Specific or transdiagnostic? The occurrence of emotions and their association with distress in the daily life of patients with borderline personality disorder compared to clinical and healthy controls
Introduction
In clinical psychiatry, we are currently witnessing a debate on categorical systems and transdiagnostic mechanisms (Clark et al., 2017). For instance, the categorical definition of borderline personality disorder (BPD) in ICD-10 (World Health Organisation, 1992) as “emotionally unstable personality disorder” points to affective instability as a disorder-specific feature. Yet, empirical evidence has revealed that affective instability is, for example, also present in patients with posttraumatic stress disorder (PTSD) and patients with eating disorders, and that affective instability is not able to distinguish between these categorical disease groups (e.g., Santangelo et al., 2014; Houben et al., 2016; Santangelo et al., 2016). Accordingly, affective instability is now considered to be a transdiagnostic feature.
However, the DSM-5 (American Psychiatric Association, 2013) defines BPD not solely by affective instability but also by other criteria, such as inappropriate anger. It has not yet been extensively investigated whether the frequency and the intensity of emotions are specific for certain disorders, in line with categorical systems, or whether they are present across disorders, in terms of a transdiagnostic approach. For example, the Research Domain Criteria project (RDoC; Cuthbert and Insel, 2013), highlights the domains “Positive Valence Systems” and “Negative Valence Systems” as underlying transdiagnostic mechanisms of affective experience, neglecting the role of specific emotions. However, Schoenleber and Berenbaum (2012b) recommend consistently considering the influence of specific emotions when studying the features of personality disorders, over and above the influence of general negative and positive affect.
Ambulatory assessment (AA) methodology has been used in a multitude of studies investigating emotional processes in patients with BPD and is well suited for describing which emotions specifically characterize the everyday experience of patients with BPD (Trull, 2018). AA allows repeated real-time assessments with minimized retrospective bias and is therefore ideally suitable to assess affective experience in the most relevant context, the daily life of patients (Trull and Ebner-Priemer, 2013).
Although altered affective experiences such as anger are an essential part of the pathology of BPD (American Psychiatric Association, 2013), little research has been conducted in daily life, and findings do not clearly favor the categorical or the transdiagnostic model. To the best of our knowledge, only two empirical investigations using AA directly target either the occurrence or the intensities of a broad range of specific emotions in patients with BPD. Trull et al. (2008) found a higher instability of sadness, fear, and hostility in patients with BPD than in depressive patients, but no difference was found between the intensities of these specific emotions. The particular finding that the BPD group did not report more intense hostility than the depression group is surprising, given the DSM-5 diagnostic criterion describing “inappropriate, intense anger” as a feature of BPD (American Psychiatric Association, 2013). Altered intensities of specific emotions, however, were found in the study of Ebner-Priemer et al. (2007). Comparing patients with BPD to healthy controls (HC), they revealed heightened frequencies and intensities across all the measured negative emotions and lowered frequencies of positive emotions. The lack of clinical controls might have been a possible reason for the largely unspecific differences and precluded statements on specificity.
In our study, to improve on previous designs of AA studies investigating a broad range of specific emotions, we included additional clinical groups and HC. In detail, using a design similar to the one used by Ebner-Priemer et al. (2007), we compared the everyday frequencies and intensities of specific emotions (joy, interest, anxiety, anger, sadness, shame, disgust, jealousy, guilt) in patients with BPD to those in patients with PTSD and patients with bulimia nervosa (BN) as well as HC. Thus, we intended to enrich the ongoing debate on categorical vs. transdiagnostic models with empirical evidence of specific emotions as a hitherto understudied aspect of affective experience. Regarding specificity, numerous studies have highlighted the central role of two specific emotions in BPD, namely, anger (e.g., Morse et al., 2009; Stepp et al., 2009; Tomko et al., 2014; Mancke et al., 2017) and shame (e.g., Rüsch et al., 2007; Gratz et al., 2010; Rizvi et al., 2011; Schoenleber and Berenbaum, 2012a; Chapman et al., 2014; Mneimne et al., 2018). Moreover, in BPD symptomatology, anger and shame seem to be related inasmuch as the experience of shame might lead to anger, which was shown in the laboratory (Scheel et al., 2013) and in daily life (Scott et al., 2015). A more recent EMA study investigated the association among social rejection, anger, shame, and aggressive urges in participants with BPD symptomatology and revealed that perceived rejection predicted increases in both anger and shame (Scott et al., 2017). Moreover, Lis et al. (2018) reported hypersensitivity to injustice, which mediated the frequency of hostile behavior in subjects with a clinically relevant degree of BPD features.
However, it is largely unclear which specific emotions cause distress in BPD. To have a specific emotion more often or to feel it more intensely does not necessarily mean that this emotion is particularly impairing. For this reason, we were interested in extracting the additional effect of the quality of a specific emotion on distress beyond the mere influence of positive and negative affect. We consider this to be important for treatment, which should target patients’ most impairing affective experiences.
To replicate previous findings on the frequency and intensity of specific emotions, we tested whether patients with BPD would report negative emotions more frequently, positive emotions less frequently (hypothesis 1a), and negative emotions but not positive emotions more intensely (hypothesis 1b) than HC. Extending previous research, we hypothesized that anger and shame would occur more frequently (2a) and intensely (2b) in patients with BPD than in clinical controls. In exploratory analyses, we addressed the distress associated with specific emotions beyond the mere influence of positive and negative valence.
Section snippets
Subjects
The sample of 43 patients with BPD, 28 patients with PTSD related to childhood abuse, 20 patients with BN and 28 HC is part of a larger investigation on affective dysregulation, which has already resulted in publications on affective instability (Santangelo et al., 2014; Ebner-Priemer et al., 2015; Santangelo et al., 2016) and emotion sequences (Kockler et al., 2017). Depending on their respective groups, the patients met the DSM-IV criteria for BPD, PTSD, or BN. Trained postgraduate
Sample characteristics
Details of the sample of the 119 female participants consisting of 43 patients with BPD, 28 patients with PTSD, 20 patients with BN, and 28 HC are provided in table 1. The average age of the study participants was 28.6 years (range: 18 to 48). With regard to age, the BPD group did not differ significantly from the clinical controls and the HC (Kruskal-Wallis-H = 4.15, p = .13). On average, 42% of the patients in the clinical groups were treated with psychotropic medication. Among the comorbid
Discussion
This is the first study to investigate the frequency, intensity, and distress associated with specific emotions in patients with BPD compared to clinical controls and HC. Patients with BPD experience all of the assessed negative emotions more frequently and nearly all of the negative emotions more intensely than HC, except for disgust. This confirms our hypotheses and largely replicates previous findings (Ebner-Priemer et al., 2007). The findings related to the positive emotions were less
Funding
Parts of this research were funded by the German Research Foundation (DFG) under EB 364/6-1 and EI 379/10-1.
CRediT authorship contribution statement
Tobias D. Kockler: Conceptualization, Data curation, Formal analysis, Methodology, Visualization, Writing - original draft. Philip S. Santangelo: Methodology, Validation, Writing - review & editing. Matthias F. Limberger: Methodology, Validation, Writing - review & editing. Martin Bohus: Funding acquisition, Resources, Writing - review & editing. Ulrich W. Ebner-Priemer: Conceptualization, Methodology, Resources, Project administration, Supervision, Writing - review & editing.
Declaration of Competing Interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ulrich W. Ebner-Priemer is consultant for Boehringer Ingelheim.
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