Cognitive Emotion Regulation Strategies in Borderline Personality Disorder: Diagnostic Comparisons and Associations with Potentially Harmful Behaviors

Longitudinal examination of borderline personality disorder symptoms and drug use: The influence of negative and positive emotion dysregulation

Borderline personality disorder (BPD) is associated with greater substance use. Emotion dysregulation has been implicated in both BPD and substance use, yet there is limited research examining the role of emotion dysregulation in the BPD-substance use relation. We examined the independent and interactive associations of BPD symptoms and emotion dysregulation in reported drug use over 1 year. Participants (N = 143) were over-recruited for BPD, assessed via interview, and completed measures of negative and positive emotion dysregulation. Drug use frequency was assessed with monthly surveys over a 1-year period. Results demonstrated interrelations among BPD symptoms and both negative and positive emotion dysregulation. However, when modeling BPD and emotion dysregulation together, only higher BPD symptoms were associated with more frequent drug use. Findings support the relation of BPD symptoms and emotion dysregulation but suggest that emotion dysregulation may not account for drug use frequency above and beyond BPD in community-recruited populations.

Borderline personality disorder and multidimensional impulsivity: The roles of positive and negative emotion dysregulation

BACKGROUND

Risky, self-destructive impulsivity and emotion dysregulation are core features of borderline personality disorder (BPD). Yet impulsivity is multidimensional and has rarely been comprehensively assessed in BPD. Impulsivity has been linked to negative emotion dysregulation, yet explorations of the role of positive emotion dysregulation have been neglected. The current study attempts to extend existing literature by identifying the pattern of associations of specific domains of impulsivity, using both self-report and behavioral measures in BPD, and the role of both negative and positive emotion dysregulation in this link.

METHODS

Adults with BPD (n = 48), subthreshold BPD (n = 37), and without BPD (n = 78) completed a diagnostic interview, self-report measures, and multiple behavioral tasks. We examined correlations between primary variables, then examined the role of negative and positive emotion dysregulation in the association between BPD and specific domains of impulsivity.

RESULTS

Negative emotion dysregulation accounted for the link between BPD and negative urgency, (lack of) premeditation, and (lack of) perseverance, while positive emotion dysregulation accounted for the relation between BPD and sensation seeking.

LIMITATIONS

Key limitations of this study include using a relatively homogeneous sample and using abbreviated versions of one behavioral task, among others discussed.

CONCLUSIONS

These findings locate the precise impulsivity impairments in BPD and highlight the differential roles of negative and positive emotion dysregulation. Understanding the impulsivity deficits associated with BPD will further explain the impulsive behaviors associated with this disorder, and the contexts in which they occur, which may streamline clinical treatments.

Cognitive Coping Strategies among Inpatient Adolescents with Depression and Psychiatric Comorbidity

The aim of the present study is to describe and measure the cognitive emotion regulation strategies of inpatient adolescents with clinical depression, aged 13-18, and to analyse these coping strategies in relation to different comorbidities of Major Depressive Disorder (MDD).

METHODS

There were 112 adolescents with MDD who were admitted to hospital and 78 healthy adolescents included in the study. The Cognitive Emotion Regulation Questionnaire (CERQ) was used to assess nine specific cognitive coping strategies. A cognitive coping style model for depression in adolescents was described by analysing the differences between the two groups. The CERQ scores in MDD participants, grouped by comorbidity, were also assessed.

RESULTS

Adolescents with MDD had significantly higher scores for Self-Blame and Catastrophising strategies, and significantly lower scores for Positive Refocusing, Refocusing on Planning, and Positive Reappraisal. Adolescents with MDD and Borderline Personality Disorder (BPD) traits had significantly higher scores for Rumination, Catastrophising, and Blaming Others than adolescents with MDD and anxiety or with no comorbidity.

CONCLUSIONS

Clinical depression in adolescents is associated with a cognitive profile that consists of an increased use of maladaptive coping styles and low employment of adaptive strategies. Early identification can contribute to the development of specific, individualised prevention and intervention programmes, while further longitudinal studies are necessary to adequately measure the outcome of these interventions.

The relationship between childhood emotional abuse and borderline personality disorder: the mediating role of difficulties in emotion regulation among Lebanese adults

OBJECTIVE

The present study investigates the mediating effect of difficulties in emotion regulation in the association between childhood emotional abuse and Borderline Personality Disorder (BPD) among Lebanese adults.

METHOD

This cross-sectional study, involving 411 participants, was conducted between March and August 2022. Lebanese individuals from all governorates of the country were recruited using the Snowball Sampling technique. Three self-report scales were utilized to complete this research; the 'Difficulties in Emotion Regulation Scale-Brief Version (DERS-16)' which evaluates the difficulties in emotion regulation of individuals, the 'Childhood Trauma Questionnaire-Short Form (CTQ-SF)' which grants a subjective evaluation of the general childhood environment of the participants, as well as the 'Borderline Personality Questionnaire (BPQ)' which measures Borderline Personality Disorder traits, that demonstrate significant convergence with the disorder.

RESULTS

The results indicate that DERS-16 played an indirect effect role between childhood emotional abuse scores and Borderline Personality Disorder. Higher emotional abuse scores were significantly associated with higher DERS-16 scores, which in turn was significantly associated with higher BPQ scores. Moreover, childhood emotional abuse was directly associated with higher BPQ scores.

CONCLUSION

This work suggests that, among the different forms of childhood abuse, emotional abuse may have a role in the development of Borderline Personality Disorder. Training on emotion regulation strategies would potentially benefit individuals in preventing BPD development and facilitating therapeutic processes.

Multilevel associations of emotion regulation strategy use during psychotherapy for depression: A longitudinal study

BACKGROUND

People with depression select avoidant emotion regulation (ER) strategies more often than engagement strategies. While psychotherapy improves ER strategies, examining the week-to-week changes in ER and their relationship to clinical outcomes is warranted to understand how these interventions work. This study examined the changes in six ER strategies and depressive symptoms during virtual psychotherapy.

METHODS

Treatment-seeking adults (N = 56) with moderate depression severity completed a baseline diagnostic interview and questionnaires and were followed for up to 3 months as they completed virtual psychotherapy in an unrestricted format (e.g., individual) and orientation (e.g., cognitive-behavioral therapy; CBT). Participants completed weekly assessments of depression and six ER strategies along with assessments of CBT skills and participant-rated CBT components for each psychotherapy session. Multilevel modeling was used to examine associations between within-person changes in ER strategy use and weekly depression scores, controlling for between-person effects and time.

RESULTS

Depressive symptoms, rumination, and experiential avoidance decreased non-linearly over time while cognitive reappraisal and acceptance increased non-linearly. Controlling for CBT skills, within-person increases in acceptance and cognitive reappraisal, as well as within-person decreases in experiential avoidance, were associated with fewer depressive symptoms over time. People who reported greater CBT components in their sessions also reported fewer depressive symptoms over time.

LIMITATIONS

The study was unable to make more causal inferences or standardize the type, baseline, or length of psychotherapy received.

CONCLUSIONS

Improvements in ER strategies were associated with depression symptom reduction during psychotherapy. Future research to elucidate ER strategies as mediators of treatment response is warranted.

Less is more: Decreasing the frequency of maladaptive coping predicts improvements in DBT more consistently than increasing the frequency of adaptive coping

It is well-established that participation in dialectical behavior therapy (DBT) results in patients using adaptive coping strategies more frequently. Although coping skill instruction may be necessary to promote decreases in symptoms and behavioral targets in DBT, it is unclear if the frequency with which patients use adaptive coping skills leads to these outcomes. Alternatively, it is possible that DBT also leads patients to use maladaptive strategies less frequently and that these reductions more consistently predict improvements in treatment. We recruited 87 participants with elevated emotion dysregulation (Mage = 30.56; 83.9% female; 75.9% White) to participate in a 6-month course of full-model DBT delivered by advanced graduate students. Participants completed measures of adaptive and maladaptive strategy use, emotion dysregulation, interpersonal problems, distress tolerance, and mindfulness at baseline and after three DBT skills training modules. Both within- and between-person maladaptive strategy use significantly predicted module-to-module changes in all outcomes whereas adaptive strategy use significantly predicted changes in emotion dysregulation and distress tolerance, although the size of these effects did not significantly differ between adaptive and maladaptive strategy use. We discuss the limitations and implications of these results for optimizing DBT.

Nonsuicidal self-injury and rumination: A meta-analysis

Trait rumination is the tendency to overthink and focus on negative emotions and events and is related to a number of psychological disorders and maladaptive behaviors including nonsuicidal self-injury (NSSI). The purpose of this study was to conduct a meta-analysis of the relationship between trait rumination and NSSI behaviors. Results from 60 samples showed small effect sizes between trait rumination and NSSI engagement, NSSI frequency, and the number of methods used to self-injure in cross-sectional samples. Results from 13 samples showed small effect sizes between trait rumination and NSSI engagement and NSSI frequency in longitudinal samples. Moderator analyses indicated that this relationship is similar whether the type of rumination is depressive or not and is generally consistent across different ages, genders, and ethnicities. These results help clarify the role of trait rumination as a risk factor for NSSI.

Acute effect of physical exercise on negative affect in borderline personality disorder: A pilot study

Background

Physical exercise is an evidence-based treatment to reduce symptoms and negative affect in several psychiatric disorders, including depressive, anxiety, and psychotic disorders. However, the effect of physical exercise on negative affect in patients with borderline personality disorder (BPD) has not yet been investigated. In this pilot study, we tested the safety, acceptability, and potential acute effects on negative affect of a single session of aerobic physical exercise in adults with BPD.

Method

After completing a negative mood induction procedure, 28 adults with BPD were randomly assigned to a 20-minute single session of stationary bicycle or a control condition (emotionally neutral video).

Results

No adverse effects attributed to the physical exercise were reported and it was considered acceptable to patients. Following the negative mood induction, both conditions decreased the level of negative affect with a medium effect size but there was no significant difference between them.

Conclusion

The results suggest that a single 20-minute session of physical exercise does not produce a reduction of negative affect in BPD. Future research should consider the duration and intensities of physical exercise with the greatest potential to reduce negative affect both acutely and in a more prolonged manner in this patient group.

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.

Structural Features Related to Affective Instability Correctly Classify Patients With Borderline Personality Disorder. A Supervised Machine Learning Approach

Previous morphometric studies of Borderline Personality Disorder (BPD) reported inconsistent alterations in cortical and subcortical areas. However, these studies have investigated the brain at the voxel level using mass univariate methods or region of interest approaches, which are subject to several artifacts and do not enable detection of more complex patterns of structural alterations that may separate BPD from other clinical populations and healthy controls (HC). Multiple Kernel Learning (MKL) is a whole-brain multivariate supervised machine learning method able to classify individuals and predict an objective diagnosis based on structural features. As such, this method can help identifying objective biomarkers related to BPD pathophysiology and predict new cases. To this aim, we applied MKL to structural images of patients with BPD and matched HCs. Moreover, to ensure that results are specific for BPD and not for general psychological disorders, we also applied MKL to BPD against a group of patients with bipolar disorder, for their similarities in affective instability. Results showed that a circuit, including basal ganglia, amygdala, and portions of the temporal lobes and of the orbitofrontal cortex, correctly classified BPD against HC (80%). Notably, this circuit positively correlates with the affective sector of the Zanarini questionnaire, thus indicating an involvement of this circuit with affective disturbances. Moreover, by contrasting BPD with BD, the spurious regions were excluded, and a specific circuit for BPD was outlined. These results support that BPD is characterized by anomalies in a cortico-subcortical circuit related to affective instability and that this circuit discriminates BPD from controls and from other clinical populations.

An Examination of Stress Generation and Stress Exposure Models in Relation to Symptoms of Borderline Personality Disorder

Research examining life stress as a precipitant, co-occurrence, and consequence of psychopathology often has implications for two explanatory models: stress exposure, where stress causes symptoms, and stress generation, where symptoms cause stress. Preliminary evidence suggests that both processes are evident in borderline personality disorder (BPD). The present study examined 101 adults who self-reported at least three symptoms of BPD at prescreen, with 30% of the sample meeting full diagnostic criteria for BPD. Cross-lagged panel analyses were used to examine the relationships between BPD symptomatology and four forms of life stress. Stress exposure and stress generation were not supported for either form of chronic life stress. Results supported stress generation in both dependent and interpersonal episodic life stress, and stress exposure for interpersonal episodic life stress. These findings evidenced small effects only. Findings point to the impact of interpersonal stress on changes in symptomatology over time.

Emotion regulation, mindfulness, and self-compassion among patients with borderline personality disorder, compared to healthy control subjects

Objectives

Emotion regulation difficulties are a major characteristic of personality disorders. Our study investigated emotion regulation difficulties that are characteristic of borderline personality disorder (BPD), compared to a healthy control group.

Methods

Patients with BPD (N = 59) and healthy participants (N = 70) filled out four self-report questionnaires (Cognitive Emotion Regulation Questionnaire, Difficulties in Emotion Regulation Scale, Five Facet Mindfulness Questionnaire, Self-Compassion Scale) that measured the presence or lack of different emotion-regulation strategies. Differences between the BPD and the healthy control group were investigated by Multivariate Analysis of Variance (MANOVA) and univariate post-hoc F-test statistics.

Results

People suffering from BPD had statistically significantly (p<0.05) higher levels of emotional dysregulation and used more maladaptive emotion-regulation strategies, as well as lower levels of mindfulness and self-compassion compared to the HC group.

Conclusion

In comparison to a healthy control group, BPD patients show deficits in the following areas: mindfulness, self-compassion and adaptive emotion-regulation strategies. Based on these results, we suggest that teaching emotion-regulation, mindfulness, and self-compassion skills to patients can be crucial in the treatment of borderline personality disorder.

Common and different gray and white matter alterations in bipolar and borderline personality disorder: A source-based morphometry study

According to the nosological classification, Bipolar Disorder (BD) and Borderline Personality Disorder (BPD) are different syndromes. However, these pathological conditions share a number of affective symptoms that make the diagnosis difficult. Affective symptoms range from abnormal mood swings, characterizing both BD and BPD, to regulation dysfunctions, more specific to BPD. To shed light on the neural bases of these aspects, and to better understand differences and similarities between the two disorders, we analysed for the first time gray and white matter features of both BD and BPD. Structural T1 images from 30 patients with BD, 20 with BPD, and 45 controls were analysed by capitalizing on an innovative whole-brain multivariate method known as Source-based Morphometry. Compared to controls, BD patients showed increased gray matter concentration (p = .003) in a network involving mostly subcortical structures and cerebellar areas, possibly related to abnormal mood experiences. Notably, BPD patients showed milder alterations in the same circuit, standing in the middle of a continuum between BD and controls. In addition to this, we found an altered white matter network specific to BPD (p = .018), including frontal-parietal and temporal regions possibly associated with dysfunctional top-down emotion regulation. These findings may shed light on a better understanding of affective disturbances behind the two disorders, with BD patients more characterized by abnormalities in neural structures involved in mood oscillations, and BPD by deficits in the cognitive regulation of emotions. These results may help developing better treatments tailored to the specific affective disturbances displayed by these patients.

The borderline interpersonal-affective systems (BIAS) model: Extending understanding of the interpersonal context of borderline personality disorder

Prominent explanatory models for borderline personality disorder (BPD) are intrapersonal in nature and hold that it is an emotional disorder. However, the empirical support for emotional models of BPD is mixed. Refinements to BPD explanatory models are needed to increase the precision with which BPD can be understood and treated. Drawing on existing theoretical and empirical research in BPD, this manuscript presents the Borderline Interpersonal-Affective Systems (BIAS) model. The BIAS model purports that harmful early life relationships and subsequent conflictual relationships lead individuals with BPD to develop a sensitivity to interpersonal threat in the form of attentional and appraisal biases. Individuals with BPD are posited to 1) experience heightened emotional reactivity specifically to perceived interpersonal threat and 2) engage in destructive behaviors both to regulate increasing emotion and to meet interpersonal needs. We review the empirical support for each component of the BIAS model, along with the role of the cognitions, emotions, and behaviors of significant others in influencing BIAS model processes in individuals with BPD over time. The BIAS model highlights a novel way of understanding and integrating interpersonal and emotional components of the disorder. Key directives for future research and clinical implications are discussed.

Quality or quantity? A multistudy analysis of emotion regulation skills deficits associated with borderline personality disorder

Linehan's (1993) biosocial theory posits that people with borderline personality disorder (BPD) have emotion regulation skills deficits characterized by (a) less frequent use of adaptive emotion regulation strategies, (b) more frequent use of maladaptive strategies, or (c) poorer quality strategy implementation (i.e., strategies implemented less skillfully). We tested these possibilities among participants with BPD, major depressive disorder (MDD), or no disorder (controls). Study 1 participants (N = 272) were recruited online; Study 2 participants (N = 90) completed in-person diagnostic assessments. The BPD groups reported greater use of maladaptive strategies than the MDD (d = .35) and control (d = 1.54) groups and lower quality implementation than the MDD (d = -.33) and control groups (d = -.97). BPD participants reported similar use of adaptive strategies as the MDD group (d = -.09) but less use than controls (d = -.47). BPD may be uniquely characterized by overuse of maladaptive strategies and poorer quality emotion regulation implementation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Emotion dysregulation in adults suffering from attention deficit hyperactivity disorder (ADHD), a comparison with borderline personality disorder (BPD)

BACKGROUND

Emotional dysregulation (ED) is now considered as an important symptom of attention deficit hyperactivity disorder (ADHD). It is believed to have a considerable impact on the severity of the disorder, one's global functioning, and the prognosis. Our research aimed to evaluate and compare ED and cognitive emotional regulation strategies between ADHD and borderline personality disorder (BPD) patients.

METHODS

Four hundred six French-speaking outpatients (N = 279 ADHD, N = 70 BPD, N = 60 BPD + ADHD) were assessed with the Emotion Reactivity Scale (ERS), the Cognitive Emotional Regulation Questionnaire (CERQ), The Basic Empathy Scale (BES-A), the Adult ADHD Self-Report Scale (ARSV-v1.1) and the Beck Depression Inventory II (BDI-II). ADHD, BPD and comorbid patients were compared with each other and with samples of controls extracted from already published data.

RESULTS

ADHD patients, although having higher ED than samples derived from the general population, had less ED, better control over their emotions with higher use of adaptive cognitive strategies and lesser use of non-adaptive strategies than BPD patients. However, ADHD subjects had similar scores as BPD subjects when looking at difficulties in perceiving self and others. ED generated considerable distress in all groups and was also positively associated with ADHD symptomatology. ADHD patients with comorbid BPD had the highest scores of ED.

CONCLUSIONS

Our results suggest that there may be similarly inefficient cognitive emotional regulation skills leading to ED in both disorders (ADHD and BPD). However, ADHD patients showed a higher use of adaptive cognitive emotional strategies and a lower level of ED than BPD patients.

Effectiveness of a 5-Week Inpatient Dialectical Behavior Therapy for Borderline Personality Disorder

OBJECTIVE

The goal of this study was to evaluate whether symptoms are reduced and emotion regulation improves when patients with borderline personality disorder (BPD) receive a 5-week course of inpatient dialectical behavioral therapy (DBT) and if changes in emotion regulation are associated with changes in symptoms.

METHODS

Forty-four patients with BPD receiving a 5-week course of DBT in a German psychiatry clinic participated. The short version of the "Borderline Symptom List" (BSL-23) was the patient-reported outcome. To measure emotion regulation, the "Self-Report Measure for the Assessment of Emotion Regulation Skills" (SEK-27) was administered. Wilcoxon tests were performed to evaluate whether pre-post changes in the BSL-23 and SEK-27 reached statistical significance. Effect sizes (d) were calculated and correlations between the pre-post differences for both measures were computed to test associations between changes in emotion regulation and changes in symptoms. Completer (n=33) and intention-to-treat (n=43) analyses were performed.

RESULTS

Symptoms (BSL-23) were reduced and emotion regulation (SEK-27) improved during the 5-week inpatient DBT treatment (completer and intention-to-treat analysis: P<0.001). Effect sizes reached d=0.47 for the BSL-23 and d=0.84 for the SEK-27 in the completer analysis, and d=0.38 for the BSL-23 and d=0.68 for the SEK-27 in the intention-to-treat analysis. Improvements in emotion regulation (SEK-27) were correlated with reductions in symptoms (BSL-23) in both the completer (r=0.54; P=0.001) and the intention-to-treat (r=0.59; P<0.001) analyses.

CONCLUSIONS

These findings indicate that a 5-week course of inpatient DBT can effectively reduce symptoms in patients with BPD and that the more patients' emotion regulation improves, the more the patients benefit from the therapy.

The NIMH Research Domain Criteria (RDoC) Initiative and Its Implications for Research on Personality Disorder

PURPOSE OF REVIEW

We discuss the implications of the Research Domain Criteria (RDoC) initiative for neuroscience research on personality disorder (PD). To organize our review, we construct a preliminary conceptual mapping of PD symptom criteria onto RDoC constructs. We then highlight recent neuroscience research, often built around concepts that correspond to RDoC elements, and discuss the findings in reference to the constructs we consider most pertinent to PD.

RECENT FINDINGS

PD symptoms were strongly conceptually tied to RDoC constructs within the Social Processes domain, implicating brain systems involved in interpersonal rejection, facial emotion perception, and self-referential processes. Negative and Positive Valence Systems were conceptually associated with many PD symptoms, with particular relevance ascribed to the latter's Reward Valuation construct, which could reflect a more widespread disruption of computational processes involved in estimating the probability and benefits of a future outcome. Within the Cognitive Systems domain, the Cognitive Control construct mainly related to PD symptoms associated with impulse control, suggesting a connection to neural circuits that underlie goal selection and behavioral control. Arousal and Regulatory Systems could only be conceptually mapped onto PD symptoms through the Arousal construct, with different symptoms reflecting either a higher or lower biological sensitivity to internal and external stimuli. The RDoC framework has promise to advance neuroscience research on PD. The Social Processes domain is especially relevant to PD, although constructs falling within the other RDoC domains could also yield important insights into the neurobiology of PD and its connections with other forms of psychopathology. Identifying RDoC constructs (e.g., habit formation) that subserve more fundamental processes relevant to personality functioning warrants further investigation.