A Look at Emotion Dysregulation in Borderline Personality Disorder

A Look at Emotion Dysregulation in Borderline Personality Disorder

None of us enjoys feeling negative emotions. By definition, it is an aversive experience, and given the option, all of us would generally prefer to avoid feeling distress. That being said, most people are able to manage things when they are upset, navigating through uncomfortable sensations to accomplish goals and staying with their negative emotions as needed in order to avoid costly consequences. For others, however, negative emotions serve as an almost insurmountable obstacle or at least seem that way while the experience is actively occurring.

The impact of emotions on behavioural outcomes and suicide risk is the focus of my research, so I am always excited to read about new studies in this area. Today, I want to discuss a study just published in a special issue of Personality Disorders: Theory Research and Practice by Kim Gratz, Zachary Rosenthal, Matthew Tull, Carl Lejuez, and John Gunderson looking at emotion dysregulation in borderline personality disorder (BPD). You will recall from prior PBB articles on BPD, individuals who struggle with this diagnosis are often characterized by rapidly shifting emotions and a reduced tolerance for negative emotions that leads to the frequent use of harmful behaviours (e.g., self-injury) in an attempt to reduce such feelings. In a past article, we described evidence for this tendency through a discussion of a publication by Nock and Mendes and I hope you will consider reading that article as a supplement to today’s discussion.

In the current study, Gratz et al wanted to experimentally measure the degree to which individuals with BPD actually exhibit difficulties regulating emotions relative to individuals without BPD. Even though low distress tolerance and a tendency to engage in harmful behaviours in response to negative emotions are central facets of our theoretical understanding of BPD (Linehan, 1993), few studies have directly tested this assumption and the bulk of those that have done so have utilized self-report measures of emotion dysregulation rather than directly observing the phenomenon.

For the purpose of this study, the authors defined emotion dysregulation as a combination of the following four characteristics…

  • Lack of awareness, understanding, and acceptance of emotions.
  • Lack of access to adaptive strategies for modulating the intensity and/or duration of emotional responses.
  • An unwillingness to experience emotional distress as part of pursuing desired goals.
  • The inability to engage in goal-directed behaviours when experiencing distress.

Gratz and colleagues wanted to directly test whether individuals with BPD struggled particularly with the final two of those four components and designed a study that included 35 participants, 17 with BPD and 18 without BPD. The focal point of the study was a computer task known as the Paced Auditory Serial Addition Task – Computerized (PASAT-C; Lejuez, Kahler, & Brown, 2003), which requires participants to perform basic math computations at an increasingly fast pace. Each time a participant makes an error, a loud and aversive explosion noise is heard. Toward the end of the task, the pace of the problems is quick enough to be essentially impossible, thereby assuring that the participant is bombarded with aversive noises signally poor performance on the task. Eventually, the participant is given the option to quick the task and the length of time that the participant continues is used as a measure of their willingness to persist in goal directed behaviour while distressed (actual measures of distress are also included to ensure that quitting does not simply signify boredom). In the case of this particular study, participants were told that the longer they persisted, the more time they would have on a subsequent task and that their performance on that later task would determine how much money they earned for participating in the study. This was actually a bit of deception, as all participants were given equal compensation, but the researchers wanted to ensure that participants were motivated to continue in the task.

Before analyzing their data, Gratz and colleagues hypothesized that individuals with BPD would be more likely to quit the task early, an indication that they are less willing to experience distress for the sake of a goal, and that they would perform worse on the final round of the PASAT-C, an indication that they struggle to engage in goal-directed behaviours when distressed. Their results supported some, but not all of their hypotheses.

Despite the fact that both groups reported equal levels of distress in response to the PASAT-C, individuals with BPD were more likely to quit the task early than were individuals without BPD. In other words, it is not that individuals with BPD necessarily feel more distress, but rather that the experience of distress is viewed as less tolerable. So, while most individuals are willing to experience moderate to severe levels of distress when a task seems important enough to warrant discomfort, individuals with BPD have a harder time drawing that same conclusion and instead prioritize reducing negative emotions by whatever means necessary, even if there are both short and long-term costs associated with their efforts to escape.

Contrary to hypotheses, individuals with BPD did not perform worse on the task. As such, the evidence did not support the notion that individuals with BPD struggle to succeed in tasks when they do persist through the experience of negative emotions. In all honesty, this did not surprise me, although I do understand why the authors (who know significantly more about that topic than I do) believed it might be true. BPD is not characterized by failures in performances, but rather difficulties managing the experience of negative emotions. In this sense, I think that individuals with BPD are more likely to be characterized by the belief that they will falter or currently are faltering when upset than they are to actually struggle with a task. In this sense, they are plagued by distorted automatic negative thoughts in need of remediation.

Gratz and her colleagues were careful to explain several limitations in their study, some of which warrant mentioning here. First of all, the sample size was quite small and, additionally, the excluded individuals who met the criteria for depression. Given that a substantial number of individuals with BPD are also depressed and depression could impact task performance, it is possible that this significantly impacted the results. Additionally, although the PASAT-C is a fascinating task that has provided some important findings, it is unlikely to parallel the types of experiences that prompt strong emotional responses from individuals with BPD outside the lab and, as such, might not be the best measure for examining emotional responses in BPD. In the Nock and Mendes 2008 study the distress was primarily interpersonal in nature and the findings were a bit more consistent with those hypothesized here. As someone who has used the PASAT-C in laboratory tasks before, I am aware of how distressing it is for the participant, but I do wonder at times how it compares to more interpersonally-based tasks like the Distress Tolerance Test.

Despite these limitations, this study had obvious value. First of all, the authors made a strong effort to experimentally measure a topic – emotion dysregulation – that often only gets examined through self-report, a useful but inferior form of measurement. Secondly, the authors administered structured clinical interviews to obtain their diagnoses, an approach we have described before as the most valid and reliable way to reach a diagnostic decision. Studies like this help us make sure that our assumptions about particular diagnoses actually reflect reality and we can use data like these to further our understanding of mental illness and to help design treatments that target the most impairing symptoms of a given disorder.

This post is by Mike Anestis who is a doctoral candidate in the clinical psychology department at Florida State University

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