Investigating the effects of emotion dysregulation and repetitive negative thinking on alcohol hangover anxiety and depression

Alcohol hangover refers to negative physical (e.g., fatigue, nausea, diarrhea, and headache) and mental or psychological (e.g., anxiety and depression) symptoms that may follow a single episode of alcohol consumption as blood alcohol concentration approaches zero (Verster et al., 2020). Approximately 75% of people experience at least mild hangover symptoms following excessive alcohol consumption (Harburg et al., 1993, Howland et al., 2008), which is associated with functional impairment such as missing work or school, difficulty thinking, and motor skills (Gunn et al., 2018, Hingson et al., 2016, Stephens et al., 2008). Most research to date has examined physical symptoms of hangover and associated physiological causes (Penning et al., 2010). Considerably less is known about cognitive and emotional symptoms such as anxiety and depression (Bruce et al., 2019, Milton et al., 2019), which approximately 22% of drinkers report experiencing (van Schrojenstein Lantman et al., 2016). Further, a majority of research in this area has used experimental animal designs (e.g., Karadayian et al., 2013, Leite and Nobre, 2012, Schank et al., 2012). The few studies that have examined cognitive and emotional aspects of hangover among clinical alcohol abuse (e.g., Palmer et al., 2019) and general or student samples (Alford et al., 2020, Bruce et al., 2019, Gunn et al., 2021, Gunn et al., 2018, Marsh et al., 2019, McKinney, 2010, Murgia et al., 2020) have identified relevant underlying factors such as shyness (Marsh et al., 2019) and hangover sensitivity (Bruce et al., 2019).

One factor potentially relevant to the experience of hangover anxiety and depression is emotion dysregulation, which is a multidimensional construct characterized by a lack of awareness, clarity, and acceptance of emotions, and difficulties controlling impulsive behaviors and engaging in situationally appropriate and flexible strategies to modulate emotional experiences in pursuit of goal-directed behavior when experiencing negative emotions (Gratz & Roemer, 2004). Emotion dysregulation is a transdiagnostic factor relevant to the etiology and maintenance of various forms of psychopathology (Sloan et al., 2017) including non-hangover related anxiety and depression (i.e., anxiety and depression symptoms experienced in non-hangover contexts), borderline personality disorder, and substance abuse (Aldao et al., 2010, Sloan et al., 2017). Emotion dysregulation also plays a role in alcohol use. Maladaptive or ineffective emotional responding is positively associated with intense craving (Petit et al., 2015) and elevated alcohol consumption during periods of heavy drinking among patients with an alcohol use disorder (Kopera et al., 2015). Thus, emotion dysregulation may contribute to problematic drinking behavior and subsequent hangover symptoms. Emerging evidence also suggests that emotion dysregulation may play a role in the association of anxiety and depression with alcohol use (Buckner et al., 2021, Kim and Kwon, 2020, Morris et al., 2021). Specifically, individuals who report experiencing current hangover (versus those without a hangover) subjectively report greater overall emotion dysregulation, non-acceptance and lack of clarity about current emotions, and more difficulties modulating emotional and behavioral responses (Gunn et al., 2021). Thus, perceived emotion dysregulation or diminished cognitive and emotional resources for effective emotion regulation processing while hungover may exert a direct effect on subsequent hangover symptoms, including anxiety and depression.

Research is also limited in examining factors that may influence the relation between emotion dysregulation and hangover anxiety and depression, such as repetitive negative thinking (RNT). RNT is a transdiagnostic factor defined as intrusive thought patterns that are difficult to disengage from, repetitive, capture mental capacity, and are perceived as unproductive (Ehring et al., 2011). This conceptualization encompasses the experience of worry and rumination, which are implicated in the development of anxiety (Goodwin et al., 2017) and depression (Vanderhasselt et al., 2016) symptoms respectively, though researchers suggest RNT is a more robust predictor than either worry or rumination (Klemanski et al., 2017). Indeed, some evidence indicates RNT may operate in tandem with emotion dysregulation in the context of non-hangover anxiety and depression (Everaert and Joormann, 2019, Klemanski et al., 2017), as well as in the relation between non-hangover anxiety and alcohol-related functional impairment (Sorid et al., 2021). Accordingly, identifying the impact of RNT on emotion dysregulation-hangover anxiety and depression relations may serve to further improve understanding of potential mechanisms by which hangover anxiety and depression develop.

Several aspects of RNT are likely to enhance negative effects of emotion dysregulation. RNT consists of a focus on negative emotions (Ehring and Watkins, 2008, Spinhoven et al., 2015) and characteristics of RNT such as rumination are associated with maladaptive emotion regulation strategies, including suppression and non-acceptance of emotion (Liverant et al., 2011). Individuals who experience emotion dysregulation such as lack of understanding and acceptance of emotions and who also ruminate on, or have difficulties disengaging from negative thoughts and emotions may experience more pronounced and persistent symptoms. RNT is also associated with the experience of more prolonged negative emotional states (Watkins & Roberts, 2020), which may exacerbate symptoms among those who experience difficulties refraining from impulsive behaviors when distressed. This interaction may be particularly relevant in the context of alcohol use given evidence that RNT (Devynck et al., 2019) and emotion dysregulation (Berking et al., 2011) are associated with alcohol abuse and may facilitate the development and maintenance of problem drinking behavior, including hangover.

Despite evidence that emotion dysregulation (Sloan et al., 2017) and RNT (Spinhoven et al., 2015, Topper et al., 2014) are associated with non-hangover anxiety and depression symptoms, research remains limited in examinations of these transdiagnostic factors in hangover specific anxiety and depression. The current study aimed to prospectively examine the role of emotion dysregulation on subsequent hangover anxiety and depression symptoms among university students, a non-clinical population associated with heavy alcohol use (Colby et al., 2009) and high rates of hangover (Slutske et al., 2003). High baseline emotion dysregulation was hypothesized to predict greater hangover anxiety and depression at 2-week follow-up. In addition, this study aimed to identify the role of RNT on the emotion dysregulation-hangover anxiety and depression relations. High RNT at 2-week follow-up was hypothesized to moderate these relations, such that high RNT would be associated with stronger emotion dysregulation-hangover anxiety and depression symptoms relations.

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