اختلال در نظم احساسات به عنوان یک عامل نگهداری ویژگی های اختلال شخصیت مرزی

We examined within-individual changes in emotion dysregulation over the course of one year as a maintenance factor of borderline personality disorder (BPD) features. We evaluated the extent to which (1) BPD symptom severity at baseline predicted within-individual changes in emotion dysregulation and (2) within-individual changes in emotion dysregulation predicted four BPD features at 12-month follow-up: affective instability, identity disturbances, negative relationships, and impulsivity. The specificity of emotion dysregulation as a maintaining mechanism of BPD features was examined by controlling for a competing intervening variable, interpersonal conflict. BPD symptoms at baseline predicted overall level and increasing emotion dysregulation. Additionally, increasing emotion dysregulation predicted all four BPD features at 12-month follow-up after controlling for BPD symptoms at baseline. Further, overall level of emotion dysregulation mediated the association between BPD symptom severity at baseline and both affective instability and identity disturbance at 12-month follow-up, consistent with the notion of emotion dysregulation as a maintenance factor. Future research on the malleability of emotion dysregulation in laboratory paradigms and its effects on short-term changes in BPD features is needed to inform interventions.

Recent findings from longitudinal studies of patients with borderline personality disorder (BPD) have challenged commonly held conceptions regarding the long-term stability and chronic nature of this illness. Specifically, findings from the Collaborative Longitudinal Personality Disorders Study (CLPS) and the McLean Study of Adult Development (MSAD) revealed that approximately 85%–90% of patients with BPD experienced symptom remission within a 10-year period [1] and [2]. The rate of BPD relapse was quite low over this extended period as well. However, these studies have also documented sustained levels of impairment in this population, which resulted in more modest rates of full recovery [1], [3] and [2]. These studies highlight the need to think longitudinally about the course of BPD and to consider factors that may facilitate or impede individuals moving across different stages of the illness, including onset, maintenance, remission, recovery, and relapse. For instance, situational changes, such as garnering more stable social support, or remissions of co-occurring Axis I disorders were shown to predict rapid and full recovery among some patients with BPD [4]. The identification of maintenance mechanisms is critical for developing and refining interventions as these are the processes that impede individuals from moving from onset to remission or from remission to recovery, for example. We posit that emotion dysregulation is one mechanism that maintains BPD features over time. Although there is no consensus on the definition of emotion dysregulation, we define emotion dysregulation as deficits in the ability to modulate the experience and expression of emotions and to maintain goal directed behavior in the presence of intense negative affect [5]. Thus, we conceptualize emotion dysregulation as distinct from negative affect or variability in affect. This conceptual distinction is important because emotion dysregulation reflects strategies and processes in the face of emotion rather than merely symptoms that define psychopathology. Emotion dysregulation has also been prospectively linked to increases in internalizing and externalizing psychopathology over a seven-month window in adolescents [6], highlighting the role of emotion dysregulation as driving increases in psychopathology over time. Emotion dysregulation is hypothesized by several theorists to play a central role in the etiology and development of BPD [7], [8], [9] and [10], giving rise to affective instability (defined as marked intensity, reactivity, and variability of moods; [11]) as well as other symptoms of the disorder such as identity disturbance, interpersonal dysfunction, and self-harm. According to these theoretical models, transactions between an individual’s innate biological disposition toward intense emotional reactivity and invalidating environmental inputs contribute to deficits in the acquisition of effective skills for regulating these intense emotional experiences. In turn, deficits in emotion regulation capacities contribute to even more intense and variable affects (i.e., affective instability) and dysregulated cognitions, behaviors, and interpersonal relations. Given the theorized role of emotion dysregulation in the developmental psychopathology of BPD, deficits in the ability to effectively cope with and modulate affect may also serve to maintain features of the disorder over time. From the view of emotion dysregulation as a maintenance mechanism, once BPD emerges, emotion dysregulation may sustain BPD symptoms and associated problematic behaviors, which is consistent with several studies illustrating a link between dysregulated emotion and behavior [12], [13] and [14]. For instance, in a sample of college students, the relationship between BPD and dysregulated behavior (reassurance seeking, binge-eating, and alcohol use) was mediated by rumination, anger rumination, catastrophizing, and brooding, even after controlling for depression [12]. Additionally, in the natural environment, rumination and intense negative affect predicted engaging in dysregulated behavior within 2–3 h [14]. Emerging evidence also suggests that emotion dysregulation is associated with interpersonal dysregulation. For instance, a cross-sectional study demonstrated that emotion dysregulation fully mediated the association between BPD and interpersonal problems [5]. In a recent prospective study, emotion dysregulation mediated the relationship between BPD symptoms at baseline and aggressive behavior over the course of a year. A number of studies also support a link between emotion dysregulation and non-suicidal self-injury or suicide behaviors. Additionally, several studies have found that individuals who engage in non-suicidal self-injury report higher levels of emotion dysregulation [16], [17], [18], [19] and [20]. Across two treatment trials, within-individual improvements in emotion regulation predicted decreases in non-suicidal self-injury over the course of 14 weeks [21], further supporting the notion that emotion dysregulation maintains non-suicidal self-injury. Although the link between emotion dysregulation and dysregulated behaviors has been examined generally as well as for individuals with BPD, the role of emotion dysregulation in maintaining other BPD features, such as affective instability and identity problems, has not yet been examined. Additionally, most studies have relied on cross-sectional reports [8], [12] and [13] or short prospective studies [14] and [22]. Hence, within-individual changes, or increases in emotion dysregulation over time, as a maintenance factor for BPD features have yet to be determined. Finally, it is not clear whether emotion dysregulation has a unique association with the maintenance of BPD features or if this relationship could be accounted for by other variables that are linked to BPD and emotion dysregulation, such as interpersonal conflict [23], [15] and [24]. The overall goal of this study was to examine emotion dysregulation (i.e., difficulties with emotion regulation) as a maintenance factor for BPD features over the course of one year. Specifically, we expected that the trajectory of emotion dysregulation over one year would predict BPD features even after controlling for BPD symptom severity and other emotion constructs at baseline, specifically angry rumination and depression. Additionally, we expected the relationship between within-individual changes in emotion dysregulation and BPD features to hold even after controlling for within-individual changes in interpersonal conflict over the course of the year. Our specific questions for the current study are as follows: 1. What are the patterns of growth (within-individual changes) in difficulties in emotion regulation over the course of one year? 2. Does BPD symptom severity predict growth over the course of one year in emotion dysregulation even after controlling for depression, angry rumination and demographic characteristics? 3. Do within-person changes in emotion dysregulation account for the maintenance of BPD features over the course of one year? That is, does growth in emotion dysregulation over one year mediate the relation between BPD symptom severity at baseline and BPD features (i.e., affective instability, identity problems, negative relationships, and self harm) one year later? Further, is mediation specific to emotion dysregulation, or can within-person changes in another core problem associated with BPD (specifically, interpersonal conflict) also mediate these associations?