness of emo-
tion could represent early processing components of emotional
competence (Salovey et al., 2002) and may be integral to
the maintenance of drug use in vulnerable groups. Cocaine-
1 As both control and cocaine patients differed in relation to anxiety disorder,
an extended analysis was also conducted excluding cocaine patients with BPD
and patients with anxiety disorder (n = 27 in total). Findings were no different
to those shown in the cocaine sample excluding BPD individuals only.
dependent individuals also reported significantly higher scores
on the strategies subscale of the DERS compared with controls
suggesting greater difficulty in developing effective emotional
coping strategies (i.e. they would be more likely to believe that
little could be done to change an emotionally stressful situa-
tion). They were also found to report significantly higher scores
on the Impulse subscale of the DERS compared with controls,
indicating difficulties with regard to inhibiting inappropriate or
impulse behaviors under stressful situations.
Difficulties applying coping strategies and avoiding impul-
sive behavior at times of emotional distress indicate decrements
in emotional flexibility, and may reflect a change in priority from
self-control to affect regulation (Tice et al., 2001). Findings are
also consistent with previous research indicating that impulse
control disorders are more common in substance abusing indi-
viduals (Kisa et al., 2005) and decreased anterior cingulate
activity during stress and a Go–NoGo task in cocaine patients
compared to controls has been reported (Kaufman et al., 2004;
Sinha et al., 2005).
A significant improvement in selective regulatory aspects
was found in the cocaine patients at discharge. They reported
improved clarity of their emotional experience and ability to
use strategies to regulate and remain focused on goal comple-
tion during distress states. Relative to controls, only problems
with impulse control remained elevated after accounting for
BPD. The clinical significance of distress-related impulsivity in
cocaine patients is highlighted within a recent study showing that
impulsivity predicts adverse life events even when statistically
controlling for substance use (Hayaki et al., 2005). Interestingly,
our recent findings also indicate that stress-induced craving in
the laboratory is predictive of shorter time to cocaine relapse
(Sinha et al., 2006). Together, this implies susceptibility to
impulsive behaviors such as drug use, lapses in judgment, poor
decision-making and an inability to control impulses during
stress. These findings highlight the need to develop treat-
ment strategies focusing specifically on distress regulation and
impulse control difficulties.
It is important to note that the assessments were conducted
over the initial few weeks of abstinence, and it is possible that
the pattern of improved emotion regulation would have con-
tinued with sustained abstinence. Also 33% of the sample was
currently dependent on alcohol and 97% were cigarette smokers
suggesting that these findings may reflect the combined effects of
these drugs on emotion regulation differences. Nonetheless, the
DERS instrument was able to discriminate between abstinent
cocaine patients and controls and reflect changes in emotion
regulation over the course of cocaine abstinence along with
good internal consistency within a cocaine-dependent sample.
These data would support the utility of the DERS as a diag-
nostic tool to assess emotion regulation in treatment-seeking
cocaine-dependent individuals.
Acknowledgements
This study was supported in part by grants K02-DA17232
(Sinha), P50-DA16556 (Sinha), M01-RR00125 (Yale GCRC)
from the National Institutes of Health and its Office of Research
 H.C. Fox et al. / Drug and Alcohol Dependence 89 (2007) 298–301
on Women’s Health (ORWH), Bethesda, MD, USA. We wish to
thank the staff at the Clinical Neuroscience Research Unit and
the General Clinical Research Center at Yale University School
of Medicine for their assistance in completing these studies.
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