Ibraheim et al. Borderline Personality Disorder and Emotion Dysregulation
(2017) 4:1
DOI 10.1186/s40479-017-0052-x
RESEARCH ARTICLE
Open Access
The specificity of emotion dysregulation in
adolescents with borderline personality
disorder: comparison with psychiatric and
healthy controls
Marina Ibraheim, Allison Kalpakci and Carla Sharp*
Abstract
Background: Research has supported the notion that emotion dysregulation is a core feature of BPD. However,
given that this feature is typical of healthy adolescents as well as adolescents with other psychiatric disorders, the
specificity of emotion dysregulation to BPD in this age group has not yet been determined. The overall aim of this
study was to examine emotion dysregulation in adolescent inpatients with BPD compared with non-BPD inpatient
adolescents and healthy non-clinical adolescents, taking into account both global emotion dysregulation deficits
and more specific impairments.
Method: The sample included 185 adolescent inpatients with BPD (M = 15.23, SD = 1.52), 367 non-BPD psychiatric
inpatient adolescents (M = 15.37, SD = 1.40), and 146 healthy adolescents (M = 15.23, SD = 1.22), all of whom were
between the ages of 12 and 17. Borderline personality features were assessed, along with emotion dysregulation
and psychiatric severity.
Results: After controlling for age, gender, and psychiatric severity, results revealed that adolescents with BPD had
higher overall emotional dysregulation compared with non-BPD psychiatric controls and healthy controls. These
differences were apparent in only two domains of emotion dysregulation including limited access to emotion
regulation strategies perceived as effective and impulse control difficulties when experiencing negative emotions.
Conclusions: Findings suggest BPD-specific elevations on emotion dysregulation generally, and subscales related
to behavioral regulation specifically.
Keywords: Borderline personality disorder, Adolescents, Emotion dysregulation
Background
Adolescence is a time of social, physical, cognitive and
emotional change [1, 2]. Socially, adolescents establish
more relationship types than in childhood [3], effectively
widening their social circle. In adolescence, the frontal lobe,
responsible for judgment and inhibition is underdeveloped
[4] relative to the limbic system, which is responsible for
emotional processing [5]. Thus, when confronted with
arousing emotional situations, there is an “activation of
strong drives, appetites, emotional intensity, and sensation
seeking,” that cannot be regulated easily [5]. For these
* Correspondence: csharp2@uh.edu
Department of Psychology, University of Houston, 126 Heyne Building,
Houston, TX 77204, USA
reasons, adolescents exhibit greater difficulties in emotion
dysregulation when compared to adults and children [5–7].
In this context, emotion dysregulation can be generally
defined as “the frequent and intense experience of emotions
combined with an inability to cope with their occurrence”
[8]. Gratz and Roemer [9] operationalized emotion dysregulation as a multidimensional construct, encompassing
emotional awareness, understanding, and acceptance of
one’s emotions, in addition to the ability to manage
emotional arousal and to act “in desired ways regardless of
emotional state.” Within this broad conceptualization,
Gratz and Roemer proposed six sub-factors of emotion
dysregulation: lack of awareness of emotional responses,
lack of clarity of emotional responses, non-acceptance of
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Ibraheim et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:1
emotional responses, limited access to emotion regulation
strategies perceived as effective, difficulties controlling
impulses when experiencing negative emotions, and difficulties engaging in goal-directed behaviors when experiencing negative emotions [9]. Though interrelated, these subfactors are thought to be conceptually distinct. Indeed, this
multidimensional structure has been validated across
multiple samples, including adolescents, and in clinical [10]
and non-clinical groups [11, 12].
While some degree of emotion dysregulation is typical
for adolescents, emotion dysregulation may be indicative of
psychiatric problems. Indeed, research has shown that
adolescents with high levels of emotion dysregulation have
been found to have elevated rates of depression [13, 14],
anxiety [15, 16], substance use [17], conduct problems [18],
attention-deficit/hyperactivity disorder [19] and suicidal
and self-harming behaviors [20]. A prototypical example in
this regard is adolescents who suffer from borderline
personality disorder (BPD). BPD is a serious psychiatric
disorder characterized by impulsivity, mood instability, and
relationship instability [21]. Some have questioned whether
the disorder can be diagnosed in adolescence, but recent research has provided evidence for the validity of the diagnosis in this age group [22–26]. Theories on the development
of BPD emphasize that problems with emotion dysregulation are a core, underlying feature of BPD [27, 28]. Indeed,
this conceptualization has become so widely accepted that
affective instability has become one of the nine defining
criteria of BPD [26]. Empirical research echoes theoretical
perspectives demonstrating a BPD diagnosis in adolescents
[29–34] and BPD symptoms [27, 35] associate with problems in emotion dysregulation [36]. It is worth noting that
these findings have been supported by data obtained from
self-reports [29, 31, 35] and from behavioral studies [30, 32,
33], with one study taking care to utilize both behavioral
and self-report data in order to support this claim [34].
Taken together, research and clinical nomenclature supports the notion that emotion dysregulation is characteristic of BPD [12]; however, there are some aspects that
current research has not yet addressed. First, no research
has simultaneously compared adolescents with BPD to
psychiatric control adolescents and healthy controls. Since
no study has compared these three groups to each other
simultaneously, it is unclear if and how emotion dysregulation in BPD differs from emotion dysregulation in adolescents with non-BPD psychiatric disorders and typical
adolescents. Second, no study—to our knowledge—has
compared these three groups on the six sub-factors of
emotion dysregulation as proposed by Gratz and Roemer
[9]. We know from previous studies that adolescents with
BPD exhibit greater emotion dysregulation than their
typical adolescent counterparts [37], but it is unclear
whether certain emotion dysregulation sub-factors are
more characteristic of this group than others. Therefore,
Page 2 of 9
more research is needed to pinpoint on which specific
sub-factors of emotion dysregulation these three adolescent groups differ. Finally, most studies have not considered the potential confounding effects of gender [38], age
[39, 40], and general psychiatric severity [41], as each of
these has been found to correlate with BPD and emotion
dysregulation, and thus may obscure the true relation between BPD and emotion dysregulation in this age group.
Against this background, the overall aim of this study was
to examine emotion dysregulation in adolescent inpatients
with BPD compared with non-BPD inpatient adolescents
and healthy non-clinical adolescents recruited from the
community. We compared adolescent inpatients with BPD
to non-BPD psychiatric controls and non-clinical adolescent
healthy controls on total score of emotion dysregulation and
the six aforementioned emotion dysregulation sub-factors
proposed by Gratz and Roemer [9]. Given that previous research has identified significant relations between emotion
dysregulation and gender [38] and age [39], we controlled
for these variables in the study analyses. Moreover, previous
research has demonstrated a relation between degree of
psychiatric severity and level of emotion dysregulation [41],
and thus we controlled for psychiatric severity to ensure that
differences among the groups in emotion dysregulation were
due to BPD pathology specifically, rather than psychiatric
severity, generally. Based on findings from previous research
[42], and developmental theories of BPD [27, 28], we hypothesized that adolescents with BPD would exhibit higher
levels of overall emotion dysregulation [11, 27, 43], as well
as on specific sub-factors of emotion dysregulation, than
both psychiatric and healthy controls, controlling for gender,
age, and psychiatric severity.
Methods
Participants
The clinical sample was recruited through an inpatient
psychiatric hospital in an ongoing research study. Exclusion
criteria included severe aggression, active psychosis, IQ <70,
and/or non-English speaking. At the time of admission,
licensed clinicians were consulted to assess whether
patients were stable enough to participate. If there was
evidence of cognitive deficits or psychosis, neuropsychological testing was completed by a licensed staff psychologist to determine whether that adolescent should be
excluded from the study. Of 711 consecutive admissions to
the hospital, 39 were excluded based on aforementioned
criteria. Of the remaining patients who were approached
for consent, 52 declined participation, three revoked consent, and 30 were excluded based on information obtained
after consent was given. Additionally, 35 participants were
excluded to missing data on main study variables. A total of
552 inpatient adolescents were given an interview-based
measure of BPD. N = 187 (33.8.%) adolescent inpatients
met criteria for DSM-IV BPD and n = 365 adolescent
Ibraheim et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:1
inpatients did not meet criteria for BPD and constituted
the non-BPD psychiatric control group.
Healthy adolescents were recruited through schools and
community resources. Adolescents were excluded if they
met diagnostic criteria for any psychiatric disorder. A total
of N = 223 adolescents consented for participation in the
present study, of which n = 34 failed to attend their
scheduled appointments and n = 3 were excluded based
on the aforementioned exclusion criterion. Additionally,
40 participants were excluded due to missing data. Therefore, the final sample consisted of N = 146 participants.
Participant characteristics and psychiatric comorbidity are
presented in Table 1.
Measures
Emotion dysregulation
Difficulties in Emotion Regulation scale (DERS, [9]). The
DERS is a self-report measure containing 36 items that
assess the following six aspects of emotion regulation: nonacceptance of emotion responses, difficulties in engaging in
goal-directed behavior, impulse control difficulties, lack of
emotion awareness, limited access to emotion regulation
strategies, and lack of emotional clarity. Each of these aspects has its own separate scale score. Each item on the
DERS was rated on a 5-point Likert scale from 1 (almost
never [0–10%]) to 5 (almost always [91–100%]), so higher
scores indicate greater difficulties in emotion regulation.
Page 3 of 9
This measure has previously demonstrated adequate psychometric properties in both clinical [10] and community
[11, 12] adolescent samples. In the present study, Chronbach’s alpha for the total score was α = .96. In addition, each
subscale had good internal consistency (α: nonacceptance
= 0.92, goals = 0.87, impulse = 0.84, awareness = 0.85, strategies = 0.93, clarity = 0.87).
Borderline personality disorder
Childhood Interview for DSM-IV Borderline Personality
Disorder (CIBPD, [44]). The CIBPD was adapted from
the borderline module of the Diagnostic Interview for
DSM-IV Personality Disorders (DIPD-IV, [45]). It is a
semi-structured interview used specifically to assess BPD
in adolescents by assessing the following DSM-IV criteria
for BPD: symptoms of inappropriate anger, affective instability, chronic feelings of emptiness, identity disturbance, transient stress-related paranoid ideation or severe
dissociative symptoms, fears of abandonment, recurrent
suicidality or self-harm behavior, impulsivity, and intense
interpersonal relationships. Trained interviewers rated
symptoms using “0” for absence of symptom, “1” if the
symptom is probably present, or “2” if the symptom is definitely present. A full diagnosis of BPD requires a score of
2 for on least five of the nine criteria. A dichotomous
score on the CIBPD was used in the analyses to determine
a diagnosis of BPD. In addition, a dimensional CIBPD
Table 1 Sample Characteristics
BPD
(n =185, 26.5%)
Non-BPD psychiatric
(n = 367, 52.6%)
Healthy
(n = 146, 20.9%)
n or M
% or (SD)
n or M
% or (SD)
n or M
% or (SD)
Age
15.23
(1.52)
15.37
(1.40)
15.23
(1.22)
Female
149
80.50%
200
54.50%
105
71.90%
Hispanic
17
10.30%
16
4.90%
41
28.10%
138
84.70%
290
89.50%
15
10.90%
Race
Caucasian
African American
3
1.80%
6
1.90%
33
24.10%
Asian
5
3.10%
13
4%
53
38.70%
American Indian/Alaskan Native
1
0.60%
0
0.00%
6
4.4%
Multiracial or other
16
9.80%
15
4.60%
30
21.9%
Depressive
120
72.70%
160
47.60%
-
-
Bipolar
22
13.30%
13
3.90%
-
-
Eating
23
13.90%
18
5.30%
-
-
Externalizing
97
58.40%
117
34.70%
-
-
Anxiety
122
73.10%
171
50.40%
-
-
Disorder
Note. BPD Diagnoses were based on the Childhood Interview for Borderline Personality Disorder (CI-BPD, [44]). Other psychiatric disorders diagnoses were based
on the Computerized Diagnostic Interview Schedule for Children [73]. Prevalence rates are exclusively with regard to positive diagnoses in which the adolescent
endorsed all necessary diagnostic criteria. Depressive Disorder includes Major Depressive Disorder and Dysthymia; Bipolar Disorder includes mania and
hypomania; Eating Disorder includes Bulimia Nervosa and Anorexia Nervosa; Anxiety Disorder includes Generalized Anxiety Disorder, Separation Anxiety Disorder,
Social Phobia, Specific Phobia, Obsessive Compulsive Disorder, Panic Disorder, Agoraphobia, and Post Traumatic Stress Disorder; Externalizing Disorder includes
Conduct Disorder, Oppositional Defiant Disorder, and Attention Deficit Hyperactivity Disorder
Ibraheim et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:1
score, which reflects the total count of ratings of the nine
symptoms (i.e. 0–18) was used. In the current study,
inter-rater reliability was conducted with 12% of the
sample, with two raters, with Kappa’s ranging from good
(ĸ = 0.77; p < .001) to very good (ĸ = 0.89; p < .001) agreement. Inter-rater reliability values were obtained for the
psychiatric control and BPD groups only.
Page 4 of 9
by scores on YSR total problems) and age. Given that three
groups were being compared, a post-hoc Fisher’s LSD test
was performed in order to restrict the family-wise error rate
to alpha. Next, a Pearson chi-square test was conducted to
determine whether adolescents with BPD were more likely
to be male or female.
Then, to determine whether there were differences across
groups in emotion dysregulation, controlling for covariates,
an analysis of covariance (ANCOVA) was performed with
group (BPD, psychiatric control, healthy control) as independent variable and DERS total score and covariates
(gender, age, and psychiatric severity) as dependent variables. If findings revealed that groups differed on emotion
dysregulation, a Fisher’s LSD post-hoc test was conducted
to clarify differences among the groups with regard to the
DERS total score. Additionally, given the focus on dimensional approaches to personality pathology, we reran analyses using continuous CIBPD and DERS total to confirm
the categorical findings.
Finally, a multivariate analysis of covariance (MANCOVA) was conducted to compare the three groups on the
DERS subscale scores, controlling for the effects of gender,
age, and psychiatric severity. If results revealed that group
predicted DERS total score at the multivariate level, we
further examined findings at the univariate level and conducted post-hoc Fisher’s LSD tests to elucidate differences
among the groups with regard to specific DERS subscales.
Psychiatric severity
Youth Self-Report (YSR, [46]) measures psychopathology.
It is a self-report that contains 112 items, each scored on a
three-point scale using 0 as “not true”, 1 as “somewhat or
sometimes true”, and 2 as “very or often true”. The measure
has a Total Problems T-score of general psychiatric functioning and two subscales: Externalizing Behavior Problems
and Internalizing Behavior Problems. Our study will look at
the Total Problems T-score.
Procedures
Approval for this study was obtained from local institutional review boards. For all participants, trained research
coordinators and clinical psychology graduate students
administered self-report assessments and conducted interviews under the direct supervision of the senior author.
Clinical adolescents completed assessments during the
first 2 weeks of their hospitalization. Non-clinical adolescents completed assessments during a scheduled assessment day. The Principal Investigator of the study met
monthly with the research team to review interview-based
assessments for reliability and training.
Results
Descriptive analyses for DERS total and subscale scores as
well as YSR total problems across adolescents with BPD,
non-BPD psychiatric controls, and healthy controls are
provided in Table 2. An analysis of variance (ANOVA)
was conducted to compare the three groups on psychiatric
severity as measured by scores on YSR total problems.
Results revealed a significant difference across groups, F(2,
677) = 202.26, p < .001. A Fisher’s LSD post-hoc test
Data analytic strategy
The data analyses involved several steps. First, descriptive
analyses on main study variables, including calculations of
means and standard deviations, were performed. Next, to
examine the bivariate relations among main study variables,
an analyses of variance (ANOVA) was conducted to compare the three groups on psychiatric severity (as measured
Table 2 DERS and YSR scores across inpatients adolescents with BPD, non-BPD psychiatric controls, and healthy controls
BPD
(n =187, 26.5%)
DERS Total score
M
(SD)
121.69
(23.43)
Non-BPD psychiatric
(n = 365, 52.6%)
Healthy
(n = 146, 20.9%)
M
(SD)
M
(SD)
(28.65)
72.66
(21.81)
99.20
Nonacceptance of emotional responses
18.06
(6.71)
14.08
(6.88)
10.79
(4.80)
Difficulty engaging in goal directed
20.20
(4.51)
17.38
(5.28)
13.23
(5.20)
Impulse control
19.35
(6.25)
14.30
(6.57)
9.63
(4.68)
Lack of emotional awareness
18.94
(5.93)
17.73
(5.92)
14.56
(5.16)
Limited access to emotion regulation strategies
29.08
(7.07)
22.07
(8.84)
14.65
(6.73)
Lack of emotional clarity
16.05
(4.98)
13.64
(5.17)
9.80
(4.02)
YSR total score
71.03
(8.45)
62.24
(9.74)
49.22
(11.00)
Note. DERS difficulty in emotion regulation scale, YSR youth self-report. Values are means that have not been adjusted to control for the potentially confounding
effects of gender, age, and psychiatric severity
Ibraheim et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:1
revealed that adolescents with BPD (M = 71.03, SD = 8.45)
had higher scores on YSR Total Problems than non-BPD
psychiatric controls (M = 62.24, SD = 9.74, p < .001 and
healthy controls (M = 49.22, SD = 11.00, p < .001). Psychiatric controls also had higher scores on YSR Total Problems than healthy controls, p < .001.
A Pearson chi-square test revealed that adolescents
with BPD were more likely to be female than non-BPD
psychiatric controls and healthy controls, Χ2 = 40.53, p
< .001. Results from an ANOVA showed that groups did
not differ significantly on age F(2, 695) = .88, p = .414.
Comparison of DERS total scores across BPD adolescents,
non-BPD psychiatric controls, and healthy controls
An analysis of covariance (ANCOVA) was conducted to
compare the three groups on the DERS total score,
controlling for the effects of gender, age, and psychiatric severity. As shown in Fig. 1, results demonstrated a significant
effect of group, F(1, 647) = 4.40, p = .013, η2p = .013.
As shown in Table 2, a Fisher’s LSD post-hoc test revealed that, controlling for covariates, adolescent inpatients
in the BPD group (M = 121.69, SD = 23.43) had significantly
higher DERS total scores than adolescents in the Healthy
controls group (M = 72.66, SD = 21.81), p = .016. Adolescents in the BPD group also had significantly higher total
mean DERS score than the non-BPD psychiatric control
group (M = 99.20, SD = 28.65), p = .031. Adolescents in the
non-BPD psychiatric group and healthy control group did
not differ on their mean DERS total score, p = .549.
The relation between CIBPD dimensional score and DERS
total score
To confirm the categorical analysis above, multiple regression analysis was conducted to examine whether
CIBPD dimensional score predicted DERS total score,
Page 5 of 9
controlling for gender, age, and psychiatric severity.
Results indicated that the predictors explained 59% of
the variance (R2 = .59, F[4, 646] = 235.36, p < .001). Specifically, CIBPD dimensional score significantly predicted
the DERS total score (β = .19, p < .001), as did psychiatric
severity (β = .62, p < .001) and gender (β = −.09, p < .001),
such that females (M = 102.40, SD = 31.56) had higher
self-reported DERS total scores than males (M = 96.66,
SD = 27.53) scores, t(696) = 2.53, p = .01. Age did not
significantly predict the DERS total score.
Comparison of DERS subscales across BPD adolescents,
non-BPD psychiatric controls, and healthy controls
A multivariate analysis of covariance (MANCOVA) was
conducted to compare the three groups on the DERS
subscale scores, controlling for the effects of gender, age,
and psychiatric severity. As shown in Fig. 1, results
demonstrated, at the multivariate level, a significant effect of group on the dependent variables, Wilks’ λ = .95,
F(12, 1284) = 2.79, p = .001, ηp 2 = .03.
At the univariate level, the groups differed on the DERS
subscale of impulse control difficulties, F(2, 167.77) = 5.72,
p = .003, η2p = .02. A Fisher’s LSD test revealed that adolescents with BPD (M = 19.35, SD = 6.25) had higher mean
scores on this subscale compared with non-BPD psychiatric controls (M = 14.30, SD = 6.57; p = .001) and healthy
controls (M = 9.63, SD = 4.68; p = .006). Groups also differed on the DERS subscale of limited access to emotion
regulation strategies, F(2, 315.29) = 7.12, p = .001, η2p = .02.
A Fisher’s LSD post-hoc test revealed that adolescents
with BPD (M = 29.08, SD = 7.07) had significantly higher
mean scores on this scale compared with non-BPD
psychiatric controls (M = 22.07, SD = 8.84; p = .001) and
healthy controls (M = 14.65, SD = 6.73; p = . 001). No other
DERS subscale differed across the three groups.
*
105
90
75
60
BPD
Psych Control
Healthy Control
45
*
30
*
15
0
Non-acceptance
Goals
Impulse
Awareness
Strategies
Clarity
Total Score
Fig. 1 DERS total and subscale scores across adolescents with BPD, non-BPD psychiatric controls, and healthy controls
Ibraheim et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:1
Discussion
The overall aim of this study was to examine emotion dysregulation in adolescent inpatients with BPD compared
with non-BPD inpatient adolescents and healthy nonclinical adolescents. More specifically, we compared adolescent inpatients with BPD to non-BPD psychiatric controls
and non-clinical adolescent healthy controls on total levels
of emotion dysregulation and the six aforementioned
emotion dysregulation sub-factors proposed by Gratz and
Roemer [9]. After controlling for age, gender, and psychiatric severity, we found that adolescents with BPD had
higher overall emotional dysregulation compared with both
non-BPD psychiatric controls and healthy controls.
Analyses that examined the relation between dimensional
scores of BPD and emotion dysregulation confirmed this
finding. With regard to specific DERS subscales, adolescents with BPD had higher self-reported scores than both
groups on Limited Access to Strategies and Impulse
Control Difficulties. The groups did not differ significantly
on any other subscales.
The finding that adolescents with BPD had higher overall self-reported emotion dysregulation compared with
psychiatric controls and healthy controls is consistent with
theoretical conceptualizations that suggest that BPD is a
central feature of the disorder [27, 28] as well as previous
studies with adults and adolescents which have shown
that those with BPD symptomatology demonstrate greater
emotion dysregulation than healthy controls [31, 47]. It is
important to note that some more recent studies contradict these findings, suggesting that difficulties in emotion
regulation are not specific to BPD [48–50], though these
studies were conducted with adults. Though a previous
study did examine the relationship between emotion
dysregulation and psychiatric severity in adolescents [41],
it did not examine patients with BPD and compare them
to other groups. Our findings showed that adolescents
with BPD had higher overall self-reported emotion dysregulation than both psychiatric controls and healthy controls, even after controlling for psychiatric severity. This
suggests that differences among groups were not simply
an artifact of higher psychiatric severity, or distress,
among the BPD group. Instead, it suggests that problems
with emotion regulation may be a BPD-specific feature,
central to the pathology of the disorder.
Within specific DERS subscales, our second finding
demonstrated that adolescents with BPD had higher selfreported scores than both groups on limited access to
strategies and impulse control difficulties. These subscales
may be conceptualized as capturing the behavioral subscales of the DERS, reflecting the components of emotion
regulation that relate to capacity to flexibly manage emotions using a variety of strategies (i.e. limited access to
strategies) and regulate one’s behavior when experiencing
intense emotions (i.e. impulse control difficulties). Indeed,
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elevations on both subscales capture aspects of the
disorder that have been well documented in theoretical
and empirical literature. Namely, when individuals with
BPD are emotionally distressed, they struggle to flexibly
use emotion regulation strategies [51] and manage impulsive behavior. In addition, previous studies acknowledge
that impulsivity is a core feature of BPD [52, 53], as those
with BPD tend to favor immediate gratification over longterm reward [54]. Indeed, research has demonstrated that
aggression [55], drug dependence [56], self-injury [57], and
other behavioral problems [58], are common in the
disorder. These findings also empirically support how
evidence-based interventions for BPD treat the disorder.
For example, dialectical behavior therapy (DBT, [28]) assumes that individuals with BPD have emotion regulation
skills (or strategies) deficits and therefore targets problem
behaviors by providing patients with myriad coping strategies so that they may flexibly access these strategies in
their daily lives. As a result, DBT has been successful in reducing impulsive behavior in individuals with the disorder
[59, 60]. Thus, our findings that those with BPD have
higher self-reported scores than both groups on the DERS
subscales of limited access to strategies and impulse control difficulties are consistent with our current understanding of the phenomenology and treatment of BPD and with
a current method of BPD treatment.
Beyond the aforementioned subscales, groups did not
differ significantly on subscales of lack of awareness of
emotional responses, lack of clarity of emotional responses,
non-acceptance of emotional responses, and difficulties
engaging in goal-directed behaviors when experiencing
negative emotions. This may reflect the fact these subscales
may capture emotion regulation difficulties found in other
disorders, not necessarily those specific to BPD. For
example, individuals with generalized anxiety disorder
demonstrate difficulty with emotional awareness [61], clarity [62, 63], non-acceptance [64], and difficulty engaging in
goal-directing behavior [63]. In addition, theoretical [27, 28]
and empirical [52] work identifies difficulties in managing
behavior as a core feature of BPD—one that distinguishes it
from internalizing disorders (e.g., depression, anxiety) in
which difficulties with emotions is also core to the psychopathology. It is also possible that subscales that did not produce significant differences were worded in such a way that
failed to capture the unique emotion regulation difficulties
that individuals with BPD experience. For example, an item
from the Lack of Emotional Awareness scale states, “I pay
attention to how I feel (reverse scored).” Though this item
is meant to capture an aspect of mindfulness inherent to
emotion regulation, is possible that this item was misinterpreted by individuals with BPD as capturing the more
ruminative aspects of emotional distress. Thus, the use of
additional measures of emotion dysregulation to disentangle these relations would be useful in this regard.
Ibraheim et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:1
On the other hand, though groups did not differ significantly on subscales of lack of awareness of emotional
responses, lack of clarity of emotional responses, nonacceptance of emotional responses, and difficulties engaging in goal-directed behaviors when experiencing
negative emotions, absence of evidence does not necessarily imply evidence of absence. Upon examination of
effect sizes for these specific contrasts, the BPD participants and healthy controls scales of non-acceptance of
emotional response and difficulties engaging in goal
directed behaviors were of medium magnitude. Again,
future research could further elucidate these findings by
including additional measures of emotion dysregulation,
as mentioned previously.
The impact of the findings of the present study is limited by several factors. Notably, the use of a self-report
measure, like the DERS, renders participant responses
susceptible to the effects of retrospective recall bias [65].
Moreover, given that emotions in individuals with BPD
are highly variable, unstable, and reactive [28, 66], use of a
one-occasion assessment of emotion dysregulation may
fail to fully and accurately capture emotion dysregulation
in this particular population. Recognizing the limits of
traditional self-report assessment of BPD mood, there has
been a recent push to use intensive longitudinal designs
(e.g., ecological momentary assessment (EMA); [67]) to
study affect problems in BPD, though it is worth noting
that nearly all studies focused on adult samples (see [68]
for a review), save for a few (i.e., [69, 70]). Future research
should not only investigate this with ecological momentary assessment, but it should also make use of behavioral
measures of emotion regulation in adolescents to complement these findings. Second, the clinical samples from this
study consisted of mostly Caucasian adolescents of high
socioeconomic status, and thus the generalizability of our
findings is limited. Moreover, the healthy and clinical
groups were not demographically matched; the healthy
control group was comprised of racially, ethically, and
socioeconomically diverse adolescents. Future studies
should match groups on socioeconomic status, race, and
ethnicity or statistically control for these variables in analyses. Third, it is possible that findings of higher levels of
emotional dysregulation in BPD participants were due to
differential levels of trust or confidence in self-reported
emotion regulation capacities, such that individuals with
BPD may have experienced less trust overall in their emotion regulation abilities compared with the other groups.
Thirdly, within the DERS, 11 out of the 34 items are
recoded in a positive direction. Given that there are more
negatively phrased items than positively phrased ones, it is
possible that findings were influenced by answering biases.
Including additional measures of emotion dysregulation,
as previously mentioned, would likely attenuate the potential effects of such a bias. In addition, our study followed
Page 7 of 9
one particular model of emotion dysregulation (i.e. [9]).
However, there are undoubtedly many other models of
emotion dysregulation (e.g., experiential avoidance model,
[71, 72]), and therefore, future studies may want to consider other conceptualizations of emotion dysregulation
when examining emotion dysregulation in adolescents
with BPD. Our study utilized only one measure of emotion dysregulation (i.e. the DERS). In order to further support findings of group differences in emotion regulation
difficulties, future studies should make use of multiple
measures of this construct. Finally, though the current
study demonstrated differences in self-reported emotion
regulation among BPD vs. psychiatric controls, we did not
investigate differences between adolescents with BPD and
specific diagnoses within the psychiatric control group. Indeed, though emotion dysregulation has been shown to be
a construct that cuts across multiple forms of psychopathology, the degree to which it differentially relates to BPD
versus specific disorders is less clear, especially in adolescents. While future research should make use of designs
that contrast BPD with unique disorders in adolescents to
elucidate these relations, we also acknowledge that high
comorbidity is the rule rather than the exception among
adolescents with severe psychopathology, suggesting that
lumping (instead of splitting) disorders may be clinically
more meaningful.
Conclusions
Notwithstanding these limitations, this study was the first
to compare adolescents with BPD to psychiatric controls
and healthy controls on emotion dysregulation, demonstrating that emotion dysregulation in general, as well as
limited access to strategies and problems with impulsivity,
more specifically, represent particularly elevated emotion
dysregulation difficulties specific to adolescents with BPD.
These findings support current conceptualizations of
BPD as representing problems with behavioral management and coping skills when emotionally distressed. It
also provides empirical support for current interventions for the disorder, validating the need to target
impulse control difficulties and enhance regulation
strategies in those with the disorder.
Acknowledgements
Not applicable.
Funding
Support for this study was provided by the McNair Family Foundation
awarded to research conducted at the Menninger Clinic as well as the
Duncan Foundation awarded to research conducted at the Adolescent
Diagnosis Assessment Prevention and Treatment (ADAPT) Center at the
University of Houston.
Availability of data and materials
De-identified data available on request form the corresponding author.
Ibraheim et al. Borderline Personality Disorder and Emotion Dysregulation (2017) 4:1
Authors’ contributions
MI carried out the literature search, ran the statistical analyses, contributed to
the intellectual development of the topic, and wrote the first draft of the
manuscript. AK ran the statistical analyses, contributed to the intellectual
development of the topic, and contributed to the manuscript. CS conceived
of the study, oversaw data collection, contributed to the intellectual
development of the topic, guided the statistical analyses and contributed to
the manuscript. All authors read and approved the final manuscript.
Competing interest
The authors declare that they have no competing interest.
Consent for publication
Not applicable.
Ethics approval and consent to participate
The IRBs of the University of Houston and Baylor College of Medicine
approved this study.
Declarations
We are grateful to the adolescents and families who participated in the
research.
Received: 14 September 2016 Accepted: 4 January 2017
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