Accepted Manuscript A Multi-Method Laboratory Investigation of Emotional Reactivity and Emotion Regulation Abilities in Borderline Personality Disorder Janice R. Kuo, Ph.D., Skye Fitzpatrick, M.A., Rebecca K. Metcalfe, B.A., Shelley McMain, Ph.D. PII:

S0005-7916(15)00069-5

DOI:

10.1016/j.jbtep.2015.05.002

Reference:

BTEP 1139

To appear in:

Journal of Behavior Therapy and Experimental Psychiatry

Received Date: 4 September 2014 Revised Date:

26 January 2015

Accepted Date: 6 May 2015

Please cite this article as: Kuo, J.R., Fitzpatrick, S., Metcalfe, R.K., McMain, S., A Multi-Method Laboratory Investigation of Emotional Reactivity and Emotion Regulation Abilities in Borderline Personality Disorder, Journal of Behavior Therapy and Experimental Psychiatry (2015), doi: 10.1016/ j.jbtep.2015.05.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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ACCEPTED MANUSCRIPT

A Multi-Method Laboratory Investigation of Emotional Reactivity and Emotion

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Regulation Abilities in Borderline Personality Disorder

Janice R. Kuo, Ph.D.1, Skye Fitzpatrick, M.A.1, Rebecca K. Metcalfe, B.A.1, & Shelley

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McMain, Ph.D.2

Ryerson University, Department of Psychology, Toronto, Ontario, Canada

Borderline Personality Disorder Clinic, Centre for Addiction and Mental Health

(CAMH) and the Department of Psychiatry, University of Toronto, Toronto, Ontario,

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Canada

Author Note:

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Correspondence should be addressed to Janice R. Kuo, Ph.D., Ryerson University,

350 Victoria Street, Toronto, Ontario, M5B 2K3 Canada; Phone: (416) 979-5000 ext. 2624; Email: [email protected]

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Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD

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A Multi-Method Laboratory Investigation of Emotional Reactivity and Emotion Regulation

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Abilities in Borderline Personality Disorder

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Abstract Background and Objectives: Borderline personality disorder (BPD) is conceptualized as a disorder of heightened emotional reactivity and difficulties with emotion regulation. However,

examining emotion regulation capabilities in this population.

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findings regarding emotional reactivity in BPD are mixed and there are limited studies

Methods: Twenty-five individuals with BPD and 30 healthy controls (HCs) engaged in a baseline

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assessment followed by the presentation of neutral and BPD-relevant negative images. Participants were instructed to react as they naturally would to the image, or to use a

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mindfulness-based or distraction-based strategy to feel less negative. Self-reported and physiological (i.e., heart rate, electrodermal activity, and respiratory sinus arrhythmia) measures were collected.

Results: Compared with the HCs, the BPD group exhibited elevated heart rate and reduced

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respiratory sinus arrhythmia at baseline. However, there were no differences in emotional reactivity in self-report or physiological indices between the two groups. In addition, the BPD group did not exhibit deficits in the ability to implement either emotion regulation strategy, with

with the HCs.

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the exception that the BPD group reported less positive emotions while distracting compared

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Limitations: This study is limited by a small sample size and the inclusion of a medicated BPD sample.

Conclusions: Emotion dysregulation in BPD might be better accounted for by abnormal baseline emotional functioning rather than heightened emotional reactivity or deficits in emotion regulation. Treatments for BPD might be enhanced by directly targeting resting state emotional functioning rather than emotional reactions or regulatory attempts.

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD Key words: Borderline Personality Disorder, emotional intensity, emotional reactivity, emotion

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regulation, mindfulness

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A Multi-Method Laboratory Investigation of Emotional Reactivity and Emotion Regulation Abilities in Borderline Personality Disorder 1. Introduction

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Borderline personality disorder (BPD) is a disorder of affective instability, conflict in interpersonal relationships, and self-destructive behaviour (Linehan, 1993). Prevalence estimates of BPD are as high as 6% (Grant et al., 2008) and approximately 23% of outpatients meet

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diagnostic criteria for the disorder (Korzekwa, Dell, Links, Thabane, & Webb, 2008). Prominent theories of BPD posit that emotion dysregulation is either the core feature of the disorder

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(Linehan, 1993) or a key facet of the disorder (Fonagy & Bateman, 2008; Selby & Joiner, 2009). Emotion dysregulation is broadly comprised of the coupling of abnormalities in emotional responding and difficulties regulating emotional responses (Linehan, 1993). 1.1 Emotional Reactivity and Regulation in BPD

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Basic emotion theorists propose that emotional reactivity and emotion regulation are two components of emotion dysregulation that have the potential to influence each other and contribute to “emotional output” (Gross & Thompson, 2007). Emotional reactivity refers to

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multi-systemic (i.e., experiential, behavioural, and physiological) changes in response to an emotionally-evocative stimulus; emotion regulation refers to the process by which an individual

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attempts to modify the emotion-generative process, often with the goal of decreasing one’s emotional intensity (Gross & Jazaeiri, 2014). A majority of emotion-based research in BPD has examined emotional reactivity using a range of methodologies including laboratory paradigms with negative images (Herpertz et al., 1999; 2000), scripts (Kuo & Linehan, 2009; Schmahl et al., 2004), and film clips (Austin, Rinolio, & Porges, 2007; Kuo & Linehan, 2009; Lobbestael & Arntz, 2010). Findings from this literature are mixed, and recent evidence suggests that

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emotional reactivity in BPD may not be pervasive, but rather, specific to emotion and/or content of the stimulus. Indeed, Kuo, Neasciu, Fitzpatrick, and MacDonald (2013) reported that individuals with BPD experience greater reactivity when sadness or anger is induced using

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personally relevant stressors compared to generalized stressors. Similarly, Limberg, Barnow, Freyberger, and Hamm (2011) found that heightened reactivity in BPD is more pronounced in response to BPD-relevant stimuli compared to generalized negative stimuli.

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In contrast to the emotional reactivity literature, there is a smaller research base

examining emotion regulation in BPD. A number of processes factor into effective emotion

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regulation, including emotion-regulation strategy choice and/or emotion-regulation strategy implementation (Jazaieri, Urry, & Gross, 2013). A handful of studies have begun to evaluate the latter by examining instructed/volitional emotion regulation in BPD. In a study examining cognitive reappraisal (i.e., generating new appraisals of a situation to change its emotional

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impact; Gross & John, 2003) in BPD, Marissen, Meuleman, and Franken (2010) found that persons with BPD did not have altered event-related potentials (ERP) while reappraising negative images compared to HCs. In contrast, functional magnetic resonance imaging (fMRI)

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studies show that individuals with BPD exhibit reduced activation of the anterior cingulate cortex during reappraisal of negative auditory scripts (Lang et al., 2012) as well as reduced

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deactivation of the amygdala (Koenigsberg et al., 2009) and increased activation of the insula (Schulze et al., 2011) during reappraisal of negative images compared with HCs. Ruocco, Medaglia, Ayaz, and Chute (2010) examined the effects of cognitive distancing, a form of reappraisal, among individuals with BPD and HCs, and found that the BPD group did not differ from HCs in self-reported sadness or mean levels of oxygenated hemoglobin in the prefrontal cortex. Thus, there is some evidence that individuals with BPD are able to effectively reduce

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their emotional reactivity using cognitive reappraisal (as indexed by ERP and self-report) upon instruction. However, this research is limited to the examination of one strategy type, i.e., cognitive reappraisal; indeed, it remains unclear whether these findings generalize to other

skilled at implementing different types of strategies. 1.2 Mindful Awareness and Distraction

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prominent emotion regulation strategies and/or whether individuals with BPD are more or less

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Two emotion regulation strategies that have received limited attention in the BPD

literature are mindful awareness and distraction. Mindful awareness involves willingly and non-

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judgmentally noticing and experiencing emotions, as opposed to evaluating, rejecting, or suppressing them (Segal, Williams, & Teasdale, 2012). Conversely, distraction involves shifting attention away from an emotionally evocative stimulus in order to reduce its impact (Sheppes, Scheibe, Suri, & Gross, 2011). Research in HCs indicates that acceptance-based strategies such

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as mindful awareness are more effective than other emotion regulation strategies (i.e., suppression, distraction) at increasing pain tolerance in HCs (Kohl, Rief, & Glombiewski, 2012). Mindful awareness also reduces self-reported discomfort (Luciano et al., 2010) and physiological

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indices of emotion (Hofmann, Heering, Sawyer, & Asnaani, 2009; Low, Stanton, & Bower, 2008) relative to other emotion regulation strategies. Similarly, distraction in HCs leads to

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reductions in self-reported negative emotions (Webb, Miles, & Sheeran, 2012; Denson, Moulds, & Grisham, 2012), reduced amygdala activation (McRae et al., 2010), quicker reductions in late positive potentials (Thiruchselvam, Blechert, Sheppes, Rydstrom, & Gross, 2011), and increased prefrontal and parietal activity (McRae et al., 2010) when participants are exposed to negative stimuli such as images or personalized stressors.

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Currently, no studies have examined whether individuals with BPD are able to implement mindful awareness upon instruction and only one study has examined the instructed use of distraction; Jacob and colleagues (2011) instructed individuals with BPD to engage in a

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distraction task, a positive memory imagery task, a soothing imagery task, and a neutral task (control) while viewing neutral and negative film clips. The authors found that all the strategies were associated with greater reduction in self-reported negative emotions and greater increase in

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positive emotions than the neutral control task after the negative film. Though informative, this study did not include a control group and thus, it is unclear whether individuals with BPD are

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less “skilled” at implementing distraction than HCs. Moreover, it remains unclear whether persons with BPD are better at applying some strategies over others. 1.3 The Present Study

We addressed the limitations in the extant literature by employing a multi-method

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laboratory design to examine emotional reactivity and volitional emotion regulation in BPD. Baseline differences were first compared between individuals with BPD and HCs. Next, participants engaged in an event-related laboratory task where they viewed neutral and BPD-

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relevant images while instructed to either 1) react naturally (i.e., reactivity condition) or 2) engage either mindful awareness or distraction (i.e., regulation condition). Self-reported ratings

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and physiological measures were collected throughout. We hypothesized that the BPD group would exhibit (a) abnormal baseline emotional functioning compared to HCs, (b) heightened change in emotional intensity from the presentation of neutral to BPD-relevant stimuli (i.e., reactivity) compared to HCs, and (c) heightened emotional intensity when implementing mindful awareness and distraction compared to the HC group while controlling for emotional reactivity

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(i.e., regulation). We further explored the relative efficacy of these two strategies and the potential modulating influence of group status. 2. Materials and Methods

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2.1 Participants

Twenty-five individuals with BPD (9 male) and 30 HCs (10 male) between the ages of 18 and 60 were included in the study. Individuals with BPD were recruited from the BPD Clinic at

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the Centre for Addiction and Mental Health (CAMH), located in Toronto, ON. The majority (92%) of the BPD participants were recruited from an ongoing Dialectical Behavior Therapy

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(DBT) skills training study. Of those, two individuals participated in the study after receiving 2 and 5 weeks of DBT skills training, respectively; the remaining participants did not yet receive treatment at the time of the study. HCs were recruited from the community through internet postings. BPD exclusion criteria included diagnosis of psychotic disorder, bipolar disorder, or

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dementia, or evidence of an organic brain syndrome or mental retardation. HC exclusion criteria included meeting diagnostic criteria for any current DSM-IV Axis-I diagnosis or endorsing four or more of the DSM-IV criteria for BPD. HCs who endorsed item “(5) recurrent suicidal

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behaviour, gestures, or threats, or self-mutilating behavior” (America Psychiatric Association, 2000, p. 710) from the BPD criteria were also excluded. Finally, HCs who were currently taking

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any psychotropic medication, beta-blockers, or anti-histamines were excluded. See Table 1 for ethnic, educational, and martial demographics and Table 2 for rates of

Axis I comorbidity among the BPD group. There was no significant difference in age between the two groups (BPD: M=32.72, SD=9.55; HC: M=30.07 years, SD=9.07), t (53) = 1.05, p = .30. A majority of the BPD participants were taking psychotropic medications: antidepressants (68%),

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD mood stabilizers (13%), benzodiazepines (40%), sedatives (14%), and stimulants (4%). No participants reported taking neuroleptics, though 20% reported taking other antipsychotic drugs.

HC Mean Age Sex

30.07 Female

66.7%

Male

33.7%

64%

36%

70%

56%

Married/common law

23.3%

20%

Divorced/separated

3.3%

24%

3.3%

0%

Less than high school

3.3%

8%

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Single

33.29

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Marital status

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Participant Demographics by Group

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Table 1

High school or equivalent

10%

4%

Some college/university

26.7%

24%

College/university

56.7%

56%

Master’s degree

3.3%

8%

European Origin/White

66.7%

56%

Black-

10%

0%

Widowed

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Highest level of

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education

Ethnicity

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Origin/Pacific Islander Biracial/Multiracial

3.3%

Middle Eastern

3.3%

Other

3.3%

0%

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13.3%

4%

8%

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Asian-Canadian/Asian

Note. Ethnicity data are missing for eight BPD participants. BPD = borderline personality

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disorder; HC = healthy control; SD = standard deviation. Table 2

Past and Current Axis I Diagnoses in the Borderline Personality Disorder Group Past

Current

4%

4%

64%

64%

--

12%

12%

12%

Alcohol Dependence Disorder

24%

16%

Substance Abuse Disorder

16%

0%

Substance Dependence Disorder

32%

4%

Panic Disorder

28%

12%

Agoraphobia without a history of Panic Disorder

16%

16%

Social Anxiety Disorder

4%

24%

Specific Phobia

8%

0%

Major Depressive Disorder Dysthymic Disorder

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Alcohol Abuse Disorder

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Other Bipolar Disorder

10

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8%

Posttraumatic Stress Disorder

12%

12%

Anxiety Disorder Not Otherwise Specified

24%

24%

Generalized Anxiety Disorder

--

40%

Body Dysmorphic Disorder

4%

Anorexia Nervosa

12%

Bulimia Nervosa

16%

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Obsessive Compulsive Disorder

11

4%

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0%

4%

2.2 Measures and Materials

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Note. Data for current panic disorder for one BPD participant was missing.

2.2.1 Screening. The Structured Clinical Interview for DSM-IV Axis-I Diagnoses (SCIDI) was administered to determine DSM-IV Axis-I diagnoses. The SCID-I is well validated and highly reliable, with inter-rater reliability Kappa values ranging from .60 to .83 for individual

1998).

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diagnoses (Lobbestael, Leurgans, & Arntz, 2011; Ventura, Liberman, Green, Shaner, & Mintz,

The International Personality Disorders Examination, BPD section (IPDE-BPD) was

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administered to determine both the presence of BPD and a dimensional score of BPD symptomology. The IPDE assesses patterns of behaviour in the past 5 years and before the age of

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25. The IPDE is well validated and has good diagnostic accuracy (Loranger et al., 1994). 2.2.2 Physiological measures. A BIOPAC 5-channel acquisition system (BIOPAC

Systems Inc., Model MP150, Goleta, CA) was used to collect the physiological data. Mindware Technologies (2011) software was used to process the physiological data in 30-second epochs throughout the baseline, and 10-second epochs throughout the experimental task.

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Heart rate (HR) was calculated from the R-R intervals in an electrocardiogram. Electrocardiography was collected along with cardiac impedance (data not reported here) using a two electrode (BIOPAC Systems Inc., Model EL503) configuration with the bioimpedance

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module for ground referencing.

Electrodermal activity (EDA) was collected as an index of sympathetic responding. Two electrodes (BIOPAC Systems Inc., Model EL507) were placed on the medial phalanges of the

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index and middle fingers of the nondominant hand (Fowles et al., 1981). EDA data was digitized at 1,000 samples per seconds and a gain of 1,000. Low- (35 Hz) and high- (.05 Hz) pass filters

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were applied. For the baseline analyses, the number of non-specific SCRs was the dependent variable. For the task analyses, the difference between the mean skin conductance level (SCL) during each trial and the mean SCL during the 2000ms fixation cross prior to that trial was the dependent variable.

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Respiratory Sinus Arrhythmia (RSA) was collected as an index of parasympathetic responding. RSA refers to the variation of heart rate with respiratory patterns and was measured through the high-frequency band (Berntson, Cacioppo, & Quigley, 1993) of spectral analysis of

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heart rate variability using Mindware Technologies HRV 2.33 software (Mindware Technologies Ltd., 2011). Respiration rate was collected using a respiratory band placed around the chest.

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2.2.3 Stimuli. Ninety-six images were selected from the International Affective Picture

System (IAPS; Lang, Bradley, & Cuthbert, 2008): 72 were BPD-relevant negative images (mean valence = 2.83; mean arousal = 5.38) and 24 were neutral (mean valence= 5.11; mean arousal = 2.90). The images selected for the BPD-relevant stimuli were informed by Sloan and colleagues (2010), who identified a set of “self-referential” BPD IAPS images. Only negatively-valenced images from this set were selected. As well, images that depicted self-harm were not selected

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given evidence suggesting that viewing these images in and of itself might regulate emotion (Shaw Welch, Linehan, Sylvers, Chittams, & Rizvi, 2008). In total, 28 of the BPD-relevant images were drawn from this set, and the remaining images depicted themes of similar content-

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women being attacked, distressed individuals, substance use, and aggressors- and had

comparable valence and arousal ratings. The 72 negative images were divided into three sets of 24 images, one for each condition (REACT, NOTICE, and DISTRACT; see below). The three

computer monitor using Eprime Version 2.0 software.

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2.3 Procedure

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sets were equivalent in both valence and arousal (ps > .29). Stimuli were presented on a 27”

Interested individuals were contacted by phone and briefly screened to assess for exclusion criteria. Individuals who passed the phone-screen completed formal assessments for DSM-IV Axis-I disorders and for BPD. Participants were assessed by a Masters and Bachelors-

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level and research assistant under a licensed Clinical Psychologist’s supervision. In order to establish inter-rater reliability, 10 individuals between the ages of 18 and 60 years of age were recruited from the community by means of flyers and online postings. Reliability assessments

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were conducted no more than 5 days apart. Inter-rater reliability for the SCID-I and IPDE-BPD ranged from κ = .74-1.0. On the day of the experiment, all study participants were asked to report

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any substances they took that day that that could potentially influence their performance on the task. Participants reported taking their psychotropic medications as prescribed, antibiotics, multivitamins, and birth control pills. 2.3.1 Baseline assessment. The laboratory task was conducted in a sound-attenuated

room maintained at room temperature (20 degrees Celsius). After participants gave informed consent, physiological sensors were attached and checked. Next, participants engaged in a 10-

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minute baseline period in which they were instructed to sit silently and still. In order to ensure a stable baseline (Jennings, Kamarck, Stewart, Eddy, & Johnson, 1992), only the last 5-minutes of the baseline period were included for all subsequent analyses.

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2.3.2 Emotional reactivity and regulation laboratory task (training and

experimental phase). After completion of the baseline assessment, participants were trained by an experimenter in the two emotion regulation strategies: DISTRACT (i.e., the distract

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condition), in which participants were instructed to decrease their emotional response by

thinking of something neutral while still attending to the distressing stimulus, and NOTICE (i.e.,

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the mindfulness awareness condition), in which participants were instructed to attend to and notice the present experience without judging or trying to change it while still attending to the distressing stimulus. The experimenter followed a standardized script during the training phase; however, the script gave the experimenter flexibility so he/she could ensure that participants

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understood the instructions for each condition and provide feedback when appropriate. Participants completed 10 practice trials for each regulation condition prior to the experimental task.

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The experimental tasks consisted of 96 trials divided into 4 blocks (alternating DISTRACT and NOTICE blocks), with each block containing 24 images. Of the 24 images per

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block, 6 were neutral REACT trials, 6 were negative REACT trials, and 12 were negative emotion regulation trials (i.e. DISTRACT or NOTICE). Participants did not alternate between DISTRACT and NOTICE strategies in a single block in order to minimize “spillover” from the other emotion regulation strategy. Neutral images were only paired with REACT instruction. In order to protect against potential effects of idiosyncratic assignments of negative pictures to condition, each set of 24 negative images was assigned to each condition, resulting in three

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versions of the task. Further, the order of the blocks was counterbalanced resulting in a final six versions of the laboratory task. At the mid-point (i.e., after the second block) and end (i.e., after the fourth block) of the experiment, participants were prompted to indicate what percent of the

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time (0-100%) they followed the DISTRACT and NOTICE instructions. The BPD group

reported following the DISTRACT instruction 74.89% of the time and the NOTICE instruction 85.14% of the time. The HC group reported following the DISTRACT instruction 86.46% of the

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time and the NOTICE instruction 92.69% of the time. See Figure 1 for trial-level illustration of

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the task.

2.4 Data Analysis

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Figure 1. Trial-level illustration of the task.

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Data were analyzed using SPSS Statistics, Version 20.0. Data were plotted and extreme

values (SD ≥ 3.5) were removed. We considered fully parametric approaches (e.g., the mixedmodel ANOVA) in choosing the modeling structure for the data. However, due to the convergence issues of fully parametric models with respect to varying levels of complexity for the covariance structures, we chose the semi-parametric Generalized Estimated Equation (GEE) approach (Diggle, Heagerty, Liang, & Zeger, 2002) as it yields robust parameter estimates, even under misspecification of the covariance structure. GEE is an extension of the generalized linear

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model and is appropriate to model clustered/multilevel data from repeated observations within individuals. Unstructured, Exchangeable, and Autoregressive covariance structures were examined. Covariance structures with the lowest QIC values were selected. A priori between-

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group pairwise contrasts testing our hypotheses are specified below. In accordance with Rothman (1990), alpha adjustments were not employed.

2.4.1 Baseline (HR, SCR, and RSA). Between-group differences in baseline emotional

(30s each, 10 epochs total) as the within-subjects factor.

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functioning was analyzed with Group (BPD or HC) as the between-subjects factor and Epoch

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2.4.2 Emotional reactivity (self-report, HR, SCL). Between-group differences in selfreported negativity and positivity and physiological activity was analyzed with Group (BPD or HC) as the between-subjects factor and Condition (neutral REACT, negative REACT) as the within-subjects factor. Mean baseline HR was entered as the covariate for the HR analysis.

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2.4.3 Emotion regulation (self-report, HR, SCL). Between-group differences in selfreported negativity and positivity and physiological activity were analyzed with Group (BPD or HC) as the between-subjects factor and Condition (negative DISTRACT, negative NOTICE) as

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the within-subjects factor. Mean self-reported negativity, self-reported positivity, HR, and SCL during the negative REACT condition were entered as covariates for each respective analysis.

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2.4.4 Exploratory analyses. Given that 40% of the BPD sample was taking

benzodiazepines, which can influence physiological activity (Siepmann et al., 2007), we re-ran all physiological analyses using a 3-level Group factor (BPD + benzodiazepines, BPD + no benzodiazepines, HC), followed by post-hoc contrasts when tests were significant. However, results should be interpreted with caution given the unbalanced sample sizes in each cell (BPD + benzodiazepines = 11, BPD + no benzodiazepines = 14, HC = 30).

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significant between-group differences in HR and RSA. Table 3

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See Tables 3 and 4 for results comparing baseline group differences. There were

Baseline Differences by Diagnostic Group Status: Means, SE, and Wald χ2

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Wald χ2, df

M (SE) HR 79.08 (2.58)

HC

71.42 (2.03)

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BPD

Group

7.04, 1**

Time

.63, 1

RSA BPD

5.16 (.29)

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Time

6.39 (.19)

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HC Group

1.13, 1

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Group x Time

Group x Time

SCR

2.53, 1 .70, 1

BPD

1.65 (.26)

HC

1.62 (.30)

Group

8.47, 1**

.62, 1

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2.00, 1

Group x Time

.71, 1

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Note. HR = heart rate; RSA = respiratory sinus arrhythmia; SCR = number of nonspecific skin conductance responses; HC = healthy controls; BPD = borderline personality disorder Table 4

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Baseline Differences By Medication Group Status: Means, SE, and Wald χ2 Wald χ2, df

M (SE)

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HR HC

71.40 (2.03)

BPD

78.92 (3.52)

BPD + Benz

79.23 (3.77)

7.08, 2*

Time

.03, 1

Group x Time

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BPD

BPD + Benz

SCR

1.22, 2

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RSA HC

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Group

6.39 (.20)

5.32 (.38) 4.94 (.44)

Group

9.80, 2**

Time

2.79, 1

Group x Time

.86, 2

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HC

1.62 (.30)

BPD

1.93 (.53)

BPD + Benz

1.29 (.49) .58, 2

Time

.36, 1

Group x Time

.62, 2

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Group

19

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Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD

Note. HR = heart rate; RSA = respiratory sinus arrhythmia; SCR = number of nonspecific skin

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conductance responses; HC = healthy controls; BPD+Benz = BPD participants taking benzodiazepines, BPD = BPD participants not taking benzodiazepines 3.2 Emotional Reactivity

3.2.1 Self-report (negativity). There was a significant effect of Condition (Wald χ2 =

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306.68, df = 1, p < .001) such that both groups reported a significant increase in negativity from the NEUTRAL to negative REACT conditions. There was no significant Group x Condition interaction (Wald χ2 = 1.65, df = 1, p = .20).

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3.2.2 Self-report (positivity). There was a significant effect of Condition (Wald χ2 = 103.30, df = 1, p < .001) such that both groups reported a significant decrease in positivity from

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the NEUTRAL to negative REACT conditions. There was no significant Group x Condition interaction (Wald χ2 = 1.13, df = 1, p = .29). 3.2.3 HR. There was a significant effect of Condition (Wald χ2 = 10.55, df = 1, p = .001)

such that both groups reported a significant decrease in HR from the NEUTRAL to negative REACT conditions but no significant Group x Condition interaction (Wald χ2 = .40, df = 1, p

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20

= .53). Similarly, analyses exploring the potential role of benzodiazepine use in the BPD sample indicated no significant Group x Condition interaction (Wald χ2 = .84, df = 2, p = .66). 3.2.4 SCL. There was no significant effect of Condition (Wald χ2 = 2.06, df = 1, p = .15)

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and no significant Group x Condition interaction (Wald χ2 = .13, df = 1, p = .72). Similarly,

analyses exploring the potential role of benzodiazepine use in the BPD sample indicated no significant Group x Condition interaction (Wald χ2 = .91, df = 2, p = .64).

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3.3 Emotion Regulation

3.3.1 Self-report (negativity). There was a significant effect of Condition (Wald χ2 =

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42.52, df = 1, p < .001) such that both groups reported greater negativity in the negative NOTICE condition relative to the negative DISTRACT condition. Pairwise contrasts indicated that there was no group difference in negativity during the negative DISTRACT condition (95% Wald χ2 CI for difference [-1.25, .12], df = 1, p =.11) or the NOTICE condition (95% Wald χ2 CI for

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difference [-.70, .68], df = 1, p =.99). There was no significant Group x Condition interaction (Wald χ2 = 2.57, df = 1, p = .11).

3.3.2 Self-report (positivity). There was a significant effect of Condition (Wald χ2 =

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13.28, df = 1, p < .001) such that both groups reported greater positivity in the negative DISTRACT relative to the negative NOTICE condition. Pairwise contrasts indicated that there

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was a significant group difference in positivity during the negative DISTRACT condition (95% Wald χ2 CI for difference [.00, .52], df = 1, p =.05) such that the HC group reported greater positivity during the DISTRACT condition than the BPD group. There was a trend toward a group difference in negativity during the negative NOTICE condition (95% Wald χ2 CI for difference [-.36, .02], df = 1, p =.08) such that the BPD group reported greater positivity during the NOTICE condition than the HC group. In addition, there was significant Group x Condition

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interaction (Wald χ2 = 8.79, df = 1, p = .003). Post-hoc analyses indicated that the HCs reported significantly greater positivity during the negative DISTRACT condition relative to the negative NOTICE condition (95% Wald χ2 CI for difference [.22, .74], df = 1, p < .001) whereas the BPD

χ2 CI for difference [.-.07, .17], df = 1, p = .43).

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group did not exhibit a significant difference between the two conditions in positivity (95% Wald

3.3.3 HR. There was no significant effect of Condition (Wald χ2 = 1.73, df = 1, p = .19).

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Pairwise contrasts indicated that there was no group difference in HR during the negative DISTRACT condition (95% Wald χ2 CI for difference [-1.83, .19], df = 1, p =.11) or the

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NOTICE condition (95% Wald χ2 CI for difference [-.91, 1.00], df = 1, p =.93). There was a trend toward a significant Group x Condition interaction (Wald χ2 = 3.05, df = 1, p = .08) such that the HC group exhibited significantly higher HR in the negative NOTICE relative to the negative DISTRACT condition (95% Wald χ2 CI for difference [-1.49, -.03], df = 1, p =.04),

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whereas there was no significant difference in HR between the two conditions in the BPD group (95% Wald χ2 CI for difference [-.53, .75], df = 1, p =.74). Analyses exploring the potential role of benzodiazepine use in the BPD sample indicated no significant Group x Condition interaction

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(Wald χ2 = 3.68, df = 2, p = .16).

3.3.4 SCL. There was no significant effect of Condition (Wald χ2 = .07, df = 1, p = .79).

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Pairwise contrasts indicated that there was no group difference in SCL during the negative DISTRACT condition (95% Wald χ2 CI for difference [-.05, .04], df = 1, p =.87) or the NOTICE condition (95% Wald χ2 CI for difference [-.05, .07], df = 1, p =.86). There was no significant Group x Condition interaction (Wald χ2 = .79, df = 1, p = .77). Analyses exploring the potential role of benzodiazepine use in the BPD sample indicated no significant Group x Condition

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interaction (Wald χ2 = .42, df = 2, p = .81). See Table 5 for Descriptives by Group and Condition across indices.

Means and Standard Errors by Group and Experimental Condition Negative

React

React

BPD

2.03 (.14)

5.25 (.33)

5.35 (.29)

4.49 (.27)

HC

1.50 (.11)

5.23 (.23)

5.35 (.21)

3.93 (.23)

BPD

4.43 (.44)

2.32 (.22)

2.56 (.07)

2.60 (.07)

HC

4.08 (.28)

2.37 (.22)

2.38 (.07)

2.86 (.11)

BPD

70.74 (.87)

70.14 (.94)

70.94 (.32)

71.05 (.26)

72.83 (.63)

70.99 (.35)

70.23 (.43)

-.06 (.01)

-.09 (.02)

-.09 (.01)

-.08 (.03)

-.09 (.02)

Self-reported

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HR

HC

73.44 (.63)

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∆ SCL

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positivity

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negativity

BPD

-.07 (.02)

HC

-.07 (.02)

-.06 (.01)

Distract

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Neutral

Self-reported

Notice

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Table 5

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Note. BPD = borderline personality disorder; HC = healthy control; HR = heart rate; ∆ SCL = change in average skin conductance levels from the two seconds prior to the onset of each image

4. Discussion

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to the average SCL during the image presentation.

Our findings suggest that individuals with BPD do not experience heightened emotional reactivity and, in general, are able to implement mindful awareness or distraction as effectively

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as HCs. However, we did find evidence of abnormal baseline physiological activity as indicated by elevated HR and reduced RSA. Our finding of elevated baseline HR in the BPD group is

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consistent with the majority of the research examining baseline emotional intensity in BPD (Elices et al., 2012; Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2010; Kuo & Linehan, 2009). Moreover, our study is the second to report reduced RSA, an index of heart rate variability mediated by the vagus nerve (Porges, 1995) in BPD. Attenuated basal vagal activity is indicated

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as a marker of emotional vulnerability to negative emotional states, and is linked with several negative clinical outcomes including panic, anger, and hostility (see Beauchaine, 2001 for review). Thus, extant data suggest that individuals with BPD exhibit deficits in baseline

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emotional functioning, specifically, heightened emotional intensity and vulnerability. Together, our findings suggest the “core” of emotional pathology in BPD may not explained by emotional

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“response” patterns per se, but rather by abnormalities in general emotional resting state. 4.1 Emotional Reactivity and Regulation in BPD Consistent with many previous studies, we did not find evidence of heightened emotional

reactivity in BPD (Herpertz et al., 1999; Herpertz et al., 2000; Kuo & Linehan, 2009; Schmahl et al., 2004). Further, while there was a significant main effect of condition for self-reported negativity and positivity in the hypothesized directions, our physiological data indicated that all

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participants exhibited cardiac deceleration from presentation of the neutral to BPD-relevant images. Though unexpected, this finding can be explained by motivational models proposing a relationship between cardiac deceleration and an orienting response to stimuli depicting

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unpleasant or threatening content (Bradley, 2009). According to this model, the content depicted in the BPD-relevant stimuli may have been more biologically-relevant than the neutral stimuli, thus necessitating heightened orienting and sensory input (Bradley, 2001).

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Moreover, our findings generally suggest that individuals with BPD are able to

effectively reduce emotional reactivity when instructed to implement mindful awareness or

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distraction strategies. Though this is contrary to what is hypothesized by prominent theories of BPD (e.g., Linehan, 1993; Selby & Joiner, 2009), our finding is consistent with previous reports suggesting that individuals with BPD do not differ from HCs in their ability to implement different forms of cognitive reappraisal (Lang et al., 2012; Marissen et al., 2010; Ruocco et al.,

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2010). The only exception was our finding that HCs reported greater positivity during the DISTRACT trials (while controlling for reactivity) compared with the BPD group, suggesting that individuals with BPD may be less effective at engaging in distraction than HCs.

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Our results also indicate that persons with BPD do not exhibit differential abilities in the implementation of mindful awareness versus distraction. Rather, it was the HCs that reported

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greater positive emotions when implementing distraction versus mindful awareness. These findings are particularly intriguing when taken in conjunction with a study by Lindenboim, Comtois, and Linehan (2007) who found that, among BPD women in treatment for DBT, distraction and mindfulness were two of the most commonly practiced skills. Thus, it is possible that we did not detect differences between the two strategies because we examined two emotion regulation strategies that happen to be the most effective for this group.

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4.2 Limitations, Implications, and Future Directions A limitation in this study is that we did not exclude BPD participants on psychotropic medications. As medication use can influence psychophysiological responding (Licht, de Geus,

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van Dyck, & Penninx, 2010), it is possible that this altered emotional responding in the BPD group, resulting the illusion of a lack of group differences. However, given that 70% of

individuals with BPD report the use of psychotropic medications (Hörz, Zanarini, Frankenburg,

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Reich, & Fitzmaurice, 2010), our findings are more generalizable to the BPD population at large. As well, many individuals in the BPD group met for current major depressive disorder (64%)

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and social anxiety disorder (24%), both of which are linked with heightened self-reported intensity and physiological activity (Staebler, Gebhard, Barnett, & Renneberg, 2009; Wang, Zhao, O-Neil, Turner, Liu, & Berk, 2013; McTeague, Lang, Laplante, Cuthbert, Strauss, & Bradley, 2009). Thus, it is possible that the baseline alterations identified in the BPD group are a

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marker of psychopathology in general, rather than specific to BPD. Indeed, clinical control groups are needed to more precisely delineate differences among diagnostic groups. Moreover, given that one of the core components of BPD consists of interpersonal distress, it may be that

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our stimuli, though BPD-relevant, did not effectively target the more “key” clinically-relevant themes that are more likely to elicit reactivity. Further, though our stimuli were BPD-relevant,

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emerging evidence suggests that emotional reactivity in BPD may be emotion-specific (Kuo, et al., 2013; Gratz, et al., 2010). Thus, it’s possible that the images in the study did not elicit the core emotions that are relevant to BPD. In addition, this study may be limited by its lack of inclusion of potentially key covariates. Research has indicated a link between respiratory patterns and autonomic activity such as HR and RSA (Brown, Beightol, Koh, & Eckberg, 1993; Furedy & Shulhan, 1986), leading some to argue that respiration must be controlled for,

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particularly in RSA analyses (Grossman, Karemaker, Wieling, 1991). Further, though some findings suggest that sex does not influence autonomic reactivity indices such as HR and SCR (Codispoti, Surcinelli, & Baldaro, 2008; Sarlo, Palomba, Buodo, Minghetti, & Stegagno, 2005),

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others suggest that it does (Bianchin & Angrilli, 2012). It is possible that these variables exerted confounding effects on physiological indices thereby impacting results.

Our findings provide implications for potential therapy targets for individuals with BPD.

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First, though our results indicate that individuals with BPD can successfully reduce their

emotional reactivity via regulation, the elevated baseline emotional state places this group at a

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“disadvantage.” That is, individuals with BPD likely need to recruit greater emotion regulatory resources than HCs in order to reduce their reactivity to a more manageable level. Thus, acquiring emotion regulation skills might not be as important as ensuring that individuals with BPD strengthen these skills.

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Several future directions are recommended. First, emerging research suggests that effective emotion regulation involves flexibly selecting emotion regulation strategies based on the intensity of the stimulus (Sheppes, et al., 2011). Thus, future studies should examine the

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choice of emotion regulation strategies in BPD and evaluate specific factors that predict strategy selection in this population. In addition, given that emotion dysregulation in BPD might be better

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explained by some components (i.e., baseline functioning) versus others (i.e., reactivity and regulation), future studies should examine how different components are related and whether specific components are differentially associated with BPD-relevant maladaptive behaviors such as self-harm and impulsivity. Finally, recent evidence also suggests that emotion dysregulation mediates the relationship between BPD and cognitive processing (Dixon-Gordon, et al., 2013). Thus, while our data suggest that emotion regulation strategies have comparable effects on

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emotional responding, it is possible that these strategies have differential effects on cognitive or social functioning. Thus, future studies should examine cognitive and/or social sequelae of

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various emotion regulation strategies in BPD.

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD Declaration of Interest

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There is no interest to be declared.

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References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: American Psychiatric Association.

RI PT

Austin, M. A., Riniolo, T. C., & Porges, S. W. (2007). Borderline personality disorder and

emotion regulation: Insights from the polyvagal theory. Brain and Cognition, 65, 69-76. doi:http://dx.doi.org/10.1016/j.bandc.2006.05.007

SC

Beauchaine, T. P. (2001). Vagal tone, development, and gray's motivational theory: Toward an integrated model of autonomic nervous system functioning in psychopathology.

M AN U

Development and Psychopathology, 13, 183-214.

doi:http://dx.doi.org/10.1017/S0954579401002012

Berntson, G. G., Cacioppo, J. T., & Quigley, K. S. (1993). Respiratory sinus arrhythmia: Autonomic origins, physiological mechanisms, and psychophysiological implications.

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Psychophysiology, 30, 183-196. doi:http://dx.doi.org/10.1111/j.1469-8986.1993.tb01731.x Bianchin, M., & Angrilli, A. (2012). Gender differences in emotional responses: A psychophysiological study. Physiology & Behavior, 105, 925-932.

EP

doi:http://dx.doi.org/10.1016/j.physbeh.2011.10.031 Bradley, M. M. (2009). Natural selective attention: Orienting and emotion. Psychophysiology,

AC C

46, 1-11. doi:http://dx.doi.org/10.1111/j.1469-8986.2008.00702.x Bradley, M. M., Codispoti, M., Cuthbert, B.N., & Lang, P.L. (2001). Emotion and motivation I: Defensive and appetitive reactions to picture processing. Emotion, 1, 276-298. doi:http://dx.doi.org/10.1037//1528-3542.1.3.276 Brown, T. E., Beightol, L. E., Koh, J., & Eckberg, D. L. (1993). Important influence of respiration on human R-R- interval power spectra is largely ignored. Journal of Applied

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD

30

Physiology, 75, 2310-2317. Retrieved from http://jap.physiology.org/content/jap/75/5/2310.full.pdf Codispoti, M., Surcinelli, P., & Baldaro, B. (2008). Watching emotional movies: Affective

doi:http://dx.doi.org/10.1016/j.ijpsycho.2008.03.004

RI PT

reactions and gender differences. International Journal of Psychophysiology, 69, 90-95.

Denson, T. F., Moulds, M. L., & Grisham, J. R. (2012). The effects of analytical rumination,

doi:http://dx.doi.org/10.1016/j.beth.2011.08.001

SC

reappraisal, and distraction on anger experience. Behavior Therapy, 43, 355-364.

M AN U

Diggle P.J., Heagerty .P, Liang K. Y., & Zeger S. L. (2002). Analysis of longitudinal data (2nd ed.). New York, NY: Oxford University Press, Oxford Statistical Science Series. Dixon-Gordon, K.L., Gratz, K.L, Breetz, A., & Tull, M. (2013). A laboratory-based examination of responses to social rejection in borderline personality disorder: The mediating role of

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emotion dysregulation. Journal of Personality Disorders, 27, 157-171. doi: 10.1521/pedi.2013.27.2.157

Elices, M., Soler, J., Fernández, C., Martín-Blanco, A., Jesús Portella, M., Pérez, V., . . . Carlos

EP

Pascual, J. (2012). Physiological and self-assessed emotional responses to emotioneliciting films in borderline personality disorder. Psychiatry Research, 200, 437-443.

AC C

doi:http://dx.doi.org/10.1016/j.psychres.2012.07.020 Fonagy, P., & Bateman, A. (2008). The development of borderline personality disorder--A mentalizing model. Journal of Personality Disorders, 22, 4-21. doi:http://dx.doi.org/10.1521/pedi.2008.22.1.4

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD

31

Fowles, D. C., Christie, M. J., Edelberg, R., Grings, W. W., Lykken, D. T., & Venables, P. H. (1981). Publication recommendations for electrodermal measurements. Psychophysiology, 18, 232-239. doi:http://dx.doi.org/10.1111/j.1469-8986.1981.tb03024.x

RI PT

Furedy, J. J., & Shulhan, D. L. (1986). Effects of respiratory depth and rate on HR and TWA: An indirect assessment of the respiratory confound in cognitive task difficulty manipulations. Physiology & Behavior, 37, 515-517.doi:http://dx.doi.org/10.1016/0031-9384(86)90217-9

SC

Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., . . . Ruan, W. J. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline

M AN U

personality disorder: Results from the wave 2 national epidemiologic survey on alcohol and related conditions. Journal of Clinical Psychiatry, 69, 533-545. doi:http://dx.doi.org/10.4088/JCP.v69n0404

Gratz, K. L., Rosenthal, M. Z., Tull, M. T., Lejuez, C. W., & Gunderson, J. G. (2010). An

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experimental investigation of emotional reactivity and delayed emotional recovery in borderline personality disorder: The role of shame. Comprehensive Psychiatry, 51, 275285. doi:http://dx.doi.org/10.1016/j.comppsych.2009.08.005

EP

Gross, J. & Jazaeiri, H. (2014). Emotion, emotion regulation, and psychopathology: An affective science perspective. Clinical Psychological Science, 2, 387-401.

AC C

doi:http:/dx.doi.org/10.1177/2167702614536164.

Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social

Psychology, 85, 348-362. doi:http://dx.oi.org/10.1037/0022-3514.85.2.348

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD

32

Gross, J. J., & Thompson, R. A. (2007). Emotion regulation: Conceptual foundations. New York, NY: Guilford Press. Grossman, P., Karemaker, J. and Wieling, W. (1991). Prediction of Tonic Parasympathetic

RI PT

Cardiac Control Using Respiratory Sinus Arrhythmia: The Need for Respiratory Control. Psychophysiology, 28, 201–216. doi:http://dx.oi.org/10.1111/j.1469-8986.1991.tb00412.x Herpertz, S. C., Kunert, H. J., Schwenger, U. B., & Sass, H. (1999). Affective responsiveness in

SC

borderline personality disorder: A psychophysiological approach. The American Journal of Psychiatry, 156, 1550-1556.

M AN U

Herpertz, S. C., Schwenger, U. B., Kunert, H. J., Lukas, G., Gretzer, U., Nutzmann, J., . . . Sass, H. (2000). Emotional responses in patients with borderline as compared with avoidant personality disorder. Journal of Personality Disorders, 14, 339-351. doi:http://dx.doi.org/10.1521/pedi.2000.14.4.339

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Hofmann, S. G., Heering, S., Sawyer, A. T., & Asnaani, A. (2009). How to handle anxiety: The effects of reappraisal, acceptance, and suppression strategies on anxious arousal. Behaviour Research and Therapy, 47, 389-394. doi:http://dx.doi.org/10.1016/j.brat.2009.02.010

EP

Hörz, S., Zanarini, M. C., Frankenburg, F. R., Reich, D. B., & Fitzmaurice, G. (2010). Ten-year use of mental health services by patients with borderline personality disorder and with

AC C

other axis II disorders. Psychiatric Services, 61, 612-616. doi:http://dx.doi.org/10.1176/appi.ps.61.6.612 Jacob, G. A., Arendt, J., Kolley, L., Scheel, C. N., Bader, K., Lieb, K., . . . Tüscher, O. (2011). Comparison of different strategies to decrease negative affect and increase positive affect in women with borderline personality disorder. Behaviour Research and Therapy, 49, 6873. doi:http://dx.doi.org/10.1016/j.brat.2010.10.005

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD

33

Jazaieri, H., Urry, H., & Gross, J. J. (2013). Affective disturbance and psychopathology: An emotion regulation perspective. Journal of Experimental Psychopathology, 4, 584-599. doi:http://dx.doi.org/10.5127/jep.030312

RI PT

Jennings, R.J., Kamarck, T., Stewart, C., Eddy, M., & Johnson, P. (1992). Alternate

cardiovascular baseline assessment: Vanilla or resting baseline. Psychophysiology, 29, 742-750. doi:http://dx.doi.org/10.1111/j.1469-8986.1992.tb02052.x

SC

Koenigsberg, H. W., Fan, J., Ochsner, K. N., Liu, X., Guise, K. G., Pizzarello, S., . . . Siever, L. J. (2009). Neural correlates of the use of psychological distancing to regulate responses to

M AN U

negative social cues: A study of patients with borderline personality disorder. Biological Psychiatry, 66, 854-863. doi:http://dx.doi.org/10.1016/j.biopsych.2009.06.010 Kohl, A., Rief, W., & Glombiewski, J. A. (2012). How effective are acceptance strategies? A meta-analytic review of experimental results. Journal of Behavior Therapy and

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Experimental Psychiatry, 43, 988-1001. doi:http://dx.doi.org/10.1016/j.jbtep.2012.03.004 Korzekwa, M. I., Dell, P. F., Links, P. S., Thabane, L., & Webb, S. P. (2008). Estimating the prevalence of borderline personality disorder in psychiatric outpatients using a two-phase

EP

procedure. Comprehensive Psychiatry, 49, 380-386. doi:http://dx.doi.org/10.1016/j.comppsych.2008.01.007

AC C

Kuo, J. R., & Linehan, M. M. (2009). Disentangling emotion processes in borderline personality disorder: Physiological and self-reported assessment of biological vulnerability, baseline intensity, and reactivity to emotionally evocative stimuli. Journal of Abnormal Psychology, 118, 531-544. doi:http://dx.doi.org/10.1037/a0016392 Kuo, J. R., Neacsiu, A. D., Fitzpatrick, S., & MacDonald, D. E. (2013). A methodological examination of emotion inductions in borderline personality disorder: A comparison of

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD

34

standardized versus idiographic stimuli. Journal of Psychopathology and Behavioral Assessment, doi:http://dx.doi.org/10.1007/s10862-013-9378-x Lang, P. J., Bradley, M. M., & Cuthbert, B. N. (2008). International affective picture system

RI PT

(IAPS): Affective ratings of pictures and instruction manual. Technical Report A-8.

Lang, S., Kotchoubey, B., Frick, C., Spitzer, C., Grabe, H. J., & Barnow, S. (2012). Cognitive reappraisal in trauma-exposed women with borderline personality disorder. Neuroimage,

SC

59, 1727-1734. doi:http://dx.doi.org/10.1016/j.neuroimage.2011.08.061

Licht, C. M. M., de Geus, E. J. C., van Dyck, R., & Penninx, B. W. J. H. (2010). Longitudinal

M AN U

evidence for unfavorable effects of antidepressants on heart rate variability. Biological Psychiatry, 68, 861-868. doi:http://dx.doi.org/10.1016/j.biopsych.2010.06.032 Limberg, A., Barnow, S., Freyberger, H. J., & Hamm, A. O. (2011). Emotional vulnerability in borderline personality disorder is cue specific and modulated by traumatization. Biological

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Psychiatry, 69, 574-582. doi:http://dx.doi.org/10.1016/j.biopsych.2010.10.024 Lindenboim, N., Comtois, K. A., & Linehan, M. M. (2007). Skills practice in dialectical behavior therapy for suicidal women meeting criteria for borderline personality disorder.

EP

Cognitive and Behavioral Practice, 14, 147-156. doi:http://dx.doi.org/10.1016/j.cbpra.2006.10.004

AC C

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Lobbestael, J., & Arntz, A. (2010). Emotional, cognitive and physiological correlates of abuserelated stress in borderline and antisocial personality disorder. Behaviour Research and Therapy, 48, 116-124. doi:http://dx.doi.org/10.1016/j.brat.2009.09.015

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD

35

Lobbestael, J., Leurgans, M., & Arntz, A. (2011). Inter-rater reliability of the structured clinical interview for DSM-IV axis I disorders (SCID I) and axis II disorders (SCID II). Clinical Psychology & Psychopathology, 18, 75-79. doi:http://dx.doi.org/10.1002/cpp.693

RI PT

Loranger, A. W., Sartorius, N., Andreoli, A., Berger, P., Buchheim, P., Channabasavanna, S. M., . . . Regier, D. A. (1994). The international personality disorder examination: The world health Organization/Alcohol, drug abuse, and mental health administration international

SC

pilot study of personality disorders. Archives of General Psychiatry, 51, 215-224. doi:http://dx.doi.org/10.1001/archpsyc.1994.03950030051005

M AN U

Low, C. A., Stanton, A. L., & Bower, J. E. (2008). Effects of acceptance-oriented versus evaluative emotional processing on heart rate recovery and habituation. Emotion, 8, 419424. doi:http://dx.doi.org/10.1037/1528-3542.8.3.419

Luciano, C., Molina, F., Gutiérrez-Martínez, O., Barnes-Holmes, D., Valdivia-Salas, S., Cabello,

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F., . . . Wilson, K. G. (2010). The impact of acceptance-based versus avoidance-based protocols on discomfort. Behavior Modification, 34, 94-119. doi:http://dx.doi.org/10.1177/0145445509357234

EP

Marissen, M. A. E., Meuleman, L., & Franken, I. H. A. (2010). Altered emotional information processing in borderline personality disorder: An electrophysiological study. Psychiatry

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Research: Neuroimaging, 181, 226-232. doi:http://dx.doi.org/10.1016/j.pscychresns.2009.10.006 McTeague, L. M., Lang, P. J., Laplante, M., Cuthbert, B. N., Strauss, C. C., & Bradley, M. M. (2009). Fearful imagery in social phobia: Generalization, comorbidity, and physiological reactivity. Biological Psychiatry, 65, 374-382. doi:http://dx.doi.org/10.1016/j.biopsych.2008.09.023

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD

36

McRae, K., Hughes, B., Chopra, S., Gabrieli, J. D. E., Gross, J. J., & Ochsner, K. N. (2010). The neural bases of distraction and reappraisal. Journal of Cognitive Neuroscience, 22, 248262. doi:http://dx.doi.org/10.1162/jocn.2009.21243

RI PT

Porges, S. W. (1995). Cardiac vagal tone: A physiological index of stress. Neuroscience and Biobehavioral Reviews, 19, 225-233. doi:http://dx.doi.org/10.1016/0149-7634(94)00066-A Rothman, K.J. (1990). No Adjustments are Needed for Multiple Comparisons. Epidemiology, 1,

SC

43-46.

Ruocco, A. C., Medaglia, J. D., Ayaz, H., & Chute, D. L. (2010). Abnormal prefrontal cortical

M AN U

response during affective processing in borderline personality disorder. Psychiatry Research: Neuroimaging, 182, 117-122.

doi:http://dx.doi.org/10.1016/j.pscychresns.2010.01.011

Sarlo, M., Palomba, D., Buodo, G., Minghetti, R., & Stegagno, L. (2005). Blood pressure

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changes highlight gender differences in emotional reactivity to arousing pictures. Biological Psychology, 70, 188-196. doi:http://dx.doi.org/10.1016/j.biopsycho.2005.01.005 Schmahl, C. G., Elzinga, B. M., Ebner, U. W., Simms, T., Sanislow, C., Vermetten, E., . . .

EP

Bremner, J. D. (2004). Psychophysiological reactivity to traumatic and abandonment scripts in borderline personality and posttraumatic stress disorders: A preliminary report.

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Psychiatry Research, 126, 33-42. doi:http://dx.doi.org/10.1016/j.psychres.2004.01.005 Schulze, L., Domes, G., Krüger, A., Berger, C., Fleischer, M., Prehn, K., ... & Herpertz, S. C. (2011). Neuronal correlates of cognitive reappraisal in borderline patients with affective instability. Biological psychiatry, 69, 564-573. doi:http://dx.doi.org/10.1016/j.biopsych.2010.10.025

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD

37

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2012) Mindfulness-based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. New York, NY: Guilford Press. Selby, E. A., & Joiner, T. E., Jr. (2009). Cascades of emotion: The emergence of borderline

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personality disorder from emotional and behavioral dysregulation. Review of General Psychology, 13, 219-229. doi:http://dx.doi.org/10.1037/a0015687

Shaw Welch, S., Linehan, M.M., Sylvers, P., Chittams, J., Rizvi, S.L. (2008). Emotional

SC

responses to self-injury imagery among adults with borderline personality disorder.

Journal of Consulting and Clinical Psychology, 76, 45-51. http://dx.doi.org/10.1037/0022-

M AN U

006X.76.1.45

Sheppes, G., Scheibe, S., Suri, G., & Gross, J. J. (2011). Emotion-regulation choice. Psychological Science, 22, 1391-1396. doi:http://dx.doi.org/10.1177/0956797611418350 Siepmann, T., Ziemssen, T., Mueck-Weymann, M., Kirch, W., & Siepmann, M. (2007). The

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effects of venlafaxine on autonomic functions in healthy volunteers. Journal of Clinical Psychopharmacology, 27, 687-691. doi:http://dx.doi.org/10.1097/jcp.0b013e31815a255b Sloan, D. M., Sege, C. T., McSweeney, L. B., Suvak, M. K., Shea, M. T., & Litz, B. T. (2010).

EP

Development of a borderline personality disorder-relevant picture stimulus set. Journal of

AC C

Personality Disorders, 24, 664-675. doi:http://dx.doi.org/10.1521/pedi.2010.24.5.664

Staebler, K., Gebhard, R., Barnett, W., & Renneberg, B. (2009). Emotional responses in borderline personality disorder and depression: Assessment during an acute crisis and 8 months later. Journal of Behavior Therapy and Experimental Psychiatry, 40, 85-97. doi:http://dx.doi.org/10.1016/j.jbtep.2008.04.003 Thiruchselvam, R., Blechert, J., Sheppes, G., Rydstrom, A., & Gross, J. J. (2011). The temporal dynamics of emotion regulation: An EEG study of distraction and reappraisal. Biological

ACCEPTED MANUSCRIPT Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD

38

Psychology, 87, 84-92. doi:http://dx.doi.org/10.1016/j.biopsycho.2011.02.009 Ventura, J., Liberman, R. P., Green, M. F., Shaner, A., & Mintz, J. (1998). Training and quality assurance with structured clinical interview for DSM-IV (SCID-I/P). Psychiatry Research,

RI PT

79, 163-173. doi:http://dx.doi.org/10.1016/S0165-1781(98)00038-9

Wang, Y., Zhao, X., O-Neil, A., Turner, A., Liu, X., & Berk, M. (2013). Altered cardiac

doi:http://dx.doi.org/10.1186/1471-244X-13-187

SC

autonomic nervous function in depression. BMC Psychiatry, 13, 187-194,

Webb, T. L., Miles, E., & Sheeran, P. (2012). Dealing with feeling: A meta-analysis of the

M AN U

effectiveness of strategies derived from the process model of emotion regulation.

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Psychological Bulletin, 138, 775-808. doi:http://dx.doi.org/10.1037/a0027600

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Individuals with BPD exhibit increased heart rate and reduced respiratory sinus arrhythmia at baseline compared with healthy controls Individuals with BPD do not exhibit greater emotional reactivity compared with healthy controls Individuals with BPD do not exhibit deficits in the ability to engage in two different emotion regulation strategies (i.e., mindful awareness and distraction) compared with healthy controls.

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