Article Summary
Kuo, J. R., & Linehan, M. M. (2009). Disentangling emotion processes in borderline personality disorder: physiological and self-reported assessment of biological vulnerability, baseline intensity, and reactivity to emotionally evocative stimuli. Journal of abnormal psychology, 118(3), 531.
Borderline Personality Disorder is defined as “A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts.” The essential features of a personality disorder are “impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits” (APA, 2013).
In 1993, Marsha Linehan proposed a theory of Borderline Personality Disorders (BPD), according to which individuals who meet the criteria for BPD are biologically vulnerable to emotion dysregulation (an inability to modify and regulate emotional states). Such individuals experience high emotional intensity and react strongly to stimuli evoking emotional reactions (Linehan, 1993). According the model proposed by Linehan, individuals with BPD have high baseline rates of negative emotions and tend to react intensely to emotionally evocative stimuli. As the individual is unable to effectively modulate and regulate these intense emotions and his or her environment is consistently invalidating, meaning not accepting and acknowledging their emotions and feelings, the constant transaction between an emotionally vulnerable individual and the invalidating environment affects the individual's emerging psychic structure and personality.
The stimuli consisted of films that were found by previous research to evoke specific emotions, including sadness, fear, anger and a neutral film that does not evoke any emotion. In addition, participants were exposed to a personally relevant condition that was based on information given prior to the experiment, as the participants were asked to give an example of the most recent or vivid event in which they felt sad, angry, fearful and emotionally neutral.
The results indicated that the BPD group showed significantly higher biological vulnerability than the SAD and control group. This was examined by calculating the difference between these measures prior to and following exposure to the stimuli, taking into account any reactions to neutral stimuli. Researchers found that the difference in heart rate and skin conductance among the BPD group was higher.
In addition, the BPD group exhibited higher emotional intensity, as measured by baseline rates of skin conductance, and self-reported negative emotions. However, the BPD group did not differ from the other two groups in their emotional reactivity, meaning a general tendency to experience a reaction to emotionally evocative stimuli.
This article investigated a theoretical construct of Borderline Personality Disorder, which is a diagnosis first introduced by the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, in 1980 (Millon, 1981). Prior to the 1980s, individuals presenting with BPD symptoms, mainly problems regulating emotions and thoughts, impulsive and reckless behavior and difficulty sustaining relationships with others, may have been diagnosed as psychotic (for those individuals presenting with severe symptoms and psychotic episodes), or otherwise their diagnosis would focus on a co-morbid disorder. Individuals suffering from BPD tend to exhibit high rates of co-morbidity, meaning other disorders that are co-occurring, such as depression, anxiety, substance abuse, eating disorders, suicidal behaviors and self-injury (Morey& Zanarini, 2000).
It was only in the 1980s that the psychiatric classification system had incorporated the axis system, acknowledging the different aspects of psyche and mind. The axis system includes five dimensions; the first axis consists of clinical disorders such as autism, mental disorders and depression. The second axis consists of personality disorders such as borderline personality disorder, antisocial personality disorder and schizotypal personality disorder. The third axis takes into account an individual's general medical conditions such as asthma or diabetes, while the fourth axis refers to psychosocial and environmental problems that may be present including economic, social or occupational problems. The fifth axis consists of a global evaluation of functioning, meaning an assessment of the individual's ability to function in daily life (APA, 2013).
The fact that an individual may receive a multi-axial diagnosis corresponds to the difference between personality structure and disorders. Otto Kernberg, a psychoanalyst from the object-relations school of thought, proposed a view consisting of two dimensions; the first is the level of organization, and the second is the level of introversion versus extroversion. An individual’s placement on this “grid” system (the level of personality organization on the “y” axis and introversion or extroversion on the “X” axis) determines their pathology and its severity. The three levels of personality organization as proposed by Kernberg are neurotic, psychotic and borderline. It is important to note that by ‘borderline’, Kernberg was referring to the classical psychoanalytical term, delineating an interim level between neurotic to psychotic, not to be confused with Borderline Personality Disorders (Kernberg, 1995). The neurotic level is considered the healthiest level, utilizing mature defense mechanisms, exhibiting intact reality testing and a consistent sense of self and others. The opposite level within the personality organization dimension is the psychotic level. Such individuals utilize immature defenses, have an inconsistent sense of self and others and their reality testing is compromised. Personalities organized at the borderline level generally exhibit intact reality testing, though they tend to rely on primitive defense mechanisms and have a fragmented sense of self (Kernberg, 1995). Indeed, this inconsistency in sense of self and others is also a marked characteristic of BPD.
Personal opinion
Linehan’s model reflects a combination of nature and nurture as explaining factors. According to Linehan’s theory, Borderline Personality Disorder traits and symptoms are the result of a combination between biological propensity and vulnerability (‘nature’) and environmental factors (‘nurture’). While Linehan attributes the environmental factors to invalidation, other accounts of environmental and innate mechanisms may vary. For instance, Gunderson and colleagues (2011) investigated the familial dimension of BPD. Through interviews and genetic testing, they have found that individuals with BPD usually have at least one more family member meeting BPD criteria. Their investigation focused on four constructs of BPD symptoms, including behavior, cognition, affect and interpersonal relations, and found that the most common factors were the affective and interpersonal dimensions rather than behavioral and cognitive aspects. To this extent, their research indicates that the family environment contributes to its members' affect and interpersonal relationships, and not behaviors and thought patterns or perceptions.
Linehan’s model reflects a combination of two perspectives on psychopathology; the traditional psychodynamic perspective, emphasizing early childhood experience and relationship with parents, and the medical-psychiatric perspective, focusing on neurobiological constructs underlying psychopathology. While each perspective contributes to understanding and treating psychopathology, they are unable to explain the individual differences. If in fact early childhood experiences are the cause of pathology, how would these models explain the fact that individuals from similar backgrounds may not develop this disorder? Similarly, if neurobiological constructs are at play, how would the models explain the fact that individuals with similar neural constructs receive different diagnoses, if at all?
It seems that the only way to account for individual differences would be combining biological predispositions and environmental influences. To this extent, Linehan proposes one such solution. Other theorists may focus on different environmental factors such as early childhood trauma (for instance, Bandelow et al., 2005), and other biological or inherited predispositions such as attention mechanisms or temperament (Rothbart et al., 2002).
In conclusion, personality disorders and the axial system of psychiatric classification in general reflect a perception of the human psychological construct as multidimensional. In addition, the axial system and prevalent theories of personality disorders recognize the contribution of an individual's environment in developing psychopathology and the form it takes. Factors such as environment, psychosocial stressors and general medical conditions contribute to individual differences in vulnerability and susceptibility to psychopathology, as well as influencing the manner in which it would manifest. The research by Kuo and Linehan discussed above is an example of the state of the art in research into psychological disorders, attempting to ascertain and verify etiological models of psychiatric disorders. It also reflects the growing tendency to move from unipolar explanations such as a pure psychoanalytic or pure medical explanation towards a more holistic approach.
References
American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders: DSM 5. Bookpoint: US.
Bandelow, B., Krause, J., Wedekind, D., Broocks, A., Hajak, G., & Rüther, E. (2005). Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with borderline personality disorder and healthy controls. Psychiatry Research, 134(2), 169-179.
Gunderson, J. G., Zanarini, M. C., Choi-Kain, L. W., Mitchell, K. S., Jang, K. L., & Hudson, J. I. (2011). Family study of borderline personality disorder and its sectors of psychopathology. Archives of general psychiatry, 68(7), 753-762.
Kernberg, O. F. (1995). Object relations theory and clinical psychoanalysis. Jason Aronson.
Kuo, J. R., & Linehan, M. M. (2009). Disentangling emotion processes in borderline personality disorder: physiological and self-reported assessment of biological vulnerability, baseline intensity, and reactivity to emotionally evocative stimuli. Journal of abnormal psychology, 118(3), 531.
Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
Millon, T. (1981). Disorders of personality: DSM-III, axis II. New York: Wiley.
Posner, M. I., Rothbart, M. K., Vizueta, N., Levy, K. N., Evans, D. E., Thomas, K. M., & Clarkin, J. F. (2002). Attentional mechanisms of borderline personality disorder. Proceedings of the National Academy of Sciences, 99(25), 16366-16370.
Widiger, T. A., Costa Jr, P. T., & McCrae, R. R. (2002). A proposal for Axis II: Diagnosing personality disorders using the five-factor model.
