Mindfulness
DOI 10.1007/s12671-016-0572-2
ORIGINAL PAPER
Behavioral Assessment of Mindfulness Difficulties in Borderline
Personality Disorder
Hannah J. Scheibner 1 & Stefanie Spengler 2 & Phillipp Kanske 3 & Stefan Roepke 4 &
Felix Bermpohl 1,2
# Springer Science+Business Media New York 2016
Abstract Although mindfulness plays an important role in the
treatment of borderline personality disorder (BPD), few studies
have investigated whether individuals with BPD show difficulties in mindfulness. Those studies have relied exclusively on
questionnaire data. Here, we used a more objective, behavioral
assessment of mindfulness difficulties in BPD that allowed us
to distinguish difficulties in mindfulness, prolonged mindwandering, and difficulties in awareness of mind-wandering.
Twenty-five individuals with BPD and 28 healthy controls
performed two mindful breathing tasks. Frequency of mindfulness versus mind-wandering was assessed in the experimenterprompted mindfulness task, where participants were
interrupted at random intervals and asked whether they had
just been mindful or mind-wandering. Awareness of mindwandering was assessed in the self-prompted mindfulness task,
where participants were asked to press a computer key whenever they noticed mind-wandering. Length of mind-wandering
was assessed in both tasks. In individuals with BPD, we found
Electronic supplementary material The online version of this article
(doi:10.1007/s12671-016-0572-2) contains supplementary material,
which is available to authorized users.
* Hannah J. Scheibner
hannahscheibner@posteo.de
1
Berlin School of Mind and Brain, Humboldt-Universität zu Berlin,
Unter den Linden 6, 10099 Berlin, Germany
2
Department of Psychiatry and Psychotherapy, Charité
Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
3
Department of Social Neuroscience, Max Planck Institute for Human
Cognitive and Brain Sciences, Leipzig, Germany
4
Department of Psychiatry and Psychotherapy, Charité
Universitätsmedizin Berlin, Campus Benjamin Franklin,
Berlin, Germany
a lower frequency of mindful episodes. In addition, individuals
with BPD indicated longer mind-wandering episodes in the
experimenter-prompted task. However, individuals with BPD
detected mind-wandering episodes as accurately as healthy
controls in the self-prompted task. Finally, difficulties in mindfulness observed in the behavioral tasks positively correlated
with participants’ reports of mindfulness difficulties in everyday life. Using behavioral tasks to specify difficulties in mindfulness in BPD, this study indicated that although individuals
with BPD mind-wander longer and more often, their awareness of mind-wandering appear unaffected. This indicates that
mindfulness difficulties can be reported by individuals with
BPD and that therapists can build on this awareness through
mindfulness-based treatments of BPD.
Keywords Mindfulness . Mind-wandering . Borderline
personality disorder . Behavioral research
Introduction
Borderline personality disorder (BPD) is a complex, serious
mental illness characterized by pervasive patterns of instability in emotion regulation, impulse control, interpersonal relationships, and self-image (Skodol et al. 2002; Lieb et al. 2004;
Leichsenring et al. 2011). The disorder puts a heavy burden on
its patients and on society, as treatment often takes years
(Zanarini et al. 2003) and incurs high annual medical costs
(Wagner et al. 2015). Consequently, studying the underlying
factors that play a role in borderline personality disorder is an
important task in clinical research: one such factor may be
patients’ difficulty in staying focused on experiences in the
present moment (Linehan 1994). These difficulties have been
described as difficulties in mindfulness (Wupperman et al.
2008, 2009).
Mindfulness
Mindfulness, a concept derived from the Buddhist tradition, has been defined in modern Western psychology as
non-judgmental attention to and awareness of the present moment (Kabat-Zinn 1994). It stands in stark contrast to a key
problem for individuals with BPD: to pay attention to and be
aware of their own feelings and emotions. While self-reports
of patients with BPD suggest that they experience difficulties
in staying mindful (Baer et al. 2004), this has never been
investigated using a more objective, behavioral assessment.
Behavioral mindfulness exercises have been implemented
in several new psychotherapies, including dialectical behavior
therapy (Linehan et al. 2007; Soler et al. 2012), acceptance
and commitment therapy (Hayes et al. 2006; 1999), and
mindfulness-based cognitive therapy (Williams and Swales
2004; Sachse et al. 2011), all of which have been effective
in treating BPD. For example, in DBT, mindfulness is taught
as a set of skills that evolve around a mindful attitude (wisemind), acceptance and non-judgment, as well as mindfulness
exercises fostering mindful attention (mindful observing, describing, participating) (Linehan 1993; Welch et al. 2006).
Mindfulness exercises include focused-attention mindfulness
exercises, in which practitioners learn to concentrate on one
particular momentary experience, such as sensing their own
breath. Practitioners aim to focus on the given experience for
as long as possible. As soon as their thoughts wander off and
they notice that they are no longer focused on the experience,
practitioners non-judgmentally and calmly return their focus
to the momentary experience. With practice, this simple exercise trains practitioners to stay mindful for a prolonged period
of time.
Mindfulness exercises consist of at least three distinct
phases (Hasenkamp et al. 2012): (1) mindfulness—the phase
during which the practitioner succeeds in focusing on the
present moment; (2) mind-wandering—the phase during
which the practitioner’s mind wanders off; and (3) awareness
of mind-wandering and refocusing—the phase during which
the practitioner becomes aware of the mind-wandering and
then returns to the mindfulness task. A similar process can
be observed in everyday life, when people shift between being
concentrated on their momentary experience, drifting off, and
becoming aware of mind-wandering. Consequently, if practitioners experience mindfulness difficulties, these may arise in
any of the three phases, i.e., difficulties in focusing on the
present moment, prolonged periods of mind-wandering, and
difficulties in awareness of mind-wandering.
Although mindfulness plays an important role in BPD
treatment, it is not clear whether patients with BPD actually
experience more difficulties in mindfulness than healthy individuals. To date, few studies have examined whether BPD
may be specifically associated with mindfulness difficulties.
While individuals with BPD may benefit from mindfulness
training, even if they do not experience more mindfulness
difficulties compared to healthy controls, it is of scientific
and clinical relevance to elucidate potential mindfulness differences in BPD.
Without exception, studies that have examined mindfulness difficulties in patients with BPD have relied on questionnaires: Wupperman et al. (2008, 2009, 2013) showed that
participants with BPD traits scored low on the Mindful
Attention Awareness Scale, a questionnaire that measures trait
mindfulness (Brown and Ryan 2003). Lower scores on the
mindfulness questionnaire were not only related to higher
scores on BPD traits, but also predicted greater deficits in
emotion regulation and interpersonal problem solving.
Similarly, Baer et al. (2004) reported that patients with BPD
scored lower on four out of five subscales of the Kentucky
Mindfulness Inventory compared to two student samples.
While mindfulness questionnaires, as employed in these
previous mindfulness studies in BPD, are valuable and useful
in screening mindfulness difficulties and developing
treatment-related mindfulness improvements, a potential challenge with mindfulness questionnaires is that subjects differ
widely in their conceptual understanding of mindfulness
(Grossman 2008; Sauer et al. 2013). This may impact subjects’ understanding of the questionnaires. Individuals with
difficulties in mindfulness may not be aware of their difficulties at all and thus would have difficulties reporting them
(Burg and Michalak 2011). Additionally, to improve mindfulness training in BPD, it seems critical to understand which
aspect of mindfulness is affected, that is, to understand whether individuals with BPD have difficulties in staying mindful,
have difficulties in becoming aware of mind-wandering, or
experience prolonged periods of mind-wandering. While no
previous research has investigated whether individuals with
BPD are less aware of mind-wandering, Fonagy and
Bateman (2007, see also: Choi-Kain and Gunderson 2008)
have argued that individuals with BPD have an unstable capacity for mentalization, which includes an unstable ability to
be aware of their own mental processes. To summarize, additional methods of assessing different aspects of mindfulness in
a more objective manner are required.
One alternative to questionnaires is the behavioral assessment of mindfulness, either via thought probes over the course
of the day or via thought probes during mindfulness exercises.
Thought probes during mindfulness exercises, especially, may
help to assess different aspects of mindfulness. Both types of
behavioral assessment have so far only been studied in healthy
individuals, but not in BPD. Killingsworth and Gilbert (2010)
developed a smartphone app to sample participants’ thoughts,
feelings and activities in everyday life. They found that
independent of the type of activity, participants were less
happy when their minds were wandering. Burg and
Michalak (2011) and Frewen et al. (2008, 2011, 2014) collected thought probes during mindfulness exercises, employing
an experimenter-prompted mindfulness task. They asked
healthy participants to perform a focused-attention practice,
Mindfulness
during which participants were interrupted multiple times.
Participants had to report whether they were in a mindful or
mind-wandering state at the moment they were interrupted.
These studies showed that the ratio of mindful versus mindwandering moments was correlated with data from mindfulness questionnaires as well as certain aspects of well-being
(Frewen et al. 2011). Using a self-prompted mindfulness task,
Hasenkamp et al. (2012) asked experts to perform a focusedattention meditation exercise. In this study, participants were
not interrupted by experimenters, but rather had to press a
button whenever they noticed that they had just been mindwandering. The investigators argued that this moment of selfprompted interruption indicated the awareness and refocusing
phase between a mind-wandering phase and a new mindfulness phase. Employing this task for fMRI, they identified
distinct neural correlates of these three phases, supporting
the idea that mindfulness, mind-wandering, becoming aware
of mind-wandering, and refocusing are separate processes.
In the current study, our aim was to assess mindfulness
difficulties in BPD with an objective behavioral mindfulness
task, allowing us to investigate different phases of mindfulness exercises: mindfulness, mind-wandering and awareness
of mind-wandering. Specifically, we asked participants to perform a focused-attention exercise similar to Burg and
Michalak (2011) and Frewen et al. (2008, 2011, 2014) and
Hasenkamp et al. (2012). During the first exercise (experimenter-prompted mindfulness task), participants were
interrupted at random intervals and asked whether they were
just mindful or mind-wandering, and if they were mind-wandering, for how long they had mind-wandered. During the
second exercise (self-prompted mindfulness task), participants
were asked to interrupt themselves whenever they became
aware of mind-wandering and report length of mind-wandering. The thought probes allowed us to assess frequency of
mindfulness and mind-wandering, length of mind-wandering,
and awareness of mind-wandering. We hypothesized that individuals with BPD were (1) less frequently mindful, (2) were
less aware of mind-wandering, and (3) showed longer mindwandering periods than healthy controls.
Method
Participants
Twenty-six individuals with borderline personality disorder
(BPD) according to DSM-IV (American Psychiatric
Association 1994) and 30 healthy controls were recruited for
the study. Individuals with BPD were recruited from local
hospitals as well as via online advertisement. Healthy controls
were recruited via online advertisement. One individual with
BPD and two healthy controls were excluded due to technical
problems during data collection, leaving 25 individuals with
BPD and 28 healthy controls. Diagnosis of BPD was
established using the Structural Clinical Interview II for
DSM-IV (First et al. 1997). Participants were screened for
comorbidity using the Structural Clinical Interview I and II
(First et al. 1997; First et al. 1998; Wittchen et al. 1997) and
the Mini-International Neuropsychiatric Interview (Sheehan
et al. 1998; Ackenheil et al. 1999). Three trained clinical psychologists administered all clinical interviews.
BPD and control participants were included when they
reported to have little to no experience in mindfulness exercises, i.e., less than 10 h of lifetime mindfulness training, and
no mindfulness training within the last 3 months. Healthy
control participants had to have no current or past mental
illness according to DSM-IV. Exclusion criteria for individuals with BPD included bipolar disorder, current major depression, psychotic disorder, a body mass index below 18,
or current alcohol or substance dependence. Five individuals
with BPD were diagnosed with current PTSD, one individual
met the diagnosis of current panic disorder, seven individuals
met the diagnosis of agoraphobia, five individuals met the
diagnosis of social phobia, and two individuals met the diagnosis of bulimia nervosa. Twelve individuals with BPD also
met the diagnosis of one or more additional personality disorders: avoidant personality disorder (n = 6), paranoid personality disorder (n = 6), and obsessive-compulsive personality disorder (n = 3).
Individuals with BPD and control participants did not significantly differ in age, sex, or level of education. For the
pu rp ose of samp le d esc rip tion , we ass esse d t he
Montgomery–Åsberg Depression Rating Scale (MADRS)
(Montgomery and Asberg 1979) and the Borderline
Symptom List-23 (Bohus et al. 2008), as well as the verbal
intelligence test (BWortschatztest^) (Schmidt and Metzler
1992) and the general attention and concentration test (Bd2^)
(Brickenkamp 1962). For a summary of sample characteristics, see Table 1.
Procedure
The study design was reviewed by the local ethics committee
and the investigation was carried out in accordance with the
latest version of the Declaration of Helsinki. Informed consent
of the participants was obtained prior to participation and after
the nature of the procedures had been fully explained. The
experiment took place in a research wing at the local hospital.
Here, participants were tested individually and in a semisoundproof room. All participants were tested between 3:30
and 4:30 p.m., and the timing of the interruptions during the
mindfulness exercise was the same for all participants. At the
beginning of a test session, participants filled out the two
mindfulness questionnaires as well as the borderline symptom
list (BSL)-23 and the vocabulary test. Participants then
learned the mindfulness breathing exercise. The instructions
Mindfulness
Table 1 Sample characteristics
BPD
(n = 25)
Control group
(n = 28)
Test for group differences
Sex, n
Female
20
21
X2(1) = 0.189, p = 0.750
Male
Age, years
5
36.44 (9.87)
7
33.75 (11.2)
t(51) = 0.923, p = 0.361
range
Years of education
23–59
11.76 (1.49)
19–63
11.85 (1.43)
t(51) = −0.243, p = 0.809
7.04 (1.40)
0.14 (0.45)
t(51) = 24.73, p < 0.0005
1.89 (0.67)
12.86 (8.25)
0.16 (0.17)
0.84 (1.27)
t(51) = 13.13, p < 0.0005
t(51) = 7.621, p < 0.0005
106.2 (9.77)
96.72 (10.61)
104.11 (12.41)
100.82 (9.67)
t(51) = 0.68, p = 0.502
t(51) = −1.47, p = 0.147
Number of BPD criteria
BSL-23
MADRS
Verbal intelligence score, BWortschatztest^
Attention and concentration score, Bd2^
Data are given as mean (standard deviation) unless otherwise specified
BPD borderline personality disorder, n subsample size, BSL-23 borderline symptom list, MADRS MontgomeryÅsberg Depression Rating Scale, BWortschatztest^ verbal intelligence test, Bd2^ general attention and concentration test
for this were recorded by a certified mindfulness trainer and
played to participants via earphones and simultaneously presented on the computer screen. Participants first practiced the
breathing exercise for 3 min. For all mindfulness exercises,
participants were left alone in the room. After 3 min, the experimenter entered, repeated the instructions of the certified
trainer and asked if participants had any more questions about
the exercise. Participants then performed the experimenterprompted mindfulness task. After a short break, participants
received instructions for the self-prompted mindfulness task
that were again repeated by the experimenter. Then, participants performed the self-prompted mindfulness task.
Experimenter-Prompted Mindfulness Task
Participants performed a mindful breathing exercise. They
were instructed to focus their attention on the sensation of their
breathing. Whenever participants became aware that their attention wandered off task, they were asked to calmly and nonjudgmentally return their attention to their breathing. During
the exercise, interruptions induced by a computer-triggered
meditation bell ring (Fig. 1) prompted participants to indicate
where their attention was when the bell rang. Participants answered using the computer keyboard (1 = Bfocused on their
breathing^, 2 = Bdistracted^). When participants indicated that
they had been distracted, they further indicated for how long
they had been distracted (1 = B1–5 s^, 2 = B5–30 s^, 3 = Bmore
than 30 s^). After participants had answered the questions,
they continued the mindful breathing exercise until they were
interrupted again. In total, participants were interrupted 13
times within 20 min. The time between interruptions varied
between 30 s and 3 min. Outcome variables analyzed in the
experimenter-prompted mindfulness task included the frequency of mind-wandering and mindful episodes and the
self-reported duration of mind-wandering. Note that frequency of mind-wandering and mindful episodes are inversely related to each other in our task and cannot be disentangled.
Self-Prompted Mindfulness Task
Participants performed a mindful breathing exercise with selfprompted interruptions (Fig. 1). Participants focused their attention on the sensation of their breathing. Whenever participants became aware that their attention had wandered off from
the task, they were asked to press a computer key. They should
then further indicate how long they had mind-wandered (1 =
1–5 s, 2 = 5–30 s, 3 = more than 30 s). After participants answered this question, they continued with the mindful breathing exercise until they again noticed that they had mindwandered and again pressed a computer key. In total, the exercise lasted 20 min. Outcome variables analyzed in the selfprompted mindfulness task included the number of computer
key presses (awareness of mind-wandering), reported duration
of mind-wandering, and the awareness coefficient. The selfprompted mindfulness task allowed us to assess how often
participants became aware of their own mind-wandering.
Besides identifying how often participants became aware of
mind-wandering, we intended to account for differences in
overall percentage of mind-wandering. The following example may illustrate why this was critical in the present study: If
two participants A and B are equally aware of mind-wandering, but participant A mind-wanders on average 40 % of the
time, participant A is twice as likely to detect mind-wandering
compared to participant B who mind-wanders on average only
20 % of the time. To account for differences in percentage of
mind-wandering during the experiment, we calculated the
Bawareness coefficient.^ The awareness coefficient consists
of the number of noticed mind-wandering episodes in the
Mindfulness
A
Experimenter-Prompted Mindfulness Task
Where was
your mind right
now?
How long have
you been
mindwandering?
30 sec – 180 sec
B
Self-Prompted Mindfulness Task
How long have
you been
mindwandering?
self-paced interval
Fig. 1 The experimenter-prompted mindfulness task (a) and the selfprompted mindfulness task (b). When participants heard the bell ring,
they closed their eyes and performed the mindful breathing meditation.
In the experimenter-prompted mindfulness task, another bell interrupted
participants after 30–180 s. They then had to indicate where their thoughts
were at the moment of interruption (mindful or mind-wandering) and, if
they were mind-wandering, report for how long they had been mindwandering. In the self-prompted mindfulness task, participants themselves pressed a computer key whenever they noticed that they had been
mind-wandering and further reported for how long they had been mindwandering
self-prompted mindfulness task divided by the percent of
mind-wandering episodes in the experimenter-prompted
mindfulness task. A higher score indicates more awareness
of mind-wandering. After the two behavioral mindfulness
tasks, participants performed the d2 attention and concentration test and the diagnostic interview.
experiencesB) and presence (e.g., BI watch my feelings without getting lost in them^). Items are rated on a 4-point Likert
scale from Brarely^ (1) to Balmost always^ (4). Both questionnaires are targeted to non-mindfulness-practitioners.
Measures
All analyses were conducted using SPSS statistics 22.0 software package for Windows and all hypotheses were tested with
a two-sided significance level of α = 0.05. To test whether individuals with BPD are less frequently mindful and mindwander more often, we compared the two groups with regard
to the amount of mind-wandering and mindful episodes, respectively. For this purpose, we computed participants’ mean
frequency of mind-wandering across all 13 trials in the
experimenter-prompted task, and compared the groups using
an independent samples t test. To study participants’ awareness
of mind-wandering, we computed the sum of self-prompted
interruptions in the self-prompted mindfulness task for each
participant. Then, we tested for group differences using an independent samples t test. In addition, we compared awareness
of mind-wandering independent of differences in mindwandering by comparing participants’ awareness coefficient
(see earlier). We again employed an independent samples t test
to analyze group differences on the awareness coefficient. To
test whether participant groups differed in length of mind-wandering, we used a Mann–Whitney U test with median length of
Mindfulness Questionnaires
In order to compare participants’ performance on the two
mindfulness tasks to questionnaire data, we administered the
Mindfulness Attention Awareness Scale (MAAS), as well as
the Short Version of the BFreiburger Fragebogen zur
Achtsamkeit^ (Freiburg mindfulness inventory) (FFA). The
MAAS (Brown and Ryan 2003; Michalak et al. 2008) is a
questionnaire that assesses mindfulness in everyday life. It
consists of 15 negatively posed items (e.g., BI find it difficult
to stay focused on what is happening in the present^ or BI do
jobs or tasks automatically, without being aware of what I am
doing^). On a 6-point Likert scale from Balmost always^ (1) to
Balmost never^ (6), participants indicated how frequently they
had the respective experiences in everyday life. The FFA
(Buchheld et al. 2001; Walach et al. 2006) employed in the
present study is a 14-item short version. It consists of two
subscales: acceptance (e.g., BI accept unpleasant
Data Analyses
Mindfulness
Results
Mindfulness and Mind-Wandering Episodes
We found that individuals with BPD were less often mindful
than control participants (t(51) = −4.09, p < 0.0005). On average, control participants were mindful during 52 % of the trials
(M = 52.47, SD = 15.81) whereas individuals with BPD were
mindful during 32 % of the trials (M = 32, SD = 20.55)
(Fig. 2a). Conversely, control participants were mindwandering during 48 % and individuals with BPD during
68 % of all trials (Fig. 2b).
Awareness of Mind-Wandering Episodes
Length of Mind-Wandering Episodes
In the experimenter-prompted mindfulness task, individuals
with BPD reported longer mind-wandering periods than
healthy controls (MdnBPD = 2 vs. Mdncontrol = 1.5, U = 232,
p = 0.028). In the self-prompted mindfulness task, however,
we did not find a significant difference in mind-wandering
length (Mdn BPD = 2 vs. Mdn control = 1.25, U = 329, p =
0.671) (Fig. 2e).
Potential Duration Effects Within Each Mindfulness
Exercise
One additional concern we wanted to address was whether the
difference between BPD patients and healthy controls (HCs)
100
80
A
*
60
40
100
*
60
40
20
0
0
Mind-wandering Episodes
(Experimenter-Prompted Mindfulness Task)
*
C
30
20
10
Count / Percent
Mindful Episodes
(Experimenter-Prompted Mindfulness Task)
40
0
B
80
20
50
1.0
ns.
0.8
D
0.6
0.4
0.2
0.0
Awareness Coefficient
Awareness of mind-wandering
(Self−Prompted Mindfulness Task)
E
3
BPD
HC
Median
Count (n)
Fig. 2 BPD borderline
personality disorder. Asterisk
significant group differences from
two-tailed independent t tests at
p < 0.05. a–d Values are means,
with standard deviations
represented by vertical bars. e A
box plot displays median and
interquartile range. a Compared
to a healthy control group,
individuals with borderline
personality disorder (BPD) were
less frequently mindful and b
more often mind-wandering in the
experimenter-prompted mindfulness task. c Awareness of
mind-wandering episodes was
assessed in the self-prompted
mindfulness task; individuals
with BPD detected more
mind-wandering episodes than
healthy controls. d However,
when number of mind-wandering
episodes was accounted for,
groups did not differ in detected
mind-wandering episodes, i.e., in
the awareness coefficient. e
Individuals with BPD mindwandered longer than the control
group in the experimenterprompted mindfulness task, but
not in the self-prompted
mindfulness task
Percent %
We found that individuals with BPD detected more episodes
of mind-wandering than healthy controls (MBPD = 26.16,
SDBPD = 15.42 vs. Mcontrol = 16.32, SDcontrol = 10.19, t(51) =
2.77, p = 0.008) (Fig. 2c). The awareness coefficient did not
differ significantly between groups (MBPD = 0.38, SDBPD =
0.18 vs. Mcontrol = 0.36, SDcontrol = 0.22, t(51) = .349, p =
0.729) (Fig. 2d). This indicates that the BPD and the control
group did not differ significantly in detecting mind-wandering, when the analysis was controlled for the mind-wandering
frequency. Figure 3 illustrates periods of mind-wandering and
mindfulness in the self-prompted mindfulness task, as derived
from participants’ key presses and reported length of mindwandering.
Percent %
mind-wandering as the dependent variable and group (BPD vs.
healthy controls) as the independent variable.
2
1
Lenght of Mind-wandering, Boxplot
(Left: Experimenter-Prompted Mindfulness Task
Right: Self-Prompted Mindfulness Task)
Mindfulness
Fig. 3 BPD borderline
personality disorder. HC healthy
control. Mindfulness and mindwandering phases are displayed
based on the participants’ key
presses and the self-reported
length of mind-wandering in the
self-prompted mindfulness task.
Each row represents one
participant, with the upper rows
representing healthy control
participants and the lower rows
borderline personality disorder
participants. White represents
mindfulness and black
mind-wandering phases. The
middle two rows represent the
averaged mind-wandering of each
group at each time point, darker
color indicating more mindwandering, lighter color
indicating less mind-wandering.
For illustration purposes, B1–5 s^
was equaled to 5 s, B5–30 s^ was
equaled to 20 s, and Bmore than
30 s^ was equaled to 40 s or since
the last computer key press, if this
was less than 40 s apart
was more pronounced toward the end of each mindfulness
exercise. Frewen et al. (2011, 2014) used a similar paradigm
as our experimenter-prompted paradigm and found good construct validity (Frewen et al. 2011) and test-retest reliability
(Frewen et al. 2014) for a 15-min task. Several other studies
have asked meditation novices to perform mindfulness exercises of 20 min or longer (e.g., Johnson et al. 2015; Prätzlich
et al. 2016; Fennell et al. 2016). However, since we here
assess mindfulness difficulties in a patient group, patients
may have particular difficulties with the exercise length. For
this purpose, we compared performance in the first and second
half of each exercise between groups. A detailed description
of results can be found in the Supplemental material. In sum,
group differences existed in both the first and second half of
each mindfulness exercise. The only difference was found in
the length of mind-wandering in the self-prompted mindfulness task. Here, individuals with BPD reported to mindwander longer than HC in the first but not second half of the
task.
lower scores on both questionnaires (MAAS: t(51) = −8.69,
p < 0.0005 and FFA: t(51) = −8.74, p < 0.0005). In the FFA,
the group difference was found on both subscales (acceptance:
t(51) = −7.3, p < 0.0005 and presence: t(51) = −7.76,
p < 0.0005). Across groups, the percentage of mindful episodes
in the experimenter-prompted mindfulness task was positively
correlated with both the MAAS and the FFA (r = 0.545,
p < 0.0005 and r = 0.282, p = 0.041, respectively) (Table 2).
The more mindful participants were in the experimenterprompted mindfulness task, the fewer mindfulness difficulties
they reported in the questionnaires. Length of mind-wandering
was not correlated with scores on the mindfulness questionnaires. In the self-prompted mindfulness task, number of detected mind-wandering episodes was negatively correlated with the
MAAS score (r = −0.419, p = 0.002) as well as the FFA score
(r = −0.320, p = 0.019) (Table 2). The more mind-wandering
episodes participants reported, the less mindfulness they reported in the questionnaire. There was no correlation between the
questionnaire score and the awareness coefficient (MAAS:
r = −0.058, p = 0.681, FFA: r = −0.172, p = 0.218).
Mindfulness Difficulties in Everyday Life
To test whether the differences observed in our behavioral tasks
were paralleled by findings in questionnaires assessing mindfulness in everyday life, we compared scores on the mindfulness
questionnaires between groups. Individuals with BPD showed
Influence of Attention, Intelligence, Depression,
or Demographic Variables on Task Performance
Groups did not differ in sex, age, level of education, verbal
intelligence, or d2 score (Table 1). We did not find any effects
Mindfulness
Table 2 Inter-correlations for
main study variables
Correlation coefficients
1
1. Mindful episodes
2
3
4
–
(Self-prompted mindfulness task)
2. Awareness of mind-wandering
−0.483**
(Experimenter-prompted mindfulness task)
3. Awareness coefficient
4. MAAS
5. FFA
0.105ns
0.545**
0.282*
–
0.772**
−0.419**
−0.320*
–
−0.058ns
−0.172ns
–
0.566**
Inter-correlations for main study variables. Pearson’s r correlation coefficients are displayed
MAAS Mindfulness Attention Awareness Scale, FFA Freiburg Mindfulness Inventory, ns not significant
**p < 0.01, *p <0 .05
of sex, age, or level of education on measures of mindfulness.
Since our male sample was very small, future studies are
needed to explore in how far participants’ sex influences
mindfulness difficulties. Individuals with BPD scored higher
on the MADRS than control participants. We reanalyzed all
statistical tests, with verbal intelligence, d2 score, and
MADRS entered as covariates. The group differences reported
earlier remained significant when each of these covariates was
controlled for.
Discussion
This is the first study using behavioral mindfulness tasks to
investigate difficulties in mindfulness in BPD. We found that
individuals with BPD were less frequently mindful than a
control group in a mindful breathing exercise, the
experimenter-prompted mindfulness task. In the
experimenter-prompted mindfulness task, individuals with
BPD mind-wandered not only more often, but also longer.
Although individuals with BPD had difficulties staying focused on their breathing, they did not have difficulties in becoming aware of mind-wandering in the self-prompted mindfulness task. The group differences observed in our mindfulness tasks was not due to non-specific differences in education, age, or verbal intelligence. Taken together, these results
suggest specific difficulties in mindfulness in BPD.
While previous mindfulness studies in BPD exclusively
relied on questionnaire data (Baer et al. 2004; Wupperman
et al. 2008, 2009, 2013), here, we employed a behavioral
mindfulness task. The behavioral assessment of mindfulness
offers several advantages. First, behavioral mindfulness tasks
allow us to disentangle different aspects of mindfulness,
namely: difficulties in being mindful, duration of mind-wandering, and awareness of mind-wandering. We found a characteristic pattern of mindfulness difficulties in BPD: individuals with BPD mind-wandered more frequently and longer,
documenting difficulties in being mindful. At the same time,
they also detected their mind-wandering more frequently.
Consequently, individuals with BPD seem to have difficulties
in staying mindful, but not in awareness of mind-wandering.
Second, behavioral mindfulness tasks offer a more objective measure of mindfulness compared to mindfulness questionnaires. It may be argued that findings from mindfulness
questionnaires are potentially confounded by interindividual
differences in awareness of mind-wandering in everyday life.
Interestingly, in our behavioral tasks, we did not find such
differences in the awareness of mind-wandering. The awareness coefficient did not differ between groups. Therefore it
seems likely that questionnaire data in BPD are not to a great
extent confounded by differences in awareness of mind-wandering. In accordance with these considerations, we found that
behaviorally assessed mindfulness difficulties were associated
with mindfulness difficulties on two established mindfulness
questionnaires, the MAAS and the FFA. In conclusion, mindfulness difficulties identified in our more objective behavioral
task under experimental conditions corresponded to questionnaire data, capturing difficulties subjectively experienced in
everyday life. Our findings suggest that both questionnaires
and behavioral tasks may similarly be used to assess mindfulness difficulties in BPD.
Third, the behavioral mindfulness task provides a relatively
sensitive tool to quantify mindfulness, mind-wandering, and
awareness of mind-wandering. This tool can, in the future, be
used to characterize and compare mindfulness difficulties in
further patient populations that might show different patterns
of mindfulness difficulties (cf. Williams 2008, for depression;
Fossati et al. 2012, for other personality disorders; and
Smalley et al. 2009, for ADHD). In addition, this tool can be
used in BPD to investigate which aspects of mindfulness improve after mindfulness training and which aspect of the task
is particularly predictive of clinical improvements.
Some limitations of our study should be pointed out. First,
the two behavioral mindfulness tasks revealed discrepant findings regarding the length of mind-wandering episodes. In the
experimenter-prompted mindfulness task, individuals with
BPD mind-wandered not only more often, but also longer.
This finding was not paralleled in the self-prompted
Mindfulness
mindfulness task where durations of mind-wandering did not
differ significantly between groups. A possible explanation
for this discrepancy between tasks is that the emphasis on
awareness of mind-wandering in the self-prompted mindfulness task may have helped individuals with BPD to interrupt
mind-wandering and thus reduce the length of mindwandering episodes. Another explanation may be that the order of experimental tasks affected participants’ performance.
In our study, the experimenter-prompted task was always
assessed before the self-prompted task. Indeed, exploratory
post hoc analyses revealed that individuals with BPD and
healthy controls differed in length of mind-wandering in the
first half of the self-prompted task, but not in the second half
of the self-prompted task (see Supplemental material).
A second limitation is that, similar to behavioral mindfulness tasks previously studied in healthy participants, we used
a focused-attention breathing exercise to assess mindfulness,
mind-wandering, and awareness of mind-wandering. We acknowledge that other mindfulness exercises exist that could
have yielded different results. For example, participants could
be asked to mindfully focus on other internal sensations, such
as their own heartbeat or bodily sensations. Farb et al. (2015)
argue that Bthe relationship between interoceptive constructs
across domains … is largely unknown^ (p. 3). Indeed, a study
that examined participants’ awareness of heartbeat via the
heartbeat perception task did not find any difference between
individuals with BPD and healthy controls (Hart et al. 2013).
Two other studies found that while patients with BPD had
impaired pain perception, patients’ proprioception and exteroceptive sensitivity was not impaired (Pavony and
Lenzenweger 2013; Cárdenas-Morales et al. 2011). In addition, we instructed participants to report mind-wandering,
which may have prompted participants to monitor mindwandering more closely than they would in everyday life.
Given such discrepant findings, future research is needed to
explore in how far our results can be generalized to mindfulness difficulties in other domains. In addition, focusedattention exercises are often contrasted to open-monitoring
exercises (Lutz et al. 2008). In these exercises, participants
do not focus their attention on one particular aspect of their
momentary experience (e.g., their breath), but rather try to be
mindfully aware of any thought, bodily sensation, and noise
that they experience. Since this type of exercise is more comparable to mindfulness practice in everyday life, it seems desirable to test if a similar pattern of mindfulness difficulties
would be found studying such exercises. In the present study,
we chose focused-attention exercises, because openmonitoring exercises are often more difficult to understand
for the lay person, and many meditation practices argue that
one first needs sufficient practice in focused-attention before
beginning open-monitoring meditation.
A third limitation is that some of our participants with BPD
suffered from comorbid anxiety disorder or comorbid bulimia
nervosa. Participants’ comorbidities may have influenced
their difficulties in mindfulness. For example, researcher have
shown that patients who suffer from anxiety disorders have
higher interoceptive accuracy (Domschke et al. 2010), a concept closely linked to mindfulness. On the other hand, it may
be argued that BPD is a disorder that is characterized by frequent comorbidities (Lieb et al. 2004; Leichsenring et al.
2011) and excluding all comorbid disorders may have skewed
the external validity of our findings.
A fourth limitation concerns participants’ time estimates of
mind-wandering. To estimate the duration of mind-wandering
may be a difficult task and the subjective experience of time
may not correspond to the actual duration. To simplify the
task, we decided to only provide participants with three categories (1–5 s, 5–30 s, 30 or more seconds) that should be more
easily distinguishable from one another. Nevertheless, our
measure of length of mind-wandering remains a subjective
measure and must be interpreted with caution.
Lastly, some researchers argue that mind-wandering is not
always maladaptive and that mind-wandering may be beneficial, for example, when task demands are low (Smallwood
2013). Individuals with BPD often experience intense emotions (Skodol et al. 2002; Linehan et al. 2007). One could
speculate that mind-wandering may offer a way for individuals with BPD to cope with intense emotions. Future studies
could investigate mind-wandering in BPD under different task
conditions, and also assess the content of mind-wandering
(e.g., see Kanske et al. 2016).
Why is it so difficult for individuals with BPD to stay
mindful? Several clinicians and researchers argue that individuals with BPD attempt to cope with their intense and highly
unpleasant emotions (Ebner-Priemer et al. 2015) by suppressing their feelings or avoiding attention to their bodily sensations and needs (Guttman and Laporte 2002). As a consequence, individuals with BPD may have learned over time
not to be mindful of their own emotions and bodily processes.
In line with this theory, individuals with BPD in our study
show difficulties in focusing mindfully on their breath.
While the described coping strategies might have been helpful
in certain situations in the past, they can become dysfunctional
over time and hinder the psychotherapeutic process.
To summarize, this is the first study to investigate mindfulness difficulties in BPD using a behavioral mindfulness task.
We found that individuals with BPD patients mind-wandered
more frequently and longer than healthy controls, while their
awareness of mind-wandering was not altered. The interruption of mind-wandering (represented in awareness of mindwandering episodes in our task), is often considered the key to
mindfulness practice (Grabovac et al. 2011). It may be speculated that individuals with BPD could profit from their intact
awareness of mind-wandering if this was emphasized in psychotherapy. Patients’ awareness could be seen as a Bfoot in the
door^ to mindfulness training, as it may help patients to
Mindfulness
recognize how often they are mind-wandering. Over time, if
patients learn to stop mind-wandering whenever they become
aware of it, they may be mindful more often. Although mindfulness exercises have already been implemented in treatment
of BPD (for example: Linehan et al. 2007; Lynch et al. 2007),
therapies could to a greater extent utilize exercises similar to
the self-prompted mindfulness task that emphasize awareness
of mind-wandering. The experimenter-prompted mindfulness
task and the self-prompted mindfulness task may be used to
monitor improvement of mindfulness difficulties throughout
therapy.
Acknowledgments The authors thank A. Stippl, S. Heinrich
(Humboldt-Universität zu Berlin) and A. Daniels (Freie Universität
Berlin) for assisting with participant recruitment and data collection and
M. LaRue for manuscript editing.
Funding The study was supported by the German Research
Foundation (DFG BE 2611/2-1).
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
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