Journal of Affective Disorders 157 (2014) 52–59

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Research report

Emotion regulation strategies in bipolar II disorder and borderline personality disorder: Differences and relationships with perceived parental style Kathryn Fletcher a,b,n, Gordon Parker a,b, Adam Bayes a,b, Amelia Paterson a,b, Georgia McClure a,b a b

School of Psychiatry, University of New South Wales, NSW, Australia Black Dog Institute, Hospital Road, Randwick, NSW 2031, Australia

art ic l e i nf o

a b s t r a c t

Article history: Received 25 November 2013 Received in revised form 3 January 2014 Accepted 3 January 2014 Available online 10 January 2014

Background: Bipolar II disorder (BP II) and Borderline Personality Disorder (BPD) share common features and can be difficult to differentiate, contributing to misdiagnosis and inappropriate treatment. Research contrasting phenomenological features of both conditions is limited. The current study sought to identify differences in emotion regulation strategies in BP II and BPD in addition to examining relationships with perceived parental style. Method: Participants were recruited from a variety of outpatient and community settings. Eligible participants required a clinical diagnosis of BP II or BPD, subsequently confirmed via structured diagnostic interviews assessing DSM-IV criteria. Participants completed a series of self-reported questionnaires assessing emotion regulation strategies and perceived parental style. Results: The sample comprised 48 (n ¼ 24 BP II and n ¼ 24 BPD) age and gender-matched participants. Those with BPD were significantly more likely to use maladaptive emotion regulation strategies, less likely to use adaptive emotion regulation strategies, and scored significantly higher on the majority of (perceived) dysfunctional parenting sub-scales than participants with BP II. Dysfunctional parenting experiences were related to maladaptive emotion regulation strategies in participants with BP II and BPD, however differential associations were observed across groups. Limitations: Relatively small sample sizes; lack of a healthy control comparator group; lack of statistical control for differing sociodemographic and clinical characteristics, medication and psychological treatments; no assessment of state or trait anxiety; over-representation of females in both groups limiting generalisability of results; and reliance on self-report measures. Conclusions: Differences in emotion regulation strategies and perceived parental style provide some support for the validity of distinguishing BP II and BPD. Development of intervention strategies targeting the differing forms of emotion regulatory pathology in these groups may be warranted. & 2014 Elsevier B.V. All rights reserved.

Keywords: Borderline personality disorder Bipolar II disorder Emotion regulation Parental style

1. Introduction Bipolar disorder (BP) and borderline personality disorder (BPD) are commonly misdiagnosed (Zimmerman et al., 2010), compromising subsequent treatment and patient outcomes. In a recent study, almost 40% of psychiatric outpatients diagnosed with BPD had been overdiagnosed with BP (Zimmerman et al., 2010). As overviewed previously, differentiation between the two conditions is difficult due to several shared phenomenological features (Bayes et al., 2014). Such features include ‘affect storms’ in BPD resembling hypomania (Kernberg and Yeomans, 2013), the chronic nature of BP II (Ayuso-

n Corresponding author at: Black Dog Institute, Hospital Road, Randwick, NSW 2031, Australia. Tel.: þ 61 2 9382 3708; fax: þ 61 2 9382 8207. E-mail address: k.fl[email protected] (K. Fletcher).

0165-0327/$ - see front matter & 2014 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2014.01.001

Gutierrez and Ramos-Brieva, 1982; Cassano and Savino, 1997; Benazzi, 2001, 2007; Vieta et al., 1997; Mantere et al., 2008; Baek et al., 2011; Judd et al., 2002, 2003a, 2003b, 2003c, 2005) as for BPD, and the shared features of impulsivity and emotion dysregulation (ED) (Bayes et al., 2014). Clinical differentiation is seemingly more difficult in differentiating BPD from the bipolar II sub-type (BP II), due in part to the absence of psychotic features in BP II, arguing for a focus on how best to discriminate these two conditions. A recent review of the co-occurrence of BPD and BP disorders concluded that there appears to be a stronger association between BPD and BP II disorder than BP I disorder, highlighting the need for direct comparisons between BPD and the BP II sub-type specifically (Zimmerman and Morgan, 2013). Very few studies have sought to identify discriminating features for BPD and BP II, as overviewed previously (Parker, 2011).

K. Fletcher et al. / Journal of Affective Disorders 157 (2014) 52–59

In a recent large-scale comparison of depressed outpatients diagnosed with BP II or BPD, the latter group had significantly poorer social functioning, higher rates of post-traumatic stress disorder and substance use disorders, more suicidal ideation and attempts, and reported more anger, paranoid ideation and somatisation (Zimmerman et al., 2013). The authors concluded that such findings supported the validity of the two as separate conditions, in contrast to previous suggestions that BPD exists on the bipolar spectrum (MacKinnon and Pies, 2006; Angst et al., 2011; Akiskal, 2004; Perugi et al., 2003; Smith et al., 2005; Perugi et al., 2011). We recently reviewed studies contrasting BP (I or II) and BPD features, focusing specifically on studies delineating the BP II subtype (Bayes et al., 2014). Non-specific features included subtle differences in impulsivity profiles, treatment response, childhood trauma, self-harm rates, neurocognitive features and comorbidity profiles. However, the review identified a series of key differentiating features for BP II disorder including (i) a family history of BP, (ii) a distinctive onset period for depression, (iii) failure of the condition to remit over time, (iv) phenomenological differences in depressive features (e.g. melancholic, agitated and mixed symptoms being over-represented) and elevated mood states (e.g. prolonged elation with little or no anxiety, increased energy, creativity, grandiosity and productivity, episodic irritability/anger during hypomania) and (v) differences in emotion dysregulation (ED). The latter included those with BP II experiencing more frequent and intense shifts between euthymia, depression and elation; whereas those with BPD tend to experience more frequent and intense lability between euthymia, anxiety, anger and depression (Reich et al., 2012).

1.1. Emotion dysregulation (ED) ED is a core feature of BPD but can also be present in BP II. ED has been variably defined, with some equating ED with temperamentallybased emotional intensity or reactivity (Livesley et al., 1998), whilst others differentiate ED by the quality of the emotional response (Linehan, 1993; Thompson and Calkins, 1996). More recently, ED is considered to be distinguishable from temperamental emotional vulnerability (see Mennin et al., 2005), and referring more broadly to the use of maladaptive strategies in response to emotional distress (Gratz and Roemer, 2004). Gross (1998) defines emotion regulation as the “processes by which individuals influence which emotions they have, how they have them, and how they experience and express these emotions” (p275), regarding such processes as automatic or controlled at an unconscious or conscious level. The current study adopts this definition, whereby ED is considered as a multidimensional construct which can involve reduced awareness, understanding, and acceptance of emotions; lack of access to adaptive strategies for modulating the intensity and/or duration of emotional responses; an unwillingness to experience emotional distress during pursuit of desired goals; and an inability to engage in goal-directed behaviours when experiencing emotional distress (Gratz and Roemer, 2004). Despite the central role of ED in both BPD and BP II, we are not aware of any studies to date that have directly compared these groups in terms of the self-reported strategies used to regulate emotions. Studies assessing such groups separately are now briefly overviewed. Poor affect evaluation and tolerance of negative and neutral stimuli is well documented in individuals with BPD (Donegan et al., 2003; Stern et al., 1997), coupled with a tendency to make negative interpretations of interpersonal interactions (Renaud et al., 2012). Individuals with BPD have difficulty using the cognitive strategies of reappraisal and suppression to regulate intense affect (Paris, 2012), while thought suppression has been

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associated with the frequency of self-harm behaviours in this group (Chapman et al., 2005). Other studies contrasting those with BPD and healthy controls reported lower emotional awareness (i.e. inability to differentiate emotions in self and others) and clarity (i.e. limited understanding of the nature of their emotions) (Levine et al., 1997, Leible and Snell, 2004), along with a greater tendency to use avoidant regulation strategies (Bijttebier and Vertommem, 1999) in the BPD group. In an experimental investigation, those with BPD were less willing than healthy controls to experience distress in order to pursue goal-related behaviour, however did not evidence greater difficulties engaging in such behaviour when distressed (Gratz et al., 2006) – with the latter finding suggesting that particular aspects of ED may be more or less relevant to BPD. In a study contrasting emotion regulation strategies in individuals with BPD and those with dysthymia, the BPD subjects tended to employ a range of maladaptive strategies including internalising, externalising, emotional avoidance and disorganised strategies suggesting desperate, flailing and impulsive attempts to escape psychological pain (Conklin et al., 2006). Studies examining emotion regulation difficulties in BP have generally focused on the BP I sub-type or combined BP sub-types in their analyses. As overviewed previously (Fletcher et al., 2013), studies investigating cognitive emotion regulation in BP and healthy controls have reported more frequent use of maladaptive coping strategies in response to negative life events in those with BP (Green et al., 2011), including a greater tendency to ruminate about negative affect (Johnson, et al., 2008; Gruber et al., 2011) and engage in suppression (i.e. inhibit emotion-expressive behaviour) (Gruber et al., 2012). In a study examining coping profiles in the bipolar sub-types, those with BP II were significantly more likely to use maladaptive cognitive emotion regulation strategies (e.g. self-blame, rumination, catastrophising, blaming others) and less likely to use adaptive strategies (e.g. positive re-focusing, planning, positive reappraisal, putting into perspective) than healthy controls (Fletcher et al., 2013). 1.2. The role of developmental factors in ED Developmental factors can increase the risk of ED and, consequently BPD (Linehan, 1993). Linehan (1993) proposed that an invalidating developmental context (characterised by caregiver intolerance toward expression of emotion, coupled with intermittent reinforcement of extreme expressions of emotion) results in the child being unable to understand, label, regulate or tolerate emotional responses. This in turn leads to oscillations between emotional inhibition and extreme emotional lability, and an inability to solve the problems contributing to such emotional reactions. Similarly, adverse events during childhood (e.g. ongoing experiences of neglect or abuse) may be causally linked to ED, driving dysfunctional behaviours and interpersonal conflict that further reinforce ED (Skodol et al., 2002). This pattern is likely to persist into adulthood, and be associated with ongoing difficulties in regulating emotions. As overviewed by Laulik et al. (2013), unpredictable and intrusive parenting received during childhood has been associated with BPD (Paris, 1996; Reich and Zanarini, 2001), and preoccupied patterns of attachment are overrepresented in this group (Fonagy et al., 1996). Indeed, childhood maltreatment (comprising various forms of abuse or neglect) is considered to be the most widely validated psychosocial risk factor for BPD (Keinanen et al., 2012). Similarly for mood disorders, early adverse experiences are hypothesised to have long-lasting consequences on neurochemistry, brain structure and affective behaviour (Alloy et al., 2006). Maltreatment is thought to interfere with the child0 s ability to regulate their emotions by promoting chronic arousal, while the family environment fails to provide the child with learning

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K. Fletcher et al. / Journal of Affective Disorders 157 (2014) 52–59

opportunities to develop emotion regulation skills (Cloitre, 1998). However, few studies have examined these aspects in bipolar disorder, and findings are mixed. There is some suggestion of parenting characterised by low warmth and acceptance, high overprotection, poor attachment relations and childhood abuse in this group, with such features associated with a worse illness course (Alloy et al., 2005; Miklowitz, 2007). A recent study investigating family characteristics prior to age 16 in a large sample of bipolar patients and healthy controls reported that parental psychopathology (paternal substance use, and maternal depression in particular) and poor relationships with parents were associated with a distinct increased risk for bipolar illness, and explained 65% of the variance in outcome (Chen et al., 2013). While the link between early maladaptive attachment relationships and longer-term emotion regulation difficulties appears relevant for both BPD and BP II, associations between these factors have not been formally examined and compared in these groups. 1.3. Study aims The current study had two aims. First, to determine whether bipolar II and BPD groups differ in terms of emotion regulation strategies and perceived parenting style. Second, to examine the associations between emotion regulation strategies and perceived parenting style in both groups. Identification of features that differentiate between the two conditions would assist with both diagnostic clarification and development of intervention strategies targeting the differing forms of emotion regulatory pathology.

2. Methods 2.1. Sample Participants were recruited from two tertiary referral mood disorder clinics (Black Dog Institute Depression Clinic, Lawson Clinic) (n ¼30), two private outpatient hospital clinics (The Sydney Clinic, Wesley Hospital) (n¼ 5), two public outpatient hospital clinics (Cumberland Hospital, Prince of Wales Hospital) (n¼ 11) and from the general community via newspaper advertisements (n ¼2). Written informed consent was obtained as per the requirements of the human research ethics committees of the University of New South Wales and the South Eastern Sydney Local Health District. Participants were eligible for screening if they had received a prior clinical diagnosis (from a general practitioner or psychiatrist) of BP II or BPD. Participants were invited to complete a series of self-report questionnaires (detailed below) prior to their clinical assessment with the study psychiatrist (AB). Structured clinical interviews were conducted to confirm participants met formal DSM-IV criteria for BP II or BPD. Participants were included in the BP II study sample if there was concordance between clinician diagnosis and DSM-IV diagnosis derived from the MINI International Neuropsychiatric Interview (MINI; Sheehan et al., 1998). Similarly, the BPD study sample comprised those where concordance was achieved between clinician diagnosis and DSM-IV diagnosis, derived from the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV) (Zanarini et al., 1996). Participants were excluded if: (i) clinician diagnosis and DSM-IV diagnosis differed; (ii) DSM-IV criteria for both BP II and BPD were met; (iii) unable to provide written informed consent or comprehend English; (iv) less than 18 years of age; (v) currently experiencing psychosis or substance dependence (assessed by study clinician); (vi) co-morbid Axis I disorders (excluding major depressive disorder and anxiety disorders) present, e.g. ADHD, autism

spectrum disorders, eating disorders, schizophrenia (assessed by study psychiatrist); and (vii) co-morbid Axis II disorders (excluding BPD) or organic conditions were present (assessed by study psychiatrist). Demographic details including mood disorder history were collected as part of the clinical assessment. 2.2. Self-report questionnaires 2.2.1. Emotion regulation The Cognitive Emotion Regulation Questionnaire (CERQ; Garnefski et al., 2001) is a 36-item measure assessing nine cognitive strategies (both functional and dysfunctional) for regulating emotion in response to threatening or stressful life events: (1) self-blame (CERQ-SelfBlame) (e.g. ‘I feel that I am the one to blame for it’), (2) acceptance (CERQ-Accept) (e.g. ‘I think that I have to accept the situation’), (3) rumination (CERQRumination) (e.g. ‘I dwell upon the feelings the situation has evoked in me’), (4) positive refocusing (CERQ-PosRefocus) (e.g. ‘I think about pleasant experiences’), (5) planning (CERQ-Planning) (e.g. ‘I think about a plan of what I can do best’), (6) positive reappraisal (CERQ-PosReapp) (e.g. ‘I think I can learn something from the situation’), (7) putting into perspective (CERQ-Perspective) (e.g. ‘I tell myself there are worse things in life’), (8) catastrophising (CERQ-catastrophise) (e.g. ‘I continually think how horrible the situation has been’), (9) otherblame (CERQ-Blame) (e.g. ‘I feel that others are to blame for it’). Each strategy is rated on a 5-point scale (1 ¼ ‘Almost never’; 5 ¼ ‘Almost always’), with higher scores indicating more frequent use. CERQ sub-scales have acceptable internal consistency, ranging from α ¼.68 to α ¼.86 (Garnefski and Kraaij, 2006). Cognitive emotion regulation strategies have been shown to account for considerable amounts of variance in emotional problems, supporting its factorial validity (Garnefski and Kraaij, 2007). Furthermore, the cognitive strategies of self-blame, rumination, catastrophising and positive appraisal correlate with symptoms of depression and anxiety at baseline and follow-up (Garnefski and Kraaij, 2007). The Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, 2004) is a 36-item measure assessing six strategies to regulate emotion: (i) non-acceptance of emotional response (DERSNonAccept) (e.g. ‘When I’m upset, I feel guilty for feeling that way’), (ii) difficulties in adopting goal-directed behaviours (DERS-Goals) (e.g. ‘When I’m upset, I have difficulty concentrating’), (iii) difficulties in controlling impulsive behaviours (DERS-Impulse) (e.g. ‘When I’m upset, I become out of control’), (iv) limited access to emotion regulation strategies (DERS-Strategy) (e.g. ‘When I’m upset, it takes me a long time to feel better’), (v) lack of emotional identification or clarity (DERS-Clarity) (e.g. ‘I am confused about how I feel’), and (vi) lack of emotional awareness (DERS-Aware) (e.g. ‘I pay attention to how I feel’ [reversed]). Each strategy is rated on a 5-point scale (1¼‘Almost never’; 5¼‘Almost always’), with higher scores indicating more frequent use. The development study (Gratz and Roemer, 2004) quantified internal consistency for each sub-scale in the order of .80 or higher, while test-retest reliability was high (ICC¼.88 for total scale score). 2.2.2. Perceived parental style The Measure of Parental Style (MOPS) (Parker et al., 1997) is an abbreviated version of the Parental Bonding Index (PBI; Parker et al., 1979) but with an additional ‘abuse’ scale (Parker, 1989). The MOPS assesses perceived parental styles (with responses obtained separately for the mother and father) during the first 16 years of the respondent0 s life across three domains: abuse (psychological, emotional, or physical) (Mo-Abuse, Fa-Abuse) (e.g. ‘physically violent or abusive of me’), indifference (Mo-Indifference, Fa-Indifference) (e.g.

K. Fletcher et al. / Journal of Affective Disorders 157 (2014) 52–59

‘uninterested in me’) and over-control (Mo-Control, Fa-Control) (e.g. ‘overprotective of me’). Each item is answered on a 4-point scale (0¼‘Not true at all’, 3¼‘Extremely true’). Higher scores indicate more dysfunctional parenting. The measure has been validated in clinical samples of outpatients with depressive and anxiety disorders, with internal consistencies for each sub-scale ranging in α0 s from .76 to .93 (Parker et al., 1997).

2.2.3. Depressive symptoms Current depression severity was quantified via the Quick Inventory of Depressive Symptoms – Self Report (QIDS-SR16; Rush et al., 2003). The QIDS-SR16 includes all DSM-IV criterion symptoms for major depressive disorder (MDD), each rated on a 0–3 scale (higher scores¼ more severe) over the past 7 days. High internal consistency (α ¼.86) was reported in an outpatient sample of individuals with chronic MDD (Rush et al., 2003). The QIDS-SR is sensitive to symptom change and concurrent validity has been established (Trivedi et al., 2004) with the Medical Outcomes Study 12-item Short Form (SF-12), a self-report measure of physical and mental functioning (Ware et al., 1996).

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3. Results 3.1. Sociodemographic and clinical profile A total of 90 participants (n¼ 66 BP II, n¼ 24 BPD) were eligible to participate in the study. Females were over-represented in the BPD group relative to the BP II group (87.5% vs. 50.0%) and BPD subjects were slightly older (36.7 vs. 32.8), thus participants were age and gender-matched for subsequent analyses. The final study sample comprised 48 participants (n ¼ 24 BP II, n¼ 24 BPD), with a mean age of 32.9 (SD ¼ 11.3). Sociodemographic details are outlined in Table 1. Marital status and highest level of education were comparable between groups, however participants with BPD were significantly more likely to be unemployed. Clinical profiles (Table 1) differed between groups – those with BPD reported a younger age of depression onset, while a significantly higher proportion of this group relative to those with BP II reported lifetime suicide and intentional self-harm attempts. In terms of current depression severity, QIDS-SR scores were significantly higher in the BPD group. Family history of depression and bipolar disorder were comparable between groups.

2.3. Statistical analyses 3.2. Emotion regulation and perceived parental style in BP II and BPD Groups were compared on socio-demographic variables using t-tests for continuous dependent variables, and the chi square statistic for categorical dependent variables. DERS, CERQ and MOPS sub-scale score comparisons (with Bonferroni post-hoc corrections) were undertaken using one-way between-groups analysis of covariance (ANCOVAs), with diagnosis as the independent variable and with current depression severity (QIDS-SR) entered as a covariate. Partial correlations were used to examine relationships between MOPS, DERS and CERQ sub-scale scores, controlling for current depression severity.

DERS, CERQ and MOPS scores were compared between groups (Table 2), controlling for current depression severity. Those with BPD scored significantly higher on two DERS sub-scales (DERSImpulse, DERS-Strategy), three CERQ sub-scales (CERQ-SelfBlame, CERQ-Catastrophise, CERQ-Blame) and five of the six MOPS sub-scales (Mo-Indifference, Mo-Abuse, Mo-Control, Fa-Abuse, Fa-Control). Significantly lower sub-scale scores were quantified in the BPD group relative to the BP II group for CERQ-Planning, CERQ-PosReapp and CERQ-Perspective.

Table 1 Sociodemographic and clinical profile. BP II (n¼24)

BPD (n¼ 24)

Test 2

p-value

Marital status – n (%) Divorced Separated Married or defacto Never married Employment statusa – n (%) Employed (full time or part-time) Unemployed Retired/Pensioner Student Home duties Highest level of education – n (%) Some secondary/some high school completed Completed secondary/high school Diploma/advanced diploma Bachelor degree Graduate diploma/graduate certificate Postgraduate degree Age of depression onsetb – mean (SD) Lifetime suicide attempt – n (% yes) Ever intentionally self-harmedc – n (% yes) Family history of depressionc – n (% yes) Family history of bipolar disorderc – n (% yes)

1 (4.2) 2 (8.3) 9 (37.5) 12 (50.0)

1 (4.2) 1 (4.2) 6 (25.0) 16 (66.6)

χ ¼ 1.5

.68

14 (58.3) 3 (12.5) 0 (.0) 6 (25.0) 1 (4.2)

4 (16.7) 11 (45.8) 1 (4.2) 6 (25.0) 2 (8.3)

χ2 ¼ 11.5

.02

3 (12.5) 6 (25.0) 3 (12.5) 6 (25.0) 1 (4.2) 5 (20.8) 16.8 (5.2) 7 (29.2) 11 (47.8) 16 (72.7) 9 (39.1)

3 (12.5) 7 (29.2) 6 (25.0) 4 (16.7) 2 (8.3) 2 (8.3) 13.3 (4.2) 16 (66.7) 20 (83.3) 16 (66.7) 6 (26.1)

χ2 ¼ 3.1

.68

t ¼2.5 χ2 ¼ 6.8 χ2 ¼ 6.6 χ2 ¼ .2 χ2 ¼ .9

.02 .01 .01 .65 .34

QIDS-SR – mean score (SD)

9.4 (5.7)

13.4 (11.3)

t ¼  2.5

.02

a b c

Includes participants receiving disability pension/sickness benefits (n¼ 8). Data missing for n¼ 1. Data missing for n ¼2.

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K. Fletcher et al. / Journal of Affective Disorders 157 (2014) 52–59

Table 2 Emotion regulation scores controlling for current depression severity – estimated marginal means. p-value

Effect sizea

.9 1.3 4.6 4.6 3.9 1.3

.34 .26 .04 .04 .05 .25

.02 .03 .09 .09 .08 .03

(.3) (.6) (.7) (.7) (.7) (.8) (.8) (.7) (.6)

5.7 .7 .1 2.1 4.6 6.5 5.9 8.3 8.0

.02 .42 .76 .16 .04 .01 .02 .01 .01

.11 .01 .00 .04 .09 .13 .11 .16 .15

(1.3) (.9) (.7) (1.2) (1.1) (.6)

5.1 15.8 8.1 2.7 5.9 12.7

.03 .00 .01 .11 .02 .00

.11 .28 .16 .06 .12 .24

BP II (n¼24) Mean (SE)

BPD (n ¼24) Mean (SE)

DERS-NonAccept DERS-Goals DERS-Impulse DERS-Strategy DERS-Clarity DERS-Aware

18.0 18.2 15.2 22.4 14.3 16.7

(1.4) (.7) (1.2) (1.4) (.8) (.9)

19.9 19.4 19.0 26.8 16.5 18.2

(1.4) (.7) (1.2) (1.4) (.8) (.9)

CERQ-SelfBlame CERQ-Accept CERQ-Rumination CERQ-PosRefocus CERQ-Planning CERQ-PosReapp CERQ-Perspective CERQ-Catastrophise CERQ-Blame

12.3 13.4 13.1 8.6 12.0 12.3 12.9 8.8 7.9

(.7) (.6) (.7) (.7) (.7) (.8) (.8) (.7) (.6)

14.6 12.6 13.3 7.1 9.8 9.3 10.1 11.8 10.5

3.5 1.6 3.4 4.9 2.2 1.8

(1.3) (1.0) (.7) (1.2) (1.1) (.6)

7.7 7.2 6.5 7.8 5.9 5.2

Mo-Indifferenceb Mo-Abuseb Mo-Controlb Fa-Indifferenceb Fa-Abuseb Fa-Controlb a b

F

Effect size ¼ partial eta squared. Data available for n¼22 BP II, n ¼22 BPD.

Table 3 MOPS relationships (partial correlations) with emotion regulation measures: BP II (n¼ 22). Mo-Indifference

Mo-Abuse

Mo-Control

Fa-Indifference

Fa-Abuse

Fa-Control

DERS-NonAccept DERS-Goals DERS-Impulse DERS-Strategy DERS-Clarity DERS-Aware

 .09  .02 .09  .05 .05 .43

.43 .10 .42 .32  .13 .33

.25 .07 .13 .34  .01 .02

 .09  .11  .15  .19  .39 .38

.41 .26 .43 .37  .23 .39

.42 .36 .51n .40  .00 .35

CERQ-SelfBlame CERQ-Accept CERQ-Rumination CERQ-PosRefocus CERQ-Planning CERQ-PosReapp CERQ-Perspective CERQ-Catastrophise CERQ-Blame

.32  .03  .30  .21  .30  .11  .29 .10 .01

.29  .27 .05  .31  .29  .27  .37 .13 .14

.44  .06 .26  .13  .15 .05  .10  .09 .27

 .08 .04  .53n .09 .11 .20  .10  .10  .27

.19  .14 .05  .27  .19  .23  .31  .02  .16

.21  .22 .02  .45n  .25  .36  .45n .10  .00

n

po .05.

3.3. Relationships between perceived parental style and emotion regulation MOPS data were available for 44 participants (n ¼22 BP II, n ¼22 BPD). In the BP II sample (Table 3), a positive association was quantified between DERS-Impulse and Fa-Control (p ¼.02), while negative associations were quantified between CERQ-PosRefocus, CERQ-Perspective and Fa-Control (both p ¼.04). CERQ-Rumination was negatively associated with Fa-Indifference (p ¼.02). In the BPD sample (Table 4), CERQ-Accept was negatively associated with Fa-Abuse (p ¼.03). A positive association was quantified between CERQ-Catastrophise and Mo-Control (p ¼.02). Finally, CERQ-Blame was positively associated with Mo-Abuse (p ¼.02), Mo-Control (p ¼.01) and Fa-Indifference (p ¼.01).

4. Discussion As overviewed by Koole (2009), emotion regulation is associated with positive mental health outcomes (Gross and Munoz,

1995), increased physical health (Sapolsky, 2007), relationship satisfaction (Murray, 2005) and work performance (Diefendorff et al., 2000). Emotion dysregulation underpins both BPD and BP II, however knowledge regarding the use of strategies to regulate emotions in these groups is sparse. A range of maladaptive and adaptive emotion regulation strategies were contrasted between BPD and BP II participants. A differing emotion regulation profile was observed between groups. Overall, BPD participants scored significantly higher than those with BP II on a number of maladaptive emotion regulation strategies, including difficulty controlling impulsive behaviours, having limited access to emotion regulation strategies, and a tendency to self-blame, catastrophise and blame others. In addition, those with BPD were significantly less likely than those with BP II to use adaptive cognitive emotion regulation strategies including planning, positive re-appraisal and putting things into perspective. This profile is broadly consistent with previous studies of emotion regulation in BPD patients, characterised by maladaptive strategies including internalising, externalising, avoidance, use of disorganised and impulsive strategies, and

K. Fletcher et al. / Journal of Affective Disorders 157 (2014) 52–59

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Table 4 MOPS relationships (partial correlations) with emotion regulation measures: BPD (n¼ 22). Mo-Indifference

Mo-Abuse

Mo-Control

Fa-Indifference

Fa-Abuse

Fa-Control

DERS-NonAccept DERS-Goals DERS-Impulse DERS-Strategy DERS-Clarity DERS-Aware CERQ-SelfBlame

 .02 .12  .14 .09 .13 .23 .05

 .15  .10  .03 .04 .26 .17 .08

 .20 .00 .07 .05 .14 .07 .40

 .10  .23  .28 .14 .21 .05  .28

 .04  .29  .18 .11 .30 .12  .37

.02  .25  .27 .11 .22 .22  .04

CERQ-Accept CERQ-Rumination CERQ-PosRefocus CERQ-Planning CERQ-PosReapp CERQ-Perspective CERQ-Catastrophise CERQ-Blame

 .17  .23  .42  .10  .29  .09 .34 .23

 .11  .23  .32  .08  .16  .13 .36 .49n

.07  .02  .13 .11  .05 .01 .50n .54n

 .30  .36  .38  .24  .41  .39 .26 .56n

 .48n  .30  .19  .10  .42  .18 .04 .30

 .22  .06  .27  .19  .42  .29 .08 .12

n

po .05.

difficulties using adaptive strategies such as re-appraisal to regulate intense affect (e.g. Conklin et al., 2006; Bijttebier and Vertommem, 1999; Gratz et al., 2006; Paris, 2012). As noted earlier, disrupted attachment relationships during childhood are a theorised precursor to enduring emotion regulation difficulties. Perceived parental style was contrasted in BP II and BPD groups, and associations with emotion regulation strategies were examined. Those with BPD scored significantly higher on the majority of the perceived parental style sub-scales, indicating a maternal relationship characterised by indifference, abuse, and over-control and a perceived paternal relationship characterised by abuse and over-control. These results are consistent with reports of dysfunctional parenting styles of parents of those with BPD as negative, uncaring, over-controlling and over-protective, lacking in empathy and affection, conflictual, invalidating and critical, less nurturing, under-involved and emotionally withholding (Sansone and Sansone, 2009). Higher rates of unfavourable parenting in BPD relative to controls and other psychiatric conditions have been reported in a number of studies (e.g. Bandelow et al., 2005; Lobbestael et al., 2005; Zanarini et al., 2000). While rates of childhood trauma (i.e. emotional, physical or sexual abuse) are high in both BP and BPD – in the order of 50% and 60–80%, respectively – these groups may differ in terms of the form of the trauma experienced and/or their vulnerability to these experiences (Bassett, 2012). This is an area that requires further investigation, particularly with respect to those with a BP II condition. Differential relationships between perceived parental style and emotion regulation strategies were observed across BPD and BP II participants. Dysfunctional maternal relationships were uniquely related to maladaptive emotion regulation strategies in BPD participants. Specifically, an abusive maternal relationship was significantly associated with increased self-blame, while an overcontrolling maternal relationship was related to an increased tendency to catastrophise and blame others. While studies have generally not teased out the role of dysfunctional parenting received from the mother vs. the father, one study reported that only the combination of maternal inconsistency and maternal over-involvement predicted BPD in an adolescent sample (Bezirganian et al., 1993). However, links with emotion regulation were not assessed in this study. In relation to the father, dysfunctional paternal relationships were relevant to emotion regulation strategies in both BPD and BP-2 groups, however some unique relationships were observed across groups. In BPD participants, an abusive paternal relationship was associated with a reduced tendency to use the adaptive emotion regulation strategy of acceptance. In BP II participants,

an over-controlling father was negatively associated with the adaptive cognitive emotion regulation strategies of positive refocusing and putting things into perspective, and associated with increased difficulties in controlling impulsive behaviours. Finally, while paternal relationships characterised by indifference were relevant for both BPD and BP II groups, differential associations were observed – including an increased tendency to blame others in BPD and increased tendency to ruminate in BP II. The relationships observed between perceived dysfunctional parenting and maladaptive emotion regulation strategies are broadly consistent with theoretical perspectives for BPD (Linehan, 1993; Livesley et al., 1998; Westen, 1991) and literature suggesting that exposure to certain types of parenting practices or maltreatment during childhood increases vulnerability to mood disorders (see Alloy et al., 2006 for a review). However, results were correlational, based on a cross-sectional study design. Longitudinal prospective follow-up studies in BPD and BP II are needed to clarify such relationships, as it is unclear whether results reflect scarring effects of illness or pre-morbid factors. Such studies would also assist in determining whether there is a causal link between dysfunctional parenting and emotion regulation difficulties in adulthood. Furthermore, the development of BPD and BP II is likely to be mediated through multiple pathways attributed to several risk factors (Chen et al., 2013), with the current study only focusing on one such factor. Indeed, emotion regulation difficulties are not entirely the result of traumatic experiences, and are likely to represent a heritable variation in cognitive processing exaggerated by adverse life events. Geneenvironment interactions in BPD and BP II and their associations with emotion dysregulation is a fruitful area for future investigation, particularly in light of the high heritability of both conditions. This is the first study to quantify differences in emotion regulation strategies and perceived parental style in BP II and BPD, providing some further support for the validity of positioning of BP II and BPD as separate conditions. The study had a number of strengths, including clearly defined diagnostic groups allowing for identification of differentiating features, an age- and gendermatched sample, and statistically controlling for current depression severity. Study limitations included a relatively small sample size; lack of a healthy control comparator group; lack of statistical control for a number of sociodemographic and clinical characteristics that differed between groups (education status, age of onset of depression, lifetime suicide or self-harm attempts); no assessment of state or trait anxiety – a common comorbidity of both conditions – disallowing assessment of the influence of such symptom on self-reported emotion regulation and perceived parenting style;

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medication and psychological treatment effects were not controlled for; over-representation of females in both groups, limiting the generalisability of results; and reliance on self-reported measures. As overviewed by Rosenthal et al. (2008), selfreported methods only assess the subjective experience component of emotional response systems. In light of the deficits observed in emotional awareness and clarity in those with BPD (Levine et al., 1997), this group may be limited in their ability to accurately describe emotional responses. Further, self-reports may be influenced by the dramatic style of presentation characteristic of BPD (Rosenthal et al., 2008). Future research using objective measures of physiological arousal, expressive behaviour and neural indices would complement self-report measures to broaden understanding of emotional responding in BPD and BP II. In light of the study limitations discussed, results from this study are preliminary in nature and require replication in independent samples. 4.1. Clinical implications Study findings have several clinical implications. Identification of maladaptive strategies to regulate emotion highlights specific targets for psychological intervention. The identification of emotion regulation difficulties in both BPD and BP II are consistent with the use of treatment approaches (i.e. Dialetical Behaviour Therapy or DBT) targeting ED and distress tolerance in BPD (Linehan, 1993), and provide some support for the utility of such approaches for those with BP II. However, given that those with BPD and BP II displayed differing patterns of ED, there may be a need to tailor intervention strategies to the different forms of emotion regulation pathology in BPD. For example, therapies emphasising adaptive forms of emotion regulation (in particular – planning, positive re-appraisal and putting things into perspective), reduction of excessive attempts to control negative emotions (e.g. impulsive behaviours), and promotion of acceptance and mindfulness towards inner experiences (i.e. cognitions, emotions and bodily sensations) as opposed to self-blame or blaming others may show specific efficacy for BPD relative to BP II. In order to address the developmental precursors of ED, psychological therapies focusing on attenuating the impact of toxic childhood experiences may be beneficial for both groups.

Role of funding source Funding for this study was provided by NHMRC Program Grant (1037196). The NHMRC had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the manuscript for publication.

Conflict of interest No conflict declared.

Acknowledgement The authors would like to thank Stacey McCraw and Rebecca Graham for assistance with data collection.

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