Journal of Personality Disorders, 29(2), 231–240, 2015 © 2015 The Guilford Press
DYSFUNCTIONAL RESPONSES TO EMOTION MEDIATE THE CROSS-SECTIONAL RELATIONSHIP BETWEEN REJECTION SENSITIVITY AND BORDERLINE PERSONALITY FEATURES Jessica R. Peters, MS, Laura M. Smart, MS, and Ruth A. Baer, PhD
A growing body of evidence has tied borderline personality disorder (BPD) to heightened sensitivity to rejection; however, mechanisms through which rejection sensitivity contributes to BPD features have not been identified. Rejection may lead to the dysfunctional emotion regulation strategies common in BPD, such as impulsive responses to distress, anger rumination, difficulties engaging in goal-oriented behavior, nonacceptance of emotions, and low emotional clarity. The present study used self-report measures and bootstrapping procedures to investigate the role of difficulties in emotional regulation in the relationship between rejection sensitivity and borderline personality features in a crosssectional sample of 410 undergraduates. Difficulties in emotion regulation accounted for significant variance in the relationships between rejection sensitivity and BPD features, with varying sets of deficits in emotion regulation skills accounting for associations with specific BPD features. Potential clinical implications and the need for replication in longitudinal studies are discussed.
Borderline personality disorder (BPD) is characterized by a diverse group of symptoms, including affective instability, identity disturbances, problems in relationships, and self-harm (American Psychiatric Association, 2000). BPD has been conceptualized as chronic emotion dysregulation; individuals with BPD or high in BPD features demonstrate the tendency to respond to negative emotions with numerous maladaptive strategies (Salsman & Linehan, 2012; Selby, Anestis, Bender, & Joiner, 2009). These include behaviors, such as impulsive and self-destructive actions (Bornovalova et al., 2005; Gratz, Breetz, & Tull, 2010; Peters, Upton, & Baer, 2013) and avoidance of goal-directed behavior (Gratz, Rosenthal, Tull, This was accepted under the editorship of Robert F. Krueger and John Livesley. From Department of Psychology, University of Kentucky, Lexington. Kentucky. Address correspondence to Jessica R. Peters, Department of Psychology, University of Kentucky, 111-J Kastle Hall, Lexington, KY 40506-0044; E-mail:[email protected]
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Lejuez, & Gunderson, 2006), as well as cognitive processes, such as rumination (Baer & Sauer, 2011) and decreased present-centered awareness and acceptance (Peters, Eisenlohr-Moul, Upton, & Baer, 2013). Understanding contributing factors to the emotion dysregulation in BPD is key to providing efficient, effective treatment. A growing body of evidence has tied BPD to heightened sensitivity to rejection (Downey & Feldman, 1996). Rejection sensitivity (RS) can be defined as the tendency to anxiously anticipate, readily identify experiences as, and overreact to rejection. Self-reported anxious anticipation and expectation of rejection has demonstrated very strong positive correlations with BPD symptoms (Gardner, Qualter, Styllanou, & Robinson, 2010) and BPD-related thoughts and feelings (Staebler, Helbing, Rosenbach, & Renneberg, 2010). Individuals with BPD, compared to those without, also have shown increased shame and negative affect in response to experiences of social rejection (Chapman, Walters, & Dixon Gordon, 2012). Despite the mounting evidence for an association between RS and BPD, the mechanisms underlying this relationship have not been identified. One possibility is that increased sensitivity to rejection, and subsequent difficulties responding to the induced negative affect, produce the difficulties observed in BPD. In non-clinical samples, experimental rejection inductions result in numerous negative outcomes that mirror the dys functional responses to distress characteristic of BPD, including immediate decreases in impulse control and self-regulation (Baumeister, DeWall, Ciarocco, & Twenge, 2005), rumination (Pearson, Watkins, & Mullan, 2011), increased anger and perceptions of hostility (DeWall, Twenge, Gitter, & Baumeister, 2009), and feelings of meaninglessness and reduced self-awareness (Twenge, Catanese, & Baumeister, 2003). In non-depressed individuals, rejection also serves as a cue for eventual emotion regulation via enhanced attunement toward positive information and attempts at social reconnection; however, individuals high in depressive symptoms do not demonstrate these effects (DeWall et al., 2011). For individuals with BPD, perhaps such normative regulatory responses to rejection are similarly not feasible. Instead, heightened reactivity to rejection may lead to prolonged impairment due to continued maladaptive responses to distress. Alternatively, increased sensitivity to rejection could account for the relationship between dysfunction responses to emotion and BPD features. Rejection sensitivity and emotion dysregulation may also be reciprocal processes underlying BPD. The present study provides a preliminary test of the hypothesis that rejection sensitivity, in particular, the tendency to anxiously anticipate and expect rejection, is associated with increased tendencies to engage in dysfunctional responses to negative affect, which accounts for the relationship between rejection sensitivity and BPD features. Given the multifaceted nature of BPD, features of the disorder were examined independently to determine whether different patterns of dysfunctional emotion regulation strategies would account for particular features. Due to the cross-
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sectional nature of the present investigation, it is crucial to consider alternative models. Accordingly, models with dysfunctional responses to emotion contributing to BPD features via increased rejection sensitivity were also explored.
METHODS PARTICIPANTS Participants were 451 psychology students (67.9% female, 80.8% White) at the University of Kentucky who completed an online survey including a number of self-report measures, only some of which were relevant to the present study (listed below; see Measures). Participants ranged in age from 18 to 38 years with a mean age of 19.19 years (SD = 2.09). Informed consent was obtained from all participants, and all study procedures were approved by the university’s institutional review board. Participant recruitment was designed to ensure that a wide range of BPD features would be represented; students with T-scores ≥ 70 on the borderline features scale of the Personality Assessment Inventory (PAI-BOR; Morey, 2007) comprised 18.3% of the final sample. Previous research shows that clinically significant BPD features are common in the undergraduate population (Trull, 1995; Trull, Useda, Conforti, & Doan, 1997). Clinical samples represent only the upper range of BPD severity, so the use of a student sample for the current study presented a wide range of characteristics associated with BPD and therefore more power to detect effects.
MEASURES Rejection Sensitivity. The Rejection Sensitivity Questionnaire (RSQ; Downey & Feldman, 1996) is an 18-item measure of the tendency to experience anxiety or concern about the possibility of being rejected and the extent to which an individual expects to be rejected. Respondents are provided 18 brief scenarios and are asked to what degree they think it is likely that they will be rejected (1 = very unlikely to 6 = very likely) and how concerned they are about the potential rejection (1 = very unconcerned to 6 = very concerned), providing two scores for each scenario. Scores from each question are averaged across scenarios to create two subscale scores, which were then averaged together to create a single mean score. See Table 1 for internal consistencies for all measures. BPD Features. The PAI-BOR (Morey, 2007) has 24 items measuring four aspects of BPD pathology: affective instability, identity problems, negative relationships, and self-harm. Participants are asked to respond to each statement on a 4-point scale ranging from 0 = false, not at all true to 3 = very true. In the present study, PAI-BOR scales were examined individually due to the heterogeneous nature of the disorder and to determine effects of rejection sensitivity on specific types of BPD features. Dysfunctional Responses to Emotion. The Difficulties in Emotion Regula-
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tion Scale (DERS; Gratz & Roemer, 2004) is a 36-item questionnaire assessing six dimensions of difficulties individuals may face in regulating emotions. These dimensions include: lack of awareness of emotional responses (e.g., “I pay attention to how I feel”—reverse-scored), lack of emotional clarity (e.g., “I have difficulty making sense out of my feeling), nonacceptance of emotional responses (e.g., “When I am upset, I feel ashamed with myself for feeling this way”), difficulties controlling impulses when experiencing negative emotions (e.g., “When I’m upset, I feel out of control”), difficulties engaging in goal-oriented behavior when experiencing negative emotions (e.g., “When I’m upset, I have difficulty concentrating), and limited access to effective emotion regulation skills (e.g., “When I am upset, I believe that there’s nothing I can do to make myself feel better”). Items are rated on a 5-point scale ranging from almost never to almost always. One dysfunctional response to negative affect that has been demonstrated to contribute to BPD features but is not assessed in the DERS is rumination (Selby et al., 2009). An assessment of anger rumination was chosen over assessments of more general rumination or other forms of rumination due to the stronger associations between anger rumination and BPD features (Baer & Sauer, 2011; Peters, Upton, Eisenlohr-Moul, et al., 2013). The Anger Rumination Scale (ARS; Sukhodolsky, Golub, & Cromwell, 2001) has 19 items assessing the tendency to focus attention on angry moods, recall past anger episodes, and think about the causes and consequence of anger episodes (e.g., “When something makes me angry, I turn this matter over and over again in my mind”). Participants rate each statement on a 4-point scale ranging from almost never to almost always.
DATA SCREENING A validity item was added to each instrument to assess whether participants were attending to item content and response scales. Validity items included prompts such as “Please choose ‘strongly disagree’ for this question.” Participants who incorrectly responded to two or more of the nine validity items (n = 40) were excluded from analyses; therefore, data from 411 were used in subsequent analyses.
RESULTS The results were analyzed using SPSS 20.0. Screening for skew and kurtosis showed that all variables fell within acceptable limits (Tabachnick & Fidell, 2000). Table 1 presents descriptive statistics for all study variables and zero-order correlations between study variables. All BPD scales were significantly correlated with the RSQ and all of the measures of dysfunctional responses to emotion. The majority of the DERS subscales and the ARS were significantly intercorrelated. With the
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(.81) .71*** .69*** .44*** .53*** .47*** .69*** .29*** .15** .71*** .44*** .45***
1
(.72) .68*** .35*** .54*** .52*** .52*** .52*** .12* .70*** .60*** .45***
2
(.71) .34*** .40*** .42*** .51*** .38*** .12* .59*** .60*** .41***
3
(.75) .35*** .33*** .49*** .31*** .19*** .40*** .28*** .22***
4
(.91) .45*** .55*** .45*** .11* .69*** .51*** .44***
5
(.82) .50*** .30*** .54*** .51*** .41*** .43***
6
(.77) .47*** .16** .72*** .54*** .39***
7
(.89) .00 .58*** .43*** .29***
8
(.84) .12* .04 .29***
9
(.91) .61*** .47***
10
(.95) .44***
11
(.86)
12
1.00 1.35 1.31 .83 2.20 2.30 1.97 2.92 2.56 2.11 1.79 6.79
Mean
.64 .63 .60 .57 .93 .77 .82 1.00 .80 .88 .57 2.49
SD
TABLE 1. Means, Standard Deviations, and Internal Consistencies of and Intercorrelations Between Study Variables (N = 411) Min–Max 0–2.67 0–3 0–3 0–3 1–5 1–4.80 1–5 1–5 1–5 1–5 1–4 1.32–18.01
BOR = Personality Assessment Inventory Borderline Features, AI = Affective Instability, ID = Identity Disturbances, NR = Negative Relationships, SH = Self-Harm; DERS = Difficulties in Emotion Regulation Scale, NA = Nonacceptance, LC = Lack of Emotional Clarity, ICD = Impulse Control Difficulties, DG = Difficulties in Goal-Related Behavior, LA = Lack of Emotional Awareness, LS = Limited Access to Strategies; ARS = Anger Rumination Scale; RSQ = Rejection Sensitivity Questionnaire. *p < .05, **p < .01, ***p < .001 for all tables.
1. BOR AI 2. BOR ID 3. BOR NR 4. BOR SH 5. DERS NA 6. DERS LC 7. DERS ICD 8. DERS DG 9. DERS LA 10. DERS LS 11. ARS 12. RSQ
Variable
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exception of the Lack of Emotional Clarity scale, the associations between the Lack of Strategies subscale and the other DERS subscales were significantly stronger than the other intercorrelations (t[408] = 3.64–11.61, p < .001). The ARS also demonstrated stronger associations with the Lack of Strategies subscale than with the other DERS scales (t[408] = 2.41– 6.44, p < .01 –< .001). These findings are unsurprising given that the Lack of Strategies scale assesses feelings that one does not have effective means for coping with distress and experiences those effects as overwhelming, which is probably accurate for individuals who tend to engage in other dysfunctional responses to emotions. Given both the empirical and theoretical overlap between the Lack of Strategies scale and the other forms of dysfunctional responses to emotion assessed, the Lack of Strategies scale was excluded from the following regression analyses, in order to limit the difficulties associated with multiple intercorrelated predictors. Age, gender, and race were uncorrelated with study variables with the exception of a small correlation between age and Impulse Control Difficulties (r = –.11, p < .05) and male gender and BPD negative relationships (r = .13, p < .05). Given this lack of associations between demographic variables and variables of interest, demographic variables were excluded from subsequent analyses. Hierarchical multiple regression models were estimated predicting each of the PAI-BOR scales (Table 2). The RSQ was entered in step 1 of each model and predicted a significant amount of variance in each BPD feature. In step 2 of each model, dysfunctional responses to emotion were added, including anger rumination, nonacceptance of emotion, lack of emotional awareness, lack of emotional clarity, difficulties in goal-directed behavior when upset, and impulse control difficulties when upset. The magnitude of the association between the RSQ and PAI-BOR scales was greatly reduced in the second step for all PAI-BOR scales, and a unique pattern of dysfunctional responses to emotion significantly predicted each PAI-BOR scale, with anger rumination, impulse control difficulties and difficulties in goal-directed behavior emerging as the most consistent predictors. Parallel bootstrapping procedures (Preacher & Hayes, 2004) were used to estimate indirect effects from the RSQ to PAI-BOR scales via dysfunctional emotion regulation strategies. For each PAI-BOR scale, indirect effects were estimated for each potential mediator with a significant beta weight in the regression model; other emotion regulation variables were entered as covariates. Difficulties in emotion regulation accounted for significant variance in the relationships between RSQ and all BPD features (95% CI estimates of total indirect effects were greater than 0 for all PAIBOR subscales); however, different patterns of indirect effects emerged across the PAI-BOR subscales. Impulse control difficulties, 95% confidence interval (CI) [.002, .023], difficulties engaging with goal-oriented behavior, 95% CI [.001, .010], and anger rumination, 95% CI [.014, .034], accounted for 79% of the relationship between the RSQ and BPD affective instability. Difficulties engaging
EMOTION REGULATION, REJECTION, AND BORDERLINE PERSONALITY237 TABLE 2. Summaries of Regression Models Predicting PAI-BOR Subscales (N = 411) Dependent Variable PAI-BOR Aff Inst
PAI-BOR Ident Dist
PAI-BOR Neg Rel
PAI-BOR Self-Harm
Step
Predictors
Beta
1 2
RSQ RSQ ARS NA DGB ICD LA LC
–.46*** –.09* –.30*** –.05 –.12** –.39*** –.02 –.03
RSQ RSQ ARS NA DGB ICD LA LC
–.45*** –.09* –.28*** –.14** –.21** –.04 –.09 –.27***
RSQ RSQ ARS NA DGB ICD LA LC
–.41*** –.11* –.39*** –.01 –.07 –.17** –.03 –.13*
RSQ RSQ ARS NA DGB ICD LA LC
–.22*** –.04 –.01 –.09 –.11* –.37*** –.13* –.03
1 2
1 2
1 2
R2 Change
R 2 for Model
.40***
.21*** .78***
Bootstrapped CI for Indirect Effect
.014, .034 .001, .010 .002, .023
.34***
.20*** .54***
.014, .035 .004, .017 .004–.018 .005, .019
.27***
.17*** .44***
.017, .042 .001, .014 .001, .012
.22***
.05*** .27*** –.001, .006 –.006, .010 .001, .014
BOR = Personality Assessment Inventory Borderline Features, AI = Affective Instability, ID = Identity Disturbances, NR = Negative Relationships, SH = Self-Harm; NA = Nonacceptance, LC = Lack of Emotional Clarity, LA = Lack of Emotional Awareness; ICD = Impulse Control Difficulties, DGB = Difficulties in Goal-Related Behavior; ARS = Anger Rumination Scale; RSQ = Rejection Sensitivity Questionnaire. *p < .05, ** p < .01, ***p < .001.
with goal-oriented behavior, 95% CI [.004, .018], nonacceptance of emotion, 95% CI [.004, .017], lack of emotional clarity, 95% CI [.005, .019], and anger rumination, 95% CI [.014, .035] accounted for 83% of the relationship between the RSQ and BPD identity disturbances. Impulse control difficulties, 95% CI [.001, .014], lack of emotional clarity, 95% CI [.001, .012], and anger rumination, 95% CI [.01, .042], accounted for 74% of the relationship between the RSQ and BPD negative relationships. Lack of emotional awareness, 95% CI [.001, .014] accounted for 97% of the relationship between the RSQ and BPD self-harm; indirect paths via impulse control difficulties, 95% CI [–.006, .010] and difficulties engaging with goal-oriented behavior, 95% CI [–.001, .006] were not significant. Alternative models with indirect paths from each of the dysfunctional
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responses to emotion via the RSQ to all four BPD features were also assessed. No significant indirect effects were observed for BPD affective instability or self-harm. Indirect effects from anger rumination via the RSQ were observed accounting for 8% of the total effect on identity disturbance, 95% CI [.006, .060] and 7% of the total effect on negative relationships, 95% CI [.008, .072] and from nonacceptance via the RSQ accounting for 12% of the total effect on identity disturbance, 95% CI [.002, .030].
DISCUSSION The aim of the present study was to explore how dysfunctional responses to emotion may account for the relationship between rejection sensitivity and BPD features. Dysfunctional responses to emotion accounted for a large proportion (74% to 97%) of the total effect of rejection sensitivity on all four BPD features: affective instability, identity disturbance, negative relationships, and self-harm. These findings demonstrate that while sensitivity to rejection may contribute to the full range of BPD symptoms, deficits in specific emotion regulation skills may explain how sensitivity to rejection increases vulnerability to particular components of the disorder. When alternative models were examined, in which dysfunctional responses to emotion contribute to BPD features via rejection sensitivity, few significant indirect effects were observed, and the proportion of the total effect accounted for was much smaller (7% to 12%). Anger rumination in particular demonstrated an indirect effect via rejection sensitivity to two areas of BPD features; this aspect of dysfunctional responses to emotion may be particularly reciprocal with rejection sensitivity. That said, the much smaller effect sizes of the alternative model’s indirect effects show that our original model has substantially stronger support, at least in our sample. Different sets of specific dysfunctional responses to emotion accounted for a significant proportion of the relationship between rejection sensitivity and BPD features for each symptom cluster. These findings provide additional support to a growing literature demonstrating differential associations among BPD features (e.g. Geiger, Peters, Sauer-Zavala, & Baer, 2013; Peters, Eisenlohr-Moul, et al., 2013; Stepp, Epler, Jahng, & Trull, 2008), suggesting the necessity of operationalizing BPD as a cluster of distinct features rather than a unitary characteristic. The student sample used in the current study limits generalizability to clinical settings; further research with clinical samples and longitudinal designs is recommended to examine potential clinical implications, such as the utility of targeting various dysfunctional responses to emotion based on symptom profiles. For example, reducing anger rumination and increasing goaldirected behavior under distress may diminish the effects of rejection sensitivity on both affective instability and identity disturbance; in contrast, increasing impulse control may be more important in stabilizing affective responses to anticipated rejection, and acceptance of emotions may be more important in reducing the impact of rejection on identity problems.
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A major limitation of the current study is the cross-sectional nature of the research, since mediation cannot be tested with these methods. These preliminary findings warrant further examination via longitudinal and experimental studies to explore potential mediational relationships. Using measures of rejection sensitivity beyond self-report, such as behavioral and physiological responses to rejection inductions, is also recommended. The current study used a student sample, so investigating these constructs in community and clinical samples would improve generalizability.
REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. Washington, DC: Author. Baer, R. A., & Sauer, S. E. (2011). Relationships between depressive rumination, anger rumination, and borderline personality features. Personality Disorders: Theory, Research, and Treatment, 2(2), 142–150. doi:10.1037/a00 19478 Baumeister, R. F., DeWall, C. N., Ciarocco, N. J., & Twenge, J. M. (2005). Social exclusion impairs self-regulation. Journal of Personality and Social Psychology, 88(4), 589–604. doi:10.1037 /0022-3514.88.4.589 Bornovalova, M., Lejuez, C., Daughters, S., Zachary Rosenthal, M., & Lynch, T. (2005). Impulsivity as a common process across borderline personality and substance use disorders. Clinical Psychology Review, 25(6), 790812. Chapman, A. L., & Walters, K. N., & Dixon Gordon, K. L. (2012). Emotional reactivity to social rejection and negative evaluation among persons with borderline personality features. Journal of Personality Disorders. Advance online publication. doi:10.1521/pedi_2012_26 _068 DeWall, C. N., Twenge, J. M., Gitter, S. A., & Baumeister, R. F. (2009). It’s the thought that counts: The role of hostile cognition in shaping aggressive responses to social exclusion. Journal of Personality and Social Psychology, 96(1), 45–59. doi:10.1037/a0013196 DeWall, C. N., Twenge, J. M., Koole, S. L., Baumeister, R. F., Marquez, A., & Reid, M. W. (2011). Automatic emotion regulation after social exclusion: Tun-
ing to positivity. Emotion, 11(3), 623– 636. doi:10.1037/a0023534 Downey, G., & Feldman, S. I. (1996). Implications of rejection sensitivity for intimate relationships. Journal of Personality and Social Psychology, 70(6), 1327–1343. Gardner, K. J., Qualter, P., Styllanou, M., & Robinson, A. J. (2010). Facial affect recognition in non-clinical adults with borderline personality features: The role of effortful control and rejection sensitivity. Personality and Individual Differences, 49(7), 799–804. Geiger, P. J., Peters, J. R., Sauer-Zavala, S. E., & Baer, R. A. (2013). Relationships among maladaptive cognitive content, dysfunctional cognitive processes, and borderline personality features. Journal of Personality Disorders, 27(4), 457–464. Gratz, K. L., Breetz, A., & Tull, M. T. (2010). The moderating role of borderline personality in the relationships between deliberate self-harm and emotionrelated factors. Personality and Mental Health, 4(2), 96–107. doi:10.1002/pmh. 102 Gratz, K., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. Gratz, K., Rosenthal, M., Tull, M., Lejuez, C., & Gunderson, J. (2006). An experimental investigation of emotion dysregulation in borderline personality disorder. Journal of Abnormal Psychology, 115(4), 850–855.
240 Morey, L. C. (2007). Personality assessment inventory professional manual (2nd ed.). Odessa, FL: Psychological Assessment Resources. Pearson, K. A., Watkins, E. R., & Mullan, E. G. (2011). Rejection sensitivity prospectively predicts increased rumination. Behaviour Research and Therapy, 49(10), 597–605. doi:10.1016/j. brat.2011.06.004 Peters, J. R., Eisenlohr-Moul, T. A., Upton, B. T., & Baer, R. A. (2013). Nonjudgment as a moderator of the relationship between present-centered awareness and borderline features: Synergistic interactions in mindfulness assessment. Personality and Individual Differences, 55, 24–28. doi:10.1016/j.paid.2013.01. 021 Peters, J. R., Upton, B. T., & Baer, R. A. (2013). Brief report: Relationships between facets of impulsivity and borderline personality features. Journal of Personality Disorders, 27(4), 547–552. Peters, J. R., Upton, B. T., Eisenlohr-Moul, T. A., Folsom, J. J., Talavera, N. A., & Baer, R. A. (2013). Characteristics of ruminative thought associated with borderline personality features. Manuscript submitted for publication. Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, Instruments, & Computers, 36(4), 717– 731. Salsman, N. L., & Linehan, M. M. (2012). An investigation of the relationships among negative affect, difficulties in emotion regulation, and features of borderline personality disorder. Journal of Psychopathology and Behavioral Assessment, 34(2), 260–267. doi:10.1007 /s10862-012-9275-8 Selby, E. A., Anestis, M. D., Bender, T. W., &
PETERS ET AL. Joiner, T. E. (2009). An exploration of the emotional cascade model in borderline personality disorder. Journal of Abnormal Psychology, 118(2), 375– 387. doi:10.1037/a0015711 Staebler, K., Helbing, E., Rosenbach, C., & Renneberg, B. (2010). Rejection sensitivity and borderline personality disorder. Clinical Psychology and Psychotherapy, 18(4), 275–283. doi:10.1002 /cpp.705 Stepp, S. D., Epler, A. J., Jahng, S., & Trull, T. J. (2008). The effect of dialectical behavior therapy skills use on borderline personality disorder features. Journal of Personality Disorders, 22(6), 549–563. doi:10.1521/pedi.2008.22.6. 549 Sukhodolsky, D. G., Golub, A., & Cromwell, E. N. (2001). Development and validation of the anger rumination scale. Personality and Individual Differences, 31, 689–700. Tabachnick, B. G., & Fidell, L. S. (2000). Using multivariate statistics (4th ed.). Boston: Allyn & Bacon. Trull, T. J. (1995). Borderline personality disorder features in nonclinical young adults: 1. Identification and validation. Psychological Assessment, 7(1), 33–41. Trull, T. J., Useda, D., Conforti, K., & Doan, B. T. (1997). Borderline personality disorder features in nonclinical young adults: 2. Two-year outcome. Journal of Abnormal Psychology, 106(2), 307– 314. Twenge, J. M., Catanese, K. R., & Baumeister, R. F. (2003). Social exclusion and the deconstructed state: Time perception, meaninglessness, lethargy, lack of emotion, and self-awareness. Journal of Personality and Social Psychology, 85(3), 409–423. doi:10.1037/00223514.85.3.409
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DYSFUNCTIONAL RESPONSES TO EMOTION MEDIATE THE CROSS-SECTIONAL RELATIONSHIP BETWEEN REJECTION SENSITIVITY AND BORDERLINE PERSONALITY FEATURES Jessica R. Peters, MS, Laura M. Smart, MS, and Ruth A. Baer, PhD
A growing body of evidence has tied borderline personality disorder (BPD) to heightened sensitivity to rejection; however, mechanisms through which rejection sensitivity contributes to BPD features have not been identified. Rejection may lead to the dysfunctional emotion regulation strategies common in BPD, such as impulsive responses to distress, anger rumination, difficulties engaging in goal-oriented behavior, nonacceptance of emotions, and low emotional clarity. The present study used self-report measures and bootstrapping procedures to investigate the role of difficulties in emotional regulation in the relationship between rejection sensitivity and borderline personality features in a crosssectional sample of 410 undergraduates. Difficulties in emotion regulation accounted for significant variance in the relationships between rejection sensitivity and BPD features, with varying sets of deficits in emotion regulation skills accounting for associations with specific BPD features. Potential clinical implications and the need for replication in longitudinal studies are discussed.
Borderline personality disorder (BPD) is characterized by a diverse group of symptoms, including affective instability, identity disturbances, problems in relationships, and self-harm (American Psychiatric Association, 2000). BPD has been conceptualized as chronic emotion dysregulation; individuals with BPD or high in BPD features demonstrate the tendency to respond to negative emotions with numerous maladaptive strategies (Salsman & Linehan, 2012; Selby, Anestis, Bender, & Joiner, 2009). These include behaviors, such as impulsive and self-destructive actions (Bornovalova et al., 2005; Gratz, Breetz, & Tull, 2010; Peters, Upton, & Baer, 2013) and avoidance of goal-directed behavior (Gratz, Rosenthal, Tull, This was accepted under the editorship of Robert F. Krueger and John Livesley. From Department of Psychology, University of Kentucky, Lexington. Kentucky. Address correspondence to Jessica R. Peters, Department of Psychology, University of Kentucky, 111-J Kastle Hall, Lexington, KY 40506-0044; E-mail:[email protected]
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Lejuez, & Gunderson, 2006), as well as cognitive processes, such as rumination (Baer & Sauer, 2011) and decreased present-centered awareness and acceptance (Peters, Eisenlohr-Moul, Upton, & Baer, 2013). Understanding contributing factors to the emotion dysregulation in BPD is key to providing efficient, effective treatment. A growing body of evidence has tied BPD to heightened sensitivity to rejection (Downey & Feldman, 1996). Rejection sensitivity (RS) can be defined as the tendency to anxiously anticipate, readily identify experiences as, and overreact to rejection. Self-reported anxious anticipation and expectation of rejection has demonstrated very strong positive correlations with BPD symptoms (Gardner, Qualter, Styllanou, & Robinson, 2010) and BPD-related thoughts and feelings (Staebler, Helbing, Rosenbach, & Renneberg, 2010). Individuals with BPD, compared to those without, also have shown increased shame and negative affect in response to experiences of social rejection (Chapman, Walters, & Dixon Gordon, 2012). Despite the mounting evidence for an association between RS and BPD, the mechanisms underlying this relationship have not been identified. One possibility is that increased sensitivity to rejection, and subsequent difficulties responding to the induced negative affect, produce the difficulties observed in BPD. In non-clinical samples, experimental rejection inductions result in numerous negative outcomes that mirror the dys functional responses to distress characteristic of BPD, including immediate decreases in impulse control and self-regulation (Baumeister, DeWall, Ciarocco, & Twenge, 2005), rumination (Pearson, Watkins, & Mullan, 2011), increased anger and perceptions of hostility (DeWall, Twenge, Gitter, & Baumeister, 2009), and feelings of meaninglessness and reduced self-awareness (Twenge, Catanese, & Baumeister, 2003). In non-depressed individuals, rejection also serves as a cue for eventual emotion regulation via enhanced attunement toward positive information and attempts at social reconnection; however, individuals high in depressive symptoms do not demonstrate these effects (DeWall et al., 2011). For individuals with BPD, perhaps such normative regulatory responses to rejection are similarly not feasible. Instead, heightened reactivity to rejection may lead to prolonged impairment due to continued maladaptive responses to distress. Alternatively, increased sensitivity to rejection could account for the relationship between dysfunction responses to emotion and BPD features. Rejection sensitivity and emotion dysregulation may also be reciprocal processes underlying BPD. The present study provides a preliminary test of the hypothesis that rejection sensitivity, in particular, the tendency to anxiously anticipate and expect rejection, is associated with increased tendencies to engage in dysfunctional responses to negative affect, which accounts for the relationship between rejection sensitivity and BPD features. Given the multifaceted nature of BPD, features of the disorder were examined independently to determine whether different patterns of dysfunctional emotion regulation strategies would account for particular features. Due to the cross-
EMOTION REGULATION, REJECTION, AND BORDERLINE PERSONALITY233
sectional nature of the present investigation, it is crucial to consider alternative models. Accordingly, models with dysfunctional responses to emotion contributing to BPD features via increased rejection sensitivity were also explored.
METHODS PARTICIPANTS Participants were 451 psychology students (67.9% female, 80.8% White) at the University of Kentucky who completed an online survey including a number of self-report measures, only some of which were relevant to the present study (listed below; see Measures). Participants ranged in age from 18 to 38 years with a mean age of 19.19 years (SD = 2.09). Informed consent was obtained from all participants, and all study procedures were approved by the university’s institutional review board. Participant recruitment was designed to ensure that a wide range of BPD features would be represented; students with T-scores ≥ 70 on the borderline features scale of the Personality Assessment Inventory (PAI-BOR; Morey, 2007) comprised 18.3% of the final sample. Previous research shows that clinically significant BPD features are common in the undergraduate population (Trull, 1995; Trull, Useda, Conforti, & Doan, 1997). Clinical samples represent only the upper range of BPD severity, so the use of a student sample for the current study presented a wide range of characteristics associated with BPD and therefore more power to detect effects.
MEASURES Rejection Sensitivity. The Rejection Sensitivity Questionnaire (RSQ; Downey & Feldman, 1996) is an 18-item measure of the tendency to experience anxiety or concern about the possibility of being rejected and the extent to which an individual expects to be rejected. Respondents are provided 18 brief scenarios and are asked to what degree they think it is likely that they will be rejected (1 = very unlikely to 6 = very likely) and how concerned they are about the potential rejection (1 = very unconcerned to 6 = very concerned), providing two scores for each scenario. Scores from each question are averaged across scenarios to create two subscale scores, which were then averaged together to create a single mean score. See Table 1 for internal consistencies for all measures. BPD Features. The PAI-BOR (Morey, 2007) has 24 items measuring four aspects of BPD pathology: affective instability, identity problems, negative relationships, and self-harm. Participants are asked to respond to each statement on a 4-point scale ranging from 0 = false, not at all true to 3 = very true. In the present study, PAI-BOR scales were examined individually due to the heterogeneous nature of the disorder and to determine effects of rejection sensitivity on specific types of BPD features. Dysfunctional Responses to Emotion. The Difficulties in Emotion Regula-
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tion Scale (DERS; Gratz & Roemer, 2004) is a 36-item questionnaire assessing six dimensions of difficulties individuals may face in regulating emotions. These dimensions include: lack of awareness of emotional responses (e.g., “I pay attention to how I feel”—reverse-scored), lack of emotional clarity (e.g., “I have difficulty making sense out of my feeling), nonacceptance of emotional responses (e.g., “When I am upset, I feel ashamed with myself for feeling this way”), difficulties controlling impulses when experiencing negative emotions (e.g., “When I’m upset, I feel out of control”), difficulties engaging in goal-oriented behavior when experiencing negative emotions (e.g., “When I’m upset, I have difficulty concentrating), and limited access to effective emotion regulation skills (e.g., “When I am upset, I believe that there’s nothing I can do to make myself feel better”). Items are rated on a 5-point scale ranging from almost never to almost always. One dysfunctional response to negative affect that has been demonstrated to contribute to BPD features but is not assessed in the DERS is rumination (Selby et al., 2009). An assessment of anger rumination was chosen over assessments of more general rumination or other forms of rumination due to the stronger associations between anger rumination and BPD features (Baer & Sauer, 2011; Peters, Upton, Eisenlohr-Moul, et al., 2013). The Anger Rumination Scale (ARS; Sukhodolsky, Golub, & Cromwell, 2001) has 19 items assessing the tendency to focus attention on angry moods, recall past anger episodes, and think about the causes and consequence of anger episodes (e.g., “When something makes me angry, I turn this matter over and over again in my mind”). Participants rate each statement on a 4-point scale ranging from almost never to almost always.
DATA SCREENING A validity item was added to each instrument to assess whether participants were attending to item content and response scales. Validity items included prompts such as “Please choose ‘strongly disagree’ for this question.” Participants who incorrectly responded to two or more of the nine validity items (n = 40) were excluded from analyses; therefore, data from 411 were used in subsequent analyses.
RESULTS The results were analyzed using SPSS 20.0. Screening for skew and kurtosis showed that all variables fell within acceptable limits (Tabachnick & Fidell, 2000). Table 1 presents descriptive statistics for all study variables and zero-order correlations between study variables. All BPD scales were significantly correlated with the RSQ and all of the measures of dysfunctional responses to emotion. The majority of the DERS subscales and the ARS were significantly intercorrelated. With the
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(.81) .71*** .69*** .44*** .53*** .47*** .69*** .29*** .15** .71*** .44*** .45***
1
(.72) .68*** .35*** .54*** .52*** .52*** .52*** .12* .70*** .60*** .45***
2
(.71) .34*** .40*** .42*** .51*** .38*** .12* .59*** .60*** .41***
3
(.75) .35*** .33*** .49*** .31*** .19*** .40*** .28*** .22***
4
(.91) .45*** .55*** .45*** .11* .69*** .51*** .44***
5
(.82) .50*** .30*** .54*** .51*** .41*** .43***
6
(.77) .47*** .16** .72*** .54*** .39***
7
(.89) .00 .58*** .43*** .29***
8
(.84) .12* .04 .29***
9
(.91) .61*** .47***
10
(.95) .44***
11
(.86)
12
1.00 1.35 1.31 .83 2.20 2.30 1.97 2.92 2.56 2.11 1.79 6.79
Mean
.64 .63 .60 .57 .93 .77 .82 1.00 .80 .88 .57 2.49
SD
TABLE 1. Means, Standard Deviations, and Internal Consistencies of and Intercorrelations Between Study Variables (N = 411) Min–Max 0–2.67 0–3 0–3 0–3 1–5 1–4.80 1–5 1–5 1–5 1–5 1–4 1.32–18.01
BOR = Personality Assessment Inventory Borderline Features, AI = Affective Instability, ID = Identity Disturbances, NR = Negative Relationships, SH = Self-Harm; DERS = Difficulties in Emotion Regulation Scale, NA = Nonacceptance, LC = Lack of Emotional Clarity, ICD = Impulse Control Difficulties, DG = Difficulties in Goal-Related Behavior, LA = Lack of Emotional Awareness, LS = Limited Access to Strategies; ARS = Anger Rumination Scale; RSQ = Rejection Sensitivity Questionnaire. *p < .05, **p < .01, ***p < .001 for all tables.
1. BOR AI 2. BOR ID 3. BOR NR 4. BOR SH 5. DERS NA 6. DERS LC 7. DERS ICD 8. DERS DG 9. DERS LA 10. DERS LS 11. ARS 12. RSQ
Variable
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exception of the Lack of Emotional Clarity scale, the associations between the Lack of Strategies subscale and the other DERS subscales were significantly stronger than the other intercorrelations (t[408] = 3.64–11.61, p < .001). The ARS also demonstrated stronger associations with the Lack of Strategies subscale than with the other DERS scales (t[408] = 2.41– 6.44, p < .01 –< .001). These findings are unsurprising given that the Lack of Strategies scale assesses feelings that one does not have effective means for coping with distress and experiences those effects as overwhelming, which is probably accurate for individuals who tend to engage in other dysfunctional responses to emotions. Given both the empirical and theoretical overlap between the Lack of Strategies scale and the other forms of dysfunctional responses to emotion assessed, the Lack of Strategies scale was excluded from the following regression analyses, in order to limit the difficulties associated with multiple intercorrelated predictors. Age, gender, and race were uncorrelated with study variables with the exception of a small correlation between age and Impulse Control Difficulties (r = –.11, p < .05) and male gender and BPD negative relationships (r = .13, p < .05). Given this lack of associations between demographic variables and variables of interest, demographic variables were excluded from subsequent analyses. Hierarchical multiple regression models were estimated predicting each of the PAI-BOR scales (Table 2). The RSQ was entered in step 1 of each model and predicted a significant amount of variance in each BPD feature. In step 2 of each model, dysfunctional responses to emotion were added, including anger rumination, nonacceptance of emotion, lack of emotional awareness, lack of emotional clarity, difficulties in goal-directed behavior when upset, and impulse control difficulties when upset. The magnitude of the association between the RSQ and PAI-BOR scales was greatly reduced in the second step for all PAI-BOR scales, and a unique pattern of dysfunctional responses to emotion significantly predicted each PAI-BOR scale, with anger rumination, impulse control difficulties and difficulties in goal-directed behavior emerging as the most consistent predictors. Parallel bootstrapping procedures (Preacher & Hayes, 2004) were used to estimate indirect effects from the RSQ to PAI-BOR scales via dysfunctional emotion regulation strategies. For each PAI-BOR scale, indirect effects were estimated for each potential mediator with a significant beta weight in the regression model; other emotion regulation variables were entered as covariates. Difficulties in emotion regulation accounted for significant variance in the relationships between RSQ and all BPD features (95% CI estimates of total indirect effects were greater than 0 for all PAIBOR subscales); however, different patterns of indirect effects emerged across the PAI-BOR subscales. Impulse control difficulties, 95% confidence interval (CI) [.002, .023], difficulties engaging with goal-oriented behavior, 95% CI [.001, .010], and anger rumination, 95% CI [.014, .034], accounted for 79% of the relationship between the RSQ and BPD affective instability. Difficulties engaging
EMOTION REGULATION, REJECTION, AND BORDERLINE PERSONALITY237 TABLE 2. Summaries of Regression Models Predicting PAI-BOR Subscales (N = 411) Dependent Variable PAI-BOR Aff Inst
PAI-BOR Ident Dist
PAI-BOR Neg Rel
PAI-BOR Self-Harm
Step
Predictors
Beta
1 2
RSQ RSQ ARS NA DGB ICD LA LC
–.46*** –.09* –.30*** –.05 –.12** –.39*** –.02 –.03
RSQ RSQ ARS NA DGB ICD LA LC
–.45*** –.09* –.28*** –.14** –.21** –.04 –.09 –.27***
RSQ RSQ ARS NA DGB ICD LA LC
–.41*** –.11* –.39*** –.01 –.07 –.17** –.03 –.13*
RSQ RSQ ARS NA DGB ICD LA LC
–.22*** –.04 –.01 –.09 –.11* –.37*** –.13* –.03
1 2
1 2
1 2
R2 Change
R 2 for Model
.40***
.21*** .78***
Bootstrapped CI for Indirect Effect
.014, .034 .001, .010 .002, .023
.34***
.20*** .54***
.014, .035 .004, .017 .004–.018 .005, .019
.27***
.17*** .44***
.017, .042 .001, .014 .001, .012
.22***
.05*** .27*** –.001, .006 –.006, .010 .001, .014
BOR = Personality Assessment Inventory Borderline Features, AI = Affective Instability, ID = Identity Disturbances, NR = Negative Relationships, SH = Self-Harm; NA = Nonacceptance, LC = Lack of Emotional Clarity, LA = Lack of Emotional Awareness; ICD = Impulse Control Difficulties, DGB = Difficulties in Goal-Related Behavior; ARS = Anger Rumination Scale; RSQ = Rejection Sensitivity Questionnaire. *p < .05, ** p < .01, ***p < .001.
with goal-oriented behavior, 95% CI [.004, .018], nonacceptance of emotion, 95% CI [.004, .017], lack of emotional clarity, 95% CI [.005, .019], and anger rumination, 95% CI [.014, .035] accounted for 83% of the relationship between the RSQ and BPD identity disturbances. Impulse control difficulties, 95% CI [.001, .014], lack of emotional clarity, 95% CI [.001, .012], and anger rumination, 95% CI [.01, .042], accounted for 74% of the relationship between the RSQ and BPD negative relationships. Lack of emotional awareness, 95% CI [.001, .014] accounted for 97% of the relationship between the RSQ and BPD self-harm; indirect paths via impulse control difficulties, 95% CI [–.006, .010] and difficulties engaging with goal-oriented behavior, 95% CI [–.001, .006] were not significant. Alternative models with indirect paths from each of the dysfunctional
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responses to emotion via the RSQ to all four BPD features were also assessed. No significant indirect effects were observed for BPD affective instability or self-harm. Indirect effects from anger rumination via the RSQ were observed accounting for 8% of the total effect on identity disturbance, 95% CI [.006, .060] and 7% of the total effect on negative relationships, 95% CI [.008, .072] and from nonacceptance via the RSQ accounting for 12% of the total effect on identity disturbance, 95% CI [.002, .030].
DISCUSSION The aim of the present study was to explore how dysfunctional responses to emotion may account for the relationship between rejection sensitivity and BPD features. Dysfunctional responses to emotion accounted for a large proportion (74% to 97%) of the total effect of rejection sensitivity on all four BPD features: affective instability, identity disturbance, negative relationships, and self-harm. These findings demonstrate that while sensitivity to rejection may contribute to the full range of BPD symptoms, deficits in specific emotion regulation skills may explain how sensitivity to rejection increases vulnerability to particular components of the disorder. When alternative models were examined, in which dysfunctional responses to emotion contribute to BPD features via rejection sensitivity, few significant indirect effects were observed, and the proportion of the total effect accounted for was much smaller (7% to 12%). Anger rumination in particular demonstrated an indirect effect via rejection sensitivity to two areas of BPD features; this aspect of dysfunctional responses to emotion may be particularly reciprocal with rejection sensitivity. That said, the much smaller effect sizes of the alternative model’s indirect effects show that our original model has substantially stronger support, at least in our sample. Different sets of specific dysfunctional responses to emotion accounted for a significant proportion of the relationship between rejection sensitivity and BPD features for each symptom cluster. These findings provide additional support to a growing literature demonstrating differential associations among BPD features (e.g. Geiger, Peters, Sauer-Zavala, & Baer, 2013; Peters, Eisenlohr-Moul, et al., 2013; Stepp, Epler, Jahng, & Trull, 2008), suggesting the necessity of operationalizing BPD as a cluster of distinct features rather than a unitary characteristic. The student sample used in the current study limits generalizability to clinical settings; further research with clinical samples and longitudinal designs is recommended to examine potential clinical implications, such as the utility of targeting various dysfunctional responses to emotion based on symptom profiles. For example, reducing anger rumination and increasing goaldirected behavior under distress may diminish the effects of rejection sensitivity on both affective instability and identity disturbance; in contrast, increasing impulse control may be more important in stabilizing affective responses to anticipated rejection, and acceptance of emotions may be more important in reducing the impact of rejection on identity problems.
EMOTION REGULATION, REJECTION, AND BORDERLINE PERSONALITY239
A major limitation of the current study is the cross-sectional nature of the research, since mediation cannot be tested with these methods. These preliminary findings warrant further examination via longitudinal and experimental studies to explore potential mediational relationships. Using measures of rejection sensitivity beyond self-report, such as behavioral and physiological responses to rejection inductions, is also recommended. The current study used a student sample, so investigating these constructs in community and clinical samples would improve generalizability.
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