Development and Psychopathology 17 2005 899 925 Copyright 2005 Cambridge University Press Printed in the United States of America DOI 10 10170S0954579405050431 Emotion dysregulation and the development of borderline personality disorder KATHERINE M PUTNAM a b and KENNETH R SILK c a National c Center for PTSD Boston b Boston University Medical Center and University of Michigan Health System Abstract We review the role of emotion regulation in borderline personality disorder BPD We briefly discuss the historical development of BPD as a disorder where emotional regulation plays a key role We review the concept of emotion regulation in general and explore both one factor and two factor models of emotion regulation We discuss cognitive and attentional aspects of emotion regulation and explore these regulatory controls as operating as both voluntary as well as automatic processes We then turn to other neurophysiological models of emotion regulation in general and examine how those models both neurophysiologically and neuroanatomically are expressed in individuals with BPD We examine how neuroimaging both anatomical and functional reveals the roles that various neuroanatomical structures play in the regulation of emotion in BPD We conclude by creating a neurodevelopmental model that describes how a complex matrix involving the interplay of constitutional0biological predispositions with environmental stressors as well as with parental effectiveness in response to the child s emotion expression can impact key aspects of adult cognitive affective interpersonal and behavioral functioning that culminate in a diagnosis of BPD Why then tis none to you for there is nothing either good or bad but thinking makes it so to me it is a prison Act 2 Scene 2 Hamlet William Shakespeare That dysregulation of emotion is a core feature of borderline personality disorder BPD appears to be a given In a three part review of BPD in 2002 the third and final part put forth the idea that emotional lability or emotion dysregulation was one of the two major endophenotypes of BPD Siever Torgersen Gunderson Livesley Kendler 2002 the other being impulsive aggression This idea of dysregulation of emotions as a prime driver or underlying constitutional predisposition for some of the symptoms found in BPD has been presented by others as well Linehan deAddress correspondence and reprint requests to Kenneth R Silk University of Michigan Health System 1500 East Medical Center Drive MCHC 6 Box 0295 Ann Arbor MI 48109 0295 E mail ksilk umich edu scribes deficiencies in emotion regulation along with a nonvalidating early environment and low distress tolerance with the subsequent development of poor coping skills as setting the stage for the development of borderline symptoms especially but not exclusively with respect to the clinical presentation of parasuicidal behavior Linehan 1987 1993 In Zanarini Frankenburg Hennen and Silk s 2003 6 year follow along study of BPD 90 of the BPD group endorsed affective instability at baseline in contrast to endorsement by 30 6 of the comparison cohort with other personality disorders Fifty percent of the BPD group continued to endorse this symptom after 6 years Sanislow Grilo Morey Bender Skodol and Gunderson 2002 working in the Collaborative Longitudinal Personality Disorders Study found by employing factor analysis that three factors emerged in BPD although the results can also be interpreted as representing a single factor for the disorder disturbed relatedness behavioral dysregulation impul 899 900 sivity and affective dysregulation Koenigsberg et al 2002 explored the clinical nature of affective instability in 42 patients with BPD and found when comparing them to 110 patients with other personality disorders that patients with BPD showed greater lability between the states of anger and anxiety depression and anxiety and within the various clinical manifestations of anxiety However the BPD cohort did not reveal greater lability between depression and elation Nonetheless on subjective ratings the BPD subjects did not experience greater intensity of affects than did the comparison group In the classic article by Siever and Davis on the biology of personality disorders Siever Davis 1991 affective instability is listed as one of the four dimensions of psychopathology that can be viewed as cutting across from a biological point of view a number of personality disorders Siever and Davis point out that affective instability is very closely related to BPD and perhaps histrionic personality disorder as well and they suggest that defects in the cholinergic and adrenergic systems may be important underlying neuroregulatory mechanisms that play a key role in the development of this affective instability Although Siever and Davis s 1991 work was very important in pointing out that there may be significant biological underpinnings to many of the personality disorders their initial hypothesis appears today to lack precision More recent work by Depue and Lenzenweger 2001 2005 suggests that the neurobehavioral and neurobiological systems that underlie many of the dimensions of behavior and psychopathology are the result of complex interactions of multiple systems It is this interaction among neurotransmitters and the underlying behavioral systems and no single neurotransmitter that leads to the differing phenotypic presentations of behavior among patients with personality disorders Depue Lenzenweger 2001 2005 Although some may argue that the idea of considering specific symptoms of BPD is inherently open to criticism because all symptoms found in BPD and other personality disorders are really just differing expressions of interactions of consistent neurobehavioral K M Putnam and K R Silk systems Depue Lenzenweger 2001 2005 for our purposes here we will consider emotion regulation as a somewhat separate system We isolate this system to review what is known about this aspect of behavior and to look at how this aspect of behavior particularly when it is pathological in its regulation may play a developmental role in BPD There are many researchers who do isolate the emotional regulation system and consider its dysfunction as a core component of BPD Corrigan Davidson Heard 2000 Herpertz Kunert Schwenger Sass 1999 Linehan 1993 Silk 2000 Stiglmayr Shapiro Stieglitz Limberger Bohus 2001 The inability to sustain positive affect coupled with the pervasive and unremitting distress as experienced by patients with