Accepted Manuscript

A Multi-Method Laboratory Investigation of Emotional Reactivity and Emotion

Regulation Abilities in Borderline Personality Disorder

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

PII: S0005-7916(15)00069-5
DOI: 10.1016/j.jbtep.2015.05.002
Reference: BTEP 1139

To appear in: Journal of Behavior Therapy and Experimental Psychiatry

Received Date: 4 September 2014

Revised Date: 26 January 2015
Accepted Date: 6 May 2015

Please cite this article as: Kuo, J.R., Fitzpatrick, S., Metcalfe, R.K., McMain, S., A Multi-Method
Laboratory Investigation of Emotional Reactivity and Emotion Regulation Abilities in Borderline
Personality Disorder, Journal of Behavior Therapy and Experimental Psychiatry (2015), doi: 10.1016/
j.jbtep.2015.05.002.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
 ACCEPTED MANUSCRIPT

PT
RI
A Multi-Method Laboratory Investigation of Emotional Reactivity and Emotion

Regulation Abilities in Borderline Personality Disorder

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

McMain, Ph.D.2
1

U
Ryerson University, Department of Psychology, Toronto, Ontario, Canada
AN
2
Borderline Personality Disorder Clinic, Centre for Addiction and Mental Health

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

M

Canada
D
TE
EP

Author Note:

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

C

350 Victoria Street, Toronto, Ontario, M5B 2K3 Canada; Phone: (416) 979-5000 ext.
AC

2624; Email: jkuo@psych.ryerson.ca

 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 1

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

SC
Abilities in Borderline Personality Disorder

U
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 2

Abstract

Background and Objectives: Borderline personality disorder (BPD) is conceptualized as a

disorder of heightened emotional reactivity and difficulties with emotion regulation. However,

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

PT
examining emotion regulation capabilities in this population.

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

assessment followed by the presentation of neutral and BPD-relevant negative images.

SC
Participants were instructed to react as they naturally would to the image, or to use a

mindfulness-based or distraction-based strategy to feel less negative. Self-reported and

U
physiological (i.e., heart rate, electrodermal activity, and respiratory sinus arrhythmia) measures
AN
were collected.

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

respiratory sinus arrhythmia at baseline. However, there were no differences in emotional

D

reactivity in self-report or physiological indices between the two groups. In addition, the BPD
TE

group did not exhibit deficits in the ability to implement either emotion regulation strategy, with

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

with the HCs.

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

sample.
AC

Conclusions: Emotion dysregulation in BPD might be better accounted for by abnormal baseline

emotional functioning rather than heightened emotional reactivity or deficits in emotion

regulation. Treatments for BPD might be enhanced by directly targeting resting state emotional

functioning rather than emotional reactions or regulatory attempts.

 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 3

Key words: Borderline Personality Disorder, emotional intensity, emotional reactivity, emotion

regulation, mindfulness

PT
RI
U SC
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 4

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

Abilities in Borderline Personality Disorder

1. Introduction

Borderline personality disorder (BPD) is a disorder of affective instability, conflict in

PT
interpersonal relationships, and self-destructive behaviour (Linehan, 1993). Prevalence estimates

RI
of BPD are as high as 6% (Grant et al., 2008) and approximately 23% of outpatients meet

diagnostic criteria for the disorder (Korzekwa, Dell, Links, Thabane, & Webb, 2008). Prominent

SC
theories of BPD posit that emotion dysregulation is either the core feature of the disorder

(Linehan, 1993) or a key facet of the disorder (Fonagy & Bateman, 2008; Selby & Joiner, 2009).

U
Emotion dysregulation is broadly comprised of the coupling of abnormalities in emotional
AN
responding and difficulties regulating emotional responses (Linehan, 1993).

1.1 Emotional Reactivity and Regulation in BPD

M

Basic emotion theorists propose that emotional reactivity and emotion regulation are two
D

components of emotion dysregulation that have the potential to influence each other and
TE

contribute to “emotional output” (Gross & Thompson, 2007). Emotional reactivity refers to

multi-systemic (i.e., experiential, behavioural, and physiological) changes in response to an

EP

emotionally-evocative stimulus; emotion regulation refers to the process by which an individual

attempts to modify the emotion-generative process, often with the goal of decreasing one’s
C

emotional intensity (Gross & Jazaeiri, 2014). A majority of emotion-based research in BPD has
AC

examined emotional reactivity using a range of methodologies including laboratory paradigms

with negative images (Herpertz et al., 1999; 2000), scripts (Kuo & Linehan, 2009; Schmahl et al.,

2004), and film clips (Austin, Rinolio, & Porges, 2007; Kuo & Linehan, 2009; Lobbestael &

Arntz, 2010). Findings from this literature are mixed, and recent evidence suggests that
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 5

emotional reactivity in BPD may not be pervasive, but rather, specific to emotion and/or content

of the stimulus. Indeed, Kuo, Neasciu, Fitzpatrick, and MacDonald (2013) reported that

individuals with BPD experience greater reactivity when sadness or anger is induced using

personally relevant stressors compared to generalized stressors. Similarly, Limberg, Barnow,

PT
Freyberger, and Hamm (2011) found that heightened reactivity in BPD is more pronounced in

RI
response to BPD-relevant stimuli compared to generalized negative stimuli.

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

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

regulation, including emotion-regulation strategy choice and/or emotion-regulation strategy

U
implementation (Jazaieri, Urry, & Gross, 2013). A handful of studies have begun to evaluate the
AN
latter by examining instructed/volitional emotion regulation in BPD. In a study examining

cognitive reappraisal (i.e., generating new appraisals of a situation to change its emotional
M

impact; Gross & John, 2003) in BPD, Marissen, Meuleman, and Franken (2010) found that
D

persons with BPD did not have altered event-related potentials (ERP) while reappraising
TE

negative images compared to HCs. In contrast, functional magnetic resonance imaging (fMRI)

studies show that individuals with BPD exhibit reduced activation of the anterior cingulate
EP

cortex during reappraisal of negative auditory scripts (Lang et al., 2012) as well as reduced

deactivation of the amygdala (Koenigsberg et al., 2009) and increased activation of the insula
C

(Schulze et al., 2011) during reappraisal of negative images compared with HCs. Ruocco,
AC

Medaglia, Ayaz, and Chute (2010) examined the effects of cognitive distancing, a form of

reappraisal, among individuals with BPD and HCs, and found that the BPD group did not differ

from HCs in self-reported sadness or mean levels of oxygenated hemoglobin in the prefrontal

cortex. Thus, there is some evidence that individuals with BPD are able to effectively reduce
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 6

their emotional reactivity using cognitive reappraisal (as indexed by ERP and self-report) upon

instruction. However, this research is limited to the examination of one strategy type, i.e.,

cognitive reappraisal; indeed, it remains unclear whether these findings generalize to other

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

PT
skilled at implementing different types of strategies.

RI
1.2 Mindful Awareness and Distraction

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

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

judgmentally noticing and experiencing emotions, as opposed to evaluating, rejecting, or

U
suppressing them (Segal, Williams, & Teasdale, 2012). Conversely, distraction involves shifting
AN
attention away from an emotionally evocative stimulus in order to reduce its impact (Sheppes,

Scheibe, Suri, & Gross, 2011). Research in HCs indicates that acceptance-based strategies such
M

as mindful awareness are more effective than other emotion regulation strategies (i.e.,
D

suppression, distraction) at increasing pain tolerance in HCs (Kohl, Rief, & Glombiewski, 2012).
TE

Mindful awareness also reduces self-reported discomfort (Luciano et al., 2010) and physiological

indices of emotion (Hofmann, Heering, Sawyer, & Asnaani, 2009; Low, Stanton, & Bower,
EP

2008) relative to other emotion regulation strategies. Similarly, distraction in HCs leads to

reductions in self-reported negative emotions (Webb, Miles, & Sheeran, 2012; Denson, Moulds,
C

& Grisham, 2012), reduced amygdala activation (McRae et al., 2010), quicker reductions in late
AC

positive potentials (Thiruchselvam, Blechert, Sheppes, Rydstrom, & Gross, 2011), and increased

prefrontal and parietal activity (McRae et al., 2010) when participants are exposed to negative

stimuli such as images or personalized stressors.

 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 7

Currently, no studies have examined whether individuals with BPD are able to implement

mindful awareness upon instruction and only one study has examined the instructed use of

distraction; Jacob and colleagues (2011) instructed individuals with BPD to engage in a

distraction task, a positive memory imagery task, a soothing imagery task, and a neutral task

PT
(control) while viewing neutral and negative film clips. The authors found that all the strategies

RI
were associated with greater reduction in self-reported negative emotions and greater increase in

positive emotions than the neutral control task after the negative film. Though informative, this

SC
study did not include a control group and thus, it is unclear whether individuals with BPD are

less “skilled” at implementing distraction than HCs. Moreover, it remains unclear whether

U
persons with BPD are better at applying some strategies over others.
AN
1.3 The Present Study

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

M

laboratory design to examine emotional reactivity and volitional emotion regulation in BPD.
D

Baseline differences were first compared between individuals with BPD and HCs. Next,
TE

participants engaged in an event-related laboratory task where they viewed neutral and BPD-

relevant images while instructed to either 1) react naturally (i.e., reactivity condition) or 2)
EP

engage either mindful awareness or distraction (i.e., regulation condition). Self-reported ratings

and physiological measures were collected throughout. We hypothesized that the BPD group
C

would exhibit (a) abnormal baseline emotional functioning compared to HCs, (b) heightened
AC

change in emotional intensity from the presentation of neutral to BPD-relevant stimuli (i.e.,

reactivity) compared to HCs, and (c) heightened emotional intensity when implementing mindful

awareness and distraction compared to the HC group while controlling for emotional reactivity
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 8

(i.e., regulation). We further explored the relative efficacy of these two strategies and the

potential modulating influence of group status.

2. Materials and Methods

2.1 Participants

PT
Twenty-five individuals with BPD (9 male) and 30 HCs (10 male) between the ages of 18

RI
and 60 were included in the study. Individuals with BPD were recruited from the BPD Clinic at

the Centre for Addiction and Mental Health (CAMH), located in Toronto, ON. The majority

SC
(92%) of the BPD participants were recruited from an ongoing Dialectical Behavior Therapy

(DBT) skills training study. Of those, two individuals participated in the study after receiving 2

U
and 5 weeks of DBT skills training, respectively; the remaining participants did not yet receive
AN
treatment at the time of the study. HCs were recruited from the community through internet

postings. BPD exclusion criteria included diagnosis of psychotic disorder, bipolar disorder, or
M

dementia, or evidence of an organic brain syndrome or mental retardation. HC exclusion criteria

D

included meeting diagnostic criteria for any current DSM-IV Axis-I diagnosis or endorsing four
TE

or more of the DSM-IV criteria for BPD. HCs who endorsed item “(5) recurrent suicidal

behaviour, gestures, or threats, or self-mutilating behavior” (America Psychiatric Association,

EP

2000, p. 710) from the BPD criteria were also excluded. Finally, HCs who were currently taking

any psychotropic medication, beta-blockers, or anti-histamines were excluded.

C

See Table 1 for ethnic, educational, and martial demographics and Table 2 for rates of
AC

Axis I comorbidity among the BPD group. There was no significant difference in age between

the two groups (BPD: M=32.72, SD=9.55; HC: M=30.07 years, SD=9.07), t (53) = 1.05, p = .30.

A majority of the BPD participants were taking psychotropic medications: antidepressants (68%),
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 9

mood stabilizers (13%), benzodiazepines (40%), sedatives (14%), and stimulants (4%). No

participants reported taking neuroleptics, though 20% reported taking other antipsychotic drugs.

Table 1

Participant Demographics by Group

PT
HC BPD

Mean Age 30.07 33.29

RI
Sex Female 66.7% 64%

SC
Male 33.7% 36%

Marital status

U
Single 70% 56%
AN
Married/common law 23.3% 20%

Divorced/separated 3.3% 24%

M

Widowed 3.3% 0%

Highest level of
D

education
TE

Less than high school 3.3% 8%

EP

High school or equivalent 10% 4%

Some college/university 26.7% 24%

C

College/university 56.7% 56%

AC

Master’s degree 3.3% 8%

Ethnicity

European Origin/White 66.7% 56%

Black- 10% 0%
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 10

Canadian/Black/Caribbean

Origin

Asian-Canadian/Asian 13.3% 0%

Origin/Pacific Islander

PT
Biracial/Multiracial 3.3% 4%

RI
Middle Eastern 3.3%

Other 3.3% 8%

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

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

Table 2
U
AN
Past and Current Axis I Diagnoses in the Borderline Personality Disorder Group
M

Past Current

Other Bipolar Disorder 4% 4%

D

Major Depressive Disorder 64% 64%

TE

Dysthymic Disorder -- 12%

Alcohol Abuse Disorder 12% 12%

EP

Alcohol Dependence Disorder 24% 16%

Substance Abuse Disorder 16% 0%

C

Substance Dependence Disorder 32% 4%

AC

Panic Disorder 28% 12%

Agoraphobia without a history of Panic Disorder 16% 16%

Social Anxiety Disorder 4% 24%

Specific Phobia 8% 0%
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 11

Obsessive Compulsive Disorder 8% 8%

Posttraumatic Stress Disorder 12% 12%

Anxiety Disorder Not Otherwise Specified 24% 24%

Generalized Anxiety Disorder -- 40%

PT
Body Dysmorphic Disorder 4% 4%

RI
Anorexia Nervosa 12% 0%

Bulimia Nervosa 16% 4%

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

2.2 Measures and Materials

U
2.2.1 Screening. The Structured Clinical Interview for DSM-IV Axis-I Diagnoses (SCID-
AN
I) was administered to determine DSM-IV Axis-I diagnoses. The SCID-I is well validated and
M

highly reliable, with inter-rater reliability Kappa values ranging from .60 to .83 for individual

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

1998).
TE

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

administered to determine both the presence of BPD and a dimensional score of BPD
EP

symptomology. The IPDE assesses patterns of behaviour in the past 5 years and before the age of

25. The IPDE is well validated and has good diagnostic accuracy (Loranger et al., 1994).
C

2.2.2 Physiological measures. A BIOPAC 5-channel acquisition system (BIOPAC

AC

Systems Inc., Model MP150, Goleta, CA) was used to collect the physiological data. Mindware

Technologies (2011) software was used to process the physiological data in 30-second epochs

throughout the baseline, and 10-second epochs throughout the experimental task.
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 12

Heart rate (HR) was calculated from the R-R intervals in an electrocardiogram.

Electrocardiography was collected along with cardiac impedance (data not reported here) using a

two electrode (BIOPAC Systems Inc., Model EL503) configuration with the bioimpedance

module for ground referencing.

PT
Electrodermal activity (EDA) was collected as an index of sympathetic responding. Two

RI
electrodes (BIOPAC Systems Inc., Model EL507) were placed on the medial phalanges of the

index and middle fingers of the nondominant hand (Fowles et al., 1981). EDA data was digitized

SC
at 1,000 samples per seconds and a gain of 1,000. Low- (35 Hz) and high- (.05 Hz) pass filters

were applied. For the baseline analyses, the number of non-specific SCRs was the dependent

U
variable. For the task analyses, the difference between the mean skin conductance level (SCL)
AN
during each trial and the mean SCL during the 2000ms fixation cross prior to that trial was the

dependent variable.
M

Respiratory Sinus Arrhythmia (RSA) was collected as an index of parasympathetic

D

responding. RSA refers to the variation of heart rate with respiratory patterns and was measured
TE

through the high-frequency band (Berntson, Cacioppo, & Quigley, 1993) of spectral analysis of

heart rate variability using Mindware Technologies HRV 2.33 software (Mindware Technologies
EP

Ltd., 2011). Respiration rate was collected using a respiratory band placed around the chest.

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

System (IAPS; Lang, Bradley, & Cuthbert, 2008): 72 were BPD-relevant negative images (mean
AC

valence = 2.83; mean arousal = 5.38) and 24 were neutral (mean valence= 5.11; mean arousal =

2.90). The images selected for the BPD-relevant stimuli were informed by Sloan and colleagues

(2010), who identified a set of “self-referential” BPD IAPS images. Only negatively-valenced

images from this set were selected. As well, images that depicted self-harm were not selected
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 13

given evidence suggesting that viewing these images in and of itself might regulate emotion

(Shaw Welch, Linehan, Sylvers, Chittams, & Rizvi, 2008). In total, 28 of the BPD-relevant

images were drawn from this set, and the remaining images depicted themes of similar content-

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

PT
comparable valence and arousal ratings. The 72 negative images were divided into three sets of

RI
24 images, one for each condition (REACT, NOTICE, and DISTRACT; see below). The three

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

SC
computer monitor using Eprime Version 2.0 software.

2.3 Procedure

U
Interested individuals were contacted by phone and briefly screened to assess for
AN
exclusion criteria. Individuals who passed the phone-screen completed formal assessments for

DSM-IV Axis-I disorders and for BPD. Participants were assessed by a Masters and Bachelors-
M

level and research assistant under a licensed Clinical Psychologist’s supervision. In order to
D

establish inter-rater reliability, 10 individuals between the ages of 18 and 60 years of age were
TE

recruited from the community by means of flyers and online postings. Reliability assessments

were conducted no more than 5 days apart. Inter-rater reliability for the SCID-I and IPDE-BPD
EP

ranged from κ = .74-1.0. On the day of the experiment, all study participants were asked to report

any substances they took that day that that could potentially influence their performance on the
C

task. Participants reported taking their psychotropic medications as prescribed, antibiotics,

AC

multivitamins, and birth control pills.

2.3.1 Baseline assessment. The laboratory task was conducted in a sound-attenuated

room maintained at room temperature (20 degrees Celsius). After participants gave informed

consent, physiological sensors were attached and checked. Next, participants engaged in a 10-
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 14

minute baseline period in which they were instructed to sit silently and still. In order to ensure a

stable baseline (Jennings, Kamarck, Stewart, Eddy, & Johnson, 1992), only the last 5-minutes of

the baseline period were included for all subsequent analyses.

2.3.2 Emotional reactivity and regulation laboratory task (training and

PT
experimental phase). After completion of the baseline assessment, participants were trained by

RI
an experimenter in the two emotion regulation strategies: DISTRACT (i.e., the distract

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

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

the mindfulness awareness condition), in which participants were instructed to attend to and

U
notice the present experience without judging or trying to change it while still attending to the
AN
distressing stimulus. The experimenter followed a standardized script during the training phase;

however, the script gave the experimenter flexibility so he/she could ensure that participants
M

understood the instructions for each condition and provide feedback when appropriate.
D

Participants completed 10 practice trials for each regulation condition prior to the experimental
TE

task.

The experimental tasks consisted of 96 trials divided into 4 blocks (alternating

EP

DISTRACT and NOTICE blocks), with each block containing 24 images. Of the 24 images per

block, 6 were neutral REACT trials, 6 were negative REACT trials, and 12 were negative
C

emotion regulation trials (i.e. DISTRACT or NOTICE). Participants did not alternate between
AC

DISTRACT and NOTICE strategies in a single block in order to minimize “spillover” from the

other emotion regulation strategy. Neutral images were only paired with REACT instruction. In

order to protect against potential effects of idiosyncratic assignments of negative pictures to

condition, each set of 24 negative images was assigned to each condition, resulting in three
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 15

versions of the task. Further, the order of the blocks was counterbalanced resulting in a final six

versions of the laboratory task. At the mid-point (i.e., after the second block) and end (i.e., after

the fourth block) of the experiment, participants were prompted to indicate what percent of the

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

PT
reported following the DISTRACT instruction 74.89% of the time and the NOTICE instruction

RI
85.14% of the time. The HC group reported following the DISTRACT instruction 86.46% of the

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

SC
the task.

U
AN
M
D
TE

Figure 1. Trial-level illustration of the task.

EP

2.4 Data Analysis

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

values (SD ≥ 3.5) were removed. We considered fully parametric approaches (e.g., the mixed-
AC

model ANOVA) in choosing the modeling structure for the data. However, due to the

convergence issues of fully parametric models with respect to varying levels of complexity for

the covariance structures, we chose the semi-parametric Generalized Estimated Equation (GEE)

approach (Diggle, Heagerty, Liang, & Zeger, 2002) as it yields robust parameter estimates, even

under misspecification of the covariance structure. GEE is an extension of the generalized linear
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 16

model and is appropriate to model clustered/multilevel data from repeated observations within

individuals. Unstructured, Exchangeable, and Autoregressive covariance structures were

examined. Covariance structures with the lowest QIC values were selected. A priori between-

group pairwise contrasts testing our hypotheses are specified below. In accordance with

PT
Rothman (1990), alpha adjustments were not employed.

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

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

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

2.4.2 Emotional reactivity (self-report, HR, SCL). Between-group differences in self-

U
reported negativity and positivity and physiological activity was analyzed with Group (BPD or
AN
HC) as the between-subjects factor and Condition (neutral REACT, negative REACT) as the

within-subjects factor. Mean baseline HR was entered as the covariate for the HR analysis.
M

2.4.3 Emotion regulation (self-report, HR, SCL). Between-group differences in self-

D

reported negativity and positivity and physiological activity were analyzed with Group (BPD or
TE

HC) as the between-subjects factor and Condition (negative DISTRACT, negative NOTICE) as

the within-subjects factor. Mean self-reported negativity, self-reported positivity, HR, and SCL
EP

during the negative REACT condition were entered as covariates for each respective analysis.

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

benzodiazepines, which can influence physiological activity (Siepmann et al., 2007), we re-ran
AC

all physiological analyses using a 3-level Group factor (BPD + benzodiazepines, BPD + no

benzodiazepines, HC), followed by post-hoc contrasts when tests were significant. However,

results should be interpreted with caution given the unbalanced sample sizes in each cell (BPD +

benzodiazepines = 11, BPD + no benzodiazepines = 14, HC = 30).

 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 17

3. Results

3.1 Baseline Emotional Functioning

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

significant between-group differences in HR and RSA.

PT
Table 3

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

M (SE) Wald χ2, df

SC
HR

BPD 79.08 (2.58)

HC 71.42 (2.03)
U
AN
Group 7.04, 1**
M

Time .63, 1

Group x Time 1.13, 1

D

RSA
TE

BPD 5.16 (.29)

HC 6.39 (.19)
EP

Group 8.47, 1**

Time 2.53, 1
C

Group x Time .70, 1

AC

SCR

BPD 1.65 (.26)

HC 1.62 (.30)

Group .62, 1
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 18

Time 2.00, 1

Group x Time .71, 1

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

PT
conductance responses; HC = healthy controls; BPD = borderline personality disorder

RI
Table 4

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

SC
M (SE) Wald χ2, df

HR

HC 71.40 (2.03)
U
AN
BPD 78.92 (3.52)
M

BPD + Benz 79.23 (3.77)

Group 7.08, 2*
D

Time .03, 1
TE

Group x Time 1.22, 2

RSA
EP

HC 6.39 (.20)

BPD 5.32 (.38)

C

BPD + Benz 4.94 (.44)

AC

Group 9.80, 2**

Time 2.79, 1

Group x Time .86, 2

SCR
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 19

HC 1.62 (.30)

BPD 1.93 (.53)

BPD + Benz 1.29 (.49)

Group .58, 2

PT
Time .36, 1

RI
Group x Time .62, 2

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

conductance responses; HC = healthy controls; BPD+Benz = BPD participants taking

U
benzodiazepines, BPD = BPD participants not taking benzodiazepines
AN
3.2 Emotional Reactivity

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

M

306.68, df = 1, p < .001) such that both groups reported a significant increase in negativity from
D

the NEUTRAL to negative REACT conditions. There was no significant Group x Condition
TE

interaction (Wald χ2 = 1.65, df = 1, p = .20).

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

EP

103.30, df = 1, p < .001) such that both groups reported a significant decrease in positivity from

the NEUTRAL to negative REACT conditions. There was no significant Group x Condition
C

interaction (Wald χ2 = 1.13, df = 1, p = .29).

AC

3.2.3 HR. There was a significant effect of Condition (Wald χ2 = 10.55, df = 1, p = .001)

such that both groups reported a significant decrease in HR from the NEUTRAL to negative

REACT conditions but no significant Group x Condition interaction (Wald χ2 = .40, df = 1, p

 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 20

= .53). Similarly, analyses exploring the potential role of benzodiazepine use in the BPD sample

indicated no significant Group x Condition interaction (Wald χ2 = .84, df = 2, p = .66).

3.2.4 SCL. There was no significant effect of Condition (Wald χ2 = 2.06, df = 1, p = .15)

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

PT
analyses exploring the potential role of benzodiazepine use in the BPD sample indicated no

RI
significant Group x Condition interaction (Wald χ2 = .91, df = 2, p = .64).

3.3 Emotion Regulation

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

42.52, df = 1, p < .001) such that both groups reported greater negativity in the negative NOTICE

U
condition relative to the negative DISTRACT condition. Pairwise contrasts indicated that there
AN
was no group difference in negativity during the negative DISTRACT condition (95% Wald χ2

CI for difference [-1.25, .12], df = 1, p =.11) or the NOTICE condition (95% Wald χ2 CI for
M

difference [-.70, .68], df = 1, p =.99). There was no significant Group x Condition interaction
D

(Wald χ2 = 2.57, df = 1, p = .11).

TE

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

13.28, df = 1, p < .001) such that both groups reported greater positivity in the negative
EP

DISTRACT relative to the negative NOTICE condition. Pairwise contrasts indicated that there

was a significant group difference in positivity during the negative DISTRACT condition (95%
C

Wald χ2 CI for difference [.00, .52], df = 1, p =.05) such that the HC group reported greater
AC

positivity during the DISTRACT condition than the BPD group. There was a trend toward a

group difference in negativity during the negative NOTICE condition (95% Wald χ2 CI for

difference [-.36, .02], df = 1, p =.08) such that the BPD group reported greater positivity during

the NOTICE condition than the HC group. In addition, there was significant Group x Condition
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 21

interaction (Wald χ2 = 8.79, df = 1, p = .003). Post-hoc analyses indicated that the HCs reported

significantly greater positivity during the negative DISTRACT condition relative to the negative

NOTICE condition (95% Wald χ2 CI for difference [.22, .74], df = 1, p < .001) whereas the BPD

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

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

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

Pairwise contrasts indicated that there was no group difference in HR during the negative

SC
DISTRACT condition (95% Wald χ2 CI for difference [-1.83, .19], df = 1, p =.11) or the

NOTICE condition (95% Wald χ2 CI for difference [-.91, 1.00], df = 1, p =.93). There was a

U
trend toward a significant Group x Condition interaction (Wald χ2 = 3.05, df = 1, p = .08) such
AN
that the HC group exhibited significantly higher HR in the negative NOTICE relative to the

negative DISTRACT condition (95% Wald χ2 CI for difference [-1.49, -.03], df = 1, p =.04),
M

whereas there was no significant difference in HR between the two conditions in the BPD group
D

(95% Wald χ2 CI for difference [-.53, .75], df = 1, p =.74). Analyses exploring the potential role
TE

of benzodiazepine use in the BPD sample indicated no significant Group x Condition interaction

(Wald χ2 = 3.68, df = 2, p = .16).

EP

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

Pairwise contrasts indicated that there was no group difference in SCL during the negative
C

DISTRACT condition (95% Wald χ2 CI for difference [-.05, .04], df = 1, p =.87) or the NOTICE
AC

condition (95% Wald χ2 CI for difference [-.05, .07], df = 1, p =.86). There was no significant

Group x Condition interaction (Wald χ2 = .79, df = 1, p = .77). Analyses exploring the potential

role of benzodiazepine use in the BPD sample indicated no significant Group x Condition
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 22

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

across indices.

Table 5

Means and Standard Errors by Group and Experimental Condition

PT
Neutral Negative Notice Distract

RI
React React

Self-reported

SC
negativity

BPD 2.03 (.14) 5.25 (.33) 5.35 (.29) 4.49 (.27)

HC 1.50 (.11)
U
5.23 (.23) 5.35 (.21) 3.93 (.23)
AN
Self-reported
M

positivity

BPD 4.43 (.44) 2.32 (.22) 2.56 (.07) 2.60 (.07)

D

HC 4.08 (.28) 2.37 (.22) 2.38 (.07) 2.86 (.11)

TE

HR

BPD 70.74 (.87) 70.14 (.94) 70.94 (.32) 71.05 (.26)

EP

HC 73.44 (.63) 72.83 (.63) 70.99 (.35) 70.23 (.43)

∆ SCL
C

BPD -.07 (.02) -.06 (.01) -.09 (.02) -.09 (.01)

AC

HC -.07 (.02) -.06 (.01) -.08 (.03) -.09 (.02)

 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 23

Note. BPD = borderline personality disorder; HC = healthy control; HR = heart rate; ∆ SCL =

change in average skin conductance levels from the two seconds prior to the onset of each image

to the average SCL during the image presentation.

4. Discussion

PT
Our findings suggest that individuals with BPD do not experience heightened emotional

RI
reactivity and, in general, are able to implement mindful awareness or distraction as effectively

as HCs. However, we did find evidence of abnormal baseline physiological activity as indicated

SC
by elevated HR and reduced RSA. Our finding of elevated baseline HR in the BPD group is

consistent with the majority of the research examining baseline emotional intensity in BPD

U
(Elices et al., 2012; Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2010; Kuo & Linehan, 2009).
AN
Moreover, our study is the second to report reduced RSA, an index of heart rate variability

mediated by the vagus nerve (Porges, 1995) in BPD. Attenuated basal vagal activity is indicated
M

as a marker of emotional vulnerability to negative emotional states, and is linked with several
D

negative clinical outcomes including panic, anger, and hostility (see Beauchaine, 2001 for
TE

review). Thus, extant data suggest that individuals with BPD exhibit deficits in baseline

emotional functioning, specifically, heightened emotional intensity and vulnerability. Together,

EP

our findings suggest the “core” of emotional pathology in BPD may not explained by emotional

“response” patterns per se, but rather by abnormalities in general emotional resting state.
C

4.1 Emotional Reactivity and Regulation in BPD

AC

Consistent with many previous studies, we did not find evidence of heightened emotional

reactivity in BPD (Herpertz et al., 1999; Herpertz et al., 2000; Kuo & Linehan, 2009; Schmahl et

al., 2004). Further, while there was a significant main effect of condition for self-reported

negativity and positivity in the hypothesized directions, our physiological data indicated that all
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 24

participants exhibited cardiac deceleration from presentation of the neutral to BPD-relevant

images. Though unexpected, this finding can be explained by motivational models proposing a

relationship between cardiac deceleration and an orienting response to stimuli depicting

unpleasant or threatening content (Bradley, 2009). According to this model, the content depicted

PT
in the BPD-relevant stimuli may have been more biologically-relevant than the neutral stimuli,

RI
thus necessitating heightened orienting and sensory input (Bradley, 2001).

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

SC
effectively reduce emotional reactivity when instructed to implement mindful awareness or

distraction strategies. Though this is contrary to what is hypothesized by prominent theories of

U
BPD (e.g., Linehan, 1993; Selby & Joiner, 2009), our finding is consistent with previous reports
AN
suggesting that individuals with BPD do not differ from HCs in their ability to implement

different forms of cognitive reappraisal (Lang et al., 2012; Marissen et al., 2010; Ruocco et al.,
M

2010). The only exception was our finding that HCs reported greater positivity during the
D

DISTRACT trials (while controlling for reactivity) compared with the BPD group, suggesting
TE

that individuals with BPD may be less effective at engaging in distraction than HCs.

Our results also indicate that persons with BPD do not exhibit differential abilities in the
EP

implementation of mindful awareness versus distraction. Rather, it was the HCs that reported

greater positive emotions when implementing distraction versus mindful awareness. These
C

findings are particularly intriguing when taken in conjunction with a study by Lindenboim,
AC

Comtois, and Linehan (2007) who found that, among BPD women in treatment for DBT,

distraction and mindfulness were two of the most commonly practiced skills. Thus, it is possible

that we did not detect differences between the two strategies because we examined two emotion

regulation strategies that happen to be the most effective for this group.
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 25

4.2 Limitations, Implications, and Future Directions

A limitation in this study is that we did not exclude BPD participants on psychotropic

medications. As medication use can influence psychophysiological responding (Licht, de Geus,

van Dyck, & Penninx, 2010), it is possible that this altered emotional responding in the BPD

PT
group, resulting the illusion of a lack of group differences. However, given that 70% of

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

Reich, & Fitzmaurice, 2010), our findings are more generalizable to the BPD population at large.

SC
As well, many individuals in the BPD group met for current major depressive disorder (64%)

and social anxiety disorder (24%), both of which are linked with heightened self-reported

U
intensity and physiological activity (Staebler, Gebhard, Barnett, & Renneberg, 2009; Wang,
AN
Zhao, O-Neil, Turner, Liu, & Berk, 2013; McTeague, Lang, Laplante, Cuthbert, Strauss, &

Bradley, 2009). Thus, it is possible that the baseline alterations identified in the BPD group are a
M

marker of psychopathology in general, rather than specific to BPD. Indeed, clinical control
D

groups are needed to more precisely delineate differences among diagnostic groups. Moreover,
TE

given that one of the core components of BPD consists of interpersonal distress, it may be that

our stimuli, though BPD-relevant, did not effectively target the more “key” clinically-relevant
EP

themes that are more likely to elicit reactivity. Further, though our stimuli were BPD-relevant,

emerging evidence suggests that emotional reactivity in BPD may be emotion-specific (Kuo, et
C

al., 2013; Gratz, et al., 2010). Thus, it’s possible that the images in the study did not elicit the
AC

core emotions that are relevant to BPD. In addition, this study may be limited by its lack of

inclusion of potentially key covariates. Research has indicated a link between respiratory

patterns and autonomic activity such as HR and RSA (Brown, Beightol, Koh, & Eckberg, 1993;

Furedy & Shulhan, 1986), leading some to argue that respiration must be controlled for,
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 26

particularly in RSA analyses (Grossman, Karemaker, Wieling, 1991). Further, though some

findings suggest that sex does not influence autonomic reactivity indices such as HR and SCR

(Codispoti, Surcinelli, & Baldaro, 2008; Sarlo, Palomba, Buodo, Minghetti, & Stegagno, 2005),

others suggest that it does (Bianchin & Angrilli, 2012). It is possible that these variables exerted

PT
confounding effects on physiological indices thereby impacting results.

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

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

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

“disadvantage.” That is, individuals with BPD likely need to recruit greater emotion regulatory

U
resources than HCs in order to reduce their reactivity to a more manageable level. Thus,
AN
acquiring emotion regulation skills might not be as important as ensuring that individuals with

BPD strengthen these skills.

M

Several future directions are recommended. First, emerging research suggests that
D

effective emotion regulation involves flexibly selecting emotion regulation strategies based on
TE

the intensity of the stimulus (Sheppes, et al., 2011). Thus, future studies should examine the

choice of emotion regulation strategies in BPD and evaluate specific factors that predict strategy
EP

selection in this population. In addition, given that emotion dysregulation in BPD might be better

explained by some components (i.e., baseline functioning) versus others (i.e., reactivity and
C

regulation), future studies should examine how different components are related and whether
AC

specific components are differentially associated with BPD-relevant maladaptive behaviors such

as self-harm and impulsivity. Finally, recent evidence also suggests that emotion dysregulation

mediates the relationship between BPD and cognitive processing (Dixon-Gordon, et al., 2013).

Thus, while our data suggest that emotion regulation strategies have comparable effects on
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 27

emotional responding, it is possible that these strategies have differential effects on cognitive or

social functioning. Thus, future studies should examine cognitive and/or social sequelae of

various emotion regulation strategies in BPD.

PT
RI
U SC
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 28

Declaration of Interest

There is no interest to be declared.

PT
RI
U SC
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 29

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders

(4th ed., text rev.). Washington, DC: American Psychiatric Association.

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

PT
emotion regulation: Insights from the polyvagal theory. Brain and Cognition, 65, 69-76.

RI
doi:http://dx.doi.org/10.1016/j.bandc.2006.05.007

Beauchaine, T. P. (2001). Vagal tone, development, and gray's motivational theory: Toward an

SC
integrated model of autonomic nervous system functioning in psychopathology.

Development and Psychopathology, 13, 183-214.

U
doi:http://dx.doi.org/10.1017/S0954579401002012
AN
Berntson, G. G., Cacioppo, J. T., & Quigley, K. S. (1993). Respiratory sinus arrhythmia:

Autonomic origins, physiological mechanisms, and psychophysiological implications.

M

Psychophysiology, 30, 183-196. doi:http://dx.doi.org/10.1111/j.1469-8986.1993.tb01731.x

D

Bianchin, M., & Angrilli, A. (2012). Gender differences in emotional responses: A

TE

psychophysiological study. Physiology & Behavior, 105, 925-932.

doi:http://dx.doi.org/10.1016/j.physbeh.2011.10.031
EP

Bradley, M. M. (2009). Natural selective attention: Orienting and emotion. Psychophysiology,

46, 1-11. doi:http://dx.doi.org/10.1111/j.1469-8986.2008.00702.x

C

Bradley, M. M., Codispoti, M., Cuthbert, B.N., & Lang, P.L. (2001). Emotion and motivation I:
AC

Defensive and appetitive reactions to picture processing. Emotion, 1, 276-298.

doi:http://dx.doi.org/10.1037//1528-3542.1.3.276

Brown, T. E., Beightol, L. E., Koh, J., & Eckberg, D. L. (1993). Important influence of

respiration on human R-R- interval power spectra is largely ignored. Journal of Applied
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 30

Physiology, 75, 2310-2317. Retrieved

from http://jap.physiology.org/content/jap/75/5/2310.full.pdf

Codispoti, M., Surcinelli, P., & Baldaro, B. (2008). Watching emotional movies: Affective

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

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

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

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

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

Diggle P.J., Heagerty .P, Liang K. Y., & Zeger S. L. (2002). Analysis of longitudinal data (2nd

U
ed.). New York, NY: Oxford University Press, Oxford Statistical Science Series.
AN
Dixon-Gordon, K.L., Gratz, K.L, Breetz, A., & Tull, M. (2013). A laboratory-based examination

of responses to social rejection in borderline personality disorder: The mediating role of

M

emotion dysregulation. Journal of Personality Disorders, 27, 157-171. doi:

D

10.1521/pedi.2013.27.2.157
TE

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

Pascual, J. (2012). Physiological and self-assessed emotional responses to emotion-

EP

eliciting films in borderline personality disorder. Psychiatry Research, 200, 437-443.

doi:http://dx.doi.org/10.1016/j.psychres.2012.07.020
C

Fonagy, P., & Bateman, A. (2008). The development of borderline personality disorder--A
AC

mentalizing model. Journal of Personality Disorders, 22, 4-21.

doi:http://dx.doi.org/10.1521/pedi.2008.22.1.4
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 31

Fowles, D. C., Christie, M. J., Edelberg, R., Grings, W. W., Lykken, D. T., & Venables, P. H.

(1981). Publication recommendations for electrodermal measurements. Psychophysiology,

18, 232-239. doi:http://dx.doi.org/10.1111/j.1469-8986.1981.tb03024.x

Furedy, J. J., & Shulhan, D. L. (1986). Effects of respiratory depth and rate on HR and TWA: An

PT
indirect assessment of the respiratory confound in cognitive task difficulty manipulations.

RI
Physiology & Behavior, 37, 515-517.doi:http://dx.doi.org/10.1016/0031-9384(86)90217-9

Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., . . . Ruan, W. J.

SC
(2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline

personality disorder: Results from the wave 2 national epidemiologic survey on alcohol

U
and related conditions. Journal of Clinical Psychiatry, 69, 533-545.
AN
doi:http://dx.doi.org/10.4088/JCP.v69n0404

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

experimental investigation of emotional reactivity and delayed emotional recovery in

D

borderline personality disorder: The role of shame. Comprehensive Psychiatry, 51, 275-
TE

285. doi:http://dx.doi.org/10.1016/j.comppsych.2009.08.005

Gross, J. & Jazaeiri, H. (2014). Emotion, emotion regulation, and psychopathology: An affective
EP

science perspective. Clinical Psychological Science, 2, 387-401.

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

Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes:

Implications for affect, relationships, and well-being. Journal of Personality and Social

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

 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 32

Gross, J. J., & Thompson, R. A. (2007). Emotion regulation: Conceptual foundations. New

York, NY: Guilford Press.

Grossman, P., Karemaker, J. and Wieling, W. (1991). Prediction of Tonic Parasympathetic

Cardiac Control Using Respiratory Sinus Arrhythmia: The Need for Respiratory Control.

PT
Psychophysiology, 28, 201–216. doi:http://dx.oi.org/10.1111/j.1469-8986.1991.tb00412.x

RI
Herpertz, S. C., Kunert, H. J., Schwenger, U. B., & Sass, H. (1999). Affective responsiveness in

borderline personality disorder: A psychophysiological approach. The American Journal of

SC
Psychiatry, 156, 1550-1556.

Herpertz, S. C., Schwenger, U. B., Kunert, H. J., Lukas, G., Gretzer, U., Nutzmann, J., . . . Sass,

U
H. (2000). Emotional responses in patients with borderline as compared with avoidant
AN
personality disorder. Journal of Personality Disorders, 14, 339-351.

doi:http://dx.doi.org/10.1521/pedi.2000.14.4.339
M

Hofmann, S. G., Heering, S., Sawyer, A. T., & Asnaani, A. (2009). How to handle anxiety: The
D

effects of reappraisal, acceptance, and suppression strategies on anxious arousal. Behaviour

TE

Research and Therapy, 47, 389-394. doi:http://dx.doi.org/10.1016/j.brat.2009.02.010

Hörz, S., Zanarini, M. C., Frankenburg, F. R., Reich, D. B., & Fitzmaurice, G. (2010). Ten-year
EP

use of mental health services by patients with borderline personality disorder and with

other axis II disorders. Psychiatric Services, 61, 612-616.

C

doi:http://dx.doi.org/10.1176/appi.ps.61.6.612
AC

Jacob, G. A., Arendt, J., Kolley, L., Scheel, C. N., Bader, K., Lieb, K., . . . Tüscher, O. (2011).

Comparison of different strategies to decrease negative affect and increase positive affect

in women with borderline personality disorder. Behaviour Research and Therapy, 49, 68-

73. doi:http://dx.doi.org/10.1016/j.brat.2010.10.005
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 33

Jazaieri, H., Urry, H., & Gross, J. J. (2013). Affective disturbance and psychopathology: An

emotion regulation perspective. Journal of Experimental Psychopathology, 4, 584-599.

doi:http://dx.doi.org/10.5127/jep.030312

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

PT
cardiovascular baseline assessment: Vanilla or resting baseline. Psychophysiology, 29,

RI
742-750. doi:http://dx.doi.org/10.1111/j.1469-8986.1992.tb02052.x

Koenigsberg, H. W., Fan, J., Ochsner, K. N., Liu, X., Guise, K. G., Pizzarello, S., . . . Siever, L.

SC
J. (2009). Neural correlates of the use of psychological distancing to regulate responses to

negative social cues: A study of patients with borderline personality disorder. Biological

U
Psychiatry, 66, 854-863. doi:http://dx.doi.org/10.1016/j.biopsych.2009.06.010
AN
Kohl, A., Rief, W., & Glombiewski, J. A. (2012). How effective are acceptance strategies? A

meta-analytic review of experimental results. Journal of Behavior Therapy and

M

Experimental Psychiatry, 43, 988-1001. doi:http://dx.doi.org/10.1016/j.jbtep.2012.03.004

D

Korzekwa, M. I., Dell, P. F., Links, P. S., Thabane, L., & Webb, S. P. (2008). Estimating the
TE

prevalence of borderline personality disorder in psychiatric outpatients using a two-phase

procedure. Comprehensive Psychiatry, 49, 380-386.

EP

doi:http://dx.doi.org/10.1016/j.comppsych.2008.01.007

Kuo, J. R., & Linehan, M. M. (2009). Disentangling emotion processes in borderline personality
C

disorder: Physiological and self-reported assessment of biological vulnerability, baseline

AC

intensity, and reactivity to emotionally evocative stimuli. Journal of Abnormal Psychology,

118, 531-544. doi:http://dx.doi.org/10.1037/a0016392

Kuo, J. R., Neacsiu, A. D., Fitzpatrick, S., & MacDonald, D. E. (2013). A methodological

examination of emotion inductions in borderline personality disorder: A comparison of

 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 34

standardized versus idiographic stimuli. Journal of Psychopathology and Behavioral

Assessment, doi:http://dx.doi.org/10.1007/s10862-013-9378-x

Lang, P. J., Bradley, M. M., & Cuthbert, B. N. (2008). International affective picture system

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

PT
Lang, S., Kotchoubey, B., Frick, C., Spitzer, C., Grabe, H. J., & Barnow, S. (2012). Cognitive

RI
reappraisal in trauma-exposed women with borderline personality disorder. Neuroimage,

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

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

evidence for unfavorable effects of antidepressants on heart rate variability. Biological

U
Psychiatry, 68, 861-868. doi:http://dx.doi.org/10.1016/j.biopsych.2010.06.032
AN
Limberg, A., Barnow, S., Freyberger, H. J., & Hamm, A. O. (2011). Emotional vulnerability in

borderline personality disorder is cue specific and modulated by traumatization. Biological

M

Psychiatry, 69, 574-582. doi:http://dx.doi.org/10.1016/j.biopsych.2010.10.024

D

Lindenboim, N., Comtois, K. A., & Linehan, M. M. (2007). Skills practice in dialectical
TE

behavior therapy for suicidal women meeting criteria for borderline personality disorder.

Cognitive and Behavioral Practice, 14, 147-156.

EP

doi:http://dx.doi.org/10.1016/j.cbpra.2006.10.004

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New

C

York, NY: Guilford Press.

AC

Lobbestael, J., & Arntz, A. (2010). Emotional, cognitive and physiological correlates of abuse-

related stress in borderline and antisocial personality disorder. Behaviour Research and

Therapy, 48, 116-124. doi:http://dx.doi.org/10.1016/j.brat.2009.09.015

 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 35

Lobbestael, J., Leurgans, M., & Arntz, A. (2011). Inter-rater reliability of the structured clinical

interview for DSM-IV axis I disorders (SCID I) and axis II disorders (SCID II). Clinical

Psychology & Psychopathology, 18, 75-79. doi:http://dx.doi.org/10.1002/cpp.693

Loranger, A. W., Sartorius, N., Andreoli, A., Berger, P., Buchheim, P., Channabasavanna, S. M.,

PT
. . . Regier, D. A. (1994). The international personality disorder examination: The world

RI
health Organization/Alcohol, drug abuse, and mental health administration international

pilot study of personality disorders. Archives of General Psychiatry, 51, 215-224.

SC
doi:http://dx.doi.org/10.1001/archpsyc.1994.03950030051005

Low, C. A., Stanton, A. L., & Bower, J. E. (2008). Effects of acceptance-oriented versus

U
evaluative emotional processing on heart rate recovery and habituation. Emotion, 8, 419-
AN
424. doi:http://dx.doi.org/10.1037/1528-3542.8.3.419

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

F., . . . Wilson, K. G. (2010). The impact of acceptance-based versus avoidance-based

D

protocols on discomfort. Behavior Modification, 34, 94-119.

TE

doi:http://dx.doi.org/10.1177/0145445509357234

Marissen, M. A. E., Meuleman, L., & Franken, I. H. A. (2010). Altered emotional information
EP

processing in borderline personality disorder: An electrophysiological study. Psychiatry

Research: Neuroimaging, 181, 226-232.

C

doi:http://dx.doi.org/10.1016/j.pscychresns.2009.10.006
AC

McTeague, L. M., Lang, P. J., Laplante, M., Cuthbert, B. N., Strauss, C. C., & Bradley, M. M.

(2009). Fearful imagery in social phobia: Generalization, comorbidity, and physiological

reactivity. Biological Psychiatry, 65, 374-382.

doi:http://dx.doi.org/10.1016/j.biopsych.2008.09.023
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 36

McRae, K., Hughes, B., Chopra, S., Gabrieli, J. D. E., Gross, J. J., & Ochsner, K. N. (2010). The

neural bases of distraction and reappraisal. Journal of Cognitive Neuroscience, 22, 248-

262. doi:http://dx.doi.org/10.1162/jocn.2009.21243

Porges, S. W. (1995). Cardiac vagal tone: A physiological index of stress. Neuroscience and

PT
Biobehavioral Reviews, 19, 225-233. doi:http://dx.doi.org/10.1016/0149-7634(94)00066-A

RI
Rothman, K.J. (1990). No Adjustments are Needed for Multiple Comparisons. Epidemiology, 1,

43-46.

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

response during affective processing in borderline personality disorder. Psychiatry

Research: Neuroimaging, 182, 117-122.

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

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

changes highlight gender differences in emotional reactivity to arousing pictures.

D

Biological Psychology, 70, 188-196. doi:http://dx.doi.org/10.1016/j.biopsycho.2005.01.005

TE

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

EP

scripts in borderline personality and posttraumatic stress disorders: A preliminary report.

Psychiatry Research, 126, 33-42. doi:http://dx.doi.org/10.1016/j.psychres.2004.01.005

C

Schulze, L., Domes, G., Krüger, A., Berger, C., Fleischer, M., Prehn, K., ... & Herpertz, S. C.
AC

(2011). Neuronal correlates of cognitive reappraisal in borderline patients with affective

instability. Biological psychiatry, 69, 564-573.

doi:http://dx.doi.org/10.1016/j.biopsych.2010.10.025
 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 37

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2012) Mindfulness-based Cognitive Therapy

for Depression: A New Approach to Preventing Relapse. New York, NY: Guilford Press.

Selby, E. A., & Joiner, T. E., Jr. (2009). Cascades of emotion: The emergence of borderline

personality disorder from emotional and behavioral dysregulation. Review of General

PT
Psychology, 13, 219-229. doi:http://dx.doi.org/10.1037/a0015687

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

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

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

006X.76.1.45

U
Sheppes, G., Scheibe, S., Suri, G., & Gross, J. J. (2011). Emotion-regulation choice.
AN
Psychological Science, 22, 1391-1396. doi:http://dx.doi.org/10.1177/0956797611418350

Siepmann, T., Ziemssen, T., Mueck-Weymann, M., Kirch, W., & Siepmann, M. (2007). The
M

effects of venlafaxine on autonomic functions in healthy volunteers. Journal of Clinical

D

Psychopharmacology, 27, 687-691. doi:http://dx.doi.org/10.1097/jcp.0b013e31815a255b

TE

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. Journal of

EP

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

C

Staebler, K., Gebhard, R., Barnett, W., & Renneberg, B. (2009). Emotional responses in
AC

borderline personality disorder and depression: Assessment during an acute crisis and 8

months later. Journal of Behavior Therapy and Experimental Psychiatry, 40, 85-97.

doi:http://dx.doi.org/10.1016/j.jbtep.2008.04.003

Thiruchselvam, R., Blechert, J., Sheppes, G., Rydstrom, A., & Gross, J. J. (2011). The temporal

dynamics of emotion regulation: An EEG study of distraction and reappraisal. Biological

 ACCEPTED MANUSCRIPT
Running Head: EMOTIONAL REACTIVITY AND REGULATION IN BPD 38

Psychology, 87, 84-92. doi:http://dx.doi.org/10.1016/j.biopsycho.2011.02.009

Ventura, J., Liberman, R. P., Green, M. F., Shaner, A., & Mintz, J. (1998). Training and quality

assurance with structured clinical interview for DSM-IV (SCID-I/P). Psychiatry Research,

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

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

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

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

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

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

U
Psychological Bulletin, 138, 775-808. doi:http://dx.doi.org/10.1037/a0027600
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

Highlights

• Individuals with BPD exhibit increased heart rate and reduced respiratory sinus
arrhythmia at baseline compared with healthy controls
• Individuals with BPD do not exhibit greater emotional reactivity compared with healthy
controls

PT
• Individuals with BPD do not exhibit deficits in the ability to engage in two different
emotion regulation strategies (i.e., mindful awareness and distraction) compared with
healthy controls.

RI
U SC
AN
M
D
TE
C EP
AC