Personality Disorders: Theory, Research, and Treatment 2012 American Psychological Association

2012, Vol. 3, No. 3, 273282 1949-2715/12/$12.00 DOI: 10.1037/a0027331

BRIEF REPORT

Emotional Processing in Borderline Personality Disorder

Michael K. Suvak Christopher T. Sege

National Center for PTSD, VA Boston Healthcare National Center for PTSD, VA Boston Healthcare
System, Boston, Massachusetts, and Suffolk System, Boston, Massachusetts
University
Denise M. Sloan M. Tracie Shea
National Center for PTSD, VA Boston Healthcare Veterans Affairs Medical Center, Providence,
System, Boston, Massachusetts, and Boston Rhode Island, and Brown University
University School of Medicine Medical School

Shirley Yen Brett T. Litz

Brown University Medical School National Center for PTSD, VA Boston Healthcare
System, Boston, Massachusetts, and Boston
University School of Medicine

This study examines whether individuals with borderline personality disorder (BPD) would
exhibit augmented emotional responses to picture stimuli after being challenged with an
ideographic interpersonal conflict script. Participants were 24 adults diagnosed with
BPD, 23 adults diagnosed with obsessive compulsive personality disorder (OCPD), and 28
normal controls. Participants viewed emotionally evocative pictures before and after lis-
tening to the interpersonal script while a variety of physiological measures were recorded.
Findings indicated that the interpersonal script was effective in eliciting enduring emotional
responses from the BPD group relative to the control groups. However, despite the
effectiveness of the interpersonal challenge task, there were no group differences in
emotional responding to the affect eliciting stimuli. The findings underscore the complex-
ities involved in examining emotional dysregulation in BPD in a laboratory setting.

Keywords: borderline personality disorder, emotion responding, psychophysiology, heart rate,

electromyography

Difficulty in processing and managing emo- American Psychiatric Association, 1994) crite-
tions is viewed by some as the core feature of ria of intense anger and affective instability
borderline personality disorder (BPD; e.g., explicitly identify emotion regulation problems,
Linehan, 1993). The Diagnostic and Statistical whereas other problems (e.g., frantic efforts to
Manual of Mental Disorders (4th ed.; DSMIV; avoid abandonment, repeated suicide attempts

This article was published Online First March 26, 2012. Shirley Yen, Department of Psychiatry & Human Be-
Michael K. Suvak, National Center for PTSD, VA havior, Brown University Medical School; Brett T. Litz,
Boston Healthcare System, Boston, Massachusetts, and National Center for PTSD, VA Boston Healthcare Sys-
Department of Psychology, Suffolk University; Christo- tem, and Department of Psychiatry, Boston University
pher T. Sege, National Center for PTSD, VA Boston School of Medicine.
Healthcare System; Denise M. Sloan, National Center This study was supported by a National Institute of Mental
for PTSD, VA Boston Healthcare System, and Depart- Health grant (R21MH069444-03) awarded to Brett T. Litz.
ment of Psychiatry, Boston University School of Med- Correspondence concerning this article should be ad-
icine; M. Tracie Shea, Veterans Affairs Medical Center, dressed to Denise Sloan, National Center for PTSD (116B-2),
Providence, Rhode Island, and Department of Psychiatry VA Boston Healthcare System, 150 South Huntington Ave-
& Human Behavior, Brown University Medical School; nue, Boston, MA 02130. E-mail: [email protected]

273
274 SUVAK ET AL.

or gestures, intense and unstable relationships) behavioral disinhibition (e.g., Hochhausen,

may be viewed as strategies to cope with, or Lorenz, & Newman, 2002). High arousal angry
consequences of, this core deficit. Linehan states in BPD would, in turn, alter appraisal of
(1993) posited that patients with BPD are hy- emotional cues and interfere with otherwise in-
persensitive to emotional challenges and poorly tact emotional capabilities. Ebner-Priemer et al.
manage their subsequent reactions, resulting in (2008) found support for this hypothesis, such
conflict and dysregulation. Despite the central- that BPD individuals displayed greater inability
ity of emotion to the concept of BPD, surpris- to label emotions during periods of psycholog-
ingly little research has directly examined emo- ical distress.
tional responding in individuals with BPD (for a Emotional-processing problems secondary to
review, see Rosenthal et al., 2008). One excep- contexts that trigger maladaptive schemas in
tion is a series of studies by S. C. Herpertz and BPD are also consistent with Beck and Free-
colleagues, which investigated physiological in- mans (1990) cognitive conceptualization of
dicators of emotional reactions to standardized personality disorders, which posits that when
emotion-eliciting pictures (Herpertz, Kunert, particular schemas are triggered, the threshold
Schwenger, & Sass, 1999; Herpertz et al., 2000, for emotional activation is low and readily trig-
2001). In these studies, participants with BPD gered by a trivial stimulus. This suggests that
did not show more intense responses to any of contexts or events that prime or trigger BPD-
the affect evoking pictures, failing to support relevant schemas would lead to subsequent ab-
the hypothesis of emotional hyper-responsive- normal emotional responses.
ness in BPD. The primary aim of this study was to inves-
Hazlett et al. (2007) examined eyeblink star- tigate the emotional-processing consequences
tle in response to unpleasant, BPD-relevant of exposure to a personally relevant challenge in
words (e.g., hate) and neutral words in a BDP BPD. Participants included individuals diag-
group compared with a healthy control group. nosed with BPD, individuals diagnosed with
Participants with BPD exhibited larger startle obsessive compulsive personality disorder
responses while processing unpleasant words in (OCPD), and a normal control (NC) group. We
comparison with the healthy control group; no used an extreme group approach so that any
group differences were found while processing observed differences in the BPD group could be
neutral words. However, as only BPD-relevant attributable to BPD symptoms rather than per-
unpleasant words were presented, it is unclear sonality disorder more generally. We elected to
whether the startle potentiation exhibited by the use the OCPD group because symptoms of this
BPD group was due to the fact that the words personality disorder are highly distinct from
tapped BPD-relevant themes or that they were BPD.
merely unpleasant. In addition, both the BPD We predicted that, at baseline, there would be
and healthy control groups rated the unpleasant normative patterns of psychophysiological re-
words as more arousing than the neutral pic- sponse to pleasant, unpleasant, and neutral im-
tures. Consequently, it is unclear whether the ages in the BPD group, which would not differ
results are due to differences in the valence or from OCPD and NC groups. However, after
arousal value of the stimuli. exposure to an ideographic violation-related
The empirical evidence to date suggests that challenge or prime, we expected that partici-
there may be limits, or contextual constraints, to pants with BPD would be less responsive to
emotional abnormalities in BPD. In other pleasant images and more responsive to un-
words, emotional-processing abnormalities may pleasant images relative to their baseline re-
arise in some contexts and not others. One pos- sponses, and relative to NC and the OCPD
sibility is that individuals with BPD exhibit groups.
emotional hyper-reactivity after being provoked
or triggered by conflict-laden interpersonal Method
challenges. For example, emotional-processing
abnormalities in BPD may be secondary to ep- Participants
isodes of perceived violation or perceived with-
drawal of love, which results in anger or rage, Participants were 75 adult females (n 24,
characterized by high arousal and cognitive and 23, and 28 in the BPD, OCPD, and NC groups,
 EMOTIONAL PROCESSING AND BPD 275

respectively) with a mean age of 32.89 years rise time. The startle stimulus was presented
(SD 12.19) and mean years of education binaurally through Maxwell NC-II headphones.
of 15.35 (SD 2.23). The majority (77.4%) of
the sample was Caucasian. Participants were Measures
informed that the purpose of the study was to
determine how personality affects emotions. Fi- The Diagnostic Interview for Personality
nancial compensation was provided for time Disorders (DIPD; Zanarini, Frankenburg,
and travel expenses. The study was approved by Sickel, & Yong, 1996) BPD and OCPD mod-
the local institutional review boards. ules were the primary diagnostic instruments
Most participants were recruited using flyers used in this study. This instrument assesses
posted on community and Internet bulletin symptoms consistent with DSMIV symptoms
boards. Five participants from the BPD group of BPD and OCPD. Symptoms must be present
and five from the OCPD group were recruited and pervasive for at least 2 years and charac-
from the Brown University and McLean Hos- teristic of the person during her adult life. The
pital sites of the Collaborative Longitudinal Structured Clinical Interview for the DSMIV
Study of Personality Disorders (CLPS; Zanarini Axis I Disorders (SCID-I; First, Spitzer, Gib-
et al., 2000). For the current study, BPD partic- bon, & Williams, 1996) was used to identify
ipants could not endorse OCPD diagnostic Axis I pathology in the study sample.
symptoms, and participants with OCPD could All diagnostic instruments were administered
not endorse BPD diagnostic symptoms. Partic- either by CLPS-licensed clinicians or by post-
ipants in the NC group could not meet lifetime doctoral fellows or advanced doctoral-level
or current diagnostic criteria for any Axis I or psychology students. All assessments were su-
Axis II disorders. Exclusion criteria for all par- pervised and checked for diagnostic accuracy
ticipants included lifetime psychosis diagnosis by an experienced doctoral-level psychologist.
and self-reported hearing problems. All partic- Interpersonal violation script. A semi-
ipants had to be at least 18 years old and able to structured interview was used to elicit a narra-
provide informed consent. A substantial propor- tive of an anger-provoking interpersonal con-
tion of BPD and OCPD participants reported flict with someone close to the participant. A
current psychotropic medication use (58% and 90-s narrative script was then generated from
42%, respectively); none of the NC participants the interview. The method for generating the
reported medication use. script followed the procedure developed by
Lang and colleagues (e.g., Lang & Cuthbert,
1984). Following presentation of the script, the
Stimulus Materials
participant was asked to close her eyes and
Pleasant, unpleasant, and neutral images imagine the event taking place in real time.
were selected from the International Affective Emotion Response Measures
Picture System (IAPS; Lang, Bradley, & Cuth-
bert, 2005) on the basis of normative ratings for A computerized version of the Self-Assess-
females. Pictures were displayed 4 feet from the ment Manikin (SAM; Bradley & Lang, 1994)
participant on a 27.5 (width) 15.5 (height) was used to assess self-reported changes in af-
inch computer monitor. Pictures were presented fect during the laboratory session. The SAM
for 6 s, with intertrial intervals (ITIs) ranging uses manikin figures on a 9-point scale to rep-
from 18 26 s. Consistent with procedures used resent two affect dimensions (i.e., valence and
by other investigators (e.g., Bradley, Codispoti, arousal). In addition, participants reported on
Cuthbert, & Lang, 2001), participants viewed a their experience of anger during the laboratory
total of 60 images across two blocks; each block procedure using a computerized 9-point Likert-
contained 10 pleasant, 10 unpleasant, and 10 type scale.
neutral images. Only responses to 36 images
(six pleasant, six neutral, six unpleasant per Apparatus and Psychophysiological
block) during which startle probes were pre- Measures
sented are included in the current study. The
acoustic startle probe consisted of a 50-ms burst Labtech Notebook Pro software and a Coul-
of 104-dB white noise with immediate (10 ms) bourn (Allentown, PA) amplifier stack were
276 SUVAK ET AL.

used to collect psychophysiological data. Super- viewing interval. Change in SCL during the
Lab software (Cedrus Corporation, 1999) using script and imagery periods was computed by
a 1000-Hz timer was used to display digital subtracting the mean of the 60-s baseline from
images, collect ratings data, coordinate the on- the mean of the maximum 10-s interval during
set and offset of data collection, and control the each period. SC data from five participants (3
timing of all experimental stimuli. BPD, 2 OCPD) were removed because of ex-
Startle response. The eyeblink component cessive artifacts.
of the startle reflex was measured by recording Facial EMG. Corrugator and zygomatic
electromyography (EMG) activity from Beck- facial EMG activity was recorded from Beck-
man miniature Ag/AgCl electrodes positioned man miniature Ag/AgCl electrodes filled with
over the orbicularis oculi muscle beneath the electrolyte paste, positioned according to stan-
left eye. Startle probes were presented dard guidelines (Fridlund & Cacioppo, 1986).
at 3.5, 4.5, or 5.5 s after picture onset (counter- EMG during picture processing was sampled
balanced with valence), and 9 additional probes (10 Hz) beginning 1 s prior to picture onset
were presented during intervals in which no through the 6-s picture-viewing period. Facial
picture was present, for a total of 39 probes per EMG activity in response to the IAPS pictures
block. Three of the no-picture probes occurred and to the script-imagery procedure was com-
during the 90-s interval prior to the first picture puted in the same manner as SC. Corrugator
trial. The remaining probes were interspersed at EMG data were removed for three participants
unpredictable intervals across each block. Star- (2 BPD, 1 OCPD) and zygomatic EMG data
tle data for five participants (1 BPD, 2 OCPD, 2 were removed for two participants (1 BPD, 1
NC) were removed because of excessive artifact OCPD) due to equipment malfunctions.
or equipment malfunctions.
Heart rate (HR). HR activity was re- Procedure
corded with 1-cm Beckman Ag/AgCl electrodes
positioned on the right and left inner forearms. The study was conducted over two sessions
Interbeat intervals were recorded in ms and scheduled approximately one week apart. Upon
reduced online to HR in beats per minute arrival for the first session, participants were
(BPM) in 0.5-s intervals. Change scores for the informed about the nature and requirements of
picture processing procedure were computed by the study, provided consent, and completed the
subtracting the mean of the 6-s baseline interval diagnostic interviews.
from the minimum value during the first 3 s of At the second session, participants were
picture viewing (deceleration) and from the seated in a recliner in a dimly lit, sound-
maximum value during the last 3 s of picture attenuated room, and physiological sensors
viewing (acceleration). For script and imagery were applied. A computer mouse was located
periods, analyses compared the mean of the on the right arm of the chair. The participant
60-s baseline interval prior with the script with was provided instructions for completion of the
the mean of the maximum 10 -s interval during rating scales and was administered a baseline
the 90-s script period and 60-s imagery period. SAM ratings. Following a 90-s baseline record-
HR data from 15 participants (4 BPD, 4 ing period, the participant viewed the first block
OCPD, 7 NC) were removed because of exces- of IAPS images. Each image was followed by a
sive artifact or technical malfunctions. 6-s blank screen and then presentation of SAM
Skin conductance (SC). SC was recorded ratings. Postbaseline SAM ratings were admin-
from adjacent sites on the hypothenar eminence istered, along with an anger rating to assess
of the nondominant hand with 1-cm Beckman levels of anger before the script-imagery proce-
Ag/ AgCl electrodes filled with Unibase/saline dure. This was followed by the presentation of
paste. During the IAPS blocks, sampling (10 the anger script and the imagery period, and
Hz) began 1 s prior to the onset of the image and then another set of SAM and anger ratings.
continued through the 6-s presentation interval.
Change in SC level (SCL) during picture pro- Data Analysis Plan
cessing was computed by subtracting the mean
of the 1-s baseline interval prior to the onset of For the psychophysiological data, mixed-
the picture from the mean of the 6-s picture- effects regression analyses were conducted us-
 EMOTIONAL PROCESSING AND BPD 277

ing the Hierarchical Linear and Non-Linear parable in the two personality disorder groups
Modeling Software Program (HLM6; Rauden- (2 BPD and 3 OCPD participants).
bush, Bryk, & Congdon, 2005). Dummy-coded
variables were used to analyze the categorical Manipulation Check
factors (valence, group, and condition). Primary
analyses involved a 3 (Valence: Unpleasant, Mixed-effect regression with phase (pre-
Neutral, Pleasant) 3 (Group: BPD, OCPD, script, postscript, end of experiment) analyzed
NC) 2 (Block: Baseline, Postscript) repeated using dummy-coded variables (producing a
measures comparison. For each outcome, the model analogous to a repeated-measures
first model evaluated all main effects, and the ANOVA), was conducted to assess the impact
second and third models evaluated two-way and of the state manipulation on self-reports of af-
three-way interactions, respectively. Overall fect. Summary statistics are displayed in Ta-
model fit was assessed by evaluating change in ble 1. Overall, BPD participants and OCPD
the deviance statistic (dev; which follows a participants reported significantly higher levels
chi-square distribution; Raudenbush & Bryk, of arousal than NC participants. BPD partici-
2002). pants also reported significantly higher levels of
We used a model-comparison approach to anger than both OCPD and NC participants.
examine specific main effects and interactions. However, no significant Group Phase two-
Each factor of interest was removed sequen- way interactions emerged, indicating that the
tially, the model was recomputed, and a decre- script did not differentially impact the three
ment in model fit as assessed by dev. It is groups. The findings support successful manip-
typical to test each individual main effect when ulation of the script.
controlling for all other main effects, each indi-
vidual two-way interaction when controlling for Emotional Processing of Emotion-Eliciting
all other two-way interactions, and so on. Re- Images
gression coefficients were used to depict the
nature of significant effects. This approach is The analyses were conducted in a similar
analogous to examining the omnibus F test in manner for all outcomes, with one exception.
the analysis of variance (ANOVA) and conduct- Prior to testing the primary hypotheses regard-
ing specific contrasts to elucidate the nature of ing emotion modulation of the startle response,
significant results. For estimates of within- growth curve analyses examined responses to
subject effect sizes, we report the partial corre- startles presented when no images were dis-
lation coefficients ( pr) for each coefficient. played (i.e., intertrial interval [ITI] startles) to
Kirk (1996) suggests .10, .24, and .37 for small, evaluate initial startle response, habituation, and
medium, and large effect sizes, respectively. how these processes might differ as a function
For estimates of between-groups effect sizes, of group. As expected, a strong nonlinear (i.e.,
we report Cohens d and use descriptors of natural log) habituation pattern emerged (b
effect size offered by Cohen (1988): .25, .50, .98, t 4.19, p .001, pr .45) that
and .80 for small, medium, and large, respec- accounted for 12% of the within-subjects vari-
tively. ance in startle magnitude. Group did not signif-
icantly predict either initial status or the habit-
uation effect. However, when analyzing the
Results emotion modulation of the startle response dur-
ing picture presentation, the natural log-
A series of ANOVA and chi-square analyses transformed startle serial number was included
confirmed no significant group differences in as a time-varying covariate to statistically con-
demographic characteristics (average age, years trol for habituation.
of education, and race). A greater frequency of Summary statistics for picture-processing
BPD participants met diagnostic criteria for de- variables, as well as the significant test for each
pression disorders, panic disorder, and social main effect, two-way interaction, and three-way
anxiety disorder (13, 8, and 9, respectively) interaction, can be found in Table 2. Impor-
relative to the OCPD group (5, 4, and 4, respec- tantly, the psychophysiological findings ob-
tively). Posttraumatic stress disorder was com- tained in this study are consistent with the emo-
278 SUVAK ET AL.

Table 1
Descriptive Statistics and Statistical Test for Manipulation Check
Phase
End-of-
Postscript Experiment Total Statistical test effect
Outcome and group Prescript M (SD) M (SD) M (SD) M (SD) (dev, df, r2/c)d
SAM Valence (19)
NC 5.43 (1.89) 3.32 (2.02) 5.89 (2.60) 4.87 (1.49) Group (3.97, 2, .03)
BPD 5.13 (4.02) 2.70 (2.81) 4.95 (3.86) 4.22 (2.50) Phase (879.36, 5, .50)
OCPD 5.38 (2.31) 3.18 (3.66) 5.80 (2.59) 4.75 (1.84) 2-way (1.65, 4, .01)
Total 5.32 (1.63)a 3.08 (1.64)b 5.59 (1.78)a
SAM Arousal (19)
NC 2.57 (2.51) 5.59 (3.63) 2.71 (2.52) 3.60 (2.27)a Group (6.59, 2, .05)
BPD 3.17 (3.62) 6.61 (3.61) 4.05 (4.47) 4.64 (2.65)b Phase (968.93, 5, .58)
OCPD 3.67 (3.34) 6.59 (4.07) 3.85 (3.56) 4.74 (2.71)b 2-way (2.08, 4, .01)
Total 3.08 (1.86)a 6.22 (2.23)b 3.44 (2.08)c
Angry Feelings (06)
NC 0.29 (0.86) 2.86 (3.21) 0.46 (2.25) 1.20 (1.55)a Group (10.70, 2, .08)
BPD 1.43 (2.23) 4.17 (3.52) 1.50 (4.15) 2.44 (2.62)b Phase (138.78, 5, .62)
OCPD 0.57 (2.51) 4.30 (4.33) 0.25 (1.21) 1.69 (1.84)a 2-way (6.16, 4, .05)
Total 0.74 (1.40)a 3.69 (2.21)b 0.68 (1.62)a
Note. BPD borderline personality disorder group; NC control group; OCPD obsessive compulsive personality
disorder group; SAM self-assessment manikin.
a,b,c
Used to indicate statistically significant difference among groups and phases. d Because the test of the overall effects
involving group was based on a chi-square distribution, Cramers Phi (c), which can be interpreted as variance accounted
for, is reported as an effect size indicator. For the Phase within-participants effect, r2 or the amount of Level 1 (i.e., within
participants) accounted for is reported as an effect-size indicator.

p .05. p .01. p .001.

tion-picture-processing literature (e.g., Bradley ing Block 1, participants in the OCPD group
et al., 2001). Specifically, significantly greater rated all images as more arousing than the NC
startle reflex was observed during viewing of (bocpd-nc .88, t 2.31, p .05, d .54) and
unpleasant images relative to neutral ( pr .34) the BPD groups (bocpd-nc .84, t 2.07, p
and pleasant images ( pr .49). In turn, startle .05, d .54); the difference between the NC
reflex was significantly greater while viewing and BPD groups was not significant. During
neutral images relative to pleasant images Block 2, there were no significant group differ-
( pr .21). Participants displayed significantly ences (ds ranging from .01 to .06).
greater zygomatic facial EMG activity while For HR-acceleration a significant Group
viewing pleasant images compared with neutral Valence two-way interaction emerged
( pr .20) and unpleasant images ( pr .19), (dev 9.47, df 4, p .05). Examining
whereas greater corrugator facial EMG activity regression coefficients revealed that the pleas-
occurred while viewing unpleasant images rel- antneutral and unpleasantneutral contrasts
ative to pleasant ( pr .49) and neutral ( pr were different for the BPD group compared
.40) pictures. Greater SC activity occurred with the OCPD (d for the BPD-OCPD differ-
while viewing pleasant ( pr .41) and unpleas- ence in pleasantneutral contrast .66; un-
ant pictures relative to neutral pictures, whereas pleasantneutral contrast .57) and NC groups
SC ( pr .34) activity did not differ between (d for the BPD-NC difference in pleasant
pleasant and unpleasant images ( pr .15). neutral contrast .66; unpleasantneutral con-
Significant group effects emerged for only trast .76). For the BPD group, there were no
two variables: self-reported arousal and HR- statistically significant differences across the
acceleration. For self-reported arousal, a signif- valence conditions. On the other hand, for the
icant Group Block interaction emerged OCPD and NC groups, neutral images were asso-
(dev 14.65, df 2, p .001). Examination ciated with the largest HR accelerations. Further-
of the regression coefficients revealed that dur- more, the neutral unpleasant contrasts were sta-
Table 2
Descriptive Statistics and Significant Tests for the Self-Reported and Psychophysiological Outcome Measures
Block 1 Block 2 Combined (Blocks 1 and 2)
Measure (Units) and Total M Statistical test
group M (SD) 0 M (SD) M (SD) M (SD) 0 M (SD) M (SD) M (SD) 0 M (SD) M (SD) (SD) (dev, df, r2/c)a
SAM Valence
(19) Grp (2.4, 2, .03)
NC 5.91 (2.40) 4.89 (1.89) 2.76 (1.76) 5.77 (2.47) 5.01 (1.91) 2.74 (1.57) 5.84 (2.39) 4.95 (1.85) 2.75 (1.61) 4.51 (1.71) Val (2445.9, 9, .46)
Blk (83.9, 5, .04)
BPD 5.61 (3.78) 4.68 (2.66) 2.49 (1.69) 5.18 (3.49) 4.32 (2.58) 2.70 (2.63) 5.40 (3.56) 4.50 (2.49) 2.60 (1.88) 4.16 (2.43) G x V (1.9, 4, .03)
G x B (1.27, 2, .02)
OCPD 6.02 (1.55) 5.11 (1.79) 3.04 (2.11) 5.63 (2.50) 4.80 (2.28) 3.04 (2.13) 5.82 (1.81) 4.96 (1.74) 3.04 (1.89) 4.61 (1.54) B x V (50.5, 13, .03)
G x V x B (3.79, 4, .05)
Total 5.85 (1.59) 4.89 (1.25) 2.76 (1.09) 5.54 (1.66) 4.73 (1.33) 2.82 (1.22) 5.69 (1.56) 4.81 (1.20) 2.79 (1.05)
SAM Arousal
(19) Grp (2.9, 2, .04)
NC 3.95 (2.68) 2.80 (2.43) 4.94 (2.86) 3.85 (2.73) 2.61 (2.47) 4.77 (2.63) 3.90 (2.65) 2.70 (2.39) 4.85 (2.66) 3.82 (2.34) Val (1395.5, 9, .32)
Blk (210.4, 5, .07)
BPD 4.08 (3.47) 2.88 (2.80) 4.83 (3.15) 4.08 (3.47) 2.80 (3.03) 4.61 (3.38) 4.08 (3.32) 2.84 (2.83) 4.72 (3.18) 3.88 (2.76) G x V (1.2, 4, .02)
G x B (14.7, 2, .20)
OCPD 4.86 (2.51) 3.70 (2.70) 5.75 (2.76) 3.94 (2.91) 2.79 (2.38) 4.83 (3.53) 4.40 (2.53) 3.25 (2.23) 5.29 (2.90) 4.31 (2.26) B x V (9.7, 13, .01)
G x V x B (.7, 4, .01)
Total 4.27 (1.73) 3.10 (1.57) 5.15 (1.74) 3.95 (1.75) 2.72 (1.53) 4.74 (1.82) 4.11 (1.66) 2.91 (1.46) 4.94 (1.69)
Startle Magnitude
(V) Grp (.98, 2, .01)
NC 8.90 (9.03) 9.14 (8.66) 9.47 (9.12) 9.46 (8.57) 9.28 (8.36) 10.03 (9.97) 9.25 (7.94) 9.32 (7.73) 9.93 (8.69) 9.50 (8.04)
Val (77.2, 11, .05)
Blk (18.09, 6, .02)
BPD 9.96 (9.45) 10.20 (10.25) 10.66 (10.61) 10.07 (9.59) 10.60 (10.63) 10.50 (10.59) 9.83 (8.74) 10.24 (9.52) 10.43 (9.65) 10.22 (9.35) G x V (3.4, 4, .05)
G x B (3.1, 2, .04)
OCPD 11.53 (11.85) 11.92 (12.13) 12.60 (12.74) 11.27 (11.31) 11.53 (11.45) 12.22 (12.08) 11.00 (10.89) 11.29 (11.18) 11.88 (11.57) 11.43 (11.23) B x V (9.8, 15, .04)
EMOTIONAL PROCESSING AND BPD

G x V x B (2.9, 4, .04)
Total 10.05 (7.90) 10.33 (8.11) 10.81 (8.36) 10.21 (8.19) 10.39 (8.43) 10.85 (9.13) 9.97 (7.73) 10.21 (7.86) 10.68 (8.34)

SC (log S 1) Grp (1.7, 2, .02)

NC 0.020 (.040) 0.006 (.020) 0.020 (.040) 0.010 (.040) 0.009 (.030) 0.010 (.040) 0.010 (.040) 0.008 (.020) 0.020 (.040) 0.010 (.030) Val (59.1, 9, .03)
Blk (11.2, 5, .01)
BPD 0.004 (.007) 0.004 (.010) 0.010 (.020) 0.007 (.020) 0.008 (.020) 0.010 (.050) 0.005 (.010) 0.006 (.010) 0.010 (.030) 0.007 (.020) GxV (4.2, 4, .06)
GxB (2.37, 2, .03)
OCPD 0.010 (.020) 0.007 (.020) 0.010 (.030) 0.010 (.030) 0.009 (.030) 0.010 (.030) 0.010 (.020) 0.008 (.020) 0.010 (.020) 0.010 (.020) BxV (26.49, 13, .01)
GxVxB (1.5, 4, .02)
Total 0.010 (.020) 0.006 (.009) 0.010 (.020) 0.010 (.020) 0.009 (.020) 0.010 (.020) 0.010 (.020) 0.007 (.010) 0.010 (.020)
HR-dec (BPM) Grp (3.3, 2, .06)
NC 4.65 (4.67) 3.48 (5.96) 4.04 (4.44) 4.05 (4.54) 3.97 (5.86) 5.43 (7.45) 4.35 (3.49) 3.73 (5.23) 4.73 (5.60) 4.27 (4.60) Val (10.0, 9, .00)
Blk (9.9, 5, .01)
(table continues)
279
 280
Table 2 (continued)
Block 1 Block 2 Combined (Blocks 1 and 2)
Measure (Units) and Total M Statistical test
group M (SD) 0 M (SD) M (SD) M (SD) 0 M (SD) M (SD) M (SD) 0 M (SD) M (SD) (SD) (dev, df, r2/c)a
BPD 3.22 (5.49) 3.15 (4.34) 3.25 (4.66) 3.80 (4.82) 4.08 (6.26) 3.84 (5.25) 3.51 (4.60) 3.61 (4.42) 3.55 (4.24) 3.56 (3.90) G x V (6.0, 4, .10)
G x B (.5, 2, .01)
OCPD 3.16 (6.96) 1.61 (3.80) 2.87 (4.84) 3.75 (5.66) 2.43 (4.71) 4.23 (4.85) 3.46 (4.41) 2.02 (3.28) 3.54 (4.03) 3.01 (2.82) B x V (14.1, 13, .01)
G x V x B (1.5, 4, .03)
Total 3.70 (3.37) 2.78 (2.93) 3.40 (2.73) 3.87 (2.88) 3.52 (3.37) 4.52 (3.56) 3.79 (2.44) 3.15 (2.68) 3.96 (2.79)
HR-acc (BPM) Grp (1.9, 2, .03)
NC 2.62 (7.54) 4.63 (6.84) 0.79 (5.35) 2.33 (7.56) 3.21 (4.37) 1.84 (5.95) 2.47 (6.62) 3.92 (4.73) 1.31 (4.63) 2.57 (4.48) Val (11.34, 9, .01)
Blk (5.4, 5, .00)
BPD 4.99 (7.49) 3.14 (8.09) 5.12 (8.96) 3.82 (10.67) 3.36 (8.12) 3.04 (8.27) 4.40 (8.43) 3.25 (7.03) 4.08 (6.48) 3.91 (6.31) G x V (9.47, 4, .02)
G x B (1.5, 2, .03)
OCPD 3.11 (6.86) 4.70 (9.01) 2.88 (7.55) 1.82 (10.33) 3.22 (9.33) 1.47 (6.74) 2.46 (7.18) 3.96 (7.92) 2.18 (6.31) 2.86 (6.35) B x V (9.7, 13, .01)
G x V x B (4.0, 4, .07)
Total 3.56 (4.36) 4.16 (4.65) 2.88 (4.61) 2.67 (5.57) 3.26 (4.28) 2.12 (4.12) 3.11 (4.39) 3.71 (3.82) 2.50 (3.55)
Corrugator EMG
(V) Grp (.3, 2, .004)
NC 0.01 (.04) 0.02 (.07) 0.07 (.17) 0.02 (.06) 0.02 (.06) 0.08 (.25) 0.02 (.04) 0.02 (.06) 0.07 (.20) 0.04 (.09) Val (381.8, 9, .10)
Blk (97.0, 5, .04)
BPD 0.01 (.09) 0.04 (.11) 0.06 (.17) 0.01 (.11) 0.03 (.10) 0.04 (.17) 0.01 (.09) 0.03 (.10) 0.05 (.12) 0.03 (.08) G x V (3.5, 4, .05)
G x B (1.3, 2, .02)
OCPD 0.02 (.12) 0.04 (.14) 0.06 (.17) 0.02 (.09) 0.02 (.09) 0.06 (.13) 0.02 (.09) 0.03 (.09) 0.06 (.11) 0.04 (.09) B x V (77.9, 13, .03)
SUVAK ET AL.

G x V x B (1.9, 4, .03)
Total 0.01 (.05) 0.03 (.06) 0.06 (.10) 0.02 (.05) 0.02 (.05) 0.06 (.12) 0.02 (.04) 0.03 (.05) 0.06 (.09)
Zygomatic EMG
(V) Grp (4.5, 2, .06)
NC 0.01 (.04) 0.00 (.02) 0.01 (.03) 0.02 (.08) 0.01 (.03) 0.00 (.04) 0.02 (.05) 0.01 (.02) 0.01 (.03) 0.01 (.04) Val (27.2, 9, .02)
Blk (5.1, 5, .002)
BPD 0.03 (.08) 0.01 (.10) 0.02 (.08) 0.02 (.11) 0.02 (.07) 0.02 (.10) 0.03 (.08) 0.01 (.07) 0.02 (.08) 0.02 (.05) G x V (2.2, 4, .03)
G x B (.2, 2, .003)
OCPD 0.00 (.08) 0.01 (.08) 0.00 (.06) 0.01 (.05) 0.01 (.10) 0.00 (.05) 0.01 (.05) 0.00 (.08) 0.00 (.06) 0.00 (.05) B x V (19.0, 13, .01)
G x V x B (6.23, 4, .09)
Total 0.02 (.04) 0.01 (.04) 0.01 (.03) 0.02 (.05) 0.01 (.04) 0.01 (.04) 0.02 (.04) 0.01 (.03) 0.01 (.03)

Note. Blk Block; BPD borderline personality disorder group; BPM change in beats per minute; B x V Block Valence interaction; EMG electromyography; Grp
Group; G x B Group Block interaction; G x V Group Valence interaction; G x V x B Group Valence Block interaction; HR-acc heart rate acceleration; HR-dec
heart rate deceleration; NC normal control group; OCPD obsessive-compulsive personality disorder group; SAM self-assessment manikin; SC skin conductance; Val
Valence; log S 1 log transformation of change in skin conductance in microSiemens; V change in microvolts.
a
The test of the overall effects involving group was based on a chi-square distribution; therefore, Cramers Phi (), which can be interpreted as variance accounted for, is reported
as an effect size indicator. For the within-participants effect (i.e., valence, block, and Valence Block), r2 or the amount of Level 1 (i.e., within participants) accounted for is reported
as an effect-size indicator.

p .05.
 EMOTIONAL PROCESSING AND BPD 281

tistically significant for both the NC and OCPD whether group differences in emotional re-
groups ( p .01 for the NC group and p .05 for sponding are observed when using emotion-
the OCPD condition), while the neutralpleasant eliciting stimuli that are BPD-relevant.
contrast approached statistical significance for Another issue concerns the narrow band of
both groups ( p .07 for the NC group and p methods used to examine emotional responding.
.08 for the OCPD condition). No statistically sig- Different assessment methods may produce
nificant difference emerged in HR acceleration different findings. A multimethod, multitrait
between the NC and OCPD conditions (ds ranging evaluation of emotional dysregulation would
from .01 to .27). facilitate our understanding of how affect dys-
regulation may vary as a function of the method
Discussion used to index it.
The laboratory setting may have also influ-
Consistent with some prior research (e.g., enced our ability to observe emotion dysregu-
Herpertz et al., 2001), the current study found lation thought to be central to BPD. Investigat-
that BPD individuals do not display or report ing emotional responding of BPD individuals
emotional behavior abnormalities in highly con- outside of the lab may allow for a more accurate
trolled laboratory conditions. Although the observation of BPD emotional responding in
interpersonal violation script was effective in everyday life. Another possible explanation for
eliciting arousal and anger, contrary to our pre- the lack of group differences in emotional re-
diction, the interpersonal violation script did not sponding obtained here and by others (Herpertz
differentially impact the BPD groups emo- et al., 1999, 2000, 2001) is that the emotion
tional responding to emotionally evocative pic- difficulties in BPD may not be found in all
tures, which is surprising, given that emotion individuals with BPD. Indeed, a diagnosis of
dysregulation is considered a core feature of BPD can be obtained without displaying symp-
BPD.
toms of emotion dysregulation (American Psy-
These null findings could be the result of
chiatric Association, 1994). It is possible that
many factors. First, because findings replicated
only a subset of BPD individuals display emo-
the Herpertz et al. studies (1999, 2000, 2001)
tion regulation difficulties.
using similar methods, one possible explanation
is that the stimulus set was not sufficiently evoc- Although there are a number of strengths of
ative. Static images that depict emotional scenes this study, there are limitations that should be
may not be sufficiently evocative to elicit emo- considered. First, the sample size was relatively
tional abnormalities in personality disorders. It small, although similar to that used by Herpertz
is also possible that the picture-processing in- and colleagues (1999, 2000, 2001). The effect
terval of 6 seconds was too short to reveal size of emotion regulation difficulties in BPD
differential responding. Lastly, we may have may be too small to have been detected with the
found group differences in emotional respond- sample size included in our study. The present
ing if we only used anger-eliciting stimuli, study also included only women, which may
which would have matched the anger prime limit the generalizability of our findings. How-
used in this study. ever, the majority of individuals diagnosed with
On the other hand, it is plausible that picture BPD are women (American Psychiatric Associ-
stimuli used in our study, and used by Herpertz ation, 1994).
and colleagues (1999, 2000, 2001), did not suf- Taken together, laboratory studies examining
ficiently tap BPD-relevant themes. Our group emotional responding in BPD have not docu-
recently developed a picture-stimulus set in- mented the emotion dysregulation that is
tended to depict experiences (e.g., interpersonal thought to be a core feature of the disorder and
violations) that are relevant to BPD patients has been observed in studies using self-report
(Sloan et al., 2010). The stimulus set was de- measures (see Rosenthal et al., 2008, for a re-
veloped to use in investigations of emotional view). Future studies should consider using
responding with BPD participants. Unfortu- BPD-relevant stimuli, using multiple measures
nately, the stimulus set was developed while of emotional responding, and study emotional
the study described here was underway. We responding outside of a controlled laboratory
hope that future studies will investigate environment.
282 SUVAK ET AL.

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