Emotion regulation strategies in bipolar II disorder and borderline personality disorder: Differences and relationships with perceived parental style

Abstract

Background

Bipolar II disorder (BP II) and Borderline Personality Disorder (BPD) share common features and can be difficult to differentiate, contributing to misdiagnosis and inappropriate treatment. Research contrasting phenomenological features of both conditions is limited. The current study sought to identify differences in emotion regulation strategies in BP II and BPD in addition to examining relationships with perceived parental style.

Method

Participants were recruited from a variety of outpatient and community settings. Eligible participants required a clinical diagnosis of BP II or BPD, subsequently confirmed via structured diagnostic interviews assessing DSM-IV criteria. Participants completed a series of self-reported questionnaires assessing emotion regulation strategies and perceived parental style.

Results

The sample comprised 48 (n=24 BP II and n=24 BPD) age and gender-matched participants. Those with BPD were significantly more likely to use maladaptive emotion regulation strategies, less likely to use adaptive emotion regulation strategies, and scored significantly higher on the majority of (perceived) dysfunctional parenting sub-scales than participants with BP II. Dysfunctional parenting experiences were related to maladaptive emotion regulation strategies in participants with BP II and BPD, however differential associations were observed across groups.

Limitations

Relatively small sample sizes; lack of a healthy control comparator group; lack of statistical control for differing sociodemographic and clinical characteristics, medication and psychological treatments; no assessment of state or trait anxiety; over-representation of females in both groups limiting generalisability of results; and reliance on self-report measures.

Conclusions

Differences in emotion regulation strategies and perceived parental style provide some support for the validity of distinguishing BP II and BPD. Development of intervention strategies targeting the differing forms of emotion regulatory pathology in these groups may be warranted.

Introduction

Bipolar disorder (BP) and borderline personality disorder (BPD) are commonly misdiagnosed (Zimmerman et al., 2010), compromising subsequent treatment and patient outcomes. In a recent study, almost 40% of psychiatric outpatients diagnosed with BPD had been overdiagnosed with BP (Zimmerman et al., 2010). As overviewed previously, differentiation between the two conditions is difficult due to several shared phenomenological features (Bayes et al., 2014). Such features include ‘affect storms’ in BPD resembling hypomania (Kernberg and Yeomans, 2013), the chronic nature of BP II (Ayuso-Gutierrez and Ramos-Brieva, 1982, Cassano and Savino, 1997, Benazzi, 2001, Benazzi, 2007, Vieta et al., 1997, Mantere et al., 2008, Baek et al., 2011, Judd et al., 2002, Judd et al., 2003a, Judd et al., 2003b, Judd et al., 2003c, Judd et al., 2005) as for BPD, and the shared features of impulsivity and emotion dysregulation (ED) (Bayes et al., 2014). Clinical differentiation is seemingly more difficult in differentiating BPD from the bipolar II sub-type (BP II), due in part to the absence of psychotic features in BP II, arguing for a focus on how best to discriminate these two conditions. A recent review of the co-occurrence of BPD and BP disorders concluded that there appears to be a stronger association between BPD and BP II disorder than BP I disorder, highlighting the need for direct comparisons between BPD and the BP II sub-type specifically (Zimmerman and Morgan, 2013).

Very few studies have sought to identify discriminating features for BPD and BP II, as overviewed previously (Parker, 2011). In a recent large-scale comparison of depressed outpatients diagnosed with BP II or BPD, the latter group had significantly poorer social functioning, higher rates of post-traumatic stress disorder and substance use disorders, more suicidal ideation and attempts, and reported more anger, paranoid ideation and somatisation (Zimmerman et al., 2013). The authors concluded that such findings supported the validity of the two as separate conditions, in contrast to previous suggestions that BPD exists on the bipolar spectrum (MacKinnon and Pies, 2006, Angst et al., 2011, Akiskal, 2004, Perugi et al., 2003, Smith et al., 2005, Perugi et al., 2011).

We recently reviewed studies contrasting BP (I or II) and BPD features, focusing specifically on studies delineating the BP II sub-type (Bayes et al., 2014). Non-specific features included subtle differences in impulsivity profiles, treatment response, childhood trauma, self-harm rates, neurocognitive features and comorbidity profiles. However, the review identified a series of key differentiating features for BP II disorder including (i) a family history of BP, (ii) a distinctive onset period for depression, (iii) failure of the condition to remit over time, (iv) phenomenological differences in depressive features (e.g. melancholic, agitated and mixed symptoms being over-represented) and elevated mood states (e.g. prolonged elation with little or no anxiety, increased energy, creativity, grandiosity and productivity, episodic irritability/anger during hypomania) and (v) differences in emotion dysregulation (ED). The latter included those with BP II experiencing more frequent and intense shifts between euthymia, depression and elation; whereas those with BPD tend to experience more frequent and intense lability between euthymia, anxiety, anger and depression (Reich et al., 2012).

ED is a core feature of BPD but can also be present in BP II. ED has been variably defined, with some equating ED with temperamentally-based emotional intensity or reactivity (Livesley et al., 1998), whilst others differentiate ED by the quality of the emotional response (Linehan, 1993, Thompson and Calkins, 1996). More recently, ED is considered to be distinguishable from temperamental emotional vulnerability (see Mennin et al., 2005), and referring more broadly to the use of maladaptive strategies in response to emotional distress (Gratz and Roemer, 2004). Gross (1998) defines emotion regulation as the “processes by which individuals influence which emotions they have, how they have them, and how they experience and express these emotions” (p275), regarding such processes as automatic or controlled at an unconscious or conscious level. The current study adopts this definition, whereby ED is considered as a multidimensional construct which can involve reduced 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 during pursuit of desired goals; and an inability to engage in goal-directed behaviours when experiencing emotional distress (Gratz and Roemer, 2004).

Despite the central role of ED in both BPD and BP II, we are not aware of any studies to date that have directly compared these groups in terms of the self-reported strategies used to regulate emotions. Studies assessing such groups separately are now briefly overviewed.

Poor affect evaluation and tolerance of negative and neutral stimuli is well documented in individuals with BPD (Donegan et al., 2003, Stern et al., 1997), coupled with a tendency to make negative interpretations of interpersonal interactions (Renaud et al., 2012). Individuals with BPD have difficulty using the cognitive strategies of reappraisal and suppression to regulate intense affect (Paris, 2012), while thought suppression has been associated with the frequency of self-harm behaviours in this group (Chapman et al., 2005). Other studies contrasting those with BPD and healthy controls reported lower emotional awareness (i.e. inability to differentiate emotions in self and others) and clarity (i.e. limited understanding of the nature of their emotions) (Levine et al., 1997, Leible and Snell, 2004), along with a greater tendency to use avoidant regulation strategies (Bijttebier and Vertommem, 1999) in the BPD group. In an experimental investigation, those with BPD were less willing than healthy controls to experience distress in order to pursue goal-related behaviour, however did not evidence greater difficulties engaging in such behaviour when distressed (Gratz et al., 2006) – with the latter finding suggesting that particular aspects of ED may be more or less relevant to BPD. In a study contrasting emotion regulation strategies in individuals with BPD and those with dysthymia, the BPD subjects tended to employ a range of maladaptive strategies including internalising, externalising, emotional avoidance and disorganised strategies suggesting desperate, flailing and impulsive attempts to escape psychological pain (Conklin et al., 2006).

Studies examining emotion regulation difficulties in BP have generally focused on the BP I sub-type or combined BP sub-types in their analyses. As overviewed previously (Fletcher et al., 2013), studies investigating cognitive emotion regulation in BP and healthy controls have reported more frequent use of maladaptive coping strategies in response to negative life events in those with BP (Green et al., 2011), including a greater tendency to ruminate about negative affect (Johnson et al., 2008, Gruber et al., 2011) and engage in suppression (i.e. inhibit emotion-expressive behaviour) (Gruber et al., 2012). In a study examining coping profiles in the bipolar sub-types, those with BP II were significantly more likely to use maladaptive cognitive emotion regulation strategies (e.g. self-blame, rumination, catastrophising, blaming others) and less likely to use adaptive strategies (e.g. positive re-focusing, planning, positive reappraisal, putting into perspective) than healthy controls (Fletcher et al., 2013).

Developmental factors can increase the risk of ED and, consequently BPD (Linehan, 1993). Linehan (1993) proposed that an invalidating developmental context (characterised by caregiver intolerance toward expression of emotion, coupled with intermittent reinforcement of extreme expressions of emotion) results in the child being unable to understand, label, regulate or tolerate emotional responses. This in turn leads to oscillations between emotional inhibition and extreme emotional lability, and an inability to solve the problems contributing to such emotional reactions. Similarly, adverse events during childhood (e.g. ongoing experiences of neglect or abuse) may be causally linked to ED, driving dysfunctional behaviours and interpersonal conflict that further reinforce ED (Skodol et al., 2002). This pattern is likely to persist into adulthood, and be associated with ongoing difficulties in regulating emotions. As overviewed by Laulik et al. (2013), unpredictable and intrusive parenting received during childhood has been associated with BPD (Paris, 1996, Reich and Zanarini, 2001), and preoccupied patterns of attachment are over-represented in this group (Fonagy et al., 1996). Indeed, childhood maltreatment (comprising various forms of abuse or neglect) is considered to be the most widely validated psychosocial risk factor for BPD (Keinanen et al., 2012).

Similarly for mood disorders, early adverse experiences are hypothesised to have long-lasting consequences on neurochemistry, brain structure and affective behaviour (Alloy et al., 2006). Maltreatment is thought to interfere with the child's ability to regulate their emotions by promoting chronic arousal, while the family environment fails to provide the child with learning opportunities to develop emotion regulation skills (Cloitre, 1998). However, few studies have examined these aspects in bipolar disorder, and findings are mixed. There is some suggestion of parenting characterised by low warmth and acceptance, high overprotection, poor attachment relations and childhood abuse in this group, with such features associated with a worse illness course (Alloy et al., 2005, Miklowitz, 2007). A recent study investigating family characteristics prior to age 16 in a large sample of bipolar patients and healthy controls reported that parental psychopathology (paternal substance use, and maternal depression in particular) and poor relationships with parents were associated with a distinct increased risk for bipolar illness, and explained 65% of the variance in outcome (Chen et al., 2013).

While the link between early maladaptive attachment relationships and longer-term emotion regulation difficulties appears relevant for both BPD and BP II, associations between these factors have not been formally examined and compared in these groups.

The current study had two aims. First, to determine whether bipolar II and BPD groups differ in terms of emotion regulation strategies and perceived parenting style. Second, to examine the associations between emotion regulation strategies and perceived parenting style in both groups.

Identification of features that differentiate between the two conditions would assist with both diagnostic clarification and development of intervention strategies targeting the differing forms of emotion regulatory pathology.