A Meta-analysis and Systematic Review of Emotion-Regulation Strategies in Borderline Personality Disorder

Assessing Emotion Regulation Difficulties Across Negative and Positive Emotions: Psychometric Properties and Clinical Applications of the Perth Emotion Regulation Competency Inventory in the Chinese Context

Background

Abnormalities of regulating positive and negative emotion have been documented in patients with mental disorders. Valid and reliable psychological instruments for measuring emotion regulation across different valences are needed. The Perth Emotion Regulation Competency Inventory (PERCI) is a 32-item self-report measure recently developed to compressively assess emotion regulation ability across both positive and negative valences.

Purpose

This study aimed to validate the Chinese PERCI in a large non-clinical sample and examine the clinical utility in patients with major depressive disorder (MDD).

Methods

The Chinese PERCI was administered to 1090 Chinese participants (mean age = 20.64 years, 773 females). The factor structure, internal consistency, test-retest reliability, convergent validity, concurrent validity, and predictive validity were examined. Moreover, a MDD group (n = 50) and a matched healthy control group (n = 50) were recruited. Group comparisons and the linear discriminant analysis were conducted to assess the clinical relevance of the PERCI.

Results

Confirmatory factor analysis supported the intended eight-factor structure of the PERCI in the Chinese population. The PERCI showed high internal consistency, test-retest reliability, as well as good convergent and concurrent validity. The MDD group had significantly higher PERCI scores than the healthy control group. Linear discriminant function comprised of the eight factors successfully distinguish patients with MDD from their matched controls.

Conclusion

The Chinese version of the PERCI is a valid and reliable instrument to compressively measure emotion regulation across positive and negative valences in the general Chinese population and patients with depression.

Mentalized Affectivity, Helicopter Parenting, and Psychopathological Risk in Emerging Adults: A Network Analysis

Emerging adulthood represents a critical stage characterized by heightened risks for anxiety, depression, and somatization symptoms development. Research has shown that difficulties in emotional identification, expression, and processing, as well as dysfunctional parenting styles, may exacerbate symptoms in emerging adults. The present study aimed at examining the interplay between mentalized affectivity (i.e., emotional identification, processing, and expression), helicopter parenting, and psychopathological risk in 913 Italian cisgender emerging adults (M = 24.34, SD = 2.81; 71.20% assigned female at birth), using network analysis. The results indicated moderate to strong associations between psychopathological symptoms, with emotional processing difficulties significantly associated with general anxiety, depression, and, to a lesser extent, somatization. Additionally, increased degrees of helicopter parenting from mothers were linked to increased psychopathology and higher emotional processing difficulties. These findings emphasize the importance of addressing the interconnection between symptoms and emotional processing to prevent and treat psychopathological risks in emerging adults. Moreover, interventions targeting intrusive and overprotecting parenting behaviors may promote well-being among emerging adults.

Antecedents and risk factors for borderline personality disorder: Etiopathogenic models based on a multi-level meta-analysis

BACKGROUND

Empirically-based developmental psychopathology approach identified three domains involved in the emergence of borderline personality disorder (BPD): i) underlying liabilities to develop psychopathology (i.e., early patterns of internalizing and externalizing manifestations); ii) invalidating relational experiences (e.g., childhood traumatic experiences, maladaptive parenting, problematic peer relationships); iii) regulatory mechanisms of emotions and behaviors. Nevertheless, no studies have quantitatively summarized empirical findings concerning how and to what extent these domains might be temporally associated to the emergence of BPD features from adolescence to adulthood.

METHODS

The current multi-level meta-analysis included 106 studies (N = 86,871 participants) assessing the role of previously mentioned antecedents and risk factors for BPD.

RESULTS

The analysis showed moderate effect sizes capturing temporal associations between early internalizing/externalizing psychopathological manifestations, different invalidating relational experiences, emotion/behavior regulation processes with later BPD features. The effect sizes of these domains were not statistically different from each other.

CONCLUSION

This evidence supports a transactional developmental model of BPD. Consistently, the emergence of BPD could be viewed in the light of dynamic interplays between an underlying liability to psychopathology and invalidating relational experiences across different stages of development, which are progressively reinforced through increasing alterations of emotion and behavior regulation mechanisms.

Mapping Emotion Regulation Patterns Within the Alternative Model of Personality Disorders Personality Traits

Personality pathology is associated with emotional problems that are potentially attributable to problematic emotion regulation strategy patterns. We evaluated the emotion regulation strategies associated with the pathological personality traits in the Alternative Model of Personality Disorders (AMPD). A total of 504 participants completed measures of AMPD traits and strategy usage, which were analyzed using hierarchical regressions and latent profile analysis (LPA). Regression results demonstrated that each trait was associated with a unique strategy pattern: negative affect with emotional overengagement, detachment with socialemotional avoidance, antagonism with emotional externalization/avoidance, disinhibition with emotional avoidance and overengagement, and psychoticism with strategies linked to psychotic/dissociative experiences. The LPA identified three profiles with heightened AMPD traits: an internalizing/distressed profile, an externalizing/distressed profile, and a schizoid-schizotypal profile; each had a unique strategy pattern that varied depending on trait composition. This research highlights the relevance of emotion regulation strategy patterns in the assessment, conceptualization, and treatment of personality pathology.

Emotion regulation skills as a mediator of STEM teachers' stress, well-being, and burnout

The teaching profession highly stressful, and teachers are often faced with challenging situations. This is particularly the case in STEM (science, technology, engineering, and math) education, which is a uniquely demanding and challenging field. This study examined the role of emotional regulation (ER) skills in STEM teachers' stress, well-being, and burnout. The sample included 165 STEM teachers in middle and high schools who completed standard online questionnaires on ER, stress, well-being, and burnout. They were also asked to comment on three videos depicting authentic mathematical and pedagogical situations. The results indicated that contrary to popular belief, seniority was not linked with levels of stress, difficulties in ER, lower levels of well-being, or higher levels of burnout. A structural equation model and bootstrapping analysis showed teachers' levels of stress predicted their well-being, and this link between stress and well-being was mediated by teachers' level of difficulty in ER. The study highlights the importance of STEM teachers' well-being and suggests the need to reduce stress and burnout by providing tools for teachers to regulate their emotions in the classroom.

Development of a self-report screening instrument for emotional dysregulation: the Reactivity, Intensity, Polarity and Stability questionnaire, screening version (RIPoSt-SV)

BACKGROUND

Emotional dysregulation (ED) refers to the inability to manage emotional experiences or expressions hindering goal-oriented behavior. Moderate impairment on at least two domains among temper control, affective lability, and emotional over-reactivity has been proposed to identify ED in adults with attention-deficit/hyperactivity disorder (ADHD). No screening measure designed for use in diverse psychiatric samples exists. We aimed to develop a self-report screening tool for ED based on the 40-item version of the Reactivity, Intensity, Polarity, and Stability questionnaire (RIPoSt-40).

METHODS

150 adult outpatients with non-psychotic conditions were enrolled between February and July 2023 at the Second Psychiatry Unit of Pisa University Hospital. Clinically significant ED (CSED) was defined based on the previously suggested approach for ADHD. Differences between patients with and without CSED were tested. To develop our screening instrument, a decision tree algorithm was trained by hyperparameter tuning through 5-fold cross-validation in 120 subjects and tested on the remaining 30.

RESULTS

75 subjects met criteria for CSED (50 %). CSED was associated with lower age and higher prevalence of psychiatric conditions, including minor mood disorders, ADHD, cannabis use disorders, and eating disorders. We identified a decision tree consisting of six items from RIPoSt-40 that effectively detected CSED, with accuracy, sensitivity, specificity, positive and negative predictive values of 80 % or higher in both the training and testing sets.

LIMITATIONS

Tertiary-level; no consensus on criteria; sample size.

CONCLUSION

The screening version of the Reactivity, Intensity, Polarity, and Stability questionnaire (RIPoSt-SV) demonstrates promise as a valuable tool for ED screening in clinical settings.

Examining the relationship between subtypes of rumination and non-suicidal self-injury: A meta-analytic review

INTRODUCTION

Non-suicidal self-injury (NSSI) is a highly prevalent maladaptive behavior, often used to cope with intense negative affect. Rumination is an emotion regulation strategy that leads to fixation on and exacerbation of (typically) negative affective states. However, studies examining the relationship between rumination and NSSI have yielded mixed results, showing high degrees of heterogeneity.

METHODS

The present study conducted meta-analyses (k = 50) of the association between overall rumination and NSSI, and independent meta-analyses for each of four subtypes of rumination (general, depressive, brooding, reflection rumination). Potential moderators that may influence the magnitude of these relationships were also examined.

RESULTS

A small-to-moderate positive association between rumination and NSSI was found independent of rumination subtype. Moderating effects included NSSI outcome measure and study design for overall rumination and general rumination, respectively. Race was found to moderate the relationships between both brooding and depressive rumination and NSSI, though in inverse directions. An analysis of effect heterogeneity across studies suggested that undetected moderators may be present.

CONCLUSION

Results of this study support the relationships between rumination subtypes and NSSI and identify factors that may impact these relationships. Continued research is needed to understand this association, particularly in more varied subtypes of rumination and cognitive-affective moderators.

Two Sides of the Same Coin in Female Borderline Personality Disorder: Self-Reported Guilt and Shame and Their Neurofunctional Correlates

OBJECTIVE

Patients with borderline personality disorder (BPD) report to be especially prone to social emotions like shame and guilt. At the same time, these emotions seem to play an important role in BPD pathology. The present study aimed to deepen the knowledge about the processes behind shame and guilt in patients with BPD.

METHODS

Twenty patients with BPD and twenty healthy controls (HCs) took part in an experiment that induced shame and guilt by imagining scenarios during scanning using functional brain imaging. Participants also filled out self-report questionnaires and took part in diagnostic interviews.

RESULTS

BPD patients reported more proneness to guilt but not to shame than the HCs. There was no difference in the self-reported intensity rating of experimentally induced emotions between the groups. Between-group contrast of neural signals in the shame condition revealed a stronger activation of cingulate and fusiform gyrus for the BPD patients compared to the controls, and a more pronounced activation in the lingual gyrus and cuneus for the HCs. In the guilt condition, activation in the caudate nucleus, the fusiform gyrus, and the posterior cingulate cortex was stronger in BPD patients, while HC showed stronger activations in cuneus, lingual gyrus, and fronto-temporal regions.

CONCLUSIONS

Differences in the neuro-functional processes between BPD patients and HC were found, even though the two groups did not differ in their self-report of subjective proneness to guilt and emotional intensity of shame and guilt during the experiment. While the HCs may be engaged more by the emotional scenarios themselves, the BPD patients may be more occupied with cognitive regulatory and self-referential processing.

Effect of Dialectical Behavior Therapy on Negative Affect, and Symptoms of Depression and Anxiety in Individuals with Borderline Personality Disorder during COVID-19 Pandemic

Background: This study investigated the effectiveness of dialectical behavior therapy (DBT) in patients with borderline personality disorder (BPD) during the COVID-19 pandemic, assessing negative affect, depression, and anxiety levels as indicators of health. Methods: A total of 287 participants were recruited, including BPD patients at different stages of treatment and the general population without a diagnosis of BPD. Questionnaires were used to assess the fear of COVID-19 and the referenced health indicators. Results: No differences were observed between groups in levels of fear of COVID-19, but there were differences in the health indicators studied. BPD patients in long-term treatment showed levels of negative affect similar to those of the general population, while those in early treatment stages exhibited significantly higher levels. However, no significant improvements were observed in levels of depression and anxiety in the long-term treatment group compared to those who underwent the initial treatment phase. Conclusions: These findings underscore the importance of effectively intervening in BPD, especially in stress-inducing situations such as the pandemic, and suggest the need to explore complementary approaches to addressing depression and anxiety in this clinical context.

What impact can brain stimulation interventions have on borderline personality disorder?

INTRODUCTION

Borderline personality disorder (BPD) is a severe mental disorder characterized by emotion dysregulation, impulsivity, neuropsychological impairment, and interpersonal instability, presenting with multiple psychiatric comorbidities, functional disability and reduced life expectancy due suicidal behaviors.

AREAS COVERED

In this perspective, the authors explore the application of noninvasive brain stimulation (NIBS) (rTMS, tDCS, and MST) in BPD individuals by considering a symptom-based approach, focusing on general BPD psychopathology, impulsivity and neuropsychological impairments, suicidality and depressive/anxious symptoms, and emotion dysregulation.

EXPERT OPINION

According to a symptoms-based approach, NIBS interventions (particularly rTMS and tDCS) are promising treatment options for BPD individuals improving core symptoms such as emotional and behavioral dysregulation, neuropsychological impairments and depressive symptoms. However, the heterogeneity of stimulation protocols and of assessment tools used to detect these changes limits the possibility to provide definitive recommendations according to a symptom-based approach. To implement such armamentarium in clinical practice, future NIIBS studies should further consider a lifespan perspective due to clinical variability over time, the role of psychiatric comorbidities affecting BPD individuals and the need to combine NIBS with specialized psychotherapeutic approaches for BPD patients and with functional neuroimaging studies.

Effects of psychedelic microdosing versus conventional ADHD medication use on emotion regulation, empathy, and ADHD symptoms in adults with severe ADHD symptoms: A naturalistic prospective comparison study

Adults with attention-deficit hyperactivity disorder (ADHD) often struggle with emotion regulation (ER), impacting their empathic skills and relationships. ADHD medication might not be as effective for ER issues as for ADHD symptoms. Microdosing (MD) psychedelics has shown promise for ADHD treatment and previous studies reported social-emotional benefits. Two online prospective studies investigated MD effects on ER and empathy in adults with severe ADHD symptoms across three assessments: baseline, two-, and four-week post-initiation. Study 1 examined adults initiating MD on their own (n = 233, n = 64, and n = 44) and found positive effects on ER (cognitive reappraisal and expressive suppression) and aspects of empathy (perspective-taking and personal distress). Study 2, including a control group and an ADHD symptom scale, compared individuals only MD (n = 180, n = 50, and n = 38) to individuals using conventional ADHD medication (n = 37, n = 27, and n = 28). After 4 weeks, ADHD symptoms were lower in the MD group. Only improvements in expressive suppression persisted after adding the control group. This study indicates the positive effects of MD psychedelics on ADHD symptoms and ER in adults with severe ADHD symptoms while lacking evidence for effects on empathy.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

The association between trichotillomania symptoms and emotion regulation difficulties: A systematic review and meta-analysis

BACKGROUND

Emotion regulation is postulated to play an important role in Trichotillomania (TTM). Whilst a growing number of studies have examined the relationship between emotion regulation difficulties and TTM symptoms, there have been no attempts to evaluate the overall strength of this association or the quality of the evidence base.

METHOD

This systematic review and meta-analysis aimed to synthesise findings from studies that have examined the relationship between emotion regulation difficulties and TTM symptoms, to inform future TTM treatment targets. We identified 17 studies that met inclusion criteria. From these studies, 32 correlation coefficients were extracted for meta-analysis. The Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies was used to assess risk of bias amongst the included studies.

RESULTS

There was a moderately sized association between TTM symptoms and ER difficulties, (r adjusted = 0.32, 95 % CI [0.28, 0.37], t = 15.58 (df = 11.86), p < 0.0001) that was moderated by sample size (F(df1 = 1, df2 = 30) = 4.597, b = -0.0001, SE = 0.0001, 95 % CI [-0.0002; 0.0000], p = 0.040) and differences between types of emotion regulation measures (Q(df = 1) = 4.06, p = 0.044).

LIMITATIONS

The data analysed was correlational, therefore causality was unable to be determined. Comorbidities were not able to be examined as a moderator.

CONCLUSION

This study provided a preliminary integration of the evidence and demonstrated that individuals with higher levels of TTM severity appear to exhibit decreased overall emotion regulation abilities and strategies.

The biosocial correlates and predictors of emotion dysregulation in autistic adults compared to borderline personality disorder and nonclinical controls

BACKGROUND

Emotion dysregulation (ED) is a core symptom of borderline personality disorder (BPD), whose aetiology has been attributed to biosocial factors. In autism spectrum condition (ASC), although ED is prevalent and is associated with decreased well-being (e.g. self-harm, suicidality), it has been understudied, especially in adults. It is therefore crucial to further understand ED in autistic adults to improve its treatment. Our study investigates ED, its behavioural correlates (e.g. self-harm, suicidality) and biosocial predictors in autistic adults relative to BPD and nonclinical controls (NC).

METHODS

A total of 724 participants (ASC = 154; BPD = 111; NC = 459) completed 11 self-reported questionnaires assessing ED, ASC and BPD traits, co-occurring disorders, alexithymia, emotional vulnerability and invalidating experiences (e.g. bullying, autistic camouflaging). The occurrence of ED behavioural correlates (i.e. self-harm, history of suicide attempts, and psychiatric hospitalizations) was collected. In addition, between-groups analyses, linear regressions and machine learning (ML) models were used to identify ED predictors in each group.

RESULTS

ED and its behavioural correlates were higher in ASC compared to NC, but milder than in BPD. While gender did not predict ED scores, autistic women had increased risk factors to ED, including sexual abuse and camouflaging. Interestingly, BPD traits, emotional vulnerability and alexithymia strongly predicted ED scores across the groups. Using ML models, sensory sensitivity and autistic camouflaging were associated with ED in ASC, and ADHD symptoms with ED in BPD.

LIMITATIONS

ASC and BPD diagnoses were self-reported, which did not allow us to check their accuracy. Additionally, we did not explore the transactional and the moderating/mediating relationships between the different variables. Moreover, our research is cross-sectional and cannot draw conclusions regarding the direction and causality of relationships between ED and other clinical dimensions.

CONCLUSIONS

ED and its behavioural correlates are heightened in BPD compared to ASC and nonclinical controls. In the ASC group, there were no gender differences in ED, despite the heightened exposure of autistic women to ED risk factors. BPD traits, emotional vulnerability, and alexithymia are core to ED regardless of diagnosis. Although less central, sensory sensitivity and autistic camouflaging seem to be specific predictors of ED in autistic adults.

Maladaptive daydreaming, emotional dysregulation, affect and internalized stigma in persons with borderline personality disorder and depression disorder: A network analysis

Maladaptive daydreaming (MD) manifests through experiences of excessive, long-lasting daydreaming resulting in significant suffering, including isolation, distress and shame. Considering that one of its functions is a distraction from painful feelings, it is linked with escapism and plays a significant role in disorders associated with emotional dysregulation, maintaining negative symptoms, including internalized stigmatization and social withdrawal. The current study aimed to examine cognitive (internalized stigma), affective (affect, anhedonia, emotional dysregulation) and behavioural (escapism) aspects of MD in borderline personality disorder (BPD) and depression groups. The sample consisted of 188 persons, including 102 individuals with BPD. The results showed higher scores in emotional dysregulation, internalized stigma and escapism in the BPD group compared to the depression group; the subgroups did not vary in MD rates. The network analysis revealed significant differences between groups in variables dynamics, with links between MD and self-suppression escapism, negative affect in the BPD group and MD with self-suppression escapism and social withdrawal in the depression group. Emotionally dysregulation and internalized stigma factors posed as the most robust expected influence components in both networks, suggesting that the cognitive and affective factors, not strictly behavioural, are pivotal for one's functioning and regulation strategies in the groups studied. The current study allows for clinical implications in interventions focused on persons developing MD and emotional dysregulation symptoms, including persons with BPD and depression.

Differentiating between intrapsychic symptoms and behavioral expressions of borderline personality disorder in relation to childhood emotional maltreatment and emotion dysregulation: an exploratory investigation

BACKGROUND

Borderline personality disorder (BPD) is a severe mental disorder, characterized by pronounced instability in emotions, self-image, and interpersonal relationships. Experiences of childhood maltreatment are among the risk factors for BPD. While self-damaging and aggressive acts often occur, not every person with the disorder shows markedly dysregulated behaviour. Internalized symptoms, such as shame, loneliness, and self-disgust tend to be more pervasive and persist after clinical remission.

OBJECTIVE

Here we investigated associations between BPD symptom severity, childhood maltreatment, and emotion regulation difficulties. We further explored if the Borderline Symptom List (BSL) could potentially be used to differentiate between internalized symptoms (intrapsychic strain) and externalized symptoms (dysregulated behaviours) in future research.

METHOD

187 women with at least mild BPD symptoms (65% having a diagnosis of BPD) completed the BSL 23 including its 11-item supplement (BSL-S), the Childhood Trauma Questionnaire (CTQ), and Difficulties in Emotion Regulation Scale (DERS). Participants further underwent a semi-structured clinical interview to assess BPD criteria (International Personality Disorder Examination, IPDE). Multivariate models and regression-based bootstrapping analyses were performed to test direct and indirect effects.

RESULTS

Childhood trauma severity, especially emotional abuse, positively predicted BPD symptom severity. A significant indirect effect through emotion regulation difficulties was found (k2=.56). When exploring associations with BPD criteria (IPDE), the BSL-23 mean significantly correlated with separation anxiety, identity and mood problems, chronic emptiness, suicidal ideation, and dissociation, while the BSL-S correlated with self-harming impulsive behaviour and anger outbursts.

CONCLUSIONS

Findings complement previous research, highlighting the role of childhood maltreatment and emotion regulation difficulties in BPD. While our findings need to be seen as preliminary and interpreted with caution, they suggest that the BSL may be used to differentiate between internalized symptoms and behavioural expressions of BPD in future research. Such a distinction might help to deepen the understanding of this complex heterogenous disorder.

Increases in negative affective arousal precede lower self-esteem in patients with borderline personality disorder but not in patients with depressive disorders: an experience sampling approach

BACKGROUND

Instability in self-esteem and instability in affect are core features of borderline personality disorder (BPD). For decades, researchers and theorists have been interested in the temporal dynamics between these constructs. Some hypothesize that changes in affective states should precede changes in self-esteem (Linehan, Cognitive-behavioral treatment of borderline personality disorder. Diagnosis and treatment of mental disorders, 1993), while others suggest that changes in self-esteem should precede changes in affective states (Kernberg, Borderline conditions and pathological narcissism, 1975).

METHODS

In this study, we investigated the temporal relations between negative affective arousal states and current self-esteem in daily life. Patients with BPD (n = 42) or depressive disorders (DD; n = 40), and non-clinical controls (NCC; n = 40) were assessed every 15 min for 13 h.

RESULTS

As expected, dynamic structural equation modeling showed higher levels of average daily negative affective arousal and lower levels of average daily self-esteem in the BPD group compared with the NCC group, and scores in the DD group were in-between the BPD and the NCC groups. In line with predictions based on Linehan's (Cognitive-behavioral treatment of borderline personality disorder. Diagnosis and treatment of mental disorders, 1993) model of affective dysregulation in BPD, negative affective arousal (t) and subsequent self-esteem (t+ 1) were significantly linked only in the BPD group, implying that higher negative affective arousal is followed by lower current self-esteem in the next measurement (ca. 15 min later). Importantly, self-esteem (t) and subsequent negative affective arousal (t + 1) were not significantly related (Kernberg, Borderline conditions and pathological narcissism, 1975).

CONCLUSIONS

Our findings suggest close dynamic temporal relations between affective instability and self-esteem instability in BPD, which highlights the importance of providing patients with means to effectively modulate high negative affective arousal states.

Protective factors in borderline personality disorder: A multi-study analysis of conscientiousness, distress tolerance, and self-compassion

BACKGROUND

Despite a growing literature characterizing risk factors associated with the development and maintenance of borderline personality disorder (BPD), substantially less is known about potentially protective factors in BPD.

METHODS

In a sample of online (N = 272) participants with likely BPD, major depressive disorder (MDD), or no disorder (ND) and an independent sample of in-person (N = 90) participants diagnosed with BPD, MDD, or ND, we tested the cross-sectional and longitudinal associations among BPD features and three putatively protective personality, cognitive, and affective-behavioral factors: conscientiousness, self-compassion, and distress tolerance.

RESULTS

Only conscientiousness was significantly lower in BPD than MDD (ds: .67-.73) across both studies and more strongly related to BPD features (rs: -.68 to -.59) than MDD symptoms (rs: -.49 to -.43) in dimensional analyses across both studies. However, in a multiple regression analysis including all three factors in Study 1, only self-compassion predicted decreases in BPD features (β = -.28) and MDD symptoms (β = -.21) over one month.

LIMITATIONS

Study 1 participants completed all measures online and exhibited some differential attrition at one month follow-up. Study 2 participants were all diagnosed by one trained assessor and the smaller sample size limited our power to detect effects.

CONCLUSIONS

Low conscientiousness may be most strongly related to BPD, whereas self-compassion may be a prospective transdiagnostic protective factor.

Dissociative Dimensions and Their Implications for Emotional Dysregulation Underlying Borderline Personality Disorder Features

ABSTRACT

Emotion dysregulation is considered a core feature of borderline personality disorder (BPD). The role of dissociation in BPD has been discussed from different perspectives. Nevertheless, implications of dissociation for BPD features are not clear. The current study estimated mediation effects of dissociative dimensions on the relationships between several emotion regulation strategies (ERSs) and BPD features among 281 adults recruited from the general population. The online survey administered a comprehensive self-report battery for the assessment of maladaptive and adaptive ERSs together with dissociative dimensions. Borderline personality disorder features were also self-report screened. Results showed significant indirect effects of dissociation on the relationships between ERSs and BPD features. Dissociation was a full mediator of the relationship between deficits with problem-solving skills and BPD criteria. The study confirmed that emotion dysregulation is a core feature of BPD and that the dissociative dimensions should be included as relevant maladaptive mechanisms sustaining BPD emotional difficulties.

Linehan's biosocial model applied to emotion dysregulation in autism: a narrative review of the literature and an illustrative case conceptualization

Emotion dysregulation (ED) is a transdiagnostic difficulty prevalent in autism spectrum condition (ASC). Importantly, recent research has suggested that ED is involved in self-harm and suicidality. Pre-existing models on the etiology of ED in ASC focus mainly on biological factors to ASC features, such as sensory sensitivities, poor flexibility, and sensitivity to change. However, although psychosocial factors seem to play a role in the emergence of ED in ASC as well (e.g., childhood maltreatment and camouflaging), there is a lack of a comprehensive model conceptualizing biosocial factors involved in ED in autistic people. Linehan's biosocial model (1993) is one of the leading etiological models of ED in borderline personality disorder (BPD). It conceptualizes ED as emerging from transactions between a pre-existing emotional vulnerability in the child and an invalidating developmental environment. Beyond its clinical relevance, Linehan's model has gathered empirical evidence supporting its pertinence in BPD and in other psychiatric disorders. Although ASC and BPD are two distinct diagnoses, because they may share ED, Linehan's biosocial model might be useful for understanding the development of ED in ASC. Hence, this article aims to provide an application and extension of Linehan's model to conceptualize ED in ASC. To do so, we conducted a narrative review of the literature on ED and its underlying factors in ASC from a developmental perspective. To investigate the pertinence of the biosocial model applied to ED in autistic people, we were interested on data on (i) ED and its behavioral correlates in ASC, in relation to the biosocial model, (ii) the potential biological and psychosocial correlates of ED in ASC and (iii) the overlapping difficulties in ASC and BPD. Finally, to assess the pertinence of the model, we applied it to the case of an autistic woman presenting with ED and suicidal behaviors. Our review and application to the case of an autistic woman suggest that ED in ASC encompasses factors related to both biological and psychosocial risk factors as conceptualized in the BPD framework, although in both domains ASC-specific factors might be involved.

The plasticity of ChatGPT's mentalizing abilities: personalization for personality structures

This study evaluated the potential of ChatGPT, a large language model, to generate mentalizing-like abilities that are tailored to a specific personality structure and/or psychopathology. Mentalization is the ability to understand and interpret one's own and others' mental states, including thoughts, feelings, and intentions. Borderline Personality Disorder (BPD) and Schizoid Personality Disorder (SPD) are characterized by distinct patterns of emotional regulation. Individuals with BPD tend to experience intense and unstable emotions, while individuals with SPD tend to experience flattened or detached emotions. We used ChatGPT's free version 23.3 and assessed the extent to which its responses akin to emotional awareness (EA) were customized to the distinctive personality structure-character characterized by Borderline Personality Disorder (BPD) and Schizoid Personality Disorder (SPD), employing the Levels of Emotional Awareness Scale (LEAS). ChatGPT was able to accurately describe the emotional reactions of individuals with BPD as more intense, complex, and rich than those with SPD. This finding suggests that ChatGPT can generate mentalizing-like responses consistent with a range of psychopathologies in line with clinical and theoretical knowledge. However, the study also raises concerns regarding the potential for stigmas or biases related to mental diagnoses to impact the validity and usefulness of chatbot-based clinical interventions. We emphasize the need for the responsible development and deployment of chatbot-based interventions in mental health, which considers diverse theoretical frameworks.

Emotion regulation strategies and the two-dimensional model of adult attachment: a pilot study

Introduction

Emotion Regulation plays a crucial role in human's daily lives. Extensive research has shown that people with different attachment orientations exhibit divergencies in how they perform emotion regulation strategies.

Methods

44 adults performed an experimental emotion regulation task in which they were instructed to attend, reappraise, or suppress their emotions while viewing negative and neutral images taken from the International Affective Picture System (IAPS). Afterward, participants rated valence, arousal, and emotional dominance elicited by the images. Additionally, attachment orientations were measured using the ECR-12 questionnaire.

Results

Results showed a relationship between attachment avoidance and the level of arousal during the reappraisal condition; specifically, the higher attachment avoidance levels, the greater the emotional intensity during the implementation of cognitive reappraisal strategy. Such results suggest an association between failing in downregulate intense emotions using cognitive reappraisal when there are higher levels of attachment avoidance. Consistently, we also found that lower dominance during reappraisal was associated with more levels of avoidance.

Conclusion

These results indicate that people with higher levels of attachment avoidance experience difficulties when using the cognitive reappraisal strategy to reduce the emotional impact produced by negative emotional stimuli. Our findings reinforce the idea that avoidant people experience high physiological activation when experience emotions.

Does trait mindfulness mediate the relationship between borderline personality symptoms and emotion dysregulation?

BACKGROUND

Emotion dysregulation is core to many biopsychosocial models of Borderline Personality Disorder (BPD) and is often targeted as part of their associated psychological therapies. Several distinct specialist psychotherapies are thought to be effective for people diagnosed with BPD but it is unclear whether they share common change mechanisms. Some evidence suggests that Mindfulness Based Interventions improve competency in emotion regulation as well as trait mindfulness, which are both plausibly associated with good treatment outcomes. It is unclear whether the association between the severity of BPD symptoms and emotion dysregulation is mediated by trait mindfulness. Would improvement in trait mindfulness mediate an association between lower severity of BPD symptoms and fewer problems of emotion dysregulation?

METHODS

One thousand and twelve participants completed online, single time-point, self-report questionnaires.

RESULTS

As predicted, the severity of BPD symptoms was significantly and positively associated with emotion dysregulation with a large effect size (r = .77). Trait mindfulness mediated this relationship as the 95% confidence interval for the indirect effect did not cross zero (size of direct effect = .48 and size of indirect effect = .29 [.25, .33].

CONCLUSIONS

The relationship between the severity of BPD symptoms and emotion dysregulation was confirmed in this dataset. As hypothesised, this relationship was mediated by trait mindfulness. Process measures of emotion dysregulation and mindfulness should be included in intervention studies for people diagnosed with BPD to understand if improvements in these factors are a universal occurrence with good response to treatment. Other process measures should also be explored to identify other factors involved in the relationship between BPD symptoms and emotion dysregulation.

"Holding in Anger" as a Mediator in the Relationship between Attachment Orientations and Borderline Personality Features

Insecure attachment and difficulties in regulating anger have both been put forward as possible explanations for emotional dysfunction in borderline personality (BP). This study aimed to test a model according to which the influence of attachment on BP features in a subclinical population is mediated by anger regulation. In a sample of 302 participants, BP features were assessed with the Borderline features scale of the Personality Assessment Inventory (PAI-BOR), attachment was measured with the Experiences in Close Relationships-12 (ECR-12), and trait anger and anger regulation were assessed with the State and Trait Anger Expression Inventory-2 (STAXI-2). The results indicated that anger suppression emerged as a significant mediator of the associations between both anxious and avoidant attachment and BP traits, while anger control resulted as a marginal mediator in the association between attachment avoidance and BP. Suppressing anger may reflect different forms of cognitive or behavioural avoidance of anger, which may differ on the basis of attachment orientations. We argue that these results may have important clinical implications: the promotion of anger regulation in BP should be considered a critical treatment goal.

Cognitive Reappraisal Impairs Negative Affect Regulation in the Context of Social Rejection for Youth With Early-Stage Borderline Personality Disorder

Application of emotion regulation strategies might be susceptible to the context of social rejection for individuals with borderline personality disorder (BPD). This study compared the ability of 27 outpatient youths (15-25 years old) with early-stage BPD and 37 healthy controls (HC) to apply expressive suppression and cognitive reappraisal in standard and socially rejecting laboratory contexts. BPD youths were largely as able as HCs to regulate negative affect across instruction and contexts. However, cognitive reappraisal in the context of social rejection heightened BPD negative facial expression relative to HCs. Thus, while BPD emotion regulation ability was largely normative, cognitive reappraisal might be ineffective in the context of social rejection for this group, with social rejection acting as an accelerant that heightens the expression of negative affect. Given the common experience of perceived and actual social rejection for this group, clinicians should carefully consider treatments that include cognitive reappraisal strategies because they might be contraindicated.

The Effects of Emotion Regulation on Physical and Psychological Wellbeing in University Students: The Role of Depersonalization and Attachment Style

Our ability to regulate our emotions plays a key protective role against psychological distress and somatic symptoms, with most of the literature focusing on the role of cognitive reappraisal in interventions such as cognitive behavioral therapy (CBT). This study seeks to examine the relationship between emotion dysregulation and psychological and physical distress in university students through the role of depersonalization (DP) and insecure attachment. This study will try to explain the deployment of DP as a defense mechanism to insecure attachment fears and overwhelming stress, developing a maladaptive emotion responding strategy, which affects wellbeing later in life. A cross-sectional design was used on a sample (N = 313) of university students over the age of 18 which consisted of an online survey of 7 questionnaires. Hierarchical multiple regression and mediation analysis were conducted on the results. The results showed that emotion dysregulation and DP predicted each variable of psychological distress and somatic symptoms. Both insecure attachment styles were found to predict psychological distress and somatization, mediated through higher levels of DP, whereby DP may be deployed as a defense mechanism to insecure attachment fears and overwhelming stress, which affects our wellbeing. Clinical implications of these findings highlight the importance of screening for DP in young adults and university students.

The impact of traumatic childhood experiences on interoception: disregarding one's own body

BACKGROUND

Deficient interoception, the processing and perception of internal bodily signals, has been discussed as a mechanism underlying various mental disorders. First results indicate a mediating role of interoception in the interplay of traumatic childhood experiences and adult mental disorders. Traumatic childhood experiences may hinder the adequate processing, integration, and trust in bodily signals that are important in order to understand and regulate own needs and emotions, thereby increasing the vulnerability for mental disorders. However, an overarching study investigating alterations in different interoceptive measures and trauma-related disorders as well as their mediating role between early trauma and emotion dysregulation is still missing.

METHODS

One hundred thirty-six individuals with varying levels of traumatic childhood experiences who either had a current diagnosis of major depression, posttraumatic stress disorder, or somatic symptom disorder, or no mental disorder, took part in a multidimensional assessment of interoceptive processes, including interoceptive accuracy, sensibility, and awareness. Kruskal-Wallis tests were used to compare groups regarding interoceptive processes and associations with traumatic childhood experiences and emotion dysregulation were analyzed with Spearman correlations. Furthermore, mediation analyses were computed to examine and compare interoceptive processes as potential mediators between traumatic childhood experiences and emotion dysregulation.

RESULTS

Only body dissociation, a measure for interoceptive sensibility, was significantly reduced in individuals with a current mental disorder. Body dissociation was also the only interoceptive measure significantly associated with traumatic childhood experiences and emotion dysregulation and the only significant mediator in the relationship between traumatic childhood experiences and emotion dysregulation across groups.

CONCLUSION

Results suggest body dissociation, but not other interoceptive measures, as an important feature linking traumatic childhood experiences to current emotion dysregulation, an important transdiagnostic feature. As body dissociation refers to a habitual non-attendance or disregard of interoceptive signals, integrative therapeutic interventions could help affected individuals to overcome difficulties in emotion perception and regulation.

TRIAL REGISTRATION

The general study design was preregistered; see the German Clinical Trials Register (DRKS-ID: DRKS00015182). This study's analysis plan was not preregistered.

Self-compassion and emotion regulation: testing a mediation model

Self-compassion (SC) seems to play an important role in improving Emotion Regulation (ER). Nevertheless, the results of previous studies regarding the links between SC and ER are not consistent, especially facing diverse models of ER (strategy-based vs skill-based). The goal of this prospective study was to evaluate the links between these three concepts, by testing the predictive roles of SC and ER skills on both ER adaptive and maladaptive strategies, using standardised questionnaires and visual analogue scales. Results of regression analysis showed that self-compassion positively predicts cognitive reappraisal, acceptance, problem-solving, relaxation, self-support, tolerance and ER skills and negatively predicts behavioural avoidance, expressive suppression and ruminations. Results also showed that ER skills positively predict cognitive reappraisal, expression, acceptance, relaxation, self-support and tolerance and negatively predicts behavioural avoidance, expressive suppression and ruminations. Results from a mediation model are also promising regarding both the role of ER skills on the effect of SC on adaptive ER strategy use. Even if this study can be associated with common limits of self-report measures, it highlights the role of SC in a model of ER.

Antisocial and borderline personality traits and childhood trauma in male prisoners: Mediating effects of difficulties in emotional regulation

OBJECTIVE

To investigate the prevalence of probable antisocial personality disorder (ASPD) and borderline personality disorder (BPD) among prisoners, and further examine the mediating effect of difficulties in emotional regulation (ER) between childhood trauma and symptoms of ASPD and BPD.

METHODS

A total of 1491 male participants (35.4 ± 9.69 years) were recruited from a prison in Guangdong, China. The symptoms of ASPD and BPD, childhood trauma, difficulties in ER, and suicidal behaviors were measured by self-administered structured questionnaires. Logistic regressions were performed to investigate the associations of ASPD and BPD with suicidal behaviors. Path analysis was used to examine the mediating effects of difficulties in ER between childhood trauma and symptoms of ASPD and BPD.

RESULT

Approximately, 21.2 % and 11.2 % of the participants were screened as ASPD and BPD, respectively. Probable ASPD and BPD were associated with higher risk of suicidal behaviors. Childhood trauma and difficulties in ER were significantly associated with suicidal behaviors in prisoners with probable ASPD and BPD. Path analyses showed that partial mediating effects of difficulties in ER were significant in the dimensions of clarity and strategies on ASPD, and in the dimensions of clarity, impulse, and strategies on BPD.

CONCLUSION

ASPD and BPD are two of the common personality disorders in prisoners. Difficulties in ER are key to understanding the relationships between childhood trauma and personality disorders.

How childhood maltreatment alters perception and cognition - the predictive processing account of borderline personality disorder

Borderline personality disorder (BPD) is a severe mental disorder, comprised of heterogeneous psychological and neurobiological pathologies. Here, we propose a predictive processing (PP) account of BPD to integrate these seemingly unrelated pathologies. In particular, we argue that the experience of childhood maltreatment, which is highly prevalent in BPD, leaves a developmental legacy with two facets: first, a coarse-grained, alexithymic model of self and others - leading to a rigidity and inflexibility concerning beliefs about self and others. Second, this developmental legacy leads to a loss of confidence or precision afforded beliefs about the consequences of social behavior. This results in an over reliance on sensory evidence and social feedback, with concomitant lability, impulsivity and hypersensitivity. In terms of PP, people with BPD show a distorted belief updating in response to new information with two opposing manifestations: rapid changes in beliefs and a lack of belief updating despite disconfirmatory evidence. This account of distorted information processing has the potential to explain both the instability (of affect, self-image, and interpersonal relationships) and the rigidity (of beliefs about self and others) which is typical of BPD. At the neurobiological level, we propose that enhanced levels of dopamine are associated with the increased integration of negative social feedback, and we also discuss the hypothesis of an impaired inhibitory control of the prefrontal cortex in the processing of negative social information. Our account may provide a new understanding not only of the clinical aspects of BPD, but also a unifying theory of the corresponding neurobiological pathologies. We conclude by outlining some directions for future research on the behavioral, neurobiological, and computational underpinnings of this model, and point to some clinical implications of it.

The prospective relation between borderline personality disorder symptoms and suicide risk: The mediating roles of emotion regulation difficulties and perceived burdensomeness

BACKGROUND

Despite the strong link between borderline personality disorder (BPD) symptoms and suicide risk, little is known about the mechanisms underlying this association. Theory-driven research clarifying the pathways through which BPD symptoms increase suicide risk over time is needed and may highlight relevant treatment targets for decreasing suicide risk among individuals with heightened BPD symptoms. This study examined the prospective relations among BPD symptoms, emotion regulation (ER) difficulties, perceived burdensomeness, thwarted belongingness, and suicide risk across five assessments over a 7-month period. Consistent with the interpersonal theory of suicide, we hypothesized that greater BPD symptoms would predict greater suicide risk over time via greater ER difficulties and, subsequently, greater perceived burdensomeness.

METHODS

A U.S. nationwide sample of 500 adults (47 % women; mean age = 40.0 ± 11.64) completed a prospective online study, including an initial assessment and four follow-up assessments over the next seven months.

RESULTS

Results revealed a significant indirect relation between BPD symptoms and greater suicide risk over time through greater ER difficulties and later perceived burdensomeness. Results also provided evidence for transactional relations between BPD symptoms and ER difficulties and suicide risk over time.

LIMITATIONS

All constructs were assessed via self-report questionnaire data. Our measure of suicide risk focuses on only suicidal ideation, plans, and impulses, and not suicide attempts or preparatory behaviors.

CONCLUSIONS

Results highlight both ER- and interpersonal-related factors as key mechanisms underlying suicide risk among community adults with BPD symptoms.

The Effect of Non-Invasive Brain Stimulation on the Downregulation of Negative Emotions: A Meta-Analysis

(1) Background: Emotion regulation (ER) is regarded as a core treatment target for depression and other mental illnesses. In recent years, non-invasive brain stimulation (NIBS) has been extensively used as an intervention for mental illnesses, but there has been no systematic review conducted regarding its effect on emotion regulation. Therefore, we conducted a meta-analysis of the effectiveness of NIBS for emotion regulation; (2) Methods: Systematic searches were conducted in Embase, Web of Science, PubMed, and Cochrane Library. We analyzed the effects of NIBS on tasks assessing emotion regulation using a random-effects model, and further explored the moderating role of the following factors on transcranial direct current stimulation (tDCS) studies by conducting subgroup analyses and meta-regression: target electrode placement, return electrode placement, current intensity, target electrode size, and duration of intervention; (3) Results: A total of 17 studies were included. Our meta-analysis indicated a small but significant effect of NIBS on the downregulation of negative emotions. Separate analyses indicated that repetitive transcranial magnetic stimulation (rTMS) had a medium and significant effect on the downregulation of negative emotions, whereas tDCS had no significant effect. Subgroup analyses showed that the effect of tDCS was moderated by target and return electrode placemen; (4) Conclusions: These results indicate that NIBS had a positive effect on the downregulation of negative emotions. The stimulation protocols should be carefully considered and the underlying mechanisms should be further explored.

Efficacy and tolerability of Brain Stimulation interventions in Borderline Personality Disorder: state of the art and future perspectives - A systematic review

Treating Borderline Personality Disorder (BPD) is a major challenge for psychiatrists. As Brain Stimulation represents an alternative approach to treat psychiatric disorders, our systematic review is the first to focus on both invasive and Non-Invasive Brain Stimulation (NIBS) interventions in people living with BPD, examining clinical effects over core features and comorbid conditions. Following PRISMA guidelines, out of 422 original records, 24 papers were included regarding Deep Brain Stimulation (n = 1), Electroconvulsive therapy (n = 5), Transcranial Magnetic Stimulation (n = 13) and transcranial Direct Current Stimulation (n = 5). According to impulsivity and emotional dysregulated domain improvements, NIBS in BPD appears to restore frontolimbic network deficiencies. NIBS seems also to modulate depressive features. Safety and tolerability profiles for each technique are discussed. Despite encouraging results, definitive recommendations on Brain Stimulation in BPD are mitigated by protocols heterogeneity, lack of randomized controlled trials and poor quality of included studies, including high risk of methodological biases. To serve as guide for future systematic investigations, protocols optimization proposals are provided, focusing on alternative stimulation sites and suggesting a NIBS symptom-based approach.

Childhood Maltreatment and Borderline Personality Disorder: The Mediating Role of Difficulties with Emotion Regulation

Exposure to childhood maltreatment (CM) increases the risk of developing borderline personality disorder (BPD). However, it remains unclear what mechanisms might mediate this link. One candidate of interest is difficulties with emotion regulation. This study aims to examine the pattern of relations among CM, difficulties with emotion regulation, and the risk of developing BPD. A total of 162 individuals diagnosed with current BPD and 162 matched healthy controls completed self-reported questionnaires assessing CM and difficulties with emotion regulation. The authors found high correlations between CM and BPD diagnosis (r = .73, p < .001). Difficulties with emotion regulation were found to mediate the link between CM and BPD diagnosis (p < .001). Results suggest that CM may play a key role in the etiology of BPD and that difficulties with emotion regulation might be a mediating component between CM and BPD.

Identifying self-report measures of emotion regulation and evaluating their psychometric properties: a protocol for a systematic review

INTRODUCTION

Successful emotion regulation (ER) is critical for psychological health. Disturbances in this ability are associated with several psychiatric disorders. There are several self-report questionnaires to assess ER. However, there are no studies synthesising the evidence on their psychometric properties. We aim to identify all available instruments addressing ER in adolescents or adults and to critically appraise, compare and summarise the quality of their psychometric properties. For this, we will use COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria.

METHOD AND ANALYSIS

The search process to identify eligible studies will be conducted in April 2021 including the ProQuest, PubMed, Scopus and Web of Science databases with no restriction in terms of publication date. Eligibility criteria include peer-reviewed research articles written in English or Spanish by means of patient-reported outcome measures focused on ER among participants of 13 years or older. We will assess the quality of measures according to the COSMIN Risk of Bias Checklist. The psychometric properties will be assessed by the COSMIN updated criteria for good measurement. The available evidence will be addressed by the Grading of Recommendations, Assessment, Development and Evaluations approach. Our findings will be synthesised independently for each measure, including information on their sample, theoretical model and psychometric properties when possible.

ETHICS AND DISSEMINATION

Ethical approval is not required, as this study does not involve any participants or collection of primary data. Results are expected to be published in a peer-reviewed journal in the field of youth mental health and presented at relevant meetings and conferences.

PROSPERO REGISTRATION NUMBER

CRD42021249498.

Validation of the Affect Integration Inventory in a sample of patients with personality disorders: A cross-sectional study

Affect integration is defined as the capacity to comprehend emotional experiences as meaningful and to convert this knowledge into well-adjusted motivation, communication and behavior. Thus, affect integration is considered essential for personal adjustment and well-being, and it has been operationalized through the Affect Integration Inventory. However, the validity of this questionnaire has been examined only in non-clinical respondents. Therefore, the purpose of this study was to investigate the psychometric properties of the questionnaire in a sample of patients with personality disorders (n = 87). The internal structure and consistency were addressed using Cronbach's alpha and confirmatory factor analysis. To determine aspects of convergent and discriminant validity, the correlations between the scores on the questionnaire and the scores on content-related questionnaires and scales were examined. Finally, scores from the clinical respondents and existing data from a previously collected non-clinical sample (n = 157) were compared to evaluate the external validity. The overall results demonstrated satisfactory internal consistency, a consistent factor structure, and systematic patterns of convergent and discriminant validity. Additionally, the findings indicated that the instrument clearly differentiated the clinical sample from the non-clinical sample.

Autobiographical Script-Driven Imagery Has No Detectable Effect on Emotion Regulation in Healthy Individuals

INTRODUCTION

Emotion regulation (ER), the ability to actively modulate one's own emotion reactions, likely depends on the individual's current emotional state. Here, we investigated whether negative emotions induced by an interpersonal autobiographic script affect the neuronal processes underlying ER.

METHODS

Twenty healthy participants were recruited and underwent functional magnetic resonance imaging (fMRI) during performance of distancing, a specific ER strategy, while viewing emotionally arousing pictures. Participants were instructed to either naturally experience ("permit" condition) or to actively downregulate ("regulate" condition) their emotional responses to the presented stimuli. Before each of the 4 runs in total, a neutral or negative autobiographical audio script was presented. The negative script comprised an emotionally negative event from childhood or adolescence that represented either emotional abuse or emotional neglect. The second event comprised an everyday neutral situation. We aimed at identifying the neural correlates of ER and their modulation by script-driven imagery.

RESULTS

fMRI analyses testing for greater responses in the "regulate" than the "permit" condition replicated previously reported neural correlates of ER in the right dorsolateral prefrontal cortex and the right inferior parietal lobule. A significant ER effect was also observed in the left orbitofrontal cortex. In the amygdala, we found greater responses in the "permit" compared to the "regulate" condition. We did not observe a significant modulation of the ER effects in any of these regions by the negative emotional state induced by autobiographical scripts. Bayesian statistics confirmed the absence of such modulations by providing marginal evidence for null effects.

DISCUSSION

While we replicated previously reported neural correlates of ER, we found no evidence for an effect of mood induction with individualized autobiographical scripts on the neural processes underlying ER in healthy participants.

Emotion regulation strategies among individuals with borderline personality disorder relative to other groups: A review

Borderline personality disorder (BPD) is associated with difficulties in emotion regulation (ER) abilities. Investigations of ER strategies in BPD have been less robust. This systematic review identified 55 studies comparing ER strategy use between individuals diagnosed with BPD versus psychiatric and non-psychiatric comparison groups. Individuals with BPD reported more frequent maladaptive and less frequent adaptive ER strategy use than non-psychiatric controls. Results were less consistent relative to psychiatric comparison groups, though individuals with BPD reported greater self-criticism and avoidance. Groups responded comparably to instructed use of adaptive (but not maladaptive) ER strategies. This body of research would benefit from further examination of the roles of psychiatric comorbidity and problematic behaviours in the relationship between BPD and ER strategies.

From emotional intelligence to suicidality: a mediation analysis in patients with borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is a serious mental illness with a high suicidality rate between 40 and 85%. However, little is known concerning psychosocial risk and protective factors associated with suicidal behaviors in this clinical group. The main focus of the present study was on examining the relationship of emotional intelligence (EI) with suicidal behaviors and its mediators (e.g., depression, self-esteem, addiction potential, and disorder severity) among patients with BPD.

METHODS

In this cross-sectional study, a total of 220 participants (including 110 patients with BPD and 110 healthy controls) in Zahedan, Iran, were examined using clinical interviewing and self-report measures of EI, suicidal behaviors, depression, self-esteem, addiction potential, and BPD symptom severity. The data were analyzed using SPSS v25.0 software at the significance level of p < 0.05.

RESULTS

Our preliminary analysis showed higher levels of EI, depression, and self-esteem in the BPD group in comparison to healthy controls (p < 0.001). Furthermore, our findings showed that higher levels of addiction potential, BPD symptom severity, and depression and lower levels of self-esteem and EI were likely to be related to suicidal behaviors of the BPD group. Our results also supported the overall hypothesis that addiction potential, depression, BPD symptom severity, and self-esteem had a mediating role in the impact of EI on suicidal behaviors in the BPD group.

CONCLUSIONS

According to these findings, we have come to believe that training EI possibly plays a directly and/or indirectly potential preventive and therapeutic role in suicidal behaviors among patients with BPD. However, further longitudinal studies must be carried out to clarify the cause and effect relationship between EI, depression, self-esteem, addiction potential, BPD symptom severity, and suicidal behaviors.

A Comparison of Adolescent versus Young Adult Outpatients with First-Presentation Borderline Personality Disorder: Findings from the MOBY Randomized Controlled Trial

OBJECTIVE

The increasing focus on adolescent personality disorder has tended to ignore evidence of the developmental continuity of the period from puberty to young adulthood. This study aims to: (1) describe the characteristics of a sample of young people with borderline personality disorder (BPD) who had no previous history of evidence-based treatment for the disorder and (2) compare their characteristics by participant age group.

METHODS

One hundred and thirty-nine young people (15 to 25 years) with BPD, newly enrolled in the Monitoring Outcomes of BPD in Youth randomized controlled trial, completed semi-structured interview and self-report measures assessing demographic, clinical, and functional characteristics. Younger (aged 15 to 17 years; n = 64) and older (aged 18 to 25 years; n = 75) participants were compared on these same variables using t-tests, chi-square tests, and logistic regression.

RESULTS

Young outpatients with BPD had extensive and severe psychopathology and were functioning poorly. Adolescents and young adults with BPD showed substantial similarities on 20 key aspects of their presentation. Significant between-groups differences were observed in household makeup, treatment history, antisocial personality disorder, emotion dysregulation, substance use, age of commencement and extent of self-harm, and achievement of age-appropriate educational milestones. Adolescent BPD group membership was predicted by family composition and self-harm, whereas young adult BPD group membership was predicted by not achieving age-appropriate milestones, vocational disengagement, and emotion dysregulation. The final model explained 54% of the variance and correctly classified 80.2% of the sample by age.

CONCLUSIONS

Both adolescents and young adults with early stage BPD present with severe and often similar problems to one another, supporting developmental continuity across this age range. However, there are also meaningful differences in presentation, suggesting that pathways to care might differ by age and/or developmental stage. Detection and intervention for personality disorder should not be delayed until individuals reach 18 years of age.

Neural correlates of emotion acceptance and suppression in borderline personality disorder

BACKGROUND

Emotion dysregulation is a central feature of borderline personality disorder (BPD). Since impaired emotion regulation contributes to disturbed emotion functioning in BPD, it is crucial to study underlying neural activity. The current study aimed at investigating the neural correlates of two emotion regulation strategies, namely emotion acceptance and suppression, which are both important treatment targets in BPD.

METHODS

Twenty-one women with BPD and 23 female healthy control participants performed an emotion regulation task during functional magnetic resonance imaging (fMRI). While watching fearful movie clips, participants were instructed to either accept or to suppress upcoming emotions compared to passive viewing.

RESULTS

Results revealed acceptance-related insular underactivation and suppression-related caudate overactivation in subjects with BPD during the emotion regulation task.

CONCLUSION

This is a first study on the neural correlates of emotion acceptance and suppression in BPD. Altered insula functioning during emotion acceptance may reflect impairments in emotional awareness in BPD. Increased caudate activity is linked to habitual motor and cognitive processes and therefore may accord to the well-established routine in BPD patients to suppress emotional experiences.

Dyadic Emotion Regulation in Women with Borderline Personality Disorder

Background

Emotion regulation (ER) and interpersonal dysfunction constitute key features of borderline personality disorder (BPD). Here, we tested if females with BPD show impairments in dyadic ER, that is in their support seeking and creation of closeness. We investigated if women with BPD might over-rely on their male partner by excessive support seeking and establishing of closeness, during conversations with personally and relationship-threatening topics.

Methods

Thirty couples in which the women were diagnosed with BPD and 34 healthy control (HC) couples were videotaped while discussing neutral, personally threatening, and relationship-threatening topics. Support seeking was rated by three independent raters, using a naïve observer method. The creation of closeness was rated using a continuous video-rating. Perceived emotions were assessed using self-report after each conversation.

Results

Women with BPD engaged in more support seeking than HC women, especially in more negative behaviors to elicit support, they created less closeness to their partner than HCs and reported a greater decline of positive emotions in both threatening conditions. Women with BPD displayed more fluctuations than controls between creating closeness and distance in the personally-threatening situation. They reported a larger increase in negative emotions after the relationship threatening conversation compared to female HC.

Conclusions

The present study indicates an increased demand of dyadic ER in BPD. Increased negative support seeking and less creation of closeness to the partner might reflect ineffective strategies to actually receive support from the partner.

Emotional dysfunction in avoidant personality disorder and borderline personality disorder: A cross-sectional comparative study

According to the literature, avoidant personality disorder (APD) is often overlooked in research on personality disorders. In the present study, patients with APD were compared to patients with borderline personality disorder (BPD) with respect to emotional dysfunction. Emotional dysfunction was operationalized through the Affect Integration Inventory. Sixty-one patients receiving treatment at specialized outpatient hospital facilities for either BPD (n = 25) or APD (n = 36) (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) were included in a cross-sectional study. Supporting our expectations of no difference in the global capacity for affect integration between groups, the estimated difference was 0.00 (95% confidence interval [CI] [-0.53, 0.53]). On the other hand, the expected increased dysfunction in APD regarding Expression could not be confirmed. Furthermore, problems with specific affects distinguished the groups; integration of Interest was worse in APD (p = 0.01), whereas integration of Jealousy was worse in BPD (p = 0.04). In terms of prototypical modes of experiencing affects, APD was characterized by decreased access to the motivational properties of Interest (p < 0.01), while BPD was more driven by Interest (p < 0.01), Anger (p < 0.01), and Jealousy (p = 0.01). In conclusion, even though the two disorders are characterized by similar overall levels of emotional dysfunction, they differ systematically and predictably regarding specific affects and modes of experiencing. These findings carry implications for the understanding of emotional dysfunction in APD and BPD, suggesting specific areas of emotional dysfunction that could be targeted in tailored psychotherapeutic interventions.

The relationship between rumination and NSSI: A systematic review and meta-analysis

BACKGROUND

Rumination is a cognitive process that has been implicated in the onset and maintenance of a variety of psychological difficulties. The purpose of this review and meta-analysis was to examine the nature and strength of the relationship between rumination and non-suicidal self-injury (NSSI).

METHODS

The protocol for this review was pre-registered (CRD42019148186). A literature search of electronic databases PsycINFO, CINAHL, MEDLINE, and Web of Science was performed from the earliest date available to March 2020. Thirty-nine eligible papers were identified. An additional seven papers were identified from a search conducted in September 2021, resulting in a total of 46 papers. Separate meta-analyses were undertaken for NSSI frequency and NSSI history, with studies grouped by rumination type (depressive, transdiagnostic, anger, brooding, reflection, catastrophising, overall). Moderator analyses were also conducted along with a narrative synthesis of adjusted associations and longitudinal studies.

RESULTS

Rumination had a positive small association with NSSI frequency and a positive moderate association with NSSI history. The adjusted associations yielded mixed findings and most longitudinal research found rumination to be associated with prospective NSSI.

LIMITATIONS

Most included studies had a moderate risk of bias and used a student sample. A limitation of this review was that only English language papers were included.

CONCLUSIONS

Findings indicate that rumination is associated with NSSI, but more so the likelihood of engaging in NSSI overall than the frequency. Rumination-focused techniques for NSSI may therefore be of benefit. Further research is needed to understand this association, particularly with longitudinal studies that focus on state rumination rather than stable trait rumination.

PRACTITIONER POINTS

Rumination was found to have a small to moderate association with NSSI. Some individuals who engage in NSSI may benefit from psychological techniques that target rumination. Most of the studies included had a moderate risk of bias.

A meta-analysis of emotional regulation outcomes in psychological interventions for youth with depression and anxiety

Difficulties in applying emotional regulation (ER) skills are associated with depression and anxiety symptoms, and are common targets of treatment. This meta-analysis examined whether improvements in ER skills were associated with psychological treatment outcomes for depression and/or anxiety in youth. A multivariate, random-effects meta-analysis was run using metafor in R. Inclusion criteria included studies that were randomized controlled trials (RCTs) of a psychological intervention for depression and/or anxiety in patients aged 14-24, were peer reviewed, were written in English, measured depression and/or anxiety symptoms as an outcome and measured ER as an outcome. Medline, Embase, APA PsycInfo, CINAHL and The Cochrane Library were searched up to 26 June 2020. Risk of bias (ROB) was assessed using the Cochrane Collaboration Risk of Bias 2.0 tool. The meta-analysis includes 385 effect sizes from 90 RCTs with total N = 11,652. Psychological treatments significantly reduced depression, anxiety, emotion dysregulation (k = 13, Hedges' g = 0.54, P < 0.001, 95% confidence interval (CI) = 0.30-0.78) and disengagement ER (k = 83, g = 0.24, 95% CI = 0.15-0.32, P < 0.001); engagement ER also increased (k = 82, g = 0.26, 95% CI = 0.15-0.32, P < 0.001). Improvements in depression and anxiety were positively associated with improved engagement ER skills, reduced emotion dysregulation and reduced disengagement ER skills. Sensitivity considered study selection and publication bias. Longer treatments, group formats and cognitive-behavioural orientations produced larger positive associations between improved ER skills and reduced symptoms. ER skill improvement is linked to depression and anxiety across a broad range of interventions for youth. Limitations of the current study include reliance on self-report measures, content overlap between variables and inability to test the directionality of associations.

The Cognitive, Ecological, and Developmental Origins of Self-Disturbance in Borderline Personality Disorder

Self-disturbance is recognized as a key symptom of Borderline Personality Disorder (BPD). Although it is the source of significant distress and significant costs to society, it is still poorly specified. In addition, current research and models on the etiology of BPD do not provide sufficient evidence or predictions about who is at risk of developing BPD and self-disturbance, and why. The aim of this review is to lay the foundations of a new model inspired by recent developments at the intersection of social cognition, behavioral ecology, and developmental biology. We argue that the sense of agency is an important dimension to consider when characterizing self-disturbances in BPD. Second, we address the poorly characterized relation between self-disturbances and adverse life conditions encountered early in life. We highlight the potential relevance of Life-History Theory-a major framework in evolutionary developmental biology-to make sense of this association. We put forward the idea that the effect of early life adversity on BPD symptomatology depends on the way individuals trade their limited resources between competing biological functions during development.

Using the Ball-in-Bowl Metaphor to Outline an Integrative Framework for Understanding Dysregulated Emotion

Dysregulated emotion plays an important role for mental health problems. To elucidate the underlying mechanisms, researchers have focused on the domains of strategy-based emotion regulation, psychophysiological self-regulation, emotion evaluations, and resulting emotion dynamics. So far, these four domains have been looked at in relative isolation from each other, and their reciprocal influences and interactive effects have seldom been considered. This domain-specific focus constrains the progress the field is able to make. Here, we aim to pave the way towards more cross-domain, integrative research focused on understanding the raised reciprocal influences and interactive effects of strategy-based emotion-regulation, psychophysiological self-regulation, emotion evaluations, and emotion dynamics. To this aim, we first summarize for each of these domains the most influential theoretical models, the research questions they have stimulated, and their strengths and weaknesses for research and clinical practice. We then introduce the metaphor of a ball in a bowl that we use as a basis for outlining an integrative framework of dysregulated emotion. We illustrate how such a framework can inspire new research on the reciprocal influences and interactions between the different domains of dysregulated emotion and how it can help to theoretically explain a broader array of findings, such as the high levels of negative affect in clinical populations that have not been fully accounted for by deficits in strategy-based emotion regulation and the positive long-term consequences of accepting and tolerating emotions. Finally, we show how it can facilitate individualized emotion regulation interventions that are tailored to the specific regulatory impairments of the individual patient.

Body connection mediates the relationship between traumatic childhood experiences and impaired emotion regulation in borderline personality disorder

BACKGROUND

Previous studies revealed an association between traumatic childhood experiences and emotional dysregulation in patients with borderline personality disorder (BPD). However, possible mediating pathways are still not fully understood. The aim of the present study was to investigate the potential mediating role of body connection, describing the awareness of the relationship of bodily and mental states, for the association between a history of traumatic childhood experiences and BPD core symptomatology.

METHODS

One-hundred-twelve adult female individuals with BPD and 96 healthy female controls (HC) were included. Impaired emotion regulation, traumatic childhood experiences, and BPD symptomatology were assessed with self-report questionnaires. The Scale of Body Connection was used to assess two dimensions of body connection, that is body awareness, describing attendance to bodily information in daily life and noticing bodily responses to emotions and/or environment and body dissociation, describing a sense of separation from one's own body, due to avoidance or emotional disconnection. Mann-Whitney U tests were employed to test for group differences (BPD vs. HC) on the two SBC subscales and associations with clinical symptoms were analyzed with Spearman correlations. We performed mediation analyses in the BPD group to test the assumption that body connection could act as a mediator between a history of traumatic childhood experiences and emotion dysregulation.

RESULTS

Individuals with BPD reported significantly lower levels of body awareness and significantly higher levels of body dissociation compared to HC. Body dissociation, traumatic childhood experiences, and emotion dysregulation were significantly positively associated. Further analyses revealed that body dissociation, but not body awareness, significantly and fully mediated the positive relationship between traumatic childhood experiences and impaired emotion regulation in the BPD sample. This mediation survived when trait dissociation, i.e., general dissociative experiences not necessarily related to the body, was statistically controlled for.

CONCLUSION

Certain dimensions of body connection seem to be disturbed in BPD patients, with body dissociation being an important feature linking a history of traumatic childhood experiences to current deficits in emotion regulation.