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The impact of stimulus arousal level on emotion regulation effectiveness in borderline personality disorder
Author’s Accepted Manuscript The Impact of Stimulus Arousal Level on Emotion Regulation Effectiveness in Borderline Personality Disorder Skye Fitzpatrick, Janice R. Kuo www.elsevier.com/locate/psychres
PII: DOI: Reference:
S0165-1781(15)30224-9 http://dx.doi.org/10.1016/j.psychres.2016.05.004 PSY9690
To appear in: Psychiatry Research Received date: 25 August 2015 Revised date: 3 May 2016 Accepted date: 4 May 2016 Cite this article as: Skye Fitzpatrick and Janice R. Kuo, The Impact of Stimulus Arousal Level on Emotion Regulation Effectiveness in Borderline Personality Disorder, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2016.05.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
RUNNING HEAD: EMOTION REGULATION IN BPD
The Impact of Stimulus Arousal Level on Emotion Regulation Effectiveness in Borderline Personality Disorder Skye Fitzpatrick & Janice R. Kuo Ryerson University, Department of Psychology, Toronto, Ontario, Canada
Author Note: Correspondence should be addressed to Janice R. Kuo, Ryerson University, 350 Victoria Street, Toronto, Ontario M5B 2K3 Canada; Phone: (416) 979-5000 ext. 2624; Email: [email protected]
Abstract Basic emotion theory suggests that the effectiveness of different emotion regulation strategies vary with the intensity of the emotionally-salient stimulus. Although findings from studies using healthy samples are concordant with what is proposed by theory, it is unclear whether these
EMOTION REGULATION IN BPD, 2 relationships hold true among individuals with borderline personality disorder (BPD). Twentyfive individuals with BPD and 30 HCs were exposed to negative images of varying levels of emotional arousal and were instructed to either react as they normally would, distract, or use mindful awareness. Self-reported negativity ratings, heart rate, and skin conductance level (SCL) were monitored throughout. SCL data indicated that increases in image arousal resulted in larger reductions in SCL when distracting but not when implementing mindful awareness. Self-report data suggested that, in HCs, the effectiveness of mindful awareness decreased to a greater extent than distraction when image arousal increased. These findings are consistent with basic emotion research and suggest that some forms of emotion regulation (distraction) are more suited to high emotion arousal contexts than others (mindful awareness) and that, compared with HCs, individuals with BPD may be more resilient to the deteriorating effectiveness of mindful awareness with respect to increasing emotional arousal. Keywords: Emotion dysregulation; self-regulation; emotional arousal; psychopathology; mindfulness
EMOTION REGULATION IN BPD, 3 The Impact of Emotional Arousal on Different Emotion Regulation Strategy Types in Borderline Personality Disorder 1. Introduction Borderline Personality Disorder (BPD) is complex psychological disorder that is characterized by emotional instability, impulsivity, and suicidal behaviors (American Psychiatric Association, 2013). Contemporary theories suggest that emotion regulation deficits (i.e., difficulty altering emotion, often in decreasing negative emotional intensity; Gross and Thompson, 2007) are a core facet of BPD (Linehan, 1993). For example, Linehan’s (1993) model suggests that key BPD-related behaviours (e.g., self-harm, dissociation) serve emotion regulatory functions (Ebner-Priemer et al., 2007; Reitz et al., 2012), albeit, in destructive ways. Despite the theoretical significance of emotion regulation in BPD, little research has elucidated ways that emotion regulation in BPD is problematic. 1.1. Effective emotion regulation: strategy implementation Gaining clarity on emotion regulation deficits in BPD involves first identifying ways in which emotion regulation is most optimally effective for healthy individuals, and then examining whether individuals with BPD differ in these processes. Theory and research from basic emotion science suggests that one component of effective emotion regulation involves effectively implementing the emotion regulation strategy (Gross and Jazaieri, 2014). In this vein, emerging evidence suggests that individuals with BPD might, in fact, be able to effectively implement various emotion regulation strategies. Jacob and colleagues (2011) reported that individuals with BPD were able to reduce their self-reported negative emotions and increase positive emotions while engaging in a distraction task compared with a control task after viewing a negative film. In a comparison between individuals with BPD and healthy controls (HC), Marissen and
EMOTION REGULATION IN BPD, 4 colleagues (2010) found that the groups did not differ in event-related potentials when they engaged in cognitive reappraisal (i.e., generating alternative, less emotionally-laden appraisals of an emotional stimulus; Gross and John, 2003) in response to negative images. Similarly, Ruocco and colleagues (2010) found that individuals with BPD exhibit similar levels of self-reported sadness and mean levels of oxygenated hemoglobin in the prefrontal cortex as HCs when cognitively distancing oneself from emotionally-salient images. Conversely, when individuals with BPD reappraise negative images, they show more insula activation (Schulze et al., 2011), and less anterior cingulate activation (Lang et al., 2012) and amygdala deactivation (Koenigsberg et al., 2009) than HCs. 1.2. Effective emotion regulation: disengagement versus engagement strategies Thus, though mixed, growing evidence suggests that individuals with BPD can effectively implement emotion regulation strategies upon instruction. However, in addition to strategy implementation, emotion theorists also emphasize that effective emotion regulation entails successfully matching different strategies to different conditions (Gross and Jazeieri, 2014). Affective science research has highlighted two different classes of emotion regulation strategies that are differentially effective under distinct conditions (Sheppes et al., 2011); Disengagement strategies reduce negative emotional intensity by shifting attention away from emotionally-evocative stimuli to alternative content (e.g., distraction). Conversely, engagement strategies involve engaging with emotional content by holding it in working memory and processing it in some way to reduce negative emotional intensity (e.g., cognitive reappraisal). Thus, while disengagement strategies modulate attention in emotional responding, engagement strategies modulate the interpretive component of emotional responding (Sheppes et al., 2011). Sheppes and Gross (2011) propose that disengagement strategies are more effective under high
EMOTION REGULATION IN BPD, 5 emotional arousal conditions because they stop the emotion generative cycle completely by diverting attention away from the stimulus. However, while this effectively reduces the emotion, this comes with the cost of sacrificing learning because it terminates the generative cycle. Engagement strategies may be more adaptive in the long term because the emphasis they place on appraisals rather than attention (disengagement) results in deeper processing of emotional content and the facilitation of adaptive learning. However, modulating appraisals requires more cognitive resources than manipulating attention, and such semantic processing is unlikely to occur under high emotional arousal conditions, where there is competition for the cognitive resources required to effectively engage with emotional content. Thus, unlike disengagement strategies, engagement strategies might only be effective under contexts of low to moderate emotional arousal (Sheppes and Gross, 2011). Shafir and colleagues (2015) provided evidence for this theory by showing that, in response to highly arousing negative images, distraction resulted in greater reductions in self-reported emotional intensity compared to reappraisal in a sample of healthy controls (HCs). However, this difference was not observed in response to low emotional arousal negative images. Thus, consistent with theoretical models, emerging evidence in HCs suggests that the effectiveness of different emotion regulation strategies is contingent on the arousal-level of the stimulus that one is responding to. At present, it is unknown whether these effects hold true among individuals with BPD. While extant evidence suggests that individuals with BPD may not have difficulties implementing different emotion regulation strategies (Jacob, et al., 2011; Marissen, et al., 2010; Ruocco, et al. 2010), it is possible that this group does not flexibly implement the strategies that are best suited for a given level of arousal. To date, no studies have evaluated whether flexible implementation is actually useful or warranted in BPD, and whether matching emotion
EMOTION REGULATION IN BPD, 6 regulation strategies to arousal level actually optimizes effectiveness in this group. Further, a majority of studies have compared distraction (a disengagement strategy) to cognitive reappraisal (an engagement strategy) and solely relied on self-report. No research to date has examined whether these effects generalize to other strategies and/or other indices of emotion. Of note, mindful awareness is an engagement strategy that involves maintaining awareness of one’s present experiences with an attitudinal “orientation that is characterized by curiosity, openness, and acceptance” (Bishop et al., 2004, p. 232; Kabat-Zinn, 1990). Research on mindful awareness suggests that it reduces physiological reactivity (e.g., Hofmann et al., 2009) and effectively increases pain tolerance (Kohl et al., 2012) relative to other emotion regulation strategies among HCs. Further, mindful awareness and distraction are arguably two of the most BPD-relevant strategies to examine given research indicating that they are amongst the most frequently utilized strategies among a sample of individuals with BPD in DBT (Dialectical Behavior Therapy; Lindenboim et al., 2007). However, at present, it is unclear whether mindful awareness, like cognitive reappraisal, will primarily be effective under conditions of lower arousal. 1.3. The present study The present study conducted secondary analyses from a study that compared emotion regulation abilities between individuals with BPD and HCs (Kuo et al., 2016). The first aim of this study was to expand on the current literature in HCs and examine whether disengagement and engagement strategies (distraction and mindful awareness, respectively) are differentially effective as a function of stimulus arousal levels. As a second aim, we also examined whether this relationship differs across BPD and HC groups. As emotion and emotion regulation are complex processes with multiple domains, we examined emotion regulation effectiveness comprehensively across self-report and psychophysiological (heart rate, skin conductance level)
EMOTION REGULATION IN BPD, 7 indices (Gross and Thompson, 2007). Consistent with extant research on reappraisal and distraction in HCs (Shafir et al., 2015; Sheppes et al., 2014), we hypothesized that as arousal levels increase, the effectiveness of mindful awareness (engagement) would decrease but the effectiveness of distraction (disengagement) would not change. Given that no literature indicates whether these relationships would be distinct across BPD and HC groups, we considered this second question to be exploratory. 2. Methods 2.1. Participants See Kuo, et al. (2016) for a more comprehensive description of study methodology. Twenty-five English-speaking individuals with BPD were recruited from the community and an ongoing Dialectical Behavior Therapy (DBT) skills training trial at the BPD clinic at the Centre for Addictions and Mental Health (CAMH) in Toronto. Only two BPD participants had begun DBT skills training at the time of testing. BPD participants were excluded if they endorsed criteria for dementia, or a psychotic or bipolar disorder, or showed indicators of organic brain damage or mental retardation. The HC group (n = 30) was recruited from internet advertisements, and were excluded if they met criteria for any current psychological disorder, endorsed four or more of the BPD diagnostic criteria or the suicidality/self-harm BPD diagnostic criterion, or were taking psychotropic, beta-blocker, or anti-histamine medications. There were no significant differences between groups in age, t (53) = 1.05, p = 0.30, and the HC and BPD groups consisted of ten and nine males, respectively. 2.2. Materials and measures 2.2.1. Screening and descriptive measures. All participants underwent the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I; First et al., 2002). The SCID-IV is
EMOTION REGULATION IN BPD, 8 a reliable and valid measure of disorders formerly categorized as “Axis I”. For example, kappa statistics across the modules typically range from 0.6 to 0.9 (e.g., Lobbestael et al., 2010). All participants also underwent the International Personality Disorders ExaminationBPD section (IPDE-BPD; Loranger et al., 1994). The IPDE-BPD is a semi-structured interview that reliably assesses BPD pathology; the kappa statistic for the IPDE-BPD is typically in the range of 0.9 (Loranger et al., 1994). In the present study, interrater reliability for the SCID-I and the IPDE-BPD ranged from κ = 0.74-1.0. 2.2.2. Self-report measures. Following each trial in the laboratory paradigm, participants were asked to indicate how negative and positive they felt ranging from 1 (not at all) to 9 (very). Given that extant theories and research emphasize the impact of emotion regulation on reducing negative emotion, only self-reported negativity data was examined in this study. 2.2.3. Physiological measures. Psychophysiological data were collected using the BIOPAC 5-channel acquisition system (BIOPAC Systems Inc., Model MP150, Goleta, CA). Heart rate (HR) was collected using a two-electrode configuration and the bioimpedance module was used for ground referencing (BIOPAC Systems Inc., Model EL503). Mindware Technologies HRV 2.33 software (Mindware Technologies Ltd., 2011) was used to calculate the amount of R-R intervals during stimuli presentation and thus yield an average HR for each trial. Skin conductance level (SCL) was collected by placing two electrodes on participant’s medial phalanges of the index and middle fingers on their nondominant hands (Fowles et al., 1981; BIOPAC Systems Inc., Model EL507). Data were digitized at a rate of 1,000 samples per second with a gain of 1,000, and low (35 Hz) and high (0.05 Hz) pass filters were utilized. Mindware Technologies EDA 2.40 program (Mindware Technologies Ltd., 2011) was used to process the SCL data. A programmable rolling filter, which detects and edits artifacts, was
EMOTION REGULATION IN BPD, 9 applied. As SCL can be vulnerable to “drift” over time (e.g., Dawson et al., 2007), the difference between average SCL during stimuli presentation and average SCL for two seconds prior to the stimuli presentation (during fixation cross presentation) was calculated for each experimental trial and used as the outcome variable. 2.2.4. Stimuli. Ninety-six images from the International Affective Picture System (IAPS; Lang et al., 2008) were shown to participants. Twenty-four of those images were neutral in nature and only the 72 negative images were included in the present study. The 72 negative images were of unpleasant valence (M = 2.84, SD = 0.76) and ranged in arousal levels (Mean = 5.38, SD = 0.85, mean arousal ranged from 3.52 to 6.94). Twenty-eight of the 72 images consisted of images identified in previous research (Sloan et al., 2010) as BPD-relevant, and the remaining images were themes of similar content (e.g., substance use, men attacking women). Each of the images was paired with an emotion regulation strategy instruction (DISTRACT, NOTICE), or a non-regulation instruction (REACT), and did not differ according to valence or arousal across emotion regulation strategy instruction (ps > 0.29). E-prime version 2.0 software was used to present the task on a 27” computer monitor. The IAPS Image arousal score was used as the indicator of arousal level. 2.3. Procedure Prior to the laboratory task, participants were asked if they had consumed alcohol or drugs that day and, if so, were briefly assessed regarding whether this consumption would influence their task performance. No participants reported being intoxicated on any substances. After providing informed consent eligible participants were invited to participate in the laboratory task. Physiological sensors were attached and participants completed a 10-minute baseline that was not examined in the present study (data reported in Kuo et al., 2016).
EMOTION REGULATION IN BPD, 10 2.3.1. Emotion regulation task (training and practice phase). Prior to the start of the laboratory task, participants were trained in the two emotion regulation strategies, DISTRACT (i.e., distract condition) and NOTICE (i.e., mindful awareness condition) by the experimenter. For the DISTRACT condition, participants were instructed to try to change their emotional response by thinking of something neutral. For training in the NOTICE condition, participants were instructed to use mindful awareness to acknowledge their emotional experience in response to the image without evaluation or attempts to modify it. Participants were instructed to keep their eyes on the screen for the entire time the image was being shown regardless of emotion regulation strategy and were asked to verbally explain each strategy and the difference between them. The experimenter provided corrective feedback when necessary. There was a third condition, REACT (i.e., non-regulation condition), in which participants were instructed to react as they normally would in response to the images. This condition allowed for an assessment of emotional reactivity (i.e., changes in emotional intensity after the presentation of emotional stimuli), which was controlled for in all statistical analyses as doing so allows for the conclusion that emotional intensity measured during an active regulation trial constitutes a measure of emotion regulation effectiveness, above and beyond a reaction to the stimulus. Participants were trained in these strategies in two phases. In the first phase, participants were trained in distraction and practiced the DISTRACT and REACT instructions for 10 trials. Next, participants were trained in mindful awareness and practiced the NOTICE and REACT instructions for 10 trials (See Kuo, et al., 2015 for full description of training procedures). 2.3.2. Emotion regulation task (experiment phase). The 72 trials examined in the study were divided across the three conditions: DISTRACT, NOTICE, and REACT. There were four blocks in the experiment, and each block contained REACT trials and either DISTRACT or
EMOTION REGULATION IN BPD, 11 NOTICE trials (participants did not DISTRACT and NOTICE within the same block). Each block contained six neutral REACT trials (not used in the present study), six negative REACT trials, and either 12 negative DISTRACT trials or 12 negative NOTICE trials. The presentation of REACT versus DISTRACT/NOTICE trials varied randomly within blocks, with the constraint that no instruction would be presented three or more consecutive times. In order to counteract any potential confounds of yolking image assignment to condition, each block of negative images was assigned to each condition, yielding three versions of the task. Order of blocks was also counterbalanced such that, in total, there were six versions of the task. During the experimental trial, participants viewed a fixation cross for 2000 ms, followed by viewing the instruction to either DISTRACT, NOTICE, or REACT for 2000 ms. Following the instruction, the negative images were shown for 10000 ms while participants implemented the instructed strategy. Following image presentation, participants indicated how negative they felt (4000ms) and how positive they felt (4000ms; data not reported here). 2.4. Data analytic strategy Multilevel model analyses of variance (MMANOVA) is an extension of repeatedmeasures analyses of variance that allows for more flexible covariance structures, assumes that subjects are independent, and accommodates randomly missing data. MMANOVA estimates means from longitudinal data using a population-averaged approach and the model for each individual reflects a random deviation from a population-based parameter estimate (Littell et al., 1996). MMANOVAs were run for each outcome of interest (HR, SCL, and self-reported negativity) using SAS software. For each outcome of interest, a simple “empty” model with intercept as the only predictor was run in order to yield the best fitting covariance structure. The outcome, “emotion regulation
EMOTION REGULATION IN BPD, 12 effectiveness”, was indicated by the level of emotional intensity while implementing an emotion regulation strategy after controlling for general emotional reactivity (i.e., the level of emotional intensity occurring during REACT trials). For each outcome of interest, only compound symmetry and autoregressive covariance structures were considered and compared because more complex structures (i.e., Toeplitz and Unstructured covariance structures) would produce unduly large and unrealistic parameter estimates. Both Akaike Information Criteria and Bayesian Information Criteria were considered in deciding between compound symmetry and autoregressive covariance structures, and indicated that compound symmetry was the best fitting covariance structure across all outcomes. Thus, all subsequent analyses were run using the compound symmetry covariance structure. All statistical models were built beginning with the most simple to the most complex. First, analyses were run testing main effects only. Group status (HC versus BPD) was entered as the between subjects factor, and emotional reactivity (i.e., emotional intensity during REACT trials), emotion regulation strategy (DISTRACT versus NOTICE), and image arousal as indexed by the IAPS arousal score were entered as within-subjects factors. Next, analyses were run with the addition of three two-way interactions (group × emotion regulation strategy, group × image arousal, and emotion regulation strategy × image arousal). The emotion regulation strategy × image arousal interaction tests the primary hypothesis that the arousal levels would modulate the effectiveness of distraction and mindful awareness. The group × emotion regulation strategy interaction was examined and reported in the parent study (Kuo, et al, 2016), and will thus not be deconstructed in the present study but needed to be retained in the analyses to accommodate subsequent three-way interactions. Finally, analyses were run with the addition of a three-way interaction (group × emotion regulation strategy × image arousal). This three-way interaction
EMOTION REGULATION IN BPD, 13 tests our secondary hypothesis that the relationship between distraction or mindful awareness and arousal level would be different across BPD and HC groups. If none of the added interactions were statistically significant, they were not retained in the final model and the previous more simplistic model was interpreted. Statistically significant interactions were decomposed in one of two ways. For interactions between two categorical variables (e.g., Group × Emotion regulation strategy), SAS’ Least Squares Means command was used to generate expected means for each cell of the interaction and pairwise comparisons between means. For interactions between continuous and categorical variables and three-way interactions, models were reparameterized to provide simple slopes tests at each level of the categorical variable. If the three-way interaction was significant, lower-order (i.e., two-way) interactions were not interpreted. 3. Results Means and standard errors for outcomes of interest are presented in Kuo and colleagues (2016). Results from the final, reduced MMANOVA models are presented in Table 1. Results of tests examining our primary hypotheses (i.e., emotion regulation strategy × image arousal; group × emotion regulation strategy × image arousal) are detailed below. 3.1. Physiological indices 3.1.1. Heart rate. There was no significant interaction of emotion regulation strategy × image arousal and no significant interaction of group × emotion regulation strategy × image arousal. 3.1.2. Skin conductance level. There was a significant emotion regulation strategy × image arousal interaction such that, during DISTRACT trials, increases in image arousal resulted in larger reductions in SCL (β = -0.02, SE = 0.01), t(2496) = -2.04, p = 0.04, but this pattern
EMOTION REGULATION IN BPD, 14 was not observed during the NOTICE trials, (β = 0.010, SE = 0.01), t(2500) = 0.94, p = 0.34. That is, across groups, as arousal level increased, the effectiveness of distraction also increased; however, as stimulus arousal increased, there was no change in effectiveness of noticing (mindful awareness). There was not a significant group × emotion regulation strategy × image arousal interaction. 3.1.3. Self-reported negativity. There was a significant group × emotion regulation strategy × image arousal interaction predicting self-reported negativity (β = 0.45, SE = 0.17, t (2432) = 2.69, p <0 .001). Simple slopes tests indicated that higher image arousal significantly predicted increased self-reported negativity across both groups and both regulation strategy types. In partial support of our hypothesis, simple slopes tests also indicated that the relationship between image arousal and self-reported negativity was significantly larger for HCs during the NOTICE trial (β = 0.88, SE = 0.08), than HCs during the DISTRACT trial (β = 0.57, SE = 0.08), t(2433) = 2.78, p = 0.006, the BPD group during the NOTICE trial (β = 0.50, SE = 0.09), t(2432) = 3.12, p = 0.002, and the BPD group during the DISTRACT trials (β = 0.65, SE = 0.09), t(2432) = 1.94, p = 0.05. This suggests that, for the HC group, the effectiveness of mindful awareness decreased as emotional stimulus arousal increased to a greater extent than the effectiveness of distraction, and mindful awareness, or distraction in the BPD group. 4. Discussion The present study was the first to examine whether the effectiveness of two different kinds of emotion regulation strategies, disengagement (distraction) and engagement (mindful awareness), is modulated by arousal levels across BPD and HC groups. 4.1. Relationship between stimulus arousal levels and effectiveness of distraction and mindful awareness
EMOTION REGULATION IN BPD, 15 In line with Shafir and colleagues’ (2015) findings on cognitive reappraisal, we predicted that, as stimulus arousal increased, the effectiveness of mindful awareness would decrease whereas the effectiveness of distraction would not change. Our physiological data provided partial evidence for this such that, in the distraction condition, as arousal increased, there were larger reductions in SCL. This suggests that the effectiveness of distraction increases with increasing arousal levels across groups. Though somewhat contrary to our hypotheses, our findings are in keeping with basic emotion theories, which posit that disengagement strategies terminate the emotion generative cycle all together. Based on this reasoning, individuals using disengagement strategies might return to their resting levels of emotional intensity regardless of arousal level, as the entire generative cycle is terminated. Indeed, when stimulus arousal levels are highest, the participants’ emotion is presumably most intense. Thus, if distraction returns participants’ emotional intensity to the same resting state regardless of stimulus arousal level, then the largest changes in emotional intensity (i.e., emotion regulation effectiveness) would occur when participants are most distressed (i.e., under high stimulus arousal conditions). Indeed, disengagement strategies such as distraction may therefore be particularly potent under conditions of high arousal as they may act as a “great equalizer.” In contrast to our findings with distraction, our SCL data suggest that the effectiveness of mindful awareness generally does not deteriorate under conditions of increasing emotion arousal. Thus, offering mindful awareness under high emotional arousal conditions does not appear to compromise its effectiveness, though more effective alternatives are available (distraction). Given research and theory suggesting that using engagement strategies has more long-term benefits with respect to emotional learning (Sheppes et al., 2011), treatments might benefit from
EMOTION REGULATION IN BPD, 16 teaching individuals to continue to use engagement strategies even as their emotional intensity increases. 4.2. Group differences in the relationship between stimulus arousal levels and effectiveness of distraction and mindful awareness Our self-report findings suggest that the relationship between arousal and emotion regulation strategy effectiveness is further moderated by group status (BPD and HC). Among HCs, the effectiveness of mindful awareness decreases more under higher arousal levels than when using distraction, consistent with previous findings (Shafir et al., 2015), suggesting that the effectiveness of engagement strategies particularly deteriorate under conditions of increasing arousal. Among individuals with BPD, however, the effectiveness of mindful awareness is not more or less affected by increasing emotional stimulus arousal compared to distraction. Thus, in contrast to HCs, it appears that individuals with BPD do not experience differential effectiveness of emotion regulation strategy type as a function of increasing arousal levels. Of note, some higher arousal level images used in this study depicted images of interpersonal conflict, physical abuse, and traumatic events (e.g., being held at gun point). In many ways, the lives of individuals with BPD are characterized by exposure to such themes through traumatic life events (Bandelow et al., 2005; Zanarini and Frankenberg, 1997), and increased interpersonal conflict and bullying (Clifton et al., 2007; Daley et al., 2000; Sansone et al., 2013). Thus, it’s possible that these stimuli - though “BPD relevant” - were less novel to this group than HCs and, thus, not sufficiently evocative to compromise the effectiveness of mindful awareness, the way it did in the HCs. Alternatively, it is also possible that individuals with BPD are more practiced in the use of mindful awareness than HCs, and this strategy is thus more resilient to high emotional arousal in a BPD group. Given that the most prominent treatment for BPD (DBT) is mindful awareness-
EMOTION REGULATION IN BPD, 17 based (Linehan, 1993), it is possible that man individuals with BPD are likely to have come across the concept of mindful awareness even through the most basic of internet searches on BPD treatments. These individuals may have thus had more experience in this strategy than the HC group, increasing its effectiveness under high emotional arousal conditions. 4.3. Discrepancies between indices of emotional responding As is often the case in studies with BPD populations (e.g., Reitz et al., 2012; Schmahl et al., 2004), our results varied across self-report and physiological indices of emotional responding. While decoupling of various indices of emotions has been long-documented in the emotion literature (Hodgson and Rachman, 1974), it’s unclear why there was not greater coherence across indices in the current investigation. One possibility is that there is variability in the effects of emotion regulation on different dimensions of emotions such that effecting change on one emotion index may not correspond with similar changes in another index. Relatedly, there is evidence suggesting that coherence across indices is modulated by both the specific emotion elicited as well as the intensity of emotion (Mauss et al., 2005). Indeed, while general “negativity” was elicited in the current study’s paradigm, there may have been substantial variability in the specific type of emotion elicited across images, which possibly led to variation in the level of coherence across emotion indices. 4.4. Clinical implications and limitations Our findings indicate that treatments for BPD should not only aim to enhance the use of emotion regulation strategies, but to encourage the informed selection of which strategy to use. While research shows that both mindful awareness and distraction are the most frequently used strategies by individuals with BPD in DBT (Lindeboim et al., 2007; Stepp et al., 2008), some studies suggest individuals with BPD have a preference for distraction over mindful awareness
EMOTION REGULATION IN BPD, 18 (Lindenboim et al., 2007) and others show the opposite pattern (Stepp et al., 2008). Other data further suggests that BPD may be particularly characterized by disengagement-based experientially avoidant strategies (Chapman et al., 2011). It is unclear what factors individuals with BPD consider when deciding whether to employ engagement or disengagement strategies in daily life. Our skin conductance data suggests that, across groups, disengagement strategies may be more effective in high emotional arousal situations than engagement strategies. Thus, disengagement strategies (or, at least distraction) should potentially be the “strategy of choice” when emotional arousal is higher, as they appear to be optimally effective under these circumstances. However, it appears that either strategy might be equally effective (at least in the short-term) for individuals with BPD, across high and low emotional arousal contexts. Given that these individuals might be characterized by over-use of disengagement strategies in the form of experientially avoidant behaviours (Chapman et al., 2011), and that engagement strategies theoretically entail greater long-term benefits (Sheppes et al., 2011), therapeutic change may be facilitated if disengagement strategies are reserved for “last resort” situations. The present study also has some limitations. First, we examined only two strategies as examples of disengagement and engagement emotion regulation behaviours. There are a plethora of strategies available, and it is unclear whether the findings from this investigation are specific to distraction and mindful awareness, or can be more broadly generalized to disengagement and engagement strategies. However, our findings are broadly consistent with theory and research in HCs pointing to the relative efficacy of distraction and cognitive reappraisal in HCs under high and low arousal conditions, respectively (Shafir, et al., 2014). Future work should attempt to replicate these findings using other disengagement and engagement strategies. As well, though the emotion regulation strategy instructions that individuals received in this study represent the
EMOTION REGULATION IN BPD, 19 core features of engagement and disengagement strategies, these instructions are likely distinct from actual instructions that are typically given in clinical contexts. For example, while individuals in this study were instructed to distract themselves by thinking of something emotionally neutral, in clinical contexts they might be instructed to distract with pleasurable content (e.g., funny videos) or pleasurable activities (e.g., exercise, reading). Thus, while our methodology allowed for an internally valid comparison of mindful awareness and distraction, future research should examine whether our findings can be replicated with a more externally valid comparison of these strategies. It also bears mentioning the research suggesting that pronounced emotional responding in BPD may be more likely elicited by themes of rejection and abandonment, rather than general negative stimuli (Limberg et al., 2011). Though BPD relevant, it is possible that the stimuli selected in the present study were not sufficient to elicit a level of emotional arousal to potentially “impair” the effectiveness of the different strategies. Further, as noted above, that some IAPs images depict content that is arguably trauma-related (e.g., images of beaten women, individuals being held at gun point). Given that many individuals with BPD have histories of trauma (Bandelow et al., 2005), this content may systematically influence the BPD group differently than the HC group, potentially conflating comparisons between the two groups with a comparison of those with and without trauma histories. Future research in this area should aim to disentangle the relative contribution of trauma histories and trauma-related stimuli from other between-group comparisons. Another important limitation to note is that, in the present study, we did not assess for present state dissociation. Dissociation is common in BPD (Ross, 2008) and can dampen physiological responding (Ebner-Priemer et al., 2007), and may therefore have confounded our
EMOTION REGULATION IN BPD, 20 results. As we did not assess for dissociation, its potential influence on physiological indicators of emotional arousal remains unknown. Moreover, we also did not assess for the presence of comorbid personality disorders other than BPD. It is thus unclear whether there were any comorbid personality disorders within either the BPD or HC groups. Last, many individuals in the BPD group were on medications known to interfere with autonomic profiles of emotional responding such as benzodiazepines (Siepmann et al., 2007). These individuals may have different physiological profiles than others and therefore may have confounded results. However, this limitation may be at least partially circumvented by the fact that this was a repeated measures design. Regardless of limitations, this study is amongst the first of its kind in attempting to identify what contextual factors obstruct or optimize emotion regulation in BPD.
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EMOTION REGULATION IN BPD, 22 First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B.W., 2002. Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition (SCID-I/P). Biometrics Research, New York State Psychiatric Institute, New York, NY. Fowles, D.C., Christie, M.J., Edelberg, R., Grings, W.W., Lykken, D.T. Venables, P.H., 1981. Publication recommendations for electrodermal measurements. Psychophysiology. 18, 232–239. Gross, J.J., Jazaieri, H., 2014. Emotion, emotion regulation, and psychopathology: An affective science perspective. Clin. Psychol. Sci. 2, 387-401. Gross, J.J., John, O.P., 2003. Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. J. Pers. Soc. Psychol. 85, 348-362. Gross, J.J., Thompson, R.A., 2007. Emotion regulation: Conceptual foundations, in Gross, J. J. (Ed.), Handbook of Emotion Regulation. Guilford Press, New York, NY, pp. 3-24. Hodgson, R. Rachman, S., 1974. II. Desynchrony in measures of fear. Behav. Res. Ther. 12, 319-326. Hofmann, S.G., Heering, S., Sawyer, A.T., Asnaani, A., 2009. How to handle anxiety: The effects of reappraisal, acceptance, and suppression strategies on anxious arousal. Behav. Res. Ther. 47, 389-394. Jacob, G.A., Arendt, J., Kolley, L., Scheel, C.N., Bader, K., Lieb, K., ... Tüscher, O., 2011. Comparison of different strategies to decrease negative affect and increase positive affect in women with borderline personality disorder. Behav. Res. Ther. 49, 68-73. Kabat-Zinn, J., 1990. Full Catastrophe Living: Using the Wisdom of your Body and Mind to Face Stress, Pain, and Illness. Delacorte, New York, NY. Koenigsberg, H.W., Fan, J., Ochsner, K.N., Liu, X., Guise, K.G., Pizzarello, S., . . . Siever, L.J.,
EMOTION REGULATION IN BPD, 23 2009. Neural correlates of the use of psychological distancing to regulate responses to negative social cues: A study of patients with borderline personality disorder. Biol. Psychiat. 66, 854-863. Kohl, A., Rief, W., Glombiewski, J.A., 2012. How effective are acceptance strategies? A metaanalytic review of experimental results. J. Behav. Ther. Exp. Psy. 43, 988-1001. Kuo, J.R., Fitzpatrick, S., Metcalfe, R.M., McMain, S., 2016. A multi-method laboratory investigation of emotional reactivity and volitional emotion regulation in borderline personality disorder. J. Behav. Ther. Exp. Psy. 50, 52-60. Kuo, J.R., Neacsiu, A.D., Fitzpatrick, S., MacDonald, D.E., 2014. A methodological examination of emotion inductions in borderline personality disorder: A comparison of standardized versus idiographic stimuli. J. Psychopathol. Behav. 36, 155-164. Lang, P.J., Bradley, M.M., Cuthbert, B.N., 2008. International Affective Picture System (IAPS): Affective Ratings of Pictures and Instruction Manual. Technical Report A-8. University of Florida, Gainesville, FL. Lindenboim, N., Comtois, K.A., Linehan, M.M., 2007. Skills practice in dialectical behaviour therapy for suicidal women meeting criteria for borderline personality disorder. Cogn. Behav. Pract. 14, 147-156. Linehan, M.M., 1993. Cognitive behavioral treatment of borderline personality disorder. Guilford Press, New York, NY. Littell, R., Milliken, G., Stroup, W., Wofinger, R., 1996. SAS System for Mixed Models. SAS Institute Inc., Cary, NC.
EMOTION REGULATION IN BPD, 24 Lobbestael J., Leurgans M., Arntz A., 2010. Inter-rater reliability of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I) and Axis II Disorders (SCID II). Clin. Psychol. Psychother. 18, 75-79. Loranger, A.W., Sartorius, N., Andreoli, A., Berger, P., Buchheim, P., Channabasavanna, S.M., Regier, D.A., 1994. The international personality disorder examination: The world health organization, alcohol, drug abuse, and mental health administration international pilot study of personality disorders. Arch. Gen. Psychiatry. 51, 215-224. Marissen, M.A.E., Meuleman, L., Franken, I.H.A., 2010. Altered emotional information processing in borderline personality disorder: An electrophysiological study. Psychiatry Res. 181, 226-232. Mauss, I.B., Levenson, R.W., McCarter, L., Wilhelm, F.H., Gross, J.J., 2005. The tie that binds? Coherence among emotion experience, behaviour, and physiology. Emotion, 5, 175-190. Reitz, S., Krause-Utz, A., Pogatzki-Zahn, E.M., Ebner-Priemer, U., Bohus, M., Schmahl, C., 2012. Stress regulation and incision in borderline personality disorder-a pilot study modeling cutting behavior. J. Pers. Disord. 26, 605-615. Ruocco, A.C., Medaglia, J.D., Ayaz, H., Chute, D.L., 2010. Abnormal prefrontal cortical response during affective processing in borderline personality disorder. Psychiatry Res. Neuroimaging. 182, 117-122. Sansone, R.A., Chang, J., Sellbom, M., Jewell, B., 2013. Bully victims and borderline personality symptomatology. Int. J. Soc. Psychiatry. 59, 193-194. Schmahl, C.G., Elzinga, B.M., Ebner, U.W., Simms, T., Sanislow, C., Vermetten, E., Bremner, J.D., 2004. Psychophysiological reactivity to traumatic and abandonment scripts in
EMOTION REGULATION IN BPD, 25 borderline personality and posttraumatic stress disorders: A preliminary report. Psychiatry Res. 126, 33-42. Schulze, L., Domes, G., Krüger, A., Berger, C., Fleischer, M., Prehn, K., . . . Herpertz, S.C., 2011. Neuronal correlates of cognitive reappraisal in borderline patients with affective instability. Biol Psychiat. 69, 564-573. Shafir, R., Schwartz, N., Blechert, J., Sheppes, G., 2015. Emotional intensity influences preimplementation and implementation of distraction and reappraisal. Soc. Cogn. Affect. Neurosci. Advance online publication. Sheppes, G., Gross, J.J., 2011. Is timing everything? Temporal considerations in emotion regulation. Pers. Soc. Psychol. Rev. 15, 319-331. Sheppes, G., Scheibe, S., Suri, G., Gross, J.J., 2011. Emotion-regulation choice. Psychol. Sci. 22, 1391-1396. Siepmann, T., Ziemssen, T., Mueck-Weymann, M., Kirch, W., Siepmann, M., 2007. The effects of venlafaxine on autonomic functions in healthy volunteers. J. Clin. Psychopharmacol. 27, 687-691. Sloan, D.M., Sege, C.T., McSweeney, L.B., Suvak, M.K., Shea, M.T., Litz, B.T., 2010. Development of a borderline personality disorder-relevant picture stimulus set. J. Pers. Disord. 24, 664-675. Stepp, S.D., Epler, A.J., Jahng, S., Trull, T.J., 2007. Skills practice in dialectical behaviour therapy for suicidal women meeting criteria for borderline personality disorder. J. Pers. Disord. 14, 147-156. Zanarini, M.C., Frankenburg, F.R., 1997. Pathways to the development of borderline personality disorder. J. Pers. Disord. 11, 93-104.
Table 1 Final Reduced Models Across Indices β
SE
df
t
p
Group
-0.73
0.48
66.4
-1.53
0.13
HR Reactivity
0.99
0.02
51.5
47.42
<0.0001
Emotion regulation strategy
-0.05
0.24
2490
-0.20
0.85
Image arousal
0.00
0.10
2494
0.03
0.98
Group × emotion regulation
0.77
0.33
2490
2.36
0.02
Group
0.02
0.02
51.8
0.82
0.42
SCL Reactivity
0.75
0.08
52.2
9.14
<0.0001
Emotion regulation strategy
0.17
0.08
2509
2.09
0.04
Image arousal
0.01
0.01
2500
0.94
0.35
Emotion regulation strategy ×
-0.03
0.01
2510
-2.10
0.04
Group
2.00
0.73
891
2.76
0.006
Self-reported negativity reactivity
0.35
0.06
52
6.05
<0.0001
Emotion regulation strategy
0.26
0.62
2433
0.41
0.68
HR
strategy SCL
image arousal Selfreported negativity
EMOTION REGULATION IN BPD, 27 Image arousal
0.88
0.08
2432
11.04
<.0001
Group × emotion regulation
-1.87
0.92
2434
-2.02
0.04
Group × image arousal
-0.37
0.12
2432
-3.12
0.0019
Emotion regulation strategy ×
-0.31
0.11
2433
-2.78
0.0055
0.45
0.17
2434
2.67
0.0076
strategy
image arousal Group × emotion regulation strategy × image arousal Note. SCL reflects the change from average SCL during the two second fixation cross presentation to average SCL during image presentation immediately following fixation cross. HR = Heart rate, SCL = skin conductance levels, β = Beta estimates, SE = standard error, df = degrees of freedom. Highlight
Studied emotion regulation effectiveness in BPD and HC as a function of stimulus arousal levels Distraction may be more suited to high stimulus arousal conditions In HCs mindfulness was less effective than distraction when stimulus arousal increased BPD group did not exhibit differential effectiveness between strategies when stimulus arousal increased Emotion regulation in BPD may be more resilient to high stimulus arousal than HC
PII: DOI: Reference:
S0165-1781(15)30224-9 http://dx.doi.org/10.1016/j.psychres.2016.05.004 PSY9690
To appear in: Psychiatry Research Received date: 25 August 2015 Revised date: 3 May 2016 Accepted date: 4 May 2016 Cite this article as: Skye Fitzpatrick and Janice R. Kuo, The Impact of Stimulus Arousal Level on Emotion Regulation Effectiveness in Borderline Personality Disorder, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2016.05.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
RUNNING HEAD: EMOTION REGULATION IN BPD
The Impact of Stimulus Arousal Level on Emotion Regulation Effectiveness in Borderline Personality Disorder Skye Fitzpatrick & Janice R. Kuo Ryerson University, Department of Psychology, Toronto, Ontario, Canada
Author Note: Correspondence should be addressed to Janice R. Kuo, Ryerson University, 350 Victoria Street, Toronto, Ontario M5B 2K3 Canada; Phone: (416) 979-5000 ext. 2624; Email: [email protected]
Abstract Basic emotion theory suggests that the effectiveness of different emotion regulation strategies vary with the intensity of the emotionally-salient stimulus. Although findings from studies using healthy samples are concordant with what is proposed by theory, it is unclear whether these
EMOTION REGULATION IN BPD, 2 relationships hold true among individuals with borderline personality disorder (BPD). Twentyfive individuals with BPD and 30 HCs were exposed to negative images of varying levels of emotional arousal and were instructed to either react as they normally would, distract, or use mindful awareness. Self-reported negativity ratings, heart rate, and skin conductance level (SCL) were monitored throughout. SCL data indicated that increases in image arousal resulted in larger reductions in SCL when distracting but not when implementing mindful awareness. Self-report data suggested that, in HCs, the effectiveness of mindful awareness decreased to a greater extent than distraction when image arousal increased. These findings are consistent with basic emotion research and suggest that some forms of emotion regulation (distraction) are more suited to high emotion arousal contexts than others (mindful awareness) and that, compared with HCs, individuals with BPD may be more resilient to the deteriorating effectiveness of mindful awareness with respect to increasing emotional arousal. Keywords: Emotion dysregulation; self-regulation; emotional arousal; psychopathology; mindfulness
EMOTION REGULATION IN BPD, 3 The Impact of Emotional Arousal on Different Emotion Regulation Strategy Types in Borderline Personality Disorder 1. Introduction Borderline Personality Disorder (BPD) is complex psychological disorder that is characterized by emotional instability, impulsivity, and suicidal behaviors (American Psychiatric Association, 2013). Contemporary theories suggest that emotion regulation deficits (i.e., difficulty altering emotion, often in decreasing negative emotional intensity; Gross and Thompson, 2007) are a core facet of BPD (Linehan, 1993). For example, Linehan’s (1993) model suggests that key BPD-related behaviours (e.g., self-harm, dissociation) serve emotion regulatory functions (Ebner-Priemer et al., 2007; Reitz et al., 2012), albeit, in destructive ways. Despite the theoretical significance of emotion regulation in BPD, little research has elucidated ways that emotion regulation in BPD is problematic. 1.1. Effective emotion regulation: strategy implementation Gaining clarity on emotion regulation deficits in BPD involves first identifying ways in which emotion regulation is most optimally effective for healthy individuals, and then examining whether individuals with BPD differ in these processes. Theory and research from basic emotion science suggests that one component of effective emotion regulation involves effectively implementing the emotion regulation strategy (Gross and Jazaieri, 2014). In this vein, emerging evidence suggests that individuals with BPD might, in fact, be able to effectively implement various emotion regulation strategies. Jacob and colleagues (2011) reported that individuals with BPD were able to reduce their self-reported negative emotions and increase positive emotions while engaging in a distraction task compared with a control task after viewing a negative film. In a comparison between individuals with BPD and healthy controls (HC), Marissen and
EMOTION REGULATION IN BPD, 4 colleagues (2010) found that the groups did not differ in event-related potentials when they engaged in cognitive reappraisal (i.e., generating alternative, less emotionally-laden appraisals of an emotional stimulus; Gross and John, 2003) in response to negative images. Similarly, Ruocco and colleagues (2010) found that individuals with BPD exhibit similar levels of self-reported sadness and mean levels of oxygenated hemoglobin in the prefrontal cortex as HCs when cognitively distancing oneself from emotionally-salient images. Conversely, when individuals with BPD reappraise negative images, they show more insula activation (Schulze et al., 2011), and less anterior cingulate activation (Lang et al., 2012) and amygdala deactivation (Koenigsberg et al., 2009) than HCs. 1.2. Effective emotion regulation: disengagement versus engagement strategies Thus, though mixed, growing evidence suggests that individuals with BPD can effectively implement emotion regulation strategies upon instruction. However, in addition to strategy implementation, emotion theorists also emphasize that effective emotion regulation entails successfully matching different strategies to different conditions (Gross and Jazeieri, 2014). Affective science research has highlighted two different classes of emotion regulation strategies that are differentially effective under distinct conditions (Sheppes et al., 2011); Disengagement strategies reduce negative emotional intensity by shifting attention away from emotionally-evocative stimuli to alternative content (e.g., distraction). Conversely, engagement strategies involve engaging with emotional content by holding it in working memory and processing it in some way to reduce negative emotional intensity (e.g., cognitive reappraisal). Thus, while disengagement strategies modulate attention in emotional responding, engagement strategies modulate the interpretive component of emotional responding (Sheppes et al., 2011). Sheppes and Gross (2011) propose that disengagement strategies are more effective under high
EMOTION REGULATION IN BPD, 5 emotional arousal conditions because they stop the emotion generative cycle completely by diverting attention away from the stimulus. However, while this effectively reduces the emotion, this comes with the cost of sacrificing learning because it terminates the generative cycle. Engagement strategies may be more adaptive in the long term because the emphasis they place on appraisals rather than attention (disengagement) results in deeper processing of emotional content and the facilitation of adaptive learning. However, modulating appraisals requires more cognitive resources than manipulating attention, and such semantic processing is unlikely to occur under high emotional arousal conditions, where there is competition for the cognitive resources required to effectively engage with emotional content. Thus, unlike disengagement strategies, engagement strategies might only be effective under contexts of low to moderate emotional arousal (Sheppes and Gross, 2011). Shafir and colleagues (2015) provided evidence for this theory by showing that, in response to highly arousing negative images, distraction resulted in greater reductions in self-reported emotional intensity compared to reappraisal in a sample of healthy controls (HCs). However, this difference was not observed in response to low emotional arousal negative images. Thus, consistent with theoretical models, emerging evidence in HCs suggests that the effectiveness of different emotion regulation strategies is contingent on the arousal-level of the stimulus that one is responding to. At present, it is unknown whether these effects hold true among individuals with BPD. While extant evidence suggests that individuals with BPD may not have difficulties implementing different emotion regulation strategies (Jacob, et al., 2011; Marissen, et al., 2010; Ruocco, et al. 2010), it is possible that this group does not flexibly implement the strategies that are best suited for a given level of arousal. To date, no studies have evaluated whether flexible implementation is actually useful or warranted in BPD, and whether matching emotion
EMOTION REGULATION IN BPD, 6 regulation strategies to arousal level actually optimizes effectiveness in this group. Further, a majority of studies have compared distraction (a disengagement strategy) to cognitive reappraisal (an engagement strategy) and solely relied on self-report. No research to date has examined whether these effects generalize to other strategies and/or other indices of emotion. Of note, mindful awareness is an engagement strategy that involves maintaining awareness of one’s present experiences with an attitudinal “orientation that is characterized by curiosity, openness, and acceptance” (Bishop et al., 2004, p. 232; Kabat-Zinn, 1990). Research on mindful awareness suggests that it reduces physiological reactivity (e.g., Hofmann et al., 2009) and effectively increases pain tolerance (Kohl et al., 2012) relative to other emotion regulation strategies among HCs. Further, mindful awareness and distraction are arguably two of the most BPD-relevant strategies to examine given research indicating that they are amongst the most frequently utilized strategies among a sample of individuals with BPD in DBT (Dialectical Behavior Therapy; Lindenboim et al., 2007). However, at present, it is unclear whether mindful awareness, like cognitive reappraisal, will primarily be effective under conditions of lower arousal. 1.3. The present study The present study conducted secondary analyses from a study that compared emotion regulation abilities between individuals with BPD and HCs (Kuo et al., 2016). The first aim of this study was to expand on the current literature in HCs and examine whether disengagement and engagement strategies (distraction and mindful awareness, respectively) are differentially effective as a function of stimulus arousal levels. As a second aim, we also examined whether this relationship differs across BPD and HC groups. As emotion and emotion regulation are complex processes with multiple domains, we examined emotion regulation effectiveness comprehensively across self-report and psychophysiological (heart rate, skin conductance level)
EMOTION REGULATION IN BPD, 7 indices (Gross and Thompson, 2007). Consistent with extant research on reappraisal and distraction in HCs (Shafir et al., 2015; Sheppes et al., 2014), we hypothesized that as arousal levels increase, the effectiveness of mindful awareness (engagement) would decrease but the effectiveness of distraction (disengagement) would not change. Given that no literature indicates whether these relationships would be distinct across BPD and HC groups, we considered this second question to be exploratory. 2. Methods 2.1. Participants See Kuo, et al. (2016) for a more comprehensive description of study methodology. Twenty-five English-speaking individuals with BPD were recruited from the community and an ongoing Dialectical Behavior Therapy (DBT) skills training trial at the BPD clinic at the Centre for Addictions and Mental Health (CAMH) in Toronto. Only two BPD participants had begun DBT skills training at the time of testing. BPD participants were excluded if they endorsed criteria for dementia, or a psychotic or bipolar disorder, or showed indicators of organic brain damage or mental retardation. The HC group (n = 30) was recruited from internet advertisements, and were excluded if they met criteria for any current psychological disorder, endorsed four or more of the BPD diagnostic criteria or the suicidality/self-harm BPD diagnostic criterion, or were taking psychotropic, beta-blocker, or anti-histamine medications. There were no significant differences between groups in age, t (53) = 1.05, p = 0.30, and the HC and BPD groups consisted of ten and nine males, respectively. 2.2. Materials and measures 2.2.1. Screening and descriptive measures. All participants underwent the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I; First et al., 2002). The SCID-IV is
EMOTION REGULATION IN BPD, 8 a reliable and valid measure of disorders formerly categorized as “Axis I”. For example, kappa statistics across the modules typically range from 0.6 to 0.9 (e.g., Lobbestael et al., 2010). All participants also underwent the International Personality Disorders ExaminationBPD section (IPDE-BPD; Loranger et al., 1994). The IPDE-BPD is a semi-structured interview that reliably assesses BPD pathology; the kappa statistic for the IPDE-BPD is typically in the range of 0.9 (Loranger et al., 1994). In the present study, interrater reliability for the SCID-I and the IPDE-BPD ranged from κ = 0.74-1.0. 2.2.2. Self-report measures. Following each trial in the laboratory paradigm, participants were asked to indicate how negative and positive they felt ranging from 1 (not at all) to 9 (very). Given that extant theories and research emphasize the impact of emotion regulation on reducing negative emotion, only self-reported negativity data was examined in this study. 2.2.3. Physiological measures. Psychophysiological data were collected using the BIOPAC 5-channel acquisition system (BIOPAC Systems Inc., Model MP150, Goleta, CA). Heart rate (HR) was collected using a two-electrode configuration and the bioimpedance module was used for ground referencing (BIOPAC Systems Inc., Model EL503). Mindware Technologies HRV 2.33 software (Mindware Technologies Ltd., 2011) was used to calculate the amount of R-R intervals during stimuli presentation and thus yield an average HR for each trial. Skin conductance level (SCL) was collected by placing two electrodes on participant’s medial phalanges of the index and middle fingers on their nondominant hands (Fowles et al., 1981; BIOPAC Systems Inc., Model EL507). Data were digitized at a rate of 1,000 samples per second with a gain of 1,000, and low (35 Hz) and high (0.05 Hz) pass filters were utilized. Mindware Technologies EDA 2.40 program (Mindware Technologies Ltd., 2011) was used to process the SCL data. A programmable rolling filter, which detects and edits artifacts, was
EMOTION REGULATION IN BPD, 9 applied. As SCL can be vulnerable to “drift” over time (e.g., Dawson et al., 2007), the difference between average SCL during stimuli presentation and average SCL for two seconds prior to the stimuli presentation (during fixation cross presentation) was calculated for each experimental trial and used as the outcome variable. 2.2.4. Stimuli. Ninety-six images from the International Affective Picture System (IAPS; Lang et al., 2008) were shown to participants. Twenty-four of those images were neutral in nature and only the 72 negative images were included in the present study. The 72 negative images were of unpleasant valence (M = 2.84, SD = 0.76) and ranged in arousal levels (Mean = 5.38, SD = 0.85, mean arousal ranged from 3.52 to 6.94). Twenty-eight of the 72 images consisted of images identified in previous research (Sloan et al., 2010) as BPD-relevant, and the remaining images were themes of similar content (e.g., substance use, men attacking women). Each of the images was paired with an emotion regulation strategy instruction (DISTRACT, NOTICE), or a non-regulation instruction (REACT), and did not differ according to valence or arousal across emotion regulation strategy instruction (ps > 0.29). E-prime version 2.0 software was used to present the task on a 27” computer monitor. The IAPS Image arousal score was used as the indicator of arousal level. 2.3. Procedure Prior to the laboratory task, participants were asked if they had consumed alcohol or drugs that day and, if so, were briefly assessed regarding whether this consumption would influence their task performance. No participants reported being intoxicated on any substances. After providing informed consent eligible participants were invited to participate in the laboratory task. Physiological sensors were attached and participants completed a 10-minute baseline that was not examined in the present study (data reported in Kuo et al., 2016).
EMOTION REGULATION IN BPD, 10 2.3.1. Emotion regulation task (training and practice phase). Prior to the start of the laboratory task, participants were trained in the two emotion regulation strategies, DISTRACT (i.e., distract condition) and NOTICE (i.e., mindful awareness condition) by the experimenter. For the DISTRACT condition, participants were instructed to try to change their emotional response by thinking of something neutral. For training in the NOTICE condition, participants were instructed to use mindful awareness to acknowledge their emotional experience in response to the image without evaluation or attempts to modify it. Participants were instructed to keep their eyes on the screen for the entire time the image was being shown regardless of emotion regulation strategy and were asked to verbally explain each strategy and the difference between them. The experimenter provided corrective feedback when necessary. There was a third condition, REACT (i.e., non-regulation condition), in which participants were instructed to react as they normally would in response to the images. This condition allowed for an assessment of emotional reactivity (i.e., changes in emotional intensity after the presentation of emotional stimuli), which was controlled for in all statistical analyses as doing so allows for the conclusion that emotional intensity measured during an active regulation trial constitutes a measure of emotion regulation effectiveness, above and beyond a reaction to the stimulus. Participants were trained in these strategies in two phases. In the first phase, participants were trained in distraction and practiced the DISTRACT and REACT instructions for 10 trials. Next, participants were trained in mindful awareness and practiced the NOTICE and REACT instructions for 10 trials (See Kuo, et al., 2015 for full description of training procedures). 2.3.2. Emotion regulation task (experiment phase). The 72 trials examined in the study were divided across the three conditions: DISTRACT, NOTICE, and REACT. There were four blocks in the experiment, and each block contained REACT trials and either DISTRACT or
EMOTION REGULATION IN BPD, 11 NOTICE trials (participants did not DISTRACT and NOTICE within the same block). Each block contained six neutral REACT trials (not used in the present study), six negative REACT trials, and either 12 negative DISTRACT trials or 12 negative NOTICE trials. The presentation of REACT versus DISTRACT/NOTICE trials varied randomly within blocks, with the constraint that no instruction would be presented three or more consecutive times. In order to counteract any potential confounds of yolking image assignment to condition, each block of negative images was assigned to each condition, yielding three versions of the task. Order of blocks was also counterbalanced such that, in total, there were six versions of the task. During the experimental trial, participants viewed a fixation cross for 2000 ms, followed by viewing the instruction to either DISTRACT, NOTICE, or REACT for 2000 ms. Following the instruction, the negative images were shown for 10000 ms while participants implemented the instructed strategy. Following image presentation, participants indicated how negative they felt (4000ms) and how positive they felt (4000ms; data not reported here). 2.4. Data analytic strategy Multilevel model analyses of variance (MMANOVA) is an extension of repeatedmeasures analyses of variance that allows for more flexible covariance structures, assumes that subjects are independent, and accommodates randomly missing data. MMANOVA estimates means from longitudinal data using a population-averaged approach and the model for each individual reflects a random deviation from a population-based parameter estimate (Littell et al., 1996). MMANOVAs were run for each outcome of interest (HR, SCL, and self-reported negativity) using SAS software. For each outcome of interest, a simple “empty” model with intercept as the only predictor was run in order to yield the best fitting covariance structure. The outcome, “emotion regulation
EMOTION REGULATION IN BPD, 12 effectiveness”, was indicated by the level of emotional intensity while implementing an emotion regulation strategy after controlling for general emotional reactivity (i.e., the level of emotional intensity occurring during REACT trials). For each outcome of interest, only compound symmetry and autoregressive covariance structures were considered and compared because more complex structures (i.e., Toeplitz and Unstructured covariance structures) would produce unduly large and unrealistic parameter estimates. Both Akaike Information Criteria and Bayesian Information Criteria were considered in deciding between compound symmetry and autoregressive covariance structures, and indicated that compound symmetry was the best fitting covariance structure across all outcomes. Thus, all subsequent analyses were run using the compound symmetry covariance structure. All statistical models were built beginning with the most simple to the most complex. First, analyses were run testing main effects only. Group status (HC versus BPD) was entered as the between subjects factor, and emotional reactivity (i.e., emotional intensity during REACT trials), emotion regulation strategy (DISTRACT versus NOTICE), and image arousal as indexed by the IAPS arousal score were entered as within-subjects factors. Next, analyses were run with the addition of three two-way interactions (group × emotion regulation strategy, group × image arousal, and emotion regulation strategy × image arousal). The emotion regulation strategy × image arousal interaction tests the primary hypothesis that the arousal levels would modulate the effectiveness of distraction and mindful awareness. The group × emotion regulation strategy interaction was examined and reported in the parent study (Kuo, et al, 2016), and will thus not be deconstructed in the present study but needed to be retained in the analyses to accommodate subsequent three-way interactions. Finally, analyses were run with the addition of a three-way interaction (group × emotion regulation strategy × image arousal). This three-way interaction
EMOTION REGULATION IN BPD, 13 tests our secondary hypothesis that the relationship between distraction or mindful awareness and arousal level would be different across BPD and HC groups. If none of the added interactions were statistically significant, they were not retained in the final model and the previous more simplistic model was interpreted. Statistically significant interactions were decomposed in one of two ways. For interactions between two categorical variables (e.g., Group × Emotion regulation strategy), SAS’ Least Squares Means command was used to generate expected means for each cell of the interaction and pairwise comparisons between means. For interactions between continuous and categorical variables and three-way interactions, models were reparameterized to provide simple slopes tests at each level of the categorical variable. If the three-way interaction was significant, lower-order (i.e., two-way) interactions were not interpreted. 3. Results Means and standard errors for outcomes of interest are presented in Kuo and colleagues (2016). Results from the final, reduced MMANOVA models are presented in Table 1. Results of tests examining our primary hypotheses (i.e., emotion regulation strategy × image arousal; group × emotion regulation strategy × image arousal) are detailed below. 3.1. Physiological indices 3.1.1. Heart rate. There was no significant interaction of emotion regulation strategy × image arousal and no significant interaction of group × emotion regulation strategy × image arousal. 3.1.2. Skin conductance level. There was a significant emotion regulation strategy × image arousal interaction such that, during DISTRACT trials, increases in image arousal resulted in larger reductions in SCL (β = -0.02, SE = 0.01), t(2496) = -2.04, p = 0.04, but this pattern
EMOTION REGULATION IN BPD, 14 was not observed during the NOTICE trials, (β = 0.010, SE = 0.01), t(2500) = 0.94, p = 0.34. That is, across groups, as arousal level increased, the effectiveness of distraction also increased; however, as stimulus arousal increased, there was no change in effectiveness of noticing (mindful awareness). There was not a significant group × emotion regulation strategy × image arousal interaction. 3.1.3. Self-reported negativity. There was a significant group × emotion regulation strategy × image arousal interaction predicting self-reported negativity (β = 0.45, SE = 0.17, t (2432) = 2.69, p <0 .001). Simple slopes tests indicated that higher image arousal significantly predicted increased self-reported negativity across both groups and both regulation strategy types. In partial support of our hypothesis, simple slopes tests also indicated that the relationship between image arousal and self-reported negativity was significantly larger for HCs during the NOTICE trial (β = 0.88, SE = 0.08), than HCs during the DISTRACT trial (β = 0.57, SE = 0.08), t(2433) = 2.78, p = 0.006, the BPD group during the NOTICE trial (β = 0.50, SE = 0.09), t(2432) = 3.12, p = 0.002, and the BPD group during the DISTRACT trials (β = 0.65, SE = 0.09), t(2432) = 1.94, p = 0.05. This suggests that, for the HC group, the effectiveness of mindful awareness decreased as emotional stimulus arousal increased to a greater extent than the effectiveness of distraction, and mindful awareness, or distraction in the BPD group. 4. Discussion The present study was the first to examine whether the effectiveness of two different kinds of emotion regulation strategies, disengagement (distraction) and engagement (mindful awareness), is modulated by arousal levels across BPD and HC groups. 4.1. Relationship between stimulus arousal levels and effectiveness of distraction and mindful awareness
EMOTION REGULATION IN BPD, 15 In line with Shafir and colleagues’ (2015) findings on cognitive reappraisal, we predicted that, as stimulus arousal increased, the effectiveness of mindful awareness would decrease whereas the effectiveness of distraction would not change. Our physiological data provided partial evidence for this such that, in the distraction condition, as arousal increased, there were larger reductions in SCL. This suggests that the effectiveness of distraction increases with increasing arousal levels across groups. Though somewhat contrary to our hypotheses, our findings are in keeping with basic emotion theories, which posit that disengagement strategies terminate the emotion generative cycle all together. Based on this reasoning, individuals using disengagement strategies might return to their resting levels of emotional intensity regardless of arousal level, as the entire generative cycle is terminated. Indeed, when stimulus arousal levels are highest, the participants’ emotion is presumably most intense. Thus, if distraction returns participants’ emotional intensity to the same resting state regardless of stimulus arousal level, then the largest changes in emotional intensity (i.e., emotion regulation effectiveness) would occur when participants are most distressed (i.e., under high stimulus arousal conditions). Indeed, disengagement strategies such as distraction may therefore be particularly potent under conditions of high arousal as they may act as a “great equalizer.” In contrast to our findings with distraction, our SCL data suggest that the effectiveness of mindful awareness generally does not deteriorate under conditions of increasing emotion arousal. Thus, offering mindful awareness under high emotional arousal conditions does not appear to compromise its effectiveness, though more effective alternatives are available (distraction). Given research and theory suggesting that using engagement strategies has more long-term benefits with respect to emotional learning (Sheppes et al., 2011), treatments might benefit from
EMOTION REGULATION IN BPD, 16 teaching individuals to continue to use engagement strategies even as their emotional intensity increases. 4.2. Group differences in the relationship between stimulus arousal levels and effectiveness of distraction and mindful awareness Our self-report findings suggest that the relationship between arousal and emotion regulation strategy effectiveness is further moderated by group status (BPD and HC). Among HCs, the effectiveness of mindful awareness decreases more under higher arousal levels than when using distraction, consistent with previous findings (Shafir et al., 2015), suggesting that the effectiveness of engagement strategies particularly deteriorate under conditions of increasing arousal. Among individuals with BPD, however, the effectiveness of mindful awareness is not more or less affected by increasing emotional stimulus arousal compared to distraction. Thus, in contrast to HCs, it appears that individuals with BPD do not experience differential effectiveness of emotion regulation strategy type as a function of increasing arousal levels. Of note, some higher arousal level images used in this study depicted images of interpersonal conflict, physical abuse, and traumatic events (e.g., being held at gun point). In many ways, the lives of individuals with BPD are characterized by exposure to such themes through traumatic life events (Bandelow et al., 2005; Zanarini and Frankenberg, 1997), and increased interpersonal conflict and bullying (Clifton et al., 2007; Daley et al., 2000; Sansone et al., 2013). Thus, it’s possible that these stimuli - though “BPD relevant” - were less novel to this group than HCs and, thus, not sufficiently evocative to compromise the effectiveness of mindful awareness, the way it did in the HCs. Alternatively, it is also possible that individuals with BPD are more practiced in the use of mindful awareness than HCs, and this strategy is thus more resilient to high emotional arousal in a BPD group. Given that the most prominent treatment for BPD (DBT) is mindful awareness-
EMOTION REGULATION IN BPD, 17 based (Linehan, 1993), it is possible that man individuals with BPD are likely to have come across the concept of mindful awareness even through the most basic of internet searches on BPD treatments. These individuals may have thus had more experience in this strategy than the HC group, increasing its effectiveness under high emotional arousal conditions. 4.3. Discrepancies between indices of emotional responding As is often the case in studies with BPD populations (e.g., Reitz et al., 2012; Schmahl et al., 2004), our results varied across self-report and physiological indices of emotional responding. While decoupling of various indices of emotions has been long-documented in the emotion literature (Hodgson and Rachman, 1974), it’s unclear why there was not greater coherence across indices in the current investigation. One possibility is that there is variability in the effects of emotion regulation on different dimensions of emotions such that effecting change on one emotion index may not correspond with similar changes in another index. Relatedly, there is evidence suggesting that coherence across indices is modulated by both the specific emotion elicited as well as the intensity of emotion (Mauss et al., 2005). Indeed, while general “negativity” was elicited in the current study’s paradigm, there may have been substantial variability in the specific type of emotion elicited across images, which possibly led to variation in the level of coherence across emotion indices. 4.4. Clinical implications and limitations Our findings indicate that treatments for BPD should not only aim to enhance the use of emotion regulation strategies, but to encourage the informed selection of which strategy to use. While research shows that both mindful awareness and distraction are the most frequently used strategies by individuals with BPD in DBT (Lindeboim et al., 2007; Stepp et al., 2008), some studies suggest individuals with BPD have a preference for distraction over mindful awareness
EMOTION REGULATION IN BPD, 18 (Lindenboim et al., 2007) and others show the opposite pattern (Stepp et al., 2008). Other data further suggests that BPD may be particularly characterized by disengagement-based experientially avoidant strategies (Chapman et al., 2011). It is unclear what factors individuals with BPD consider when deciding whether to employ engagement or disengagement strategies in daily life. Our skin conductance data suggests that, across groups, disengagement strategies may be more effective in high emotional arousal situations than engagement strategies. Thus, disengagement strategies (or, at least distraction) should potentially be the “strategy of choice” when emotional arousal is higher, as they appear to be optimally effective under these circumstances. However, it appears that either strategy might be equally effective (at least in the short-term) for individuals with BPD, across high and low emotional arousal contexts. Given that these individuals might be characterized by over-use of disengagement strategies in the form of experientially avoidant behaviours (Chapman et al., 2011), and that engagement strategies theoretically entail greater long-term benefits (Sheppes et al., 2011), therapeutic change may be facilitated if disengagement strategies are reserved for “last resort” situations. The present study also has some limitations. First, we examined only two strategies as examples of disengagement and engagement emotion regulation behaviours. There are a plethora of strategies available, and it is unclear whether the findings from this investigation are specific to distraction and mindful awareness, or can be more broadly generalized to disengagement and engagement strategies. However, our findings are broadly consistent with theory and research in HCs pointing to the relative efficacy of distraction and cognitive reappraisal in HCs under high and low arousal conditions, respectively (Shafir, et al., 2014). Future work should attempt to replicate these findings using other disengagement and engagement strategies. As well, though the emotion regulation strategy instructions that individuals received in this study represent the
EMOTION REGULATION IN BPD, 19 core features of engagement and disengagement strategies, these instructions are likely distinct from actual instructions that are typically given in clinical contexts. For example, while individuals in this study were instructed to distract themselves by thinking of something emotionally neutral, in clinical contexts they might be instructed to distract with pleasurable content (e.g., funny videos) or pleasurable activities (e.g., exercise, reading). Thus, while our methodology allowed for an internally valid comparison of mindful awareness and distraction, future research should examine whether our findings can be replicated with a more externally valid comparison of these strategies. It also bears mentioning the research suggesting that pronounced emotional responding in BPD may be more likely elicited by themes of rejection and abandonment, rather than general negative stimuli (Limberg et al., 2011). Though BPD relevant, it is possible that the stimuli selected in the present study were not sufficient to elicit a level of emotional arousal to potentially “impair” the effectiveness of the different strategies. Further, as noted above, that some IAPs images depict content that is arguably trauma-related (e.g., images of beaten women, individuals being held at gun point). Given that many individuals with BPD have histories of trauma (Bandelow et al., 2005), this content may systematically influence the BPD group differently than the HC group, potentially conflating comparisons between the two groups with a comparison of those with and without trauma histories. Future research in this area should aim to disentangle the relative contribution of trauma histories and trauma-related stimuli from other between-group comparisons. Another important limitation to note is that, in the present study, we did not assess for present state dissociation. Dissociation is common in BPD (Ross, 2008) and can dampen physiological responding (Ebner-Priemer et al., 2007), and may therefore have confounded our
EMOTION REGULATION IN BPD, 20 results. As we did not assess for dissociation, its potential influence on physiological indicators of emotional arousal remains unknown. Moreover, we also did not assess for the presence of comorbid personality disorders other than BPD. It is thus unclear whether there were any comorbid personality disorders within either the BPD or HC groups. Last, many individuals in the BPD group were on medications known to interfere with autonomic profiles of emotional responding such as benzodiazepines (Siepmann et al., 2007). These individuals may have different physiological profiles than others and therefore may have confounded results. However, this limitation may be at least partially circumvented by the fact that this was a repeated measures design. Regardless of limitations, this study is amongst the first of its kind in attempting to identify what contextual factors obstruct or optimize emotion regulation in BPD.
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Table 1 Final Reduced Models Across Indices β
SE
df
t
p
Group
-0.73
0.48
66.4
-1.53
0.13
HR Reactivity
0.99
0.02
51.5
47.42
<0.0001
Emotion regulation strategy
-0.05
0.24
2490
-0.20
0.85
Image arousal
0.00
0.10
2494
0.03
0.98
Group × emotion regulation
0.77
0.33
2490
2.36
0.02
Group
0.02
0.02
51.8
0.82
0.42
SCL Reactivity
0.75
0.08
52.2
9.14
<0.0001
Emotion regulation strategy
0.17
0.08
2509
2.09
0.04
Image arousal
0.01
0.01
2500
0.94
0.35
Emotion regulation strategy ×
-0.03
0.01
2510
-2.10
0.04
Group
2.00
0.73
891
2.76
0.006
Self-reported negativity reactivity
0.35
0.06
52
6.05
<0.0001
Emotion regulation strategy
0.26
0.62
2433
0.41
0.68
HR
strategy SCL
image arousal Selfreported negativity
EMOTION REGULATION IN BPD, 27 Image arousal
0.88
0.08
2432
11.04
<.0001
Group × emotion regulation
-1.87
0.92
2434
-2.02
0.04
Group × image arousal
-0.37
0.12
2432
-3.12
0.0019
Emotion regulation strategy ×
-0.31
0.11
2433
-2.78
0.0055
0.45
0.17
2434
2.67
0.0076
strategy
image arousal Group × emotion regulation strategy × image arousal Note. SCL reflects the change from average SCL during the two second fixation cross presentation to average SCL during image presentation immediately following fixation cross. HR = Heart rate, SCL = skin conductance levels, β = Beta estimates, SE = standard error, df = degrees of freedom. Highlight
Studied emotion regulation effectiveness in BPD and HC as a function of stimulus arousal levels Distraction may be more suited to high stimulus arousal conditions In HCs mindfulness was less effective than distraction when stimulus arousal increased BPD group did not exhibit differential effectiveness between strategies when stimulus arousal increased Emotion regulation in BPD may be more resilient to high stimulus arousal than HC