{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T06:11:54Z","timestamp":1779257514999,"version":"3.51.4"},"reference-count":45,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T00:00:00Z","timestamp":1779235200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Psychol."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Non-medical use of etomidate has emerged as a novel psychoactive substance (NPS) threat in China. Although stress-related mechanisms have been widely implicated in substance use disorders, evidence specific to etomidate use disorder (EUD) remains limited. This study examined whether anxiety symptoms (AS) severity mediates the association between perceived stress and EUD severity, and whether difficulties in emotion regulation strengthen the stress\u2013AS severity link.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      A total of 556 male patients diagnosed with EUD were recruited from drug rehabilitation centers in Hunan Province, China (M\n                      <jats:sub>\n                        <jats:italic>age<\/jats:italic>\n                      <\/jats:sub>\n                      = 22.19, SD = 5.96). Participants completed measures of perceived stress (CPSS), AS severity (BAI), and difficulties in emotion regulation (DERS). EUD severity was indexed by DSM-5 criterion count (0\u201311). A moderated mediation model was tested using PROCESS (Model 7) with bias-corrected bootstrapping (5,000 resamples), controlling for age, educational attainment, only-child status, single-parent family status, and residence (rural vs. urban).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Perceived stress was positively associated with EUD severity. AS severity partially mediated the association between perceived stress and EUD severity. Moreover, DERS moderated the perceived stress\u2013AS severity path, such that perceived stress was more strongly related to AS severity at higher levels of emotion regulation difficulties. Consistently, the indirect effect of perceived stress on EUD severity through AS severity was stronger among individuals reporting greater emotion regulation difficulties.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>These findings suggest that AS severity serves as a potential emotional correlate in the relationship between perceived stress and EUD severity, particularly among individuals with substantial emotion regulation difficulties. Individuals with greater deficits in emotion regulation exhibited a stronger indirect effect of stress on EUD severity via AS severity. This highlights the clinical importance of targeting emotion regulation in interventions for EUD, as improving emotional coping strategies may mitigate the impact of stress. Future longitudinal studies are needed to clarify the causal direction of these associations and investigate how changes in emotion regulation over time influence EUD progression.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpsyg.2026.1778758","type":"journal-article","created":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T05:39:47Z","timestamp":1779255587000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Perceived stress and severity of male etomidate use disorder in China: a moderated mediation model of anxiety symptoms severity and emotion regulation difficulties"],"prefix":"10.3389","volume":"17","author":[{"given":"Xingmin","family":"Wang","sequence":"first","affiliation":[{"name":"Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha","place":["Hunan, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Juan","family":"Le","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha","place":["Hunan, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ying","family":"Tang","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha","place":["Hunan, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Qiuping","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Psychology, School of Humanities and Management, Hunan University of Chinese Medicine, Changsha","place":["Hunan, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jing","family":"Qi","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, Brain Hospital of Hunan Province, Changsha","place":["Hunan, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xinxin","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha","place":["Hunan, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lishun","family":"Zhao","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha","place":["Hunan, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lin","family":"Zhao","sequence":"additional","affiliation":[{"name":"Hunan Provincial Lushan Compulsory Isolation Detoxification Center, Changsha","place":["Hunan, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhenjiang","family":"Liao","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha","place":["Hunan, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hongxian","family":"Shen","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha","place":["Hunan, China"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,5,20]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1330720","DOI":"10.3389\/fpsyg.2024.1330720","article-title":"Social support and mental health: The mediating role of perceived stress.","volume":"15","author":"Acoba","year":"2024","journal-title":"Front. Psychol."},{"key":"B2","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1038\/s41583-024-00880-4","article-title":"Neural circuit basis of pathological anxiety.","volume":"26","author":"Akiki","year":"2025","journal-title":"Nat. Rev. Neurosci."},{"key":"B3","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1146\/annurev-clinpsy-032813-153734","article-title":"Advances in cognitive theory and therapy: The generic cognitive model.","volume":"10","author":"Beck","year":"2014","journal-title":"Annu. Rev. Clin. Psychol."},{"key":"B4","doi-asserted-by":"publisher","first-page":"893","DOI":"10.1037\/\/0022-006x.56.6.893","article-title":"An inventory for measuring clinical anxiety: Psychometric properties.","volume":"56","author":"Beck","year":"1988","journal-title":"J Consult Clin. Psychol."},{"key":"B5","doi-asserted-by":"publisher","first-page":"109057","DOI":"10.1016\/j.drugalcdep.2021.109057","article-title":"Assessment of craving in opioid use disorder: Psychometric evaluation and predictive validity of the opioid craving VAS.","volume":"229","author":"Boyett","year":"2021","journal-title":"Drug Alcohol. Depend."},{"key":"B6","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1007\/s11920-021-01249-5","article-title":"Biopsychosocial model social anxiety and substance use revised.","volume":"23","author":"Buckner","year":"2021","journal-title":"Curr. Psychiatry Rep."},{"key":"B7","doi-asserted-by":"publisher","first-page":"6","DOI":"10.1080\/09540261.2022.2040450","article-title":"Analysis of global prevalence of mental and substance use disorders within countries: Focus on sociodemographic characteristics and income levels.","volume":"34","author":"Castaldelli-Maia","year":"2022","journal-title":"Int. Rev. Psychiatry"},{"key":"B8","unstructured":"Etomidate (DB00292).\n          \n          2025"},{"key":"B9","doi-asserted-by":"publisher","first-page":"226","DOI":"10.1093\/ntr\/ntp198","article-title":"Do smokers crave cigarettes in some smoking situations more than others? Situational correlates of craving when smoking.","volume":"12","author":"Dunbar","year":"2010","journal-title":"Nicotine Tob. Res."},{"key":"B10","doi-asserted-by":"publisher","first-page":"108247","DOI":"10.1016\/j.envint.2023.108247","article-title":"Heat exposure intervention, anxiety level, and multi-omic profiles: A randomized crossover study.","volume":"181","author":"Fang","year":"2023","journal-title":"Environ. Int."},{"key":"B11","doi-asserted-by":"publisher","first-page":"992","DOI":"10.1037\/\/0022-3514.50.5.992","article-title":"Dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes.","volume":"50","author":"Folkman","year":"1986","journal-title":"J. Pers. Soc. Psychol."},{"key":"B12","doi-asserted-by":"publisher","first-page":"732","DOI":"10.1016\/s2215-0366(25)00267-6","article-title":"Etomidate misuse: A digital era threat to youth and a call for anticipatory control.","volume":"12","author":"Gao","year":"2025","journal-title":"Lancet Psychiatry"},{"key":"B13","doi-asserted-by":"publisher","first-page":"100","DOI":"10.1007\/s13311-019-00791-8","article-title":"Opioid craving in human laboratory settings: A review of the challenges and limitations.","volume":"17","author":"Goodyear","year":"2020","journal-title":"Neurotherapeutics"},{"key":"B14","doi-asserted-by":"publisher","first-page":"41","DOI":"10.1023\/b:Joba.0000007455.08539.94","article-title":"Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale.","volume":"26","author":"Gratz","year":"2004","journal-title":"J. Psychopathol. Behav. Assess."},{"key":"B15","doi-asserted-by":"publisher","first-page":"281","DOI":"10.1017\/S0048577201393198","article-title":"Emotion regulation: Affective, cognitive, and social consequences.","volume":"39","author":"Gross","year":"2002","journal-title":"Psychophysiology"},{"key":"B16","doi-asserted-by":"publisher","first-page":"834","DOI":"10.1176\/appi.ajp.2013.12060782","article-title":"DSM-5 criteria for substance use disorders: Recommendations and rationale.","volume":"170","author":"Hasin","year":"2013","journal-title":"Am. J. Psychiatry"},{"key":"B17","doi-asserted-by":"publisher","first-page":"370","DOI":"10.1016\/j.neuroscience.2007.09.008","article-title":"Forebrain and midbrain distribution of major benzodiazepine-sensitive GABAA receptor subunits in the adult C57 mouse as assessed with in situ hybridization.","volume":"150","author":"Heldt","year":"2007","journal-title":"Neuroscience"},{"key":"B18","doi-asserted-by":"publisher","first-page":"Cd007505","DOI":"10.1002\/14651858.CD007505.pub2","article-title":"Pharmacotherapy for anxiety and comorbid alcohol use disorders.","volume":"1","author":"Ipser","year":"2015","journal-title":"Cochrane Database Syst. Rev."},{"key":"B19","doi-asserted-by":"publisher","first-page":"S467","DOI":"10.1002\/acr.20561","article-title":"Measures of anxiety: State-Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression Scale-Anxiety (HADS-A).","volume":"63","author":"Julian","year":"2011","journal-title":"Arthritis Care Res."},{"key":"B20","doi-asserted-by":"publisher","first-page":"1259","DOI":"10.1176\/ajp.142.11.1259","article-title":"The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence.","volume":"142","author":"Khantzian","year":"1985","journal-title":"Am. J. Psychiatry"},{"key":"B21","doi-asserted-by":"publisher","first-page":"221","DOI":"10.1176\/appi.focus.25023013","article-title":"Early life stress and substance use disorders: Underlying neurobiology and pathways to adverse outcomes.","volume":"23","author":"Kirsch","year":"2025","journal-title":"Focus"},{"key":"B22","doi-asserted-by":"publisher","first-page":"2684","DOI":"10.1111\/ejn.15182","article-title":"Cortisol promotes the cognitive regulation of high intensive emotions independent of timing.","volume":"55","author":"Langer","year":"2022","journal-title":"Eur. J. Neurosci."},{"key":"B23","doi-asserted-by":"publisher","first-page":"e1","DOI":"10.1037\/pas0000582","article-title":"Psychometric properties of the Chinese version of the Difficulties in Emotion Regulation Scale (DERS): Factor structure, reliability, and validity.","volume":"30","author":"Li","year":"2018","journal-title":"Psychol. Assess"},{"key":"B24","doi-asserted-by":"publisher","first-page":"67","DOI":"10.3969\/j.issn.1000-6729.2021.01.012","article-title":"Application of Chinese version of the stress perception scale in representative community adult groups.","volume":"35","author":"Li","year":"2021","journal-title":"Chin. J. Mental Health"},{"key":"B25","doi-asserted-by":"publisher","first-page":"e70001","DOI":"10.1111\/appy.70001","article-title":"Emergence of a new threat in east asia: Severe agitation and suicide attempts linked to etomidate-infused E-cigarettes.","volume":"17","author":"Liu","year":"2025","journal-title":"Asia Pac. Psychiatry"},{"key":"B26","doi-asserted-by":"publisher","first-page":"106010","DOI":"10.1016\/j.addbeh.2019.05.034","article-title":"Stress and opioid use disorder: A systematic review.","volume":"98","author":"MacLean","year":"2019","journal-title":"Addict. Behav."},{"key":"B27","doi-asserted-by":"publisher","first-page":"e2961","DOI":"10.1002\/cpp.2961","article-title":"A systematic review of the relationship between generic and specific metacognitive beliefs and emotion dysregulation: A metacognitive model of emotion dysregulation.","volume":"31","author":"Mansueto","year":"","journal-title":"Clin. Psychol. Psychother."},{"key":"B28","doi-asserted-by":"publisher","first-page":"473","DOI":"10.1016\/j.jad.2022.04.086","article-title":"Difficulties in emotion regulation: The role of repetitive negative thinking and metacognitive beliefs.","volume":"308","author":"Mansueto","year":"2022","journal-title":"J. Affect. Disord."},{"key":"B29","doi-asserted-by":"publisher","first-page":"63","DOI":"10.1016\/j.jad.2024.07.144","article-title":"Emotion dysregulation in participants with substance use disorders: A metacognitive perspective.","volume":"363","author":"Mansueto","year":"","journal-title":"J. Affect. Disord."},{"key":"B30","doi-asserted-by":"publisher","first-page":"1094","DOI":"10.1177\/2167702619841976","article-title":"Weaker memory performance exacerbates stress-induced cannabis craving in youths\u2019 daily lives.","volume":"7","author":"Miranda","year":"2019","journal-title":"Clin. Psychol. Sci."},{"key":"B31","doi-asserted-by":"publisher","first-page":"617","DOI":"10.1186\/s12888-021-03618-z","article-title":"Anxiety severity and cognitive function in primary care patients with anxiety disorder: A cross-sectional study.","volume":"21","author":"Nyberg","year":"2021","journal-title":"BMC Psychiatry"},{"key":"B32","doi-asserted-by":"crossref","first-page":"1453","DOI":"10.1007\/978-1-4419-1005-9_479","article-title":"Perceived Stress","volume-title":"Encyclopedia of Behavioral Medicine","author":"Phillips","year":"2013"},{"key":"B33","doi-asserted-by":"publisher","first-page":"879","DOI":"10.1037\/0021-9010.88.5.879","article-title":"Common method biases in behavioral research: A critical review of the literature and recommended remedies.","volume":"88","author":"Podsakoff","year":"2003","journal-title":"J. Appl. Psychol."},{"key":"B34","doi-asserted-by":"publisher","first-page":"1484","DOI":"10.1017\/s0954579422000232","article-title":"Anxiety-specific associations with substance use: Evidence of a protective factor in adolescence and a risk factor in adulthood.","volume":"35","author":"Rieselbach","year":"2023","journal-title":"Dev. Psychopathol."},{"key":"B35","doi-asserted-by":"publisher","first-page":"343","DOI":"10.1007\/s002130100917","article-title":"How does stress increase risk of drug abuse and relapse?","volume":"158","author":"Sinha","year":"2001","journal-title":"Psychopharmacology"},{"key":"B36","doi-asserted-by":"publisher","first-page":"105","DOI":"10.1196\/annals.1441.030","article-title":"Chronic stress, drug use, and vulnerability to addiction.","volume":"1141","author":"Sinha","year":"2008","journal-title":"Ann. N. Y. Acad. Sci."},{"key":"B37","doi-asserted-by":"publisher","first-page":"e172883","DOI":"10.1172\/jci172883","article-title":"Stress and substance use disorders: Risk, relapse, and treatment outcomes.","volume":"134","author":"Sinha","year":"2024","journal-title":"J. Clin. Invest."},{"key":"B38","doi-asserted-by":"publisher","first-page":"445","DOI":"10.1037\/1064-1297.15.5.445","article-title":"Sex steroid hormones, stress response, and drug craving in cocaine-dependent women: Implications for relapse susceptibility.","volume":"15","author":"Sinha","year":"2007","journal-title":"Exp. Clin. Psychopharmacol."},{"key":"B39","doi-asserted-by":"publisher","first-page":"324","DOI":"10.1001\/archpsyc.63.3.324","article-title":"Stress-induced cocaine craving and hypothalamic-pituitary-adrenal responses are predictive of cocaine relapse outcomes.","volume":"63","author":"Sinha","year":"2006","journal-title":"Arch. Gen. Psychiatry"},{"key":"B40","doi-asserted-by":"publisher","first-page":"27","DOI":"10.1097\/yic.0000000000000100","article-title":"Use of benzodiazepines in obsessive-compulsive disorder.","volume":"31","author":"Starcevic","year":"2016","journal-title":"Int. Clin. Psychopharmacol."},{"key":"B41","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1111\/add.16001","article-title":"Emotion regulation in substance use disorders: A systematic review and meta-analysis.","volume":"118","author":"Stellern","year":"2023","journal-title":"Addiction"},{"key":"B42","doi-asserted-by":"publisher","first-page":"100270","DOI":"10.1016\/j.dadr.2024.100270","article-title":"Benzodiazepine use for anxiety disorders is associated with increased long-term risk of mood and substance use disorders: A large-scale retrospective cohort study.","volume":"12","author":"Sun","year":"2024","journal-title":"Drug Alcohol Depend. Rep."},{"key":"B43","doi-asserted-by":"publisher","first-page":"249","DOI":"10.1007\/s12024-023-00596-4","article-title":"The need to monitor emerging issues in etomidate usage: The misuse or abuse potential.","volume":"20","author":"Uhm","year":"2024","journal-title":"Forensic Sci. Med. Pathol."},{"key":"B44","doi-asserted-by":"publisher","first-page":"385","DOI":"10.1016\/s0005-7967(03)00147-5","article-title":"A short form of the metacognitions questionnaire: Properties of the MCQ-30.","volume":"42","author":"Wells","year":"2004","journal-title":"Behav. Res. Ther."},{"key":"B45","doi-asserted-by":"publisher","first-page":"11","DOI":"10.3760\/j.issn:0254-6450.2003.09.004","article-title":"Epidemiological study on psychological stress among urban residents during social transformation.","volume":"24","author":"Yang","year":"2003","journal-title":"Chin. J. Epidemiol."}],"container-title":["Frontiers in Psychology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyg.2026.1778758\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T05:39:49Z","timestamp":1779255589000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyg.2026.1778758\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,20]]},"references-count":45,"alternative-id":["10.3389\/fpsyg.2026.1778758"],"URL":"https:\/\/doi.org\/10.3389\/fpsyg.2026.1778758","relation":{},"ISSN":["1664-1078"],"issn-type":[{"value":"1664-1078","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,20]]},"article-number":"1778758"}}