Anxiety Sensitivity, Coping Motives, Emotion Dysregulation, and ...

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AND ROSE MARIE WARD, PH.D.b. aDepartment of Psychology, Miami University, Oxford, Ohio. bDepartment of Kinesiology & Health, Miami University, Oxford, ...
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Anxiety Sensitivity, Coping Motives, Emotion Dysregulation, and Alcohol-Related Outcomes in College Women: A Moderated-Mediation Model RACHEL B. CHANDLEY, M.A.,a AARON M. LUEBBE, PH.D.,a TERRI L. MESSMAN-MOORE, PH.D.,a,* AND ROSE MARIE WARD, PH.D.b aDepartment bDepartment

of Psychology, Miami University, Oxford, Ohio of Kinesiology & Health, Miami University, Oxford, Ohio

anxiety sensitivity on alcohol-related problems (but not alcohol use) was qualified by the level of emotion dysregulation. As individuals reported more emotion dysregulation, the strength of the relation between coping drinking motives and alcohol-related problems increased. Conclusions: Results replicate and extend the link between anxiety sensitivity and alcohol outcomes via the mechanism of negative reinforcement, and they further support the importance of emotion dysregulation in explaining alcohol-related problems among college women. Implications for treatment and prevention of alcohol-related problems in college women are discussed. (J. Stud. Alcohol Drugs, 75, 83–92, 2014)

ABSTRACT. Objective: The present study examined the relation of anxiety sensitivity to alcohol-related outcomes via coping drinking motives in college women. Further, the impact of emotion dysregulation on the mediational path between anxiety sensitivity and alcohol-related outcomes was investigated. Method: A sample of 223 female undergraduate drinkers from a midwestern university completed self-report surveys assessing alcohol consumption, alcohol-related problems, anxiety sensitivity, coping drinking motives, and emotion dysregulation. Results: Anxiety sensitivity was indirectly related to both alcohol-related problems and alcohol use via coping motives. The indirect effect of

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tive individuals may use alcohol to cope with the symptoms associated with anxiety sensitivity (e.g., Stewart et al., 2001). Studies have shown that coping drinking motives mediate the relation of anxiety sensitivity to alcohol use or consumption (see DeMartini and Carey, 2011, for a review); however, no studies have examined an indirect model predicting alcoholrelated problems. In addition, studies have not yet identified among anxiety-sensitive individuals what variables might place someone at greatest risk for drinking to cope or experiencing negative alcohol-related outcomes. This study investigates emotion dysregulation, one potential factor that differentiates those individuals most at risk for highly endorsing coping drinking motives and, in turn, alcohol-related problems. Studying the interrelations of anxiety sensitivity, emotion regulation, and alcohol use among college women is particularly important for two primary reasons. First, heavy episodic drinking is on the rise among college women and may be equal to that of their male counterparts (Grucza et al., 2009; Keyes et al., 2008). Also, college women more commonly exceed the National Institute on Alcohol Abuse and Alcoholism’s weekly drinking limits than do men (Hoeppner et al., 2013). Indeed, the National Institute on Drug Abuse (2012) has called for both additional research on women’s alcohol use and the development of femalespecific interventions. Second, although men typically report experiencing a greater frequency of alcohol problems than women (Harrell and Karim, 2008; O’Malley and Johnston, 2002; Perkins, 2002), some research suggests that as

NXIETY SENSITIVITY REFERS TO the fear of physical (e.g., increased heart rate) or cognitive (e.g., inability to concentrate) symptoms that accompany the experience of anxiety (Reiss and McNally, 1985). Anxiety sensitivity differs from trait anxiety—the tendency to respond fearfully to stressors in general—in that anxiety sensitivity involves a fearful response to the actual symptoms of anxiety rather than to a stressor or anxiety-provoking situation (McNally, 1989). For example, anxiety-sensitive individuals may overreact to heart palpitations by thinking that a heart attack is occurring or may misinterpret the common symptom of sweaty palms as a sign that something horrid is happening to the body. Among college students, anxiety sensitivity is associated with heavy episodic drinking (Goldstein and Flett, 2009; Stewart et al., 1995, 2001) and negative alcohol-related consequences (Goldstein and Flett, 2009). Studies that link anxiety sensitivity to alcohol use suggest that anxiety-sensi-

Received: February 21, 2013. Revision: June 18, 2013. This research was funded by a grant to the third author from the Alcoholic Beverage Medical Research Foundation (ABMRF). ABMRF had no role in the study design, collection, analysis, or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. This work is based substantially on the master’s thesis of the first author, supervised by the third author. *Correspondence may be sent to Terri L. Messman-Moore, O’Toole Family Professor and Director of Clinical Training, Department of Psychology, Miami University, 100 Psychology Building, 90 N. Patterson Ave., Oxford, OH 45056, or via email at: [email protected].

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consumption increases, women experience more negative consequences than men (Presley and Pimentel, 2006) and are more vulnerable to specific alcohol-related consequences, such as sexual assault (Lawyer, et al., 2010). Anxiety sensitivity and drinking to cope Coping drinking motives include drinking motivated by a desire to forget worries, improve mood, or cope with life’s problems (Cooper, 1994). Individuals who endorse coping drinking motives strive to avoid negative feelings by using alcohol to lessen or remove negative stimuli. Drinking to cope might be seen as producing a short-term benefit for the drinker—an immediate way to dull emotional pain. Despite this benefit, drinking to cope is consistently associated with both increased alcohol use and negative alcohol-related consequences (Cooper, 1994; Cooper et al., 1995; Kuntsche et al., 2005, 2008; Martens et al., 2008; Park and Levenson, 2002). Coping drinking motives also predict alcohol-related problems even when controlling for consumption levels (Cooper et al., 1992). Moreover, drinking to cope predicts negative alcohol-related consequences above and beyond alcohol expectancies, depressed mood, and coping ability (Park and Levenson, 2002). Anxiety sensitivity has been consistently linked to coping drinking motives, including in college students (Goldstein and Flett, 2009; Kuntsche et al., 2006; Novak et al., 2003). Individuals who are sensitive to and distressed by physical and cognitive signals of anxiety may use alcohol to dampen such elevated arousal and negative affect. Given that men report drinking to cope more than do women (see NolenHoeksema, 2012, for a review), but women report higher levels of anxiety sensitivity than men (Stewart et al., 2001), one could argue that the link between anxiety sensitivity and coping drinking motives (or to reduce negative affect) might be greater for either men or for women. Two empirical tests of this question, however, have suggested that the link is significantly stronger for (Stewart and Zeitlin, 1995) or only found in (Stewart et al., 1997) women compared with men. Given that coping drinking motives may put women at unique risk for heavy drinking (Stewart and Zeitlin, 1995), this suggests that the link between anxiety sensitivity, coping drinking motives, and problematic alcohol use may be especially pertinent for women. Indeed, DeMartini and Carey (2011) have recently proposed a theoretical model that suggests coping motives may be one mechanism that helps to explain the interrelation of anxiety sensitivity and drinking outcomes, and factors such as gender and social context may moderate this relationship. In the one study to directly test this pathway, Stewart et al. (2001) reported that coping motives (and conformity motives) mediated the relation between anxiety sensitivity and increased drinking behavior among college women but not college men (among men, the relation was mediated only by

conformity motives). Although there is some evidence for the role of coping motives as the mechanism linking anxiety sensitivity and alcohol consumption (especially for women), no studies have examined whether coping motives account for the link between anxiety sensitivity and alcohol-related problems. Given the correlation between heavy alcohol consumption and subsequent problems for women (Gruenewald et al., 2003), it is reasonable to expect that coping motives may also help to explain why alcohol problems are linked to anxiety sensitivity. Evidence suggesting that women experience more negative consequences than men do at higher levels of consumption (Presley and Pimentel, 2006) provides further rationale for examining predictors of alcohol-related problems in a sample of women. Role of emotion dysregulation Although anxiety-sensitive women are more likely to drink to cope with negative emotions, additional characteristics of an individual may strengthen this relation or lead to more problematic drinking outcomes. Emotion dysregulation, or having difficulties in the awareness, differentiation, and appropriate acceptance or modulation (e.g., cognitively, behaviorally) of negative emotional states, may differentiate those anxiety-sensitive individuals who are most at risk to drink to cope, subsequently leading to greater use or related problems. Certainly, deficits in emotion regulation have gained considerable attention as potential precursors to psychopathology, including both anxiety and substance use disorders (Aldao et al., 2010). Anxiety-sensitive individuals are acutely aware of negative emotions and their accompanying internal physiological states. Perhaps not surprisingly, given the fact that anxiety-sensitive individuals often misinterpret bodily cues and overemphasize negative emotional states, these individuals are more likely to experience problems regulating their emotions (Bonn-Miller et al., 2008). Also not surprisingly, emotion dysregulation is associated with alcohol use (frequency and quantity) in adults (Bonn-Miller et al., 2008) and distinguishes individuals with alcohol dependence from social drinkers (Fox et al., 2008). It is somewhat surprising that the role of coping drinking motives in conjunction with broader emotion dysregulation has not yet been investigated considering the suggested links between emotion dysregulation, anxiety sensitivity, alcohol consumption, and alcohol-related problems. This paucity is especially notable considering that coping drinking motives inherently involve a stated intention to try to regulate negative emotions via alcohol use. In general, individuals with high levels of both anxiety sensitivity and emotion dysregulation suffer the most negative cognitive and affective symptoms (Kashdan et al., 2008), suggesting that anxiety sensitivity’s impact on psychopathology varies by the level or presence of emotion dysregulation. Thus, emotion dysregulation seems to be an important factor to consider

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when examining the impact of anxiety sensitivity on alcohol consumption and negative alcohol-related consequences.

$50,000). Twenty-six percent of participants indicated sorority membership.

Research aims and hypotheses

Measures

The current study built on the theoretical model of the interrelations of anxiety sensitivity, coping drinking motives, and alcohol use put forth by DeMartini and Carey (2011). In a sample of undergraduate women, we first aimed to replicate the findings of earlier research establishing an indirect link between anxiety sensitivity and alcohol use via coping drinking motives (Stewart et al., 2001). Second, we extended this model to test the indirect effect of anxiety sensitivity on alcohol-related problems through coping motives. Last, we examined the impact of emotion dysregulation on this indirect effect (i.e., moderated mediation). Previous research suggests that emotion dysregulation may play an integral role in the development of drinking to cope as well as influence which anxiety-sensitive individuals are more likely to drink to cope and experience negative alcohol-related outcomes. Because coping motives mediate the relationship between anxiety sensitivity and increased drinking behavior among college women (but not college men; Stewart et al., 2001), and given that alcohol consumption and alcohol dependence rates appear to be increasing more among collegeage women than young men (Grucza et al., 2008a, 2008b), the current study focused on college women. Overall, we hypothesized that anxiety sensitivity, coping drinking motives, and emotion dysregulation, as well as alcohol consumption and negative alcohol-related consequences, would be positively correlated with each other. Second, we expected that anxiety sensitivity would be indirectly related to both alcohol use and problems via increased coping drinking motives. Third, it was hypothesized that the strength of these indirect relations would be moderated by levels of emotion dysregulation. Specifically, it was expected that as emotion dysregulation increased, so would the strength of the indirect effects hypothesized.

Anxiety sensitivity. Anxiety sensitivity was assessed with the Anxiety Sensitivity Index (Reiss et al., 1986), a 16-item self-report measure. Participants responded on a scale from 1 (very little) to 5 (very much) to questions such as “When I notice that my heart is beating rapidly, I worry that I might have a heart attack.” Higher scores indicate greater anxiety sensitivity. The Anxiety Sensitivity Index has demonstrated predictive and discriminative validity and good internal consistency (Gonzalez et al., 2008; Reiss et al., 1986); in the current sample, coefficient α = .90. Coping drinking motives. Coping drinking motives were assessed with the coping subscale of the Drinking Motives Questionnaire-Revised (DMQ-R; Cooper, 1994), a 20-item measure which assesses motives for alcohol consumption. Respondents indicate how often one drinks for a particular motive on a scale from 1 (almost never/never) to 5 (almost always/always). The coping subscale contains 5 questions such as “How often do you drink to cheer up when you are in a bad mood?” Higher subscale values indicating greater coping motives. The DMQ-R has demonstrated good internal consistency in a cross-nation adolescent sample (Kuntsche et al., 2008) and is frequently used with young adult populations (e.g., Patrick et al., 2011); in the current sample, coefficient α = .89. Alcohol variables. Three facets of alcohol consumption were assessed using the Daily Drinking Questionnaire–Revised (DDQ-R; Collins et al., 1985). Participants were given the definition of a standard drink and asked to indicate how many standard drinks she consumed per each day of a typical week. Although some DDQ-R versions ask participants to indicate the time period of consumption for each drinking episode, time data were unavailable. For the current study, the frequency of alcohol use was calculated as the number of days per week that women reported having at least one drink. The quantity of alcohol use was calculated as the mean number of drinks per drinking episode (i.e., total number of drinks over the week divided by frequency). With excellent reliability levels, the DDQ is frequently used in samples of college women (Corbin et al., 2001). Last, a mean score of two items was used to assess heavy episodic drinking (α = .94). Specifically, women were asked “In a typical week, how many times are you intoxicated” and “In a typical week, how many times do you have four or more drinks” and responded on a scale from 1 (none) to 5 (seven or more times). Alcohol-related problems. Alcohol-related problems were assessed with the Rutgers Alcohol Problem Index (RAPI; White and Labouvie, 1989), a 23-item measure of problems and negative alcohol-related consequences experienced within the past year. Participants respond on

Method Participants Participants were drawn from a sample of 241 college women from a public university in the Midwest. Only women who endorsed drinking in the past year were included in analyses to maximize variability in drinking behavior and related problems, but also to exclude abstainers who may have different motives for drinking were they to do so (Kuntsche et al., 2006). This resulted in a sample of 223 women (18 did not endorse past-year drinking) with a mean age of 20.43 years (SD = 0.95, range: 19–24). The sample was primarily White (93.2%), and of middle- to upper-class socioeconomic status (almost 70% reported family income greater than U.S.

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a scale from 0 (never) to 4 (10 or more times) to indicate their degree of experience with various negative outcomes such as fights, neglecting one’s responsibilities, or feeling physically or psychologically dependent on alcohol. Although designed for use with adolescents, the RAPI has been used with undergraduate women (e.g., Luebbe et al., 2009). The RAPI is internally reliable (White and Labouvie, 1989) and predicts alcohol dependence across young adulthood (Dick et al., 2011); in the current sample, coefficient α = .89. Emotion dysregulation. Emotion dysregulation was assessed with the Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, 2004), a 36-item self-report measure that asks participants to rate statements on a scale from 1 (almost never) to 5 (almost always) regarding awareness of, clarity about, acceptance of, and responses to negative emotions (e.g., “When I’m upset, I have difficulty controlling my behaviors”). Items are summed for a total score, with higher scores indicating greater emotion dysregulation. The DERS has been used widely with college-age adults and demonstrates good internal consistency as well as predictive validity for various forms of psychopathology

(Gratz and Roemer, 2004; Weinberg and Klonsky, 2009); in the current sample, coefficient α = .94. Procedure The university’s institutional review board approved the data collection methods. Women were recruited through fliers posted on campus and advertisements in the student newspaper into a 10-week prospective study focused on alcohol use and sexual behavior in women. Data for the current study come from the final time point of the study because it was the only time that one of the primary variables of interest (i.e., anxiety sensitivity) was collected. Participants completed informed consent before participation and were provided with debriefing and additional resources following completion. Women were compensated $25 for completing the survey corresponding to this final wave of data. Data analytic plan Zero-order relations among study variables were examined with Pearson’s correlations. Next, the model depicted in

FIGURE 1. Schematic diagram of the path model tested. For ease of presentation, error terms are not shown. Indirect effects tested are listed in the table. M = paths for which emotion dysregulation was tested as a moderator; AS = anxiety sensitivity; COPE = drinking to cope motives; FREQ = frequency of alcohol use; QUANT = quantity of alcohol use per drinking episode; HED = frequency of heavy episodic drinking; PROBS = alcohol-related problems.

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TABLE 1. Interrelations of anxiety sensitivity, coping drinking motives, alcohol use, alcoholrelated problems, and emotion dysregulation (n = 223) ASI

DMQ-R cop.

FREQ

QUANT

HED

RAPIa DERS

ASI DMQ-R cop. FREQ QUANT HED RAPI DERS

. – .30** .01 -.06 -.06 .14* .38**

. – .41** .35** .36** .53** .37**

. – .71** .65** .47** .09

. – .76** .53** .04

. – .54** .08

. – .33**

.–

M SD Range

35.73 11.07 16–69

8.98 4.11 5–25

1.58 1.30 0–6

2.97 2.54 0–10

1.94 0.87 1–4

6.76 7.89 0–39

75.63 21.21 36–138

Notes: ASI = Anxiety Sensitivity Index (Reiss et al., 1986); DMQ-R cop. = Drinking Motives Questionnaire–Revised, coping subscale (Cooper, 1994); FREQ = frequency, in days, of drinking; QUANT = mean number of standard drinks per drinking episode; HED = heavy episodic drinking; RAPI = Rutgers Alcohol Problem Index (White and Labouvie, 1989); DERS = Difficulties in Emotion Regulation Scale (Gratz and Roemer, 2004). aOne participant’s score was an outlier on the RAPI and as such this score was truncated to be the next highest RAPI score in the sample plus 1. All statistics presented include the truncated value rather than the original value. *p < .05; **p < .01.

Figure 1 was tested using path analysis in Mplus 5.0 (Muthén and Muthén, 1998–2007). Specifically, we tested indirect effects of anxiety sensitivity on alcohol use variables (i.e., frequency, quantity, heavy episodic drinking) through coping motives, and if anxiety sensitivity was indirectly related to alcohol-related problems through both coping drinking motives and subsequent alcohol consumption. To test indirect effects, all analyses used bias-corrected bootstrapping methods, which make no assumptions of normality as the Sobel test does (MacKinnon et al., 2004). To test if the indirect effect of anxiety sensitivity on the alcohol variables through coping-motivated drinking was conditional on levels of emotion dysregulation, a moderated mediation, or conditional indirect effects, model was tested (paths labeled “M” in Figure 1). According to Preacher and colleagues (2007), there are several common models to test such conditional indirect effects. For this study, we tested moderation on each path in the model through which an indirect effect was possible. Thus, we tested whether emotion dysregulation (a) moderated the relation between anxiety sensitivity and coping drinking motives, (b) moderated the relation of coping drinking motives to each of the alcohol consumption variables, and/or (c) moderated the relation of consumption variables to alcohol-related problems. Results Preliminary analyses Recall that women who reported not drinking in the past year were removed from the analyses. Such women (n = 18) did not differ from those who reported consuming

alcohol in the past year (n = 223) on anxiety sensitivity, t(224) = 1.24, p = .22, or emotion dysregulation, t(201) = 0.40, p = .69. Of those who reported drinking in the past year, participants indicated a mean age of 15.89 years (SD = 1.91, range: 6–21) for the first time they consumed an alcoholic drink, with all but one individual indicating doing so before age 21. Means, standard deviations, and ranges for all study variables are listed in Table 1. Of note, levels of alcohol consumption and problems in the current sample are consistent with other studies of college women using similar measures (e.g., Corbin et al., 2001; Luebbe et al., 2009). One participant’s score was a significant outlier (greater than 4 SD above the mean) on the RAPI. To conserve data on the other measures but address nonnormality, this participant was assigned a value equal to one unit above the next highest score on the RAPI, a method called truncation (Osborne, 2008), which significantly reduced skew (2.11 to 1.58) and kurtosis (6.89 to 2.44) of the RAPI to acceptable levels. Relations between demographic factors and primary study constructs were examined. No associations between any study variables and age, year in school, ethnic majority versus minority status, or income were found. Although cumulative grade point average was inversely related to emotion dysregulation (r = -.19, p = .01), it was unrelated to all other variables of interest. Being a sorority member was associated with lower anxiety sensitivity (r = -.14, p = .04) but was unrelated to all other variables. Given that demographic factors were overwhelmingly unrelated to study constructs, as well as the small effect sizes for the two associations found, demographic factors were not considered further in primary analyses.

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Bivariate correlations The majority of correlations for primary study variables were in the hypothesized direction (Table 1). Greater anxiety sensitivity was positively related to coping drinking motives. As expected, various measures of consumption were highly intercorrelated. Although each of the alcohol consumption variables was significantly correlated with coping motives and alcohol-related problems, none was related bivariately to anxiety sensitivity or emotion dysregulation. In contrast, alcohol-related problems (i.e., RAPI) were directly related to anxiety sensitivity and emotion dysregulation. Indirect effects The full model in Figure 1 was tested. Error terms among the three alcohol consumption variables (not shown in Figure 1 for presentation ease) were allowed to covary. Using bias-

corrected bootstrap estimates (N = 5,000 samples), anxiety sensitivity was indirectly related to each of the alcohol consumption variables through coping motives (see the table embedded in Figure 2). Of note, significant indirect effects emerged despite the fact that there were no zero-order relations between anxiety sensitivity and any alcohol consumption variable. Similarly, there was a significant indirect effect from anxiety sensitivity to alcohol problems via coping motives (over and above all consumption variables). Last, we tested specific indirect effects from anxiety sensitivity to alcohol problems that included two mediators apiece (i.e., coping motives and one of the three consumption variables, respectively). Anxiety sensitivity was indirectly related to alcohol-related problems via coping motives and heavy episodic drinking frequency. There were no significant indirect effects through the pathways that included either frequency or quantity (Figure 2). Thus, in support of hypotheses, anxiety sensitivity was indirectly related to alcohol-related

FIGURE 2. Path model of the relations among anxiety sensitivity, drinking to cope motives, alcohol consumption, and alcohol-related problems in a sample of women (n = 223). For ease of presentation, error terms are not shown. Error terms among alcohol consumption variables were allowed to covary. Unstandardized parameter estimates shown with standard errors in parentheses. Gray dotted paths are nonsignificant (n.s.). All indirect effects tested using bias-corrected bootstrapping (N = 5,000 samples). Pont estimates are unstandardized, and confidence intervals that do not include zero are considered statistically significant. AS = anxiety sensitivity; COPE = drinking to cope motives; FREQ = frequency of alcohol use; QUANT = quantity of alcohol use per drinking episode; HED = frequency of heavy episodic drinking; PROBS = alcohol-related problems; LL 95% CI = lower limit of 95% confidence interval; UL 95% CI = upper limit of 95% confidence interval. *p < .05; **p < .01.

CHANDLEY ET AL. TABLE 2. Results for conditional indirect effect of anxiety sensitivity predicting alcohol-related problems Predictor

b

SE

t

p

For portion of model predicting RAPI ASI DMQ-R cop. QUANT HED DERS DMQ-R Cop. × DERS HED × DERS

0.03 0.32 0.77 -2.63 0.06 0.00 0.06

0.04 0.38 0.31 1.66 0.05 0.00 0.02

0.62 0.84 2.46 -1.58 1.18 0.32 2.72

.54 .40 .01 .11 .24 .75 .01

DERS

Indirect effect

SE

Z

p

.05 .06 .08

.02 .02 .03

2.55 2.51 2.48

.01 .01 .01

DERS

Indirect effect

SE

Z

p

36.00 41.10 46.20 51.30 56.40 61.50 66.60 71.70 76.80 81.90 87.00 92.10 97.20 102.30

.03 .04 .04 .04 .05 .05 .05 .06 .06 .07 .07 .07 .08 .08

.01 .01 .02 .02 .02 .02 .02 .02 .02 .03 .03 .03 .03 .03

2.61 2.59 2.58 2.56 2.55 2.54 2.53 2.52 2.51 2.50 2.49 2.49 2.48 2.48

.01 .01 .01 .01 .01 .01 .01 .01 .01 .01 .01 .01 .01 .01

-1 SD = 54.42 M = 75.67 +1 SD = 96.92

Notes: RAPI = Rutgers Alcohol Problem Index; ASI = Anxiety Sensitivity Index. DMQ-R-cop. = Drinking Motives Questionnaire–Revised, coping subscale; QUANT = mean number of standard drinks per drinking episode; HED = heavy episodic drinking; DERS = Difficulties in Emotion Regulation Scale.

problems through coping drinking motives, both over and above alcohol consumption, but also subsequently through heavy episodic drinking behavior. Conditional indirect effects With support for an indirect effect of anxiety sensitivity on both alcohol consumption and problems through coping motives, the role of emotion dysregulation on these effects was considered. Emotion regulation difficulties were only tested as moderators of those indirect paths found in the model described above, and a pruned model reflecting only significant paths found in the model tested above (i.e., Figure 2) was used. Further, we tested moderation of each pathway implicated in a given indirect effect (e.g., path from an independent variable to a mediator and path from a mediator to a dependent variable). None of the indirect relations of anxiety sensitivity predicting alcohol consumption via coping motives was conditional on the level of emotion dysregulation (βs = -.01 to .02, ts = -0.69 to 0.89, all ps > .05, for the three effects tested). These findings suggest that

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coping motives mediate the relation of anxiety sensitivity to frequency, quantity, and heavy episodic drinking frequency regardless of one’s abilities to regulate negative emotions. In contrast, and in partial support of the hypotheses, the indirect effect of anxiety sensitivity on alcohol-related problems via coping motives was found to be moderated by emotion dysregulation. Although emotion dysregulation was tested as a moderator of the path from anxiety sensitivity to coping motives, the path from coping motives to heavy episodic drinking frequency, and the path from heavy episodic drinking to alcohol problems, results indicated a significant moderation for the latter path only. That is, emotion dysregulation only moderated the relation between heavy episodic drinking frequency and alcohol-related problems (b = 0.06, t = 2.00, p < .05). Probing the interaction with the Johnson–Neyman technique to determine regions of significance suggested that this effect was significant for all values on the DERS in the current sample (Table 2) but that the magnitude of the indirect effect of anxiety sensitivity on alcohol-related problems through coping-motivated drinking and heavy episodic drinking frequency became stronger as levels of emotion dysregulation increased. The indirect effect of anxiety sensitivity to alcohol problems that did not include the alcohol consumption variables was not conditional on levels of emotion dysregulation. Discussion The current study contributes three primary findings to the literature. First, consistent with Stewart and colleagues (2001), we replicated the indirect effect of higher anxiety sensitivity on greater alcohol use through the mechanism of increased coping motives in undergraduate women. Second, we extended the literature to show a similar indirect effect for higher levels of anxiety sensitivity being associated with experiencing more alcohol-related problems also via coping motives. Last, our study is the first to our knowledge to show that broader difficulty in regulating emotions influences the strength of the indirect pathway from anxiety sensitivity to alcohol problems (i.e., a moderated mediation effect). In particular, the relation between heavy episodic drinking frequency and experiencing alcohol-related problems became stronger at higher levels of emotion dysregulation. In contrast to hypotheses, emotion dysregulation did not moderate the indirect effect from anxiety sensitivity through coping motives to alcohol consumption. Although not a primary aim, findings from our test of bivariate associations among study constructs warrant brief discussion. In a broad sense, our findings are consistent with earlier research linking anxiety sensitivity and alcoholrelated problems (Goldstein and Flett, 2009). But we failed to establish a direct connection between anxiety sensitivity and alcohol consumption, contrary to at least one earlier study linking anxiety sensitivity to weekly alcohol consump-

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tion and yearly excessive drinking (Stewart et al., 1995). Like with anxiety sensitivity, higher levels of emotion dysregulation were associated with experiencing greater alcohol problems but not greater consumption. What this suggests is that a woman who has difficulty in understanding, accepting, or modulating her emotions when upset is likely to experience greater negative consequences of her drinking, even at similar levels of consumption as other women. Further, these findings add to a growing literature that individual differences in emotional experience and subsequent regulation, especially for women, may better predict the outcomes of substance use rather than frequency or quantity itself (e.g., Simons and Carey, 2002). Regarding our primary aims, and as hypothesized, anxiety sensitivity was indirectly associated with both alcohol use and alcohol-related problems through the impact of drinking to cope. This indirect link between anxiety sensitivity and alcohol use was previously found by Stewart et al. (2001). It is important to reiterate that the indirect effect predicting frequency of use, quantity of use, and frequency of heavy episodic drinking each emerged despite there being no significant bivariate relation between any of the three and anxiety sensitivity. Older guidelines for mediation suggested stopping further investigation of mediation effects in the absence of a direct effect between the independent and dependent variables (Baron and Kenny, 1986). The use of modern methods to calculate the indirect effect (Preacher and Hayes, 2008) allowed us to show that although being a more highly anxiety-sensitive woman in our sample did not directly relate to increased drinking, it did result in the adoption of coping motives that, in turn, were related to such women consuming more alcohol. The indirect link between anxiety sensitivity and alcohol-related problems found in the current study is a unique addition to the literature. Women who were more anxiety sensitive experienced a greater number of alcoholrelated problems because they were more likely to drink to cope with negative emotions and subsequently to engage in more frequent heavy drinking than were women who were less anxiety sensitive. Of the consumption variables tested, it was only heavy episodic drinking frequency that ultimately linked anxiety sensitivity to alcohol problems, despite the fact that drinking to cope also led to greater frequency of use and quantity of use. Our findings are in line with theoretical models (e.g., DeMartini and Carey, 2011) that suggest that because anxiety sensitivity is a catalyst for women to feel high levels of arousal, they then increase alcohol consumption to reap the dampening effects on perceived physiological and affective arousal, setting off a strong negative reinforcement process. Certainly, anxietysensitive women seem to experience greater problems because they are simply drinking at higher rates. Somewhat surprisingly, however, a second indirect effect emerged from anxiety sensitivity to alcohol-related problems via

coping motives that did not also go through any of the alcohol consumption variables. Laboratory-based findings that suggest anxiety-sensitive individuals report greater anxiolytic effects of alcohol (Lewis and Vogeltanz-Holm, 2002) and studies suggesting such individuals may choose to drink in unique environmental contexts (e.g., Samoluk and Stewart, 1998) raise the possibility that factors other than just greater consumption may lead to problematic behavioral outcomes. Our data suggest that at least one individual difference variable, emotion dysregulation, may help to explain why anxiety-sensitive women who drink to cope experience more problems. Although emotion dysregulation has previously been related to both coping drinking motives (Goldstein and Flett, 2009; Kuntsche et al., 2006) and alcohol-related variables (Bonn-Miller et al., 2008; Weinberg and Klonsky, 2009), ours is the first study to test its role as a moderator of the indirect effect of anxiety sensitivity on alcohol outcomes. In the current study, emotion dysregulation affected the indirect relation between anxiety sensitivity and alcohol-related problems but did not affect the indirect relation between anxiety sensitivity and alcohol consumption. Regarding problems, as the level of emotion dysregulation increased, so did the strength of the indirect relation between anxiety sensitivity and alcohol-related problems. Specifically, emotion dysregulation moderated the link between heavy episodic drinking frequency and alcohol-related problems. Furthermore, this effect was found across all levels of emotion dysregulation, suggesting that even mild impairment in the ability to regulate emotions may increase the likelihood that heavy episodic drinking frequency leads to negative alcohol-related consequences. It is conceivable that when women who choose to drink excessively to regulate their negative emotions also engage in additional maladaptive strategies to regulate these same emotions, the result is a compounded set of problems associated with alcohol use. Although highly related, consumption is but one factor among many others (e.g., not using protective behavioral strategies, engaging in risk-amplifying behaviors; Luebbe et al., 2009; Park and Grant, 2005) that predict alcohol-related problems. It may be that over and above how much a woman drinks, the extent to which she has difficulties in adaptively modulating negative affect across domains of functioning (e.g., responsibilities, social situations) may lead to compounded problems when she chooses to drink. Future research is needed to parse why emotion dysregulation seems to exacerbate problems, but not consumption, for women who are anxiety sensitive. Given that emotion regulation is a multifaceted construct (Gratz and Roemer, 2004), testing whether particular aspects of emotion dysregulation (e.g., emotional nonacceptance, impulsivity) contribute to the link between heavy episodic drinking and negative consequences seems warranted. Additional research identifying precise mecha-

CHANDLEY ET AL. nisms related to such difficulties may inform treatment and prevention. Despite the numerous contributions to the literature, this study is not without limitations. Although previous research suggests that the relation of anxiety sensitivity with drinking to cope may be an especially significant problem with women (Stewart et al., 2001), the current study did not examine whether such relations existed among men. Testing gender as an additional moderator in our model is warranted in future research. However, women are more likely to experience negative alcohol-related consequences (Park and Grant, 2005) including sexual assault (Lawyer et al., 2010), which is more likely to occur among women with high levels of emotion dysregulation (MessmanMoore et al., 2013). Generalization of findings is further affected by the use of a community-based, primarily White sample of college women. Thus, it is unknown how these variables are related among men, young women not attending college, or older or minority women. Future research should aim to extend these investigations to ethnically and developmentally diverse samples and clinical populations. Research done with clinically anxious or alcoholdependent samples may provide additional information that allows for the tailoring of emotion regulation–based interventions depending on the severity of the disorder. However, findings here suggest that even mild levels of emotion dysregulation amplify the impact of heavy episodic drinking on alcohol-related problems. Last, the retrospective, cross-sectional design of the current study precludes assumptions regarding causality or temporal relations among variables. Although it seems unlikely that coping motives or drinking would lead to anxiety sensitivity (a more stable construct), future studies should strive to replicate and extend the current findings with prospective, longitudinal designs. The results of this study carry implications for alcoholrelated prevention and intervention. Although there are limits to generalizability for our findings, it is likely that many White female college students would exhibit patterns similar to those demonstrated in the study, implying far-reaching implications for university mental and physical health programming. Generalized prevention and intervention efforts with college students do not typically tailor messages by gender, despite the fact that women experience more negative health and psychosocial consequences compared with men (National Center on Addiction and Substance Abuse, 2003; Park and Grant, 2005). Furthermore, given the role of drinking to cope in the development of alcohol-related problems, targeted secondary intervention appears warranted and may be effective if emotion regulation skills are incorporated. Future research should examine what forms of emotion-focused intervention would positively affect negative alcohol-related consequences.

91 Acknowledgments

The authors acknowledge the support of numerous research assistants, whose hard work and dedication made this work possible.

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