Personality and Mental Health (2012) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI 10.1002/pmh.1204

Difficulties with emotion regulation mediate the relationship between borderline personality disorder symptom severity and interpersonal problems

NATHANIEL R. HERR1, M. ZACHARY ROSENTHAL1, PAUL J. GEIGER1 AND KAREN ERIKSON2, 1Duke University Medical Center, Durham, NC, USA; 2University of Nevada, Reno, NV, USA ABSTRACT Problems with interpersonal functioning and difficulties with emotion regulation are core characteristics of borderline personality disorder (BPD). Little is known, however, about the interrelationship between these areas of dysfunction in accounting for BPD symptom severity. The present study examines a model of the relationship between difficulties with emotion regulation and interpersonal dysfunction in a community sample of adults (n = 124) with the full range of BPD symptoms. Results showed that difficulties with emotion regulation fully mediated the relationship between BPD symptom severity and interpersonal dysfunction. An alternative model indicated that interpersonal problems partially mediated the relationship between difficulties with emotion regulation and BPD symptom severity. These findings support existing theories of BPD, which propose that difficulties with emotion regulation may account for the types of interpersonal problems experienced by individuals with BPD and suggest further examination of the possibility that interpersonal dysfunction may worsen these individuals’ difficulties with emotion regulation. Copyright © 2012 John Wiley & Sons, Ltd.

Borderline personality disorder (BPD) is characterized by the chronic presence of a heterogeneous constellation of symptoms that include emotional (e.g. affective instability), cognitive (e.g. paranoia or dissociation when stressed), behavioural (e.g. self-injurious behaviour) and interpersonal (e.g. idealization and devaluation of others) symptoms (American Psychiatric Association, 2000). Despite the diversity in symptom presentations found among individuals with BPD, factor analytic and family aggregation studies have shown that BPD symptoms can be organized around several

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key latent variables, including emotional dysregulation, behavioural dyscontrol and interpersonal dysfunction (e.g. Sanislow, Grilo, & McGlashan, 2000; Silverman et al., 1991). Although recent research has begun to examine the neurobiological and behavioural process that may underlie the aetiology and maintenance of these core BPD factors (e.g. emotional dysregulation, Donegan et al., 2003; and impulsivity, Siever, Torgersen, Gunderson, Livesley, & Kendler, 2002), it is not yet clear how these core factors relate to and influence each other in the expression of BPD

(2012) DOI: 10.1002/pmh

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symptoms. To address this gap in the empirical literature, in the present study, we examined the relationships among problems with emotion regulation, interpersonal dysfunction and symptoms of BPD. BPD and emotion regulation Emotion regulation is a multi-faceted construct that includes both antecedent-focused (changing the environment) and response-focused (changing emotional expression) modulation of emotional experience (Gross & Thompson, 2007). Skilled emotion regulation does not imply the absence of negative emotions but rather implies that an individual can maintain goal-directed behaviour even in the presence of intense, negative emotional experiences (Fruzzetti, Crook, Erikson, Lee, & Worrall, 2009). Emotion dysregulation, in turn, includes but does not equate with experiencing strong negative emotions. Although there is no consensus definition of emotion dysregulation, one recently proposed conceptualization of this multidimensional construct includes the following: (1) lack of awareness, understanding and acceptance of emotions; (2) lack of access to adaptive strategies for modulating the intensity and/or duration of the emotional response; (3) unwillingness to experience emotional distress as a part of pursuing desired goals; (4) difficulty controlling impulsive behaviours when distressed; and (5) inability to engage in goal-directed behaviours when distressed (Gratz & Roemer, 2004). Influential contemporary conceptualizations of BPD have suggested that problems with emotional dysregulation are central to the disorder (Linehan, 1993; Paris, 1994; Siever et al., 2002). Self-report studies examining emotion dysregulation in BPD have used both cross-sectional and prospective measures of emotion regulation constructs such as negative affective intensity, affective instability and emotional reactivity (see Rosenthal et al., 2008, for a review). Individuals with BPD report significantly higher baseline levels of negative affect compared with non-clinical controls and individuals with

Copyright © 2012 John Wiley & Sons, Ltd.

other personality disorders (Henry et al., 2001; Koenigsberg et al., 2002; Levine, Marziali, & Hood, 1997). Negative affect intensity is associated with higher BPD features (Cheavens et al., 2005) and diagnostic symptoms (Rosenthal, Cheavens, Lejuez, & Lynch, 2005; Yen, Zlotnick, & Costello, 2002). In addition, studies using experience sampling methodologies have found that individuals with BPD report greater intensity of negative emotions and greater fluctuations in affective states compared with healthy controls and individuals with other psychiatric disorders (Cowdry, Gardner, O’Leary, Leibenluft, & Rubinow, 1991; Ebner-Priemer et al., 2007; Stein, 1996; Stiglmayr et al., 2005). There is evidence that experiential avoidance (i.e. the lack of willingness to experience negative emotions) mediates the relationships between anxiety sensitivity and BPD symptoms (Gratz, Tull, & Gunderson, 2008), and experiential avoidance has been found experimentally to be greater in a group of outpatients with BPD compared with outpatients with no personality disorders (Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006). Likewise, there is growing empirical evidence that self-injury, a behaviour that is characteristic of individuals with BPD, functions as a problematic strategy to avoid intense emotional experiences (Chapman, Gratz, & Brown, 2006). A common self-report tool used to measure specific problems with emotion regulation in BPD is the Difficulties with Emotion Regulation Scale (DERS; Gratz & Roemer, 2004), which assesses deficits in six emotion regulation skills, including the following: lack of emotional awareness or clarity, unwillingness to experience and accept negative emotions, difficulty controlling impulsive behaviours when distressed, difficulty accomplishing goals when emotionally distressed and perceived lack of access to strategies needed to regulate emotions when distressed. Findings suggest that problems with emotion regulation as measured by the DERS are related to higher levels of BPD features and symptoms both in undergraduate and clinical samples (Bornovalova et al., 2008; Chapman, Leung, & Lynch, 2008; Glenn &

(2012) DOI: 10.1002/pmh

Emotion REG and interpersonal functioning in BPD

Klonsky, 2009). In addition, Kuo and Linehan (2009) reported that DERS scores were significantly higher among individuals with BPD compared with healthy controls and a clinical control group composed of participants with social anxiety disorder. Across all of these studies, there is a great deal of evidence that self-reported emotional intensity, lability, experiential avoidance and emotion regulation skill deficits are associated with higher BPD symptom severity and may differentiate individuals with BPD from other samples. As a next step, it is important to investigate whether, as hypothesized by Linehan (1993), greater difficulties with emotion regulation may account for other BPD-related phenomena. Although the diagnostic symptoms of BPD are topographically different, it is possible that emotional dysregulation may functionally link all of the BPD symptoms in that each symptom is either a maladaptive strategy for regulating emotions (e.g. self-injurious behaviour; Chapman et al., 2006) or a natural consequence of dysregulated emotions. In particular, it is possible that interpersonal dysfunction, another central characteristic of BPD, falls into this latter category. BDP and interpersonal functioning Studies examining the interpersonal functioning of individuals with BPD have shown that interpersonal dysfunction may be one of the key features that differentiates BPD from other psychiatric disorders (Nurnberg, Hurt, Feldman, & Suh, 1988; Modestin, 1987; Skodol et al., 2002). In addition, longitudinal studies suggest that impairment in social functioning in BPD is stable across time (Skodol et al., 2005; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2005). Interpersonal dysfunction in BPD has also been examined experimentally, with Dougherty, Bjork, Huckabee, Moeller, and Swann (1999) showing that individuals with BPD responded more aggressively than normal controls on a competitive computer task, although the result was no longer significant after controlling for depressive symptoms. A study using a different lab-based task found that individuals

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with BPD were worse than healthy controls in their ability to fix a broken cooperative relationship in a social exchange laboratory task (King-Casas et al., 2008). Data from this study suggest that, compared with healthy controls, individuals with BPD may be less likely to perceive violations of social norms in interpersonal contexts. Research using experience sampling methods also has found evidence of interpersonal problem in individuals with BPD. Russell, Moskowitz, Zuroff, Sookman and Paris (2007) asked individuals with BPD and non-clinical controls to complete short surveys following any substantive social interactions for 20 days. They found that individuals with BPD reported more submissive, quarrelsome and extreme interpersonal behaviours than the non-clinical controls. Another study asked participants to track social interactions for 7 days using a hand-held computerized social interaction diary (Stepp, Pilkonis, Yaggi, Morse, & Feske, 2009). Although individuals with BPD reported a similar amount of social interaction per day compared with individuals with other personality disorders and normal controls, they reported interacting with fewer people overall. The individuals with BPD also reported having more disagreements, more negative emotional reactions to social interaction and more overall ambivalence with respect to social interactions. Collectively, these studies use diverse methods of measurement, which converge on the conclusion that problems with interpersonal functioning characterize BPD. The relationship between emotion regulation and interpersonal functioning in BPD Although difficulties with emotion regulation and interpersonal dysfunction are separate constructs, it is unlikely that they are orthogonally related. Theoretical models of BPD posit that poor emotion regulation leads to problems in interpersonal relatedness (e.g. Linehan, 1993; Putnam & Silk, 2005), yet few of the interpersonal functioning studies described previously assessed emotion regulation difficulties. One that did (Stepp et al., 2009) found

(2012) DOI: 10.1002/pmh

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more conflictual and emotionally intense day-to-day social interactions in individuals with BPD, as compared with those without BPD. Among the few additional studies that have examined the relationship between elements of emotion regulation and interpersonal dysfunction, results have been mixed. Support for the model that affective instability leads to poorer interpersonal functioning was found in a 2-year follow-up of undergraduates with BPD features (Bagge et al., 2004). Alternatively, Koenigsberg and colleagues (2001) found that affective problems were related to some of the diagnostic criteria of BPD (e.g. identity disturbance and suicidality) but were not related to interpersonal dysfunction. Although affective instability is one component of emotional dysregulation, additional research is needed to help clarify the nature of the relationship between problems with emotion regulation and interpersonal dysfunction in BPD. In sum, recent studies indicate that BPD is characterized by difficulties with emotion regulation and interpersonal dysfunction. However, research that examines the extent to which difficulties with emotion regulation account for the relationship between BPD symptoms and interpersonal dysfunction is needed. In the present study, we sought to test the hypothesized model (e.g. Linehan, 1993; Putnam & Silk, 2005) that emotion regulation difficulties underlie the relationship between BPD symptoms and interpersonal dysfunction. Difficulties with emotion regulation were measured using the DERS to include aspects of emotion regulation that extend beyond just intense negative affect. On the basis of the existing theoretical and empirical research (e.g. Bagge et al., 2004; Linehan, 1993; Stepp et al., 2009), we hypothesized that difficulties with emotion regulation would fully account for the direct relationship between BPD symptoms and interpersonal problems. Specific subtypes of interpersonal functioning (i.e. interpersonal sensitivity, interpersonal ambivalence, interpersonal aggression, need for social approval and lack of sociability) were also examined to determine if difficulties with emotion regulation was more associated with certain kinds of interpersonal problems. To further explore

Copyright © 2012 John Wiley & Sons, Ltd.

the relationship between emotion regulation and interpersonal dysfunction, we tested an atheoretical model specifying that deficits in interpersonal functioning may account for the relationship between BPD symptoms and difficulties with emotion regulation. On the basis of Linehan’s theoretical model of emotion regulation, we did not expect this model would be supported; however, we examined it to either strengthen arguments for the primary model or to generate questions for subsequent research. Despite the limitations of using cross-sectional data, the present study is the first that we are aware of that attempted to provide support for either or both of these models by comparing them in a single sample of individuals with the full range of BPD symptoms. Method Participants As part of a larger project examining emotional functioning in BPD, 124 participants were recruited for the present study through advertisements in a local free newspaper, on the Duke University Medical Center website and through outpatient clinics at Duke University Hospital System. Separate recruiting advertisements targeted individuals with BPD (e.g. ‘Have you ever been diagnosed with borderline personality disorder?’) and a general community sample (e.g. ‘Are you interested in a study about emotion?’). Participants completed a brief telephone screen to exclude individuals with current mania and psychosis. Participants who were between the ages of 18 and 60 years were eligible and were scheduled to complete the study within 2 weeks. Participants received $150 compensation for completion of the study. The final sample included 35 participants (28.2%) who met full criteria for BPD (see the following paragraphs for diagnostic interview description). The sample had a mean age of 36.5 years (standard deviation (SD) = 11.7 years; range. 18–58 years) and included more women (n = 83; 66.9%) than men (n = 41; 33.1%). More than half of the participants were identified as

(2012) DOI: 10.1002/pmh

Emotion REG and interpersonal functioning in BPD

African-American (n = 65, 52.4%), whereas 48 (38.1%) were Caucasian, 3 (2.4%) were Asian, 3 were Native American, 2 (1.6%) were Hispanic and 3 indicated other race/ethnicity. The sample included 37 (29.8%) participants who were married or living with a partner, 18 (14.5%) who were in an intimate relationship and living separately, 18 who were separated or divorced, 4 (3.2%) who were widowed, and 44 (35.5%) who were never married. Most participants (89%) had completed at least some college. The sample was predominantly low income, with 47 (37.9%) making less than $10 000 a year and 51 (41.1%) making between $10 000 and $40 000 a year. Measures Demographics. A self-report measure was used to obtain demographic and descriptive information, including age, ethnicity, marital status and annual household income. Structured Clinical Interview for DSM-IV, Axis I. Diagnostic exclusions and current prevalence of Axis I diagnoses were determined by the Structured Clinical Interview for DSM-IV, Axis I (SCID-I; patient version; First, Spitzer, Gibbon, & Williams, 1995), a measure with demonstrated reliability (Lobbestael, Leurgans, & Arntz, 2011). The SCID-I was administered by bachelor and master’s level assessors trained by the second author and an expert clinical assessor in the second author’s lab to reliability. Inter-rater reliability was assessed by a blind rater randomly rating 20% of video recorded SCID-I interviews. Kappas ranged from 0.63 to 1.0, reflecting acceptable inter-rater reliability. Structured Clinical Interview for DSM-IV Personality Disorders, Axis II. The Structured Clinical Interview for DSM-IV Personality Disorders, Axis II (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997) was used to assess diagnostic symptoms of personality disorders, including BPD. Participants first completed the SCID-II Personality

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Questionnaire (SCID-II-PQ), a questionnaire with 119 items assessing the presence (yes) or absence (no) of specific personality disorder symptoms. For the current study, items endorsed on the SCID-IIPQ were further evaluated using the standard SCID-II interview. This two-stage assessment process is commonly conducted, with studies suggesting a low false-negative rate for non-endorsed SCID-IIPQ items (Jacobsberg, Perry, & Frances, 1995). Structured Clinical Interview for DSM-IV Personality Disorders, Axis II interviews were conducted by bachelor and master’s level assessors trained by the second author and an expert clinical assessor in the second author’s lab to reliability. With the use of digitally videotaped recordings, approximately 10% of the SCID-II interviews were randomly re-assessed by a different trained rater. Inter-rater reliability on total BPD symptoms was evaluated using intraclass correlation coefficients (ICCs). The ICC for BPD symptoms was 0.98, indicating excellent reliability. The ICCs for all personality disorders ranged from 0.66 (schizotypal) to 1.0 (histrionic). To obtain a continuous score for BPD symptom severity that included sub-diagnostic threshold of symptoms, interviewer-rated symptoms were summed, which resulted in a possible range of BPD symptom severity from 0 (no BPD criterion behaviours present) to 9 (all BPD criterion behaviours present beyond threshold). The sample had a mean score of 2.6 (SD = 3.1) symptoms, and 35 participants (28.2%) met full criteria for a diagnosis of BPD. The DERS (Gratz & Roemer, 2004) is a 36-item measure that assesses individuals’ typical levels of emotion dysregulation across six domains: non-acceptance of negative emotions, inability to engage in goal-directed behaviours when distressed, difficulties controlling impulsive behaviours when distressed, limited access to emotion regulation strategies perceived as effective, lack of emotional awareness and lack of emotional clarity. The DERS has been found to have high internal consistency (a = 0.93), good test–retest reliability (rI = 0.88, p < 0.01) and adequate construct and predictive validity (Gratz & Roemer, 2004).

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Internal consistency in the present sample was also high (a = 0.89). Inventory of Interpersonal Problems. The original Inventory of Interpersonal Problems (IIP; Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988) is a 127-item measure of problems with interpersonal functioning relevant to samples of individuals with personality disorders (e.g. Pilkonis, Kim, Proietti, & Barkham, 1996; Scarpa et al., 1999). Pilkonis et al. (1996) developed a shortened version (47 items), which delineated five subscales: (1) interpersonal sensitivity, (2) interpersonal ambivalence, (3) interpersonal aggression, (4) need for social approval and (5) lack of sociability. These subscales were created using factor analysis with items that were associated with personality disorders and cross-validated in three separate datasets, demonstrating adequate ability to distinguish between individuals with and without personality disorders. In the present sample, internal consistency was high for the full scale IIP (a = 0.97), as well as for each subscale (a’s range from 0.89 to 0.93). Procedure This study was approved by the Institutional Review Board at Duke University Medical Center. All participants provided written informed consent prior to participating in the study. Participants completed diagnostic interviews and self-report instruments after completing lab tasks that were part of a larger study of emotion processing. Participants were given the self-report packet and then debriefed about the experiment and compensated. Data analysis We tested two models in which (1) emotion regulation problems account for the relationship between BPD symptoms and interpersonal problems and (2) interpersonal problems account for the relationship between BPD symptoms and emotion regulation problems. These models were tested using the mediation procedures outlined by Baron and Kenny

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(1986) in which we sought to establish (1) that the direct pathway from BPD symptoms to interpersonal dysfunction was significant; (2) that the pathway from BPD symptoms to emotion regulation problems was significant; (3) that the pathway from emotion regulation problems to interpersonal dysfunction was significant after controlling for BPD symptoms; and (4) that the direct effect of BPD symptoms predicting interpersonal dysfunction is reduced, accounting for emotion regulation problems. In addition, the indirect pathway from BPD symptoms to emotion regulation problems to interpersonal dysfunction was tested for significance by using the Sobel test (Preacher & Hayes, 2004). These mediation procedures can establish whether or not the DERS is measuring a critical component of BPD that fully accounts for the interpersonal problems associated with BPD symptoms.

Results Zero-order correlations between the number of BPD symptoms endorsed, the IIP total score and the IIP subscales are presented in Table 1. As shown, there was a significant direct relationship between BPD symptoms and IIP total score (p < 0.001), as well as with each IIP subscale (all p’s < 0.05). The relation between several non-BPD psychopathology variables and DERS total score was examined using univariate ANOVA in which the presence or absence of each diagnostic category was the predictor variable and DERS total score was the outcome variable. DERS total score was found to be significantly related to lifetime history of depressive disorder (F(1, 118) = 43.18, p < 0.001), anxiety disorder (F(1, 118) = 51.15, p < 0.001), and non-BPD personality disorder (F(1, 119) = 51.22, p < 0.001). All analyses, therefore, statistically controlled for the effect of these psychopathology variables. Gender, ethnicity and marital status were also examined using univariate ANOVA and were found to be unrelated to DERS or IIP total scores. Zero-order correlations also showed that

(2012) DOI: 10.1002/pmh

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SD, standard deviation; DERS, Difficulties with Emotion Regulation Scale; IIP, Inventory of Interpersonal Problems. *p < 0.05. **p < 0.01. ***p < 0.001.

15.6 (10.7) 0.80*** 17.7 (10.5) 0.82*** 0.87*** 7.5 (6.6) 0.76*** 0.62*** 0.61*** 13.3 (9.0) 0.62*** 0.63*** 0.70*** 0.54*** 70.0 (40.5) 0.80*** 0.80*** 0.94*** 0.92*** 0.89*** 86.4 (31.5) 0.81*** 0.57*** 0.66*** 0.80*** 0.72*** 0.75*** 2.6 (3.1) 0.75*** 0.62*** 0.37*** 0.53*** 0.67*** 0.50*** 0.64*** BPD symptoms DERS IIP total score IIP—ambivalence IIP—aggression IIP—sensitivity IIP—lack of sociability IIP—need for social approval 1. 2. 3. 4. 5. 6. 7. 8.

3 2 1

Table 1: Correlations between study variables; means (SD) presented on the diagonal

4

5

6

7

8

15.8 (9.3)

Emotion REG and interpersonal functioning in BPD

neither DERS nor IIP total score was related to participant’s income or age; thus, no demographic variables were controlled for in the analyses. Alpha was set at 0.05 for all analyses. First, a direct path between the number of endorsed SCID-II BPD symptoms and the IIP total score was established using hierarchical regression (b = 0.42, t(118) = 4.5, p < 0.001). To examine whether or not this path was mediated by DERS total score, first, the path from BPD symptoms to DERS total score was examined and found to be significant (b = 0.57, t(117) = 7.14, p < 0.001). Next, BPD symptoms and DERS total score were entered simultaneously with IIP total score as the criterion variable. Results show that the path from DERS total score to IIP total score was significant (b = 0.73, t(117) = 8.52, p < 0.001), whereas the path from BPD symptoms to IIP total score was no longer significant (b = 0.00, t(117) = 0.006, p = 0.99). Thus, the requirements of Baron and Kenny (1986) for full mediation were met. The Sobel test (Preacher & Hayes, 2004) also confirmed that the indirect path was significant (Sobel = 5.47, p < 0.001). This model accounted for 68% of the variance in IIP score (R2 = 0.68, F = 47.15, p < 0.001). To further examine which specific IIP subscales the DERS may be accounting for, each IIP subscale was entered separately into the first model described previously. After the control variables were entered, a significant direct path from BPD to each subscale was established for all subscales: interpersonal ambivalence (b = 0.29, t(118) = 2.63, p < 0.01); interpersonal aggression (b = 0.32, t(118) = 3.27, p < 0.001); interpersonal sensitivity (b = 0.46, t(118) = 5.01, p < 0.001); lack of sociability (b = 0.26, t(118) = 2.53, p < 0.05); and need for social approval (b = 0.49, t(118) = 5.16, p < 0.001). The DERS total score mediator was then entered simultaneously with BPD symptoms predicting each of these significant criterion IIP subscale variables. Full mediation, as indicated by a significant path from the DERS score to each IIP subscale, a now insignificant path between BPD symptoms and the IIP subscale, and a

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Table 2: Indirect path analyses for BPD symptoms predicting interpersonal problems, mediated by emotion regulation Dependent

Independent(s)

b

Emotion regulation (DERS)†

BPD symptoms (SCID-II)

0.57

7.14***

IIP—interpersonal ambivalence BPD symptoms Emotion regulation

0.14 0.68

1.15 5.55*** 4.23***

0.35

12.31***

IIP—interpersonal aggression

BPD symptoms Emotion regulation

0.00 0.52

0.04 4.87*** 3.87***

0.51

23.32***

BPD symptoms Emotion regulation

0.07 0.67

0.80 7.80*** 5.22***

0.68

46.93***

BPD symptoms Emotion regulation

0.20 0.76

1.97 7.58*** 5.11***

0.56

28.57***

BPD symptoms Emotion regulation

0.12 0.63

1.22 6.60*** 4.76***

0.60

33.74***

IIP—interpersonal sensitivity

IIP—lack of sociability

IIP—need for social approval

t

Sobel

R2 (full model) F (full model)

DERS, Difficulties with Emotion Regulation Scale; IIP, Inventory of Interpersonal Problems; SCID-II, Structured Clinical Interview for DSM-IV Personality Disorders, Axis II. † Note that this analysis was used to determine the Sobel statistic in all subsequent analyses. Models include lifetime history of depressive or anxiety disorder and lifetime history of a non-BPD personality disorder as control variables. *p < 0.05. **p < 0.01. ***p < 0.001.

significant Sobel test, was found for all subscales (Table 2). To examine a competing hypothesis, an alternative mediational model was tested in which IIP total score was the mediator between BPD symptoms and DERS total score. The paths from BPD symptoms to DERS total score (criterion variable) and to IIP total score (mediator) were significant, as reported in the analyses given previously. When BPD symptoms and IIP total score were entered simultaneously predicting DERS total score, IIP was a significant predictor (b = 0.54, t(117) = 8.52, p < 0.001), but the path from BPD symptoms remained significant (b = 0.35, t(117) = 5.10, p < 0.001). The Sobel test of the indirect path was significant, however, indicating partial mediation (Sobel = 3.98, p < 0.001). This model accounted for 77% of the variance in DERS score (R2 = 0.77, F = 75.42, p < 0.001).

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Discussion Difficulties with emotion regulation and interpersonal dysfunction are core problems in BPD. However, research has yet to clearly elucidate how these constructs relate to one another in the manifestation of BPD symptoms. Accordingly, the present study sought to examine the relationships among difficulties with emotion regulation, interpersonal problems and symptoms of BPD in a community sample of ethnically diverse adults. On the basis of Linehan’s biosocial model of BPD (Linehan, 1993), we hypothesized that problems with emotion regulation would have a central role underlying the expression of interpersonal problems in BPD. As such, a model in which difficulties with emotion regulation (measured by the DERS) mediated the relationship between BPD symptoms and interpersonal functioning (measured by the IIP) was tested. We also tested

(2012) DOI: 10.1002/pmh

Emotion REG and interpersonal functioning in BPD

variations of this model with specific interpersonal functioning subtypes as the outcome variables. In addition, we examined an atheoretical model in which interpersonal functioning mediated the relationship between BPD symptoms and difficulties with emotion regulation. The primary finding of this study supported our hypothesis that difficulties with emotion regulation would fully mediate the relationship between BPD symptoms and interpersonal functioning. In other words, although BPD symptoms were found to be directly associated with interpersonal problems, difficulties with emotion regulation fully accounted for this relationship. Furthermore, this was true for all subtypes of interpersonal functioning measured by the IIP. These findings lend empirical support to the notion that emotion regulation difficulties are a key mechanism through which individuals with BPD may experience more interpersonal problems. Our findings are supported by previous studies that found interpersonal problems to be highly related to emotion regulation or affective instability. For instance, Bagge and colleagues (2004) showed that the BPD feature of affective instability, one aspect of emotion regulation, was related to social maladjustment even after controlling for other Axis I and Axis II disorders, which led the authors to suggest that affective instability may be one cause of social problems for individuals with many BPD characteristics. Our findings also support theoretical models of emotion regulation broadly (e.g. Keltner & Kring, 1998) and in BPD specifically (e.g. Putnam & Silk, 2005), which suggest that difficulty regulating intense emotional experiences account for problems with interpersonal functioning. Furthermore, our subsequent analyses with specific subtypes of interpersonal problems showed that difficulties with emotion regulation could fully account for the relationship between BPD symptoms and each IIP subscale, lending further support to the notion that difficulties with emotion regulation underlie a broad range of interpersonal problems that are associated with BPD. Our test of the atheoretical alternative model showed that interpersonal functioning was a partial

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mediator of the relationship between BPD symptoms and difficulties with emotion regulation. This finding suggests that some of the difficulties with emotion regulation that are found among individuals with many BPD symptoms may be accounted for by interpersonal functioning problems these individuals also experience. To fully interpret this finding, however, we must take into account the test of the first model and the limitations inherent in using cross-sectional data for these analyses. When one uses cross-sectional data to examine mediation, the predictor, mediator and outcome variables are determined by a theoretical model rather than temporal sequencing. Because we compared crosssectional models, which differ only by exchanging the mediator and outcome variables, the direction of effect between difficulties with emotion regulation and interpersonal functioning could not be established; thus, some of the observed strength of the indirect pathway in each model may be inflated by any portion of the association between these variables that is due to the outcome causing the mediator (i.e. the reverse of what a mediation model specifies). The data show that BPD symptoms were directly related to difficulties with emotion regulation, which, in turn, fully accounted for the poorer interpersonal functioning associated with more BPD symptoms. On the other hand, BPD symptoms were also directly related to problems in interpersonal functioning, but these problems only accounted for a portion of the greater difficulties in emotion regulation among these individuals. As such, the test of the first model yields both a stronger result and supports existing theoretical and empirical research (Bagge et al., 2004; Linehan, 1993; Stepp et al., 2009). The results of the second model, however, suggest the need for further study to determine whether the indirect effect of interpersonal functioning was the result of statistical inflation or if there is, in fact, a bidirectional causal relationship between interpersonal functioning and difficulties with emotion regulation that leads to high levels of these constructs among individuals with many symptoms of BPD.

(2012) DOI: 10.1002/pmh

Herr et al.

There are several additional limitations that must be considered in the present study. First, self-report measures of problems with emotion regulation and interpersonal functioning were used. It is possible that this resulted in statistical relationships between measures due to method overlap and raises the question of whether or not individuals can accurately rate their own problems with emotion regulation and interpersonal functioning. However, this concern is somewhat mitigated by the fact that the measures chosen for the present study are well validated and commonly used to study these constructs as they relate to BPD symptoms in community samples similar to the present study. A related limitation is that the questionnaires chosen may not comprehensively measure difficulties with emotion regulation or interpersonal functioning and instead only assess some aspects of these complex and multidimensional constructs. Future studies designed to replicate and extend the present findings should include more objective behavioural and biological measures of emotion regulation (e.g. Herpertz, Kunert, Schwenger, & Sass, 1999; Herpertz et al., 2000) and interpersonal functioning to better understand the relationship between these two core areas of impairment in BPD. As noted previously, the study was also limited by its cross-sectional design, precluding causal inferences about the temporal nature of the relationship between difficulties with emotion regulation, interpersonal problems and BPD symptoms. Despite our results showing that difficulties with emotion regulation completely accounted for the relationship between interpersonal problems and BPD symptoms, it is possible that emotion regulation difficulties developed, at least in part, from attachment-based or other relationship problems that occurred earlier in life. Alternatively, Linehan’s (1993) biosocial model of BPD posits that the disorder stems from the interaction between a biologically mediated predisposition to emotion regulation problems and invalidation from interpersonal (mostly familial) relationships. The present data cannot be used to comprehensively evaluate the developmental, interactive or transactional relationship between

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interpersonal functioning and emotion regulation difficulties in BPD individuals; thus, further studies using longitudinal designs are warranted. Clinically, the findings of the present study suggest that the interpersonal problems found in individuals with a high number of BPD symptoms may be a function of the emotion regulation problems that these individuals experience. Addressing these emotion regulation problems in behavioural treatments may, therefore, lead to improvement in the interpersonal functioning of individuals with BPD symptoms. For instance, there are a range of emotion regulation skills in dialectical behaviour therapy (Linehan, 1993) that could be provided to patients with many dialectical behaviour therapy symptoms. Although results from the present study should not be interpreted definitively, the findings point to the possibility of exploring the sequencing of emotion regulation skill training before interpersonal skill training to reduce BPD symptoms. Before clinical interventions are tested in this manner, however, future research must be performed to better understand the temporal or causal relationship between difficulties with emotion regulation and interpersonal functioning in BPD.

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(2012) DOI: 10.1002/pmh

Emotion REG and interpersonal functioning in BPD

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Address correspondence to: Nathaniel R. Herr, Department of Psychology, American University, Asbury 321A, 4400 Massachusetts Ave NW, Washington, D.C. 20016. E-mail: nherr@american. edu.

(2012) DOI: 10.1002/pmh

Difficulties with emotion regulation mediate the relationship between borderline personality disorder symptom severity and interpersonal problems.

Problems with interpersonal functioning and difficulties with emotion regulation are core characteristics of borderline personality disorder (BPD). Li...
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