Characterizing emotional dysfunction in borderline personality, major depression, and their co-occurrence
Introduction
Although emotional dysfunction has been implicated in the development and maintenance of numerous forms of psychopathology [1], it is considered particularly central to borderline personality disorder (BPD) [2], [3], [4], [5], [6], [7]. However, given that the presence of co-occurring disorders is the norm, rather than the exception, in BPD [8], identifying patterns of emotional dysfunction specific to BPD is a crucial next step. Among the most common disorders to co-occur with BPD is major depressive disorder (MDD; e.g., 71–87%) [8], [9], which is itself associated with heightened emotional dysfunction [10], [11]. Thus, the present laboratory-based studies extend existing research by examining two specific aspects of emotional dysfunction (i.e., emotional reactivity and emotion dysregulation) in participants with and without BPD and MDD pathology.
One domain of emotional dysfunction theorized to be particularly relevant to BPD is emotional reactivity [2], [3], [7], defined as the amplitude of emotional response (across subjective, physiological, or expressive domains) to internal or external stimuli [12]. Empirical research supports the relevance of emotional reactivity to BPD. Research examining self-reported trait emotional reactivity indicates a positive association between BPD pathology and emotional reactivity [13], [14], [15], as well as greater self-reported emotional reactivity among individuals with versus without BPD [16], [17], [18]. Participants with BPD also report more frequent shifts in negative affect (NA) and greater emotional reactivity to daily negative interactions than healthy controls in studies using ecological momentary assessment [19], [20], [21], [22]. Moreover, laboratory-based studies provide further support for heightened subjective emotional reactivity in BPD (for exceptions, see references [23], [24]), finding greater self-reported emotional reactivity in response to laboratory stressors among patients with (vs. without) BPD [25] and individuals high (vs. low) in BPD pathology [26]. Finally, although studies of biological emotional reactivity in BPD (as indexed by cortisol reactivity in response to stressors) have produced mixed results [27], [28], [29], [30], recent research provides support for heightened cortisol reactivity in BPD, although only at low levels of posttraumatic stress disorder (PTSD) symptoms [29] or high levels of dissociation [30].
Another important domain of emotional dysfunction in BPD is emotion dysregulation. As defined here, emotion dysregulation refers to maladaptive responses to emotions, including: (a) a lack of awareness, understanding, and acceptance of emotions; (b) the inability to control behaviors when experiencing emotional distress; (c) lack of access to adaptive strategies for modulating the duration and/or intensity of aversive emotional experiences; and (d) an unwillingness to experience emotional distress as part of pursuing meaningful activities in life [31], [32]. Extant research provides strong support for an association between BPD and all of the dimensions of emotion dysregulation noted above (as assessed with the Difficulties in Emotion Regulation Scale [31]; e.g., [24], [33], [34], [35]). Studies using other self-report measures have also found evidence for a relation between BPD and many dimensions of emotion dysregulation, including lower emotional clarity [36], greater nonacceptance and avoidance of emotions [37], [38], and greater use of avoidant regulation strategies [33]. Finally, studies using behavioral and laboratory-based measures of emotion dysregulation indicate multiple forms of emotion dysregulation among individuals with BPD, including lower emotional awareness and clarity [39], greater unwillingness to experience distress in order to pursue goal-directed behavior [32], [34], and greater difficulties controlling behaviors in the context of distress [40].
Emotional dysfunction is also a prominent feature of MDD pathology, although the precise nature of this dysfunction is unclear. For instance, whereas individuals with both current [10] and lifetime [41] MDD exhibit greater NA in their daily lives than those without MDD, research on emotional reactivity in MDD has produced mixed results, with some studies finding evidence of heightened emotional reactivity in the laboratory among individuals with current and remitted MDD pathology [42], [43], [44] and others suggesting that both remitted and currently depressed individuals display less emotional reactivity than control [45], [46] (at least with regard to sadness [45]). Despite these inconsistent findings, however, results of a recent meta-analysis suggest that MDD pathology is associated with blunted subjective emotional reactivity to negative stimuli in the laboratory, d = −.36 [47]. Moreover, research on biological (i.e., cortisol) emotional reactivity in MDD has produced similar results, with studies suggesting that both MDD [48] and remitted MDD [46] are associated with blunted cortisol reactivity to stressors, compared with non-depressed controls (for exceptions, see references [49], [50]). Notably, investigations of emotion dysregulation in MDD pathology have produced more consistent findings, with both current and remitted MDD pathology evidencing positive associations with emotion dysregulation [41], [51], [52], [53].
Despite evidence to suggest that BPD and MDD frequently co-occur [8], [9], little research has directly compared emotional dysfunction in BPD and MDD. Nonetheless, preliminary theoretical and empirical literature suggest that BPD may be characterized by greater emotional reactivity to acute stressors and heightened emotion dysregulation, relative to MDD [54], [55]. For example, Goodman and colleagues [54] have theorized that, despite some phenotypic overlap between BPD and MDD, the nature of the emotional dysfunction in these disorders differs, with BPD characterized by episodic emotional reactivity and emotion dysregulation in response to this reactivity and MDD characterized by sustained mood problems. These researchers also suggest that BPD symptoms dominate the clinical presentation in BPD-MDD co-occurrence [54] – consistent with findings that the presence of co-occurring BPD in MDD is associated with greater depressive symptoms [56], [57].
Consistent with this theoretical literature, results of a recent laboratory study revealed heightened subjective emotional reactivity in the form of anger reactivity (but not other emotions) following a shame-specific emotion induction among participants with BPD, compared to depressed and healthy controls [55]. Moreover, although no studies have examined differences in biological emotional reactivity in BPD versus MDD, research examining other aspects of biologically-indexed emotional dysfunction in BPD and MDD suggests higher resting cortisol levels in BPD (but not MDD) versus controls [58], as well as hypo-suppression of cortisol in response to the dexamethasone suppression test in MDD but not BPD [59]. Finally, extant research provides initial support for distinct patterns of self-reported emotion dysregulation in BPD and MDD pathology. For instance, when controlling for MDD pathology, BPD pathology is uniquely associated with greater overall emotion dysregulation [60], as well as the specific emotion regulation difficulties of emotional avoidance [61], lack of access to effective emotion regulation strategies [60], and difficulties controlling impulsive behaviors when distressed [60]. Further, relative to patients with MDD, individuals with BPD report heightened levels of overall emotion dysregulation, as well as a greater reliance on maladaptive and avoidant emotion regulation strategies [62].
Taken together, results of the aforementioned studies provide preliminary support for heightened levels of certain aspects of emotional dysfunction among individuals with BPD versus MDD pathology. Nonetheless, important limitations exist. First, research has not examined the impact of co-occurring BPD and MDD pathology on emotional dysfunction; thus, it is unclear if this co-occurrence is associated with a different pattern of emotional dysfunction than BPD or MDD alone. Second, past research exploring distinct patterns of emotional dysfunction in BPD and MDD has relied on subjective assessments of emotional dysfunction; thus, differences in behaviorally- or biologically-assessed emotional dysfunction as a function of BPD and MDD pathology are unknown. Third, the one study to date that compared emotional reactivity in the laboratory among individuals with BPD versus MDD used a shame-specific emotion induction [55]. Given evidence that emotional reactivity in the laboratory is influenced by the type of stressor utilized [63], the generalizability of the results of that study to other stressors remains unclear. Moreover, although results of that study provide preliminary evidence of prolonged anger among individuals with BPD (but not MDD), the focus was on emotional responses before and after the shame induction and then subsequent recovery [55]. However, no research to date has examined the time course of emotional dysfunction in response to ongoing emotional stimuli among individuals with high and low levels of BPD and MDD pathology. This is a critical limitation of past research given theoretical and empirical literature highlighting the relevance of prolonged emotional responses (including reactivity) to BPD [25].
Extant literature highlights the need for more comprehensive and nuanced investigations of emotional reactivity and emotion dysregulation when characterizing patterns of emotional dysfunction in BPD, MDD, and their co-occurrence. Thus, the present investigation sought to examine unique patterns of emotional reactivity and emotion dysregulation in BPD pathology, MDD pathology, and their co-occurrence across both community and clinical samples. To this end, we utilized a multi-method, laboratory-based design to examine both immediate and prolonged subjective and biological emotional reactivity to a laboratory stressor, as well as both subjective and behaviorally-indexed emotion dysregulation. We hypothesized that, relative to MDD pathology, BPD pathology would be associated with heightened negative emotional reactivity to the laboratory stressor, both in general and across the specific emotions of fear/anxiety, anger, and shame. In addition, we hypothesized that BPD pathology (compared to MDD pathology) would be associated with greater levels of overall emotion dysregulation, as well as the specific dimension of emotion dysregulation involving difficulties controlling impulsive behaviors when distressed. Finally, given past evidence of greater clinical severity in BPD-MDD co-occurrence, relative to either disorder alone [64], we expected that individuals with both BPD and MDD pathology would demonstrate greater emotional reactivity and emotion dysregulation than all other groups.
Section snippets
Aims
The goal of this study was to examine patterns of emotional dysfunction associated with heightened levels of BPD and MDD pathology (and their co-occurrence) in a large sample of young adult women from the community. Levels of subjective emotional reactivity to a laboratory stressor, as well as subjective and behavioral emotion dysregulation, were examined among community women low in both BPD and MDD symptoms (Low BPD/Low MDD), low in BPD and high in MDD symptoms (Low BPD/High MDD), high in BPD
Aims
The goal of this study was to extend the findings of study 1 by examining emotional reactivity and dysregulation in a clinical sample of substance use disorder (SUD) inpatients, obtaining interview-based diagnoses of BPD and MDD, and including a biological index of emotional reactivity (i.e., salivary cortisol in response to the laboratory stressor [97], [98]). Given the high rates of both BPD and MDD among SUD patients [99], this was considered an optimal sample for examining patterns of
General discussion
The overarching aim of this research was to examine unique patterns of emotional reactivity and emotion dysregulation in BPD pathology, MDD pathology, and their co-occurrence in both community and clinical samples. Findings provide partial support for study hypotheses. With regard to emotional reactivity, although both BPD and MDD pathology were associated with heightened levels of negative emotions in general (relative to low levels of BPD and MDD pathology or an absence of these diagnoses),
Conclusions
The present research constitutes an important step forward in research on emotional dysfunction in BPD. Whereas burgeoning research has identified patterns of emotional dysfunction in BPD pathology relative to controls, there is a dearth of research differentiating emotional responding in BPD from other clinical conditions. Results of the present research suggest that individuals with heightened BPD pathology may exhibit greater prolonged negative emotional reactivity, particularly with regard
Acknowledgment
This research was supported by National Institute of Child Health and Human Development Grant R01 HD062226, awarded to the fourth author (DD), and National Institute on Drug Abuse Grant R21 DA022383, awarded to the third author (MTT). Work on this paper by the second author (NHW) was supported by National Institute on Drug Abuse Grant T32 DA019426.
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Cited by (0)
Portions of these data were previously presented at the annual meetings of the Association for Behavioral and Cognitive Therapies and North American Society for the Study of Personality Disorders in 2014.