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UMD PSYC 434 - Emotion dysregulation and the development of borderline personality disorder

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Emotion dysregulation and the developmentof borderline personality disorderKATHERINE M. PUTNAMa,band KENNETH R. SILKcaNational Center for PTSD, Boston;bBoston University Medical Center; andcUniversity of Michigan Health SystemAbstractWe review the role of emotion regulation in borderline personality disorder ~BPD!. We briefly discuss the historicaldevelopment of BPD as a disorder where emotional regulation plays a key role. We review the concept of emotionregulation in general and explore both one-factor and two-factor models of emotion regulation. We discuss cognitiveand attentional aspects of emotion regulation, and explore these regulatory controls as operating as both voluntaryas well as automatic processes. We then turn to other neurophysiological models of emotion regulation in generaland examine how those models, both neurophysiologically and neuroanatomically, are expressed in individualswith BPD. We examine how neuroimaging, both anatomical and functional, reveals the roles that variousneuroanatomical structures play in the regulation of emotion in BPD. We conclude by creating aneurodevelopmental model that describes how a complex matrix involving the interplay of constitutional0biologicalpredispositions with environmental stressors as well as with parental effectiveness in response to the child’s emotionexpression can impact key aspects of adult cognitive, affective, interpersonal, and behavioral functioning thatculminate in a diagnosis of BPD.Why, then, ’tis none to you; for there is nothingeither good or bad, but thinking makes it so: to meit is a prison.Act 2, Scene 2, Hamlet, William ShakespeareThat dysregulation of emotion is a core fea-ture of borderline personality disorder ~BPD!appears to be a given. In a three-part reviewof BPD in 2002, the third and final part putforth the idea that emotional lability or emo-tion dysregulation was one of the two majorendophenotypes of BPD ~Siever, Torgersen,Gunderson, Livesley, & Kendler, 2002!, theother being impulsive aggression. This idea ofdysregulation of emotions as a prime driver orunderlying constitutional predisposition forsome of the symptoms found in BPD has beenpresented by others as well. Linehan de-scribes deficiencies in emotion regulation~along with a nonvalidating early environ-ment and low distress tolerance with the sub-sequent development of poor coping skills! assetting the stage for the development of bor-derline symptoms, especially, but not exclu-sively, with respect to the clinical presentationof 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 instabil-ity at baseline, in contrast to endorsement by30.6% of the comparison cohort with otherpersonality disorders. Fifty percent of the BPDgroup continued to endorse this symptom af-ter 6 years. Sanislow, Grilo, Morey, Bender,Skodol, and Gunderson ~2002!, working inthe Collaborative Longitudinal Personality Dis-orders Study, found, by employing factor analy-sis, that three factors emerged in BPD ~althoughthe results can also be interpreted as represent-ing a single factor for the disorder!: disturbedrelatedness, behavioral dysregulation ~impul-Address correspondence and reprint requests to: KennethR. Silk, University of Michigan Health System, 1500East Medical Center Drive, MCHC-6, Box 0295, AnnArbor, MI 48109-0295; E-mail: [email protected] and Psychopathology 17 ~2005!, 899–925Copyright © 2005 Cambridge University PressPrinted in the United States of AmericaDOI: 10.10170S0954579405050431899sivity!, and affective dysregulation. Koenigs-berg et al. ~2002! explored the clinical natureof affective instability in 42 patients with BPDand found, when comparing them to 110 pa-tients with other personality disorders, thatpatients with BPD showed greater lability be-tween the states of anger and anxiety, depres-sion and anxiety, and within the variousclinical manifestations of anxiety. However,the BPD cohort did not reveal greater labilitybetween depression and elation. Nonetheless,on subjective ratings, the BPD subjects didnot experience greater intensity of affects thandid the comparison group. In the classic arti-cle by Siever and Davis on the biology ofpersonality disorders ~Siever & Davis, 1991!,affective instability is listed as one of the fourdimensions of psychopathology that can beviewed as cutting across, from a biologicalpoint of view, a number of personality disor-ders. Siever and Davis point out that affectiveinstability is very closely related to BPD ~andperhaps histrionic personality disorder as well!,and they suggest that defects in the choliner-gic and adrenergic systems may be importantunderlying neuroregulatory mechanisms thatplay a key role in the development of thisaffective instability.Although Siever and Davis’s ~1991! workwas very important in pointing out that theremay be significant biological underpinningsto many of the personality disorders, theirinitial hypothesis appears today to lack pre-cision. More recent work by Depue and Len-zenweger ~2001, 2005! suggests that theneurobehavioral and neurobiological systemsthat underlie many of the dimensions of be-havior ~and psychopathology! are the result ofcomplex interactions of multiple systems. It isthis interaction among neurotransmitters ~ andthe underlying behavioral systems! , and nosingle neurotransmitter, that leads to the dif-fering phenotypic presentations of behavioramong patients with personality disorders~Depue & Lenzenweger, 2001, 2005!.Although some may argue that the idea ofconsidering specific symptoms of BPD is in-herently open to criticism because all symp-toms found in BPD and other personalitydisorders are really just differing expressionsof interactions of consistent neurobehavioralsystems ~Depue & Lenzenweger, 2001, 2005!,for our purposes here we will consider emo-tion regulation as a somewhat separate sys-tem. We “isolate” this system to review whatis known about this aspect of behavior and tolook at how this aspect of behavior, par ticu-larly when it is pathological in its regulation,may play a developmental role in BPD.There are many researchers who do isolatethe emotional regulation system and considerits dysfunction as a core component of BPD~Corrigan, Davidson, & Heard, 2000; Her-pertz, Kunert, Schwenger, & Sass, 1999; Line-han, 1993; Silk, 2000; Stiglmayr, Shapiro,Stieglitz, Limberger, & Bohus, 2001!. The in-ability to


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UMD PSYC 434 - Emotion dysregulation and the development of borderline personality disorder

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