Article summary of Self-reported impulsivity in women with borderline personality disorder: the role of childhood maltreatment severity and emotion regulation difficulties by Krause-Utz et al. - Chapter


Introduction

Borderline personality disorder (BDP) is a serious mental disorder. This disorder is characterized by a pattern of instability in affect, cognition (self-image), interpersonal relationships and impulsive behavior. Also, impulsivity and emotion dysregulation are main features of borderline personality disorder. Impulsivity in this disorder has many negative outcomes and is linked to risky behavior, suicidal behavior and to difficulties in establishing and maintaining stable relationships. Impulsivity in borderline personality disorder has to do with things such as substance abuse, spending sprees, gambling, reckless driving, risky sexual behavior, sudden relationship break-ups (which also includes dropping out of treatment) and non-suicidal self-injury or self-harm. 

The impulsive behaviors described often occur during emotional stress. So, impulsivity in borderline personality disorder is regarded as a consequence of malfunctioning emotion regulation mechanisms or as a "facet of emotional dysregulation".

Severe childhood maltreatment such as emotional, physical and sexual abuse and neglect serves as a risk factor for the development of borderline personality disorder. In contemporary views, as a result of an interplay between genetic, neurobiological dispositions (increased affective sensitivity and reactivity) and stressful or traumatic life experiences, individuals with the disorder are hindered in the acquisition of functional and adaptive emotional coping mechanisms. This results in a pervasive form of emotion dysregulation, which is believed to be the core of the disorder. 

Linehan's biosocial theory focuses on the role of an invalidating environment (which is an abusive, neglectful or unstable environment) in the development of emotion dysregulation and impulsivity. According to this theory, difficulties in emotion regulation are the consequence of childhood adversities. This emotion dysregulation leads to the use of impulsive coping strategies. So, impulsivity is regarded as a response to stress. There is a lot of evidence that shows that is in line with this.

However, a remaining research question is whether the effect of childhood maltreatment on impulsivity is mediated by emotion dysregulation. Since it is known that emotion dysregulation and impulsivity are also core features of other disorders, such as ADHD and substance use disorder, the question is whether the mediation is specific to borderline personality disorder.

Severe childhood maltreatment can have a big impact on the development of self-control capacities. This includes the regulation of impulses and emotions. As children grow older, emotion regulation becomes more and more important in psychosocial development. To develop a healthy emotion regulation ability, early caregivers' interactions are very important. Children who are exposed to early negative life events, show an increased risk for developing mood and anxiety disorders. This is probably due to changes in neurobiological systems which are involved in the regulation of stress and emotions. An example of such a change is an increased stress responsiveness. Such changes can have very negative consequences across many life domains, because the ability to inhibit strong emotions is crucial to maintain goal-directed behavior and self-control. 

As mentioned earlier, emotion dysregulation and impulsivity are also core features of other mental disorders, which often co-occur with borderline personality disorder. Examples are ADHD and substance use disorder. These disorders are also associated with higher rates of childhood trauma. This means that individuals with ADHD or substance use disorder, have experienced childhood trauma more compared to people without these disorders. Emotion dysregulation serves as a mediator for the relationship between childhood trauma severity and substance abuse related impulsivity. So, childhood trauma leads to impulsivity, because (this is what a mediator tells) it leads to emotion dysregulation. Also, non-acceptance of emotions and being unable to label emotions is related to impulse control problems among problem drinkers and to higher substance use rates. However, even though there is a high comorbidity (they occur together) between borderline personality disorder and these disorders, the studies have not controlled for the presence of borderline personality disorder, which may have lead to confound results.

So, childhood maltreatment is linked to difficulties in emotion regulation and impulsivity. This puts individuals at a higher risk for developing different psychopathologies (disorders). However, it is not clear whether the effect of childhood maltreatment severity is mediated by emotion dysregulation and if this is specific for borderline personality disorder as compared to other clinical samples (such as ADHD). Answering this question might help to understand impulsivity in borderline personality disorder. This current study used self-reports to examine the role of emotion dysregulation in the relationship between childhood maltreatment and impulsivity in women with borderline personality disorder compared to healthy controls and clinical controls without borderline personality disorder. 

Impulsivity

Impulsivity is a complex construct. In this study, the authors used the UPPS Impulsive Behaviour model by Whiteside and Lynam. This model conceptualizes impulsive behavior in four ways: a lack of premeditation (which involves difficulties considering the consequences of an action and making accurate plans or precautions); increased sensation seeking (the tendency to pursue exciting activities, openness to try new potentially dangerous experiences); a lack of perseverance (maintaining task-related attention and goal-directed behaviour in demanding situations) and urgency (the tendency to act without forethought during emotional stress).

This study studied whether: higher childhood maltreatment severity predicts higher impulsivity; whether difficulties in emotion regulation statistically mediate the relationship between childhood maltreatment and impulsivity and whether this mediating relationship is particularly strong in patients with borderline personality disorder, as compared to clinical controls. The authors hypothesized that across all participants, childhood maltreatment positively predicts emotion regulation difficulties and impulsivity. They also expected that this mediating relationship would be stronger in borderline personality disorder patients compared to other groups.

Measures

Mental disorders

The Structured Clinical Interview for DSM-IV I disorders (SCID-1) was used to determine DSM-IV major mental disorders. This is a semi-structured clinical interview.

Substance abuse 

Substance abuse was measured by looking at symptoms within 12 months, such as tolerance effects; withdrawal symptoms; taking up more drugs than attempted; failure to reduce or stop taking drugs; spending more than two hours on obtaining, using or recovering from drugs; social, financial, legal, health and/or mental problems.

Borderline personality disorder assessment

To assess borderline personality disorder, the International Personality Disorder Examination (IPDE) is a semi-structured clinical interview based on the International Classification of Diseases (ICD 10) and the DSM-III-R classification systems.

Primary measures

Childhood Trauma

To assess childhood maltreatment severity, the authors used the Childhood Maltreatment Questionnaire (CTQ). This is a self-report scale with five subscales which measure emotional, sexual, and physical abuse and emotional and physical neglect.

Impulsivity

To measure impulsivity, the authors made use of the UPPS scale. This measures different facets of impulsivity, which are based on the Five Factor Model of Personality. This scale contains 45 items which are related to four subscales: Urgency ("I have trouble resisting my cravings)", (Lack of) premeditation ("I don't like to start a project until I know exactly how to proceed), (Lack of) perseverance ("I generally like to see things through to the end); and Sensation Seeking ("I generally seek new and exciting experiences and sensations").

Emotion regulation

To assess difficulties in emotion regulation, the authors made use of the Difficulties In Emotion Regulation Scale (DERS). It contains 35 items. The DERS assesses emotion regulation as: being aware of current emotional experiences ("When I am upset, I believe that my feelings are valid and important"); understanding these experiences ("I can make sense of my emotions"); being able to accept and reflect on these emotions and ("When I am upset, I feel guilty for feeling that way"); having a clear idea about how to effectively regulate and mature regulation strategies ("When I am upset, I have difficulty getting work done).

Discussion

This study looked at the effect of childhood maltreatment severity on impulsivity and at whether difficulties in emotion regulation served as a mediator for this relationship in borderline personality disorder compared to healthy controls and clinical controls. The results showed that higher childhood maltreatment and in particular emotional maltreatment, does predict more difficulties in emotion regulation and impulsivity across all groups. There was also a significant interaction effect of childhood maltreatment and group in the prediction of impulsivity. This means: the effect of childhood maltreatment severity on impulsivity was stronger for individuals with borderline personality disorder compared to individuals with ADHD. The authors also found a significant mediation effect which depended on the group. For example, in the group with borderline personality disorder, when controlled for difficulties in emotion regulation, the effect of childhood maltreatment on impulsivity was not significant anymore. 

The findings with regards to a positive relationship between childhood maltreatment severity, difficulties in emotion regulation and impulsivity are in line with the hypothesis of the authors. So, childhood maltreatment can have big negative consequences on the development of healthy emotion regulation strategies and self-control. To elaborate, it can lead to: an inability to tolerate intense negative emotions, an inability in considering the results of one's actions and an inability to focus on goal-directed behaviour when being in a negative emotional state. 

Emotional maltreatment was the only significant predictor for regulation difficulties as well as for impulsivity. This form of maltreatment therefore has a big impact. Examples of this kind of maltreatment include humiliating or demeaning behavior toward the child, psychological inability of caretakers and a failure to meet children's basic emotional and psychological needs. These kinds of behaviours often arise as a result of the parent's own unresolved childhood adversities. 

Emotional maltreatment is also linked to changes in emotional processing, including increased affect intensity and decreased distress tolerance. It is also the strongest predictor of emotion regulation difficulties later in life. When controlling for other types of abuse, emotional maltreatment was the strongest predictor for malfunctioning emotion regulation strategies and borderline personality disorder symptom severity. 

Borderline personality disorder patients reported the highest rate of traumatic exposure (particularly sexual traumas including childhood sexual abuse and being physically attacked), compared to other three groups of personality disorders (schizotypal, avoidant and obsessive-compulsive). The effect of childhood maltreatment was also more pronounced in borderline personality disorder compared to control groups. Having experienced trauma is not necessary for the etiology of borderline personality disorder, but trauma does aggravate symptoms of the disorder. This is in line with Linehan's biosocial theory. 

Limitations of this study

The authors of this article made use of a patient group and excluded comorbid patients. This is a strength of the study, but also a downfall, because it leads to a lower sample size. This sample size may lead to a lower power to detect effects. 

The authors also only included women. So, future research should include male participants. 

The self-reports that the authors used may be susceptible to bias, such as social desirability, limited awareness and insight, different subjective interpretations of measured concepts, and 'coloring' of reports by current mood. Also, childhood maltreatment was assessed in a retrospective and subjective manner, which may also involve recall biases. This is important, because individuals with borderline personality disorder may experience traumatic experiences more vividly and they show a tendency to report more negative childhood adversities.  

Previous findings also showed that self-reports and behavioral and psychophysiological measures of emotion regulation and impulsivity in borderline personality, are not correlated. Therefore, future research should make use of experimental tasks of emotion regulation, impulsivity and emotional distress.

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