Investigating Substance Use as a Coping Strategy Among Adolescent Psychiatric Inpatients: A Comparative Analysis Before and During the COVID-19 Pandemic.

The COVID-19 pandemic resulted in significant changes in daily life, potentially impacting mental health and substance use behavior. Research on COVID-related changes in adolescent substance use have yielded mixed findings. The current cross-sectional chart review study compared rates of past-year substance use before and during COVID-19 among adolescent psychiatric inpatients, and investigated how motives for coping with COVID-19 changes were related to psychiatric acuity, and past-year substance use. Count models assessed if the number of past-year days of alcohol and cannabis use was higher among adolescents (n = 491, 11-18 years, 61% female) hospitalized during COVID-19 (3/14/20 to 4/5/21) versus adolescents hospitalized before COVID-19 (8/30/2019 to 3/13/20). For a subsample of COVID-19 inpatients (n = 124; 75% female), we evaluated psychiatric correlates of endorsing substances to cope with COVID-19 changes/rules. Results indicated adolescents admitted during COVID-19 reported significantly more past-year alcohol and cannabis use days than adolescents admitted before COVID-19. Adolescents endorsed using alcohol (19%), cannabis (33%), and e-cigarettes/vaping (25%) to cope with COVID-19. E-cigarette/vaping to cope with COVID-19 was significantly related to lifetime suicide attempt. Endorsing alcohol or cannabis to cope with COVID-19 was associated with a significantly greater number of past-year use days for each respective substance. Adolescent psychiatric inpatients admitted during COVID-19 reported more substance use days than adolescents admitted before COVID-19. Using substances to cope was linked to psychiatric correlates (e.g., suicidality). Assessing the presence and function of substance use in this population may be important to identify, treat, and prevent compounding negative outcomes during times of community stress.

Daily Levels and Dynamic Metrics of Affective-Cognitive Constructs Associate With Suicidal Thoughts and Behaviours in Adults After Psychiatric Hospitalization.

The period after psychiatric hospitalization is an extraordinarily high-risk period for suicidal thoughts and behaviours (STBs). Affective-cognitive constructs (ACCs) are salient risk factors for STBs, and intensive longitudinal metrics of these constructs may improve personalized risk detection and intervention. However, limited research has examined how within-person daily levels and between-person dynamic metrics of ACCs relate to STBs after hospital discharge. Adult psychiatric inpatients (N = 95) completed a 65-day ecological momentary assessment protocol after discharge as part of a 6-month follow-up period. Using dynamic structural equation models, we examined both within-person daily levels and between-person dynamic metrics (intensity, variability and inertia) of positive and negative affect, rumination, distress intolerance and emotion dysregulation as risk factors for STBs. Within-person lower daily levels of positive affect and higher daily levels of negative affect, rumination, distress intolerance and emotion dysregulation were risk factors for next-day suicidal ideation (SI). Same-day within-person higher rumination and negative affect were also risk factors for same-day SI. At the between-person level, higher overall positive affect was protective against active SI and suicidal behaviour over the 6-month follow-up, while greater variability of rumination and distress intolerance increased risk for active SI, suicidal behaviour and suicide attempt. The present study provides the most comprehensive examination to date of intensive longitudinal metrics of ACCs as risk factors for STBs. Results support the continued use of intensive longitudinal methods to improve STB risk detection. Interventions focusing on rumination and distress intolerance may specifically help to prevent suicidal crises during critical transitions in care.

Is trait rumination associated with affective reactivity to the menstrual cycle? A prospective analysis.

BACKGROUND: A minority of naturally cycling individuals experience clinically significant affective changes across the menstrual cycle. However, few studies have examined cognitive and behavioral constructs that may maintain or worsen these changes. Several small studies link rumination with premenstrual negative affect, with authors concluding that a tendency to ruminate amplifies and perpetuates hormone-sensitive affective symptoms. Replication in larger samples is needed to confirm the validity of rumination as a treatment target. METHOD: 190 cycling individuals (M = 30.82 years; 61.1% Caucasian) were recruited for moderate perceived stress, a risk factor for cyclical symptoms. They completed the Rumination Response Scale at baseline, then reported daily affective and physical symptoms across 1-6 cycles. Multilevel growth models tested trait rumination as a predictor of baseline levels, luteal increases, and follicular decreases in symptoms. RESULTS: The degree of affective cyclicity was normally distributed across a substantial range, supporting feasibility of hypothesis tests and validating the concept of dimensional hormone sensitivity. Contrary to prediction, higher brooding did not predict levels or cyclical changes of any symptom. In a subsample selected for luteal increases in negative affect, brooding predicted higher baseline negative affect but still did not predict affective cyclicity. CONCLUSIONS: An individual's trait-like propensity to engage in rumination may not be a valid treatment target in premenstrual mood disorders. State-like changes in rumination should still be further explored, and well-powered prospective studies should explore other cognitive and behavioral factors to inform development of targeted psychological treatments for patients with cyclical affective symptoms.

Correlates of Menarcheal Age in a Psychiatric Sample of Adolescents.

ABSTRACT: Early pubertal timing is associated with more adverse childhood experiences (ACEs) and increased risk for psychopathology during adolescence. However, most work to date has used community or epidemiological samples, and it remains unclear whether these associations persist in acute clinical samples. The present study examined associations between age at menarche and ACEs, psychiatric symptoms, and emotion regulation difficulties in a sample of N = 140 adolescents on a psychiatric inpatient unit. Youth with early menarche reported higher levels of depressive symptoms, more severe suicidal ideation, and greater difficulty with emotion regulation than youth with normative age at menarche. There was a marginal effect of youth with early menarche reporting more ACEs and more anxiety symptoms. These results suggest menarcheal age, and ACEs may be useful risk factors to assess in inpatient settings to predict risk for more severe outcomes, and future research on pubertal timing in high acuity settings is warranted.

Improving rigor through gender inclusivity in reproductive psychiatric science.

Accurately defining the individuals that research involves and generalizes to is critical for rigorous and reproducible science. In reproductive psychiatry, which historically focuses on the impact of the menstrual cycle, pregnancy, and menopause on mental health, this means moving beyond characterizing samples and relevant populations as "women" in favor of language that precisely identifies the physiological characteristics pertinent to the research being conducted and accurately reflects the varied genders represented in those populations. Concrete recommendations are provided for precise use of sex and gender terminology and gender inclusivity throughout the scientific process, including study conceptualization, etiquette in research environments, recruitment, methods, and dissemination. Recommendations are discussed in depth and presented in a checklist format for ease of use by research teams. Suggested items for assessing gender and relevant sex-related physiology in the context of reproductive psychiatry are also provided.

A daily diary study of minority stressors, suicidal ideation, nonsuicidal self-injury ideation, and affective mechanisms among sexual and gender minority youth.

Sexual and gender minority youth (SGMY) are at greater risk than their heterosexual and cisgender counterparts for suicidal thoughts and behaviors (STB) and nonsuicidal self-injury (NSSI). Unique stressors (i.e., minority stressors) specific to SGMY's stigmatized identities such as discrimination or concealment of one's identity are posited to explain these disparities. However, there is limited research examining the associations among minority stressors, affective mediating processes, and STB and NSSI in SGMY's daily lives. We conducted a 28-day daily diary study to test the mediating effects of daily negative and positive affect and emotion dysregulation between minority stressors and STB and NSSI among SGMY who were recruited from clinical and community settings. Participants were 92 SGMY, aged 12-19 years old (M = 16.45; SD = 1.81; 64% cisgender; 69% White). Results indicated that on days SGMY experienced external and internalized minority stressors, they reported greater intensity of suicidal and nonsuicidal self-injurious ideation and affective distress (i.e., greater negative affect, lower positive affect, and more emotion dysregulation). Greater affective reactivity processes were associated with greater suicidal and nonsuicidal self-injurious ideation intensity on the same day. Most of the within-person associations between external and internalized minority stressors and ideation intensity were mediated by heightened negative affect and emotion dysregulation but not lower positive affect. Our results provide the first evidence of these associations among SGMY, advance the minority stress model, and have implications for clinical interventions as we identified modifiable affective mechanisms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A pilot randomized controlled trial of ketamine in Borderline Personality Disorder.

This study is the first randomized controlled trial to test the effects of ketamine in Borderline Personality Disorder (BPD). BPD remains undertreated in the community and no medication has FDA approval for this indication. People with BPD experience chronic mood disturbances with depressed mood, suicidal ideation, and severe social difficulties. In this double-blind, randomized controlled pilot study, we tested the effects of one infusion of ketamine (0.5 mg/kg, n = 10) or the psychoactive comparator drug midazolam (0.04 mg/kg, n = 12) in adults with BPD. Infusions were well tolerated in both groups. Dissociative symptoms during infusion were more intense with ketamine than midazolam (t(12.3) = 3.61, p = 0.01), but they resolved by 40 min after infusion in both groups. Post-infusion adverse events were at the expected low levels in both groups. For our primary outcome measure of suicidal ideation and our secondary outcome measure of depression, we found numerical reduction but not significant group or group x timepoint difference (p > 0.05). For our secondary outcome measures of anxiety and BPD symptoms, we did not observe group or group x timepoint differences. There was a group x timepoint effect for socio-occupational functioning (F(1,20.12) = 5.16, p = 0.03, at Day 14, ketamine group showed more improvement than midazolam group). An exploratory analysis revealed that improvement in socio-occupational functioning was correlated with improvement in depression in the ketamine group (r(8) = 0.65, p = 0.04) but not midazolam group (r(9) = 0.41, p = 0.216). This pilot study provides the first randomized controlled evidence of the effects of antidepressant-dosed ketamine in people with BPD. Our results provide reason for optimism that antidepressant-dosed ketamine will be well-tolerated in larger studies and may provide clinical benefit for mood symptoms and related impairments in people with BPD.

Destigmatizing Borderline Personality Disorder: A Call to Action for Psychological Science.

Despite recognition that borderline personality disorder (BPD) is one of the most stigmatized psychological disorders, destigmatization efforts have thus far focused on the views and actions of clinicians and the general public, neglecting the critical role that psychological science plays in perpetuating or mitigating stigma. This article was catalyzed by recent concerns about how research and editorial processes propagate stigma and thereby fail people with BPD and the scientists who study BPD. We provide a brief overview of the BPD diagnosis and its history. We then review how BPD has been stigmatized in psychological science, the gendered nature of BPD stigma, and the consequences of this stigmatization. Finally, we offer specific recommendations for researchers, reviewers, and editors who wish to use science to advance our understanding of BPD without perpetuating pejorative views of the disorder. These recommendations constitute a call to action to use psychological science in the service of the public good.

Borderline personality disorder symptom networks across adolescent and adult clinical samples: examining symptom centrality and replicability.

BACKGROUND: Numerous theories posit different core features to borderline personality disorder (BPD). Recent advances in network analysis provide a method of examining the relative centrality of BPD symptoms, as well as examine the replicability of findings across samples. Additionally, despite the increase in research supporting the validity of BPD in adolescents, clinicians are reluctant to diagnose BPD in adolescents. Establishing the replicability of the syndrome across adolescents and adults informs clinical practice and research. This study examined the stability of BPD symptom networks and centrality of symptoms across samples varying in age and clinical characteristics. METHODS: Cross-sectional analyses of BPD symptoms from semi-structured diagnostic interviews from the Collaborative Longitudinal Study of Personality Disorders (CLPS), the Methods to Improve Diagnostic Assessment and Service (MIDAS) study, and an adolescent clinical sample. Network attributes, including edge (partial association) strength and node (symptom) expected influence, were compared. RESULTS: The three networks were largely similar and strongly correlated. Affective instability and identity disturbance emerged as relatively central symptoms across the three samples, and relationship difficulties across adult networks. Differences in network attributes were more evident between networks varying both in age and in BPD symptom severity level. CONCLUSIONS: Findings highlight the relative importance of affective, identity, and relationship symptoms, consistent with several leading theories of BPD. The network structure of BPD symptoms appears generally replicable across multiple large samples including adolescents and adults, providing further support for the validity of the diagnosis across these developmental phases.

Association between Shame Aversion and Ruminative Retribution: Evidence for Moderation by Externalization of Blame and Control.

Shame aversion has been theorized to motivate aggression against the self or others as means of down-regulating shame. Additionally, the direction of aggression may depend on tendencies to attribute blame or causes internally or externally. Data from two separate samples were used to examine shame aversion and its interaction with causal or blame attributions in relation to aggression, controlling for shame-proneness, which is more commonly studied. Results indicated that shame aversion was positively associated with verbal, relational, and passive-rational aggression, as well as with ruminative retribution and non-suicidal self-injury, after accounting for shame-proneness. Most noteworthy, a significant two-way interaction indicated that the association between shame aversion and ruminative retribution (fantasizing about people getting their comeuppance) was particularly strong at high levels of externalization of blame. Findings therefore suggest that although shame-proneness may create situations in which shame regulation strategies are necessary, aggressive fantasies may be used as a regulation strategy when individuals have difficulty tolerating shame and blame others for their circumstances.

Association of Borderline Personality Disorder Criteria With Suicide Attempts: Findings From the Collaborative Longitudinal Study of Personality Disorders Over 10 Years of Follow-up.

Importance: Borderline personality disorder (BPD) has been identified as a strong risk factor for suicidal behavior, including suicide attempts. Delineating specific features that increase risk could inform interventions. Objective: To examine factors associated with prospectively observed suicide attempts among participants in the Collaborative Longitudinal Study of Personality Disorders (CLPS), over 10 years of follow-up, with a focus on BPD and BPD criteria. Design, Setting, and Participants: The CLPS is a multisite, naturalistic, prospective study of adult participants with 4 personality disorders (PDs) and a comparison group of adults with major depressive disorder and minimal PD features. Participants were all treatment-seeking and recruited from inpatient, partial, and outpatient treatment settings across New York, New York, Boston, Massachusetts, New Haven, Connecticut, and Providence, Rhode Island. A total of 733 participants were recruited at baseline, with 701 completing at least 1 follow-up assessment. The cohorts were recruited from September 1996 through April 1998 and September 2001 through August 2002. Data for this study using this follow-up sample (N = 701) were analyzed between March 2019 and August 2020. Main Outcomes and Measures: Participants were assessed annually using semistructured diagnostic interviews and a variety of self-report measures for up to 10 years. Multiple logistic regression analyses were used to examine baseline demographic and clinical risk factors, including BPD and individual BPD criteria, of suicide attempt assessed over 10 years of prospective follow-up. Results: Of the 701 participants, 447 (64%) identified as female, 488 (70%) as White, 527 (75%) as single, 433 (62%) were unemployed, and 512 (73%) reported at least some college education. Of all disorders, BPD emerged as the most robust factor associated with prospectively observed suicide attempt(s) (odds ratio [OR], 4.18; 95% CI, 2.68-6.52), even after controlling for significant demographic (sex, employment, and education) and clinical (childhood sexual abuse, alcohol use disorder, substance use disorder, and posttraumatic stress disorder) factors. Among BPD criteria, identity disturbance (OR, 2.21; 95% CI, 1.37-3.56), chronic feelings of emptiness (OR, 1.63; 95% CI, 1.03-2.57), and frantic efforts to avoid abandonment (OR, 1.93; 95% CI, 1.17-3.16) emerged as significant independent factors associated with suicide attempt(s) over follow-up, when covarying for other significant factors and BPD criteria. Conclusions and Relevance: In the multisite, longitudinal study of adults with personality disorders, identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment were significantly associated with suicide attempts. Identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment may be clinically overlooked features of BPD in context of suicide risk assessment. In light of the high rates of BPD diagnostic remission, our findings suggest that these criteria should be independently assessed and targeted for further study as suicide risk factors.

Skills to Enhance Positivity in Suicidal Adolescents: Results from a Pilot Randomized Clinical Trial.

The objective of this study was to examine the feasibility, acceptability, and preliminary effects of an intervention, Skills to Enhance Positivity (STEP) that aims to increase attention to positive emotions and experiences and to decrease suicidal events. STEP involves four in-person individual sessions delivered during an inpatient psychiatric admission, followed by one month of weekly phone calls and daily text messages with mood monitoring and skills practice. A pilot randomized controlled trial of STEP vs. enhanced treatment as usual (ETAU) was conducted with 52 adolescents. Results indicated that on average 83% of sessions were completed and that on 70% of days, participants engaged with the text-messaging component of the intervention. Acceptability for both in-person and text-messaging components were also high, with satisfaction ratings averaging between good and excellent. STEP participants reported fewer suicide events than ETAU participants (6 vs. 13) after six months of follow-up.

Differential effects of the menstrual cycle on reactive and proactive aggression in borderline personality disorder.

Borderline personality disorder (BPD) is characterized by rapidly shifting symptoms, including intense anger and aggressive behavior. Understanding how fluctuations in ovarian hormones across the menstrual cycle may contribute to symptom instability is key for accurate assessment of BPD symptoms and effective interventions. Reactive and proactive aggression, as well as anger-in and anger-out, were assessed daily in 15 physically healthy, unmedicated naturally cycling female individuals meeting criteria for BPD across 35 days. Urine luteinizing hormone surge and salivary progesterone were used to confirm ovulation and verify the cycle phase. Multilevel models evaluated cyclical differences of symptoms between cycle phases. Both forms of aggressive behavior demonstrated marked cycle effects, with reactive aggression highest during the midluteal cycle phase, co-occurring with initial increases in anger and irritability and followed by perimenstrual peaks in anger and anger-in. In contrast, highest levels of proactive aggression were observed during the follicular and ovulatory phases, when emotional symptoms and anger were otherwise at lowest levels. These findings highlight the importance of identifying the function of aggression when considering potential psychological and biological influences. Naturally cycling individuals with BPD may be at elevated risk for luteal worsening of a range of interpersonally reactive symptoms, including reactive aggression, whereas proactive aggression may occur more in phases characterized by less emotional and cognitive vulnerability and greater reward sensitivity. Research on aggression in this population should consider cycle effects. Cycling individuals with BPD attempting to reduce aggressive behavior may benefit from cycle-tracking to increase awareness of these effects and to develop appropriate strategies.

Sexual orientation differences in non-suicidal self-injury, suicidality, and psychosocial factors among an inpatient psychiatric sample of adolescents.

Within broader community samples, sexual minority adolescents (SMA, e.g., lesbian, gay, bisexual, queer) are at greater risk than their heterosexual counterparts for nonsuicidal self-injury (NSSI) and suicidal thoughts and behaviors. The present study investigated whether sexual minority orientation continues to confer additional risk for these behaviors in an already higher-risk sample of youth. Frequency and function of NSSI, suicidal behavior, and psychosocial factors were assessed in a sample of 52 adolescents (aged 12-18 years) admitted to an inpatient psychiatric unit due to suicide risk; 27 of them identified as SMA, and 25 as heterosexual (HA). Greater proportions of SMA reported engaging in lifetime NSSI, compared to HA, with a greater variety and frequency of NSSI behaviors and greater endorsement of intrapersonal NSSI functions. SMA reported higher levels of suicide ideation than HA, but not suicidal behavior. Group differences in NSSI and SI persisted when controlling for the greater prevalence of abuse and levels of peer-victimization reported by SMA. In inpatient clinical settings, SMA may be more likely than heterosexual youth to engage in NSSI, including more severe forms, and to experience suicide ideation. Providing alternative coping mechanisms may serve as treatment goals for reducing NSSI in SMA.

Ovarian Hormones as a Source of Fluctuating Biological Vulnerability in Borderline Personality Disorder.

PURPOSE OF REVIEW: To examine the potential role of ovarian hormones in biological vulnerability to borderline personality disorder (BPD). The review focuses primarily on research examining the menstrual cycle as a source of short-term lability of BPD symptom expression, while discussing the currently understudied possibility of ovarian hormone influence in the developmental course of BPD. FINDINGS: Several patterns of menstrual cycle effects on BPD symptoms and relevant features in non-clinical samples have been observed in empirical studies. Most symptoms demonstrated patterns consistent with perimenstrual exacerbation; however, timing varied between high and low arousal symptoms, potentially reflecting differing mechanisms. Symptoms are typically lowest around ovulation, with an exception for proactive aggression and some forms of impulsive behaviors. Preliminary evidence suggests ovarian hormones may exert strong effects on BPD symptom expression, and further research is warranted examining mechanisms and developing interventions. Recommendations for researchers and clinicians working with BPD are provided.

Elucidating the relationships between shame, anger, and self-destructive behaviors: The role of aversive responses to emotions.

Shame and anger are distinct yet interrelated emotions that have both been implicated in the occurrence of impulsive, self-destructive behavior (ISDB); however, the intricacies of these relations remain sparsely examined. Some research, mostly with anxiety and depression, suggests that an aversive reaction to the experience of negative emotions can result in efforts to escape or avoid such experiences. The current study sought to extend this model to the experience of shame. Consistently, we predicted that aversive reactions to shame would be associated with anger, which would be associated with ISDB. Four hundred and seventy-five undergraduate students completed a series of online questionnaires. Serial mediation was performed and r-square indicated that 35.55% of the variance in impulsive behavior was explained by this model. As predicted, shame had a significant indirect effect on anger through aversive reactions to emotions and on ISDB through aversive reactions to emotions and anger. Unexpectedly the reverse model, with an aversive reaction to anger predicting shame and ISDB, was also significant suggesting possible bidirectional relations between these constructs. This study is among the first to examine a possible mechanism by which shame can lead to ISDB, providing potential points of intervention for treatment.

Suicide Ideation in Adolescents Following Inpatient Hospitalization: Examination of Intensity and Lability Over 6 Months.

Understanding suicide ideation (SI) in adolescents, especially during the high-risk time following hospitalization for a suicidal event, is a crucial component of improving risk assessment. Most studies rely on single assessments of SI, despite the potential for SI to vary considerably over time. This study examined how indices of SI intensity (mean values) and lability (mean squared successive difference values) over a 6-month period predict suicide attempts (SAs) and self-harm, as well as how they relate to psychosocial risk factors and affective functioning, in a sample of 103 adolescents hospitalized for a SA or significant SI. Across the sample, SI intensity, but not lability, was associated with SAs and nonsuicidal self-injury at 6-month follow-up. SI intensity performed similarly to single time point SI assessments, and its relations were not moderated by SI lability. SI intensity was also associated with borderline personality disorder criteria and a history of sexual abuse. In contrast, SI lability was associated with greater negative affect intensity and lability. These findings suggest that intensity of SI may confer more risk posthospitalization, and provide support for using these statistical methods to capture two distinct parameters of SI.

Minority Stress and Relational Mechanisms of Suicide among Sexual Minorities: Subgroup Differences in the Associations Between Heterosexist Victimization, Shame, Rejection Sensitivity, and Suicide Risk.

Despite sexual orientation disparities in suicide, there is limited research examining factors associated with suicide risk among sexual minorities while considering subgroup differences within this group. This study identified differences between sexual minorities at risk for suicide and those not at risk. The study also examined heterosexist victimization, as one form of minority stress, and two relational mechanisms (i.e., shame and rejection sensitivity) as risk factors for suicidality. We examined a moderated-mediation model, in which we tested gender and sexual orientation differences in the mediating effects of the relational mechanisms on the association between heterosexist victimization and suicide risk. Participants were recruited online and completed an online survey. The sample included 719 sexual minority adults. Of the sample, 27.7% were at risk for suicide. Suicide risk varied by age, gender, sexual orientation, income, education, and relationship status. Heterosexist victimization, shame, and rejection sensitivity were significant risk factors for suicide. Shame and rejection sensitivity were mediators of the association between heterosexist victimization and suicide risk for subgroups of sexual minorities, mostly lesbian and gay individuals and to some extent bisexual individuals. The findings underscore minority stress, shame, and rejection sensitivity as key intervention points.

Exploring the pathophysiology of emotion-based impulsivity: The roles of the sympathetic nervous system and hostile reactivity.

The tendency to engage in impulsive behavior in the context of negative affect, known as negative urgency, has emerged as a powerful transdiagnostic predictor of behavioral dysregulation. Although general vulnerability to negative affect (neuroticism) correlates with negative urgency, not all neurotic individuals engage in urgent behavior. Given prior experimental evidence that sympathetic nervous system (SNS) activation may promote emotion-related impulsivity, the present study examines tonic SNS activity as a moderator of the link between neuroticism and negative urgency. Participants (N = 194) completed measures of neuroticism and negative urgency, as well as a stress task. They also underwent assessment of tonic SNS activity (cardiac pre-ejection period). The link between neuroticism and negative urgency was strengthened for individuals with higher tonic SNS activity; however, this was not the case for behavioral performance on the task. A similar pattern was demonstrated for hostile reactivity to the stress task; increased hostile response partially explained the interaction between SNS activation and neuroticism on negative urgency. These findings suggest a potential facilitative role of the SNS in hostile reactivity and emotion-driven impulsivity among more neurotic individuals.